Episode 5: Recognizing Nutritional Deficiency: 2 clinical examples

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Episode 5: Recognizing Nutritional Deficiency: 2 clinical examples

• Presenting two examples of nutritional deficiency
  • Not classical nutritional/vitamin/mineral deficiency syndrome
  • Lack of classic signs = “subclinical” deficiency
  • Veterinarians need to increase their level of suspicion that illness may be related to nutritional problems
  • Aspen
    • Presented 4/02: 13 year old spayed female Labrador retriever-shepherd mix
    • The owner – my brother – noticed weakness and exercise intolerance
      • Rapid progression over two-three weeks
      • Syncope/collapse episodes with mild exertion
      • Became unable to walk more than a few steps without resting

• Diet
  • Science Diet®

• Chemistry Profile, complete blood count and Thyroid hormone level all  normal
• Chest x-rays were normal
• 5/9/02 Evaluation of ECG via Telemedicine consultation with cardiologist
  • HR 50 BPM
  • Diagnosed as complete heart block
    • Possible degeneration, fibrosis, or inflammation of AV node
    • Recommendation: Echocardiogram and possible pacemaker implant

• Telephone consultation (Oregon – Ohio)
  • Recommended treatment
    • Nutritional support for cardiac function, electrical conductance, muscle function, general nutrition
    • Cataplex® B (Standard Process)
    • L-carnitine (Pure Encapsulations)
    • Vasculin® (Standard Process)
    • Cardio-Plus® (Standard Process)
    • Catalyn® (Standard Process)
    • Calcifood® wafers (Standard Process)

• Improvement noticed within several days after starting supplementation
• Continued progress over initial 4 weeks of supplement use
• Returned to normal activity level within 4 weeks

• 8/6/02 Echocardiogram
  • Anatomically normal heart
  • Normal contractility
  • Severe bradycardia (32 beats per minute)  with continued complete heart block

• 2/25/03 progress exam
  • Clinically normal 14 yr old dog
  • Repeat ECG:  unchanged from 5/02
  • Aspen running up and down long hill in yard with children
  • Continued supplements as initially prescribed
  • Continued Science Diet

• 9/20/05 progress exam
  • Nearly 17 yrs old
  • Stiff and slow moving, nearly blind, hearing loss, developing urinary incontinence
  • Continued bradycardia due to electrical abnormality
  • No syncope
  • Had more stamina than 4/02 prior to supplementation
• 12/05 euthanized due to deteriorating physical condition, incontinence, arthritis, etc. – no syncope, no heart failure

• Gypsy
  • Presented 8-8-05  – 4 year old spayed female golden retriever mix
  • Consultation concerning autoimmune disease, open wound on rear end, and generally declining condition
  • Owner concerned that Gypsy was dying and wanted to incorporate complementary approaches

• History:
  • Developed severe bone or joint pain at 9 months old
  • Lame, crying when touched
  • Developed immune myositis – diagnosed via muscle biopsy November 2002
    • Presented as acute-onset muscle pain and inability to open mouth
    • Muscle atrophy developed subsequently
    • Prednisone therapy initiated ( and continued daily since)

• 4-18-03 Giardia with severe diarrhea and vomiting

• Several teeth extracted due to loosening/periodontitis

• Seasonal exacerbations of muscle inflammation and dysfunction x 3 yrs.
  • Approximately October/November 2002, 2003, 2004
  • Allergic component?

• Faithfully vaccinated (yearly)
  • Last vaccine 3-8-05

• Flatulence; owner feels that abdomen is hot and distended; other dog eats Gypsy’s stool

• Medications:
  • Prednisone 10 mg once daily (continuous use since Nov 2002),
  • Thyroxine 0.7 mg twice daily

• Blood Chemistries and CBC

AlkP    AST    ALT   GGT   P    Gluc    Amyl    WBC    Neutr

8/8/05           1430      72     461      80    4.1   144                  16.9     83%

5/17/05        2738      75     596     430   6.2    44      224       20.6     83%

4/23/05        2842      75     612     410   5.5    18      248       20.7     86%

2-26-05                 4280      92     719     752   5.9    59     213       26.3     99%

1-24-05         2708      78     707     452   6.4    62     229       22.1     89%

• Diet:
  • Iams large breed (“Complete and balanced”)
  • Frozen Bil-Jac
  • Greenies (daily)

• Physical Exam:
  • Weak, lethargic
  • Thin, dry (straw) hair coat
  • Severe atrophy of masticatory muscles
  • Rear feet flat – stretching of flexor tendons/connective tissue
  • Mild pendulous abdomen (Cushingoid appearance)
  • Generalized poor muscle mass/tone
  • Supraspinatous/infraspinatous atrophy
  • Ulceration left upper lip over PM2
  • Heavy tartar with periodontitis right upper first molar
  • Left upper first molar previously extracted
  • 2 broken incisors with retained roots
  • Excessive subcutaneous scar tissue formation over pressure points –  especially severe over tuber ischii
  • Non-healing open wound over left tuber ischium present >2 months
  • Arthritis elbows – Exostoses
  • Irregular surface of left dorsal iliac crest (pelvis)- (no previous sx or trauma in hx)

• Assessment:
  • Chronic immune mediated muscle disease
  • Bizarre scar tissue formation
  • Gastrointestinal dysfunction
  • Weak, debilitated condition

