Raised muscle enzymes: EPSM? Tying up?

[flintfootfilly]

Hi

I am having investigations done on my 7 year old Dales pony, homebred. Sold as a yearling and bought back as a just started 4 year old.

Since then, he's never really been in full work because he seemed to have different lamenesses (sometimes felt like one or other front leg, definitely a stilted hind limb action with little hock flexion, and grinds to a halt from trot very regularly). Has done only walk/trot work ridden or being ponied out. I have a lot more detail, but that's a very brief summary.

He had acute colitis in December and nearly died, but seems to have made a full recovery from that. I was hoping his reluctance to work may have been due to some kind of problem associated with the colitis, but we can't find anything wrong gutwise now.

However, I now have 3 sets of blood results. One from when the acute colitis struck. The second one, two weeks later. And a third one, nearly 2 months from the colitis.

Red and white bloods are both low.

However the main thing I'm not sure about is the muscle enzymes:

AST Reference range 100-370
CK Reference range 20 -225
LDH Reference range 130-1085

Blood results (all done as resting levels):

12 Dec 2011 AST 504; CK 2517; LDH 1089 (when acute colitis struck)
28 Dec 2011 AST 472; CK2814; LDH 1341 (appeared recovered)
1 Feb 2012 AST 532; CK 2,600; LDH 1330 (appeared recovered)

Oh, he tested negative for EPSM type 1 on a hair sample.

I've not had a biopsy but must admit I'm wondering whether the CK results might point to the biopsy being the next stage? To be honest, I think I WILL ask for a biopsy because those levels of CK can't be normal, can they?

Though I don't know what levels could be considered a bit high, but unremarkable? What kind of level would an EPSM horse in a good spell show?

Flexion tests have been negative and although I can feel him being lamer on one trot diagonal, this is difficult for an observer to see.

Would be grateful for thoughts on how best to proceed.

Also, is Caroline Hahn the best person in the UK to interpret a biopsy if I do go that way? Cathy McGowan (Liverpool) seems to have cowritten an EPSM paper, though I always think of her for laminitis stuff - anyone any experience of using Liverpool for EPSM/muscle investigations? Any other vets in the UK who are well informed on this type of stuff and used to interpreting muscle biopsies?

Any guidelines on biopsying that I can pass to my vet to make sure the sample can be prepared and interpreted as effectively as possible?

Have been reading up on Stephanie Valberg's Minnesota website and Beth Valentine's Rural Heritage stuff. Also am on yahoo EPSM group and have Dr Kellon's neuromuscular course notes. Anywhere else that's useful?

All that kind of thing, please!

Thanks very much.

Sarah

 

[soulfull]

hi sorry to hear about your pony, they are so distressing when they aren't right!

The main thing is that an awful lot of horses with confirmed EPSM can and do show normal blood results. My own horse did several times, it was only the biopsy that showed what it was

Personally if I ever had another horse showing symptoms I wouldn't bother with the biopsy I would just change to the hi oil diet. Bear in mind it can take 2 or 3 months to see good results though.

I found with my horse it wasn't just a case of keeping the starch and sugar low, he actually needed high amounts of oil and vit E and selenium

hope this is of some help

Dr Beth is fab and usually very good at answering emails too

 

[dilbert]

Hi Sarah
I saw your post on the yahoo group. I treat my cob as if he has EPSM as he shows lots of the symptoms , limited grass, low starch, supplement Alcar and feed various minerals following forage analysis.

I've never had the biopsy or blood tests for tying up but so fa touch wood I'm gradually moving in the right direction.

Good luck with your boy, feel free to pm me if I can be of any help.

Nic

 

[flintfootfilly]

Thanks for your replies, and sorry not to get back to you sooner.

My vet's just looking through some info, and we're going to have a biopsy done as soon as we can arrange it.

Have been in touch with Beth Valentine, who has been very helpful.

Out of interest, what site(s) was your biopsy taken from? There seem to be 2 favoured sites (semitendinosus, literally just to the side of the top of the tail; or semimembranosus lower down the hindquarters). Then there's sacrocaudalis which is absolutely right up by the tailhead, but it seems that may be more useful for diagnosing other muscle problems.

I'm trying to go through all the stuff on management now and work out the way forward. Going to stop turning my boy out with his 2 gelding friends, because they do just spend the time playing stallion games, and if we're going to get those muscle enzymes down, then I think he needs to be a little more genteel so will pop him out with the mares instead.

