Blood Count Plateau

AcadiaJBro

Guest

My 11.5 year old eagle, Lucy, was diagnosed in mid-February with IMHA, her anemia was at a level of 16%. Onset was IMMEDIATELY after rabies and distemper vaccines administered at the same time on 2/10/17. She had also been eating dirt regularly before the crash, so may have already had low iron, etc. She also had a pre-existing heart issue, CHF, murmur of about a level 4 I think. Is on Lasix, Enalapril & Vetmedin for that. She was put on 10mg Pred twice a day, but level dropped to 12%, so cyclosporine was added at 50 mg 2x per day, along with Clopidogrel 37.5 mg 1x per day- I think this is too high…(see below regarding bleeding) Level dropped to 11.6%. After a week, level jumped to 17%, then 22%, then 24%, 27%, 25%, and 26%. Thankfully, we did not have to do a transfusion. At the 27% week, I was advised I needed to give her flea/tick preventative after a winter break. I gave her Vectra as advised, which she had been taking for 2+ years. This *may* have slowed her progress. One troubling side effect has been nose bleeds. I finally found that fish oil (I had been giving her for her CHF) has drug interactions with Clopidogrel so I immediately stopped giving it and the nose bleeds stopped (thank god!!). Since she has been stable and felt bad Pred side effects (reverse sneezing, crazy hunger, breathing stress with her heart condition), we have been tapering pretty quickly. About 50% per week, and are now down to 5mgs every other day. She seems to be doing very well with the wean. The reverse sneezing has picked up though, and she’s started eating dirt again. This may be partially because the snow has melted and dirt is available again, but the reverse sneezing caused a minor nose bleed again leading me to believe based on some research that the Clopidogrel dosage should be closer to 24 mgs/day vs. 37.5 mgs (although difficult since it only comes in 75 mg dosage) for her 26 lbs weight. My largest concern is that her levels seem to be stuck at about 26%,which is still too low. Is it possible that the Vectra set her back? And if so, what do I do about ticks (I’m in a forested area in Maine). Her clinical signs are great – wants to play again, muscle tone is returning, doing normal beagle things-digging in trash, sleeping in blankets again, normal breathing- I just want some feedback on what may be keeping her numbers down, and how to drop blood thinner dose without risking clots. Thanks!

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Patrice

Keymaster

Acadia,
This has really been difficult for you to manage all these conditions and the medications. I am really sorry to hear about the vaccines as well. There are many things going on and I want to try to focus on a few in the time I have.

Dogs and humans eat dirt around the world, called geophagia. It is certainly the most outstanding sign of all the things you have mentioned. Humans, esp in developing countries, eat (and often crave) dirt to provide certain missing nutritional elements like minerals (for instance iron) and also to eliminate parasites (such as worms like tapeworm), bacteria, viruses etc in the gastrointestinal tract. Esp in dogs, it can be a sign of hypothyroidism. It can be related to IBD inflammatory bowel disease in dogs. Bleeding, such as tumors or ulcers can also lead to dirt eating. So yes there can be some need for iron or other mineral like magnesium.

From my viewpoint this is worthy of tracking down with some targeted tests to see what is the trigger for this geophagia. So first a stool sample, if not done yet, would be very important. If there are intestinal worms it would be important to treat them immediately. Some of these can cause severe anemia.

I would also want to have a special blood test performed to measure B12 (cobalamin) and folic acid. Adding in ferritin would also be of benefit in your case. This lab has extensive information about gastrointestinal disease related to B12 and folic acid deficiencies. Be sure to read it all, skim it when you don’t understand, and ask me questions.

http://vetmed.tamu.edu/gilab/service/assays/b12folate

http://vetmed.tamu.edu/gilab/research/cobalamin-information

Please note that B12 deficiency is especially related to serious gastrointestinal disease (called SIBO small intestine bacterial overgrowth) in the small intestine that can lead to malabsorption of this important vitamin. Without proper amounts of B12 the bone marrow does not have the proper elements to make new blood cells properly and they are not able to mature properly. In many cases in dogs (and humans), oral ingestion of B12 is not absorbed properly and requires injection. This is easily done at home and is very safe, any excess is peed out. It can be very beneficial to any dog that is possibly having trouble making red blood cells. Also treating the SIBO with either metrondiazole or tylan powder (see our Second Chance Resources page for Medication Resources on tylan) can help reverse the SIBO.

I recommend you begin supplementing each day with the highest quality probiotic you can afford. I have used and recommend Natures Way Primadophilus, Optima or any brand with 14 strains and at least 35 billion CFUs per capsule. Make sure you buy a refrigerated brand.

