Visiting Vet


“I think Blinky has an eye infection, doc,” the owner says.  Blinky is a shih tzu…or a Lhasa apso. I always get those mixed up. I push back the droopy bangs that flop across her face.  Gooey green glop leaks from the corners of her eyes and there is crusty stuff all along the lid margins. Her conjunctiva is red and inflamed. I grab a small plastic bag containing two little white strips of special paper.

“This is a Schirmer Tear Test,” I tell Blinky’s mom. “To evaluate her tear production.” Folding down the tab at one end, I tuck the strip under the outer corner of Blinky’s lower lid and glance at the clock, hoping she will sit quietly for 60 seconds.

The Schirmer tear test is a simple but elegant diagnostic tool. The strip is made of a material like blotting paper, with very specific absorbency,  marked off like a ruler in millimeters in indelible ink. At the top is a thin line of water-soluble blue dye. As Blinky’s eye waters, tears moisten the paper, picking up the blue dye which travels down the calibrated strip. At the end of 60 seconds, all I have to do is read where the blue dye has reached on the tiny ruler. A normal dog produces at least 15 millimeters of tears per minute. Blinky has made three.

Keratoconjunctivitis sicca, also known as KCS or “dry eye,” is the result of decreased production of the watery component of the tear film which is made primarily by glands found in the nicitans (third eyelid.) Tears function to nourish, lubricate, and protect the eye as well as remove debris and bacteria. Without adequate tears, Blinky’s eyes are constantly dry and irritated. Her body tries to compensate by producing more mucous (which is different from tears), creating that gooey, crusty situation. And her owner may be correct about that infection because secondary bacterial infections frequently ensue.

KCS is a relatively common disorder in dogs, though much rarer in cats. Breeds predisposed to it include cocker spaniel, West Highland white terrier, bulldog, shih tzu, Lhasa apso, bloodhound, Boston terrier, springer spaniel, Pekingese, pug, Samoyed, Yorkshire terrier, and cavalier King Charles Spaniel, to name just a few.  These dogs are all prone to what is called immune-mediated lacrimal adenitis, or primary KCS, in which, for some unknown reason, the dog’s immune system starts attacking and destroying its own tear glands. This is the cause of the majority of KCS cases. Dry eye can also occur as a result of severe conjunctivitis or infections such as canine distemper virus. Sometimes dry eye can be a side effect of medications such as sulfa drugs or the NSAID analgesic etodolac. Luckily, medication-related cases often resolve if recognized promptly and the drug in question is discontinued.

What else can cause KCS? There is a condition dogs get called “cherry eye,” which is a prolapse of the gland of the third eyelid. It looks like a big red blob sticking out of the corner of the eye. Back when I was a student, we were taught to simply sedate the dog and snip it off.  It took ten minutes and was an inexpensive procedure. The problem was we were also removing most of the tear glands. Breeds prone to cherry eye are also prone to KCS, but our surgery was substantially increasing the risk of dry eye later in life. It took a while for veterinarians to realize this connection, but nowadays we try to treat cherry eye with a procedure that keeps those glands intact. Things like trauma, radiation for cancer, and other surgeries can also cause KCS by affecting the nerves responsible for blinking or proper eyelid closure.

Blinky’s little strip of paper barely turned blue. With no history of surgery, drugs, or injury, this was probably immune-mediated KCS. “She’s going to need medication to stimulate tear production,” I explained. Topical cyclosporine helps her remaining glands to produce tears and is also anti-inflammatory. We usually start with a commercial veterinary ointment that is an 0.2% preparation twice daily. (Many owners may use a cyclosporine eye medication themselves because KCS occurs in people as well.) “It takes time to see results, “ I advised. “Let’s recheck her Schirmer tear test in a month.” If this didn’t work, we would have a compounding pharmacy prepare stronger eye drops of one or even two percent cyclosporine.

“Can’t I just use artificial tears?” Blinky’s mom asked.

“Sure,” I replied. “As long as you can put them in every two hours for the rest of her life.” The reality is that to provide adequate lubrication, artificial tears need to be applied very frequently. They can be useful as an ancillary treatment, especially in the early weeks, but are rarely a reasonable long-term solution. They also often contain preservatives that may be irritating after a while. But before starting any medications, we had to check one more thing.

“Dogs with KCS are also prone to corneal ulcers,” I said. “I’m going to put a drop of fluorescein stain in her eye. It starts bright orange, and then turns day-glo green. Don’t worry.  It washes off.”  The surface of the cornea is normally impermeable to water. With KCS, the dry surface is easily damaged. If the cornea is abraded, water-soluble dyes such as fluorescein will make any ulcerated areas visible with its bright green color. Blinky’s corneas were fine. She went home with cyclosporine, an antibiotic ophthalmic ointment for secondary infection,  and a recheck appointment in a month.

KCS is painful. Left untreated, it can lead to severe corneal damage. The eye may respond to the chronic irritation by producing a brown pigment that can eventually cover the entire surface, causing blindness. Medication can sometimes reverse the vision loss, but not always,  and lifelong treatment is usually needed. It makes me appreciate how such simple things as tears can be so crucial for vision and a good quality of life.


Michelle-JasnyThe Saturday afternoon call was about Slippers, a two-year-old cat. “She didn’t come home last night,” her mom reported. “She returned this morning, but didn’t eat and acted oddly.” “Oddly how?” I asked.

“Skittish, quiet,…and foaming at the mouth.” That phrase immediately evokes rabies. The movie Old Yeller, with its vivid images of dog turned vicious. Folk tales filled with slobbering, rabid wolves.

It’s true: excessive drooling is often a sign of rabies, which is a severe, almost invariably fatal virus usually spread via the saliva of an infected animal. Symptoms may include all kinds of altered behavior, from unusual shyness to extreme aggression. Because it is contagious to people, extreme care must be taken whenever we have even the slightest suspicion of rabies, but to date, there has never been a case on the Island and Slippers was current on vaccinations, so I wasn’t worried.

“Plenty of things can make a cat drool,” I said. “A bee sting or spider bite in the mouth. A toothache. Anything that tastes bad. Even an upset tummy.”  Her owner decided to watch her and schedule an appointment if she didn’t improve. That night I drifted to sleep thinking, “she probably feels better already.”

