Introduction There were five pups in the litter, normal in size, enviable in both conformation and color. The dam and sire were healthy and had completed their health tests prior to breeding, so no one was prepared for what happened next

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A Hard Look at Polyarthritis from a Breeder's Perspective

by Rita Roberts

 

Introduction

There were five pups in the litter, normal in size, enviable in both conformation and color.  The dam and sire were healthy and had completed their health tests prior to breeding, so no one was prepared for what happened next.

Out of that litter of five, two were affected with juvenile onset polyarthritis, one faded after an administration of Albon at 13 days and two were unaffected.  One that was unaffected was spayed. No issues have been noted in this bitch but no thyroid testing has been done, yet, either.   The second unaffected bitch is to be spayed due to erratic heat cycles.  This puppy bitch was determined to have a high TgAA value and was started on soloxine.

So what is juvenile onset polyarthritis?

Polyarthropathy

Juvenile onset polyarthritis, or polyarthropathy, (also called immune mediated polyarthritis, or IMPA).  Polyarthropathy in Akitas is also classified as a non-erosive arthropathy and so is also classified as a NEPA (Peeples).  It is mainly characterized by episodic immobility and extremely painful locomotion caused by joint pain, and recurring high fevers (Cohn).  

  Appetite will also decrease and affected animals are usually described as "unthrifty" (Merck).  In this litter,  episodes were accompanied by digestive upset which included both vomiting and episodic diarrhea which would certainly limit appetite and vigor.  During a typical Akita attack, there will be an obvious lack of animation and disinterest in normal activity due to the extraordinary pain and stiffness.  This is seen as weakness and perhaps in inability to get up or walk.   See polyarthropathy article on this website. Early symptoms in young pups may be misdiagnosed by attending practioners and it would behoove owners and breeders to be aware of the classic signs of onset.


Age of Onset

 The Merck Veterinary Manual (8th edtn) equates immune-mediated meningitis (aseptic) with episodic polyarthritis, stating that Akitas may be diagnosed as young as 12 weeks old.   A case study outlined in the Journal of the American Veterinary Association outlines 2 specific cases where aseptic meningitis was concurrent with the onset of this disease (Dougherty) causing additional neck stiffness and undoubtedly adding to a small animal's discomfort and difficulty of diagnosis due to arteritis (see polyarteritis nodosa).

  Dr. Jean Dodds has more accurately pin-pointed typical age of onset in a family of Akitas at 14 weeks but all occurring before 8 months (Dodds).  The likely contribution of shared genetics was also observed in the JAVMA case study.  Prognosis for all Akitas diagnosed with IMPA is generally not good, with many owners electing euthanasia over long-term maintenance or the Akita finally succumbing to renal failure. According to the literature, hepatitis is not an uncommon sequela to this disease and in this shares similarities to human juvenile rheumatoid arthritis (Peeples).

Animal Model for Autoimmune Disease

In an unpublished work done at the University of Georgia College of Veterinary Medicine, Dr. Rachel Peeples outlined that more research is needed into IMPA as it could be an excellent example for human juvenile rheumatoid arthritis (JRA) which shares several major similarities as suggested in the Dougherty paper.  Further she states the following regarding IMPA:  "juvenile onset polyarthritis...may be the first characterized example of a canine overlap syndrome".  Overlap syndrome is simply a way of stating that more than one autoimmune disease is acting concurrently on an individual.  

We know that in Akitas, where one autoimmune disease is present in a pedigree, we can see several others as well in related individuals.  More research is needed to elucidate whether or not Akitas really are the model for human autoimmune disease.    

Stress as a trigger

Stress of various sources have been anecdotally linked to the onset of episodes as well as recorded in Dr. Jean Dodds case histories of Akitas suffering from IMPA (Dodds).  These stressors, called "triggers" can lead to episodes lasting hours,  even two days, in length.  Episodes are physically stressful to the animal and often hard for owners to deal with. 

