CIMDA

Hi

My name is Audrey and I have 2 beardies and a mini schnauzer.

beardies are Mcduff and Mctavish and mini schnauzer is Narra.

Mctavish was 2 on 5th November and he had an issue with nails separating from quick believed at first to be injury related.

However yesterday my vet took him to theatre and discovered that it was worse than we thought he said as soon as he tried to clean etc they were splitting and some fell off.

So they made decision to remove all nails and start treatment for SLO his bloods and nails have been sent off for testing.

So any advice and help would be greatly appreciated.

Hes currently on antibiotic and prednisone painkillers and I started vitamin e yesterday.Salmon oil.

Hi Brooke

Septic arthritis commonly occurs in more than one joint and there is always a hot swelling, as would be expected if there was infection present.  So it seems unlikely that Pep has this form, also I would presume that any infected fluid would have shown up on the small amount of synovial fluid the vet took from her joint.   Personally, I wouldn't use antibiotics unless Pep needed it.   I think the swelling around the anus is not related to Pep's joint problem.

Prednisolone is an anti-inflammatory drug in the right dose, and it seems Pep is on that dose, and it is not specific to any particular area, so perhaps the increase in pred could have reduced the swelling around her bottom.   Pep doesn't fit in to the clinical signs of Felty's syndrome, so I wouldn't worry about that, and her IMPA wouldn't have been Rheumatoid arthritis.  The presentation is different and Pep doesn't have deformed legs etc.

DVJM360 is a very good website for all veterinary conditions, but I wouldn't over read because it will just drive you crazy.  See this link:


http://veterinarymedicine.dvm360.com/recognizing-and-treating-immune-mediated-polyarthritis-dogs

I do hope you escape the fires.  Stay safe.

Jo

Hi Jo,
Unfortunately it looks like this dreaded fire danger weather is not going to let up and they are predicting more on its way next week. 

I have an appointment on Monday to do bloods and check Peps liver levels. We will see what that comes back with, I am expecting not great results.

I am very sorry to hear that one of your dogs had cancer and was in terrible pain. Your description makes sense to me and makes me less inclined to think that’s what pep has.

I have been wondering and reading more about infectious (septic) arthritis. Pep didn’t have a red area that was particularly hotter over her joint or any wounds so this was disregarded. But I have been reading (not sure how reliable the info is as it’s from the internet) but it can be caused by

• penetrating trauma;
• haematogenous spread;
• ear infection;
• gastrointestinal infection;
• urinary tract infection;
• pyoderma;
• anal sac infections;

I also read that ‘It is well recognised that pre-existing joint disease can predispose to haematogenous spread. Examples of this include osteoarthritis, immunemediated joint disease and blunt trauma that can precede the infection by a few days.’’
Typical physical examination findings are:
• lameness – more chronic cases may be mild
 • warm swollen joint with pain on manipulation;
 • redness or discolouration of overlying skin;
• joint effusion;
• local lymph node enlargement;
• muscle atrophy; and
• monoarticular.

All of these she had except the joint didn’t really feel a lot warmer than others and it wasn’t red. Pep has brown skin and tan hair covering her elbow so I’m not sure how you could see red. Can we rule septic arthritis out based on this?
Is a trial of antibiotics an option?

I have remembered after reading the above info. At our most recent vet appointment that was maybe a few weeks prior to this all happening. Around peps bottom she had a little cut and bit of swelling. We just left it to monitor as she has had trouble with her anal glands in the past and has had times where she has gotten pussy and swollen around her bottom when she has been dragging it on the pebblecrete.
Is it possible she could have septic arthritis or am I reading too much into it? The swelling has reduced but could the pred do that? She is still in pain on that elbow and dipping her head when she walks. We are now on 1/2 tramadol twice daily and 15mg pred twice daily.