An hour later, awakened by another call. Not Slippers, but Elisha, a 14-year-old cat,  diagnosed last year with hyperthyroidism. One of the most common endocrine abnormalities in older cats, hyperthyroidism is usually caused by a benign but hormone-secreting tumor of the thyroid gland. Symptoms often include excessive eating, drinking, and urination, combined with weight loss, and sometimes unusual behavior. I once diagnosed a case whose only sign was that the cat had suddenly started lying down in puddles in the driveway.

“Sorry to bother you so late,” his owner said. “Elisha was outside and killed a rabbit, then raced inside all agitated and panting with his mouth open. He looks uncomfortable and freaked out.”

Could Elisha walk? Was he limping? Were his gums pink? Was there blood anywhere? Any coughing, vomiting, diarrhea, difficulty breathing, seizures? As we talked, Elisha calmed down. “Maybe he was stung by a bee, “ I suggested, “or bitten by the rabbit.” Within an hour, Elisha’s owners reported his symptoms were gone, so I went back to sleep. For an hour, ‘til the next call.

“Slippers really isn’t right,” her owner said anxiously. “She’s had four episodes running madly around the house and drooling.” I shook myself awake and said to bring her right over.

Slippers had a high fever and was dehydrated. She was lethargic, barely moving on the table.  At one point she blinked her eyes in an odd, twitchy fashion and began to drool, but it passed quickly. I drew blood, gave fluids, and prescribed antibiotics for infections such as tick-borne diseases. “Maybe the odd behavior is a reaction to the high fever,” I theorized.

But then, just as we were finishing, Slippers became frantic and I witnessed firsthand what the owners had been seeing at home. This was not a fever reaction, nor a typical seizure like epilepsy. With the fever, sudden onset, and bizarre behavior, this was almost certainly some kind of infection affecting her brain. It might be bacterial, or protozoal, even parasitic, but we had to include viral, and specifically rabies, on our differential. Even though Slippers was vaccinated. Even though it would be a first for the Vineyard. Dispensing anti-convulsants along with the antibiotics, I sent her home with instructions to keep her confined, minimize human exposure, and consider taking her to a specialist in the morning.

Over the next week, Elisha, the hyperthyroid cat, had occasional episodes of agitation, panting, and acute distress lasting up to an hour. When he arrived for an exam I noticed his heart rate was elevated and he had lost weight. “Is he getting his thyroid medication faithfully?” I asked. Not so much. Apparently in the rush of summer, Elisha had missed a significant number of doses.

Hyperthyroidism increases a cat’s basal metabolic rate. The medication lowers it back to normal. Elisha’s bouts of bizarre behavior might simply be uncontrolled hyperthyroidism, his body jazzed up like a person on cocaine or speed. I suggested medicating him without fail and see if the episodes resolved. I gave them a handy device called a Pet Piller and taught them all my tricks for medicating kitties. (Thus will read my epitaph: “She sure knew how to pill a cat.”)

Slippers, on the other hand, was getting worse fast. Impossible for her owners to medicate, she had scratched them repeatedly, and, with the possibility of rabies, however remote, anxiety levels were running high. They brought her back and forth for me to treat but despite our efforts, her condition deteriorated. An agonizing decision was made. Slippers was suffering, the episodes increasingly intense, her prognosis poor. We had to let her go, and we had to be sure it wasn’t rabies.

While making arrangements for testing, I spoke with West Tisbury Animal Control Officer Joannie Jenkinson. She too had been dealing with a cat with bizarre and aggressive behavior. For a moment I was afraid. I was pretty sure Elisha just needed more medication, but what about Slippers, and this other cat?  They both went outside and lived within a few miles of each other. Could the cases be related? Had a rabid bat, skunk, or raccoon somehow gotten here, tangled with these cats, leading to the first rabies outbreak on the Vineyard?

My fears were soon laid to rest. Elisha’s symptoms resolved with regular thyroid medication.  Case solved. The other cat? Their veterinarian didn’t find anything medically wrong and the cat’s behavior improved. Slippers’ rabies test came back negative. That brought a big sigh of relief to all of us who had been exposed, but only small comfort in the face of losing such a young and beloved cat. So what was the cause of her severe and tragic illness? I wish I knew. All I can say for sure is that it wasn’t rabies.


Michelle-JasnyReturning from camp, my daughter thought she might have poison ivy on the back of her leg. “Let me see” I said, expecting to find a small area of the classic poison ivy rash. Instead, there was a huge red patch, swollen and hot to the touch, more than seven inches across. It looked truly awful. “We’re going to the doctor,” I insisted, horrified.

I imagine this is how many a dog owner feels when their woofer, Wifi, develops the skin condition colloquially referred to as a hot spot. You know, those big red weeping sores that seem to appear overnight? The ones that make you feel like a neglectful parent?

Don’t blame yourself. Technically called “pyotraumatic dermatitis,” hot spots arise incredibly quickly. “Dermatitis” just means inflammation of the skin. Duh. “Pyo” refers to pus, the gooey stuff oozing from those sores. It’s the word “traumatic,” that gives us the clue to why hot spots start and progress so rapidly. Here’s what happens. Something makes Wifi itchy. He scratches or chews the affected area. In other words, he traumatizes the skin. Bacteria that are normal inhabitants of the skin can now establish a secondary infection. Wifi is even more uncomfortable. He licks, scratches, and/or chews even more and the cycle perpetuates. It’s like when you dig at that poison ivy rash until it bleeds, and then gets infected. Your mother was right when she said, “Don’t scratch!”

Hot spots occur most frequently in hot weather and are most often found under the ears, on the cheeks, or on the hips, rump, or thighs. They can present as one large spot, or multiple smaller lesions. The location can suggest the underlying cause. First, check for fleas. Although it is possible to have fleas all year round on the Vineyard, like tourists, they tend to peak in the summer. Fleas like to congregate along Wifi’s caudal dorsal midline. That means the top of his back, toward the tail. Hot spots on the rump or thigh are often associated with fleas. Check by using a very fine-toothed comb called a flea comb. Run it down his back to the base of his tail multiple times. Don’t just look for hopping critters. Look for tiny black specks. No, it’s not dirt from rolling in the driveway. It’s flea poop. If you don’t believe me, put it on a wet paper towel and watch as a rusty, red halo spreads around the black speck. Fleas eat blood, so flea poop will “bleed” on that damp paper towel. And where there’s flea poop, there are fleas. Check his groin and belly too. On dogs with very thick undercoats, fleas may gravitate to the less densely furred regions on the underside.