Supportive care has traditionally included anti-inflammatories and corticosteroids (an immunosuppressant)  in high doses to shut down the reaction that is thought to cause these episodes.  Cyclophosphamide has also been used with some success (Randell).  Holistic therapies have been tried with some success in this case (see Illustration) as well as nursing intervention on the part of the dedicated owner who spent a great deal of time recording events as treatment was provided, medical record fashion, at home.  (Subsequent treatment and diagnosis have been greatly aided by this written record.)  The owner noted that the onset of the initial episode (and a subsequent episode in a litter mate) was preceded by the administration a  vaccine.

Stress itself may be good or bad, invasive or external and is solely dependent on the individual's ability to deal with it.  Akitas, particularly, seem to not deal with the stress of combination vaccines in all cases with lepto and parvo being especially hard for them to manage in combination.  There has been some evidence that has linked this to related lines of Akitas.  In Dr. Dodds case histories, Akitas from susceptible families were less likely to have onset of IMPA when combination vaccines including modified live virus (MLV) were avoided (Dodds). However no study has been organized to further support these findings.  

Trigger stressors post -disease onset identified in this case from records kept by the breeder and owner and notes appearing in lab records appear to include excitement (visit to breeder's home), sensitivities to common drugs including Flagyl-which elicited a strong reaction within the hour,  general emotional upset, lack of sleep, or even physical exertion.  A particular episode is noted to have occurred after a very active day of playing in the yard!   This harmless activity is normal for any other dog, but for an IMPA Akita, has to be monitored.  In which case, IMPA in Akitas may have much in common with human Chronic Fatigue Syndrome (CFS).  

When a breeder looks at a problem situation such as this, what are they supposed to think?  There are very few litters in the world that are affected with juvenile onset polyarthropathy, even though Akitas appear to be at a higher relative risk than other breeds.  What can be learned and what is gained by reviewing what happened?   A lot. 

 The breeder wished to share this story while protecting their identity to try and help someone else struggling with either the exact same problem, or a similar one. They feel that by airing this, it will perhaps prevent the tragedy that happened to this otherwise wonderful litter and contribute to the ongoing effort to reduce the number of Akitas who succumb to autoimmune disease. Furthermore, the breeder and owner are quite adamant that the puppy who survives today, did so due to prompt interventions with non-traditional courses of therapy including acupuncture and homeopathy in addition to traditional supportive care such as anti-inflammatories and analgesics.  

Initial Signs and Symptoms Something was Wrong

The difficulty is that juvenile-onset polyarthritis is rarely seen.  Veterinarians seeing their first case must first eliminate other diagnosis (Cohn).  Breed and age at which symptoms are first reported are the hallmark factors that aid in timely diagnosis.    

The most information is available on the female pup that was diagnosed with IMPA.  She was still at her breeder's when it was determined that something was definitely not right at 9 weeks.  The pup was found unable to rise and apparently suffering a seizure- like episode with uncontrollable head wobbling and the inability to stand.  This pup also was unable to control urination.  The breeder immediately rushed the young pup to the emergency vet.

Attending emergency vets assumed possible puppy hypoglycemia.   A blood panel done at that time showed nothing more than a slightly elevated Glucose of 111 mg/dl (last meal was recorded as 12 hours prior with a snack at approximately 10 pm)  and a slightly elevated temperature of 103.9.  The breeder was recommended to follow up with the normal veterinarian on the following day.

A full blood work panel done at the owner's vet just one day later had Alkaline phosphatase highly elevated at 274 IU/L with a normal range of 5/131 IU/L.  Protein and albumin were low at 4.6 and 2.6 g/dL, respectively.  A CBC revealed unusually elevated white blood cells with a barely normal red blood cell count and depressed hemoglobin and hematocrit.  Neutrophils were off the charts at 17024 and 76% of the differential.  MCV/MCH/MCHC  levels were at this time, and on every test recorded afterwards, depressed.

The attending primary clinician noted no fever (101.6), but due to the abnormal blood work, which in part showed an  unusually elevated white blood cell count,  prescribed Clavamox and suggested a repeat of the blood work in a weeks time.  

The following week, the pup was retested.  At this point, the pup hadn't been eating well at all but drinking constantly.  Again, the temperature was recorded normal in the office.  At this time, the veterinarian ordered a recheck of the blood work and a hepatic profile.

