Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Mitch B/M results

On a positive note Mitch's PCV remains stable at 28 and his platelets are at 50. The highest they have been since starting meds. However his platelets have jumped up and down within a day and it could be a very different story tomorrow. If he remains the same we can bring him home tomorrow. (We were told the same last Friday and he plummeted the next day!) On a bleaker note the bone marrow aspirate shows lots of red blood cell precursers (thats good) but the number of megakaryocytes (platelet making cells) has actually dropped since his last aspirate (and they were only at normal levels then).He has also been on cyclosporine since then for 2 weeks. The vet is rightly concerned and we can only wait and see now if anything should miraculously happen to help him produce more megakaryocytes. The issue with the megakaryocytes may or may not be an immune issue. I almost wish it is, at least then there is a chance of recovery otherwise there is little hope. Vincristine was discussed again as it releases many platelets at once but the fact is there are few megakaryocytes to release them from and at the moment he is not critical. What I don't understand is why the platelets keep jumping up and down whilst the megakaryocytes drop in number? Any ideas on why he is so low on megakaryocytes? Maybe none of this is auto immune although he did become ill quickly with a high fever so indicative of such and all other possible avenues have been explored. Platelet Count History since 28/07. 77,pred started,65,42,2,blood transfusion 7,bone marrow biopsy&cyclosporin started 7,8,28,17,19,9,bone marrow biopsy,50. Trying to stay positive. If anyone has any links or anything that might help me understand what is happening although I think I had read everything available! I cannot find much on immune mediated destruction of megakaryocytes though. kath

Kath Scotland

Mitch has come home this afternoon. His PCV is 28 and his platelets 44 today. I was shocked by how much muscle he had lost and he looks like a patch work quilt with all the shaved bits. He is very weak but still very much Mitch just very toned down. He just wants to eat, drink, pee and poop. He has to go back on Wednesday to see what is happening with his platelets. Glad to have him home, sad about his physical condition, but worried and also hopeful for the future days and weeks.

Kath Scotland

Kath: Good to hear that Mitch is home! I remember how startling Sheba looked, too, but it will pass. With care and time Mitch will regain his muscle mass, his fur will grow back and he will be back to a more bouncy version of himself! Rita, Mike and Sheba

Rita IA

Kath, I know how awful it is to see the physical changes due to the drugs and the weakness from the disease but just try to hold onto the positives. Mitch is home where you can shower him with love. Laughing at eat, drink, pee and poop. That will be your life for a while but just keep looking towards the day that you can reduce the meds and have Mitch back to his ol' doggy self. Penny

Penny Lyle reek Calif

Not sure I can cope with the stress of this! When he came home he was ravenous would quite literally of eaten anything but we gave him a small meal of high quality dog food which he ate well. His faeces have been very loose but this was mentioned at the vets - no blood had been seen for about a week now. He has passed several lots of loose faeces now since we got him home at 5pmish but the last one definately had fresh blood in it plus he now also refuses point blank to eat anything - we have tried all his usual and cooked fish etc for him but cannot tempt him. He has had his meds without food which worries me. I don't think we should of brought him home, he has been eating well at the hospital and not passing blood. We have kept him calm as well- not confined to a cage but not freedom to roam either. Will see what the morning brings and then ring them in the morning but I think it was perhaps the wrong time to bring him home today.

Kath Scotland

Kath - I am sorry you are having a rough time with Mitch's first night home. I remember the mixed emotions of those first nights - so happy to have them home but nervous about what might happen. But, all in all, while it's nerve-wracking for us, I think they are more comfortable being in their familiar, loving home and, hopefully, that is good for healing. Maybe his first regular meal was a bit much after his can rest a bit and then offer something bland, it would sit with him better? I hope you are having a better night as it goes along. Best Regards, Bonnie

Bonnie Chicago

Kath: Mitch may just be stressed from the drive home and over excited about finally being home. Just give him some love and a little time - he may just need some time to "decompress" and feel safe again. We'll keep you in our thoughts and prayers and hope he feels a little better tomorrow. Rita, Mike and Sheba

Rita IA

Kath, I remember these first days very well. Kahlu had awful diarrhea and there was blood at one point too. While this is a concern, it is not unusual. If he has an ulcer, he probably has a tummy ache and that could be the reason he is not eating. Make sure you give him the stomach protectants at the times the vet prescribed. Some have to be given hours before or after meals and other medications. I remember seeing pills in Kahlu's stools, they went right through him. But it did slowly get better. I think it is a good thing Mitch is home. He gets more rest, peace and quiet and best of all he is with you! We will be thinking of you, Brigitte & Kahlu

