Coffee heat rising

In the Dog (and Doc) Dept: Trust Your Gut…

Remember how I was wondering whether a possible misdiagnosis of Valley fever by MarvelVet might be what’s killing my dog? Well…yeah. Just talked to NewVet: the results of the second Valley fever test are back. And no.

No. She does not have and never has had Valley fever.

So basically: we have destroyed this dog’s health and very probably killed her by giving her fluconozale on top of prednisone. Or prednisone on top of fluconozale, however you wish to look at it.

That is not a benign combination. What can it cause? Adrenal gland dysfunction.

And yeah, again. That is exactly what has happened. It destroyed Cassie the Corgi. Her health is permanently ruined, and really, if I had a backbone I’d put her down now.

This has happened under the watch of the Great Skeptic. Remember, I am the one who keeps carping away that one should QUESTION AUTHORITY. Don’t take what your doctor (or a vet) says without looking it up yourself, understanding what ails you, and understanding what the proposed treatments will do for you and to you. Sometimes the treatment is worse than the disease.

That certainly is the case here. We basically killed this dog by putting her on a cough suppressant with prednisone plus an antifungal in the absence of no empirical evidence that a fungal infection was what ailed her. Instead, what ailed her was what was obvious: a bronchial infection that was going around the city at the time and that, probably thanks to the dog’s old age, advanced to pneumonia. She should have been treated with an antibiotic. In fact, when NewVet put her on doxycycline for a UTI, her cough cleared right up.

Shit.

Trust no one. Believe nothing.

 

Walmart(!) Neutralizes a Day from Hell…

A cold day in Hell…

Yes. Walmart, bless its corporate heart, managed to bring a quick, neat end to what started out as a Day from Hell, morphed briefly into a sad but real Day from Heaven, and then began to slide downhill again.

Cassie the (Ailing) Corgi had a pretty good day yesterday — at some moments possibly even rising to a 10 on a scale of 1 (about to expire) to 10 (back to normal). Foolishly, I thought, oh gosh! she’s gonna be OK!

You’d think I’d know better by now, wouldn’t you? 🙄

Beginning about 1 in the morning, she started coughing again. And coughed the rest of the night away. By morning she was so exhausted she was immobile.

I call the New Vet at 8 a.m., the instant they open.

In the interim between the time the dogs and I roll out of the sack and the time I can reach the vet, I pick up the laptop and, in the course of glancing at the news and waypoints, visit a complicated draft “page” at Plain & Simple Press where I store material waiting to publish it. Yesterday I spent HOURS updating and fully formatting it, an endless, tedious, mind-numbing job.

This morning? It was A.L.L. G.O.N.E.

Yes. Hours of brain-banging work, disappeared. And no, I couldn’t retrieve it for love nor money. But there wasn’t much time to fret about it…

The vet’s staff asks me to bring in the dog at 8:45.

This was pretty tight because I had to sing at a funeral at 10. And this was not one I was about to miss, since it celebrated the life (and presumed afterlife) of a lovely friend.

Okay. Brush teeth. Wipe off yesterday’s make-up. Throw on some fresh make-up. Lift the dog into the car, where she collapses in a limp pile. Fly through the rush-hour traffic, to the extent that one can fly through such a thing, and make it with eight minutes to spare. Time ticks by as the vet and I and her underlings discuss. It’s pushing 9:15. I still haven’t fed Ruby and still am not dressed in the requisite black duds and still have a half-hour or more to get back to the house and another 15 minutes to get down to the church. Nor, we might add, have I had breakfast or even so much as a swallow of coffee.

Seeing that I’m getting anxious, they suggest I leave the dog at their clinic, where they will test her again for the alleged, never-proven Valley fever and test for heartworm, which can cause the same kind of coughing, lassitude, exercise intolerance, and bloating. At this point, the new vets persist in the theory that the problem is not the diagnosed adrenal tumor but in fact is yet-to-be-provable Valley fever. This is entirely possible: dogs frequently test negative on the first try at Valley fever testing. It has, however, been more than 4 weeks (by far) since the first effort, so if she does have the disease, by now she should test positive. They want to put her back on fluconazole. I tell them I’d rather put her down, it made her so sick. They propose another concoction that has even worse side effects.

