Red Blood Cell Breakdown - Vet Stumped

[Guest PiagetsMom]

This is going to be a "book", but I want to give as much info as I can. We've been having some issues with Maya, who recently turned 6 yrs old - this starting mid/late November.

A couple of months ago, Maya spent 2 nights boarded at our vet while we were out of town. While there, she had blood in her urine, and thinking they were dealing with a UTI, Dr. Miller treated her with Baytril and set up an appt for a 10 day recheck. About a week later, she was slow in getting up out of bed, and was not eating well - which is very unusual for Maya. I figured maybe it was the Baytril affecting her stomach.

Dr. Miller examined her, and while he said that although typically Baytril doesn't affect the stomach, anything was possible, and gave her a shot of Famotadine. He decided to do a more thorough exam and found that she was very sensitive to a spot on her lower back/spine - she consistantly yelped when he would press in that spot. He suggested running an xray and some bloodwork, just as a precaution, and we did. It did not show anything of significance, and he felt it might be a soft tissue injury. He gave her a shot of Rimadyl, suggested I finish the Baytril along with a prescription for Rimadyl, and give 15 mg of Pepcid twice a day.

While I was waiting for our meds, One of the vet techs came out to get a urine sample - she peed with a large amount of blood. I was told that they would spin it there to check it and the doctor would get back with me. A couple of hours later I get a call from the vet asking if I could bring Maya back in. Apparently, the blood in the urine is not "normal" for a UTI. Maya's tests show that her red blood cells are breaking down throughout her system, but Dr. Miller does not know why. Her bloodwork did not show any major issues with kidneys, liver, etc.

He mentioned different possible causes - a muscle issue/injury, or parasites among them. Maya was tested for tick borne diseases before she was adopted out and she tested positive for Babesia and was given 2 treatments for that. He is aware of that, but wanted to test for that as a precaution. He gave her a prescription for Doxycycline 100 mg, which we did two rounds of.

He also wanted to run a chest and stomach xray, which he did, and after consulting with a radiologist they agreed that Maya's heart was enlarged, even for a greyhound. He mentioned that depending on the other blood tests we were waiting for, we might have to look into the heart issue with an EKG/ultrasound. In the meantime, we kept an eye on her packed cell volume, which has held steady. The tick titer results came back negative, and the remainder of her bloowork did not show anything of importance.

We did do the ultrasound of her heart and spleen. The spleen was fine, and while her heart was enlarged, there were no tumors or other issues that Dr. Miller was concerned might be causing the problem.

Here's a good one for you, and something that seems rather bizarre......although a subsequent urine sample spin still showed the red blood cell issue, through all of the testing we did, there was no more visible blood in her urine - until I took her for her ultrasound and had to drop her off and leave her there from 8:30 am until 2:30 pm. While she was there, they took her out to do a urine test, and she was peeing blood again.

Dr. Miller seems to feel that whatever Maya's issue is, stress seems to be a factor. He ran another round of bloodwork to check for immune system problems, but those all came back normal. He said there were some other tests that he could run if we wanted to continue on, but it seems we're just looking for a needle in a haystack of some sort. He suggested I take her home, and as long as she was acting normal, eating well, and I could not see any blood, to just keep an eye on her for any other symptoms. We did do another urine check mid-December, and while I could not see any blood in her urine, her urine does look a darker yellow than normal, and her test showed signs of microscopic bilirubin. We agreed to do another round of bloodwork after the first of the year.

The last couple of weeks we've had some behavioral changes with Maya, mainly with Mirage. The pups have always co-existed well together, with no issues. We had an episode of "snarkiness" out in the yard, which I heard, but did not actually see. With all of the trips back and forth to the vet Mirage has been a little "smelly" of her, so possibly that was it. Also, for some reason Maya has been very grumbly when she is in a bed and Mirage is close by.

