Unusual collapsing: vet still pushing Myasthenia gravis idea

[Deeinnz]

Hi again everyone,

Still not much further ahead in a definite diagnosis for Bossdin's weird 'episodes'. I still think it's highly likely it's a severe case of BCC, and or, he's also started having mild 'focal' seizures, and or it still could be mild fainting at times.

I have now got some of these collapses on video and have taken them to my vet. My vet is still wanting to test for Myasthenia Gravis, despite Bossdin not having a single other symptom (that fits MG) bar the collapsing. And the test costs a small fortune because it has to be sent to America, and some of the drugs to treat it (but not sure which ones) are not even available here in New Zealand.

So I'm just wondering if anyone on here has any experience with this disease? I understand why my vet is pushing the idea cos it's auto-immune in nature and we already know Bossdin has some other auto-immune disorders.  But it just don't fit his symptoms really.

Thanks 

Dee

[Jo CIMDA]

Hi

Other than these 'episodes',  how is Bossdin in himself? The dogs that I have known with MG show very typical symptoms, and as this has been going on for a while now I would have expected Bossdin's symptoms to have developed further if it was MG.

Did they ever fit a 24/48 hour heart monitor on him?

Jo

[Deeinnz]

Hi Jo,

That's the thing, besides these 'episodes' Bossdin is most of the time, happy as larry. Sometimes he seems a bit quiet at home or a bit 'different' but that could be because he's bored (because I restrict his activity now even at home). When golfers see him on the golf course they can't get over how well and happy he looks. And often he drags me round the golf course playing golf with his buddies no problems at all.

I specifically asked again about the 24 hour monitor (but need to clarify details of what happens if he damages it when he collapses while wearing it) and my vet said "These videos are more typical of neuromuscular diseases (like myasthenia gravis) or neurological (partial seizures) than cardiogenic causes such as an arrhythmia." And then said the monitor would probably be normal, but she would refer the videos to the specialist for a second opinion if I wanted.

I'm getting incredibly frustrated and disappointed in them to be honest. I've given them really detailed descriptions and now video clips and don't think they are really listening to me. At least now she agrees they could be partial/focal seizures. I've got him on video doing a totally out of the ordinary 'head bobbing' thing, and 'eye blinking' where he clearly is in an altered mental state, and if you look carefully you can see the 'convulsing/chest heaving' thing I've consistently talked about. So why she's going on about MG, given the huge cost, is beyond me.

Searching for more on Syncope on line I found this:

Apr 01, 2008
By Henry Green III, DVM, DACVIM
CVC IN WASHINGTON, D.C. PROCEEDINGS

"During a syncopal event, animals will usually collapse into lateral recumbency and may have concurrent stiffening of the limbs, opisthotonous, urination and vocalization. However it is uncommon to see persistent facial fits, persistent tonic/cloned motion, defecation, postictal dementia and neurologic deficits with cardiovascular mediated syncope. What may often confuse one who witnesses a syncopal event is that on occasion some animals may have "convulsive syncopal episodes" (CSE) that results from severe hypotension or asystole.

Typically CSE are preceded by loss of muscle tone whereas seizure activity is usually preceded by atypical limb or facial movement or even staring spells prior to the loss of body tone. "

Bossdin always loses muscle tone first, he will get the wobbles first, sometimes collapsing and then will sometimes (but not every time) do what I've previously called 'the chest heaving thing'. But I realise now, it's not really his chest that heaves, it's the top part of his back (lumbar/loin area) that starts to rise up and heave/convulse and then it kind of spreads to his chest/rib area. He is never stiff though, he's always soft and floppy. And sometimes I think he has stopped breathing, because he closes his mouth and goes totally quiet (like he's dead) but I don't know for sure because I always panic at that point and rub him really vigorously and talk to him really loudly and blow gently across his nose just in case. He is often really tired for 5-10 mins after an episode like that but then is perfectly fine again and carries on as normal.

His appetite is great, his toilet habits are normal, his eyes are bright most of the time.

Dee

[Catherine]

It does sound more like a neurological illness. Have you seen this site about seizures? http://www.canine-epilepsy-guardian-angels.com/site_map.htm

Are you able to post a link to the video of him having an "episode" on here? Or able to put the video on YouTube or something. I am sure someone will see it and know what is causing the problem.