I fly out the door and arrive at the funeral rehearsal right at 10 a.m., to the director’s surprise (since I’d emailed her that I’d be late). On the way there, I reflect that she was also taking prednisone during the last go-round with fluconazole. Prednisone had some mighty baleful effects on the dog. It occurs to me that there could be some drug interaction.

The funeral comes off very lovely. Dear friend and leader on the choir who just had hip surgery showed up and, amazingly, managed to get up the stairs and participate in the whole ceremony. Old friends who have been off the choir, beautiful voices, also attended: a joy to sit with them and listen to them sing again.

Later, when I get back to the house, I look the drug interaction question up and discover — from Pfizer, the horse’s mouth — that discontinuing fluconazole causes increased metabolism of prednisone, which leads to adrenal insufficiency. Which would explain quite a lot…possibly we could try the fluconazole in the absence of prednisone to see if it will go down any more easily.

Along about 3 p.m., I get back to the veterinary. Cassie is barking and looking pretty perky. WTF? She was at Death’s Door in the morning…I had to carry her through the house to the car and then carry her from the car in the vet’s door.

They did another chest X-ray, since they never were able to extract the image I paid for from MarvelVet. They also did a heartworm test and sent off for another Valley fever titer.

However, it’s beginning to look like the dog probably does not have Valley fever. The white area around the lung and heart that MarvelVet cited as proof of his hypothesis was gone; the sound of her chest has been clear for several weeks, and still is. New Doc believes the problem is and has been a bronchio-pneumonia, probably of bacterial origin because the doxycycline we gave her for the UTI she developed seemed also to help clear up the cough…and doxy is the drug of choice for doggy pneumonia.

Unfortunately the doxy made the dog so sick I had to take her off it after 19 days (of 21 prescribed). She thinks, though, that the dog may be on the mend, and she’ll be OK if we can soothe the cough.

So she suggests Robitussin DM, in a dosage she specified.

 As for the adrenal tumor, this new intelligence just in:

  • New Vet doubts that any of the dog’s symptoms have been caused by the adrenal mass, which the sonogram doc believes to be nonmalignant. New Vet says most adrenal tumors in dogs have no symptoms (this is not altogether accurate, but let’s put our money on it for the moment.)
  • She thinks the bloat probably originated with the prednisone, which should not have been given in conjunction with fluconazole.
  • Other more classic fluconazole side effects, including anorexia and stupor and obvious misery and diarrhea and labored breathing, were caused by…yeah: fluconazole.
  • Taking her off the prednisone without titering her off even more slowly than I did would have caused adrenal symptoms, and giving fluconazole at the same time as prednisone can cause adrenal insufficiency that may or may not go away in the absence of the drugs.
    • Read: we’re talking about an iatrogenic problem aggravating a misdiagnosed ailment…
  • She doesn’t seem to have an explanation for the extreme swings in the dog’s well-being: yesterday Cassie was at a 9 or even a 10 on the 1-10 scale; this morning she was back down at a 1 or 2.
  • The dog does not have and probably never has had a collapsed trachea.

So…if our furry friend picked this up while nosing around in the grass during a doggy walk (which is how such infections spread among dawgs), I guess I should feel lucky Ruby didn’t get it, too. Actually, Ruby did cough some, very mildly and for just a few days; she may have had it and thrown it off because she’s so much younger.

This poses the possibility, though, that Cassie could recover. Maybe.

Now, as for that Robitussin DM: for veterinary purposes, the stuff has to have 20 mg of dextromethorphan and 200 mg of guaifenesin per 10 milliliters of sauce. Ohhkayyy…

So I figure I’ll trudge down to the Walgreen’s, stand in line till the cows come home, ask a pharmacist to direct me to the correct concoction, and…ugh, how awful does that sound?

