Just for fun

RE: Just for fun

Martin Atkinson — Wed, 17 Aug 2016 15:17:13 GMT

Well I was going to go for lungworm.

But I had a somewhat similar case in a 2 yr old Springer inherited from another vet who had put it on a monster dose of corticoids for a diagnosis of AHIA without even a Coombes test and it was not even anaemic just a bit weak with a low normal PCV. Prior to that they'd had it on Salzopyrin for diarrhoea. When it came to me the PCV was lower than before they started the steroids, it had melaena and haematemesis. In our work up it had a +ve Coombes test, PFKD was -ve and we also tested for Ach R antibody which was -ve. In the end I just weaned it off the steroids and it got better. Reading between the lines they'd probably created the original problem with a weird way of treating diarrhoea and exacerbated it with the steroids.

RE: Just for fun

Andrew Kent — Wed, 17 Aug 2016 13:24:53 GMT

[quote user="Robin Grimmer"]

Thanks Andy! Can you clarify the terminology of PRCA? As I understood it PRCA meant immune mediated destruction of RBC precursors in the bone marrow, but it was 13 years since I did my certificate. Has it changed in that time?

[/quote]

There is such a grey area with nomenclature of these problems, they tend now to be grouped as 'non-regenerative immune-mediated haemolytic anaemia'.

I believe the original convention was that PRCA was destruction of the very early red cell precursors with maturation arrest the term for later precursors. In term aplastic anaemia was used if all cell lines were involved.

But all of these terms have largely fallen out of favour (probably due to the confusion!)

Andy

RE: Just for fun

Thomas Johnson — Wed, 17 Aug 2016 09:46:58 GMT

[quote user="Sarah Keir"]

I expect the vomiting was related - all those inflammatory mediators?

[/quote]

It could be, but he had no further vomiting after that initial episode.

RE: Just for fun

Robin Grimmer — Tue, 16 Aug 2016 23:42:09 GMT

RE: Just for fun

Andrew Kent — Tue, 16 Aug 2016 23:02:32 GMT

[quote user="Robin Grimmer"]

That's what I said - that's the definition of Pure Red Cell Aplasia! I did think though in this breed PFKD was going to be the diagnosis.

[/quote]

The defining feature of PFK deficiency is a chronic regenerative anaemia (which is usually compensated) which is what would have made it unlikely here from the description of the smear.

Andy

RE: Just for fun

Sarah Keir — Tue, 16 Aug 2016 19:04:37 GMT

I expect the vomiting was related - all those inflammatory mediators?

RE: Just for fun

Thomas Johnson — Tue, 16 Aug 2016 18:50:50 GMT

[quote user="Adrian Caunter"]

So........ Here's what happened.... The advice I was given from the RVC was to monitor the dog overnight for further decrease in PCV and if this occurred to go ahead and transfuse. They advised not starting any treatment until a diagnosis was reached as the transfusion should buy enough time. Obvious enough in hindsight but I've definitely had cases before when the PCV has continued to drop dramatically and I've gone ahead and started steroids etc before results are back. Not rocket science but I thought an interesting take home point none the less! The PCV remained stable and the dog did indeed have a bone marrow biopsy at the referral institute the following day. This showed a very reactive marrow but with evidence of phagocytosis of the red cell precursors. Turns out the dog had a form of IMHA where the red cell precursors in the marrow alone were targeted. Dog presumably presents chronically as it needs the mature red cells to naturally be removed from circulation and not get replaced to get the anaemia. Started on standard immunosuppressive treatment and is now doing very well. Fun case

[/quote]

I saw a case of this last year as a second opinion from another practice, it had presented to them as vomiting and collapsed, but was back to normal when it arrived at their surgery. Its bloods at that time showed a mild non-regenerative anaemia, PCV 30%. They focused their investigations on the vomiting and didn't find any cause for that, and despite a drop in the PCV after a week to 26% they thought it was an anaemia of chronic disease.

He presented to me a week later and had a PCV of 21%. I did a bone marrow biopsy and the report was similar to your patient's. I suspect the vomiting episode was unrelated, and I wonder if he would have presented as your case did if he hadn't had the vomiting episode.

He had a blood transfusion as his PCV continued to drop after starting immune suppressive treatment. Apparently speed of response depends on which of the red cell precursors are targeted by the immune system, if they are very early progenitor cells it can take 2 months from starting treatment for new red cells to get into circulation, if reticulocytes are the target then it's less than a week.

Unfortunately my patient showed some response to treatment initially but we were never able to completely stabilise him and he was euthanased 3 months after he presented.

RE: Just for fun

Robin Grimmer — Tue, 16 Aug 2016 11:02:12 GMT

[quote user="Clive Ansell"]

[quote user="Robin Grimmer"]That's what I said - that's the definition of Pure Red Cell Aplasia! I did think though in this breed PFKD was going to be the diagnosis.[/quote]

Surely this would not be a true primary red cell aplasia? the bone marrow is functional and is able to produce normal erythrocytes. In this case precursors are targeted in an autoimmune reaction, so primarily an autoimmune mediated anaemia - interesting case all the same.