Next, check Wifi’s ears, especially if the hot spots are on his face, neck, or cheek. Look deep into the ear with a good light, not just on the inside of the flap. A healthy ear should be clean and dry. If you see redness, debris, or detect an odor, Wifi may have an ear infection and you should consult your veterinarian. Other things that may make Wifi itch include such things as pollen or food allergies, wounds, tick bites, hair matts, or chronically wet coats from swimming. Dogs who swim need to be rinsed off with fresh water to remove sea salt and pond scum. Towel dry him vigorously. If his ruff or pantaloons stay damp, you can even use a hair dryer judiciously, being careful not to burn him.

But sometimes, no matter what you do, Wifi ends up with a nasty hot spot. So now what? Treatment begins with gently clipping and cleaning the area. Be advised that although these infections are superficial, they are incredibly tender. Even the nicest dog may take exception to your touching it, no less coming at him with a pair of clippers. Do not get bitten. When in doubt, have your veterinarian do the job. It is not uncommon for a hot spot to be so sore that sedation is needed before we can clean it up, but getting the area open to the air is essential because it helps it to start to dry and heal. Do not use scissors. Really. It’s easy to inadvertently cut or stab a squirming patient. (Then you have a dog with a hot spot and a laceration.) Use clippers.

Next, we need to make Wifi stop self-traumatizing. There are products that can be applied topically that taste bad to discourage him from licking or chewing. Check with your veterinarian first. Some human medications contain things that are toxic when ingested, such as zinc oxide. Whereas  people rarely decide to lick off topical ointments, Wifi has no such inhibitions. (Then you have a dog with a hot spot and zinc poisoning.) As someone who has trouble not scratching when I have an itch, I think it is unkind to use an Elizabethan collar on a dog with a hot spot without simultaneously doing something to relieve the discomfort. Our goal should be to stop the itching, not just to prevent the scratching. Oral antihistamines or corticosteroids can provide relief. Topical antibiotics are also used on superficial hot spots but about a third will have deeper infections, warranting oral antibiotics.

In case you were wondering, dogs do not react to poison ivy, so that’s not the cause of Wifi’s hot spot. Dogs are just not sensitive to urushiol, the oil in the ivy that gives humans that annoying rash. My daughter? She didn’t have poison ivy either. The doctor said it might just be a bacterial infection, but there was a small chance it was erythema migrans, the bull’s-eye rash sometimes seen in the early stages of Lyme disease in humans. (Dogs don’t get erythema migrans either, even though they do get Lyme disease.) In either case, a course of that magic doxycycline would help, along with topical corticosteroids to relieve the itching — and a mother to keep reminding her, “Don’t scratch!”


I still think we’re often flying by the seat of our pants when it comes to diagnosis, treatment, and long-term implications of tick-borne diseases.

Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at:

Yaretzi, a handsome eight-year-old golden retriever, had a pretty typical history for an Island dog when it comes to tick-borne diseases. Lyme-vaccinated as a puppy, he still got infected as a young dog, but we caught it early and treated him. At five, he once again tested positive for Lyme and also for another tick-borne disease, Anaplasmosis. Additional tests indicated he had been exposed, and made antibodies, but was probably not actively infected with organisms.

“We don’t really know what we’re talking about when it comes to these diseases,” I admitted to his owner. Maybe I exaggerate our ignorance. There’s plenty of erudite information published in veterinary journals and textbooks, but I still think we’re often flying by the seat of our pants when it comes to diagnosis, treatment, and long-term implications of tick-borne diseases.

The important thing was by eight years old, Yaretzi was testing negative again and feeling great. Except for one thing. “He drinks an awful lot of water,” his mom said.

Excessive drinking is technically called polydipsia. Excessive urination is polyuria. The two often go together. Medical folks just say “PU/PD.” When owners report polydipsia, the first thing we do is document it, by having them measure their pet’s water for 24 hours. A normal dog drinks between 20 and 70 milliliters per kilogram body weight per day. For a 30-kilo dog like Yaretzi, that’s roughly three to nine cups. Water consumption varies with exercise, salty foods, and hot weather. We don’t consider it true PD until a dog consistently drinks more than 100 milliliters per kilo daily. For Yaretzi, that’s almost 13 cups. Measuring total daily urine output, well, that’s harder to get owners to do. With true polyuria, urine is usually abnormally dilute.

Yaretzi’s daily water consumption measured borderline high. His urine, unusually dilute. His owner, exceptionally dedicated.

The list of possible causes for PU/PD is enormous. We began running tests. We ruled out diabetes and kidney failure. Endocrine tests ruled out underactive thyroid and the adrenal gland disorder called Cushing’s disease. His liver function proved normal with a bile acids test. Urine cultures ruled out bacterial infection. His white blood cell count was consistently low but we found no explanation for this. Yaretzi went to a specialist who repeated some tests, and added others. Ultrasound showed a few small nodules on his spleen, but the specialist thought these benign and unrelated to his PU/PD. More samples were collected to determine serum sodium level and osmolality, urine sodium fractional excretion and osmolality, and a urine protein: creatinine ratio.

Huh? What? Wait! Don’t turn the page! No more big words, I promise. Okay, maybe just a few. Protein-losing nephropathy (PLN) and diabetes insipidus (DI.)  You need classes in pathophysiology and endocrinology to fully understand, but since you probably want to get to the beach, here’s the short version.

Kidneys are made up of thousands of tiny units called nephrons that filter the blood. The parts that do the filtering are called the glomeruli. These work like strainers, letting little molecules like electrolytes pass through, while keeping cells, and bigger molecules like proteins, in the blood. Other portions of the nephron then balance electrolytes and pH. When the glomeruli get injured, the holes in the strainer get too big. Stuff that is supposed to stay in the blood, like protein, leaks out into the urine. A little protein in the urine can be normal, which is why special tests beyond standard urinalysis are needed. Yaretzi had an elevated urine protein: creatinine ratio, confirming abnormal protein loss via the kidneys, i.e., PLN. Over time, dogs with PLN become protein-depleted. Usually this is evident on basic blood tests, but Yaretzi’s was apparently in the very early stages, and his blood protein levels still normal.

What causes PLN? Most cases are thought to be the result of chronic inflammation or infection. Here’s your short course in immunology. The immune system makes antibodies against foreign proteins (called antigens.) Antibodies stick to antigens. These antibody-antigen complexes get trapped in the glomerular membranes. The immune system attacks those trapped complexes, inadvertently damaging the glomeruli. This inflammatory condition is called glomerulonephritis (Oops, another big word). Underlying diseases that produce the antigens can be anything from chronic dental disease, to Lyme, to cancer. Another disease that can also damage glomeruli and lead to PLN is called amyloidosis.  Definitive diagnosis of the cause of a case of PLN requires kidney biopsy, but we rarely recommend going to these lengths. Instead we treat any underlying problems identified and then just treat the symptoms.