Why do that when I can order it up from Amazon?

Right.

Right?

R-i-i-g-h-t.

Amazon offers approximately 87 gerjillion variants of Robitussin DM. The only one that has this particular proportion of active ingredient-to-active-ingredient-to-inactive-ingredients comes in “prepackaged spoonsful.”

Say what?

I do not want spoonsful, prepackaged in plastic waste or not. This stuff has to be hoovered up into an oral syringe so it can be squirted down the hound’s gullet.

Now in the middle of evening rush hour, whereinat you can not turn east out of my neighborhood because of the effing stupid “reverse lanes” the city has inflicted on us, I set out for the nearest Walgreen’s, which rests near the corner of GangBanger’s Way and Commuter Nightmare Parkway East. This, I dread, because I’ve been harassed in that store’s parking lot before and do not look forward to more harassment. The other nearby Walgreen’s is here in the ‘hood — couldn’t pay me to unlock my car doors in front of that place, especially not at dusk. The third Walgreen’s is way on down East Commuter Nightmare Parkway; though I can turn into its parking lot (where I also have been harassed), turning out of it in a direction that will bring me home is, shall we say, highly problematic.

O shit o hell o damn i do NOT want to do battle with any one of those dreary Walgreen’s.

But…right about then it dawns on me that I don’t hafta. There’s a Walmart on the way to Nearest Walgreen’s. It’s on my side of the road (no illegal or risky left turns across torrents of traffic) and its exit guides me straight to a left-turn lane that sets me on my way home, via Gangbanger’s way. Hot dayum!

Get into Walmart. It’s crowded — I have to park a long way from the front door. This — crowdedness — is a good thing, because drug-addicted panhandlers tend not to pester anyone when there are a lot of people in the parking lot. Into the store without incident. Quickly snab a fine young pharmacist; tell him the challenge. The kid is ready to rise to it. We sally forth into the cold nostrum aisle, and darned if he doesn’t find a version of Robitussin DM that comes close to the required proportions.

I say this is 20 mg of dextromethorphan and 200 mg of guaifenesin to 20 milliliters of sauce, not to 10. He points out that the solution to this is simply to give the dog twice the suggested dose.

Yeah. Well: we do have the possibility that a rushed vet could have the proportion wrong.

I say the solution is even simpler: give her the suggested dose and see if it works. Often OTC stuff like this will work with less than the recommended dose. If it does: bully. If it doesn’t, so then I just give the second half of it. He allows as to how this is an acceptable plan.

I grab the dope, head for the door, and in spite of a hectic scene find a cashier standing there all by his little self. Pay and shoot out the door without having to wait a minute.

Traipse to the far end of the crowded parking lot: not a single panhandler in sight. Yes!

Thank you, Walmart! Who’d’ve thunk it?

Dog: Can’t win department

Or is it the Department of Little Women?

I do have the worst feeling I’m being little-womaned here. But on the other hand, one also has to admit that the vet is emitting every sign of trying to be helpful…many of which signs are above and beyond the call of duty. But…but, indeed… Read on:

So at 8:30 this morning — Sunday — I present myself and my dog at the office of the charming and genuinely concerned (I do believe) MarvelVet. I explain that the dog has been much better after I unilaterally took her off the fluconase, a drug for Valley fever. She has begun to eat again, and she’s acting more like her old self: shaking off the deathly lethargy and resuming her favorite barking habits. The cough is gone.

He remains convinced that the dog does have Valley fever. That may be true. But in the absence of empirical evidence, my stand is that we have no proof of it, and that we’re making her unnecessarily sick by giving her a drug whose side effects include complete inappetence, extreme thirst, uncontrollable incontinence, lethargy, loss of interest in surroundings, inability or unwillingness to move around, diarrhea, vomiting, and gastric distress.