One day later, the pup was at the emergency clinic because she had lost the use of each of her legs, one at a time.  The owner recorded her temperature at that time as 103.9.   The temperature recorded at the emergency clinic was recorded as normal at 102.4, however, the heart rate was elevated at 200 bpm and a copious amount of urine was passed twice that was described as "grossly dilute."   The pup was admitted and treated for the tachycardia.

Future episodes would be similar:  lethargy accompanied by fever, vomiting and diarrhea. The pup was monitored at home with fevers reaching as high as 107 with the owner often resorting to ice baths to reduce them at home.  (In the case of the 107 temp, a late night at the emergency vet.)   The pup continued to refuse food, exhibiting an anorexia that is recorded again and again throughout the chart notes, and would go from a very carefree pup to one that seemed deathly ill.  Diarrhea was episodic as well but fecals continued to come back negative.   Blood panels all still showed elevated white blood cell counts and alkaline phosphatase.  At various places in the chart notes, the veterinarians speculate regarding meningitis or panosteitis, both of which were ruled out. 

Meanwhile, the second pup was now experiencing similar episodes of weakness and inability to stand.  Joint taps were done on the second affected  pup, the male,  followed by a second set.  Neutrophils were discovered in the second joint tap.  Blood work on the male pup came back very similar to the female's in all respects.  

Following examination at the local university veterinary teaching and referral hospital, blood tests were run to check the immunoglobulin levels in the female affected pup.  IgA was recorded at 25 mg/dl, IgG at 513 mg/dl and IgM at 598 mg/dl. When an immunoelectrophoresis came back with an elevated alpha-2 fraction, the chart was noted as "appearing to be a chronic inflammatory disorder." At this point, there was no doubt that both the surviving male and this female were effected by IMPA. Further invasive testing, such as joint taps, were refused on this pup due to concerns regarding subsequent reactions to anesthesia. 

Meanwhile holistic therapy was begun for this pup at the recommendation of Dr. Charles Loops, a holistic veterinary practioner who consulted on this case, and with some suggestions from Dr. Dodds upon review of case notes.  

Today, this pup is now the only surviving affected puppy from this litter and turned a year old this month!


Treatment Options  

When asked, the owner states the following:   "...the key to keeping (name removed to protect privacy) alive is a blend of traditional and non-traditional medicine."  

This viewpoint is new, a lightening rod for criticism in the veterinary community,  making some veterinary visits antagonistic and frustrating for both parties.  It will probably be a long time before enough scientific is accumulated to support the position of taken by the owners in this case, but they feel confident they did the right thing.  At least it is supported by the furry evidence (see below)!   

The pup that survived weighed in at 47 pounds at 12 months and is maintained on Soloxine (for a low thyroid), 5 mg prednisone daily and 10 mg on bad days and Reglan as needed.  The owners have also been supplementing her with a soy prednisone at 50 mg given at 25 mg twice a day.   Sea Silver and Calcera Carbonica were used temporarily as prescribed by a holistic vet. A full outline of the nutraceuticals used in this case is listed in the Illustration. Torbutrol has been prescribed to help control the pain when episodes due occur.  Acupuncture has also provided some substantial relief, the owner says.

Diet has varied over the past year due to stomach upset and bouts of anorexia, but was variously I/D or sweet potato and rice with white fish or chicken meat but is also fed fruits such as blueberries and receives Reglan whenever and as needed.  At the time of this writing, the pup is reported to have an excellent appetite, something the owner is particularly proud to report.

Recently, this pup  battled bravely back from a particularly nasty episode combined with pneumonia.  I think there is certainly an Akita with the will to live in this dog. 


Sorting out what went wrong

What factors may have contributed to the unexpected problem with this litter and can they be identified as triggers?



Suspicions center on the possible contributions from dosing from external chemical sources.  In addition,  preventative health vaccinations were given immediately preceding conception, during the heat cycle.

Having avoided vaccinations two years prior to breeding, the bitch was brought current on all vaccines while in season so that she would have a high titer during gestation.   Also, chemical spraying took place over the breeders home.  This was estimated to have occurred between the 7th and 36th day of gestation.  Finally, the bitch started to cough when the pups were 13 days old.  Fearing the beginning of a respiratory infection, she was given Clavamox and the pups were given a preventative dose of Albon for some loose stool.  This directly coincides with the fading puppy male's date of death according to the breeder and while we can't directly correlate his death to what happened, it is a notable coincidence.

