IMHA?

Re: IMHA?

Graham Bilbrough — Wed, 05 Nov 2014 13:22:21 GMT

I agree with getting someone to microscopically examine the blood film. It is (nearly) always money well spent. But, I am in little doubt as to the presence of reticulocytes in the circulation.

When you say you 'covered for lungworm', I would urge some caution. Dispensing an efficacious product is NOT the same thing as eliminating it from you list of causes. We are confident the patient is 'losing or splitting' blood and the question is why? Angiostrongylosis is a relatively common cause.

Please do switch on the dot plots. They are invaluable. The 'guts' of your analyzer are the same as used as many of the reference labs and you are only currently looking at half of the details. The IDEXX VetLab Station (the computer with touch screen that governs your suite of analyzers) sends the entire report to your practice management software as a pdf as well as strings of text and jpegs. We try to make it as easy as possible.

We know that many practice management software companies do an imperfect job of importing the results. As such, we offer some free-of-charge software so that you can have pdf's sent to a desktop on any computer.

http://www.idexx.co.uk/smallanimal/inhouse/vetlab/interlink.html

Generally, I urge caution when looking at results in practice management software. There are examples that do not import error messages(!!), flags and even the appropriate reference intervals. Remember, the various asterisks and codes are there to help you interpret the data and without them you are working with limited information.

I'll climb off my soap box now.

All the best

Re: IMHA?

Kate Richardson — Wed, 05 Nov 2014 12:57:51 GMT

[quote user="claire godfrey"]The anaemia had improved and was regenerative . They have decided not to ask the lab to perform a smear.[/quote]

Do you know why they didn't want a smear? If due to costs, I feel this may be false economy- in investigation and treatment of any anaemia problem, examination of a smear is imperative. I can't emphasise how important I feel it is.

Otherwise ditto everything Christopher said.

Re: IMHA?

Christopher Saul — Wed, 05 Nov 2014 12:47:14 GMT

Hi Claire,

I'm glad to hear the dog is improving; that's the main thing. However something you've just said has worried me:-

[quote user="claire godfrey"]The dog is bright and has passed some tarry faeces so are assuming it is a GI bleed currently???[/quote]

Yes, that is a real possibility. But much more worryingly, it's possible that GI bleeding was the primary problem (you don't always get very overt melena with significant GI haemorrhage, so the fact that melena wasn't noted in the first place does not eliminate this).

If GI haemorrhage was the primary cause of the anaemia in the first place, then steroids would be contraindicated as they are ulcerogenic and could be making things worse.

But of course, it could have been IMHA , so you would have to be cautious about withdrawing the steroids also! I really think it is very important to get a smear examined, ideally including one off the original pre treatment sample, to look for reticulocytosis or other markers of IMHA. I would also get a full haemogram (including smear and reticulocytes via new methylene blue stain) done on a fresh sample.

Whatever the cause, gastroprotectants and a highly digestible diet are of course essential.

I hope this helps a little

Please keep us posted

Chris

Re: IMHA?

Claire Godfrey — Wed, 05 Nov 2014 09:21:50 GMT

Hi all,

Sorry for the delay in replying, I only work part time, I wasn't in on Monday but handed the case back to the vet who had been dealing with her during the week. They repeated the bloods and I have printed them off to post on here but have left them at work. The anaemia had improved and was regenerative . They have decided not to ask the lab to perform a smear. The dog is bright and has passed some tarry faeces so are assuming it is a GI bleed currently???

Have covered for lung worm also and dog has gone home.

Graham - I will definitely be looking at the dot plot CPD link. I have never known what to do with them. The idexx machine sends the results to the patient records but it doesn't send the dot plots. Will do the CPD and then see if I can convince the practice to turn them on! Especially as I guess then there is no point in printing them out so can save on the paper and ink as you said.

Thanks very much everyone for your help. I just wasn't convinced and it is difficult when you are not there all the time!

Re: IMHA?

Christopher Saul — Mon, 03 Nov 2014 23:52:31 GMT

Have we got any results from the reference lab re the smear?

Re: IMHA?

Graham Bilbrough — Mon, 03 Nov 2014 22:04:42 GMT

Hi, Ceri

How are you? How is life at Cibyn? Let's chat off-line.

The dot plots vary somewhat by analyzer. Here's a good place to start.

ProCyte Dx Dot Plots: What Are They and How Do I Use Them?

https://www.idexxlearningcenter.com/idexx/user_activity_info.aspx?id=1679

You'll need to register for a (free-of-charge) IDEXX Learning Center account if you don't already have one.

All the best

Re: IMHA?