Brigitte BC Canada

Kath, I have been pouring over a veterinary hematology textbook tonight. There is a lot in there and I can highlight those things that I understand and that may be helpful for you to understand. First, thrombocytopenia can be termed primary or secondary. Secondary causes of this can include things like tick diseases, drugs, infectious diseases, neoplasia (tumor, cancer) or a systemic autoimmune disease. Primary is IMT immune meditated. Antibodies attack platelets and can even attack megakaryocytes. This leads to destruction of platelets and their precursor cells. Of note, fever is reported in less than 10% of dogs with primary IMT. Of those dogs with fever, it's important to do a complete diagnostic to rule out underlying infections that may also be indicated by symptoms of a depressed attitude, lymphadenomegaly (enlarged lymph nodes), ticks and arthritis (systemic immune mediated disease like polyarthritis or dermatitis). Neoplasia could be suggested by lymphadenomegaly, splenomegaly (suggests a secondary thrombocytopenia), other masses or cachexia (eating but still losing weight). I know this a lot of big language but what the gist of the chapter is saying is that, in essence, a dog can have immune mediated autoimmune hemolytic anemia and the thrombocytopenia could or could not necessarily be related to the cause of the anemia. The diagnostic challenge of the attending vet is to sort out what is the underlying cause, primary immune disease or an insult like tick disease or infection. They go on to describe the bone marrow aspiration, recommending in this case also a core biopsy. Why? They want a more detailed look at the structure of the marrow, whereas an aspirate looks more at the cells. They say that performing a biopsy is of questionable value and may be useful prognostically rather than diagnostically. This means that they can do the biopsy but not even after its done can they say for sure what the cause is (and of course it follows, how to treat it.) The prognosis will be more definite, meaning that the outcome of the dog's treatment will be clearer (it will be successful or it may not). This is where your megakaryocytes come in. They should see, in the biopsy, evidence of normal or increased numbers of these cells, especially immature ones (in response to a shortage in the blood stream). A small number or absence (aplasia) suggests a poorer prognosis and a delayed response to appropriate therapy. In humans, and in dogs, it is possible to have a response of increased megakaryocytes but still have an autoimmune response to them that causes continued thrombocytopenia. This is what Dr. Dodds talks about in a sideways way. *Autoimmune disease can reach to the cell precursors in the marrow.* Not a lot of vets understand this well or know how to treat it well. Treatment starts with corticosteroids 2m/kg every 12 hr. This stabilizes the patient. This treatment is tapered over weeks or months and maintained at a minimal effective dose. Additional treatments are not based on controlled and randomized trials but rather come from clinical experience (and bias). Azathioprine, cyclophosphamide and vinicristine have been used with inconsistent results. Danazol, cyclosporine and human gamma globulin may be useful in refractory cases (not responding to treatment). Combination therapy of reduced doses is recommended to lessen side effects of one particular drug. (So thus, use prednisone, aza (?), cyclosporine, danazol, HGG together at lower doses) Splenectomy (removing the spleen) has mixed results and there doesn't seem to be a clear history of success. Based on this text, *I* would not remove the spleen as a treatment for this condition. Platelet transfusions are not all that helpful but in cases of life threatening emergencies, they are acceptable treatments and require multiple units. In many cases, recovery occurs from 2-35 days. If there is relapse due to stressors patients may require chronic treatment. Sometimes the expense and questionable prognosis leads to a cessation of the treatment. Treatment of secondary thrombocytopenia requires that there be a diagnosis of some underlying cause and treatment of that. That is as variable as the vet's decision to check out all possible causes. However, the biopsy may point to an autoimmune cause if there is a lower number of megakaryocytes. This has been *my interpretation* of this text and may not necessarily reflect the true meaning of the author(s). I have tried to simplify it where possible. I think this is truly the limit of my understanding at this point. I suspect that your vets may have access to the very same text I have been studying, it is the best available. They may have better understanding of the meaning of the text. But at least you can now discuss this with them in an educated manner and understand what they are saying. i will be thinking of mitch tonight patrice

Patrice NYS

Thankyou all so much for your support and easing my mind that I am not alone. Mitch had a good night (better than mine) and awoke this morning wanting to eat anything and everything! He has not yet passed faeces but that is probably a good thing. I think that had we planned ahead a bit better we could of avoided upsetting his tummy. I hadn't bought in any 'special food' and my cupboards were pretty bare (can't even focus on shopping!) and picking him up was, well, although mentioned I had expected him to drop again and have to stay in. In our haste we picked up some small dog dog food (high quality) on the way home he has been on a sensitive diet at the vets but we couldn't get this particular diet at the weekend anywhere. My husband has gone out this morning to a large pet store to get some specific sensitive stomach food. I wi sh I had asked the discharging vet if we could get some off her but she didn't seem to worried about what his diet should be so I didn't either. Patrice, thank you so much for the time and effort you have gone to in typing all the info for me. I will go back and print it in a mo. I think the info is generally what the vets and I are understanding at the mo (plus some more for me - so def. not a wasted effort and I think they are now as confused as I am. The general feeling is that his immune system is also attacking his megakaryocytes as well as the platelets and the meds may need more time to work or they may be an underlying problem with production of the precurser cells. Despite having a negative ehrlichiosis test they have put him on doxy now and are redoing this test again although as they say they 'never' see it - he may be the first I guess and there is nothing to lose. Thankyou all so much for your support Kath