It started at night - both pups sleep in our room at the foot of our bed in their beds - they're about 4-6 ft apart, and we've had ZERO issues for the last 2 years. Whenever Mirage would stir or reposition himself, she would growl.....then it escalated to a growl and bark. A few days later it happened in our front sitting room, where they both have beds and usually rest/hang out during the day. And, then New Year's Eve we had my parents over and both pups were in the living room with us in their beds......Maya grumbled at Mirage, and then shortly afterwards, lifted her head and looked at him, growled and bared her teeth. At that point, I moved them both and babygated Maya in our bedroom until my parents left.

So, considering it was time for bloodwork, we went back to the vet on Friday. Dr. Miller examined her, and she was again very sensitive in her lower back, and now also when he manipulated her right rear leg. We did another urine spin, and it still showed an increase in bilirubin, so the red blood cell break down is still happening and he feels that although we haven't been able to find it, there is something going on systemically with Maya. He took blood samples and sent us home with Rimadyl twice a day for the back.

I heard from Dr. Miller this (Sunday) morning, and while her blood count is good, there are some slight changes. Her muscle enzymes are elevated, which could account for the back issue, and her bloodwork shows that her body is being stimulated to produce more red blood cells. We've tested her thyroid twice previously, and Dr. Miller felt that it was not too low in greyhound values, but he feels that on this last test it is now testing a "little low". He wants to consult with Dr. Haug, the veterinary behaviorist that we worked with previously for her opinion, but he is of the thought that considering her behavioral changes, now might be the time to try her on thyroid meds. He'll get back to me after he's spoken to her.

Sooooo........if you've made it this far, thank you! I always appreciate Batmom's advice and I've been talking with her throughout (thank you, Jey!)....... Jey also thinks it's a bizarre situation, so on the outside chance that this might ring a bell for anyone else out there who has had a similar situation, I'm sharing. Thanks in advance for any input anyone might have!

[MaryJane]

Can you provide blood work and urine results?

[tbhounds]

Wonder if it's her kidneys?? Cut to the chase and contact an expert :-)

 

 

http://www.coutovetconsultants.com

[Batmom]

Can't remember if/when/what all we talked about before -- in addition to kidneys, 100% sure she doesn't have 1. babesia, 2. leptospirosis, 3. UTI?

[Remolacha]

No clue, but at this point I would consult with an expert, Dr C, or if there is another greyhound specialist in the area.

 

Oh, wanted to add, the snarkiness with Mirage is probably because she doesn't feel well.

[FiveRoooooers]

If hypothyroidism is suspected, starting Maya on soloxine won't hurt her and it might help.

[MP_the4pack]

Auto immune Hemolytic anemia?

[Guest PiagetsMom]

Can you provide blood work and urine results?

 

I don't have the latest test results/values - I only spoke by phone with Dr. Miller this morning.

 

Wonder if it's her kidneys?? Cut to the chase and contact an expert :-)

 

 

http://www.coutovetconsultants.com

 

I am passing this info on to Dr. Miller - thank you.

 

Can't remember if/when/what all we talked about before -- in addition to kidneys, 100% sure she doesn't have 1. babesia, 2. leptospirosis, 3. UTI?

 

Yes, all of her tick titers and testing were negative. The bloodwork shows normal kidney values. Just ran another urinalysis/urine spin again Friday and it does not present as a UTI.

 

 

Auto immune Hemolytic anemia?

 

Dr. Miller ran tests to check her immune system to see if this would not be some sort of breakdown/attack on her body - those results were all normal.

Edited January 5, 2014 by PiagetsMom

[MaryJane]

Do a urine culture - do not rely on having them look at it through a microscope. Have them send it out for a culture and make sure that they get specific gravity and protein/glucose/bili on the urine.

 

Can you provide the bloodwork results in a post. What about platelets, do you have values for those?

[JohnF]

Auto immune Hemolytic anemia?

I was going to mention that too. And Babesia as a possible cause.

