Blood and Lymph Disorders of Dogs

Blood transfusion in dog treated with large amounts of eye medication Question: My dog Thor recently became quite passive and didn't eat normally. He is a 9 year old diabetic that takes 14 units of insulin twice a day. I get worried easily so I took him to the vet. The vet determined he needed a blood transfusion as his red blood count was 21. I hope this is a valid number. He also said his previous tests showed 43. Thor did get the transfusion and a drug baytrol 60 #14 because the vet does not know what is wrong. It has only been one day....but Thor is still very quiet and doesn't eat as normal...but he does eat something. He goes back to the vet tomorrow to do more tests for his diabetes, red blood counts, etc. Let me say one more thing. Thor recently had cataract surgery at a surgical center for this type of work and was on a massive amount of eye drugs because one eye was not responding to the drugs. It has been several months of the massive drugs. As of now he only gets prednisone acetate. Could these drugs be the problem? Can you recommend anything to try to help Thor? I recently lost my beloved 14 year old german shepherd and I don't want to lose Thor. thank you so much for being there. Sherrie Answer: Sherrie- I think that it is possible that the medications for the eye may be linked to the anemia. Many medications can induce either immune mediated thrombocytopenia (platelet deficiency) or immune mediated hemolytic anemia (IMHA). If one of these diseases is present, there should be recognizable clinical signs pretty quickly. In the case of the immune mediated thrombocytopenia a platelet count is often all that is necessary to confirm the presence of this problem. This is often done as part of the complete blood count but may have to be specifically requested at some laboratories. If would be a good idea to ask if a platelet count has been done and if so, what the results were. Immune mediated hemolytic anemia is a little harder to diagnose as this diagnosis is often based on the appearance of red blood cells in a blood smear and the presence or absence of reticulocytes, or developing red blood cells. Reticulocyte counts almost always have to be requested separately from complete blood counts because they require different staining techniques. If there are high numbers of reticulocytes and unusually shaped red blood cells referred to as spherocytes, it is very likely that IMHA is present. The reason that I started with those two diseases is simply that they are sometimes involved in drug reactions. The diagnosis of the cause of anemia can be a little complicated because there are a number of disorders that can lead to anemia, including intestinal parasites, blood loss from undetected trauma, gastric or intestinal ulcers, kidney failure, liver failure, cancers (several), chronic illness (including diabetes) and probably at least a hundred other known causes. This makes it necessary to make a pretty thorough diagnostic effort to determine the cause of anemia. I'm not sure that I understand why a blood transfusion was given prior to making at least a tentative diagnosis with a hematocrit of 21 unless it was clear that there was a serious ongoing loss of blood. This may complicate making a diagnosis slightly. Things like this are always a judgment call and your vet was able to see your dog's overall condition so it is possible that this was the best option at the time. The hematocrit is the percentage of the blood which is made up of red blood cells. The normal range varies from lab to lab but generally runs around 32 to 50. If the last hematocrit of 43 was recent this may give you some idea why your vet felt that a transfusion was necessary first. The first step in making a diagnosis when anemia is present is to determine if the anemia is regenerative or not. A regenerative anemia is one in which the body is attempting to respond to the loss of blood by releasing young red blood cells (reticulocytes) and/or making new blood. A non-regenerative anemia is one in which there is no apparent effort by the body to respond to the blood loss. In general, regenerative anemias tend to be more of a crisis situation and non-regenerative anemias tend to cause slow loss of red blood cells over a long period of time. There is a three day (minimum) period of time in which the body can't respond to blood loss very well. It takes about this length of time to start making new red blood cells and for high numbers of reticulocytes to make it into the blood stream from the bone marrow. This time period can confuse the differentiation between regenerative and non-regenerative anemias -- but only for a few days. The most common cause of regenerative anemia in older dogs is probably IMHA. Sometimes the IMHA is secondary to another disease process like ehrlichiosis or cancer, though. Hookworms, severe flea infestation, severe tick infestation, gastric ulcers, traumatic blood loss, toxic damage to blood (onion poisoning, zinc poisoning, acetaminophen toxicity, others) and damage to red blood cells from diseases such as heartworms, other heart diseases, cancer and vasculitis. Non-regenerative anemia occurs when something is stopping or inhibiting the production of red blood cells. Because there is no way for the body to respond to this problem a slowly developing anemia occurs as the red blood cells are used up. The average red blood cell in dogs probably lives a little more than 100 days but due to the continuous overlap of red blood cell production it may only take 60 days or so for anemia to develop with even small amounts of continuous blood loss that the body can not respond to. Unfortunately, there are hundreds of causes of non-regenerative anemia because almost any chronic disease can inhibit red blood cell production if it goes on long enough. Vitamin B deficiencies and iron deficiencies can cause failure to produce red blood cells. Kidney failure causes anemia because the kidneys produce the hormone that stimulates red blood cell production (erythropoietin) and because red blood cells don't live as long when the kidneys aren't doing their job of removing blood toxins well. Anemia occurs with hormonal diseases such as hyperadrenocorticism and hypothyroidism. Some drugs directly suppress bone marrow, including sulfa-trimethoprim antibiotics, chloramphenicol, toxic levels of estrogen and chemotherapeutic agents. Cancer can cause non-regenerative anemia by suppressing red blood cell production, robbing the body of essential nutrients, causing organ damage and in several other ways. We have seen anemia in several of our patients with diabetes, especially when we have trouble getting good regulation of their insulin dosage. So far this has always been non-regenerative anemia that has improved as we gained better control over the diabetes management or at least reached a point where the anemia became stabilized even though we couldn't make it go away completely, as long as there weren't other complicating factors like kidney failure. Hopefully it is apparent why it is so important to know which type of anemia is present. Once this is known, it is possible to narrow the search for a cause in a more systematic way. It also helps in planning appropriate therapy, including the timing of treatments such as blood transfusions. There is a big difference between giving a blood transfusion for a one-time blood loss with a normally functioning bone marrow and giving blood transfusions to patients who are not making blood, where multiple transfusions may be necessary and careful cross-matching of the blood as well as matching the patient's and donor's blood types becomes necessary due to the potential need for multiple transfusions. I can't tell from the information that you know so far what the most likely diagnosis is. Hopefully as your vet does more testing it will be possible to come to an understanding of why this anemia is present. It can take a great deal of testing to rule out all the possible diseases that can cause anemia, especially when non-regenerative anemia is present. Keep working with your vet and don't rule out things like X-rays, ultrasound examination, gastroscopy or other tests designed to look for underlying causes if it is not readily apparent why the anemia is present. Good luck with this. Make sure that your vet has a complete list of all medications that Thor has had recently, including an over-the-counter medications. If he isn't eating a commercial dog food be sure to mention that, as well. Think about the possibility of toxins, such as toy ingestion or eating metal (zinc is in pennies and was in some of the bolts used on older pet carriers -- probably ones from at least 15 to 20 years ago if you still have one of those). Watch him urinate to make sure that there is no blood in the urine and consider bringing a stool sample to your vet's in case it is hard to get one from him at the office. Mike Richards, DVM 6/20/2004 What is ALT and band cells in Blood panel readings Question: Dr. Richards, Please explain what ALT is from a blood panel reading. Punkin's ALT reading was 64 (5-60 normal range) and band cells of 4 ((0-3 normal range). I think band cells have something to do with infections. Punkin is currently being treated with an ear infection. Would this type of an infection qualify as the cause for the band cells? Tony A.

