I.V.A.S. ACUPUNCTURE CASE REPORT
Elisabetta Puggelli
DVM,
Montemurlo -PO-, Italy
ABSTRACT
Dog. Female,
boxer, 7.5 years old with nephrotic syndrome arising from leishmaniasis,
treated for leishmania and Qi Deficiency with good results.
HISTORY
Astra is a 7.5 year old female boxer, non-spayed, with regular heats.
She has been given all recommended vaccinations and heartworm prophylaxis.
She is fed with homemade food (pasta, rice, vegetables, meat, rather
than canned food).
She had never had health problems until the day she was taken to the
clinic. Her symptoms were: inappetence, polydipsia, polyuria with loss
of urine, especially during the night, dribbling after urination, frequent
and copious clear urination, loss of weight, depression. She craved
warm places, lay in the sun, and did not want to be taken for her daily
walk.
EXAMINATION FINDINGS
When she was brought
to the clinic, the Western medical physical examination showed that
Astra was weak and thin. Temperature was normal, auscultation of heart
and lungs was normal, abdominal palpation showed no irregular findings,
as did eye examination. No otitis, regular stool, pale membrane mucosae,
regular nodes, oral tract and pharynx normal, no neurological problems,
coat was dry and lustreless, muscles were hypotonic. TCM examination
indicated that the constitutional type related to the five elements
of Astra was "earth type" (1). The patient had normal shen, was thin,
weak, with lustreless coat, tired with slow movements, lethargic, with
cold extremities. Her tongue was pale, thin. The pulse was deep, slow,
empty. At palpation, points BL 20 and BL 23 were painful.
DIAGNOSTICS
A complete blood
check was carried out (hemochrome, biochemical and hemostatic profile,
see Table 1). The following values showed alterations: creatine, BUN,
phosphorus, RBC; in addition, some coagulation values were abnormal.
All these values
showed that Astra suffers from kidney deficiency with anemia. A urine
check was carried out (see Table 2) which showed abundant proteinuria
with low specific gravity. Echocardiography showed no irregularities.
The abdominal ultrasound showed only a slightly hyperechoic renal cortex
and small anechoic areas with slightly enlarged suprarenal glands (see
Tables 3 and 4).
We performed a fine
needle aspiration of the node and a bone marrow biopsy. These revealed
the presence of leishmaniasis. We performed a serologic test for Ehrlichia
canis, which was negative. The IFAT test (direct immunofluorescence)
for leishmaniasis, performed by an outside laboratory, resulted positive
with an antibody titer of 1:640.
WESTERN MEDICAL
DIAGNOSIS
After all tests and complete examination, we diagnosed a nephritic syndrome
resulting from leishmaniasis. Canine leishmaniasis is a systemic protozoal
disease of mononucleate phagocytes. The most important characteristic
of this disease is how and to what extent the host's immune system is
affected. There can be various clinical manifestations of the disease,
which can attack numerous different organs with varied symptoms.
EASTERN MEDICAL
DIAGNOSIS
Leishmaniasis infection indicates a heat/dampness attack as a consequence
of Wei Qi deficiency. Inappetence and depression account for the results
of pulse examination that showed a Qi deficiency. Urine loss, especially
during the night, reveals a Yang deficiency in the kidney. The pain
felt at palpation of BL 20 reveals that the spleen is affected (leishmaniasis
affects the reticuloendothelial system) and palpation of BL 23 reveals
that the kidney is affected (nephritic syndrome). According to the eight
principles, the pathology presented by Astra is internal, cold, Yin
deficiency with Qi deficiency in the spleen.
TREATMENT PRINCIPLES/TREATMENT RESULTS
The main treatments
are:
- To benefit Qi,
and especially Wei Qi
- To benefit Spleen
transformation and transportation function and dispel Heat and Dampness
- To benefit kidney
water metabolism function
- To benefit kidney
marrow functions
- To heat kidney
Yin and Yang
Main points used:
- BL 20 (Pi Shu)
1.5 cun lateral to the caudal border of the spinous process of the
12th thoracic vertebra. Spleen shu point, benefits spleen function
of transformation and transportation, nourishes blood.
- BL 23 (Shen Shu)
1.5 cun lateral to the caudal border of the spinous process of the
2nd lumbar vertebra. Shu point of kidney, tonifies Kidney Yin, strengthens
the marrow, benefits kidney function of dominating water metabolism,
nourishes the blood.
- BL 28 (Pang Guang
Shu) lateral to the 2nd sacral foramen, in the depression between
the medial border of the dorsal iliac spine and the sacrum. Shu point
of bladder, regulates water passages in the Lower Burner.
- ST 36 (Zu San
Li) 3 cun below ST 35, one finger-breadth from the cranial crest of
the tibia, in the belly of the m. tibialis cranialis. Earth point,
He point, Horary point. It is a major tonification point. Tonifes
Yin and Yuan Qi, tonifes Qi and blood. It strengthens the body, regulates
Yin and Wei Qi.
- CV 3 (Zhong Ji)
4 cun caudal to the umbilicus, on the midline. Alarm point of Bladder
Meridian, resolves urogenital problems.
