How JustAnswer Works:

  • Ask an Expert
    Experts are full of valuable knowledge and are ready to help with any question. Credentials confirmed by a Fortune 500 verification firm.
  • Get a Professional Answer
    Via email, text message, or notification as you wait on our site.
    Ask follow up questions if you need to.
  • 100% Satisfaction Guarantee
    Rate the answer you receive.

Ask Dr. Gary Your Own Question

Dr. Gary
Dr. Gary, Dog Veterinarian
Category: Dog Veterinary
Satisfied Customers: 16848
Experience:  DVM, Emergency Veterinarian, BS (Physiology)
Type Your Dog Veterinary Question Here...
Dr. Gary is online now
A new question is answered every 9 seconds

My 13 yr. old dachshund has elevated liver enzymes (ALP 918

Customer Question

My 13 yr. old dachshund has elevated liver enzymes (ALP 918 & ALT 227). This started when he had his teeth cleaned and some pulled 3 months ago. 2 wks ago he coughed and breathed rapidly with very bloodshot eyes. Vet x-rayed and found a moderate bronchial pattern to suggest bronchitis. Clavamox and steroid eye drops given, but 2 wks. later, still an issue. He is extremely itchy all over, waters from his eyes, and has skin peeling off the bottoms of his foot pads. I have read up on this for many days and wonder if he doesn't have a systemic (or lung) fungal type infection. The vet, to appease me, gave me Ketoconazole for him. Is that safe for his liver? I have spent $3K on him this yr. alone, and want answers! Bloodwork, ultrasound, x-rays, exams. You would think something would get figured out! Vet says no pneumonia 2 wks ago & lungs sound better now, but not perfect. Could he have Blastomycosis? He has all the signs of it. I am happy to fax all his results if needed. Help! Trish
Submitted: 4 years ago.
Category: Dog Veterinary
Expert:  Dr. Gary replied 4 years ago.
Hello,

Where do you live?
Has he had a bile acids test to check liver function?
Has he had a liver biopsy done?
How is his breathing now?
Customer: replied 4 years ago.

Dr Gary,

 

I live in Boise, Idaho. Jake has never had a bile acid test or a liver biopsy. He is breathing somewhat better since the antibiotic 2 wks. ago, but still not completely normal. The liver biopsy was discussed in the beginning. Besides being so expensive, I didn't want to knock him out again and cause more trauma to his system. I asked what we do either way and the vet said Denosyl, so just began to treat his liver. My main concern is how hard on his liver the Ketoconazole will be. His bloodshot eyes are a concern and I feel a sign of "something". He's never had this happen before in 13 yrs. When I see the vet it seems we are coming up with zero answers and he just keeps acting like it's probably just some allergic bronchitis and that he is fine. And although I would love to believe that myself, the continued coughing after 2 wks. and still bloodshot eyes are a concern to me. The vet said that his heart looked fine, he has an enlarged liver, but no pneumonia was present with the x-ray. He's always had anal gland issues and has them expressed every 2 months or so. He just had this done 3 wks. ago., yet is still licking his bottom. He chews all his feet, licks his arms and but and rubs his face and chin all over everything. It's like he is itchy all over. He's always had a little of this, but now it's extreme. Last Sept. he had itchy skin and when they tested it, it was yeast. He got Ketoconazole back then for 2 wks. to clear that up. His bloodwork actually looked great before the teeth cleaning. It seems that ever since that happened he has been just struggling along now. I wish I had never got this done.

 

My thought is that the vet could have at least ruled out other things by doing a fecal test, urinalysis, cytology, etc. I don't want to tell him (or suggest) how he should do his job, but for the prices, seems he should be reaching a bit further. All the hours of reading I've done have educated me, but also have made me worry more. From what I read, Ketoconazole is not only hard on the liver of pets, but it also stops the adrenal glands from over producing steroid (cushings dogs). My vet didn't even know this. Strange? Maybe I should just look for a new vet. Smile

 

Thanks for you help,

Trish

 

 

Trish Maxwell, Realtor

Keller Williams Realty Boise

1065 S. Allante Place

Boise, Idaho 83709

(XXX) XXX-XXXX - cell

(XXX) XXX-XXXX - fax

Email: XXXXX@XXXXXX.XXX

Website: www.Customer.com

Expert:  Dr. Gary replied 4 years ago.
Thanks for the additional info,

Not an easy case, but here's the problem list I have:
Increased liver enzymes
Recurrent skin infections
Labored breathing
Coughing
Red eyes

