Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Patrice just got back from Vet

Just got back from the Dr. they took blood and will let me know tomorrow the results. Patrice I gave him a copy of what you wrote about and he will consider sending the blood tests to Dr. Jean Dodds. I trust my vet and he encourages me to do my own research. Dufy's labs on 8/11 were: Adj WBC total 62.9, RBC 4.11 HGB 9.0, Htc 30.5 MCV 74.1,MCH 21.9,MCHC 29.6 Platelet count 404, Polys 93% 58497, Lymph 1% 629, Monos 5% 3145,Eos 1% 629, Nrbc 1 Dufy's labs on 8/15 were:Adj WBC total: 90.3, RBC 3.31,HGB 7.5, HCT 24.9,MCV 75.3,MCH 22.6, MCHC 30.1, Bands 2% 1806, Polys 89% 80367, Lymph 1% 903, Monos 8% 7224,Nrbc 5 Dufy had gained a pound back since Monday and Dr. thought he looked better. He seems to be acting better. So I'm hoping for better blood results tomorrow. Thank You everyone for what ever input and support you can give me. So glad to have found you. Connie and Dufy

Connie Washington

Connie, That is good news that your vet is willing to conference with a specialist. The diagnosis and treatment process can begin much faster this way. In general I see an increase in white blood cells and a decrease in red blood cells. And this happened over a short period of 4 days. Each lab has their own reference range of normal numbers so some of these values I am looking at could be considered normal or some could be borderline abnormal. I would have to see their particular scale. However, the RBC, HBG, HCT and the M values are pretty standard for all labs and on your test they are lower in just 4 days. They only indicate a mild to moderate anemia right now but the downward trend is not appropriate and should not continue at this rate. For instance, the HCT hematocrit (or PCV packed cell volume) went from 30.5% to 24.9% in 4 days. Normal values are about 37-55%. Mild anemia would be above 30% and moderate would probably be considered the upper 20's. More severe symptoms of anemia will more pronounced once the HCT reaches the mid teens. What should be happening at this point is that the body cells will "request" more oxygen because there are not enough red blood cells to carry the O2. The kidneys will respond to this request and release increased levels of a hormone that stimulates the bone marrow to make more red blood cells. All three kinds of blood, red blood cells, white blood cells and platelets, are made from the same precursor cells (a template). They respond to this hormone and begin to mature through various cell stages. Baby red blood cells (the last stage for these cells before maturing) are called reticulocytes. You should request that the next lab test show a value for these cell types. It is very important to monitor them at this particular time. The marrow should be responding by making a whole lot of these cells and they should be seen in large numbers in the blood right now. From this number we can determine if there is Regenerative anemia or Non-regenerative anemia. This will tell you if the cells are being destroyed in the circulating blood or if they are being destroyed in the bone marrow before they even get a chance to mature. If there is hemolytic anemia, RBC will be destroyed in the blood circulation. There would be signs of this in the CBC complete blood count and the chemical screen test. You would in addition see symptoms like blood in urine or feces, yellow coloring in mucus membranes like the eyelids. This is the part of the term AIHA, HEMOLYTIC that means destruction of cells. AI means autoimmune. This is usually considered to be caused by rogue white blood cells called Killer T-cells that have "lost" their proper instructions. What I do also see is a indication of a very large response of white blood cells. This can be in response to an infection but it can also be considered an inflammatory response to some challenge in the body other than an infection. In and of itself this kind of response can be responsible for causing anemia. Your lab shows two items of interest. Bands (baby white blood cells), 2%. These are immature white blood cells that have visible bands. When they appear they call this a "left shift." In large numbers they indicate response to severe infection or inflammation. 2% is probably somewhere around high normal or could be above that depending on your lab's values. Another value is Nrbc 5. These are nucleated red blood cells. They are counted as white blood cells on the test and so you will see the letters ADJ at the beginning to indicate that they have adjusted the values on the test results to account for these cells. I do believe 5 is still somewhere in the high normal range but could be above normal, but I can't be sure what your lab uses for reference. These cells do indicate something is happening that is wrong. There are a variety of reasons for them to be there. Which one is the right diagnosis??? Sometimes treating the source of infection or inflammation is the required treatment to stop the anemia. One cause could be exposure to lead. Lead poisoning disrupts the bone marrow. There is lead in pennies so sometimes when a very young puppy suddenly has these symptoms it is a good idea to do an x-ray looking for a penny. Remove the penny and remove the problem. Another cause is a form of leukemia in the bone marrow where white blood cells proliferate and overwhelm the production of red blood cells. Sampling the bone marrow is a test that helps diagnose this. Treatment may include some form of cytotoxic drug (cancer drugs). The risk with these drugs is that they can suppress the bone marrow and make the anemia even worse. There can be a disease of the spleen or a tumor in the body that can drive this kind of inflammation. A good abdominal x-ray can often rule this out. Treatment may be removal of the spleen or any abnormal mass. Hemangiosarcoma is an aggressive form of cancer that tends to be on blood filled organs like the spleen or heart. Autoimmune hemolytic anemia is another cause for these test results. While it is easy to see the signs and symptoms of this condition, it is far more difficult to discover the actual cause for this condition. So often the attending vet will treat as if this were AIHA, using high dose immunosuppressant drugs like prednisone. If there are positive signs of recovery, then they can say that it was probably AIHA. So in a nutshell. There should be a bit more diagnostic work done. Ask for a chemical screen to be done. Ask for a reticulocyte count on the next CBC. Ask if they have done a thorough physical exam, palpating the abdomen carefully and if they feel that an x-ray may be appropriate. Have they done a complete history? Has Dufy been exposed to a tick disease? Did they test for this? If not, ask for a SNAP 4DX test. This will look for 3 tick diseases and heartworm. It is a simple blood test with a yes or no result. Has there been recent vaccinations? Is Dufy still intact? Has he had any bees stings or exposure to lawn chemicals? Is there any chance he could have ingested a pesticide somewhere? Does he have regular and severe allergies during the year? Skin and ear problems? Digestive problems? To a practiced eye, all these things are fairly easy to sort out. That comes from clinical experience. If a vet treats 1 or 2 cases a year, it is not as easy. A specialist can certainly help here and your regular vet can continue to do things like routine lab tests and physical exams. my best patrice

