Ask the Vet: Challenging UTI's

by Mark Nunez, DVM

© courtesy Chris Abbas via Flickr.com

Dear Dr. Mark:

I have a 6 yr old Shih Tzu who has been sick for six weeks. She was diagnosed with a urinary tract infection and has a history of bladder stones and urinary tract infections. I kept telling my vet that she had no other symptoms (frequent, straining or painful urination). Then her left neck lymph node swelled to a huge, hard knot. The vet said she was trying to fight off infection, but eventually removed it and pathology was benign (it was 60% necrotic). 

The lymph nodes on her tummy swelled, then bleeding occurred again, but only for a day. Further problems included an erosion type sore on belly, then another on eye, and another large neck node. Now she has sores all over her belly. 

Blood work was normal 2 was ago except slight anemia. What is wrong with my dog? I took her to an internal specialist too, have spent $3200 so far, and no diagnosis. She continues to lose weight and get weaker. I am force feeding her every bite she eats.                    --Julia

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Dear Julia,

If your dog has a bladder stone she will be predisposed to UTI's.  Many times the bacteria live inside of the stone and antibiotics cannot reach that far.  A course of antibiotics will treat an active UTI, but very soon after the course the infection will return.  Removing the stone is the best course of action, no question about it.  

The situation with the lymph nodes is concerning.  I would, at the very least, have more of them aspirated or biopsied.  When any tissue is necrotic it can be difficult to see what is truly going on.  The anemia is also a concern.  There are many causes of anemia and this should be explored further.  

"Normal" bloodwork does not always mean that there is not something very serious going on.  Many times, even in the face of an obvious infection, the white blood cell count will be normal.  This is because we measure cells that are in circulation.  We cannot measure cells that leave circulation in order to fight an infection with in tissue.  The site of infection may be loaded with white cells, but the circulating population can look quite normal.  

I wish I had more insight for you as to what is going on.  I hope someone finds an answer for you and your dog very soon.

Best wishes, Dr. Mark

© courtesy m.n.
Mark Nunez, DVM

Dr. Nunez is a practicing veterinarian while also assisting patients through The Balanced Canine blog and his own online veterinary pharmacy. Have a question for Dr. Mark? Send it to AllThingsDogBlog@gmail.com. You can also follow Mark on Twitter.

Want to read more from Dr. Mark? Try these, or visit his archives: 

Digestion in Senior DogsMore on Dogs and AllergiesDogs and AllergiesDogs Who Eat Bugs

Ask the Vet: More on Pet Allergies

by Mark Nunez, DVM

Daniel Y. Go via Flickr.com

Dear Dr. Mark,

I've read that long-term use of prednisone can cause Addison's disease, Cushing's disease, and a dependence on the drug to the point where his body will not be able to produce its own corticosteroids. Is this true? Should the veterinarian be prescribing something other than Prednisone for long-term treatment of an allergy? Is there something I can be doing to help control the allergies at home? Sorry for the long questions. Thank you!

Cynthia D.

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Dear Cynthia:

Prednisone is the best medication for controlling the symptoms of allergies, no doubt about it.  However, it has a lot of side effects, especially with long-term use.  The list of side effects includes:  increased thirst, increased urine production, increased appetite, thinning of the skin and coat, dull/dry coat, weight gain, water retention, panting, vomiting, diarrhea, elevated liver enzymes, pancreatitis, iatrogenic Cushing's disease, GI ulceration, lipidemias, activation or worsening of diabetes, muscle wasting, increased susceptibility to infections and behavior changes (depression, lethargy, aggression).  Pred does not cause Addison's disease.  Cats tend to tolerate it better than dogs and side effects are rarely seen in cats.

This said, I would not, and do not, hesitate to use prednisone in my patients that need it.  There is no medication out there that works better to relieve the symptoms of a moderate to severe allergy flare up.  In some cases, it is the ONLY thing that helps.  I use pred without hesitation, but my goal is to minimize its use.  The best way to accomplish this is with allergy shots (immunotherapy, IT).  I recommend that all of my patients get allergy tested (if I suspect environmental allergies to pollen, dust, etc...) and start IT.

Nothing will cure allergies; there are only different ways of managing the symptoms.  IT is the only form of treatment that addresses the underlying cause, which is an over active immune system.  Other options only treat the symptoms.  Atopica (cyclosporin) is another long term treatment option that can take the place of pred, however, it is not without it's own set of side effects which includes: vomiting, diarrhea, anorexia, gingival hyperplasia, increased susceptibility to infections, and neoplasia (cancer) when used in combination with other immunosupressive drugs (pred).

Both pred and Atopica (the two should not be used together) also have MANY drug interactions and can be contraindicated if your dog is on certain heart medications, insulin, anti seizures medications (specifically phenobarbital), cyclophosphamide, erythromycin, mitotane, live-attenuated virus vaccines, non-steroidal anti-inflammatories (Rimadyl, Deramaxx, Metacam), antifungal medications, and synthetic estrogens.