Answer: Tony-

ALT is an enzyme that usually stays inside liver cells. Rises in ALT values occur when liver cells are damaged enough to leak the enzyme. A very small elevation like this is most likely to be just a statistical variation (Punkin's normal level for this particular enzyme may fall out of the normal range). It would be reasonable to check this level again in a month or so and see what has happened to it, though.

Band cells are immature neutrophils. The bone marrow doesn't like to release immature cells and will only do so when demand for the cell type is high. Since neutrophils fight infection and are attracted to inflammation, these processes cause rises in the band cell levels. The percentage of band cells is not nearly as meaningful as the actual number of them (obtained by multiplying the percentage by the total white blood cell count). If this number is way out of the normal range then it is best to look for a source of infection or inflammation that may not be obvious. Once in a while ear infections are inflammatory enough to cause rises in the band cell levels. If Punkin continues to have elevations in band cells after the ear infection seems to be controlled it might be a good idea to consider the possibility of another problem. Rechecking the physical exam findings, disease history, etc. may be necessary to look for something that wasn't showing up previously.

Mike Richards, DVM 8/18/2001

Polycythemia vera and other possibilities when excessive RBC's are produced Question: Hi I have a 7 yr old Rottie who has become ill in the last 10 days. We did not think much of it He vomited one day, but then had a weird episode where his eyes were moving side to side for minute . Well he has been to 2 vets, blood show elevated RBC ( his blood was really thick) 70%. , plus low glucose and loosing protein in urine. Ultrasound shows nothing, heart is great. Basically is happy, skipped dinner onece but now is eating fine. He wants to play even though they say to keep him calm because of the blood being so thick. They drew off a pint and replaced it with fluid , which seems to have helped but for how long ? Also he first began this with exessive thirst and urinating. He does leak a little overnight, not peeing just prob cannot hold it. The soonest they vet could get us in at the UT vet school id May 16th and I cannot stand it. What if waiting is making him worse? Can you recommend anthing? Have you heard of similiar probs? He was never sick in his life before this. I live in concord and can get to the school in about 25 min. I will go any time any day if anyone can help me. Appreciate your time. Thanks Tricia Answer: Tricia-

The neurologic signs (the eye movement) and vomiting may be induced by the high red blood cell count (polycythemia). Drinking a lot and urinating a lot also can occur with this condition. It would be pretty hard for your dog to get dehydrated enough to cause the packed cell volume (PCV) to reach 70%, although this is remotely possible. If this were the case, the blood protein levels should be elevated. If there were not, then it is more likely that this is a problem in which too many red blood cells are being produced. The first step in evaluating this problem is to try to figure out if there is a problem leading to dehydration or if the red blood cell numbers are actually elevated in otherwise normal serum. Your vets probably did this prior to withdrawing the blood that was taken to lower the red blood cell count. The next step is to try to figure out why there are more red blood cells than there should be. This can happen when there is too much erythropoietin being produced. This is the hormone that stimulates production of red blood cells. This happens when the body is responding to a situation in which there is not enough oxygen being carried in the blood. Heart failure is obviously one possible cause of this, as well as chronic lung diseases, severe obesity and toxins that interefere with hemoglobin. It sounds like your vets also have tried to rule out these problems. In some instances direct damage to the kidneys, where the hormone is produced, can cause increased production of the hormone, although usually the opposite problem occurs and not enough of the hormone is produced when the kidneys are damaged. There are situations in which a hormone that the body responds to like erythropoeitin is being produced for some reason. The most common cause is a tumor that can produce a similar hormonal effect. There are a number of tumors that sometimes do this. Sometimes it is possible to find these using diagnostic procedures such as X-rays, ultrasound examination or CT or MRI scans. Some dogs just produce too many red blood cells due to a primary problem in the bone marrow, referred to as polycythemia vera. The recommended treatment for this condition is to remove blood and replace it with fluids when the PCV gets too high. If it is necessary to do this too frequently (more than once a month, for instance), then it may be helpful to use hydroxyurea to cause decreased production of red blood cells. It is a good idea to be going to the university. They can do the testing necessary to rule out kidney disease and have the ability to look for hidden tumors a little more effectively than the average veterinary practice. They may also have more information on medical treatment of this condition if it is polycythemia vera. I know it has been hard to wait but your vets have done the right things so far.

