Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Ethel

Ethel is a 10 year old spayed female Lhasa Apso. Ethel was diagnosed with IMHA on July 25th, 2008. She experienced a very rapid onset of IMHA, appearing healthy that morning, then collapsing during a bath around 2:00PM due to an apparent seizure with loss of bladder and bowel control. We called her regular vet and were told they were busy and might be able to see her in a few hours, so we rushed her to the emergency veterinary hospital where she was admitted to the ICU with a PCV of 27% at 5:30PM. Prior to her IMHA onset, Ethel had been experiencing recurrent ear infections treated topically with Animax, and had chronic skin allergies for the past four years since moving to Vermont from Connecticut. Her skin allergy treatment consisted of alternating shampoos with oatmeal and tar based products. She was overdue for vaccinations and had last received heartworm preventative five months prior and Frontline for ticks two months prior. Her only ongoing medications were 1/4th of a GlycoFlex III every other day for hip dysplasia and predisposition to cruciate ligament ruptures as evidenced by her littermate sister who had two cruciate replacement surgeries, though she also received a supplement containing cordyceps, reishi, maitake, shiitake, and turkey tail mycelia called "Mush" from Fungi Perfecti in an additional attempt to control her allergies. Two years prior, she experienced bloody diarrhea attributed to a food intolerance which was alleviated by Hill's Prescription Diet I/D. As the pet food recalls came out and Hill's products were implicated, we switched her over to Canidae Platinum (which contains glucosamine and chondroitin) which she has tolerated well. We believe she has celiac or another form of gluten insensitivity, as wheat-based products twice caused a relapse of her colitis. Once admitted to the hospital, Ethel received two x-rays to rule out an ingested foreign object and check for internal bleeding. Nothing was noted other than slight enlargement of the spleen and liver. Tests run included a CBC, chem profile, electrolyte check, and urinalysis. Abnormal results included slightly elevated glucose (128 mg/dL), RBCs low at 4 M/uL, hemoglobin low at 8.1 g/dL, elevated platlets at 492 K/uL. Spherocytes were noted on the blood smear, and the urine was dilute and negative for bilirubin. Blood total bilirubin was normal at 0.5 mg/dL. She was given 20mg prednisone orally and kept overnight, during which her PCV dropped to 19%. Ethel remained lethargic but she was eating and drinking. The evening of July 26th, her next CBC indicated RBCs down to 2.78, HGB at 5.7 and a PCV of 24%. Neutrophils and monocytes were elevated, at 23.9 and 2.5 K/uL respectively. Her white blood count increased to 31.5 K/uL compared to 13.5 a day earlier. She was kept on prednisone and stayed overnight again. A Schirmer test indicated keratoconjunctivitis sicca. She was started on doxycycline and famotidine, and had a negative result on a heartworm / lyme / ehrlichia test. Overnight her PCV dropped to 17%. Reticulocytes were evident on the blood smear, indicating regenerative anemia. On July 27th, Ethel's PCV rose to 24%, and she was started on azathioprine 50mg PO SID. She was scheduled for an ultrasound with an internal medicine specialist for the next day, and the ER vet felt that Ethel was staying there only for monitoring, and therefore we could bring her home. We brought her home that evening, and she vomited an hour after her evening dose of prednisone and famotidine. We monitored her pulse and breathing all night to check for any need to return to the ER. She was extremely thirsty and urinating large amounts. She was hungry every two hours, as the ER had been feeding her on that schedule to monitor for inappetite, but she stayed hungry. Each different vet over the first three days first believed Ethel had IMHA, then questioned the diagnosis due to her low bilirubin, age, and history, but following exams each vet became convinced that she was an atypical presentation of IMHA. The July 28th ultrasound was negative for cancer or tumors. A bright liver indicated to the specialist that her hemolysis was occuring primarily in the liver. Her PCV had again dropped to 19%, and she was readmitted to the ICU on the advice of the specialist. She was placed on IV fluids, 30mL/hour, and switched to IV dexamethasone after we reported she had missed her morning dose of prednisone by spitting the pill out. The azathioprine and famotidine were continued. The evening of the 28th her PCV had fallen to 15% and we began to strongly consider requesting a transfusion; she received no transfusion or oxyglobin during her hospitalization. Over the next two days, Ethel stayed in the hospital and continued to receive IV dexamethasone. PCV tests run every eight hours began to show improvement, and