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Old 12-24-2012, 04:00 AM   #1 (permalink)
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Default Update on Biscuit and new treatment!

Hello Everyone,

I'm sorry that I haven't been able to post any update on Biscuit and our trip to Boston to visit with Dr. Sisson. We came back to San Jose around 12:30AM Saturday and I got a terrible cold and cough as a souvenir from the Boston’s weather. I’ve been bed ridden since. I have decided to start a new thread to provide some detail update.

Before we get into the medical and technical detail, Ann and I wishes to send our deepest gratitude and appreciation for all of the support we’ve been getting to help us cope and continue our search to find the best treatment for Biscuit.

Biscuit is doing well, seizure free from what we can tell, and seem to also be improving slowly but gradually day by day. His meds continue to make him to have increase appetite and is always looking for food. He pees and poops all over the place, pretty much where ever he feels like it. He is still circling clockwise and pace around a lot, like being restless.

The trip went well and we were able to meet up with Dr. Sisson. Prior to the trip we had already were in email communication with Dr. Sisson in which he direct us to immediately increase the dosage of the Prednisone. You can see more detail about Dr. Sisson comment below.

Dr. Sisson spent an hour with us giving Biscuit a thorough check up and also discusses his treatment, requires testing plan with us. He also thinks that Biscuit has loss some vision from both of his eyes and cannot be sure if the vision would ever return to normal. All other vital signs seem to be OK. Dr. Sisson said one of the reason Biscuit is tilting his head to the right as well as walking to the right in a tight clockwise circle is due to the auto-immune disease attacking the left side of his brain.
He also said without first performing the spinal tab procedure, which he also add that there is a safe way to do if minimizing the risk is you know how, would have been a better way to help determine if Biscuit is dealing with GME or Necrotizing encephalitis. He also adds that if it is Necrotizing encephalitis, then the prognosis will not be that good. Since a Spinal Tap procedure is too late, he is going to start Biscuit on a new treatment of medication and schedules, and the goal hopefully is to eventually take Biscuit completely of the Prednisone.

Below is Biscuit current medication dosage and schedule, including testing schedules.

[PREDNISONE 5mg]
2 tablets 5mg, 10mg twice per day for 2 days
1.5 tablets 5mg, 7.5mg every 12hrs for 17 days
1.5 tablets 5mg, 7.5mg once per day for 35 days
1 tablet 5mg, 5mg once per day for 60 days
1 tablet 5mg, 5mg once every other day for 60 days

[LEVETIRACETAM 50mg/ml (Keppra)]
Give 1 mL, 50mg orally every 8 hours

[PHENOBARTIBAL 16.2mg]
1/2 tablet, 8.1mg every 12hrs (twice daily)

[MYCOPHENOLATE 200mg/ml 45]
Give 0.15 mL, 30mg every 12hrs (twice daily)

[LEFLUNOMIDE 10mg]
3/4 tablet, 7.5mg once daily in evening for 1.5yrs

Leflunomide Blood test require: need Leflunomide blood level test 20 to 23 hours after the medication is given in 14 days

[CYTARABINE 100mg/ml 45]
Give 0.2 mls, 20mg Inject by syringe under skin every 12 hours for 4 total doses on 11th and 12th days of every month.

Cytarabine Blood test require: Have a CBC done 3-5 days before each treatment is given. Have a CBC done 6 days after last 4 injections is given 1st time only.

[LOMUSTINE 5mg]
Give one 5 mg capsule, 5mg on the 27th day of each month

Lomustine Blood test require: Have a CBC done 3-5 days before each treatment is given. Have a CBC done 6 days after Lomustine is given.

Here is a summary of the email correspondence between myself and Dr. Sisson. It is quiet lengthy but I felt that it may in return help someone else that may be dealing with similar symptoms with their dogs.

