Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Kahlu relapsing? :(

Nobody said this would be easy. But of course we all hope that our dog will be the one that will recover quick and never relapse.... Kahlu had a PCV yesterday, that came back a little lower again. (39) so we decided to do a full CBC right away. The results today showed just a slight drop. Here is the pathologist report: Please note -history on req says resolving IMHA Prior sample reviewed also The HCT has dropped a bit but of concern is noted polychromasia and increased nrbcs on his sample. There are a few equivacol spheroyctes also noted. Concerned for possible early recurrence of disease. Monitor very closely. (end of quote) The vet recommended to go back to 5mg pred every day from 2.5 EOD. Kahlu seems just a bit subdued but happy to go on walks and play eating and pooping is normal. He still is on antibiotics for UTI. He seems a bit paler too. But then I think with this disease we also start to see things. His HCT is 49. So now that I got my crying out of the way, I am ready to fight again! I am worried that this low dose is not enough. Should we be more aggressive? I think I kind of understand what is happening. He is making a lot of retics and there is some destruction? Patrice, if you have some time, could you explain it in your words? You are so good at explaining it that my little brain understands. Silka, the Antinuclear test Riley had done is also called a Coombs test. Kahlu had it done and it came back negative. Take care everybody, Brigitte & Kahlu

Brigitte BC Canada

This could just be a momemtary upset and not a relapse. Try not to get yourself all upset and worried. I am not savvy with figuring out the counts, etc., but I am hoping and praying this is an unrelated matter, and not anything to worry about. I will be thinking of you and Kahlu :) It looks like Kahlu's counts are still very, very good!

Mardi Northern Calif.

Oh man, hang in there Brigitte! I'm confused as to why the PCV and the HCT would be so drastically different...I know there often not exactly the same but 39 and 49 seem kind of far apart? But, like Mardi says, I'm figuring this stuff out too, I'm no expert. When I asked my vet the "what if Tiggs relapses" in the past...she always told me he'd have to go back to full immunosuppressive doses again (which in his case, the initial dose for him being near 65 lbs was 120mg/day). So, I don't know about the little increase if it is a relapse. Hopefully you can get some answers (us too, dang it, we're in the same damn boat...). Thinking of you and Kahlu! xo melissa and tiggs

melissa slc

Brigitte! I got such a shock when I read your thread post. Your numbers are too good to be a relapse, and I also wonder about the PCV/Hct numbers being so different, I thought they should be similar. Lets hope Patrice chimes in soon, because I dont really know, but I would imagine you never stop worrying. Thank you for the advice re the Coombs test, I always wondered whether they were the same thing, now its good to know. Its a good thing that its negative for Kahlu - I dont believe it is a relapse - you may have just caught things early to be able to get them back under control. Golly, what else can I cross for Kahlu ang Tiggs. My best wishes to you Brigitte, keep us up to date. Silka

