Karen Norling is no stranger to the diseases that can befall our canines. A dog owner for many years, she has experienced her fair share first hand with her beloved dog, Oreo, as she recalls here.
My first Miniature Schnauzer, “Oreo,” suffered from a number of them: when he was 13 months old, he acquired canine parvovirus. Despite his having been appropriately vaccinated against it, he had to stay in the hospital for 10 days and nearly died.
When he was two years old, he was diagnosed as having epilepsy after several grand mal seizures. When he was three, his bladder began forming stones. He underwent surgery, on more than one occasion, to remove these stones. Eventually, he began suffering from potentially life-threatening bouts of pancreatitis that landed him repeatedly in the hospital. Finally, when he was nearly 12 years old, he acquired hemangiosarcoma (a malignant cancer of the cells that form blood vessels). 60 days after I received his diagnosis, he slipped away.
As you can see, Oreo suffered enough disease for two or three Schnauzers. Fortunately, however, my husband, Jim, and I were always able to provide him the level of care that would bring him back to good health (except for the hemangiosarcoma). Such was not the case with “Jazz,” another of our Schnauzers. Just months ago, Jazz was diagnosed as having a disease neither Jim nor I had ever heard of: “immune-mediated hemolytic anemia” (IMHA).
Never could I have imagined that his subtle lack of appetite one Saturday evening would foreshadow one of the most painful, most bewildering experiences of my life . . .
“Jazz doesn’t want any popcorn tonight,” I remarked to Jim. “I’m a little worried.”
“He’ll be fine by tomorrow,” Jim responded. “It’s probably nothing.”
The next morning, Jazz stayed in bed while Jim and I went down to the kitchen for breakfast. Normally, Jazz would wake up with us, stretch for a moment or two, then follow. Why wasn’t he standing at my feet?
“Go potty, Jazz?” I called upstairs.
Immediately, he trotted down to the laundry room where I was holding the door open. Per usual, he climbed down the three shallow steps that led to the grass and started sniffing. I went back to the kitchen for a few moments, then returned to the open door. “Come on in,” I coaxed him, but he just stood there looking at me. “Come on, baby,” I tried again. Again, he just looked at me. Apparently, he didn’t want to climb up the steps.
Without much hesitation, I scooped him into my arms and carried him inside, noticing a reddish-orange splotch on my sweatshirt as I set him down in the family room. Uh-oh, I thought. He must have a cut on one of his paws. Either that, or his urine has blood in it—which would mean he probably has a bladder infection.
Concluding that the blood was coming from his urine, Jim and I hopped into our car and took him to the local emergency clinic. By the time we obtained a sample of his urine for the doctor to see - less than two hours after I’d noticed the splotch on my shirt - it looked like pure blood.
Would a bladder infection look like this? I swallowed hard. What is going on? (I later learned that what appeared to be blood in Jazz’s urine was actually hemoglobin released from broken blood cells.)
Frightened as I was, I continued to believe that the doctor would take care of anything that threatened Jazz’s well being. After sitting more than two hours in the waiting room, while Jazz was being evaluated, Jim and I were taken back to see “Dr. Ford.”
“I believe Jazz could have what we call ‘immune-mediated hemolytic anemia.’” Dr. Ford explained. “Immune-mediated hemolytic anemia [IMHA] occurs when the immune system ‘turns on itself’ and begins destroying its own red blood cells. As a result, Jazz’s ‘packed cell volume’ is quite low.”
“Packed cell volume?” I wondered out loud.
“Packed cell volume [PCV] is the percentage of blood made up of red blood cells versus the percentage of plasma,” she responded. Normal can be anywhere from 37% to 55% in canines. Jazz’ is 18%. See how his tongue looks discolored?” she opened his mouth. “How the whites of his eyes are jaundiced?”
I thought his tongue looked a little off, but I honestly had not noticed the jaundice (yellow) in his eyes.
“There are two types of IMHA,” she continued. “Primary [idiopathic] and secondary. We can’t identify a cause for primary IMHA. We can, however, identify a cause for secondary IMHA--such as: cancer, infectious diseases, reactions to certain drugs, or tick-borne diseases, like Lyme disease. Unfortunately, I believe Jazz has primary IMHA which is generally more difficult to treat.”