- CV 6 (Qi Hai)
1.5 cun caudal to the umbilicus, on the midline. Sea of Qi, regulates
and tonifes Qi. It tonifes Yuan Qi, blood, Yin.
- SP 3 (Tai Bai)
on the medial aspect of the second toe, distal to the tarso-metatarsal
joint, on the postero-medial aspect of metatarsal II. Earth point,
Source point, Horary point. Major point for tonifying the spleen.
Benefits spleen transformation and transportation.
Chronology of
treatments:
At first, before
the diagnosis of leishmaniasis was confirmed, we started treating Astra
for the kidney pathology with fluids therapy (physiological saline solution,
lactated Ringer's solution and glucose solution) for a total of 60ml/kg
die in the first four days, followed by a maintenance treatment of 35ml/kg
die. Astra was also given albumin, as the tests continued to indicate
a considerable hypoalbuminemia. (Baxter Human Serum Albumin 20% Solution®),
150 ml/die for 4 days.
Astra was also given Omega-3 essential fatty acid, ACE inhibitors, Benazepril
chlorhydrate 10 mg/ die (Fortekor 20®), and followed a low-phosphorus
diet (Hill's Prescription Diet K/D).
The dog showed no
improvement. She still had little appetite, partly because she did not
like the new food. She was thin, lethargic and continued to lose urine.
I started to treat her with acupuncture: I administered moxibustion
on BL 20, BL 23-28, CV 6 and CV 3. On the following day, the customer
told me that the dog had not lost urine during the night, and so I continued
to perform acupuncture with two more treatments, one five days after
the other. The dog started eating again and was more lively.
Once we had the
results from the laboratory, we began with the treatment for leishmaniasis:
allopurinol twice a day (Zyloric®) to be continued for 12 months, metrodinazole
(25mg/kg) and spiramycin (1,500,000 IU/kg) twice a day (Stomorgyl 20®)
to be continued for 3 months. I continued with the acupuncture treatments,
and the fourth treatment included moxibustion on BL 20-23 and CV 6.
I used #8 Seirin needles (0.30 x 30mm) in points ST 36 (depth of 1mm)
and Spleen 3 (depth 0.5mm) with tonification method (rapid-heavy thrust,
slow-gentle lift, slow-small amplitude, clockwise, push needle slowly
to proper depth, then rapidly pull it up to just beneath the skin, pressure,
with channel course). In the meantime, as the dog had suspended fluids
therapy, she was treated only with oral therapy at home and was taken
to the clinic exclusively for the acupuncture treatments. The fifth
and sixth treatments were performed weekly with the same methodology
and same points as the fourth treatment.
At the end of the
acupuncture treatment, while still doing oral therapy, the dog's weight
increased and she recovered appetite, no longer lost urine, was lively,
and did not crave warm places. The mucosae were not pale and she was
willing to play again. The tongue recovered color and the pulse was
fuller.
I must say that the owner of the dog is very happy with the results,
as the dog, after six months, is still healthy. The blood examination
still shows altered but stable creatine (3.00 mg/dl) and BUN (38.3 mg/dl)
values. The antibody titer has gone down to 1/80.
DISCUSSION
When Astra arrived at the clinic, she showed symptoms that could possibly
refer to a kidney pathology, confirmed afterwards by the lab tests.
Considering that the dog lived in an endemic area for canine leishmaniasis,
we thought of this possible differential diagnosis, taking into account
that the ultrasound did not reveal major anomalies and the Ehrlichia
test was negative. After leishmaniasis had been ascertained by FNA of
the node and IFAT test, we deduced that the kidney pathology was connected
to leishmaniasis.
Considering that the dog was weak, depressed, and showed little desire
to move when she arrived at the clinic, while at the same time her Shen
was normal, it was plausible to think of Qi deficiency. Qi deficiency
is characterized by: pale face, pale tongue, lethargy, little desire
to move, weak pulse (2). Kidney Yin no longer nourishes kidney Yang,
and we thus have nocturia as a consequence of kidney Yang deficiency.
Kidney Yang Xu is characterized by frequent urination, some dripping,
increased frequency at night, pale urine color, increased volume (3).
The deficiency symptoms disappeared with tonification and by benefiting
the deficiencies through moxibustion and with needles in tonification
on BL 20,23,28- CV 3,6, -SP 3, ST 36. The animal's energy and tonicity
was restored, and even though she was still under maintenance treatment
and the values were still slightly altered but stable, Astra recovered
her normal health as before the disease.
Considering that leishmaniasis is a disease that affects the immune
system, I believe that an acupuncture treatment is very useful as it
acts upon the balance of the body, succeeds in restoring energy, and
in increasing immunity. Consequently. the animal can produce an effective
and protective immunitary response, which is able to stop the disease
from developing even if the animal has already been infected.
