New to AIHA, dog in trouble

Keymaster

Rick,

I am so sorry to read about Brandy. This does clearly sound like AIHA esp with the results that you have provided. Can you provide us with her age and weight please?

Dexamethasone is similar to prednisone but is usually given this way, in a much larger starting dose in hospital. Prednisone is also an immunosuppressive. Both act immediately to suppress the immune system when given in high doses.

It is common for the PCV to drop some after a transfusion. Do not worry about this right now. You are correct in thinking she may need another transfusion.

The question at this point is was there a specific trigger that started this hemolytic destruction? What tests did they do to check for triggers that might need to be treated?

At minimum they should have checked, esp at this time of year, for tick diseases. They should have asked you questions about anything that Brandy might have eaten such as rat poison or food with onions or garlic. Did Brandy recently have vaccinations or is there a chance she had a bee sting? Is she an outdoor dog? Does she go to wild areas where she might contract certain diseases like Leptospirosis? Has Brandy been a healthy dog or does she perhaps have allergies? An older dog should have a thorough check of the internal organs to look for growths. We always like to see a complete checkup.

The goal now is to stabilize Brandy and stop the destruction. She is actively regenerating new blood cells, you can see that by looking at two results you posted:

2+ Polychromasia is present. This means that there is variability in the color of some of the red blood cells. These reticulocytes, which are immature “baby” red blood cells, still contain RNA from their development stage and when viewed on a slide that has been stained with blue, show this strong variation of color. It is simply an observation that was made in the lab and is not something bad.

2+ Anisocytosis is present. This means that there is a variability in the size of some of the cells. The reticulocytes, those new baby blood cells, are larger because of the RNA inclusion. So on the blood smear they appear much larger.

An automated blood analyzer will see these variations and note them. But usually in a case like this, a competent clinic will view a blood smear under a microscope as well. We hope that your clinic takes great care in how they collect and handle blood. Please pay attention to this process as mistakes can be made that impact treatment decisions.

So now she is at home and you have been handed over the nursing care. That is pretty scary. She is very sick and she will be very tired. Give her the space to recuperate and esp today, keep the house quiet. No visitors.

Plan on making easily digestible food, a simple diet of cooked skinless chicken (saute it in a pan to make it smell good) and overcooked white rice with a little of the chicken broth will be a perfect start. She may respond to the good smells.

Make a list of all supplements she normally gets, we may need to eliminate some of them that might interfere with her treatment.

A great concern now is serious clotting. I hope they addressed this with you. If they did not you need to contact them and ask if you can put Brandy on low dose aspirin therapy immediately. The blood is not stable right now and clots can form quickly and travel. If you see any signs of difficulty breathing, sudden unsteadiness etc, please take her to the emergency clinic.

Another serious concern is stomach ulcers caused by the Prednisone. She must be on some kind of stomach protection. We usually recommend over the counter stomach acid prevention that is used for humans. You can get something like Pepcid or Prilosec. Depending on her weight she will need at least one, if not two a day, and given about an hour before meals.

On your next visit, discuss protecting the liver from the prednisone. Liver enzymes, indicating damage, will begin to elevate. The liver is processing the drug. This is normal. And the liver is regenerative. If there was no organic liver disease prior to this, the liver usually will rebound and recover once the dosage of prednisone is reduced.

You are going to see many changes, the first of which are increased hunger (hopefully!) and thirst. She will be peeing constantly. You may have to sleep downstairs with her to let her out at night. She can’t help herself, don’t be upset with her. She may pant and seem uncomfortable. This too, is a side effect of excess cortisol (prednisone) in the body. It causes the body to be on alert and prepare for stress.

Keep an eye on her stools. You may see dark stools and orange urine indicating red blood cell destruction. It is hopeful that after a few days on the prednisone the destruction will stop. But sometimes they need to increase the dose or add another drug to help do the job.

We are always here to help you, day or night. We urge you to be polite and respectful when you visit your vet’s clinic, but be mindful that you are Brandy’s advocate. You are with her constantly, your vet only sees her for about 20 min. In all cases ask politely that you be with her when she is in clinic. Stay out of the way and be quiet but make sure this happens. If you need an excuse say that you are a student and want to learn.

Ask for copies of all her records. We are able to review that bloodwork for you and explain it to you. When you have a question, ask here first. We will give you the background you need so you can discuss this intelligently with your vet. Your goal is to be a partner in her care, not sitting in the back seat.

We are always optimistic, each dog has a chance at the same positive outcome if the treatment is approached in carefully thought-out approach.

my best, patrice

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Patrice

Keymaster

Rick,
Thank you for the complete history. This is important information.