Mike Richards, DVM 5/9/2001

Blood clots Question: Dr. Richards, I am so glad to have an opportunity to ask some questions regarding my male poodle, Bubba. We adopted Bubba out of the Shelter 3 yrs. ago. The Vet estimates he is about 8 yrs. old now. He has some health problems. Incontenence, Inflammed Bowel Disease and now a really serious one which was just diagnosed last night from an Ultra sound, he's developing blood clots. We noticed before Christmas that he was slowing down on his nightly walks, and it progressed to the point recently where we haven't been taking him out for exercise because he started wavering around and finally just sits. We took him to an orthopedic surgeon and he wanted to do a myleogram of his back, but when his blood panel came back his B.U.N count was a little high and they thought anesthesia would be to risky. A regular xray of his back was taken but showed nothing. The internist then did another blood test and his electrolytes were a bit out of whack. But more disturbing than anything was that he didn't have a pulse in his back legs, or in his neck. When they checked his blood pressure it was very low. The internist said it sorta faded away, and then came back lightly. After doing the ultrasound yesterday, she discovered a large clot in his stomach. She doesn't know if he has them in his neck, but is suspicious there might be some because there was no pulse there. Because he is on 2.5 mg. of prednisone 3 days a week for his Inflammed Bowel disease, she said it is too risky to start him on 1/2 tab baby aspirin right away. So, we're going to decrease his prednisone to 1.25 mg. 3 days a week starting tomorrow, Feb. 12 and then on Tuesday start the baby aspirin which is suppose to thin his blood. He's also on Flagyl for the Inflammed Bowel disease, and was on Propagest for the incontenence, but was taken off of that this week. She also suggested to have him lay on a heating pad for warmth. We're not suppose to let him jump, or walk around much. The internist is taking blood tests to see if she can determine what's causing these blood clots. She will be sending them to a teaching hospital here in California called U.C Davis. This is going to take approximately until next Thursday 2/17 for the results. What I am really scared of is Bubba developing a blood clot in his lungs or brain. My question to you is, have you ever heard of this before? How was it treated? What can I do in the meantime until the tests come back to keep him safe? Is this treatable? What are his chances of living a normal life? What makes blood clots form like this? Any advice or suggestions would be greatly appreciated. Thank you Regards, Peggy Answer: Peggy, In an eight year old, or older, dog with a large blood clot in the abdomen, my first concern would be to rule out hemangiosarcoma, if possible, as a cause of the problem. This is a cancer which often affects the spleen, leading to splenic bleeding and subsequently blood clots in the spleen or abdomen. Sometimes splenic hematomas (contained bleeding) occur for other reasons and they are often discovered by accident, so I can't really be sure how much trauma it takes to produce splenic hematoma. When these rupture, as sometimes happens, bleeding can occur. Dogs also get aneurysms, just like humans, so these can be a cause of abdominal bleeding as well. Other cancers, bleeding disorders, pancreatitis, gastric ulcers, kidney disorders, liver disease, toxins, such as warfarin, and blood parasites can all lead to bleeding in the abdomen. Keeping Bubba quiet is a good idea. If he stops eating, seems weak, doesn't respond normally when you pay attention to him or anything at all worries you, contact your veterinarian immediately. Make sure that you know where to go in an emergency, because if the abdominal bleeding that led to the blood clot starts up again, you will need to know exactly where to go for help if it occurs at a time when your regular vet isn't available. Don't spend a lot of time guessing if a problem is occurring, get Bubba checked if you even suspect there is a problem. Dogs do not seem quite as prone to problems from clots breaking up in the blood system and moving to the lungs as humans are. If there is any suspicion of liver disease after examining the lab work, it would be a good idea to stop using metronidazole. Although it is rare, metronidazole can cause liver damage and might contribute to a problem with bleeding if it is due to decreased liver function. This is unlikely, though. It isn't going to be possible to give you the recommended treatments until the cause of the blood clotting can be identified. Hopefully, the lab work will show something that can be treated. As you know more, I'll be glad to try to help you understand the diseases or treatments that are diagnosed and recommended.

Mike Richards, DVM 2/13/2000

Blood transfusions

Question: Thank you for your information on a recent problem (September on von Willebrands disease). At that time, we were preparing for surgery and routine coagulation studies in my 6 year old vWD affected Doberman were abnormal (PT >40 and PTT >100) on repeat studies. The dog remains clinically well. The blood was analyzed at Cornell coagulation laboratory and found to be totally normal!! (Sent by FedX on ice pack). We are continuing to prepare for surgery as one huge lipoma (5" x 7") is obviously enlarging. I read with interest your discussion on blood transfusions. Dog's blood type is negative DEA 1.1 (several years ago). Should fresh frozen plasma or cryoprecipitate also be typed and cross-matched prior to administering? Dog will have the (nail guillotine) bleeding time done prior to the actual operation. R.

Answer: R.-

A "major" crossmatch is done when red blood cells from a donor are combined with serum from the proposed recipient. I am not actually sure why this is called the major crossmatch but I remember it this way -- if red blood cells from a donor are attacked by the serum of the dog that will receive the blood it is a major problem. The reason for this is that the dog will continue to produce antibodies and to attack the red blood cells until they are destroyed, until the immune system can be controlled or until the dog dies from the effort. A "minor" crossmatch is done when serum from the donor is combined with blood cells from the recipient. If there is a reaction this is a comparatively minor problem because the amount of antibody is limited to the amount already in the serum. No more will be produced because the aggressive immune system is in the donor --- whose body isn't getting the transfusion. So there may be a reaction if the blood types are not compatible but it will be limited in its effect and its duration. So it is best to go ahead and do the minor crossmatch when giving a patient plasma or cryoprecipitate but it is probably not absolutely necessary to do this. This is especially true if it isn't likely that an alternative donor's plasma or cryoprecipitate is available.

