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2013-01-16 3:05 PM

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Subject: veterinary question

My two-year old dog is on two immunosuppressant drugs for immune-mediated thrombocytopenia.  He very nearly died this weekend of the TCP.  And while his red blood cell volume is (finally, thank God, though it is still a LONG way from normal)improving, his white cell count is abnormally high and rising.  The immunosuppressors should cause a drop in white blood cell count, shouldn't they? 

My vets don't offer any explanation; does anyone here know anything that might address my confusion?

Scott



Edited by scott319 2013-01-16 3:05 PM


2013-01-16 3:18 PM
in reply to: #4581509

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Subject: RE: veterinary question

While I am not a vet, any time I see elevated white blood cell count I look towards two sources, infection and disease of the bone marrow. If there was an infection the immunosuppresents would still suppress the immune system which would actually allow the infection to grow. In this case I would look at any sort of Bone Marrow disease. I know for humans those can be detected, sometimes, via Periphreal blood smears but most often through a bone marrow biopsy.

Again I am not a vet, the above are just my thoughts. I would consider getting a second opinion with a specialty vet/clinic if at all possible.

Also, very sorry your puppy is not feeling well. Those time can be so very hard to deal with though I am glad some of his counts are improving!

2013-01-16 6:37 PM
in reply to: #4581509

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Subject: RE: veterinary question
Tcp is a lowering in platelets. From your post ( low red blood cells) it sounds like your dog has IMHA. The WBC is high due to the immune system being in overdrive. It can take weeks to see the WBC lower. I assume the drugs your dog is on are prednisone and azothioprine. They are the standard treaent for IMHA and Tcp. It takes time for the drugs to work. Hopefully you will see results soon. It is not uncommon for dogs to even need blood transfusions while the drugs are building up in the system. I would say 60 to 70 percent of dogs will respond to treatment. Heartworm disease would drastically reduce this high success rate. Hopefully your dog doesn't have this serious disease with the IMHA.
2013-01-17 12:32 PM
in reply to: #4581785

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2013-01-17 1:47 PM
in reply to: #4581509

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Subject: RE: veterinary question

Thanks, all.  My vet says it is Immune-Mediated, but does not say it is Hemolytic Anemia.   (He is still in the "ideopathic" state of mind, I guess?)   The drugs are indeed the ones you stated.  Yesterday's PCV was to 13.6%, up from a measured low of 10.8%, platelets are extremely low but rising slowly, so the trend is good.  It was just the WBC that was confusing me.

The dog is now walking a bit, and no indications of any organ failures.  It's been scary, though - my wife woke me in the very wee hours of Sunday morning because she thought the dog had died.

At any rate, it's looking better now.  I have hope for the mutt.

Thanks again,

Scott



Edited by scott319 2013-01-17 1:49 PM
2013-01-17 10:43 PM
in reply to: #4581509

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, Wisconsin
Subject: RE: veterinary question

Hi Scott - 

Glad your dog is hanging in there.  Some of these immune-mediated conditions are tough.   To clarify, I see comments about two different disease conditions above:  ITP (Immune Mediated Thrombocytopenia - a condition affecting platelets; the cells that help with blood clotting) and IMHA (Immune Mediated Hemolytic Anemia- a condition affecting red blood cells).  Dogs can become anemic with both conditions. 

With ITP, the very low platelet levels result in spontaneous bleeding.  These dogs often have unexplained skin bruising, nose bleeds, or bloody vomitus or diarrhea.   The platelet numbers are often very, very low and protein levels (albumin & TP) are often low as well due to blood loss/hemorrhage.    

In IMHA, there is destruction of red blood cells - resulting in anemia.  These dogs aren't bruising or bleeding per se, but they are can have red tinged urine due to broken down red blood cells.  These dogs usually have normal protein levels since they are not bleeding, and they can have normal platelet numbers.

We always look for an underlying cause (cancer, recent vaccines, recent new medications, infectious diseases) but I'd say many, many cases are idiopathic meaning - we don't know the cause.  Both ITP & IMHA can be considered "idiopathic" conditions.

Regarding the elevated WBC count - as others mentioned, that is very typical of IMHA and the reasons can be multifactorial.  As the bone marrow is working very hard to produce new red blood cells, the over-stimulation can increase WBC numbers.  Also, some of the elevation may be due to the inflammatory response as the body is dealing with red blood cell breakdown products.   Finally steroid (prednisone) also can contribute to the elevated WBC count.  I will say...I personally see these high WBC counts more commonly with IMHA, rather than ITP.  Regardless, I'd say the WBC elevation is the least of your concerns right now.

