Idiopathic thrombocytopenia in dogs

[hazelrunpack]

Since you really don't know what you're dealing with, about the only thing you can do is deal with it a day at a time Evaluate how Timber is feeling from day to day and make your decisions when they become necessary.

I was just looking for information on Imuran since I'm unfamiliar with it. Not sure what I'd do about it--but I'd for sure check with the vet and see if it's something that requires weaning.

I wish I had more advice for you, SW!

[SuperWanda]

Imuran is aka azathioprine and is a chemotherapy drug. We were using it as a strong immuno-suppressant, not as a cancer fighter.

This would be the 5th week we have been using it. Started out giving 1 tablet every day for 7 days and now every other day.

My vet wants us to stay on it but I don't know if I should.

[hazelrunpack]

Did he have a compelling reason to keep her on it? If not, it can't hurt to ask him how to discontinue it. Ethically, if you tell him you want her off it, he should tell you how to do it safely. And he may have a specific reason for leaving her on it...

[SuperWanda]

All I could find on the net is that you could stop without tapering because it is not like steroids in that it leaves your body slowly over time just as it takes awhile to take effect.

[SuperWanda]

I can call and ask -- she just said that it has an ant-inflammatory effect and it would make her feel better. She is thinking in terms of this being a cancer now.

...just talked with the pharmacist about this and she said to taper the steroids but you can just stop the Imuran. It may take a long time though to get that drug out of her system.

Timber just ate a bowl of cherrios and milk and had a vitamin. (I know this is not ideal but it is something)

Any other thoughts as to what a dog could eat if they don't like the smell of meat?

[MaxaLisa]

SW, I've just seen a lot of these cases on the tick list - mostly tick diseases, some cancers, some autoimmune in the mixed, and some with all three.

In "the real world", I'm actually a mathematics professor, so I'm constantly evaluating the odds and tendency and the logic of treatment. For example, how long has your dog been on immune suppressants primarily, what has gotten better, what hasn't?

I also have dogs which have complicated medical issues, where things don't show up on tests well. I actually think we have strains in California that they don't have the right tests for.

My Max has a history of perianal fistulas (mostly seen in GSDs). Treatment for that is pred, cyclosporin, or Imuran, so I am familiar with those meds. On the PF list, those are predominantly the meds that dogs respond to. They made it worse for Max. I stopped all the regular meds, and put him on a doxycycline/niacinamide protocol and he started getting better. I searched the blog of a lyme MD and found a multi-antibiotic protocol that he uses for coinfections, and I put my dog on a protocol to mimic that. It took a combination of three different antibiotics to get him better and healed up. In some sense, it flies in the face of common sense and everything conventional. (Btw, I was working with a dermatologist through this, but I started the drug regimines on my own.) Oddly, I am in an area where they say that we don't really have tick diseases.

And the bottom line, is that it might not be a tick disease, for either your dog or mine. But if there is a lack of satisfactory response to the current treatment, and a high likelihood that there is another treatment to try that will not make things worse, then you gotta go in that direction.

Seems to me that pure autoimmune has been ruled out, and you are down to cancer and/or infection, neither of which respond favorably to immune suppression (though a few cancers do seem to respond to pred, which doesn't seem to be happening here).

Have you tried different types of proteins when feeding?

I'm a big fan of vanilla or unflavored whey protein (with no artificial sweeteners), mixed in a favorite liquid. For my girl, it used to be apple juice (and the natural sugars are good when they are not eating). For Max, he loves the green barley drinks, but will also drink the apple juice. The whey protein gives them lots of nutrients, and it's also a cancer fighter.

Did you see anyt of the digestive stuff get better with the decrease in doxy? If not, you might have to add some probiotics, or anti-acids, or l-glutamine for the stomach to tolerate it. All these drugs are hard on the body - all of them.

When Max was on cyclosporine for his fistula, similar to Imuran, I did stop it completely at once, though he was not on it long. He felt a little bit better each day, but it took about a couple of weeks for the antibiotics to start undoing the damage that was done by the suppression.

Do you know which white blood cells are increasing? Neutrophils? Bands? Monocytes? etc?

[SuperWanda]

No, I don't know which blood cells are increasing but I could find out.

