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September 2000

Bailey

Bailey is a 9 ˝ year old, neutered male, Cocker Spaniel owned by Angela of Shawnee, KS. Bailey was first "officially" diagnosed with autoimmune hemolytic anemia in February, 1999 during a relapse of ITP (Idiopathic Thrombocytopenia Purpura). ITP is a disease that occurs when the immune system attacks and destroys the platelets (the part of the blood that forms clots to prevent bleeding). As the platelets decrease, bruising and internal bleeding can result.

In late 1995, Angela noticed "splotches" on Bailey's abdomen. By the end of the day the splotches were gone and Bailey seemed perfectly normal. Angela now believes that those splotches were Bailey's first ITP incident.

On July 3, 1996, Bailey went into his vet for an ear flushing. The vet noticed bruising on the inside of the ears. Bailey's platelets were immediately checked and they were down to 11,000 (most veterinary laboratories state that a normal platelet count ranges from 200,000 to 500,000). Bailey's PCV was a normal 45. Bailey was diagnosed with ITP and given 30 mg prednisone for 3 weeks. He was also given 250 mg of Tetracycline per day to prevent infections. Bailey had a rapid rise in platelets and by September 1996 had a platelet count of 361,000. His prednisone had been tapered off over the preceding months and was discontinued in September 1996.

On June 12, 1997 Angela noticed bruising on Bailey's abdomen and tongue. Testing revealed a platelet count of 8,000 and a PCV of 42. Bailey was diagnosed with ITP and transferred to a 24 hour surgical hospital. By June 14, Bailey's PCV had dropped to 19 but he was not diagnosed with AIHA, because it was believed the dropping PCV was caused by internal bleeding. According to Angela, " a decreasing PCV is fairly common during a severe enough ITP episode due to internal bleeding. If it (PCV) stops decreasing or goes up when the platelets go up, they can determine the anemia is not immune-mediated." Bailey was given an injection of Vincristine (a chemotherapy drug that causes a rapid release of platelets) and put on 25 mg of prednisone (once daily), 50 mg Imuran (once eod), and 125 mg of the antibiotic Clavamox (twice daily). A bone marrow aspirate showed normal cell production. On June 16, Bailey was sent home with a PCV of 25 and platelet count of 115,000. By June 27, Bailey's PCV was up to 40 and his platelets were 300,000. By November, Bailey's platelets remained steady at 300,000. His prednisone was discontinued, while he remained on Imuran. The Imuran was tapered off slowly and finally discontinued in August of 1998.

On February 12, 1999, Bailey had an appointment to have his teeth cleaned. However, since he had a cough, his vet thought it would be wise to wait to do the sedation and teeth cleaning until the cough cleared up. During a visit to the groomers on February 14th, another vet noticed Bailey's cough and gave him a Cephalosporin injection , (an antibiotic on the list of " suspected triggers" for autoimmune diseases) and prescribed Amoxicillin. The next day, Angela noticed a small bruise on the inside of Bailey's leg. She immediately took him to the 24 hour emergency hospital. Bailey's platelets had dropped to 9,000, he had severe autoagglutination (clumping of the red blood cells) and a PCV of 32. He was diagnosed with both ITP and AIHA, a condition known as Evans Syndrome. Bailey was given an injection of Cytoxan and started on prednisone, Imuran and Heparin. A second Cytoxan injection was given 7 days later. Bailey was hospitalized for 9 days during which time his PCV dropped to 24. Bailey was released from the hospital on February 24th with a PCV of 33 and a platelet count of 375,000. Prior to his release from the hospital, the Heparin was discontinued. The prednisone was continued at decreasing levels until it was discontinued at the end of August 1999. The Imuran was decreased until it was down to 25 mg every other day. Angela and her vet hoped to keep Bailey on this maintenance dose of Imuran for the balance of his life to prevent further relapses. However, in June, 2000, Bailey's vets decided that he needed to be weaned off the Imuran because his white blood count had been steadily decreasing over the past 6 months. The Imuran was decreased to 25 mg every 3rd day. On June 23, Angela noticed a small red dot on Bailey's abdomen. By the time Angela and Bailey arrived at the emergency vet hospital (a 20 minute drive), Bailey's entire abdomen was covered with red bruises. His platelet count came back as 0 with a PCV of 43. Bailey was admitted to the emergency hospital and given an injection of vincristine, 30 mg prednisone and his Imuran was increased to 25mg every other day. Within a few days his platelet count rose to 23,000 but the PCV dropped to 27. When Bailey was released from the hospital, his PCV had climbed to 36 and his platelets were 200,000. At his checkup on August 17, 2000, Bailey had a platelet count of 376,00 and a PCV of 42. Bailey is currently taking 30 mg prednisone per day, 25 mg Imuran every other day, .3 mg Thyroxine daily, 250 mg vitamin C and 400 mg vitamin E each day. While on the high doses of prednisone, Bailey also takes 1 tablespoon Maalox per day to relieve gas and bloating.

