Ami James - stones, skin issues, enlarged liver, and more

[spamgirl]

It was recommended that I post here to get another opinion from Traci about my dog's condition. I apologize if I'm doing this wrong!

Ami is a half maltese, half yorkie dog born on Jan 1. 2007. 10 pounds before these conditions began.

His original conditions (at first vet check ups)

Collapsing trachea
Allergic to rabies shot (eyes swelled, went hyper & crazy, trouble breathing, etc.)
Mild knee issues
Vomits after antibiotics if food in tummy

The bad stuff started with random infections (nose, ears, eyes, toes, tip of penis, anus, etc.), diarrhea, bloody pee, arrhythmia.

Was treated for worms and all sorts of stuff a bunch of times to treat the diarrhea but never tested positive for them.

The doctors couldn't figure it out until I insisted on a urine test, they found oxalate crystals. Xray showed 6 large stones, 2 of which were in the urethra.

He had blow back surgery April 9/09, his bladder ruptured over night. I rushed him to the hospital on the 10th (my daughter's birthday) and they removed the stones and fixed him up. He healed from that fine.

Bladder stones were then treated with Urinary SO dry, potassium citrate 150mg/ml 0.05mL 3x/day and have never come back.

First x-rays showed an enlarged liver (before even changing diet or giving any medications) which hasn't gone away. Blood work is fine, though.

Obesity due to food, treated with exercise but little weight lost (weighs 15 pounds now).

Panting, shallow breathing, raspy when breathing, redness at the back of his mouth (either the skin condition or from panting so much).

Eye infections with pus, lower eye lid developed a white spot which looked like the inner lid was turning inside out. Treated with Tobradex and hydroxyzine, hasn't come back.

Ear itchiness treated with Otomax as it comes and goes.

Between the pads on the bottom of his paw/around his claws/dew claws and now between the toes on the top of his foot the skin is red/scaling/itchy/swelling - treating with Germistat washes daily, Cephalexin, immunosupport capsules, Welactin, but it won't completely go away. The scaling and major redness is gone, but the toes on his right hind foot are massively swollen.

Anal sac infection for many years treated with catheterization and infusion Dec. 21/11. We're still watching this.

Lower lip redness, itching, by long teeth.

Stomach gets red, hot, nipples swell randomly - this might just be excitement as it also happens whenever we go to the vet.

Sometimes nose drips but usually just when the nose itself is dry, like after sleeping.

Currently on:

Cephalexin 125mg 2x/day
Amitryptiline 5mg 2x/day
Hydroxyzine 10mg 2x/day
Otomax 15gm 2x (as necesasry)
Potassium citrate 150mg/ml 0.3ml 3x/day
Welactin 1/2 gelcap 1x/day
Rx vitamins immunosupport capsule 1x/day
Germistat 4% bath on feet 1x/day
Urinary SO dry switched to Hypoallergenic HP Jan. 4/12
Increased potassium citrate to 0.3 3x/day due to change in food Jan. 8, when we switched the food his pH dropped to 5 all day. I've been increasing steadily and at .3 I have him at a peak of 6.5. Still fiddling with this.

Since going on the hydroxyzine his eye problems have stopped. With the amitryptiline his panting has stopped, but he's still chewing on his toes when he has the opportunity. The scaling is gone and they're not red and raw anymore. His right hind paw is worse today (the hair loss is progressing up around his toes and towards the top of his foot) but it may be because he's been chewing on it - he got his cone off for 2 minutes a few days ago and it was off when I woke up yesterday morning. His ears are randomly itchy and I treat them with otomax as necessary. Today his chin is itchy near his pointy teeth, it's often itchy there and the skin is pink and bumpy - but it doesn't look anything like his feet.

Here are some photographs:



I stopped going to my first vet when they ... did a poor job with my cat at the end of her life. I lost my trust in them and switched to another vet who I really like. She's been treating him since August. She found the anal sac infection which they totally ignored. I trust her greatly, but having another opinion is always welcome.

