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Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog
Satisfied Customers: 28936
Experience:  University of California at Davis graduate veterinarian with 45 years of experience.
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7 year old springer spaniel. Possible Horners syndrome, although

Customer Question

7 year old springer spaniel.
Possible Horners syndrome, although no conclusive recent cause. Also and more importantly a low white blood cell count, middle of the low range now and gradual weight loss despite 50% less exercise.
Submitted: 2 years ago.
Category: Dog
Expert:  Dr. Michael Salkin replied 2 years ago.
Aloha! You're speaking to Dr. Michael Salkin
I'm sorry that your question wasn't answered in a timely manner. I need to know what symptoms you're seeing in Finnley that suggest Horner's syndrome and I need to review all of Finnley's test results - not just his white blood cell count - to be more informative for you. I also need to know if his white blood cell count has been rechecked.
Horner's describes a lack of sympathetic innervation to the eye. Symptoms may include miosis (smaller than usual pupil), ptosis (dropped upper eyelid, causing a smaller palpebral fissure/smaller than normal space between the two lids), enophthalmos (a "sunken" appearing eye), protrusion of the third eyelid, and absence of the blink reflex. Risk factors include blunt trauma, cervical/thoracic spinal cord damage (from FCE or IVDD/fibrocartilaginous enfarct or intervertebral disk disease) or infiltration (lymphoma, e.g.), surgical trauma or neoplastic infiltration of the neck, intracranial neoplasia, otitis media or other middle ear lesions, and retrobulbar inflammation or mass. If the middle ear is the source, a head tilt, nystagmus ("flicking" of the eyes), and/or facial paralysis may be seen as well.
A decreased absolute leukopenia (lack of white blood cells) indicates a poor prognosis. Neutropenia (decreased neutrophils)is usually caused by excessive tissue consumption of neutrophils during severe inflammation and/or reduced bone marrow production.
I understand that you might not have a copy of Finnley's test results at home but his vet should be able to give you one that you could upload to our conversation. You can scan it into your computer and send me the link or photograph the page(s) and send the images by using the paperclip icon in the toolbar above your message box (not if you're using the chrome browser) or by using an external app such as imgur.com or dropbox.com
Please respond with additional information and further questions or concerns if you wish.
Customer: replied 2 years ago.

Hello. No problem about the delay. It was Sunday (and although that is a working day in this part of the world, I wouldn't have expected you to reply).

We have the blood results here for yesterday & the previous set done in May. I will scan them in and attach.

The problem first occurred in March this year. His third eyelid just started all of a sudden covering over his eye (approx 1 third of his eye would be covered at any one time). It was generally always better in the mornings than in the evenings, as I assume having it closed overnight relieved the issue somewhat. By lunchtime it generally looked sore, droopy etc & by dinnertime, it was very upsetting to look at.

We initially were given a few different type of eye drops to try. He was also prescribed anti biotics for a short period. He had a sedation to have his eyelid and surface of the eye inspected, with no lumps or bumps found (photos attached)

Another vet was called in & he identified that he thought Finnley had all of the signs shown in the disease description for Horner's Syndrome on the Associate Database (copy attached). He prescribed phenylephrine eyedrops and they worked immediately to take away the symptom (we used at tiny amount twice a day, but now the symptom is much improved, so we just use them occassionally, when he seems to be struggling)..

The problem is, that although we can use the drops and make his eye look better, we don't know the cause & we are only treating a symptom, not the problem. The Vets here in Muscat say that the only way to find out if he has nerve damage, which could be causing this, is to have an MRI, but we cannot locate a flatbed MRI scanner in Oman. We have contacted the Sultan's Cavalry Centre and the Minister for Health, but they have nothing we can use. I have tried contacting the British Vetinary Centre in Abu Dhabi, as they seem to be more technologically advanced than anywhere in this country, I am waiting on a reply to see if they have a scanner.

