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Dr. Deb
Dr. Deb, Dog Veterinarian
Category: Dog
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Experience:  I have bred dogs and shown dogs for 20 years.
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I recently lost my baby, Tacitus - 5 yr old cocker spaniel,

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I recently lost my baby, Tacitus - 5 yr old cocker spaniel, due to ITP this past Friday, 07/26/2013. He was bleeding into his organs. However, he did not show any of the signs that the internet describes as symptoms of a sick doggy. Even up to the point that we took him to the vet, he was totally alert and happy to be going with us. He seemed to act like as if we were going on a trip, he looked out the window. he wanted to get in front of the car. No sign he was sick except for the bleeding. He was NOT lethargic, nor was he bleeding from his eyes or nose or mouth, he would eat properly, he run and played around, he did EVERYTHING he normally did. Late Wednesday, he started to have blood stains in his pee, by Thursday morning, he was peeing blood and had blood in his poo. We took him to the vet the same day Thursday, where they told us he had ITP. Unaware that he had previously had treatment for ehrlicia, a tick born virus usually in dogs from texas (we live in CA but we brought him from texas). The vet started to give him blood transfusions and many other treatments (at the end costing a total of 9,500$). once we found out he had been treated for ehrlicia, we begged the vet to give him vitamin K, to stop the bleeding because the transfusions weren't doing anything and the bleeding spread to his lugs and other organs. they did x-ray and showed he did not have cancer or any obstructions in his intestines. he was completely healthy except for the ITP and enlarged spleen. other than that, he was COMPLETELY healthy. he did not get into rat poison most definitely, that's what they first vet tried to accuse us of. I was wondering what is the proper treatment for ITP with history of ehrlicia. We begged the vet to use vitamin k, but she blatantly refused, and was so angered b our suggestion she huffed and puffed and stomred out the room. then the director told would not let us explain ouir reasonining, cutting us off mid-sentence saying, "vitamin k is not going to work" or "nope, not gonna work." we even had the previous vet that cared for him from texas call from texas to the vet here in SF, CA but she still refused to administer the Vitamin K. she kept pumping him with blood transfusions, filling our dog with blood with no where for it to go besides the rest of his organs. I want to know the proper procedures for such cases.

Submitted: 11 months ago.
Category: Dog
Expert:  Dr. Deb replied 11 months ago.

Hi Walter, I'm Dr. Deb.
I recently came online and see that your question hasn't been answered. I'm so sorry that you've had to wait for a response, especially given the nature of your question.

Please accept my sincere condolences on your loss; I know this must have been heartbreaking for you and your family.

The diagnosis of ITP is not necessarily an easy one to make and while I'm not disputing this diagnosis, the causes of a low platelets are varied. If you'll indulge me for a moment, I'll cover the possible causes which then might dictate possible treatment options.
1. Increased destruction as might be seen in Rickettesial or tick diseases. In a case like this or any case where a tick disease might be a factor, I'd start these patients on Doxycycline immediately.
Unfortunately, Vitamin K is not the standard treatment for a tick disease although it would be if a rodenticide was suspected (see below).
Auto-immune diseases such as ITP can also cause increased destruction as you know. High doses of steroids are the initial treatment of choice.
If ITP is suspected and steroids are not effective after 7-14 days, then other immunosuppressive drugs should be considered:

a) Azathioprine (Imuran®). Combination therapy with prednisone and azathioprine has been reported to have longest survival times.

b) Cyclosporine (Neoral®): Neoral® is preferred over Sandimmune® because of more consistent absorption. However it has used on a limited basis because it is costly and requires therapeutic drug monitoring within the first 24-48 hrs then every few weeks

c) Leflunomide: 4mg/kg every 24h. Leflunomide has been reported in a few studies to be effective in treating immune-mediated and inflammatory diseases. Very expensive.

2. Decreased production in the bone marrow. Some sort of underlying cancerous problem would be suspected. It would take a bone marrow biopsy to detect such a problem and obviously the prognosis is poor.

3. Sequestration such as in the spleen. Unfortunately, this is usually associated with a cancerous process, too, such as lymphoma. An ultrasound with a needle aspirate can be helpful in making this diagnosis.