Chance had heart disease and was on these drugs you mention. Heart disease complicates things and the side effects of these drugs complicates things. They do not act independently of each other. Probably the most important thing my vet told me was that the heart likes things dry, while the kidneys like things wet. Two of the drugs you are using are attempting to remove excess fluid from around the heart, and in excess can cause havoc on the kidneys as they desire fluid to work properly. It is a very careful balancing act to dose these properly. To complicate this the prednisone completely redistributes body fluids around, causing dehydration and muscle wasting. Grab the skin at the nape of the neck and gently pull it up fully, let it go and watch to see how long it take for the skin to flatten. If it is a long time, your dog is very dehydrated. There may be drinking and peeing all the time.

I’ve given you a lot to think about but I do want to try to help you understand what may be happening, why the PCV HCT is hovering around the middle 20’s. This is not an easy thing to explain. It’s called anemia of chronic disease. We’ve see this with many dogs that have come here for our help.

“Anemia of chronic disease is a multifactorial anemia. Diagnosis generally requires the presence of a chronic inflammatory condition, such as infection, autoimmune disease, kidney disease, or cancer. It is characterized by a microcytic or normocytic anemia and low reticulocyte count. Values for serum iron transferrin are typically low to normal, while ferritin can be normal or elevated. Treatment is to reverse the underlying disorder.”

“In response to inflammatory cytokines, increasingly IL-6, the liver produces increased amounts of hepcidin. Hepcidin in turn causes increased internalisation of ferroportin molecules on cell membranes which prevents release from iron stores. Inflammatory cytokines also appear to affect other important elements of iron metabolism, including decreasing ferroportin expression, and probably directly blunting erythropoiesis by decreasing the ability of the bone marrow to respond to erythropoietin.”

I know this is a mouthful. Inflammatory cytokines are released into the blood stream for many reasons. You may have heard of this in relation to cancer, but there are many inflammatory conditions that can up these levels as well. This is the chronic condition that the body is reacting to. It could be a virus or bacteria. It could be any number of things like gastrointestinal disease.

So the body, in an attempt to alleviate this chronic inflammatory condition will withhold iron stores. Why? Because it knows that things like viruses or bacteria for instance also need iron to successfully reproduce. As you read above you see the word erythropoiesis, this is the medical term for the making of red blood cells in the bone marrow.

So the thought is that the body tries to self preserve and starve the “invaders” by depriving them of iron stores. This in turn, blunts the process of making blood and you end up with a mild to moderate anemia that doesn’t seem to respond to medications.

I’ll give you a human condition as an example to help you better understand. As we age our kidneys become less efficient. There may even be some degree of mild to moderate kidney failure. This can lead to anemia of chronic disease. You’ve seen this, I am sure, in an elderly relative, the pale and flaccid skin, clearly anemic. These people are treated with injections of erythropoietin. This is a hormone produced by the kidneys. When the body senses that there is not enough oxygen coming to the body cells it calls out to the bone marrow to make more red blood cells. This hormone is erythropoietin. So the making of blood is directly related to the health of the kidneys. Isn’t that fascinating? Unfortunately for dogs, this drug may work, but it is very difficult to obtain for veterinary use.

So what is the answer here? More testing and targeted treatment of any possible condition that is contributing.

And the heart disease is one thing that will contribute to this. The heart is less able to pump oxygen rich blood to the body because the mitral valve keeps flopping partially open and regurgitating some of that blood back into the chamber. It’s not making it to the body. So humans or dogs with heart disease also live in a state of moderate anemia. (Anemia, medically, is defined by the lack of enough oxygen making it to the body cells. While this is directly related to the number of red blood cells, it is really the amount of hemoglobin in each red blood cell that truly defines the ability of the body to provide this oxygen.)

The other things you are worried about are also other triggers. I don’t like ingested flea and tick products. For now, you need to protect with topicals like Frontline. I also recommend that you reconsider activity in areas where there are a lot of ticks. If this were your grandpa and he had emphysema you would not take him into a city with severe smog. Avoid worrying about ticks by avoiding the areas where they linger. If you do go somewhere like that, add a bandanna and even a doggie body suit, that is impregnated with permethrin. This is a very safe way to repel ticks. We wear clothing like this when we walk in the woods. Our dogs have Frontline on and wear impregnated bandannas. I also towel them off immediately once we leave the trail, before they get in the car, to remove any wandering ticks. They all get a good pet down after this and maybe even a bath with Ivory dish soap, known to remove seed ticks that are not attached yet. For those of you reading this, you cannot imagine what it is like to walk out your door and find ticks all over your pant legs and this is what Maine is like. Each tick is a time bomb waiting to infect you and your dogs.

I am also a bit concerned about the reverse sneezing. This can be simply that, just plain old doggie sniffles. But it can also be related to something like a nostril tumor or a fungal infection. The nasal infections are very tenacious and can lead to serious illness. I would want a particularly careful examination of the nostrils if possible. You are in an area where there can be dirt containing these particular fungus. Snuffling the ground is all it takes to inhale a spore. I know someone I see every day whose dog had this and Cornell tried to treat it, unsuccessfully.

