Signalment/location:
10.5-year-old male, neutered, mixed-breed (pit/cur/pug/pom) dog, approximately 30 lb. St. Louis, Missouri.
Relevant medical history:
- Previous pancreatitis flare in December/January. Confirmed by ultrasound. Treated on an outpatient basis with Cerenia, zofran, sq fluids, buprenorphine. Started on Hill's Rx low-fat i/d food.
- During ultrasound, they saw elongated lymph nodes. Did aspiration and cytology. Diagnosed him with Large B Cell Lymphoma.
- Started supportive therapy comprised of prednisone 20mg qd and famotidine 20mg qd.
- Early April: Chronic moderate, normocytic, hypochromic and mildly regenerative anemia; hematocrit around 27%. Assumed this was due to cancer progression. Did not treat in April. Reticulocytes were high. Most recent hematocrit (Late August) was 31% after 2-3 weeks on oral iron supplementation.
-July: First episode of collapse/stroke/syncope. Fell face forward and then to the side immediately after pooping. Was down for a few seconds, stood up, and was wobbly. Regained full functioning within 1 minute. No paddling, no postictal signs, did not lose bladder or bowel control or consciousness.
- Early August: Second episode of collapse/stroke/syncope. Laying in bed, sat up and started waving head around like he was seeing things that weren't there, horizontal nystagmus, disorientation, ataxia. Did not loose consciousness or bowel or bladder control, no paddling. Episode lasted 4 to 5 hours, regained full functioning. Went to ER where they said it was likely a stroke not a seizure. Neurological exam was normal.
- Mid August: Did repeat ultrasound that showed an enlarged liver with nodular hepatic hyperplasia believed to be benign and caused by the prednisone. Gallbladder sludge/possible early mucocele; currently takes ursodiol. Normal spleen, pancreas, stomach and intestines, with NO enlarged lymph nodes.
- Late August: Underwent a second lymphoma workup that included IDEXX Cancer Dx, result was negative. Also, did chest and abdominal xrays, unremarkable; blood pressure, normal; and CBC and full Chem panel: Hematocrit 31%, improved from 27%. Platelets remained elevated at 822, decreased from 1,109. WBC was 19.4 with neutrophilia and monocytosis, interpreted as an inflammatory leukogram. No blasts, blood parasites, schistocytes or keratocytes were identified. Chemistry showed ALT 304, ALP 351, GGT 33 and lipase 998, all improved from July labs.
- Fully tapered off of prednisone in late September. Around the same time, he started ursodiol, omeprazole, oral iron, dasuquin, and continued on famotidine.
- Since then, he has had significant itching, flaky skin, and extreme shedding. Vet ruled out fleas and mites. Started on medicated baths and hydroxyzine for allergies with no improvement after 3 weeks.
- Currently on a medication washout/dechallenge. Only taking ursodiol and famotidine.
- In the last two weeks, he has had periods of inappetance except towards high value foods and treats, occasional episodes of loose stool/diarrhea (no blood), unproductive gagging (not regurgitation, not bloat, not coughing). He's developed spots on his stomach near his groin that look like very faint bruises, but they sit on top of the skin and can become crusty. The vet said these were normal in aging dogs and did not perform skin cytology.
That brings us to present day.
Yesterday, October 26, he suddenly began trembling visibly, whining, holding his tail tucked and acting frightened/uncomfortable. I took him to the ER. His temp was 103, but all other vitals were normal. Because the hospital had a 6 hour wait and he appeared stable, we left and arranged a morning urgent-care appointment with a nearby hospital.
Today, October 27th, he initially appeared slow but ambulatory. While walking toward the back door for his morning potty, he became wobbly, fell face-first into a recliner and then lay limp on his side for several seconds. In the seconds it took for me to reach him and pick him up, he was already alert. Afterward, he walked outside, urinated normally and returned inside. There were no lingering side effects.
About 45 min later, he had an identical episode as we were leaving for the appointment. No side effects, no loss of consciousness, bowel, or bladder control. It reminded me of those fainting goats/syncope.
At today’s veterinary appointment:
- Temperature was 102.9°F.
- Lost 1.5lbs since Sept 25th appt. Current weight 29.5lbs.
- Heart rhythm sounded normal on examination.
- Neurological exam was normal.
- Gums remained pink, but mildly tacky.
- His abdomen felt normal to the veterinarian, without obvious distension or pain.
- He received sq fluids and Cerenia.
- A CBC and full chemistry panel were sent to the laboratory; results may not be available until Friday.
- I also requested SNAP 4Dx Plus be done since he does accompany me on hikes and float trips and we have a lot of wildlife around.
After returning home, he ate very enthusiastically, urinated and defecated normally, and has eaten a little more since then, but still not his usual amount. He is resting comfortably and can move around independently, but he still seems more subdued than usual (I know this could be the cerenia) and possibly mildly unsteady. I may be scrutinizing every movement because I am anxious/worried, but he does not seem completely back to baseline.
He does not have access to any toxic foods or environmental poisons. His diet is strictly Hill's lowfat i/d, but I do provide boiled or freeze dried chicken breast or minnows as treats and an occasional Dentalife dental bone.
Questions:
Do the brief limp episodes sound more consistent with syncope, seizure, stroke/vestibular disease, weakness from GI illness/dehydration, or something else?
In addition to the pending CBC, chemistry panel, and SNAP 4Dx, would you recommend pancreatic lipase testing, blood pressure, ECG/Holter monitoring, abdominal ultrasound/FAST scan, or another test? I cannot afford a $4k MRI, especially if it would not change his treatment plan. They told me Clopidogrel was the only option to treat dogs with strokes and he can't take it because of the unresolved anemia.
Could adrenal suppression after long-term prednisone and a completed taper cause this combination of weakness, GI symptoms and collapse? Would resting cortisol or ACTH stimulation testing be reasonable?
Given his anemia and collapse, should his spleen or abdomen be re-imaged even though the spleen appeared normal on ultrasound in August?
Are there other differentials or warning signs I should specifically discuss with his veterinarian?
Could this be liver cancer? If so, what specific tests should I request?
I understand that no one can diagnose him through Reddit, and he is actively under veterinary care. I am mainly hoping for ideas about reasonable next diagnostic steps while we wait for the laboratory results.
Any ideas would be appreciated. I love this dog more than anything else in this world and the last 11 months have been absolute hell. I would just like to know what's going on, so I can help him.