His owner said that Romeo had been weak Thursday night, but since Romeo was better by Friday, he canceled his appointment. That may have been, but on Saturday, he looked really bad. He was not eating; he was exercise intolerant to the point of weakness and almost collapsed.
Saturday is not the best time to come in with a major illness. And this was a major illness. I could tell that Romeo had lost or destroyed
a lot of his blood. Still in the exam room, I knew that this was probably a liver or splenic tumor that has ruptured or an Auto-Immune-Hemolytic Anemia or serious infectious disease. Blood work and radiographs were possible, and advanced testing and ultrasound were not as easy on a short staffed day. We started with x-rays and blood work. Radiographs did not show the splenic or liver tumor that the history would suggest. Blood work showed a significant anemia. We talked about the possibility of hospitalization and ER hospitalization.
Secondary Immune Mediated Anemia can be caused by some of the red cell parasites and rickettsial diseases. Hemotrophic Mycoplasma, Ehrlichia, Anaplasma, Babesia, Leishmaniasis, and heartworms are all causes of secondary IMHA. Most of these respond to doxyclicline, but I only sent Romeo with a week’s supply (in case he died), some multivitamins with iron, and discussed the ER for emergencies. Carly and Sophia discussed how to give the medication and got him a piller tool to help get them down.
On Monday, Romeo looked worse. Seems that Romeo did not want to take his medicine. Repeat blood work showed Romeos hematocrit had dropped from a low 27% to a life threatening 11%. We discussed the need for medicine again and did the ultrasound and a few more blood tests. The ultrasound did not find a liver or splenic tumor; however, the right kidney was poorly visualized and remains a mystery. With the tumor diagnosis less likely, we started Romeo on immune suppression doses of prednisone and sent blood for a Combs test. Unfortunately, the owner misunderstood and did not start the medicine until the next morning.
A Combs test is a test of autoagglutionation of the blood. Normal blood should smooth out on a surface. AIHA blood will clump together microscopically to the point that clumps can be seen without a microscope. Our in-house Combs test on Monday was not positive; however, Tuesday, a drop on the floor did seem to have some agglutination before we cleaned it up. A blood sample was sent to Cornell University for a definitive test that would take a couple of days. On Tuesday Romeo was even more anemic than the day before. We go over medication again until I think we have achieved communication.
IMHA is a disease in people, dogs, cats, and a wide range of other species. Up to 75% of the dog cases do not have a diagnosable cause and therefore are primary. Cocker Spaniels are the most common breed, with more poodles, Irish setters, and Old English sheepdogs than other breeds. Primary IMHA means the RBCs are purposely destroyed by the body’s own immune system. This is an allergic or II hypersensitivity reaction. In other words, the body is allergic to its own blood.
In secondary IMHA, RBC destruction is caused because the immune system reacts to something else. Red Blood Cells are destroyed by mistake or as innocent bystanders. The infectious diseases can be part of that and should be treated before corticosteroids in the absence of a positive Combs test. Actually, Romeo should have been treated with IV fluids, hospitalization, type-matched blood transfusions, medicines, and intensive care. That was not possible and we worked with what we could.
By Thursday, Romeo was looking better! He was eating and drinking and had more energy. His gums and blood work looked better, and his hematocrit was up to 15%. His test results confirmed that Romeo had a positive direct Combs test. He has primary AIHA. He is responding well to the medication, and we will monitor his blood work and then try to wean him down over the next few months. In six months, he may be able to go off medication, but the disease may also come back. I hope not; Romeo was a gift from this widower’s wife. He means the world to his owner. For now, at least, Romeo looks a lot better.