Here is how I would proceed- my thought is that we need to tie this all together into one diagnosis.
My main differentials are:
1. Fungal disease (Blasto)
2. Hepato-cutaneous syndrome where the liver failure leads to cutaneous/ skin signs
3. Auto-immune disease- Lupus is a concern

Tests that are worth running and minimally invasive:
1. Urine blasto test- we can easily rule out blasto by sending out a urine fungal screening
2. Bile Acids Test- this is the only way to check liver function. It's a blood test and we run it over 2 hours. If normal, then the liver function is normal and we ruled out liver disease, hepato-cutaneous, liver cancer.
3. Coomb's/ ANA- this tests for auto-immune disease like Lupus. Again it's a blood test and gives us information right away with minimally invasive techniques.
4. Tonometry on the eye- this tests the eye pressure like the puff of air at the ophthalmologist. If low, then this is inflammation behind the cornea (uveitis) that is common with Blasto. If high, then it's glaucoma (not likely). If normal, then the red eye is likely conjunctivitis and topical steroid drops should help.

More invasive testing if needed:
1. Liver Biopsy- if the bile acids is abnormal, then we need a liver biopsy to get the diagnosis on what's wrong with the liver- cancer, auto-immune, hepato-cutaneous, chronic active hepatitis, hepatitis, ect.
2. Trans-Tracheal Wash- if everything is normal, then I'd get a wash of what's in the lungs (under light anesthesia) to find out what is causing the signs in the lungs- pneumonia, fungal disease, cancer

As for the Ketoconazole and the liver- it's not really that bad on the liver. If we have elevated bile acids, then I'd alter my dose but even a diseased liver can handle Ketoconazole. I really want a diagnosis of fungal disease before starting it though, as Ketoconazole for fungal disease is a 4-6 month treatment protocol, not the 7-14 days like with skin yeast infections. We can also use it to suppress the adrenals, but we use a higher dose and honestly nobody is really doing this anymore. When you stop the Ketoconazole, the adrenals rebound nicely and it actually doesn't work all that well to suppress the adrenals. It's more of a possible adverse effect, not an expected effect.

To be honest, this case would be best handled by an internal medicine specialist. I know they're more expensive, but at least you'll get the diagnosis after one visit as opposed to throwing multiple drugs at him and ending up at square one over and over again.

I hope this helps give you some information to work with, let me know if you have any other questions.
Customer: replied 4 years ago.

Wow! That's the most extensive and best info. I've gotten so far. Thank you!! Wink Last question:

 

How do I find a vet that specializes in Internal Medicine? Should I maybe seek a professional in an Emergency / Specialty center? We have one here called WestVet. I would like to bring all my current paper results and your email.

 

Thank you for all your help. Now I will be able to get to the bottom of it.

 

Trish

 

Expert:  Dr. Gary replied 4 years ago.
Trish,

To find an internal medicine specialist, go here:
http://www.acvim.org/websites/acvim/index.php?p=3

To find an emergency vet, go here:
http://veccs.org/hospital_directory.php

WestVet looks like a good referral/ ER facility (just checking out their site) where they can offer the diagnostics needed as well as 24 hour care. That's the route I'd go to get the diagnostics done and get to the bottom of this.

Good luck and let me know what you find.
Dr. Gary, Dog Veterinarian
Category: Dog Veterinary
Satisfied Customers: 16848
Experience: DVM, Emergency Veterinarian, BS (Physiology)
Dr. Gary and other Dog Veterinary Specialists are ready to help you
Customer: replied 4 years ago.

Dr. Gary,

 

How do I get a referral from you for Dr. Ochoa at WestVet in Boise, Idaho? She is the only internal medicine specialist in Boise, and works by referral only. I don't want to have to go to Jake's original vet again for this. Can you help out so that I don't have to do that?

 

Thanks!!

Trish :o)

 

 

Expert:  Dr. Gary replied 4 years ago.
Trish,

I can't refer a patient I haven't seen- you'll have to just call your vet and ask them to fax records to the internist. Just tell them that you want a second opinion- they won't be mad.

