Bristol and AIHA

Kerrie

Guest

I’m typing this as I watch my 10 year old Beagle mix sleep. Last Wed she was diagnosed with AIHA. It was sudden. She stopped eating Monday and by Wednesday morning her Crit was 15 and her bilirubin high, the dog was yellow. Cue Blood transfusion (our lab/pit mix made the donation). She had a Dexamethasone injection and was sent home on Mycophenolate, Doxy and Pred to start Friday am. She deteriorated over night so amid Hurricane Dorian (we are in SC), we drove to the ER Vet. She was down to 10. They typed her and we needed to do another transfusion. She remained hospitalized, transferred to our vet in the am for observation. Her Crit went up to 26 but by the morning was down to 18. We rode the rollercoaster all weekend, up and down she went. At some point a blood smear was done and Babesiosis was suspected and she was now on a second antibiotic, injectable pred, and the Mycophenolate. Her bilirubin also had come down. By Sunday she was down to 11 and the ER Vet brought his own dog in for a transfusion hoping the fresh blood might give her some extra oomph. She only got as high as 16, truly disappointing. I believe at this point cyclosporine was introduced.
We visited her several times over the hospitalization because we loved her and because she refused to eat, drink or pee for the staff. And every time she was perkier, ate for us, peed for us and drank.
Monday am she had a sonogram which showed nothing abnormal other than an enlarged spleen which is expected. Our regular vet, who actually hadn’t seen her at all was doom and gloom. I think he is an amazing doctor, and incredibly skilled but I think his late arrival on this scene skewed his view. He wasn’t very hopeful and felt she was going in the wrong direction.
On the other hand the ER doctor who had seen her since the second day on a near daily basis said he was “cautiously optimistic” . She was eating and drinking for us and her demeanor was much brighter and he said it wasn’t the same dog from Thursday. His advice was let the last transfusion run its course and see if her body would fight. He told us we did a lot more than most owners could or would and we should have no guilt if her level dropped and we decided to “call it”. My husband and I agreed. She stayed one more night and we decided to take her home Tuesday (yesterday). Her level, 12.1 @10am, was very disheartening. She came home on Cyclosporine, pred, mycophenolate, doxy, and clindamycin. All appropriate dosages from what I’m seeing on this site.
I wasn’t sure she was going to make it through the night. She ate(with less gusto), drank, urinated and defecated (1st time, yay) but she was weak and wiped out. She was breathing rapidly at times and her heart beat was crazy. This morning she looked awful. She did everything she was supposed to but just looked like she wanted to die, weak and stumbling. I figured it was time and reached out to a mobile vet to come to the house to euthanize. While waiting for them to call back, on a whim I cooked 2 scrambled eggs knowing she wasn’t going to eat, well she did, and she took her morning meds.

I was shocked. So we took her for a quick PCV at our vet, agreeing before hand if the level was down we would euthanize and if the level was the same or up we would try 1 more day. It was up .5 to 12.6%. Still awful, but the first time her value and remained stable. No crazy fluctuating.

So that’s why I’m here. I have sent her info to Dr. Dodd for a consultation. Asking for guidance and to review the protocol. But I want any advice that can help this dog. Her current value isn’t exactly compatible with life, but the ER doctor said he would base it on her demeanor as well as the Crit value. I know another transfusion would help, but I really don’t want to put her through it if the immunosuppressants aren’t kicking in. Some dogs won’t respond and I guess I’m looking for when that point is? Are we there now? Can we wait and see or are we risking further damage? She isn’t suffering thus far and I’m encouraged as long as she is eating and drinking, even though that may be a side benefit of the Pred. Can you provide any suggestions that might help us? From what I’ve read most dogs have a much higher value at this point in the process. Meaning they have higher PCV values after 3 blood transfusions and meds. Am I correct in this thought?
As it stands today, we are waiting and seeing. If she maintains her depressed demeanor but is eating and drinking I’ll check her level tomorrow with the same decision point.
Thanks for your time.

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Patrice

Keymaster

Kerrie,
You have had a very frightening few days and you still have the fortitude to fully understand most of what is happening and plan out carefully what you are going to do. This attitude is so important in the coming days. Way to go Mom!