4. Rodenticide poisoning. Even if there's not a high suspicion that this is the problem, treating with Vitamin K can be started since there is no downside to doing so.

5. Cancer elsewhere in the boy.

So, my approach to thrombocytopenia would be to start Doxycycline, start steroids, (usually I give an injection of Vincristine once if ITP is suspected), consider other immunosuppressive drugs if indicated, give transfusion if the platelets are low enough, start Melatonin (since it has been shown to increase platelet production), and give the owners a guarded prognosis.

If a rodenticide is suspected or is even a long-shot possibility, then I'll start Vitamin K at the same time.

Although the vet may not have felt that Vitamin K was indicated if they were certain that no rat poison had been ingested, it wouldn't have been harmful. I have to confess I don't understand the attitude that was shown to you either. It has no place in communication with owners as far as I'm concerned.

I know that you are absolutely devastated by Tacitus' death since everything happened so incredibly quickly. I also have to wonder whether or not he might have gone into DIC (LINK) given his rapid decline. This is a complicated cascade of events but ultimately is fatal.

Even though I know this isn't what you necessarily will want to hear, I would be doing a disservice to both you and him if I were less than truthful and honest. I hope you understand.

I also hope this helps you to understand what treatment options are usually considered in these cases.

Again, my condolences to you and your family. Deb

Dr. Deb, Dog Veterinarian
Category: Dog
Satisfied Customers: 6094
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Expert:  Dr. Deb replied 11 months ago.
Walter:
I just wanted to thank you for the rating and the bonus; they are greatly appreciated.

My heart goes out to you and your family at this incredibly sad time. Regards, Deb

Kindly ignore the information request.
Customer: replied 11 months ago.


thank you for your information. the thing that gets to me is that he did not have any symptoms described. no lethargy. no red spots. gums a little light in color but still pink. no noticeable bruising. no discharge from his mouth or nose or eyes or ears. no bleeding from his skin. not weak. he ate normally. he slept normally. he ran without signs of pain or discomfort. he jumped on the couch. he played with our other baby. he was panting but not for long periods of time. usually, 10mins at most until we opened a window/door. he liked to sit outside. we took his temperature and it was at 100. I'm just trying to understand why it happened so quick. he was lively, alert, fully functional. but when tested, we were told he was anemic, he had no platelets, or were so low that they could not be detected by the machine. by the time we left him at the vet, the other thing I noticed that his hind legs shaking. I figured because he was scared by then. they did x-rays and ultrasounds and nothing else was wrong besides ITP and enlarged spleen. maybe he could have had other ailments but the first results mostly indicated ITP. the vet did say that his platelets were gone and vitamin K was not something that would help. they wanted him to attain more platelets by immunoglobulin transfusions, frozen plasma, match-donor blood and a list of other things. they also used doxycycline along with other meds. sadly, nothing worked and he basically died in 24hrs.

Expert:  Dr. Deb replied 11 months ago.
Walter:
You're more than welcome.
I sensed that you were struggling with the fact that he had no prior symptoms but this is often the case with very acute cases of thrombocytompenia and in cases where the platelets have basically bottomed out.

If there is a more gradual reduction of platelets, then you're more likely to see the signs you mentioned. In most cases, signs don't develop until the platelets are <40,000 but in some cases, they won't show up until they are 5,000.

I'm quite familiar with Ehrlichia and Anaplasmosis since I live in New England where tick diseases are endemic. I've also seen my fair share of ITP cases although the tick diseases certainly outnumber them.
I obviously don't know what his blood work showed but if he was non-responsive to Doxycycline, then this is not likely to have been a tick disease, even though he might have been anemic as well.

The enlarged spleen can also be seen with tick diseases but it can be seen with lymphoma or other cancers as well. I wouldn't expect it to be enlarged with a rodenticide poisoning.
Given how rapidly he passed and failed to respond to any treatments, then I have to suspect cancer as a possible underlying problem with DIC as a possible sequela. I know he seems awfully young for cancer but, unfortunately, it happens to even young and middle-aged dogs.

ITP can be primary or can be secondary to a large number of conditions including infection, cancer, drugs and vaccines. I suspect that this was not a primary condition but rather secondary.

Deb
Customer: replied 11 months ago.

