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Author Topic: Precursor Immune Mediated Haemalytic Anaemia and IMHA  (Read 58 times)

trudiej

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Precursor Immune Mediated Haemalytic Anaemia and IMHA
« on: June 05, 2021, 08:27:38 PM »

Hi there

I have an 8.5 year old male bearded collie who, just over a week ago became listless and lethargic. Prior to this, he had been having regular anal gland checks following recurring infections which took several courses of antibiotics to shake off (the checks had all been fine). He had also had what we thought was an allergy, with some sneezing and a runny nose, for which we were giving him Piriton - this hadn't totally cleared up, but had seemed to improve.

Following a check at our local vets his bloods showed he was very anaemic and an ultrasound showed a mass on his spleen, so we were referred to a specialist vet, who following a series of tests, have given the diagnosis and treatment plan below:

TESTS PERFORMED:

External blood smear examination: this showed evidence of very mild regeneration, but this was inadequate for the degree of anaemia. A type of red blood cell called spherocytes were observed, which are most commonly seen with IMHA.

Urinalysis: the urine was concentrated and did not contain excessive protein. Some crystals were observed, which occur with storage of urine. Bilirubin with bilirubin crystals were also present (likely secondary to IMHA).

Splenic nodule cytology: evidence of new red blood cell production, with some inflammation (common in conditions which cause systemic inflammation such as IMHA).

Splenic parenchyma cytology: evidence of new red blood cell production, with some inflammation (common in conditions which cause systemic inflammation such as IMHA).

Bone marrow cytology: there was evidence of an increase in the number of red blood cells within the bone marrow, which were then being consumed by white blood cells. This is consistent with precursor immune mediated anaemia.

Bone marrow histopathology: pending.


DIAGNOSIS

Precursor immune mediated haemolytic anaemia (PIMA) and immune mediated haemolytic anaemia (IMHA): these are conditions in which the body attacks its own red blood cells. In the precursor form, this occurs within the bone marrow. With IMHA, this occurs within the circulation.


TREATMENT

Prednisolone 20 mg twice daily

Ciclosporin 100 mg: give one capsule twice daily with a 50 mg capsule. This is an immunosuppressant. Side effects can include a reduction in appetite, vomiting and diarrhoea. We recommend freezing these tablets to reduce these side effects.

Unlicensed medication:
Clopidogrel 18.75 mg: give 2 tablets once daily. This helps prevent the risk of blood clots, which can be seen with Fergus’ condition.


FOLLOW-UP

If Fergus remains clinically stable, repeat PCV is advised approximately every 2 weeks to assess for a regenerative response. Once PCV is within the normal range, we would advise sending a blood smear externally to assess for ongoing spherocytosis If resolved, then dose reductions of prednisolone can be commenced. Prednisolone should be reduced by 20-25% every 3-4 weeks, with repeat PCV performed prior to every dose reduction to ensure there is no relapse in anaemia.


QUESTIONS

This was a bit of a shock....., is there anything I should be doing to help Fergus?
Any questions I should be asking of the vet/specialist?
I notice on some posts, a tummy protectant is advised, I asked the specialist vet about this, and she didn't consider it was necessary?

Anything else you think I should be aware of?

Any/all help most gratefully received.

With thanks; Fergus' worried parents

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Catherine

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Re: Precursor Immune Mediated Haemalytic Anaemia and IMHA
« Reply #1 on: June 05, 2021, 09:19:57 PM »

What was Fergus's PCV amount? If it is quite low I would want to have his PCV tested every few days, certainly more often then every two weeks at first. Also I would definitely want him having something to protect his tummy otherwise he could get more problems.

Here is a good reduction protocol for when his PCV starts to rise:

Immunosuppressive Protocols for Oral Prednisolone in the Dog.
Ref: Clinical Immunology of the Dog & Cat by Michael J Day  – 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/q12hrs (every 12 hours)

Dose                Duration (based on clinical effect)

1.0mg/kg/q12h             10-28 days
0.75mg/kg/q12h            10-28 days
0.5mg/kg/q12h             10-28 days
0.25mg/kg/q12h                         10-28 days
0.25mg/kg/q24h                         10-28 days
0.25-0.5mg/kg/ Every other day      at least 21 days
0.25-0.5 mg/kg/ Every third day       at least 21 days

Azathioprine (a cytotoxic drug) can be used in combination with prednisolone at 2mg/kg/24 or 48 hrs and dose gradually reduced, when remission is achieved, over a period of months.
Clinical response to Azathioprine may take up to 6 weeks. (Plumb’s Veterinary Drug Handbook)

Don't forget the gastroprotectant!


Have you checked out the information here?: http://cimda.co.uk/smf/index.php?topic=11.0 and here: http://cimda.co.uk/smf/index.php?topic=16.0
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trudiej

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Re: Precursor Immune Mediated Haemalytic Anaemia and IMHA
« Reply #2 on: June 06, 2021, 07:21:05 PM »

Hi Catherine

Thanks for the reply; Fergus's PCV was 21, 19 and 22 - the 22 being the result of a test done on Wednesday 2 June.

Would you consider this low enough to warrant another blood test during this coming week (he's booked in at vets for next blood test on 15 June), and should we consider a biochemical test, as well as the PCV test, to check liver and kidney function?

I will speak to the vet regarding a tummy protectant - is there one you'd particulary recommend for Fergus's condition?

On reading the articles you linked to; should Fergus be on a broad spectrum anti-biotic? And should we consider a low fat food; he is currently on a grain free salmon, trout, asparagus and sweet potato kibble (it says the crude fat content is 11%).

Many thanks.

Trudie

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Catherine

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Re: Precursor Immune Mediated Haemalytic Anaemia and IMHA
« Reply #3 on: June 06, 2021, 08:53:06 PM »

The normal range approximately in the UK for PCV (HCT) is 37 -55 so even allowing for variations 22 is quite low. So yes I personally would want to test Fergus as soon as possible. Hopefully the PCV will have started to increase again but I would still test more regularly. It would not hurt to keep an eye on his kidneys and liver but the liver enzymes will rise anyway with the steroids so do not be too shocked.

Omeprazole is one gastroprotectant but it did not agree with my dog but I found Zitac (Cimetidine) was good. Some you have to give apart from other medication.

I can not see any reason for an antibiotic unless Fergus has other issues. Also if he has been fine on his normal food I would stay with it - you do not want to change too much at once.
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Jo CIMDA

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Re: Precursor Immune Mediated Haemalytic Anaemia and IMHA
« Reply #4 on: June 07, 2021, 10:17:29 AM »

Hi and welcome

I am sorry that Fergus has non-regenerative anaemia.  Unfortunately this is a known inherited condition that can be seen in beardies. 

Catherine has given you the information that you need, so there is not a lot more than I can add,  just to reiterate that Fergus should be on 1mg/kg/12hours prednisolone and it is best to give a low fat diet and give perhaps four smaller meals than one or two larger ones.  This makes it easier for this pancreas to deal with and may prevent pancreatitis.  Also, as far as I am concerned, there is no good reason not to give a gastroprotectant because if it isn't given there is a risk of the stomach becoming ulcerated and  if an ulcer develops then it may bleed which will cause regenerative anaemia.    As Fergus' immune system is significantly suppressed you should be careful about taking him to a popular dog walking area where he may pick up infections.  Often a course of antibiotics is given at the start of treatment as a precaution. 

I do hope Fergus  is starting to feel better. 

Jo
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