Illustration 1:


Puppy

1

2

3

4

5

affected?

Y

N

Y--Deceased

N

? Deceased

sex

F

F

M


F

M

color/coat

Fawn/blk 

Coated


black/wht

Coated


Hooded /blaze

Normal 


Fawn/black

Normal


Blk/wht pinto

normal coat



chemical exposure?

Y  sterilized biosolids --between day 7 and day 37 gestational age

Y

 


Y

 


Y

 


Y

 


vaccine

8 wks Ft Dodge Max 5 w/CVK vaccine

all recommended  vaccines 

8 wks  + Parvo 

8 weeks + holistic nosodes

N/A

medication

5 mg Prednisone (daily)  Soloxine and Torbutrol + holistic therapies:  Sea Silver, She was put on Disterperinum and Calcarea Carbonica temporarily.

According to her owner this is the current regimen: Soloxine .3 BID, Pred 5mg.,  Soy Pred (natural hydrocortisone) 25mg BID, she also gets (most twice) daily: milk thistle, CoQ10, Bromelain, Tagamet, Folic Acid, Transfer Factor, liquid Glucosamine.   Pulsatilla Zincum She's off the Calcarea Carbonica and Silicea. 


 Spayed at 10 months. No supplements.


 Immuran and Prednisone

Soloxine. To be spayed due to erratic heat cycles.

N/A

 

 

 

 

 

 

 

 

 

 

 

 

Common Denominators

What can we tell by what the pups who eventually developed polyarthropathy had in common at birth?  Was there anything different in the way they were cared for?  See Illustration .

  From the chart, you can see that of the surviving four pups, two pups were long coats, one was affected, one was not.  One of the pups was a  male, who was eventually fatally affected.  Of the three female pups, one had yet to have a heat cycle at 10 months of age and was spayed after two inappropriate aggressive behaviors were noted. The other was a long coat female, who for all intents and purposes, appears normal, however she was also recently spayed for erratic heat cycles.   Of the two pups affected with polyarthropathy, one was fawn with black markings and the other was white with a black head and blaze. One affected pup was in the same home with another unaffected pup. Both pups who eventually developed juvenile onset polyarthropathy were described as "small" and "undersized", noticeably so by 10 weeks.  This size difference however  is most likely explained by severe digestive upset and malaise as both pups were born of normal size, but may also be explained by their early introduction to high doses of prednisone.  One of the unaffected pups has had a completely traditional course of veterinary preventative health care, including all its vaccines and no supplements.  The second unaffected pup was vaccinated once only and then moved to a non-traditional, or homeopathic preventative health care plan.   So what is the common denominator?

The breeders' suspicions trend toward the combination Fort Dodge vaccine given on December 21.  This was a combination, "5-way" vaccine which included corona, parvovirus, adenovirus and  only 8 days prior to the first episode of immobility and tremors in the most severely affected puppy, which is still alive. Furthermore, the male that was fatally affected was only "mildly" affected at 10 weeks and having not been diagnosed with polyarthritis, yet,  was vaccinated with a straight dose of Parvo.  This vaccination triggered a severe reaction within 48 hours.  Veterinarians providing care dosed this pup with 60 mg of Prednisone and Immuran to shut down the reaction. However, by March 11, this male had developed severe dehydrating bloody diarrhea and bloody vomiting.  Rather than watch him suffer, his family opted to put him to sleep.

This sort of story is hard to accept for most veterinarians who would rather not see an outburst of pre-vaccine illnesses such as distemper, rabies and parvovirus.  These diseases can undoubtedly be easily prevented by the timely and careful administration of vaccines.  Vaccines are a part of the greater duty of veterinarians to protect the public health and the health of the greater pet population.  However, it should be noted where possible complications may arise, and in Akitas it has been noted before, that all caution when administering vaccines should be used.   

It has be to stated that not all Akitas given combination vaccines go on to develop serious disease.  Many are extremely healthy and suffer no ill side effects.  There has to be another component, and that component may very well be genetic susceptibility.