We got the blood results of our baby, Tacitus. out of all the list of diseases on there, he was negative for all EXCEPT Ehrlichia. the one disease the vet refused to accept was what was his actual condition. she said it was not ehrlichia. i saw what treatment is for this disease and she only did the doxycycline.


we took him to our regular vet and she suspected rodentcide. which we told her was not it as we are very sure he didnt get to any. she did say that vitamin k would be given to a rodentcide toxicity but did not do so because she was afraid to give it to him without knowing why he was bleeding. they are the ones who refurred us to the emergency vet. we also got a summary report and half the stuff stated on there were never told to us. and it seems one report to the next, information changes.


 


this just feels like its worse the more we find out.

Expert:  Dr. Deb replied 11 months ago.
Walter,
I find this additional information somewhat distressing although probably not as much as you do.
There would have been no harm in starting Vitamin K even without a rodenticide being confirmed. While it doesn't look as if this was a real possibility in Tacitus' case, it would have been prudent to cover all bases by administering it to him.
I don't typically see tick diseases present with platelets as low as you initially described to me; this is more consistent with ITP. But I always start pred and doxy together if there's any question about what might be going on; I may or may not start Vitamin K. If the numbers don't start increasing within 7-10 days with Doxy, then this is not likely to be a tick disease and more likely ITP.
Obviously Tactitus's condition deteriorated quite rapidly which is one more reason why I'm not certain that a tick disease was primarily responsible for his non-response to treatment....this is not at all typical for the tick diseases (including Ehrlichia) that I see.

Doxy is the mainstay of treatment for Ehrlichia. Occasionally Chloramphenicol or imidocarb might be used but I've not personally had to resort to these other drugs in treating it.

I can understand how upsetting this must be, even after the fact. I suspect you strongly believe in your heart and mind that if Vitamin K had been administered to him that he would be alive today. Sadly, we'll never know whether this would have been the case or not.

I know you're still struggling with understanding what happened with him and I'm truly sorry that you're not able to find the answers which will help you move on.

Deb

Customer: replied 11 months ago.


it's not that i believe vitamin k would have made saved him but if there was a chance that it would have, i wish she would have taken it.


 


if he was going to die, then so be it but she didnt want to try. she said she wouldnt give him an injection because he would die frmo anaphalactic shock. we asked to give it to him orally but she said no because he would choke on the pill due to him not breathing well.


 


after reviewing the summary, she gave him other pills and many other shots. seems she could have given it to him, if he was going to die anyway, it would not have hurt.


 


we called various times to ask how he was and every time they said he was doing well. the report, however, says otherwise. maybe they didnt want to alarm us. Everytime we called them, it seems we were always given different information.


 


i guess what i'm struggling with more is that i really dont know what they did to him and it seems they didnt treat him well. and i just wish i knew what the treatment would be for Ehrlichia which may have caused the ITP. we asked for a detailed list but they only gave us the summary after we begged them to send it to us but they gave the run around.


 


if i knew the proper procedure then i guess i would be more at peace that they did try everything to save him. and i would be more at peace. but like you said, now we can never know if it would have worked. and as soon as he died, i didnt know we had the option to hold the body until we could get a necropsy or give us time to decide what to do with th remains, they just said, "would you like a private or group cremation" they didnt ask if that was an option, they made it seem that was our only choice. i dont know the process after they die since this is my first dog to die. now i feel they rushed to cremate him to get rid of evidence.


 


what i'm struggling i guess is that i just feel they are being not right about this.


 

Expert:  Dr. Deb replied 11 months ago.
Walter:
I can definitely understand your feelings. It sounds to me like there was a definite breakdown in communication from their end of things which is contributing to your sense of unease and disquiet about how he was treated. This breakdown happened during his hospitalization and would appear to be continuing after the fact, unfortuantely.

From the sounds of it, he was given the standard treatments for Ehrlichia and ITP which would be Doxy and steroids....and transfusions.

As far as what options you had after he had passed, offering an autopsy is something that many vets feel uncomfortable with because of owner reactions. They are often quite horrified at the prospect so some vets will avoid adding more unpleasantness by mentioning the possibility.
This obviously doesn't make it right but might help you to understand why it wasn't mentioned at the time.

Deb

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