Ok, let’s jump right to the diagnosis of Babesiosis. Your vets were very smart to test for tick diseases in the early diagnosis stage.

IMHA immune mediated hemolytic anemia, is destruction by the immune system of red blood cells (hemolysis) that is MEDIATED by some outside factor, a parasite. The mediator in this case is the babesiosis. And it is treatable. How she contracted it is still up in the air, it could be from a tick but it can also be contracted from other dog’s bites. It is also possible that she has been a carrier and is finally expressing the disease fully. I have several resources for you to read about this disease on this website.

See this webpage:
https://www.secondchanceaihadogs.com/parasite-resources
Near the bottom you see a picture of a dog’s yellow gums and another of a microscopic picture of cells. Both articles discuss babesiosis. Open them both and then you can click on the upper right arrows to open them in a tab so you can save and print them.
https://www.secondchanceaihadogs.com/parasite-resources

A third study is also available, that your vet might want to read. Go this page:
https://www.secondchanceaihadogs.com/canine-disease-resources
Click on Case Report, An Unusual Case of Babesiosis.

Babesiosis is a tick disease that is a bit different than other tick diseases. It can’t be cured by treatment only managed. Many dogs are able to fight it successfully and simply remain carriers the rest of their lives. One breed in particular is known for their carry status, Pit Bull Terriers. Babesiosis is endemic in this breed plus Greyhounds and they are both carriers. You mention your Beagle is a mix, is it possible that the parentage might include Pit Bull Terriers?

Babesiosis is fought almost exclusively in the spleen. The spleen has multiple duties, first to store blood, second to remove old worn out red blood cells and either eliminate or re-purpose the parts, third is the important immune system functions it provides, one of which is to search out RBC that contains parasites and then effectively damage and destroy them (and in the process destroy the RBC as well.) So right now your dog’s spleen is actively fighting this disease. That is a very important thing to keep in mind.

I’ve been on a tick list, Tick-L, for many years, moderated by a scientist, and we have discussed Babesiosis at length. One of the conundrums of treating dogs with Babesiosis is the use of high dose immuno-suppressive drugs, like prednisone and dexamethasone. We sure do want the immune system to stop destroying RBC so suppressing it seems like the best thing to do. But we forget that the spleen is also working right now, very hard, to destroy this tick disease. So it’s fine edge sword that we use predisone but also need that spleen to do their job.

One of the two papers I have linked you to was written by Protatek Reference Lab, who are the largest lab to test for parasitic diseases in the country. That is all they do and they are infamous. So, you will read this, and the first treatment they mention is chemotherapy. This can reduce or even eliminate symptoms, though the dog remains a carrier. This depends on whether the causative strain is Babesia canis, which are “more readily cleared than those caused by B. gibsoni.”

The next comment they make is “Doxycycline and Clindamycin are affordable, generally well tolerated treatment options for dogs with low to moderate titers against B. canis and showing mild clinical signs of Babesiosis. However, these drugs will not clear the infection.” I suspect your doctor has already added doxy, though you didn’t mention the drug you said an additional antibiotic. I’m guessing your lab may have found high titers so this may not be as successful as you wish.

Finally Protatek mentions “In the US the “big gun” treatment is Imidocarb Dipropionate ( Immizol). The drug is usually administered in 2 injections (given 2 weeks apart). The drug is most effective in clearing infections caused by B. canis. Although the drug is beneficial in treating clinical disease caused by B. gibsoni, it is less effective in clearing the infection caused by this agent.”

So the first thing you need to find out is which strain your dog is infected with, B. canis or B. gibsoni. I am sure your lab report has identified this. From there you and your vet can conference about these three treatment options.

Immizol is very expensive and must be ordered in a quantity sufficient to treat the dog twice. But Protatek comments “In dogs that are exhibiting low antibody titers and are asymptomatic, this treatment is not worth the risks and side effects.” We saw some miraculous cures with this drug. There are some side effects to the administration, but they carefully note in this paper to the veterinarian how to completely eliminate this during administration.

The second paper is a review written by veterinarians and is very complete in all details. You should read this carefully and try to understand as much as possible. Then sit down with the vet and go over each section to see what has been accomplished, check them off, and what still needs to be reviewed.