I have also tried to find info about erosive poly arthritis which has been difficult. But I came across a list of types and one being Felty’s syndrome. The info mentions an enlarged spleen which pep has. When we had an ultrasound done a number of years ago early in her diagnosis the specialist found this and at the time said she wasn’t sure if it was significant. Felty’s syndrome also involves rheumatoid arthritis. Pep was diagnosed with impa and now it is looking to be erosive. I’m not really familiar with the difference between the two. Rheumatoid arthritis gets treated with immune suppressing drugs too. We never tested pep for the Rheumatoid factor. Could her impa have been rheumatoid arthritis? I didn’t think so but don’t know enough about it. I thought I’d read you never achieve remission with rheumatoid arthritis and it requires lifelong drugs and not a good prognosis. Pep was on such a low dose of pred there for ages so that wouldn’t seem to me that she could have had rheumatoid arthritis.
I might need to give the reading a rest for a bit as it can be easy to read to much into things.

Oh Brooke, I am so sorry all these things have come at once.  I have seen on the TV,  the fires in Queensland and it must be such a worry for you, on top of all the investigations to find out what is wrong with Pepper's leg.

I do think a slight increase in pred is a good way to go.  Did the blood results show a marked high level of liver enzymes?  I hope not, but as you know the liver can take some pounding,  producing exceptionally high enzymes before it becomes a significant problem.  I hope the blood results show that you have room to increase the preds before having to truly worry about her liver.  I know you give liver support, so this should help.

It is so frustrating after having x rays done that a definitive diagnosis can't be reached but I have always been under the impression that cancer is not difficult to diagnose, so the fact that it is not obvious on the x rays  has to be a good thing for Pep. One of my dogs had cancer in the bone on his foreleg,  just above his wrist, and the pain was excruciating for him, and it was not a swelling that reduced because it was bone mass, not fluid,  so again I am hopeful that this is not Pepper's problem. 

From the feedback, it is likely to be an isolated joint problem, maybe due to older age, or the start of IMPA.  Rheumatoid arthritis is very rare and it also occurs in more than one joint.  I know the photograph you describe in Prof Day's book, and it is quite alarming. 

All you can do is to try the increase in pred and hope it brings Pepper some good relief.  Perhaps restrict her exercise for a week.  You have bigger things to worry about at this time.  I wish you safety,  for you and your family, and your neighbours and pets, and if you are evacuated then I hope you can return home very soon.

Take care
Jo

The specialists said peps X-rays could be erosive poly arthritis or cancer. They said there was shadow down towards her wrist which looked like fluid consistent with poly arthritis. The small strange area in the middle of her bone they didn’t see as anything of significance at this point. They suggested bone or tissue samples to be sure, if joint fluid was inconclusive..
The joint fluid sample taken came back not showing any cancerous cells. My vet didn’t write on their form peps history of poly arthritis so as not to taint their response. The pathologists report said there were no cancerous cells and increased neutrophils which they suggested as being suspected poly arthritis.

The swelling in her elbow went down when we went to the vets on Thursday then it went back up again and she struggled to walk at all on Friday. It was also really hot Friday which is when she has always had trouble walking even prior to what’s going on now. By Saturday she was walking better. The swelling started to go down Saturday arvo and was significantly down Sunday. She was better again Sunday with her walking and today once she was walking was the best she has been in a while. Still dipping her head and having some little stumbles when getting up but quite better than she has been.

Tomorrow we are forecast for catastrophic fire danger where we live and we live right on the bush. I am very apprehensive about tomorrow. I’m worried about our family, our house, our business (which we run from home) and Pep. Pep is normally terrible in the heat (in terms of not being able to walk well) and she doesn’t handle change or stress well. I’m worried how she will be if we have to go evacuate. So i have decided with my vet to slightly increase her pred more and reassess in a few days when the fire danger has subsided some. Her liver won’t handle increased pred for long but I can’t afford to put her on other drugs like cyclosporine again and she is too old to put her through that again anyway. We have been holding off increasing in hopes she will improve. But with the catastrophic weather forecast for the next few days I think we should try increase, to try get her more comfortable with all that could be going on. If we wait too long  and don’t go up we may have to go up even higher in dose and then we will have less time due to her livers health. We also need to be concerned about her pancreatitis.
We are in a bad place right now with no good options

Hi Jo,

Yes that’s why I have been so puzzled that it seemed just to be that joint in particular.
So I decided to go ahead with the X-ray to see what was going on and if there was a fracture. Once i decided and booked the appointment her swelling began to decrease and she started gradually walking better. She still has some swelling and is still dipping her head when walking on that leg but even during the day while she was at the vet our vet noticed a decrease in swelling. She is only at 10mg once daily which she has been on for 4 days now. Unfortunately they sedated her (with pain relief). I really don’t like doing that but felt like it was important to see what was going on before upping the pred. As I don’t feel her liver will last long with a much higher dose.

