Patrice - 66. page

[Patrice]

Sheena wrote:

Hi Erica

Here is some important stuff for you to take to the internist.  The spleen is an amazing organ which is a blood cleaner & in dogs acts like a bag of blood (like a transfusion almost) that can quickly be released into the blood system – that’s why they can suddenly wake up & run like the wind!

Been looking at splenectomy information for you to discuss on the 11th

Extract from http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=569903&sk=&date=&pageID=7

Splenectomy 

Splenectomy is considered one of the last-choice treatments in canine IMHA. The benefits arise from removing one source of B cells and splenic macrophages, the primary culprits in the removal of antibody-coated erythrocytes.²⁴ It is undetermined how effective this procedure is in routine IMHA cases, since only one recent clinical study has been done to assess it as a forerunner of treatment.³⁷Although this study did show increased survival with splenectomy (58% survival vs. 37.5% in the control group), the sample size was small.

Consider splenectomy only in patients that have not responded to immunosuppressive medications, require high-dose and long-term medications to maintain a remission, or are experiencing severe side effects from medications. As there is a risk of developing marked infection after splenectomy, it is not recommended for patients taking multiple immunosuppressive medications.¹

Looking in my human haematology book, spleen examination:

Ultrasound to image the spleen for examining structural detail & check the blood flow.  This can also detect whether or not blood flow in the splenic, portal & hepatic veins is normal, as well as liver size & consistency.  CT, MRI & PET scans give a more detailed examination of fine structures.

Check for haemangiosarcoma, cysts, tumours, splenic torsion, splenomegaly (enlarged spleen), hypersplenism (this means enlargement of the spleen & reduction of at least one cell line in the blood in the presence of normal bone marrow function – maybe this is what your vet is thinking about?) & hyposplenism. Functional hyposplenism is revealed by the blood film findings of Howell-Jolly bodies (bits of DNA remnants from circulating immature red cells – immature cells with DNA still present were mentioned in Tilly’s blood tests) or Pappenheimer bodies (siderotic granules on iron staining). This is why it’s so important for Tilly to have this blood film analysis done.  Hyposplenic patients are also at risk from infections, e.g. those that have their spleen removed.  After removal of the spleen, platelets can rise, so there is a risk of  clotting, so aspirin/heparin therapy would be needed,  also susceptibility to infections is drastically increased & antibiotic therapy is needed.  Long term alterations in cell counts can be seen in humans, including persistent low platelets, low lymphocytes or low monocytes.

You may be interested to know that blood cells can be formed by the spleen (& liver) – this is called extra-medullary haematopoeisis.  Embryos produce their blood cells that way in early stages & sometimes if bone marrow failure occurs, the stem cells will migrate back to the spleen & liver – amazing.

Hope this will give you some help & the internist can discuss these things with you.

Sheena

Sheena wrote:

Hi Erica

Here is some important stuff for you to take to the internist.  The spleen is an amazing organ which is a blood cleaner & in dogs acts like a bag of blood (like a transfusion almost) that can quickly be released into the blood system – that’s why they can suddenly wake up & run like the wind!

Been looking at splenectomy information for you to discuss on the 11th

Extract from http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=569903&sk=&date=&pageID=7

Splenectomy 

Splenectomy is considered one of the last-choice treatments in canine IMHA. The benefits arise from removing one source of B cells and splenic macrophages, the primary culprits in the removal of antibody-coated erythrocytes.²⁴ It is undetermined how effective this procedure is in routine IMHA cases, since only one recent clinical study has been done to assess it as a forerunner of treatment.³⁷Although this study did show increased survival with splenectomy (58% survival vs. 37.5% in the control group), the sample size was small.

Consider splenectomy only in patients that have not responded to immunosuppressive medications, require high-dose and long-term medications to maintain a remission, or are experiencing severe side effects from medications. As there is a risk of developing marked infection after splenectomy, it is not recommended for patients taking multiple immunosuppressive medications.¹

Looking in my human haematology book, spleen examination:

Ultrasound to image the spleen for examining structural detail & check the blood flow.  This can also detect whether or not blood flow in the splenic, portal & hepatic veins is normal, as well as liver size & consistency.  CT, MRI & PET scans give a more detailed examination of fine structures.