Mike Richards, DVM 11/12/99

Estrus and blood clotting ability Question: Mike Heard a story tonight that I thought I check out with you. Young derby bitch in Canada this past summer inhaled or swallowed a weed grass spear that apparently caused a lung abscess. That abscess failed to clot, blood filled the lung(s) and the dog was dead the next morning. It's been suggested that had the bitch not been in season, she might have had more time for the abscess to have been diagnosed. Does estrus affect hemalizing? B. Answer: Bob- Estrus does interfere with blood clotting. That is the reason that a lot of vets try not to spay bitches when they are in heat. The risk really isn't all that great but there is noticeably more bleeding. I am not sure of the exact reason this occurs, though. I think that it would have to take a significant primary bleeding problem to lead to death in this sort of incidence, estrus is unlikely to cause enough bleeding all by itself. That's just my opinion, of course. Mike Richards, DVM 11/17/99

Non Regenerative Anemia and erythrapoietin (eprex2000) treatment Question: Dear Dr Mike I am writing from Melbourne, Australia in hope that you may be able to assist me with my 5 years old dog "Kobi". Kobi is a Red Heeler (otherwise known as an Australian Cattle Dog). Two weeks ago Kobi became quite lethargic and her gums and tongue were extremely pale. I took her to the local vet and they kept her for a couple of days on a drip which included an anabolic steroid. Her condition worsened and she was rushed to a specialist who gave her two blood transfusions. Her red blood count was 6. After the blood transfusions her red blood count came up to 25. A bone marrow biopsy was performed and the specialist advised me that there were no evident of toxins or the other known problems which could be causing this. They told me they had no idea what could be causing her bone marrow not to produce new growth of red blood cells. The specialist advised me that we could consider giving her injections of erythrapoietin (eprex2000) which may stimulate the bone marrow. We took her home and a week later her blood count was 32. Well, I thought my prayers had been answered. However, on Sunday 24/10/99 we took her for another blood test and it had dropped to 28. On Thursday 28/10/99 her blood count had further reduced to 25. We have decided to proceed the erythrapoietin (eprex2000) treatment. The specialists have advised me that this is our only hope and there is a possibility that her immune system will eventually start attacking it as the erythrapoietin (eprex2000) is from humans and not dogs. Therefore, we are hoping the treatment will give her bone marrow a kick start and bring it back to normal. As this is such a rare problem and the specialist in Australia have limited knowledge of it, I was hoping that you may have more experience in this area. If you could shed some light on some other treatment etc. I would much appreciate it. As this is a matter of urgency I would appreciate any knowledge you may have as soon as possible. I love my dog very much and would do anything to prolong her lif

Thank you very much for your time Yours sincerely, Sharon. & Kobi

Answer: Sharon- I am a general practitioner but I do a lot of research on various veterinary topics, as you can see from our web site. Everything that I have seen suggests that your veterinarians have done the right things (examining the bone marrow, etc.) and that they are giving you the best information on erythropoeitin available. I wish you good luck with this situation and I wish that I did know something more that you could do. Mike Richards, DVM 11/3/99 Bleeding disorders that occur in schnauzers Q: To begin, at the beginning of 1998, I had five dogs-all Schnauzers a mother, a father and three of their offspring, we bred them once-five puppies-four were sold, kept one, two were returned to me at age six months as the owner did not care for them properly-hence I had five Schnauzers ( my point-keep in mind all my Schnauzers are/were related). Dogs-almost strictly inside dogs, fenced yard-up-to-date on all vaccines, on heartworm preventive. Regular veterinarian visits during their lives. Riley-daddy dog- euthanized early 1998-end stages of cancer. Ginger-female spayed offspring-died June 1998 age-10. Symptoms-spots on her stomach, I noticed as giving her a bath..appeared to be blood blisters. While drying her notice she kept licking her lips, looked in her mouth, there was traces of blood..I thought I had possibly poked her mouth with the comb. She seemed to feel fine. I was quite concerned and took her to the vet the next morning which was a Thursday. Concerned of some sort of poisoning-started Vitamin K inject while waiting for bloodwork results. Ran blood work. (don't remember but I believe the white blood count was extremely high and meds started.) Platelet count in the toilet Medications, IV, Blood transfusion, etc. Dog worsened, Platelet count