tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS

Date:   15 August, 2008
Focus: Small animals - dogs, cats, hamsters & rabbits
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Making veterinary medicine alive
to a veterinary student studying in Australia
using real case studies and pictures

Epilepsy in an older dog
The owner has to accept the high risk that his epileptic old dog may die on the operating table
Slyvester's owner consulted me one day some two years ago for a second opinion. Slyvester had been licking his paw and one big red skin lump of over 2 cm in diameter appeared. Vet 1 had recommended surgery to remove the growth.

"It could be a lick granuloma," I said. "Let me know if my anti-inflammatory injection and antibiotics worked. You still have to clean the skin lump daily."
Surprisingly the lump disappeared as I anticipated that surgery would be required for such a big lump.

I visited Slyvester a few times as he always go to the owner's office. He jogged with the owner every morning and was as slim and fit as the owner. 

When he had a fit on May 14, 2008, the owner phoned me: "What is the cause?"

I referred the owner to the competition as I wanted the owner to have a different opinion. Fits are hard to treat unless the cause is known and so a different opinion would be good for Slyvester. One of the causes of fits is bacterial infection of the brain. Now, Slyvester had a very foul breath in 2008 and would not let me examine his mouth. His owner could not do it too. Despite several advices to do dental check up, the owner was not keen. General anaesthesia in an old dog would be risky and Slyvester might die.

So, it was better to have a bad breath dog rather than a dead one from an owner's point of view.

On August 10, 2008, Slyvester came in after suffering 6 fits within 24 hours.

"I gave Slyvester 'steroids' in his rectum twice," the owner said. "The other vet had given them to me in May when Slyvester had his first fit."

"What is the name of the 'steroids?" I asked. "They must be rectal diazepam tubes". As the owner did not bring his medication to me, I asked him to go home to get them.

The 'steroids' were 5 mg rectal gel tubes named 'Stesolid'.

Now, how should this case be managed? There was one possible cause of Slyvester's epilepsy. A high fever caused by bacterial infection. The source of the bacteria would be most likely from the foul mouth. There could be other sources but the mouth had plenty of stinking bacteria. A high fever would cause the fits but since Slyvester was given 2 rectal tubes of diazepam which controlled fits and lower the body temperature, Slyvester had no fever and no fit on his arrival at the surgery. 

"It is never easy to diagnose the cause of epilepsy in any older dog," I said to the owner. "Blood and urine tests will be taken for testing. It is possible that bacteria from the decayed teeth have had caused a high fever and damaged Slyvester's brain."

Slyvester did not have fits now. He was given an IV drip of 5% dextrose saline.

I said to the owner: "You have to take the risk of Slyvester dying on the operating table today. He may die under general anaesthesia to remove the decayed teeth to get rid of the bacteria. This may be the last time you will see Slyvester alive."

Anaesthesizing a dog with epilepsy is very high risk. Why not wait till his epilepsy was controlled. But procrastination might give time for more bacteria to further damage the brain tissues. It was possible that the physical damage of the brain by the bacterial toxins had been done. It was better not to wait.

At this time, I felt quite angry that the dental work could have been done after Slyvester's first fit and before that. The owner just ignored my advices and I felt sorry for Slyvester whenever I see him. Only 2 weeks ago, Slyvester's owner took me around Mount Sophia with Slyvester to pick up some 'organic' mangoes littering the roads. They were organic in the sense that the mango trees were not farmed commercially and therefore are healthier with no insecticides. I went with Slyvester and the owner to gather some mangoes and Slyvester appeared his drowsy self. Slyvester seemed to have a very high tolerance to toothache as in many dogs of the bull terrier breed.    

The owner would be worried that Slyvester would die under general anaesthesia. Slyvester had no problem during his first general anaesthesia when I removed 9 loose teeth some 2 years ago. But he was much older now.

From the owner's point of view, why tempt the God of death?

But what choice has he got now? 6 seizures. More would come. The owner understood and accepted the high risk of general anaesthesia. If Slyvester had a seizure during anaesthesia, he would die. And it was hard to forecast when the next seizure would come.

Slyvester had 2 vials of diazepam rectally given by the owner. So he could not fight back much as I put the gas mask onto him. He could still move his mouth away with his muscular neck and two men had to hold onto him.

The minimal gas amount was used. No intubation was possible as he had a very painful mouth. Ulcers and bleeding in the gums.

20 loose teeth were removed. 4 strong canine teeth and a molar with exposed root were the remaining strong teeth left. Slyvester did not have a fit.

