Tuesday, May 1, 2012

What Doesn't Kill Her Will Make Her Stronger? Koda's Story

JJ is my dear friend. Her dog, Koda, is almost two years old, adorable Australian Shepherd girl. Koda has already had more struggles with her health than most old dogs ever will. Since a very young age, Koda had pee problems

When trying to get to the bottom of it, JJ was told that "puppies pee". And that was the beginning of their medical frustrations.

That got sort of solved, but not really resolved. Koda has been also suffering with frequent UTIs. This also never got explained or resolved.

Last fall Koda struggled with fleas and severe flea allergies. Was treated with prednisone, however remained a self-mutilating itchy dog who was peeing like crazy, again, on top of that. She also contracted tapeworm, so was treated for that.

Koda started becoming more and more fearful of everything. JJ also said that Koda seems to be having some vision problems, however, her eyes checked out when examined. With old issues lingering, and new ones piling up, this brings us to the recent events.

Picture this if you can. You and your sick dog are sitting in a little room, waiting for a specialist.

The internist pops in looking very ... sober ... and asks you what [the hell] you expect her to do.

So let's rewind.

The original vet visit was due to stool trouble, which turned into difficulty defecating. Blood test also revealed possibly low platelets. The vet prescribed FortiFlora, Amoxicillin (a penicillin-type antibiotic) and a stool softener three days later when Koda was still unable to go. This helped Koda with the eliminating. Follow-up blood test was scheduled.

The follow-up blood test showed some further drop in platelets and elevation in white blood cells.

In addition to the antibiotic, Koda was put on a massive dose of steroids. When JJ told me that Koda is getting six pills of prednisone a day I asked what the diagnosis was.

She wasn't told what the diagnosis was, not even when she asked. 

Apparently something to do with the immune system, that's all JJ got out of them.

Based on the little information available, the only thing we could figure the vets were suspecting was Immune Mediated Thrombocytopenia. Why else such a high dose of steroids?

Meanwhile, Koda was more and more depressed, very low energy and rapidly losing weight. 

So back to the vet. New blood test was done.

When I asked JJ for an update, she told me that the vet said that Koda's liver and kidneys were now in trouble also. 

That didn't sound good at all. How many things could go this wrong this fast while on prednisone? Could it be some kind of infection after all? No adjustment to the treatment was done, and no diagnosis in sight.

Clearly at a loss, they referred Koda to a specialist, but it was unclear when they'll be able to see them.

Meanwhile, JJ had an appointment with a different vet, which she made some time back. Hoping for some new insights she acquired copies of the lab work. I was very worried about Koda and asked to see the lab results.

Seeing the blood test results actually made me feel more hopeful.

I have seen, and discussed, enough Jasmine's lab results that I couldn't help but wonder why they told JJ that Koda's kidneys were in trouble. 

I wasn't seeing it on these results. I asked some of my veterinary friends, and they couldn't see any problem there either.

That was good news, the labs didn't look half as bad as it sounded from what JJ was told.

The liver was not happy, but was it because of the original problem or because of all the prednisone? The platelets were below normal, but they didn't seem anywhere near levels that would call for drastic measures? (I have seen some really low platelets after Jasmine's hyperthermia).

More importantly, after all the steroids, the platelets showed zero improvement.

So what is going on?

That appointment with the different vet didn't, sadly, bring any insights either. I was hoping they might at least do something about the prednisone Koda was still on, but that didn't happen.

My feeling is that they didn't want to get in the middle and washed their hands of the case.

They put Koda on a glycogen replacement supplement, which at least made her feel better.

They didn't offer any ideas, but they did drop another bomb – the word chemo, yet again, with no explanation or substantiation.

JJ was still waiting to get the appointment with the specialist, and Koda was still miserable and eating 6 prednisones a day (now for almost a month).

That was when I decided we needed to talk to somebody I can trust and I turned to VetLive.

Finally I was talking to somebody who was making sense! Dr. Laci of VetLive started by asking a lot of questions.

Right on! You cannot get answers without asking questions!

