Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - A question about Mitch

Mitch is being maintained on 6.5mg of prednisolone daily. He weighs approx 7kg. His PCV and platelets have both been around 25 for a number of months now. We are pretty sure his bone marrow was damaged severely early in the disease(findings on bone marrow biopsy/aspiration).We have been hoping his counts will increase but to no avail. He was diagnosed with evans 7 months ago. The question I have is that does it seem likely that maybe it may no longer be his immune system attacking the blood and keeping the counts low or could it be that his bone marrow is so damaged that it will never reach pre-evans numbers. I hate to think he has been on all these meds for so long to supress his immune system if in fact his immune system is no longer playing a part.

Kath scotland

Kath, if I can remember correctly you tried everything with Mitch and had tonnes of testing done also. Have you considered consulting with a TCVM? Sometimes they can work wonders. Good luck. I'll keep Mitch in my thoughts and prayers. Johnny & Tessy

Johnny

Kath, I am sorry that Mitch is not rallying the way you had hoped. I know that it's very hard to understand the physiology of the body at times. And I know it is easy to think that the marrow is damaged. Think of the bones and the marrow inside as something that is alive and growing everyday, just like our skin or our hair. They are not static, but a very dynamic part of our body. There are two kinds of cells that break down bone and build it up everyday, all day and night long. We remake bone all the time. You can probably guess where I am going with this. This bone making process, called remodeling, requires nutrition like calcium and other minerals. The marrow needs special amounts of vitamins and minerals to make blood every day. Each type of cell, the red and white blood cells and the platelets all begin their life from the same precursor cell. Any lack of proper nutrition will hamper this process. Its not always related directly to lack of good food. Can the body properly assimilate this food or is something wrong with this process? Josh and I went around and around for over a year trying to find out what the issue was with Sway. Her blood tests were showing some kind of nutritional deficit to the red blood cells, causing them to not be well formed and fragile. In the end, his vets found a liver shunt that was bypassing the blood going to the liver. This meant that nutrition was not getting to the liver and thus not getting to the marrow. In addition, if the kidney is not contributing the proper hormone in the right amount to stimulate the marrow, there will be anemia as well. So testing the kidneys is very important. Another cause of this kind of chronic anemia is termed "anemia of chronic disease." This is an inflammatory process in the body that negatively impacts the bone marrow. These types of causes need to be explored. It could be a growth of some kind elsewhere in the body. And finally, yes, there can be a problem with the marrow. The number of white blood cells inside the bone could be greater than they should be and crowding out the red blood cells. This is a problem with lymphocytes. Each of these things requires some kind of test, unfortunately. And some of them can be expensive. How is he doing overall? Is he lethargic and not eating well? Is he interested in what is going on in the household? If he seems to be in good spirits, he may have adapted to this lower count. These are discussions to be had with a specialist. I hope you are able to find some answers soon. I will be thinking about you tonight. patrice

Patrice NYS

Thanks for your responses. Johnny - you remember correctly, we have tried everything including the less often tried things such as vincristine, human immunoglobulin, cellcept. Nothing has shown any kind of significant increase if any at all. The vincristine and human immunoglobulin did nothing suprisingly . Could you explain to me what a TVCM is? Patrice - thanks for your very detailed reply. I have mitch on multivitamin/mineral supplement to help fill any gaps nutritionally. Mitch has been scanned and x-rayed and blood tested? to check for tumours etc - nothing found. Any specific test for shunts, treatment if found? We were with the specialist vets at the university hospital for a long time where they explored so many avenues and in the end we were refered back to our usual vet( who has their permission to liase with them) as they just could not, despite extensive efforts explore further or try any other meds. I thimk the feeling was he would fade away but 4 months on after they referred him back he is still here. I would love to be referrred back now to see if there are more avenues to be explored as his will is clearly so strong however the cost alone is just impossible to continue down this route. The last 7 months have seen vets fees of £8000. Mitch is good in himself, he eats well, plays with his toys, (I now know why I never bought him a squeaky toy before!) I take him to the farm where my kids ponies are kept and he walks 200yds but gets carried whilst he recovers and then tries to chase a few pigeons! He gets cold easily and he needs to wear a coat and after a while gets wrapped in a blanket and cuddled by anyone available at the time! My more recent concerns are that his breathing seems to be restricted in his throat area, this has been an issue for several months now but seems to be getting worse. His chest/lungs are clear. The salivary glands under his tongue are very inflamed and again have been for a few months - they seem to increase and decrease in size but always inflamed. I wondered if a similar inflammation in his throat could be causing the noisy breathing? Auto immune issues? He is losing more hair - both front feet and a small patch on his side. His skin looks darker on his neck now, I think I will ask for his thyroid testing again. Could his thyroid glands be inflamed and restricting his throat? As you see so many questions.

