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Posted on Thursday, May 3, 2001 - 8:42 pm:

Dear Sir,

I live in the Republic of Panama, I have an eight-year-old hanovarian/selle français gelding and my horse is ill with SOMETHING that is causing his anemia! Unfortunately we have not been able to determine what it is and so far it has been one shot in the dark after another and it is always at the expense of the horse.

Up until 2 months ago this horse, Maharishi, was known around Panama for throwing me off. Then he began to calm down considerably. At first we congratulated ourselves on having finally calmed him down. Then he became increasingly sluggish until one day I rubbed a hole in his fur with the spurs. On that day we decided that something was not right and we did a complete Hemogram and a Bilirrubin test. The results are listed below.
(I must apologize for the results being in Spanish but I dare not translate them in case I do it incorrectly.)

March 11, 2001

Hematologia


White cells: 7,500 x MM3
Red Cells: 6.52 X 10(6) MM3
Hemoglobina: 11.0 GM%
Hematocrito: 29.3 %
Plaquetas 105,000MM3

DIFERENCIAL:

Neutrofilo 42%
Sedimentacion MM/HR
Linfocito 51%
Monocito 3%
Eosinofilo 3%
Basofilo 1%
Bandas --

Reticulocitos..
Cel. Falciformes
No se observan Alteraciones Hematicas.

Bilirrubina

Bilirrubina Directa 0.5 mg%
Bilirrubina Indirecta 2.2 mg%
Bilirrubina TOTAL 2.7 mg%

Apart from his sluggish behavior under saddle the horse shows no signs of being ill. He has not had a fever. His appetite is excellent, he is sweating normally and he appears healthy!

Our veterinarian diagnosed the horse with a sub-clinical form of Piroplasmosis. (He has never ever had ticks since I have owned him but I have only had him for a year and a half and he was badly neglected previously.) He recommended the following treatment:-

1. Dypirona (Apirin) and Berenil(Ganaseg) which he injected himself.
2. Hemathopan B12 20cc for 5 days
3. 8 tablets of Folic Acid per day for 14 days
4. 16 tablets of Sulfato Ferroso per day for 14 days
5. 30 cc of Red Cell per day until the quart bottle was empty.
6. Continued light riding

We followed his advice 100%.

Two weeks later we decided that we really didn’t notice any change in the horse. I was just doing basic warm-up exercises with him. No jumping or heavy work at all. So… we did another blood test.

March 23, 2001

Hematologia

White cells: 8,100 x MM3
Red cells: 6.86 X 10(6) MM3
Hemoglobina: 10.8 GM%
Hematocrito: 30.1 %
Plaquetas 109,000MM3


DIFERENCIAL:
Sedimentacion MM/HR
Neutrofilo 29%
Linfocito 66%
Monocito 1%
Eosinofilo 3%
Basofilo 1%
Bandas --

Reticulocitos.. Cel. Falciformes
No se observan Alteraciones Hematicas.

Bilirrubina

Bilirrubina Directa 0.5 mg%
Bilirrubina Indirecta 2.3 mg%
Bilirrubina TOTAL 2.8mg%

After these results, our Veterinarian recommended doubling the dose of Red Cell to 60cc, Folic Acid to 16 tablets and Sulfato Ferroso to 32 tablets to be given twice a day. He told us to give him 10cc of Biodyl for 5 days. Furthermore on our own initiative we started him on a double dose of a vitamin and mineral supplement and we are giving him 2 eggs (shells and all) in his feed. He is still on this regimen today.

Ten days or so later we began to see some results. Maharishi was trotting and cantering with much more impulsion. Although he was still relatively calm, he was much lighter on his feet. We even began to take him over 3-4 small fences and he was moving forward. Just to be sure he was on an upward track we took his blood on April 6, 2001.

