Saturday, December 25, 2010

Rant About Quality Of Life Versus Quantity, And Differential Diagnoses

So Jasmine recently broke out with a third skin infection in quite a short time.

This time it was a nasty bacterial folliculitis (inflammation of hair follicles) around the base of her tail.

She lost a bunch of fur which left her with bald patches. The infection now seems to have cleared up with antibiotics and topical treatment, and even though her vet warned us that further hair loss might still occur, we are hoping that won't be the case.

Taking care of the infection is only the first step though.

Now we have to figure out what is going on allowing these infections to happen.

Most bacterial skin infections in dogs are secondary to another disease such as parasitism, allergies, endocrine (hormonal) disorders or abnormalities in the immune system.

Parasites (fleas, mange ...) have been ruled out. That leaves us with allergies, hormonal issues or immune system issues. Wow, such lovely choices, so hard to pick!

Of course the first conclusion to jump to are allergies.

They are extremely common and Jasmine's allergy spot blood test is a long list of things she's allergic to. We are controlling her food allergies with a custom home-cooked diet. Controlling exposure to environmental allergens is another story, particularly since she tested positive to so many of them, including pollens and grasses.

Allergy shots are an option with limited number of allergens.

Approximately half the dogs receiving immunotherapy will have an excellent response. About 25% will have a so-so response. About 25% will not have any response at all.

Viva of Kenzo the Hovawart is responding to the treatment very well. She has tested positive to dust mite allergy only though.

The more offending substances, the lesser the chance the treatment will work and the higher the likelihood of complications.

That leaves supportive treatments and limiting exposure. But Jasmine is allergic to whole bunch of grasses too.

This brings me to the question of quality of life versus quantity.

Her vet loves Jasmine and has her best interest in mind. However, with the main, however logical, suggestion being eliminating exposure to hay/grass—not only what she gets into but even whom she sees, what would become of Jasmine's life?

“If she was my dog she would not see grass or hay ever,” he noted.

Say what? How would one even remotely manage something like that short of locking her in a clean room? I'm sure there are plenty of couch-potato dogs out there who'd be perfectly happy with such a plan.

Jasmine, however, is an outdoor dog!

She loves her family and her den, but what she really lives for is spending time outside. Taking that away from her would be fate worse than death!

I still clearly remember the look on her face when after her surgeries she could not go for her walks. The disappointment that quickly turned into resignation. The profound sadness in her eyes.

Come to think of it, I believe that for her there isn't a choice between the quality and quantity of life.

If she was deprived of her time outside, she would die of sadness within a month! I am sure of that.

So what happens from here? Are we going to manage her outbreaks until things finally get out of control?

We are not convinced that her skin issues do stem from allergies, and if so, there is no real proof that the grasses are at the root of it.

It is winter now and there is snow on the ground!

Yes, she has allergies. But she is not an itchy dog! She doesn't spend her days in agony scratching and licking herself. In fact, my observation is that she doesn't get itchy until something is already brewing.

There is no discernible pattern to anything. I've been charting details about weather, air quality, and locations she's been to, for a long time now. There is no pattern! (To be on the safe side, we are now tracking eye redness as well.)

However logical, allergies are not adding up to us.

It walks like a duck, it quacks like a duck … what if it isn't a duck?

Differential diagnosis, please!

I have to give our vet all the credit in the world. As convinced as he is that it is allergies, he is still listening to what we are saying.

So while we are implementing all the reasonable suggestions to minimize Jasmine's exposure to allergens, we will also be working on a differential diagnosis.

If it wasn't allergies, what would it be?

Yes, allergies are extremely common, but they are also most commonly over-diagnosed.

If I had allergies and broke my leg—could I pin the broken leg on the allergies?

Well, possibly, if I sneezed hard enough to fall off a balcony …

We are not saying that allergies cannot be at the root of the problem. But we are not feeling it.

Jasmine has a number of other issues going on, maybe the answer lies there. Maybe it's something perfectly simple we are missing.

That is a mistake we don't want to make. Look one way and miss a truck hurtling at us from the other direction.

If the push came to shove, what do you think would be more important to your dog? Quality of life or quantity?


PS: If you wanted to flex your diagnostic muscle

It started with Jasmine suddenly licking at her right flank one night mid fall. I went to look and there was something that looked like a bug bite. I put on some Polysporin and it seemed to have done the trick. She left it alone again. Then came back to it. As we were seeing her TCVM vet, I had him look at it and he didn't find anything suspicious about it.

Then it happened again just prior her teeth cleaning and stem cell treatment. Again, it didn't seem to be anything to worry about and it was fine again.