Kath scotland

Kath, Hyperpigmentation, or a darkening of the skin is a symptom of thyroid problems as is the loss of hair. I would get thyroid testing done ASAP. Here is a link from the Meck veterinary manual that you might want to read; http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/40602.htm&word=thyroid Many many AIHA/IMHA dogs also have hypothyroidism. Getting that problem corrected can aid in the recovery a great deal.

Joanne MN

Kath, TCVM is Traditional Chinese Veterinary Medicine. I'm not sure if htis is available to you or not over there. I've heard lots of good things about it with regards to treatment of AIHA/IMHA. Lots of people use this form of Eastern Veterinary medicine along with the western methods with really good results. Have htey not checked Mitch's thyroid? Even if the thyroid is alright it could still be benificial to add a small dose to help stimulate the bone marrow.

Johnny

Thanks, I will have thyroid tests taken again when his next bloods are taken, this has been checked previously but it was several months ago now. I will look into the TCVM as well Johnny - not sure of it's availability in the UK.

kath scotland

Kath, There is an indirect way to monitor the possibility of a liver shunt by tracking the "M" values of the red blood cells. They represent the general health of the RBC in a way that can help interpret the cause of the anemia. The type of anemia that can possibly indicate a portosystemic shunt is called Microcytic Anemia. In generalized terms this means that the red blood cells are overall smaller than normal and that there are many more different sizes of red blood cells than normal. This indicates "something" is wrong with how they are made or how they matured. Then there is a short list of the things that can contribute to causing this maturation problem. Liver shunts are on this short list, but it is directly related to iron deficiency in the bone marrow. The liver is responsible for storing iron in large quantities. Once this storage is depleted there can be continued moderate anemia. This paper I am including the link to indicates that one study showed as many as 66% of dogs with this particular form of moderate anemia are found to have a portosystemic shunt. I mentioned this to Josh very early in Sway's treatments. His vets denied this could be the case, but over a year later an ultrasound found the shunts. So from my experience with Josh, vets may be resistive to investigating this possibility. From here on in, Josh is the expert. He educated himself about liver shunts and knows all the details of diagnosis and treatments. I highly recommend you read this short paper on microcytic anemia. http://www.vet.uga.edu/vpp/clerk/mwoods/index.php my best patrice

Patrice NYS

Patrice, Mitchs latest M values were as below. I believe he is macrocytic not microcytic? Normal values in brackets. MCV 88 (61-80) MCH 25.7 ( 20 -26) MCHC 29.2 (30 - 36) Higher than normal biochemistry are - Urea ALT Alk Phosphatase Gamma GT Bile acids (reduced greatly since coming off cellcept though) cholestrol Triglycerides Lipase Lower than normal Red cells White cells Platelets