Unfortunately the X-ray showed up a quite large area missing from the outside edge of her elbow. Like a bite had been taken out of it. A big corner piece missing   There was also a strange marking almost looked like a little hole/chip midway down below her elbow & before her wrist, in the centre of her bone that only showed on one X-ray. My vet has sent to a specialist to get their opinion on whether they think cancer or erosive poly arthritis. I was only reading up again on this the previous night prior to her X-ray. There is a picture of a staffy in michael j days book with rheumatoid arthritis and it always catches my eye. I did have X-rays done of pep a few months after she initially got diagnosed with impa to check if it looked erosive but at that point everything looked fine. I also mentioned about doing the blood test to check for the rheumatoid factor back then, but I don’t think we ended up doing it as the vet at the time said they didn’t believe that was it and I don’t know if the test was even available in australia then.
My vet also took a small amount of fluid from peps joint (not enough to make the noticeable decrease in her joints swelling) while she was sedate. Normally she would ask me prior to doing this but when I came to pick her up she asked did I want to send it off. Since it was already collected I agreed. She wanted to see if that could give more of an idea if the cells were cancerous or just likely impa.

So we are now waiting to hear back on the results from the fluid taken and the specialists thoughts on her xrays. We have have decided to stay at 10mg once daily until we get results. My vet said she more thinks it’s impa and erosive rather than cancer. But it really seems to be that one joint that is causing trouble which is not consistent with impa. I know erosive poly arthritis is really rare but also cancer in the elbow is rare too. But this is pepper and she seems to like going for the more rare diseases

My vet wants to try arthritis injections with pep but I feel the risk is too high. But if this is erosive impa we would have to assume all her other joints will be bad too and therefore I think we need to take a risk and try give her some joint supplement to try even slightly help. She is only on rose hip canine for her joints at the moment which is only anti inflammatory and doesn’t have any effect on trying to prevent/heal damage. So my vet has given me 4cyte to try. We are waiting until after the weekend before trying just in case. It has rosemary extract in it which in the past I had read could cause seizures. My vet assured me she doesn’t feel there being a problem and this is the best option to try.
I was rereading over my old notes last night and found some that said MSM (found in egg shells) given to dogs with RA showed no cartilage degeneration. So I want to mention this to our vet. I did at one point give pep ground up egg shells at a certain dose. So I’ll need to try find my notes on that. We have had to stop her fish oil due to her pancreatitis.

I really value your feedback Jo. With your vast knowledge it greatly helps to have another opinion and some extra knowledge from someone who follows and sees the story of all these dogs with impa and other similar disorders. We are forever great full for all your help over the years

Hi Brooke

Usually, IMPA will not occur in only one joint.  The typical presentation is swelling on multiple joints, and usually with a high temperature.

The dose of pred is now an anti inflammatory dose, so perhaps this will do some good and reduce the inflammation in the joint. You can only try.

 If Pepper can have the x-ray without being put under sedation or a general anaesthetic then you may as well go for it if the increase in preds isn't effective.  It may show up the cause.

Euphrasia is a homoeopathic tincture that can be use to soothe the eyes.  Just a couple of drops in cooled boiled water can help but if Pepper's problem is immune mediated then it probably won't have much effect.

I do hope this increase in pred will do the trick.

Jo

Hi Jo,
It’s nice to hear from you again. I hope all is well with you.

Yes pep has been on optimmune (cyclosporine) eye ointment for a couple of years or so now. I also regularly throughout the day put hylofresh lubricating tears in her eyes. Her body never likes this time of year and it is very dry here in australia this year in particular. We’ve also had heavy smoke from fires some distance away. Lots blowing around and lots of people have had trouble with hayfever and allergies, so I’m wondering if this has had an effect on her too. Possibly causing her red eyes. They have improved some the last couple of days and the air has also cleared from the smoke.

