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Tuesday, 4 January 2011

Would a definite diagnosis make a difference?

We have a beautiful male Whippet named Alfie who will be three years old in February. Ever since he was about four months old he has suffered intermittent gastrointestinal problems with vomiting and diarrhoea. (He tested positive for giardia when he was seven months old and was treated with panacur.) As well as the gastro problems, Alfie suffers from a more serious health problem, that seems to follow a bout of vomitting and/or diarrhoea. It first occured when he was 10 months; he presented with a high temperature, general lethargy and discomfort with movement such as lying down or getting up. He did not respond to treatment with antibiotics. Eventually the vet prescribed steroids following Alfie's obvious discomfort when his neck was examined, and a noncommittal diagnosis of steroid-responsive meningitis was put forward. I did not want to go down the road of having a spinal tap carried out to confirm the diagnosis.
This condition has recurred another four times during the past two years, each time being treated with steroids - which bring about an almost miraculous recovery within 24 hours. He has been kept in overnight at the vet's on a drip on at least three occasions to ensure he does not dehydrate due to his high temperature.
He has just finished his most recent course of steroids and the vet is suggesting that we refer him to a neurologist if the condition recurs again, in order to get a definitive answer. This would mean a ferry ride and car drive (we live in the Channel Islands) when he is ill to the nearest specialist in the south of England. Alfie is insured so cost is not an issue, but the thought of the journey with the high temperature and obvious discomfort he shows really worries me. Would a definite diagnosis make a difference to his treatment? He responds to steroids so I wonder if a diagnosis, which could be inconclusive, would make any significant difference to his health management. I don't want him to be reliant on steroids forever, but if this works then is long-term treatment a realistic option?
I have to say when he is well you would never think he'd had an ill day in his life - he is energetic, loving and playful.
We would appreciate others' thoughts especially if you have been through something similar.
Jo Lamb, Guernsey

Steroid-responsive meningitis is often a condition diagnosed by excluding other causes for the clinical signs the patient is showing, and by response to treatment with corticosteroids. It is also a condition liable to flare up, such that long-term therapy with low-dose corticosteroids is not unusual.
It is because of this recurrent nature of steroid-responsive meningitis that your vet will have advised referral for a definitive diagnosis. If it was confirmed as the cause of your dog's bouts of illness, then all your questions and concerns about his treatment and long-term outlook could be addressed with a far greater degree of certainty. Long-term treatment with corticosteroids is not without its concerns but if needed for medical reasons then the benefits should outweigh any disadvantages.
It is however always your decision and I can quite appreciate your worries about referral, not least in your situation where travel involves a considerable journey including a ferry ride, and when Alfie is very unwell. On that basis, then a response to corticosteroid treatment when a flare-up occurs can be acceptable, provided there is full recovery with treatment. Compromise is not necessarily the wrong route to take.
I particularly remember a Border Collie who presented on an August Saturday with such acute neck pain that she had become stuck in the passenger footwell of her owner's car. I did refer her because I was worried about a slipped inter-vertebral disc in her neck, but she was diagnosed as having steroid-responsive meningitis and responded very well to methylprednisolone. When we began reducing the dose, she did have flare-ups, which settled once the dose went back up an increment. She has now been off treatment for three years.

Alison Logan, vet


  1. Mmm difficult one BUT as he is still so young I think I would investigate further. No chance of flying him over? Try local aero clubs - many of them are dog lovers and an appeal there might prove fruitful.

  2. Hi Jo
    My puppy also has Steroid Responsive Meningitis. I haven't had it confirmed with a spinal tap but the treatment certainly points to SRMA . It is certainly not easy dealing with it and can get quite complicated, is it a relapse, is he tired, is he stressed which can bring on a relapse?
    My puppy has had one relapse, meaning I had to start the whole treatment again. The side effects from the medication leaves my puppy looking and behaving far from the puppy he should be. But we strive on knowing that the prognosis is good.
    A shining light has been the following website. They have been so supportive and helpful. the lady that runs it, Jo Tucker, has kept me sane!
    Are you aware of it?...

  3. Ideally, any dog with pyrexia (a high temperature), lethargy and neck pain, should have investigations to obtain a specific diagnosis, as there are numerous conditions that may present with these signs, and the treatment and prognosis can be quite different with each condition. Steroid responsive meningitis (SRM)is just one of a number of inflammatory conditions that may affect the spine of a young dog, in addition to non-inflammatory causes, such as deformity of the spine. In Alfie's case, the positive response to the steroid therapy indicates it is probable that SRM, or a similar type of non-infectious meningitis, is the cause of his signs and thus it is unlikely that making a definitive diagnosis is necessary at this time, especially since he is responding favourably to courses of steroids that are only necessary every six months on average. However, if the frequency and severity of Alfie’s signs progress and become less responsive to therapy it may be worth considering investigations, including analysis of the fluid that surrounds the brain and spinal cord (the cerebrospinal fluid or CSF). There are other drugs in addition to steroids that may be used for managing SRM, but these too can have side effects, and are thus generally only prescribed when a specific diagnosis has been made. The distance you live from a specialist referral centre is an important consideration since, as you mentioned, it is necessary to weigh up the pros and cons that affect Alfie's welfare.

    Malcolm McKee Specialist in Small Animal Orthopaedics, Willows Referral Service, Solihull, West Midlands

  4. Hi there. My lovely lab/collie cross has also recently been diagnosed with SRM. It has taken over a week for us to finally find out why my healthy, fit, eight and a half month puppy went from being her energetic, playful self to a stiff, painful and fatigued shadow of herself.
    When we first noticed something wasn't right, the vet gave her an examination. She had noticed that she had a slight vaginal discharge and it was initially believed that she may have a vaginal infection. The next day however, she came into season. Her condition seemed to get steadily worse over the next few days. She became more generally unwell, not keen for diet/fluids, increasingly stiff and fevered despite the antibiotics that she was on. After a fourth visit to the vet, she had bloods and a pelvic scan. Her bloods revealed an elevated WCC but her pelvic scan showed a normal uterus. It looked more likely that something neurological was going on. She was taken to the vet school and has had a lumbar tap, confirming SRM.
    She has started her long term course of steroidal treatment tonight and hopefully we can bring her home tomorrow.
    When something like this happens it is normal to look at reasons why this could happen. She hasn't had any problems and as she is only coming up for 9 months, it is not a long time to reflect over possible causes. She had one episode of diarrhoea which she recovered from following treatment. ?Cause of diarrhoea. Could the cause have triggered an auto-immune response?
    The other more worrying possible cause that I have been investigating today is the use of the Advocate treatment for dogs. I have learned that herding breeds can be extremely sensitive to this drug. The result of side effects are a whole range of neurological disorders including SRM. No-one at my vet practice has ever advised me re this potential side effect. It is just assumed that best practise means you get your dog set up on these regular worming/flea protection plans without due consideration of the potential harm that these drugs can do. We vaccinate our pets annually as advised by vets, yet many animals have reactions to these drugs, which may not even be required on an annual basis anyway.
    I am not sure what has caused this problem in my dog, however the more research I am doing, it is looking more likely that Advocate was the cause as I had administered her last dose only 2 days before her problem started. I am fuming that steps I have been advised by my vet to 'protect' my lovely pet has caused long term damage. It is about time that healthcare organisations for animals and humans began to look and question it's relationship with drug companies for research, education and sponsorship which compromises the health of the patients they are supposed to be protecting.