You mention Clopidogrel and this is to protect from clotting dangers. I am concerned about low platelets and need more information.

If you are able I would like to see any of the recent CBC’s and chem screens you have had done. I would like to review several other values on these tests as well.
You can upload these to us via the Urgent Advice page. Please only upload 3 files at a time, we are on a share server. thank you.

I am sure you have many more questions, please ask away.
my best
patrice

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AcadiaJBro

Guest

Wow! Thanks for the quick and comprehensive response. I’ll have to take a bit to read everything over and digest it. In the meantime, a few quick clarifications/additional info… Lucy has a history of lungworm. It took a long time to diagnose (like months!) because my vets told me that it’s extremely rare in this area and they initially thought she may have a collapsing esophogus. She’s had reinfestations a couple of times as well, but I’m pretty sure that the initial infestation left her with scar tissue in her lungs and esophogus that has contributed to some lingering coughing over the years. It was a bad infestation that left her vomiting blood, bloody diarrhea, and coughing almost nonstop. I suspected this as being the anemia trigger initially because she has always been a big grass eater/vomiter, and combined with the dirt, it’s always a factor (but when diagnosed, the ground was and had been snow covered for a while). Her stool sample came back clean though. She’s also always been very sneezy and snorty and coughed even before the heart condition emerged, my vet thought she may have allergies and I gave her Zyrtec at his recommendation. Within a couple of hours she had a huge nosebleed because it dried her out too much. I’ve been giving her milk thistle for liver protection (looked into Sam-e but found a study that said it can cause bleeding and we don’t need any more of that). Lucy takes famotidine and hasn’t had a black stool (except immediately after nose bleeds), so I don’t suspect any GI bleeds. She also has tolerated the meds well with no vomiting and only minor diarrhea the first few days of cyclosporine. The Vectra flea/tick was a topical medicine and I really cannot avoid tick infested areas – I live in the deep woods and I can’t make Lucy stay inside. She is contained to the mowed yard for the most part with a wireless collar fence system. I’ve never actually found a tick on her, but pulled one out of my leg a few years ago (it tested positive for lyme) and have found them crawling on myself and my daughter. Lucy also has very bad teeth. Her breath reeks and I do everything I can with dental chews, dental toys, water additives, and brushing, but it’s a losing battle. There is visible decay on some back teeth – they bleed when I brush, but she doesn’t seem to be bothered by them when eating. She had regular cleanings when she was healthier, but that option is out now with the heart condition. Not being able to have anesthesia also really eliminates any extensive nasal exam. My parents had her brother and he also was a big reverse sneezer. Sadly, he passed last fall from kidney failure. I’m pretty sure it was brought on by being severely overweight and diabetic (undiagnosed), so those aren’t problems for Lucy. And lastly, I asked the vet at my last visit what Lucy’s baseline CBC level was and he said that when her heart condition was diagnosed when she was otherwise healthy, it was 40, still relatively low from what I’ve seen. She gets her CBC done again on Friday, and if it holds steady, we’re going to stop the Pred altogether, then after a while on just the Atopica, hopefully start tapering that down too. I’ll get a copy of the CBC report and post it her. Thanks again!

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Patrice

Keymaster

Acadia,
Thank you! The explanation of the lungworm, the subsequent probable scar tissue in her lungs and esophogus, and the continued coughing explains quite well why she continues to eat dirt.

Our body has a type of cell called a mast cell that is preloaded with histamine, it is a partner to our immune system. These types of cells are located in many locations, and line the walls of the whole gastrointestinal system as well as the respiratory system, plus many other areas like skin (which is considered an organ.)

These cells perform an ancient protective function in the GI tract. If the GI tract, along with the immune system alert system, “invaders” trigger the mast cells and their response would be to release histamine in large quantities, it’s purpose is to create irritation and local inflammation. This would cause violent vomiting and diarrhea in an attempt to remove whatever parasite or other bad thing in the GI tract. This would expel the “invader.” You and I know how this works when we get a flu or the cold and our eyes water, our nose runs, we sneeze, cough etc. All due to histamine

This system had to have been activated by the lungworm, leading to the massive release of histamine (creating highly inflamed tissue), subsequent coughing and other various attempts to eliminate the invader, leading eventually to the excessive irritation of the cells of the lungs and associated esophagus (ulcers that erode internal tissues.) The scaring that was left is probably irritated this same mechanism, leaving these areas highly inflamed and possibly continuing the ulceration.

So thus Lucy’s attempts to stop this pain by eating dirt make perfect sense. In fact around the world many many humans engage in eating different types of clay in an attempt to heal internal wounds. It can almost be treated like a ritual. the eating of the clay.

