Anaemia with no biochemical abnormalities

RE: Anaemia with no biochemical abnormalities

Anthony Dennison — Thu, 24 Sep 2015 09:07:17 GMT

[quote user="Laurence Webb"]Obviously aware that this thread started over a year ago, but if you have a tight fisted boss (like me) you can do just as well spinning down a haematocrit tube (cost <1p), measuring the height of the rbc then dividing it by the height of the entire sample (rbc + serum). Obviously that will be more accurate with longer tubes than short ones so will depend on your centrifuge.[/quote]

Our centrifuges don't have haematocrit tube holders. I know, it's ridiculous, something I have been fighting for since this thread!

RE: Anaemia with no biochemical abnormalities

Laurence Webb — Wed, 23 Sep 2015 23:31:22 GMT

[quote user="Anthony Dennison"]I'll also be asking for us to have PCV readers brought[/quote]

Obviously aware that this thread started over a year ago, but if you have a tight fisted boss (like me) you can do just as well spinning down a haematocrit tube (cost <1p), measuring the height of the rbc then dividing it by the height of the entire sample (rbc + serum). Obviously that will be more accurate with longer tubes than short ones so will depend on your centrifuge.

This might involve your tight fisted boss buying a 15cm ruler! (I am the boss and I do have a PCV reader, but it would work just as well)

RE: Anaemia with no biochemical abnormalities

Miriam Lodewyks — Wed, 23 Sep 2015 22:01:47 GMT

Following this post with interest as I've recently seen 2 cats with very similar stories. Luckily both survived. One with restricted funds, so only did the basics. The other insured, so was able to rule out just about everything. Both turned out to be a couple of weeks post-vaccination, and both managed to compensate, then regenerate sufficiently. The 2nd patient tested negative on the coombs and agglutination, but I put both on prednisolone (among other things) and wonder how many of you would do the same? And are there any common toxins that could cause this sort of thing... I hate pointing the finger at vaccinations, too easy a target!

RE: Anaemia with no biochemical abnormalities

Kate Richardson — Wed, 23 Sep 2015 11:59:04 GMT

back to basics initially, characterise the anaemia first into regenerative or non regenerative, then go from there. Mycoplasma PCR is very sensitive as far as I am aware.

RE: Anaemia with no biochemical abnormalities

Anthony Dennison — Wed, 23 Sep 2015 09:50:31 GMT

[quote user="Rory Bell"]

The for and against, as I see it (and this is a personal view) are;

Although very uncommon, they (M. haemofelis in particular) can cause life threatening haemolytic anaemia
If I'm going to immunosupress a cat with anaemia, I'd like to be sure there is not an underlying infection (even if, as Martin pointed out, there is the potential for a secondary immune mediated component to the anaemia)
It's a potential zoonosis
The cats that I see with anaemia rarely have straightforward explanations for their anaemia
Against that is the cost of testing, and thats obviously pertinent. For sure, if confronted with a cat with immune mediated haemolytic anaemia and limited finances, then steroids and doxycycline (or pradofloxacin, because thats effective against mycoplasma, available in liquid form, and isn't going to destroy their retinas) would be a much better way of spending the clients money than on a low yield test looking for mycoplasma.

Cheers

[/quote]

Just coming back to this thread as I've got another anaemic cat - coming back in today for a Coombs test. I was going to request a mycoplasma PCR as well but now I'm not so sure it's worth it.

Otherwise, any new developments on treatment except doxycycline and steroids? Tried to do a literature search but mainly got methods of detection and prevalence!

Re: Anaemia with no biochemical abnormalities

Christopher Saul — Fri, 31 Jan 2014 19:24:22 GMT

[quote user="Rory Bell"]Excellent post by Chris[/quote]

PS thank you Rory I'm very flattered. I sometimes worry that I might have missed something, that a diplomate might pick me up on....