If there is question about whether you are dealing with primary ITP or IMHA, looking at the protein levels and a saline agglutination test can help determine that.  Also, sending a CBC (complete blood count) to a lab for pathologist review can be helpful too as there are certain characteristics of cell morphology that are typical of IMHA.  Some dogs can have both ITP & IMHA (known as Evan's syndrome) and the prognosis, unfortunately, can be worse. 

Wow!  A PCV of 10% and even 13% is incredibly low.  I start thinking about administering a blood transfusion to any pet dropping below 20-25% that is showing any clinical compromise.  There are no absolute guidelines but I pretty much transfuse any pet with a PCV as low as your dog's.  Normal PCV, FYI, is about 35-55%.  It can take days for the immunosuppressants to begin working and often pets needs the support of transfusions in the meantime.  The only way to truly give platelets (if ITP is the primary problem) is with a fresh whole blood transfusion.  If it's IMHA, stored whole blood or packed red blood cells can be helpful too.

Best wishes with your dog.  He sounds pretty sick.



2013-01-18 8:24 AM
in reply to: #4581509

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Subject: RE: veterinary question

SpottedCow -

Thank you for the very detailed response.  My internet searching had also indicated IMHA, but since the vet didn't use that term, my wife convinced me that I ought not to say it either.  She's a pretty smart lady, my wife, and I decided to take her advice.

His condition definitely includes destruction of red cells - PCV plunged from 29% on Tuesday last week to 10% on Saturday, and his urine was indistinguishable from blood on Thursday and Friday.  By Saturday, he could no longer stand.  We have opted not to transfuse, at least not yet, as we were cautioned by one of the more senior vets at the practice that, because his body was already destroying his own blood, any foreign blood might cause the problem to be magnified.  Platelets, by the way, were below 20 on Friday last week.  I don't know the platelet count of the most recent CBC, but we are seriously lucky this dog is still alive, I think.

All bloodwork is scary for this pooch, but as I noted previously, he is showing some signs of slow recovery.  PCV is up a bit, and his energy level is better though still far less than normal, as one might imagine.

Thanks again, both for your medical knowledge and for allowing me to have this outlet for my concerns.

Scott

2013-01-18 11:24 PM
in reply to: #4581509

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Subject: RE: veterinary question
Glad to hear your pup is feeling a little bit better, Scott.  Prayers that he continues to heal.
2013-01-21 10:05 AM
in reply to: #4581509

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Subject: RE: veterinary question

Likely the final update on this topic.

First, thanks to all for the well-wishes and information.  It helped, a lot.

Second, George is recovering, it seems.  Platelets and White cells back in the normal range as of this morning, and PCV up to 26%.  He is now walking, eating everything in sight (which is unusual for him, even before he got ill.  My guess is that's the steroids talking) and seems pretty happy again.  In a couple of weeks we will try to get him back into his pre-illness routine, which included about an hour of playtime with his dog friends each morning, and a 45-minute to one hour walk each night.  Right now, he is at a single short (about 20 minutes) walk once a day.  We expect to take him off the immune suppressors, tapering off, starting in a couple of weeks, as well.  The only problem now is a bit of incontinence.  But we have learned to wear shoes in the house, and deal with it.

Thanks again,

Scott

2013-01-21 2:49 PM
in reply to: #4581509

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, Wisconsin
Subject: RE: veterinary question

Great to hear!!!  Dogs never cease to amaze me  Fingers crossed that he'll continue his road to full recovery!

2013-01-21 11:55 PM
in reply to: #4581509

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Subject: RE: veterinary question
Great news!  Yeah, the pred works great, but the increase in eating and urinating aren't so fun!  Best of luck to you and your pooch.


2013-01-22 12:19 PM
in reply to: #4581509

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Subject: RE: veterinary question
Glad you dog is doing better!  My guy had ITP a few years ago, almost lost him.  I thought about putting him on a raw food diet, but the vet said since he had a compromised immune system, that he should eat cooked food.  Better safe than sorry.
2018-04-09 6:20 PM
in reply to: scott319


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Subject: RE: veterinary question
My dog, Suki, has been struggling since before December with Thrombocytopenia. Recently, they have upgraded her diagnosis as Evan's Syndrome. This scares the crap out of me. We started an immuno suppressant about 2 weeks ago and she is still on the steroid. I'm a bit discouraged because her platelets do not seem to be responding to the new treatment. The only thing that seemed to help is high doses of steroids.

She is currently on 20 mg once a day of steroids plus the immuno suppressant. Her platelets today were at 91, they have been as low as and they could barely draw blood. Her blood pressure was low and her veins would not give blood.

The bloodwork that seems out of whack is the following:

MCV 75.0 fL slightly high
MCH 26 pg slightly high
PLT 91 K/uL low
PDW 19.9 fL
PCT 0.10%

Questions: Am I expecting too much too soon? She seems to be in pain or at least inflamed, is that common?

Thank you for your advice.
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