Saba - 10 year old vizsla with IMPA

[polly]

Thinking of you and Saba. Best wishes- keep cool today.

[Jo CIMDA]

I have to agree with you Rebecca.

IMPA will usually show with shifting lameness not just at the back end. Does she have a high temperature that is usual with an active inflammatory AI  disease. Is she in pain as one would expect? Are her muscles on her back legs very soft?  Did her blood show any clotting?

Hang on to those good points - they are all positive signs. 

Jo

[Becca]

She didn't have a temperature on Friday when they took the tap. As to shifting lameness I can't tell as she can't stand other than with us supporting her with a towel slung underneath. So either the IMPA has gone totally crazy - in which case you'd expect a temperature - or it's a combination of IMPA and muscle wastage - or it's something else.
Her muscles are totally wasted. I almost wonder if there is some other disease going on destroying them as it seems too severe for the pred alone. It now seems to have weakened the muscles around her swallowing - not a problem with food yet but increasingly sloppy water drinking.
I sense / imagine her breathing is ever so slightly better today but that is an hour by hour proposition. It's still rapid but not frantically so.
Eating well although now slightly more selective - veggies get left. However that could be the leflunomide affecting her. She's alert and trying to catch flies.
I wish she could rest properly - if she does close her eyes it's for a brief time only.
So hard knowing if we are doing the right thing.

[Becca]

A new possibility has been thrown in to the mix and it definitely ties in with the recent symptoms - idiopathic polyradiculoneuritis or Coonhound paralysis. There is a theory that it is an auto immune reaction to a toxin - possibly a bacteria which can be found in raw chicken which has been part of Saba's diet.
Symptoms - progressive paralysis, change in bark, muscle wasting but still eating, drinking and alert.
Bad news - no specific test other than eliminating alternatives and based on clinical signs. No treatment other than nursing them through for anything from 3 weeks to 3 months. Some may not make it but most recover to some extent.
Does it sound odd that I would be happy she had this? Yes, but at least we would know what is going on and there would be that important thing called hope. I wouldn't feel so panicky about the lack of improvement at this stage.
Heading to specialist on Friday - she wants to run some neuro tests.

[Jo CIMDA]

Hi Rebecca

Another likely possibility is a disease called myasthenia gravis (MG)  One of the main symptoms of MG is megaoesophagus (MO) .  This is when the muscles in the throat are affected and the muscles lose motility, resulting in swallowing being a problem.  Dogs with MO can be helped by raising the water bowel to straighten the neck, and elevated feeding, usually by the feet being on one level and the bowel on a higher level eg., standing at the bottom of the stairs and feeding bowel placed on the second or third stair.  This may be difficult for you with Saba because of her hind leg weakness.  Also there may be a risk of food inhalation (in the windpipe) so care must be taken when she eats or regurgitates that she doesn't take it down the wrong tube. Keeping the head upright for a while after food may help this.  https://www.vetinfo.com/canine-myasthenia-gravis-symptoms.html

I have known several dogs to have MG.  It can often be diagnosed by a simple blood test to check for specific autoantibodies. The usual dose of prednisolone is not recommended in the treatment of MG because it causes muscle weakness. A drug called Pyridostigmine is usually prescribed.  Take a look at this link.

http://www.petplace.com/article/drug-library/library/prescription/pyridostigmine-mestinon

Hope you can sort this out very soon.

Jo

[Becca]

Thanks Jo - I'll throw that into the mix as well on Friday. My sense of this is that Saba has something more akin to Coonhound paralysis than MG which seems more moderate i.e. they can stand but stumble and wobble. She is pretty much paralysed in all four limbs and it has been progressive. She can only haul herself an inch at a time with her front end.
Her breathing is easier today after a restless night. I ended up outside with her at 3am for an hour but she settled after that and we had 4 hours of sleep without her being disturbed. She must be so frustrated and there's not a lot I can do to help her just now.

[Jo CIMDA]

Hi Rebecca

I am so pleased her breathing is easier.  It doesn't sound like she is in pain.  If this is so then it won't be IMPA.

Roll-on Friday and fingers crossed you have a good meeting with the vet.

She has an excellent mum.

Jo

[polly]

So many possibilities.  Caring for her must be very difficult when she has to be half carried outside.  At least it is not as hot today. I hope the visit to the vet tomorrow  gives some more answers.  Is someone able to stay  home with her most of the time or are you back at work?

[Becca]

We're lucky Polly. Both my partner and I are largely retired and pretty much home bodies. This would be an impossible situation if we were both still working as she is very anxious if she doesn't have one of us in sight and needs to be moved or taken outside regularly. She is determined not to make any mess inside so barks when she needs to go out. Poor girl gets so upset when she has to wee or poo lying down on the grass but it actually is providing a bit of physio for her as she tries to drag herself away with her front end. I seem to have won the lifting duties so hopefully my back holds up!

I'm nervous about tomorrow - my worst fear would be confirmation of some other condition where the paralysis didn't reverse. I'll let you know where we get to.