she was released July 30th after her most recent PCV came out at 25%. Her discharge medications were prednisone 10mg PO BID, 25mg azathioprine PO SID, doxycycline 50mg PO SID for 9 more days, and 20mg aspirin PO SID for 4-6 months, along with a miconazole shampoo for candidiasis. The specialist deals only with acute cases, so we were told to visit our regular vet for followup CBCs. From July 30th until her next blood test on August 6th, Ethel was extremely hungry and thirsy, and was very nauseous and uncomfortable after receiving her doxycycline for about an hour each evening. A dose of homeopathic Nux Vomica 30C resolved her nausea in five minutes, but we did not want to continue that for more than three days so she unfortunately had to deal with the nausea until the doxycycline was complete. Not trusting the regular vet that could not see her in her crisis, we chose another that we ended up not being very happy with, and she was seen on August 6th. The new vet prescribed OptImmune (cyclosporin 0.2%), twice daily for the keratoconjunctivitis, famotidine 5mg PO BID and tresaderm for ear infection, along with another two weeks of doxycycline. We did not administer the two additional weeks of doxycycline as a second tickborne disease test came out negative. Additionally, a zinc-carnosine GI protectant called GastriCalm was prescribed, but we chose not to give this either as administering zinc post-IMHA seemed like the wrong thing to do. Her CBC at this time (run by a new lab) indicated RBCs up to 3.8 M/uL, HGB up to 9.4 g/dL, and marked regeneration of reticulocytes. We held off on giving Ethel the famotidine as she did not appear to need it at this point, she seemed to be better tolerating the doxycycline by now. At this point, Ethel began to appear bloated, and we took her back to the ER vet for an exam on August 8th, along with a follow-up CBC so that we could compare against test results from the same lab where her initial tests were done. The ER vet performed another x-ray, which indicated a lot of food and fecal matter in her, but no obvious signs of a problem. The ER vet advised us not to feed her as much as we had been due to her ravenous hunger. Her PCV came out at 34%, and her CBC showed RBCs up to 4.7, HGB 10.4. Ethel is definitely doing better. Since August 8th, we continued the medication as directed, cutting the azathioprine to every other day on August 17th, at which point we began administering the OptImmune twice daily, and resumed famotidine on August 20th after considering the prednisone ulcer risk. She became gradually more bloated over this time, and began losing muscle mass, becoming quite bony and pear-shaped, although she has more energy now and will play with her toys longer and longer. Her extreme hunger persists, and she will attempt coprophagia if we do not prevent it. Today, August 27th, we took Ethel in to a new internal medicine specialist vet. Blood was drawn for a CBC that we should get the results of tomorrow. Her weight is down to 19.4 pounds. The new vet described as Ethel as "obviously Cushingoid", and we agree. Pending the CBC results, the vet prescribed an immediate cutback to 10mg once daily on the prednisone, vs the 20mg she has been receiving. We do have some concerns about the 50% reduction in dosage, but understand that Ethel is showing symptoms that the steroids are bothering her so we need to begin tapering her off. We are currently wrestling with the idea of cutting back to 15mg daily at first, though the vet seemed very confident with the reduction to 10mg. We are to monitor her gum color daily, and the vet agreed with us that Ethel should not be vaccinated again for anything. The vet did not see much utility in supplementation with vitamins C or E, silymarin or CoQ-10, but did suggest yogurt with bifidus and half a fish oil capsule each week to provide omega fatty acids. So that's Ethel's story. She's a beautiful, fun, caring dog that is making some good progress. Through all of this, her sister Lucy (the runt) has shown no symptoms at all other than depression that Ethel cannot play as rough as she always used to. I guess I am not really writing with any questions, as I know everybody has a different opinion on the prednisone taper, but I just had to get Ethel's story out there. It has been a very hard month for us all, but she continues to inspire us with her will to live and happy disposition. We have learned from all this to treasure each day with our pets, and to study, study, study. The key to dealing with this disease is knowledge. We read so much about IMHA that four different ER vets asked us if we were vets ourselves, and we are nothing of the sort. But if you understand enough about the disease to ask the right questions, and can show up to the hospital enough that your dog and the staff know you care, you can start to work through this. -Brian