In addition to this, the heart is most likely enlarged, as is common in congestive heart failure. In dogs, the heart is located in a location where any change in size can press on and impact the esophagus. So coughing and attempts to clear the throat are very common in dogs with heart disease, in fact it is probably the most defined symptom. As fluid continues to build up around the lungs, this can also cause more pressure and discomfort on this area.

Dogs however, do not express allergies in the same way humans do, with respiratory symptoms, they express allergies with skin and eye issues, biting their coat until they are raw sometimes, eyes dripping copious goop. Chance had terrible allergies, called canine atophy. So your vet was a little misleading about this. The dosing of humans antihistamines does work against the massive release of histamine by mast cells, so it may have made her other throat symptoms better, temporarily. If fact modern stomach acid protection are actually a form of antihistamine drug.

Please be cautious about you read on the internet. SAM-e is not dangerous! S-Adenosyl-L-methionine is a chemical that is found naturally in the body and is made in the body from methionine, an amino acid found in foods. It helps regulate key functions in living cells. It does this by being a methyl donor, in fact it is the most important methyl donor in our body! As we age or become ill it decreases in quantity and all those other processes suffer from this lack. One in particular is liver function. When we take prednisone for instance, the liver metabolizes this drug. Each time this process occurs there is liver cell death. Eventually this leads to an inflamed and damaged liver. SAM-e is used widely, combined with Silybin, the critical purified essence of milk thistle, to help the liver restore new cells and heal.

There is a veterinary supplement called Denamarin, that I have used and many others owners have used, that is a high quality veterinary blend of SAM-e and Silybin dosed exactly for dogs and cats. This supplement can quickly reduce high levels of liver inflammation. You can read about this here.
http://www.denamarin.com/#about-denamarin

A science based explanation of the role of SAM-e in methylation:
“Methylation is the chemical reaction in which a methyl group, composed of one carbon and three hydrogen atoms, is passed from one molecule to another. This simple transfer of a methyl group can activate as many as 40 to 100 different processes in the body, such as the synthesis of DNA, proteins, neurotransmitters and processes that help suppress viruses, promote bone density and protect against heart disease. SAM-e is a methyl donor, it gives up its methyl groups to molecules that are involved in these different biochemical reactions. SAM-e’s donations transform the receiving molecules into active substances that are involved in various vital activities that are responsible for health and well-being.”

I was at my vets this morning and we discussed the rise in tick populations in western NYS. She just attended a veterinary seminar on Lyme disease, and being the proactive vet she is, started a heated discussion with this group about how, going forward, they are going to diagnose and treat emerging new tick diseases along with the current diseases. They agreed there is an end point at which they will no longer be able to dose every dog that has been bitten by a tick with doxycycline, prophylactically, because this will end up creating doxy resistant tick diseases. The message is, dog owners need to be extremely proactive in preventing tick bites. The safety valve of treating after every bite is not going to be there. The kind of outdoors that I once knew is shrinking, the warmer climates are increasing tick populations such that they are in places that never saw them. They are also hitching rides over air transport to countries that were previously tick free. She agreed that my having my three dogs tested with a SNAP 4DX test three times a year, every four months, was one of the best solutions to protect my dogs from tick diseases.

I am cautious about any tick product that also attempts to control fleas. Many of the ingredients used to do this are called insect growth regulators IGR and these have drawn scrutiny by governing bodies who regulate these products, there is talk of removing them from the market because they are not without serious side effects and can make some dogs ill. Fleas can be a nuisance but they aren’t necessarily life threatening.

Thus my recommendation to use Frontline. It’s job is to cause neurological havoc to a tick’s nervous system (and should not be used on Collie breeds). Applied topically this seeps into the oil pores in the skin and coats the body. Ticks slugging through this stuff get coated and are unable to attach to the dog, their mouth parts paralyzed. They will die eventually but some people can be confused why they may still see them wandering around.

Manual removal is also a good technique and an owner has to be constantly alert that this is done properly. I like my method of repelling them with permethrin impregnated clothing, it works on me as well.

The importance of doing another CBC and chem screen is that these values are never stagnant, they are dynamic from one day to the next. I am really looking forward to these current values to see where Lucy is at. I am wondering if improving her overall health will improve her ability to heal. Can we optimize her ability to heal with diet and supplements while we attempt to understand how all of her conditions are contributing to this disease process?

Would you also request a full thyroid panel from your vet? Many dogs that develop these conditions have hypothyroidism.

You can read Dr. Dodds excellent protocol on this page titled: Immune Mediated Hematological disease.

https://www.secondchanceaihadogs.com/hemopetresources/

On this page you can read about hypothyroidism and watch a few videos.
https://www.secondchanceaihadogs.com/canine-hypothyroidism-resources/

What questions do you have for me?
my best
patrice

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