Check for haemangiosarcoma, cysts, tumours, splenic torsion, splenomegaly (enlarged spleen), hypersplenism (this means enlargement of the spleen & reduction of at least one cell line in the blood in the presence of normal bone marrow function – maybe this is what your vet is thinking about?) & hyposplenism. Functional hyposplenism is revealed by the blood film findings of Howell-Jolly bodies (bits of DNA remnants from circulating immature red cells – immature cells with DNA still present were mentioned in Tilly’s blood tests) or Pappenheimer bodies (siderotic granules on iron staining). This is why it’s so important for Tilly to have this blood film analysis done.  Hyposplenic patients are also at risk from infections, e.g. those that have their spleen removed.  After removal of the spleen, platelets can rise, so there is a risk of  clotting, so aspirin/heparin therapy would be needed,  also susceptibility to infections is drastically increased & antibiotic therapy is needed.  Long term alterations in cell counts can be seen in humans, including persistent low platelets, low lymphocytes or low monocytes.

You may be interested to know that blood cells can be formed by the spleen (& liver) – this is called extra-medullary haematopoeisis.  Embryos produce their blood cells that way in early stages & sometimes if bone marrow failure occurs, the stem cells will migrate back to the spleen & liver – amazing.

Hope this will give you some help & the internist can discuss these things with you.

Sheena

[Patrice]

Sheena wrote:

Hi Erica

A couple more questions as I am also puzzled about the continuing reticulocytosis;

Was the mycophenolate added after the cyclosporine?  If so, how long after & was it because she was still non-regenerative (no reticulocytes)?  Has Tilly had her spleen / abdomen scanned – if so what were the results?  At what date did Tilly first reach a normal PCV & RBC level?

I can’t find much scholarly research on mycophenolate use in dogs in relation to AIHA/IMHA so have looked more a the human stuff & it’s use for other dog problems!  It seems again that the many side effects (such as effect on liver & pancreas) are reduced very quickly when dosage is reduced, which is good.  I know you are not at that stage just yet, but it cheers you up to know these things!

Cyclosporine also has a number of side effects – have you noticed any enlarged lymph glands on Tilly?  Apparently this is fairly common, as are warts (papillomas) as well as affecting the liver & pancreas.

I can see why your vet is thinking about continuing haemolysis – do you know what tests they have done to confirm that?  Does she have any bilirubin in her wee that you know of?  It would be darker than normal wee.  There are a few blood tests your vet can do to test for haemolysis.  I think they should maybe do more blood smear/manual slide interpretations in view of the possible error ratio in the WBC/Platelet count because of the great number of reticulocytes.  If the WBC is not accurate, then the percentages of granulocytes will not be correct either.  My gut feeling on this is still that the drugs are causing most of these anomalies and that her eye infection may be contributing too. They are so susceptible to infection on these drugs & I would recommend getting some treatment in case it gets worse.  Worzel had a horrible sore leg (from them shaving him so hard) which didn’t heal up even with antibiotic cream until we had reduced the prednisolone by 75%.

I confess I am still flumoxed on the reticulocyte front, although one lab sheet I use doesn’t class 3% as that high in the presence of AIHA/IMHA actually.  I think you should see what happen on the next blood test – when is her next appointment?

Sheena

[Patrice]

Sheena wrote:

Erica

Will look into continuing reticulocyte production.  I think another blood test in the near future might give us a better picture too.

Sheena

Sheena wrote:

Erica

Will look into continuing reticulocyte production.  I think another blood test in the near future might give us a better picture too.

Sheena

[Patrice]

Joe – just to let you know – thinking about you and Nauset.

Love and Happy New Year, Linda (and Sadie)

[Patrice]

Linda wrote:

Sheena – glad you have it covered.  Vally and you are awesome for getting back to Erica.  Sorry I have not responded (although not much help in the bloodwork arena).  Sorry to just write, but thinking of you and as Sheena says – always something!!!

Happy New Year to all.  Will check posts – away and limited use on ipad, but will keep checking.

[Patrice]

Sheena wrote:

Hi Erica

Had a look at various resources – lymphocytes low, monocytes high point to long-term high dose corticosteroid (prednisolone) use which is called Cushings disease.  Raised neutrophils points to bacterial infection BUT can also be caused by corticosteroids.  So it’s hopefully just the long term effects of the drugs.  Again, raised platelets points to inflammation OR those corticosteroids.  Automatic counting systems at labs can apparently mistake platelets for red blood cells, but it does say platelets “appear” increased on your test.  It would be worth getting a coagulation profile done to make sure all is well, especially if they creep toward the 1,000,000 level (that would be 1,000k on the lab report).  I also read that hypothyroidism can cause platelet counts to rise, but I suspect it’s just those corticosteroids again!  It looks like the weaning off the prednisolone will help all these things & she is doing really well as far as PCV Haemoglobin & RBC –  fantastic normal Ievels.  I also noticed that they have corrected the WBC count when they looked at the sample under the microscope because of the presence of nucleated RBCs, so this may be a “false” high WBC reading as a calculation has to be done – see https://ahdc.vet.cornell.edu/clinpath/modules/hemogram/NRBC.HTM

It also says that nucleated RBCs are often seen in haemolytic anaemia during regeneration, so don’t worry about that. High levels of reticulocytes are seen with nucleated RBCs too.

