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My grand-dog is a 6 yo Bernese Mountain Dog. Recent (<2

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My grand-dog is a 6...
My grand-dog is a 6 yo Bernese Mountain Dog. Recent (<2 weeks?) symptoms include weight loss of about 7-10 pounds, loss of appetite, vomitting, diarrhea, slight lethargy. Blood work a week ago showed hematocrit of 20%, platelet count of 63,000, white count of 17,000, red cells and bilirubin (+++) in urine. An ultrasound showed nothing remarkable except, pehaps, a slight thickening of a portion of the stomach wall. Follow-up CBC 1 and 4 days later showed platelet counts of 73,000 and 109,000, respectively, white counts of 20,000 and 18,000 respectivley, and, since I don't have the whole report in front of me, I'm not certain what else it showed. I do know that the crit came up some during that time. One WBC differential showed "granulocytes" of 69% and lymphocytes of 25-ish %. Another vet lab looked at one of the CBCs and noted 84% neutrophils, 8% lymphocytes and 6% monocytes, I think. As I said, I don't have the values in front of me. This was read to me by my daughter. Her vet put Gabby on i/d canned dog food, which she eats, but usually vomits during the next hour. Any ideas? The vets have mentioned hemolytic anemia, perhaps, but want to rule out ulcer before beginning treatment. We actually had a cocker spaniel who had hemolytic anemia and I don't recall the vomitting and diarrhea being a part of her symptoms. Thanks for any info you can provide. She has another appointment this afternoon with her vet.
Patti Petersen, worried Grandma
Submitted: 6 years ago.Category: Veterinary
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Answered in 5 minutes by:
3/1/2011
Veterinarian: Dr. Gary, Veterinarian replied 6 years ago
Dr. Gary
Dr. Gary, Veterinarian
Category: Veterinary
Satisfied Customers: 19,882
Experience: DVM, Emergency Veterinarian, BS (Physiology)
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Hello.

This sounds like pretty classic IMHA (immune mediated hemolytic anemia) to me. The hallmark of signs are anemia, increased total bilirubin and increased white counts. When we look at a blood smear, we see a regenerative anemia and spherocytes (dark staining red blood cells indicative of increased bone marrow proliferation).

The vomiting and diarrhea are very common with IMHA as these dogs are systemically ill.

My typical treatment for IMHA is:
1. Prednisone (steroid)
2. Imuran (Azathioprine)- another immuno-suppressive med
3. Pepcid (Famotidine)- to help settle the stomach
4. Anti-vomiting meds (Cerenia or Anzemet) as needed
5. Blood transfusions as needed- usually when the Hct drops < 15% and the heart rate/ respiratory rates go up

I'm worried about your dog too- she should be started on immuno-suppression asap.

Here is a link to more info on IMHA that you can read over to give more information:
http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1390

I hope this helps, let me know if you have any other questions.
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Customer reply replied 6 years ago

Dr. Gary...

I wrote you a further note on this case yesterday (including the fact that auto-agglutination is negative) and haven't received your latest thoughts. But,wanted you to know the current thinking on Gabby's situation for your future reference. The key here, apparently, is her breed--Bernese Mountain Dog. Though the diagnosis has not been confirmed (she's having spleen and liver biopsies today), evidently Bernese Mountain Dogs are often plagued with a disease called histiocytosis, which can have several different forms. One of them, however--malignant histiocytosis--is uniformly fatal, and that's what our vets think Gabby has. It can mimic IMHA, without the auto-agglutination present in IMHA. Hopefully, you'll add this one to your data base for future questions such as mine. Patti Petersen

Veterinarian: Dr. Gary, Veterinarian replied 6 years ago
Patti,
I didn't see a note yesterday, sorry.
The auto-agglutination is usually only positive in ~ 50-60% of my IMHA cases. The fact that it's negative does not rule out IMHA. The main thing I look for is a regenerative anemia with spherocytes on the blood smear. That nails down the diagnosis.
Histiosarcoma is definitely something to keep in the back of your mind being a berner, but hopefully this is not the case here. I would expect to see some histiocytes either in the blood or in one of the biopsies or even some skin lesions or enlarged lymph nodes. Nothing yet is pointing to histiocytic disease but that should be ruled out soon.
Keep me posted on what they find in those biopsies and how she's doing.
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Customer reply replied 6 years ago

Dr Gary

I WILL let you know the biopsy results...thanks for your continued interest. I feel like the weight of the world has been lifted because you think it still may be IMHA instead of histiosarcoma. Not that IMHA is any picnic, but the other is truly terrifying.

To be continued...

Patti Petersen

Veterinarian: Dr. Gary, Veterinarian replied 6 years ago
Good deal, I'll keep an eye out.
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Customer reply replied 6 years ago

Dr. Gary

Re: the ongoing saga of Gabby the Bernese Mt Dog...her liver and spleen needle biopsies were both negative for histiocytes. Is this a good sign? They finally agreed to treat with prednisone, even though the possibility of a stomach ulcer had not been ruled out. After 24 hours on 40 mg prednisone, twice a day, she looks considerably perkier! She'll have another CBC tomorrow, so we'll be able to see if that blood picture has improved. Her appetite seems better (I'm always hungry when I take prednisone, too!), but I'm not sure if she's keeping everything down. No vomiting in the house recently, but difficult to tell if she's vomiting outside. Her last CBC on Friday showed 43,000 platelets and 17% hct. Is this still sounding like IMHA to you? By the way, I'm not sure I ever mentioned that the vets had not observed any spherocytes in the blood smears as of last Thursday--don't know about Friday. Thanks again for sticking with us on this...it's nice to have another opinion, and my daughter, Lissa, routinely asks what Dr. Gary is thinking.

Patti Petersen

Veterinarian: Dr. Gary, Veterinarian replied 6 years ago
Hi. Good, the negative biopsies are great.

This does still sound like IMHA. To differentiate between IMHA and a stomach ulcer, you need to look at the total protein and BUN. The TP (total protein) will be ~ 6-8 if IMHA and then low (< 5.5) if an ulcer. The BUN will be normal or just slightly elevated if IMHA and > 2-3 X normal if an ulcer.

IMHA sounds likely. I would want him on Imuran and Pred together. I would also put him on an antacid like Pepcid to protect the GI tract against the Pred.
Dr. Gary
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