ADVICE PLEASE

Re: ADVICE PLEASE

Rob Reid — Fri, 27 Aug 2010 16:08:16 GMT

[quote user="Amie Glaves"]I had a 9m old FE Beagle present with severe acute neck pain and pyrexia not related to an injection. I was baffled, neck rads were wnl, wasn't brave enough to do a CSF tap and she responded marvelously to dex and then pred. I put it down to a steroid-responsive 'itis too![/quote]

Beagles are particularly prone to an immune-mediated meningitis or necrotising vasculitis - the owners call it Beagle Pain Syndrome. I have seen a few cases now.

Dogs present between 6 and 18 months of age with pyrexia and neck pain, blood results tend to be normal, x-rays unremarkable. I too have not done a CSF tap on these, but having spoken to others who have, they tell me that results are often unremarkable although you can get a slight increase in protein doing an acute episode.

Diagnosis really is made by ruling out other things and by response to steroids - dex and preds is the way to go, make sure you use high enough dose of pred! These cases usually improve very quickly but I have had one who presented at 7 months old who had a another flare-up at 18 months.

I believe the AHT is running a genetic screening program for these cases, so if you see one it would be worth contacting them.

Re: ADVICE PLEASE

Amie Glaves — Fri, 27 Aug 2010 15:43:39 GMT

I had a 9m old FE Beagle present with severe acute neck pain and pyrexia not related to an injection. I was baffled, neck rads were wnl, wasn't brave enough to do a CSF tap and she responded marvelously to dex and then pred. I put it down to a steroid-responsive 'itis too!

Of course there is always the possibility that she got better in spite of what I did - not because of what i did. D'oh!

Re: ADVICE PLEASE

Tracey Kernaghan — Fri, 27 Aug 2010 14:05:03 GMT

I had a case once of a young springer spaniel puppy with neck pain, fever, depression and increased WBC that went on to develop juvenile cellulitis after a few days. We decided that one probably had the form of juvenile cellulitis associated with polyarthritis and that the polyarthritis was in the intervertebral joints. CSF was normal. The dog did respond to immunosuppressive treatment.

Re: ADVICE PLEASE

Mark Holmes — Wed, 18 Aug 2010 12:10:36 GMT

The reason she was on Onsior is because it is supposed to clear the system quickly and therefore allows a change onto pred more readily. As an update I have ventured down the pred route 3mg/kg , and she has improved markedly. I increased the antibiotics to cover toxo just in case whilst I wait for results on toxo titre.

Thank you all for your input.

Mark

Re: ADVICE PLEASE

Richard Carter — Wed, 18 Aug 2010 10:48:23 GMT

Problem is that if is auto-immune reaction, can be myositis/neuritis as easily as polyarthritis, esp if no swollen joints and taps already done are negative for WBC. Also have now given onsior so need to dry out before preds/ dex. I usually start with dex as dose then definitely given with more or less predictable response time period.

Re: ADVICE PLEASE

Anthony Todd — Wed, 18 Aug 2010 08:55:26 GMT

[quote user="Malcolm Ness"]this is not good quality evidence.[/quote]

The perfect squelch.......Serves me right doesn't it!

However, and in the stubborn interest of my education, it does suggest that dex might be a more potent glucosteroid than pred and, as I said, that has been my impression.

I could say that [quote user="Malcolm Ness"]Pred at an appropriately high dose is always my first choice for immunosuppression.[/quote] is just an opinion and I can't help feeling that a single dose of dex, by injection, is unlikely to aid a septicaemia and would give the OP and owner a quicker and more definite indication of benefit.

I would be grateful to be corrected.

Re: ADVICE PLEASE

Malcolm Ness — Wed, 18 Aug 2010 08:28:44 GMT

[quote user="Anthony Todd"]http://news.cancerconnect.com/dexamethasone-superior-to-prednisone-for-induction-therapy-in-childhood-all/[/quote]

Without wanting to stray onto the subject of Evidence based medicine, this is not good quality evidence.

Species is wrong; disease is wrong; not even the same type of disease; not enough detail on methodology to draw any conclusion; don't know the journal so would have to look into source material in more detail; the paper is not published and therefore not properly peer-reviewed - it is only the abstract from a conference proceedings printed here; "stats" are opaque (there are no sig levels, no indication of methodology and, more importantly in a clinical paper, there are no confidence intervals) so we can't tell whether the differences are real and if they are, what they might mean.

