12 year old mixed breed; new IMHA diagnosis

[Ashley]

Hi, all,

Sad to be saying hello under these conditions, but happy to have found this site and what seems to be a very thoughtful and empathetic group of people.

I find myself here after a week of rollercoaster emotions dealing with my sweet pup, Flynn, a 12-year-old mixed breed (perhaps border collie or sheltie and who knows what else). His entire 12 years have been….well, strikingly healthy. That changed last week.

Started with an evening of diarrhea, followed by him vomiting once in the morning. Didn’t worry too much at that early point – they get stomach upsets from time to time, and it’s normal, in my experience. I tend to keep an eye and wait for signs of improvement. By evening, after he skipped his breakfast and also his dinner, laid around lethargically, and hardly drank water (if at all), I was beginning to worry. Finally, after he spit out the “good” treats and some straight up chicken, I brought him to the emergency vet. They diagnosed him with pancreatitis (elevated lipase/results of lab work suggested it, plus a pain reaction when they palpitated his belly in that area), dosed him with Cerenia (anti-nausea) and subcutaneous fluids, and I was on my way home with antibiotics (metranazidole) and painkillers (buprenex).
The next day, I started to get worried that he was dehydrating when he STILL wouldn’t eat or drink. Followed up with my vet, and we agreed to check him in overnight.

He was on the upswing the next day, or so we thought, until they noticed his urine was reddish, ran some lab work, and discovered low hematocrit (33.6) and upon a blood smear, indications of IMHA (agglutination, and some other characteristics the vet mentioned). She quickly started him of prednisone and two antibiotics (Baytril and doxycycline), plus Carafate to coat the stomach.

They next day, hematocrit was lower (32.8) so she added azathioprine. He came home with me that evening, because no one staffs the clinic overnight, and I was beside myself after reading about IMHA on the internet. His urine was pure crimson red that evening, and I almost fell over when I saw it.

Since, he is up and down. Today, mostly down. His using is no longer red (it looks normal), and we had another blood test yesterday, which had good news of hematocrit at 38.4 (low normal) but he is so, so, so lethargic. He has been eating chicken and egg whites, but sticking his nose up at most everything else.

We have no idea what caused the IMHA, though I am glad that his numbers and condition have not been as dire as some I’ve read about yet, as it seems we had the good fortune of being at the vet when everything started.

I guess what I’m here to ask about and solicit opinions on is: (1) should I expect this level of lethargy as a result of the drugs? Or is this the anemia speaking? Or both? It’s hard to not panic that he’s crashing in between checkups. (2) Has anyone ever heard of pancreatitis or the drugs I mentioned triggering sudden IMHA? Or vice versa (remember, pancreatitis occurred BEFORE the immunosuppressants, which I understand can cause pancreatitis on their own)? Or should I think that this was all a coincidence and the two conditions are unrelated?

He has been 100% healthy and full of vim and vigor up until these two side by side occurrences. I can’t imagine what happened. I fed a new chew (Honest Kitchen tall beams, which are fish skins, basically), he at some people food, and we had a trip to a tick-plagued area, but he’s on tick preventive and I’ve never found a tick on him (no results in from tick panel yet, but we’re waiting on it).

Curious what you all think…and looking for moral support as I try to navigate my cycles of panic throughout the day.

Thanks for your time, and so much for any thoughts or ideas you can share.

[Vally]

Hi Ashley and welcome. Sorry a bit slow to answer (I’m having some problems with my almost 95 year old dad).

Yes, I too am sorry to meet people here because I know we meet because our dogs are very sick, but it also binds us because we all know what we are each going, or have gone, through.

You were great to rush Flynn in for treatment. Quick treatment gives you a huge advantage.

With the breakdown of the red blood cell, the urine becomes discoloured. It’s a very good sign that the urine has now cleared.

Flynn well done on that great blood test of 38.4.

As Flynn’s blood count has gone up and you’re seeing the lethargy, then I would say yes it’s a result of the drugs, particularly the prednisone. What dose is he on and what is his weight? It’s a miserable drug because of the side effects it causes, but we all have great respect for it. If you read the side effects you’ll see why Flynn may not be feeling so good right now:
https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone

It’s not unusual to see pancreatitis with AIHA dogs because, as you say the drugs can trigger it. You’re question is interesting, and I’m going to keep searching. I did find a reference to an underlying disorder of the immune system may target red blood cells and the pancreas, but they were talking about CATS, so I don’t know. I’ll run it past Patrice, the site owner, she’s very cluey about all things.

One thing I did find though, and that relates to the thyroid. Has Flynn’s thyroid levels been checked. Hypothyroidism can certainly trigger pancreatitis and it can also trigger AIHA, so make sure Flynn has that checked.

It may also be that Flynn had some sort of infection, and I note the vet is treating with Doxycycline. That may be another trigger for both pancreatitis and AIHA.

See this about pancreatitis:
https://www.secondchanceaihadogs.com/AIHA_Terms/pancreatitis

Again, Ashley you and Flynn are very welcome here. Ask anything at all.

My very best, Vally, (angel Bingo) and the new pest Saba.

[Ashley]

Good morning Vally (and of course, sweet angel Bingo- I am so sorry for your loss, even if it has been some time, and Saba :)),

Thank you so much for your compassionate and thoughtful reply. Understood on the delay; I know how difficult it is to take care of ailing family. My kindest thoughts go out to you.

Flynn went back for a check-in yesterday; his HCT dropped to 36. The vet said this can happen, and it’s not uncommon, and while she seemed somewhat concerned she didn’t ring alarm bells. She set up another test for Thursday (this check-in test occurred Monday evening). Does that sound right to you, or should we be testing more frequently?

