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Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - need advice on blood work
| I'm taking my dog Mac to the vet tomorrow morning for another round of blood work. Each week, they take a vial of blood from his jugular, then use an in-house lab for the results. They test the following and I've included last weeks results: RBC--3.97 HCT---26.9% HGB--11.9 %retic---1.0% Retic--39.6 K/uL WBC--13.45 %neu-88.9% %lym--2.2% His ALT and ALKP were also elevated into the high range, but barely. 129 and 258 respectively. %mono--5.0% %eos-3.3% %baso-.5% They said the Lym was low at .30 K/uL Since we are on week 13 of this illness, do you think it makes sense to also want a thyroid panel? He's been just bouncing around with these numbers and not making any big leaps upward, except for the first week. Also, someone mentioned spinning out one of the blood tests seperately--which one would that be? I'm almost paranoid that my vets machine isn't calibrated correctly---can't you just hear that conversation tomorrow---Ha! Has anyone else felt this way? I see the vet at 8:00 tomorrow morning, so any advice you have for me at this point in the game would be much appreciated! Thank you all.... Oh! He's currently on 25mg azathioprine and 50mg pred.Today was his last day on doxcy. Also tummy protection medicine. |
| Jane MN |
| dr. dodds has had us on thyroid medication for the last year, she is a big advocate for keeping that in check so there is definately no downside to doing a thyroid panel |
| josh/sway california |
| I would defiantly have the thyroid test done. |
| Cheryl & Ginger Pineville PA |
| Jane, Yes, it's advisable to have another vial drawn tomorrow and follow Dr. Dodds instructions at www.hemopet.com for preparing and shipping the blood. Use the form to request a thyroid panel. You can call (or your vet can call) and ask any questions. Remember they are west coast for phone calls (4 hours behind east). Hypothyroidism can contribute to poor blood production. Chance is on (and has been for many years) a regular dose of .6mg Soloxine two times a day. It's relatively inexpensive and such an easy treatment to follow. Mac's hematocrit (HCT) is 26.9%. The other values, hemoglobin HGB and red blood cells RBC are in line with this value. This is not normal, but it isn't in the severe anemia range either. The less red blood cells there are, the less hemoglobin it has to carry oxygen to the body cells and the lower the overall PCV packed cell volume. This packed cell volume is the thing that I mention you should always ask for when you have a CBC complete blood count done. This test is done visually, by putting a small amount of blood in a small tube and spinning it to separate the white stuff (plasma) from red stuff (rbc's and platelets etc). They hold it up against a chart and can tell exactly what the PCV is. The machine that does the CBC actually interprets the results from a kind of photographic viewer and estimated counting. I feel that in critical applications, it can be slightly inaccurate. The PCV is a more accurate look. So compare the PCV and Hematocrit, they should be the same number but often they are not. Trust the pcv. Lym is lymphocytes. These are the white blood cells that are responsible for so much of the protection of the body against foreign agents. They are specifically called T-lymphocytes or killer t-cells. Unfortunately in AIHA or IMHA, the t-cells are often the ones that have gone crazy and have lost their ability to recognize the own body's cells as opposed to foreign cells. So in our treatment protocol we want to used "cytotoxic" drugs to suppress these t-cells. This will hopefully stop the body from destroying red blood cells. I am most concerned about Mac's percentage of reticulocytes and the absolute numbers for reticulocytes: retic---1.0% and Retic--39.6 K/uL. When the body senses that it's not getting enough oxygen to the body cells it "calls" for more blood cells to be made in the bone marrow. This is a normal activity that our body does everyday. And normally these baby blood cells mature in the bone marrow and are released into the blood stream ready to go to work carrying oxygen. We call these immature cells reticulocytes. When we have anemia, and that is usually considered a PCV or HCT of less than about 37% (normal range is about 37-45 or so), the body knows that it needs to make more of these baby blood cells. If the anemia is severe enough the bone marrow will just shoot these things out into the general circulation right away even though they can't really carry oxygen yet. They will then spend a few days maturing in circulation. They can be seen in the blood as cells that still carry their RNA inside of them. Using a mathematical formula, we are able to determine the number of and percentage of reticulocytes by looking at the number of RBC and the hemoglobin, and determine if the body is reacting properly to this lower PCV. This is called the reticulocyte production index. With a pcv or hct of 26.9% there should be a large reaction by the bone marrow to this lower number and there should be lots of reticulocytes in the blood. In your case, there aren't. 1% is a normal number for a dog or human that has a normal pcv, but in a human or dog with anemia of 26.9, that number should be more like 2.5% or even as high as 5%. The absolute number should be at least over 60,000 and your number is at 36.9k (36,900). This is called non-regenerative anemia. It means the bone marrow is not responding the way it should. I know this well because this is where we were at a little over a year ago. A slowly decreasing pcv/hct and a absolute number of reticulocytes at 13,600. In addition Chance was not making white blood cells either, a very serious condition. What your vet should understand tomorrow, and what you will know, is that autoimmune destruction can begin AT THE BONE MARROW PRECURSOR CELL STAGE. If they don't understand that now, and many vets just don't get that, it means that the marrow is devoid of precursor cells. Now there can be various causes of this condition, but it's important in dogs to