did not improve. Started to vomit blood Nose bleed. Toxicology test came back negative to any toxic substances Only thing I could come up with was I had found a tic on her ear two weeks prior. Ran Tic Titer for tic borne illness Came back-Tentative Diagnosis of (spelling wrong I am sure) Irriclia Canis Vet took Ginger home with him at night to monitor her closely. On Sunday morning early-Ginger died. Diagnosis-Thrombocytopenia (tentative irriclia canis.) So to the Vet Friday am, with traces of blood in her mouth, red spots on her stomach, not seeming to feel bad...then dead on Sunday. NEXT... Dax-Ginger's Brother age 10 died November 1998. Started acting weird..hiding under the table did not want to go outside. To the vet-bloodwork all normal-urine normal-nothing specific Few days later started to tremble. Back to the vet--seemed that it could possibly be a disc problem, limited range of motion-but nothing major very slight..still acting weird. Trembling continued... seemed to be in pain... Xrays-showed nothing really.. Limited Reflexes-resisted exam-however, never whimpered or cried in pain. Possible disc problem--meds and keep in confined to a cage for weeks to see if it would calm down... Brought him home, in the cage, hours later he had severe nose bleed..called vet 12:30 am. came to the office Bloodwork, everything coming up normal. A second nose bleed occurred sometime during this ordeal-days later. Dog did not improve, trembling got worse had to keep him on pain meds... Coming up with nothing-my vet recommended an internal specialist... Went to see specialist and she gave me several possible causes: Possible disc in upper area (neck) of spine-major surgery ($1500) and this was the least likely of the causes Possible brain tumor that had eaten through the nasal plate-under anesthesia go up through nose and see what was there. Spinal meningitis, could do spinal tap Dog was in very poor shape, in pain, and probably would not survive any of the procedures. I elected to take Dax back to my vet, had him euthanized.. feeling there was no other alternative. I feel guilty to this day as I was hoping probably beyond hope that something could be done and I feel the dog suffered more than he should have. Necropsy-Inconclusive February 99 Mother dog-Cyndi Age (13)-Acting a little weird...seemed to be a little bloated..took her to the vet-liver values elevated, heart murmur (which we were aware of) ...decided to cut to the chase-vet did liver biopsy- came back with Chronic Active Hepatitis. Dog on heart medicine daily and Metronidizole, since surgery and medication ALT and ALK Phos..(I think) one has come down one has remained the same.. Dog seems to be doing well. Last blood test though was Lypemic (?) Bear remaining offspring seems to be doing fine. Any comments on this--I have grown very paranoid about my animals- My vet is paranoid too-(I say weird acting he says bring it in). I am almost ridiculous about taking them to the vet for every little thing..I can't seem to get this out of my mine and worry constantly that it will happen again...Any comments, ever dealt with or seen anything like this. A: Your schnauzers, being related, are likely to be prone to one of the bleeding disorders that occur more commonly in schnauzers than in most other breeds. Von Willebrand's disease and immune mediated hemolytic anemia are both supposed to occur in miniature schnauzers more often than other dog breeds. Since your dogs did make it to older ages, cancers such as hemangiosarcoma, that are often associated with bleeding, also seem possible, although this is usually possible to find on a necropsy (autopsy) exam. Hyperlipidemia, which also occurs commonly in schnauzers sometimes causes platelet numbers to fall but usually lipemia of the magnitude associated with this problem is visible in a blood sample and noted on the lab forms and in the cholesterol and/or triglyceride levels on blood panels that include these values. Schnauzers are also prone to pancreatitis and that will sometimes lead to bleeding disorders -- but has a lot more signs in a dog than in a cat and also usually causes recognizable changes in lab values. All of these disorders can follow family lines or are known to be inherited disorders. The odds are that not all family members would be affected. Since the one blood sample was noted to be lipemic, it might be worthwhile to do more specific testing (cholesterol and triglyceride levels) since this condition can lead to other problems (it is thought to be a complicating factor in several other illnesses). Your puppies (if they are 10, which is what I think from the note) are reaching the upper end of middle age or the early part of their geriatric years and having problems like chronic active hepatitis is more likely in this age range. It is sometimes hard to accept that when you have several older dogs at one time -- because they do seem to be ill very frequently in that situation, sometimes.