When asked about the current state of Bailey's health, Angela replied, " Bailey has been excellent health-wise for the last year and a half. This last ITP relapse really caught us off guard. It's pretty clear that he needs to be on maintenance drugs to keep from relapsing and the Imuran just doesn't work for him. The challenge is to find the right drug and dosage that will keep him on the thin line between relapse and a white blood cell count that is too low. Besides this pesky immune system problem Bailey has, he is the happiest healthiest dog you'll ever meet!"

Bailey Update, July, 2001

Bailey recovered quickly from his ITP relapse in July 2000. His prednisone was reduced by 5 mg every 8-10 weeks. Bailey's white blood count (WBC) began steadily increasing and by December 2000 it was very high. He also started to have bouts of diarrhea. Bailey's vet believed the diarrhea was due to an intestinal infection, probably Colitis, resulting from a suppressed immune system. Bailey was started on antibiotics and his diet was switched to Prescription W/D. Over the next couple of months the diarrhea continued on and off and Bailey was on antibiotics 2 more times. Because it was feared Bailey might relapse due to the antibiotics, he was kept on 20 mg prednisone per day as well as 25 mg Imuran every other day. By March Bailey weighed 26 pounds down from 35 pounds in December and his abdomen remained severely distended.

While palpating Bailey's abdomen on March 21, 2001, the vet felt a mass on Bailey's spleen. On March 22, Bailey had an ultra-sound which revealed a mass on his spleen, about the size of a golf ball. The CBC results from the previous day showed the PCV had dropped to 22 with the platelets being normal. Because of his past history Bailey was diagnosed with AIHA and started on oral Cytoxan, his dosage of prednisone was increased to 30 mg per day and the Imuran was continued at 25 mg eod. Bailey's PCV remained at a steady 20-22 throughout Friday. Angela brought him home that night with instructions to keep him calm and bring him in both Saturday and Sunday for PCV checks.

Saturday's PCV remained near 20. Sunday morning, Bailey was very lethargic and he could barely walk. His PCV had dropped significantly. He was given Oxyglobin which brought his PCV back up into the 20's but by the next morning, it was down to 15 and he was having difficulty breathing. He was started on Heparin. That afternoon, Monday the 26th, he was given a transfusion of whole blood. By evening, he had improved dramatically and by the morning of the 27th, his PCV was in the upper 20's and he was alert and active. Although it was determined that he was producing new red blood cells and all other bodily functions seemed to be working right, it could not determined for certain what was happening. The internist gave Angela two different options: 1. The AIHA could be from the mass on Bailey's spleen and it needed to be removed (while his PCV was up). 2. It was a normal case of AIHA and he could add Danazol into the mix to try to boost his PCV. The internist did try to get a biopsy of the mass on the spleen but was unable to do so. It was his opinion that it was a harmless growth from the long-term use of Prednisone and Imuran.

Tuesday March 27th, Bailey was doing so well that the internist discussed with Angela the possibility of bringing Bailey home that evening. It had been 24 hours since the transfusion with no side-effects. Bailey had been taken off his IV and had been eating solid food all day. Angela decided to leave Bailey at the clinic because she didn't feel comfortable having him at home while he was on Heparin. She went to see Bailey after work and he was very alert, happy and active. Angela left, confident that Bailey was now on the road to recovery and would be back home in a couple of days.

At 6pm, Bailey was taken out of his cage to go outside. The tech commented that Bailey practically jumped out the cage he was so excited. Once outside, Bailey had a tarry, bloody stool and immediately collapsed. Another ultrasound was preformed which revealed excessive bleeding in the abdomen. Bailey was started back on IV. He continued to expel bloody stool and his PCV crashed. He was given Oxyglobin but went into cardiac arrest. CPR revived him. The internist called Angela and told her to come to the clinic as soon as possible. He explained what had been happening and told her that they would do everything they could to keep him stabilized until she got there. Bailey arrested again and started expelling large amounts of bloody fluid from his nose. The internist decided not to make any further efforts to resuscitate him.

