Our Journey with Polymyositis
By Kristin Mersinger
In November 2009, the sweetest little Kooiker, Bristow, registered name Rosewood’s Cato, came in to the world. He was instantly a part of the family. Bristow’s quirky spirit and loving disposition imprinted on everyone he met. They commented on how beautiful his earrings were and how well behaved he was.
Everyone referred to Bristow as my shadow. Where I went, he was sure to follow. We did everything together – hiking, swimming, playing in the snow. Had I known the fate of his future I would have done more with him.
In April 2018, we had noticed Bristow’s breathing had changed. It appeared labored, pushing more from his diaphragm. He also seemed to be having trouble making our normal walking distance without taking breaks. We took a trip to the vet where they took chest x-rays and did blood work. The diagnosis was haziness in his chest, so possible lung infection. All of the blood work came back great except for his CPK levels – those were slightly elevated, but not enough for the vet to see a cause for concern. We put him on antibiotics for 2 weeks. About 1 week later, Bristow was unable to make it out of the front yard. I took him to the ER where they did additional x-rays and blood work. Everything came back the same – haziness in chest and CPK levels slightly elevated. Both the vet and the Critical Care doctor stated the CPK levels could be elevated due to his physical state at the time the blood was withdrawn. We continued with the antibiotics and were referred to an Internal Medicine specialist because of the labored breathing.
In May 2018, we made our way in to see the Internal Medicine specialist. Upon arrival, Bristow’s heart rate elevated to around 220. He was immediately admitted in to the ER. They were able to get him to relax and eventually put him on oxygen. All the vets, doctors, specialists were in agreement that something was wrong with Bristow, we just didn’t know what. Multiple tests (CT scans, radiographs, ultrasounds, etc) were done and all of which concluded “unremarkable”. The day Bristow was to be brought home from the hospital, one of the Critical Care doctors showed a few specialists a video of Bristow walking. They decided to test and treat for Myasthenia Gravis – a disease that causes weakness and rapid fatigue of muscles under voluntary control. Treatment was Mestinon and Prednisone. A few days passed and Bristow was walking and playing again. He wasn’t back to 100% but we were so happy that he could walk down the street. About 2 weeks later, we received the test results – negative. However, we continued with the treatment because of the positive results. The Critical Care doctor then referred us to a neurologist.
In August 2018, we met with the neurologist. He was not convinced (and I agreed) that he had Myasthenia Gravis for two reasons: 1.) Bristow did not have any issues with his esophagus and 2.) the elevated CPK levels. The neurologist believed it was Polymyositis and mentioned a correlation between the disease and elevated CPK levels. However, he wasn’t ready to do further testing because he wasn’t familiar enough with the Kooikerhondjes and Bristow wasn’t showing symptoms (aside from the labored breathing). We decided to run his bloodwork one more time – if his CPK levels were elevated, he would order an Electromyography (which is an electro diagnostic medicine technique for evaluating and recording the electrical activity produced by skeletal muscles). The results – normal CPK levels. We decided to take him off the Mestinon but kept him on the Prednisone.
At this point, I’m sure you can imagine how frustrating this process was for us and for poor Bristow. He was such the brave boy. Researching this disease became a full-time job for me. The vets and specialists (along with myself) were so unfamiliar with the breed, we didn’t know where to begin. One Critical Care doctor’s heart was struck by Bristow and she stood by us until the end. She researched with me, sat with me, was just there to support me. Any disease I could find with similar symptoms, I would shoot off to her and she would talk me through why it might or might not be that disease.
In September 2018, I noticed an odd change in the way Bristow was drinking and eating. Something seemed off with his tongue. He was also salivating significantly. We had a follow up appointment with the neurologist, and he noticed his tongue immediately. He mentioned seeing this happen with Vizsla’s and Corgi’s – he called it tongue atrophy. We changed up medications and increased dosages. He was on a high dose of two different types of an immunosuppressant, antibiotics and pain medication. This is where things went downhill quickly.
A little note about Bristow: he was a very stubborn pup. If he couldn’t do something, he lost interest. Food was as high of reward as we could get. He would walk on water for cheese, popcorn, bananas. It was difficult for me to figure out what he was able and willing to eat as he could no longer chew food. We placed a piece of cheese in front of him and he turned away from it. My heart broke with that simple gesture.
