Red Blood Cell Breakdown - Vet Stumped

[NeylasMom]

Talking out of my arse at this point, but with a PCR, my understanding is the dog needs to be off of ABs for a specified period of time (somewhere around a month I believe) before being tested. So if Dr. Miller pulled blood and submitted the sample for PCR analysis a week into ABs isn't it possible that you are looking at false negatives?

 

Although if I recall a titer of 1:640 isn't alarmingly high, sort of on the cusp of whether you treat or not. Did she have other symptoms of babesia that might have indicated an active infection way back when?

1) Red urine on several occasions. The one with UA results posted had no RBCs (or very low: 6-10 RBC/HPF isn't very significant), so this indicates either hemoglobin or myoglobin in the sample. Unfortunately, there is no easy way to differentiate between hemoglobin and myoglobin. Myoglobin would indicate rhabdomyolysis. Hemoglobin would point toward a hemolytic condition (breakdown of RBCs).

Just out of curiosity, is there no definitive way to tell the difference? Is it possible to put a sample under a scope and tell by looking at the cells for example? Or do you simply need to rely on other findings/symptoms to support one or the other?

[Batmom]

There are some simple tests you can do to distinguish hemoglobin from myoglobin in the urine.

 

You actually wouldn't see cells .

 

 

ETA: Since they saw hemolysis in the last blood sample 1/2/14, urine would also likely contain hemoglobin on that date. (It's really easy to see hemolysis in a blood tube; harder to figure out why it's there!)

 

The in-house tests are almost always dipsticks, which read both hemoglobin and myoglobin as blood and sometimes state the amount in terms of RBCs (number of cells). Should just say "blood" and a value indicator for how much, but some of them do report as if there were cells there when there might not be.

Edited January 10, 2014 by Batmom

[Guest PiagetsMom]

Jen, I wasn't Maya's original adopter, and don't have info on her when she originally went up for adoption. I don't know if she was symptomatic at the time she tested positive for the Babesia.

 

I did speak with Dr. Miller this evening. He was actually up at Texas A&M, and had taken Maya's records and tests results with him to get input from A&M. After he speaks to them and gets their input, he is going to consult with Dr. Couto.

 

Regarding the issues we've been discussing:

 

He has considered Rhabdo, but he affirmed that you would see myoglobin in the urine, and that has not been present. It's on, but down the list of considerations for him.

 

She was tested and was negative for immune hemolytic anemia.

 

I mentioned Leptospirosis per Batmom, and we have not tested for that. Maya is vaccinated for it. While he said that would not be at the top of his list of considerations, as you usually see the liver and kidney's involved and Maya's don't appear to be, we could certainly test for it.

 

We have not done a urine culture, but Dr. Miller does not feel that we're dealing with a UTI based on the previous urine tests that have been done and Maya's other test results.

 

As to the behavioral issues with Mirage, he agrees that it could or could not be related to Maya's medical issues, but either way, there is no easy fix for behavioral issues. He would like to get a definitive answer and treatment for Maya's medical issues first, and then if the behavioral issues are not alleviated, working with the veterinary behaviorist would probably be necessary.

 

So, at this point he will confer with A&M, and then contact Dr. Couto for a consult. If there's still no consensus as to what we're dealing with, he mentioned an appointment with an internist.

 

Oy....

Edited January 10, 2014 by PiagetsMom

[NeylasMom]

Sorry you really don't have any more answers yet, but it sounds like your vet is being thorough. Did he say how he knows there's no myoglobin in the urine? I'm just curious, trying to round out my knowledge of non-RBC dark urine.

 

I really hope you get some answers soon. I know this must be frustrating for you.

[Guest PiagetsMom]

While having tested negative for Babesia does make it far less likely that is the current problem, I believe it does not make it impossible. It may be possible for circulating parasites to be low enough that it wouldn't be picked up, even by PCR. Though I'd think if it was that low it would greatly reduce the chances the dog would be symptomatic of Babesia. Just something to think about.

 

Yes, I forgot to mention that we did once again discuss the Babesia and the possiblity that it is some sort of parasitic issue that we could be dealing with. This is something Dr. Miller has repeatedly mentioned, so I assume it's got a place higher on his list of possibilities.

 

Sorry you really don't have any more answers yet, but it sounds like your vet is being thorough. Did he say how he knows there's no myoglobin in the urine? I'm just curious, trying to round out my knowledge of non-RBC dark urine.

 

I really hope you get some answers soon. I know this must be frustrating for you.

 

I don't know, Jen - it didn't occur to me to ask him how he knew. Dr. Miller was on a cell phone, and I had my list in front of me, taking notes, and trying to cover as many questions as I could for answers. But, I'm hoping during his consults someone much more knowledgeable than I am will ask him that!

Edited January 11, 2014 by PiagetsMom

[JJNg]

While having tested negative for Babesia does make it far less likely that is the current problem, I believe it does not make it impossible. It may be possible for circulating parasites to be low enough that it wouldn't be picked up, even by PCR. Though I'd think if it was that low it would greatly reduce the chances the dog would be symptomatic of Babesia. Just something to think about.