“It sounds counterintuitive,” I said, “but he needs a low protein diet. I’m prescribing a medication that reduces protein loss through the kidneys, and low-dose aspirin to minimize risk of blood clots. Omega-3 fatty acids are also helpful. They’re already in the recommended prescription diet.”

Our last question was whether Yaretzi also had diabetes insipidus (DI), a rare disorder that occurs when the pituitary gland doesn’t make enough antidiuretic hormone (ADH)  or when the kidneys themselves are unable to respond properly to ADH. Dogs with diabetes insipidus pass huge quantities of very dilute urine, then drink excessively to compensate. Once the specialist has all the final laboratory results back, we will test for DI by giving Yaretzi a small dose of synthetic ADH. If his kidneys are able to respond, his urine should become more concentrated, and he should drink and pee less, confirming the problem to be inadequate pituitary ADH production. We suspect, however, that the problem is in his kidneys, that whatever is causing his PLN also interferes with his kidneys responding properly to ADH.

A complicated case. We don’t have all the answers yet. Are those past episodes of tick-borne disease exposure implicated? Golden retrievers have a high incidence of cancer. Is there a tumor hiding somewhere? Maybe he has some unidentified genetic abnormality? It’s a puzzle we hope to solve. In the meantime, his mother just keeps filling his bowl with water, and his days with love.


So let’s all keep our cool this summer. Understand the limitations of Island life. And don’t leave Tamale panting in the car. Seriously.

Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at:

Yup. It’s summer. Here’s how I can tell. Over the last few days I have seen three panting dogs sitting in parked cars with the windows cracked. Several people have just shown up at my door with animals after hours and continued knocking until I answered. Others stop me at the grocery store and the beach for advice about everything from ticks and skunks to diarrhea and cataracts. Did I mention the three panting dogs in parked cars? So once again, here are some veterinary reminders for summer on the Vineyard.

Number one. I can’t believe I have to say this again. Don’t leave your dog in the car! Seriously, don’t you people ever go on Facebook? Even my rare forays into social media tell me that FB is plastered with posters about the dangers of hot cars. Do you think your dog is immune? I know, I know. You’re just running in for a minute. Uh-huh. Is there really such a thing as “running in for a minute” on the Vineyard in July? Have you seen the lines at the Black Dog counter?  It only takes a few minutes for a car to become an oven. Dogs who are older, overweight, pug-faced, and those with heart and respiratory problems are at greatest risk, but pets of all sizes and ages succumb to heat stroke.

I’m going to be blunt. There is simply no excuse for leaving your dog in the car in the summer. If Tamale, the terrier, has separation anxiety, talk to your vet about treatment. If you’re worried he might pee on the rental carpets, use a crate. If his potty schedule interferes with your tennis time, change your game. Heat stroke is a potentially fatal condition that is completely avoidable. If Tamale cooks in the car, it is your fault. No excuses.

Heat stroke can also occur just being outside or from excessive exertion. Don’t take Tamale to the beach during the hottest part of the day. Most Island beaches don’t allow dogs during summer anyway. Check local regulations. If you do have access to a dog-friendly bit of shoreline, provide a water bowl and shade for Tamale.  Don’t let him bother wildlife or other visitors. If he poops, clean it up. That doesn’t mean burying it in the sand for the next toddlers with plastic shovels to discover or leaving it trailside in a plastic bag. Take that doggy bag home to the trash.

Don’t ask Tamale to run alongside your ten-mile noon bike ride. Remember: he doesn’t get to “coast.”  While you’re gliding downhill catching your breath and a breeze, Tamale is still running. If he is already fit, it may be okay to exercise during cooler hours, but plenty of vacationing dogs end up with heat exhaustion, injured joints, pulled muscles, or severely blistered feet from overdoing it. Dogs will run their hearts out to follow you. The fact that Tamale can run that far doesn’t mean he should.

Speaking of exhaustion, let’s talk veterinarians. If you’re not a year-rounder, you may not realize that a handful of small town veterinarians here goes from providing service to a local population of fewer than 20,000 people to five times that in summer. And, yes, many of those hundred thousand summer folks bring pets. Unlike New York, Boston, Los Angeles, or wherever you’re from, we have no 24-hour emergency clinics or referral specialty practices. The docs seeing patients all day are the same ones seeing emergencies all night.

If you come here often with a pet, establish a relationship with a local practice. Bring vaccination history and medical records, especially if Tamale has chronic problems. Learn the veterinarian’s office hours and emergency policy. No matter which practice you use, always telephone first. Please, don’t just show up unannounced. This is for your benefit as well as ours. Many local practices are small. There is no guarantee a doctor will be available if you arrive without notice. They might be on a farm treating a colicky horse or in surgery spaying a dog. It might even be the doctor’s day off and some practices only provide emergency care for regular clients. Call first.

After hours, most Island veterinarians forward their calls to an answering service. You may hear one short ring, then a long pause. Don’t hang up. That’s your call being transferred. It will ring again momentarily. Since my practice is home-based, I often hear people call five or six times in a row, hanging up during that pause instead of waiting for the call to forward. You won’t reach anyone that way. Be patient. After it forwards successfully, let it ring. Answering services try their best but sometimes take a while to pick up. Once you get through, make sure you leave the correct phone number, then stay off the phone so the doctor can get through. Make sure your ringer is on. If you don’t hear back within 20 minutes, call again. This all sounds obvious, but I can’t tell you how often one of these necessary steps eludes an owner seeking emergency veterinary care.

Although we do our best to take care of Tamale’s medical needs, if round-the-clock care, elaborate diagnostics, or specialized surgery or treatments are indicated, be prepared to go off Island. Don’t blame the local docs. You don’t expect your family physician to perform appendectomies or MRIs right in her office, right? We won’t always have the necessary equipment, staff, or specialty skills. What we can do is help with referral and travel information — the ferry, the Patriot boat, taxis on the mainland. A few owners have even chartered small planes. Cape Cod Veterinary Specialists in Buzzards Bay have a van that in certain situations may be able to meet you right in Woods Hole.

So let’s all keep our cool this summer. Understand the limitations of Island life. Reserve after-hours calls for true emergencies. Always phone ahead. And don’t leave Tamale panting in the car. Seriously.


