New Diagnosis – Need Support – Paranoid

Maria

Guest

Hello, my name is Maria and I have been reading this forum for the last couple of weeks. My baby, Hunter has been diagnosed with a low grade ? IMHA. I have been trying to get my head around what I thought was a tummy ache or perhaps another bout of pancreatitis. After the diagnosis, of course I sit at my computer to try and educate myself on this disease. I did nothing but send myself into a hole, a very depressing hole. Then, I found this forum! You made me believe there is some hope. Although it’s clear, that this is a very complex and a lot of attention is involved.

I have so many questions as I panic at every little thing. My vet is wonderful, but is also very busy so I truly don’t have anyone to talk to. My friends think I have lost my mind and don’t understand all that is involved.

He is 5 years old. 15″ beagle. Weighs 36.5 pounds. Yes, I think they consider this obese. He really doesn’t look obese though. A couple of days before he got sick, I had been giving him rawhides to clean his teeth (made in USA), something I rarely do because he use to have GI issues. Hasn’t had them for the last two years. But as a 1 and 2 y/o he was on so many meds. Mostly a motility pill and Zantac and to this day he has to eat 3 small meals otherwise he’ll throw up bile. He has been a little handful but I love him. So back to when he got sick. He threw up a couple of days once, mostly bile, then he refused to eat breakfast one morning but ate lunch and dinner normal. The next day, the same. I knew for sure he was off as beagles don’t miss a meal. I took him in and my vet thought he probably had an upset stomach and because of all his GI issue she recommended we to an extensive blood workup and see if perhaps it was pancreatitis. The next day she called me and ask me to bring him in because his PCV was 35% and his is normally 51-55%. So she wanted to check his gums and explained that from his panel she was afraid it might be IMHA and they can decline fast. I took him right in and he seemed alert, gums were pink, but she wanted me to a see a specialist to do some more extensive test. We went two days later and they kept him from 10-5 doing so many test. When I had the consultation with the specialist he went through everything and he told me he most likely has a low grade IMHA and we needed to start treating it.

We went onPrednisone 20mg 2 x day
doxycycline 100mg 2 x day
clopidogrel 75 mg 1/4 tab once a day

For one week and then recheck CBC

His PCV numbers had climbed from 35% on Saturday to 39% on Wednesday with no meds but the specialist felt that was still in the same range. So to consider that no real change.

After a week on these meds, I took him into get his CBC rechecked. He was at a 48.5%. I was excited but my primary vet didn’t seem to excited? Or at least she didn’t seem to me. She consulted with the specialist and said we would start giving him cyclosporine 100mg 2 x day for one week and then begin to taper off by 25%. We are on our 4th day of tapering. I am not sure what to look for. Since he has been on these meds he has all the pred side effects (thirsty, urinating a lot, starving, panting, a slightly different breather pattern), but since introducing the cyclosporine he seems more tired. He just wants to lay on the wood floor. His back legs tremble a lot and I assume that’s due to the pred. His gums remain pink. The vet did mention on our last call that he was not anemic.

He has been on his medication now for 28 days. I am watching him closely has we have started tapering and I have read they can relapse. I truly hope not. I have so many blood reports and I just wish I knew what I was reading. All I am going by is his PVC as that’s what most people look at, but I am sure there is more to understand that goes along with this all.

I am suppose to give him his heartworm treatment as I am late due to all this going on. I did consult with Dr. Dodds and asked her about it as I was afraid to administer. She recommended I do not give him Sentinel which he has been on and administer Heartgard. My vet was fine with that. I am really panicked to give it to him though I know I have to.

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Patrice

Keymaster

Hi Maria,
I have your tests in front of me, thank you for sending them! They are from earlier this year, do you have anything more recent?

On the summary from 6-20-18 the report indicated that ” Labwork showed mild regenerative anemia.” But then the report goes on to state that there is value of 379,200 reticulocytes. These two things do not match (mild regenerative anemia and this extraordinarily high retic value.)

