Swollen Limb - Update Dec 21/11 - Uh-oh...

[Drache613]

Hello!

I was hoping that the swelling would be getting better.
Did you ever send me the blood test results? Honestly, I think it is the beginning of gout, with the swelling getting worse with being on the medications. I am glad that she is off of them. I know they said that there were not any kidney dysfuctions, but, sometimes, gout does not present itself clearly, at first. I would just like to see the blood test results, to see if anything was missed.
They can aspirate some fluids out of the joint capsule & possibly the tissue surrounding the area, to see if there is any tophi present. Did they do that already? I know they checked for other things the last time, but did they check for tophi or uric acid being present?

I would like to see a copy of the blood test results. It sounds & looks like the beginnings of gout to me.
The calcium is very high still though. The normal readings for the calcium when ionized is a range of 1-3mmol/L so the 10.91mmol/L is high.
I don't see any eggs either. The bone density looks good, also, the bones appear nice, white & straight.


Let us know how things are going!

Tracie

 

[baby_geek]

Hi Tracy,

I was hoping the swelling would be getting better by now as well. I'm so happy she is in good spirits despite all of the swelling. I would be worried sick if she was acting the same as many of the critically ill bds on this forum.

I don't think I did ever send you the blood results (it took me a while to receive them myself). They ran an avian profile for some reason (I realize they are very similar species but you would think they would have a reptile profile)

"HCT - 35% (Reference 17-50%)
WBC - 6.0 x 10E9/L (Reference - 6.736-19.946)
Lymphocytes - 35%
Monocytes - 15%

Thrombocytes numbers appear adequate, some thrombocyte clumping present. Moderate to severe toxic change some degenerated cells present, 5-7 per 50 power field.

Glucose (serum) - 9.7 (Reference 7.72-16.2)
Calcium - 10.91 mmol/L (Reference 1.2-3.1)
TP - 55 g/L (Reference 45-95)
Albumin - 23.9 g/L
Globulin - 31 g/L
A/G ratio - 0.8
AST - 51 U/L
CPK - 2262 U/L
Uric Acid - 5.8 mg/dL (Reference 1.6-11.4)
ALT - 60 U/L

Sample was slightly icteric
No reference intervals for this species but calcium is significantly elevated. This could reflect a reproductively active female but concern for vitamin D excess. CK likely due to handling. No other obvious abnormalities. Any signs of soft tissue calcification? Any evidence of eggs?"

Have you heard of primary hyperparathyroidism in reptiles before? That could be 1 explanation for her calcium levels being so high as she has been radiographed 3 times and there is definitely no signs of eggs happening...

They have not done an aspirate of the joint cavity - the vet took a swab sample and made a smear on a slide and sent the remaining for bacteriology testing.
I am hoping to hear back from her this coming week (although we all know how busy the vets can get at times and it may be pushed to the back burner) :roll:

 

[Drache613]

Hello,

Well, according to the Reptile meds book that I have, the Uric Acid level really shouldn't be any higher than 4.
Yes, I have heard of thyroid trouble with reptiles, & it is hard to detect. I don't think it is metabolic bone disease, at all, or eggs. That would have definitely already been seen.
The Parathyroid hormone helps to regulate the calcium. They can do tests to check that hormone level.

I really am leaning towards pre-gout, possibly. Her levels are pushing 6. When was this test done? Keep in mind that once the uric acid levels reach around 10, you can usually start to see tophi build up on or around the joints on a radiograph or an x-ray.

They can test her for thyroid problems, it certainly wouldn't hurt to look in that area. One problem can cause other things to be thrown out of balance, also.

I hope we get this figured out!

Tracie

 

[baby_geek]

Yes, we are reaching that level of 6 for the uric acid levels. Her blood work was taken April 6th. Wouldn't her level be above 'normal' at that point when she already had hard, swollen joints? Or could the value have still been within the normal range and have visible swelling? I would expect there to be no physical abnormality until her levels were high... I guess each animal is individual - maybe Squishy's normal value is 2 or 3 and 5.8 is abnormal for her.