If provoked, even normally calm dogs will snap at people they know.

Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at:

“Be careful,” the owner cautioned as we led Rita, the shepherd cross, into the living room. “She’s getting grouchier in her old age.” My assistant Elise and I were on a house call for Rita’s annual physical, heartworm test, Lyme booster, and toenail trim. Routine stuff. We have cared for Rita since her owner rescued her in 2003. As a young dog in Georgia, Rita had a litter of pups and was kept tied outside constantly. She may have been mistreated, judging by how she cowered when approached. Since then, Rita has had a long medical history. Treatment for heartworm infection acquired down south. Cruciate ligament surgery, first her right knee, then her left. She was a good patient, though nervous, but right from the start hated having her nails clipped. Many dogs feel that way. At first we used tranquilizers for pedicures, but over time Rita got used to us. We usually worked with her at home, where she was less anxious.

Elise coaxed Rita onto the couch, hugged her head with one arm, and held a front leg for me to draw blood with the other. Rita didn’t flinch as I poked in the needle. “Good girl,” I said, examining her front half, then moving around to examine the tail end. Since I was already behind her, I trimmed the nails on one hind paw. Rita didn’t flinch. “Good girl,” I said, reaching for the other hind foot tucked underneath her. Rita pulled her foot farther away. I reached deeper between the cushions and her tummy.

In a split second, without warning, Rita slid downward, rotated, and bit Elise’s face. Elise was still valiantly hugging the dog, so for a moment I thought she wasn’t hurt. Then I saw the wound on her chin. Dog bites are often just punctures where teeth penetrate skin. This was far worse. Had Elise jerked back as Rita snapped? Or maybe Rita bit, then yanked? It  happened so fast. Regardless, the result was several long, jagged gashes.

According to the Center for Disease Control, almost four and a half million Americans are bitten by dogs every year. Half are children. One in five requires medical attention. The majority occur in someone’s home. Most victims are owners, family members, friends, relatives, visitors, or babysitters. Between four and eight percent are work-related.  Around 30 Americans are killed by dogs annually. There is much controversy about breed statistics, but nowadays pit bulls and pit bull crosses appear responsible for the greatest number of severe injuries and lethal attacks. Other breeds often implicated include rottweilers, German shepherds, bull mastiffs, Akitas, dobermans, and chow chows, but any dog can bite, from feisty little Chihuahuas to big, goofy Newfies.

Who is responsible when a dog bite occurs? Many states still abide by the old common law “One Bite” rule that says “the first bite is free.” If you didn’t know Fido was prone to biting, then no one can really blame you when he nips the kid pulling his tail. But after that first freebie, if you let Fido run loose at the beach, on the bike path, even in your yard, then you are liable if he bites again. Ignoring local leash laws may legally constitute negligence. And really, you’re a responsible human being, right? You know your dog can bite? You restrain him. Period.

Because less-than-honest owners simply won’t mention Fido’s first bite, many states, including Massachusetts, have a “Strict Liability Law” that says unless the victim was trespassing, teasing, tormenting, or abusing the dog, the owner (or whoever is responsible for the animal, including pet sitters and, sometimes, landlords) is strictly liable. If the victim is under the age of seven, the child is generally presumed innocent of provocation. You really shouldn’t leave a young child alone with Fido anyway. As veterinarians, people often ask our advice after their dog bites. Most of us agree that after two unprovoked incidents, sadly, it’s time to consider euthanasia. Why not just confine the dog? You can try, but the reality is no matter what you do, mistakes happen. The gate doesn’t latch. Fido jumps the fence. Someone lets him slip out the door. And another person gets hurt.

Rita fled behind the couch. If it were me, I would have been wailing hysterically, but Elise just lay down, stoically applying pressure to her wound, blood running down her neck, while I rushed her to the emergency room. Stitches. Lots of stitches. Antibiotics. Pain medication. I was kicking myself mentally. The owner had mentioned earlier that when trying to clip Rita’s nails by herself recently, Rita had bitten her. Was that her One Free Bite? Or was it “provoked,” since it involved toenails? Was today’s bite reason to advise euthanasia? Liability laws may recognize circumstances in which a dog (or owner) is not considered at fault, such as when the victim is trespassing, committing a felony, provoking the dog, assisting police or military — or when the victim is a veterinarian or veterinary assistant. They actually call it “The Veterinarian’s Rule,” acknowledging that being treated by the doctor may be painful or make some dogs unusually scared or defensive. We routinely muzzle many patients, but we were just so used to Rita, we didn’t think it necessary.

Rita’s owner has taken the event very seriously. Though not considering euthanasia, she is confining Rita appropriately. We now use a muzzle, especially when handling Rita’s feet. A careful eye exam revealed cataracts and we suspect declining vision may be leading to her  increasing defensiveness. Another Island veterinary practice sent a nice Get Well fax, saying “It could have been any of us.” That’s the truth. A cautionary tale for everyone who works or lives with dogs. Any dog can bite, given the right circumstances. Use common sense. Use caution. We feel lucky everyone involved handled themselves with grace, compassion, and responsibility. Elise, most of all. She is one tough cookie, already back at work, fearlessly holding big dogs while I clip their nails.


I watched Anastasia walk. Ears? Fine. Eyes? Normal. Teeth? Perfect.

Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at

As usual, I started my morning perusing the day’s schedule. Although we computerized decades ago, I have never let go of my good old-fashioned, spiral-bound, paper appointment book, where we scrawl in good old-fashioned number two pencil — owner’s name, pet’s name, species, reason for visit, phone number. The day looked fairly routine. Recheck cat with hyperthyroidism. Lyme booster. Annual physical. House call to cat at assisted living residence. Dog with red eye. Cat with head tilt. I paused. Who had the head tilt? A 13-year-old Russian Blue cross named Anastasia whom I had known since she was a little four-pound kitten.

Holding the head angled to one side is referred to by veterinarians as a “head tilt.” It can be a symptom of a wide range of problems, from the benign to the life-threatening. Head tilts in cats usually fall into three categories. The first group is cats experiencing discomfort around the head or neck from things like ear infections, bite wounds, abscesses, or dental disease. In these cases, the animals are just intermittently tilting their heads in response to pain or itchiness, such as that caused by the teensy ear mite, Otodectes cynotis.