Again, I hope I did this correctly!

[Traci]

Approximately what dates (month or year) did each (or set of) symptoms present? Which of the symptoms is Ami currently presenting? Is the foot pad infection/swelling the most progressing of his symptoms?

What tests have been done for the following: parasites, viral infection, immunological, fungal infection, pemphigus, allergen testing?

What bloodwork exactly, has been done, most recently?

Have any tests been sent to an outside lab? (for example, immunology profile, bacterial or fungal cultures, etc)

Was an ultrasound ever considered to evaluate the liver enlargement?

How long did you feed Urinary SO, and did the itching, oozing, etc, occur before or after feeding Urinary SO?

Have home environmental allergens/irritants been ruled out?

Re: the anal sac infection - was corrective surgery ever discussed with you?

What is the Amitryptiline prescribed for? If it is for excessive licking or chewing, either the dose should be lowered, or ceased altogether and an alternate type drug considered. Here's where I question prescribing BOTH the Amitryptiline and the Hydroxyzine because one could be enhancing/aggrivating the effects of the other.

Did the vet consider that combining Amitryptiline with Hydroxyzine might be contributing to some aggrivation?

How long has Ami been on the medications you've listed?

Has oral prednisone been considered?

Have you considered seeking the opinion of a board certified veterinary dermatologist? Your first vet (as well as the second), should be discussing that and recommending a consult with one.

I would first start with bacterial and fungal cultures, to determine exactly what type of infections are occuring, and the source. It sounds like Ami is immunocompromised with all the infections, but it could be that there are more than one type of infection, so cultures are imperative. Also, with the licking, chewing, and locations of the infections, he could in fact, be spreading the infections to other areas just by licking and chewing etc.

I would consider skin allergy testing, which is more accurate than blood testing for allergies. The veterinary dermatologist can tell you what your options in testing are, taking into account Ami's history and his current state of health and symptoms.

A full immunology (and or fungal) panel done by an outside lab might be useful to rule out viral infections, pemphigus, etc. That should have been done at the start.

I think the first order should be getting a consult with the veterinary dermatologist - get all Ami's health records (and xrays, tests, etc) faxed to the dermatologist so he has a chance to review before your consult. Your current vet can do this as well as get the referral for you. Don't wait another minute on this, Ami has been through a heck of a lot (as well as a heck of a lot of medications), he needs a veterinary specialist on this case.

[spamgirl]

I should mention that I've had Ami in a surgical cone since early December to keep him away from his toes and ears.

Approximately what dates (month or year) did each (or set of) symptoms present? Which of the symptoms is Ami currently presenting? Is the foot pad infection/swelling the most progressing of his symptoms?

The most recent eye and ear issues have been off and on since August. He's been chewing on the worst foot since Feb. 2010. The chin is only a few weeks that I've *known* about it. I think the rest have dates on them.

Currently his ear is itchy off and on. His chin is pink, bumpy, itchy. All four feet are affected to varying degrees by hair loss and itchiness. His right hind toes are swollen.

The itchiness in his ear and feet are the most distressing symptoms, and it's just the one foot that *might* be progressing, although it seems his other feet are slowly getting a bit better.

What tests have been done for the following: parasites, viral infection, immunological, fungal infection, pemphigus, allergen testing?

None. The vet says she doesn't think we need to do any of those as we're already treating for fungus, parasites would cause different symptoms, and allergy testing is expensive and he just came out of the anal surgery. She's holding off on any testing until April to see how switching the food goes.

What bloodwork exactly, has been done, most recently?

Nothing since April 2010, and it was just basic yearly bloodwork. I don't have access to copies.

Have any tests been sent to an outside lab? (for example, immunology profile, bacterial or fungal cultures, etc)

Nope.

Was an ultrasound ever considered to evaluate the liver enlargement?

No, just x-rays as the bloodwork showed no issues.