[12-14-12] reply from Dr. Sisson
There is not enough information here to help you. I would need a copy of the complete medical record, the infectious disease test results they did and a CD with the full MRI scan on it. It is unfortunate they did not do a spinal tap. It is not too risky to do it with the problem this dog has if it is collected in the lumbar spine and done carefully. However now that he is taking prednisone therapy it is too late to do it most likely. Unless the MRI shows some signs compatible with encephalitis there is no definite diagnosis here. Assuming this dog does have autoimmune encephalitis the prednisone dose they are using is way too low for a dog of this weight to effectively treat that disease.

[12-17-12] reply from Dr. Sisson
If you want me to review all the records and make treatment recommendations you need to contact my secretary Lisa Canale, copied on this email and reachable at 617-541-5140, to establish a medical record so I have some place to put this information. In addition there is a $511.00 initial fee to review all of this and develop a treatment plan. There is then a $125.00 monthly fee for the 1.5 to 2 years needed to treat this. Unless you fly here with him for me to examine him once I cannot legally prescribe or change any treatments. The only other option if you cannot come here (coming here is a far better option) is to have your local veterinarian write a brief letter asking me to take over this case and that same veterinarian would have to be willing to fax written prescriptions to me for all medications I prescribe; so that I can legally send them to you. I addition, that veterinarian would have to be willing to draw blood tests and fax them to me when I ask to monitor therapy. You need to do this quickly since if this dog really has an autoimmune inflammatory disease of the brain he will not survive long unless this prednisone dose is increased. However if there is not something obvious on this MRI, other than the congenital malformation seen, then without analyzed spinal fluid making a diagnosis will be difficult. -Allen Sisson

[12-17-12] reply from Dr. Sisson
I just read through all of this. Is Biscuit back at home with you since 12/15/12 on the following medications?:
16.2 mg Phenobarbital – tablet every 12 hours
2.5 mg of Prednisone every 12 hours
50 mg of Levetiracetam (Keppra) every 8 hours

If that is the case what condition is he in? Is he able to crawl? Is he able to walk at all with assistance? Is he eating well with normal formed stools?
The dose of prednisone of 2.5 mg twice a day is not high enough if he really has autoimmune encephalitis and it needs to be increased immediately to 10 mg twice a day for 4 days then lowered from there. However, he will very likely develop severe diarrhea with blood in it with that dose increase if you do not immediately change his food to a prescription cat food named Feline w/d. You should not increase the prednisone until you get this food, and you need to get this food from your veterinarian right away; so that you can increase the prednisone dose as soon as possible. He is in danger of another relapse causing severe, brain damage if this dose is not increased soon. Although 2.5 mg of prednisone twice a day might be enough to prevent the progression of signs, it is not enough to cause full remission of necrotizing encephalitis if that is what he has.

The fact that he has relapsed with this severity of seizures is not good. There is some chance that he may have permanent brain injury at this point.
I agree with your doctors that it is probably too late to do a spinal fluid analysis now, but it would have been best to do one before therapy started to know if this dog really has autoimmune encephalitis or not. I have not yet seen all of the MRI images, but I do suspect from their description of them that an autoimmune brain disease is likely. -Allen Sisson

[12-17-12] reply from Ann to Dr. Sisson question above
Hi Dr Sisson, I am Vinh's wife (Ann) and would be the one answering most of your questions about Biscuit. Yes Biscuit been home since 12/15/12 and on all the medications you listed except keppra is only 50mg - every 8 hrs. And Cytosar every 2 weeks. He's able to walk on his own but his head slightly titled on the right. Sometimes he would start circling to the right. He's restless most of the times and doesn't sleep much. He poop once a day and his stools are formed. He just started grawling at me when I picked him up today. His conditions are ok but just slow. He follows me most of the times around the house and can follow my voice. He's more alert today and he's walking around the house nonstop at the moment. I picked up some canine w/d food today is that ok or does it have to be feline w/d. He been on canine i/d since he was in ER and I have been feeding that to him 4 times a day to him. Should I start giving him feline w/d once I increase his predisone?