PHEW!!!!!  I really hope this helps.  I would not worry about splenectomy at the moment – RBCs, HGB & PCV are fine.  I suspect these other blood test anomalies are due to the drugs as every single thing I looked up mentioned corticosteroids & Cushings Disease – it is the most obvious cause BUT she might also have an infection that needs treating too.  I hope everything will soon improve with lowering the pred even more during the weaning process.

 

Let me know if I’ve not explained anything properly  ……   and don’t worry too much as all the red stuff looks great!

Best wishes

Sheena

PS It’s after midnight, so I’m off to bed now!

Sheena wrote:

Hi Erica

Had a look at various resources – lymphocytes low, monocytes high point to long-term high dose corticosteroid (prednisolone) use which is called Cushings disease.  Raised neutrophils points to bacterial infection BUT can also be caused by corticosteroids.  So it’s hopefully just the long term effects of the drugs.  Again, raised platelets points to inflammation OR those corticosteroids.  Automatic counting systems at labs can apparently mistake platelets for red blood cells, but it does say platelets “appear” increased on your test.  It would be worth getting a coagulation profile done to make sure all is well, especially if they creep toward the 1,000,000 level (that would be 1,000k on the lab report).  I also read that hypothyroidism can cause platelet counts to rise, but I suspect it’s just those corticosteroids again!  It looks like the weaning off the prednisolone will help all these things & she is doing really well as far as PCV Haemoglobin & RBC –  fantastic normal Ievels.  I also noticed that they have corrected the WBC count when they looked at the sample under the microscope because of the presence of nucleated RBCs, so this may be a “false” high WBC reading as a calculation has to be done – see https://ahdc.vet.cornell.edu/clinpath/modules/hemogram/NRBC.HTM

It also says that nucleated RBCs are often seen in haemolytic anaemia during regeneration, so don’t worry about that. High levels of reticulocytes are seen with nucleated RBCs too.

PHEW!!!!!  I really hope this helps.  I would not worry about splenectomy at the moment – RBCs, HGB & PCV are fine.  I suspect these other blood test anomalies are due to the drugs as every single thing I looked up mentioned corticosteroids & Cushings Disease – it is the most obvious cause BUT she might also have an infection that needs treating too.  I hope everything will soon improve with lowering the pred even more during the weaning process.

 

Let me know if I’ve not explained anything properly  ……   and don’t worry too much as all the red stuff looks great!

Best wishes

Sheena

PS It’s after midnight, so I’m off to bed now!

[Patrice]

Sheena wrote:

Hi Erica

Will get back to you in half an hour or so – hope I can come up with some answers for you.

Speak soon!

Sheena

Sheena wrote:

Hi Erica

Will get back to you in half an hour or so – hope I can come up with some answers for you.

Speak soon!

Sheena

[Patrice]

Erica wrote:

Thank you Vally and Sheena for your replies!  Sheena, I’ll email you Tilly’s full report.  Her Hgb, MCV and MCHC were normal both in August and now.  She has not taken iron or any other supplements aside from Greenies Dental Chews in the interim.  She remains on full doses of cyclosporine and mycophenolate.

In the past 1.5-2 weeks Tilly has grown a small bump on her lower right eye lid which is likely a blocked duct or small infection and probably explains her current elevated WBC.  It’s shrinking on it’s own so I didn’t bother having it formally evaluated and treated.

My understanding is the vet feels the spleen is still destroying RBCs so removing it should stop the anemic process and help her effectively get off the meds.

I think I will email Dr. Dodds first and see if she will evaluate the labs too, how to best arrange contact with my vet, etc.

Many, many thanks to you all.  Wishing a healthy and happy 2014 to all of you.

Erica

Erica wrote:

Thank you Vally and Sheena for your replies!  Sheena, I’ll email you Tilly’s full report.  Her Hgb, MCV and MCHC were normal both in August and now.  She has not taken iron or any other supplements aside from Greenies Dental Chews in the interim.  She remains on full doses of cyclosporine and mycophenolate.

In the past 1.5-2 weeks Tilly has grown a small bump on her lower right eye lid which is likely a blocked duct or small infection and probably explains her current elevated WBC.  It’s shrinking on it’s own so I didn’t bother having it formally evaluated and treated.

My understanding is the vet feels the spleen is still destroying RBCs so removing it should stop the anemic process and help her effectively get off the meds.

I think I will email Dr. Dodds first and see if she will evaluate the labs too, how to best arrange contact with my vet, etc.

Many, many thanks to you all.  Wishing a healthy and happy 2014 to all of you.

Erica