Her protein intake is very minimal she used to get 5 superworms a day (35 superworms a week) and since being off the antibiotics she is getting 2 superworms per day (14 bugs a week). She also gets her 0.5-1 cup veggies with some liquid acidophilis on top. Should she be getting less bugs than that? I need to be able to give her 1/day minimum as she is still on the metacam and that is the least stressful way to get it into her at the moment.

I question the hyperparathyroid only because she is given calcium 2 times a week and her levels are just so high... I got scared tonight... I was rearranging her cage and giving it a good disinfection and I found a stash of 20 shrivelled up eggs under her log. My biggest concern is that they looked like shrivelled up egg yolks - there was absolutely no white to them... I've never left eggs in her tank for very long so I do not know what they typically look like when they are dehydrated but I would think you would see a shrivelled up shell it them.

I do not know when these were laid (it could have been from February when I was away and maybe my caretaker did not see them. It could also be relatively recently. I will be asking her tomorrow at work) If there is no shell to these 'eggs' could they have not shown up on a radiograph? And if so when did she not produce the shell? She has more than enough calcium floating around to make a shell as hard as a chicken's! Could there be something wrong with her cage set up?

These little guys can make life so incredibly difficult and stressful! To relax a bit she sat in the living room window with the cats today to soak up some very low uv rays through the glass. She is still a little nervous about looking out the window but is getting calmer every time (we have a lot of bald eagles in our area...)

He likes to rest his paw on her foot... <3

 

[maverickgtr]

When my beardie Isis laid infertile eggs earlier this year, she laid about half while I was in class and the other half sometime after I went to bed and when I got up the next morning and got back from class [slept in after trying to stay up for Isis's second laying of eggs... didn't work...], I cleaned out her remaining eggs and they were more yellow than white. Also kinda shriveled. The pics you posted look similar, just slightly more yellow and shriveled.

Hope this helps and best of luck getting her feeling better!

 

[Drache613]

Hello,

Wow, infertile eggs. Poor girl.
She must have had follicles at the time you had x-rays done, as they will only show up on an ultrasound, not an x-ray. Then, she did lay them. I don't think it is an egg yolk, but the infertile eggs sometimes are very hard & yellow. They got shelled, but they dried out. I have seen pictures of eggs that looked like that.
I don't think she has a parathyroid gland problem no, now, especially with the eggs. That would have been why her calcium levels were a little higher.
I hadn't paid close enough attention to the TP (total protein) but, it is high, which is indicative of egg production. The Albumin & Globulin are both elevated also. They are not terribly high, but enough to show egg production.
Your setup looks pretty good. How far is the UVB light from her & how thick is the screen on top of her tank? Remember, that the screen will filter out a pretty good amount of the UVB also. You might want to consider either cutting a hole in the screen or try mounting the tube underneath of the screen for better coverage. The UVB light needs to be roughly 6-8 inches from her, for full effectiveness. Your basking lights look fine, how many watts are they together?

How is she doing tonight?

Tracie

 

[baby_geek]

Okay - new update...

The person who was looking after Squishy while I was away did not move items around in her cage to look for the eggs... she also laid only 13 eggs when she did find them. I am going with the eggs were there since Feb as that is what makes the most sense.


She can get about 5 inches from her UVB light if she climbs to the top of her log/plant. She normally sits about 7 inches away from it. THe screen on top is pretty large (I would be worried about crickets escaping if I fed them to her) so I don't think it is filtering out too much UVB. The basking lights combined are currently 80 watts (her 100 watt burnt out and we have no more at the moment so I put 2 40s in.

She seems to be a bit quiet tonight. She had already put herself to bed when I got home from work (however I did work later tonight) so I brought her out, fed her the drugged superworms and tucked her in my housecoat. She is passed out on my chest keeping nice a warm.

I received a call from Squishy's regular vet today and she was able to meet up with the reptile specialist in the area. He was unable to make a diagnosis from her file so he has sent all of the test results to a gentleman in California that 'literally wrote a textbook on bearded dragons'. I am hoping that they will get back to me next week with some answers... it seems to be a complete mystery for all involved.