Even if you take these numbers at face value you could report that Dex induction kills twice as many patients as Pred!!

Re: ADVICE PLEASE

Anthony Todd — Tue, 17 Aug 2010 20:41:55 GMT

[quote user="Malcolm Ness"]Often the response will be delayed by a day or two and incomplete or absent if lower doses are used [/quote]

This has been my observation with pred and I wonder why it is still your first choice?

In a desperate search for support I found this;

http://news.cancerconnect.com/dexamethasone-superior-to-prednisone-for-induction-therapy-in-childhood-all/

but maybe I'm grasping at straws and the above doesn't apply?

Re: ADVICE PLEASE

Malcolm Ness — Tue, 17 Aug 2010 08:21:48 GMT

Pred at an appropriately high dose is always my first choice for immunosuppression. Often the response will be delayed by a day or two and incomplete or absent if lower doses are used and there is a strong feeling that your first chance is your best chance with immune mediated disease. Certainly, I have struggled most to control those cases that others have given low dose steroids to previously and this experience is mirrored by my other half, a referral dermatologist,[in her dealings with immune mediated skin disease.

[quote user="Anthony Todd"]the dreaded steroids[/quote]

Steroids are great drugs - its not their fault that they are frequently used inappropriately!

Re: ADVICE PLEASE

Anthony Todd — Mon, 16 Aug 2010 22:17:40 GMT

Far be it for me to go where angels fear to tread, but if you are contemplating the dreaded steroids why not use a more potent short acting one by injection?

Reassess depending on response.

Re: ADVICE PLEASE

Mark Holmes — Mon, 16 Aug 2010 16:14:59 GMT

Thank-you for your help Malcolm, would you suggest in future a lumbar puncture rather than cisternal? She does just look like an SRM-V dog and whilst that is not good enough diagnostically I have, in previous cases with no funds just had punt (should that now be Euro... not quite the same ring to it) on pred and I suppose paradoxically had better, although much less complete results.

To be honest I am fairly comfortable waiting it out a bit longer as long as she does not get worse, but the owners are getting frustrated by the lack of improvement which may just tip the balance.

Thanks once again, I will keep you up-dated

Mark

Re: ADVICE PLEASE

Malcolm Ness — Mon, 16 Aug 2010 15:42:10 GMT

Polyarthritis can be very painful but signs are invariably easily and confidently localisable to joints on careful clinical examination. Immune mediated polyarthritis will normally give obvious and typical abnormal joint fluids.

I assume you have ruled out the possibility of an injection abcess related to the vax which could account for all these signs.

Steroid responsive meningitis-vasculitis (SRM-V) would still be high on my list - a cisternal CSF tap would be "up-stream" of a lesion in the C cord which could account for the pain and the apparent shoulder signs via nerve root signature while giving you a normal CSF sample.

However, I would be reluctant to start cortic0steroids without some support for this provisional diagnosis (or if things progressed to the point where euthanasia is contemplated). If you do use steroids, use a proper dose - 2-4mg per kg initially.

Discospondylitis, a migrating pharyngeal fb plus a host of wierd and wonderful things would also be on the list of differentials.

If possible, stand back and let a little time pass while using NSAID and antibiotic. Frequent repeated clinical exams conducted with as open a mind as you can might change your view on the case.

Re: ADVICE PLEASE

Gina Dungworth — Mon, 16 Aug 2010 13:55:23 GMT

Definitely sounds like one for Malcolm, in that case. Hadn't heard of an autoimmune arthropathy that only affected the spine, but I suppose all things are possible.

Re: ADVICE PLEASE

Mark Holmes — Mon, 16 Aug 2010 13:06:12 GMT

Red cells morphologically normal, presented 5d post vac and symptoms present 24 hrs prior to this. An immune mediated 'itis is all I can come up with. I am under the impression that you can get an immunemediated polyartropathy that is limted to the small joints of the spine but I don't know if this is accurate of how likely it is. Maybe if Malcolm is on here he might be able to help.

Re: ADVICE PLEASE

Gina Dungworth — Mon, 16 Aug 2010 12:53:47 GMT

It definitely sounds like it could be an immune mediated something or other. Any idea when the owner first saw signs in relation to the period between vaccination and presentation? What are the dog's red cells like?