 

http://www.vcahospitals.com/main/pet-health-information/article/animal-health/autoimmune-hemolytic-anemia-in-dogs/2135

[Guest PiagetsMom]

I was going to mention that too. And Babesia as a possible cause.

 

http://www.vcahospitals.com/main/pet-health-information/article/animal-health/autoimmune-hemolytic-anemia-in-dogs/2135

 

Again, I think we've tested for this, but I'll be sure to ask Dr. Miller about it when I talk to him. Maya tested positive for babesia when she was originally adopted out, and received injections as treatment. Dr. Miller has retested her, and her results were negative.

 

 

 

Can you provide blood work and urine results?

 

Sorry, MaryJane - not to ignore you, but after looking I only find the first set of blood work results from November. I wish I could figure out how to provide those in a post but here are the values that were not normal:

 

WBC was 3.81 - normal is 5.50-16.90 - low

 

Platelet count was 167 - normal is 175-500 - low

 

HGB was 18.2 - normal is 12.0-18.0 - high

 

RDW was 18.8 - normal is 14.7-17.9 - high

 

Everything else was in the normal range. Don't know if that helps in any way because we've done additional blood work and I don't have those results on paper.

 

 

 

Edited January 5, 2014 by PiagetsMom

[tbhounds]

The values you just posted are normal gh values :-)

[MaryJane]

 

Again, I think we've tested for this, but I'll be sure to ask Dr. Miller about it when I talk to him. Maya tested positive for babesia when she was originally adopted out, and received injections as treatment. Dr. Miller has retested her, and her results were negative.

 

 

 

 

Sorry, MaryJane - not to ignore you, but after looking I only find the first set of blood work results from November. I wish I could figure out how to provide those in a post but here are the values that were not normal:

 

WBC was 3.81 - normal is 5.50-16.90 - low

 

Platelet count was 167 - normal is 175-500 - low

 

HGB was 18.2 - normal is 12.0-18.0 - high

 

RDW was 18.8 - normal is 14.7-17.9 - high

 

Everything else was in the normal range. Don't know if that helps in any way because we've done additional blood work and I don't have those results on paper.

 

 

 

 

 

Those are OK. Can you post the urine values?

[Guest PiagetsMom]

The values you just posted are normal gh values :-)

 

Yes, Dr. Miller continues to tell me that nothing significant is showing up with her testing. Even the elevated muscle enzymes and the slightly lower thyroid in her blood tests from this week would not be something he would be concerned about in an otherwise healthy greyhound, but knowing that there is some issue going on with Maya, he feels they are worth taking notice of.

 

 

 

Those are OK. Can you post the urine values?

 

I'm not finding those in the paperwork I've looked through, but I'll look again. What I can tell you as it was explained to me is that with a UTI, the red blood cells normally settle and form a sediment in the bottom of a urine sample after spinning. In Maya's sample, they do not separate, but are broken down and remain throughout the sample. Her blood work also showed evidence of this happening in her bloodstream as well, and as I understand it, indicates that this is not just a UTI that we're dealing with but instead some sort of systemic issue that we've not been able to identify.

 

I feel very confident in Dr. Miller's greyhound knowledge - he's one of the primary vets for our GPAH, and treats many of the retired adopted greyhounds in his practice. When he's been at a loss, he's not hesitated to look for a consultation. I emailed him Dr. Couto's info, and I will check with him tomorrow to make sure that he received it.

Edited January 6, 2014 by PiagetsMom

[4My2Greys]

I sure hope your vet can figure something out. I know how frustrating it is when something is wrong and not having an answer to what is the cause. As far as her behavior goes, it could be thyroid related or it may be that because she is not well she feels vulnerable and thus is growling to keep Mirage away.

