Concerned about my dog, seizure or passing out?

[dkerns9]

Hello, my dog became sick late friday night on January 29, 2009.  She was walking to our bedroom and fell over, she then lost control of her bladder, however she remained concious throughout.  Once she finished, she walked on as if nothing happened.  My wife took her to the vet and they ran some blood tests to check her liver, which came back normal.  The vet put her on phenobarbital for seizures and said she had eplipsey, i didnt like this generic diagnosis.   Again, on sunday morning of this week, we called for our cat and she (the dog) came running (like always), she went to jump on the bed and kinda stopped herself and fell over and peed again.  She became very tired and didnt seem to move much.  However, she has ate throughout and continues to eat.  On wednesday, i was petting her snout and she raised her head up and began to pee again.  So i decided to get another opinion from a different vet, and took her yesterday.  she always gets nervous in the car and usually throws up and slobbers everywheere, yesterday was no exception, however she again peed to and from the vet.  

The vet did additional blood work since the other vet only checked her liver.  He told his that he was leaning to something more organic (not sure what this is) than eplipsey since she us 5 and never had an episode like this before.  He mentioned anemia and brain tumors and a bunch of other possible causes.  I was going to see ig you could provide some insight, or maybe some other questions I could ask him.  he noted that if a brain tumor is suspected, that we will have to get an MRI, usually around $2,000.  We are willing to do whatever, what is the next step?

[Jim Humphries, B.S., D.V.M.]

I am so glad Dr. G has been of such help.  As you can imagine chronic heart disease is complex and long term, but many times management is very good.  

As for your generous offer for a donation, we are proud to do this here for MedHelp as a public service.  However if you would like to make a donation to a worthy organization, I would suggest the American Society of Veterinary Journalists.  (www.ASVJ.org)  They are a 501 (c) (6) certifying organization and all of us here work toward ASVJ Board Certification.  The physical address for ASVJ is on their contact page.  

Thank you and Thanks to Dr. G for his outstanding advice.  

[dkerns9]

Thanks doc!  Its just so emotional!  The day my wife and I came back from fishing almost 3 years ago this june and this little beagle was running down the roaad with no hair from her neck to tail and you could see every rib in her body just keeps coming back to me.  She had just had pups, and several people found little beagle pups mixed with something in the same area we found her!  After pulling 36 ticks off her, and 3 vet visits of $150 to get rid of worms and her shots she became our little girl.  

I swore I would never get this attached to another animal!  i told myself that since I was a junior in high school in 1999 when we had my dog put to sleep I had for 12 years!  However, they just grow on you!  THIS IS THE LAST ONE!!!  lol.....my wife and I keep saying that, until the next stray dog looking for a home comes walking along.

[Arnold L Goldman, D.V.M.]

Hi again,

First, you are doing all you can and you have sought and are receiving the best vet med can offer. If there's an arrythmia, the wearable monitor ("Holter") should catch it.
if indeed the dog is having seizures, an MRI may be recommended, however don't assume the worst. Many more dogs have epilepsy than have brain tumors. Also many brain tumors may be removed and if on the surface cause little impairment.

As far as prices, while advanced care is moderately costly it still remains quite a bargain compared to the same care for people. Don't rush to judgment now. While I don't recommend stopping the pursuit of a diagnosis for the episodes now, should the cardiac workup be negative, you could simply decline or put off an MRI and go to anti seizure medication. I wouldn't choose that course myself unless I had to, because the use of these medications are for life and may have their own adverse effects. Best to use only if have to. The MRI if offered may be the final step needed to put a name on what has been occurring. You have come this far........

I appreciate your continued efforts to keep us informed. Please do continue.

Sincerely,

Dr. G

[dkerns9]

so if they find nothing on this home monitor we are back at square one.  Maybe they are seizures?  Then that makes it possible that it is a brain tumor.  How do they check for brain tumors?  Cat scan or an MRI?  Arent the prices outragious?  If it is a brain tumor, and these are seizures how do we keep her comfortable?  

Also the dr. mentioned that she was a candiate for having Addisons Disease.  So we are at a loss.  I just hate to see her have these episodes.  

