Veterinary Detective Story

If you've made it this far, you've seen my blog, and were curious enough to click through.

If you really like my blog, you could even support it with a tip or donation.

But why contribute to an economics professors pocket change when you can help do some good in the world?

You see, Blueberry is one of our dogs, and we've been nursing her through a related series of congenital health problems for 11 years now. It's quite the veterinary detective story, and it's detailed below.

If you contribute here, I pledge to use the funds to defray the cost of Blueberry's medication, food, and veterinary bills. I'd even post updates about her health.

So, what's up with our dog?

We got Blueberry in April 1993. She is a female purebred blue merle Shetland Sheepdog, with multiple champions on each sides of her family tree. (Our previous dog had been a stray mutt that we first met when she crawled under our gate to steal pizza, so we intentionally went to the opposite extreme with this pet.)

On the evening of the third day of having Blueberry, she started having severe seizures. My better half had to give our 8 week old puppy CPR (yes ... you heard it here first ... mouth to snout) to revive her. She said that Blueberry had been conscious, but stiff as a board, and unable to breath or otherwise function for several minutes.

(Let this be a warning to all you professors out there that the reason you're not supposed to switch your classroom without notifying anyone is so campus police can find you in a hurry because your puppy needs mouth to snout resuscitation.)

Blueberry was fine the rest of the night, but did have a seizure in front of me and the veterinarian the next morning. They kept her for observation.

They determined that she wasn't having seizures at all - she was going through tetany. Seizures are neurological - your neurons goof up and tell your muscles to contract. Tetany is when the muscles contract on their own. All that most people know about tetany is that the similarly named tetanus is characterized by lockjaw - a form of involuntary muscular contraction of the face.

Tetany is life threatening because the muscles that control your breathing can contract and stay in that contracted position until you expire from lack of oxygen.

Tetany is also very rare. The biomechanics of it are that muscles contract by pumping calcium that is in solution in your blood into the muscle cells. When the calcium level on the outside gets low enough the muscles contract. So, the only things that can cause tetany are situations which lead to a calcium shortage in your bloodstream (known clinically as hypocalcemia).

So, our veterinarians treated the hypocalcemia the textbook way - with an intravenous shot of calcium in solution. The only problem with this is that it is very risky because the rush of calcium can stop your heart. And they were doing this to our 8 week old puppy.

And, it didn't appear to work. Blue continued to periodically undergo tetany for the rest of the day.

The alternative diagnosis was distemper (this can cause seizures, and would explain why the calcium injection didn't work). Distemper is usually fatal, but it is important to know that an animal has this because it is contagious. The vets recommended taking Blue to the veterninary school up the road at the flagship state university which shall remain nameless. There they would be able to do a spinal tap on her to determine if she had distemper (the alternative is a post-mortem). They would also be able to use her to help the students understand unusual canine presentations. Grasping at straws, we agreed.

The next morning I took the hour drive up there with Blue. She had several tetanic episodes in the car. Distemper is usually fatal, so I did not expect to see the cute little fur ball again.

But, she lived. And her "seizures" dissipated. Note that the flagship state university decided that the hypocalcemia diagnosis was dead wrong, and had gone whole hog with the distemper diagnosis. So, they had nothing else to go on.

On Saturday they called and said we could pick her up. But ... oh wait they said ... now she's blind and she whimpers a lot. We think the former is from retinas she tore loose during her "seizures" and the latter is from brain damage. They were never really able to explain how sure they were that she was brain damaged now that they'd had to discount distemper.

We went and got her and brought her home, shaved head and all. It was so bad we seriously discussed stopping the car and drowning her in a ditch to put her out of her misery.

The first night was the worst. She whimpered all night. At some point, I thought it would be a good idea to take her out to pee. I'm not sure why, but I know it was about 3 in the morning, and there was a thunderstorm in the distance. And that little puppy could see the lightning flashes.

Sunday was no better, but we were starting to confront the reality that we were going to be caring for a disabled dog. We knew we would have to contact the breeder and complain, but we also had heard stories of how breeders will euthanize puppies with problems so that it doesn't reflect badly on their business. We were not willing to do that.

On Monday, we took Blue back to our vet for the first time in 6 days. They put her on the floor, watched her navigate, and announced that she was not blind. They also looked her over and announced that the flagship state university veterinary school had broken her foot in three places putting a catheter in. So, they set her leg and put a cast on her. She was a changed puppy. Wouldn't you be? And no tetanic episodes for 4 days.