 

[Drache613]

Hello,

How is Squishy doing?
Yes, it is a large possibility that the eggs are somewhat old.
That is a good distance for the UVB, she should be fine with that right now.
Is the swelling still the same, or has it increased? I hope the specialist can figure something out. I think it is an imbalance of some sort, & possible gout or at least gout like symptoms coming on.

Please keep us posted on her!

Tracie

 

[baby_geek]

Hi Tracy,

Long time no post. Things have been relatively stable. Squishy has days where she sleeps all day and then is up and ready to go the next day. This seems to happen every 1-1.5 weeks. I called the clinic early last week for an update and they got back to me today. To recap, her vet, the 'reptile vet' in the BC lower mainland area and a specialist (Dr Fry in California) have all been involved. I received an e-mail today from my clinic with a not so good prognosis... here is what was said:

Hi Fred, (Dr. Fry)
I'm sorry to impose on your good nature, but "Squishy" is owned by one of my previous partner's technicians,and Tina (my partner) and the bearded dragon's owner are now at an impasse re treatment.
My thoughts are that this animal has a bacterial arthritis in at least the elbow and the digit, probably a hematogenous spread from a focus of infection elsewhere.They have tried Baytril of course with no results(no surprise given the lesions).Management appears to be excellent.
I can't see much hope for this animal in the long term,but Tina has been very kind to me and I told her I would seek out your opinion.
I hope the attachments work out ok...I had a little trouble.
All best wishes,
Dave (Dr. Huff)

Which was replied with:

Hi Dave,
There are several points of interest with respect to Squishy's radiographs and lab results:
The left upper appendage both above and below the radio-/ulnar humeral articulation is very troubling with both osteolysis, as well as new bone formation. Alas, unfortunately, much more than just arthritis.
Then there are the massively altered and very abnormally elevated total protein, globulin and albumen fractions; the CPK is moderately elevated but at this level, it could be ascribed to (either or both) the administration of intramuscular enrofloxacin and or physical restraint. The uric acid is totally "off the chart." At that level, I suspect that this lizard has already developed renal (and, perhaps, peripheral articular) gout. The icterus is troubling and reflects potential hepatic pathology and malfunctioning. I am not particularly excited about the calcium level for this taxon. However, it would have been very helpful to have determined the phosphorus and potassium levels. The latter would be of particular help in formulating a prognosis -- which, as you already know is guarded.
Treatment: broad-spectrum bacteriocidal (not bacteriostatic) antibiotic(s), fluid therapy, and compassionate nursing. Tincture of Holy Water wouldn't be a bad idea also!
Very best to you both,
Fred

Do you have any suggestions? How should we go about treating this? Squishy is still in god spirits 95% of the time, still has a great appetite and is also still on Metacam for pain management...

 

[Drache613]

Hello,

Do you have the latest blood test for me to look at? What is the Uric acid reading at?
I had a strong feeling she had gout from the beginning & the antibiotics that were given greatly affected the kidneys.
If you start on the Allopurinol treatment immediately & flush her system with fluids, you stand a chance at stablizing her. This must be done immediately.
I would take her off of the Metacam simply because some of the side effects of the renal & hepatic dysfunction.
She can get on the Colchicine for help with swelling & discomfort. It works very well with the raAllopurinol.

Let me know how she is doing.

Tracie

 

[baby_geek]

Hi Tracie,

What would have caused the gout to comeon so quickly? She was a pet store beardie when I got her 5 years ago and she has had good care since then. What is her life expectancy? I just purchased 2 more ReptiSun 10s 3 days ago (I haven't even received them yet) and I would love it if she would be around to be able to use both of them...

She hasn't had another set of blood work done yet although I am tempted to have the vet do it to see where her levels are sitting now compared to her last work up.

What concentrations of Allopurinol (100mg, 200mg, 300mg) and Colchicine (0.5mg, 0.6mg, 1mg) should I be purchasing and what dose should I be giving her? I'm going to call the vet this morning once they open up and make an appointment to get her checked out. How will I get these drugs into her?

