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Pets

Sick Dog: Deciding what to do…or not to do

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Cassie is getting steadily worse. Today she can barely drag herself around, and she refuses to eat anything, even a single piece of the fancy kibble I give her for treats. Twice now, this dog has been so sick that I thought she might die, very soon.

I’ve made another appointment with the “second opinion” vet — turns out the one I saw out there was actually a part-timer, a kind of visiting vet, but now the regular guy (who sees my son’s dog) is back. This afternoon, he will have the joy of seeing a cranky old lady and her sick little dog.

This is what I think…oh, no. Make it this is what I’m sure of: The drug given for supposed Valley fever, fluconazole, is making her very sick. All of the symptoms she’s suffering, except for the bloody urine and the wheezing, are listed as side effects of fluconazole. We do not have any empirical proof that the dog actually does have Valley fever: the first test came back negative for Valley fever. This is not uncommon, and so we moved forward with the first vet’s diagnosis.

The longer the dog is on this drug, the sicker she gets. Today she will eat nothing at all, and she can barely move around, except to piss out an occasional lake on the family room floor. She is incontinent and unable to get to the back door before it all comes pouring out. Of the phenomena she’s suffering, almost every one of them appears in the University of Arizona Medical School’s list of fluconazole side effects in dogs:

  • loss of appetite
  • nausea
  • vomiting
  • diarrhea
  • excessive drinking and urination, or leaking urine while asleep
  • lethargy

If she doesn’t start to eat, she’s going to starve to death. I cannot afford to hospitalize a dog and keep it on life support so as to administer a toxic drug on the off-chance that three to six months of such treatment will beat back a fatal disease.

I can see four reasonable scenarios to explain what’s going on:

Possibility 1: She in fact had the contagious bronchitis that was going around, but because she’s elderly, it took longer for her to get over it and so it was mistaken for a chronic, endemic disease. In this scenario she does not now and never has had Valley fever; what ails her is either a respiratory infection or the side effects of the drug.

Possibility 2: She does have Valley fever acquired fairly recently and, as is not uncommon, it hasn’t shown up as a positive titer yet. In that case the drug is causing most of the symptoms, with the exception of the cough.

Possibility 3: She’s had Valley fever for awhile (just about any human or dog or horse that lives for any length of time in the low deserts of Sonora, Arizona, and California harbors Valley fever, usually asymptomatically) and it has advanced to the point where it is causing symptoms. In that case, the drug is still causing most of the symptoms, but it’s not likely to do much good.

Possibility 4: Now for something completely different! She has neither bronchitis nor Valley fever, but some as-yet-undiagnosed ailment that is much more serious. Her symptoms may be indicative of that…or may be the side effects of a drug she doesn’t need.

Just talked to First Opinion Vet, who finally had time to call me (it’s the lunch hour here). His money is on Possibility 4. He thinks there’s something more going on than Valley fever. He says the only way we can find out is to mire ourselves in every more complicated and expensive tests, and where the end-point would be is anyone’s guess. He feels that is not a good thing to do to the dog…and I will say, neither do I. Even if I could afford to be sucked into a vortex of medical testing for a dog that is at the end of its natural lifespan, my sense is that it would be cruel to put her through that — especially since it’s likely to be pointless.

As for me, I’m putting money on Possibility 1: she had bronchitis, was inappropriately treated for it, and got over the cough in the normal course of events. And what we’re looking at now is the result of a drug that did nothing for the ailment but has worked wonderfully to make her spectacularly sick.

I had already decided, before His Vetship called, to take her off the drug, stand back, and watch what happens. If she dies, she dies. Like all of us, she’s gonna die anyway. When he called and heard my whinge — and more to the point, heard that the dog not only is not improved but is lots worse — he agreed that we should quit giving her ALL the drugs, including even the small amount of Temaril-P. If it’s true that the worst of the ailment arises from the drugs’ side effects, she may feel a little better even if the underlying problem is something we haven’t figured out yet.

Which, IMHO, is a veterinarianly way of saying “ooops!”

Let’s see what happens next.

Doggy Ups and Downs

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Each day, Cassie has her ups and her downs. And it seems that each down gets deeper. She’s in a bad way every morning, but then seems to revive a bit around noon.