Rob Loxley — Mon, 03 Nov 2014 21:14:49 GMT

try https://www.idexx.com/pdf/en_us/smallanimal/vetlab/lasercyte/lasercyte-dot-plot-poster.pdf for starters

Re: IMHA?

Ceri Gruffudd Jones — Mon, 03 Nov 2014 21:11:06 GMT

Graham, Dot plots - very pretty, but I don't know how to read them. Can you direct me to an 'Idiot's guide'? Thanks, Ceri

Re: IMHA?

Graham Bilbrough — Mon, 03 Nov 2014 15:03:18 GMT

My bet is that it will be regenerative by today and it would be great to see another CBC. On the second set of dot plots--I hope I have them in the right order!--I can see some reticulocytes with very high fluorescence. These are relatively immature. The bone marrow has started to respond. Was the dog overtly stressed on any of the venepunctures? This can influence the concentration of reticulocytes in the circulation.

On the white blood cell dot plot, I can see what I believe to be immature neutrophils (see the 'hump' on the pink cluster). Also, the lymphocytes have been somewhat overestimated. I think this is an inflammatory leukogram with bands, low eosinophils and lymphocytes.

I will be interested to see the comments on the blood film.

As an aside, we need to get that printer working. You have the dot plots switched off--the most useful part of the whole report! Most practices prefer to have the results sent as a pdf directly to a folder on their computer desktop. It saves money on ink cartridges and means you always have a copy to hand.

Thanks

Re: IMHA?

Martin Atkinson — Mon, 03 Nov 2014 14:32:18 GMT

You say there's no obvious site of bleeding have you x-rayed/ultrasounded for intra-cavity bleeds? I would add lungworm to my worry list as it is a young dog, inherited clotting factor disorders and DIC

Re: IMHA?

Andrew Kent — Sun, 02 Nov 2014 22:29:45 GMT

Right now this is either non-regenerative or pre-regenerative which makes IMHA less likely unless very acute. I would be repeating the haematology tomorrow and if still non-regenerative then your investigations will likely change.

Re: IMHA?

Claire Godfrey — Sun, 02 Nov 2014 19:30:39 GMT

Sorry the top two pictures are the most recent bloods and the bottom two the original bloods.

The dog is very bright now and mm colour is pinker although the bloods appear worse.

Will be getting a second opinion and getting the lab to look at the smear tomorrow.

Re: IMHA?

Claire Godfrey — Sun, 02 Nov 2014 19:28:19 GMT

Hi all, thanks for your input

I have the blood results, hope this is readable as the printer wouldn't work!

Re: IMHA?

HollyK — Sun, 02 Nov 2014 18:09:15 GMT

Did you do a total solids to try and distinguish between haemorrhage and haemolysis? I would maybe be thinking of rat poison or even flea anaemia (thinking of the small breed) being more likely than IMHA given the young age?

Re: IMHA?

Robin Grimmer — Sun, 02 Nov 2014 09:00:48 GMT

That's pretty young for imha. AFAIK it's unlikely in dogs less than one year old, but I stand to be corrected!

Re: IMHA?

Claire Godfrey — Sat, 01 Nov 2014 21:25:51 GMT

Thanks all.

The dog is 6months old and has never been out of the country.

Sorry been one of those days. Will post full results tomorrow.

Claire

Re: IMHA?

Andrew Kent — Sat, 01 Nov 2014 17:55:06 GMT

Hi Claire,

I think you need more information than this to diagnose IMHA. the most important being evaluation of a blood smear. Perhaps the external lab could do this on the sample you submitted for the Coomb's.

what age is the dog? And, as graham says, could you post the full results?

Andy

Re: IMHA?

Graham Bilbrough — Sat, 01 Nov 2014 15:55:32 GMT

Hi, Claire

Can you share the full results, especially the haematology including dot plots please?

Thanks

Graham

Re: IMHA?

Robin Grimmer — Sat, 01 Nov 2014 13:14:00 GMT

I probably would have checked a blood smear first before starting on the preds. Any history of travel abroad?

Re: IMHA?

Claire Godfrey — Sat, 01 Nov 2014 11:30:59 GMT

not pyrexic although wbc increased to 22.77 (5.05-16.9)

urine is normal,

no jaundice evident.

reticulocytes have increased from 21.2 to now 59.9 ( 10-110).

will check a smear

thanks

claire

Re: IMHA?

Hannah Wynne Richards — Sat, 01 Nov 2014 10:49:22 GMT

What's the urine like?

Wynne

Re: IMHA?

Kirsten Simpson — Sat, 01 Nov 2014 10:37:47 GMT

Have you made a blood smear and examined it for spherocytes /reticulocytes or had a reticulocyte count etc? Is the anaemia regenerative? Have you done a slide agglutination test? The worst ones I've seen are severely icteric and pyrexic too.