aspergillus spp. – The Ongoing Adventures of Sheba

MRI results – 3 fungal lesions

Long day at the vet for Sheba. We went in for MRI at 8:30am. Doc called around 11:30 to tell us she was awake and to please come by between 1 and 2 to pick her up and speak to the neurologist and internist. When we got there the neuro showed us the MRI. She has 3 lesions, the one big one between the dorsal spinal processes between her shoulder blades, then two smaller ~1cm lesions in the vertebral spaces further down the thoracic spine.

MRI sag

Then we waiting a bit to see the internist regarding meds. He’s thinking even though the histopath says Penicillium spp. it could still be Aspergillus spp. and since that has a better prognosis and similar treatment with more empirical evidence, we’re going to pretend its Aspergillus. He also ordered a galactomannan test which would be helpful to judge drug response if it is Aspergillus. So, we’re going to double up on the itraconazole for a month. Then redo the MRI and galactomannan to see her response. Because we can only be on that increased dose of itraconazole for a month or so we will need to either begin amphotericin B infusions (potential kidney failure and other nasty side effects) or restart the terbinafine (MAJOR diarrhea!). Terbinafine also doesn’t work as well in dogs as it does in humans or petri dishes. With the spinal lesions we also have to worry about compression of the spinal cord and fracturing vertebrae. At least the neurologist told us our Ruffwear WebMaster with BrushGuard is probably the best harness to have with her specific location of lesions!

And for those of you wondering, yes, Sheba’s medical costs are throught the roof (over $10k so far)! But we’re not rich, we just happen to have insurance for her that pays 90% with no cap. $72 a month sounded pricey when we signed her up at 9 months, but it has definitely paid off!

Here’s another MRI view marking the lesions:

MRI Markers

Tripawd Day 13

My brain has been fried from lack of sleep and migraines, but I think I’m almost caught up on sleep! Now that the firework are (mostly) over. Her last fentanyl patch came off Sunday, we’re doing ok on 150mg Tramadol every 8 hours. Poop is still very loose (think chocolate sauce for ice cream, minus the ice cream), and she’s not on the antibiotic anymore so we’re decreasing the Gabapentin with a plan to take he off by Friday. The crying has finally stopped, after consulting with our vet a few times she decided the confinement period is over. Sheeb is now allowed to roam about the house, cushion hopping, though we’re still keeping a close eye on her and helping her when she goes potty. She has a hard time keeping balanced when she squats. Probably the pain meds plus sedatives.

Stitches came off yesterday, but she started licking and chewing the incision so the cone’s not going anywhere! Abdominal ultrasound was clear, but we did find out the sentinel node biopsy that they took when they thought it was cancer turned out to have Aspergillus spp. in it, so this is no longer an isolated osteomyelitis, but systemic disease. Because she is a female German Shepherd and therefore more prone to more severe incarnations of the infection, her prognosis is very guarded and will depend on how she responds to treatment. Once it spreads to the spine and she shows signs of paralysis or paresis she will need to be put down.

WTF!? We were supposed to have a consult with a new internist, apparently her staff forgot to tell her that so she was very unprepared. Didn’t even have Sheba’s records from across the office. She showed us how to check her lymph nodes, symptoms to look for and agreed to add terbinafine, and antifungal that is commonly used in conjunction with azole antifungals when there is systemic disease. She’s supposed to give me a call with the microbe ID and susceptibility results (shouldn’t be back yet) when it does finally come in. At least its not infectious to the other dogs, but we’re looking at 2-3 years not that we know there’s lymph node involvement. That microbe ID will give a better clue as to the growth speed of the fungus and give us an idea of how long it’ll take to spread globally.

Sheba was getting kinda depressed, but her brother-from-another-mother, Monsta Man Zia came up for a visit and snap her right out of it! You just can’t say no to the energy of an Australian Shepherd!

“Ruff” night! Tripawd Day 7

Last night around bedtime Sheba started whining/crying inconsolably. The fentanyl wasn’t going to peak until 10am today so I gave her tramadol and an extra trazodone (as directed). No luck, she cried off and on all night, played musical beds and eventually ended up in my bedroom. Ruth called the vet this morning to ask the surgeon what we should do because by then she was maxed out on all her pain and anxiety meds. Doc recommended a short walk and a car ride. It sorta helped, but she’s still crying intermittently. I think she’s finally realized her leg is not coming back and is depressed. She went to sleep with a leg, then woke up and it was gone. I don’t think it would be unreasonable at first to think it might reappear the same way. Poor brother Buster is worried and tries to console her, even though she doesn’t always appreciate it.

Buster is trying to be supportive, but Sheba doesn't appreciate being breathed on! — Buster is trying to be supportive, but Sheba doesn’t appreciate being breathed on!

We finally have an ID on the fungus – Aspergillus spp. which GSDs are known to be susceptible to, the surgeon was already worried about spinal cord involvement prior to surgery. Because its not in the nasal cavity (the usual location of infection) she could not give us a prognosis. When we go in for future removal on Tuesday we’ll consult with the infectious disease specialist as well. We already knew she’d require monthly monitoring and potentially months to years of antifungal treatment. Unfortunately I can’t find much information about disseminated aspergillosis that doesn’t already involve the lungs (Sheba’s are clear). Bedtime meds seem to have kicked in and Sheba finally stopped crying, hopefully we’ll sleep better tonight. I’ll leave you all with some puppy pics!