He now says, “Those are symptoms of Valley fever.”

I say, “That is a list of fluconase side effects that appears at the University of Arizona Medical School’s web page.” He replies with the usual snort that you can’t believe anything you read on the Internet. I reply that the University of Arizona Medical School is a credible source.

See? That is little-womaning: the assumption that if a woman says something, it must be stupid, uninformed, or both.

So used to that kind of male behavior am I that it doesn’t especially bother me — beyond the obvious annoyance factor. What does bother me is that those are NOT the symptoms of Valley fever, nor are they the symptoms she presented with. I took her to the vet because she had a persistent cough, not because she was peeing on the floor (she was not), consuming undue amounts of water (she was not), off her feed (she was not), lethargic (she was, to a degree), or suffering diarrhea or vomiting. This circumstance presents one of two possibilities:

  1. Either he doesn’t know the difference between the symptoms of Valley fever and the side-effects of a powerful medication; or
  2. His mind is made up and he simply refuses to listen to what the little woman has to say.

He proposes to have another vet, who’s a specialist, do a full-body ultrasound of the dog, in hopes of getting to the bottom of the problem. He says he will arrange this at no cost to me. Tentatively now, this is slated for Tuesday.

Okay. If he’s being honest, this could be useful.

Or not.

I am very wary about it. Why?

For one, the Mayo Clinic states — in reference to human cases, as you might expect — that the best course of action for Valley fever is usually no action: rest and hydration is the recommended treatment.

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.

And then over here at Medscape, we have this statement about work-up (i.e., testing and physical examination) for Valley fever:

Because most patients recover spontaneously, pursuing documentation of coccidioidal infection is not imperative unless the patient is immunocompromised or has signs of severe progressive disease or dissemination. Diagnosis requires isolation of the organism in culture, identification on histologic specimens, or serologic testing.

[Medscape is a website for physicians and clinicians. You have to subscribe to get the full dope on most topics.]

At this time, the dog does not have signs of severe progressive disease or dissemination. To the contrary, she’s showing every sign of improvement.

In any event, does this strategy apply to dogs? I truly do not know. However, I see that the University of Arizona’s website invites questions…and so… Yes. I just sent off a query asking if dogs respond differently to Valley fever infections than humans do….and specifically asking whether those two blurbs of advice apply to dogs. Watch this space for a report.

My friend whom I quoted as having lost three dogs to Valley fever says she actually has had four die of the disease. Each time she spent phenomenal amounts of money trying to keep the dog alive. One dog was on medication for years…and the stuff was costing her $300 a month.

Three hundred dollars is my entire household budget, exclusive of utilities.

Valley fever represents a huge profit center for the veterinary industry. Says the UofA Med School: “Owners spend hundreds to thousands of dollars each year, especially in Arizona, diagnosing, treating, and following up care for their dogs with Valley Fever. It is estimated that valley fever costs all Arizona dog owners at least $60 million per year.”

Holy sh!t. No wonder the guy wants to get the dog on fluconase, proof that it’s needed be damned.

He told me to put her back on the stuff. I said if we were going to do that, it would be better to put her to sleep, because it makes her so sick that she effectively has no life. This was when he tried to tell me the side effects were Valley fever symptoms — even though it’s dead obvious the dog has none of the “symptoms” now that the drug is wearing off. He backed down when I said I would put her down before I’d give her any more of the stuff.

I did have to point out to him that with a Ph.D. and a job as a technical editor, I do know the difference between a university medical school’s data and a woo-woo web page. It’s hard to convince some people. 😉

He tried to tell me she was not behaving in a normally peppy way. I refrained, having already said quite enough, that at 12 years of age a dog is not supposed to be peppy.

He handed me, also free, a half-dozen cans of PD and urged me to feed it to her. For those who aren’t into long-term pet ownership, PD is short for “Prescription Diet”: it’s a spectacularly expensive dog food distributed exclusively through veterinaries. He thought it would help her feel more like eating. And it’s true, she does need to gain back some weight.