How long did you feed Urinary SO, and did the itching, oozing, etc, occur before or after feeding Urinary SO?

We began in August 2009 and the foot chewing started in Feb. 2011.

Have home environmental allergens/irritants been ruled out?

We don't use chemicals of any sort around him, and he's confined to a small area of my home (my office) so we closely control what he has access to. The fact that the allergy is inside the bottom of his feet is what is so weird. We've removed all plastic from the area even with no results. There also have been no changes since the time when this all began in this area of the house.

Re: the anal sac infection - was corrective surgery ever discussed with you?

As this is the first time they did the wash-out and packing, they wanted to see how that went first. So far, so good.

What is the Amitryptiline prescribed for? If it is for excessive licking or chewing, either the dose should be lowered, or ceased altogether and an alternate type drug considered. Here's where I question prescribing BOTH the Amitryptiline and the Hydroxyzine because one could be enhancing/aggrivating the effects of the other.

It's to calm him down and get him to forget about his feet.

Did the vet consider that combining Amitryptiline with Hydroxyzine might be contributing to some aggrivation?

Never mentioned it, but he's only been on the amiltryptiline for a week or two.

How long has Ami been on the medications you've listed?

Amiltryptiline - Dec. 27th, 2011
Hydroxyzine - Dec. 16th, 2011
Cephalexin - Dec. 19th, 2011
Potassium Citrate - Aug. 2009
Immunity booster - Nov. 2011
Welactin - Oct. 2011

Has oral prednisone been considered?

With his liver in the condition it is, I'd rather not use steroids at all.

Have you considered seeking the opinion of a board certified veterinary dermatologist? Your first vet (as well as the second), should be discussing that and recommending a consult with one.

I should mention I live in Canada. I'm not sure if we have any around here. I should also mention that my husband is unemployed and I make $5/hour doing piecework online, so we're currently fighting not to lose our home. We don't really have any money for any more vet bills.

I would first start with bacterial and fungal cultures, to determine exactly what type of infections are occuring, and the source. It sounds like Ami is immunocompromised with all the infections, but it could be that there are more than one type of infection, so cultures are imperative. Also, with the licking, chewing, and locations of the infections, he could in fact, be spreading the infections to other areas just by licking and chewing etc.

I would consider skin allergy testing, which is more accurate than blood testing for allergies. The veterinary dermatologist can tell you what your options in testing are, taking into account Ami's history and his current state of health and symptoms.

A full immunology (and or fungal) panel done by an outside lab might be useful to rule out viral infections, pemphigus, etc. That should have been done at the start.

I think the first order should be getting a consult with the veterinary dermatologist - get all Ami's health records (and xrays, tests, etc) faxed to the dermatologist so he has a chance to review before your consult. Your current vet can do this as well as get the referral for you. Don't wait another minute on this, Ami has been through a heck of a lot (as well as a heck of a lot of medications), he needs a veterinary specialist on this case.

OK, I'm going to have to figure out how to pay for it first... but thanks for the advice!

[Traci]

Simple "itchiness" in any of the body areas you've mentioned, could indicate allergies - whether to food or environmental, remains to be determined.

But, combined with fur loss, abrasions, and/or infected wounds, demands further testing, both for allergens as well as immunological. Even a simple skin-scrape and/or culture could be helpful (non-invasive), to rule out the simplest things like specific mites, flea bit allergy, etc.

I'm concerned when you say that you're already treating for fungus. One cannot actually treat fungal infection without testing for specific infection, and once that is achieved and/or confirmed, then antifungal meds are used, not antibiotics. It is possible Ami is suffering from more than one type infection, sometimes it can be both. Cultures are necessary to identify the specific infection in which to choose the appropriate medication.

In this case, I would think that bloodwork (particularly the CBC) would show inflammation, but since bloodwork hasn't been done since almost a year ago, I'd strongly recommend it now (including the immunology panel to an outside lab).