assume that this just might be the case, autoimmune, and to treat it that way, aggressively. They might tell you they don't know what the cause is, as they told us, but it's treating it that matters. You may also be looking at future blood transfusions as the number of RBC's diminish and the pcv drops, not being replaced by new ones. Talk to your vet about how they do transfusions and where they get the blood from. Be prepared now so that if you do need to get one, it won't be an emergency. You should be seeing a specialist if you have not already and if you cannot find someone to help you that seems to understand this condition well, then it might be advisable to contact Dr. Jean Dodds for advice. She has 20+ years experience in treating severe autoimmune conditions and can advise a protocol of treatment for your vet to follow long distance. Sending your thyroid blood test in to hemopet will obtain this access to her advice. If you don't feel comfortable contacting her see if your vet will do that when then send in the thyroid paperwork. I can tell you that we had a rough time with treatment but that today Chance is healthy and active at the ripe old age of 10.5. I am extremely grateful to Dr. Dodds for helping me save his life. Good luck tomorrow and let us know what happens. patrice |
| Patrice NYS |
| Jane, I just read your earlier post about Mac. You said he was diagnosed with anaplasma. Did they treat this very aggressively with doxycycline? Have you had more tests done at this point? If they diagnosed this tick disease, it is possible that there might be another tick disease as well, they sometimes happen this way. Read my friend Gil's web site about these tick diseases. Anaplasma about 3/4 of the way down the page: http://blackgsd.googlepages.com/ehrlichiosis Patrice |
| Patrice NYS |
| Patrice, I'm just back from the vet with Mac's bloodwork results--thank you for your wise words earlier. 8-21 8-28 ALT -131 u/L ALT-67 U/L ALKP-265 ALKP--233 RBC--3.97 RBC-4.14 HCT-26.9 HCT-29.3 HGB--11.9 HGB--12.0 %retic-1.0 %retic-1.3 RETIC-39.6% RETIC--52.6% PCV- unknown PCV--32% WBC--13.45 WBC-12.08 LYM--.30 LYM--.95 Everything else was in the normal range. My vet did not want to do a thyroid at this time because she said the prednisone all summer will skew the results, and he is not exhibiting any symptoms of hypothyroidism. True. Your comments on his retics have me concerned. When he was admitted in May to the vet hospital, I see his retics were 34.8%, and % retics-1.1%. These numbers have vascilated only a small degree in the weekly blood tests since. One week in June they were 94.7%, but five days later back down to 56%. Any thoughts on this? The thought that goes through my head is that , given the low numbers--shouldn't he be dead, or at least have gone through more of a crisis by now? Really, if you were to look at him today you'd think he was perfectly healthy. I don't get it. I'll be doing a lot of reading up on this over the weekend. To answer your other questions about the tick diagnosis, he tested positive for anaplasma upon admission and was started on Doxcy. He has been on it almost all summer, he just finished his last pill this morning. His Coombs test was negative. Ultrasound performed at U of M was normal. His spleen had been enlarged in May. Interestingly enough, I went to the U of M Internal Medicine department for a second opinion, and that vet cut his prednisone in half! I'll pause here while you take some time and get yourself together. She thought he was on way too much and just cut 'er right in half! I didn't know anything so I didn't question it, but my regular vet had a fit. The next week we went back to 50mg and I haven't been back to the UofM since. My vet is consulting with a specialist in the Twin Cities named Dr Meg Baho. I might be going down there in two weeks if he doesn't keep improving. Did you happen to blog about Chance's recovery anywhere on this site? I would love to read about him, and congratulations for beating this awful illness! Thank you also for taking the time to respond to my questions. You are amazingly helpful..............Jane |
| Jane MN |
| Jane, I see at quick glance a very positive sign! Reticulocytes have increased from 39,600 to 52,600 and the percentage is up to 1.3% This isn't a huge jump, but it is significant enough because there has also been an increase in the number of red blood cells: from 3,970,000 to 4,140,000. And the hematocrit is up from 26.9 to 29.3. The critical number, the PCV, is 32!!! Yeah!! This is closing in on a normal number. The hemoglobin, or oxygen carrying agent, is also up a little from 11.9 to 12. These are all signs that Mac is making his own blood and the reticulocytes are maturing successfully and are able to carry the important oxygen around. This may be the beginning of a large regenerative period and it would be interesting to see the results of another CBC in a week if you can afford it. You will see general improvement in Mac, more energy, better appetite, redder gums etc. I remember when I was beginning to get discouraged with Chance, it had been almost two months, and Dr. C came in with his CBC. Before she said anything, I said, "please, even if you have to lie to me, tell me there is some progress!" And she said, "I don't have to lie to you, look at this regeneration!" His numbers were small, just like yours, but it was significant because it meant that the marrow was beginning to respond to the therapy! Your historical reticulocyte numbers (the up then the down) reflect this inability to make blood properly in the bone marrow (in response to the need for more cells caused by the drop in the number of red blood cells). It's important to understand that red blood cells live for about 120 days. They begin to age out and are taken apart and the cellular material is either recycled or removed from the body. This is normal. Mac has been riding along on the RBC he made up to 120 days ago but have not been replaced. Thus, Mac's hematocrit has not had a dreadfully sudden drop as is the case with dogs that have sudden hemolytic anemia. (please check your bilirubin number if you have