April 6, 2001
Hematologia


White cells: 7,500 x MM3
Red Cells: 6.95 X 10(6) MM3
Hemoglobina: 11.0 GM
Hematocrito: 30.0 %
Plaquetas 180,000MM3


DIFERENCIAL:

Sedimentacion MM/HR
Neutrofilo 57%
Linfocito 40%
Monocito 2%
Eosinofilo 1%
Basofilo 0%
Bandas --

Reticulocitos..
Cel. Falciformes
No se observan Alteraciones Hematicas.

Bilirrubina

Bilirrubina Directa 0.4 mg%
Bilirrubina Indirecta 1.6 mg%
Bilirrubina TOTAL 2.0 mg%

We were all very pleased with the results and our Vet. recommended that we continue with the same supplements for another 2-3 weeks and then stop.


Before stopping all the supplements, I did one more blood test just to be sure and I was SHOCKED at the results:


April 27, 2001

Hematologia


White cells: 8,400 x MM3
Red Cells: 6.65 X 10(6) MM3
Hemoglobina: 10.4 GM%
Hematocrito: 28.3 %
Plaquetas 117,000MM3


DIFERENCIAL:

Sedimentacion MM/HR
Neutrofilo 60%
Linfocito 35%
Monocito 4%
Eosinofilo 1%
Basofilo 0%
Bandas 0%

Reticulocitos..
Cel. Falciformes
No se observan Alteraciones Hematicas.

Bilirrubina

Bilirrubina Directa 0.4 mg%
Bilirrubina Indirecta 2.3 mg%
Bilirrubina TOTAL 2.7 mg%

I immediately called our Vet. and he told me to take another blood sample and fecal sample to another Veterinarian that specialized in Hematology, which I did of course. I was not given the results but I have talked to both of the Vets on the telephone and the results of the tests show that Maharishi has “an autoimmune condition" If I understand it correctly, they found a protein in Maharishi’s blood that is too high and his white bloods are destroying his red blood cells????? They are not sure to what it is due because there is no evidence of any parasites in the horse’s blood or his feces.

However, they have recommended a treatment of Calimycina 15cc IV 2x/day for 7 days and Dexametasona 4mg 10cc IV for 2 days, then 8cc for 2 days, then 6cc for 2 days, then 4cc for 2 days and finally 2 cc for 2 more days. Also we are to continue with all the previous supplements that we are giving him.

Here is where I would be extremely grateful for your advice. A friend had a horse with very similar symptoms earlier this year, he was given the same treatment and he died! I have been told that the Dexametasona is delicate and dangerous drug. The Veterinarian is not sure of what the horse has. He thinks that he had Piroplasmosis or a rickettsia in the past but we have no way of knowing for sure(apparently tests for these parasites are not available in Panama). I am worried about injecting this horse with more strong medication seeing as he is already weak and I risk destroying his blood cells even further.

Upon the advice of a doctor for humans who is recommending against giving steriods without more tests, I did some further tests that our Veterinarian did not ask for and I have just received the results. Again I apologize that they are in Spanish but I do not know how to translate them correctly.


BILIRRUBINA TOTAL Y FRACCIONES

Bilirrubina Total : 3.20mg/dl
Bilirrubina Directa: 0.69mg/dl
Bilirrubina Indirecta: 2.51mg/dl


S.G.O.T./A.S.T 3.02 U/L
S.G.P.T./A.L.T. 12.0 U/L
Fosfatasa Alcalina 156.0 U/L
Creatinina 2.4 mg/dl
Nitrogeno Urea 15.0 mg/dl
Urea Total 32.1 mg/dl
Calcio 12.2 mg/dl
Fosforo 2.8 mg/dl
Sodio 140 mEq/L
Potasio 3.9 mEq/L
Cloruros 98.0 mEq/L
CO2 Total 32.0 mEq/L


PROTEINAS Y A/G

Proteinas Totales 6.3g/dl
Albumina 2.9g/dl
Globulinas 3.4g/dl
Albumina/Globulinas 0.85


I would be ever so grateful for any recommendations that you can give me. I am terribly afraid of giving the horse the wrong medication and making things worse for him.