They asked to confirm the dose of prednisone, relative to Koda's weight (36 pounds when the treatment was started). They asked about the rate of her weight loss, how much Koda's activity level decreased, drinking and urination, and detailed information regarding stool amount, quality, color and texture.
VetLive: Color also matters more than you would think. Are any stools grey, yellow, green tinged, or even unusually greasy? When she was having trouble with bowel movements, how frequent were they? Were they normal to hard or soft and poorly formed? Has she had a rectal exam?
Koda was drinking ton of water and urinating proportionately large amount. She was eating more and more food, while losing weight. Her activity decreased probably by 70%. Koda's nick name used to be “psycho dog”; now she would barely respond to her name.

Koda's stools are formed most of the time, but soft. Fairly normal color.
VetLive: Is there any yellow tinge to the whites of the eyes, her mucous membranes, vulva, thin skin of the ears, or any other skin on her body that is skin and normally pink in color?
Fortunately, Koda was showing no signs of jaundice.

They asked about the behavioral changes and the time frame in which they occurred.

Koda started avoiding things and people she's known most of her life.

VetLive asked about the vision issues and suggested at home tests to evaluate the situation, to get an idea whether they should include the issue in the relevant symptoms: a cotton ball test and a small maze.
With the cotton ball test, the purpose is to test her vision with something that is near silent when dropped and has practically no smell that she can follow. Drop several cotton balls in front of her, and in her range of peripheral vision. Watch to see if she can follow them. The maze test is fairly self-explanatory—set up a small maze of some chairs, etc. and see if she has any trouble navigating this.
Koda passed both tests, she mainly has issues when it gets dark.

They asked whether JJ could see any improvement in Koda after the treatment was started. 

There was no improvement whatsoever, on the contrary. Koda became lethargic, started panting heavily, suffered from urinary incontinence and complete lack of stamina.

VetLive reviewed the lab work. They explained that any severe or prolonged blood loss, increased internal destruction of platelets, or impaired bone marrow production can lead to short-term (acute) or longer term (chronic) deficiency of platelets. Many diseases have thrombocytopenia as one component of the condition. For example many serious infections, neoplasia, immune system disorders, pancreatitis, and various drug therapies such as some anti-cancer treatments can result in thrombocytopenia. Some antibiotics can also lower platelet levels.

Koda was on the Amoxicillin.

VetLive also asked about the possibility of tick borne diseases. This would be of high interest, because ehrlichial diseases can cause mild to severe thrombocytopenia in dogs. 

They did run some tests for infections, including tick borne diseases and JJ was told the results were negative.

VetLive also didn't see any reason to worry about Koda's kidneys.

VetLive: I am not worried about kidney. I see the BUN slightly up at 31 on 4/17, but corticosteroid administration raises the value, and also, she is concentrating her urine wonderfully and there are no other signs on the lab work to make me think kidney. Also, decreased muscle mass can cause mild elevations in BUN. It does take significant losses so I am not sure if this could be a cause, but regardless a BUN of 31 with other normal values is not a flag to me.

Interestingly enough, hepatic insufficiencies often decrease BUN production. Decreased BUN may be an indication for hepatic function tests—not what is going on.

I also see that her liver values were normal before treatment. I am not terribly worried about the liver values since she was on high levels of pred.

A bile acids test would let us know if the liver is functioning properly. This test isn't perfect, but it is a good screening test for hepatic dysfunction and is easy to do. If you have enough money to do that, it would confirm if liver is a problem. Glucocorticoids are a regular and important cause of severely raised ALT and alk phos in dogs. Doing every test that will give us new info is the best course of action obviously, but the protocol for her values when systemic glococorticoids have been administered is to stop the drug therapy if possible and re-evaluated in 1-3 months. Given how quickly she is deteriorating, a bile acids test would give us valuable info without waiting 1-3 months, but I just wanted to give you that info to demonstrate that how commonly those values can be artificially raised.

VetLive also made notes regarding the platelets.

VetLive: Quoting from my professor in school and one of the gods of veterinary small animal internal medicine, Michael Willard

“Platelets circulate for approximately 5 days in dogs...Platelets are released into the blood in proportion to stimulation from thromobopoietin; criculating thrombopoietin concentration is controlled by the total circulating platelet mass, not absolute number; therefore there may be mild thrombocytopenia with macroplatelets.”