After reviewing everything that had happened, the internist determined that the high doses of Prednisone and Imuran, and the length of time Bailey had been on them, led to probable ulceration of the intestines. The problem just progressed from there and ended up rupturing. The lowered PCV over the last few days was not AIHA. It was from internal bleeding. The bloody fluid from the nose indicated a massive blood clot in the lungs and at that point, the internist felt there was nothing that could be done. He remarked, that even if they would have been able to determine what was really going on earlier, the only course of action would have been to stop the Prednisone, which could have, and most probably would have, triggered a relapse of AIHA/ITP.

According to Angela, "what killed Bailey in the end was the drugs, not the disease, I don't want that to make people wary of using them, even long-term, on their dogs. Bailey had been on 25mg of Imuran eod for over 2 years and high doses (30mg - 20mg every day) of Prednisone for 8 months. He had been through 4 or 5 relapses of ITP and one case of AIHA. I'll be the first one to stand up and say that long-term Prednisone or Imuran use is necessary to keep a lot of dogs from relapsing."

October 2000

Devil

Devil is a 5 year old neutered male Boxer, owned by Elizabeth and Randall of Hockessin, DE. Devil was diagnosed with autoimmune hemolytic anemia on March 31, 1999.

According to Elizabeth, "Devil was a typical, goofy, lovable, high energy Boxer prior to AIHA. His change in disposition at the onset of AIHA was one of the tip offs that something wasn't right." In addition to the lethargy and drastic reduction in energy level, Elizabeth also reports Devil "suffered from a depression of sorts." Other signs of the AIHA were pale gums and excessive panting.

Upon presentation at his vet, testing revealed Devil had a PCV of 24. He was started on 80 mg prednisone per day, Doxycycline, and Sucralfate. About 6 weeks after the AIHA diagnosis, Devil was started on Cytoxan every other day for three months. Elizabeth said," I know this (Cytoxan schedule) seems to fly in the face of what every other vet does but my internist feels that the 4 days on, 3 days off is a cancer treatment and that AIHA needs to be dealt with differently." (Editors note: While this regime of Cytoxan did work well for Devil, it should be noted that according to the Veterinary Drug Handbook, Eighth edition, page 163 under the topic of cyclophosphamide (Cytoxan) we find the following quote for dealing with IMHA "Initially at 2mg/kg/day IV or PO for 4 days; no treatment for 3 days then repeat cycle)."

According to Elizabeth, "as we were climbing back up the PCV ladder, Devil began to look like he was crashing". He began to exhibit pale gums, excessive panting over and above that associated with prednisone and a decreased PCV. Elizabeth was advised to take Devil to the University of Pennsylvania where he was diagnosed with bleeding ulcers. It was determined the ulcers were a direct result of the prednisone and that they were causing Devil to lose red blood cells, thus the decreased PCV. Devil was placed on both Cytotec and Cimetidine for the ulcers. Elizabeth recalls, "once we straightened out his stomach, his PCV began to climb again." Devil's prednisone was slowly decreased over the next several months until it reached a dosage of 5 mg every third day. Elizabeth commented "I don't think we'll tempt fate and take him off it (prednisone) completely. He seems to have no adverse reactions at this low dosage." Devil continues to see his vet every 2-3 months for blood checks. He had a PCV of 50 at his last checkup on August 18, 2000. Devil is no longer given heartworm or flea prevention. In addition, Elizabeth and her vet have decided that Devil should receive no vaccinations in the future.

When asked to comment on the current state of Devils health, Elizabeth responded, "I think I would say we are very lucky. We caught his AIHA early, we had informed vets who worked with us and never ever underestimated how insidious this disease is. Surely we don't love Devil anymore then the next person loves their dog, or fought any harder or worked any harder or prayed any harder, we were just one of the lucky ones. He responded and continues to respond. We have our sweet, playful, goofy boxer back and we are so thankful. He does all the things his sister does with the exception of long runs with my husband. He is a typical 5 year old boxer- quieter, naturally then when he was a pup, but still has that ability to get into mischief."

Devil Update, August 2007

Elizabeth wrote recently with the following Devil update.

“I just wanted to send you a quick note to tell you that I had to let my Devil go. It was almost two months ago but it has taken me this long to be able to write about him without a flood of tears. The years and years of prednisone finally took its toll. He had lost so much muscle mass that his back legs just gave out so we carried this huge dog up and down the stairs. On the last day, I went downstairs to get my husband to come up and get Devil off the bed, but Devil must have felt frisky because he jumped off. I heard the thud and then heard him crying and knew I couldn't do this to him any longer. Before we took him to the vets he was under the kitchen table, I glanced his way and saw that he was intent on making eye contact with me. When he looked into my eyes I knew he was ready. We were with him in the end and held him and loved him and he went very peacefully. Of course, I miss him each and every day and will for a long, long time to come. Devil was an extraordinary dog, and what a survivor! He lived for almost 8 1/2 years past his AIHA diagnosis. He was such a trooper.