Genetics

The complete health history of this litter must necessarily include it's genetics but nothing is known at this time about the genetic contribution to this disease in the Akita dog.   Investigations of pedigrees has lead some to believe that at least part of the reason is behind IMPA is genetic (Dodds/Dougherty).

 In this particular case, there have been no identified cases on the four generation pedigree of this litter that can be confirmed as having produced IMPA.  We do know the bitch's dam had produced lymphocytic thyroiditis at a ratio of  4 affecteds out of 21 pups that have lived to reproductive age.  Unfortunately, further information on this particular pedigree that might contribute to our knowledge has been anecdotal,  and so cannot be included in this article.    

After investigating the pedigree, it can be assumed that one of two things has happened, this litter was entirely and completely a fluke, or there has been an under reported incidence of IMPA in this Akita population-- possibly due to missed diagnosis opportunities, euthanization used as a "culling method", or perhaps the overlap of this disease with SLE and meningitis or perhaps even the desire to keep recurring problems in a pedigree quiet.  The reason is unknown, but more information is needed. 


Typical Care 

Is it possible to identify the specific trigger that began the episodes of IMPA in this litter or that perpetuate the episodes in the surviving littermate?  Nothing that happened in this litter is particularly unusual for a typical breeder to see.  Typical purebred litters will have fading pups, mom might develop an ear infection or hot spot requiring a trip to the vet and careful administration of a prescribed antibiotic.  Pups are typically wormed and vaccinated, albeit not usually starting at 13 days old; but it's entirely normal for a vet seeing loose stool in a litter to prescribe a dose of Albon so nothing worse goes wrong later.  Vaccinating bitches prior to whelping is also typical for some breeders as well.


What has to be looked at is the possibility that in a genetically susceptible breed, such as Akitas, we need to take extra care, not typical care, when addressing such common concerns in a litter and prior to breeding.  This should be of special concern for breeders knowledgeable enough to know their particular line may be especially susceptible to immune mediated problems. 

In defense of this breeder:  It was probably impossible to prevent the onset of symptoms.  Much more information is needed to shed light on the genetic basis for this disease (if any), triggering mechanisms, treatment options and preventative measures (if any).  In fact, polyarthropathy is now being studied in Akitas by the University of Missouri by Dr. Cohn.  Perhaps further case studies such as this one will contribute to accurate and timely diagnosis.  If you know of a family of Akitas that might contribute to this investigation, please contact a GHC member today or write to Dr. Cohn.

Acknowledgements:  

Special thanks to the breeder and to the owner for their PATIENCE as this article has gone through several face-lifts and delays.  You are undoubtedly the most dogged pair I've had the pleasure of corresponding with.  Keep up the good work!

Thanks to Dr. Rachel Peeples, Barbara Bouyet and Dr. Jean Dodds.

Thanks to the fur-face who continues to amaze us all.  

References:

Cohn, Leah, A Unique Juvenile-Onset Polyarthritis Syndrome of Akita Dogs, Akita Club of America, GHC, August 2003. http://www.akitaclub.org

Dodds, Jean, Vaccine Protocols for Dogs Predisposed to Vaccine Reactions, JAAHA 37:1-4, 2001.

also available on-line at:  http://www.cavaliers.co.uk/articles/vaccineprotocols.pdf

Dougherty SA, Juvenile-onset polyarthritis syndrome in Akitas, JAVMA, Mar 1; 198(5): 849-56, 1991.

McEachern, Nancy,  Immonological Reactions in the Akita,


http://www.natural-akita.com/JPTeez/html/reactions2.html

accessed 10/15/03.

Peeples, Rachel, "CANINE IDIOPATHIC IMMUNE-MEDIATED NONEROSIVE ARTHRITIS:
JUVENILE-ONSET POLYARTHRITIS IN AKITAS", VPAT 5360-G. Rowland, University of Georgia College of Veterinary Medicine, 1999.
 

Randell, MG, Hurvitz, AI, Immune-mediated vasculitis in 5 dogs, JAVMA, 183(2): 207-11, 1983.

 

A happy, stable dog pictured with her unaffected litter sisters.



                             



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