Here are the reference values from Cornell to match the number of reticulocytes to the degree of regeneration.
Degree of Regeneration Absolute reticulocytes (/uL)
None < 95,000*
Mild 100,000
Moderate 300,000
Marked ≥ 500,000

In addition, anemia is defined as none, mild, moderate or severe. On this test the HCT was 39% which can be considered none to mild depending on the lab references.

Reticulocytosis is an increase in the production of immature red blood cells in the bone marrow in a response to anemia. The lower the HCT, the greater the number of reticulocytes must be produced to normalize the blood. In this case, since Hunter was at 39% HCT, his body should have been only making about 60,000-80,000 reticulocytes not 379,200! Why is this?

The comments under Erythrocytes (which are red blood cells) is wordy but it is simply identifying that there are differences in the size and coloring of the RBC. For instance reticulocytes are larger for about 4-5 days than RBC and they have a “reticular” patterning inside which makes them a different color. (“marked
polychromasia with increased numbers of nucleated red blood cells.”) They quickly drop the reticular (nucleated )pattern which is really the RNA inside the cell and begin to look more like a RBC.

So to be clear the whole process of rapidly making reticulocytes in great numbers and sending them out into the blood earlier than normal leads to a lot of differences in cell types, sizes and coloring which is exactly what all the words on the lab report are saying.

So later in the report in the Interpretation they note “Markedly regenerative anemia.” I can’t be sure why they said it wasn’t and then it was from the same report.

What is important is that there were a large number, 50%, of spherocytes. These are RBC that have a little “bite” taken out of them. They appear smaller, less concave, and paler than normal. In many cases with this many circulating spherocytes it is an indication that the spleen has been very busy attempting to destroy RBC by taking a “bite” out of them, in an attempt to remove them from circulation.

The most usual case is that the immune system is targeting these RBC for destruction and that is the job of the spleen every day, to get rid of old worn out RBC, but certainly not in large numbers. But if the cells contain something like a tick disease and that could trigger this destruction. But the immune system can also become errant and begin destroying these marked RBC for the wrong reasons.

The lab also notes “Spherocytes can also be seen with blood transfusions and zinc
toxicity. ” So the question is did they do any transfusions and did they investigate the possibility that Hunter may have swallowed a coin? Some older coins contain zinc. Or it could be possible that something you gave him contained zinc.

I am very leery of rawhides. They tend to be swallowed in chunks that are glue-like globs and they compact in the intestines causing digestive blockages. Throw any you might have left away, please.

Now I am looking at the April 21 report, first the chem screen.

The first thing that is abnormal is the high-ish Globulin level (3.8, normal high is 3.6). There can be a variety of reasons why this is a bit high. Ehrlichia (tick disease) or heartworm infection, chronic liver disease, auto-immune diseases, chronic infections, inflammatory responses and dental disease. Most of these things can be tested for and treated.

ALKP is a bit high at 161 (high normal 131) but that it isn’t very high. This is an enzyme released usually by the liver when there is cell damage. It is quite common when prednisone is being taken as the liver processes this drug and we always expect to see this value rise while on prednisone. Once it is removed the value will go back to normal.

Bilirubin is just a touch high and that is usually a sign of RBC destruction. So we must be looking at the tail end of whatever occurred in the recent past before these tests. All other chem screen value are normal. This is a sign of a relatively healthy dog.

On the CBC it is important to note this comment: “Agglutination observed; hemogram may be affected” This means that there was some damage to the red blood cells during handling, either during the blood draw or afterwords the tube was mishandled. This changes many of the values on the test and skews the results. It is important that the tech get this job done correctly.

MCV mean corpuscle volume is a touch high, 80 vs normal 79. It simply is noticing the number of larger reticulocytes.

NRBC nucleated red blood cells, again this is the reticulocytes with their RNA still inside, this is considered a sign of retitculocytosis, or the making of many new red blood cells. It should be high considering there are 379,200 reticulocytes!

Monocytes are 1% higher than normal, and the absolute value is 902 vs high normal of 840. These are the vacuum cleaners for the bad stuff in the body, which is usually an indication of infection.

Again, let me mention again, the Reticulocyte percentage is 7.9 with an absolute value of 379,200. I usually only see values like this in dogs with a HCT of 9-12%, not 39%!

