Need Help - Osteosarcoma, Uncontrolled Hyperthermia

[Rickiesmom]

This is going to be long, please bear with me, as we have no diagnosis for Jeff's problems and as you will see at the end, we desperately need an answer:

July 10 Jeff went in to see a neurologist at our very good referral hospital, because he was showing signs of hind end weakness (no limp, but increasing trouble getting up). Because of his age (9.5) and history of IMHA, the neuro consulted with the anaesthesiologist before Jeff was sedated for imaging. They used drugs he had had before without issue.

Two big pieces of news came out of that session: he had osteosarcoma at the top of his right femur and as he came out of sedation he had gone into a hyperthermic state, there were 6 people working to cool him down, and in answer to my question, yes, he was very much at risk.

They pulled him through, and bloodwork afterwards, and later, as well as abdominal ultrasounds showed, thankfully, no organ damage. His temperature continued to stay on the high side though, and his platelets were falling, so Jeff remained in ICU. He was very painful, a combination of the osteo and the manipulations required to get the right diagnostic images, so they catheterized him to avoid moving him too much. Endless testing found no cause for the stubborn high temperature or platelets, and the working hypothesis was that cytokines released by the tumor were wreaking havoc.

July 17 we discussed the situation with his surgeon - this surgeon is very good and someone I completely trust. He felt the best bet was to remove the leg (and its cytokine generating tumor) as soon as the platelets were high enough. It might be soon because they had started an upward trend.

July 18 platelets were at around 100, so with Amicar on board, Jeff's leg was removed. He remained in ICU to recover, and they continued to monitor his temperature, which gradually came down to around 101 - 102.

July 22 we brought Jeff home on Gabapentin and Metacam, as well as an antibiotic, chloramphenicol, as he had a bladder infection that included a very resistant bacteria. In spite of which his appetite gradually improved and he was getting very good at getting around on three legs. When walked on the street for a short distance, he'd dig all feet in when we turned around, because he wanted to go further. Only thing was that he was licking a lot - everywhere, I thought at first behavioral, then wondered about a reaction to the antibiotic.

July 31 his stitches came out and there was one small area that oozed a little, but otherwise it was all good. His bloodwork was also good - platelets 199 - he received his first chemo treatment - Carboplatin. Came home and initially did OK. Appetite a little off, then gradually completely off - Cerenia did not help.

August 1 - that area of the incision oozed a little again, but I cleaned it up, applied some neosporin, and it seemed fine after that.

August 2 his temperature was up - 103 - took him in, and they again put him on fluids with a fan. Examined the problem area of the incision, deemed it a little puffy, looked at it with ultrasound to see if there was a pocket behind it - there was a small pocket of fluid which they sampled and sent out for culture. Fluid was like serum with a bit of blood. WBC count up a little, otherwise bloodwork all good.

They took him off the chloramphenicol in case it was causing a reaction that resulted in the incessant licking, and also thought it would make him feel better and improve his appetite.

No one knew for sure why his temperature is staying so stubbornly high. Working hypothesis was that it might be infection in the incision (that pocket area). Meantime, they gave him one dose of Pred - 10mg. Not something anyone wants to do with a dog on chemo, but it was meant to help with the temperature.

August 4 they called in the morning - temperature holding at 102, if no change during the day, he could come home that evening. He was also eating a bit - combination of food I had brought for him and A/D, and was going outside to do his business OK.

We went down around 4:30 to visit and hopefully bring him home. I looked at his chart - during his stay the highest temperature had been on August 3 - a tad over 104. And his latest reading was up from 102 to 103.5, therefore, they kept him overnight.

August 5 he received another dose of Pred the previous evening (I was in tonight but didn't have access to his chart, but my understanding is that he got Pred if his temperature hit 104.) This morning it was 102 and they had the preliminary culture back, showing gram negative bacteria. They were going to put him on IV Baytril and keep him overnight so he could have enough time on IV abx for it to act. If his temperature held, we would be able to bring him home tomorrow.

