scott@vtx-cpd.com

Hello Nadia.

Thank you so much for reply. Brilliant, there are indeed lots of signs of fragmentation injury to the red blood cells.

I have copped part of the smear report from the pathologist below:

“Microscopic Description

A single blood film is examined. The history reports a moderate acute anaemia, icterus, and suspected
immune-mediated haemolytic anaemia.

Platelets: platelets of variably distributed across these films and rare small platelet aggregates identified,
precluding definitive assessment of numbers. Morphology appears unremarkable.

Erythrocytes: Anisocytosis +. Polychromasia +. Echinocytes +. Acanthocytes + Schistocytes +. Keratinocytes
Spherocytes +. Occasional metarubicyte. Rare erythrocytes. Occasional ghost cells.

Leukocytes: Dohle bodies +. Occasional neutrophils demonstrate mild cytoplasmic basophilia. Rare band
neutrophils are identified. The analyser differential is confirmed and morphology appears unremarkable.”

So… A mixed bag really! There are low numbers of spherocytes and ghost cells. While the latter may be artefactual, depending on sample age, this keeps the possibility of immune mediated destruction on the table. However, low numbers of spherocytes are slightly non-specific and therefore in saline agglutination at 1:50 or Coomb’s testing could
be considered for further clarification. The remaining erythrocyte changes may be observed with increased
erythrocyte fragmentation injury, but also with altered erythrocyte membrane phospholipid composition for
which differentials include renal or hepatic disease. Fragmentation can occur because the red blood cells are being damaged as they travel through the vasculature (e.g. being sheared through fibrin clots in disseminated intravascular coagulation; DIC) or they are mechanically fragile (e.g. iron deficiency anaemia). In these situations, acanthocytes are frequently accompanied by other red blood cell changes, indicative of fragmentation injury, i.e. schistocytes and keratocytes.

We did perform an in saline agglutination which was negative and we then performed a Coomb’s which was also negative.

Full abdominal ultrasound was performed and revealed a 3cmx4cm splenic mass. No free fluid was detected.

What would be your next steps?

Scott 🙂

Replying to Nadia C. 09/07/2023 - 12:42

Brilliant!

Maybe our paths will cross! Thank you again for the great questions.

I really hope you are enjoying the course!

Scott 🙂

Replying to Nadia C. 08/07/2023 - 22:29

Hello Nadia.

Thank you for your response. I agree, practically we also take blood from the catheter at the time of catheter placement. We will then be using those catheters for multiple IV infusions/IV lines. We would then normally take repeated blood samples from the jugular vein. It think it is less practical to take a blood sample from a peripheral catheter when it has been in for a few days. The exception would be if we have a central line in place. The great benefit of central lines is the ability to take repeated blood samples.

Really interesting that you work as an in patient vet. That must be quite a rewarding role?

Scott 🙂

Replying to Carolyn C. 28/06/2023 - 06:46

Hello Carolyn.

Your key problem list and DDX are perfect!

I think ruling Addison’s out in this case is a great shout. We did run a basal cortisol which was 100 nmol/l. Any result over 55 nmol/l is not consistent with Addison’s, so we were confident this was not the problem in this case. I was less suspicious of Addison’s as there was a lymphopenia, but good rule out! I love the possible link between the Addison’s and GI bleeding and anaemia and low albumin too. We can sometimes see increases in potassium due to haemolysis. This is not uncommon in samples that have been transported to the lab. If in doubt, I would run the sample again on a fresh one in house.

Again, great thinking regarding the possibility of liver disease in this case. In order for glucose and albumin to go down there would have to be over 75% liver function loss. I think this is less likely in this case. We can sometimes see albumin go down a little with a negative acute phase response. This could be due to almost any infections or inflammatory disease. Often the globulin will increase in these situations (as it is an acute phase protein), which it has not in this case.

In the emergency stetting we did do a POCUS scan of the chest and abdomen and there was no free fluid. The in saline agglutination was negative and we had a look at a blood smear. I have shared the blood smear images. I would love to hear your thoughts.

Thank you again for your brilliant suggestions.

Scott 🙂

Replying to Nadia C. 24/06/2023 - 16:14

Another great question Nadia!

Bleeding due to amyloidosis is mostly a problem in cats. It can be a reason that cats would present with abdominal bleeding. The amyloid will deposit abnormally in the liver. This is an insoluble protein and will cause a change in the liver architecture. This makes the tissue more friable and prone to splitting/fracture. This is what makes the tissue more prone to bleeding.

I hope that makes sense!

Scott 🙂

Replying to Carolyn C. 28/06/2023 - 06:00

Hey Carolyn!

Really great question. So the answer does depend a little on the type of test being carried out, but generally better to do vegetarian if possible. This will probably not be too problematic for a few days in cats, but I understand your concern.

This study is helpful:

https://pubmed.ncbi.nlm.nih.gov/31509050/

In real life I would probably stick to Purina HA if possible (wet or dry based on this study) before doing FOB testing. I hope that helps.

Scott 🙂

Replying to Francesca Lamb 06/07/2023 - 09:24

Hey Fran!

I hope you are well and enjoying the course! I totally get it, it does seem like a bit of a scary procedure. It really is something that you should not have to resort to on many occasions. The blind BAL will suffice in most cases. This is really reserved for the super sick cases that you are worried about the GA in. I will try and look for more resources and chat through the procedure more at the live Q&A to get you feeling a bit more confident about it!

Scott 🙂

Replying to Kathryn B. 03/07/2023 - 16:04

Hey.

I have probably confused things a little by sharing the later blood results from day 23! The one thing we can be confident of is that the blood glucose was persistently high. The dog was diabetic… feel like that is not too much of a give away! 🙂

The main intervention between the 2 time points was insulin therapy was started.

There were some more investigations along the way too…

Scott 🙂