So it is possible this was AIHA IMHA. If so we are looking at the tail end of the event, as he appears recovered. I am not sure why your vet is not satisfied with these values. I should also note that in some cases there is a small internal bleed that can lead to this kind of high retic values and that could be a small tumor or perhaps a stomach ulcer due to the prednisone or a bout of serious bowel inflammation (colitis.) Have these things been checked for? Did the vet tell you to use some kind of stomach protection to protect against ulcers? If not use the generic version of pepcid, on regular tab 30 min before the first meal of the day. One per day is enough.

In any case, if you are using cyclosporine it is possible to begin decreasing the prednisone carefully as the cyclo is doing the main job of immunosuppression. If you are seeing rear leg weakness and trembling then it indicates that he needs to have this dose reduced.

Here are my recommendations for reducing prednisone. Do not do this without your vet go ahead! This must be done very carefully and you need your vet to monitor Hunter during the process.
https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction

What questions do you have for me?
My best patrice

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Maria

Guest

Hello Patrice, and oh my, thank you so very much for all the discerning this information you have provided. I have to admit, my head is spinning. You make many valuable notes here that I need clarification from my vet.

ZINC: I usually never change his food or introduce different type of treats due to his GI issues. We saw a specialist for at least to years to get it under control. He basically would produce a lot of acid so if he didn’t eat every 3-4 hours he would vomit bile. We got it under control with small feedings, Zantac and a motility pill and he has done great for the last 3 years. The specialist thought he would just grow out of it and he did. He also thought that when they neutered him the may have torn his esophagus and once it healed everything would be okay.

Right before this happened he go sick, he ate some horse pine shavings. I noticed he was very constipated and a looked at his fecal an noticed the shaving. I took him in immediately because I was afraid he was obstructed. They gave him and some type of oil and he got better.

Another thing we did a few days prior to him getting sick was play fetch with a battery operated kid toy (lil’ fishys). He does bite into them at times but I noticed the ones we played with that week had not been punctured. Not sure if when batteries get wet something can seep out? And if that something could be Zinc?

Last week I started thinking about copper. We have a salt water pool. Salt water pools can corrode metal pipes. I took some water into the pool store and had it tested and there was copper noted in the pool. Not sure if that would have been enough?

You mention AIHA IMHA, not the same?

Are the medications he’s one making this worse if something different is wrong with him?

He has had no transfusions.

On page 2 of 3 of the Animal Diagnostic Clinic, I see they did do a lot of imaging and I did ask them if they saw anything like a penny. Because I did ask that specific question to the specialist and he said usually that’s the first thing the look for in the abdomen.

They did do a infectious disease test and she told me it was normal. Would that have shown the tick borne disease?

Do you recommend I make an appointment with my vet and go ask these questions face to face?

We have been reducing the prednisone by 25% since this past Tuesday, July 16 and our next CBC check is July 31st.

I am so sorry I have so many questions. And, again, I can’t thank you enough for the education. It is so hard for me to know what I am looking at.

Regards,

Maria

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Patrice

Keymaster

Maria,
It’s often the case that owners are very eager to “nail” the cause of the AIHA IMHA. The reality is that in many cases they will never know what caused it. It’s good to try to associate recent events with the onset of the symptoms but sometimes it can become burdensome as the owner begins to rack their brain trying to figure out what they did wrong and what did they miss.

When Chance was seriously ill I too was trying to find the cause because even the specialist was unable to determine a cause or come up with a treatment. I have medical training and so I began to study veterinary hematology to try to find answers. That is when I began to understand his condition better. But I have to tell you that it’s been 11 years since he first became sick and I am still finding new information about what was really wrong, research that simply was not available in 2007.

So it sounds like the techs, when trying to remove the tracheal tube after the surgery, had trouble and essentially scarred the trachea and esophagus. But it wasn’t the quantity of the acid but probably rather acid reflux backing up into the esophagus that was bothersome. A dog’s stomach acid is quite acidic, usually around 1-3 pH, whereas most human’s stomach acid is 4 pH and above. This is normal in dogs and how they digest their food properly. But acid reflux is a dangerous condition because it can damage tissue and is likely contributed to his serious problems. Those delicate tissues in the throat are not meant to tolerate extremely acidic conditions.