In regards to your questions, Flynn is on 20 mg of Prednisone, every 12 hours. He is also on Azathioprine 50mg, every 24 hours. He started taking the drugs Wednesday (Pred) and then Thursday (Aza) after hematocrit went from 33.6 to 32.8 overnight (again this was last week; this week’s two readings have been 386. and now 36).

We have not tested for thyroid issues; maybe best to ask my veterinarian to test for them when I go back on Thursday.

Also, you wrote that it may be that Flynn has some sort of infection- did you mean the infection could trigger IMHA, or the doxycycline? I want to make sure I’m understanding your note; I don’t think I saw doxycycline on the triggers list on this site, but maybe I missed something elsewhere!

He seems so low. It breaks my heart. Worse, I can’t tell if I should be panicking that his pancreas is flared or flaring, or his body is lysing RBCs, or if it’s just the drugs. He is eating (very pickily- I just made up that adverb now- boiled chicken, some egg white, a little bit of GI formula wet dog food from the vet, but not much else interests him), no vomiting, normal stools (one did have a small streak of red blood yesterday but since have been normal- the vet and I discussed and it may just be a little upset or that he hadn’t passed a stool for days and days after his pancreatitis bout); he does get up to go outside with me, and occasionally comes to check on me (especially if I start to cry), but otherwise he just lays there. It hurts to see him like this. I check his gums every two hours and can never decide if they are more pale or I am imagining things out of worry.

My poor guy. Thanks for giving him and I a place to come and be with others who understand the challenge and sadness.

Best,
Ashley

[Ashley]

Vally, I forgot to add re: medicine dosage, Flynn is 27 pounds.

[Vally]

Morning Ashley, although it’s my night. I’m in Sydney Australia.

Okay, with Flynn being 27 pounds,the prednisone dosage is a bit high, but it’s sometimes started higher than usual to help it to work quickly. It’s generally given at a dosage of 1mg per pound, divided into two doses.

A drop from 38.4 to 36 is really truly nothing. Flynn may have been slightly more hydrated than the previous test, maybe a bit more stressed, the weather? Anything can make an impact and it can change from one hour to the next, so as long as there is no steady decline, then there is no need for concern. Having said that though, I know every time Bingo’s went down even a tiny bit, I’d be really nervous until the next test and be worried waiting on the results.

I would definitely ask about Thyroid. Bingo was 7 when diagnosed and the first thing that came up wrong in testing was his thyroid, so I’m pretty certain that was probably the culprit, but we never really had any answers, as many others. Bingo actually survived the disease. He remained in remission until I lost him to a cancer in January last year.

An infection can trigger IMHA. Doxycycline is a safe drug for our dogs.
A streak of blood in poo usually isn’t too worrisome. Black stools are more to watch out for.

Don’t check his gums if he’s been lying around, they’ll always be paler then. Check them when he’s awake and more alert. With a PCV in the mid 30s though, Flynn is doing really good, I promise.

If you have a copy of blood test results, use the Urgent Advice and send them through. I’ll make sure Patrice sees them.

Vally & Saba

[Ashley]

Thanks, Vally. Your post gave me a lot of comfort. It’s hard not to know what to worry about and what not to worry about when you’re new to this condition and all that is involved with it. The tip on the pale gums is an excellent one, that I’ll keep in mind going forward. I don’t have the most recent results on hand, but do know that they showed a decrease in WBC in addition to RBC (the vet said this is good, as it means the drugs are suppressing the WBCs as planned).

It also gives me comfort to hear of Bingo’s success and subsequent years of good health. When you google IMHA, it’s hard not to find yourself in a dark spot pretty quickly. Aside from the general ominous articles, it seems every commenter begins with, “Heartbroken…we just lost our dog to this condition…” or some variation. Maybe it’s that most of the posters are grief-driven, and those with happier outcomes tend not to feel that need to release pain through sharing it with others that prompts the sad posts. At any rate, I am happy to have found this forum, which provides a somewhat more balanced reflection of the reality of the disease, and success stories! Hope is an important thing.

I plan to ask for a copy of bloodworm on Thursday, and I also plan to request a thyroid test. Will keep you posted on the results! Cross your fingers for us!

[Ashley]

To clarify, I don’t mean the vet said decrease in RBC/hematocrit was good- but rather, her comment was re: the WBC count specifically.

[Ashley]

OK- after today’s bloodwork, I can really use multiple brains coming together to help. Flynn’s HCT dropped, 36.6 down to 33.2. Adding to concern reticulocytes (spelling??) are now dropping. 4/14 was 37.9, 4/16 was 21.1, now 4/18 is 5.3 (!!!). Not sure if the immunosuppressants are suppressing development, or if they are being attacked as well?? I attached all three labs as images to my urgent advice message, please let me know if you have any questions on these!!

Doctor says we can try changing azathioprine 50mg for my 27 pound Flynn from twice per day to every other day (not sure if this is culprit or if doing so will endanger him??)…we could also do bone marrow test to see if marrow is suppressed. Or I could drive 3 hours to a teaching hospital that has very good round the clock care to try to solve this. Or…what?? I am not sure how to make heads or tails of this, and my emotions and anxiety about this downward trend are particularly unhelpful.
Also to note, I left w/levothyroxine per the treatment protocol you have posted by Jean Dodd. Also testing for thyroid, but should I start the levo regardless of results, per that protocol???

Any advice, thoughts, etc. greatly appreciated as Flynn and I face this awful challenge…