Buffy, a 10-year-old spayed female Cockapoo, came to Veterinary Referral Hospital of Hickory when her owners noticed she was ataxic. They reported she had been losing her balance and falling over, especially after shaking her body. After falling, Buffy also had trouble getting back up. She occasionally leans to the left, but has no head tilt or nystagmus. Her appetite was abnormal, and she wasn’t as energetic as usual. She was not vomiting or sneezing, and she had no diarrhea.

A Veterinary Referral Hospital of Hickory emergency veterinarian examined Buffy, and found that she was bright, alert, and responsive. Her pain score was 0, and her temperature and pulse were normal. She had no ocular discharge, no nasal discharge, and no oral masses or foreign bodies. She had mild ear discharge. Her heart and lungs sounded normal, her abdomen was soft and non-painful, and there was no muscle or joint pain. Her coat was healthy.

The ER doctor performed a neurological exam and noted that Buffy’s gait was normal and she had no proprioceptive deficits. There were no signs of the reported ataxia. She had no cranial nerve deficits and was ambulatory on all four legs. The emergency doctor ordered bloodwork.

Buffy’s bloodwork came back normal except for her pO2 and her saturated oxygen, which were elevated. Her white and red blood cell counts were normal. Her bloodwork was as follows:

 

Test Value Reference Range
pO2 76.6 24.0-54.0 mmHg
cSO2 95.9 40.0-90.0%
pCO2 28.9 30.0-47.0 mmHg
Bicarbonate 20.4 16.0-28.0 mmol/L
cTCO2 21.3 18.0-28.0 mmol/L
pH 7.443 7.360-7.460
BE, ECF -3.7 -5.0-5.0 mmol/L
Sodium 147 140-151 mmol/L
Potassium 3.9 3.5-5.0 mmol/L
Chloride 116 106-127 mmol/L
Calcium, ionized 1.33 1.13-1.42 mmol/L
Anion gap 15 5-22 mmol/L
Lactate 1.57 0.60-3.00 mmol/L
Glucose 95 63-124 mg/dL
HCT 42 36-55%

 

 

Test Value Reference Range
WBC 6.15 6.00-17.00 103/uL
NEU 4.82 3.62-12.30 103/uL
LYM 0.92 0.83-4.91 103/uL
MONO 0.24 0.14-1.97 103/uL
EOS 0.15 0.04-1.62 103/uL
BAS 0.02 0.00-0.12 103/uL
NEU% 78.4 52-81%
LYM% 14.9 12-33%
MONO% 3.9 2-13%
EOS% 2.5 0.5-10%
BAS% 0.3 0-1.3%
RBC 6.16 5.10-8.5 106/uL
HGB 14.9 11-19 g/dL
HCT 39.3 33-56%
MCV 63.7 60-70 fL
MCH 24.1 20-27 pg
MCHC 37.8 30-38 g/dL
RDW 14.2 12.5-17.2%
PLT 313 117-490 103/uL
MPV 8.4 8-14.1 fL

 

 

Test Value Reference Range
BUN 6.9 9-29 mg/dl
Creatinine 0.7 0.4-1.4 mg/dl
BUN/Creat ratio 9.9
Phosphorus 3.7 1.9-5.0 mg/dl
Calcium 10.5 9.0-12.2 mg/dl
Corrected Ca 10.5 9.0-12.2 mg/dl
Total protein 6.3 5.5-7.6 g/dl
Albumin 3.5 2.5-4.0 g/dl
Globulin 2.8 2.0-3.6 g/dl
Alb/Glob ratio 1.3
Glucose 100 75-125 mg/dl
Cholesterol 342 120-310 mg/dl
ALT 39 0-120 U/l
ALP 29 0-140 U/l
GGT <10 0-14 U/l
Total Bilirubin <0.1 0-0.5 mg/dl

The Veterinary Referral Hospital of Hickory emergency veterinarian had discussed several possibilities with Buffy’s owners, including vestibular disease, wobbler syndrome, and CNS disease. Since her examination alone did not provide a definitive answer, the ER doctor recommended spinal survey radiographs in addition to the baseline labwork.