Within this review there is a caution about the use of prednisone, which I mentioned above. We had several owners on Tick-L who were treating very sick dogs with Babesiosis. The question we hammered out for several days was, should this dog be on prednisone??? If the spleen is doing all this work with their immune system elements, is it counterproductive to be suppressing that part of the immune system? So in the end we felt it might be beneficial to reduce the dose of prednisone and provide additional treatments (such as mentioned in this review) as soon as possible.

Maintaining homeostasis is a critical part of treatments for dogs fighting babesiosis. This means making sure that they are physiologically stable. Blood transfusions mean a boost in more things than just more red blood cells. Whole red blood transfusions provides many other blood elements that are of great value and go a long way in making the patient stable. One problem dogs with anemia suffer is hypovolemia, low blood volume. This is helped with transfusions. A proper diet is also critical, easily digested foods are important. Even if the appetite isn’t there, syringing food into the mouth can be a way to keep the nutrition up.

I am also concerned, as your vets may also be, about low albumin. This is a protein made by the liver that is carried in the blood. It helps maintain the fluid inside the blood vessels. With tick diseases we sometimes see low albumin as one sign. This can lead to fluid leaking out of the blood vessels into areas like the abdomen and we want to avoid that.

So your conversation with your vet should be twofold, first address these reviews and studies and see if there are additional treatments and medication adjustments you can make right now.

Second it to address making sure your girl stays stable while she is being treated. We have noticed here on Second Chance for years, that if a dog is stable and healthier they can tolerate their treatments better.

Make no mistake your girl is working very hard, overtime, to get better. This is something we forget when we are caring for our sick dogs, they are fighting too. If she is showing the will to live then it is your choice to honor that if you wish. My vet told me many years ago with Chance, that we can’t put down humans who are having trouble making blood, we just have to keep helping them until they get better. I learned from that and fought for Chance. He survived and I do believe your girl can muster if she is given the correct treatments. She may never be free of this disease, and you will have to take some cautions in her life so she can survive, but I do believe it is worth it.

If you have any trouble reading the articles and need something explained, ask me. Any other questions you have for me?
my best patrice

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Kerrie

Guest

Update on Bristol. Babesiosis Titer was negative. I believe it was Hemopet Labs that performed the test, it was a DNA test. While we waited, I had Bristol at the Vet every morning at 9am with the same assumption, if her PCV was higher, we would go one more day, if it was lower we would consider euthanasia.
Wednesday, it was 12.6, up .5%, it wasn’t a good day. She hardly ate, threw up what she did eat and was weaker than the day before.
Thursday am a CBC showed her down to 12%, but her WBC went down and her “new” red blood cells were almost double what they were on Monday. She was a little brighter than the day before yet her breathing and heart rate were faster. The Vet, who had been the diagnosing vet last Wednesday, said I don’t want to sway you either way, but if this was my dog, I’d keep going, One day at a time.
Last night was brutal. Bristol was a little twitchy and trembling. Her breathing seemed erratic, slow sometimes, rapid other times and some occasional panting. She wanted nothing to do with food. We added Carafate because I was concerned about her belly. She hated it. I was crying and forcing her to eat, forcing her pills down her throat. She was stressed and angry, turning her back on me. I was so upset to do it but I knew I had to. During the night her breathing slowed and I mean it really slowed. I used a rice bag to keep her warm and I checked her at least half a dozen times to make sure she was breathing. It wasn’t the roughest night so far, but it was bad.
In the morning she was very blah, but she showed some interest in a scrambled egg. But while lying on the bed, flat, not making eye contact with me, my husband yelled for our daughter to come and eat. She shot up to sitting position. We looked at each other and warmed her up some chicken breast, she wolfed the small amount down. She made a move toward the bowl of oatmeal my husband was carrying for our daughter, we gave her a little. We were hopeful.
At the vet, we discussed another transfusion, because really how long can a dog live at 12%, even if she was stable. It had been the first time she was stable for more than 6 hours. The vet was disinclined, as Bristol had had 3 already. She looked a bit weaker to the vet, but her heart wasn’t as fast as the day before and her respiration looked better. Then the blood work…just a PCV today because the Vet doesn’t want to take too much blood from her.
And it came back 17!
We aren’t out of the woods yet, and I’m not overly enthusiastic, but it is a move in the right direction. The Vet said tomorrow am for a CBC and no change in the protocol (Which Dr Dodds reviewed made a few minor suggestions that were well received by my Vet) Pred, Doxy, Clindamycin, Mycophenalate, Cyclosporine, carafate as needed, pet-tinic, and the possible addition of a thyroid med.
I really don’t think she would be here with out this website. I think I might have lost all hope and given up. I’m not a coulda woulda shoulda girl. I’m a put your big girl panties on and do the heavy lifting kinda girl. But I believe a Higher Power led me to you. I am incredibly grateful. I know there aren’t any guarantees here and the time is all borrowed at this point. But I feel that I am making informed decisions for the better for Bristol. Thank you for that.
Kerrie