Okay, some people say they can see these mites with the naked eye, but to my 59-year-old peepers, ear mites are microscopic. (Dogs rarely get ear mites but they do get frequent bacterial or and/or yeast ear infections, which may lead to skin infection that spreads down the neck or across the side of the face. They will often rub their faces on the floor and shake their heads vigorously. Cats are less melodramatic.) Your veterinarian can diagnose and treat ear mites, abscesses, skin and external ear infections easily.

Many cats will also tip their heads when eating a particularly hard or chewy item. This may indicate oral pain, so your veterinarian will want to take a good look in your cat’s mouth, but for some cats it is just a normal, idiosyncratic feeding behavior. The key point is that with all  these conditions, these cats can and will hold their heads in a normal position at least some of the time, and careful examination reveals a demonstrable cause for their behavior.

If Anastasia’s head tilt is truly constant, then the problem is probably in her vestibular system, the body’s balance mechanism that helps an animal know which way is up. The middle and inner ear comprise the peripheral vestibular system which then connects via the eighth cranial nerve to the central vestibular system in the brain. It is not always easy to determine if the problem is peripheral or central. Symptoms of peripheral vestibular disease may include persistent head tilt (always to the same side), rhythmic horizontal or rotary flicking of the eyes called nystagmus, walking in circles, falling to one side, an uncoordinated gait called ataxia, and vomiting. It can be caused by trauma to or infection of the middle or inner ear, nasopharyngeal polyps, tumors, or drugs that are damaging to the inner ear, but in cats far and away the most common type of peripheral balance disorder is idiopathic feline vestibular syndrome.

The pathophysiology of feline vestibular syndrome is unknown, hence the term “idiopathic.” It comes on very quickly, often in the matter of a couple of hours. Most common in older cats,  any age may be affected. It occurs more frequently in late summer and early fall, though no one knows why, but can happen any time of year. When an owner sees their kitty suddenly staggering around, walking in circles, sometimes unable to stand, it is not surprising that they assume the worse, but feline vestibular disease is actually no big deal.

For the first one to two days, cats may feel “seasick,” leading to loss of appetite, nausea, and vomiting, but this usually resolves quickly. Diagnosis is made based on the history, clinical signs, and ruling out other problems. You can do every test in the book, from blood work to X-rays to MRI, and they will all be normal. There is no specific treatment, although in severe cases your veterinarian may prescribe anti-nausea medications such as Dramamine ® or Antivert ® but no mediation of any kind has been found to alter the course of the disease. The most important thing is nursing care, keeping Anastasia in a safe, protected environment and providing easy access to food and water until the signs resolve. Most cats start improving within days and recover completely over several weeks.

This doesn’t mean that if your cat is staggering around, you can skip a visit to the vet. There are many serious problems with similar signs, and you need a professional to assess the situation. Central vestibular disease can be the result of head trauma, infections, brain tumors, even “stroke,” though that is rare in cats.

Signs of central balance disorders are very similar to those of peripheral disease but may include weakness on one side of the body and proprioceptive deficits. (Proprioception is the ability to sense the body’s position, motion, and equilibrium. In other words, to know where your feet are.) Animals with central disease may have altered mental status, seeming depressed or even stuporous. With peripheral disease, Anastasia might be disoriented but she would still be completely alert and responsive.

When our little Russian princess arrived, I realized the main reason for her visit was simply her annual physical and rabies vaccination. She waltzed out of her carrier, head completely straight. “Tell me about the head tilt,” I asked, looking her over.

Well, it seems her dad likes to hand feed Anastasia delicious little tidbits. Her owners noticed she would tilt her head to one side as she licked the proffered treat. I watched Anastasia walk. Ears? Fine. Eyes? Normal. Teeth? Perfect.

“I think she’s just a dainty eater,” I concluded, inwardly laughing at myself for having spent my morning worrying about those two words, “head tilt,” scrawled in my appointment book in good old-fashioned number two pencil.


Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at

Yves had always been a cat who liked to eat. A seasonal resident, I saw him every summer.  When he was four years old, I suggested reducing the amount he was being fed. At six, I advised a prescription weight loss diet. It was a difficult regimen for his owners to maintain. Yves lived strictly indoors and didn’t get much exercise, and the other cat in the household had different health problems, requiring different food. By 11 years old, Yves was tipping the scale at 21 pounds.

“He’s at risk for all kinds of diseases, especially diabetes,” I said, not unsympathetically, considering how many years I have struggled with my own battle of the bulge. His family committed again to helping him lose weight and last winter we sent them off with more diet food, recommending monthly weigh-ins with their winter veterinarian.

Spring arrived. Seasonal folks began returning. Memorial Day weekend, Yves’s mother called. “We’ve been here two weeks,” she said. Yves had been fine until yesterday. “I am worried he might have some kind of blockage. He’s been vomiting and crying and he’s not eating.”

“He’s still an indoor cat?” I asked. Cats who go out have greater risk of ingesting things that may upset their tummies, anything from mice to antifreeze, but Yves never ventured to the great outdoors.

“Any flowers like lilies in the house?” I asked. Ingestion of houseplants is a common cause of gastroenteritis for indoor cats and lilies in particular are extremely toxic to cats, leading to potentially fatal kidney failure.

“No, no flowers,” his mom said. “He does like to eat some garlic chives we have in a pot.” Uh-oh. Garlic, onions, chives, all members of the Allium family,  can cause a serious reaction in cats called hemolytic anemia. It was too much to figure out by phone, so I suggested they bring him in.

When Yves arrived, it was apparent he was very sick: he lay listlessly on the exam table. He was dehydrated, despite the fact he had been drinking lots of water. He seemed almost too weak to stand and cried softly when I gently palpated his abdomen. His bladder felt full and tense.

Could he have a urinary tract blockage? This common problem in neutered male cats can lead to similar symptoms, though usually owners report frequent trips to the litter box and straining without producing any urine.

Or could it be allium toxicity from those chives? The whites of his eyes looked slightly jaundiced. Or something else?

I put him on the scale and did a double take. Last time I had seen Yves nine months back he weighed 21 pounds. Today he weighed 14. He had lost a third of his body weight.  Had his family finally succeeded with the diet? This was a pretty dramatic change. I asked his owners to leave Yves with me for a few hours so I could run some tests.

Diabetes is a disorder of metabolism caused by an insulin deficiency. Insulin is necessary to move glucose (a form of sugar) from the blood into the cells, where glucose fuels the body.  When an animal does not produce sufficient insulin to properly utilize glucose, this leads to the classic diabetes symptoms of increased drinking, urination, and appetite, combined with weight loss. If an owner notices these signs and goes to the veterinarian, the diagnosis is usually made fairly easily and appropriate treatment instituted, such as dietary changes and insulin injections to correct the deficiency.

