Immune-Mediated Thrombocytopenia: A Frustrating Disease

IMT is difficult to treat in dogs and cats, and the outcome is unknown. I’m a veterinarian, and here is my own dog’s story.

Caption here. By: Dr. Debora Lichtenberg, VMD
I diagnosed my own pup, Coco, with IMT 2 weeks ago. By: Dr. Debora Lichtenberg, VMD/Petful

Immune-mediated thrombocytopenia (IMT) … Idiopathic immune-mediated thrombocytopenia … A mouthful of a disease.

It’s also called immune-mediated thrombocytopenia purpura (ITP).

As frustrating as the crazy names of this disease are, the disease is even more frustrating to treat. IMT is more common in dogs — middle-aged female dogs, poodles and Cocker Spaniels are over-represented, in fact — but cats can acquire it too.

What Is IMT?

IMT refers to immune-mediated destruction of platelets.

Before I lose you, it’s this simple: Platelets help in the clotting of blood for our pets as well as for ourselves. If you didn’t have platelets, a small bruise could be a disaster. Platelets help to seal up a blood vessel and stop the bleeding and the bruising.

In immune-mediated destruction of platelets, a body (whether dog, cat or human) attacks its own platelets. The body views this fantastic little platelet as an enemy and destroys it. This destruction must be stopped in order to survive. We need what are called immunosuppressive levels of drugs to counteract the destruction. The first line of defense: corticosteroids, nasty but lifesaving drugs in many instances.

Signs and Symptoms

The most common symptom of a low platelet count (thrombocytopenia) is bruising. There may also be blood in the urine and feces or nosebleeds, but the hallmark sign is small bruising for no reason. These are called petechiae.

Here’s Why It’s Frustrating

  • It’s idiopathic, meaning we don’t know the cause — perhaps an infection or a neoplastic process or even a toxin — but again, we just don’t know.
  • It has an unknown outcome.
  • It is usually treated with high doses of corticosteroids (prednisone, for example), which have many side effects.
  • If the treatment begins to work and the disease goes into remission, we have to be careful about stopping treatment too soon.
  • The pet can stop treatment, but the disease could return after remission.
  • Diagnosing, monitoring the disease and additional drug therapy, if indicated, can get very expensive.

“But My Dog Looks Fine”

Imagine your veterinarian giving you the bad news that your healthy-looking dog, usually a fairly young or middle-aged dog, has a bad disease. The vet tells you:

  • We don’t know what caused it.
  • We don’t know if your dog will respond to treatment.
  • We have to use dangerous drugs at high doses to treat the disease.
  • The treatment might or might not work.
  • The disease might return after remission, and that it might cost you a lot of money — but we don’t know how much.

You might think your vet doesn’t have a clue what she’s doing, and your head is spinning from this confusing and depressing information. That’s how most clients react.

Caption. No need to repeat credit line.
Coco loves to lie on her back. I noticed a lot of bruising on her belly — the first warning sign of IMT.

My Puppy Has IMT

About 2 weeks ago, I diagnosed my own 18-month-old pup with IMT. This really sucks.

Coco’s History

Coco is a fairly new rescue for me. We adopted her last summer from a family who had to rehome her. She is a Dixie dog who looks like a tiny, dark wolf running in the snow with golden eyes.

She loves to turn over on her back, spread-eagled, and one morning, I bent down to rub her tiny belly and noticed pretty significant bruising (petechiae). I then looked at her gums (mucus membranes) — sure enough, her entire mouth was full of petechiae.

Time for an emergency vet visit. Fortunately, that just meant taking her to work with me across the driveway.

Her automated platelet count was 0. She actually had about 15,000 platelets, but if this didn’t turn around fast, she was headed for the ICU and transfusions. In the saddest scenario, she would not recover.

Coco’s Treatment

Because I’ve treated this disease so many times with outcomes ranging from complete failure (the dog dies) to a quick and lasting remission, my mind was immediately spinning. I was thinking the worst but hoping for the best.

It really stinks when you have to give your own dog a serious diagnosis. I’ve treated dogs with IMT who did not recover. And because the treatment can be harsh, I remember the angry clients who got so frustrated by treating IMT that they took it out on me. It’s understandable.