Silka Melbourne Australia

Bridgette, I have researched this for quite a bit of time tonight. I think the answer may lie in this article about Metarubricytosis. "One of the normal stages of erythroid development is the metarubricyte. Frequently referred to as a nucleated red blood cell (nRBC), these immature erythrocytes are the last developmental stage to contain a defined, intact nucleus and immediately precede the appearance of polychromatophilic erythrocytes (reticulocytes) http://www.vet.uga.edu/vpp/CLERK/Smith/index.php Ok, blah blah, what does this really mean? It would be helpful for you to at least browse around this article, look at the nice slides and read their captions. Your lab report indicates: "noted polychromasia and increased nrbcs" Nrbc is "nucleated red blood cell." Polychromasia means that there are many different "colors" (chroma) to the cells when they are stained to view under a microscope. Thus, they are saying that the cells that they are seeing are not all the normal biconcave smaller red blood cells that have a small pale center. The second slide down shows a few of these normal RBC near the top. (Once you start looking at slides of normal red blood cells, you will understand what they should look like.) A nucleated red blood cell is a metarubricyte. When the lab tech uses a special color of stain, they can see the remnants of the RNA left from the maturation process inside the cell, it stains a blue color. They can now identify this as a cell that is pretty close to being a reticulocyte (baby blood cells). Go back and refer to the top graphic to see this progression of cell types. So, this would be happening in response to anemia. Very important point here. Kahlu doesn't seem to be anemic. Why would there be this stimulation of the bone marrow??? I am not sure, this is a very complex article and I will have to read it a few times more to fully understand it. This is a diagnostic challenge and you can read in the article what criteria they use to sort out this diagnosis. In any case, for some reason, the bone marrow is responding to a call for more red blood cells to be made. The lab also notes "a few equivocal spheroyctes." These are a type of RBC that is sphere shaped rather than the nice round shape. They seem to be able to carry and transfer oxygen ok, but their membranes are more fragile. Sometimes, the spleen sees them as an old worn out RBC's and destroys them. Thus, the spleen can be a site of destruction. Seeing these in the blood, along with cells that the spleen has taken a "bite" out of are possibly indicative of hemolytic anemia. However, the lab report states "equivocal." This means that there isn't certainty of why these are there and what they really mean. A hesitation on the part of the lab tech to try to explain their presence. Also in this article is a section titled "Familial Macrocytosis and Dyshematopoiesis of Poodle." I draw your attention to this because Kahlu is indeed a poodle. I note that they mention: "This hematopoietic abnormality often is an incidental finding on the complete blood count and bone marrow aspiration and is unassociated with clinical signs of disease." What they don't go into deeply is whether this familial condition is benign or not and what they do to treat this. I am also a bit confused at the wide difference between the Hematocrit and the PCV. For all intents, these are pretty much the same thing. The HCT is more defined in reference to all the other blood elements, thus it is a percentage of a whole that consists of a large group of elements. The PCV is a visual representation of supposedly the same thing. I have noticed every time that the automated analyzer shows a HCT that is lower than the PCV. My vet is puzzled by this too. But she explains that the PCV is pretty accurate. She also mentioned that in many cases, anemia is really defined by the hemoglobin content on the test. If this is normal or near normal, then the body would not consider itself "anemic." Make sense? Now for the UTI. The kidneys provide the hormone that tells the bone marrow that the body needs more oxygen, so "make more blood!" If the kidneys are compromised by infection, it is possible that there is some problem with the erythropoietin being produced. This could definitely cause problems with blood manufacture. So for now, it might be helpful to focus on this underlying infection, get that resolved. All this stuff I have written can be put into the back of your mind as just plain research. Talk it over with your vet to get their input. They have clinical experience that will help sort out why this article might or might not apply to your situation. I would ask them if they carefully palpated the spleen just to make sure it isn't enlarged. Also, it seems that stress can be a factor in the production and circulation of these different cell types. Keep Kahlu on the quiet side for now. Trim down the routine stuff to the necessities. my best patrice

Patrice NYS

Thank you so much Patrice for spending all that time to research our problem. If you have to read it a few times, it will take me a few times more and i know i will not fully understand it. I will give it a try anyway. I find it interesting that you see a connection between the UTI and this. I always felt there would be more to it. The poor guy has been constantly on antibiotics and nothing seems to help. I think this needs to be further investigated. Regarding PCV/HCT maybe I made a mistake? I got those numbers over the phone and not as a printout. I will call tomorrow and double check. I won't get much sleep tonight anyways so I better start reading that article. Thank you very much Patrice to give of your valuable time and everybody else for your thoughts and kind words. I will keep you posted. Brigitte & Kahlu

Brigitte BC Canada

OMG...I almost swallowed my heart when I read your post. The absolute best thing in the case of a relapse (if this is even what it is) happened for you...you caught it VERY VERY early. I'ld be going in the next day or so just to check things out. Was the PCV of 39 and HCT of 49 done the same day? Maybe I'm reading it wrong. Any way he got into something he wasn't supposed to? Now would be the time to wrack the brain and try to think of everything possible. I wish I would have thought of this in the beginning but with time I started to forget. If you can identify the trigger then that would solve soooo many problems. Keep positive for Kahlu's sake and know that he'll be in my thoughts and prayers. Sending strong healing vibes form the East coast for ya Kahlu. Get better for mummy. Johnny & Tessy

Johnny

Since everybody doubted the difference in PCV and HTC (including myself) I called the vet to double check. So i was out one point, RBC was 40 and HTC 49 still a big difference. the blood was drawn the same day, by a different person though. Could blood be damaged and look like that? I guess that would be wishful thinking. I did some reading of that article that Patrice found (bless your heart!!!) I get some of it, but it is still quite confusing why his blood looks the way it does but he is not anemic. Not yet anyway. He looks and acts pretty good too. I am very tempted to go in next week and have blood sent to Dr. Dodds. The vet wants to see him again the end of next week, but I am scared to wait that long. You all know how the waiting is. We have never done a urine analysis while Kahlu was on antibiotics to see if they even work. ( I suggested it once) We always did them after he was of antibiotics for a few days. The culture always came back positive, so I think that needs more investigating. I know that the pred will make him prone to infections, but he has been on low doses for a long time now. Johnny, I wish we would know the trigger. I think it was a combination of immunizations, flea treatment and a bit of cleaner he licked. All this happened over 3 months. Who knows. But I am 100% sure he did not get immunized, had a flea treatment or licked cleaner in the last 10 months! Thank you all very much for your thoughts and support, thinking of you all, Brigitte & Kahlu