Thank you so very much in advance.
Sincerely yours,
Nathalie F. Barnes

Posted on Friday, May 4, 2001 - 10:45 am:

Hello Nathalie,
I will review this over the weekend but in the meantime the combination of antibitotics and oral folic acid supplementation has been shown to do exactly what you are experiencing: low blood folacin levels which may cause anemia. With your vets approval, the folic acid should be stopped, the antibiotic continued, and the horse be allowed to graze good green grass. The mechanisim for this is explained in Equine Medications and Nutriceuticals: Antibiotics and Antimicrobials: Trimethoprim Sulfa.
DrO

Posted on Monday, May 7, 2001 - 6:50 am:

Hello Nathalie,
I am interested in how the samples were taken for the blood tests, were the horses exercised before the blood was taken? I would also like the normals from the laboratories, these vary from lab to lab. The liver enzyme numbers (AST and ALT) indicate possible lab error as they are unlikely to be this low. Also is EIA a problem in your area and if so have you rerun a Coggins test?

That said in general these numbers are all within acceptable limits. The March 23rd WBC numbers may indicate a viral infection (low neutrophil / lymphocyte ratio).

I think you are putting too much emphasis on the exact number and not the trends. The fact is that these values fluctate normally and even if you ran the tests on the same sample several times in a row you would get slightly different values. So watch the trends and not any one test.

If I understand right your horse is now behaving normally and appears healthy and has no abnormalities on a physical exam, is that right? If so it is not apparent from your post and the lab work that your horse has had anything more than a viral infection particularly if your first sample was taken from a resting horse and the PCV was artifically low because of it.
DrO

Posted on Thursday, May 24, 2001 - 6:54 am:

Hi Nathalie,
These two posts were knocked off during the server change so I thought I would put them back.
Lisa

By Nathalie F. de Barnes (Nfbarnes) on Wednesday, May 23, 2001 - 12:37 am:

Dear Dr.O:

Thank you for replying and I apologize for not get back to you earlier. After having spoken to our veterinarian some more and also having noticed that the horse was spiking a fever every afternoon between 38.7 and 38.9 degrees Celsius, he told us that the horse has developed a disease called "autoimmune hemolytic anemia." SP??? And that if I didn't listen to him and apply the antibiotics and the Dexamethasone, Maharisi would die!

Faced with no other options and with my veterinarian angry that I was even questioning his diagnosis, we treated Maharishi with the Dexametasona and the Calimycina. He seemed respond well and after 10 days of the steriod and 15 of the anti-biotic he was fever free and was shooting around the turn out ring like a canon.

We waited until May 19th to do another blood test. The blood work came back much improved and we all rejoiced. PCV 33% Hemoglobin 11 White Cells 10800 Neutrophilos 57 Lymphocytes 35 Monocites 4 Basofilo 1 Eosinofilos 3 Platelets 135,000 Red Cells 6.38 million Total Proteins 7.1 Aglutination of red cells 1:2

Total Bilirrubin 3.06 Direct Bilirrubin 0.48 Indirect Bilirrubin 2.53

No evidence of Hemoparasites, nor "morulas" nor immature cells.

Unfortunately on May 21st when the vet came back out to check to see if I could begin riding again. Maharishi had a fever again, 39.2 degrees celsius and the veterinarian told that he had had a relapse. Now he is back with the same treatment because the vet says that his system is attacking and destroying his own red blood cells again and that he has a 50% chance of survival.

I don't know what to do any more!!!! I have consulted with two other vets here. One has suggested that although there is no evidence of babesis in the blood to treat him for piroplasmosis again anyway! Another said to do nothing and wait and see. My vet doesn't like it when we get second opinions and he is the veterinarian with the largest equine practice in Panama. Sooo in some ways we must take a leap of faith but I just wish I wasn't so ignorant about what is really happening inside the horse and why his chances are so bleak! Can you explain "Autoimmune hemolytic anemia??" Do you have any other ideas?

