Visiting Veterinarian : Lucky, the unfortunate Sheltie
With Thanksgiving fast approaching, then Chanukah, Christmas, New Year's, I muse at my keyboard. I should write something topical. My mind is blank. I free-associate, hoping for inspiration. Turkey. Bones. Ham. Christmas trees. Tinsel. Chocolate. Leftovers. Company. Travel. Stress. Depression. Chocolate. Drat.
Try again. Turkey. Poultry. Poetry. I like poetry. I try writing a spoof of "Over the river and through the woods." It's terrible. I am feeling less thankful every minute. Thankfully, my secretary interrupts my angst. "Lucky is here."
Lucky is a middle-aged Sheltie adopted by his current owner from the MSPCA six years ago. Other than minor problems, he seemed a healthy dog. Then, three years ago, Lucky got itchy. Very itchy. In fact, he began chewing himself raw. "Let's rule out fleas," I suggested, prescribing flea control and a short course of the corticosteroid prednisone to calm the itch. Lucky improved. But the problem soon recurred, then worsened. He developed generalized pyoderma, a descriptive term meaning "pus in the skin," manifested by pustules scattered across his body. Poor Lucky. His ears were red, his back so sensitive he would almost fall over scratching if you rubbed his rump. "Probably allergies," I pronounced.
Dogs can be allergic to many things including pollen, mold, dust mites, fleas, and foods. People with inhalant allergies get respiratory symptoms — red, itchy eyes and runny noses. Allergic dogs get itchy skin, technically called pruritus.
"To pin down the cause, we'd need to stop the prednisone for a few months, then allergy test," I advised. "A hypoallergenic food trial is also indicated." But these things are expensive and finances were a concern. Couldn't we just prescribe something for the itch? Antihistamines are the safest for long-term use, but different antihistamines work for different dogs, and for some dogs, none work. It's trial and error. Prednisone, on the other hand, almost always relieves pruritus and side effects are rarely a problem if it is used judiciously for short periods.
"The prednisone really helps," Lucky's dad prompted. I concurred. Lucky was so uncomfortable I couldn't see stopping prednisone abruptly.
"We'll wean him off soon," I said, and we agreed as they departed.
Months later, Lucky returned. Dad had been in the hospital. He had done his best keeping up with Lucky's care, but the dog's skin was dramatically worse. "Prednisone didn't help this time," he reported. "Could it be mange?" Well, yes. Mange is caused by tiny mites. Demodectic mange mites are easily found in skin scrapings under the microscope. Sarcoptic mange mites, however, are much harder to find. Negative scrapings do not completely rule out their presence, so it is common practice to simply treat if there is a suspicion of sarcoptic mange. I scraped Lucky's skin multiple times. Nada.
"I had a rash, too, a while back," the owner mentioned. Since people sometimes get transient cases of sarcoptic mange from their dogs, this history, along with the acute onset, and lack of response to prednisone, made sarcoptic mange a serious consideration. Standard treatment is high doses of ivermectin. But there's a catch. Individuals of certain breeds, including Shelties, sometimes carry a genetic mutation making them hypersensitive to ivermectin. Give it to the wrong dog and you'll kill the mutt along with the mites. We could test Lucky for the mutation. Or we could use a different protocol. We opted for the latter.
The next year is a long, sad story. Constrained by cost and the owner's health, we continued our hit-or-miss approach. Mange treatment. Antihistamines. Antibiotics. Prednisone. Different corticosteroids. Lucky would improve — then he'd relapse.
"We can't keep giving steroids," I despaired. "It's dangerous, and it isn't working anyway." We finally tried a pricey medication called Atopica, and hypoallergenic food. "This should help," I promised. And it did. A little. At first. Then not so much. The expense eventually outweighed the minor improvement.
Lucky's dad sought a second opinion, then a third. I welcomed others' input and heartily suggested a consult with a dermatologist, but that wasn't logistically possible. Finally, in September, three years after this all began, Lucky came to me again. He looked truly awful. Depressed. Miserable. Covered in weeping sores, pustules, scabs, with huge bald patches and barely any fur. He's really suffering, I thought helplessly, wondering for a moment if I should recommend euthanasia.
"He can't go on like this," I said. Lucky's owner looked at me hopefully. Referral to a specialist or extensive diagnostics were still not realistic options but he loved that dog.
"Tell me what to do," he said. I wished I knew.
So we started over. From square one. Having already treated for sarcoptic mange, we repeated skin scrapings to rule out demodectic again. We checked for yeast and ringworm. His owner agreed to a thyroid test. Lucky's levels were borderline low, so we added thyroid supplements. We started again on hypoallergenic prescription diet, a different one this time, and I made his dad swear not to give even a bite of anything else. I discussed the case with veterinary dermatologists online. We started long-term antibiotics, not just for a few weeks, but for months. We continued aggressive flea control, whether or not we saw any evidence of fleas, eschewed corticosteroids and tried new antihistamines, one after another. We instituted frequent medicated baths and agreed on regular rechecks every two weeks to monitor progress, reinforce the plan, and tweak our protocol.
I sit at my desk looking futilely for a Thanksgiving topic when my secretary interrupts my angst. Lucky's here. I walk into the exam room. After two months of uninterrupted everything-but-the-kitchen-sink empirical therapy, I see that, for the first time in a long time, Lucky is growing fur. Actual fur. All over — well, more or less. There are still thin patches and an occasional small sore, but he hasn't had this much hair in ages.
He's still itchy, but he looks good. He smells good. He feels good. I want to dance in the streets.
Lucky has fur! Now there's something to be thankful for.