We saw my vet yesterday and she said the swelling in peps elbow could not be normal arthritis. She thinks that sort of level of swelling could only be caused by impa. I asked about cancer and she said it is very uncommon in the elbow where her swelling is. She also thought that with the amount of swelling if it were cancer than she doesn’t believe Pep would be walking at all and would be in extreme pain. She suggested an X-ray which may show white coloured fluid if it is impa. She said fluid from impa is higher in protein and can show more of a white colour on xrays. If it were cancer there should be some sort of signs of erosion around the bone. Sorry that may not be the actual terminology she used but that’s how I understood.

I asked what we would achieve from an X-ray? If it’s impa we have to up the pred. If it’s cancer we up the pred/pain killers. She said ‘yes that’s correct, unless you plan on cutting her leg off.’ (Which I don’t.) So I decided not to do the X-ray for now. I really don’t like upping the pred but there didn’t seem like any other option. I had upped her tramadol the previous night and it didn’t help and she started to be a little sedated.
Her limp/walk had also gotten worse after I wrote on here. Not the true ‘eggshell walk’ but due to the pain swelling in her front elbow there was more emphasis on that leg.
I agreed to go up to 10mg once a day. This is under immune suppressing doses. But the last time she had a true relapse, not quite 4 years ago. That is the dose I gave her (even though our vet wanted me to give twice this). I tried 10mg and it took a couple of days but she came good at that dose. So that is where we are up to. Trialling 10mg of pred (once daily) for a few days with the 3/4 tramadol twice daily. If no response I may consider the X-ray. I’m not sure what else to do. Then I guess we go up pred more


One of her limp nodes in her neck was slightly more enlarged than normal, no fever and her other joints were a bit swollen but slightly less than the last time I saw our vet in September. At which point she had said her back hocks were a little swollen. But likely normal arthritis.

Our vet didn’t think it was septic as there was no increased heat in that joint and no wound where contaminants could have gotten in.

Is there anything else that could cause an extremely swollen elbow? Could she have fractured it jumping off the lounge? She has a lot of muscle wastage in her chest, which is very noticeable seeming she is a staffy.

Hi

I am sorry that your dog has CAH.    I do hope the Atopica and increase in prednsiolone will bring relief and achieve remission. 

If the increase in pred becomes intolerable you might try another immunosuppressive drug called leflunomide.  Have a look at this link.  It gives a lot of information about treatment and also ideas of what supportive liver supplements to give such as SAMe.  Denamarin is a very good liver support that is often used now.

https://todaysveterinarypractice.com/canine-chronic-hepatitis-diagnosis-treatment/

If your dog is on long term, high dose prednisolone then it should be on a gastroprotectant such as Omeprazole.  If you are not giving a gastroprotectant then please ask you vet for a prescription.

I hope you see and improvement very soon.

Jo

Hi Brooke and welcome back!

I am so pleased that Pepper has managed to achieve long term remission with IMPA.  It was a long journey for her and you.

From what you have written, it seems that this limp, and swelling around the joint, is isolated to just one leg and this indicates that it is more likely to be an injury or just old age - how wonderful that can be said about Pepper!

Personally, I wouldn't give more pred and if she is only on 2.5mg a day I doubt it is having much effect other than her adrenal glands won't be making as much of her daily requirement of glucocorticoid. So have you considered weaning her off the pred and going down the route of a conventional anti-inflammatory, such as Rimadyl or Metacam?  I wouldn't touch Previcox because that caused kidney failure in one of my dogs.   

If you would prefer to try alternative remedies, you could try Yumove (not sure if you can get it in Australia).  I know of many people who give CBD oil to their arthritic dogs, but it would be better if you had your vet's blessing.   

Arnica is a good remedy to promote healing but I don't know if it will help in this case.  Rhus Tox is a good homoeopathic remedy for stiff joints, so that might be worth a try or if you have a homoeopathic pharmacy in OZ they may be able to make a remedy just for Pepper.

Resting is essential when treating an injury but it is very difficult to control what Pepper will get up to when you are not around.

Do you give Pepper dry eye ointment?  If not then in the UK you can buy Viscotears from the chemist, and I would give those a try.

I do hope she improves very soon.

Lovely to hear from you.

Jo