Brigitte BC Canada

Brigette, Ok, this was most likely HCT 40 and PCV 49. That makes perfect sense. The number for the RBC would be something like 5.5 (million). The HCT always tend to run lower than the PCV. But that PCV would be more accurate. This is not anemia. Not even close. Yes, the blood can be easily damaged. Drawing blood properly is a accomplished skill. Yes, you may want to at least send a copy of the lab report to Dr. Dodds. Her fee for reviewing stuff like this is $30-40. The form is on her website. So I would follow up on the urinalysis. In order to get a "clean catch" the vet can actually use a large syringe and go right through the side of the body into the bladder. I know this sounds horrible, but it really is a very easy test and will give the most accurate results. Then they culture the bacteria and can prescribe the exact antibiotic that is needed, not guess at it. If there is an infection, let's see what happens once you clear it up. This could take 10-14 days on an antibiotic. Lots of drinking of clean water. If you want to force fluids more than dogs naturally want to drink, try what I use with Chance. I get the Pedialyte Popsicles and freeze them. He loves them. I think some restful sleep is in order for both of you. If this were me, I would put the worry aside for now. If Kahlu is eating etc ok and seems pretty much himself, he will be okay while you wait to see the vet again. my best patrice

Patrice NYS

Hello Patrice, no, this time i got it right. the test they did at the vet, the PCV was 40 and the HCT that came back from the outside lab was 49. I know it is strange. Two weeks ago we had the same thing PCV 41 5 days later the HCT came back 51. I wanted to send blood to Dr. Dodds anyway to get Kahlu's thyroid properly assessed. My vet wanted to wait with that until he is off prednison completely. I think I just want to do it now. At the same time she can look at the blood and hopefully have some idea what is happening. About the UTI we probably had this test done 3 or 4 times! i know it sounds awful to stick a needle in their belly, but Kahlu was ok with it. He was on novamoxin every time for at least 3 weeks when the urine analysis came back positive with e-coli. After the last time the vet decided to just leave him on the antibiotics until he is off the pred. I never felt good about that. I really value your opinion. thank you so much for your input. I feel so much better now that I have a plan of action. Best wishes, Brigite & Kahlu

Brigitte BC Canada

Hi Brigite I am hoping and praying Kahlu is not relapsing. Please know that if he is, there is hope. Just look at Ginger who has relapsed twice since her initial diagnosis in 2007 and each time she has bounced back after starting all over with the pred, aza and cyclo. I know how frustrating this can be, but hang in there and know that we are praying for you and Kahlu. Cheryl & Ginger

Cheryl & Ginger Pinevile pa

Brigitte, Just checking in to see how Kahlu is doing. Also want to send some healing vibes and prayers to him. Hugs, Johnny & Tessy

Johnny

Johnny, thanks so much for your good wishes. It feels good not to be alone in this! I think I am very blessed with my vet. I was waiting for the clinic to open and give her my plan of action. Low and behold the phone rings and it is her. she had a sleepless night and did some research. She has the same feeling as me, that we need input from Dr. Dodds and follow up on the UTI. We are both not clear if we are over or under reacting. I feel so good getting Dr. Dodds involved again and hope she has some insight. Kahlu seems perfectly normal, so I am desperately hoping we either caught the relapse just in time or it is something unrelated. Best wishes, Brigitte & Kahlu

Brigitte BC Canada

I am here thinking about you and Kahlu and keeping you in my thoughts and prayers. Be brave......

Mardi Northern Calif

Brigitte, I am so happy you have such a caring Vet. That is not always easy to find. When I say caring I mean one that will look for more answers and involve you in the decisions. Best of luck to you and Kalhu

Penny Lytle Creek Calif

Wow Brigitte, what a wonderful vet, you are indeed blessed. I hope all this gets sorted out soon for Kahlu and you - and us too, so we can stop worrying! Get better soon Kahlu. Best wishes, Silka

Silka Melbourne Australia

This thread was discussed between 11/12/2009 and 15/12/2009

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