Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2018056
Abstract:
This case report is about Hoku, a 22 year old Quarter Horse cross gelding with Cushings disease, recurrent hoof abscesses, and a right eyelid laceration. He had a poor appetite because of his Cushings medication (Pergolide), was lame in the left hind leg and his eyelid injury was being managed by his regular veterinarian. He received three acupuncture treatments targeted to address his current ailments. By the end of his treatments, his appetite had improved significantly, his lameness had resolved, and his eyelid laceration had healed.
History and presentation:
Hoku is a 22 year old Quarter Horse cross gelding. Chief complaints include a lacerated lateral upper eyelid of the right eye, hyperadrenocorticism, intermittently decreased appetite, and recurrent hoof abscesses. The hoof abscesses have been occurring intermittently for 8 years since he was moved to his current stable where environmental conditions are consistently humid, rainy and moist. On presentation he had an abscess that ruptured out of the plantar coronary band in both hind feet and was grade II/V lame on the left hind. He was diagnosed with hyperadrenocorticism by his regular veterinarian four years ago based on clinical signs including dermatitis, muscle atrophy and a long hair coat. No labwork was done at the time to confirm the diagnosis but he responded well to therapy. He is currently receiving 0.5 mg Pergolide every 24 hours by mouth). The dose was decreased from the initial 1 mg every 24 hours by mouth because his appetite became poor. Since the dose was adjusted, he has mild intermittent hyporexia. 3 weeks ago he had a traumatic laceration of his upper right lateral eyelid from shaking his head while in a cross-tie, and this wound has been managed by the regular veterinarian. Other medical history includes a 10 x 2 cm scar about 7 cm ventral to his left tuber coxae. The cause is unknown because it happened before his current owner bought him.
Physical examination and clinical assessments:
Physical examination findings were as follows. The patient was ambulatory with a mild lameness noted at walk in the left hind limb (grade II/V). Muscular tone and mass were within normal limits. He had normal hind limb circumduction bilaterally. There were no restrictions to thoracolumbar bending. Sacroiliac palpation was not reactive and tuber coxae palpation was normal. The pupils were bilaterally symmetrical. The right eye had blepharospasm with mild clear ocular discharge and a 1.5 cm laceration from the lateral upper eyelid directed medially. The left eye was normal. The rest of his physical exam was within normal limits.
Differential diagnoses:
Differential diagnoses for hyperadrenocorticism include adrenal dependent hyperadrenocorticism and pituitary dependent hyperadrenocorticism. Differential diagnoses for the left hind lameness include hoof abscess, osteoarthritis, traumatic injury to the limb, septic arthritis, and laminitis.
Definitive (or putative) Diagnoses:
1. Diagnosis of lameness secondary to hoof abscess in both hind feet: Hoku was responsive to hoof testers on both hind feet and a site where an abscess had ruptured was visible on the heel bulb of each foot.
2. Diagnosis of hyperadrenocorticism: ADH vs PDH unknown. Positive response to pergolide therapy- improvement of clinical signs associated with HAC
3. Diagnosis of traumatic eyelid laceration: Known history of trauma to this region
Medical decision making:
The following protocol was planned:
-Organ shu points (to neuromodulate sympathetic supply to specific organs)
1. For poor appetite: Spleen shu (BL20), stomach shu (BL21), large intestine shu (BL25)
2. For adrenal support: Triple heater shu (BL22), kidney shu (BL23), and BL52
-Local eye points: BL2, GB1
-Autonomic points: Bai hui, GV14, ST36 (improve appetite, immunomodulation, increase vagal tone)
Medical Acupuncture and Related Techniques:
Treatment 1 (1/26/19): Bai hui, GV14; Bilateral: BL10, BL 20-23, BL 52. BL 2 on the right only
Treatment 2 (2/9/19): Bai hui, GV 14; Bilateral: ST 36, BL 20-25, BL 52. No eye points- becoming head shy because of eyelid surgeries
Treatment 3 (2/17/19): Bai hui, GV14; Bilateral: BL 20-25, ST36. No eye points- even more head shy at this point.
These acupoints were treated at each point with a filiform stainless-steel needle (AP needle Seirin brand, 0.20x30mm for treatment 1, and 0.25x30mm for treatments 2 and 3). The angle of needle insertion was 10 to 20 degrees, with horizontal insertion. During the treatment, the needling stimulation and manipulation consisted of simple insertion without lifting, thrusting, twirling, or rotating. The needles were retained for 10 min.
Outcomes:
After treatment 1, Hoku’s owner noted improved appetite immediately. Subsequent treatments resulted in even more improvement in appetite. Hoku’s left hind lameness resolved and owner has been riding again. His eyelid laceration healed over the course of the treatments.
References:
Curacore Integrative Medicine and Education Center. “Medical Acupuncture for Veterinarians Equine Point Mini-Manual”, 2017.
Parker TL et al. “The innervation of the mammalian adrenal gland”. Journal of Anatomy; 1993;183:265-276
What I learned from the case:
This case was a great opportunity for me to practice equine acupuncture and hone some of my techniques I learned from Curacore. I used both blue and purple needles in different sessions. The blue needles seemed to bend more under the tissue so I came to prefer to purple needles. I also was able to try different depths and insertion techniques to see what Hoku did best with. I was reminded that the needle can be placed superficially and still have an effect, and to think about the planes of tissues that the needle goes through and where I wanted to target. Finally, this case report format helped me to start with my exam and take a big step back to think about the patient as a whole and what approach I wanted to take. He was not tolerant of many needles so I tried to be selective with the points to maximize the effects.