Monday, March 21, 2011

A veterinary post - woohoo!

This weekend wasn't too bad at work. Saturday evening was inexplicably busy, while Sunday night was extremely slow. It's usually the opposite case. Everything I saw Saturday, with the exception of a pancreatitis case, was "treat and street." Minor wounds, laceration repairs, limping dogs, vaccine reactions, and the like. I both like and loathe this kind of night. It's nice not to admit a bunch of critical patients that need very close monitoring, but it's not very lucrative for our business.

We had a happy story this week with a very nasty disease. It doesn't usually have happy endings. On Tuesday, we were transferred a small, sweet Lhasa Apso named Maggie. She had seen her vet that day for lethargy, anorexia, and weakness. She turned out to have immune-mediated hemolytic anemia, a nasty, nasty disease in which the body turns on its own red blood cells and starts destroying them. She was young, she had not ingested any metal products that would cause this, and there was no other obvious underlying cause for her malady. Thus, we treated her as an idiopathic IMHA.

Idiopathic means "idiots don't understand the disease." Not really. It's just a term that means a disease without a clearly understood underlying cause. IMHA is frequently like this. It can be caused by many things - cancer, dogs eating pennies or other zinc containing objects, heartworm disease, and the like, but in most young dogs (especially of certain breeds), the cause is never found. Treatment is major immune suppression. Basically, shut down the bone marrow to stop it from attacking the red blood cells.

Unfortunately, the drugs we have to do this with all have a lag time of 2-5 days before they really start to take effect. Thus, the patient must be maintained and stabilized until the drugs can begin to work. This includes a blood transfusion (sometimes multiple), careful maintenance of hydration, the addition of low-dose aspirin (these patients are VERY susceptible to clot formation/thromboembolic disease), and sometimes oxygen therapy.

I usually give people a 4-8 day hospital stay estimate and a cost of $2000-4000 to treat. Prognosis is decent in the initial time frame IF people can financially go the distance. Unfortunately, the disease can relapse throughout the dog's life and it is likely the patient will stay on some sort of immunosupressant for the rest of its life. It's not a good disease. Many patients are euthanized for financial and quality of life reasons.

Maggie's owners wanted to go the distance. And they did. Maggie needed her first blood transfusion on Thursday, 2 days after diagnosis. She rapidly destroyed that blood as it was given to her, and she required a second transfusion on Friday night. Her condition looked dire. She was weak, extremely lethargic, and her belly, eyes, gums, and ears were all highlighter yellow (the breakdown of the red blood cells releases large amounts of bilirubin into the body, which is a yellow pigment). Her prognosis looked grim.

Still, we persisted. We placed a nasoesophageal feeding tube to start trickle feeding her and supporting her nutritionally (often overlooked in the critical patient!), continued her prednisone, cyclosporine, and aspirin, as well as fluids and gastroprotectants. We held our breath.

On Saturday, she rallied. Her PCV stabilized. Her skin began to look less yellow. She became more alert and licked food when offered. She walked outside and wagged her tail. Sunday, she was bright enough, eating enough, and her yellow color was almost gone. It was remarkable. I haven't seen an IMHA turn around quite that drastically or quite that fast.

Sunday night, she went home to her owners. They were thrilled, as they had confided in me Friday night that they "didn't have much hope for her." I had reassured them that this was a tough disease to control, but when owners were dedicated emotionally and financially, we could usually get remission. I was thrilled to be right - for whatever period of time! Maggie's owner promised to bring her back to visit us sometime soon. He was very grateful for our help and never complained about the expense of the blood transfusions and intensive care she had received. She was a wonderful patient, and he was a wonderful client.

It was a good end to this week. Oh, and we have our first kitten of the spring season. A 4 day old, blind, deaf, rat of a kitten. He sure is with a white face, chin, and paws. He's quite scrappy.


Fi from Four Paws and Whiskers said...

well done - my own beautiful Golden Retriever had it badly when she was 7 - and survived with tree transfusions and huge expense... we kept her on immuno suppressants for three years - and she was looking amazing. Unfortunately, she also bit out two yr old granddaughter across the face and had to be euthanised. Such a loss for us all - and needless to say, a huge shock. We wonder if she was starting to get hip pain and Phoebe jumped on her... or just grumpy due to her meds... we will never know now!
I used to read the AIHA forum - i get the impression many animals die, perhaps due to lack of experience in treating the condition by vets?
Anyway - have a pat on the back :)

Nicki said...

What a happy ending! I've not had much good luck with IMHA. I had one live-and they were financially limited and was treated as an out-patient no less! She died a few years later of unusual neuro symptoms. Don't know if it was related.

Karen Whiddon said...

I have lost two dogs to IMHA. Both eight years apart, at eight years of age. Different breeds, one female, one male. The first one I just did what the vet said - gave her prednisone. She didn't make it. SHe was a sheltie - poodle mix.

Fast forward 8 years and my male mini-Schnauzer was feeling punky. Even though my vet said having another dog get this disease would be like getting hit by lightning twice, I'll never forget opening the crate when I got home and seeing him barely able to stand, swaying with that look in his beautiful brown eyes.

I knew. I just knew. We took him immediately to the 24 hour clinic. He had a blood transfusion, they used artificial blood. He fought the hard fight, but he died - some $3,000 later.

After that, I felt cursed. As each of my other dogs reached 8 years old, I watched them like hawks. I switched vets. So far, so good. My female mini-schnauzer is 12, my male 10, and my Boxer is 5.

It's good what you do and I'm glad you were able to save that dog!

Holly said...

Yay for the little dog and you and the owners!

The Homeless Parrot said...

Fi - that's terrible! I am so sorry to hear about your Golden and her euthanasia.

As to treatment of the disease and veterinary inexperience, I cannot comment. Some vets do not keep up with the literature, true. There was a recent paper that compared prednisone alone against pred + azathioprine + aspirin - and found a better outcome with that treatment, so it is definitely important to keep up with the lit. On the other hand, as an intern, I worked with specialists, and they also lost many of these patients. Part of the problem is that we just don't understand WHY these dogs develop IMHA.

All we know is that the immune system turns on the body. If we could figure out WHY, we might be able to cure it! It's a bad disease, one way or the other.

The Homeless Parrot said...

Nicki - the majority of mine "die" due to euthanasia. It is an expensive, challenging disease to treat, and the prognosis is guarded, so a lot of my experience is euthanasia. In the rare cases where I've had owners go the whole distance, most of mine have survived. I can think of 3 at least, and 1 that I did lose, despite EVERYTHING we did.

The Homeless Parrot said...

Karen, I'm sorry to hear about your losses - that is terrible!

Fi from Four Paws and Whiskers said...

My Saffy was on initial pred - then pred + azathioprine, finally weaning off the preds... we kept her on azathioprine for three years - mainly because on an alternate day regime, we were all too scared to wean her off. We felt the risk of recurrence exceeded the risk of side effects. The hassle and expense of regular blood tests was another factor in the decision! Prior to the incident with the granddaughter she was happy and healthy and was at the groomers three days earlier - and they were all impressed with her condition and happy nature. Life's a bummer sometimes...
And that's without our earthquake!