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Patrice

Keymaster

Kerrie,
I am delighted to read about Bristol showing a strong will to live! Dr. Dodds is my guardian angel, having saved Chance, so I am very glad to hear she is helping.

You’re on the downswing right now. The prednisone is probably at the highest dose they can prescribe, you’ve been giving it long enough for some really scary side effects to show up.

As Vally and I both know well, the hardest part of this group of diseases is that the side effects of the drugs seem worse (are worse) than the diseases. But when you start to see small forward steps you can begin to see a time in the future when she will get better and the prednisone can be decreased. The drugs must be used and sometimes that is the hardest thing to accept because we are reluctant to drug our animals to the max.

You’ve added cyclosporine and that will become extremely effective and you will be able to slowly decrease the prednisone. That is why we always recommend a secondary immunusuppressant drug be added, to reduce the need for prednisone. Your vet and Dr. Dodds will explain to you how to do the reduction carefully and slowly. Here is what we recommend for how to decrease prednisone, perhaps a bit more conservative than some vets, but was developed from our experience with dogs we have helped and from some dogs that had relapses when they reduced the prednisone too quickly.
https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction

In 2007 Chance was extremely sick from just being solely on prednisone. His liver was extremely inflamed and painful. Besides having bone marrow failure (not making red blood cells) he also was not making white blood cells so he needed to be on antibiotics constantly and those made him feel ill too. He had different behavior, as you have noticed, did not want to be petted and behaved antisocially. That is absolutely normal. Do not take it to heart. I let Chance have his space. When he recovered, which took the whole year, he was himself again. He looked good and he felt good. He was not exactly the same dog going in that came out of the illness, but still “Chance.” Vally has had similar experiences with Bingo.

We both committed ourselves to help owners like you because we know how much better it feels to have someone help make uncomfortable decisions. I am also very committed to education because I think it helps us make less emotional decisions. So many owners have no knowledge of these conditions and suddenly find themselves in an emergency room with the vet, who is using all these complicated words, they don’t even know what they are talking about. Then they hand the owner an outrageously expensive estimate. How do you make a good decision in that kind of pressure cooker? You can’t. So we are here to do the heavy lifting; the research, and pass that on to the owner in a way they can understand.

So about transfusions. Physicians and vets use a common term, transfusion trigger, when deciding whether to administer one or not. First they evaluate the findings from the test results. Once they have done that then they evaluate the patient. Are they feeble, unable to stand up and walk to relieve themselves? Does your dog perk up when you or a staff member visit? Even a tail wag is a good sign. Do they seem hungry and willing to eat some food, drink water?

So one dog could have a PCV of 12% but be very alert and perky while a dog with a PCV of 28% can hardly stand. Clearly the first dog probably doesn’t need a transfusion right yet if they are this stable, but the second dog does need it, they are not stable and need the benefits of not only red blood cells but all the other cellular elements in blood that make us feel better. This is the thought process your vet went through, talking with staff and evaluating Bristol.

Make no mistake, Bristol is working very hard right now to get better. She has a strong will to live. I would agree that if you can, honor that. We have seen some amazing comebacks in many dogs. I have faith.

We are always here to help. Any questions you have, let us know.
My best Patrice

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