[12-17-12] reply from Dr. Sisson
Canine w/d is fine if he will eat it. Not all dogs will. The feline w/d tastes better. If you use canine the canine r/d would be better as dogs eat it better generally. It is important he eat only the feline or canine w/d or canine r/d as his only diet. You should increase the prednisone as soon as possible. I really need to see you ASAP. The question is what day you can come. Your dog needs to start on other medication as soon as possible and I cannot do that legally unit I see him. Since he is doing better than described in the records now you should only give the 10 mg of prednisone twice a day for 2 days not 4 and then follow the rest of the schedule I gave you. -Allen Sisson
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Last edited by vinhle68; 12-24-2012 at 04:08 AM. Reason: grammar and text corrections
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Old 12-24-2012, 04:21 AM   #2 (permalink)
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Hi uncle Vihn and auntie Ann Albert sends his love to you both and biscuit his honorary brother !!..., well I'm so pleased to head he is seizure free at least , my prayers are with you all and wee baby biscuit , Albert is on prednisone also and atopica chemo drug and aspirin and liquid stomach settler , it's on going he took a wee bad turn yesterday his bloods have dropped and he was being sick all over the place , I took him to the vets he had bloods done and another injection for his nausea it's heart breaking it really is I know what you are feeling and going through , they are just so precious to us ... I only wish we could take the pain and problems from them as I know I'm strong enough to deal with them rather than our wee boys I hope you and Ann try have a special Christmas my love is sent ten fold to you all and of course wee biscuit xxx
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Old 12-24-2012, 04:50 AM   #3 (permalink)
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Oh Lyndsy,

I'm so sorry to hear that poor little Albert is not feeling well again. How is he doing today? I trully hope that his condition would either stabelize or better improves so he can have a wonderful Christmas and New Year with his loving Mommy!

Bless your heart for being strong and courageous for little Albert! Hang in there and we are cheering for you both!
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Old 12-24-2012, 07:16 AM   #4 (permalink)
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It sounds like you have been getting excellent care for sweet Biscuit. I hope there will be continued improvement and that Dr. Sissons treatment plan will be effective. I was speaking about Biscuit to my mother yesterday (she had 2 Maltese and is a lover of the breed). Oddly, the conversation of Biscuit came up because the young child (age 7) who lives next door to her has suddenly become dangerously ill. Seizures to the point they have induced coma due to the brain swelling. As of yesterday a.m. they still do not know the cause. Labs have been sent from AL to the Mayo Clinic for evaluation and are awaiting findings. Biscuits health reminds me so much of this childs ~ it's actually quite odd. We are wondering if an auto-immune disorder has effected him and also if there is permanent brain damage at this point. My heart breaks for you all and I wish there was something we could do. Please know that we are with you in spirit. Please keep us update on Biscuits journey to healing. Hugs.
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Old 12-24-2012, 07:28 AM   #5 (permalink)
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Ann, Vinh and Lyndsy, my heartfelt prayers for biscuit and Albert..I.will pray for a Christmas miracle for your two boys. Sending much love from my house to yours
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Old 12-24-2012, 07:28 AM   #6 (permalink)
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So happy you made the trip and appointment with Dr. Sisson. Thanks for keeping us updated on Biscuit, so glad he has been siezure free and the best part that he is home with you and Ann. Prayers continued for Biscuit.
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Old 12-24-2012, 07:51 AM   #7 (permalink)
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Ahh thanks so much , yes Alberts stable just blood test after blood test at the moment poor Albert loved the vets when he wasn't ill !! He now shakes terrible n pees ma wee man , I hope all the poorly pups on here and everywhere will have a gentle node Christmas xx
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Old 12-24-2012, 08:28 AM   #8 (permalink)
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Both Albert and Biscuit are in our hearts and prayers... we keep watching the updates and praying for good news. Love and nose kissies little puppies...
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Old 12-24-2012, 08:50 AM   #9 (permalink)
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Vinh and Ann, I have been wondering how Biscuit was doing and so happy to see a post. So glad you made the trip to Boston and hope that the plan to treat Biscuit will be a great success. I know how difficult it is to watch your little boy go through all this but I pray for him to stabilize and get well. Please keep us posted!
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Old 12-24-2012, 09:38 AM   #10 (permalink)
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Thanks Michelle means so much xx
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