I haven't seen too much increase in her appetite since reducing the doxy but it's only been reduced for the last two doses.

I just gave her some Bio-K (probiotic acidophilus liquid) and I will try those different protein suggestions.

Still off the smell of meat and eggs so she just has some yogurt with the probiotic, toast with butter and goats milk.

I tried rice but for whatever reason that was not appealing.

She is on dexamethasone (a brother of prednisone). She started 50mg of pred on October 5 and switched straight to 8mg dex on November 8. I didn't realize but when our regular vet came to take blood she said she was probably experiencing withdrawl symptoms because of the switch but the internist never told us that. She just said to replace one with the other because they are brother medications. She has been on the Imuran since Oct 18.

BTW, how old is your dog Max?

[MaxaLisa]

I'm just curious about the white blood cells. I don't think there is a specific pattern, but sometimes they can give you some clues.

Beef, chicken, liver, vegetables, minced olives, edible mushrooms, etc, try everything!

Max is 9 1/2 years. He's had issues all his life, they are progressing, only slowly when on abx though. In the end, it will probably take him, or turn cancerous, if it hasn't already. He is a work in progress

[SuperWanda]

I guess I just don't understand why the vet is not happy with the jump in platelets? They were 54 and now 141. That seems significant and to me something must be helping that.

Maybe that doesn't mean anything if the RBC are 2.2 and WBC are 41.6 though?

[hazelrunpack]

I agree about the platelets. Something is helping in that regard.

Anemia (decrease in RBCs) can be caused by internal bleeding or by destruction of red blood cells. My guess is that the vet is thinking there's a hidden cancer that's causing internal bleeding

How far out of norm is the WBC count? White blood cells come in a number of varieties--some WBCs are more commonly seen when the body is fighting a parasite, some when there is a bacterial infection, some when there is allergy-related inflammation, some when the body is fighting cancer, etc. As MaxLisa mentioned, sometimes the pattern of WBC activity can tell you something about what the problem is...

Your vet should be willing to sit down and talk to you (or talk over the phone) about what his suspicions are and why he thinks that way.

Did Timber eat anything tonight?

[MaxaLisa]

I think you answered your own question. If they had the right treatment, all parameters would be getting better. The platelets are getting better, but there is an increasing problem with the red and white blood cells, which basically tells them they don't have the right diagnosis

[SuperWanda]

Yes, Timber had some of my chicken sausage and toast with liver pate even though she won't touch any chicken or liver that I make for her. I'm thinking she likes things with spices that disguises the smell of the meat? If that is the case I may end up buying her some hot dogs. I know that is not healthy but some "all beefs" would give her a little iron maybe?

I was also wondering if the Imuran is decreasing the red cells but not sure why it would increase the platelets at the same time???

I think the trouble is the vet does not know. It didn't seem like she thought the platelets going up a good sign since the RBC were low and the WBC were high? I don't know what a normal RBC is? I think we started out at 4.8 or 5. Apparently Timber was a little low 2 years ago with the RBC so when she was slightly anemic it wasn't a big issue. I'm not sure what a normal WBC count is either. I know the only time the WBC count went down a little was when we were on the metronidazole antibiotic. After that we switched to Baytril and now WBC is high but I'd have to get another test to see what the doxycycline is doing.

The results should be sent to the internist as well so I'd be interested to get her opinion.

However, at this point, I feel it has been long enough and she continues to get worse in some respects so I don't know if I'm right to get her off the meds or not but that's the thing -- no one seems to know. If they suspect cancer now but they also want me to continue meds, I just don't feel comfortable with it anymore. Why didn't I go to medical school?

[MaxaLisa]

I hope that you will be able to mix some of the tempting things with some more healthy things to get some nutrition in her - I know how difficult it is!

Originally Posted by SuperWanda

I was also wondering if the Imuran is decreasing the red cells but not sure why it would increase the platelets at the same time???

I think this is the way it goes.....the drug regimen with the Imuran is bringing the platelets up, but there is another process that is destroying the red blood cells. That other process is either infection or cancer The Imuran itself should not damage the RBC, but it can make things like infection or cancer worse, which can increase the RBC destruction and increase the WBC.