If I have missed on ages, sex or situations, please fill me in and I will be glad to rethink this. Mike Richards, DVM 8/1/99 Bleeding disorder in Sheltie Q: Dear Dr. Mike, I am so thankful to have found your website and even more the subscription Vetinfo Digest. I'll try not to make this too lengthy, but I have to explain my situation, so you'll know what my resources are. My husband was transferred to Venezuela about a year ago, and vet care here is cetainly nothing like we were accoustomed to in the US. We came with 3 shelties who were all fine until recently. I had an 18 yr old female, extremely active, and playful. She began bleeding from the nose about 3 weeks ago during the night and we took her in to the vet the next morning, as there are no "emergency clinics" for animals. The vet told us that he suspected blood pressure or teeth, after the exam he said the problem was here teeth, so he removed 4. Her teeth were in pretty bad shape. I brought her home the next day and she was fine for about 5 days. She woke me up in the middle of the night "walking in circles" and very disoriented and obviously ill. I took her back to the vet. He told me at that point, that she had a type of dog "flu" and gave me a prescription for 3cc, 250mg "Keforal" (monohidrato de cefalexina) every 8 hrs for 5 days, and baby aspirin every 8 hrs. I started to treatment, and she condition continued to deteriorate quickly. She stopped eating w/i 2 days and was so weak she was having trouble standing. I was panicked at this point, and contacted a vet in the US. She told me to take her off the medicine and try to hydrate her w/Pedialyte and see if I could get some food in her (baby food, rice puree). I had to use a syringe for both, but I was able to get her to take food and water this was for another 2 days. I saw a little improvement, but then she began to vomit the food. The vet from the US said we had to get her on an i.v. as soon as possible, so we did. The vet here told us that she was simply dying of "old age". I brought her home w/an i.v. knowing that she probably wouldn't live much longer. She died last week. I am very aware that 18 is quite old for a dog, but because her health was so good only week before, I concerned that we probably got a misdiagnosis for her. So here is my current situation. My second shelty (11 yrs) has been uninterested in eating for about 1-1/2 weeks. I can coax him by adding oil or some canned food to his normal purina diet, but he really doesn't want to eat. He normally races the 3rd shelty to finish in 30 seconds his entire bowl. I took him to the vet here in Venezuela, he did a blood test and told us that there was a problem w/his liver. He again prescribed "keforal" 5cc every 8 hrs for 5 days and something called Doce Plex (he said would increase the appetite). I took his temperature last Friday and it was 103.2 and gave him 2 baby aspirin immediately. He temperature dropped to 102 very quickly, so I've been giving him the aspirin 2 every 12 hours and he began to eat again. Today, Sunday I did not give the aspirin, and the temperature has again risen to 103 and he's loosing his appetite. I have not given him any of the medicine the vet prescribed because I'm very concerned this may be the same illness the 18 yr old had. The fact that neither of them have ever had any serious illness, were in very good health and both began with high fevers within a week of each other makes me feel that the coincidence is too much and it may be something contagious. I know you probably cannot diagnose the problem without seeing the dog, but if you can give me some idea about the medicine the vet has prescibed here and if it's ok for me to continue the aspirin, I would appreciate it. I feel very desperate here and any information you can give me will be better than what I'm getting here. Thank you for your help and for the web site, I am so glad I found it. Rhonda A: Dear Rhonda- Cephalosporin based antibiotics are relatively safe and have a reasonable spectrum of action. It is not likely that the antibiotic chosen caused problems with your sheltie who died. While it is not possible to be sure of that, the odds are pretty low that it was a factor contributing to his death. While it isn't possible to make a diagnosis over the computer I can give you some idea of disorders that might cause the clinical signs that you are seeing. One of the first and foremost worries in a dog with bleeding disorders and fever is ehrlichiosis. This is a parasitic infection and it wouldn't be unusual to have more than one dog in a household affected by the condition. While your second sheltie doesn't have obvious bleeding problems at this point it would still be worthwhile to at least consider this infection. It responds better to tetracycline class antibiotics than to cephalosporins. Leptospirosis is a bacterial infection that usually affects the kidneys but sometimes causes only liver related signs. It can produce fevers of some duration, as well. This infection might respond to cephalosporins but penicillins are considered to be the first choice medications at the present time. Cancers, especially cancers that are spreading (metastatic cancers) are another source of persistent fevers in dogs. Your sheltie is in the age range in which cancer has to be considered in the differential diagnosis for almost any unexplained illness. Babesiosis, another parasitic illness, is also a potential cause of all of the clinical signs seen. This illness requires specific therapy because it won't respond to any of the common antibiotics, to the best of my knowledge. The current treatment is imidocarb diproprionate, which is available in the United States and probably is available in Venezuela, as well. While there are a lot of other possible problems these are some that come to mind when there is a persistent fever. I am not absolutely certain that your dog has a persistent fever, since it isn't too unusual for dogs to have temperatures of 103 degrees in our clinic even when nothing is wrong, it is unusual for dogs to maintain this sort of temperature range at home when they are calm. The normal temperature for a dog is around 101.5 degrees Fahrenheit. The biggest problem you have is obtaining a diagnosis. While I think of cephalosporin antibiotics as being among the safest to use there is a lot of potential for them to be ineffective since they don't work for all diseases. Babesia organisms can sometimes be identified on red blood cell smears. There is a serology test for this disorder but a lot of dogs are positive because they have been exposed who aren't actually ill with the disease. Ehrlichia titers are possible but to confirm the illness it is usually necessary to have two samples, one taken during the acute illness and one during the convalescent period. Due to this, the rule of thumb is to treat for the disease if it seems likely to be present and worry about a diagnosis when it is possible to get one. Just to make things even more complicated a lot of dogs that have babesiosis also have ehrlichiosis since both are carried by ticks and ticks can be infected with both organisms at the same time. It would be worth asking your veterinarian there if either of these diseases is prevalent in the area. If so, it might be worth attempting to make a diagnosis or possibly treating for them if diagnosis doesn't seem possible. I hope that this helps some. I think that you have to trust the vet there to some degree. So far, I don't think that what was tried has been out of line or risky. If you work to stay informed and keep communicating with your vet I think that you can work through this. If your vet needs specific information on diagnostic or treatment options I will send what I can find