TABLE 1
HEMOGRAM
| |
Value
of the patient |
Normal
value
in the dog |
| RBC (mil/mm3) |
3,650,000 |
(5.5-7.9) |
| |
|
|
| MCV(fl) |
70 |
(70-77) |
| HCT (%) |
25.6 |
(37-55) |
| |
|
|
| WBC (migl./mm3) |
5,500 |
(6-16) |
HGB (gr/dl)
|
7.5 |
(12-18) |
| MCH (pg) |
20.6 |
(12.5-24.5) |
| MCHC (gr/dl) |
29.4 |
(32-36) |
| |
|
|
| PLT (migl/mm3) |
129,000 |
(200-500) |
| MPV(m3) |
9 |
(5-7) |
| PCT (%) |
0.116 |
(015-030) |
LEUKOCYTE FORMULA
| |
Value
of the patient |
Normal
value
in the dog |
| Segmented neutrophil |
3,615 |
(3,000-15,000) |
| Lymphocyte |
1,152 |
(100-4,800) |
| Eosinophilic granulocyte |
262 |
(100-1,250) |
| Monocyte |
209 |
(150-1,350) |
BIOCHEMICAL PROFILE
| |
Value
of the patient |
Normal
value
in the dog |
| ALT |
16 |
(<50) |
| ALP |
80 |
(<170) |
| Tot. Protein |
6.7 |
(5.5-7.5) |
| Albumin |
1.7 |
(2.5-4) |
| Globulin |
5.2 |
(2.54.5) |
| A/G Rapport |
0.3 |
(0.5-1.7) |
| BUN |
136 |
(<40) |
| Creatine |
3.3 |
(0.5-1.5) |
| Glycemia |
92 |
(80-110) |
| Calcium |
9.8 |
(9.12) |
| Phosphorus |
6.5 |
(2-6) |
| Hematic Potassium |
147 |
(3.7-5.8) |
| Hematic Sodium |
4.5 |
(141-154) |
HEMOSTATIC PROFILE
| |
Value
of the patient |
Normal
value
in the dog |
| APTT (sec.) |
17.2 |
(12.4-16.6) |
| PT(sec) |
8.5 |
(5.4-7.4) |
| FDPs (mg/mL) |
>2.5 |
(<2.5)
|
| Monocyte |
209 |
(150-1.350) |
| D-Dimer of fibrin |
0.34 |
(0.01-0.33) |
| Antithrombin III
(%) |
63 |
(100-148) |
| Fibrinogen (mg/dL) |
916 |
(150-400) |
TABLE 2
URINALYSIS
| |
Value
of the patient |
Normal
value
in the dog |
| Specific gravity |
1012 |
(1015-1040) |
| pH |
6 |
(5.5-7) |
| Leukocyte |
++ |
(neg.) |
| Nitrite |
Neg. |
(neg.) |
| Ketone |
Neg. |
(neg.) |
| Glucose |
Neg. |
(neg.) |
| Protein |
+++ |
(neg.) |
| Bilirubin |
Neg. |
(neg.) |
| Urobilinogen |
Neg. |
(neg.) |
| Hb/Mb |
trace |
(neg.) |
TABLE 3
ECHOCARDIOGRAPHY
TABLE 4
ABDOMINAL ULTRASOUND
HOURS ATTENDED
1999- Acupuncture course organized by SCIVAC- Cremona with IVAS speakers
(C.Robinson, C.Muller, J.Still, U.Wurther, L.A.A.Jansen, A.M.Shoen,
D.H.Jagger) (23-27 February, 26-29 May, 27-30 October).
2000- S.I.A.V. International Seminar on "Main locomotorium pathologies
in the dog. Diagnosis and therapy in Traditional Chinese Medicine" held
by Emil Van Den Bosch. (11 June)
2000- Bevas Course
- Lectures of 28-29 October with Marvin Cain on "Five Elements and equine
acupuncture"
2001- Veterinary
acupuncture seminar on "Medical bio-cybernetic approach in the competition
horse" held by Andreas Roesti. (17 February)
2001- Veterinary
acupuncture seminar on "San Jiao syndrome in the dog" held by Andreas
Roesti. (18 February)
2001- Workshop on
"Practical bovine acupuncture" held by Oswal Kothbauer (11-12-13 May)
2001- Bevas Course
- Lectures of 26-27 May with J.B. Limehouse and P.Taylor-Limehouse on
"Urinary disease, Bi syndromes, 8 principles"
2001- S.I.A.V. Second
International Seminar, "Clinical use of the five elements with horses"
held by Peggy Fleming and Are Thorensen. (9 June)
2001- S.I.A.V. Second
International Seminar, "Clinical use of the five elements with small
animals" held by Peggy Fleming and Are Thorensen. (10 June)
------
(1) S.I.A.V. Second
International Seminar, "Clinical use of the five elements with small
animals" held by Peggy Fleming and Are Thorensen (10 June 2001).
(2) Jim Skoien C.A.
Dipl. Ac. ,"The Eight Principles", The I.V.A.S. Veterinary Acupuncture
Course Notes, Page 4-5-16
(3) John B.
Limehouse D.V.M.,"Urinary Disease", The I.V.A.S. Veterinary Acupuncture
Course Notes, Page 8.1.4