Would silkworm enzyme help out with her discomfort at this time? I hate the idea of taking her off the metacam if there is nothing else for pain management on board. (What is your website again?)

Should this drug combination decrease or eliminate the swelling? Will she be 'back to normal' after being on the meds? How long will it take to notice the effects?

I figure I will treat her for whatever is necessary until she goes downhill health wise - at which point I will need to say good bye. She is just so 'normal' besides the swelling - she is eating, splashing around in her bath, shedding, defecating normally (urates are a little firm but not hard), running around the house like a mad woman when she is tired of looking out the front window. She is really difficult to get to drink anything so I stick her in the bath regularly to help with hydration.

Thansk for all your help, as a tech it seems I always get the 'trouble makers'.

 

[Drache613]

Hello,

The last uric acid reading I see is 6 or so. Why did the vet say her uric acid level was off the charts if they haven't done another blood test recently? Just wondering. The level of 6 is far from "off the charts" range, so unless they can see the uric acid levels without doing a blood test, it would be interesting to see her new levels.

Gout can "seem" to come on quickly, but if the reptile is healthy, you may not see it immediately or when they are younger. Most of the times, it does not affect younger lizards, but lizards older than 4. Reptiles' systems are slow to show digression & the kidneys can actually function practically at 100% when they are in fact actually only at 75%. That makes it hard to see anything on a blood test because it will still show normal levels until the kidneys become compromised at around 35-40%. They are very hardy lizards. She probably most likely had some slight kidney damage when you got her, but that was impossible to know at that time. That makes it very difficult to be proactive to prevent gout when you have no idea of prior damage to the kidneys.
So, it has most likely been a slow but steady decline of her kidneys which gave no outward signs or symptoms until just recently. It really is no one's fault, reptiles are hard to diagnose! Gout can be caused by several things including poor genetics, chronic dehydration, poor diet, or too cold of atmosphere for basking, etc. The damage was already set in motion before you got her so unfortunately there was no way you could have known when you brought her home at that point.
I would get the 300mg Allopurinol & any of the mg of the Colchicine, but probably the 1mg it would be easier. I highly recommend getting her started on fluid therapy immediately either at the vets or at home. Try starting at 10mls daily, for awhile to help stabilize & get the uric acid levels dispersed & diluted better so they can be excreted more readily with the medication.
The medications are oral, so it should be relatively easy to get the medication into her. Remember, this medication will be for life, to help manage a chronic health condition.
The Colchicine helps with the swelling which is caused by the tophi or the uric acid build up in, on, or around the joints or surrounding soft tissues. The uric acid levels need to come down, if they are over 10, which is the level that normally begins to cause swelling at that point of tophi buildup.
I can review the dose with you, so see what the vet says regarding the dose & I will see if I agree with the vet on the dose!
The Serrapeptase is a good anti-inflammatory yes. It can help with pain management, if you want to try it.
I will PM you my website & my email, so we can discuss the dosing.
Do you have any new pictures of her now so I can see more of the swelling?

I understand how frustrating this is. Our boy, Napoleon, was a "pet store" dragon & basically the same thing happened to him & what has happened to Squishy. Napoleon is 8+ give or take. We have had him for over 4 years now & he has been on Allopurinol for a little over 2 years & is doing quite well for a dragon with gout. I can post some pictures if you would like. However, I do always worry about him.

I will try to help as much as possible, to save Squishy. I wish that I could see her.

Tracie

 

[baby_geek]

Hi Tracy,

Thanks for all of the information it was great to get some insight as to what may have happened and whether or not I will get another beardie in the future - I wouldn't want to go through this ever 5 years or so and to make sure I didn't do something wrong.