The vet was still suspicious of the whole situation. If it wasn't distemper, they were back to hypocalcemia as a diagnosis. The primary cause of hypocalcemia is hypoparathyroidism. So, they drew some blood and sent it half way across the country to the only lab that can do a canine parathyroid test at even bigger state university (they did their jobs well, so I may as well tell you that this test was done at Michigan State). The test came back a week later showing low parathyroid function ... but that doesn't mean much because your parathyroid function is supposed to fluctuate in response to serum calcium levels. Maybe her parathyroid looked OK because she was juiced up on calcium by now.

So, we learned a lot about hypoparathyroidism. The parathyroids are little glands in and on the thyroid gland itself. Their only job is to regulate the low end of the calcium concentration in the blood. If the calcium level gets too low (and tetany might result) the parathyroids pump out a hormone that tells the body to suck some calcium out of the bones. There's never a shortage of calcium, because there is so much in the bones, but it does need to be in the blood in the right concentration at all times.

There really isn't anything you do for hypoparathyroidism itself, so our vet started Blueberry on the standard treatment for hypocalcemia. This is oral DHT - a chemical similar to Vitamin D. If you eat it, the intestines suck more calcium out of the food you eat straight into your bloodstream. Blue started getting a big drop of a DHT tincture on teaspoon every morning. And the "seizures" didn't come back.

Now it was time to call the breeder. She offered to take Blue back and give us another puppy for free. We got the message. We gave her an alternative deal. Since Blue is (more or less) blind, and has a cast, what she really needs is a companion. A sort of seeing-eye-puppy for our puppy. The breeder agreed. And that's how we got our other dog, a male tri-colored Shetland Sheepdog we named Bounder of Adventure. He's 6 weeks younger than Blue, twice her size (he's a moose), and dumb and smart at the same time. He sings a mean Star Spangled Banner too. Here's a picture of the two of them from 11 years ago ... and you can even see Blue's cast .

So, Blue and Bounder grew up with us. Blue's leg heeled just fine. She sees, but what she sees as right in front of her is actually off to the side - if she runs towards you she will veer to the left until you pass from her field of sight, and then start over again. So we think she did detach a retina that reattached by itself. But, Blue has always been jumpy, skittish, and standoffish with people. Wouldn't you be?

Flash forward nine and a half years. We'd moved to a new apartment, then our first house, then across the country to a new house and a new vet who we clued in to all these details. The only new development with Blue is some odd fatty deposits on her hips - saddlebags on a dog. With her long fur we always joked that she looked like she was wearing a bustle. Oh, and she was extremely sensitive to touching her sides - she'd even learned to snap at us if we said "we're going to touch your sides". And not even a hint of tetany.

So, I'm sitting in a lazy boy around 10 P.M. when Blue comes and sits by my feet. She starts making some odd noises, then falls to the floor, unable to extend or control her leg. The tetany is back!

I call my vet, and fortunately he'd had an emergency surgery earlier in the day that he was staying all night with because he didn't think it was going to make it. He says to bring her out, and I did.

He concurs that this is tetany, and gives Blue a does of intravenous calcium solution. Over the space of an hour or two, she slowly recovered. He sent me home with a saline drip for her, since she seemed dehydrated.

Later, we talked about what had happened. Why was her tetany coming back? Her hypocalcemia had been under control, what had happened? My vet gave me unusual advice: you two are smart people - and I'm confused about this dog - so why don't you start thinking outside the box about all the possibilties for what could be going wrong? The vet suspected a kidney problem, but Blue just didn't seem to have any unusual urinary behavior.

I'm an economist, not a veterinarian. The limit of my physiology experience in A.P. Biology. My wife on the other hand taught physiology to nursing students. Every idea I came up with, she patiently or impatiently told me was flawed.

Blue had two more episodes, each about 3 months apart. The vet noted that we didn't need to be paying for his emergency services, and gave us a hypo full of calcium solution and directions on how to inject it into Blue's muscles (which is safer if you are inexperienced). The last episode, I actually gave her the shot while my better half held her steady. She recovered from all of them.

