Is it primary IMHA or is there an underlying cause

[arikanisil]

Hello dear cat people,

I need some advice from experts.

My 3,5 y.o. male cat is sick for about 1-1,5 years. I will explain everything below. I know it's not possible to diagnose without seeing a cat, but this is not what I'm looking for. After reading my cat's story, can someone have an idea about what did we miss? What diseases we should suspect and check?
(Location: Istanbul, Turkey)

Everything started in March2020 with licking concrete. Our veterinarian suspected lack of minerals and gave him a vitamin/mineral support malt. It helped for few months. Then my cat showed; weight loss, apetite loss, yellow skin, lethargy symptoms. After the tests (which is in June2020) he was diagnosed with jaundice and got treatment. He was also corona positive. Things went a bit well in the following 6-7 months. He was lethargic from time to time, but immun-supportive meds (called Zylexis) helped us during that period.

At the end of Dec20, he got very sick again. Pale skin, weight loss, lethargy and very severe anemia, so he got blood transfusion at new year's eve.

Then I thought anemia is not a disease, it's a symptom of some diseases indeed. So I insisted our veterinarian to search for the real disease.

Felv, Fiv and geartworms are eliminated due to quick tests (done twice).
No Fip symptoms even though being corona positive (no fluid accumulation, no neuroligical symptoms etc)
Organs are doing well, no problem with them due to ultrasound (including heart)

Haemobartonalle was positive so he got doxisicline treatment for 22 days (before diagnosing IMHA). And doxisicline treatment did not help improving the blood levels (erythrocyte, hematocrit and hemoglobin levels). Indeed, these got worse after the doxisiclin treatment. So, our veterinarian thought it was not haemobartonella.

Also, auto-agglutination has been detected in blood samples (by external laboratory).

All these took almost 2 months, after the blood transfusion and finally our veterinarian's final diagnose was IMHA and we started prednisolone treatment with a dosage of weight*2.

His blood levels increased significantly and we started to decrease the prednisolone. My cat was fine, blood tests were fine. When we stopped prednisolone treatment, his blood levels dropped again. Significantly. And only in 5 days.

So we started prednisolone again. But this time, he was not responsive to the treatment at all. He also got chlorambusil in addition to prednisolone (as a second immunosupresive agent). And this decreased the WBC levels (which was normal before) and did not help red blood cells at all.

At the moment, my cat is taking the dosage of weight*4 prednisolone, his physical condition got worse in the last feew weeks (lost weight, stopped eating). His hematocrite level is 12,5 and erythrocyte level is 2,8.

We dont know why he is not responsive to the treatment, why prednisolone doesn't work.

Our veterinarian started doxisiclin treatment again (this time; in addition to prednisolone), because he thinks the haemobartonella attacked due to low immunity. But I think, he thinks like this just because all other possibilities are eliminated.

So, thank you for reading this all.
Can someone tell me what else should we check? Did we miss anything?

 

[silent meowlook]

For some reason I can’t see the blood work. To blurry.
What kind of test was done to diagnose coronavirus? Was it a blood tiger? If so, what was the range?

A hematocrit of 12.5 is dangerously low. As I am sure you have been told, a second transfusion is more risky for reactions than the first.

Hemobartonella, aka Microplasma comes from fleas and is diagnosed with a blood smear or a blood test called a microplasma PCR. That being said, I wouldn’t want them taking any blood with that low a hematocrit.

The Prednisolone is usually given with the doxycycline and it is a long course of meds. Usually months and when all symptoms are resolved the pred is gradually tapered off. But, it isn’t working this round and it may be due to to low a dose, or this could be cancer.

He is obviously in critical condition now. I am sure you have thoroughly checked your home for anything toxic he could be getting into. Also I am hoping he is inside only now.

There is a website called VIN Veterinary information network. Have your vets reach out to them for guidance. Veterinarians all over the world collaborate on cases and they may be able to find out more there.

I am sorry he is so ill.

 

[arikanisil]

For some reason I can’t see the blood work. To blurry.
What kind of test was done to diagnose coronavirus? Was it a blood tiger? If so, what was the range?

A hematocrit of 12.5 is dangerously low. As I am sure you have been told, a second transfusion is more risky for reactions than the first.

Hemobartonella, aka Microplasma comes from fleas and is diagnosed with a blood smear or a blood test called a microplasma PCR. That being said, I wouldn’t want them taking any blood with that low a hematocrit.

The Prednisolone is usually given with the doxycycline and it is a long course of meds. Usually months and when all symptoms are resolved the pred is gradually tapered off. But, it isn’t working this round and it may be due to to low a dose, or this could be cancer.