The most concerning thing is that he has been gradually losing weight. Before coming over here last year, Finnley weighed on average 24-25kg. He is currently 21.6kg, which I know is still a healthy weigt, but it is low for him. He had blood tests done at the start of May, as we were concerned about his weight & his general lack of energy and poor joint movement (he was struggling to get on and off the sofa in particular). The results weren't great, his White Blood cells were in the low area, as you can see. We have been giving him Synoquin EFA with his daily meal eversince (he was on Science Plan Advanced Fitness, but we can't get that here, so now he is on Royal Canin Mobility), he also has a liquid vitamin daily now, as his skin and coat are quite dry and hair has been disappearing from his tail..

Yesterday, still concerned about his weight, I asked for the bloods to be redone. Again, they were not very positive. The vet gave him a hemo injection, as she said he was showing up as a bit aneamic. But we have no current treatment plan to understand the underlying cause of what is happening with Finnley.May bloods page 1May bloods page 2August bloodsEye pic 1Eye pic 2Eye pic 3Eye pic 4Horners Syndrome page from vet

Customer: replied 2 years ago.
It says that if I rate the answer the question gets closed, but I am waiting for a response to the reply I sent this morning, so I want to wait to rate the answer until I have this response. However, my inbox is being plagued with requests for a rating, which is becoming very irritating.
Expert:  Dr. Michael Salkin replied 2 years ago.

Thank you for posting that information! The good news is that although the total white blood cell count is slightly decreased, the absolute numbers of the neutrophils and lymphocytes are normal and so an important leukopenia (lack of white blood cells) doesn't really exist. Rather than anemia, his hematocrit is mildly elevated - probably due to dehydration. The MCV (mean corpuscular volume) increase isn't significant. There's no need for a "hemo injection". The result was misread. His chemistries are nicely normal. (Amylase is of no value.) I'm most concerned about his weight loss. Horner's + weight loss is worrisome for neoplasia but if present, there's no confirmation of that in the blood work. I understand your difficulty in finding advanced imaging. I often work with customers in the Middle East and it frustrates us all that such limitations exist. You should be able to return to our conversation after rating. I don't know why you're being told that you can't. If you have further questions in that regard, please contact***@******.*** and please continue our conversation if you wish.

Dr. Michael Salkin and other Dog Specialists are ready to help you
Customer: replied 2 years ago.
Thank you. Would you agree then that an MRI is the next action to take? Is there anything else you can think of that might help ascertain exactly what is going on? Any further specific blood work etc?
That is OK then, I am happy to provide a rating, so long as it doesn't close the conversation :-)
Expert:  Dr. Michael Salkin replied 2 years ago.
It's my pleasure. We should be able to converse for at least a month without this closing. Thank you for your kind accept. I appreciate it.

Thyroid testing (T4/total thyroid) should be performed although weight loss isn't consistent with hypothyrodism. An MRI of the brain and cervical spine is indicated when Horner's is confirmed. The good response to phenylephrine might be evaluated in this manner:

Mydriasis (pupillary enlargement) occurs in 45 minutes when the lesion is central/upper motor neuron. Unfortunately, results have been inconsistent and so the reliability of the test is controversial. I can't tell if Finnley's pupil was miotic (smaller than usual) in those pics. Can you tell me, please, if miosis were seen concomitant with his third eyelid prolapse? If not, Horner's may not be present.

Approximately 50% of cases of Horner's syndrome in dogs are idiopathic (unknown cause) and the syndrome generally resolves without treatment in <6 months.
Customer: replied 2 years ago.
Hi
Yes, the vet did say it was miotic. I am not sure that this was particularly noticeable to the layperson, but I remember him saying so and asking me to compare to the other eye. He did seem to be correct (I just wouldn't necessarily have noticed it myself).

The eye does seem to be resolving itself. It is much better than it was. Like I say, we barely use the drops anymore, I don't think I have used them in over 10 days..