Brian Vermont

brian- just based off of your post here alone you seem to be going to great lengths for your dog, which is always really cool to see... ethel is clearly in good hands i just wanted to mention that this is our 15th month since my dog was diagnosed and its been about 11 months since we did an 80% med reduction due to the fact that the high meds were ravaging her body and almost killed her before AIHA did... and she is still around for me to talk about this a full year later so it definately helped with her individual case. i wish yall the best

josh/sway california

Brian, thank you for sharing Ethel's story. Our dog, Toby, was diagnosed about the middle of July. He, too, was becoming "Cushingoid." Our vet reduced the Prednisone by half just as your vet did. We saw an improvement in Toby's overall condition almost immediately. The rapid reduction really concerned me, and I still worry every day, but it's great to see Toby feeling better. I hope the reduction will help Ethel also. Karen PS: I love your dogs' names. I bet they're every bit as comical as the "original" Ethel and Lucy.

Karen H. Missouri

Thanks for Ethel's story. Please keep us posted on her treatment and progress, she sounds like she's on the right path and she's got a great family to help her get better. melissa and tiggs

melissa slc

Thanks for all the kind words. We did finally get some results back from Ethel's latest blood work (late Friday), and her hematocrit was up to 41.3 as of Wednesday. Getting the test results out of the vet was like pulling teeth, we just weren't ready to taper her down just on word that "she's fine", we needed to see the actual numbers. Schirmer tests were 7mm and 8mm in the right and left eyes. We did manage to get the specialist who saw Ethel in the hospital to agree to see her again on Wednesday and for the near future, due to the difficulty we've had finding an appropriate primary vet. Pending the appointment, we've cut Ethel back to 15mg of prednisone (10mg in the morning, 5mg in the afternoon), her original discharge orders. We really hope he will be comfortable with us reducing to 10mg/day very soon. Reading about the great results your dogs have had with significant reductions in prednisone has definitely pushed us to seek the same. She seemed to be having a lot of trouble digesting her food well, and has been losing weight, so we put her on a digestive enzyme supplement with her food. It is definitely working, and she is starting to get more energy. Using the OptImmune in her eyes three times a day instead of two seems to be improving the KCS the last couple days. We're looking into supplemental silymarin and fish/flax/borage oils for liver support and anti-inflammatory benefits. Ethel has always been such a playful, fun dog that she deserves every effort we can put in to bringing her fully back to health. Her and her sister are as inseparable as the original Lucy and Ethel, so we have to do it for Lucy too.

Brian Vermont

Brian, It sounds like you are well informed on what is necessary to help your dear Ethel. I am sorry to read that the Vet is not easily forth coming with information. It is so much easier dealing with this when you have a Vet that is open to your input. Good luck to you and your little girl. Penny

Penny Lytle Creek Calif

We received Ethel's latest hematocrit values, and she has managed two weeks straight at 41.3 and 41.6, so she certainly seems to be doing better. Last Thursday we tapered her down to 10mg/day of prednisone. She had a bad day yesterday, threw up multiple times overnight and about four more times during the day, but we were able to get her meds into her. Her specialist did not seem very concerned about the vomiting, he just wanted us to make sure she was continuing to drink. Our guess is that her vomiting was primarily stress-induced. There was a small fire out in the woods behind our place on Sunday, so there were about 20 vehicles and 30 people outside our house for about 4 hours which really stressed her out, then we got the remnants of hurricane Ike with very heavy winds and terrible humidity. We were uncomfortable and so was Lucy, so it makes sense that Ethel wasn't feeling well. Our other theories are allergies coming back due to the pred reduction, or hopefully not an ulcer. Since going down to 10mg/day she has been having a recurrence of a stuck epiglottis that leads her to choke somewhat and breathe very strangely, but sticking a hand over her nose and making her swallow resolves that. She slept well last night and has been doing well so far today. The vet feels we can now move to blood tests every four weeks rather than two, so hopefully that will result in less stress for her too. She is finally gaining a little weight back, back up to 20.2 pounds, but still two pounds lighter than before her IMHA crisis. Her fur is thinning and she continues to look Cushingoid. So up until yesterday Ethel seemed to be making wonderful progress, but we have to understand that there are down days too. Thank you all for your support!

Brian Vermont

Brian, Those are very nice numbers. Hopefully the vomiting was just from your little excitement. One of my dogs allergies are starting to kick up too. Fortunately his usually lasts about 4-6 weeks. Something in the air this time of year. Is the specialist anymore forth coming now that Ethel is into her second month? Keep us posted on your dear girl's progress. Penny

Penny Lytle Creek Calif

Hi Penny, We aren't going back to the difficult specialist, we instead returned to her original specialist and he is wonderful. He is extremely communicative, listens to us, cultured her eye goop (E. coli and hemolytic strep, something to follow up on at some point) and gave us antibiotic eye drops that actually fixed her eyes. Ethel seems to have year-round allergies ever since we moved here -- what's odd is that her sister's previous year-round allergies disappeared as soon as we moved here. Way too much excitement. But she was VERY good and kept pretty relaxed, it seemed, instead of barking and being scared the whole time like I expected when they all showed up...

Brian Vermont

Brian, Having a Vet that communicates and listens helps so much. I know they need to distance themselves sometimes just to be able to do their jobs but it meant a lot to my husband and I when we lost our fight with our Salome that the Vet actually sat and cried with us. Wishing you and Ethel the very best. Penny

Penny Lytle Creek Calif

Hi Brian, I'm glad to hear things are getting better for Ethel! I hope she continues to improve and is fully recovered soon. Would you please let me know the digestive enzyme supplement you're giving her. My Maddie is having similar symptoms and started having IBS issues soon after being diagnosed with IMHA. Thanks for your help, Darla

Darla Stockton

Hi Darla, The digestive enzyme product we have been using is called "Pet Guard Natural Digestive Enzyme Blend (for dogs)", a powder that comes in about a 4oz jar. The label calls for using 1/4 tsp for a dog of Ethel's weight (~20lbs), but we have been using only about 1/16th to 1/8th of a teaspoon with each meal. I hope this product, or something similar, can help Maddie out. Specifically this product contains bromelain, amylase, cellulase, lipase, acid protease, alpha galactosidase, phytase, L. acidophilus and L. bifidus. Hope this helps.

Brian Vermont

This thread was discussed between 27/08/2008 and 22/09/2008

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