Mike Richards, DVM 3/1/99

Blood pressure monitoring in dogs Q: Dr. Mike My 8 year old JR terrier was diagnosed with grade III/VI systolic murmer recently, and during the exam, her blood pressure was taken. Her systolic pressure was 180. The examining Veterinarian suggested that we have a follow-up reading taken a few weeks later for comparison to see if her pressure was consistently high. I was wondering why blood pressure is not routinely checked in dogs. Wouldn't there be a benefit to this exam? I have noticed that few clinics in my area have the equipment to perform this exam, and wondered why that was. Thanks in advance for any light you might shed on this subject. I haven't seen this discussed anywhere else. Maureen A: Maureen- Blood pressure monitoring in dogs and cats will become more common as time goes on. At present there are some problems with equipment and there does not seem to be a clear consensus on blood pressure normal values. It is harder to measure blood pressure in dogs and cats than it is in humans because of the variances in size, anatomy and willingness to sit still and allow the process to take place. There are three methods for obtaining reasonably accurate blood pressure measurement. The oldest and most accurate is placement of a catheter directly into the artery and direct measurement of the pressure using a manometer. Most vets are not really anxious to place arterial catheters in patients for routine monitoring of blood pressure. Two methods of "indirect" blood pressure measurement are also used. One uses a Doppler system and the other an oscillometric system. The oscillometric system is probably more accurate but doesn't work well for pets weighing less than fifteen pounds making it impractical for use in most cats and many small dogs. It measures both systolic and diastolic pressure. The Doppler system only measures systolic pressure. It can be used in any size patient but is not considered to be as accurate and requires a trained operator. The definition of hypertension varies from reference to reference. Dr. Morgan's "Handbook of Small Animal Practice" lists the range for normal arterial blood pressure as 130 to 180 for systolic pressure and 60 to 100 for diastolic pressure and makes no distinction between dogs and cats. I have seen references that suggest that anything over 120 may be hypertension in the cat and that the high end of normal systolic pressure in the dog may be as high as 210. Blood pressure is known to vary among breeds of dogs and that may explain some of the reported differences. Blood pressure devices cost between $900 and $3500 new. It is possible to buy oscillometric units used from the human market and modify the cuffs for pets but the savings aren't all that great after doing that and the machines are more sensitive to the human blood pressure ranges which are lower than those of pets making them a little more inaccurate for vets. To be able to monitor blood pressure with reasonable accuracy the cuffs must be correctly sized. One of the problems with veterinary medicine is that this cost must be recovered in some manner and the office visit price is usually competitive in veterinary medicine so that isn't a good place to make it up. But people are used to having their blood pressure taken as part of an office visit at their doctor's so a separate charge can be hard to justify, too. So vets are buying one or two machines that are probably not going to be money makers and for which the accuracy is a little questionable and normal values hard to find. Many vets, looking at all of this, opt not to buy the machines. I have to admit at this point that I am one of the vets who has opted not buy a blood pressure monitor. It is next on my list of equipment to purchase but I keep hoping that someone will come out with a machine that works easily in cats and larger dogs and has less room for operator error. With all of that said, I think your vet should be commended for taking a progressive course and at least trying to monitor blood pressure. Unless some of us do that and pioneer the effort there never will be more accurate information and better machines. Mike Richards, DVM Blood Disorders Q: Dr. Mike, I have a Rottweiller that has Anemia. He has been in the vet for 2 weeks now and has lost 20 lbs. He had a transfusion 4 days ago. His red blood cell count went to 21 12 hours after his transfusion but has now dropped again to the 16 range. My vet is at her wits end about this dilimma and I don't want to loose my dog. She is calling the Louisiana State University Veterinary Hospital here in Baton Rouge, and many others in the veterinary field, I don't know how much help they have been. Could you please call her so the two of you can brainstorm together. Many thanks, Chip W A: Chip- I am sorry, but your vet has made a good choice in calling the specialists at Lousiana State. If she can not find help for your dog there, there are very good hematologists that the Virginia-Maryland Regional College of Veterinary Medicine in Blacksburg, VA. Any of them would probably be willing to speak with her. It is much better for her to be speaking with specialists than with me. I am pretty sure that your vet has considered these options, but immune mediated thrombocytopenia, immune mediated hemolytic anemia, ehrlichiosis, intestinal parasites such as hookworm, drug reactions, cancer, chronic kidney disease, disorders of blood formation, loss of blood in the urine and coagulation disorders are all possible problems. Sorting through these quickly, which is often necessary, can be very difficult. I hope that things are improving now. Mike Richards, DVM Dog Nosebleeds Q: DEAR DR. MIKE: Maggie, a nine year old part german shepherd and wolf, is suffering from nose bleeds sometimes when someone walks by the house and even when she is sound asleep. Maggie has had Xrays, scope and a biopsy - all results were negative. Maggie is on 1000 mg vitamin C and horsetail (homeopathic remedy). There seems no explanation as to why these nose bleeds occur. She is happy, alert and eats real well. Can you suggest any cause for these nose bleeds. Any help would be appreciated. Carol A: Carol- Nosebleeds can occur for a lot of reasons. In older dogs a major concern would be nasal tumors or nasal infections. Tumors can be pretty hard to find even with endoscopy and X-rays in some cases but the tests for this make it less likely. In any age dog bleeding disorders need to be considered when nosebleeds occur. Ehrlichia canis, immune mediated thrombocytopenia, immune mediated hemolytic anemia and other causes of bleeding should all be considered. In older dogs a fairly common cause of bleeding disorders is hemangiosarcoma, a type of tumor. Heartworms can cause nosebleeds in the later stages of the disease. Sorting through all these possibilities will require additional testing. It can be difficult and take several tries to identify the cause of bleeding disorders. Mike Richards, DVM Blood transfusion - aplastic anemia Q: Dr. Mike, I have read you Q&A article on aplastic anemia in dogs. I was shocked to see that another dog owner is experiencing the exact same problem as myself. I have a 10 year old Shih-Poo that was diagnosed with idiopathic aplastic anemia 8 weeks ago. This diagnosis alone would not be so interesting, except it's only effecting her red blood cells, as is the case with the 6 year old Terrier in your article. There were many test, including COOMBS, bone marrow test, and a wide variety of other blood test, conducted by three different vets. All were unremarkable except for the red blood cells. She is currently having a second blood transfusion and started an antibolic steroid therapy (prednesone) three days ago. My question is, how many transfusions can a dog have and what are the success rates of this type of therapy. She has not been typed and matched since I am not near a university (Evidently, this is the only place they do typing and matching), however she is receiving blood from the same donor as the first transfusion. As you can expect, after a ten year relationship with her, this is taking it's toll on my emotions. She has been very normal between transfusions and maintains a normal life otherwise. The only time she is abnormal has been at the immediate onset and the one recurrence. The only symptom is paleness and increased breathing. Any advice you could offer would be greatly appreciated. Thanks, Troy.

A: Troy- In theory, if your dog receives compatible blood, it should be possible to repeat blood transfusions on a nearly indefinite basis. Unfortunately, the odds of this being the case are not very good. Dogs have up to 13 blood types, although only about six of them seem to be of clinical significance. The potential for adverse reactions varies some among the blood types but eventually your dog will have problems using random donors that are not blood typed and where cross matching is not done. Cross matching is possible for most clinics to do. It helps to have an agglutination viewer but it is not absolutely essential. The directions for doing this are in one of the Kirk's Current Therapy books (I can't remember which one) and in a Clinics of North America from November of 1995 on transfusion medicine (Kristensen and Feldman, ed.) It is a little time consuming and not very satisfactory for emergency transfusions but entirely feasible for situations in which there is a half hour or so to plan for the transfusion. Several labs will accept canine blood samples from veterinarians for blood typing. We do not routinely do this but it isn't a bad idea to know your dog's blood type. There are also canine blood banks and it is possible to find typed blood and blood products from them in some instances. In most cases, continued transfusions are not very helpful in immune mediated hemolytic anemias. They are sometimes necessary as an emergency measure but unless the destructive process can be controlled there isn't much hope for the patient. If the destructive process can be controlled, there isn't need for future blood transfusions. A common cause of immune mediated hemolytic anemia or other bleeding disorders in older dogs is hemangiosarcoma tumors. This is especially true if there is a poor response to immunosuppressive agents like prednisone. Mike Richards, DVM