[MaryJane]

 

 

 

 

I'm not finding those in the paperwork I've looked through, but I'll look again. What I can tell you as it was explained to me is that with a UTI, the red blood cells normally settle and form a sediment in the bottom of a urine sample after spinning. In Maya's sample, they do not separate, but are broken down and remain throughout the sample. Her blood work also showed evidence of this happening in her bloodstream as well, and as I understand it, indicates that this is not just a UTI that we're dealing with but instead some sort of systemic issue that we've not been able to identify.

 

 

 

 

If you suspect a UTI - you culture the urine. That does not look like it has been done. This should be done to rule out this issue.

 

As you stated, it looks like there may be another issue with the hemolysis (red cell breakage). They should do the indices along with a CBC and that will be able to measure the red cell breakage.

 

Hope you get to the bottom of this ...

[Tallgreydogmom]

I third or fourth contacting Dr Couto. I trust my vet but I also want Dr Couto to look at the results. He brings new ideas and experience to the table.

[Guest greybookends]

Does she have what appear to be bruises on her. My Monty's red blood cells were breaking down and he had what appeared to be large bruises all over him. I lost him less then 2 weeks after he first exhibited any signs anything was wrong. His last day he was jaundiced(liver) and looked like he had taken a severe beating. I hope you get some answers soon and that your girl will be alright.

[krissn333]

All I keep thinking of is when Jen's Violet had rhabdo. Usually rhabdo advances quickly though so not all of the pieces of the puzzle are there, but, the tenderness near the kidneys and urinating blood make me think of that.

[NeylasMom]

When he spun her urine down, you said he reported they were not normal RBCs. Do you know why? Is it because they didn't separate out and pack down? If so, that would be an indication that you're seeing myoglobin in the urine and that along with the tenderness along the spine and back legs and elevated muscle enzymes (can you give more details about this - which one(s) and her levels) all scream rhabdomyolysis to me. The seemingly chronic situation doesn't as much, but rhabdo can he stress induced so I'm thinking its possible that without proper treatment and continued stress inducing events that *could* be what's going on. That's presuming it is myoglobin in the urine and the elevated enzyme is the one I'm thinking of so I hope you have or can get that info.

 

The other thing that doesn't totally fit is that you would expect stress on her kidneys, but if they're mild episodes she may be avoiding that.

 

Behavioral changes just tell me she's in pain. Which if she is suffering from rhabdo would make total sense. At any point along the way, have you noticed her standing a bit hunched over or walking with a very stiff gait, particularly in her back legs?

[NeylasMom]

I was still half asleep and brain-farting on the name of the enzyme, assuming it's CPK? If so, please post all values that have been measured along the way.

[Guest PiagetsMom]

Does she have what appear to be bruises on her. My Monty's red blood cells were breaking down and he had what appeared to be large bruises all over him. I lost him less then 2 weeks after he first exhibited any signs anything was wrong. His last day he was jaundiced(liver) and looked like he had taken a severe beating. I hope you get some answers soon and that your girl will be alright.

 

No, no bruises on Maya.

 

 

When he spun her urine down, you said he reported they were not normal RBCs. Do you know why? Is it because they didn't separate out and pack down? If so, that would be an indication that you're seeing myoglobin in the urine and that along with the tenderness along the spine and back legs and elevated muscle enzymes (can you give more details about this - which one(s) and her levels) all scream rhabdomyolysis to me. The seemingly chronic situation doesn't as much, but rhabdo can he stress induced so I'm thinking its possible that without proper treatment and continued stress inducing events that *could* be what's going on. That's presuming it is myoglobin in the urine and the elevated enzyme is the one I'm thinking of so I hope you have or can get that info.

 

The other thing that doesn't totally fit is that you would expect stress on her kidneys, but if they're mild episodes she may be avoiding that.

 

Behavioral changes just tell me she's in pain. Which if she is suffering from rhabdo would make total sense. At any point along the way, have you noticed her standing a bit hunched over or walking with a very stiff gait, particularly in her back legs?