I visited this afternoon and noticed his heart rate seemed a little fast. Asked someone to check it - don't have the number but she said while a little high, not concerning. However, at the same time she took his temperature. It was just under 104. She rubbed his feet and abdomen with diluted alcohol to help him cool a little. (He is still on fluids and has a fan trained on him.)

He is incredibly thin, and on his short walk, energetic going out, but weak on the return. ACA carried him back in. He isn't eating any of the goodies I brought from home, in fact, he tried to bury the plate.

My hope is that the Baytril needs more time to become effective, but I am so worried, and so frustrated because while the infection is the working hypothesis, it isn't a definitive cause.

The only tests I know they haven't run are a fecal and a thorough TBD. He had TBD testing done at NC State in 2013 and 2015 which were negative, not sure if worth running again. He had a negative fecal in the Spring, and when I brought it up, while they weren't opposed to running it, they said there was nothing in the bloodwork or the stool form to suggest a problem.

I ask the hospital to initiate a consult with Dr C, but in the meantime, would like to hear from anyone with an experience that might suggest what is wrong, or a direction to pursue.

Thank you so much. I am heartsick with worry.

[GreyPoopon]

I don't have any advice, but send sympathy and hugs. I hope (medically) difficult Jeff pulls off another brilliant recovery.

[Batmom]

How has he been about being at the vet/in hospital? Only reason I ask is, one of mine could shoot up to 105 F in minutes, just from the stress of going to the vet for an exam. She was perfectly healthy, just anxious. If he needs to be in hospital, maybe worth adding an anti-anxiety drug to see if that helps him? Best thoughts.

[Houndtime]

Shine also spiked 104 just being at the vet. I am sorry that your boy is doing so poorly. I will keep him in good thoughts.

[FiveRoooooers]

My heart hurts for you and your family. I am glad that a consult with Dr. C has been initiated.

[Rickiesmom]

An anti-anxiety drug is a good idea. He was on one right after the initial hyperthermia, but not since. My sense is that he is more depressed than anxious, but the relief may be the same.

 

Unfortunately, it appears Dr. C is out of the country, this is the response I received:

 

"I will have limited access to email, so if this is an urgent consult on your pet, please contact your family vet. I will likely reply to emails within 48-72 hours (for both owners and veterinarians). Thanks!"

[ramonaghan]

Sending many hugs your way and for Jeff.

[Remolacha]

[FiveRoooooers]

FWIW, Dr C was out of the country when I emailed him about Seamie. His response still came very, very quickly.

[Time4ANap]

FWIW, Dr C was out of the country when I emailed him about Seamie. His response still came very, very quickly.

 

Same here when we needed some x-rays reviewed. Hope Jeff is feeling better and home with you soon.

[MaryJane]

My Adam had issues with hyper-temperature and it did make the amputation and follow-up visits difficult. The initial hyper-temperature episode showed up when Adam was waking up from his dental -- once he started moving around, he went into hyper-temperature. When we faced the issue with osteo, all the doctors were aware and would take special steps to ease his anxiety - luckily there was a resident that fell in love with him and stayed with him and did most of the care while he was in the hospital. Without her, I probably would never have been able to bring him home. We did a special protocol to be able to do the chemo and that was to give him two 300mg gabapentin 2 hours before the appointment and that would chill him out so that he would not get anxious - made him very clumsy and his 3 legs would literally get intertwined (so I would have to be very careful) but, it kept his temperature down.

 

In your case, it sounds like the hyper-temperature was happening mostly in the hospital and when it happened at home, it was the day after chemo so, it might be from anxiety.

 

Good luck.