He survived the general anesthesia. Then he had a fit 2 hours later. And more seizures. Was his brain irreversibly damaged now? How to help him live a normal life?  More veterinary follow ups are necessary for Slyvester.

The record of the history and follow up to August 14, 2008 is written below.

Thursday, August 14, 2008

9. Epilepsy in a 7-year-old Miniature Bull Terrier (draft blog)

Epilepsy - 7-year-old Miniature Bull Terrier

May 14, 08. One fit. I asked the owner to consult the competition as it would be good for the owner and Slyvester to get a different first opinion. Causes of fits in the older dog are notoriously difficult to find out.

The vet said that there was nothing abnormal in Slyvester's blood test and examination. The vet prescribed phenobarb 30 mg and advised 2.5 tablets 2 times per day for 2 weeks. The owner was told that Slyvester would need the drug for life. Slyvester did not complete the 2 week of medication. As to the cause of this fit, it was not possible to pin point. The owner had antibiotics given. I advised dental examination under general anaesthesia some months before and even after the first fit to remove bacteria multiplying in Slyvester's mouth. Slyvester had objected to any mouth touch and always looked lethargic with his head down whenever I visited his owner at the office.

As there was the possibility of deaths under general anaesthesia, the owner was not keen on my recommendation. More than one year ago, I had extracted 9 decayed teeth from Slyvester under general anaesthesia but the bad breath had returned in 2008. Slyvester is fed mainly home-cooked food. His coat condition is normal. His weight is normal and he exercised with his owner by jogging every morning around Mount Sophia area. Therefore hypothyroidism as a cause of his lethargy was ruled out.

Aug 9 08. National Day, Singapore
Slyvester At home

2 pm lst fit (Stesolid rectal tube with 5 mg diazepam gel given by owner) > 45 sec
10 pm 2nd fit (Stesolid rectal tube with 5 mg diazepam gel given by owner) > 45 sec

Aug 10 08. Sunday
Slyvester At home

7am 3rd fit (toilet roll into mouth to prevent tongue biting). 8 am 4th fit
8.30 am 5th fit
10 am 6th fit
Shorter 15 sec. "Massage his shoulder and talk to him," the owner said. "Fits become shorter in duration when I massage him. I also stuffed thick towel into mouth to prevent tongue biting."

"Why didn't you give Slyvester the rectal diazepam," I asked.
"I wanted to observe how often he gets fits."

Epilepsy - 7-year-old Miniature Bull Terrier
Aug 10, 08.
Slyvester at Toa Payoh Vets at 2 pm

Miniature Bull Terrier.Male, 7 years. Epilepsy. Toa Payoh Vets
tpvets_logo.jpg (2726 bytes)1518. Owner had given 2 rectal diazepam gels. Blood and urine taken for testing. Drip given IV.
Miniature Bull Terrier.Male, 7 years. Epilepsy. Toa Payoh Vets
tpvets_logo.jpg (2726 bytes)1519. Owner accepted risk of his dog dying during anaesthesia. A very high-risk anaesthestic situation. 

2.10 pm IV catheter inserted. Took blood samples. Took urine sample via catheter.
2.15 pm IV 5% dextrose saline 200 ml
3-4 pm General anaesthesia gas. Extracted 20 loose teeth.
6 pm 7th fit of <20 seconds

Aug 11, 08.

4 am 8th fit (rectal diazepam)
7 am 9th fit of <20 seconds
10 am 10th fit of <20 seconds
2 pm 11th fit (diazepam 15 mg IM).

Epilepsy --- Clusters of seizures. Miniature Bull Terrier, Male, 7 years. Toa Payoh Vets
tpvets_logo.jpg (2726 bytes)1520. Cluster of seizures continued. Blood test of very high white cell count indicated a bacterial infection.  

Aug 12, 08.
No fits
3 pm Jaws chattering (diazepam 15 mg slow IV drip).

Miniature Bull Terrier.Male, 7 years. Epilepsy. Toa Payoh Vets
tpvets_logo.jpg (2726 bytes)1522. IV diazepam given on Aug 12, 08. No fits up to 8 pm Aug 13, 08 when he was discharged to a happy owner. Reviews and medication necessary for some time.  

Aug 13, 08.
Gave orally phenobarb 30 mg x 1, Potassium Bromide 200 mg tablet x1 at 3pm, 9.30 pm on Aug 13 (at home). No fits. 8 pm Goes home.

