Romeo the Rottweiler-mix, four years old but looking twice his age, came in last week for an evaluation after spending a sleepless night seizuring. They’d started last night—short bursts of violent, head-bashing convulsions (the grand mal variety) that eventually landed him in the local emergency hospital.

The following morning his brain was quieter, but addled nonetheless. He recognized family and friends but his relationship to his surroundings was reminiscent of Grace Kelly`s Vertigo with all those 1960’s, pre-psychedelic patterns swirling about her head.

Romeo had always had seizures. On phenobarbital (the most common canine anti-convulsive medication) he had lived comfortably (with barely one seizure per month to speak of).

His parents were diligent caretakers, ensuring that his medications were always at hand and administered regularly, careful that his phenobarb blood levels and liver enzymes were measured quarterly, and aware of unusual behavior patterns that might indicate a decline in the medication’s effectiveness or an increase in its potency.

Romeo’s last twelve hours had not been part of his typical seizure pattern. Perhaps his disease, presumed to be epilepsy, was changing its ways. Epilepsy has a way of doing anything it wants (meaning we are at a loss to explain most anything about it). But a seizure cluster, as we call this acute, multi-seizure manifestation of the disease, is a good reason to look closer at Romeo’s whole body—not just his brain.

Apart from his confused state (common after clusters) Romeo appeared physically normal. His bloodwork, however, revealed a startlingly high white blood cell count and a mild decrease in his red blood cells (anemia). What the heck is happening here? No obvious evidence of infection was found to explain the elevation in the bacteria-fighting white blood cells we saw in his blood. Excepting the possibility of some sort of bacterial infection of the nervous system (which would often carry a fever and more pronounced central nervous signs), I could make no story for this finding. 

Next step? Referral. No dice. Romeo’s parents wanted us to try our best without the long drive to (and expense of) the neurologist. The internist was similarly out of the question.

Consultation with my friendly internist and the neurology literature yielded no promising conclusions, either. Perhaps some hidden infection has lowered the seizure threshold making way for the cluster that ensued. Maybe he does have a spinal meningitis or some other bizarre neurological infection that might have gone untreated all this time, hence his lifelong seizures.

In cases like this we won’t get any closer to determining the fundamentals of this disease process without a spinal tap. But that wasn’t where this case was headed. (And I can’t do a spinal tap to save my life.)

So out came the antibiotics. I chose appropriately considering the possibility of a bacterial meningitis and upped his dose of phenobarbital for good measure.

After 24 hours, Romeo’s doing great. But I can’t help feeling frustrated knowing there’s an answer out there—one I can’t have unless his parents comply. The tantalizing possible existence of an underlying disease process to explain his lifelong seizures makes the situation worse for the eternal optimist in me.

Wouldn’t it be great if we could uncover a reason for Romeo’s monthly seizures? What if we could definitively treat it? Wouldn’t it be great if he’d no longer have to take pills every day that might eventually damage his liver and shorten his lifespan? How about the possibility of his return to a normal four-year-old’s exuberance and quality of life?

If his owners would just wake up to the same rosy vision I think we might really have a shot at this. But sometimes it’s just easier for everyone to keep doing what they’re doing than to reach for the long-shot diagnoses that will likely lead to frustration and which will definitely deplete funds. Oh well. So much for my sugarplum visions…and my hopes of curing my vertiginous Romeo.