AIHA is autoimmune hemolytic anemia. Let’s break it down: Autoimmune simply means that the immune system has become intolerant of “self.” Hemolytic means: hemo (blood or blood cell) while lytic or lysis means the destruction of the cell. So self destruction of the body’s red blood cells (in this circumstance, there are many autoimmune conditions in dogs an humans but they all area similar, intolerance of self.) This was a common term used for many years, without clear evidence of what the title really meant. But now-a-days we could say that this is an attack on “self” that seems to unprovoked, the immune system simply became intolerant.

IMHA is immune mediated hemolytic anemia. So broken down. Immune obviously involves the body’s immunity against disease, invaders, parasites etc. Mediated mean helped by, assisted by or brought about by, so the condition is mediated by some force, whether it is identifiable or not.

But in more recent years researchers and vets are becoming more convinced that most of the cases in the past they felt were just the immune system going haywire on its own were really caused by some trigger or triggers.

So now the diagnostic science of these conditions is slowly turning in the direction of attempting to identify the outside factors, the triggers and the direct causes of the immune system becoming intolerant of “self.” Thus, initial visits are becoming more lengthy, with more diagnostics and more opportunities to save dog’s lives. So IMHA is really the more correct terminology, “something” mediated the immune system to begin attacking its own red blood cells. It honors the science of diagnostics as a valid approach to treating canines.

This is really why I made this website, because I believe good diagnostics are the keystone to saving dog’s lives. If your car seems to be driving funny, you might sit in the driver’s seat for an hour worrying about all kind of things like maybe you will need to have the engine rebuilt. However it you get out of your car and actually look at your car you might see a flat tire.

A third companion to AIHA and IMHA is some form of bone marrow failure, a far more serious and difficult condition to understand and treat. This is what Chance had an he was literally not making RBC or white blood cells (neutropenia.) A true death sentence if we couldn’t figure out how to help him make blood again.

So it appears the vet did several of the gold star diagnostics which is super. That goes a long way in demonstrating that they were trying to find every possible treatable trigger they could. I don’t think you need to quiz your vet on the things I have mentioned. They were questions I had about his diagnostics that have been answered.

Ok, so you did decrease the prednisone by 25%, excellent. That is exactly what we recommend here on Second Chance. Read the page link I posted yesterday about how to proceed with further reductions. This is as much as you should decrease in about every 3-4 weeks.

Questions are good, they help you learn. So you asked about how infections or other invaders of the body that alert the immune system can lead to AIHA IMHA. Good question.

There is a condition we see regularly here on Second Chance that leads many dogs to continue to have a chronic or refractory anemia. This means it is difficult to treat. This is often related to “anemia of chronic disease.” The body, when trying to fight invaders, attempts to withdraw resources from the invader so they have less of the materials they need to survive.

So let’s say we have an infection that has led to an inflammatory condition. There is a release of inflammatory cytokines like tumor necrosis factor and the interleukins etc. into the body. This suppresses the production of red blood cells in the bone marrow. In addition the body begins to attempt to reduce the amount of iron available to the “invader” and withholds it from circulating in the body. Thus the bone marrow doesn’t get enough iron to properly produce new red blood cells. The are poorly made and ineffective, leading to a chronic low grade anemia. In these cases the original condition cause must be discovered and treated before the dog will begin to recover from anemia. How all this works is simply amazing. The body is simply restricting its resources to make blood while it attempts to destroy and drive out invaders such as infections.

Since he has had serious gastrointestinal problems in the past it would be worthwhile to have him tested for several important nutrients, folate, cobalamin (B12) and possibly iron. See this website for an extensive explanation for why there can be cobalamin deficiencies in gastrointestinal diseases. My Chance had a deficiency of B12 due to malabsorption and I supplemented him at home with B12 shots.

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

These nutrients are critical for the making of blood, without them there can be a continued manufacture of poorly made RBC which have trouble surviving and tend to have a lower hemoglobin count. The tests can be done via this lab.

My best patrice

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