I did have my forage analysed, but must admit I never did the full balancing of it, so now is definitely the time to make sure that's all in order.

Out of interest, where do you buy the Alcar from? It just looks horrendously expensive?

Thanks again for your replies. Will let you know how we go.

Sarah

 

[flintfootfilly]

Oh, I forgot to add, but it seems that 350 is about the highest level of CK in a resting blood sample that can be considered normal. I've now seen that mentioned in stuff by Sue Dyson, Stephanie Valberg and Beth Valentine..... and I'm happy to take their word on it! Anything above that appears to warrant further investigation (unless there are known stressful events within the last few days which might account for it).

So at least I am very clear now that my boy's bloods warrant further investigations, especially a biopsy.

Sarah

 

[dilbert]

I buy my Alcar from equimins, it's not on their website you have to phone and as for it by its proper name Acetyl Carnitine (I think), I pay about £40ish quid and it lasts a couple of months or so frankie gets 10g a day.

 

[harrietSJ]

Hello!

I buy my alcar also from equimins - when you call its code 836 I seem to recall. Should feed 1g per 100lbs body weight apparently - though you'll know this as on the yahoo group too! There is also a facebook help group which is also good if you need (EPSM/PSSM in horses)

They need magnesium to absorb this too - equimins again.

Dr Richard Piercy at the RVC is where my vet wanted to send my biopsy (in the end the blood test diagnosed him so didn't have to go that route).
http://www.rvc.ac.uk/staff/rpiercy.cfm

He has collaborated with S. Valberg on a number of articles.

Hope it goes well - mine was diagnosed just under a year ago - we have had our ups and downs but it is more or less managed I think at the moment - while was under insurance I had monthly blood tests so I can determine how his muscles feel with what is going on inside which have been really useful. When the AST is raised he gets REALLY grumpy, when its within normal then he is fine... CK has never gone down below 500 but I'm working on it......

 

[flintfootfilly]

Thanks for the reply.

Funny you should post it today, as Max just had his biopsy yesterday afternoon, and I had confirmation that the sample arrived at Edinburgh this morning, so hoping to hear in the next week or so.

I know that he's definitely not type 1 EPSM (as the hair sample came back negative), but hopefully the biopsy will show whether he's type 2, or not (and in which case it's back to the drawing board!).

If he is confirmed type 2, then I'd be really interested to hear what enzyme levels others have found. It's interesting to hear that your boy's CK didn't come down below 500, even with monthly blood tests.

I must sign up to Facebook again and check out the EPSM group.

Thanks again.

Sarah

 

[harrietSJ]

I know my friend who has a type II confirmed by biopsy (as they don't have the genetic code for type II I seem to recall it came back with a -ve diagnosis as this was not present, but there was quite a lot of glycogen pooling in the biopsy so he does have PSSM - it was worded very strangely anyway) - he had a blood test recently as his enzymes were completely normal

There do seem to be quite subtle differences between the type I and Type II's be really interested to hear your results, fingers crossed you get some confirmation either way

PS - I take the CK not below 500 as a personal insult that I am still not doing something right! I WILL get there!

 

[flintfootfilly]

Another brief update.

We've had the biopsy results, and one more set of resting bloods:

Resting bloods after 3 weeks of no work but plenty of turnout on the yard/arena were:

AST 533 and CK 3378, so still way above accepted normals.

Caroline Hahn at Edinburgh (who we sent the biopsy to) says the AST/CK levels are significant and suggest a form of recurrent exertional rhabdomyolysis, but they were unable to find anything in the biopsy to support an EPSM diagnosis.

Beth Valentine suspects that he is EPSM, and that we just haven't sampled part of the muscle which is showing the EPSM changes.

However, one way or another, at least I know for sure now that he has some form of recurrent exertional muscle disease, and that I need to look at ways to bring his muscle enzymes down as much as I reasonably can.

Diet/exercise regime for RER is pretty much the same as for EPSM, so at least there's no dilemma as to which is the way forward.

Would be interested if anyone is willing to share their EPSM horse's blood results over time, especially where these are linked to changes in diet and/or exercise.

I'm hoping to redo bloods in a month or so, and see if we have any changes after building up exercise from scratch again and starting to introduce a very small amount of oil into the diet.

Sarah

 

[harrietSJ]

Hi there,

So there was no glycogen pooling in the muscle cells in the biopsy?

