The Trouble With Diseases Like IMHA – And the Great Unknown

Despite all the research and the advances in human and veterinary medicine, sometimes the hardest words to hear are “We just don’t know.”

By: MyFWCmedia
Anemia is a difficult diagnosis to give. By: MyFWCmedia

“It’s a 50/50 shot.”

“Anywhere from 70 to 30%.”

“Odds are, we just don’t know.”

These are words you might expect to hear at a racetrack, but you don’t want to hear them from your veterinarian. And I hate saying them. Trouble is, with all the knowledge we have in veterinary medicine, there are still some stinky diseases out there where the outcome is like a crap shoot. Odds are…we just don’t know.

It feels lousy having to tell a client that her pet has a disease, and that the prognosis is impossible to predict.

Clients have very troublesome reactions:

  • “What do you mean you don’t know if she’ll respond or not? Don’t you know what medicine to use?”
  • “You mean even if it costs me an arm and a leg, she still might not make it?”
  • “When to stop treatment? How could you say that? I’ll do anything to save my dog.”

A Bad Disease

The disease I resent the most when it comes to the great unknown is immune-mediated hemolytic anemia (IMHA), also known as AIHA (autoimmune hemolytic anemia). This diagnosis warrants a difficult conversation between me and a pet parent.

Here’s why:

  1. The outcome for my patient is unknown, despite the best treatment that money and veterinary medicine can provide.
  2. Treatment may be very expensive, often requiring referral to a specialty hospital.
  3. My patient may linger for a long time on a seesaw of improvement and relapse.
  4. If my patient pulls through the crisis, lifelong monitoring/medications/side effects are probable.

A typical case of IMHA goes something like this: Mrs. Goodperson brings in her sweet tempered Molly, a 5-year-old Cocker Spaniel that has just been a little “off” as of late. The dog has been lethargic for 2 days, and Mrs. G is concerned. Molly has otherwise been a healthy dog.

Miss Molly appears tired on the exam table but is still wagging her tail. She does not appear critically ill. Her temperature is slightly elevated. Mrs. G tells me she’s eating a little at home. Then I peek inside her mouth. Her gums are white. My heart sinks. Her pale gums, which should be a healthy pink, indicate that she is extremely anemic.

Don’t Miss: 25 Dog Health Warning Signs

Why would Molly, who lives life as a fluff muffin on a couch, lose a lot of blood and become acutely anemic?

In the video below, Greg Martinez, DVM, explains more about anemia and blood transfusions:

The top reasons for anemia in dogs are:

  1. Loss of blood from trauma, such as being hit by a car
  2. Bleeding internally, such as from a tumor that has begun to bleed
  3. Autoimmune anemia, where the red blood cells within the body are being destroyed

I take a quick listen and feel Molly’s abdomen. Internal bleeding is possible but unlikely from my initial exam. Mrs. Goodperson has already told me that Molly has been home safe and sound. No history of trauma. I worry that Molly is suffering from IMHA.

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There is no simple blood test to diagnose IMHA, but a few quick tests and X-rays point me in the direction of a fairly certain diagnosis.

Why Causes IMHA?

Just as Molly’s outcome is unknown at this point, we also don’t know what caused this dog’s IMHA. Here are some things we do know about why this disease occurs.

  • Certain breeds, including the Cocker Spaniel, are predisposed to IMHA.
  • Infections, cancer, vaccines or stress of any kind may “trigger” IMHA in predisposed animals.
  • Environmental factors, such as toxins or external stresses, may also serve as triggers.

In other words, just about any insult to the body can “trigger” an inappropriate immune response in a certain population of dogs and cats.

Symptoms are not always visible. By: bhaven

In most of my cases of IMHA, we never find a cause. The pet hasn’t been in recently to receive vaccinations or hasn’t been sick. In Molly’s case, one day she was fine, and the next day she seemed down and out. That’s the typical presentation.

So now I come face to face with Mrs. Goodperson and have to tell her that Molly is:

  • Gravely ill, even though she may not appear that way on the surface
  • Needs 24-hour monitoring and immunosuppressive medication until she is stable
  • May need multiple blood transfusions if her anemia becomes critical
  • May not survive despite all this aggressive treatment

At this point, Mrs. G is in shock. Only time will give us the answers she so desperately wants. It will be a waiting game of emotional ups and downs. Thrills when Molly’s anemia improves, and grave disappointment if she crashes again.

To the best of my ability, I lay out a game plan but stress to the pet family that they have to brace themselves for an emotional roller coaster. They can feel overwhelmed, in despair and heartbroken. Recently, a friend of mine brought in her little puffball of a Havanese. With a heavy heart, I diagnosed IMHA.