 

Yes, Jen - they did not separate and pack down. I don't have the specifics on which muscle enzymes were elevated, or the level - Dr. Miller said "slightly". When I speak to Dr. Miller I'll try to determine if the enzyme is CPK, and the values.

 

I have to say that before Maya was boarded for the couple of nights at the vet she had no issues that I was aware of. In fact, I was completely surprised when I picked her up and they told me she'd had blood in her urine the night I dropped her off, and they'd started treating her for a UTI. She'd had no UTI symptoms beforehand.

 

To answer your other question, Jen - Yes, about a week after bringing her home from boarding and while on the Baytril, she was not eating well, slow to get out of bed, and walking "hunched" and restless around the house. That's when I took her back in to the vet and they ran the xrays, which didn't show anything of concern, and Dr. Miller assumed it was a soft tissue injury and put her on Rimadyl.

 

Looking at her General Workup report from that visit, her "History" is listed as "Hematuria treated with Baytril. This AM seemed a little lethargic and anorexic progressing to anxiety and pain. Hematuria at VVC"

 

The exam notes everything normal except for "Painful palpation L-6 spinous process"

 

I'll absolutely be asking if he feels Rhabdo would be a consideration, especially considering she was again painful in the L-6 area, and this last visit, also painful when he manipulated her right rear leg. To my eye, though, she has seemed to be moving fine, is not walking "hunched" and has not appeared to be in any physical pain or discomfort.

Edited January 6, 2014 by PiagetsMom

[Guest BiancasMom]

I would ask for a referral to an Internist. Sometimes things that seem so unusual for regular veterinarians are quite obvious to specialists, since that what they are there for.

[NeylasMom]

Honestly, in my totally uneducated opinion (outside of I learned everything I darn well could about rhabdo when Violet went through it ), this really does sound like that could be what's going on. Care of the Racing Greyhound has rhabdo divided into 3 levels of severity and the mildest is described as often resolving on its own. It seems to me that it's quite possible that her stay at the vet's caused it, but she hasn't fully recovered as she's had additional episodes of stress that are causing it to recur, maybe to a milder extent.

 

If the CPK enzyme is elevated, that would be another indicator that that's what's going on. The other thing I would ask them is if they've been looking for casts in her urine. That would be your earliest indicator that her kidneys are stressed/becoming damaged, before anything would show up on blood work.

 

Treatment is generally supportive care - IV fluids, which is solely to support the kidneys (you would probably want to weigh whether the stress from the vet would outweigh potential benefits at this point, although if there were casts in her urine I would do them and possibly give a sedative so she isn't stressed while receiving them), medication for the muscle pain - typically Tramadol although initially Violet needed a Fentanyl patch. I would be careful about giving more NSAIDs again because of hte potential stress on the kidneys. Gabapentin may also be useful. Also, high levels of anti-oxidants. I can't remember specifically which ones they gave at the moment, but I can look it up if you'd want.

 

Obviously I might not be right about this, but I would strongly consider it.

I would ask for a referral to an Internist. Sometimes things that seem so unusual for regular veterinarians are quite obvious to specialists, since that what they are there for.

I was also going to suggest something along these lines. Or consult with Dr. Couto or Dr. Radcliffe. I don't know how closely to paid attention to my story with Violet, but if I hadn't already been fairly well educated about heat issues and rhabdo in greyhounds, I firmly believe the vet would have just sent us home. We only got the correct dx because I pushed and pushed, but as soon as we got to the specialty facility, everyone knew exactly what was going on and how to treat it. I still believe the first vet we saw failed to provide good care, but the bottom line is that most vets in a regular practice aren't going to encounter some of these oddities often, if at all.

[4My2Greys]

Rhabdo is what I was thinking last night with the bloody appearing urine and muscle breakdown, but you had mentioned RBCs in her urine and with rhabdo you will find the myeglobin. If rhabdo is what your looking at I am surprised at how many vets miss this.