Baffling anaemia case!

RE: Baffling anaemia case!

Anthony Dennison — Tue, 15 Mar 2016 13:52:28 GMT

No access to onions or leeks at all?

RE: Baffling anaemia case!

Mair Tyler — Thu, 10 Mar 2016 23:43:31 GMT

So, a wee update on this case! The owner was on holiday for a while so I didn't see the dog for a little while. We reduced the pred dose down as the dog had been peeing everywhere, no deterioration in dog with reduced pred dose. Pretty much no change in haematology (PCV still 26%) when o came back from hols.

Started her on Azathioprine alongside the lower pred dose 1 week ago. Saw her today, subjectively she seemed a bit better -o reports she's a bit more lively, gained 1.5kg in the week. But haematology unchanged -PCV 26%!

Today we also got back her faecal occult blood test (after correct diet for 5 days) and that was positive. At the moment I've suggesting continuing to trial the azathioprine but if still no improvement by next week, plan is probably to go down the gastroscopy/colonoscopy/exp lap route.

RE: Baffling anaemia case!

Thomas Johnson — Mon, 22 Feb 2016 10:34:28 GMT

[quote user="Anthony Dennison"]

[quote user="Chris Milligan"]Extravascular IMHA can present in this way also - with positive coombs and normal ISA. Tick Borne Disease and neoplasia (spleen, spleen, spleen!) would also be of concern.[/quote]

I had a recent IMHA case in a cocker that had a lesion on it's spleen on abdominal scan during the 1st diagnosis. It had gone at a recheck 8 weeks later, with normal PCV.

[/quote]

I had a similar case recently, dog presented with IMHA and IMTP, and had a 9cm mass on the tail of its spleen, I decided not to FNA it as it had a platelet count of 6 (148-484) and I couldn't seen any platelets on the blood film. The splenic mass disappeared and the IMHA and IMPTP responded very well to prednisolone. I did a splenectomy as I was worried about recurrence of the mass when we came off the prednisolone, it looked normal and no abnormalities were found on histopathology.

RE: Baffling anaemia case!

Anthony Dennison — Mon, 22 Feb 2016 09:59:23 GMT

I had a recent IMHA case in a cocker that had a lesion on it's spleen on abdominal scan during the 1st diagnosis. It had gone at a recheck 8 weeks later, with normal PCV.

RE: Baffling anaemia case!

Chris Milligan — Sat, 20 Feb 2016 09:48:38 GMT

Extravascular IMHA can present in this way also - with positive coombs and normal ISA. Tick Borne Disease and neoplasia (spleen, spleen, spleen!) would also be of concern.

I couldn't see it in your initial notes but have you done a coag profile?

I had a similar case recently and the dog turned out to be in a very protracted chronic DIC brought on by chronic inflammation from a FB embedded in the stomach wall - not a normal case by any stretch but food for thought.

RE: Baffling anaemia case!

Rob Davis — Sat, 20 Feb 2016 09:02:50 GMT

[quote user="Mair Tyler"] suggested increasing the pred dose (which I don't want to do as she was already wetting the floor at home on 1mg/kg/day!)[/quote]

You could try switching to medrone.

RE: Baffling anaemia case!

Mair Tyler — Fri, 19 Feb 2016 21:20:32 GMT

Thanks for all the suggestions so far!

I spoke to the clin path specialist at the lab today. He reckons it stil seems most likely to be IMHA but refractory to treatment ad suggested increasing the pred dose (which I don't want to do as she was already wetting the floor at home on 1mg/kg/day!) or adding in azathioprine so that's what I'm going to try...

Lungworm? I would have expected evidence of coagulopahy or coughing too. Only had one case of lungworm at our practice andthat was a dog born down south so not convinced it's as common up here as we are led to believe by certain parasiticide manufacturers!!

I suspect there will be some other underlying factor (probably neoplasia) that's just not rearing its head fully yet... Will let you know how she does.

RE: Baffling anaemia case!

Martin Atkinson — Fri, 19 Feb 2016 16:38:11 GMT

[quote user="Robin Grimmer"]If the hemorrhage is internal, then that could lead to an increased bilirubin as the blood is broken down.[/quote]I believe that is what Virginia is intimating although it was a little ambiguous.

RE: Baffling anaemia case!

Robin Grimmer — Fri, 19 Feb 2016 16:19:16 GMT

[quote user="Virginia Campbell"]

[quote user="Robin Grimmer"]I'd expect imha cases to have a much lower pcv and I would have expected a response to pred. Haemorrhage seems more likely.[/quote]

Why the bilirubinemia though?

[/quote]

If the hemorrhage is internal, then that could lead to an increased bilirubin as the blood is broken down.

RE: Baffling anaemia case!

