Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - PCV up, then down

Hello everyone. My beloved girl Roxy was diagnosed with IMHA a week ago, and has been fighting hard since then. She has had one transfusion (Monday I think) and has been responding "as well as could be expected" says her vet, an Internal Medicine specialist at a large hospital. Last night they were talking about letting me bring her home today. She seemed a little brighter, happy to see me (I visit her twice a day) and her PCV, which was 14 at its lowest point, seemed to be holding stable at 24. This morning they called to say that it had dropped again to 20. I know this can't be good, but what does it indicate? Is it the ominous sign I fear that it is? Roxy is on Prednisone and/or Dex (they have switched a couple of times) as well as Cyclosporine and baby aspirin. Please tell me what the drop in PCV might mean. I am exhausted and heartsick.

Karen New Mexico

Also -- I should have mentioned that Roxy is regenerative. And of course her meds have not been reduced at all yet, so that doesn't explain the drop. I will ask the vet when I see her this morning whether they have tested the thyroid, and whether spherocytes (?) are present. Is there anything else I can do? I've been feeding her roast chicken and a little kibble when I go, even though she has started eating their hospital food. She is a red heeler cross (maybe Chow?), 10 years old,and weighs 55 lbs. I don't know what dosage of meds she is on, but this is a specialty hospital ("we get the weird cases") and there are currently 2 other dogs there with IMHA. This is to say that I THINK my dog is in experienced hands. Sorry to blather on.

Karen NM

Several things can cause a decrease in a PCV. I don't think it's a reaction tothe transfusion cause she's been holding steady all week after getting it. It might be due to insufficient drug dosages or it could even be her being over hydrated when they did the test! ALSO, it might be a difference in doing a PCV for one test (the 24%) and a hematocrit (being 20%). Lots of times when they are in the hospital they usually only do PCV (a fast spin test and cheaper) to get a percentage just to follow and every so often they'll run a full CBC with the hematocrit just to see what the rest of teh numbers look like. PCV's are always higher than HCT's and they basically tell and mean the same thing! If Roxy isn't home yet now would be a good time to clean up before she gets home...WITHOUT chemicals. Avoid all chemicals around these dogs! This is what I did while Tessy was hospitalized that way when she did get home I had more time to focus on her healing! ALSO, if you want to (and I highly recommend it) go and get some milk thistle powder. Also get some Pet Tinic...you might have to order this online! Ask for copies of ALL the bloodwork done so far! They shouldn't have a problem with this and if they do INSIST o ngetting them. Let us know what you find out or when you get Roxy home. Lots of thoughts and prayers, Johnny & Tessy

Johnny

Thank you so much Johnny! I have been trying to clean up for her return, just getting rid of dust and vacuuming and such (it's a horsey household, need I say more?) and setting up pet gates so I can keep her quiet. I will do as you suggest, and get hold of those tonics. I had a good visit with her this morning, and the vet told me that, as you say, the PCV test is not very fine-tuned, just an eye-ball judgement holding the vial up to a chart ... She said she wouldn't even call this a set-back, yet -- that clinically Roxy seems to be doing pretty well. Another test gets done this afternoon, so we'll see. The dosage on the pred is 20 mg twice a day. I told her that from what I was reading on your website that seemed on the low end for a 55 lb dog. She didn't agree, but I will pursue this further with her boss, the IM specialist. At least I know that we have room to go up if we need to. I will also speak to him about doing a trough test, which they don't usually do. But the vet said that it probably could be done. So I need to be persistent, I guess. For anyone else who might be reading this, I want to tell you that the receptionist who was on duty last weekend, when I took Roxy in 4 times in 2 days, told me that she admired my persistence in insisting that my dog was REALLY SICK and that they had NOT gotten to the root of the problem yet. I can tell you that the next dog I have that is peeing blood, seems weak and wobbly, and so forth, will not leave the vet clinic without at least considering IMHA as a possibility. I just had never heard of it before. Praying that I don't have that again with any dog, of course ... This is a wonderful website. Thank you for being there.

Karen New Mexico

Shesh...the symptoms you describe should have been a HUGE red flag for ANY vet!!! Very first thing ANY vet should do with these symptoms is a blood panel including chemistry and electrolytes! Yeah, 40mg daily of pred IS NOT enough for a dog that size. The recommended minimum starting dose for a dog that size if 1mg/pound divided to give twice daily. Read Joanes Meisha's Hope Website.... http://www.cloudnet.com/~jdickson/treatment.htm And pay particular attention to the success stories to give you hope! What's teh dosage for the cyclosporine? Did they run a thyroid panel yet? Ultrasounds or xrays? Tick panel? Do you know a trigger? Thoughts and prayers, Johnny & Tessy