• Plan:
  • #1. Nutritional support/supplementation
  • #2. Diet change (eliminate possible dietary antigens)
  • #3. Adjustment
  • #4. Dental – cleaning/extractions (relieve pain and reduce inflammation)

• Initial supplementation
  • SP Canine Musculoskeletal Support™
    • Nutritional support for muscle/joint/connective tissue
    • SP Canine Enteric Support™
      • Nutritional support for gastrointestinal function
    • SP Canine Hepatic Support™
      • Nutritional support for liver function
      • Chronic inflammatory/immune mediated responses
      • Elevated liver enzymes
    • Recommended initial reduced dosage with gradual increase to label dose over two weeks

• Telephone follow-up: 8-10-05 (2d.)
  • Owner reported that Gypsy is noticeably improved; more energy

• Progress exam: 8-17-05 (7d.)
  • Gypsy was “bouncing around the house”
  • Playing with other dogs and with toys
  • Abdomen not hot or as distended
  • Other dog stopped eating Gypsy’s stool
  • Flatulence considerably decreased and less odorous
  • Ulcer in mouth nearly healed
  • Began raw food diet (no diet change at that point)

• 8-29-05 Chiropractic Adjustment
  • Owner felt that Gypsy had been painful around the ribs/shoulder area – occasionally yelping when petted/held
  • Stamina improved
  • Continued decrease in flatulence

• Progress exam: 9-21-05 (6 wks)
  • No pain, no yelping
  • Great activity level/NRG
  • Excellent appetite
  • Hole over left tuber ischium was beginning to decrease in size
  • Plan was to begin reduction in prednisone then discontinue –  if no adverse response to lower dose

• Progress exam: 10/24/05 (10 weeks)
  • Bright, alert, and responsive
  • Increased muscle mass evident in face and head
  • Normal yawn without restriction in opening
  • Active, energetic
  • Visibly improved coat – thickness, decreased dryness
  • No typical autumn conjunctivitis
  • On prednisone 2.5 mg every other day
  • Little flatulence
  • Normal stool
  • Hole in skin at left tuber ischium healed completely
  • Mild pruritus and scattered superficial staph pustules abdomen
  • Marked decrease in gingivitis
  • 11# weight loss
• Treatment recommendations and diagnostics
  • Chiropractic adjustment
  • Complete blood count and chemistry profile
  • Continue supplements and raw food diet
  • Continue prednisone reduction
  • Clean teeth approximately Jan. 1 if no relapses after discontinuing prednisone

Blood Chemistries and CBC

AlkP    AST    ALT   GGT   P    Gluc    Amyl    WBC    Neutr

10/24/05     177       38       99       5     6.2   104      —          9.84     82%

8/8/05           1430      72     461      80    4.1   144                  16.9     83%

5/17/05         2738      75     596     430   6.2    44      224       20.6     83%

4/23/05         2842      75     612     410   5.5    18      248       20.7     86%

2-26-05         4280      92     719     752   5.9    59     213       26.3     99%

1-24-05         2708      78     707     452   6.4    62     229       22.1     89%

• Progress exam 1/25/06 (5 months)
  • Lean body condition, active, energetic, vocal
  • Prednisone  2.5 mg every 3 days for the previous 4 weeks
  • Off Canine Hepatic Support™ x 3 weeks
  • Little flatulence
  • Normal stool
  • No pruritus
  • W = 62.4#  (initially 79.2#)
  • Thick plaques of calcified SQ fibrous tissue persist
  • Atrophy of muscles of mastication unchanged
  • Generalized increased muscle mass
  • Excellent hair coat – thick, dark red, shiny

• Plan
  • Chiropractic adjustment
  • Repeat blood work
    • Complete blood count and chemistry profile
    • Thyroid profile
    • Continue Canine Enteric Support ™ and Canine Whole Body Support ™

• Blood Chemistries and CBC

AlkP    AST    ALT   GGT   P    Gluc    Amyl    WBC    Neutr

1/25/06        40      40      54       1     5.4   119      – –        10.4      82%                  

10/24/05      177       38                 99       5     6.2   104      —          9.84     82%

8/8/05           1430      72     461      80    4.1   144                  16.9     83%

5/17/05        2738      75     596     430   6.2    44      224       20.6     83%

4/23/05        2842      75     612     410   5.5    18      248       20.7     86%

2-26-05         4280      92     719     752   5.9    59     213       26.3     99%

1-24-05         2708      78     707     452   6.4    62     229       22.1     89%

• Continued regular spinal manipulative therapy for on-going wellness care
• Gradual reductions in supplementation
• Continued  Canine Whole Body Support ™ (Standard Process) and fresh food diet
• Gradually tapered dose and discontinued Canine Enteric Support ™ (Standard Process) 11-06 through1-07 with no adverse effects

• Euthanized in 2012 due to advancing age-related illnesses

• Key points to emphasize about Aspen and Gypsy:
  • In both cases, these dogs were eating “complete and balanced” major name-brand foods
  • They did not present with signs typical of classic nutritional deficiency
  • Nutritional supplementation yielded immediate improvement
    • Broad-spectrum support essential
    • Exact factors unknown
    • Likely to have been several factors simultaneously