Greyhound with anaemia/thrombocytopaenia

RE: Greyhound with anaemia/thrombocytopaenia

Lucy Fleming — Wed, 08 Jun 2016 12:53:43 GMT

[quote user="Martin Atkinson"]but this still sounds more like autoimmune thrombocytopaenia or DIC.[/quote]

[quote user="cathal rafferty"]Fair point. Are you thinking the anaemia is down to bledding secondary to the low platelets then?[/quote]

Could it be IMHA and IMTP (Evan's syndrome)?

RE: Greyhound with anaemia/thrombocytopaenia

David Mills — Tue, 07 Jun 2016 12:57:52 GMT

[quote user="cathal rafferty"] We use pred with azothioprine after a paper in jsap ( Swann et al) a few years ago showed it the best combination.[/quote]

I'm not sure the paper supports this. Whilst there was a mortality difference between groups, the numbers were too small to determine why (only 42 in the study, of which 10 died whilst hospitalised). Long term survival was superior in the preds only group (MST preds 452, axa/preds 194), though this was not statistically significant. Also, the preds only group had the lowest dosage of preds compared to other groups.

The study has many flaws (referral population, referred after 4 days, many received transfusions, high mortality rate, low numbers, retrospective) and so conclusions are very limited from this. I certainly wouldn't be switching from preds only protocol on the basis of this.

It's open access:

http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.2011.01074.x/epdf

[quote user="Martin Atkinson"]The platelet count is 23x10^9/l - have you ever seen an AHA with a count that low[/quote]

20% of the dogs in the above study had a count <50, I've certainly seen them in the 20s.

[quote user="CatherineThomas"]The coombs test was negative but I realise it could be a false negative.[/quote]

In the study, only 30% were positive on Coombs, 62% on saline aglutination.

[quote user="CatherineThomas"]decided to start her on doxycycline and preds.[/quote]

Good plan. I think this is IMHA.

RE: Greyhound with anaemia/thrombocytopaenia

CatherineThomas — Mon, 06 Jun 2016 22:43:01 GMT

There's no petechiae and no signs of bleeding anywhere.

RE: Greyhound with anaemia/thrombocytopaenia

cathal rafferty — Mon, 06 Jun 2016 22:04:58 GMT

Fair point. Are you thinking the anaemia is down to bledding secondary to the low platelets then?

Are there any patechiae anywhere on her Catherine?

RE: Greyhound with anaemia/thrombocytopaenia

CatherineThomas — Mon, 06 Jun 2016 20:17:48 GMT

Thanks.

Her PCV was down to 24% today, tbil only up slightly to 13 and protein levels remained the same.

The coombs test was negative but I realise it could be a false negative.

We've sent today's sample off to check for regeneration and decided to start her on doxycycline and preds.

RE: Greyhound with anaemia/thrombocytopaenia

Martin Atkinson — Mon, 06 Jun 2016 13:17:43 GMT

[quote user="cathal rafferty"] it seems more likely a haemolytic anaemia. [/quote]The platelet count is 23x10^9/l - have you ever seen an AHA with a count that low? I note it says awaiting Coombes test but this still sounds more like autoimmune thrombocytopaenia or DIC.

RE: Greyhound with anaemia/thrombocytopaenia

Edward Jones — Mon, 06 Jun 2016 11:13:43 GMT

[quote user="cathal rafferty"]We use pred with azothioprine after a paper in jsap ( Swann et al) a few years ago showed it the best combination.[/quote]

A comment on this - whilst I don't disagree, I had a Labrador on this combination that developed severe pancreatitis from the azothioprine. With hindsight I could have recognised it sooner - the dog was reported to be off colour for about 24 hours after each azothioprine tablet - initially only mildly, but got progressively worse over a couple of months.

I don't know how common this complication is, but it's worth looking out for.

RE: Greyhound with anaemia/thrombocytopaenia

cathal rafferty — Mon, 06 Jun 2016 00:02:52 GMT

I don't think the propalin's involved here. Thinking out loud...

The anaemia is regenerative so the bone marrow is working. There's no sign of blood loss though it can't be totally ruled out, but it seems more likely a haemolytic anaemia. The splenic changes I guess could fit with either scenario.

The tbil was slightly raised but that biochem is 5-6 days old, so I'd want to repeat that. If it's greatly increased, it's definiitely haemolytic.

The other thing is the kidneys, I think a upc would be a good idea and the repeat biochem would give you an idea of how fast she is losing protein.

If there isn't a protein losing nephropathy, then i'd start treatment for the haemolysis. A pcv of 30 is quite marked for a greyhound. We use pred with azothioprine after a paper in jsap ( Swann et al) a few years ago showed it the best combination.

RE: Greyhound with anaemia/thrombocytopaenia

CatherineThomas — Sun, 05 Jun 2016 22:43:25 GMT

She does tend to have a delicate stomach but the past few days her faeces have been quite firm, there's no vomiting and no obvious blood in the faeces but they do have an orange tinge to them. Because of her picky eating at the moment I don't really want to stop giving her meat for the occult blood test. There's no obvious free fluid in the abdomen.

I hadn't thoughht of Addisons, but would that be enough to explain all of these abnormalities?

RE: Greyhound with anaemia/thrombocytopaenia

CatherineThomas — Sun, 05 Jun 2016 22:26:02 GMT

I'm actually self-employed, but the practice I worked for before has been really good and let me do all of the above investigation with staff discount.

Part of me thinks that I should do everything properly like I would advise a client to and so I should persue a full diagnosis before embarking on a treatment plan (which could eliminate the chances of reaching a full diagnosis). But the other part of me is worried that she's deteriorating and could have a crisis before we are able to reach that diagnosis and that the investigation is too risky. She seems relatively stable at the moment and is just a bit quiet.

I'll be taking her back in tomorrow to re-assess pcv and platelets at least but can't decide what I should do after that.

RE: Greyhound with anaemia/thrombocytopaenia

Kate Richardson — Sun, 05 Jun 2016 22:20:23 GMT

So you've got hypoalbuminaemia and anaemia- with a regenerative anaemia- blood loss? Any GI signs- could do a faecal occult blood test. Still would want to consider haemolysis as you've also got a mild increase in bilirubin and bilirubin in the urine, but would have thought the haematologist would have commented if he thought his was likely- platelets could be low secondary to blood loss/consumption if there's no signs of active blood loss. Poss intra-splenic blood loss- no pockets of fluid in the abdomen? Protein in urine looks high also so I'd evaluate with a UPC if you can- could explain the low albumin but doesnt explain the anaemia. If coags are ok, then you could fnab the spleen quite safely under sedation if you feel confident or have a colleague who could? I don't think it would be super risky as long as there is no evidence of bleeding into any body cavity. I'd also have a chat with the lab as well re the anaemia- macrocytic and hyperchromic- doesn't fit with chronic blood loss/iron deficiency. Also your Na is low and K high normal- could Addisons explain everything? Just my rambling thoughts. Hope it helps

RE: Greyhound with anaemia/thrombocytopaenia

Martin Atkinson — Sun, 05 Jun 2016 21:55:07 GMT

With a PLT count that low I would say you've either got an autoimmune thrombocytopenia or DIC possibly due to splenic pathology. Biopsying anything at the moment is likely to be very risky. I've brought patients back from the brink with AITP with a shot of vincristine as it releases platelets from the bone marrow then start on preds. IMO you have little to lose if major investigation and surgery are not practical but I'd be saddened if your practice won't help you out.