[NeylasMom]

I was going to suggest trying the Gabapentin as well if you do suspect anxiety. It's not likely to do any harm and does have good evidence to back using it off label for anxiety. You do need somewhat higher doses like MaryJane mentioned. If he's on it continually something like 400 my every 12 might be sufficient. At this point it seems like its worth a try and it will help with any discomfort, which could also contribute to stress.

[greysmom]

My feeling as well is that this may be some sort of anxiety reaction.

 

My other thought was in all the imaging if they got a good view of his heart? With his prior hyperthermia event, and the chemo, I might be a bit worried about how his heart is doing - it's possible the cancer had already metasticized to his heart, or the chemo caused a bad reaction - then on top of his panting it's working overtime and spiking his temp and now it can't come down???

 

It seems I read somewhere that some post-anesthesia hyper-/hypo events may be caused or exacerbated by a lack of potassium. Potassium is a key heart supplement too. I don't know how easy it is to run a level and check.

 

Just typing out loud and brain storming. Hope you can figure out what's going on and he can come home.

[Rickiesmom]

Thank you all so much for your thoughts. Jeff was originally sent home with Gabapentin - 300mg twice per day I think (don't have his meds here, I took them with him when we returned to the hospital). It is possible, even likely he is still on it, will ask about that today and proceed accordingly.

 

Mostly, I really want him home, and you have reinforced that. I feel like I'm losing him an ounce at a time. Also would like them to run blood work again if they haven't done so since he was admitted. Will ask when they call this morning.

 

About his heart - they did a full abdominal ultrasound following the initial hyperthermic event, and another follow up one on July 24 and found no issues. I know his heart as well as his organs were a concern following the event, and both u/s were done by an internal med specialist. That said, I will ask what his heart rate has been like during this stay.

 

The hospital should call soon with an update, and I have added to my list of questions based on your input, for which I am inexpressibly grateful.

 

Will post again after I hear from the hospital.

[KF_in_Georgia]

 

It seems I read somewhere that some post-anesthesia hyper-/hypo events may be caused or exacerbated by a lack of potassium. Potassium is a key heart supplement too. I don't know how easy it is to run a level and check.

 

 

 

Actually, the danger is too much potassium post-anesthesia. See here.

[BatterseaBrindl]

[Rickiesmom]

His temperature was up to just under 105 last night. The gave him another 10mg of Pred. No one is happy about this given that he has an infection. His temperature this AM when I spoke with the hospital was down a bit to 104, still high but at least heading in the right direction. Hopefully it will also encourage him to eat.

 

The really unfortunate news is that the final culture report indicates that the bacteria are resistant to Baytril, which may help explain that there is no real improvement, including in his temperature behavior. They are putting him on Cesazolin, which worries me a bit due to his IMHA, but what to do - the infection must be addressed. Because of this change, they want him on IV for 24h, so I can't bring him home until tomorrow AM. I am going down there early in the morning to beat traffic, so I am ready to bring him home as soon as they confirm he is good to go. They want him home too, so unless it becomes medically inadvisable for some reason, we have to wait "only" one more long day.

 

He is on Gabapentin 300mg three times per day. Currently this and the abx are the only drugs he is receiving. I didn't pursue an anti-anxiety drug since the Gabapentin is probably addressing that somewhat, certainly he has seemed pretty sleepy whenever I've visited.

 

Asked about an anti-nausea drug in case it would help with eating, the intern said she would check with the oncologist.

 

He's lost about 2.2 pounds since he was admitted on Thursday, they are weighing him every day. They are also monitoring his electrolytes daily, and I asked about running at least a CBC before discharge so we have a new baseline. Not sure if they will run a full chemistry as well, I left that up to them.

 

So on the upside, he will be on an antibiotic that should address this infection, but it means he is stuck there until tomorrow. We are all, however, of the same mind about him coming home, so I am confident they will discharge him as soon as they feel they can responsibly do so. Meantime I will plan on a long visit with new temptations he will hopefully eat, and something to read while he sleeps beside me.

