Monthly Archives: May 2013

Hepatocutaneous syndrome, email to and from Dr. Jean Dodds

Dear Jamie: Hello ! Your special companion seems to be doing very well as far as the liver function is concerned at this time, so I would keep her on the liver cleansing herbs and liver cleansing diet. Her alkaline phosphatase (ALK P) remains high but that level is normally slightly elevated in geriatric dogs (up to 250 IU/L would be normal at her age]. The ALK P is a “dump” enzyme that reflects the excretion of enzymic activity emanating from the metabolic activity of the liver and adrenal glands. So it goes up when the liver metabolism is working harder. The ALT, by contrast, reflects her liver cell-specific function and is basically normal (that’s good). Do you know if they measured bile acids or GGT ? Either of these tests would measure bile flow through the liver as a measure of liver function.

One more thing, are you giving the Soloxine at least an hour before or three hours after foods or treats that contain calcium or soy — to ensure its complete absorption (these foods bind thyroxine and impair or delay its absorption). Best wishes, Jean

—–Original Message—–
From: Jamie Goff [mailto:jamie@jamiegoff.com]
Sent: Tuesday, November 13, 2012 10:02 PM
To: hemopet@hotmail.com
Subject: Consult needed from Dr. Dodds

I have a 13 y/o female lab diagnosed with hepatocutaneous syndrome. I have started her on milk thistle, the liver cleansing diet and she has received 2 amino acid infusions (650 mg aminosyn iv over 12 hrs)

She was diagnosed on 10/25 and treatment was begun immediately

She is also hypothyroid on Soloxone 0.5 bid (total T4 was 0.9 on 10/5/12) She is epileptic, controlled with phenobarb and k bromide over the last 6 years. Upon diagnosis, we did rapid phenobarb withdrawal and she was placed on keppra 500 mg q 8 hr and has had no seizures during transition period (weaned her off phenobarb in 1 week)

I can send all her lab work, but liver enzymes are slightly elevated:

11/7/12: 10/5/12

Alk phosphatase: 516. 506
ALT: 117. 143
AST: 41. 52
Cl: 125. 133
Anion gap: 9.3
Serum iron: 62
Albumin: 2.5. 2.8
Hct: 32.4. 35.8

Clinically, the margins of her mouth have lesions, as do pads of all 4 paws and she either hurts or they itch, as she wants to lick them constantly.

Her meds:
Tobramycin eye drops for right eye infection Prion 1/4 tab q day K bromide 400 mg/3cc bid Soloxone 0.5 mg bid Oral amino acid supplements Zinpro biscuits 6-8/ day Tramadol 50mg prn (mostly gets during amino acid infusions) Cefoodoxime 200mg qd for bacterial infection of paws Miconazole into ear canals q day

We want to make her comfortable and do not want to prolong her suffering, if none of this is going to improve. Please advise how to go about getting consult from Dr. Dodds, as we want to make sure we are doing all we can for our “baby”! (Also, want to find out how long before diet changes might actually help)

I can send labs results and clinical notes from Auburn College of Veterinary Medicine where Zoë has been diagnosed and treated.

Thank you so much!

Jamie

Hepatocutaneous syndrome: no Aminosyn 10% available

Another week later, no great outcome this time with the amino acids! Because they didn’t have Aminosyn 10% available, they had used Trophamine 10%. It’s also an amino acid infusion and used with infants (as well as animals!)

Unfortunately, we didn’t see much resolution of the lesions, but maybe they weren’t advancing quite as fast as without it! By this time, she was growing both cocci and malassezia (both bacteria and yeast infections) in her paws and also developed a yeast infection in her ears. We continued on the amino acids, soloxine and Keppra, while continuing to alternate tramadol and gabapentin for pain.

Many times in the evenings, I would just hold her in my arms as she slept, it seemed both she and I needed the close contact! What an awful disease and all because of phenobarb for her seizures for all those years!!! If only I could go back and switch her to Keppra!

Hepatocutaneous syndrome: honeymoon’s over :(

Well, it only lasted for a week, on November 5th, we noticed that she was licking her lips like crazy, then on the 7th, the lesions were back on her lip margins! The tops of her feet were also becoming red and weepy and her nose even had a big crack that was widening from the top to her lips!

We called Auburn and they agreed to work her in for another Aminosyn treatment, so off we went! I left her overnight and raced back the next day to get her. Don’t know who was more excited to see the other, even though she didn’t feel good, her tail was moving about 90 miles an hour!

The more reading I did on the disease, the more depressed I got!! Most everything I read online talked about euthanizing these sweet dogs with hepatocutaneous diagnosis! So much praying and so many tears!! How could I not at least try to heal her liver with Dr. Dodds diet and see if I could give her skin an opportunity to resolve!

Hepatocutaneous syndrome: after the diagnosis, the honeymoon

After receiving the diagnosis of hepatocutaneous syndrome, we arrived home with a very tired puppy and even though she was still having difficulty walking, she walked up the three steps to the front door! We watched closely over the next week and realized the Aminosyn was actually working!! The lesions stopped progressing and in fact, even seemed to improve! We decided that she was doing so well that we wouldn’t put her through another dose of Aminosyn, so on our re-check at Auburn, we chose to not put her through another 12 hr. ordeal. We alternated Tramadol with Gabapentin for pain relief over the next several weeks to help with the discomfort she must feel from the lesions that still remained.