I do not subscribe to the “old dog illness” theory. Neither does my vet. Chance, who was my inspiration for this website, was an older larger breed when he was diagnosed. What I said to my vet, before I knew what the problem was is that “he looks dumpy to me.” She firmly told me that we owners confuse how humans look as they age with how dogs age. If our dogs are kept healthy, they do not look dumpy as they age! He was not healthy at that time.

Brandy is a medium sized dog with an expected life span of up to 15 years. I am never completely satisfied with “underlying medical issues” as a complete diagnosis. In general, unless a dog is very sickly as a puppy (perhaps due to genetic deficits in a pure breed), I am not convinced of a definitive exclusive diagnosis of Addison’s Disease.

Pancreatitis is, unfortunately, a condition of equal opportunity owing to a dog’s less than hygenic eating habits. However, in most dogs, this is usually a singular event following social gatherings like holidays (too much turkey fat sneaked under the table) or food stealing as a young hungry dog (the whole turkey.) If properly taken care of at that time by a vet, most dogs usually recover from these one time events and can go back to eating a normal diet eventually, being mindful of keeping it on a lower fat side. Prednisone has been linked as a possible contributor as well.

I am not exactly sure why they prescribed multiple courses of antibiotics (unless you are referring to Metrondiazole) for this condition, but I do know the outcome of frequent antibiotics in a dog. SIBO small intestine bacterial overgrowth (good bacteria is destroyed by the antibiotic leaving room for bad bacteria to proliferate.)

The small intestine is the organ of digestion where all food is assimilated into the system as nutrients. The loss of good bacteria in the SI leads to SIBO which causes severe inflammation of this organ and malabsorption of important nutrients. The other outcome is that the colon receives a great deal of undigested food and bad bacteria plays havoc creating diarrhea, gas and perhaps even colitis.

Addison’s Disease can be known as the Great Pretender, with vague symptoms similar to other conditions. Has your vet ever done an ACTH stimulation test? This should have been done as a rule out years ago. I am surprised it took you 3 vets to find some help.

For others reading this: Addison’s disease results in basically the opposite of too much cortisol (Cushings), resulting in low levels of cortisol, and leaves a dog constantly struggling to handle stress conditions properly. Weakness, collapse, poor appetite, vomiting, diarrhea, problems regulating body temperature etc are all the vague symptoms of this condition. Because the body’s daily needs for cortisol are extremely variable, they may appear to be relatively fine, but when stressed, they may be very ill.

What is possibly an explanation for all of this is a companion condition to SIBO called Leaky gut syndrome (which could result from pancreatitis). The inflamed SI leads to leaky “spaces” in the walls of the small intestine. Undigested food, toxins, and bacteria leak into the bloodstream.

These noxious wastes can lead to allergies of the skin and respiratory system, joint pain (arthritis), irritable bowel disease, autoimmune disorders, diabetes, and many other issues related to the Pro-Inflammatory Response.

I am going to guess that there was some autoimmune component to this condition, possibly resulting in some level of destruction of the adrenal glands. If that is the case, then it is possible that Brandy has had a tendency to other autoimmune conditions as well since then (hypothyroidism?.) This can result in what is called a Pro-Inflammatory response. High levels of pro-inflammatory cytokines such as Tumor Necrosis Factor and certain interleukins result in negative changes to how the body handles “stress.”

The main player in AIHA is usually considered to be the T-cell lymphocytes. These reactive white blood cells are usually our protectors. But these killer T-cells can also lose their original instructions and begin attacking “self.” Suppressing them is sometimes the only solution to stopping the destruction. Unfortunately, the side effects of suppression on the rest of the body are quite serious.

There are other treatment protocols for Addison’s that may be more satisfactory than simply prednisone. Fludrocortisone (trade name Florinef) and a monthly injection called Percorten-V (desoxycorticosterone pivalate, DOCP) may be alternatives.

I don’t normally recommend that folks see an alternative veterinary professional but I think in Brandy’s case this would be a good consultation, once she is stable. I would also advise that you be very cautious about administering kelp. This nutrient rich supplement can contain so much iodine that it can suppress and cause thyroid dysfunction leading to hypothyroidism. Kelp supplements can contain iodine in amounts that are up to several thousand times higher than the daily tolerable upper limits for iodine (in excess of 500-1,100 mcg iodine daily). I was attending a Dr.Dodds’ seminar when she first learned that studies had shown this to be the case. Who knows what dog foods and supplements contain since they are so loosely regulated.

So the top priority is stabilizing Brandy so she can withstand the immunosuppression that is required to halt the autoimmune destruction of the red blood cells. Keeping her healthy is very important right now with lots of rest, good nutrition and very low stress. As the days go by you will be more comfortable with providing care for her. Right now, let us take on the heavy worry for you. Be kind with yourself so that Brandy feels at ease.
my best, patrice

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