Re: Anaemia with no biochemical abnormalities

Christopher Saul — Fri, 31 Jan 2014 19:20:13 GMT

Aw I'm really very sorry mate. As the others said, you can't save them all. Even IF (and this is a big if) there was nothing going on beyond simple IMHA then the prognosis is guarded. IMHAs often don't make it even with aggressive treatment. And of course if there was an underlying cause then this could have made the prognosis even worse.

Please don't judge yourself too harshly. The fact you are upset just shows that you care. You're a great vet and doing a good job.

Chris

Re: Anaemia with no biochemical abnormalities

Hannah Wynne Richards — Fri, 31 Jan 2014 12:29:28 GMT

I would probably have done exactly the same as you - with exactly the same results.

Can't win them all - can do one's best with them all - and you have.

Wynne

Re: Anaemia with no biochemical abnormalities

Rory Bell — Fri, 31 Jan 2014 12:19:16 GMT

Hi Anthony

My sympathies, mate, it's rubbish when something like that happens. I'm not at all convinced that you could have achieved a better outcome with this cat though. She was, as you said a feisty, stressy cat who had at one point at least had a severe anaemia. In cats like this sometimes less is more - putting her through a battery of tests at that point might easily have resulted in decompensation to the point where she arrested and died. There's no easy answer I'm afraid, but I honestly don't think you did anything wrong at all. Dealing with cases like these is always a bit of a balancing act, and there is no one approach that is universally correct. Again, I do not think this was your fault, bad things happen sometimes.

Hope you are off duty this weekend, if so then get yourself a beer or two at the end of the day today....probably not the most PC way of de-stressing, but it works for me....

cheers

rory

Re: Anaemia with no biochemical abnormalities

John Flynn — Fri, 31 Jan 2014 12:15:11 GMT

[quote user="Anthony Dennison"] I just feel awful that I didn't do more, or didn't manage the clients' expectations better. Not a great start to the day.[/quote]

Don't beat yourself up.

You can't save them all.

Your approach was reasoned and took into account the welfare of the cat; there's no reason to believe that more 'intensive' and potentially stressful treatment would have led to a different outcome, or, if it had, that that outcome would have been superior (living hospitalised at a vets in fear for a week longer and then being euthanased without going home would have been a different outcome that would probably have been inferior, for instance).

I would be proud to show the level of care and dedication to your patients and their owners that you clearly do.

Re: Anaemia with no biochemical abnormalities

Anthony Dennison — Fri, 31 Jan 2014 12:06:34 GMT

Thanks everyone for your help with this case, everyone's views have been most useful.

Unfortunately after being given oral baytril last night the cat suddenly decompensated. For approximately an hour she was having seizure like episode, then passed away.

She had been quiet but stable until then, sleeping a lot, eating very little. Her respiratory rate was normal, no signs of distress. The cat really hates the vets which is why I was trying the minimal approach, so she wouldn't be stressed. She was due to come in today for a repeat haematology today.

If faced with a case like this again, I will bear this in mind and be more aggressive with my investigations and treatment, and push for hospitalisation so we could have given more suitable medication and monitored more closely. I'll also be asking for us to have PCV readers brought. I just feel awful that I didn't do more, or didn't manage the clients' expectations better. Not a great start to the day.

Re: Anaemia with no biochemical abnormalities

Rory Bell — Thu, 30 Jan 2014 19:39:21 GMT

Excellent post by Chris with which I completely agree and have nothing really further to add to Anthony's case regarding clinical approach. I particularly like (and agree) with the assertion that cats are compulsive liars when it comes to diagnostics!

Regarding prevalence of mycoplasma infections in cats (at least in the UK); there have been a few studies, most from Bristol who have (Severine Tasker in particular) done the vast majority of research into this infection.

