What We Know Now....

It's been an intense past 24 hours and I'm overtired. I've also got a full schedule of patients to see, myself, today. I'm trying to bang this out in my one break in my schedule today because, by the time I'm done and back home tonight there's no way I will be able to write coherently. 

I also want to say, from the get-go, Michael and I both appreciate the barrage of calls, text-messages, emails, Facebook-comments, etc... and we're sorry that we just don't have it in us right now to respond to everyone individually. Please, please, please; understand it's not anything personal. There's also the fact that repeating the same information over and over from person to person makes it feel incredibly awful for us. That's one of the reasons we have this blog. We can put the info here and it can save us the upset of discussing and re-discussing the latest on Riley. Which brings me to that: Riley had a bunch of tests yesterday and we have a lot of information. 

 This is the order in which the information came to us: 

RILEY'S EGD (Esophagogastroduodenoscopy): For the most part, it was pretty normal. Abnormal findings were some grass in his belly at the pylorus (opening to the duodenum (small intestine) from the stomach. Also, there was a single piece of paper towel sitting in the pylorus and across it into the duodenum. It was adherent to the lumen-- as though it was pasted onto the lining of the "tube" of his small intestine. It wasn't causing a blockage-- clearly, food has been passing through just fine. But this was an odd finding.  We're not sure how he got the paper towel, though we know he was eating grass.  Lots of dogs eat grass when their tummy hurts.  All of this said:  The lining of his esophagus, the sphincters on the stomach, the lining of the stomach and the duodenum were all very normal.  No masses.  No ulcers.  They still took some biopsies just to look at and make sure they are as histologically normal as they appear.  

RILEY'S MRI:  Riley had a second MRI of his brain and cervical spinal cord.  As you recall, his first one was back in February 2010.  There is a LOT going on so, item by item:

* There is Otitis in his Right Ear; inflammation of the inner ear. (in the above picture, the arrow is on that area.) Unlike in humans, the shape of the ear canal and the underlying anatomy of the ear make it very difficult to assess the presence of deep, inner-ear inflammation or infection in dogs on routine physical exam.  

* There is a region of lower-grade inflammation in the medulla adjacent to the region with Otitis.  (in the picture above, this is the grey-ish area, to the right of the cursor.  Note:  the opposite side of the brain, which should be a mirror image, is not grey.)

* The large Syrinx remains.  When compared to the size/length/thickness on the previous films, there is no significant change, but it's still huge. (In the above picture, it's the long, white horizontal "cord" running from the base of his brain stem on the left into his neck.  The tiny black line at the bottom of it is his actual spinal cord.  The cord is compressed by the large, white Syinx.)  As Riley's Neurologist said, "It's probably the biggest syrinx that I've ever personally imaged on a patient."  Not a distinction one wants to have.  

* There is increased fluid in the fourth ventricle as compared to his prior films.  This, in turn, is putting pressure against the Cerebellum, and squeezing it in the skull.

Okay-- in  plain English?  The last two findings basically show a relatively stable case of Caudal occipital malformation syndrome (COMS)/Syringomyelia in a Cavalier King Charles Spaniel.  

The prior two findings, however, point towards the events of this past summer, when we thought he might have a deep penetrating inner ear infection.  The  inner ear "lights up" on the MRI on the right whereas it does NOT on the left.  The fact that the adjacent area in the brain (the Medulla) is lighting up, too, would hint at a possible local-spread or Meningitis.  Based on this, they wanted to do a Spinal Tap.  We said yes...

RILEY'S SPINAL TAP:  So ,technically speaking, they didn't do a spinal tap.  They did a Cisternal Puncture, which is a procedure where they pass a hollow needle through the posterior atlanto-occipital membrane into the cerebellomedullary cistern.  So they shaved the back of his head and "tapped" the cerebral spinal fluid from the area up high:

The rationale was that if there were anything infectious, our best chance of catching it would be right up in that local area, not all the way down in his lumbar spine.

They didn't expect this to be an infection- so this was mostly done to rule out that as a possibility.  

The CSF Analysis (results) came back overnight and are as follows:

These findings confirm that there is no infection. However, this also confirms that there is inflammatory disease in the presence of syringomyelia.   

The Neurologist was clear that he sees this very often in Cavalier King Charles Spaniels with a history of early-onset syringomyelia.  They can develop these autoimmune inflammatory processed in and around the structures of the syrinx.  Though there is very little by way of hard data in large sample prospective studies on the matter, he assured me that he is dealing with this all of the time and that steroids are usually the way to go.

They gave Riley a bolus injection of Solumedrol at a high dose (240 mg) and we are starting him up on 5 mg of Prednisone every 12 hours.  We will do this for the next 2-3 weeks before starting a very, very, very slow taper over a 2-3 months period.  The hope is that this will attack the inflammation and his neurologic reasons for inappetance will resolve.  

One potentially complicating factor in all of this is that steroids, on their own, increase thirst and hunger.  So it might be a bit difficult to figure out exactly why Riley is eating, if he does start eating again.  However, this should be readily apparent if he looses his appetite again when we start the taper.

Last night, when we came home from our 12 hours away from the house, Riley was fit to be tied.  He wanted nothing to do with any of us, much less his food.  He ate nothing.  He drank nothing.  He passed out and we were fine with that, because we know what he had been through.

I believe the steroids have kicked in because he woke me up crying at 3 AM to go outside and it was insane how much he urinated!  ....that's steroids for ya!  Still, he didn't want to eat his breakfast so we made the "paste" and "force fed" him again.  I am wondering if  his persistent inappetance this morning is in some way related to his being scoped/biopsied yesterday? Riley's Neurologist, in an an email  just a few minutes ago, said, "I cannot comment on scoping and its effects on anorexia, but I wouldn't be too discouraged yet... [the results]  do confirm inflammatory disease even in the face of SM, so I am very optimistic that the steroids will improve things."

Stay tuned...