Patrice NYS

I made an error. There is no lead in pennies, there is zinc. This causes a type of anemia called Heinz Body. Very easily seen on blood smear exams and indicates the blood cells are rupturing. Lead poisoning is a cause for bone marrow failure. A paint chip the size of a dime that has lead in it can cause severe health issues if ingested. Giving a dog a large amount of onions, say in leftovers, can also cause a form of Heinz Body anemia.

Patrice NYS

Patrice, The lab work that was done on 8/15 had the reticulocyte 9.4 Absolute reticulocyte 311140. So maybe this is a good sign? I hope I get some good news today. Dufy seems to be good sometimes and not other times. Last night had to get up with him twice to take him out to pee. He really gets upset and starts panting heavy when he has to pee. He had always been a good dog about holding his pee that I think it is upsetting to him that he can't control it. It seems to be getting worse but I guess it is the Meds. that are causing this to happen. Thank you so much you are so helpful. Will let you know what I find out today. Thanks so much, Connie and Dufy

Connie Washington

I got the test results from yesterday. The Dr. said they are better some even better that an week ago so keep giving Meds and test again next week. Adj. WBC total: 57.0 RBC 3.74 HGB 9.1 HCT 31.9 MCV 85.5 MCH 24.4 MCHC 28.6 Platelet count 446 Bands 2% 1140 Polys 86% 49020 lYMPH 1% 570 mONOS 11% 6270 NRBC 18 Lab comment: Markedly regenerative anemia. Retic count is 23% 921,000 retics/ul No spherocytes seen, and saline agglutination continues to be negative. Nuc rbc's are metarburicytes and rubicytes, likely reflecting the regenerative response. Neutrophilia has decreased somewhat. Few bands and slight toxic change in a few neutrophils. Also they say cannot get accurate platelet count due to clumping. Platelet estimate is adequate. Marked Polychromasia. What does all that mean? Is clumping in the platelets bad? Anyway the Dr. seems to think he is slowly getting better.

Connie WashingtonI

Hi Patrice, Wondering if you have any input on this last blood tests on Dufy? Like I said above in my note I don't know what they mean about the clumping in the platelet. Thanks you Connie

connie Washington

Connie, When a vet tech draws a blood sample they will prepare a slide with a blood smear. Platelets may tend to clump near the feather edge. It is normal for platelets to clump. If the clumping is significant, they may estimate the number of platelets. They understand this and they have ways to determine if the number is adequate. If they have marked the test results this way, I would trust them. Marked polychromasia simply means that the colors of the red blood cells being measured by the automated analyzer are very different. Reticulocytes are baby blood cells that still have the RNA inside of them from when they were first made (NRBC nucleated red blood cells). This is a blueish cell inclusion that differentiates them from mature red blood cells. After about 3-5 days this RNA will be dropped and the cells will then appear to be the proper color to the automated analyzer. A count of 23% reticulocytes is *extremely high* regeneration and is a direct response to the degree of anemia. So this means that there are a large number of reticulocytes in the blood and not as many red blood cells. In a few days that will reverse. All associated values will rise: RBC, HGB, HCT. Getting better is an understatement. I have rarely seen regeneration on this forum this high. Have they made any tentative guesses at to what started all this? my best patrice

