Recurring IMHA after remission – Could thyroid be the problem?

Trina

Guest

My 7yr old blond border collie, Vienna, was initially diagnosed with IMHA in March 2019 secondary to Bartonella from a tick bite. She initially presented with vomiting off/on for 12 hours, perky, playing and no other symptoms. PCV 40. Diagnosed her with a UTI and kept her 2 nights on IV fluids. She had been drinking water just fine but I agreed. On day 3, I picked her up from ER vet and she looked horrible. A few days later they said her urine culture grew e-coli and changed her antibiotic from amoxy. to Enrofloxacin. She was ok but still not great. Then she became lethargic. Returned to ER vet and this is when her PCV dropped to below 20. She had 3 transfusions before her meds kicked in. She was in the mid-20’s for a few weeks then hit the mid-30’s and her last PCV check on July 3, 2019 was 46. She was off all meds at that point.

On July 30, 2019, she was lethargic and no appetite. Took her to her vet not even thinking it was IMHA again. Her PCV was 18. Transferred to Emergency Vet for transfusion and restarted all meds (Doxy, Enro, Prednisone, Mycophenlate, aspirin.) Up to 24. After 2 more transfusions, she was stable at 19 so we took her up to NC State Vet Hospital on 8/6/19 since they specialize in IMHA. They reviewed her past records and completely reversed everything we had been previously told. Even though she greatly improved on Doxyclyclene and Enrofloxacin, they stated her IMHA was not caused by Bartonella. Also, apparently there are 8 indicators in the blood work that point to a definitive IMHA recurrence. She had none. So we were at square one and I was up all night with worry. They retested her CBC the next morning and now she had 4 of the markers. Her ultrasound also showed stomach thickening which she had back in Feb/March and completely resolved but now that was back. Did not appear to be cancer since it did not grow larger than the initial ultrasound. Put her on intravenous meds, tube in her stomach for nutrients since she threw up her only meal, stomach protectant for possible ulcer, fluids, frozen plasma to counteract fluids. No transfusion. Her PCV went from 20, 23, 20, 19. On day 3, she had 6 markers for IMHA recurrence. Discharged on day 4. She has been good and stable since we brought her home on 8/10. Return to local vet tomorrow 8/11. Her body is adjusting to a lower RBC but we will return sooner if she looks worse.

My questions are:
1) I cannot recall anyone saying anything about her thyroid. I am going to ask about this being tested tomorrow but since everyone has been wrong since the beginning I feel like we are back to square one.
2) Also, what about vitamins to stimulate the red blood cell production as I know she is regenerating on her own.
3)Did her ulcer mask the IMHA indicators? 4)Could the antibiotic prescribed initially for her UTI have caused the IMHA?

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Patrice

Keymaster

Hi Trina,
I’d be very curious to see the CBC and Chem Screen from the university.

I am not sure what their complete objection was to the diagnosis of Bartonella. It is known that some dogs never clear their system of Bartonella. You could call them carriers if you want, but in any case it can relapse in some dogs. There isn’t a specific treatment for this disease.

I also want to know if anyone has checked for all tick diseases. The easiest and cheapest screening test is called SNAP4DX+ It tests for 4 tick diseases and heartworm. The test only takes a small amount of blood and the results are ready in about 8 minutes. See this page about the Snap Assay Device and look at page 5 for this test. https://www.secondchanceaihadogs.com/wp-content/uploads/2017/02/SNAP-Assay-Technology.pdf

It is very possible this is also one or more chronic tick diseases. I am concerned about coinfections of Lyme, Erhlichiosis and Anaplasmosis. This test will look for these. Lyme has a particularly strong co-infection with Bartonella.

I think it’s important to stop for a second and think about the kinds of things that can lead to the expression of IMHA in dogs. Owners often want to know why their dog is so sick and that is understandable. So did I. But sometimes the triggers that lead to these diseases; AIHA, IMHA, non-regenerative anemia, bone marrow failure are multiple and sometimes those triggers can not be identified and more importantly treated. In those cases it is critical to do enough tests to determine if a treatable condition exists.

One of the things we know about Border Collies is that they have a particular genetic disorder from a mutation called MDRI that affects how they respond to certain medicines. This defect allows certain medications and other agents to pass through the blood-brain barrier. Using certain drugs in a Collie that carries this mutation can cause serious reactions. MDR1 is the abbreviated name of the gene called Multi-Drug Resistance.
Here is a list of some of those:
1. Antiparasitic agents: ivermectin, milbemycin oxime, selecamectin, moxidectin, abamectin
2. Gastrointestinal agents: loperamide (over-the-counter antidiarrheal agents, e.g., imodium AD, some formulas of Kaopectate and PeptoBismol)
3. Anticancer agents: oxorubicin, vincristine, vinblastine
4. Immunosuppressive agents: Cyclosporin, cyclosporin A, tacrolimus
5. Cardiac agents: digoxin, quinidine
6. Antibiotics: erythromycin, grepafloxacin
7. Steroids: dexamethasone, hydrocortisone
8. Tranquilizers: acepromazine
9. Pain control: butorphanol, ondansetron

Some drugs that could affect sensitive Collies:
domperidone
paclitaxel
mitoxantrone
etoposide
rifampicin
morphine

I wanted you to know this for your reference but also understand that this particular genetic defect is probably not related to IMHA but might cause other symptoms in tandem.