There's no harm in trying the hypoallergenic diet to rule out food allergy, but be prepared to expect up to at least 6 weeks to determine if the new diet is effective. If Ami's itchiness, fur loss, tendency to lick and chew aren't decreasing, then the next step would be immunology and dermatology testing.

Likewise, it might be worth trying a temporary course of corticosteroids to at least see if Ami responds favorably. While I agree that he is susceptible to liver problems, it depends on the degree and seriousness of the issues at hand. If he is constantly uncomfortable, and causing further harm by self-aggrivating those areas and increasing the risk for constant infection, then corticosteroids can be considered at least for relief of symptoms while other testing is explored. I would of course, check liver function (bloodwork) prior to administration of any corticosteroids.

An example: eosinophilic granuloma complex, or immunological disease that may cause dermal problems and plaque-like areas. Sometimes they only affect a certain area of the body (like foot pads, or, abdominal area, or around face, mouth, neck and ears). This is where bloodwork and immunology panels come in useful for ruling those out, or, confirming in which to treat effectively.

I'm not sure confinement to one small area in the home is productive. It may be causing him undue stress (and stress can worsen many conditions). Plus, if he is overweight, he doesn't have the opportunity to run and romp about the house for exercise and play. If you're fairly certain there are no home environmental issues affecting him, then there shouldn't be any reason he can't have access to the entire home.

Your vet should be able to consult with any of the veterinary universities in Canada for further advice and/or referral to a veterinary dermatologist. A quick phone consult should only be the cost of a long-distance phone call (depending on your vet's pricing policy) - and a professional opinion is definitely warranted in this case. You'd be surprised what just a simple professional phone consult can achieve, many times it gives the primary vet direction, and keeps costs down for you.

Whatever the costs, ask the vet about payment arrangements. Most vets, if you are an established client, will consider payment arrangements.

[spamgirl]

Simple "itchiness" in any of the body areas you've mentioned, could indicate allergies - whether to food or environmental, remains to be determined.

But, combined with fur loss, abrasions, and/or infected wounds, demands further testing, both for allergens as well as immunological. Even a simple skin-scrape and/or culture could be helpful (non-invasive), to rule out the simplest things like specific mites, flea bit allergy, etc.

I talked to the vet a few days ago about doing a scrape and she said that both mites and scabies would present much differently than what she was seeing, so she didn't recommend it.

I'm concerned when you say that you're already treating for fungus.

I could be wrong, but that is what I thought the wash was for?

If he is constantly uncomfortable, and causing further harm by self-aggrivating those areas and increasing the risk for constant infection, then corticosteroids can be considered at least for relief of symptoms while other testing is explored.

He's not really showing *any* discomfort now. He hasn't tried to get his cone off in a few days and he isn't trying to scratch his ear. That's why I don't want to introduce steroids at this point.

I'm not sure confinement to one small area in the home is productive. It may be causing him undue stress (and stress can worsen many conditions). Plus, if he is overweight, he doesn't have the opportunity to run and romp about the house for exercise and play. If you're fairly certain there are no home environmental issues affecting him, then there shouldn't be any reason he can't have access to the entire home.

He's not allowed out of this area due to other concerns, not just his health. We live in a tiny condo, it wouldn't provide him any running space anyway.

I was taking him out for daily runs but when he got sick I was worried a grass allergy might be the problem. I've kept him indoors for a month and he hasn't gotten significantly better so I have to assume that it wasn't something outside that was the trigger.

Thanks

[Traci]

You mean the germistat? It is maybe more effective on some types of bacteria rather than fungal infection - I don't think there's enough evidence to suggest it can treat many forms of fungal infections.

[spamgirl]

You mean the germistat? It is maybe more effective on some types of bacteria rather than fungal infection - I don't think there's enough evidence to suggest it can treat many forms of fungal infections.

Ah, I must have misunderstood... with so much going on right now that's not surprising. I printed off your posts and dropped them off at the vet today and I'll be visiting her again in a few days to speak about it. Thanks again for your advice!