Buffy’s spinal radiographs did not reveal any signs of disc disease in the back. Our ER doctor recommended outpatient care with conservative medical treatment of Buffy’s symptoms, and a revisit to Veterinary Referral Hospital of Hickory for additional diagnostics if her condition did not improve. Buffy was discharged with Cerenia (24 mg) to curb suspected nausea/motion sickness, by virtue of smacking lips and some excessive drooling.

Eight days later

Buffy came back to VRHOH just over a week later, with her owners reporting that she still had episodes of falling over after shaking her body, plus intermittent ataxia. She still had the occasional left head tilt and sometimes leaned or stumbled to the left. Her appetite had improved slightly, but was still not completely normal.

Her owners report that though she had not worsened since her last visit to Veterinary Referral Hospital of Hickory, she also had not improved (except on occasions when she was taken for a walk). She had not been scratching her ears or shaking her head, and while she was still mildly lethargic, she perked up for things she enjoys, such as walks or visitors.

The same emergency veterinarian examined Buffy again, and again, her physical examination was unremarkable except for her neurologic exam. This time, the doctor observed Buffy’s occasional stumbling and ataxia when Buffy shook her body. However, the rest of her neurological exam remained unremarkable. The emergency veterinarian discussed the possibility of vestibular disease and CNS disease, and also discussed the possibility of inner ear disease, musculoskeletal disease, and orthopedic disease. The emergency doctor sent Buffy home with a prescription for Prednisolone (3 mg/ml) and Methocarbamol (500 mg), with instructions to watch for signs of improvement; if not, the emergency doctor’s recommendation was to follow up with a specialist.

Eleven days later

Buffy returned to VRHOH within two weeks of her last visit. Her appetite improved while on the Prednisolone, but the Methocarbamol did not improve her tremors. Dr. Scott Helms examined Buffy at this visit, and performed another physical exam, which was unremarkable. Based on his exam, Dr. Helms suspected idiopathic peripheral vestibular disease. Dr. Helms recommended glucosamine and gabapentin to keep Buffy comfortable and pain-free. Buffy was discharged with Dasuquin soft chews for dogs 0-59 pounds, to be given once a day for 4-6 weeks.

Seven days later

A week later, Buffy returned to VRHOH for her recheck and saw Dr. Scott Helms. Her owners say her ataxia is worsening, and she now has a left-sided head tilt and circles to the left. She also has positional left-sided ventral strabismus. Dr. Helms checked for ear disease on Buffy’s left ear, but saw no evidence of it.

Dr. Helms discussed several options with Buffy’s owners: referral to a neurologist, a CT scan, or a trial of prednisone. Buffy’s owners elect to have a CT scan, and it was scheduled for the next day.

With normal bloodwork the next day, Buffy is cleared for her CT scan. Her scan images show a mass effect in the lateral aspect of the right side of Buffy’s cerebellum. Dr. Helms’ final diagnosis is paradoxical central vestibular disease secondary to a right-sided cerebellar mass, presumed to be a tumor. Buffy’s owners elect to begin steroid therapy to attempt to reduce peritumoral swelling. Dr. Helms prescribed Buffy Prednisone (20 mg) – a half tablet per day for 10 days.

Eight days later

Buffy’s steroid therapy was ineffective, even at higher doses, and her owners proceed to follow-up with a neurologist. The bulk of Buffy’s tumor – an atypical meningioma – was removed, and she began a course of radiation therapy. As of her last radiation session, Buffy was doing well. She tolerated treatment well and had no side effects.

Buffy was a minority case with a serious underlying cause of her vestibular disease rather than the common idiopathic peripheral disease. Veterinary Referral Hospital of Hickory specialists and veterinarians are fortunate to have extensive resources at their disposal to evaluate and diagnose cases. Whether patients need a simple diagnosis and medication for a short-term problem or an extensive workup and surgery for a more complex problem, the veterinarians at Veterinary Referral Hospital of Hickory are well-prepared.