Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Linda Filshie — Thu, 29 Mar 2018 21:41:39 GMT

What a shame for all concerned. Thanks for the update though.

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Sara Ramsey — Thu, 29 Mar 2018 18:58:57 GMT

Afraid not

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Julie Innes — Thu, 29 Mar 2018 07:50:20 GMT

Sad to see your update, but sounds like the right thing for the wee guy. Are they willing to let you do a post mortem?

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Sara Ramsey — Thu, 29 Mar 2018 07:11:15 GMT

Thanks gain for input, sadly this dog has been put to sleep.

We did the transfusion, and 20 hours later his PCV was the same. Splenic FNA: extra medullary haematopoiesis but couldn't rule out neoplasia (though I think unlikely) . I started ciclopsporin along side the prednisolone but PCV dropped to 13% and he was becoming more sad so owners opted to PTS after a nice day spoling him home.

Very sad and frustrating. His bilirubin only got to 51, never had spherocytosis, continued to be highly regenerative.

I considered offering a splecnectomy with a intra-operative/post operative blood transfusion as seemed no point giving more blood whilst spleen appeared to be removing RBC immediately. However he was getting sicker and O wanted his last day/hours to be with them..not on an operating table.

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Sara Ramsey — Thu, 29 Mar 2018 06:58:22 GMT

Thanks gain for input, sadly this dog has been put to sleep.

Very sad and frustrating. His bilirubin only got to 51, never had spherocytosis, continued to be highly regenerative.

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Linda Filshie — Sun, 25 Mar 2018 14:30:26 GMT

Whew what a weekend

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Sara Ramsey — Sat, 24 Mar 2018 22:22:09 GMT

Also had admitted today..feline pleural effusion, profoundly cold and shocked dog attack, 2 X raisin ingestion, a bad vestibular syndrome, pancreatitis dog.....and an anorexic Tegu

I work with a great team but v.glad someone else is in charge tonight before I head back into war!

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Sara Ramsey — Sat, 24 Mar 2018 22:18:51 GMT

Thanks for replies!

He has had some packed RBC today and then scan just showed a patchy looking spleen with some focal hypo-echogenicity areas which have been FNA'd

He is on 1mg/kg pred bid. I have stopped Ronaxan. He has had some V+ and D+ so on gastro-pro and cerenia.

He finished apoquel about 2 weeks ago and the cephalexin around 6 weeks ago. Normal dose I would think (back home now).

The previous IMHA cases I have seen have been pyrexic, acutely unwell and icteric+++, this guy doesn't quite fit ..his pcv stayed at 19 to 20% for three days without immune suppression then dropped to 15% but hopefully we have bought him some time. Thank again !

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Anthony Dennison — Sat, 24 Mar 2018 09:54:19 GMT

[quote user="SER"]

Male, neuter, 6 years old. Vaccinated. No foreign travel. Had horrible ulcerative skin erruption on head a few weeks ago. Tx: steroids, apoquel, cephalexin. Very weird and acute but cleared up.

[/quote]

I've seen a few IMHA cases post cephalosporin treatment. What dose did you use?

[quote user="SER"]But: no spherocytosis, negative saline agglutination, coombes negative. [/quote]

Coombes test and saline agglutination aren't always positive in IMHA. Check with your lab whether they do the Coombes at room temperature or the cold-agglutinin version (done at 4 degrees)

[quote user="SER"]Tx: pred, clopidogrel, omeprazole and ronaxan. No response. pCV today 15%, strongly regenerative. Neutrophilia++, platelets 117.[/quote]

What dose of preds is the dog on? Could potentially add in ciclosporine to the mix, depending on what finances can allow, potentially also a mycophenolate CRI (though this would be off licence). Bloods sound like a regenerative anaemia with a big inflammatory response ----> IMHA.

[quote user="SER"]Having diploma level US scan tomorrow and likely transfusion.[/quote]

Good idea, to spot any potential tiny tumours causing the IMHA. Transfusion will definitely help this dog as it's likely the PCV will drop a bit further before it improves. Have you blood typed the dog in preparation?

[quote user="SER"]Considered BM biopsy but is regenerative and wbc response seems appropriate.[/quote]

I don't think you need to go down that route. Only really needed if it's non regenerative or something else weird going on.

[quote user="SER"]Am I missing something obvious. VERY intense owner and dog getting worse.[/quote]

No, doesn't sound like you've missed anything, pretty thorough!

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Linda Filshie — Fri, 23 Mar 2018 23:08:00 GMT

This kind of stuff always happens on the run up to a weekend. I believe that is what is referred to as the Law of Sod :/

A tranfusion is at the very least going to improve things and buy you some time while you see if you can mine the brains of the collective wisdom for anything else useful. At best it will fix him and in that case you might never pinpoint the cause, but gifthorses and their mouths come to mind in that scenario.

Now there's nothing else you can do about it tonight so try and relax/go to bed. I'm just about to take my own advice.

Best of luck.

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Sara Ramsey — Fri, 23 Mar 2018 22:56:06 GMT

Thank you so much for your reply. ..I'm kind of dreading tomorrow what with the usually Saturday stuff that goes on!

. I suppose if it is not an anti-body mediated destruction then that might fit and the transfusion might see him through. Wishful thinking !

I think he has been off the cephalexin a few weeks but not sure as colleague managed that presentation.

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Linda Filshie — Fri, 23 Mar 2018 22:53:52 GMT

And apologies for the turbo posting but would be an interesting case to write up for JSAP perhaps...

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Linda Filshie — Fri, 23 Mar 2018 22:43:24 GMT

Just doing some more reading. This from vetfolio:

"Drug-induced immune-mediated hemolysis involves several proposed mechanisms of action. The major proposed mechanism for penicillin- and cephalosporin-associated IMHA is adhesion of drug or drug breakdown products to the RBC membrane, with subsequent induction of complement attack or cell removal by the MPS"

RE: Minature Shnauzer: haemolytic anaemia but not typical IMHA..help!

Linda Filshie — Fri, 23 Mar 2018 22:41:11 GMT

Some kind of toxin associated haemolysis perhaps? When did he stop the meds for the skin eruption? A quick google search shows up that Min Schnauzers can suffer from a hereditary RBC osmotic fragility but seems a bit old for that to be showing up.

Strongly regenerative picture supports a functional bone marrow. Lack of fragmentation of RBC suggests not microangiopathic so probably not tumour. If immune would expect spheroctyes/positive coombs...

In summary I don't think you're missing anything hugely obvious but will be interested to hear what others think.

Fingers crossed for you and the dog. It's always worse when the owners are very intense but remember they're just worried.