Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018027
Abstract:
This case report describes Mike, a 10 year old (presumed), male neutered cat. He lives with two other cats and uses an enclosed catio for outdoor experiences. He was presented in October 2018 for an acupuncture consult because of his left (OS) periocular excoriation, epiphora, chemosis, and rubbing, for the past two years. Since then, he had become distant and anxious. Oral gabapentin helped with symptoms, but because he disliked being medicated, it interfered with his relationship with his owners. Physical exam showed a body condition score (BCS 6/9), rumpled fur, with alopecia and epiphora, OS. Myofascial exam yielded atrophied temporal and masseter musculature and decreased muscle mass of his rear legs; specifically hamstrings, quadriceps, and gluteals. There was also a medially luxating patella on the right, which didn’t apparently bother him.
History and Presentation
Mike had an unknown history before his adoption from a rescue organization in July 2014. He was tested at that time, for FeLV and FIV, both tests were negative, and the urinalysis and complete blood work were within normal limits. Three months later he had a dental with many extractions, and moderate gingivitis was noted. In February 2016, gingivitis had progressed to stomatitis. Once again he had full bloodwork and a dental, this time with a boarded veterinary dentist, who performed a full mouth extraction. Post extraction recovery was rough, with months of medial canthal bleeding from OS, a sialocele on the left side of his tongue, inappetence, and lethargy. Cat received buprenorphine and mirtazapine, for a short time during recovery. During the two years that followed, his left eye responded to intermittent use of neomycin, polymixin, dexamethasone ophthalmic solution. This diminished conjunctivitis and chemosis, but not rubbing and scratching. In March 2018, he was examined by a board certified ophthalmologist and she determined that he was experiencing a cyclic herpes flare up OS. It was recommended to moist warm pack eye and use moisture drops as needed. Two months after his visit to the ophthalmologist, he presented with severe periocular alopecia,inflammation, and excoriation OS. There was also epiphora and severe conjunctivitis, OS. He had become much more distant and anxious. He was treated with injectable 43.2mg cefovecin subcutaneously, 6mg robenacoxib orally for 3 days, and 25-50 mg gabapentin orally every 12h. Update two weeks later, reported that his eye was looking better, and owners felt like there was a reduction in pawing, especially during the second week of treatment with gabapentin alone. It was recommended to stay on gabapentin.
Physical Exam and Clinical Assessment
Physical exam of Mike on day 1 of acupuncture evaluation, yielded a quiet cat with BCS 6/9. There was faint periocular new hair growth and epiphora OS. His full mouth extraction demonstrated healthy oral tissue. Myofascial exam yielded bilateral temporal and masseter muscle atrophy. There was bilateral decreased muscle mass of his hamstrings, quadriceps and gluteals. A medially luxating patella was found on the right. No obvious trigger points were found. Owners also indicated that he was a shy cat, made even more so by his continued anxiety regarding his left eye discomfort . His good friend, another cat in the household of three cats was beginning to get sick. Although gabapentin decreased the symptoms regarding his left eye, the dosing itself was affecting his relationship with his owners. Thus, gabapentin was intermittently administered.
Problem List:
-Anxiety and increased shyness perceived after full mouth extraction, sick cat friend, and regular dosing with gabapentin.
-Left eye (OS) excoriation and drainage: chronic, which did respond to gabapentin dosing.
-Decreased muscle mass( temporal and masseter ) secondary to full mouth extraction and consequent mastication changes, with neural and vascular damage.
-Decreased muscle mass in his hind legs secondary to osteoarthritis, intervertebral disc disease, and a medially luxating patella.
Differential Diagnoses (Ddx)
-Ddx for his emotional state: Chronic trigeminal neuritis: pain, tingling,and numbness. His cat friend was sick and dying. He disliked being medicated with gabapentin.
-Ddx for periocular aggravation and unilateral epiphora: trigeminal neuritis and vascular abnormality, secondary to full mouth extraction; with consequent abnormalities to the orbital oculi muscle, facial sensation, and lacrimal gland. The ophthalmic branch of the trigeminal nerve has both sympathetic and parasympathetic fibers. And/or a unilateral cyclic herpes flare up.
Putative/Definitive Diagnosis
-Anxiety: From neural dysfunction secondary to a full mouth extraction. His housemate friend who had been in a leadership role is now sick. Worry regarding being medicated.
-chronic periocular excoriation: Neuritis secondary to full mouth extraction. It wasn’t until his full mouth extraction that his left eye started to bother him. The ophthalmic exam with a board certified ophthalmologist felt that he was dealing with a cyclic herpes infection, however, the conjunctivitis, chemosis, and epiphora occurred after he started to rub and scratch his left eye.
Medical Decision Making
Given the cat’s response to gabapentin, in terms of possible neural pain, it was thought that perhaps he would respond to acupuncture and massage. These modalities had the potential to help this patient in many ways. One goal would be to help his well being and demeanor by bringing into homeostasis his autonomic system. He likely had a stimulated sympathetic nervous system due to his anxiety and discomfort. In terms of his periocular discomfort we can neuromodulate this area directly through the, trigeminal, facial, and lacrimal nerves. By releasing his myofascial restrictions, secondary to osteoarthritis or neuritis, his rear limb muscle atrophy can be addressed with massage and acupuncture.
Acupuncture Treatment (AT). All began with myofascial exam and passive touch. All ended with passive touch and effleurage.