“Is it serious?” I asked, assuming that as long as Jazz received the best care, he’d fully recover.
“The prognosis is guarded. 70% to 30%,” she replied.
Whew! More than two thirds of the dogs who have it, survive, I thought. So he’s got a good chance of making it. Little did I know I had completely misunderstood Dr. Ford. In reality, she was saying that, in her experience, 70% of the dogs who have primary IMHA die from it and only 30% survive.
In retrospect, I think the misunderstanding was an absolute blessing. For if I had understood what Dr. Ford meant, I surely would have crumbled right then and there. Dr. Ford kept Jazz overnight, administering an IV that contained prednisone (a drug that suppresses the immune system) and cefazolin (a drug that prevents bacterial infection of internal organs), and monitoring his PCV.
Early the next morning, just before Jim and I picked Jazz up and took him to Dr.Sitch, his regular veterinarian, we learned that his PCV had not decreased overnight, as Dr. Ford thought it might (the fluid from the IV could have diluted his blood enough to lower the PCV). But it hadn’t increased, either.
At this point, Dr. Sitch looked after Jazz, reconnecting the IV the emergency clinic had started, likewise, continuing to monitor Jazz’ PCV. Late that afternoon, she called and recommended that I take Jazz to Cleveland’s “internal medicine” clinic because his PCV had decreased to 17% since morning. If his PCV continued to drop during the night, Dr. Sitch explained, he might need a transfusion. (The veterinarians at the internal-medicine clinic work around the clock and specialize in diseases such as IMHA).
Despite my fear of hearing her say “no,” I asked Dr. Sitch if she thought Jazz had a fair chance of pulling through. She answered that while the IMHA had begun to affect his liver (not a good sign), she definitely thought it would be worth our efforts to “keep trying.”
Jim and I both took Jazz to the internal-medicine clinic early that evening. About an hour after one of the techs took Jazz to the back, Jim and I spoke with Dr. “Belmont” (the doctor who would be taking care of Jazz). Dr. Belmont told us that he, like Dr. Ford, believed Jazz was suffering from primary IMHA and that among the more severe cases of primary IMHA (Jazz’s case was very severe), approximately 80% of dogs die, and only 20% live.
Suddenly, I broke out in a tingly sweat and felt as if I couldn’t breathe. 80% to 20% in favor of death? That’s when it dawned on me that I had misunderstood Dr. Ford’s “70% to 30%” comment. She had meant 70% die and 30% live. How could I have been so stupid? How could I have kept thinking Jazz’s odds of surviving were much higher than they were? (Note: in less severe cases of IMHA, more than 50% of dogs survive)
“Jazz may ultimately need a blood transfusion,” Dr. Belmont continued. “But we don’t like to do transfusions if we don’t have to because the immune system often destroys the transfused red blood cells as quickly as it destroys the patient’s own red blood cells. Most dogs that die of severe IMHA, die from ‘pulmonary embolism’ [a blood clot in the lungs]. But paradoxically, some die from internal bleeding.”
The last thing Dr. Belmont discussed with us was whether or not we wanted to sign a “do not resuscitate” (DNR) form. “You don’t want to be asked this question in the middle of the night,” Dr. Belmont reasoned. “It’s best to think about it now.”
My heart plummeted to the pit of my stomach as I signed the form. Nevertheless, I knew I was doing the right thing: I wasn’t going to allow Jazz to suffer even more if his chances of surviving long-term were essentially 0%. If it came down to that, I would have to let him go.
Before Jim and I left the clinic that night, I cuddled Jazz in my lap and gently stroked the side of his face. Though he wasn’t feeling well, his ears perked up, and his tail wagged a bit whenever Jim or I talked to him. Jim seemed to think he was improving. I wasn’t so sure.
The next morning someone from the clinic called to tell me that Jazz had undergone a transfusion during the night and that he seemed a bit better.
Not knowing whether to feel good or bad about the transfusion, I simply looked forward to visiting him that evening.