But…BUT… She’s regained her appetite and is now eating just fine. The baby food scheme worked to jump-start her eating. After I got her eating that stuff, I poured half a bottle of it over a regular plate of her food, and she inhaled it. And this evening? During the battle to feed Charley, Ruby, and Cassie without being tripped or pounced by any of them, I forgot about the baby food whilst struggling to get her and a plate of food behind a door where Charley and Ruby couldn’t grab it. She inhaled her dinner anyway.

And PD…hmmm. It’s distributed in New Zealand. Know what that means? It means it’s likely made in China. They are very secretive about where the product is manufactured — can’t even find a clue at the venerable Dog Food Adviser watchdog site. If they’re not telling you, they don’t want you to know. Eh?

Her cough is essentially gone. She chokes on water — as she always has (the pup does, too: it seems to be characteristic of corgis) — and that causes her to wheeze, but once that passes, she no longer is coughing. That suggests to me that it’s every bit as likely that she had bronchitis as that she has Valley fever. Maybe more likely: she wouldn’t get over the cough that quickly on just a few days of the poisonous “cure,” and it would have come back by now if she really hand VF.

He noticed she was breathing rapidly, which indeed is something that she does. I couldn’t tell you if she’s always done it, because I haven’t been sensitized to the pattern of her breathing before this. However, here we have a genuine woo-woo Web page that suggests it’s no BFD:

Tachypnea is the term for rapid breathing in dogs and unless consistent or combined with other symptoms is usually nothing to worry about.

Laboured, difficult breathing or Dyspnea is more serious and you should consult your vet immediately as it could be the sign of a serious problem. Read on to find out…

Ohhkayyy…reading on: Potential causes:

Heat.

Nope: not while snoozing on a bed in an air-conditioned bedroom.

Mitral valve disease

Could be, I suppose. Cardiac problems have already been suggested as a possible cause of the coughing.

Congestive heart failure

Another strong possibility. Remember: she’s 12 years old.

Cancer

“However, lung tumours (Adenocarcinoma) are the exception and can cause coughing and panting along with rapid breathing. This form of cancer is more common in dogs over 10 years of age and could be the cause of older dogs breathing fast or more heavily than usual.”  Hmmmm…. Yeah, that’s a possibility. But MarvelVet said, when asked, that the X-ray he made showed no sign of cancer in her lungs.

Anemia

Usually caused by a hookworm infestation. Not likely in our parts: hookworm is not endemic here, and these dogs spend most of their time loafing in the house.

Cushing’s Syndrome, which results from overproduction of cortisol caused by a benign tumor of the adrenal gland.

Unlikely: she doesn’t have any of the other symptoms.

Collapsed trachea, in which the tracheal rings begin to collapse, and as air is squeezed through, a characteristic honking cough results. This also can cause fast breathing while the dog is resting.

Highly likely. The habit of choking when drinking water is also suggestive. And how is collapsed trachea treated? By golly: “Cough suppressants, bronchodilators, corticosteroids (to control inflammation), and/or antibiotics. In obese patients, weight loss helps decrease respiratory effort. Although treatment is not curative, a study released in 1994 showed that 71 percent of dogs treated medically showed a good long-term response.”  And what has caused Cassie’s cough and other symptoms to go away: Temaril-P…an antihistamine with a small amount of prednisone. Uh huh!

Why did I need to be told, eh?

Am I being irrationally paranoid about this? MarvelVet is a nice man, a visibly intelligent man, who seems to be genuinely, heartfelt concerned about the welfare of dogs and cats. He is an excellent vet.

Seriously: am I utterly off the wall to suspect overtreatment, a rush to possibly unnecessary treatment, and a strong money motive here? Maybe I’m too suspicious, too skeptical, too jaded after so many other experiences along those lines.