it to ensure this is not elevated) This was not the case with Chance either. He just stopped making new cells to replace the old ones! So the hematocrit drops more slowly, gradually. In Chance's case, his white blood cell numbers began to slowly slide too. Why does the marrow stop working? Well, tick diseases certainly do play a role in this process sometimes. They are insidious and like to hang out in blood cells, causing their damage there. In some cases they search out and live in body tissues (and bone marrow can be considered a body tissue) making it harder to eradicate them. Marrow can sometimes develop a form of leukemia. There can be suppression of the process by some medications, exposure to heavy metals or forms of malnutrition from various causes can impair the process. Hypothyroidism can impact the process as can kidney disease (because the kidneys make a very important hormone that signals the making of blood). Tumors can also cause subtle changes in the body that lead to an impairment of Hemopoeisis (making of blood). Or, in Chance's case, the autoimmune destruction occurs against the red and white cell precursor cells in the bone marrow. Since his bone marrow biopsy was devoid of cells, we have to assume that they were either destroyed after they were made or the body had a hard time making them. So now in your case, do you need to know why they were not being made or why they were having a hard time maturing? Well, if your numbers continue to rise and return to near normal ranges, you could say the treatment is successful and that most likely it was either the tick disease or an autoimmune disease. The spleen will enlarge when it is fighting a tick disease. It can be a site of great destruction of blood cells as it battles the tick disease. It can also be a site of platelet destruction as well. This is a far more serious consequence. If the spleen returns to normal size and your vet examines Mac and says it is ok, then you probably can just forget about it for now. I would, however, keep an eye on that. You can remove a dog's spleen in cases like this with very little ill effect. The fact that Mac has been on doxycyline all summer is significant. You have a vet who is up on the latest treatment for tick diseases and this vet very likely saved Mac's life. Treating the first sign of a tick disease hard and long will ensure that it does not reoccur in the future. I have a dear friend who went for a long time undiagnosed and under treated for Lyme disease. She lives in constant pain and disability. She can no longer work and is unable to engage in the kind of activities she used to in the dog world. The prednisone was possibly reduced because of the known exposure to tick disease. It is rarely used in a known case of tick disease as it suppresses the immune system while it is trying to fight the disease. And some dogs are able to fight off exposure to a tick disease on their own! I can't say that is always the case, sometimes folks do use prednisone in treatment protocols for ticks, so it's not an absolute. In addition your alkaline phosphatase alk and the alanine aminotransferase alt numbers are dropping. This indicates that there was a small amount of damage to the liver, from the prednisone and the doxy. These numbers are not very high, but do need to be watched that they drop some more. This is a common side effect of these drugs and is to be expected. The liver is regenerative and can recover from small insults. I wish I did have time to get something up about Chance, I will eventually. I have written a couple of pages for Gil's tick disease website on reticulocytes that are waiting for me to do the final draft. But they are not published yet. Here is a link to some pictures of Chance, in his health, his illness and his recovery. You can see the difference in his body from the beginning of the summer to the end, around October 2007. Patrice http://www.flickr.com/photos/patricel/sets/72157602714279765/ |
| Patrice NYS |
| Patrice, We just returned home from our cabin in Northern Mn (probable site of tick infestation) and I came in, turned on the computer and read your very comforting words---- Thank you for the encouragement! I had to laugh when I read that you wanted your Vet to lie about results so that you could have good news--I did the same thing two weeks ago. When Dr.N opened the door I took one look at her face and said " I don't like the look on your face, I'm not coming in!" You do such a wonderful job explaining these things, are you a vet yourself, or in a medical field? I always considered myself kind of a 'science girl', but this blood work stuff really has me baffled---I need to read things over and over before it makes any sense to me. I'm getting it, though. I have noticed a little upswing in Mac's general energy level. Two weeks ago at the cabin he wasn't nearly so enthusiastic about a walk. He did have an encounter with a hornet nest on Friday. He somehow got his front paw caught in the crotch of a tree and landed on the nest. Probably chasing a squirrel. The hornets were swarming him and he got many bites, but when I finally got cell phone reception to call a local vet she said the prednisone probably saved him! This marks the one and only day I was thrilled he was on that drug, as the rest of his body has taken a beating from it. Muscle wasting, eye infections, staph infections, bad coat, bloated rib cage, etc. But, I guess we're all suffering with the same side effects. And of course, he IS still alive. Dr. N wants to see him again for blood work in two weeks, but I think I'll have her test him again this week while he's boarding with her. I need to know that this isn't a fluke. His billirubin is .5mg/dL, by the way. Thanks again Patrice.....you don't know how I value your input. And your Chance is such a handsome fellow! He looks GREAT--good for your family! I'm hoping Mac is in such good condition in another six months. It really gives me hope.... Take care, I'll keep posting the weekly grind. Jane |
| Jane MN |
This thread was discussed between 27/08/2008 and 02/09/2008
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