[/quote]

Strictly speaking, PRCA would include all causes of absence of red cells, eg parvo virus has been reported.

However, PRCA is pretty much interchangeable as the term for immune mediated destruction of the red cell precursors. I had a case of this for my medicine orals! Admittedly it's somewhat confusing terminology.

RE: Just for fun

Clive Ansell — Tue, 16 Aug 2016 10:42:45 GMT

[quote user="Robin Grimmer"]That's what I said - that's the definition of Pure Red Cell Aplasia! I did think though in this breed PFKD was going to be the diagnosis.[/quote]

RE: Just for fun

Hannah Wynne Richards — Tue, 16 Aug 2016 08:39:30 GMT

Interesting one

Wynne

RE: Just for fun

Robin Grimmer — Mon, 15 Aug 2016 23:26:38 GMT

That's what I said - that's the definition of Pure Red Cell Aplasia! I did think though in this breed PFKD was going to be the diagnosis.

RE: Just for fun

Adrian Caunter — Mon, 15 Aug 2016 21:58:58 GMT

RE: Just for fun

Robin Grimmer — Mon, 15 Aug 2016 14:00:40 GMT

[quote user="David Mills"]

Phosphofructokinase deficiency

[/quote]

I think we have a winner.

RE: Just for fun

Virginia Campbell — Mon, 15 Aug 2016 10:58:18 GMT

Is there such a thing as haemolytic anaemia that's so chronic that bilirubin normal as able to be cleared, no autoagglutination etc? Sorry my internal med knowledge is bit lacking! I might be inclined to Xray for a metallic foreign body and ask about any potential for odd poisoning eg zinc skin cream, and ask if it has been seen to habitually lick or chew anything unusual. Is it on normal food with no weird supplements?Still would not expect rbcs to look so completely normal though. Is it a farm or future gundog, or a family pet? 9 months is young!

RE: Just for fun

Hannah Wynne Richards — Mon, 15 Aug 2016 08:22:01 GMT

Why not a bone marrow biopsy?

Wynne

RE: Just for fun

Emily Rainbow — Mon, 15 Aug 2016 07:29:22 GMT

At this point I'd probably be looking at doing an abdo scan and faecal occult blood test.

Tho have the admit I'm quite perplexed!

RE: Just for fun

David Mills — Sun, 14 Aug 2016 22:44:34 GMT

Phosphofructokinase deficiency

RE: Just for fun

Adrian Caunter — Sun, 14 Aug 2016 21:57:02 GMT

agreed! lytes were sadly all normal though!

RE: Just for fun

Linda Filshie — Sun, 14 Aug 2016 21:54:28 GMT

Did biochem include electrolytes? Weirdo cases always make me think Addisons until proven otherwise...

RE: Just for fun

Adrian Caunter — Sun, 14 Aug 2016 21:48:59 GMT

they were indeed. Not microcytic or hypochromic. good shout though!

RE: Just for fun

Emily Rainbow — Sun, 14 Aug 2016 21:34:26 GMT

Were the red cells normal on the smear? Thinking iron deficiency anaemia?

RE: Just for fun

Robin Grimmer — Sun, 14 Aug 2016 21:29:01 GMT

If the dog was well then it must be chronic so has become adapted to its low PCV. Pure Red Cell Aplasia?

RE: Just for fun

Adrian Caunter — Sun, 14 Aug 2016 21:24:47 GMT

Yes agree totally with you both. Won't drag this stage out any further, just wanted to check people didn't have widely different views at this point in time. Personally I thought this was a nailed on IMHA case. Classic history and signalment. Went with bloods and PCV was 10 so hurrah us! This is where it got weird though... PCV was 10 but the dog was seemingly unaware of its illness. . Running around the consult and barking. Rest of bloods including total protein normal. There was no increase in bilirubin, no increase in white cells. No positive in house agglutination. The blood smear showed very occasional spherocytes but no evidence of regeneration, no nucleated cells, no anisocytosis and no polychromasia. Urine analysis was normal and FAST scan no fluid. So... I thought IMHA but now all the tests seem to suggest chronic bone marrow... this is where I got stuck. What do you guys reckon now?

RE: Just for fun

Emily Rainbow — Sun, 14 Aug 2016 21:06:56 GMT

Agree, would start with blood smear, haematology and biochem.

Normal faecal output?

RE: Just for fun

Robin Grimmer — Sun, 14 Aug 2016 20:50:27 GMT

Differential diagnosis for pallor would be either poor perfusion or anaemia. So do a PCV first. If low could either be haemorrhage eg rodenticide poisoning, lungworm or haemolysis eg IMHA. If PCV normal then is poor perfusion so would want to rule out cardiogenic eg congenital heart disease. Was there a murmur present?