So, we decided to do the Electromyography. The neurologist confirmed the readings of Polymyositis, but the only way to get a full diagnosis was to do the biopsy. And so, we did. I don’t regret doing the biopsy, but I wish I would have done it in May when Bristow was so much stronger. The results of the biopsy – Polymyositis. The neurologist was saddened by Bristow’s decline, but wasn’t ready to give up on him. He gave us a high calorie food to feed with a syringe. Which neither Bristow nor myself were thrilled about. A couple of days after, Bristow finally stopped walking. I carried him from his bed to the yard and back again. The spark was gone from his eyes. It was clear that he was done fighting. My husband said something very powerful that convinced me it was time to say goodbye. He reached down, scratched his head and said, “I’m going to miss you, buddy. I’ve been missing you for a while now.” It was time to let go of my shadow.
I encourage you take notice of the little differences in your pup. Don’t be afraid to ask your breeder questions. Polymyositis is hereditary so learn about your pup’s pedigree. The more we understand this disease, the faster it can be treated.
Please feel free to contact me or Susanne Martin with any questions
Kristin Mersinger (email@example.com)
Polymyositis in Het Nederlandse Kooikerhondje
BVM (PhD student)
Dr. Paul J.J. Mandigers
DVM, PhD, DipECVN, DipRNVA, DipEBVS.
Clinical Associate Professor in Neurology
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
Yalelaan 108, 3584 CM Utrecht, The Netherlands
Polymyositis in the Kooikerhondje appears to present in two forms that can either present themselves separately or combined.
The first type is marked by abnormal locomotion and locomotion problems due to general weakness, muscle weakness or stiffness. Most dogs presented with a stiff gait although the exact presentation varies based on which muscle groups are affected. The second type is marked by drinking, eating and swallowing problems. Both types may be present in the same dog. Other clinical signs are lethargy, weight loss, dyspnoea, general weakness, and/or exercise intolerance. Most of the symptoms present between one year and two years of age and there is no apparent predilection for age. Male dogs might be more likely to suffer from the disease than female dogs however.
Diagnosis is made based on the clinical symptoms, blood examination (elevated CPK), an electromyogram and histopathology. The latter is of the utmost importance.
As this disease is most likely immune mediated the basis of the treatment consists of corticosteroids in combination with oral supplements. The response to this treatment varies.
Currently we are investigating this disease (Paul Mandigers: firstname.lastname@example.org). As it is most likely hereditary we seek DNA samples of affected Kooikerhondjes. As written above the disease has to be confirmed with histopathology.
How can we help each other?
1. If you have a Kooikerdog under treatment with clinical signs that may fit a polymyositis please notify us. We would like to receive a copy of the patient record including blood test results and of the pedigree.
2. If the CK (or CPK) level is clearly elevated it is most likely a polymyositis case. The next step is to make an EMG (electromyogram) and/or sample muscle tissue. We are happy to get them examined for you. Ideally, we would like to receive a small sample (1 cm by 1 cm by 0.5 cm) of the triceps muscle and of the femoral biceps. Please put the two samples in a 4 to 10% buffered formalin container. You can send it to: Dr. P. Mandigers, University Clinic Faculty of Veterinary Medicine, Yalelaan 108, 3584 CM Utrecht (00 31 30 253 9411).
3. If the CK level is not clearly elevated please consider testing for myasthenia gravis as this is a disorder that occurs in this breed as well.
4. In all cases: if possible, make a video of the moving dog or when the dog is eating/swallowing. Videos can be sent in any format using www.wetransfer.com to email@example.com
5. In all cases we would like to get a DNA sample. We need 4 ml of EDTA blood. Please send it together with a copy of the pedigree to: Dr. P. Mandigers, University Clinic Faculty of Veterinary Medicine, Yalelaan 108, 3584 CM Utrecht (00 31 30 253 9411)
Based on the diagnosis we can advise you or your veterinarian on the treatment of your dog.
Yvet Opmeer and Paul Mandigers