Patrice NYS

Patrice, Thank you, your remarks make me feel even better. They have not said anything about what might have caused all this to happen. The only thing that is worrying me right now is that he has been on the azathioprine for 5 days now and the last couple of day he has been breathing heavier that usual and his bad leg, he has had a torn legiment for a couple of years now seems to be bothering him more. The last blood was done only two days after he start this med and I understand it takes a while for it to work so I don't think it had anything to do with the improvement. So I'm worried that it might be doing more harm that good. I'm sure it has caused his bowels to become looser. I think I will call the Dr. tomorrow and ask him about if he really needs it. Anyway he has his blood done again Weds. so hope things are even better so he can return to normal and maybe some day be off all meds. I'm not a big pill taker so I hate seeing him on this stuff although I know that it is what he needs right now. Thanks Again Connie

Connie Washington

you are still on prednisone, correct? this is most likely the cause of the heavier breathing as the cortisol levels rise in the body above what is normally required. many body systems will respond as though they are under stress, including the heart and lungs. there will be more peeing and appetite will increase. are you seeing these things also? it's too early to tell if there will be meds reductions at this point. this is the call of the attending vet. please don't decrease or stop any med that has been prescribed until you hear from the vet. p

Patrice NYS

Thank Patrice, Yes he is still on prednisone and yes he does pee and eat a lot and the Dr. told me that would happen. We get up during the night for him to pee. He really starts heavy breathing then because he was always so got at controlling his bladder(sp?) that I think it upsets him but I keep telling him it O.K. The other thing he does is he licks his feet and legs a lot. I don't know what I would do without your advice. You have been so helpful. Thanks Again, Connie

Connie Washington

Patrice, Took Dufy to the Dr. yesterday for his blood work again and he had gained another pound so that is good. Got the blood work back today and he has improved a little more on most things. Adj. WBC total 49.9, RBC 3.94, HGB 9.6, HCT 34.5, MCV 87.6, MCH 24.4 MCHC 27.8, Platelet count 246, Bands 1% 499, Polys 86% 42914, Lymph 2% 998, Monos 11% 5489, NRBC 2, Reticulocyte 10.7 % Absolute Reticulocyte 421580. Comments: Platelet estimate adequate. Slight polychromasia.What does that mean? Slide Review: CBC findings continue to improve-mild anemia is continues to be strongly regenerative indicating an adequate marrow response, but could also be some low grade hemorrhage or hemolysis. This scares me what does that mean? Platelets are adequate. The neutrophilia is mostly mature with few bands noted but no convincing toxic change at this time. Stress lymphopenia. Wondering what that means too. The monocytosis suggests an increase need for tissue phagocytes/chronic inflammation. Source of inflammation? Prior hemorrhage? Interpret with history and clinical findings and continue to monitor. When they ask source of inflammation could the fact that he has had for over a year a torn legiment in his right back leg which seems to have gotten worse over the last few months causing him to not what to put much weight or pressure on it. Or re they talking about another kind of inflammation? And prior hemorrhage he had his spleen removed a few years back because of a big hemotobin (sp) on it. They sent sample in at that time to check for cancer and said there was none. I'm sorry I have so many questions but I am so worried and what him to get well. Sometimes he seems to be better and then other times not. He eats and drinks but by the end of the day and sometimes first thing in the morning he seems to be really wobbly on his legs like he is going to fall over. I usually only have to get up with him once in the early morning hours to go to the bathroom and sometimes he acts like he really doesn't want to go outside but once I get him out he goes to the bathroom right away. Any advise you can give me is great. Thank You so very much, Connie

Connie Washington

Hi again, Dufy seems to be getting worse with his weakness. Didn't get up at all last night and when he did this morning he was really shaky. He is still eating and drinking but not drinking as much acts like he is water logged. I am taking him in tomorrow for the test for ticks. I know they think I'm crazy there because I keep asking for more tests. But before all this happened he had matter in his eyes all the time and a runny nose. Dr. just thought it was an infection. It has been better now that he has been on all these meds. But also got a bumpy rash on his tummy back on his right side by his leg just a few days after started getting sick. We did loose one dog to a tick disease about three years ago. Hope you will ready my posting before this one too as it has his last blood test results. Thank You, Connie