I have a whole year's worth of blood tests, approx 1 per month with notes of when the oil diet started and when I started adding l-carnitine etc but it'll take me a bit of time to type this up but am more than happy to share so will do this over the next few days for you.
Or PM me your email address and I can attach the spreadsheet for you (I am a muscle enzyme geek)

It is definitely worth starting an exercise/how bad they feel/act diary as I now use this quite a lot to look back and know what tiriggers things off/how to manage him after an event etc etc...

I already have my supplements fairly stabilised and seem to be working more or less for us, but my vet had a talk recently fro a company called supafix who produce a herbal liquid called 'set free' which he said there have been some great results from Apparently.. I haven't tried it as don't want to disrupt the path I am already on, but just thought would mention it - they were very helpful when I spoke to them.

 

[flintfootfilly]

Thank you! Have pm'd you as it would be great to see your enzyme spreadsheet. I don't have one of those yet, though I guess I may soon have to have one!!

Have just tried googling Set Free but I can't find anything about the herbal liquid. Do you know any more about it, to help me track it down please?

Will definitely keep a good diary. It's been interesting looking back in Max's work log, but I've not been able to find any links to changes in his behaviour/performance so far.

Thanks again.

Sarah

 

[KautoStar1]

I have a horse who has displayed PSSM type symptoms. Last spring he suddenly went off his work, became stiff and lethargic, but never actually tied up. Blood tests were normal except his CK levels which were at about 720. Immediate box rest, bute and then turn out in a small paddock and bring back into work slowly. Vets wondered if this all attributed to a change in pasture as we had recently moved and he’d been fine before. I also had one of the top equine nutritionists in the country review his diet and while it wasn’t bad, she made certain recommendations to ensure he has a low starch / low sugar diet. His hay is soaked and he has a low cal balancer, speedibeet and linseed oil for energy and a handful of unmolassed chop. No other additives. He’s muzzled in the field (always has been as he’s a greedy beast) and the instructions from vet and nutritionist were to keep him trim and fit. He returned to full work and seemed back to his normal happy self. After his initial rest and diet amendments, his bloods were re-taken and CK levels about 250 (so still above normal, but not worryingly so). However, a blood test in Dec showed the CK levels back up at 850, yet he was fit and well and working happily. My vets suggested regular blood tests to try and see what was normal for him. And I spoke to another vet for a 2nd opinion and his view was the same in that 1st we need to know what is ‘normal’ and while he is well, treat him as such. So, all this time, he has appeared to be fine. He’s worked 6 days a week, either hacking, schooling or lunging and he also has 1/2hr on the walker approx. 3 times a week, but in the last 2-3 weeks he’s seemed a bit lethargic again. He’s not mega fit by any means, but I would expect with his work load that he wouldn’t tire as quickly as he seems to be doing right now. He had a course of B-Sure as a pick me up, but still I would say he’s ‘not quite right’. I’ve not done anything different since he came right, just carried on with the routine. The only thing that changed for him was a new field mate, who he does play with quite a lot and of course now the spring grass is coming through. But he’s muzzled, so you would think his grass intake is kept fairly well in check.
Vet coming again on Monday for more bloods and a check-up, but I am at my wits end now because I don’t know what else I can do. Unless there is some medication he can have ???
And the other thing I am starting to wonder is whether this is all related to a low grade pain somewhere and the CK levels are raised as a result of this. Either way, it’s a very frustrating condition for the owner to manage and clearly not nice for the horse.

 

[dilbert]

I've never had Frankies bloods analysed for EPSM type changes.....is it helpful do you think?

 

[flintfootfilly]

Dilbert, I'm sorry I can't remember your pony's details in terms of signs that he may have EPSM?

I found that having bloods taken which showed abnormal muscle enzyme levels did at least get my vets believing that there WAS something wrong with him, whereas up to that point another vet just thought he was "stubborn".

I'm not sure how long I'll continue having repeat blood tests, but whilst I'm trying different strategies to try and get him more comfortable, I thought it would be helpful to see how each of those changes affect the enzyme levels. So far, no change! And there will come a time where I drop the blood tests, but at the moment I think they are a useful way to calibrate my observations of whether he's better or worse.

However, some EPSM horses can show normal muscle enzyme levels at rest, and may only show increases after exercise, so a resting blood may or may not show anything unusual.

The yahoo EPSM group is really helpful for more detail.

Sarah