Spaniel with AIHA or not?

Re: Spaniel with AIHA or not?

Martin Atkinson — Thu, 19 Sep 2013 15:48:23 GMT

[quote user="Michael Woodhouse"] I've always taken low levels to mean non specific binding in the ELISA test rather than a low level of the antibodies.[/quote] I guess that is how Axiom interpret the test then. I expect it to be -ve as there is no hint of megoesophagus but there must be something causing it to be profoundly weak with a PCV of 36%.

Re: Spaniel with AIHA or not?

Michael Woodhouse — Thu, 19 Sep 2013 13:26:52 GMT

Martin - I've always taken low levels to mean non specific binding in the ELISA test rather than a low level of the antibodies.

Could be the steroids.

Whatever happened to Mr Fox - he was a really useful guy to have around.........

Re: Spaniel with AIHA or not?

Martin Atkinson — Thu, 19 Sep 2013 10:05:43 GMT

ACh receptor Ab result 0.11nmol/l, Axiom state <0.6 is normal/-ve. I would have thought that any result was +ve as surely there should be no antibody in a normal animal?! Proviso of course is that this could be affected by the steroid therapy. Dog is still steadily improving, its PCV is stable at 36-37% and its excercise tolerance is getting better day by day. Still plan A: continue to reduce steroids gradually and see what happens while treating gastric ulceration/helicobactor, I may repeat the ACh R Ab test if/when its off steroids if its still weak.

Re: Spaniel with AIHA or not?

Michael Woodhouse — Fri, 13 Sep 2013 22:06:24 GMT

Wait for the result back. Mestinon nasty stuff.

We get the syrup from these guys

http://www.creopharma.com/about-creopharma

May save you a bit of research.

Re: Spaniel with AIHA or not?

Mark Hedberg — Fri, 13 Sep 2013 16:56:20 GMT

Anecdotally when I had helicobacter i was on ranitidine+amox clav+ clarithromycin and it worked fine. The lack of omeprazole didn't seem to be an issue, although i was on a high dose of ranitidine.

Re: Spaniel with AIHA or not?

Martin Atkinson — Fri, 13 Sep 2013 15:26:06 GMT

[quote user="Michael Woodhouse"]

We have 1 dog with MG. He tested positive for ACh Ab on steroids. They suppress immunity but do not obliterate it.

My wife spoke to some internal medicine person who said Edrophonium no longer available. Do the Ab test.

[/quote] Thanks Michael 'twas wot I thought. Presumably the next thing is just to treat with pyridostigmine and see what happens. Incidentally, no result back from ACh Ab test yet but dog is improving day by day as I reduce the preds, gaining weight, getting stronger and the PCV is only going one way - up! Gastric biopsies showed non-specific ulceration and contents culture showed helicobactor. The jury is out on the significance of this in dogs but gastric ulceration+helicobactor+dog with weird autoimmune disease on preds = give it some antibiotics, so its now on pot. amox. and metronidazole, bloody thing will be rattling soon! In humans they reckon omeprazole is better that Zantac and its only single daily dose - any views on this in dogs anyone?

Re: Spaniel with AIHA or not?

Michael Woodhouse — Thu, 12 Sep 2013 22:27:50 GMT

We have 1 dog with MG. He tested positive for ACh Ab on steroids. They suppress immunity but do not obliterate it.

My wife spoke to some internal medicine person who said Edrophonium no longer available. Do the Ab test.

Re: Spaniel with AIHA or not?

Martin Atkinson — Mon, 09 Sep 2013 16:31:43 GMT

I don't know is the answer but given that it had a Coombes test +ve @ 1:128 when on immuno-suppressive doses of steroids its worth a try, If the test is negative but the dog still weak once we're off steroids and its not anaemic I may try again. I thought about a Tensilon test but a: I'm not sure where I can get it from (NVS don't stock it - any ideas folks?), b: its not a specific test and c: the dog was here having haematology so I just collected a bit more blood.

Re: Spaniel with AIHA or not?

Rob Loxley — Mon, 09 Sep 2013 13:48:45 GMT

[quote user="Martin Atkinson"]Sample taken for acetylcholine receptor antibody[/quote]

How long might the suppression of antibodies by the previous high-dose steroids last?

Re: Spaniel with AIHA or not?

Martin Atkinson — Mon, 09 Sep 2013 12:08:56 GMT

[quote user="Anthony Dennison"]

Could the tiredness be due to Myasthenia Gravis?

[/quote] Another update. I've decided this is a good call especially as the HCT is almost normal now we've got the dog on antacids despite lowering the dose of preds. Sample taken for acetylcholine receptor antibody.

Re: Spaniel with AIHA or not?

Martin Atkinson — Fri, 06 Sep 2013 13:10:20 GMT

[quote user="Anthony Dennison"]

Could the tiredness be due to Myasthenia Gravis?

[/quote] Good God I don't want to make this any more complicated that it already is! No suggestion of megoesophagus but it is a Springer so possibility of congenital MG I guess. If it was acquired though steroids should make it better not worse. Hmmm.

Re: Spaniel with AIHA or not?

Andrew Kent — Fri, 06 Sep 2013 10:37:36 GMT

[quote user="Anthony Dennison"]

Could the tiredness be due to Myasthenia Gravis?

[/quote]

I would think it likely to be a side effect of the steroids

Re: Spaniel with AIHA or not?

Anthony Dennison — Fri, 06 Sep 2013 10:31:08 GMT

Could the tiredness be due to Myasthenia Gravis?

Re: Spaniel with AIHA or not?