But Yves had been on a strict diet, so his weight loss hadn’t seemed unexpected. Of course he acted hungry. He was on a diet. And monitoring water consumption and urine output in a house with multiple cats isn’t easy. So, not surprisingly, his diabetes went undiagnosed.

When a diabetic animal goes untreated, the body starts breaking down its own tissues in an effort to “feed” itself. One of the byproducts of this is the production of substances called ketones which build up in the blood. Eventually the untreated diabetic cannot maintain proper fluid, electrolyte, and acid-base balance and develops what is called diabetic ketoacidosis. Abbreviated “DKA,” it is a true medical emergency. Symptoms include excessive drinking and urination, muscle weakness, depression, loss of appetite, vomiting, liver enlargement, jaundice, abdominal pain, seizures, and eventually death.

Yves’s laboratory tests were consistent with a diagnosis of DKA. His blood sugar was high. He had ketones and glucose in his urine. Many DKA patients have other underlying illnesses such as bacterial infections or heart disease that contribute to the onset of the crisis. In Yves’s case, his liver enzymes and bilirubin levels were very elevated, indicating serious inflammation of the liver and bile ducts called cholangiohepatitis. Up to 90 percent of cats with DKA will present with liver disease, pancreatitis, cancer, kidney failure, or other such issues.

Treatment is challenging. Fluid and electrolyte imbalances need to be corrected and carefully monitored. The patient needs insulin. Blood glucose levels have to be checked frequently, sometimes as often as every one to two hours. Any and all underlying problems must be identified and addressed.

“You should consider taking him to a referral  hospital,” I advised. Further testing could evaluate the severity of his liver disease. Round-the-clock nursing and access to specialists might give the best chance of recovery. “If he makes it, he will likely need daily insulin injections,” I added.

The statistics are sobering. One study reported the mean hospital stay for DKA cats to be a costly five days, and of those that survived, almost half had a recurrence later. I have seen DKA described as a “very complicated multifactorial metabolic nightmare that even the best vets have a hard time getting under control.” Considering all these factors, especially Yves’s age and not wanting to prolong his suffering, his owners decided it was time to let him go — a sad but compassionate choice when faced with this complex and often deadly disorder.


We may never have a definitive answer. We’re just glad she’s back on her feet and hope she stays that way.

Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at

Stormy is an Australian shepherd in the prime of her life. Last winter at her annual physical examination, her owner mentioned she had been limping recently. Watching her walk, she was a little gimpy on her right front leg, but I couldn’t find any obvious explanation. “Probably a strain or sprain,” I said. Stormy was also significantly overweight, an extra stress on her joints and muscles. “Try to get a few pounds off her,” I advised, sending home pain medication and instructions to rest.

The foreleg lameness resolved quickly, but three months later, Stormy returned. She  had lost three pounds (though still more than pleasantly plump) but there was another issue. She had suddenly developed marked weakness in her hind end. “She just flops over while she’s walking,” her owner said.

Stormy was bright, alert, and responsive. She’d pull herself to her feet and walk willingly, but then her caboose would start swaying and finally she’d drop to the floor. Her temperature was normal and other than the gait abnormality everything looked fine.

“She seems a little tender here,” I said tentatively, palpating her lower back, but it wasn’t definitive. Could be fibrocartilaginous embolism ( a neurological deficit caused by a little plug of stuff occluding the blood supply to the spinal cord) or intervertebral disk disease (a disease in which the little shock absorber between two vertebrae protrudes and presses on the spinal cord.) “She seems stable,” I concluded. “Let’s try rest and anti-inflammatories.”

Two days later, Stormy’s mom called. The dog was no better. Should we be doing something more?

“We can take X-rays,” I offered, though neither of the two diseases on our differential would necessarily show up on radiographs. “Really an MRI would be the next best test, but maybe she just needs a little more time,” I suggested.

I was wrong. Stormy’s condition continued to deteriorate. By the next day she could barely stand, her front legs now almost as weak as her hind.  She spent most of her time lying flat on her side unless her owner hoisted her up with a sling, then she would try to ambulate. Stormy came for a recheck. Dr. Buck did a careful neurologic exam. Stormy could still move all four legs, but that was the only good news. Some of her reflexes were exaggerated while others were diminished. She was trembling all over and had severe neck pain. It was now clear the location of the lesion was not in her lower back. It had to be either in her neck, or even her brain. It was time to consult a neurologist.

Up at VCA South Shore Animal Hospital, Stormy underwent a battery of tests. Blood work, urinalysis, chest X-rays, abdominal ultrasound, then finally MRI and a spinal tap under anesthesia. The MRI confirmed meningomyelitis in her neck. This means there was  inflammation of the spinal cord and surrounding membranes, but it does not identify the cause. She was started on corticosteroids, called prednisone.

Many readers may have taken prednisone yourselves if you’ve ever had a bad allergic reaction, like to poison ivy, or any significant inflammatory disease or auto-immune issues.

She also got gabapentin, a medication currently in vogue for animals with “neuropathic” pain.  But what was causing the problem? The specialists listed possible diagnoses including Steroid-Responsive Meningitis Arteritis (SRMA) and Granulomatous Meningioencephalomyelitis (GME.) Wow. Those are some big words.

Let’s start with SRMA, a disease of unknown cause, thought to be immune-mediated. In other words, for some reason Stormy’s immune system starts attacking her own nervous system. There are two reported forms, acute and chronic. The acute form comes on fast with a stiff neck, pain, fever, and characteristic changes found in the cerebral spinal fluid. The chronic form has a more protracted course with more neurological deficits.

SRMA strikes young adult dogs, like Stormy. Breeds thought to be predisposed to the condition include Bernese mountain dogs, boxers, German short-hair pointers, Norwegian duck tolling retrievers, and beagles. In fact another name for SRMA is Beagle Pain Syndrome.   There is no way to make a definitive diagnosis in a living dog. Basically, if an individual fits the clinical picture and no other explanation can be found, then it’s time to try corticosteroids. If the dog gets better, Bingo! It’s “steroid-responsive.”