He is obviously in critical condition now. I am sure you have thoroughly checked your home for anything toxic he could be getting into. Also I am hoping he is inside only now.

There is a website called VIN Veterinary information network. Have your vets reach out to them for guidance. Veterinarians all over the world collaborate on cases and they may be able to find out more there.

I am sorry he is so ill.

Hi Silent Meowlook,

Thank your for your response and suggestions. Here are the answers:

It was only the last 4 bloodwork. Here I attach the all CBCs as diagrams (including the treatment). There were some other values, such as Eos, Bas, MCH etc, but these could give an idea. If you want, I can also add them, and biochemistry as well.

For coronavirus diagnose;
Elisa test is done on July 4th 2020. It was S6 positive.
on Jan.12nd 2021, rt-PCR is performed and it was corona negative.

Yes, you're right. Our veterinarian does not suggest second blood transfusion because of low immunity at the moment.
He also detected that spleen is growing. But he doesn't recommend it because of 1. The chance of succes is low, 2. Anesthesia is way too risky atm.

Haemobartonella is detected on Jan.12nd. It is detected in mycrobiology and serology tests.
But we did not re-run the tests after completing the 22 days of doxycycline treatment (in that period, my cat did not take pred, it was only doxycycline).
And now, during the second doxycycline treatment, we use it combined with pred (20 mg/day). Plus aspirine.

Sure, I checked home for anything toxic. Nothing is found. It is probably because of vaccines or immune booster as per our veterinarian's opinion (combination vaccine on 31st of May, 2020. And immune booster has taken 4 times between Jun.2020-Dec.2021).

I thought about cancer a lot of times. As far as I learnt, best way to detect is bone marrow biopsy. On the other hand, our veterinarian did not support this idea.
On May.30th, 2021: Her performaned full ultrasound. And organs were very well.
So I thought, if that would be any type of cancer, it should have been spreaded to at least one of the organs in this whole 1 year. (But this last sentence is my opinion. Our veterinarian neither confirmed nor rejected this, he was just silent.)

Yes, he is inside. He is an indoor cat since I got him from street (when he was 6-7 weeks old).

Thank you for informing about VIN. I will definitely talk about it with our veterinarian and ask him to be a member, if he's not yet.


And if all these additions makes sense in some other way, I'd highly be happy to hear about it.

 

[silent meowlook]

For sure you shouldn’t do anything to stress him at all right now.
Did I read that your giving aspirin? Not every day right?
What is the reasoning for that?
I am so sorry your kitty is so sick.

 

[arikanisil]

Yes, you're right, no need to stress him. This is why, we didnt perform bone marrow biopsy and tried to detect cancer via ultrasound of organs.

Yes we give him aspirin, but not everyday. The dosage is; 1/4 tablet, once in every 3 days.

Our veterinarian said; aspirin is used to avoid the risk of tromboemboli (I think, this is a risk for imha patients). But I know, this decreases the PLT count, which is alr

 

[arikanisil]

For sure you shouldn’t do anything to stress him at all right now.
Did I read that your giving aspirin? Not every day right?
What is the reasoning for that?
I am so sorry your kitty is so sick.

But I know, this decreases the PLT count, which is already low.
(Sorry, mistakenly sent previously).

We have an appointment with vet on Tuesday. He wanted to see, if the spleen is still getting bigger and to see how doxy-pred treatment goes.

What I'm trying to do now is; giving him meds, making sure that he eats, and searching for answers for "did we miss something? what causes him to not respond to the treatment?"

Thanks for your warm wishes for him.

 

[fionasmom]

I have little to add except to say that I hope, for all your efforts, that your cat can be helped to recover. My cat vet does use 1/4 aspirin every 3 days for cats with tendencies to clot or prescribes clopidogrel for them.

 

[arikanisil]

I have little to add except to say that I hope, for all your efforts, that your cat can be helped to recover. My cat vet does use 1/4 aspirin every 3 days for cats with tendencies to clot or prescribes clopidogrel for them.

Yes, clot or tromboembolubare same thing i guess. Aspirin is to avoid it.

Thank you for your nice wishes.

 

[silent meowlook]

How is your kitty?

 

[MissClouseau]

Hi there. I’m late but I’m also from İstanbul. I suggest taking consultation from an internal medicine specialist. There is Adakent Veteriner w/ Alper Bayrakal, or Nilufer Aytug at Animalia for example.