Johnny

Johnny -- Well, I think what misled the vets (she was seen by a different one each time) were two things: first, the CBCs kept coming back within the normal range (the only red flag -- a BIG one, looking back -- was very high-normal bilirubin in both urine and blood); and second, she did finally (3rd visit, I think) have an ultrasound, which showed a growth on her left adrenal. The vet said that in his experience it looked like a benign tumor, but still indicated either Cushing's or another form of adrenal disorder. That other form, he thought, might be causing some of the symptoms I was seeing by creating peaks and valleys in her adrenalin. So although I agree with you that they should have caught this, I also see why they didn't. At least they finally did. I asked about the thyroid panel this morning. She said that since they had bloodwork from a month ago (her last checkup at her regular vet) and the thyroid panel was normal, they didn't need to do another one. She explained something about not being able to get an accurate one anyway, because with such a sick dog, the thyroid goes a little whacko anyway (a technical term) and they can't really tell anything from the panel. Do you agree with this? I think they said the cyclosporine is at 125. Not sure. Apparently my darling dog has become quite difficult to pill ... I have twice found pills in her bed, one of them being 25mg cyclosporine. I had a talk with the vet techs on duty and they agreed to put a note on her door about making sure she had swallowed her pills! I don't know if they've run a tick panel. I am currently having the kitchen remodeled (or was, I called a halt to it when she got sick) and my gut feeling is that the stress of all the strangers in the house, being shut up in the bedroom all the time, and just the general disorder of having the kitchen ripped out, may have been to much for my very sensitive, very excitable dog. I couldn't understand why she seemed so distressed all the time -- she was pretty overwrought and out of breath, even for her. Now I think that this had already started, and the stress just brought it to a head. I don't really know. No recent vaccines, but a treatment with Droncit 4 weeks ago, followed by HeartGard and a 2 week regimen of vetprofen for a supposed sore back (according to regular vet). I was already feeling that something was going on even a month ago, so I had her checked, but when everything came back normal I told myself that she was "just" stressed and tired. I guess that's a common story. With the possible adrenal tumor, I know this is an even more complicated case. But for now, and until she is stable , the IMHA takes center stage. Sorry to be so long-winded, and thanks for your input and support.

Karen NM

Are you sayihng she was showing symptoms WHILE the CBC results were normal??? I wonder if they ever tossed around the idea of addisons disease? Considering there's a growth seen on the adrenal! Maybe Patrice might know more on addisons. It's also very likely all the drugs that were given the 4 weeks prior may be the trigger! Johnny & Tessy

Johnny

Yes, that's correct. I noticed a decline in her energy about 6 weeks ago. She had one night when she was in pain, hunched up -- thought she had back pain. Xray showed spinal arthritis, CBC "excellent" according to vet, given vetproxen for 2 wks. Energy was variable, off and on, but never her usual self. The rest is as I have described. Like you, I wonder if all the drugs (plus the stress) triggered this. I don't know about the addison's possibility. Isn't that like Cushings? I'll ask the vet. Patrice?

Karen NM

Karen, Patrice is like our forum expert so to speak! I'm pretty sure she know's more than most vets!!! Addisons is the opposite of cushings but can show similar symptoms I think. Johnny & Tessy

Johnny

Johnny -- I must have had a brain cramp when I answered your last post ... I just remembered that the possibility of Addison's is what the specialist initially suspected. Roxy was due to have an ACTH stimulation test on Monday morning, but collapsed Sunday and was diagnosed with IMHA. You have raised a very interesting question, though -- it sounds like the symptoms could be confused, and the dog might even respond favorably to the treatment for IMHA, even if it is Addison's instead. Given that we know she has the tumor on her adrenal, this will be one of the FIRST things I ask my vet tonight. (Some things may not fit, like the blood-filled urine and enlarged spleen. I will let you know what I learn.)

Karen NM

Karen, I am sorry that Roxy has been diagnosed. It sounds like you have a few things going on and I hope that they can get to the bottom of it soon. It does sound like her Pred is a bit low dosed. Also if you look at the side effects on the vetprohen it does list IMHA as a possible side effect. There is a contact number to report 800 835 9496. Penny