[Deeinnz]

Hi Catherine,

Thanks for your reply. Yes, I've been on the guardian angels site. I even mentioned to my vet about checking his thyroid because Jean Dodds recommends that re possible causes for seizures. I've also read tonnes of other stuff on seizures (and have sent some to my vet) written by specialists in the field.... it's amazing how many vets put stuff on line. Up until yesterday vet was saying it didn't look like seizure. I think vet is wrong.

I have just resized a 6 minute video of him having what I think is a partial or focal seizure (that the vets have seen, and seem to have discounted). How do I post it onto this group? I will if I can. Failing that I will try to post it to my facebook account and could make people friends so they can see it (I don't want it public for everyone to see).

Thanks,
Dee

[Catherine]

I am not sure. I would think you would have to post a link to the video. I do not know if you can use Photobucket or Flickr or something like that and then post the link on here. I do not use Facebook. Perhaps someone else is more technical.

[Deeinnz]

Ah, I've managed to get it onto my Facebook account. If anyone on here who does use facebook wants to view it, send me (Dee Sorrell) a friend request then I can let you see it. I will look into photo bucket (never heard of it though).
Thanks

[Jo CIMDA]

Bossdin always loses muscle tone first, he will get the wobbles first, sometimes collapsing and then will sometimes (but not every time) do what I've previously called 'the chest heaving thing'. But I realise now, it's not really his chest that heaves, it's the top part of his back (lumbar/loin area) that starts to rise up and heave/convulse and then it kind of spreads to his chest/rib area. He is never stiff though, he's always soft and floppy. And sometimes I think he has stopped breathing, because he closes his mouth and goes totally quiet (like he's dead) but I don't know for sure because I always panic at that point and rub him really vigorously and talk to him really loudly and blow gently across his nose just in case. He is often really tired for 5-10 mins after an episode like that but then is perfectly fine again and carries on as normal.

His appetite is great, his toilet habits are normal, his eyes are bright most of the time.

Dee

Hi Dee

I find your post very interesting.  One of my dogs had syncope episodes prior to her being diagnosed with autoimmune haemolytic anaemia.  This is not uncommon when the level of red blood cells falls below the norm' resulting in inadequate oxygen to the brain.  This was particularly noticeable when she jumped up and got excited, perhaps because someone came to the front door.  She would just collapse but she didn't lose consciousness.  After a while she would naturally recover and get to her feet but she would be wobbly.

That is not the interesting bit though - very recently, and since the last time we discussed Bossdin's problem on the forum,  My mother-in-law had a routine knee replacement operation. She had all the usual pre op' tests and was considered a good candidate for surgery.  It all went well, but when they tried to get her out of bed after the operation, she collapsed.  It was called, at the time, "fainting". Her sodium levels were low so they put her on a sodium  iv drip and she seemed to stabilise but only for two days (I presume it took that time for her sodium levels to drop once again).  This continued and after one week they transferred her to another hospital.

I won't go into all the distressing details but I was unfortunate enough to witness one of theses "fainting" episodes and to my mind, she had died.  It was very clear that this was not a faint but 'something' cut off the supply to either her heart or her brain.   Your description of what happens to Bossdin reminded me of that distressing event.  Just before my mother in law collapsed she told me she was feeling dizzy.  Within a minute she said she wanted to lie down.  I tried to get her to deep breath but then she lost consciousness and she appeared to lose any signs of life in her body and her face expression alarmingly changed, similar to your description of Bossdin. Apparently, according to a nurse,  she had no pulse in her wrists at this time.

The hospital didn't know what caused this only that her sodium level dropped along with her blood pressure.  She had two more episodes, witnessed by doctors and nurses, before they moved her to the Cardiac Care Unit (CCU). The hospital staff said they had not seen this before - this seems very hard to believe!  She was monitored in CCU for 48 hours and nothing abnormal showed up - other than low sodium and low blood pressure.  She seemed unable to conserve sodium and her potassium was a bit higher than normal.  They checked her adrenal function and that was ok, so she didn't have Addison's. 

They moved her back to a normal ward and within two days it happened again.  They fitted her with a heart monitor and it happened again a couple of days later.  The monitor showed that her heart stopped beating.  They took her back to CCU and fitted a pacemaker that day,  and they also put her on hydrocortisone (Florinef) to balance the sodium/potassium levels - and she has never looked back.

Syncope can happen for many reasons and this is just one of them but I think it is one that should be considered.  I see the first post on the forum with this problem was back in December 2012.  I would have thought if Bossdin had MG it would have progressed further by now.

Good luck Dee.  It's so difficult not knowing.

