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Author Topic: Immune Mediated Haemolytic Anemia  (Read 661 times)

Tanya2604

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Immune Mediated Haemolytic Anemia
« on: August 18, 2018, 03:07:20 PM »

Hi everyone, we are new to this forum and will go to any lengths to get our Saluki Springer Cross, four year old, Violet well again.

Violet fell ill on Friday 3rd July and this was noted due to her lack of appetite and not wanting to walk, totally out of character.  The story is long, but to cut it short, after two stays in hospital and vets appointments she was diagnosed with IMHA.  We are over six weeks on now and Violet remains very ill.  She has been prescribed Prednidale 5mg tablets and was on 20mg a.m. and 20mg p.m.  She has is also currently prescribed Ferrous Sulphate 200mg taken a.m. and Omeprazole 20mg taken p.m.  During her illness she was also prescribed Azathioprine 50mg once daily, this was stopped and replaced with Ciclosporin 100mg, once daily - but this made her very ill with diarrhoea and had to be stopped.  She is currently on Prednidale 20 mg a.m. and 15 mg p.m.  She is a different dog, quiet and lethargic, weight loss and muscle loss, no interest in her ball and toys that she loved to play with.  Because she has been stuck at home for weeks we have purchased a dog pram to take her out for the mental stimulation and she loves this.  We have researched foods and she is being fed chicken, red salmon, dark green vegetables and bone broth with apple cider vinegar.  She enjoys her food and eats well due to the steroids and is not picky with her green veg.  Her PCV has plateau'd for many weeks, can anyone explain if this is due to the high steroid dose and if it is likely to increase as we decrease the Prednidale please?  Also, any other tips for feeding or ways to promote red blood cell production would be much appreciated with any advice, experiences or knowledge.  By the same token, if anyone is experiencing similar and we can help in any way, please approach us.  Such a difficult and unpredictable process and we just want Violet to be well again.  Thanks for reading our post and we look forward to chatting with you, Tanya and Nick and Violet.
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Jo CIMDA

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Re: Immune Mediated Haemolytic Anemia
« Reply #1 on: August 18, 2018, 04:03:52 PM »

Hi and welcome

I am so sorry your Violet has AMHA.  It is good that she is still hungry.   I have a few questions to ask if you don't mind?

How much does Violet weigh?

Does Violet have non-regenerative IMHA (immune destruction within the bone marrow) or regenerative (Immune destruction within the circulation of the blood or spleen etc......?

Has Violet had anything to protect her stomach from the preds, such as Omeprazole or Ranitidine?

Can you please write down the drug protocol she has been on - dose reduction and duration,  and PCV?

What is her PCV now?

Lots of dogs find cyclosporine difficult to tolerate, especially at the start of treatment.

Sorry for all the questions.

Jo


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Tanya2604

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Re: Immune Mediated Haemolytic Anemia
« Reply #2 on: August 18, 2018, 05:13:52 PM »

Hi Jo,

Thank you so much for taking the time to read our post and your reply.

To answer your questions Violet has been given Omeprazole to protect her gut.  She currently weighs around 18 kg, fluctuating 18/19 over the last few weeks - she was 22 kgs.  She has the regenerative IMHS, we were told possible from a parasite so was treated for around a month with antibiotics.

We think her PCV is around 3.6/3.8 having been at that level for around four weeks.  Over the last four weeks she has been on 8 x 5mg Prednidale (4 morning four afternoon) and this was changed yesterday to 4 x 5mg morning and 3 x 5mg afternoon.  She takes Ferrous Sulphate with her morning dose and Omiprazole with her afternoon medications.

I hope this answers all your questions - Thanks again.
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Jo CIMDA

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Re: Immune Mediated Haemolytic Anemia
« Reply #3 on: August 19, 2018, 02:51:25 PM »

Hi

If Violet has regenerative anaemia caused by a parasite, and she has been treated for that parasite, then I would have expected her PCV to have increased by now.  So is a parasite infestation the only cause of her anaemia?   

A dog with regenerative anaemia will have high immature red blood cells (reticulocytes).  This proves that her bone marrow is regenerating and therefore the anaemia is being caused by destruction of the red blood cells within the circulation of the blood or by other sites of destruction eg., liver, spleen.  Examination of a blood smear should give the vet more information about what is going on. See this link:

http://www.eclinpath.com/hematology/anemia/causes-of-anemia/
Causes of anemia

Immune-mediated hemolytic anemia

IMHA RBC destruction
Red blood cell destruction in IMHA

Immune-mediated hemolytic anemia (IMHA) is most common in the dog but can occur in other species. Classically these are acutely developing regenerative anemias, in which RBC are coated with antibody (IgG usually, but also IgM and IgA) and/or complement (C3b) and are prematurely removed from circulation by macrophages in the spleen (mostly), liver and bone marrow (extravascular hemolysis).  In some animals, complement fixation by antibodies (IgG and IgM) can result in a concurrent intravascular hemolysis (see image to the right). IMHA can be primary or secondary to drugs (e.g. penicillin in horses) or erythroparasites (e.g. Babesia sp., Mycoplasma haemofelis).

The following features in a blood smear help us identify an IMHA:

IMHA
IMHA in a dog
•Moderate to many spherocytes: This characterizes most IMHA in dogs (spherocytes are harder to identify in other species). Note that small numbers of spherocytes may be seen in disorders other than IMHA, including transfusion of stored RBCs, fragmentation injury, and abnormal macrophage function (e.g. hemophagocytic syndrome, hemophagocytic variant of histiocytic sarcoma). Therefore spherocytes do not always indicate an IMHA.
•Agglutination. This should be distinguished from rouleaux formation by dilution with saline (using a ratio of 1:4 to 1:10 RBC to saline – rouleaux should disperse whereas agglutination is usually still present on slide agglutination tests or microscopic examination of the diluted blood.
•Positive direct Coombs test. A direct Coombs test assesses for the presence of immunoglobulin (IgM, IgG) or complement (C3b, C3d) on RBC using a Coombs reagent, which consists of species-specific anti-Ig and/or anti-C3. A positive Coombs test is supportive evidence of IMHA, but false positives and negatives do occur.
•Thrombocytopenia (mild to moderate mostly, sometimes severe): This can be a common concurrent finding, which in some dogs is also immune-mediated (combined immune-mediated hemolytic anemia and thrombocytopenia is called Evan’s syndrome).
•Inflammatory leukogram: Leukocytosis due to a neutrophilia with a left shift and monocytosis



Sometimes it is not possible to identify the primary cause of regenerative anaemia because there are numerous, possible underlying conditions.  If the anaemia doesn't resolve, and the primary cause can't be identified, sometimes the removal of the spleen is considered.

Regenerative anaemia can also have a pattern of spontaneously resolving only to appear at a later date.  I have known a few dogs to have this pattern to their regenerative anaemia and the removal of the spleen was the answer.  In cases like this the dog can then lead a normal life without drugs.  That is not to say this is the cause of Violet's regenerative anaemia.

Are you able to take Violet to see a specialist?   Sometimes it is very challenging for even the specialists to figure out the cause of regenerative anaemia. 

One thing for sure is Violet can't stay on very high doses of preds for much longer because this will start to produce severe drug induced side effects. Perhaps with the reduction of preds the PCV will rise and you may find this problem has resolved. 

If Violet's liver enzymes are high, and this is to be expected, then you might consider giving her a liver support such as Denamarin.  As the preds are lowered the liver enzymes will reduce back to normal levels. 

Jo


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