 

Babesia canis is the species that is more likely to be cured with imidocarb injections, and less likely to become dormant and chronic, so that makes it less likely as well, but not impossible. I'm just guessing here too, but I wonder if a low grade infection could be low enough to not be picked up on PCR but still cause some very minor symptoms. Maya's labwork abnormalities are pretty mild, with some possible indications of hemolysis and regeneration without any anemia.

 

There are some simple tests you can do to distinguish hemoglobin from myoglobin in the urine.

 

I'm not aware of any that are clinically used in veterinary practice. Did a quick Google search and it looks like there are some tests used in human medicine.

 

I'm interested to hear what Texas A & M and Dr. Couto say.

[Batmom]

Idexx (and probably the other big labs) can do a urine myoglobin. Wouldn't expect that to be done in-house.

[Remolacha]

I have been following (as well as I could) all this, and all I can say is you must be and trying figure out what is going on! It does sound like your vet is thorough and not afraid to ask for help from experts, so hopefully you will get some answers and get her well

[kudzu]

Batmom, can you share with us what IDEXX test or tests you are referring to? Do you know which lab does this for IDEXX?

[Batmom]

Idexx test is a urine myoglobin -- I think there's only one, should be able to search it on the Idexx site and get the number. Don't know which all of their labs do it. Antech probably does it as well.

 

Most times, if you're seeing hemolysis in the blood sample (red plasma), I'd think you'd assume that blood (but no intact cells) in a fresh urine sample was hemoglobin .....

[tbhounds]

Idexx # 964 urine myoglobin :-)

[kudzu]

Thank, tbhounds!

[carronstar]

Checking in this morning.

[Guest PiagetsMom]

Haven't heard back from Dr. Miller. I know that he is back in the office today so I assume that there was nothing definitive from his A&M consults, or I probably would have heard from him. I did see on Dr. Couto's site that consults are usually responded to in 48 hours, so hopefully sometime early this week I'll hear some word from that.

 

Overall, physically, I'm not seeing anything from Maya that concerns me. Dr. Miller instructed me to cut back on the Rimadyl to "as needed" if she seems in discomfort -. we had a walk this morning and she seemed to be moving fine. In fact, I think her urine might be somewhat lighter in color than the very dark yellow she's had. It's really more the behavioral issues that seem to have moved to the forefront.

 

Last night we had both our sons and their wife/gf and my parents over for dinner. The pups see this group often, so it's not anything out of the ordianary for Maya, but while Maya was friendly, she also seemed somewhat restless. Usually she will visit, and then go off to one of her beds in another room and camp out there. Last night she would come and go and eventually put herself in a bed in the living room where we all were. That in itself was unusual, but at one point everyone was laughing and things got a little loud and Maya raised her head and growled and barked - much as she's been doing with Mirage. It surprised the heck out of all of us.

 

I guess what I find strange is that she has several other options for beds in quiet rooms that she frequents, but she chose to locate herself in the middle of everything, and then was reactive to it. It's been the same several times with Mirage - Maya has chosen to lay down in close proximity to where he's laying, but then reacts when he moves in any way. You'd think, or at least I would, that if she's that sensitive at the moment, she would not be putting herself in the position/location to be aggitated.

Edited January 13, 2014 by PiagetsMom

[Burpdog]

She's on rimadyl with a platelet problem? Big no-no

[JJNg]

I don't think a platelet or clotting problem has been mentioned?

[Guest PiagetsMom]

I don't think a platelet or clotting problem has been mentioned?

 

No, it hasn't been mentioned. Platelets were in the normal range on Maya's last blood draw.

 

Edited to add that I just spoke to Dr. Miller's office, and he is in the process of consulting with Dr. Couto.

Edited January 14, 2014 by PiagetsMom

[krissn333]

The odd things she's doing - placing herself close to Mirage but then barking at him...sounds like things Ace used to do. She doesn't feel well so she wants to be close-by for comfort, but, she also feels the need to warn anyone that gets "too close" (per her definition of "too close") or makes her uncomfortable.

 

Hope Dr. C has some ideas for you. Has her thyroid been checked?

[FiveRoooooers]

This is *totally* random, but have Maya's ears and hearing been checked? Thinking about sensitivity to the noise levels last night.

[Guest PiagetsMom]

The odd things she's doing - placing herself close to Mirage but then barking at him...sounds like things Ace used to do. She doesn't feel well so she wants to be close-by for comfort, but, she also feels the need to warn anyone that gets "too close" (per her definition of "too close") or makes her uncomfortable.

 

Hope Dr. C has some ideas for you. Has her thyroid been checked?

 

Maya's had her thyroid checked (a full thyroid panel) a couple of times when we were working with the veterinary behaviorist last year. Both she and Dr. Miller agreed that it was not too low in greyhound values. This last round of blood work a couple of weeks ago Dr. Miller once again checked her thyroid, and it was slightly lower than her previous test, although as with other results, not so low as to be something Dr. Miller would normally consider treating. He did feel it was something to keep on the table, however, considering the change in her behavioral issues.