Kath Scotland

Kath, The guidelines to diagnosing the type of anemia with an abnormal MCV (mean corpuscular volume) say that with clinical findings of anemia and an abnormal MCV<80 there is a indication of either hemolysis or blood loss of some kind. Or there is a chronic disorder of red cell production in the bone marrow. In this case, where the MCV<80 (greater than 80 but less than 100), there is macrocytic anemia. So this means the cells are larger (but not by much in this case) than the normal RBC. The most common cause of macrocytic anemia is megablastic anemia that is a deficiency of B12 or folic acid or both. This can occur either because of poor intake of B12 or extremely poor absorption in the small intestine of B12 and/or folic acid. There is a test on a pancreatic panel that tests the B12 and folic acid levels. Here in the US I have been able to break out that test from the complete pancreatic panel to reduce the cost significantly. Chance has a chronic low blood level of B12 so I give him shots every 10 days and occasionally monitor his blood level with this test. The other cause of megablastic anemia (and thus a mild macrocytic anemia) is hypothyroidism. The two ways that this can affect the B12 and folic acid levels are by impairing the absorption of B12 and folic acid in the small intestine and by impairing the production of erythropoietin by the kidneys. Erythropoietin is a hormone that influences the bone marrow to make red blood cells. In addition some kinds of liver disease can cause macrocytic anemia. The liver stores not only iron but large quantities of B12 and folic acid. If this are depleted and the liver is having trouble storing more of these nutrients, it will result in a large deficiency. This will result in production deficits in the marrow. The biochem results are showing some indications of possible liver impairment and/or some level of pancreatitis. If this were me I would not hesitate to have a pancreatic test called cPL Canine (specific) pancreatic lipase. I would also have a B12 and folic acid blood levels test done. If the results don't point directly to pancreatic inflammation but the B12 and folic acid are both low (or one is low and the other normal), then I would pursue examination of the liver further. This is a more complex diagnostic test and the indications for things like liver biopsies are not straightforward. I would also pursue a complete hypothyroid panel with Hemopet, including the antibody test. Treatment for pancreatitis would be resting the pancreas by withholding food for a few days. Then begin a modified diet that combines enzyme supplementation with meals There is an excellent product on the market just for dogs that is very safe and effective. The treatment for hypothyroidism is inexpensive and very simple: 2 small tablets of Soloxine a day. Dr. Dodds will dose according to symptoms, age, sex and breed. Hypothyroidism is not a static condition. As the gland is destroyed by the body over time, it becomes less and less effective at running the body's metabolism. It is a slow process and sometimes is not noticed because of this. My gut reaction is that there is some level of hypothyroidism and it is contributing to a deficiency of B12 and folic acid. Once you know the results of the B12/folic acid test you can begin supplementing with regular shots of B12. It takes a very long time to bring the liver storage values of these nutrients back to a normal level. Say about 3 months? The results of the chem test are showing some level of systemic inflammatory process. I would supplement with fish oil at 1000mg (one fish oil capsule) per 10 pounds of dog per day. Fish oil will help reduce this systemic inflammation. Also supplement with 400mg of Vit E. Continue with any liver support supplementation you are giving and modify the diet so that there is little challenge to the liver (avoid red meats esp). my best patrice

Patrice NYS

Thankyou so much for all the info Patrice, I am so grateful for the effort you put in to helping others. There is a lot of info there that whilst I understand it all am still sbsorbing it! I will try to remember what I can and raise issues at our next vet visit. Mitch was treated with erythropoieten for a time and vit b shots in the hope it would help although like everything else tried showed no difference. Maybe we did not continue long enough as you say it takes months. I will take on board all you have said and will get some supplements you recomend. Is Vit b absorbed equally well if I buy some to give orally? How much fish oil per lb? Mitch is on a white meat diet currently. This has been a year of auto immune issues in our family, besides Mitch, my horse has been diagnosed with auto immune uveitis, my father in law with MS, my mother in law with Wegeners Granulomacitis(sp?) (both also auto immune) and my husband is currently awaiting results for WG also as he has battled with many of the health issues his mum has been displaying.

Kath Scotland

Kath, Wow, you have been through a lot from all sides haven't you. I am sorry for all the problems you are having to deal with. Hopefully you are in line for some positives soon. If you look on the page right above "Add your comment to this thread" You are able to print the page. It would probably be easier for you to have a print out instead of trying to remember everything you want to ask the Doctor on your next visit. Keeping you and Mitch in my thoughts and prayers. Penny

Penny Lytle Creek Calif

This thread was discussed between 03/03/2010 and 06/03/2010

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