Also for ultrasound, a lot of vets here send to Dr Halil Mahzunlar at Trio Veteriner. Ultrasound can get tricky. Regular vets might be missing something. As one of the vets I know says, “Anyone with the ultrasound machine can look but can they understand what see? No.” There is also VetMri center on the Anatolian side if it’s ever needed.

Sure, I checked home for anything toxic. Nothing is found. It is probably because of vaccines or immune booster as per our veterinarian's opinion (combination vaccine on 31st of May, 2020. And immune booster has taken 4 times between Jun.2020-Dec.2021).

Combo vaccine is usually called FVRCP in English :-) Was this a booster shot or first? I’m guessing it was an annual booster. There is a test to check antibodies. I highly recommend that first instead of vaccinating him again. The test is almost twice more expensive than the vaccine but the chances are he will have enough antibodies to get vaccinated.

I can’t be much of help medically on this case but I highly recommend getting a second and third opinion from specialists. Make sure you print out all the tests done, the treatment they have tried and how your cat responded etc and take with you to the new clinics.

I’m glad your boy has a parent as good as you. I hope you get all the good news

 

[arikanisil]

How is your kitty?

Hello,

Thank you for asking.
I didn't reply before, bcs our veterinarian postponed the appointment today and we just came back from the clinic.

My cat has eaten on his own since yesterday morning (even though the amount is so so so little). This is why, I was expecting an increase in his bloodwork. Perhaps it was not enough, I thought we will see an increasement. But unfortunately, the CBC result was worse than last week. So, doxycycline did not work and it seems haemobartonella was not the case.
We re-considered other possible diseases, but our veterinarian insists that it's Primary IMHA and no other underlying cause. As per his opinion "this is a hard case, difficult to get response to the treatment".

Today, he started cyclosporine in addition to prednisolone. He says "Prednisolone+Cyclosporine treatment for IMHA is a consensus published by an internal medicine school in USA". Actually, I have also read that treatment at some academic papers, too.
And he wanted to see my cat next Wednesday again, to see if this treatment works.

At the end, I don't know. Not only my veterinarian's opinon, but I also read a lot of papers, watched the videos of veterianarians from all over the world. And I have no idea what else this disease could be or no idea why we can't get a response. Just hoping to see better results next week.

Thank you

 

[arikanisil]

Hi there. I’m late but I’m also from İstanbul. I suggest taking consultation from an internal medicine specialist. There is Adakent Veteriner w/ Alper Bayrakal, or Nilufer Aytug at Animalia for example.

Also for ultrasound, a lot of vets here send to Dr Halil Mahzunlar at Trio Veteriner. Ultrasound can get tricky. Regular vets might be missing something. As one of the vets I know says, “Anyone with the ultrasound machine can look but can they understand what see? No.” There is also VetMri center on the Anatolian side if it’s ever needed.




Combo vaccine is usually called FVRCP in English :-) Was this a booster shot or first? I’m guessing it was an annual booster. There is a test to check antibodies. I highly recommend that first instead of vaccinating him again. The test is almost twice more expensive than the vaccine but the chances are he will have enough antibodies to get vaccinated.

I can’t be much of help medically on this case but I highly recommend getting a second and third opinion from specialists. Make sure you print out all the tests done, the treatment they have tried and how your cat responded etc and take with you to the new clinics.

I’m glad your boy has a parent as good as you. I hope you get all the good news

Hello,

No it's not late and thank you so much for your suggestions.

Yes it was a booster shot. And I noted the test to be done before vaccinating. If my cat heals, I will definitely do that before going into vaccine thing.

I researched about many veterinarians in Istanbul, and heard about Dr Halil and Dr Nilufer. They were the ones I considered good enough. Dr Alper, never heard of, but I will search.
Then I found our current veterinarian (Dr Murat Ilgun, at PetHome). He had a lot of IMHA cases (which I personally met some of them), and also, he is studying PHD at the moment (internal medicine field).
So, because he is not only a practitioner at the clinic, but he is also at the academic field and reading articles, following new treatment methods etc, I choosed him. So far so good, I can't complain about his service. But I will re-consider the ones you suggested again.

(PS: I have written my cat's latest status as a reply to a previous message).

Thank you.

 

[arikanisil]

Hello all,

I am happy to share that Prednisolone+Cyclosporine treatment works well.
We started this treatment at Sept.'9 and my cat's bw is a lot better. His physical status is also good (he is as playful and healty as before IMHA).

We are still at the beginning/high dosage of Pred+Cyclosporine but our veterinarian may reduce the dosage tomorrow. Because it's almost been 2 months at this high dosage. So, it might be the time for tapering off. We'll see.

