Page 6 - Clinical Connections - Spring 2022

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Page 6 - Clinical Connections - Spring 2022
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ºÚÁÏÉç RESEARCH    STUDY    VETERINARY SERVICES       ºÚÁÏÉç.AC.UK
         Case Study

        IMMUNE-MEDIATED HAEMOLYTIC ANAEMIA

        Erica Tinson, Lecturer in Veterinary Emergency and Critical Care


              uddy, a six-year-old Labrador was   in the evaluation of underlying causes of   IMHA and steroid treatment. Clopidogrel
              presented to ºÚÁÏÉç Small  Animal   his disease and the transfusion medicine   and rivaroxaban were started to treat
        B Referrals  in  early  January  for   team  needed  to  be  intimately  involved  to   this hypercoagulable state. Owners and
        investigation of severe anaemia.    effectively plan for his blood products.   referrers were therefore advised to expect
          He was diagnosed with immune-mediated   Buddy required packed red blood cell   Buddy to display intermittent tachypnoea.
        haemolytic anaemia (IMHA), which, in the   transfusions on five occasions from the 8th   He is likely to need to anticoagulant therapy
        absence of evidence of a trigger factor,   of January. Due to a high level of transfusion   until  his  inflammatory  state  has  resolved,
        was considered to be non-associative   dependency and clinical deterioration,   which will be marked by his IMHA going into
        (idiopathic).                       he also underwent therapeutic plasma   remission.
          During physical examination, Buddy   exchange. He had 10 units of red blood cells   Buddy developed an abscess of this right
        was quiet but alert and responsive. His   – which had the transfusion team working   thoracic limb while in hospital. It is suspected
        mucous membranes were pale and icteric   very hard to keep up with the demand – and   to be associated with a previous intravenous
        and  capillary  refill  time  was  two  seconds.   eight plasma transfusions.  catheter. Fortunately, Buddy responded well
        His sclera were notably icteric. His cardiac   The  plasma  exchange  proceeded  to antimicrobial treatment, but was still lame
        auscultation was normal and did not identify   uneventfully,  and  Buddy showed  signs   on the day of discharge. For that, he was
        a murmur or arrhythmia. His heart rate was   of improvement over the following days.   prescribed paracetamol and physiotherapy
        140bpm and his pulses were synchronous   He  was  transitioned  to  oral  prednisolone   at home, in addition to additional analgesia
        but bounding.                       and azathioprine was added as a second   if required.
          His   thoracic  auscultation  was  immunosuppressive agent during his period   Buddy's  PCV  at  the  time  of  discharge
        unremarkable, and his respiratory rate was   of treatment at the ºÚÁÏÉç.   was 31%.  The referring vets reviewed
        36 per minute. He was soft and comfortable   On the 18th of January Buddy developed   him 10 days later. Buddy’s PCV remained
        on abdominal palpation. His peripheral   marked hypoxaemia and dyspnoea that   static  post-discharge  and  a  decision  was
        lymph nodes were normal on palpation.   progressed to severe respiratory distress   made to start weaning his steroids slightly
          Buddy remained under the primary care   the following day. Investigations and clinical   with a close watch on his blood work. He
        of the Critical Care Service due to his high   suspicion  were  consistent  with  pulmonary   unfortunately is still lame and a review
        dependency for blood products and the   thrombosis.                     consultation with our Orthopaedic Service
        instability that caused.  The Critical Care   Fortunately, Buddy made a good   has been recommended. Another option for
        team  discussed his  case with the Internal   improvement over the next few days,   review of this ongoing lameness was for the
        Medicine team daily to maintain a wholistic   though there persisted an ongoing risk   primary care vet to take radiographs of the
        approach to his care. In addition to this, the   of thromboembolic events due to his   leg and the ºÚÁÏÉç team can help review them
        Diagnostic Imaging team were pertinent   hypercoagulable state secondary to the   remotely.
                                                                                 If Buddy is clinically well and his PCV is
                                                                                improving, we can consider tapering his
                                                                                prednisolone dose at that stage by 25%. If
                                                                                he continues to respond well to treatment,
                                                                                his  prednisolone  dose  can  be  tapered  by
                                                                                25% every two weeks as long as he is
                                                                                clinically well and physical examination
                                                                                and  haematology,  including  blood  smear
                                                                                examination, does not raise concerns of
                                                                                a relapse.  Azathioprine will mostly likely
                                                                                be continued  for eight weeks after the
                                                                                prednisolone has been stopped as long
                                                                                as  there  are  no  side  effect  with  its  use.
                                                                                We advised for serum biochemistry to be
                                                                                performed every six to eight weeks as long
                                                                                as Buddy is on azathioprine.
                                                                                 Get involved – we need cases to help
                                                                                canine  autoimmune  research.  This  is  one
                                                                                of  our  projects, concerning IMHA and
                                                                                biomarkers.



                                                                                      For small animal referrals, please call:
                                                                                     01707 666399
                                                                                      Email:
         Buddy receiving a blood transfusion from the ºÚÁÏÉç team  py                   qmhreception@rvc.ac.uk

        6   Spring 2022
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