Other medical options for controlling the symptoms of allergies include Benadryl, Claritin, Zyrtec, and Hydroxyzine.   These are all antihistamines and tend to only work on mild cases and at high doses.  There are a number of shampoos and leave on conditioners that have cortisone in them.  The most common one I use is Epi-Soothe.  This can be a good option, but is labor intensive.  Omega-3 fatty acids (fish oil), specifically Welactin, can also help and I recommend this specific brand for all allergy patients.  The brand is important because nutraceuticals are not FDA regulated and vary significantly in their bioavailability and action.

Thank you for your question and I hope I’ve helped you get a better understanding of how to treat allergies. Part I of this question was answered earlier and is linked below for reference.

Dr. Mark

courtesy M.N.

Dr. Nunez is a practicing veterinarian while also assisting patients through The Balanced Canine blog and his own online veterinary pharmacy. Have a question for Dr. Mark? Send it to AllThingsDogBlog@gmail.com. You can also follow Mark on Twitter.

Want to read more from Dr. Mark? Try these, or visit his archives: 

Dogs and Allergies (Part I of this same reader's question) Dogs Who Eat Bugs Diabetes and Allergies Combined
Dr. Mark's advice does not replace an actual examination with a veterinary professional.

Ask the Vet with Dr. Mark: Diabetes and Allergies Combined

by Mark Nunez, DVM

© courtesy Warchild via Flickr.com

Hi Dr. Mark,

I have an eight year old Tibetan Terrier that has diabetes and cataracts. I inject him twice a day with 26m of insulin. I also walk him at least three times a day.

He has recently been covered in a rash, which he constantly scratches, causing it to bleed. The vet gave us cream to put on and a special shampoo to bathe him with. He has been on Piriton (for allergy) and a prolonged course of antibiotics (20 days), but to date the problem still exists. What else can we do?

Many thanks, Mr G. Alland

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Hello Mr. Alland,

Diabetes can be a difficult disease to manage, both the primary issue and all of the secondary issues that can arise because of it.  If your dog has allergies (it's called Atopy in pets) along with diabetes, you are in between a rock and a hard place.  Nothing works better for resolving the discomfort associated with allergies than our good buddy Prednisone.  The flip side of this particular coin is that Pred will wreak havoc on his diabetes.  Fortunately there are options.

The best option is to have him tested for allergies (assuming it is not a food allergy) and start him on allergy shots (immunotherapy).  Skin testing is the gold standard of allergy testing, but is not often done due to expense, the need for shaving large areas of fur, and the need for sedation or general anesthesia.  Blood tests are the next best option and they are getting much more accurate.  I use Veterinary Allergy Reference Laboratory, Liquid Gold and get great results.  The goal of immunotherapy is to decrease the amount of medications needed to control your dog's symptoms.  It will not cure his allergies, but should decrease the frequency and severity of symptoms.

Other medications and nutriceuticals that can help include Atopica, Claritin, Zyrtec, Hydroxyzine, Benadryl, and Welactin.  Atopica is an immunosuppressant (this is how Pred works) that can help.  It does not affect diabetes the same way that Pred does and does not have the other side effects that long term Pred use has.  It is best used with antibiotics (in the beginning) and then can be tapered to the lowest effective dose.  Occasionally Ketoconazole is used in conjunction with it because it increases the effect of Atopica. 

Claritin, Zyrtec, Hydroxyzine, and Benadryl are all anti-histamines and are much more effective that Piriton.  Anti-histamines in general give variable results and need to be used at high doses.  

Welactin is a fish oil supplement for dogs and cats.  It is far superior to most fish oil supplements that are on the market.  Many of them do not have a high bio-availability, Welactin does.  If you choose to use another form, you may need to triple, or at the very least double the recommended dose.

Shampoos are another VERY important component of treatment.  Up until recently, it was believed that the primary way of allergen exposure was via inhalation.  We now know that contact with the skin plays a much larger role.  Oatmeal based shampoos are fine for maintenance, but medicated shampoos are often needed.  Ketochlor is my favorite anti-microbial shampoo.  It covers both bacteria and yeast.  Shampoos that contain cortisone can also help control itching.  Depending on who you ask, some people feel the cortisone may be absorbed through the skin, so use with caution in your case.  Epi-Soothe is my favorite shampoo of this class. Epi-Soothe also comes in a cream rinse that can be left on, or rinsed off.

Food allergies can ONLY be diagnosed with a food trial. The best diet for this purpose is Hill's Z/D Ultra (find online here), but there are many others that fit the bill. In order to do this properly, your dog cannot have anything other than the special diet to eat for at least 3 months. At the end of the 3 month period an assessment is made on how well he did. If there was complete resolution, we have our diagnosis. If there was improvement, but not complete resolution, he may have environmental allergies (atopy) along with food allergies and he should be tested, and if there was no improvement, it's not a food allergy.