Prevalence rates are low: two studies looking at samples submitted to Bristol (and assuming these samples were submitted because practitioners had at least some pre-test suspicion that the cat might be infected) had prevalance rates 1.5 - 3% for M. haemofelis (the most pathogenic) and 1.5% for Candidatus M. turicensis (intermediate pathogenicity; i.e. may cause anaemia particularly in immunosuppressed cats) and 10 - 15% for M haemominutum (usually non pathogenic, which probably explains why it's relatively more common). Of course, we don't know much about these cats; were they actually anaemic, and if so did they have haemolytic anaemia as would be expected for a clinically significant infection?

To answer that, a separate study , again from Severine and others, looked at prevalence of retroviral infection and mycoplasma infection in anaemic cats found no association between infection and anaemia in these cats compared to an equal number of non anaemic cats.

So it would appear that mycoplasma infections in cats are uncommon, and are uncommon causes of anaemia. Its testing therefore worthwhile?

The for and against, as I see it (and this is a personal view) are;

Although very uncommon, they (M. haemofelis in particular) can cause life threatening haemolytic anaemia
If I'm going to immunosupress a cat with anaemia, I'd like to be sure there is not an underlying infection (even if, as Martin pointed out, there is the potential for a secondary immune mediated component to the anaemia)
It's a potential zoonosis
The cats that I see with anaemia rarely have straightforward explanations for their anaemia
Against that is the cost of testing, and thats obviously pertinent. For sure, if confronted with a cat with immune mediated haemolytic anaemia and limited finances, then steroids and doxycycline (or pradofloxacin, because thats effective against mycoplasma, available in liquid form, and isn't going to destroy their retinas) would be a much better way of spending the clients money than on a low yield test looking for mycoplasma.

Cheers

Re: Anaemia with no biochemical abnormalities

Toby Birch — Thu, 30 Jan 2014 16:30:20 GMT

I have had a confirmed case. The lab got very excited as often tested for but rarely found.

Re: Anaemia with no biochemical abnormalities

Kate Richardson — Thu, 30 Jan 2014 14:57:58 GMT

[quote user="Anthony Dennison"]

Ideally the cat would be on oral doxycycline, but that's never going to happen. I've previously tried suggesting crushing them up and mixing them with water, this didn't go down well.

Baytril is a compromise, the owner felt more comfortable popping a syringe into the corner of the cats mouth and squirting rather than waiting to find tablets spat out round the house.

[/quote]

Does the cat have any favourites such as pate, cheese spread, strong flavoured fish such as tinned sardines or tuna? Vivi treats can also be surprisingly well taken. I find that doxycycline crushed and mixed in a small amount of the above can often be accepted by the cat, they don't seem to have a really nasty taste. Or maybe I have just been lucky. In australia they have a doxy paste, shame we don't have it here. And remember to warn with baytril re retinal blindness.

Re: Anaemia with no biochemical abnormalities

Anthony Dennison — Thu, 30 Jan 2014 14:39:25 GMT

[quote user="Gillian Mostyn"]

[quote user="John Flynn"]i think ground up tablets likely to be just as bitter?[/quote]

Baytril tablets are beef flavoured, so I would have thought they'd be a bit better than the syrup?

Oops.... have just looked at the NOAH website and seen baytril flavour solution for cats.... has this product passed me by???

[/quote]

Ideally the cat would be on oral doxycycline, but that's never going to happen. I've previously tried suggesting crushing them up and mixing them with water, this didn't go down well.

Baytril is a compromise, the owner felt more comfortable popping a syringe into the corner of the cats mouth and squirting rather than waiting to find tablets spat out round the house.

The cat is doing ok today, showing more interest in food and being a bit more feisty. Next step is another full haematology

Re: Anaemia with no biochemical abnormalities

Martin Atkinson — Thu, 30 Jan 2014 09:38:44 GMT

[quote user="David Mills"]Out of interest, how many GPs have seen a confirmed case of M.felis? I never have, but I've seen many, many cats with IMHA.[/quote]I used to see quite a lot 20 years or more ago but not seen confirmed one in a very long time, AFAIR a number of cats with M. felis will also show signs of IMHA because of the immune reaction to the disease just to complicate matters. Don't see many cats with IMHA either, probably more with autoimmune thrombocytopaenia.