Squishy has not had any additional bloodwork since the original testing so I'm not sure why he claims her levels are off the chart. I have my shopping list for when I see the vet on Thursday. I would like to do a joint tap of her elbow and send it off for both aerobic and anaerobic cultures before we consider doing any antibiotic work. Once the results come back - if something grew - then she will need to be treated but I don't want to make anything harder on her kidneys than necessary. I want to do a follow-up blood work - this time with a different company. The first place we sent her bloodwork did not have a very comprehensive reptile panel (they didn't even test phosphorus levels which is important in reptiles). And I would like to get her started on the Allopurinol and Colchicine as soon as possible.

I've added some pictures for you to see:

Her good leg:

Her ankle - the one we opened back in March - which has remained less swollen than prior to opening it up (it is also shedding a bit where we made the incision) and her long toe is swollen:

Her bad elbow (her whole front left arm is getting ready to shed so it is all white and thick looking):

Her head (she is about to shed 1/2 of her head - they have the weirdest shedding patterns):

I will keep you posted - again she seems to be happy and healthy which is why I am going ahead with treatment... if she was really sickly I wouldn't put so much time and effort into her even tho' I love her.

 

[Drache613]

Hello,

Thanks for the updated pictures, I appreciate it. I do see the swelling though, but honestly, I don't see why we can't get her taken care of now.
As for anymore antibiotics, that would be a no. Even if there is slight infection, it will need alternative methods of treatments. Napoleon cannot handle any antibiotics at all, his beard turns black & he just doesn't feel well on any meds. I thought he had a respiratory issue awhile back & tried treating with Baytril. After one dose, his beard was black for a week. It really had a negative affect on him.
So, we will have to look at alternative ways to treat an infection, if anything were to be present.
How is Squishy doing?
Yes, starting her on the treatment immediately is important along with oral fluids daily, as well.

Let me know how she is doing.

Tracie

 

[baby_geek]

Hi Tracy,

So Squishy's appointment was this morning. Things went well. The vet would prefer to put Squishy back on the Baytril but understands my hesitation with doing that. She wants me to think about the Baytril as it isn't as hard on the kidneys as some of the other bacteriocidal antibiotics. I told her let's see how the gout meds work first and consider it later if needed. Thankfully Squishy had no negative effects of the Baytril - she still ate, gained weight, and was alert and active.

The vet is looking into having the Allopurinol compounded into a suspension as as Squishy is so small that accurately dosing her would be difficult. She would like to start at a low dose of 10mg/kg which Squishy is only 320gm therefore 3.2mg of drug. With even the smallest tablet (100mg) I would need to take a very small amount. Allopurinol also has the ability to cause allopurinol stones in dogs so she would like to start with a conservative dose and work up if we aren't seeing results in the event the same problem will occur in reptiles.

As for the Colchicine she is very hesitant to try that as it isn't a benign drug. She is going to see if she can find some papers that actually prove it helps as it can have a lot of side effects and she doesn't know if we could justify using it unless there is proof it works.

We have decreased her metacam dose until I receive the silk worm enzyme (I ordered it a day or 2 ago from your site) and then we will wean her off the metacam and onto the silk worm enzyme assuming it helps out with pain management. Our main goal is to keep her comfortable because if she isn't comfortable and there is nothing more we can do for her I'm not going to let her suffer. She will be comfortable until the day we can do nothing more for her.

We are going to do a follow up blood panel a few weeks after she starts her treatment to see if it is helping with her uric acid levels. She is on 6-10 mls of water a day depending on how much of her greens she eats. I was worried about trying to get that much water into her as she isn't a big drinker even tho' she gets a bath every 2 days - she tries her hardest not to drink. I was able to get the 6 mls into her without too much difficulty as I added about 0.05mls unsweetened apple sauce to it and I took her to work so I could give it to her throughout the day. She drank 2 mls at a time and I was able to do that 3 times today. I'm going to try for the full 10 mls tomorrow and see if I can get it into her. The problem is that she is only awake for about 4 hours after I get home from work and 10 mls would be a lot for her to drink in that short of a time. We will see how it goes.

I would also like to start her on black cherry juice (or extract) do you know where I can find it? Will health food stores have it or would it be easier to order it online?

So at this point I am waiting to hear back from her as to whether or not the pharmacy can compound the Allopurinol to a smaller concentration and we will go from there.