I hope I have shed some light on this for you and have given you new options to try.  I tell all of my clients who have pets with allergies that allergies are 2 things, expensive and frustrating.  It cannot be cured, only managed in different ways.  Best of luck to you :-)

Dr. Mark

Dr. Nunez is a practicing veterinarian while also assisting patients through The Balanced Canine blog and his own online veterinary pharmacy. Have a question for Dr. Mark? Send it to AllThingsDogBlog@gmail.com. You can also follow Mark on Twitter.

Want to read more from Dr. Mark? Try these, or visit his archives:


The Dangers of Animal BonesTuberculosis and DogsTiming of FeedingArthritis Treatment and Prevention

Ask the Vet with Dr. Mark: The Dangers of Animals Bones

by Mark Nunez, DVM

© courtesy Mateuszz via Flickr.com
Natural Bones Have Multiple Dangers

Hello Dr. Mark: My husband hunts deer. He brought home some deer bones for Rex, our Jack Russell mix. I suggested he cook them to kill parasites or germs but he wanted to feed them raw. What do you recommend regarding raw vs. cooked bones? I wanted to cook them on the grill.

Wendy

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Hello Wendy,

You are correct, cooking them would kill harmful bacteria; however, the risk of stomach and intestinal problems would still remain.  Many people feel that dogs need bones in their diet, but this is simply not true.  If they are eating a high quality diet (home cooked OR commercially purchased) they will be getting all of the appropriate vitamins and mineral they need.  In addition, there are MANY safe alternatives for keeping their teeth clean and their gums healthy.  


While cooking the bones helps to decrease the risk for bacterial contamination, it makes them more brittle and more likely to splinter.  These splinters can lodge anywhere in the mouth, esophagus, stomach, or intestines.  I have also seen bones cause intestinal obstructions, with or without intestinal perforation.  The bottom line is the risk does not out weigh the benefit when it comes to bones.  I recommend finding safer alternatives for oral health and for dogs that just love to chew on things.  Thanks for the question!

Dr. Mark

© courtesy m.n.
Dr. Nunez

Dr. Nunez is a practicing veterinarian while also assisting patients through The Balanced Canine blog and his own online veterinary pharmacy. Have a question for Dr. Mark? Send it to AllThingsDogBlog@gmail.com. You can also follow Mark on Twitter.

Want to read more from Dr. Mark? Try these, or visit his archives:

• Are Amoebae Dangerous to Swimming Dogs?
• My Dog Licks his Packmate’s Eyes
• Dog Care: Do's and Don'ts for First Time Dog Owners

Dr. Mark's virtual advice is not a substitute for an actual examination with a veterinarian.

Ask the Vet with Dr. Mark: Tuberculosis and Dogs

by Mark Nunez, DVM

© Carrie Boyko
TB is Serious in Dogs
Please Read Dr. Mark's Advice

Dear Dr. Mark: Hello there. My dad was just called by his doctor telling him it's a possibility he may have TB. My concern is for my 7 yr. old dog that stays with him while I'm at work. I'm concerned because I've read where the treatment in dogs can be toxic and they usually end up having to put them to sleep. I'm not wanting to accept that. Can you please tell me what I can expect as far as treatment options and what symptoms I should be looking for. I will also be contacting her veterinarian first thing tomorrow to schedule her an appointment.

Sincerely, Kathy G.

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Hi Kathy,

The risk of transmitting TB to your dog is pretty low, but not zero.  Dogs are more resistant to TB infection than humans are.  The symptoms in dogs can involve coughing, but will likely be lethargy, decreased appetite, vomiting, and weight loss.  Unfortunately there are about a thousand other diseases that present with these symptoms.  


The approach to preventing transmission would be the same precautions that we take to prevent transmission in humans, namely no spitting, coughing, or sneezing around your dog and good environmental hygiene.  Also, follow all of the same precautions that his doctor recommended for prevention in humans.  


Once the infectious period has ended with TB, we do not have to worry about transmission.  If your father's MD is comfortable with him being around other people, chances are he is okay to be around your dog.  


Skin testing is possible, but I would recommend that you go to a specialty hospital or veterinary college (if there is one in your area) to get this done.  If the result is negative, have the test repeated in 6 weeks to be sure.  If he should show positive, unfortunately euthanasia is what is typically recommended because of a poor response to treatment and the public health risk. Thanks for the question!

Dr. Mark

Dr. Nunez is a practicing veterinarian while also assisting patients through The Balanced Canine blog and his own online veterinary pharmacy. Have a question for Dr. Mark? Send it to LetsAdoptaDogPark@gmail.com. You can also follow Mark on Twitter.

Want to read more from Dr. Mark? Try these, or visit his archives:

• Arthritis Treatment and Prevention
• Safe Dog Chews
• The Toughest Decision

Dr. Mark's remarks do not replace an actual examination with a veterinarian.