I wanted to mention that, as I saw platelet clumps noted on every test. I did see one manual count done of the platelets and they recorded they saw 4-5 per high powered field. Between 8 – 29 platelets/100x oild immersion field is normal for canines.

I think it would be in Koda's best interest to have a manual platelet count performed by Idexx. If  on a budget, as we most are these days, I would start here.

A tick panel would also be great, but I know it is more costly (not sure how much), and you can wait to find out the platelet count before pursuing it.

At the dose of prednisony that Koda has been on, it is expected that she would experience side effects of increased appetite, thirst, and increased urination. Heavy panting also is seen with high doses of prednisone, along with lethargy and depression. Prednisone at these high doses also can cause muscle wasting. It usually does cause weight gain, not weight loss, but just kind of a loss of tone to the body and sagging muscles and tissue without much definition.

Can you tell me if she was experiencing any of these before the prednisone? It is my understanding that she was experiencing some fearful behavioral changes. If she was having an excessive appetite, thirst, panting, etc. before the steroids that completely changes my differential list of illnesses.

VetLive recommended to discuss (with her vet or the specialist) taking Koda of the prednisone.

Regardless of the reasons that there may have been to start such an aggressive course of steroids, it was really time to evaluate what good this drug was doing, and more importantly, what harm.
VetLive: Animals that have received glucocorticoids systemically, other than with "burst" therapy (probably what she had for her flea allergy), should be tapered off the drugs.

Patients who have received the drugs at such high doses as Koda should be tapered off slowly as her internal corticosteroid function may return slowly. Should she undergo a "stressor" (e.g., surgery, trauma, illness, etc.) during the tapering process or until normal adrenal and pituitary function resume, additional glucocorticoids should be administered. I think you will see an improvement in a variety of things with Koda is we can get her off the steroids.
Finally we got some information that made sense! 

If you need a second opinion, start with VetLive. Truly. They offer second opinion service, where they'll review available labs and medical history, I was really impressed and relieved, finally a voice of reason!

This has helped to make some sense of all the mess.

Meanwhile, Koda got to see the internal medicine specialist. So fast forward to the latest update.

Picture this if you can. You and your sick dog are sitting in a little room, waiting for a specialist.

The internist pops in looking very ... sober ... and asks you what [the hell] you expect her to do.

So, we go back to day 1, when JJ went to the vet for Koda-can't-poop issues, and they did a blood test that revealed low platelets. They put Koda on antibiotics for the not-being-able-to-poop and scheduled to take blood again and sent it out to the lab.

[Internist: Antibiotics lower the platelet count. Platelets aren't considered low until they're getting near a 30 count (30,000); your dog's are near 100,000; I fail to see a problem.]
[Internist: Your dog was put on antibiotics for a UTI.]
[Client: What UTI?]
[Internist: There were white blood cells in her urine.]
[Client: Are you reading the right paperwork? There was no presence of infection according to my vet.]
[Internist: .....]

Second vet visit: They take blood and send it out to Idexx for a CBC

[Internist: I see here that no manual count was ordered. Why did you refuse it?]
[Client: A whosawhatsit?]

Third vet visit: we pick up a high dose of prednisone and a high dose of antibiotics.

[Internist: Where are the rest of the diagnostics?]
[Client: ????]
[Internist: You know, like xrays, ultrasounds...? Did you refuse them?]
[Client: ......... no. They didn't mention any. I didn't know they needed more than the blood test results, didn't know the low platelets aren't low enough to do something about (she needs monitoring...not immunosuppressant therapy).... I had to trust that the vet had my dog's best interest in mind.]
[Internist: Right. Great. Wonderful. Why did they also give her those antibiotics?]

[Internist: Well, she's not dead; you're lucky. I think we can rule out serious infection at this point.]
[Client: ..............]

Fourth vet visit: Dog losing weight; take more blood and send it to the lab. Contact internist when the results are ... weird.