Connie Washington

Connie, Connie writes>Slight polychromasia. What does that mean? Polychromasia means multiple or many different colors. Reticulocytes, baby blood cells, have RNA inside of them from their development period. RNA is a blueish color. The cells are also larger because of this inclusion. The automated analyzer makes many measurements and one of them is to look at the colors of the red blood cells (usually to find overly pale cells which indicates low hemoglobin). It sees many of these reticulocytes that are more of a blueish color and notes that there is polychromasia. It is also seeing less hemoglobin in the mature cells and therefore sees them as a different color than normal. It isn't bad or good, only shows that there is a high state of regeneration. In about 3-5 days the reticulocytes mature into red blood cells and drop the RNA. Connie writes>Slide Review: CBC findings continue to improve-mild anemia is continues to be strongly regenerative indicating an adequate marrow response, but could also be some low grade hemorrhage or hemolysis. This scares me what does that mean? Yes, I was thinking about this before but did not say anything at that time because I wanted to see what would happen on the next test. Let me try to explain this to you in a way I think you will understand. Follow me carefully here. Let's say you have a glass. You want to fill it with water. You go to the tap and turn it on, filling the glass. Eventually it reaches the top and you turn off the tap. You are now done with filling and won't refill it until you have drunk some of the glass of water. You will go to the tap and turn it on really slow and refill the glass with a tiny bit. (In our body, we normally "top off" the number of red blood cells everyday by making a small number of new ones and getting rid of old ones.) Let's take that same glass and put a large hole in the bottom. You go to the tap and turn it on and begin to fill the glass. You are able to fill the glass but you are surprised when the glass does not stay full, it keeps getting lower. You turn the tap up higher and try to keep it full but it just runs empty. You realize that as long as there is a hole in the bottom of the glass you are not going to fill it with water. So you have to patch that hole. (In our body, something is destroying red blood cells and the body is trying to replace them quickly.) Are you following me with this? Bone marrow responds to a request for more red blood cells by cells in the body when they need more oxygen. These body cells signal to the kidneys to produce a special hormone that will stimulate the bone marrow to "make more baby blood cells NOW please." When the marrow responds this is called regenerative anemia and the process in the marrow is called reticulocytosis, making lots of baby blood cells (turning on the tap for more water). Obviously, the body cells don't really know what the cause of the low oxygen is, they just want more oxygen! So you can imagine that any kind of loss of blood in the body will begin this process. (Why is the glass not staying full?) When there is hemolytic anemia (heme = blood, lytic or lysis means destruction) (anemia = low number of hemoglobin carrying red blood cells), cells are being destroyed. The body responds by sending the message to the marrow to make more reticulocytes. (Keep filling the glass) In AIHA autoimmune hemolytic anemia, IMHA immune mediated hemolytic anemia, if the immunosuppressive drugs are effective and they stop this hemolytic process the massive numbers of reticulocytes should magically turn into new mature red blood cells in a number of days. THIS MEANS THE BODY CELLS SHOULD STOP SIGNALING THE MARROW FOR MORE BABY BLOOD CELLS. (Patching the hole in the bottom of the glass) If there is continued hemolysis or there is blood loss in the body somewhere else there will be this continued request for more blood cells to be made. (There is still a hole in the bottom of the glass) Do you follow this analogy with the glass? There is a "hole in the bottom" as indicated on the blood tests by this continued highly regenerative state. The lab tech is noting that they feel that there is either continued autoimmune hemolysis or blood loss somewhere else in the body. So either the immunosuppressive drugs are not doing an adequate job or the vet needs to do more diagnostics to discover if there is blood loss somewhere else. The most common internal loss of blood for these dogs with AIHA that can generate this continued high bone marrow response can be gastrointestinal. In other words the digestive tract can be bleeding somewhere. (The thing that needs to be patched) So it's one thing or another. Short of being able to just open up the body to take a peek, the vet has to use tests to evaluate the situation and fall back on their clinical experience to figure out what to do next. (What is the reason the glass won't stay full and the tap keeps running) Connie wrote> Platelets are adequate. good Connie wrote> The neutrophilia is mostly mature with few bands noted but no convincing toxic change at this time. Stress lymphopenia. Wondering what that means too. The body is also regenerating white blood cells. Neutrophils are the most common white blood cells and are in the greatest numbers in the body. Watching them on the blood tests tells the vet a lot about inflammatory processes inside the body. If there are infections or other irritants the body will make a lot of white blood cells. If a larger than normal of neutrophils exhibit banding