Aplastic Anemia Q: My formerly healthy 6 year old welsh terrier has been diagnosed with aplastic enemia - probably of the bone marrow. She is very weak and loggy. She has already had 2 blood transfusions - and we are awaiting results to a 2nd bone marrow test to see if the winstrel/pregnesone/clavamox combination has been able to jump start her bone marrow into producing red blood cells.(She has been on this combination for 3 weeks) We understand the dire nature of her illness, but are hoping for a miracle. If this most recent test result comes back showing no new activity, how long is it reasonable for us to hang on and hope the drugs work? We want to do everything we can for her - but I don't want her to suffer. She still has some bright times. Is there anything else we can do? Is there anything else we can do to make her more comfortable? Thanks for your help, J. A: It is important to identify the reason that your dog has stopped producing red blood cells if at all possible. Bone marrow biopsies are a good way to do this. Causes of non-regenerative anemia include ehrlichiosis, cancer, drug reactions, toxins, endocrine diseases, kidney failure, severe inflammatory diseases, severe iron deficiency, heredity (giant schnauzers) and a condition known as erythroid hypoplasia/aplasia. Assuming that the infectious, toxic and cancerous causes have been ruled out (to the extent possible) that only leaves the idiopathic, or unexplained hypoplasia/aplasia problem. The biopsy will help to rule out other causes. If you live in an area with ehrlichiosis then testing for it is important, too. Erythroid hypoplasia is usually treated with the combination of medications that your vets are using (although the anabolic steroid used may vary some -- Rhea Morgan's book "Small Animal Medicine"suggests using oxymetholone (Anadrol Rx)). Some dogs are reported to have spontaneous recoveries and others do respond to treatment. Recurrence of the disease is possible even in dogs that do respond to therapy. It is always hard to figure out when "enough is enough" in a situation like that. I'd guess I'd keep trying until I was sure nothing else was causing the problem and until treatment really seemed to be ineffective. It just seems worth trying in this particular disease. Mike Richards, DVM Aplastic Anemia - Part2 Q: Dr Richards, Thanks for your response about my dog Theo. The bone marrow results returned showed that almost all her blood and chemistry came back normal (it wasn't before) - EXCEPT for the red blood line, which is still not producing any new growth. However, there has been some anecdotal discussion that this bone marrow shut down may have been caused by a toxic reaction to the Lime tick vaccine she received. We are trying to gather any evidence that dogs who are shocked by Lime vaccines -DO recover. Do you know of any? I know you don't have all the paperwork or numbers you need to be categorical - but does this case look like there's any hope?? A: I have looked through the database of the Veterinary Information Network and did not find any references to aplastic anemia or red blood cell precursor suppression as a result of Lyme vaccination. There are many anecdotal reports of a Lyme disease-like syndrome post vaccination. This is currently thought to be an immune mediated reaction that can occur with vaccination or natural infection but I am not aware of any research that clearly establishes that there is a problem or what the nature of the problem might be. There is evidence that an immune mediated reaction of this sort occurs in hamsters but that doesn't mean it occurs in dogs, for sure. It is not a reaction which causes anemia. It is joint soreness, weakness, etc, as might be seen with a natural infection of Lyme disease. That isn't to say that the vaccine could not be the cause. But so far, this relationship is not being reported in the veterinary literature to the best of my ability to determine that.

It would be a good idea to call the vaccine manufacturer and to ask your vet to report this as a possible problem. Many times suspected reactions go unreported and that delays noticing them when they occur in small numbers of pets. Even if there is not a clear causal relationship if there are enough anecdotal reports someone will look into it.

Mike Richards, DVM

Aplastic Anemia - Coomb's test

Q: Hi Dr Mike.I wrote you earlier in the week about my 6 year old Welsh Terrier who had been diagnosed with aplastic anemia of the bone marrow. We talked about whether or not it was vaccine related. Since then I have taken her to a specialist at The Animal Medical Center here in New York. They have stabilized her with a matched blood transfusion, while they look for the reason her bone marrow shut down in the first place. I have to keep her on a diet of cottage cheese and rice for three days, then they want to check her stool with a Coombs test. They are also checking for internal bleeding. What is a Coombs test looking for? If there is internal bleeding, is this something treatable? I know its hard to answer these questions without alot of very specific information. But could you just orient me? Thanks again for your help - and the incredible service you provide. J. A: A Coomb's test is a test for antibodies or complement (another protein/enzyme that works with antibodies) attached to the surface of red blood cells. It is possible to do a general test for these without knowing the specific antibody due to similarities between most of the antibodies that attach to red blood cells. When a bacteria, a drug or anything else attaches itself to red blood cells (rbcs) the body tries to attack it with antibodies as it would if it wasn't attached to rbcs. This can lead to lysis of the red cells, which is usually referred to as immune mediated hemolytic anemia (IMHA). So a positive Coomb's test indicates a strong possibility of IMHA. This test can also be positive for other reasons, including ehrlichia, demodecosis and severe infections. It is possible to have a negative Coomb's test and still have IMHA, as well. Even though the most commonly run Coomb's test is kind of a general screen, it is possible to test for specific types of antibodies, if desired. Sometimes this helps in establishing a prognosis if IMHA is suspected.

Hope this helps some. Mike Richards, DVM

Wolf with Anemia Q: I have a wolf involved with anemia (maybe ehrlichiosis). Please help me!!! Every advice will be really appreciated. A: Ehrlichiosis is certainly a likely cause of anemia. If there is fever, weight loss, bleeding tendencies, lymph node enlargement or splenic enlargement, lethargy or depression or other systemic signs of disease, it is even more likely. There are laboratory tests that can be done on blood to test for this and allow a more specific diagnosis. It is usually responsive to tetracycline or doxycycline antibiotics. If you live in a place in which imidocarb dipropiontate is available it is supposed to work even better for this but it is not approved in the U.S. Blood transfusion may be necessary in severely affected dogs. It is a good idea to rule out immune mediated hemolytic anemia (IMHA) before giving blood transfusions. Ehrlichiosis usually causes a non-regenerative anemia (no reticuloctyes or young red blood cells) and IMHA usually causes a regenerative anemia (lots of reticulocytes). There are a huge number of things that can cause anemia so you may need to work with your vet to determine the exact cause and treat it, if possible. This can be frustrating and involve considerable testing but in the long run having a diagnosis is much better.

Good luck with this. Mike Richards, DVM