Penny Lytle Creek Calif

Oh golly, I have missed this until now. I am sorry. A benign (something that appears to not be malignant) tumor on the adrenal gland is often responsible for pushing the bodies whole system of producing cortisol out of whack. In general what happens is that the adrenal glands keep getting a message to "make more cortisol, NOW!" This is not good and causes a condition called Cushing's disease. Dosing a dog with Cushing's disease with prednisone is like a double whammy, adding even more cortisol to a body already flooded with too much. What does cortisol do for the body? We often think of the adrenal glands when we say "fight or flight." You know this as that feeling you get when you almost have an auto accident. You feel highly stimulated from the rush of adrenaline. Well, at the same time the body prepares for injury or extreme activity by releasing cortisol to help with the stress of the moment. It controls blood sugar levels, the metabolism of fat, muscle contractions, how the kidneys work, how the nervous system sends and receives instructions, the heart and blood vessels, and how the immune system will respond. So cortisol is our stress regulator. And it can be serious whether there is too much or too little. It must be in the correct amounts at all times in the body. For dogs, this is especially true, when even the sighting of a squirrel in the yard can be as alarming to them as you or I seeing a car careening towards us. Too much cortisol in the body for long periods of time can cause serious side effects that are damaging to body organs and systems. Ask anyone here whose dog has been on high doses of prednisone. Their dogs are expressing a condition called Iatrogenic Cushing's Disease or symptoms of excess cortisol caused by administration of a corticosteroid. Luckily, once the prednisone is carefully reduced, the condition usually goes away. Treatment is thus directed, in this case, to the growth on the adrenal gland. There are several other reasons why this should be removed that are related to the size of the tumor and the generally larger size of the adrenal gland. Benign tumors are often successfully removed and the other gland generally behaves normally from then on. These surgeries are not without great risk, depending on the condition of the dog's health at the time. They are also expensive. If the tumor is found to be malignant, then there is a greater risk of the cancer metastasizing. There is a drug (ketoconazole) that can be administered prior to surgery that suppresses hormone production and will reduce some of the negative side effects of the high cortisol. This will help the body heal better once the surgery is done. Since cortisol also stimulates the immune system you are seeing some of the side effects of that in the spleen. Its normal job is to provide elements of the immune system, get rid of old worn out blood cells and help the body fight certain attackers like tick diseases. The spleen can get itself worked up, become confused and begin attacking normal blood cells that have been targeted by the immune system as supposedly containing "non self" attributes. It becomes enlarged. Splenectomies are occasionally done in this case to remove the source of high destruction of red blood cells. They are not always fully successful and I generally don't recommend them for dogs that are already severely ill and may not handle the surgery well. Otherwise, dogs can live a very normal life minus the spleen. What to do. If this were me, I would be visiting my board certified specialist immediately. This is not a case for a local vet, no matter how specialized they are. Clinical experience is the key element here. How many dogs has the specialist seen and treated with this condition and how successful were they with these cases. And if this were me, I would be optimistic that the prognosis would be good unless my dog was elderly. If you have the ability to see a specialist, it would be well worth the time and money to do so. Please don't be scared and don't try to second guess what you have done so far. You are doing what you need to do with the amount of understanding that you have of this. I think you have great courage and a good head on your shoulders. Take a deep breath and begin asking a lot of questions. Do you have anything more you want to ask of me? my best patrice

Patrice NYS

Patrice, This is why we call you the expert! I wish you would teach some online physiology class. Thank you so much for explaining things in words that I can understand. I am sure this will be a big help to Karen. Best wishes, Brigitte

Brigitte BC Canada

Update on Roxy Well, everyone, so far so good! I didn't update before because I had my hands full with Roxy coming home on Sunday night, and also I wanted something "solid" to relate. This morning, we went back to the vet for her first PCV since Sunday, when it was fairly stable around 27 (after a low of 14). So today, it was 36!! I'm trying not to be too elated, since I know we still have a long road ahead (hopefully) and of course she is not feeling too well, yet -- but so much better than she was! Trotting a bit when we go outside, eating and drinking well (of course, with the drugs on board), sleeping well, gums increasingly pink, pee pale, almost clear (no blood). So this is all good news, and I hope everyone else who is going through an IMHA crisis with their pet will take heart. These are early days yet, but I couldn't ask for better results at this stage. Hopefully the trend will continue. Patrice: thanks so much for your very clear explanation! A couple of things: both internal med docs treating her have had upwards of 200 to 300 cases of IMHA, with an overall 60% survival rate. I hear what you are saying about needing a specialist, but I also feel that we are in pretty good hands -- at least, so far, so good. When I spoke with Dr. Ries, who has been in charge of her case, at discharge, he said, "Don't think for a minute that I have forgotten about that tumor! But we'll revisit it at a later time." So I am hoping that, even though he says flatly that this has been "a very weird case, and weird is what I do every day!" (it is a referral hospital) he feels confident that it has been IMHA that has been threatening Roxy's life, not the adrenal tumor -- even if the tumor may have been a triggering factor. I have to say that she may have had a perfect storm of triggers, between the tumor, the stress, and the vetprofen (which I will NEVER use again!). All I can say about the Cushings possibility (I have a horse with Cushings, so I'm familiar with it, even though it is different in dogs than in horses) is that she seems to be responding favorably to the pred and Cyclosporine. What that indicates I don't know. This is a pretty confusing case, I guess, but I'm feeling grateful that I have my dog back at home, and that she seems to be feeling better day by day. Thanks again SO MUCH for your concern, and I'll keep you posted! ---Karen and Roxanne

Karen New Mexico

also, to Penny -- Thanks for the number. I called them and they are going to file a report. Good thinking! ---Karen.

Karen NM

Karen, that's great news!!! I hope your vet figures out the tumor issue. Sounds like he's on top of things! Give Roxy some hugs for me. Johnny & Tessy

Johnny

Hi Karen I was so very happy to read that Roxy is showing signs of improvement. Please keep us updated on how Roxy is doing. Sending our prayers Cheryl & Ginger

Cheryl & Ginger Pinevile PA

Karen, I just caught this thread about Roxy and I am so glad she is doing better. A PCV of 36 is great! There is so much information to digest that it makes your head spin but it sounds like you have been doing a great job. After all you have found this site and with Johnny and Patrice and the wonderful souls on this board you have great healing energy around you. hugs, Gwen and Gracie Gracie was diagnosed on Oct. 13, 2010( Columbus Day)). It has been 4 months. There is hope!

Gwen R

This thread was discussed between 12/02/2011 and 18/02/2011

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