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Author Topic: Immune mediated anemia with suspected auto immune skin condition  (Read 75 times)

Suewill

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Hello-
I have an eight year old Vizsla who ~1.5 years ago had abnormal lab values along with lack of appetite and lethargy that lead us to a veterinary internist. Her lab values were suspect of liver disease and an ultra sound showed possible stomach ulcers and gall bladder pathology. She was put on ursodiol and seemed to have “gotten better.” ~8 months following, she became lethargic and a anorexic again prompting a vet visit. Labs showed abnormal liver values along with a positive lepto test. She was put on antibiotics for lepto which had zero effect and lead us to a different vet/emergency clinic. She has been hospitalized twice and has been undergoing treatment for the last year. Lepto is no longer a working diagnosis. She was briefly thought to be in liver failure but now has a working diagnosis of immune mediated anemia. Over the last year, she has had issues with low platelets (8000 requiring vitamin K injections and hospitalization). The platelets seemed to have recovered some but she continues with anemia. This has been ongoing for a year now. She is on 30mg prednisolone, denamarin, 250mg ursodiol, 20mg omeprazole and 100mg of atopica (cyclosporine) daily with limited impact other than keeping her RBCs “stable.” In addition, she seems to have a relapsing skin condition where she develops plaques and sores in her groin, perianal area, chest and back that are reoccur on a 6 month cycle. The skin is thought to be auto immune at this point but it’s unclear. She did have it biopsies at one time and the results showed calcinosus cutis but has no their symptoms that relate to that. Both my vet and myself are questioning that biopsy at this point. Of note, the skin condition occurred *before* initiating pred so it’s thought to NOT be related to the pred but some other pathology. So hard because we still don’t have a definitive diagnosis for any of it. Just changing symptoms. :-/. Anyone have anything similar? Especially the relapsing skin plaques related to auto immune diagnoses?
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Jo CIMDA

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Re: Immune mediated anemia with suspected auto immune skin condition
« Reply #1 on: May 12, 2020, 10:03:31 AM »

Hello and welcome

I am sorry that your Vizsla has had such a rough time.  The symptoms that you describe could be a multi-systemic autoimmune disease called SLE, abbreviation of systemic lupus erythematosus.

Below are some notes:

SLE - Systemic Lupus Erythematosus
SLE is a multi-systemic disease that can affect many parts and systems of the body.  It is categorised into major and minor signs.
Major signs can be:
Shifting lameness (polyarthritis), anaemia and thrombocytopenia (blood abnormalities), skin lesions, kidney nephritis (inflammation)
Minor signs can be:
Inflammation of the heart, lungs & muscles, mouth ulcers, enlarged lymph nodes, gastrointestinal signs (vomiting and diarrhoea), central nervous system may be affected causing: Behavioural changes, seizures, and staggering (ataxia).

Clinical signs can be extremely varied and not all dogs with SLE will show the same symptoms. An antinuclear antibody blood test (ANA) can be useful in diagnosis but a negative result still does not rule out SLE.
The dog will normally demonstrate signs of pain and stiffness in the joints and this may be accompanied with anaemia, skin lesions and one or more of the minor signs.  One would expect the dog to show other clinical signs such as high temperature, enlarged lymph nodes, thrombocytopenia, lethargy, depression, lack of appetite, muscle weakness (myositis) sometimes causing weakness of the throat muscles (megaoesophagus).   Megaoesophagus is a serious complication and if this is present then the quicker correct treatment is started the more chance you have of limiting the effects.  A dog will have difficulty in drinking and eating and this can cause recurring aspirate pneumonia.  The primary autoimmune disease may have been brought under control but the effects of megaoesophagus may not resolve completely.
SLE can affect any body system/s. A definitive diagnosis may not be achieved, but it may be presumed, based on clinical evidence and response to treatment.  Again knowledge of breed predisposition and family history will be beneficial in obtaining a diagnosis.   Dogs can have periods of remission and relapse.
 


Regardless of whether the problem is SLE or a combination of other autoimmune diseases, the treatment is the same, and that is with immunosuppressive therapy.    Prednisolone is the main stay of treatment and this is usually started at 1.1mg/kg/12hours (Ref: Plumb's Veterinary Drug Handbook, Eighth Edition),   It is prudent to add another immunosuppressive drug, especially in a larger dog to limit the side effects of the pred.  See below an excellent immunosuppressive drug protocol for prednsiolone that can be confidently used as a guide. 

Your girl is already on cyclosporine.  I don't know how much your girl weighs but the recommended  dose for immunosuppression is: 
Empirical dosages generally range from 3-6mg/kg twice daily or 5-7.5mg/kg once daily.   Ref: Plumb's Veterinary Drug Handbook, Eighth Edition.

As your girl has been on pred for a while it may not be appropriate for the dose to be increased, but that depends on whether or not she is showing lots of side effects.  I wonder if getting a referral to an internal medicine  specialist might be an option.  It is all about getting the dose and duration of drugs right and then using a good reduction protocol.

Example: Reduction Protocol for prednisolone:
Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
Professor Michael DayBSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 


Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.
This example is based on a dog receiving an induction dose of 1.0mg/kg/q 12hrs (q = every)
Dose                           Duration (based on clinical effect)
1.0mg/kg/q 12h                          10-28 days
0.75mg/kg/q 12h                       10-28 days
0.5mg/kg/q 12h                         10-28 days
0.25mg/kg/q 12h                        10-28 days
0.25mg/kg/q 24h                        10-28 days
0.25-0.5mg/kg EOD                    at least 21 days
0.25-0.5 mg/kg every third day      at least 21 days

Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of the drugs.
Prednisolone:  "Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight."  Plumb's Veterinary Drug Handbook Eight Edition.


It is good she is on a gastroprotectant but be sure that you don't give Omeprazole with the other drugs because it can inhibit absorption.  The best thing is to give it at night or after one hour of giving other drugs or give omeprazole two hours after other giving other drugs.

I think getting the dose of medication correct is the key and then a good weaning off protocol.  I do hope you can discuss this with your vet.

Best wishes
Jo








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Catherine

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Re: Immune mediated anemia with suspected auto immune skin condition
« Reply #2 on: May 12, 2020, 04:39:25 PM »

Has Stella ever had a full thyroid blood test?
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Suewill

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Re: Immune mediated anemia with suspected auto immune skin condition
« Reply #3 on: May 14, 2020, 06:05:41 PM »

In response to Jo- we have an internal med veterinarian already on her team that initiated her cyclosporine and my complex care vet consults with him regularly. She usually sees the internist in person every 6 months for updates ultrasounds.

In response to Catherine- thyroid was tested back when this all started last year and was normal.

As of yesterday, we are trialing a small decrease in pred to see if her PCV at minimum remains stable (was 27% as of Tuesday) with the hopes of decreasing enough to be able to biopsy the skin again in the future.
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Jo CIMDA

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Re: Immune mediated anemia with suspected auto immune skin condition
« Reply #4 on: May 21, 2020, 12:22:53 PM »

Hi

My apologies for the late reply.

A PCV of 27% is promising.  Lets hope it will continue to rise and she will be stable. 

Skin biopsies are not very successful in definitively diagnosing specific skin conditions, and certainly not whilst the dog is immunosuppressed, so I hope your vet will be prepared to wait until the drugs have been weaned of completely or at least down to a very low every other day dose before performing a biopsy.

Best wishes

Jo


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