[dkerns9]

well doc, back from OSU and still no answers.  They cardiologist up there looked at the x-rays and said she seen no heart enlargement and no fluid in kidneys.  They ran an EKG and an ultrasound and both came back good.  She now has an at home EKG monitor on her that we have to press a button on the next time she has an episode.  All her bloodwork came back good.  She did have some protein in her urine, which they said could be a concern.

[Arnold L Goldman, D.V.M.]

By the way pulmonary hypertension may be linked to heart disease left sided heart failure, to lung disease or to other systemic diseases including systemic hypertension. In this case, with syncope it sounds like an arythmia needs to be pursued first. Your cardiologist will discuss all of this. Again, good luck!
Dr G

[Arnold L Goldman, D.V.M.]

Hi,

You ask some darn good questions!

First, congestive heart failure is the terminal phase of many heart diseases and results when the heart "decompensates" for whatever the underlying specific condition may be.
If there is fluid in the lungs (pulmonary edema) it is implied there is "congestion" and that because the heart disease has gotten that far, it is now "failure" as decompensation has occurred. In early heart disease congestion and pulmonary edema has not yet occurred.

Abnormal rhythms ("arrythmia"), if severe enough may be heard by auscultation (listening) but are best evaluated on an electrocardiographic trace because it can be seen and measured. I cant say unless I see (or possibly hear) your dogs rhythm. Your cardiologist will tell you this.

Pneumonia is a lung disease and would be unlikely to exist simultaneously in a dog with heart failure. Its just long odds to develop two serious conditions simultaneously
Pulmonary (lung) edema may be confused by some doctors as pneumonia, if they believed heart disease did not exist. On xray images, fluid from edema and fuid from infection or inflammation (pneumonia) may look similar.

Right sided heart disease may be accompanied by fluid accumulations often in the abdomen and left sided heart disease by fluid accumulation in the lungs however often both can be found as both sides of the heart may be affected and x ray imaging is an insensitive method of deciding this. So yes. there may be pulmonary edema with heart disease where on the x ray images it seems the right side is most enlarged.

As far as donations, I will forward your offer to the leader of the Pet Docs On Call project, Dr, Jim Humphries, and he will advise you on whether that is an option and what is appropriate. You are kind to offer to help us with this public information and public outreach project.

Please do let us know what the diagnosis is, what is planned and how your dog is doing, once you know. Hopefully, the specialists will get to the "heart" of the matter shortly  ;-)

Sincerely,

Arnold L. Goldman DVM,MS
MedHelp & PDOC

[dkerns9]

could this be linked to pulmonary hypertension?

[dkerns9]

hey doc, thanks so much! as soon as i read your posts, I called OSU and got her in for this thursday at 9:15 AM to see a cardiologist.  Does this sound like heart failure to you?  abnormal rhythms?  I just think its something that when she is resting and gets up real fast causes her to pass out.  Because on sunday, we gave her a bath which always makes her nervous and she did fine.  Once the bath was done she was acting like a puppy!  Playing, chasing the cat and all that.

whats your take on the pneumonia?  the right side heart enlarged?  

do you have any good questions I may want to ask the vet at OSU

where do i send a donation to this website, as you have been an awesome help.

[Arnold L Goldman, D.V.M.]

Hi again,

I am concerned that despite your history of further episodes, visible abnormalities on x ray imaging that no electrocardiogram has been taken. It is likely that if sncope exists something will be found on the elctrocardiogram, perhaps aided by a "Holter Monitor" which records electrocardiographic tracings for 24 hours or more.

I think it is time to pursue a second opinion, ideally with a board certifed veterinary cardiologist (credential is DACVIM-cardiology), alternatively with any board certified internist or at the very least with someone skilled in cardiac diagnostics. Abnormal heart rhythms may not intermittant but quite serious. If OSU is close by, thats a great option for further pursuit of your dogs problems. I wouldnt hesitate now, as 2 weeks is a long time. Self refer if need be. Tell the receptionist your dog is having syncope.

Good luck and please let us know how things turn out.

Very best regards,

Arnold L. Goldman DVM, MS
MedHelp & PDOC

[dkerns9]

is this the same as congestive heart failure?