I think the trouble is the vet does not know.

I think that right now there is no way for anyone to really know.

I don't know what a normal RBC is? I think we started out at 4.8 or 5. Apparently Timber was a little low 2 years ago with the RBC so when she was slightly anemic it wasn't a big issue. I'm not sure what a normal WBC count is either. I know the only time the WBC count went down a little was when we were on the metronidazole antibiotic. After that we switched to Baytril and now WBC is high but I'd have to get another test to see what the doxycycline is doing.

Labs have different normals. Idexx normal for RBC is 5.5-8.5 and WBC is 5.7-16.3, I don't know if those numbers apply for the test that you have. Platelet normals are 164-510, at that lab at least.

Diseases like ehrlichia or babesia can take years to settle in and cause this type of damage. I'm willing to bet that 2 years ago, this disease process was present.

Baytril is not a good tick disease antibiotic, I'm not surprised that it hasn't helped. I think it might help a bit with Bartonella, but that's not a disease where you are going to see this blood profile. The metronidazole is sometimes used to get at lyme cysts, but is also used in the treatment of babesia, which can do exactly what you are seeing in Timber:
http://www.gopetsamerica.com/dog-health/babesiosis.aspx

However, at this point, I feel it has been long enough and she continues to get worse in some respects so I don't know if I'm right to get her off the meds or not but that's the thing -- no one seems to know. If they suspect cancer now but they also want me to continue meds, I just don't feel comfortable with it anymore. Why didn't I go to medical school?

Yes, it's very confusing and frustrating. In my mind, it seems you should be ramping down the immune suppressants, and ramping up antibiotics that fight ehrlichia and babesia. I'm throwing in babesia here, because of the response to metro.

[SuperWanda]

She is very weak and struggles to get up and walk. The only way to get in and out of our house is with stairs so we have a ramp for her but she doesn't have the strength to go up and down herself. She uses all her strength just to pee and collapses in the snow to recover before needing help back inside. She is still drinking excessively so we are up through out the night, getting our jackets and boots on and trying to help her in and out. We are both extremely tired and this whole situation has taken it's toll on our entire family.

[MaxaLisa]

I see several options, none of which are the clear winner.

Continue what you are doing. It seems to me that you will see a continued decline.

Decide that she is too sick, and you do not want her to suffer anymore

Stop as much of the immune suppression stuff that you can, taper the others, and try a doxycyxline, clindamycin, metronidazole protocol, or at least the first and the last of those three. Mind you, I dislike metro a lot because some dogs get neuro side effects, but her history indicates there was improvement on this.

I am so sorry Timber and your family are facing this

[SuperWanda]

Thanks MaxaLisa,

Do you know if it does happen to be some kind of infection and you are getting a destruction of platelets and/or red blood cells -- is that caused by the infection itself or by the immune system? I ask this because if the immune system is causing the destruction don't you want to stop that by suppression with the steroids? or once you stop the infection does the immune system stop the destruction of the cells?

I hope that question makes sense -- I basically want to know if the infection is causing the immune system to attack the cells or if the infection is directly attacking the cells?

[MaxaLisa]

Originally Posted by SuperWanda

I hope that question makes sense -- I basically want to know if the infection is causing the immune system to attack the cells or if the infection is directly attacking the cells?

I can't say with certainty, I think either can be true. It is true that infection causes inflammatory processes in the body that can cause this.

I have seen treatment with doxy raise both platelets and red blood cells. The general wisdom is to use the immune suppressing drugs only if the platelets get at a life threatening low level. In general, steroids will interfere with the doxy treatment.

In a few dogs, though not the general case, this has turned into an ongoing inflammatory/autoimmune process, thought to be separate from the infection, though originally caused by the infection (if that makes sense).

I don't know if you have seen this, but he's the only dog known on the tick list to have beaten ehrlichia risticii, an ehrlichia transmitted typically by drinking water and not by ticks: http://www.vintagegoldens.com/jasperstory.html There are many success stories of other types of ehrlichias, including anaplasmosa!

I have started to put some tick links together here:
http://www.germanshepherdhome.net/fo....html#Post1594
The diseases that you would want to look at would be the ehrlichias, anaplasmosa, babesia.