Jo

[Deeinnz]

Wow Jo,

Thank you for sharing that information. I can imagine how terrifying it would be to witness in your mother-n-law. I have actually read one other account on a blog forum somewhere (I've read so many I can't remember which one now) where a vet actually described a dog doing exactly the same thing as your MIL. The vet just happened to have the stethoscope on the dog at the time and heard its heart stop beating for 40 seconds. So I've also had that in the back of my mind.

Also in my mind was this, from Henry Green III, DVM, DACVIM :" Neurocardiogenic (vasovagal) reflex resulting in syncope is less common in animals than in people however there are reports of syncope that occurs secondary to sudden bradycardia following bouts of tachycardia in especially in small breed dogs with advanced valvular disease. In cases of neurocardiogenic syncope acute sympathetic activity (induced by excitement) provokes a strong reflex vagal response that results in bradycardia. Ventricular mechanoreceptors play a huge role in this reflex in that their activation due to forceful contraction results in a surge in afferent neural traffic stimulating paradoxical brainstem response to vagal activation. "

Which to my non medical mind means dog gets excited, heart beats really quickly then suddenly heart beats really slowly resulting in less oxygen to brain etc. Bossdin has had episodes, or the beginning of episodes after being very excited and intense.... or being suddenly stressed. I think syncope is a valid possible diagnosis....... 

BUT, what I have discovered, since researching focal and complex focal seizure disorders is that giving honey immediately you notice the dog starting to go into an episode stops the event from progressing. I have now done this 5-6 times and it works....so far.  He will still sometimes seem tired and won't want to move/walk for 5-10 minutes but the honey has stopped the heaving and collapsing and he's back to total normal once he's ready to walk again.

Bossdin also sometimes shows a pre-aura or change of energy before an episode is eminent and if I catch that in time (I have once) and redirect him and give honey it stops it happening.

My problem now is with regard to the holter monitor, along with the cost of paying for using it if it is damaged in any way they will charge me another $500 ! They 'think' it will be ok if Bossdin rolls on it.... which he might do as they have seen him on video running flat out and then he stops and throws himself on the ground and rolls ( I never know when he will do this so can't stop him). And of course they want me to make sure he collapses while wearing it. So for now I've said no as it's too risky and I don't think they are being fair.  I may ring around other vets and see what their policy's are on things like this. I'm also thinking I might be better to have a heart ultrasound/scan done to see if that shows any abnormalities. Unfortunately, not being able to work, I only have limited funds so have to pick carefully which tests to do.

If it was true syncope and a heart problem do you think the giving honey would be having the effect it is?

Dee

[Jo CIMDA]

Hi Dee

Mentioning that honey can reverse an episode made me think about the possibility of hypoglycaemia (low blood sugar) being the cause of Bossdin's episodic collapse.  This is only another condition on the very long list of differentials,  but have you or your vet thought about the condition,  Insulinoma? 

Dogs with an Insulinoma are unable to conserve their blood sugar because the pancreas produces too much insulin.  General,  associated clinical signs of hypoglycaemia include:  fatigue,  generalised weakness, collapse, muscle tremors, altered behaviour, confusion/disorientation, ataxia, inco-ordination, apparent blindness, stupor and seizures. This may be precipitated by exercise or excitement, and resolution of clinical signs follow after feeding or administration of glucose.   Information extracted from Canine Medicine and Therapeutics by Neil Gorman.

You may get more info from this site (and many others)

http://www.martinreferrals.com/collapse-in-dogs/     

(This vet referral centre in the UK has recently been brought to my attention.  They are supposed to be fantastic.  I know they are in the UK but sometimes Specialists will often respond to an enquiry from an owner or their vet and it might be worth an email to them.

http://www.provet.co.uk/cardiorespiratory/5a67ff9.htm

http://www.pethealthnetwork.com/dog-health/dog-diseases-conditions-a-z/insulinoma-dogs

Your mind must be saturated with all the differentials but I suppose you just have to work through them.

Keep the honey handy!

Jo

[Deeinnz]

Thanks for those contacts Jo, I will look at them immediately after posting this.

Insulinoma.....yep, been there done that. Starved him, took him for a short toilet walk on a really cold day before the blood test.... he collapsed..... 2 hours later we sedated him, took the blood sample, then I had a full abdominal ultrasound done looking for a tumour on the pancreas. Nothing showed up. Eventually the glucose/insulin test came back.... it had to be sent away.... and it was inconclusive at 50. And I've read if they don't do whatever it is they do to the blood samples quick enough it can give a not so accurate figure. So because the ultrasound was totally clear I don't think it is that.