[Daisy May]

Thinking of you Becca. My dog has IMPA also, so I've been reading your posts with great concern. Hope to hear better news from you soon.

[Becca]

We visited the specialist today who agrees we have a case of Coonhound / polyradiculoneuritis. She thinks the paralysis is more severe than normally seen with MG and the fact that there has been improvement in her breathing rather than continued deterioration point to Coonhound. We've decided to treat - or more to the point, not treat - it as such unless there is a deterioration. The key now is physio and hydrotherapy.

The other predicament we face is that pred wastes muscles and that is the opposite of what we need at the moment. She has therefore recommended reducing the pred from 7.5mg to 5mg daily. In my normal contradictory way, I'm now a little nervous about this given the IMPA or at least inflammation is still apparent in the joint tap and the fact that we are tapering at the rate of knots. However I understand her logic and we'll just have to hope the leflunomide is doing its stuff.

The vet upped the time frame for recovery from Coonhound to potentially 6 months.....ugh! But we have hope again and that's the bottom line.

Liver enzymes much improved so that was the good news. Potential problem is a muscle enzyme which hadn't been tested before but given her weakness, they decided it should be. It is moderately to markedly elevated. The vet didn't sound as concerned as I expected - she thinks it could be that Saba has been recumbent for so long plus she thinks she might have hit the neck muscle and caused some trauma when collecting blood. So that is just one for monitoring.

Daisy May - I hope you have an easier path to recovery than this is proving. It truly is a roller-coaster. We just seem to have hit bad luck with Saba's reaction to imuran and pred and then this other disease hitting us blindside.

[polly]

Good to hear that there are some improvements and that you have been given hope  that physio etc may help.
I hope that  the lifting doesn't cause you to need physio as well.

I can't comment on the medication aspects- would be guided by  the specialist vet who seems to agree with  Jo as I know nothing about leflunomide .

Saba  is very lucky to have owners who are in a position to stay home and take care of her.

[Jo CIMDA]

Hi Rebecca

You have a plan, and I always think the path forward is far better when you know what you are dealing with and there are strategies in place. 

You have already seen positives from lowering the preds, and that will continue as the dose is reduced further and stopped altogether.  Leflunomide should do the job of suppressing the immune system, without muscle weakness side effects which are inevitable with long term pred use.

As Polly says, Saba is so very lucky to have you care for her, and we all look forward to knowing her progress over the coming months.

All the best

Jo

[Becca]

A mixed update on Saba.

The good news is that she is regaining strength and has even managed to walk a few steps unaided today. It's wobbly and it's short lived but it is a long way from where she was a week ago. Her liver enzymes had halved last week from the very high levels and have almost halved again in today's blood results. She continues to eat, catch flies and loves her morning visit to the park to see her buddies.

The bad news is that we decided to measure the muscle enzyme last week as there is concern at the amount of muscle wastage we have seen with her. It was above 1700 whereas I gather the normal is 400. This week it is back to 1100. On this basis the specialist believes there is a muscle myopathy going on and has suggested we should be increasing the pred again. I'm reluctant to given the trend is improving, albeit not as strongly as we might like and pred is not going to help us in the fight against the polyradiculoneuritis. We have agreed to give it another week with just the 5mg pred daily plus the leflunomide.

I have two questions. Is there any reason other than yet another immune disease involving muscle myopathy that the CK result would be running high? The vet did mention the fact that she is basically full time recumbent might boost it a little but she didn't think as much as this.  The second question is, if we do face a muscle myopathy, are we just fighting a losing battle with IMPA, polyradiculoneuritis and muscle myopathy? Is it just too much to expect her to fight on three fronts?

[Jo CIMDA]

Hi Rebecca

I am not a vet but my take on Saba's elevated CK and her muscle atrophy is this.

Since drastically reducing the preds you have seen an improvement in her strength, and her liver enzymes and CK enzymes have reduced.  One of the main causes of all three of these symptoms is overuse of corticosteroids (prednisolone). 

There is no doubt that Saba's prednisolone reduction regime was incredibly slow and even if she does have an additional muscle disease, polyradiculoneuritis, her drug history alone would suggest that these symptoms could reasonably be due to the high and prolonged doses of steroids. 

If you see the links below one of the causes of high CK is hyperadrenocorticism, which is Cushing's disease.  The fact that the CK and liver enzymes have reduced, in my opinion,  can only be due to the much reduced dose of prednisolone.

I think you have a lot to be happy about right now and if her body is given the chance to repair itself from the insult of the preds then I think (I hope ) you will see a much improved Saba soon.

I don't think you are losing this battle, I think you are just starting to win it.

Good luck

Jo


http://www.the-vet.net/DVMWiz/Vetlibrary/Lab-%20creatine_kinase.htm

http://researchonline.jcu.edu.au/9250/1/13_clinical_udpate_Drug_induced_muscle_disorders_published.pdf