Martin Atkinson — Fri, 19 Feb 2016 16:16:32 GMT

[quote user="Robin Grimmer"] Do you get lungworm up there?[/quote]That was my initial thought but all the lungworm cases I've seen have resulted in frank haemorrhage or petechiae/echimoses so the parasite is causing anaemia by interfering with the clotting mechanism rather than destroying red cells per se. Never say never though so still worth looking for larvae in a poo sample.

This has an unresponsive IMHA written all over it but time for a referral me thinks.

RE: Baffling anaemia case!

Mark Hedberg — Fri, 19 Feb 2016 15:41:45 GMT

Can you test for babesia or ehrlichia? Well worth ruling out, there was a letter in vet times warning about babesia even in dogs that haven't travelled.

RE: Baffling anaemia case!

Virginia Campbell — Fri, 19 Feb 2016 15:27:00 GMT

[quote user="Robin Grimmer"]I'd expect imha cases to have a much lower pcv and I would have expected a response to pred. Haemorrhage seems more likely.[/quote]

Why the bilirubinemia though?

RE: Baffling anaemia case!

Rob Davis — Fri, 19 Feb 2016 13:20:01 GMT

I'm certainly no expert but my thoughts:

I agree it seems like IMHA - if it's haemorrhage and you've ruled out haematuria and scanned chest and abdomen, that only leaves GIT - worth checking stools if not already done.

If IMHA then may require higher prednisolone dose - formulary states 1.1-3.3mg/kg BID as starting dose for immunosuppression. Also could consider adding azathioprine though it does take a little longer to kick in.

RE: Baffling anaemia case!

Kara Gibson — Thu, 18 Feb 2016 08:47:11 GMT

I'm based in Hong Kong and we see a lot of Babesia here. Actually these tend to respond well to preds as the red blood cell destruction is immune mediated (albeit against Babesia antigen) in the short term. Of course using preds for any significant length of time usually worsens the situation. I think this is unlikely in this case.

RE: Baffling anaemia case!

Virginia Campbell — Wed, 17 Feb 2016 20:59:16 GMT

Urgh, bet it's one of those slow, annoying, don't-crash-quickly-but don't-respond well-either old animal IMHAs. Perhaps worth a few weeks' worth of doxycycline just to try to rule out blood parasites. Check hasn't got a constant source of zinc somewhere like licking zinc skin cream off the owners. Poss quick abdo rads to check for zinc FB.

If this is a neoplasia-driven IMHA it's going to be a pain to find. I had one 10yo mini schnauzer who grumbled on for months, not too bad and dog and bloods improved on pred and Atopica (no azathioprine - I feared pancreatitis) but never 100% well and never really had a normal PCV or reticulotyte count; eventually crashed and burned. Don't know if it was undiscovered neoplasia or a chronic pancreatitis that we never really got on top of driving it.

Still, a week down the line is early days.

RE: Baffling anaemia case!

Robin Grimmer — Wed, 17 Feb 2016 20:57:44 GMT

I'd expect imha cases to have a much lower pcv and I would have expected a response to pred. Haemorrhage seems more likely. Anti coagulant exposure? Do you get lungworm up there?

RE: Baffling anaemia case!

Francisco Gomez — Wed, 17 Feb 2016 20:45:12 GMT

Vaccinated?

RE: Baffling anaemia case!

Francisco Gomez — Wed, 17 Feb 2016 20:27:42 GMT

Having a quick look at your case, you've got 3 major things that interests me:

PCV is low (and regenerative), Tbil is high and Coombs test is positive. My first reaction was to think: something is destroying RBCs, and Coombs +ve indicates it is likely to be your own patient.

Considering that a negative SAT doesn't exclude IMHA, I'd think IMHA is a the very top of your differential. Perhaps in a older dog, you haven't given it enough time to recover.

Against that diagnosis, and a bit further down the list, I guess I would've expected a lower PCV (personal experience only). If it was a non bleeding liver tumour, I'd think the anaemia wouldn't have been highly regenerative and if it was infectious/blood parasite I would've expect a worsening with immunosuppressive dose of prednisolone.

I was also expecting some abnormal RBCs if they're being destroyed by something...

RE: Baffling anaemia case!

Joyce Whitehead — Wed, 17 Feb 2016 20:16:43 GMT

There have been some recent case reports from (I think) the south of England of dogs with Babesiosis who had never travelled, it is thought an imported rescue dog one was in contact with had brought in infected ticks. Just a thought from left field...

RE: Baffling anaemia case!

Mair Tyler — Wed, 17 Feb 2016 17:55:17 GMT

No, always been in Scotland.

RE: Baffling anaemia case!

Mark Hedberg — Wed, 17 Feb 2016 17:49:28 GMT

Any history of travel, vector borne disease? Smears not always foolproof.