Thanks very much in advance for any thoughts on this frustrating problem.

Sincerely yours, Nathalie

By Nathalie F. de Barnes (Nfbarnes) on Wednesday, May 23, 2001 - 12:56 am:

Dear Dr.O, I have looked up Autoimmune Haemolytic Anemia but it only gives me a defination and not the possible treatments and chances at a successful outcome. Can you give me those?

Thanks, Nathalie

Posted on Thursday, May 24, 2001 - 7:24 am:

Many horses have a few episodes then stop, but with repeated episodes the prognosis goes down. It is presumed in the first case to be due to "secondary factors" like infection, allergies, and toxins. While primary AHA will persist and probably worsen over time. It can be difficult to predict early but the majority of time unexplained AHA is not a permanant problem.
DrO

Posted on Thursday, May 24, 2001 - 2:53 pm:

Dear DrO.
Thank you for that info. In this case I am guessing that the AHA came from the bout with Piroplasmosis. If the AHA diagnosis is correct is the treatment with the steriods and antiboitics correct as well? (As soon as Maharishi began the treatment again his fever was gone.) How long on average should a horse be treated with these medications before one can reasonably expect them not to have a relapse? Do you have any idea what dosages are usually applied?

And what is primary AHA?

With kind regards,
Nathalie

Posted on Friday, May 25, 2001 - 4:02 pm:

Yes I think so. Though the steroids are the only required treatment for the AHA if there is a chance that their is concurrent infection then the antibiotics are reasonable.
DrO

Posted on Tuesday, May 29, 2001 - 11:33 am:

Autoimmune Hemolytic Anemia. Interesting. I have a horse who has been on Lixotinic for the last 6 months. His CBC is normal while on the Lixotinic but DrOps off if we even wean him to half-dose. He suffers from moon blindness which is also autoimmune. Last year he had some sort of an infection/episode with a huge WBC and a 14.1% hemocrit. Spiked a 105F fever. Dr. O - are you going the same place as I am? Maybe I've been missing something for all these months. What is the AHA telltale symptom? Thanks

Posted on Wednesday, May 30, 2001 - 9:05 pm:

Hello 3rsatsmf,
It boils down to simple any unexplained progressive anemia should be suspect for this. It is not that rare in horses.
DrO

Posted on Sunday, Jul 22, 2001 - 12:56 am:

Dear DrO,
I know that it has been a while since I last logged in but after your last explanation about secondary AHA, I felt relatively assured that my horse had a mild complication from his bout with what we assume to have been Piroplasmosis. His last blood work up had come back relatively normal and I started working him again slowly and gradually build up to a regular work out and prepared him for the jumper season. The day (yesterday) before entering him in his first show I took another blood test to be sure he was okay. Imagine my dismay when his Hemoglobin came back at 9.7%!!! He looks great, he still eats well. But of course today he had a fever of 101.7F. The vet thinks he has just had a minor relapse and has him on steroids and anti-biotics again. But I am terrified that he could indeed have a primary AHA which you mentioned. So now I come to my question. What exactly is primary AHA versus secondary AHA? How many bouts of secondary AHA can a horse have before his prognosis looks dim? Is the outlook getting bleaker for my poor horse? How do you know if the horse has primary or secondary AHA? He was working so well this last month and looks so good. I just can't believe he has an incurable illness!
Thank you for your time.
Nathalie

Posted on Monday, Jul 23, 2001 - 6:49 am:

Natalie, hemoglobin is usually not reported a s a percentage. Are you saying the hematocrit is 9.7% or the hemoglobin is 9.7 and if so what are the units? Best is to report to me both the hematocrit and the hemoglobin concentration, making sure you include the units.
DrO
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