Day 1 AT #1: GV20, GV14, Bai Hui. Cat relaxed and became very quiet on the blanket. Bilateral TH21. Then left SI19, GB2. Cat remained calm for 20 minutes. Seirin 0.15 x 15mm needles.
The first treatment had the following goals: help balance his autonomic system from the stress of his chronic ocular discomfort and the stress of his household friend becoming ill, these would be GV20, GV14, Bai Hui. Neuromodulation of his chronic ocular discomfort with TH21, GB2, SI19, initiated connection to the facial and trigeminal nerves.
Day 7 AT #2: Physical exam was unchanged outside of right gracilis muscle being tense. GV20, GV14, Bai Hui,. Cat relaxed as before. Then TH21, SI19, GB2, as before.
Added TH17, to address another facial nerve point. Used Seirin 0.15x15mm needles.
Day 15 AT #3: This day, cat came over and laid down next to me at the start of the appointment. Slight epiphora lower lid, OS. GV20, GV14, Bai Hui. TH21, SI19, GB2,TH17 as before. Added GB20 to address head and neck pain as well as eye problems neuromodulating cranial cervical spinal nerves. Used Seirin 0.16x15mm.
Day 27 AT#4: Physical exam as before, but today his omotransversarius muscle right and left demonstrated taut bands, periocular fur regrown including eyebrow whisker on the left eye. GV20, GV14, Bai Hui, TH17. GB21 added to address local and regional muscle tension related to the spinal accessory nerves. Seirin 0.16x15mm used.
Day 69 AT#5: Physical exam demonstrated relaxed cervical muscles, epiphora left eye. His left front antebrachium and paw were tear-stained. Again, he came and laid down next to me before his treatment. GV20, GV14, Bai Hui, TH21, SI19, GB2,TH17. Added BL2 left, for neuromodulation of the trigeminal and facial nerves. ST36 was added for creating crosstalk between the trigeminal and vagus nerve, by way of the nucleus tractus solitarius. This point generates parasympathetic stimulation helping to tone down inflammation and support the immune system. Seirin needles 15x15mm.
Outcomes Discussions, and References
For five days after the first AT, Mike would raise his paw to scratch his face, then would stop and go about his business. Day six and seven he did scratch a little, but far less than when on the gabapentin. He seemed happier at home and more active. There was also less ocular discharge OS. There is evidence that acupuncture can induce analgesia for the relief of dental pain
(Silva S.A.,Acupuncture for the Relief of Pain of Facial and Dental Origin. Anesth. Prog, 1989, 36:242-248) And (Lao L, et al., Evaluation of acupuncture for pain control after oral surgery:a placebo-controlled trial, Arch Otolaryngol Head and Neck Surg 1999, 125(5):567-572).
The evening after his second AT, Mike slept peacefully. Mike’s eye began to drain again, but the weather had grown colder and owners suspected when out in the catio, the air bothered him. The irritation passed, and energy once again was up and he was leaving his eye alone. He seemed to be really content. By seven days post acupuncture he was better than ever.
The third AT, it was reported that his left eye became a little runny, but hadn’t been scratching or rubbing. Sometimes he would start to scratch and correct his behavior. Overall the owners felt that he was doing really well, with increased energy.
It has been shown that the effects of acupuncture are reversible with naloxone, an opioid antagonist. Acupuncture reduces cardiovascular reflex elicited by a toothache, which is associated with the adrenergic system. (Ji-Yeon, et al, Acupuncture on c-Fos expression in Brain after Noxious Tooth Stimulation of the Rat, The Journal of Chinese Medicine, 2006, Vol.34, No.06, pp989-1003).
At his fourth AT, it was reported that the cat’s demeanor was energetic and relaxed, unlike his agitation in prior years. His left eye demonstrated epiphora, but he made no attempt to scratch. If he lifted his leg to scratch, he stopped before actually doing it. He had become a lap cat and allowed his owners to groom him. His left eyebrow whisker had regrown.
At his fifth AT, it was reported that the cat had begun to scratch his left eye a little with his left hind leg, and rub his left eye with his left front leg He was still mellow and no obvious anxiety was observed. Owners thought that he needed a tune up. Again, the cat laid down next to me as I was getting ready to evaluate and treat him.
Reports of day one and two after his 5th AT, were that that he was blissfully calm and relaxed. No scratching was observed. Per owners, a marked improvement. Day 3, he was observed scratching his left eye once with his left hind leg. Owner massaged his face. Day four through seven, cat was calm and cuddly, and urged the owner to gently caress his forehead and the bridge of his nose. He was visibly relaxed by it. Anxiety was absent and there was no evidence of scratching or anxiety. Day eight through sixteen, the cat’s demeanor was much improved, calm and interactive. The owners have managed any symptoms at home with gentle facial massage and acupressure.
Describe Your Medical Acupuncture Experience
This case has been enlightening on so many levels for me. It was a good reminder to always look at a case with fresh eyes if progress isn’t occurring. By seeing the case for the first time, two years after the full mouth extraction and reviewing the whole record to find out when symptoms started, it gave me a bird’s eye view of the landscape by which his symptoms lay. Another aspect of this case, was that by developing a working knowledge of the cranial nerves affecting the face and eye, I could target his problem areas with dry needling, and massage. By targeting peripheral points I could modulate his autonomic system, which created a sense of calm and energy. Lastly, the cat’s response to his AT by walking over and laying down next to me was heartwarming and solidified a successful choice of treatment.