Today I noticed she wasn’t in her normal nest. Or anywhere else. Thinking I’d accidentally left her outside, I went running around calling her: no response. Finally I found her in the clothes closet, squirreled away in a corner.

This is not a good sign. In all the ten years this dog has lived here, she has never gone into that closet. Maybe once or twice to sniff at a shoe, but really: she doesn’t go in there.

The other not-good sign: she flat refused to eat this morning. I managed to coax a few bites down her by mixing some of the food with water to make a kind of soup. But she wouldn’t even take all of that. Either she’s having a difficult time swallowing or just doesn’t feel like being bothered. My money’s on the latter: my guess is she simply doesn’t want to eat any more.

If you’re going to let Nature take its course, you’ve gotta listen to Nature and understand what She’s telling you. Today She definitely was trying to say something…

The vet’s office called to say he wanted me to come pick up some Temaril tablets to try to deal with the refusal to eat issue. Why, I don’t know. Temaril is a cough suppressant. She’s stopped coughing, and he knows it.

I am now flat broke, budgetwise: $5 left to live on for the rest of the month. I transferred a hundred bucks over from emergency savings to get through the next week…hope I won’t have to spend much of it, but am basically out of food except for what’s in the freezer and what’s growing in the backyard.

At any rate, the UPs: Along about noon, the dog seems to revive. This is becoming a pattern. But every day, the morning “down” seems worse than the previous day’s. Really, today I thought she might not be alive by the time I got back from the vet’s — it’s an hour of driving, round trip. So I pull the car into the garage, climb out, and hear Cassie barking on the other side of the door!

She hasn’t barked in days.

Fling wide the gates…and lo! There’s Cassie standing there bright-eyed and wagging, looking normal as apple pie.

WTF?

The garage door is open. Ruby is still in the car — I’d taken her with me because I thought there was such a high chance Cassie would pass while I was out fighting traffic, and frankly, I do not want Ruby to decide to eat the remains.

She is a dog, you know…

So Cassie walks outside, Ruby being locked in the vehicle and so unable to make her escape to Yuma. Cassie strolls around, sniffs, pees, acts pretty damn normal. I get the mail, we stroll back inside as though this were just another day in Paradise.

Right away, while she still is acting like she’s going to live, I mix up some more dog food swill, causing her to get about half the remainder of this morning’s dog food down, along with about a third to half a cup of water.

Vet called just a minute ago. I pointed out that Temaril was for a cough and she’s stopped coughing. He said it contains a steroid to reduce inflammation, and can sometimes make an ailing dog feel better. Before I left the Funny Farm, I’d given her one of the remaining half-tablets from the previous bottle. He says it can act pretty fast, and that might explain her apparent revival. He also speculated that she may just feel bad when she wakes from a night of snoozing and it could take several hours for her to begin to feel better.

I reminded him that she’s 12 years old. He said…yeah…but made no further comment on her superannuation. He did remark, though, that Corgis are unusually tenacious dogs, and so one shouldn’t give up on her too soon.

/p>

Doggy Update: Death Refuses to Have Her

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So Cassie the Beleaguered Corgi seemed better after mid-morning. She kinda sprang back. Along about 2:00 p.m., we had an appointment with a vet at the clinic where my son takes his dog. My, that was a refreshing drive: only took about 10 minutes to get there, as opposed to the 40-minute drive required to arrive in MarvelVet’s precincts.

I explained my questions and misgivings to this vet. She allowed as to how these were reasonable questions and thought that indeed there was some ambiguity in the various indications. All in all, though, she agreed with MarvelVet that what ails the dog is probably Valley fever.

However, on this check-up Cassie seemed significantly better. Whereas MarvelVet was alarmed because he could hear the congestion in her little chest, today no such sounds were audible. Her temperature was down to normal. Her cough has been better most of the day. She only wheezed once at the vet’s office.

She (vet) also said the fluconazole should have few bothersome side effects in dogs. She thinks Cassie has been dragging because of the ailment, not because of the cure. And she suggested testing her again in three or four weeks, by which time she suspects the titre will change from negative to positive.

Hm.