then the vet must evaluate if this is a toxic left shift. The tech and the vet are trying to sort out if the message the white blood cells are sending is an expected increase in numbers or is it in response to an infection. Right now they are saying no, this is not toxic. Stress lymphopenia indicates that another type of white blood cell, lymphocytes, are at low numbers. This is a direct relationship to being treated with corticosteroids like prednisone. So the words Stress Lymphopenia can also be called Cortico-Steroid Induced. Connie wrote>The monocytosis suggests an increase need for tissue phagocytes/chronic inflammation. Source of inflammation? Prior hemorrhage? Interpret with history and clinical findings and continue to monitor. When they ask source of inflammation could the fact that he has had for over a year a torn legiment in his right back leg which seems to have gotten worse over the last few months causing him to not what to put much weight or pressure on it. Or re they talking about another kind of inflammation? And prior hemorrhage he had his spleen removed a few years back because of a big hemotobin (sp) on it. They sent sample in at that time to check for cancer and said there was none. No, this really has nothing to do with the ligament, that is a localized inflammatory response. They are trying to find internal inflammation that might be in response to internal bleeding or infections. Removal of the spleen is important to note in this disease only as it generally is the source of a large amount of autoimmune destruction of red blood cells and is infrequently surgically removed to stop that destruction. Having no spleen moderately hampers Dufy's ability to fight off certain tick diseases and participate in the immune system. This large growth that was removed (hematoma) several years ago indicates that the spleen possibly was involved in making blood at that time. It is not uncommon for this to happen. The spleen made blood for us when were in the uterus and did not have bones in our body yet. But it will stop doing that once we have a skeletal structure. It is not clear why this happens but it is called extramedulliary hemopoesis. It can sometimes happen because of bone marrow disease. Connie wrote>I'm sorry I have so many questions but I am so worried and what him to get well. Sometimes he seems to be better and then other times not. He eats and drinks but by the end of the day and sometimes first thing in the morning he seems to be really wobbly on his legs like he is going to fall over. Prednisone is very hard on the body systems and there are significant side effects the longer it is used. One of the most visible side effects is muscle wasting and excessive peeing. Not having strong muscles around the joints for support can make anyone wobbly. The side effects can make anyone feel washed out and weak. The real goal in treatment should be to add another immunosuppressive drug in addition the prednisone so it can take over the bulk of the job. Then the prednisone can be reduced slowly. Until the pred is reduced the side effects will begin to add up. I am not trying to diminish how awful this is. I watched this happen to Chance and I was horrified everyday as I saw a once very powerful Giant Schnauzer become a bag of bones and unable to even stand to move his bowels. It upsets me all over again just to remember. If I could have given anything, my own life, to stop this from happening I would have probably signed on the dotted lines. Instead of sitting around crying I decided to start researching so I could find out how to help him. I stayed up all hours of the night reading a veterinary hematology textbook and searching the internet. I asked my vet hundreds of questions, which they patiently answered for me, and I emailed Dr. Dodds back and forth for a long time. I promised myself that if I wanted to cry I would wait until he got better and then I would allow myself to sit down and cry for days if I needed it. I didn't, he got better and life returned to normal. I can't promise that any dog with AIHA is going to get better if the owners know and understand a lot about the process. But I think it makes you feel better when you know the real details behind what the tests say and what the vet is trying to explain to you. It gives YOU power to make decisions. If, in the end, your dog returns to health then you can say "I did this. I made this decision and it saved my dog's life." Or alternatively, "I made these decisions that were right but sometimes medicine cannot save a patient no matter how hard they try." I agree that testing for tick disease should have been done the first day this was diagnosed. Sadly it is often not done, either because there doesn't seem to be large numbers of REPORTED tick disease in an area or the vet is not current on the signs and symptoms of the disease. And even if the vet doesn't want to test, it is probably always a good idea to treat with doxycycline for a week to see if there is any improvement. If there is then it might indicate that there is a tick disease. The rash is most likely a staph infection. Keep it carefully washed and dry with mild soap. Wash your hands before and after touching Dufy. Avoid contact with other dogs or humans that have compromised immune systems. There is an excellent antibiotic that will clear this up. Please post your results when you get them. my best patrice

Patrice NYS

This thread was discussed between 18/08/2011 and 27/08/2011

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