[hazelrunpack]

SW, I'm sorry this isn't getting any easier for you and Timber. No advice, just wanted to let you know I'm thinking of you.

[SuperWanda]

Thank you MaxaLisa, Hazel,

The internist called. She thought that based on the white cells - both neutrophils and bands are increasing that it's not likely an infection but a cancer.

We will monitor her over the weekend but no improvement has been seen with her appetite and she is very, very weak.

Thanks to everyone here for their support and concern for our Timber.

[MaxaLisa]

Originally Posted by SuperWanda

Thank you MaxaLisa, Hazel,

The internist called. She thought that based on the white cells - both neutrophils and bands are increasing that it's not likely an infection but a cancer.

That's the same thing that the university vet said about my dog before she passed away. However, hers was a very different situation than this, although I believe that she had an infection that had spread to her brain.

I should add, that when my mother had an acute infection that she lost her entire colon to, it was the neutrophils and bands that increased, which ultimately resolved. This textbook discusses the same blood profile as an indication of infection:
http://books.google.com/books?id=3PJ...ection&f=false

"The most commonly encountered reason for neutrophilia is an acute bacterial infection."
http://www.msdlatinamerica.com/ebook...sid673577.html

I'm so sorry that you have reached this point with Timber, I will be thinking of you.....

[SuperWanda]

Still pretty slow and weak here but we have discovered that she really likes hot dogs.

We have been on the doxy for 4 days now and I am not noticing any changes.

If she did have an infection wouldn't she have a fever???

I know we have a tentative diagnosis of cancer but it really bothers me to not know for sure.

I guess we have to put away the diagnosis and just judge based on how comfortable she is. This has been going on since the end of September/beginning of October so that's a long time to feel so lethargic and depressed.

[MaxaLisa]

The fever is iffy, depends on the status of the immune system. My girl's temperature was going up a 1/2 a degree every so many days as her neutrophils were rising, still not enough to technically be called a fever. Previously, with all her infections, she never ran a fever.

If you're still giving any immune suppressants, response to doxy may be depressed. But after about a week and no response whatsoever, that's really not a good sign.

Since doxy can be a cancer fighter, at least this is not something that is hurting her.

Sept/Oct is a long time to be in this position, it is not looking good, but I always hope for the long shot, and then in the end, you know you really did try everything.

I am so sorry that she isn't turning around. I am very glad though that she likes hot dogs - something that she will eat

[Goldfields]

Originally Posted by SuperWanda

I guess we have to put away the diagnosis and just judge based on how comfortable she is. This has been going on since the end of September/beginning of October so that's a long time to feel so lethargic and depressed.

Good idea seeing the diagnosis isn't definite, and don't forget that with Arie it took her 8 months to beat Evans Syndrome. If Timber doesn't have that, neither might she have what MaxaLisa thinks she has. I'd suggest having a bit of faith in your Vet who probably needs to go through a process of elimination to reach the right conclusion. You could always go to another Vet for a second opinion.

[hazelrunpack]

She any better today, SW?

[SuperWanda]

No, not really any better. Still very, very weak and sleeping a lot.

Her gums are very pale and to feel better I think she would need a blood transfusion at this point. Very anemic and hardly any appetite.

Still struggling with a decision because do you get a transfusion to buy you more time to treat a illness that you may not even have. She may improve a little but then have to go through this all again if it is some kind of cancer and that would be very hard.

Again, it is so hard when you still have unanswered questions but maybe there is no wrong answer here. I don't know.

[MaxaLisa]

I am so sorry...

Even if it's infection, it may be too advanced now, and may have done too much damage.

My thoughts are with you in this *very* difficult decision.

[Rgeurts]

Originally Posted by SuperWanda

No, not really any better. Still very, very weak and sleeping a lot.

Her gums are very pale and to feel better I think she would need a blood transfusion at this point. Very anemic and hardly any appetite.

Still struggling with a decision because do you get a transfusion to buy you more time to treat a illness that you may not even have. She may improve a little but then have to go through this all again if it is some kind of cancer and that would be very hard.