Late in the summer of 2003 I decided to sit down in my office and really research this on the internet. The one thing we knew for sure was that she'd had tetany, and tetany is caused by hypocalcemia. I searched every search string I could think of. I took lots of notes. I read a lot of anecdotes. And I came up with an interesting list: a rundown from most to least probably of causes for hypocalcemia. It's a pretty bizarre list: hypoparathyroidism is first, followed by pseudohypoparathyroidism (the parathyroid is fine but the body isn't responding to the hormone), vitamin D deficiency, gross calcium deficiency (often seen among severe alcoholics on a bender), and acute pancreaitis.

The more I read, the more I realized that while the first 4 were causes, each should be effectively treated by the DHT we gave Blue every day. Her bloodstream should be flush with so much calcium all the time that we should probably have been worried about her depositing excesses of it all over her body.

So, where on Earth was all her serum calcium going? Somehow it was dropping and producing occassional tetany, even though Blue should have been flush with serum calcium at all times. The better half remarked that it won't do any good to follow the vet's advice to check her kidneys because she's probably getting so much calcium into her system that she's blowing it out in her urine constantly.

So I started reading up on pancreaitis. First off, it commonly kills dogs. They eat so much fat from their families being "nice" to them that they overload the ability of their pancreas to handle it. But we never let Blue do anything like that. Second, pancreaitis is nasty - your body gets flooded with your own digestive enzymes leading to death by widespread organ failure. Most of the time it isn't chronic because you don't survive the first bout.

And how does pancreaitis cause hypocalcemia? When the pancreas starts helping digest less, poorly digested fats start accumulating in the bloodstream. These react with serum calcium to form soap-like chemicals. These can't be easily eliminated so the body deposits them towards the outside of the back and hips.

And how can you tell if a dog has pancreaitis? Sensitivity to the side of the abdomen on which the enflamed pancreas lies.

And we had a dog who sprouted saddlebags on a reasonable diet, and flipped out when you threatened to touch her sides.

When it dawned on me, I printed out tons of stuff from the internet, and took it home to the resident physiologist who said now this makes sense.

I then took it to the vet who didn't quite see it that way. But, he was intrigued, and suggested a full fasting blood panel to look at both her kidneys and pancreas. And maybe he was right ... pancreaitis in dogs is associated with both kidney and gall stones.

I took Blue in for her venipuncture in the morning. The vet called back later to tell us that we'd have to do the whole thing over again because he could tell from just looking at the blood that we had forgotten to fast her - there were visible fat globules in her blood sample. I said ... um ... not only did I fast her for 12 hours, but it was actually more like 18 hours because we'd been on the run that day.

The blood work came back showing Blue's triglycerides, cholesterol, and amylase (a pancreatic enzyme) to be off the charts - quite literally several standard deviations above normal (500+ on her cholesterol). And there was a bunch of other stuff that was less screwed up, but indicitive of abdominal bleeding (perhaps an ulcer). Nothing there or in the physical consistent with stones though.

So the vet says, it really doesn't matter what the cause is, but this dog is extremely lipemic, and that is probably screwing up her kidneys, pancreas, and serum calcium levels. So, he put her on a prescription diet food with almost no fat in it, and some fish oil supplements to balance that out. It took about 4 months for this to get her bloodwork down into normal ranges. During that time she lost over 20% of her body weight.

But Blue is old, and now she needed something for arthritis too. Pumping her up on calcium probably didn't help that situation either. The vet was leery of giving her an anti-inflamatory because of the possible ulcer. But that part of the bloodwork moved in the right direction too, and eventually we got her on an anti-inflammatory along with a Pepcid Complete to keep her stomach acids under control and supply her with even more calcium.

So Blue will be twelve just before Valentine's Day 2005. She is happier and more chipper than she has been in a long time. But every day she needs DHT (just in case), Deramaxx (for arthritis), Pepcid Complete (to avoid an ulcer), prescription food (with no fat), and fish oil (with healthy fats). She isn't too expensive, but she costs a lot more than running this blog does.

So, if I tugged at your heartstrings enough, and you'd like to help defray some of those costs, I'd be thrilled. 'Cause after all, what's more important in life ... weblogs or cute little dogs?

Comments

[Kathryn Price]

Thank you for your story. My six year old Shiba Inu recently had either a seizure or tetany, and we're still trying to figure out which it was, and what caused it.

My main question is this: During the tetany, were Blueberry's arms and legs pulled up in front of her, or stretched out behind?