[dkerns9]

hey doc, after having 2 good days where she ran around the house and ran around outside, she had 2 more episodes this morning.  We took her to the vet and he listened to her heart for nearly 5 minutes and kept saying it sounds good, and couldnt hear a problem.  However, he took an x-ray and seen that the right side of her heart is enlarged and has some pneumonia in her lungs.  He placed her on an antibiotic and a diuretic and wants to see her again in 2 weeks.  He noted he is unsure what could have caused her right side of her heart to become enlarged and that her heart worm tests came back good.  Should I be asking any more questions?  He wants to see her again in 2 weeks.  he noted that it was up to us if we wanted to take her to a cardiologist at Ohio State, which we do if he and you think its necessary.  

[Arnold L Goldman, D.V.M.]

Another thought: sometimes heart rhythm abnormalities are inconsistent and hard to find on a random electrocardiogram. In such cases there is benefit to having the dog wear a "Holter monitor" which is basically an electrocardiogram recorder sewn into a vest. A dog wears this for 24 hours or more and the veterinarian can then transfer the recoding to a monitor and speed it up to view the results over 24 or more hours. That way occasional "runs" of abnormal rhythm can be detected. Perhaps that is a direction to go if syncope is suspected.

Dr G

[Arnold L Goldman, D.V.M.]

I had wondered whether it could be syncope, which as you may know is an entirely different class of problem. In that case electrocardiogram, chest x-rays and blood pressure are additional tests that may help clarify how to proceed. Often syncope is related to an abnormal heart rhythm or heart disease. In any case anti-seizure medication plays no role in syncope treatment. In that case she may need medication to normalize that rhythm or even a pacemaker. Your doctor may want to order an echocardiogram too, which is the best overall test for heart disease analysis. Please do keep us informed of how your dogs situation is doing.

Regards,

Dr G

[dkerns9]

Thanks again, our vet called yesterday with the 2nd blood test results.  They too came back good.  He noted he is not sure, but what we describe is a syncope and not a seizure.  

After being off the medication for approx. 36 hours now she has been running around, playing doing things she has not done in over a week while on the meds.

[Arnold L Goldman, D.V.M.]

Hi again,

3 additional things to consider:

1. The primary goal of antiseizure medication is to decrease the frequency, duration and severity of seizures, not to avoid side effects like mild to moderate sedation. Uncontrolled seizures can reinforce themselves by further enhancing the brain's "seizure pathway" by a mechanism that is poorly understood (at least by me).
The more seizures that are allowed to occur in some animals, sometimes the more seizures that will occur in future. Also some dogs can end up with status epilepticus, a state of perpetual seizures that requires hospitalization to undo. If your doctor has decided your dog actually needs seizure medication at all, he/she likely has in mind the goals of preventing these unwanted consequences and the worsening of the seizure condition.


2. A steady state of antiseizure medication in the blood, and at a known level, is required to suppress seizures. Dose by dose decisions to skip or delay medicating because there are side effects or because there have not been seizures lately will be counterproductive and may lead to more seizures than otherwise would have occurred. Once begun, unplanned delays or cessation of medication dosing may cause "escape" by the "irritable" brain cells that initiate the seizure pathway and activity. You want consistent dosing as near to a consistent schedule as possible. An hour one way or the other is acceptable in most cases, but skipping doses, decreasing doses or altering the schedule is not


3. Medication side effects tend to decrease or stop as the body accustoms itself to the medications. Expect to live with these side effects for 4 to 8 weeks. Once the therapeutic blood level is achieved (known only through a blood test) an assessment can be made whether that medication is adequate to suppress seizures, Less than one seizure a month while on medication might be a reasonable goal. If seizures continue at an unacceptable level, then a transition to another medication may be initiated. Thereafter your doctor may attempt to taper the first medication. It may yet be necessary that both medications be continued. This entire process of achieving therapeutic benefit while minimizing side effects may take some time and patience on your part. It is as much art as science and you should grant your doctor the latitude to achieve a workable success. There is not one formula that guarantees quick, cheap success.


All that said, you might inquire of your doctor why phenobarbital was chosen first. While it has been the first drug of choice for many, many years, some veterinarians, myself included now reach for potassium bromide (KBr) first and only change to or add phenobarbital or other drugs if KBr is ineffective or itself has intolerable side effects.

