Aplastic anemia – time to remission – Second Chance AIHA Dogs

Tharin

Guest

Hello,

my dog was diagnosed of probably aplastic anemia (bone marrow puncture suggested this, see bottom). As she had anaplasmosis allready a year ago, we first thought it’s a relapse of the anaplasmosis and lost weeks by treatment with antibiotics.

She then went down to HCT of 16,2%, PLT 38 (148-484) and got a transfusion after bone marrow puncture in emergency vet clinic.
Was put on prednisolone 2mg/kg once daily plus 20mg omeprazol. HCT right after transfusionwas 27,7%, PLT 49.

3 days after the transfusion CBC showed HCT 24%, PLT 21 and ciclosporin was added, 50mg twice daily for 3 days, then 100mg twice daily.

Another 4 days later HCT 17,9%, PLT 40 and been told in the vet clinic to check blood less often at my “house vet” (we did check in between, cause PLT falling: 5 days after tansfusion: 19, 6th day: 21 and then 30), cause this might cause anemia, too, but check again after 3 days, better 5.

Checked after 3 days HCT 16,7%, PLT 105, so Ciclosporin now 150mg twice daily in the local clinic.

Check again 4 days later HCT 16%, PLT 313 in that clinic.
Been told, there is no response and I should consider killing her (I don’t think euthanize is the right word, cause this suggests death is a better option then life).

Since the immunosuppression my dog does not seen sick at all – beside of course the anemia symptoms like fast heart rate and little energy. But she’d go for walks – I didn’t do, cause I panic, when I meassured her heart rate. :>
Before suppression she was like having a flu or so, when the anemia wasn’t showing off the typical symptoms yet – then anemia symtoms added of course with anemia.
Although the clinic vet is convinced, that there is no hope if there is no affect of the meds yet (PLT count doesn’t seem to be of any value for this vet?), she gave out Mycophenolate.

After 3 days of Mycophenolate HCT 14,6%, PLT 469 (WBC slightly over top).
Again suggestion to kill my dog, allthough at the appointment before she said, she’d be ok with even giving human immune globulins, when there is no response.

My house vet and me kind of insisted on giving Milk another transfusion (donor was a friend’s dog – clinic would not have given pRBCs or whole blood from their donors) that day – yesterday.

I read some research papers, that describe response times usually about 38 days or up to 2 month in median and also quite some time longer, if the bone marrow is affected.
I know in humans – who initially recieve the potent treatment with ATG – it usually takes 2-4 month to see affect, but can also be longer like 6 month or maybe more. So I would think, it takes more time than 3 weeks of pred and 2,5 weeks of ciclosporine to get reticulocytoses and therefore regeneration?
Am I wrong in seeing the super improvement of platelets as a response?

My “house vet” is very commited and also does not think of killing the dog, that doesn’t suffer at all – just might show anemia symptoms, if not treated. After tranfusion she’s really fine.
All the liver, kidney etc. counts are really good – we were astonished considering her medication. Just the ALT is slightly off (162 (10-125), is was more off under doxy (about 250) treatment, when we still thought it’s anaplasmosis.

I am not so sure, that the mycophenolate was a good decision. Or just a bit more time for the ciclosporin to work would have been better. My dog got a bit worse after adding the mycophenolate (clinically and per day decline of RBC, HCT, HB in those 3 days). But it’s just 3 days, so maybe just coincidence.

Looking forward to your replys.
Tharin

Bone marrow cytology said:
“As far as assassable there could be a mid grade hypoplasia of all cell lines.
Additionally there are hint of a lymphoplasmatic infiltration.

Etiologically this could be due to – between others – immun mediated
processes, estrogenintoxication or medical dug intoxication (for example
cytostatica, phenylbutazone, trimethioprim-sulfonamide), parvo virus infection or a chronic Ehrlichiosis/Leishmaniosis.”

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Tharin

Guest

Hi, Vally and Patrice,with

thank you for your super fast ansers!
I just filled out the consultation request for Dr. Dodds a few hours ago.

I just sent you the overview of the CBC, PCR/antibodytests of all the blood parasite stuff and medications via the urgent advice link. Let me know, if you did not get it, please.
(Forgot to mention there: The colors indicate different labratories.)

Milki is a English-Bull-Terrier-Cross of 9 years, female and spayed. She is a thyroid patient. Her values weren’t cleary, but she seemed better off with the Thyroxin regarding her behavior (more relaxed – she had really bad childhood and therefore a lot of problems). And weaning off made here spook very easily.
She weighs right now 18.6kg=41lbs, if spring Usual weight before all of this was about 19,5-20 kg = 43to44lbs. Weight loss is mainly muscle. She used to be very athletic.

Medication right now:
1/d Omeprazol 20
1/d 40mg Prednisolon
2/d 150mg Ciclosporin
2x/d 250mg Mycophenolate
1/d 80mg Enrofloxacine (WBC count litte high on last CBC)

I read Chance’s story. That really gives hope and power to fight the odds.

Even if I am the driver of the bus, I can’t go without gasoline, so to speak. I am in the lucky situation, that I can do the blood draw, cross match myself and my vet (not the clinic one) is totally on our side, Milki and mine. I am allready looking for ways to get pRBC with my vet. He is not negative at all, it’s just the clinic vets – who allready have all the transfusion equipment, even for pRBCs, but will not provide it. But – as mentioned – we’ll do on our own, if forced to do. We just need to find the fitting donors. :)

There were no spherocytes seen in blood smear, so it’s unlikely a hemolytic thing going on. Coombs negative, too.

I am not sure about the ciclosporine dosis hightened at 150mg twice daily just because no reticulocytosis was seen then. I testet (in human lab) for ciclosporine level on this dosage and it was 965 ng/ml 10 hours after morning dose and 2 hours before evening dose. It’s way out of range for humans. Don’t know about therapeutic range for dogs.
Clinic vet does not care and commited vet does not know about range preferred for aplastic anemia.

With the immunosuppressants the loss of RBC/HCT/HB dropped to even smaller (if I calculated right) then the expected daily loss.
Platelets were very big and “fluffy”, when count was low. Now they go back to normal size and look. Also the clotting seems way more normal, when doing a blood draw (was very fast before – so glad, she did not get thrombosis!).
But the erythrocytes become smaller with anemia. But MCHC higher. Pathologist did not evaluate the blood smear as micocytic though. Do you understand that? I could understand microcytic-hypochromatic, but microcytic-normochromatic? Or is it likely a meassurement artifact in the hematology automat – cause in the blood smear the experts (lab and pathologist) did say normocytic-normochromatic?
(The automat is a Procyte DX.)

You are so right about the warning for blood typing! My vet and me are very cautious about it. That’s why I did a cross match myself with major/minor and incubation time (30min) as well as mix of whole blood with incubation time. The clinic mixes a drop of donor and recepient blood on object slide and examines it directly. I’m a bit spooked with that method, so I did it the matching myself – and let the clinic do it their way again, so double check. ;)

Thank you so much.
Tharin

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