An integrative therapy for paraplegia dog with ehrlichiosis†

An eight-months-old male Golden Retriever was referred to Veterinary Teaching Hospitalof IPB University with clinical signs of non-ambulatory paraplegia, tail paralysis, urinary and faecal incontinence, pale mucosa, and loss of sensory and motoric responses on both pelvic limbs. The hematology examination showed thrombocytopenia (125x10 3 /μL), monocytopenia (0.09x10 3 /μL),and no significant decreased of hematocrit (36.88%). Rapid diagnostic test and blood smears were positive for Ehrlichiacanis infection. Abdominalsonogram showed splenomegaly and hepatomegaly with hepatic vessels dilatation. An integrative therapy was done using medications (vitamin B-complex, cyproheptadine, methylprednisolone, doxycycline, and Fundamin E ® ), herbal (Gui Pi Tang ® and Fu Fang Ejiao Jiang ® ), acupuncture, micro-radar, and Tuina massage. The dog was able to walk and run after 10 th session of the intensivetreatment then discharged from the hospital after two months. One week after, the dog started dragging his toe. A customized shoe then made to prevent furtherinjury to the affected limb. The acupuncture was continued once a week for the following two months. The dog is still able to walk and run at his last visit 5 months later. This shows that an integrative therapycan give a good performance in recovering ambulation of paraplegia dog with ehrlichiosis.


■INTRODUCTION
History and anamnese: An eight-months-old male Golden Retriever, weighing 25kg, presented for pelvic limbs and tail paralysis. The owner reported that the dog suddenly cannot walk after playing with his fellow dogs at home and suspected lumbar trauma. The dog has not received any treatment for 2 weeks.

Clinical findings:
The physical examination showed a general weakness, pale mucous, stiffness at both thoracic limbs, pelvic limbs and tail paralysis without signs of pain at the palpation along the vertebrae (Figure 1a). The heart rate was 122 beats per minute, respiration rate of 44 times per minute, and body temperature of 39 o C. Several wounds found on his rear due to dragged pelvic limbs. Severe skin irritation on his abdominal and inguinalarea was marked due to urinary and faecal incontinence. Neurological examination disclosed an alert mental status and nonambulatory paraplegia with mild muscle atrophy at both pelvic limbs. Proprioceptive deficits were detected at all four limbs, but more severe in pelvic limbs. Patellar, withdrawal, and anal reflexes were decreased.

■ MATERIAL AND METHODS
Diagnostic tests: No abnormalities found in the radiograph and blood chemistry examinations. The hematology examination showed thrombocytopenia (125x10 3 /µL), monocytopenia (0.09x10 3 /µL), and no significant decreased of hematocrit (36.88%). The blood smears and rapid tests were positive for Ehrlichia canis infection. Hepatomegaly and splenomegaly were significantly observed in dog's sonogram ( Figure S1).

Differential diagnosis and prognosis:
The diagnosis based on conventional medicinewas non-ambulatory paraplegia and ehrlichiosis. In Traditional Chinese Veterinary Medicine (TCVM), this condition called local Qi and Blood stagnation at lumbar area leading to KID yin deficiency with blood deficiency. The prognosis was good due to young age and positive response towards the integrative therapy.

Treatments:
The dog was hospitalized and received vitamin B-complex (Neurobion ® 200mcg/kg once per day PO) and cyproheptadine (Pronicy ® 2mg/kg twice per day PO) for a week. Then the medication changed into methylprednisolone (2mg/kg twice per day PO), multivitamin (Fundamin E ® one tablet daily), doxycycline (5mg/kg twice per day PO), and herbal Fu Fang Ejiao Jiang ® (20mL per day PO) for 2 weeks. Gui Pi Tang ® one tablet per day PO then used to replace Fu Fang Ejiao Jiang ® for the following one month. Acupuncture, micro-radar, and Tuina massagewere delivered together, three times per week, for the first two months. Then it decreased into once per week for another two months after he discharged from the hospital. There were 40 acupoints chosen for this case, but one session of acupuncture only used up to 15-20 acupointsbased on the patient's condition at that very moment of therapy (See Table S2.1 and Table S2.2 for the list of acupoints and herbal functions).

■RESULTS AND DISCUSSION
Results: The recovery process of integrative therapy can be seen in Figure 1. (b-f). The dog finally can stand, walk, and run on his own on 10 th session and was discharged after 2 months (16 sessions of therapy). Then he came back one week later dragging his right pelvic limb. The skin around the paw was injured due to the friction against the ground. A customized shoe then designed for his right pelvic limb. The dog started wearing the customized shoe in January 2019 and showed a good recovery.   et al. 2009). We used the acupuncture as the main therapy for the dog. Acupuncture has the ability to reduce the pain due to its analgesic and antiinflammatory effects and has been clinically proved to help recover ambulation in paralysis animals (Xie & Wedemeyer 2012). Meanwhile, the customized shoe was made to correct and conditioning the 'dragging toe' limb into a normal posture and gait as well as protect the nail and skin from the damage of being dragged along the ground.

■ CONCLUSION
The combination of western (conventional) and eastern (Chinese) medicine, can be used to give greater results in a shorter amount of time in treating paraplegia dog with ehrlichiosis. Figure S1 showed the the sonogram of the patient. Hepatomegaly and splenomegaly were significantly observed as a concequnce and also an indicator of blood parasite infection. Vessel dilatation can also be seen in both liver and spleen. Figure S1. The sonogram of the dog: (a) hepatomegaly with hepatic vessels dilatation, and (b,c,d) splenomegaly. Table S2.1 showed the acupoints chosen and used in this case. There were 40 acupoints chosen, but in one session of therapy we only used about 15 to 20 acupoints, based on the patient's condition at that very moment. The clinical indication and function of each acupoints can also be seen in Table S2.1.