Phenobarbital is very convenient in many ways compared to KBr, for example it comes in defined pill sizes and is dirt cheap, whereas KBr is supplied as a powder which must be compounded or formulated at added expense, however, KBr overall may have less side effects and phenobarbital can occasionally (fairly rarely) cause liver toxicity. I still use plenty of phenobarbital mind you, I just happen to favor KBr now. Liquid KBr can be poured into food too, whereas with phenobarbital, the dog must be pilled and pilled effectively. No sneaking behind the couch to spit these out Im afraid. Its too important.

I hope this added perspective will be helpful to you. Thanks for the opportunity to answer your important questions.

For all MedHelp readers: it is important that your doctors explain to you all the pertinent details of your pets illnesses and treatment strategies, and in enough detail that you understand why as well as what. We do understand that the overwhelming amount of information you may have to hear can become impossible to absorb while still trying to accept the reality of your pets illness. Forums like MedHelp can be helpful to fill in the blanks. In the end, you have to trust and communicate with your doctors and they have to communicate effectively with you. It is your partnership with them that will lead to the best quality of life for your animals.

Sincerely,

Arnold L. Goldman DVM, MS
MedHelp

[dkerns9]

Thank you so much!  She has been getting the Phenobarbital and eems to barley function.  We gave it to her yesterday at 7:00 AM and I was going to give it to her again around 7 or 8 last night.  However, at about 7:45, she got up and was running around.  We took her outside, she ran in the snow, the first time in a week.  So we decided not to give her the Pheno.  As we discussed this matter with the vet.  he said it should not make her that tired, but when on it she acts nearly drunk.  Again this morning, she is very alert.  He told us he could prescribe another med but felt Pheno was the best.  I think she is having a negative reaction to the meds, is that possible?

[Arnold L Goldman, D.V.M.]

Dear dkerns9,

Seizures, which it sounds like your dog actually has been having, are a disorder of episodic and inappropriate brain electrical activity. That said, the causes are numerous, thus seizures like cough should noit be looked at as a diagnosis, but rather a symptom, just as  a cough can be a "cold" or lung cancer and every grade of seriousness in between.

Your first doctor may not have communicated to you the breadth of the tests that were run, as typical biochemical panels and cell count panes run by commercial labs look at much more than just liver associated values. That may have been unfortunate as you clearly want more info than that and in more detail. That doctor owes you complete explanations.

Looking at your dog's signalment (species, age, etc) and assuming initial lab tests were unremarkable ("normal") the most likely diagnosis is eplilepsy. Eplilepsy is simply seizures of undefined cause. Of course that cannot be said until after an effort is made to be sure no other cause can be found. How extensive (and expensive!) that effort is depends on the neurologic examinatoion the veterinarian does and its findings, your willingness to pursue and pay for advaced testing and the history of seizure frequency, progress and other factors. Epilepsy is therefore a diagnosis of "exclusion" which means after nothing else that can be treated is identified, the seizures are treated as the primary problem.

Even with treatment, epilepsy induced seizures cannot be fully eliminated in all cases.
The goal is control: fewer, shorter seizures. And because the medications used to lessen seizures have side effects whether to begin treatment is determined on how often and how severe seizure activity may be.

Before the advent of advanced imaging: MRI, CT often the work up of a presumed epilepsy case would stop after CBC, chem profile, urinalysis and maybe chest and abdominal xrays. Together these items often are called a "minimum database."

Today, however, with advanced imaging more widely available, it is less difficult to pursue the possibility of visible, anatomic brain abnormalities such as tumors. That said. not every seizure case necessarily needs these tests to survive. These tests simply exclude anatomic changes.

Deciding whether to pursue them or not should depend on whether the neurologic exam your doctors have done has abnormalities or not, whether you want or can afford the imaging and whether you are prepared  for negative results. The outcome could be that you are still giving  the anti-seizure medications you have now, or even no medication, as the case indicates. Also some dogs on medication(s) still seizure from time to time and there are some that cannot be controlled even on multiple medications.

Clarify for yourself which doctor you trust and want to stick with, and follow their recommendations. Do ask for and expect complete explanations. Please let us know how things progress with your dog. Good luck!

Sincerely,

Arnold L. Goldman DVM, MS
MedHelp & PDOC