My concern is the eye combined with this weight loss, complicated by the blood results, making us wonder if his eye is(was) a sign of an underlying problem. I wouldn't like to wait too long, hoping it could correct itself, doing nothing to help him, if there is anything at all that we can do to find out what is going on with him.
Expert:  Dr. Michael Salkin replied 2 years ago.
Thank you for the additional information. If that eye is remissing, I don't see a need for MRI. Once again, the blood results are essentially normal. The Horner's may be idiopathic and likely to remiss unaided. His weight loss may be acceptable if he still looks good. I know I'm painting a rosy picture but it's a valid one. I don't see the need for additional blood work although a T4 would complete the usual biochemical testing for Horner's. It's either "watchful wait" or MRI at this time...and I'd hold off on the MRI unless more symptomology arises.
Customer: replied 2 years ago.
OK thank you.
Expert:  Dr. Michael Salkin replied 2 years ago.
You're quite welcome. I'm going to check back with you in a few weeks for an update. Feel free to return to our conversation - even after rating - prior to my contacting you if you wish.

Please disregard the info request.
Customer: replied 2 years ago.
Thank you
Expert:  Dr. Michael Salkin replied 2 years ago.
Speak to you soon.
Customer: replied 2 years ago.

Finn continues to lose weight, we can easily feel and see his ribs now. I have noticed that he is eating his dinner and going straight out to the toilet, within 5 minutes or so. This seems to be a regular pattern for him now... I have booked a T4 blood test at the vets tomorrow. Is there anything else I should do/ask them do you think?

Expert:  Dr. Michael Salkin replied 2 years ago.
X-rays of his chest and abdominal ultrasound would complete a conservative diagnostic workup. Any luck with the MRI?
Customer: replied 2 years ago.
No :-(
The place in Abu Dhabi still haven't replied. I have sent a second request for information via their website...
We are making plans to travel to Germany, to his normal vet it the end of October, export certificate arranged etc..
Thank you. I will see what they say tomorrow.

Bonnie
Expert:  Dr. Michael Salkin replied 2 years ago.
Frustrating...I understand. Please keep me posted and for now overfeeding Finnley would be prudent.
Customer: replied 2 years ago.

Hi


 


I have just got back from the vets. I have attached the T4 test results (which they told me are absolutely fine) and the Chest Xrays. Unfortunately the clinic doesn't have an ultrasound, so this is all I could get done today. They told me that his heart is large (which my partner already knew - as he was told this at Finn's very first checkup as a puppy). Also however, they have said that there is alot of grainy space in the image, which is the lungs. They said this should show up as black, but it is quite grey.

Expert:  Dr. Michael Salkin replied 2 years ago.
Thank you! Actually, the X-ray technique is too poor to evaluate the chest properly. The lateral view especially is badly underexposed. The V-D view is better but still underexposed, lacks contrast, and gives the impression that the lungfields aren't clear but I suspect that they are. The heart does appear larger than normal on the lateral view but not so on the V-D view.

I would request that the films be repeated and the technique improved.
Customer: replied 2 years ago.
That is exactly what my partner said when he saw them. He said that as Finn has no known respiratory issues, it made more sense that the X-rays had been badly done, rather than Finn suddenly having serious lung problems. It is scary, because this is reportedly the best vets in Muscat, but now we've had misleading diagnosis twice in quick succession - first with the blood results and now with these X-rays.
Expert:  Dr. Michael Salkin replied 2 years ago.
I understand your logistical constraints. Unfortunately, inadequate equipment and talent are endemic worldwide. Keep me posted, please.
Customer: replied 2 years ago.
OK. Thank you. It is very reassuring to have your support. I will have to be brave and say that the X-rays need to be re-done I guess. What were we expecting to see on the chest X-ray? What are we looking for?
Expert:  Dr. Michael Salkin replied 2 years ago.
X-rays are part of the hunt for an etiology of Horner's and weight loss. Neoplasia is a primary concern. Keep feeding Finn!