I go into more detail at the above URL but, basically, she had a slow buildup - five minutes or so of stiff legs and side muscles, where she was wobbly and concerned-looking. Then she vomited and defecated, and suddenly she was like a marionette, standing upright on her hind legs and starting to fall over. We laid her down on the floor. She started rubbing her face on the carpet and then wound up on her stomach, with her legs straight out behind her and her arms rigid at her sides. The worst of it lasted less than a minute, then she slowly recovered. By twenty minutes later she could walk around, forty minutes later she was acting like nothing happened (except being tired, not wanting to play, and being more emotionally needy than usual).

We are in the midst of a snowstorm today, so additional blood tests will have to wait another day or two. Your blog entry has given me some more ideas of what tests to run, and any feedback you have would be very helpful and appreciated.

Thanks,

-Kathryn

[Dave Tufte]

I pasted my reply to the e-mail here.

Hi:

I am so glad that you read this. I hope my answers (below) help.

At 02:00 PM 1/6/2005, you wrote:
A new comment has been posted on your blog voluntaryXchange, on the post
Veterinary Detective Story.

http://voluntaryxchange.typepad.com/voluntaryxchange/2004/09/veterinary_dete.html

IP Address: 216.192.69.23
Name: Kathryn Price
Email Address: kathryn@bandia.net
URL: http://www.livejournal.com/users/caitriona_nnc/67098.html
Comments:

Thank you for your story. My six year old Shiba Inu recently had either a
seizure or tetany, and we're still trying to figure out which it was, and
what caused it.

My main question is this: During the tetany, were Blueberry's arms and
legs pulled up in front of her, or stretched out behind?

In front. Usually she senses that something isn't quite right and lays down normally (on her chest rather than sides) near us. So, naturally her legs are in that position already. The few times that we have found her in mid-tetany, she has usually rolled to her side, but again the legs are more forward than back.

I go into more detail at the above URL but, basically, she had a slow
buildup - five minutes or so of stiff legs and side muscles, where she was
wobbly and concerned-looking.

I can confirm concerned-looking.

I'm not sure about wobbly. Ours has trouble standing because she can't control her legs properly.

Then she vomited and defecated,

That has never happened to us.

and suddenly
she was like a marionette, standing upright on her hind legs and starting
to fall over.

Blueberry never stands like that, so I can't say.

We laid her down on the floor. She started rubbing her face
on the carpet

Facial itching is definitely a symptom (even in humans). I read that online somewhere, so I don't have a cite handy for you.

and then wound up on her stomach, with her legs straight out
behind her and her arms rigid at her sides.

Never seen that.

The worst of it lasted less
than a minute,

Blue's last much longer - 20 minutes minimum.

then she slowly recovered. By twenty minutes later she
could walk around, forty minutes later she was acting like nothing happened
(except being tired, not wanting to play, and being more emotionally needy
than usual).

That seems reasonable.

We are in the midst of a snowstorm today, so additional blood tests will
have to wait another day or two. Your blog entry has given me some more
ideas of what tests to run, and any feedback you have would be very helpful
and appreciated.

Blood tests are not that informative with hypoparathyroidism. Hypoparathyroidism itself should only be detectable when calcium is low anyway (because it's a lack of response to something that doesn't happen too much anyway). A serum calcium test is informative, but then you need to figure out how they got that way.

I hate to say this, but I am suspicious of your symptoms. The "she vomited and defecated, and suddenly she was like a marionette" part makes me think poisoning (for the first part) and stroke (for the second). Of course, I hope it isn't either one. Typically, Blue is only able to move her head during tetany, and then only through a limited set of movements that she can only do repetitively (say like, small circles). She pants the entire time (probably can't expand and contract her lungs fully), and she "drools" in that her mouth is open, and she's panting, and the saliva more or less just falls out of her mouth (but not in too excessive quantities). Occasionally she will try to stand and fail due to lack of flexibility (but only at the beginning and end of the episode).

Keep me posted on your bloodwork. I have now gone and read your webpage after writing all this. I can's say much about hypokalemia. But, it would not be unusual to have a blood test after tetany show reasonable calcium. Tetany is a mechanical response of your muscles to low serum calcium. It will persist until that calcium goes back up again. Complete hypoparathyroidism is 100% fatal by asphyxia because it cannot end. But, that rarely if ever happens because the system keeping serum calcium high enough is so simple. If you survive tetany, your blood will be normal for calcium every time if it is sampled after the tetany has passed.

DT

P.S. Where's it snowing that hard?

Thanks,

-Kathryn

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