In the meantime she got a moist pododermatitis on her foot (bacteria confirmed with cytology). It was believed to have started as a result of self-trauma due to allergies. We were buying that one, as her toes did seem to have been an issue off and on. Resolved with antibiotics.

Then at the end of  November the thing on the flank flared up again and this time some fur was coming out as well. Saw the vet immediately. The conclusion was a superficial folliculitits to pyoderma believed to be a result of a romp through the burrs and brambles. It cleared with topical treatment, though there is a small bald patch left from it.

And then the recent major break out of folliculitis around her tail base, which led to substantial hair loss and bald patches. Staph and Dermatophilosis found. Seems now under control with antibiotics.

However, last night she suddenly started paying attention to her left flank this time. I found a tiny spot again, pretty much exactly the same area as the right flank previously, but looks drier, more like a scrape than a bite this time. Used Dermacool and it doesn't seem to bother her for the time being.

But that's how the right flank started originally too, very low key.

Previously diagnosed issues:
  • hypothyroidism - recent T4 21 (13-51 normal)
  • eosinophilic gastroenteritis
  • bilateral ACL tear
  • arthritis
  • history of muscle injuries
  • she had history of skin issues prior hypothyroid diagnosis

Previous not really diagnosed issues:

  • episodes of pacing and panting going on progressively for 5 years now, improved with TCVM
  • this year new licking at front feet and scratching at front elbows with marked episodes

She is not itchy otherwise. Also are the feet actually itchy or are they burning, tingling – how would one know?

Other notes:
  • her coat has been very fine, redish tint, and her nails wear off easily
  • since she's been shaved for her surgeries the undercoat is overtaking the top coat (the first winter she grew virtually undercoat only)
  • her coat gets smelly easily after being wet (even after bath); doesn't dry well
  • her feet smell bad sometimes
  • licking of private parts
When emailing with Dr. Laci of VetLive I noticed one thing: last year Jasmine's T4 levels were 36 in August and 42 in September on half the dose she is on now. This March suddenly they dropped to 14. They are now 20 with double the dose. Surely something seems to be going on there ...?

    Further reading:
    Five Common Causes of Itching in Dogs
    Dog skin disorders
    Bacterial Infection (Pyoderma) of the Skin in Dogs
    Folliculitis in Dogs

    Related articles:
    Please help Jasmine


    1. Unless she tested positive for house dust mites or mold spores, or unless the food allergy has reared it's ugly head again, I would put allergies lower on the list here. Thre is no substantial exposure to seasonal environmental allergies this time of year. Consider re evaluating her diet and possibly changing protein sources to a novel one (one she has not eaten before). Discuss this with your vet as it is more complicated than just changing foods. Also consider some other type of immune system problem, one that might never be specificaly diagnosed as these can be quiet illusive. If the ball keeps coming back to allergies, discuss cylcosporin with your vet. Wish you luck.

    2. Dear Keith. Well, she did test positive for house dust among many other things. Her list is very long. Would all of the allergies be of the same severity? Probably not.

      The reason he's convinced of the grasses/hay is that she does have some minimal potential exposure to hay at this time when she visits friends' horse farm. But there is no pattern between her reactions and the visits or any other locations she goes to.

      Will keep the cyclosporin in mind.

      Illusive - that is Jasmine's middle name. Nothing with her works as would be expected. So much so that if she presents with an issue her vet sits there thinking out loud, "here is what I would do with any other dog - but this is Jasmine." Even her TCVM came to conclusion that everything about her is unique (and illusive).

      Thank you so much, have wonderful holidays!

      Changing protein source is on the list of considerations.

    3. What are you feeding her? Especially if it is cooked--many dogs are allergic to the cooked form of a food and not the raw one. Have you ever tried feeding raw? A species appropriate diet (ie, all meat, all raw) can do wonders for "allergies." Even a dog with a list of allergies as long as your arm can sometimes "recover" when fed raw. (If interested, join the yahoo group rawfeeding for expert help from people who aren't trying to sell you anything...)

      Best of luck!

    4. Cooked versus raw is a big dilemma for us. All three of her vets seem to agree that cooked is the best option for her.

      While it is something that is constantly on my mind, I haven't worked up the courage to go against all three vets on that.

      Her diet is based on

      At this point it is unclear to us whether her skin issues are from allergies or not. She was a dog with chronically bad stools and terrible appetite. Now with the diet and TCVM herbs she's been on, those have improved tremendously.

      But the barf diet is still something in the back of my mind.

    5. I did not know that Jasmine had so many allergies! Since she isn't all itchy and scratchy, like Dr. Keith said, maybe it's an immune system problem.

      Have you ever tried feeding Jasmine rabbit? You can get it at most Asian food markets.