Thur Aug 14, 2008

9 am Phoned owner. No fits overnight.
9.30 am. Owner gave orally phenobarb 30 mg x 1, Potassium Bromide 200 mg tablet x1.

1.30 pm I visited Slyvester at owner's office in downtown. Slyvester quiet under the table. Sedation is a side effect of the drug. He moved up to go to the back room trying to get far away from me. He never bites me but he is never fond of me.


Polyphagia. Owner said: "Dog is very hungry. Tried to topple the food container last night. Followed me everywhere." "Hunger is a side effect of medication," I advised.

Polydipsia and polyuria. Drinks a lot and passes a lot of urine.

Sedation: Depends on dose.

Less lethargic. Owner remarked: "I notice that Slyvester looks more alert and not so sleepy after extraction of his 20 loose teeth." This was despite phenobarb medication which causes drowsiness. I had noticed Slyvester being very tired looking for past months and had a foul breath and did not permit anyone to touch his mouth.

Cause of epilepsy. Owner wants to know what is the cause of Slyvester's epilepsy.
"The majority of causes of epilepsy in dogs are unknown and the epilepsy is termed idiopathic epilepsy," I said.

"Various causes of epilepsy include hereditary causes in dogs less than 5 years old but Slyvester is 7 years old, damage to the brain by injury, toxins and diseases. In Slyvester's case, total white cell count from blood sample revealed higher than normal. I believe it would be that Slyvester's brain was infected. Encephalitis caused by bacteria leading to high fever and convulsions on National Day. The most obvious location of bacteria would be from the mouth. 20 loose teeth with exposed roots were infected and extracted.

Also, the extreme pain in his mouth may finally aggravate his fits."

One of the tips of Slyvester suffering from severe mouth pain when the owner said: "Slyvester cries every day when he opens his mouth." Ms Tan, the 2nd year Victoria College student did mention it in her report which I asked her to write. She wrote, "The dog yelps in pain when it yawns, not surprising when you look at the state of its teeth."

I advised the owner to reduce dosage by half the amount from 9.30 pm on Aug 14, 2008 and wait and see if there are fits and let me know promptly.

It is best is to give the least dosage that is effective as dog gets hungry and sedated with phenobarb.

 Will need to monitor closely. If the cause of the fits is the mouth bacteria and the brain damage is not lasting, it is possible that Slyvester need not go onto anti-epileptic medication for life as he now has epilepsy with a cluster of 11 fits.

Only time will tell whether he can go off the medication.  So far, the Gods have been kind to Slyvester. I hope this hardy bull terrier would live a normal life going jogging with his owner soon.

I was really glad that he needs not suffer from a very painful mouth every day when he wakes up or yawns.

Dogs with idiopathic epilepsy can live a normal life if he is given anti-epileptic medication at the most effective least dosage and carefully monitored with blood tests and examinations.

Dogs with seizures with known causes removed will not have fits anymore.  


Sunday August 10, 2008

A bull terrier was brought in later in the afternoon for a blood test. His stomach hurt when touched and could only be carried at the shoulders and hind legs. It had suffered from fits in May and had a relapse yesterday. The previous blood test at (the name of  competiting vet practice) showed no anomalies. The fits last around 30-45 seconds and subsided when some medicine was inserted through the anus. It lasts 8 hours before the fits return again. His spine was prodded and the dog whined when the middle back was pressed, indicating pain, as when the stomach was pressed. Blood samples were taken (3 tubes) and sent to the lab. Two samples were taken to verify the consistency of the results. The dog yelps in pain when it yawns, not surprising when you look at the state of its teeth. Most were rotting away. The teeth were extracted as quickly as possible, gassing the dog at intervals to minimise the pain. The pain from the decaying teeth could be cause of the fits. A urine sample was also taken, which hinted at a problem in the kidneys. After the majority of his teeth were removed, the remaining were scaled. The dog was then put on a drip and left to rest. However, he had a fit about an hour later.
Bull Terrier, male, 7 years. Seizures over 20-60 seconds. Toa Payoh Vets
tpvets_logo.jpg (2726 bytes)1521. Dog had much less painful mouth.  4 canine teeth & 1 molar teeth remained. 20 loose teeth extracted. 

Ms Tan commenced her seeing practice in August 2008. She intends to study veterinary medicine and surgery after her A levels in 2009.

All interns at Toa Payoh Vets are required to write their observations if they want to see practice at Toa Payoh Vets as writing sharpens their observations and make veterinary medicine and surgery alive to them.

Epilepsy is a series of seizures or fits

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All rights reserved. Revised: August 15, 2008