So what are some of the big triggers for IMHA and exactly which of those did your multiple vets test for?

Dr. Dodds has written a fantastic explanation called The Canine Immune system and Disease Resistance. See this article:
https://www.secondchanceaihadogs.com/wp-content/uploads/2017/06/The-Canine-Immune-System-and-Disease-Resistance.pdf

She has a good summary in the middle of the page:
“The four main causative factors of autoimmune disease have been stated to be: genetic predisposition; hormonal influences, especially of sex hormones; infections, especially of viruses; and stress.”

She discusses thyroid contributions to immune diseases, as well as vaccinations, and cancer.

At the bottom in Table 1 she goes into detail about triggers for the expression of autoimmune disease. She lists genetic or familial history as one of her main four factors. Border Collies are one of about 8 breeds who are known to have a strong tendency to autoimmune conditions.

So if we combine the four main causative factors we find Vienna has genetic predisposition, possible exposure to viruses and stress. We don’t know about her hormonal influences or infections. These would be something to evaluate as possible triggers as well. If there is an infection treatment might help.

So what can we do about these triggers? We can’t control genetic influences, but we might be suspicious of the bacteria infection she had, Bartonella.

You asked about hypothyroidism and the connection with IMHA and other conditions like bone marrow failure and non-regenerative anemia and you mention that her coat fell out. Prednisone can definitely cause the coat to fall out but it can also be related to hypothyroidism and is one of the first signs of it in dogs. Chance was a Giant Schnauzer, they have hair not fur, and his coat was completely shot, he did not grow much hair during his treatments and what he had was like a brillo pad.

The thyroid gland plays a large role in the body and influences many systems and organs. You might think of it as the leader of the band. With illness the thyroid gland can slow it’s contribution to certain processes, one of which is the production of red blood cells and platelets in the bone marrow. If there is a refractory anemia, one that doesn’t seem to respond to treatment, utilizing the “push” power of thyroid hormones can “jump start” the production of red blood cells. The thyroid tests may show a normal value in a dog but it might be at the very lowest normal value. Stimulating the thyroid gland in these cases with thyroid hormone can actually encourage the bone marrow to produce again. She this reference from Dr. Dodds, one of the most poignant statements is “Anemia is often the first sign of hypothyroidism” :
https://www.secondchanceaihadogs.com/wp-content/uploads/2016/07/Thyroid-Hematopoiesis.pdf

So a number of dogs we have helped, and both my Chance and Vally’s Bingo responded to thyroid supplementation. Chance had already been diagnosed with hypothyroidism previously. This was a critical additional treatment for the IMHA.

Vitamins. Well, a dog can get most of all their needs through food. If they are not eating well then supplementation is appropriate, but it’s wise to be cautious. Some supplements in too great of a quantity can do great harm. Iron is one of these because it is stored in the liver and too much could lead to toxicity. So avoid specific iron tablets.

If you want a quick and easy supplement Dr. Dodds always recommend Pet Tinic. So the type of anemia that is related to nutritional deficiencies is not very common. The major ingredients the bone marrow needs to build new red blood cells are B12 (cobalamin), iron (ferritin) and folic acid. These are generally stored in the liver. If the liver is inflamed or has other organic disease it might not store or release enough. So there can be a deficiency that is related to problems with the liver.

There can also be a deficiency of B12 due to specific disease of the small intestine. This is common in dogs and is called SIBO small intestine bacterial overgrowth. This inflammatory condition can interfere with absorption of nutrients, most specifically B12. No amount of oral administration will supplement this, it is given as an injection. I gave these to Chance when he had bone marrow failure, along with his thyroid supplements.

Other than these, the best nutrition is easy to digest foods. High quality lean protein is very important, as is moderate to low fat and easy to digest carbs. The diet we usually recommend is Dr. Dodds liver sparing diet:
https://www.secondchanceaihadogs.com/wp-content/uploads/2015/08/Cleansing-Diets.pdf

Finally. Ulcers are a huge problem in the treatment of IMHA. Too many vets ignore how volatile the combination of the extremely low pH of the dog’s stomach acid is combined with the erosiveness of prednisone and forget to offer stomach protection. I have seen many cases of ulcers in dogs being treated and some dogs have died from their ulcers. The blood loss on a regular basis can lead to it’s own contribution to anemia. Even simple generic pepcid once a day 30 min before meals is an easy supplement.

Since I haven’t seen any of the paperwork or tests it’s really hard for me to pin down exactly what is happening. I feel that the vaccination combined with her exposure to Bartonella and her being a Border Collie could have contributed. These are 3 of Dr. Dodds main triggers. If she was stressed out that could have also contributed.

You may never know everything. When Chance was so ill, there wasn’t a lot of information available, it was long ago enough that the internet didn’t have much. It literally took 10 years before new research came out and I was able to carefully piece together all of it to finally figure out what had happened. I knew a lot and I had a good idea what it was, but it was the research that finally showed me I was correct.

What was important was that Dr. Dodds had faith that her protocol would work for him and that he would survive, even though all the medical experts said that he probably wouldn’t. Administering the protocol, with blind faith, was the most important thing I did.

We were both quite pleased he survived and returned to his normal self again. With each dog we help, though, I do relive all the pain of watching Chance get sicker each day. It never is easy to watch other dogs go through this.
Have I answered some of your questions? Patrice

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