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Aug 102011

Dog Dylan’s story began March 18, 2011.  She was diagnosed with Autoimmune Hemolytic Anemia (AIHA)/Immune Mediated Hemolytic Anemia (IMHA) , on March 19th, 2011; when my quest to save her and her second life as an AIHA survivor began.

Life for us all here changed that Friday morning when I noticed that Dylan hesitated to eat her breakfast.  This was an alarm to me for sure, the anxiety I felt was immediate since she had not done so ever that I could recall. I knew something was wrong and that I needed to pay closer attention to her. This is my default response to any unexpected behavior.  When I got home after a lunch time meeting, Dylan had thrown up her dinner in her kennel.  So as soon as I could, I took it outside to clean it and while doing so, Dylan went for a pee.   This might seem unimportant, but I later regretted not seeing this.  At the time, I had to clean a kennel before I could let the other dogs out.  While I was cleaning it, I ended up taking  a phone call from a customer who was heading out of own and needed some help before leaving.  I told Hew during that conversation that I felt something ominous was wrong.  I just had the feeling!

Sure enough, when Dylan went out in the evening, around 7:00 pm, she went to take a pee and  I must say, something startled me.  I could clearly see her, but something was drastically wrong, my anxiety immediately jumped to  a new level and I could feel my heart beating rapidly.  The color of her pee was not at all yellow, nor was it clear.  It was a dark red and looked like blood. Well if the alarm bells were not clanging before, they sure as hell were now.  And I do mean “hell.”  I don’t use this term lightly either.

At that moment, I had to decide what to do and it was an important decision.  I had to decide whether to take her to he emergency clinic where I had taken Jagger 2 years earlier, or wait until my vet clinic in North Vancouver opened in the morning.  Some might think that is a no brainer decision, but no decisions from then on would be easy.  I knew the kind of care she would get at the animal emergency hospital and I knew the costs would mount quickly.  I was concerned I might be making decisions based on financial restrictions and that recommended procedures were not always the same as what my own veterinarian would do.  In the end I decided to watch her very closely and decide to go to emergency if the problem worsened and required an immediate decision.  That night I watched her closely for any signs of more trouble.  My experience with Jagger had taught me that bad can things happen quickly.

Despite what I know now in hind site, I still think that was a good decision, although Dylan’s anemia over the next few days did become critical and very much touch and go.  The emergency clinic may not have diagnosed the problem until morning and delayed giving medication until they had test results.  If this was true, then there was nothing to be gained at the emergency clinic the night before.  They could not get test results immediately anyways.  Secondly, a transfusion may have been offered as a solution and although it might be a good choice in some cases, it would never be my first choice.

Saturday morning, Dylan was noticeably weaker, but no other overt signs and so I called Mosquito Creek Veterinary Clinic first thing at 9:00 AM when they opened.  They were fully booked, as I expected, but once I described the red pee, and along with the anxiety and concern in my voice, that got their attention. Dr. Janice Crook, Dylan’s Veterinarian, had me quickly check her eyes and gums.  Her gums were pale with brown patches and she had brown patches in the whites of her eyes.  Janice immediately knew the likely problem was AIHA/IMHA and had us come in immediately.  Although I knew they would take us in that day, like they had for previous issues, I would never have accepted waiting until Monday from any vet that cares for my dogs. This is a requirement! I knew I had to move quickly now.  I knew this was serious.  My responsibility was clear.

I am grateful for the care I get from all the veterinarian’s at Mosquito Creek and how they understand what our dog’s mean to us.  They have always made room for my dogs when conditions warrant it.  Janice did a quick exam and took a blood sample.  I had brought in a collected sample of her pee, which I got just prior to her going into the clinic.  Dylan was put on very high dose prednisone (steroid) immediately to suppress her immune system quickly. Her immune system was attacking her Red Blood Cells (RBCs) and if it was not stopped, it would soon kill her.  Not good news!

We discussed other treatment options such as azathioprine and cyclosporine, but decided against them initially.  Dylan’s attack was very acute in nature and it was certainly unlikely that azathioprine would have anything to do with saving her as it takes 2 – 3 weeks to act.  Cyclosporine may have helped, as it does act much faster, but it is still considered a better tool for assisting in getting off prednisone for most other immune mediated diseases. Prednisone is considered the best first choice. This was the first of many tough decisions that would have to be made and most take multiple drugs from the outset.

Another factor in the decision was from what I refer to as a minimalist perspective.  I believe chemical stress is an important factor and that by adding multiple substances we were going to make it much harder on Dylan’s liver and other organs.  Also, the eventual outcome as I discussed with Janice, was to attempt to remove prednisone as the treatment went along if we were lucky (this depends a lot on the nature of the trigger and the attack itself).  Removing prednisone and other drugs too gets more complicated since there are interactions and multiple substances to be reduced.  I had real trouble with the thought of using so many hard drugs simultaneously and my experience wit Crohn’s disease in people was the primary reason.

So we decided go with the initial treatment with prednisone alone.

That afternoon and evening were tough.  The anxiety of knowing what she was up against was immense.  I immediately started researching the disease and what I learned was not great.  There was no sleeping that night it seemed, as I watched Dylan breathe.  Trying to stay unafraid and calm was not possible it seemed.  I put a lot of effort into doing things, but I remember beginning to go around in circles emotionally.  Calm and determined, then fearful and anxious. I certainly can say I never felt confident in anything at the time.

The next day, the blood test came back and in particular showed anemia and a profile indicative of AIHA/IMHA including evidence of RBC destruction.  The report stated that the damage was intra-vascular (inside the blood vessels).  Initially her case was classified as “poorly regenerative,” but this was not true, thankfully.  The fact that the damage was so new and had not spread everywhere was likely why reticulocyte (immature RBC’s) generation had not ramped up yet.  We know that later it did and that she was fully regenerative.

Poorly regenerative, or non-regenerative would have been worse.  I have learned since, that the autoimmune attack can occur at different stages of blood cell development.  Destruction to mature red blood cells can occur and is what was occurred in Dylan.  The physiological machinery necessary to build red blood cells was not under attack in her case and we now know was functioning fully.  Her cells were being attacked after they matured, so she was “Regenerative” (generating replacement RBC’s, reticulocytes).

The immune system can also attack at the building phase and in fact at any stage of the blood cell building phase and can in fact attack the precursor cells and impact development of platelets and/or white blood cells as well.  This non-regenerative anemia means the body is not able to build replacement red blood cells with low reticulocyte numbers and that the attack must be stopped in order to start building cells.  This will result in a longer delay to get mature Red Blood Cell numbers up.  Transfusions are used in this case to provide mature cells until the body machinery can begin replacing them as this process does take time. I have seen multiple transfusions used and have heard of as many as 9 so far in the time since this began.

So there I was, completely dazed, anxious and uncertain.  Dylan had started her new life battling AIHA/IMHA as so many other dogs have done.  There were so many questions and no answers, just more questions. The battle had begun, but what we were up against had not sunk in at all yet!  Quick detection and diagnosis were a big factor in what was about to happen next.

Part 2:
Dog Dylan: Autoimmune Hemolytic Anemia, The First Battle to Save Her Life – Riding the Roller Coaster

Part 3:
Dog Dylan: Autoimmune Hemolytic Anemia – The Battle of Prednisone!

Richard Ford



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