Immune mediated condition or not???? Anemia, low platelets and enlarged spleen!

[Kylee]

Hello team,

I hope you can help! We are trying to help a rescue dog who is currently in Turkey. Unfortunately, he has been seen by different vets and none of them concur about his condition. One moment they say he could possibly have an immune mediated condition (IMPT or IMHA), the next they don't.

He has anemia and a low platelet count and an enlarged spleen. He also showed a positive IgG for Ehlrichia (IgM negative). He has been on prednol and doxycycline on and off now for 4 weeks because the vets just cant agree on his condition. One vet just wants to perform a splenectomy and says the ehlrichia is no longer active (as all he did was a PCR). The other vet says he's too ill for an operation but also doesn't quite know what to do next. I have attached his bloodwork from the past 4 weeks in one overview.

He is not showing any signs of being poorly - however we need guidance on the best course of action for him. He is a 4 year old, non-castrated labrador. He has not had any vaccinations yet. He's currently on 16mg Prednol and 4x doxycycline per day.

Thank you for any advice you can give as we are truly at a loss 

I can't upload a document, so here some details of his blood results over a 5 week period:

Platelets: 54   50   114   94   88
RBC: 3.58   4.56   3.69   4.45   5.05
HCT: 27.1   34.5   25.7   30   33.2
HGB: 8.7   11.1   9   10.5   11.9

WBC: 4.63   5.67   5.19   7.7   6.08
PCT: 0.83   0.61   0.17   0.14   0.99
TP: 10.2            9.1
GLOB: 7.7            6

[Catherine]

Do you have the normal range values please?

If he has low haematocrit and platelets together then that can be Evans Syndrome. See here:https://cimda.co.uk/smf/index.php/topic,13.0.html Also he would need to be started on a higher dose of Prednisolone. See here:

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 base on a dog receiving an induction dose of 1.0mg/kg/q12hrs

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!

[Kylee]

https://live.staticflickr.com/65535/54527593930_640a56abd5_n.jpg

Hi Catherine,

Thank you so much for responding - I tried to upload with FLickr with the link above but not sure it has worked - so I have also pasted them below...



Value   Normal Range           20/04   28/04   05/05   10/05   15/05
RBC   5.65 - 8.87 M/uL   3.58   4.56   3.69   4.45   5.05
HCT   37.0 - 61           27.1   34.5   25.7   30   33.2
HGB   13.1 - 20.5 g/dL   8.7   11.1   9   10.5   11.9
MCV   61.6 - 73.5 fL           75.7   75.7   69.7   67.4   65.7
MCH   21.2 - 25.9 pg           24.3   24.3   24.3   23.5   23.6
MCHC   30.0 - 38.0 g/dL   322   321   348   34.9   35.9
RDW   13.6 - 21.7%           14.2   14   12.6   14.1   13.5
%RETIC   %                         0.4   1.3   
RETIC   10 - 110 K/uL                 16.1   58.6                  
WBC (Leukocytes)6.0 - 17  K/uL   4.63   5.67   5.19   7.7   6.08
NEU   3.6 - 12.3           3.12   2.82   2.96   5.51   3.91
%NEU   52-81                   67.4   49.8   57   71.6   64.3
MONO   0.1 - 2.0           0.61   1.06   0.82   0.8   0.52
%MONO   2.0 - 13           13.1   18.7   15.9   10.4   8.5
EOS   0.0 - 1.6           0.12   0.17   0.15   0.09   0.17
%EOS   0.1 - 10           2.6   3   2.9   1.2   2.8
LYM   0.8 - 4.9 K/uL           0.78   1.62   1.25   1.29   1.48
%LYM   12.0 - 33.0           16.9   28.5   24.2   16.7   24.4
PLT   148 - 484 K/uL           54   50   114   94   88
MPV   8.7 - 13.2 fL           15.4   12.1   15   15.3   11.3
PDW   9.1 - 19.4 fL           15.6   15.7   13.7   14.7   14.8
PCT   0.9 - 5.8           0.83   0.61   0.17   0.14   0.99
CREA   .5 - 1.8 mg/dL           0.67            
BUN   7 - 27 mg/dL           12.2            
BUN/CREA 4.0 - 27           18.2            
TP   5.0 - 7.2 g/dL           10.2            9.1
ALB   2.6 - 4 g/dL           2.5            3.1
GLOB   2.5 - 4.5 g/dL           7.7            6
ALB/GLOB 0.8 - 2.0           0.3            0.5
ALT   10 - 125 U/L           46            
ALKP   13 - 83                   48            
GGT   5.0 - 14           10            
TBIL   0 - 0.9 mg/dL                       0.4

[Catherine]

Thank you. Has he been having 16mg of Prednol the whole time or just recently? If it is now autoimmune then for a labrador, (weight about 36kg), he should be having 36mg of Prednisolone every 12 hours, plus a gastroprotectant for his tummy.

I have notified Jo Tucker, so hopefully, she can advise you a bit more.

[Kylee]

Hi Catherine

Thank you for your guidance - he's been on 16mg on and off as they wanted to taper down and then put him back on again, so it's been really frustrating, but clearly he needs to be on a higher dose.

I'd really like to understand also what the vet needs to look at/ investigate to be able to determine for sure whether he has an autoimmune disorder or not - they have been really reluctant to do additional testing although I have asked for it numerous times. They even say a urinalysis and blood smear are not needed although I think it's imperative to get an overall picture of his condition.

We just want this lovely boy to get better and know how to proceed...

Again thanks for your input !

Regards
Kylee

[Catherine]

Jo's computer is not working properly, but I have talked to her about your post. Here is her reply:

Given that this dog has tested positive for Ehlrichia, and is showing many of the typical clinical signs,  and also is being treated appropriately, I doubt, at this stage,  that there is secondary immune mediated complications.

Fortunately, in the UK ehrlichiosis is rare, so I don't have enough experience to give any advice, but I would ask for a further test for ehrlichia to see if there is any difference in the IgG levels which will hopefully indicate that the medication that he is having is bringing this under control.

Sorry to be so vague.  Please get back to us if there is an immune mediated cause.

This is an informative website:

https://vcahospitals.com/know-your-pet/ehrlichiosis-in-dogs


It is difficult to advise without seeing the dog, or knowing the full details, but I hope some of it helps.

[Kylee]

Thank you so very much - yes it does help!

Unfortunately one of my dogs has secondary IMPA due to ehrlichioses, therefore I wanted to seek further advice based on your extensive knowledge also.

We will continue to monitor the ehrlichia and hope his bloods improve.

Thank you again - if we find out more I might come back to you if an immune mediated condition is suspected.

Kind regards
Kylee