So, we weaned her off the phenobarb rapidly over a week period and began Keppra 500 mg 3 times a day. We also started her on an antibiotic, Omega-3 fatty acids (free form snip tips) 3 per day. She continued on soloxine 0.6 mg for her hypothyroidism and zinc methionine for her skin

Link

October 25, 2012: After receiving our diagnosis of hepatocutaneous syndrome, we were advised that giving Aminosyn 10% (amino acids in an Intravenous form) can be helpful in getting some improvement for the skin symptoms. We opted to have these administered over 12 hours and spent the night tossing and turning, worrying about our “girl”! They have to place a “central catheter” to get the medication to a large enough vein that it doesn’t cause problems with vein irritation by giving it in a smaller vessel.

We picked her up the next day and began our research on what this disease is about and what treatments and cures exist. Once I realized that Dr. Jean Dodds had had great success with treating liver disease with diet and milk thistle, I knew I could at least treat the underlying liver disease and hopefully give her body time to heal the skin lesions.

It’s funny how having a diagnosis made many of Zoe’s idiosyncrasies now make sense: drooling, head pressing (she would go to a wall or to a piece of furniture and press her head against it), increased thirst, leg weakness and ataxia are all signs of liver disease–and all things that Zoe had begun doing over the last 6 months!
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Outline

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The diagnosis of hepatocutaneous syndrome

Zoe’s skin lesions continued to deteriorate. Her paw pads appeared that they might just crumble off her feet…she licked on them continuously, so we alternated pain meds and Benadryl to try to give her some relief. In the midst of this, her lip margins began to have big black scabs appear all along her muzzle.

Understanding that Zoe was so sick and not knowing what was wrong was such a helpless feeling! It was so scary and feeling like at any moment, she was going to die and what IF we could have done something to save her?! But we HAD to have a diagnosis in order to know what to do!

Our vet arranged for us to be seen at Auburn’s Veterinary School in order to get her off the phenobarb, so we could continue to give her a anti-fungal for her paw yeast infection, since the interaction was so bad before! My husband and I drove the 2 hours there with me in the back seat just loving on her to keep her comfortable.

Within 10 minutes of having the vets at Auburn examine her, we had the diagnosis: hepatocutaneous syndrome, but they wanted to do a liver ultrasound to determine if she had the honeycomb appearance consistent with the disease and unfortunately, she did. We did NOT want her to go thru the needle biopsy of her liver, since her symptoms so closely matched the disease, we opted to forgo thatimage test. The news was not good, the prognosis was just plain AWFUL!

I started my research immediately! I found TONS of information about Dr. Jean Dodds and her liver cleansing diet and started Zoe on that right away. The diet was very time consuming at first until I got the hang of how to make enough food for about a week and freeze it. Also, found poly-vi-sol with iron to help with her anemia and Missing Link supplements to add to each meal.

Precipitating factors for her seizures

I stopped giving her the thyroid supplement and placed a lamp in the foyer area that we left on during the night to illuminate the foyer, so there would be no strobe effect into this area. Her seizures actually stopped and the last seizure she had was just before she received her last Leventa dose. (It’s been about 2-1/2 years since she last had a seizure)

So, back to last September….in the middle of the night, I was awakened by a distinct memory of something I learned in graduate school…..cytochrome P450….what if Zoe’s phenobarb was interacting with the antifungal! We took her the next am to our vet and had a phenobarb level drawn: it had increased from 22 to 80.6!! No wonder she couldn’t walk or stand without assistance! So, I have NO DOUBT that GOD divinely orchestrated that I could remember something I haven’t used in over a decade! We stopped the antifungal and decreased her Phenobarb until her levels came back to a therapeutic range and she could actually walk on her own again.

Her liver labs on 10/5/12 were:
Alk Phos: 506
ALT: 142
AST: 52
GGTP: 20
Hct: 35.8 (slightly anemic)
T4: 0.9 (hypothyroid, barely within range)

This indicated that her liver was working really hard and her labs were elevated as a result.

Hepatocutaneous syndrome, how we used nutrition to heal her!

We have no children and 2 dogs. our oldest, Zoë, a 12 year old lab mix is such a sweetie, just loves to be loved and she loves to eat!
Her medical background was significant in that she had a history of seizures that had been somewhat controlled on both phenobarbital and potassium bromide. Over the previous 3 years, we had moved to a different house and Zoe’s seizures had actually increased! Using documentation, we were able to determine a couple of factors that precipitated her seizures: About an hour after giving her the thyroid supplement, Leventa, she MANY times had a grand mal seizure, many times with postictal blindness that would take about an hour or two to resolve! The other precipitating factor was the leaded glass windows on either side of our front door would cause a “strobe” effect when lights of cars driving by at night would reflect into the foyer. (The very area Zoe would lounge in the early morning hours). She was on phenobarb for about 7 years prior to the onset of symptoms of her paws and intermittently had had increased liver function tests.

Late September of 2012, my sweet girl suddenly started licking her paws (a lot!). It continued to worsen, with her paws cracking and weeping….thinking it was related to a yeast infection, our vet started her on an antifungal. Within a few days, she could no longer walk without assistance, she would stumble and had NO strength to even be able to urinate without being supported to squat (otherwise she would just fall down).