    6. Her list is very long, though only chicken and egg proteins. Lots of other things though.

      We did try emu some time back, but it was no different than with beef she is on. Though I am considering trying a different protein.

      The fact that she isn't really itchy I find strange for the allergies theory. She will go after her front feet during her episodes, usually at least half way into it, but it is only assumed that they are itchy. For all we know they could be burning or tingling too ...?

      Sucks that dogs cannot verbalize things.

    7. What does Jasmine take for supplements?
      Any products to augment the health of her skin/immune system?
      With any type of allergic skin disease or joint problems, I would definitely use an omega 3 fatty acid (fish preferable to flax oil).
      Additionally, for her joints, a non-beef based (i.e. not with beef or other meat flavors considering her skin) glucosamine/chondroitin sulfate/MSM oral joint supplement and/or injectable Adequan. I know you have done Stem Cell Therapy for Jasmine's elbows/etc.
      Chinese herbs that help to clear heat, clear wind, move blood, promote Wei Qi (the "forcefield" that protects from invading pathogens), etc can help with skin and joint problems.

    8. Jasmine is on UbaVet, MSM, ProZyme, Florentero, omega-3 (Aller G-3 gells) and vit E. Plus Chai Hu Jia Long Gu Mu Li Tang from her TCVM. Safflower oil in food.

      Did injections, started getting a reaction to them. We feel that with the stem cells her joints are probably the happiest part of her body right now.

    9. As a human with allergies, I can tell you that new allergies emerge constantly. The propensity to become allergic is lifelong and once the body decides to make antibodies to some common thing, that's it.

      Since you're preparing her food, have you considered organic meat? I've known humans who have allergic outbreaks to meat that's been given antibiotics.

      The feet would be the contact point for a lot of allergens. Have you tried putting boots on her?

      my non-medical 2 cents on top of my 2 cents above... erm below my other 2 cents above... trust your gut. You know your dog. It may indeed be due to one of the other million or so causes of skin problems. I've been right so often when I insist "no, it isn't that" to a vet. I won't know what it is but I know what something isn't. (This is not always a happy thing, as I knew that Twiggy didn't have just a UTI and it turned out she had bladder cancer)

    10. I hear you, we have allergies also (pollens mainly). We get most of her meat from a local farmer, so I think that one is as organic as it gets.

      Haven't tried the boots yet, from the reaction I've seen from other dogs we are quite worried it would just lead to an injury.

      So sorry to hear about Twiggy. Yeah, that might sometimes be the reason one wouldn't want to listen to their gut.

      My gut is however telling me it is something other than allergies, we are hoping that it might be thyroid.

    11. I had a lab who suffered severe allergies from May till end of Oct. Hot spots, skin bacterial infections. She passed away 5yrs ago at age 15. The only option given to us was antihistimes which never worked and prednisone during those mths only - she started on pill every day for 5 days then half pill for 3 then half every other day. Pretty much that was her routine for 15 yrs. She did suffer significant hindend weakness beginning at 12 but made it with help till 15. Coming forward, if someone suggested allergy shots I might consider it today to try. Good luck. I'm with you, how does a dog avoid grass... poor things :(

    12. Has 'healthy dog' become an oxymoron? Strange thing is that she broke out with all the infections FROM October on. It was December now when she broke out with the worst one. That's one of the things that make me think not allergies.

      I am trying to stay away from prednisone ... last summer I was almost convinced to put her on it when she suffered the drug induced hyperthermia (different drug) and an abscess was found in her abdomen. I don't want to think what could have happened if I did put her on the prednisone.

      Prednisone is a last resort drug for me, though I was pretty close to agreeing to it few times.

      Hoping to convince her vet to run a full thyroid panel and maybe some clues come from that.

    13. Gosh, I just hope you can her vets can get all her problems figured out. Ace seems to have itchy skin all the time and it must be allergy related. I don't know if it's food or environmental. Since it doesn't seem to be TOO bad for him, I just let him deal with it.

      Why do the vets suggest cooked vs. raw for Jasmine? I'd like to get Ace on a raw diet.

    14. Dear Lindsay, I surely hope so too. I am still feeling that the thyroid is involved. That would be the 'good' diagnosis with a solution. So hoping that might be it. If not, the other options are not so hot.

      That is the thing - Jasmine is not an itchy dog. Not unless something is already going on with her skin. That's why I'm not feeling the allergies. Yes, she has them, but ... Not feeling it as a reason for this.

      re: cooked versus raw
      There is the argument some nutritionists make that many foods are easier to digest cooked than raw.

      Plus with how delicate her system is they feel that she wouldn't be able to deal with potential bacteria (e.g. e-coli, salmonella) successfully.