[spamgirl]

Sorry for taking so long... so he got his bloodwork done twice, and it's all perfectly normal. Ditto for two full UAs. He was on the hypoallergenic food for a few months and it didn't help at all. I put him on a clean diet which is acceptable for his stones (chicken, peas, broccoli and apples) and he was getting less itchy. I had him on coconut oil which totally stopped the pus in his eye and the itchiness in his ears. Sadly, the doctor said he had stones again so I put him back on potassium citrate and it seems to have brought all the problems back. When I looked at the xrays, it turned out it was just a rib in the way of his kidney and he has no stones. I took him off the potassium citrate, but it seems the damage has been done. The pus is back in his eye, he's horrifically itchy everywhere and he's miserable. I'm hoping taking him back off the pot. cit. will get him back to where he was last week (mostly itch-free and no pus at all in his eye).

That said, what would be the next step as far as the infections go? His anal glands are still infected (even though he had them flushed and packed with antibiotics), his sinuses appear infected (and thus the leaking pus in his eye), although his ears seem fine at the moment. The infections don't go away, even after multiple long doses of antibiotics. They disappear for a bit and then reemerge. So should he see some sort of specialist?

Thanks

[Traci]

Yes, please review my posts above for the testing options.

I'm assuming what you've listed are ingredients in a "home-made" diet. But, I caution you, unless you've gotten the advice/opinion/direction from a board-certified vet nutritionist, and a diet formulated by such a nutritionist, then what you're feeding may be deficient in a host of vitamins/minerals, etc. It may be that this process of elimination might lead your primary vet to a food allergy, but the point is, the diet needs to be sufficient for his health, age, and formulated properly.

The infections aren't normally indicative of food allergies, so again, I strongly suggest immunology, fungal infection rule outs etc. That he doesn't respond to, or flare-ups occur after antibiotic use, either indicate poor antibiotic choice, or that the condition is specific to something else (like antifungals etc). And again, without cultures, there's really no way to rule out fungal disease.

Look into oral health problems, sinus problems. It could be fungal. It could be bacteria that the vet can't specify because she didn't culture a sample.

You indicated before that you couldn't afford additional vet bills, however, either an online or phone consult with a board-certified veterinary dermatologist could be helpful. Generally, the primary vet would actually refer you to one where you'd have to see the specialist, but a phone consult could still be useful for direction, case histories, etc. Have you even asked your vet about it?

Check the brand/manufacturer on the potassium citrate - certain brands may contain unneccessary ingredients, or those he may be allergic/sensitive to. Avoid "natural", "herbal", etc, and anything with unproven ingredients. Your vet should be able to help you with this.

This has been going on for a long time, and your dog must be miserable. Without a specialist's opinion and direction, you might always have these problems to contend with. So, for that reason, I strongly advise your vet consult the specialist on your behalf. Your dog is only 5 years old, much too young to have all of these problems. Infections, when persistent or severe, can lower the immune system, making the dog highly susceptible to a host of diseases, something you need to prevent NOW.

Lastly, there shouldn't be any harm in trying a low-dose course of prednisone, that is, IF the specialist advises it. Talk to your vet about that, but first get some cultures done, talk about immunological/viral/fungal problems, talk about getting a specialist involved.

[spamgirl]

Lastly, there shouldn't be any harm in trying a low-dose course of prednisone, that is, IF the specialist advises it. Talk to your vet about that, but first get some cultures done, talk about immunological/viral/fungal problems, talk about getting a specialist involved.

What *exactly* should I ask my vet for? She doesn't feel we should be doing anything at this point but monitoring him. I actually printed off your previous posts and gave them to her in Jan, but I don't think she did anything about them.

Also, I asked about immunilogical/viral/fungal issues in the past, and she didn't seem very knowledgeable. This is why I need an exact quote of what to bring up with her. Thank you