After 10 days of medications, ICU monitoring and multiple blood transfusions, my little patient had a series of setbacks. Her little body fought all our medicine and destroyed all our blood transfusions. The caretaker made her own decision that enough was enough. This little dog would not be one of the lucky patients who would respond to the first few days of medications and go home with a bounce in her step.

My friend wrote me and my staff a letter after losing her best little friend. She wrote that I had told her from the beginning what might happen, and that she did not feel blindsided when her pup was on a downward slope. Deep sadness and a feeling of helplessness, yes. But unprepared, no.

Despite all the research and the advances in human and veterinary medicine, sometimes the hardest words to hear are “We just don’t know.” Acceptance gives some relief to our grief, but it’s not an easy pill to swallow.

Dr. Debora Lichtenberg, VMD

View posts by Dr. Debora Lichtenberg, VMD
Dr. Debora Lichtenberg, VMD, is a small animal and exotics veterinarian who has split her time between a veterinary practice in Pelham, Massachusetts, and her studio in New York City. Dr. Lichtenberg is a graduate of the University of Pennsylvania School of Veterinary Medicine with 30 years of experience. Her special interests are soft tissue surgery and oncology.

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  1. Carla
    March 19, 2015

    Dear Debora, My 6 years old Norwegian Forest Cat was recently diagnosed with IMHA. I realise now that my vet has been telling me way too little about this illness, thanks so very much!
    Carla, The Netherlands

  2. Jaclyn Phillips
    May 15, 2015

    I lost my 8 year old lab mix to this unforgiving disease, a year ago. We did everything we could for her, but she died within 3 weeks of diagnosis! My heart goes out to anyone who faces this disease, but there are success stories about survival, although few and far between!

    1. Melissa Smith
      May 15, 2015

      So sorry to hear about your loss, Jaclyn!

      1. Jaclyn Phillips
        May 15, 2015

        Thank you so much! Her anniversary was very difficult on me! I still have 3 other dogs, but I believe the bond that I shared with my Max for those 3 weeks, just made our love stronger! I never thought she would die from this disease! Even on her last vet visit, which was less than 3hours before she died at home. The vet told me, at that visit, that he has never seen a dog come back with liver values as high as hers have gone! The vet said that I should leave Max there, so they can check her over. But I said I would rather take her home! She died surrounded by love! And that was the first time I let her see me cry. I told her I was crying because I was going to miss her so much!

        1. Melissa Smith
          May 15, 2015

          It takes such a strong person to be able to love unconditionally through something like that. I am sure that Max could feel how much you loved her!

          1. Jaclyn Phillips
            May 17, 2015

            Thank you so much. I know that Max knew I loved her before she got sick! I feel she waited for the vet to tell me she wasn’t going to make it. Then she knew I was somewhat prepared, and so it was her time to leave! I consider Max the strong one! But thank you again!

            1. Melissa Smith
              May 17, 2015

              No, thank YOU for sharing Max with us!

  3. zazen5
    March 02, 2017

    My family lost my Chloe of 6 years. We adopted her and her mom from Pawsitive match. I feel grateful to have known her for the time I did. I believe I never took her for granted and last week I cuddled her when I came home from work. We all still are in shock. Saturday my wife spotted Chloe peeing what looked like blood into the snow. We immediately took her in to the emergency animal hospital where she was diagnosed with IMHA that was idiopathic. No toxins showed up or foreign objects on the x ray and immediate immunosuppressive meds were started. On sunday she was blood matched and received a transfusion. All the while her bilirubin counts were sky high but no liver damage. Her hemo went to 28, then dropped to 18, then went to 23. My wife was excited but thought maybe we had false hope. This was on Monday when we visited. The vet said she would phone at 6 am tuesday morning. She didnt phone. My wife phoned at 630 am. Vet said Chloe was resting quietly. Wife was upset. Nevertheless we both went to work. At 810 am my wife phoned. Chloe’s level of consciousness was not good and hemoglobin levels were low. I rushed to the pet er. My wife was there already and I had brought our daughter. The vet indicated that consciousness was not good and that a further transfusion would prolong suffering. At 11:33 am the pet administered a sedative and Chloe died immediately even before the heart arrestor med. I feel sadness and anger that Chloe died too soon. She was the best dog ever. I take comfort in knowing I will be with her again in Heaven although I have some time to wait. What I do now is tell Chloe’s mom Emma who is 2 years older than Chloe when I go home each night I sit and tell her “you are loved”. I also if not extremely necessary no vaccinations for Emma ever again. I dont want the risk. The lack of preparation for this disease is what makes it so awful. Dont take people or your pets for granted, life is fragile.

    1. Melissa Smith
      March 03, 2017

      Thank you so much for sharing such a painful experience with us. You are so right, no one should ever take their pets for granted.


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