I would have felt more optimistic about the perked-up ears and wagging tail Jazz greeted us with that night had I not noticed that the whites of his eyes were slightly more yellow than they had been the night before and that his tongue was a little more discolored.
“I still think he’s getting better,” Jim smiled.
“His eyes look worse to me,” I shook my head.
The next morning Dr. Belmont called with what seemed to be good news: “Jazz is sitting right here looking at me. I’m going to have one of the girls get him some pancakes and eggs from McDonald’s.”
“So he’s doing better?” I asked. “He still might recover?”
“I wouldn’t rule it out.”
A couple hours later, Dr. Belmont called back to tell me that Jazz had “enjoyed his pancakes and eggs.” A sense of optimism enveloped me. I couldn’t wait for Jim to return from work so the two of us could visit Jazz again.
That night, when the tech led him out to us on a leash, he held his ears high and bounced just a little as he walked. As had become usual, I held him on my lap, close to my heart, gently nuzzling his face. But whatever optimism I might have experienced, in the wake of Dr. Belmont’s call earlier that day, faded when I looked at the whites of Jazz’s eyes and noticed they were even deeper yellow than they had been the night before. I was certain of it.
I felt terribly sick to my stomach and shaky. I cannot handle losing him, I silently cried as I cradled him in my arms and continued to pray for the miracle I’d been praying for all along.
Maybe Jim is right, I said to myself as I climbed into bed that night. Maybe Jazz is getting better, and I just don’t see it. The phone rang about 5:30 the next morning, and I knew even before I answered it: Jazz was gone. Why else would anyone call so early?
“We started to give Jazz another transfusion during the night. We’re so sorry. He passed away.”
I could hardly believe my ears. How could a perfectly healthy seven-year-old dog become sick and die within three days despite receiving the best, most aggressive treatment? My neck and shoulders began to tremble, and I felt as if I might fall, unconscious, to the floor. I was every bit as stunned as I was broken-hearted. My baby died of a merciless disease I’d never even known existed.
In the weeks that followed Jazz’s passing, I asked everyone I could think of if they had heard of “canine IMHA.” (Humans can also acquire primary or secondary IMHA, though it is not nearly as virulent in humans as it is in canines)
I asked my hairdresser. I asked other dog owners. I asked Miniature Schnauzer breeders. I asked my friends and family. I even asked my own doctor. And the answer, across the board, was “No.” Considering the fact that not one person I asked had heard of this deadly disease, I concluded that it is relatively rare compared to other potentially-fatal canine diseases that can be successfully treated or prevented such as: diabetes, epilepsy, pancreatitis, distemper, parvovirus or Bordetella.
But whether it is relatively rare or not doesn’t really matter when you consider that it can strike any dog - mixed breed or purebred - at any age, for essentially any reason (though it most often strikes: Cocker Spaniels, English Springer Spaniels, Collies, Poodles, Irish Setters and Old English Sheepdogs).
Sadly enough, by the time your dog exhibits the symptoms of IMHA (mild loss of appetite, lethargy, pale gums, discolored urine), it might very well be too late to do anything to help him - as it was in Jazz’s case. Worse yet, even if he survives his first episode, he might relapse—fatally—months or years later.
For now, researchers are simply trying to establish a safe, effective treatment for primary IMHA - a treatment that would allow dogs to survive not only the disease itself, but the complications that so often arise from it. Once such a treatment is established, researchers can then concentrate on finding a means of prevention or a cure. In the meantime, treatment protocols will remain painfully inadequate and costly.
Indeed, I pray that I never have to stand helplessly on the sidelines again watching this intractable disease drain the life from another of my dogs, or anyone else’s dog(s), for that matter.
A Final Note From Karen...
I am making a point of contributing to IMHA research any way I can in the hope that an effective treatment - at the very least - will be discovered. You can contribute, too, with the realization that, at present, primary IMHA could touch your life as harrowingly as it touched mine. Here’s how you can help:
The Cummings School of Veterinary Medicine at Tufts University is currently involved in clinical research to try to improve the treatment of dogs with IMHA. You can send your donation online or by phone: (508) 839-7905 or by visiting them online at http://www.tufts.edu - whatever method you choose, please specify that your donation be used for IMHA research.