So, fingers crossed for keeping this improvement in his health in lower dosages.

Thank you all for your support and guidance.

 

[arikanisil]

How is your kitty?

Dear Silent Meowlook,

I wanted to write you directly.
I am happy to share that Prednisolone+Cyclosporine treatment works well.
We started this treatment at Sept.'9 and my cat's bw is a lot better. His physical status is also good (he is as playful and healty as before IMHA).

We are still at the beginning/high dosage of Pred+Cyclosporine but our veterinarian may reduce the dosage tomorrow. Because it's almost been 2 months at this high dosage. So, it might be the time for tapering off. We'll see.

So, fingers crossed for keeping this improvement in his health in lower dosages.

Thank you for your support and guidance.

 

[andreiamlm]

how is your kitty currently doing? Hope all continues to be good.

May I ask you if you did the bone marrow biopsy? We suspected the same IMHA in our cat Chibi case too but he has low levels in the three lines, and the bone marrow biopsy informs us it was working not working efficently but still working and during a few months that we have gave him prednisolone and cyclosporine it was working ( he had previoously needed two blood transfusions a feed tubing) and he even had a 33% hematocrit but now he's very sick so I was asking you if maybe in any of your reading or consults it was discussed treatment for the bone marrow if the anemia wasn't IMHA.

thank you so much, all my best wishes for you and your kitty

 

[fionasmom]

arikanisil

The OP has not returned to TCS since the last post of November 4. Just FYI. I am sorry that you are facing this with your cat.

 

[arikanisil]

how is your kitty currently doing? Hope all continues to be good.

May I ask you if you did the bone marrow biopsy? We suspected the same IMHA in our cat Chibi case too but he has low levels in the three lines, and the bone marrow biopsy informs us it was working not working efficently but still working and during a few months that we have gave him prednisolone and cyclosporine it was working ( he had previoously needed two blood transfusions a feed tubing) and he even had a 33% hematocrit but now he's very sick so I was asking you if maybe in any of your reading or consults it was discussed treatment for the bone marrow if the anemia wasn't IMHA.

thank you so much, all my best wishes for you and your kitty

Hello,

I am sorry to hear about your cat Chibi. I hope he/she gets better soon.

My experience with may cat's disease is not going well.

We started cyclo+pred treatment on Sept.15th. In the beginning, first few weeks everything went well. We even have seen above %30 HCT. But unfortunately, his blood levels decreased in the beginning of November. At that time, we didn't even start tapering off the dosage, we were at the starting dosage of cyclo and pred.
My vet changed the treatment into pred+leflunomide+dexhametazon at 10th of November. But the next day, my cat got very yellowish so quickly. That means; there were blood distruction and it was very fast. The bloodwork showed the same. So, At November 11th, he got blood transfusion. Because, we didn't have time to wait for leflunomide to work.
My cat was a bit better for the following 2 weeks. But then, his levels decreased again.

Now we're back to cyclo+pred. But this time, my vet added dexhametazone. Just waiting for them to show their magic.

We haven't done bone marrow biopsy. First of all, I did not not want to put more stress on my cat. Because he's already very stressed bcs of all these. And secondly, I live in Istanbul and I could not find any hospital that I can trust to perform it.
All other elimination tests are done (Felv, Fiv etc) and came back negative. Corona was positive at one test and negative at the second test. Ultrasound was clear.
Combining CBC and biochemistry tests, we are quite sure it's primary IMHA.

But... I am still looking for answers.
There are few immunomediators to use in this disease: Pred, Dexhametazone, Cyclo, Leflunomide, Cholorambucile and Mychophenolate Mofetil.
We are trying each of them and trying to find a temporary solution.

I don't know if all these helps. But I hope you find the answers you're looking for.

Best of luck to you and your Chibi.

P.S: There is also a facebook group, which is specialized for IMHA in cats. In that group, only this disease is discussed and all members have similiar problems. You can find many other people there, who has similiar experiences and possibly more information/knowledge than me.

 

[fionasmom]

Thanks so much for replying. I wish I had anything constructive to add to this and wish you both success. Please let us know how things progress if you are able.

 

[arikanisil]

No, I thank you for the nice reply.
I couldnt wrote much before. Bcs I was so sad and frustrated bcs of not getting response to treatment and not finding answers. But i will write.

 

[arikanisil]

Thanks so much for replying. I wish I had anything constructive to add to this and wish you both success. Please let us know how things progress if you are able.

No, I thank you for the nice reply.
I couldnt wrote much before. Bcs I was so sad and frustrated bcs of not getting response to treatment and not finding answers. But i will write.