”This email is, of course, just a snapshot into the agonizing decision we had to make. These decisions are never made in one day, they are a culmination of watching closely and hoping and praying over many, many weeks. There are not words to describe the bond I had with Devil. To say that I will miss him each and every day is a vast understatement, but they are the only words I have. I know Devil is in a better happier place and I find peace in that knowledge.

“I recently made a donation to the Meisha’s Hope AIHA/IMHA Fund #338 at Morris Animal Foundation “In Memory” of our dear Devil. I look forward to the day when better treatments and a cure will be found for AIHA/IMHA so that no other dogs and their caregivers will have to battle this most difficult disease.”

November 2000

Kona

Kona Summer Mischief, affectionately known as "Kona" to her family and friends is a 9 year old spayed female American Cocker Spaniel owned by Lynne and John of Snohomish, WA. Kona was diagnosed with autoimmune hemolytic anemia on October 4, 1998.

When asked to describe Kona's symptoms prior to her AIHA diagnosis Lynne replied, " we noticed that Kona was very listless. She would get up and walk about halfway across the room and then abruptly sit down. We knew something was wrong. Normally, when we would put her 50 foot retractable leash on, she would be jumping up and down with excitement. On 10/4/98 she was not excited about it at all, and barely walked to the end of the driveway before she sat down."

Kona was immediately taken to the emergency vet clinic where testing revealed a PCV of 14. She was diagnosed with autoimmune hemolytic anemia, given an Amoxicillin injection and started on prednisone. Kona was hospitalized at the emergency vet clinic overnight. The next day she was transferred to her regular vet where she was hospitalized for 4 days. Her discharge medications included Prednisone, Baytril and Carafate. Kona's prednisone was slowly reduced over a number of months until it was totally discontinued. Two years have now passed since Kona's AIHA diagnosis, and she continues to be doing very well on no medication whatsoever. Kona's last measured PCV was 42 on March 23, 2000. Because Kona lives in the Pacific Northwest where heartworms are not a problem she does not receive any heartworm preventative, nor does she receive flea preventative. According to Lynne, " Kona is groomed by a professional every six or eight weeks. The groomer has never seen any indications of fleas on her." Kona has received no vaccinations since her AIHA diagnosis.

When asked to comment on the current state of Kona's health Lynne replied "Although our little girl, Kona, is getting on in years, she is remarkably healthy. She is more playful then she has been in years. She always comes to greet me when I come home from work. She seems to enjoy life and likes to investigate everything. Kona likes going for walks, and for the first time can go off-leash because she never strays far from us. She is much more mindful now of where we are and what we are doing. She comes to us quite often now for cuddling or to play with her toys (something she very infrequently did before the AIHA diagnosis.)"

December 2000

Mumu

Mumu is an 8 ˝ year old spayed female Shih Tsu or Shih Tsu cross owned by Kelly and Chris of North Vancouver, British Columbia, Canada. Mumu was diagnosed with Immune-mediated hemolytic anemia on May 25, 1999.

According to Kelly; " Mumu had been diagnosed with a back problem ( disc trouble) some time before the IMHA. Mumu would quiet down if her back was bothering her. I assumed, for perhaps a week before her crisis, that Mumu's uncharacteristic quiet behavior was a result of a painful back. But I became concerned when Mumu didn't eat for a couple of days, and then I noticed that Mumu's breathing wasn't normal and her tongue and gums were so pale. The vet suspects that Mumu had suffered with IMHA for some time before diagnosis and her body had become somewhat accustomed to functioning with the anemia."

Mumu was taken to her local vet where testing revealed a PCV of 14.2. Mumu was diagnosed with Immune-mediated hemolytic anemia and thrombocytopenia. She was immediately sent to a 24 hour emergency clinic where x-rays were taken to look for any usual mass or an enlarged spleen. The vets at the emergency clinic explained the seriousness of the disease to Kelly & Chris and outlined a possible treatment program which included hospitalization, transfusions, oxygen and heparin. The cost of this treatment was estimated to be between $5,000 and $10,000, (Canadian dollars) depending on how long Mumu would need to be hospitalized. The emergency vet also made a point of telling Kelly & Chris that even with all the care in the world this disease often proves fatal. Because Kelly and Chris felt the estimate they were given for Mumu's care was out of their financial grasp, they decided they could not offer Mumu these treatments. They asked the vet for any possible way to treat Mumu that would fall within their means. Mumu was sent home the following day for what everyone thought would be palliative care, under the supervision of their local vet. According to Kelly, " Mumu seemed to focus on survival, and she seemed like a completely different dog for the longest time after diagnosis. Mumu was unable to move. We fed her through a feeding syringe, we also syringed her water, orally. We held Mumu up to go potty. She didn't walk, bark, eat or anything at all. It seemed she just focused on breathing."