 

This is *totally* random, but have Maya's ears and hearing been checked? Thinking about sensitivity to the noise levels last night.

 

Jan, Maya's hearing is good - I don't know if it's possible for her hearing to be "too" sensitive Although Dr. Miller and I have discussed her hearing and vision, he hasn't been concerned about them. It was a strange situation the other night, and the first time Maya has reacted to people. Her previous reactivity has been directed at Mirage.

[NeylasMom]

Any word from the consult with Dr. C?

[Guest PiagetsMom]

Not yet, but I know they've spoken.

 

We leave tomorrow for a long weekend and the pups will be with our dog sitter (Robbie), who is also the kennelmaster at our GPAH, so they're in good hands. I've made him aware of Maya's issues, and Dr. Miller knows Maya will be with him. It's a trip we've had planned, and Dr. Miller didn't see a need for us to cancel. If for some reason he needs her to be brought in for any further testing, he'll contact Robbie to bring her in.

 

I'm hoping I'll hear from him today before I go, and I'll update if I do. If not, I'll call Dr. Miller when we return and update then.

 

Thanks for asking, Jen.

Edited January 16, 2014 by PiagetsMom

[Guest PiagetsMom]

Real quick update as there's not really much to update with.

 

I dropped the pups off with Robbie on Thursday night, and on Saturday Maya had bloody urine. Robbie called Dr. Miller, who had him bring in a urine sample. She was put on 750 mg of Chephelixon twice daily. The blood stopped the next day. She did have one accident in Robbie's house, but Maya is a marker, and Robbie pet sits many other greyhounds. The first time I took Maya to Robbie's she walked in, checked out one of the beds on the floor, and promptly peed on it, so it's hard to say if this was anything other than marking. Otherwise, Robbie said she was active, eating well, and seemed fine.

 

Texas A&M had no ideas for Dr. Miller. Dr. Couto has been given access to all of Maya's medical records and test results to date. Everyone seems to be in agreement that stress is a factor in whatever is going on with Maya. He and Dr. Miller seem to be focused on the two issues that we've discussed here previously:

 

1) Rhabdo continues to be a consideration, but Dr. Couto feels that it's difficult to make that diagnosis without the myoglobin in the urine. He would like for a urine sample be sent to UC Davis for further testing.

 

2) Babesia - both feel that, as kudzo suggested, It may be possible for circulating parasites to be low enough that it wouldn't be picked up, even by PCR. We will be running further tests for that.

 

Dr. Miller had me bring in a urine sample this morning, and he called to tell me that it was normal, and he didn't feel that it would be of any benefit to send this sample along to UC Davis. If there is more blood in the urine I will run a sample in for him, but until that happens, he's asked me to bring in a weekly urine sample to check to see if it would be viable to send to UC Davis.

 

If I have anything definitive to update, I surely will, in the hopes that anyone else who might ever find themselves with a similar situation may be helped by it!

[NeylasMom]

1) Rhabdo continues to be a consideration, but Dr. Couto feels that it's difficult to make that diagnosis without the myoglobin in the urine. He would like for a urine sample be sent to UC Davis for further testing.

Do they actually know there was no myoglobin in the urine, particularly this last sample? Did they send it off for that test tbhounds posted the code for by any chance? Any signs of pain or muscle soreness with this recent episode?

 

So tough. I want you to of course have answers, but I don't want Maya to have more off urine. Just hoping you can get it sorted out soon.

[Guest PiagetsMom]

Very quick update:

 

Maya had an "off" day yesterday, starting with a "yelp" when I was giving her morning greeting. The rest of the day she seemed to be moving somewhat differently, maybe slightly tucked or hunched, and we had a snarky episode with Mirage,

 

Dr. Miller had asked me to bring her in for another round of bloodwork to follow up on the babesia, and to bring a urine sample for testing.

 

On first out around 7:30 am, her urine was a very dark yellow, and I was able to get a good sample. By the time I got her to the vet at 11 am, she was peeing blood. Dr. Miller immediately sent me back out to get another sample, and he'll be sending both in to UC Davis for testing per Dr. Couto - they will be testing for myoglobin in the urine.

 

Those results will be a week or more in coming back. The bloodwork will be coming back in stages, and Dr. Miller will call with those.

 

Yesterday I was searching for a way to describe Maya to Dr. Miller, and I've heard the expression about people as to "not being comfortable in their own skin"......that would be the best way to describe Maya. I know that she is not a "spook", but she is very, very sensitive. We have decided to try Maya on a low dose of Soloxine to see if it might help with her behavior - Dr. Miller had mentioned trying this after our last round of bloodwork and her change in behavior, but we put it on the back burner while trying to find the cause for the red blood cell break down.

 

Dr. Miller feels that her most recent thyroid results would be in the "gray" area - not necessarily too low for a greyhound and under normal circumstances probably not treated. However he feels that most dogs tolerate the Soloxine well, and even if we do not see any improvement with it, it won't harm her, and we can always taper it off and stop if it does not help. So, we'll give it a try......I really hope it will help her.

 

If you would, please send some good thoughts Maya's way!

Edited February 6, 2014 by PiagetsMom