The incubation period for Valley fever is 7 to 28 days after exposure. If you believe this is a new infection, that would make sense: this summer we had several dust storms that blew into the hood. Because we’re in the rain shadow of the North Mountains, we do tend to be protected from so-called “haboobs,” a stupid sell-newspapers name for dust storms, but this year they were pretty fierce. So…yeah…maybe she picked this up over the summer.

But the truth is, if you live in Arizona’s low desert, you’re exposed just by virtue of living here. You can harbor the fungus for a long time without ever noticing. The if something happens to dent your immune system, voilà! You notice…  And 12 years of doggy age — some 70 years± of human years — most surely is enough to dent your immune system. WhatEVER,,,the likelihood of her having picked it up over the past decade or so is extremely high.

So this vet: she’s from Trinidad. I liked her a lot. She spent a lot of time examining the pooch and chatting with the human, and it was clear she really knew what she was talking about. Yeah: I was impressed.

She and her husband, an IT dude, are so revolted by the political situation in our country that they’re seriously thinking of moving back.

And therein lies the brain drain issue: they’re only two of the many young professionals I know who speak of leaving the country. Permanently. If we haven’t stupided down America enough, the present administration is busily delivering the coup de grâce: when all the bright young men and women leave, we’ll have only a few smart old people left to keep the nation on track. And once they’re gone? Bye-bye American Republic, hello Banana Republic.

But as for the dog? She seems much better right this minute. She drags in the morning, but by mid-day perks up. There’s hope that she may still have a year or three of the good life. Or maybe even…greatness…

 

Doggy & Human Ups and Downs

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Luckily for the Human, it had agreed to host a dear friend and cat for an hour or so, while hordes of Realtors swarmed through their house, which they’re putting up for sale. They didn’t want to be there, and they surely did not want their cat there, while a bunch of strangers cavorted around the place. So the wife went to the beauty parlor and the hubby and kitty came over to the Funny Farm.

This provided a therapeutic break for the Human. I really needed some company this morning. The damn computer was working hard to thwart me at every turn — had a helluva time trying to catch up with the gerjillion tasks running late, and whenever I did manage to get something more or less posted, it invariably went up wrong, so I had to delete stuff and try to dork with it to get it to do what it was supposed to do and UGHHHH! I hate that kind of thing under the best of conditions, but when with even a small degree of extra stress, it drives me CRAZY!

And there was plenty of extra stress. Cassie the Corgi seemed even sicker than usual. She had a hard time eating the food I put in front of her. And when I smushed some dog food around her morning pill to get it down her, Ruby pounced and grabbed it.

Honestly, I do not know which dog swallowed the pill, but I’m pretty sure it was Ruby.

So this means that every time I have to medicate Cassie, I’ll have to lock Ruby behind a door in another room. One more fun hassle to make life grand.

Things went downhill from there. Mostly in the computer department.

Enfin, with the cat and the guest here, the dogs were locked up in the back bedroom. Good place for ’em!

When I returned from delivering my friend home and released the hounds, strangely enough Cassie seemed much more perky.

This morning I’d have said she was pounding on Death’s Door. Five hours later, she trots into the backyard, chases Ruby a short way across their racetrack, and appears to have lost the limp.

Yes. A limp is a symptom of disseminated Valley Fever, so as you can imagine the fact that for the past few days she has barely been able to hobble up the hall has been making me crazy. Yet another of the many things to make one crazy.

But she limps all the time. She’s always limped off and on, ever since I got her 10 years ago. Just not this badly.

Maybe it’s not from whatever is ailing her, but maybe she was injured. I have to lift her both on and off the bed. It’s possible I accidentally twisted her or kinked something, unknowing, and maybe that’s why she was limping. Or maybe Ruby gave her a whack when I wasn’t looking. WhatEVER. For a brief shining moment, she’s been limp-free.

In about 40 minutes, I’ve got to start yet another long trek toward Scottsdale, this time to visit the vet my son uses. I want a second opinion about the Valley fever theory. Several second opinions to address several concerns:

To wit: Can we please get empirical proof that this dog really has Valley fever before putting her on a drug that’s clearly making her sick and then proposing to keep her on it for six months to a year? Or more?