Martin Atkinson — Thu, 05 Sep 2013 16:51:08 GMT

Update on this case for those interested. PFK deficient gene test came back negative/normal. Occult blood positive in faeces. X-ray showed radiopaque possibly metallic object in intestines but looked like ileum/colon. Barium meal showed no abnormalities and radiopaque object had vanished when X-rayed the next day. Have been reducing preds slowly and HCT remained stubbornly at 34%, put on Zantac and Antepsin. Had ultrasound and endoscopy today, NAD on ultrasound except a hyperechoic area in the hepatic artery with blood flowing around it! Endoscopy showed multiple echymoses in gastric lining presumed to be the source of bleeding secondary to the steroid therapy, Awaiting histology on that, but still plan A - wean off preds and monitor PCV. Dog remains very bright but tires easily still.

Re: Spaniel with AIHA or not?

John Flynn — Fri, 30 Aug 2013 10:29:50 GMT

[quote user="Martin Atkinson"]

[quote user="John Flynn"]How positive?[/quote] Coombes test 1/128

[quote user="John Flynn"] was this an automated in-house analyser result?[/quote] original vet used outside lab, we've had consistent results with QBC, micro-haematocrit and outside lab. so I don't doubt the accuracy.

[/quote]

Everything sounds like IMHA other than the lack of an initial convincing anaemia in spite of profound clinical signs.

I think you're right to be keeping an open mind about concurrent disease here in addition to presumed (clinically mild at best??) IMHA.

Can't think of anything different than your suggested plan.

Would be interested to hear how it pans out!

Re: Spaniel with AIHA or not?

Martin Atkinson — Fri, 30 Aug 2013 09:01:29 GMT

[quote user="John Flynn"]How positive?[/quote] Coombes test 1/128

Re: Spaniel with AIHA or not?

Robin Grimmer — Thu, 29 Aug 2013 22:55:00 GMT

It's not AIHA if the initial PCV was 36%. That's only slightly below the normal reference range and wouldn't be low enough to cause any clinical signs by itself, so there must be something else going on. AIHA cases present with a much lower PCV, often below 15%. A moderate anaemia in this case would be due to anaemia of chronic disease, or poss iron deficiency eg due to g/i blood loss. I think the WBC and liver parameter changes are steroid induced as you say. The trouble is as has been on high doses of preds, it makes diagnosis now difficult. I would wean off the preds while monitoring HCT and use gastric protectants as you are doing. Then it's back to the drawing board.

Re: Spaniel with AIHA or not?

John Flynn — Thu, 29 Aug 2013 20:33:50 GMT

[quote user="Martin Atkinson"]Coombes test even on high doses of preds was positive.[/quote]

How positive?

[quote user="Martin Atkinson"]pale mucous membranes and was diagnosed as AIHA on the basis of a HCT of 36%[/quote]

Either clinical signs not due to anaemia or HCT measured/recorded incorrectly - was this an automated in-house analyser result?

[quote user="Martin Atkinson"]RBC auto-agglutination on a smear[/quote]

If a genuine finding, that's pretty specific for IMHA I would have thought and I wouldn't see what a Coomb's test at the time would have added to that. Any other reported findings on smear? In general I would suspect that a vet bothering to examaining a blood smear had made a competent assessment until proven otherwise, so I would be continuing steroids on assumption of correctly diagnosed IMHA unless proven otherwise.

[quote user="Martin Atkinson"]I've reduced the preds to every other day and his HCT has risen to 34%[/quote]

[quote user="Martin Atkinson"]So plan is now is to put on gastro-protectants/antacids, slowly reduce the preds while monitoring HCT[/quote]

Sounds like a good plan to me based on what you have in front of you.

Re: Spaniel with AIHA or not?

Martin Atkinson — Thu, 29 Aug 2013 18:53:28 GMT

Dose of preds given by first vet was 50mg daily for a 17kg dog a bit high I thought. for a first line dose especially as the HCT was virtually normal, I've now got it on 25mg alternate days. My first alternative choice of immuno-suppressant would have been cyclosporin but new graduate tells me azothiaprin is a better choice for AIHA. Blood smear showed mildly regenerative anaemia, some anisocytosis, poikilocytosis, acanthocytosis, and a few spherocytes and scanty polychromatic cells seen, Reticulocytes 3 %, Absolute Reticulocytes. 127.50 x10^9/l nothing else abnormal. Regards exercise tolerance he was virtually unable to walk before preds, and this was very sudden onset and why I was barking up the PFK tree, I even thought of Addisons but not indicated by the bloods although how much has this been effected by the steroids?. Now very bright and willing but tires after 10 minutes chasing ball. Also mm now nice and pink even though HCT paradoxically is lower than when they were (apparently) white!

Re: Spaniel with AIHA or not?

Becky Filby — Thu, 29 Aug 2013 18:09:24 GMT

I think your plan for imaging to look for underlying causes sounds sensible but would second ciclosporin in preference to azathiaprine if the PCV falls again. Does sound like AIHA with a GI bleed complicating recovery of the PCV though. What was the blood smear like? Any hint of an underlying cause on this? In terms of the exercise tolerance how severe is this? We have had a few classic AIHA dogs that have been more lethargic and exercise intolerant while on pred but have made steady improvements as the dose has been lowered ,so if no other causes found it could just be the pred, although wouldn't have expected pale membranes just from this

Re: Spaniel with AIHA or not?

Rob Loxley — Thu, 29 Aug 2013 17:40:08 GMT

What dose of pred; some 'immunosuppressive' doses are very high with a real risk of GI ulceration causing further blood loss? Is there not quite a lag before azathioprine kicks in if PCV starts falling again; cyclosporin is another immunosuppresive to consider. Can't see any reason not to do some imaging to rule out an underlying cause (VN's cat recently with IMHA secondary to a chest full of mets...).