Kath Scotland

Brigitte, You have raised another question in my head. If anyone can help with this. I was giving Mitch's bag of meds with all instructions etc. They are once, twice or three times a day. I questioned timings of protectants etc and she(discharging vet) seemed to say he got them all together(morning, aft, or evening lots) with food but I could give the stomach protectants earlier than others. I can see why it must be so difficult to split them more and feed him as well but having read a little myself some should be with/without food and others not within 1/2 hrs of other meds or food.Not so easy! As you are all very unfortunately experienced in this area could anyone help with a plan based on him needing the following meds.I was just told how many times a day to give them. I am a little concerned that meds may not be working so well because they are all I believe being given with food and several at once - although this was the discharging vets take on it. Mitch has to have Atopica (cyclosporine)- once a day (morning sometime) Doxycycline - once a day (evening sometime) Prednisolone 2x a day zantac syrup 2x a day Antepsin(sulcrafate) 3 x a day and also fit in some food for him! I am finding it really hard to split these as i belive atopica not within 2hrs of food, doxy with food,pred with food,zantac ? and antepsin 2hrs from other meds and 1hr from food. Arghh! I gave him his antepsin at 7am today hoping to give him pred and zantac with food at 9am and atopica at 10am but he was starving and I ended up giving him the pred and zantac with food at about 7.40am. He sat at the side of my bed squeaking at me! So good to hear that though after refusing all food last night though. I cannot believe how much I need my hand holding right now I am usually so in control of everything in my life! So glad I have the support of you all here. Kath

Kath Scotland

Kath: For "best results" the Atopica should be given either 1 hour before food or two hours after. With Sheba we always gave it to her after she'd eaten and while it wasn't always exactly two hours (sometimes 1 1/2 hours) that seemed to work well. If I'm not mistaken the doxy and pred can be given with food. As for the Zantac, etc. - I'm not sure as Sheba never took anything. She has a cast iron stomach and never had a problem. A lot of people have found that making a chart or getting one of those pill minders has helped keep everything straight. It can get confusing when you're talking about 5-7 medications several times a day! Hang in there - it does get better and we're all here for you. Rita, Mike and Sheba

Rita IA

Kath, I am a scatterbrain at the best of times, so I used a calendar for all the medications and the food. This way I could really go over what can go together and what can't. I could write down what time I gave medication or food. I also put in the calendar how the bowel movements were. then you remember when you talk to the vet. I also used one of those pill containers. The problem was I could not find one for 7 medications, so I used a weekly one for one day and relabeled with the correct times. This way I would know right away if I forgot something and it could be readjusted. Because I was so sleep deprived it was all a blur. Without these aids there would have been no way I could keep track of everything. I am still writing everything down, because it gets confusing giving one pill every 3 days, one every 2 days etc. Try to give the sucralfate at least 2 hours away from any other meds or food. I know it is a juggling act, but if I can do it everybody can! Best wishes, Brigitte & Kahlu

Brigitte BC Canada

Thanks Brigette, Well I did my best for a day but Mitch was readmitted tonight as his diarrohea was getting worse and he was also vomiting, couldn't keep his meds down and was refusing to eat. He was very depressed too. Just got back from the Dick Vet hospital and awaiting an update on bloods etc.

Kath Scotland

Kath I was very sad to hear that Mitch had be readmitted to the hospital but maybe that is the best place for him at this time. Please know that we are sending our thoughts and prayers and hope he gets over this bump in the road soon. Cherl & Ginger

Cheryl & Ginger Pineville PA

I am so sorry. Be strong for your pet and for your own peace of mind and welfare....I will say a prayer tonight that things will turn around...

Mardi Northern Cali

I am sorry it did not work out this time. Mitch is clearly in good hands and getting quality care. Stay positive, it can happen! I will think of you and Mitch, Brigitte

Brigitte BC Canada

Kath So sorry to hear that Mitch is not doing so great,but I'm sure although you want him home,you're now slightly relieved he's back where the experts are. It's too much of a worry when they're home and really unwell, and you feel totally helpless and not only that, stressed to the hilt because you don't have a clue what's going on internally, with regards to platelet count specifically and especially since that can change so dramatically from day to day. Keep us informed. Kathleen and Nollaig

Kathleen North Ayrshire

Kath, I am sorry that Mitch's trip home was not more succesfull. Hopefully they can get him back on track in hospital. Penny

Penny Lytle Creek Calif

Mitch's platelets have dropped back down to 28, his pcv remains stable. His stomach is settled and he is eating again. He is being re-reviewed tomorrow with another specialist. Not looking good for him. Kath

Kath Scotland

Kath, Try to look at the positive things. He has eaten and his PCV is stable. Try to visualize him healthy and happy, it can happen! Thinking of you and Mitch, Brigitte

Brigitte BC Canada

I am so sorry. I know how you feel. It's a big waiting game. One minute your hopeful and optimistic, then you get the test results and you feel crushed again. I think I feel sicker than Oliver does at this point! Mitch can still turn around. Just don't give up and take care of yourself too....Your health is just as important. I'm thinking of you both.

Mardi Northern Cali

This thread was discussed between 21/08/2009 and 24/08/2009

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