The dog came down with a cough at the time some sort of respiratory infection was epidemic. The cough improved when treated with antibiotics and a cough suppressant, but it persisted longer than expected. Is it not possible that it took her longer to get over a viral bug because, for godsake, she’s 12 years old! She is an elderly dog. Like an elderly human, she may not recover from infections at the speed of light. Is it not reasonable to suspect that the elevated neutrocil and monocyte values might reflect an ordinary viral respiratory infection, not Valley fever? Might the congestion Dr. B saw on the X-ray be pneumonia or bronchitis, rather than Valley fever?

Does it really make sense to dose a 12-year-old dog with a drug that makes her sick, and to keep her on it past her normal life span? Seriously?

Damn it! I hate to be one of those patients. But my innate skepticism just will not go away.

And my innate skepticism has served me exceptionally well in the past. One might even call it, say, a kind of survival mechanism.

Second Opinions…and you didn’t think of this…WHY???

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Ever realize your mental field of vision has some blind spots? Like you don’t think of the MOST obvious things, just because the circumstances were outside the routine parameters?

Like, for example, one of my Standard Operating Practices. To wit:

Whenever a doctor utters some pronouncement, always get a second opinion.

During the late, great boob adventures, I learned that one in spades: always, ALWAYS get a second opinion.

Seems like common sense, doesn’t it? You could even say it seems, yes, “obvious.”

Well. Then howcum it’s not obvious to get a second opinion when the person uttering the pronouncement is not a medical doctor but a veterinarian?

Even when that veterinarian is a very smart vet, a very excellent vet, indeed quite possibly the best vet in the Valley? His opinion is highly informed. Highly smart. Very likely right. But still…we are lookin’ at one man’s opinion here. One man’s highly lucrative opinion…

Comes the crack of today’s dawn, Cassie is really not well. Although her cough is gone, she’s visibly very sick. This pining away began slowly in the days after I began administering the Valley fever drug fluconazole, and as of today, she has developed a limp. She’s still eating, but not with normal corgi enthusiasm. She has become intermittently incontinent: if not taken outside often, she may urinate, apparently involuntarily. Yesterday, when I came home after a 3-hour absence, I found her sitting at the door in a lake of urine.

But the cough is gone.

But…the cough was gone before we started her on this stuff…

What if the drug itself is what’s making her sick now?

The reason she’s on the drug, even though the Valley fever test came back negative, is that MarvelVet doesn’t believe the test. He says (correctly) that the test often produces false negatives. Looking at other elements of the test results — neutrophil, monocyte, and albumin levels — he deduced enough probability that she might have Valley fever to justify putting her on fluconazole.

Hm. Izzat so?

With this nagging thought in mind, I called my son’s vet and got an appointment tomorrow. Then trotted over to MarvelVet’s office to pick up the new bottle of pills he’d ordered up…and, while there, asked for a copy of the test results. These, I intend to offer to the Second Opinion Guy, along with a raft of questions…

Why might a lowly editor in mathematical biosciences question the diagnosis of a graduate of a fancy university veterinary program? Well…

  1. Neutrophil and monocyte levels can be elevated (as Cassie’s are) by any infection. She had a severe cough for a couple of weeks, which could have resulted in these elevated readings.
  2. The albumin level was low but not outside the reference range. Here, too, any infection can affect albumin level, as can liver damage. Fluconazole elevates liver enzyme levels, often an indicator of a liver damage. Also, at 12 years of age, this dog is elderly; “normal” values shift in older animals.
  3. No symptoms of disease were ever evident before this episode. The dog shows normal signs of aging – slowing down a bit, a little grizzled around the muzzle – but has been active, playful, alert, and always ready to eat, until the current coughing spell occurred. The coughing could be caused by Valley fever, but it also could be caused by a severe respiratory infection. So, I suspect, could the elevated neutrophil and monocyte levels.
  4. A contagious bronchitis has been going around the Valley, to the extent that on first hearing about the cough. Dr. B assumed that was the issue. In a daily mile-long walk, Cassie sniffs a lot of dog pee and often greets other peoples’ dogs, and so it is reasonable to believe she was exposed to a contagious disease.
  5. The incontinence and lethargy are classic signs of fluconazole side effects. She experienced neither before exposure to the drug. I’m concerned about keeping the dog on a drug with many unpleasant and dangerous side effects for 6 to 12 months, especially since there appears to be a possibility that the problem is a bronchial infection, not Valley fever.
  6. Where humans are concerned (not dogs), the Mayo Clinic states the first line of treatment is rest, even in the event of severe symptoms:

Rest
Most people with acute valley fever don’t require treatment. Even when symptoms are severe, the best therapy for otherwise healthy adults is often bed rest and fluids — the same approach used for colds and the flu. Still, doctors carefully monitor people with valley fever.

The dog improved notably when I started tricking her to ingest more water. She cannot drink well because, like many corgis, she chokes when she tries to drink. However, when a small amount of kibble is floated in water, she manages to take in the whole bowl of 1/4 to 1/2 cup water without gagging. When she drinks more water, she seems to feel better. As long as she’s not sinking below the waves in a lake of pee…

So the questions to address with a) Second-Opinion Vet and then, depending on what S-OV has to say, with b) First-Opinion Vet are all what-ifs…

What if…the coughing really was caused by the bronchitis that F-OV originally diagnosed? What if…the reason the cough persisted so long was simply that she’s 12 years old: a very aged dog. By one account,that would make her between 69 and 74 years old, in human years. And that assumes that she really is 12 years old. She could be significantly older…remember, I got her at the Humane Society. Ever watched dog rescue folks at work? They have only the vaguest clue. When asked what a dog’s age is, they come up with a number based on such things as the condition of the dog’s teeth and its overall appearance. Typically they’ll say “two” because people think that’s the age at which a dog is house-trained and stops eating the furniture. If she’s just one year older than that, then she’s in the range of 74 to 78 human years. Two years older, and we’re lookin’ at the equivalent of a human in her late 70s or early 80s.  Which, we might add, is exactly how this dog is acting.

So what if she actually had a severe case of bronchitis and took longer than a week to throw it off, a) because it was a bad bout of it and b) because she’s an old lady and old ladies don’t get over sh!t very fast. If that were the case, it would explain the high neutrophil and monocyte levels and the low albumin level.

And given that we can’t really know, one way or another, if that’s true in the face of the unreliability of the Valley fever titre test, what if the Mayo Clinic is right? What if the best first-line approach is to leave her alone? Would she be harmed by taking her off the side-effect plagued drug and watching to see what happens?

Do we really want to put a dog that’s at the end of her natural life span on a drug with many unpleasant and dangerous side effects for 6 to 12 months? That is, for longer than, under the best of conditions, the dog is likely to live?

Seriously?

 

 

Cassie the Corgi, Redux

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So around 6 p.m. the vet’s staffer called and said the dog’s Valley fever test came back negative.

Hallelujah!

However, said she, he wanted to talk with me but he had just gone into emergency surgery. Okay.

Along about 8 p.m., he calls. He says he suspects the test is a false negative (which, if xyou look it up, you’ll find is commonplace) because the X-ray looked very telling and other aspects of the blood tests he ran are strongly indicative of Valley fever. Yea verily, the UofA College of Medicine’s page on canine Valley fever reports, “Sometimes tests are negative early in the infection, especially the Valley Fever blood test, and they may need to be repeated in 3-4 weeks to establish the diagnosis.”

Having already come across this factoid in my first round of frantic reading-up on Valley fever as it manifests itself in dogs, I’m inclined to suspect he’s right.

He suggested we keep on giving her the fluconazole, at least until such time as we can run some other tests or watch and wait. He was heartened when he heard that the dog seemed to have revived late in the day, despite pounding at Death’s door, and that she seems more alert and active today, though she’s still obviously under the doggy weather. That she’s eating and drinking normally are positive signs.

Interestingly, they compound the drug at their office, which allows them to give it to patients for significantly less than you can get it if you have to go to a pharmacy with a prescription in hand.

She’s still plainly sick. But she seems a little better today, or at least, she has seemed so for a few hours. She’s flopped on the floor just now…need to pick her up, put her back on the bed, and turn on the steamer for her again. Poor old dog.