[Internist: It's the pred; everything is the pred. Her muscles are wasting away, her liver is being damaged - reversible for now; keep her on it and it'll be a different story - and all of the blood changes and values are being caused by pred.]
[Client: ...............]
[Internist: The values on the first test are relatively normal; there are a few things we could test for --- Oh, wait, we can't do anything.]
[Client: ...???]
[Internist: The pred. There's not a test I can do while she's on it. It will give false readings, unreadable readings, and nothing to go on. It's a useless waste of money to run any diagnostics.]
[Client: Hence the, "What exactly am I supposed to do today?" comment.]
[Internist: Sounds about right.]

I ended up giving her Koda's real history (hate to say it like that), and we did decide to run a few tests. The only thing she got from the vets were the blood tests that Idexx ran. They didn't even include the one they did, or the baseline on in her records.

First, she did an ultrasound to make sure everything inside was all right, hadn't suddenly exploded, or developed strange masses. For all the damage the pred is doing, her internal organs are holding up surprisingly well. (Good dog!)

Second, we worked a little on the fact that she always has an infection - usually like a UTI - and she took a culture to see if she has an antibiotic resistant bacteria or something silly that is preventing the infection from going away. They also took another urinalysis. We are waiting on the results.

They told me watch for pinpoint bruises - they look like someone took a sharpie marker and pushed dots into the skin, and they usually happen around the ears, belly, etc. 

They also told me how to wean Koda off the pred. After she's off, they'd like me to do a work-up (it doesn't have to be there, but they'd like the results one way or the other).

As per her tapering schedule... it will be a full MONTH AND A HALF before any conclusive tests can be run. 

You know, the tests that should have been run before someone went off and decided to put her on the drug in the first place? (The internist implied very, very many times that SHE should have been the one making the call about whether to put the dog on pred, and that failing all of that, Koda should have been tapered off the pred before we scheduled to come about two to three weeks after she was done.)

Meanwhile, Koda is miserable.

We got to see an internist who genuinely couldn't help us because of the way Koda's case was handled.

The internist was very polite, but she made a few things clear. My veterinarian(s) jumped to a conclusion, didn't communicate the reasoning to me, got offended when I asked, and put my dog on a drug after deciding on a diagnosis without what the internist would call "any evidence". (Her WBC was normal, but her lymphocytes were high...that indicates something else to the internist that... oh, wait. She can't test for because the dog is on pred. The pred in combination with the high lymphocytes could have killed her, regardless of the antibiotics.)

So now we wait.


  1. OMG. What a story. This would have made me completely crazy. Hang on in there JJ and Koda!

    1. I know, right? But of course they wouldn't discuss what they're doing and why with the client who clearly knows nothing ... They could try that on me ...

  2. What a horrible time Koda and JJ have had.

    We went thru similar issues with Delilah where my vet thought she might be having seizures. Luckily for us, my vet was open to looking at and hearing other options.

    Dr Landau http://landauvet.com/ was amazing and helped Delilah. He saw her twice but coordinated with my vet. I'm not sure how close Koda and JJ are to him, but it might be worth a phone call. With the wonders of the internet he may be able to help.

    Please keep us updated on Koda's recovery.

    1. Thank you, Jodi, yes, very frustrating time! Koda lives in Ohio. I think the specialist does know what she's doing, except cannot do much until the steroids are out of the system.

      Jodi, would love to publish Delilah's story too, if you're interested.

  3. Wow - what a horror show. I don't know what we would do in a situation like this. I ask a LOT of questions and challenge my vets if I'm unsure of their answers but honestly, I'm not a vet, I don't know. I have to, to some degree at least, believe they do have my dog's best interest at heart.

    Luckily I live in near one of the premier veterinary schools in the country and when push comes to shove, I take my dogs there. We've been lucky so far but I really feel for your friend.

    Please let us know how Koda does now that she has someone willing and able to help her...

    1. Hi Leslie, the vet refused to answer any questions, that was part of the problem. I'm glad your vets work with you and that you have the benefit of having a veterinary school near by.

      Koda is hanging in there; first order of business is getting the steroids out of the system so a diagnosis can be made.