GME is an “aseptic inflammatory disease of the central nervous system.” Just like SRMA, the cause is unknown, it can be acute or chronic, and definitive diagnosis is only made on postmortem, although MRI and CSF taps can be helpful in ruling out other disorders. GME has three forms — focal ( affecting one location in the nervous system), disseminated (involving many locations in the nervous system), and ophthalmic (affecting the optic nerve and eye). Symptoms vary depending on location and severity of lesions. Progressive loss of use of the legs is frequently seen. Other signs may include seizures, head tilt, lethargy, blindness, facial abnormalities, walking in circles, and balance disorders. Middle-aged,small breeds, especially terriers and toy poodles, are most commonly affected. GME also may respond to corticosteroids, but sadly, most dogs do not survive more than one to five months, even with treatment.

The neurologists admitted that Stormy did not exactly fit the picture for any one disease. Her CSF tap did not show the changes typically seen with SRMA. On the other hand, she is not a breed in which GME is usually reported. Another possibility was cancer lurking somewhere in the central nervous system, but none could be found on any of the tests. We know so little about these types of progressive neurological diseases, that it can be both frustrating and heartbreaking for owners, but Stormy responded well to the prednisone and within a few weeks was walking almost completely normally. She will be on steroids for several months, gradually weaning down the dose and watching closely for signs of relapse.

We may never have a definitive answer. We’re just glad she’s back on her feet and hope she stays that way.


Choosing to do “nothing” can be tough, but sometimes it may be the right thing to do.

Michelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at


At 11 years old, Nana, the beagle, has been through a lot in her life. A skin condition from demodectic mange mites. A difficult pregnancy with only two of six puppies surviving. A mammary gland infection called mastitis while nursing. A painful infection behind her eye called a retrobulbar abscess. Tick-borne disease. But Nana is a survivor, taking each challenge in stride, still cheerful, still wagging her tail. Then a few years back she developed a lump on her hip.

“It doesn’t feel like a lipoma,” I said, referring to a type of benign fatty growth frequently seen in older dogs. Her owners consented to a “fine needle aspirate,” a quick diagnostic  procedure done in the exam room without anesthesia. Although rarely sufficient for definitive diagnosis, a pathologist can often give a general idea of what we are dealing with from an aspirate like this — in Nana’s case, possibly a malignant tumor.

“The pathologist says it’s probably a kind that doesn’t tend to metastasize,” I reported.  Cancers with high metastatic potential often spread from their original location to distant sites in the body, such as lungs, lymph nodes, or bones. Those with low metastatic rates tend to stay in one place but can be locally invasive and aggressive, causing serious damage. I still advised X-rays prior to surgery, just to be sure there was no evidence the cancer had spread. Her films looked fine so we proceeded to surgery.

Removing the growth, it was hard to tell where tumor ended and normal tissue began. Some masses are well-encapsulated, shelling out easily, but not this one. We cut as wide as possible, and sent it for biopsy. The final diagnosis was nerve sheath tumor, a low-grade malignancy with minimal risk of spread but significant chance of eventual recurrence.

“They can’t say for sure that we got it all,” I explained. “It may never come back, or it may regrow.” I offered options. More surgery. Referral to an oncologist. Radiation therapy.

“Let’s wait and see if it comes back,” Nana’s owners decided.

Time passed. Nana ate rat poison and was treated on emergency. She was okay. Nana binged on a stash of snack food, eating them bags and all — Fritos, Cheetos, Smartfood popcorn. Everything eventually passed. She was okay. Two years after her surgery, Nana started having a series of minor complaints. A swollen eye. Dental tartar. A fatty lump on her chest. A small lump reappearing on her hip. A cough. Addressing one concern after another, we eventually got to the cough. Her heart sounded fine, so not cardiac disease. Her lungs were clear, her temperature normal, so pneumonia was unlikely. Perhaps she had caught an upper respiratory infection, like kennel cough. We prescribed antibiotics, advising a recheck if the cough didn’t improve.

A few weeks later, the cough was better but not gone. A chest X-ray looked normal, and we made a presumptive diagnosis of allergic bronchitis, a common problem in older dogs.

“It’s worse in the mornings,” her mom shared. “Maybe the wood stove is bothering her.”

A logical theory, I agreed. We tried cough suppressants. We tried corticosteroids. The lump on her hip was growing slowly. We wanted to pursue a second surgery, but preferred to wait until the cough resolved.

“I think she’ll improve once spring comes, and we stop using the wood stove,” her mom said. Months passed. April arrived. Nana’s cough did seem better, though not 100 percent.

“It may never clear up entirely,” I sighed, suggesting we start preparing for surgery with preoperative blood tests. We offer two “levels” of screening. Her mom opted for the more comprehensive one. Good call. Everything came back completely normal, except one test. Nana’s calcium levels were elevated.

“It’s called hypercalcemia,” I explained, “but very often it is a spurious finding caused by lab error.” We repeated the test, this time fasting Nana overnight before the blood draw, and sending it to the big reference lab instead of running it here on our little machine. But the retest came back with the same results, confirming the hypercalcemia was real.

“Hypercalcemia of malignancy” is a condition in which a cancer produces a substance similar to the hormone normally responsible for regulating calcium levels. The body gets fooled, thinking it’s supposed to release calcium from the bones into the blood, thus causing the hypercalcemia. Lymphosarcoma and anal gland carcinomas are the most common tumors associated with this problem, not nerve sheath tumors. I checked Nana again. Her anal glands were fine. Maybe we were missing something? Although we had taken X-rays five months previously, we decided to snap more before proceeding with surgery.

There it was. A mass in her chest, just above and in front of her heart in an area called the cranial mediastinum. It was a really large mass, the size of a hefty avocado, compressing her wind pipe and bronchi. Without a biopsy, we couldn’t determine exactly what kind of cancer, but the radiologist doubted it was related to the nerve sheath tumor on her hip. Most likely it was a heart base tumor arising from the aorta or pulmonary artery, hemangiosarcoma, lymphosarcoma, or even a thyroid tumor. The radiologist was frank. “Masses in this location are often quite vascular making successful sampling both difficult and risky. CT or MRI . . . would be very informative but would require anesthesia and is more expensive.”

Definitive treatment requires definitive diagnosis, but was putting Nana through risky and painful procedures in her best interests when the long-term prognosis is very guarded?  We had followed a long trail, through the many maladies of her youth to a tumor on her hip, from a cough to hypercalcemia to a second, far more serious tumor. For now, Nana is still wagging that tail. We are trying various medications in hopes of controlling her cough and keeping her comfortable. Her owners have some difficult decisions to make. Choosing to do “nothing” can be tough, but sometimes it may be the right thing to do.