JustAnswer in the News:

 
 
 
Ask-a-doc Web sites: If you've got a quick question, you can try to get an answer from sites that say they have various specialists on hand to give quick answers... Justanswer.com.
JustAnswer.com...has seen a spike since October in legal questions from readers about layoffs, unemployment and severance.
Web sites like justanswer.com/legal
...leave nothing to chance.
Traffic on JustAnswer rose 14 percent...and had nearly 400,000 page views in 30 days...inquiries related to stress, high blood pressure, drinking and heart pain jumped 33 percent.
Tory Johnson, GMA Workplace Contributor, discusses work-from-home jobs, such as JustAnswer in which verified Experts answer people’s questions.
I will tell you that...the things you have to go through to be an Expert are quite rigorous.
 
 
 

What Customers are Saying:

 
 
 
  • It was so professional, so personally concerned (as we were) and you answered all of our questions. George and I are so happy that I found "JustAnswer" on my Google search -- you are now in my "Favorites" list! And, yes we do love our kitty - she makes our life complete! Bev & George Boca Raton, FL
< Last | Next >
  • It was so professional, so personally concerned (as we were) and you answered all of our questions. George and I are so happy that I found "JustAnswer" on my Google search -- you are now in my "Favorites" list! And, yes we do love our kitty - she makes our life complete! Bev & George Boca Raton, FL
  • Wonderful service, prompt, efficient, and accurate. Couldn't have asked for more. I cannot thank you enough for your help. Mary C. Freshfield, Liverpool, UK
  • This expert is wonderful. They truly know what they are talking about, and they actually care about you. They really helped put my nerves at ease. Thank you so much!!!! Alex Los Angeles, CA
  • Thank you for all your help. It is nice to know that this service is here for people like myself, who need answers fast and are not sure who to consult. GP Hesperia, CA
  • I couldn't be more satisfied! This is the site I will always come to when I need a second opinion. Justin Kernersville, NC
  • Just let me say that this encounter has been entirely professional and most helpful. I liked that I could ask additional questions and get answered in a very short turn around. Esther Woodstock, NY
  • Thank you so much for taking your time and knowledge to support my concerns. Not only did you answer my questions, you even took it a step further with replying with more pertinent information I needed to know. Robin Elkton, Maryland
 
 
 

Meet The Experts:

 
 
 
  • Dr. Debbie

    Dog Veterinarian

    Satisfied Customers:

    902
    Companion animal veterinarian practicing for over 10 years.
< Last | Next >
  • http://ww2.justanswer.com/uploads/DE/debkatreyn/2011-11-28_33650_682e.64x64.jpg Dr. Debbie's Avatar

    Dr. Debbie

    Dog Veterinarian

    Satisfied Customers:

    902
    Companion animal veterinarian practicing for over 10 years.
  • http://ww2.justanswer.com/uploads/VE/vetforyou/2012-6-20_33122_PearlPhoto.64x64.jpg Dr. Andy's Avatar

    Dr. Andy

    Medical Director

    Satisfied Customers:

    13796
    UC Davis graduate, emphasis in dermatology, internal medicine, pain management
  • http://ww2.justanswer.com/uploads/doggfone1/2009-07-16_133633_vet_pic.jpg Dr. Scott's Avatar

    Dr. Scott

    Veterinarian

    Satisfied Customers:

    9550
    12 years of small animal, equine and pocket pet medicine and surgery.
  • http://ww2.justanswer.com/uploads/RY/rydergar/2012-6-6_192240_IMG0328.64x64.JPG Dr. Gary's Avatar

    Dr. Gary

    Dog Veterinarian

    Satisfied Customers:

    7758
    DVM, Emergency Veterinarian, BS (Physiology)
  • http://ww2.justanswer.com/uploads/AN/andrewDVM/2012-4-27_12585_iStock000011751407XSmall.64x64.jpg Dr. Drew's Avatar

    Dr. Drew

    Dog Veterinarian

    Satisfied Customers:

    6598
    Small Animal Medicine and Surgery
  • http://ww2.justanswer.com/uploads/1I/1ISUDVM/2011-3-1_22028_Honeymoon2005075294928803490646858.64x64.jpg Dr. Bruce's Avatar

    Dr. Bruce

    Veterinarian

    Satisfied Customers:

    6377
    13 years of experience as a small animal veterinarian
  • http://ww2.justanswer.com/uploads/BI/bigislandvet/2013-2-21_214244_IMG0357.64x64.JPG Dr. Michael Salkin's Avatar

    Dr. Michael Salkin

    Big Island Vet

    Satisfied Customers:

    6049
    University of California at Davis graduate veterinarian with 41 yrs. of experience.