Mumu initially received 15 mg of prednisone twice per day, 16mg Imuran once per day and 500 mg of Sucralfate for stomach protection, three times per day. When it became apparent the meds were not working for Mumu the prednisone was boosted to 30 mg twice per day. When this high dosage of a prednisone led to many side effects, the prednisone was cut back to 25 mg twice per day. In June 1999, the prednisone dosage was lowered to 12.5 mg twice per day and the Imuran was lowered to 8 mg once per day. The Imuran dosage and schedule had been modified a few times during this period. In July, 1999, the prednisone/Imuran combination stopped working for Mumu and her PCV began a slow slide downward. Mumu's vet suggested she be taken to a veterinary internal medicine specialist for a consult. At the suggestion of the specialist Mumu received both an ultrasound and bone marrow biopsy. The results of the bone marrow biopsy indicated that Mumu was producing mature red blood cells, but not as many as one might expect in the case of anemia. The high prednisone dose and/or the Imuran could possibly have been impeding red cell production. The ultrasound results indicated that the liver and kidneys appeared generally normal, any minor anomalies may have reflected the medication. The bladder, and stomach appeared normal. The spleen while quite small, appeared normal, unusual for IMHA cases. The abdominal lymph showed no evidence of enlargement. The gall bladder did show signs of "sludge". As a result of the bone marrow aspirate (and Mumu's clinical signs--sliding PCV and signs of pancreatitis ), Mumu's medication protocol was changed. On August 26, 1999 the Imuran was stopped, cyclosporine started and a very gradual weaning off of the prednisone began. Mumu was started on cyclosporine (Neoral, liquid) at a dosage of 45 mg twice per day. After the first trough level test on September 9, 1999, the cyclosporine dosage was increased to 50 mg twice per day. According to Kelly, " I think that it is important to note that although Mumu developed ulceration/inflammation in her sublingual folds (under the tongue), Mumu was not given antibiotics. This inflammation was possibly a side effect of the cyclosporine. Mumu's vets felt that because many drugs, antibiotics included, can alter the level of the cyclosporine in the body, antibiotics could cause complications. We used an oral rinse instead." The prednisone was slowly tapered off as the PCV started to rise and after a tapering process of nearly a year, Mumu was totally off the prednisone in August, 2000. Mumu continues on 50 mg cyclosporine twice per day. Mumu had a PCV of 40 at her last blood test on November 2, 2000, with all other parameters being stable. Kelly noted that "cyclosporine also involves a more specific type of blood test called trough level testing." When asked to explain that test she replied. "This is quite a ritualized event. We feed Mumu her breakfast, and then take her to the vet, who draws her blood at precisely cyclosporine administration time. Then we give her the cyclosporine at the vets office on time. The trough levels (which for us are sent to the U of FL at Orlando) are separate tests from the CBC's. The trough level measures the amount of cyclosporine in the blood, at the lowest time. It's meant to determine how much of the drug the animal is absorbing and able to use, hence what dose is needed." In addition Kelly commented that, "food also changes the amount of cyclosporine absorbed by the dog. That's why a strict feeding schedule is also very important and also why it's important to feed the same food all the time, within two hours before and after the cyclosporine." Mumu has not been vaccinated since her IMHA diagnosis nor has she received any heartworm or flea preventative.

When asked to comment on the current state of Mumu's health, Kelly, replied, "Mumu is back to her old self; a feisty little trouble maker who enjoys intimidating and dominating all other dogs around her. It seems to me that Mumu doesn't take life as seriously as she used to. Before, intimidating another could be a life or death situation. Today, Mumu appears to enjoy getting into trouble but her "bloodlust" is gone. Mumu follows me everywhere, as she used to, and seems to take life in stride." Kelly also added, "I think it is important that people should know that it is possible to treat a dog despite financial hardship. I don't believe in euthanising a dog unless absolutely necessary, and although it seemed to me a few days into the disease that Mumu was suffering, my husband, the vet and I decided, based on a bit of an improvement in her blood work, that we should continue treating her and give Mumu more time to see if she was willing to fight the fight."

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