Again, it is so hard when you still have unanswered questions but maybe there is no wrong answer here. I don't know.

I'm so sorry to hear about Timber. I feel horrible, but I haven't kept up with this thread. I sincerely hope you get some answers. Just to let you know, we are going through similar issues with our baby. His is immune-mediated. He was also put on Azathioprine 5 weeks ago. Aftet the second week he showed very minor anemia. 3 weeks later he is in the hospital having a transfusion (just this past Saturday evening). The Azathioprine and Prednisone caused internal bleeding (they think, but do not know for sure) and the Azathioprine stopped him from effectively regenerating new blood cells. His RBC was down to 8.8%. Our vet was completely amazed that he was still with us. They immediately called in a donor and gave him a transfusion. The day before, we had been at the holistic vet for the same reason (black stools, lethargy). The holistic vet gave us an herb to help stop the bleeding and reduce inflammation. Our vet said we would most likely be back in on Monday for another transfusion. Our vet did reccomend stopping the azathioprine and so did the holistic vet. Our vet then said to wean him down instead as he could not live through a seizure. So we cut the dose by 33%. The next day she said to stop it completely. I'm very happy to say that today was a good day. Hubby took him in, they ran a blood count. He's still only at 14%, but they said he's generating new red cells "like mad". So a transfusion was not needed. The bleeding has stopped and he is hopefully now on the mend. Sorry for the length of this post, but I wanted you to know that we are going through something similar with the same drugs. The holistic treatment may help yours as well. If you would like the name, let me know. It also helps to rebuild the blood. Our baby went downhill SO fast on Azathioprine and it was terrifying. My heart (and prayers) go out to you and Timber

Nanook had the same symptoms from the anemia: loss of appetite, pale gums, nose and tongue, unable to lift himself at all (hubby had to carry him) and could barely open his little eyes. Our vet did not expect him to make it long and was preparing us for the worst. After the holistic treatment, transfusion and a couple of tummy meds combined with removing the azahtioprine, he is now eating, walking and giving hubby and I "high fives" expecting his treats

[SuperWanda]

Rgeurts, I have sent you a pm. Thank you for the information and I hope your two continue to improve! I have been reading about Nanook and hoping he makes a full recovery. I'm so sorry you are going through this. It is very difficult.

Timber is eating a little better -- I don't want to be overly optimistic so we continue to take it one day at a time. Her gums are still pale and she is still very week. Sleeping a lot but as I continue to wean the steroid dose down she seems to be sleeping better. The weather here is giving her something to be happy about as she often lies out on the deck and loves to eat the snow.

I am still hoping for a miracle but am worried her anemia may be due to a hidden cancer and if so, will continue to drop.

I haven't given and azothiroprine since Friday -- not sure how long it stays in your system. If her RBC started to go up after discontinuation of that drug I would be very encouraged. I know that it can cause low platelets and white blood cells but wasn't sure about the RBC, is that what your vet thought?

[SuperWanda]

Also, did you just cut the dose of the azathioprine down to 33% for just one day before you completely stopped it? and no seizures.

I got nervous after stopping mine last Monday so gave her one on Friday but haven't given any since.

[Rgeurts]

Originally Posted by SuperWanda

Also, did you just cut the dose of the azathioprine down to 33% for just one day before you completely stopped it? and no seizures.

I got nervous after stopping mine last Monday so gave her one on Friday but haven't given any since.

Hi SuperWanda,

We cut the dose for the one day, then stopped it all together. So far, so good. It's more the prednisone that worries them. It has done so well in controlling the meningoencephalitis, but has just wreaked havoc on his poor little body. He isn't doing too well today. He has lost his appetite and is very lethargic again, though not as bad as he was. The Azathioprine can inhibit the production of bone marrow, and in turn, can stop the production of red blood cells, which is why they had us stop. Since we stopped, he is generating new blood cells, but we are not sure if they are able to mature. We will find that out on Friday. The herbs did help to stop the bleeding. His liver enzymes were also severely spiked which our regular vet and specialist said was to be expected and there was nothing really to do except monitor it.
The holistic vet disagreed, gave him a holistic powder and his liver is back to normal after only 5 days on the powder , so there must be something to it. I will reply to your pm