Re: Anaemia with no biochemical abnormalities

Thomas Johnson — Thu, 30 Jan 2014 08:40:49 GMT

[quote user="David Mills"]

Out of interest, how many GPs have seen a confirmed case of M.felis? I never have, but I've seen many, many cats with IMHA.

[/quote]

I remember seeing one when I was a student seeing practice, I've been qualified for ten years and haven't seen one since.

Re: Anaemia with no biochemical abnormalities

David Mills — Wed, 29 Jan 2014 21:17:52 GMT

Out of interest, how many GPs have seen a confirmed case of M.felis? I never have, but I've seen many, many cats with IMHA.

Always struck me as something taught at universities and CPD, occasionally seen at referral centres, nice neat story, yet it is always very high on people's rule-outs. From what I can reading various sources, the prevalence is thought to be very low in the UK (not that I can find any UK-specific prevalence studies). I just wonder - not a criticism of OP - how justified we can be pursuing a disease that may be incredibly rare? How many PCRs do we need to use on various cats (i.e. NNT) to find one? And even if we find some DNA it doesn't necessarily equate with causation...

Re: Anaemia with no biochemical abnormalities

Gillian Mostyn — Wed, 29 Jan 2014 21:16:28 GMT

[quote user="John Flynn"]i think ground up tablets likely to be just as bitter?[/quote]

Baytril tablets are beef flavoured, so I would have thought they'd be a bit better than the syrup?

Oops.... have just looked at the NOAH website and seen baytril flavour solution for cats.... has this product passed me by???

Re: Anaemia with no biochemical abnormalities

John Flynn — Wed, 29 Jan 2014 20:57:55 GMT

[quote user="Gillian Mostyn"]I would grind up the tablets and mix into a suspension then - don't try to give a cat oral baytril solution. It tastes foul and you won't get near it with a syringe again! [/quote]

i think ground up tablets likely to be just as bitter?

if the expert recommendation is a FQ, then perhaps veraflox might be a little more palatable, or can you stll get ibafloxacin gel to squirt on feet for them to lick off?

Re: Anaemia with no biochemical abnormalities

John Flynn — Wed, 29 Jan 2014 20:44:27 GMT

[quote user="Anthony Dennison"]Also, we can only do a PCV by running a haematology on the lasercyte. No haematocrit tubes or PCV readers (it's something I'll be bringing up in my review next week, along with drip pumps).[/quote]

Probably not much help, but when I did horses I used to take a 1ml syringe of anticoagulated blood and stand it upright for an hour or more for a rough PCV.

While that would seem msot wasteful in an anaemic cat... it would pick up a gross automated haematology PCV error (a calculated value for such machines usually...) and if you have enough blood left in the EDTA sample you had already run it doesn't need to be that fresh and would be going to waste otherwise...

Re: Anaemia with no biochemical abnormalities

Gillian Mostyn — Wed, 29 Jan 2014 18:34:00 GMT

[quote user="Anthony Dennison"]No haematocrit tubes or PCV readers[/quote]

You're not a million miles from us - let me know if we can help with this!

[quote user="Anthony Dennison"]the specialist I spoke to did say there was some evidence of using oral enrofloxacin at 5mg/kg SID to help. I think sticking a syringe into the side of the cat's mouth and squirting may be more succesful. [/quote]

I would grind up the tablets and mix into a suspension then - don't try to give a cat oral baytril solution. It tastes foul and you won't get near it with a syringe again!

Re: Anaemia with no biochemical abnormalities

Christopher Saul — Wed, 29 Jan 2014 18:30:42 GMT

[quote user="Gillian Mostyn"]

[quote user="Christopher Saul"]Oh I forgot to add; normal TBil doesn't eliminate haemolysis, especially in cats. Cats in particular can lie. I had an IMHA the other week with a TBil of 3 despite the fact it had a PCV if 15% and haemolysing like a son-of-a-gun[/quote]

I wouldn't have ruled IMHA out, but it would have made me think it was less likely. Good to know!