 

He is in a two-sided enclosure, so lots of room and also easy for staff to have eyes on him, and spend a little time with him when they can, so it's about as good as it can be, just not home.

[NeylasMom]

Makes sense that he wouldn't be improving much with the wrong AB so hopefully this gets him on the right track. I think the anti-nausea med is a no brainer. They can give him an injection of Cerenia. My vet loves Cerenia, says it has some anti-inflammatory properties as well so it my give him a much needed boost. Especially with what you described about him trying to bury the dish it does sound like he's nauseous. Keep us posted!

[racindog]

Yes it sounds like the new antibiotic is just what the doctor ordered. I remember Bobber had fever that they could not keep down as well one time. Her condition continued to deteriorate even IV antibiotics didn't help. The vet tried pretty much all the antibiotics with no results and then tried one that was not labelled for dogs but horses. She also had an accupuncture treatment. Regardless there was immediate improvement and she recovered quickly. Turns out it was a systemic kidney infection. Though that was 15 years ago I still have the vial of that antibiotic in the fridge just in case I have another dog with a similar issue(as that vet is no longer in the country). So anyway- since we know the antibiotic Jeff is not on is effective I just have to believe he will make a quick and full recovery as Bobber did once she got the right antibiotic. Prayers going up from KY!

[carronstar]

[MaryJane]

I vaguely remember another dog that had an infection that was near impossible to get rid of after the amputation and I think that she used a hyperbaric chamber - it was Twiggy (correct me if I am wrong). You might want to go back and see the old posts. This was years ago ... maybe like 5 or 6.

[mychip1]

I wish I had advice - but just can send prayers.

[Rickiesmom]

I vaguely remember another dog that had an infection that was near impossible to get rid of after the amputation and I think that she used a hyperbaric chamber - it was Twiggy (correct me if I am wrong). You might want to go back and see the old posts. This was years ago ... maybe like 5 or 6.

 

Thank you for this. Jeff seems to be responding to the antibiotic (update in next post) but should it return, this is very good to know about !

[Rickiesmom]

Good visit with Jeff! He still isn't eating any of the food I brought from home yesterday, so today I brought cubed grilled steak (seasonings cut off), Cantanaar cheese, which is 19% MF so not super-rich, ice cream and, only to help with pills, liverwurst.

 

To my delight, he ate the steak and the cheese without hesitation. Hopefully no digestive issues later, because so good he has something in his tummy. No interest in the ice cream, and somewhat surprisingly, in the liverwurst either. Still, it was wonderful to see him want to eat something!

 

His temperature at noon had started to come down, it was 103. At 6PM it was an incredible 99.5 ! I almost hugged the tech! It is quite a dramatic drop, so it will be interesting to know what the next readings are. Hopefully they stabilize in this general range.

 

Although he slept much of the time, his overall aspect seemed better, and when not out cold he objected if I stopped petting him, so not nearly as lethargic as before. So maybe, finally, this antibiotic will clear up the infection and all the issues it has caused.

 

Unless something changes, things look pretty hopeful for coming home tomorrow, though clearly some discerning grocery shopping will be needed before the discharge appointment!

 

I cannot tell you how relieved I am, or how grateful I am for all your support and input - I used so much of it in conversations with the hospital.

 

More tomorrow once I hear in the morning.

[Annette]

So good to see that Jeff is improving. When Pogo had his leg amputated he came home but would not eat. We could not pill him. He actually clamped down pretty hard on Roy's hand and we were surprised that he did not draw blood. When we took him back to the vet school he was running a fever of 106. Pogo ended up being at the vet school for a total of 9 days. When he finally recovered it was like he never skipped a beat. He hopped onto our bed (where he was not allowed) so we put the plastic desk mat back up there to keep him off. We didn't think he would jump on the bed as a tripod. Pretty soon he was running more that he ever did as a "4 on the floor".

 

Sending gentle hugs and healing thoughts your way.

 

Annette