We enjoyed meeting the dogs and their owners.

The owner reported some decreased mobility. It seemed like her joints were sore and that she was a bit less active all of which are not unusual for a 12 year old large dog. The doctor did a complete physical and felt like she did have some degenerative changes in her knees. A senior blood profile (chemistries, CBC, urinalysis) was recommended with the plan to start Molly on NSAIDS, anti-inflammatory medications, for her arthritis if labs were okay. The labs were received the next day at which time we learned Molly had a low grade urinary tract infection as well as a dangerously high calcium level,
hypercalcemia.

What is Hypercalcemia? Hypercalcemia is too high level of calcium in the blood. The body’s parathyroid gland closely regulates calcium in a very narrow range between 9-11.5. Too much calcium in the blood puts severe stress on the kidneys and can lead to kidney failure. A diagnosis of excess calcium should be followed up and a cause found as soon as possible to prevent permanent damage.

What causes hypercalcemia? There are many causes of excessive calcium and figuring out the cause is crucial to treating the problem. One cause of excess calcium is too much parathyroid hormone (PTH). This can be hormone secreted by the parathyroid hormone itself or from a tumor elsewhere in the body that is secreting a hormone that is so similar to the parathyroid hormone (PTH-rH) the body responds as if it is PTH and mobilizes calcium. This occurs with anal gland tumors and lymphoma. Kidney disease, because of the inability of the kidneys to excrete calcium, can also be responsible as can excessive levels of vitamin D , which can happen from over-supplementation, rat bait, or human
psoriasis creams.

On additional testing, Molly’s parathyroid hormone was found to be elevated more than 20 times the normal level. With this discover the next step was an ultrasound of her neck to look for a tumor in the tiny parathyroid glands found on either side of the larynx (Adam’s apple). A 5.5 mm mass was discovered on the right side and Molly was scheduled for surgery where the mass was removed. Post-operative Molly had to have calcium levels monitored closely since removing the source of the hormone can cause an unsafe drop in calcium levels. The calcium levels quickly returned to normal and her owners noticed that she was more active and felt better soon after her surgery. A few days post-operative we received the good news that the tumor was a benign adenoma. This neoplasm would account for the clinical syndrome of hyperparathyroidism and thus the hypercalcemia.

We have seen several hypercalcemia cases recently from various causes. Whereas most of the others had symptoms of drinking and urinating large amounts. Molly’s case demonstrates why it is so important for routine screening since sometimes we can pick up disorders that otherwise would have gone undetected until damage was too severe to reverse.

VeterinaryPartner.com has an article with more detailed information about hypercalcemia.

Wednesday came in one day in January not eating or drinking and feeling lethargic. An unusual behavior for this year and half old rambunctious Pit Bull mix. She was urinating brownish red urine and had been vomiting for a day. She had lost 3 lbs recently and her gums were very pale and even had a yellow color to them. We were able to perform lab tests here in the clinic and get a diagnosis that same day that would allow us to initiate rapid and life saving treatment. Wednesday had a severe form of anemia called Immune Mediated Hemolytic Anemia (IMHA).

Immune-mediated hemolytic anemia is a condition where the patient’s immune system begins attacking his or her own red blood cells. In this condition the red blood cells become quickly coated with tiny antigens, essentially marking these red blood cells for destruction. When the red blood cells are destroyed the patient becomes anemic, and will feel cold and weak. Because the red blood cells are being destroyed internally (and not lost through bleeding), the patient will become yellow-tinged (jaundiced) rather than pale. Once they have lost most of their red blood cells the patient will no longer be able to oxygenate their body and death is imminent. Quick detection and treatment usually provides a 75% or better chance of surviving. Similar disorders involve the platelets only (thrombocytopenia), which causes bleeding problems or a combination of both (Evans syndrome, see archived article on Harley) a very difficult disorder to get a handle on.

Anemia is often measured in terms of percentage or pack cell volume (PCV), which is the percent of the blood that is red blood cells. Normal for a dog is about 45-55% and Wednesday’s PCV on day one was 24%. She was started on high dose steroid treatment, which suppresses the immune response against her own cells. Unfortunately this treatment usually takes 3-5 days to make a difference and the next day her PCV was 17% and she was feeling worse.

We needed to buy her time with a blood transfusion so our drugs had a chance to do their job. She was given 2 units of universal donor blood which brought her count back up to 24% and she was started on Cyclosporine a drug used in transplant patients to prevent rejection. The next 3-4 days were touch and go and she required close monitoring. She almost needed more blood but on the  5th day her PCV started climbing. It climbed all the way to normal over the next month.

Wednesday continues to do well but is still on medication. She must be monitored regularly as we slowly wean her off the immunosuppressive drugs. It is also possible she may have a relapse but most dogs with this problem go on to live normal healthy lives. We do not know what caused Wednesday’s IMHA which is frequently the case with this syndrome. Depending on which of several studies are examined, 60-75% of IMHA cases do not have apparent causes.

In some cases, though, there is an underlying problem: something that triggered the reaction. A drug can induce a reaction that stimulates the immune system and ultimately mimics some sort of red blood cell membrane protein. Not only will the immune system seek the drug but also it will seek proteins that closely resemble the drug and innocent red blood cells will be consequently destroyed. Drugs are not the only such stimuli; cancers can stimulate the same reaction Red blood cell parasites often transmitted by ticks create a similar situation except the immune system is aiming to destroy the infected red blood cells. The problem is that it gets over-stimulated and begins attacking the normal cells as well.

There is some thinking that vaccination can trigger IMHA. Insect bites have also been implicated. Both have been associated with the development of AIHA. The relationship between recent vaccination and IMHA development is one of the factors that has led most veterinary schools to go to an every 3-year schedule for the standard DHLPP vaccine for dogs rather than the traditional annual schedule. We here at Allandale Veterinary Clinic practice the same philosophy and avoid excessive vaccination.

Wednesday’s story has a happy ending thus far, she is robust and active again and the owners are pleased she is doing well. If you note similar symptoms in your pet, tired anorexic and pale gums, don’t delay, get them in for an exam right away.