[/quote]

Glad to be of assistance Gillian. It is more of a cat thing. Never trust what a cat tells you; they are compulsive liars in many respects.

Re: Anaemia with no biochemical abnormalities

Anthony Dennison — Wed, 29 Jan 2014 17:40:24 GMT

[quote user="Christopher Saul"]

To sum up, I would suggest trying to establish just how critical this patient is, and giving an oxyglobin or blood transfusion if necessary. Having done this I would definitely get a repeat FBC done by the reference laboratory to monitor the regenerative response. If the retic count is climbing then you can prob rule out non-regenerative anaemia. it would also be useful to see what's happening with the PLTs and neuts, as a pancytopenia would suggest a bone marrow issue and may provide indication for a bone marrow aspirate.

Slide agglutination / coomb's?

Imaging +/- faecal occult blood to rule out haemorrhage

Doxycycline, testing for FIV/FelV and m. haemofelis.

Have a chat to the pathologist.

[/quote]

No ramble at all Chris, you've covered all points and this is an excellent summation!

I know it's not the same as slide agglutination, but previous IMHA cases I've seen have even auto-agglutinated in the EDTA tube, which I couldn't see with prolonged close inspection. I didn't think to do it with the sample I took but the next sample I will check this.

Nothing obvious on abdominal ultrasound scan, no free fluid and no obvious mass (I couldn't feel one on palpation either). However, the scanner at my branch was middle range in the early 90's so resolution isn't fantastic.

Annoyingly, after scanning the cat was in no mood for further prodding so taking bloods was near impossible. Despite getting stressed she did not have any respiratory distress like she was unstable, which I found encouraging. Also, we can only do a PCV by running a haematology on the lasercyte. No haematocrit tubes or PCV readers (it's something I'll be bringing up in my review next week, along with drip pumps).

FIV/FeLV negative, sorry forgot to mention that in my OP.

The cat is actually a little brighter today; she actually tried to eat me which is more like her normal self, so I am less worried than I was yesterday.

I discussed the case with one of the Idexx medicine specialists, who seemed to err on the side of haemolysis rather than decreased production. No mycoplasma was seen on the smear but as mentioned, this doesn't rule it out.

Tablets are a big no no with this cat. Many have tried to worm her, all have failed. However, the specialist I spoke to did say there was some evidence of using oral enrofloxacin at 5mg/kg SID to help. I think sticking a syringe into the side of the cat's mouth and squirting may be more succesful.

There is some money available for this case but the cat isn't insured and I don't want to spend all the money available on diagnosis and have nothing for treatment. Post scan I gave an injection of Baytril to start the course, some vit B12 and a steroid injection.

I'm going to ring the owner to see how she is tomorrow, Idexx do have some sample left so I can run either Mycoplasma PCR or Coombes test, not both. If she is deteriorating or the owner is particularly worried, I am more inclined to check for Mycoplasma.

Re: Anaemia with no biochemical abnormalities

Gillian Mostyn — Wed, 29 Jan 2014 17:25:14 GMT

[quote user="Utlendigur"] after having seen a cat bleed out from jugular venepuncture - don't know how it was to sample but it came back shortly after with a massive haematoma and just wouldn't stop[/quote]

I can't begin to imagine how a single venepuncture could do that amount of damage - I can only assume the jugular was badly lacerated or the needle hit other structures...??? If a cat will die from a single clean stick to the jugular.... it is doomed!

I use jugulars for everything - I think I have used one leg stick in last 5 years and that was because the dog was too scared/aggressive to hold still, but we could just about hold onto its leg!

I simply can't draw the sample quick enough from a leg for my liking, and the cats wriggle more so seem to have more pain - but, like everything, we all have our own preferred technique. We were told at college, however, that we should be aiming to take jugular samples in cats to get the best quality sample.