I also wonder if....god forbid... he might be having faints and focal and complex focal seizures on different occasions. His symptoms and the different ways the collapses have presented actually suggest both could possibly be going on. But then, as I've previously said, to the best of my knowledge he loses muscle tone first......  god it's so complicated.... no wonder the cardic vets write how difficult it can be determining syncope from seizure.

I'm definitely going to push for a cardic ultrasound to be done.

Thanks again for your input, it's greatly appreciated.

Dee 

PS: Been on the Martin Referrals page from your link read this : "Opisthotonus is common with a more severe/prolonged syncopal episode (associated with cerebral hypoxia) and can mimic a seizure." Googled that..... and that is exactly what Bossdin did in the video I have of him taken on 2 Nov. I have emailed them, hopefully they will respond.

[Jo CIMDA]

Good luck Dee.  I know you are on his case.  I do hope you get a reply from your email to the cardiologist in the UK.  It's worth trying.

Jo

[Deeinnz]

Thank you Jo,

I hope so too re Martin Referral's replying.

I'm going to ask my vets if we could put the holter monitor on him, then if one of them came with me to the golf course (I have suggested this in the past but they have ignored it) I'm sure he would collapse quickly as soon as he saw some players Teeing off. He gets so beside himself with excitement and joy at that part. They could see exactly what happened and then when he was over it, they could take the monitor off him .... thus preventing the risk of any damage to it.

For now I'm restricting him severely..... no watching Tee shots etc as he's had 'episodes' (or almost had them) these last two days.

Dee

[Amshura]

Dee coming in a bit late to this discussion...ref your comments. Insulinoma.....yep, been there done that. Starved him, took him for a short toilet walk on a really cold day before the blood test.... he collapsed..... 2 hours later we sedated him, took the blood sample, then I had a full abdominal ultrasound done looking for a tumour on the pancreas. Nothing showed up. Eventually the glucose/insulin test came back.... it had to be sent away.... and it was inconclusive at 50. And I've read if they don't do whatever it is they do to the blood samples quick enough it can give a not so accurate figure. So because the ultrasound was totally clear I don't think it is that.
I have had 2 dogs  with INSULINOMA. I lost my  dog in August. I was highly suspicious over a year earlier when he started having transient episode s of staggering & falling about. All tests proved inconclusive, but in April things dramatically took a downward spiral, it took  3  insulin/glucose ratio blood testing  before we got  a diagnosis. Ultra sound likewise proved ineffective, these tumours rarely show up on screening.  With discussion with my vet and because of my previous experience with this type of tumour, my dog had careful monitoring, but we were 90 per cent certain what it was and unfortunately this was eventually proven to be correct. Given his age (almost 12)I  was not prepared to  go down the surgical route has i had  with a younger dog but the specialist vets at the AHT told me then that  often   it takes  an INSIDE look to positively confirm this type of tumour, they can be like grains of sand. Have you taken any videos of his episodes? such may assist in diagnosis. JAMES did very well on steroid medication, this was the treatment I opted for in his age group.
EXCITEMENT, exercise, weather conditions ALWAYS prove trigger factors in my dog(s) having the type of transient attacks that you have described....so familiar from my own experiences. I think you need referral to an endocrinologist or one of the excellent team I   met at the AHT. these tumours are rare. One onocolgist told me  that he had never   encountered one before he had been told about my dog SOAMES.  SOAMES diagnosis was only proven after MONTHS of frustration which is why I was so on the ball with  my more recent dog .

SYLVIA

[Deeinnz]

Wow Sylvia thank you so much for your input.....

And I'm so terribly sad to hear you lost your beloved dog in August. *hugs*

This bit you wrote:
"EXCITEMENT, exercise, weather conditions ALWAYS prove trigger factors in my dog"  YES! Same with Bossdin. I have been telling the vet for ages that the weather can often play a role in his collapses.

Crikey that is such scary information though, what you have been through and how long it took to get a correct diagnosis.

I have two good videos of him having episodes on my facebook page (they are hidden) I can't send them via email.... I've tried and tried to resize them down but they are still far too big. That's because the original file size is 400MB. If you could send me a friend request via facebook  Dee Sorrell in NZ I can let you see them.

The funny thing is though... after he had the terrible episode of 2 Nov in my hall way, we went to the golf course later that day and I took 3 other videos of him running around (and I mean running) totally normally. Did your dogs ever have an episode and then be perfectly fine and able to run like normal afterwards?

thanks so much for writing,

Dee