Coco’s Progress

Within a few days of treatment, Coco’s petechiae (bruising) faded, and no new bruising appeared.

Most important, her platelet count returned to normal within the week. She is responding perfectly to treatment but still exhibiting some of the side effects of the prednisone.

Caption here. This is Coco againxxxxxxxx. Photos by: Debora Lichtenberg, VMD/Petful
Steroids turn Coco into a dog who just won’t quit tearing up the house.

As I mentioned, Coco’s platelet count remains in the lower normal range. This is good news.

But she is showing some problematic side effects from the steroids, and this is what I want to share with you in case your pet is prescribed steroids for a serious problem.

What Is a Steroid?

A sidebar here about the terms “steroid” and “corticosteroid”: Many clients hear the word “steroid” and are confused. They might be thinking about anabolic steroids, not corticosteroids.

Anabolic steroids are those testosterone-like drugs that are misused by athletes and body builders. When your veterinarian talks about using a “steroid,” she is almost always talking about a corticosteroid.

Corticosteroids are used to control many diseases, ranging from allergies to immune-mediated diseases to certain cancers. Cortisol helps control many metabolic and physiologic processes, including stress response, inflammation, immune response, protein metabolism and electrolyte levels, to name a few.

The most common side effects of corticosteroids are increased thirst and appetite. The no-brainer follows — more urination.

The medical shorthand we use for this syndrome is PU/PD/PP (polyuria/polydipsia/polyphagia) (increased urination/increased thirst/increased appetite).

There is also a kind of steroid crazy where the dog is just nuts! Eating, drinking, urinating and running around like a maniac.

corticosteroids
Coco’s brush with death was a good reminder that dogs need to be protected from themselves when taking corticosteroids.

Coco Attempts Suicide on Steroids

Already crazy and still struggling with potty training, Coco on steroids is faster than a speeding bullet. Able to leap tall cabinets in a single bound. More powerful than any locomotive.

Super-steroid dog Coco has tried to eat anything not nailed down — and has found many things we thought were nailed down: Ancient Chinese takeout condiments. Human gummy vitamins. Newly purchased coffee.

I wait in line at the fabulous Porto Rico Coffee in NYC and cherish my purchase. But Coco, on steroids, broke into my organic Sumatra. The coffee is now embedded into a carpet that will never recuperate because she chose to bury it indoors, not eat it.

I was finishing up Saturday morning appointments and left Coco at the house for the last 30 minutes. I arrived home to find she had scaled a counter and put herself into a toxicosis state by eating an ancient bag of semi-sweet chocolate chips in a high, closed cabinet.

At times like this, I wish I had a nanny-cam. How the (bleep) did she get into that cabinet?

Saving My Own Dog

My dog had ingested a lethal dose of chocolate. She was shaking, had tremors and was on her way to a seizure. Time to go into ICU mode with my own dog.

Classic treatment for chocolate toxicosis is immediate emesis (making the dog vomit). Success! The vomit included the pound of semi-sweet chocolate chips and an undigested fortune cookie with the wrapper. Yay!

I gave her activated charcoal to absorb more toxin and monitored her 24/7 until she was out of danger. Soon enough, she was doing just fine. But what is the lesson learned?

If Your Dog Must Take Steroids

Keep an open conversation going on with your vet. Your dog may exhibit many side effects. It is impossible to predict how she’ll be affected.

The dosage and the type of steroid is always negotiable. If the side effects are severe, your vet may try to change the dosage, the particular drug or change drugs completely.

This Vet Always Learns From Her Own Pets

Coco is exhibiting intense steroid-induced hunger. House-training, which was going well, is a bigger challenge right now.

These are big reminders for me to be even more sympathetic to others experiencing these problems when their pet is on lifesaving steroids.

Vets must listen. A client might say something like, “Poco’s driving me crazy with her appetite on prednisone.” Or, “She’s peeing so much I can’t take it.” A vet might say, “Yes, it’s a common problem.” But what we need to say is, “How bad is it? What’s going on? Give me specifics.”

Coco could have died if I had not come right home after work. The house is pretty pet-proof, but not if she’s on a steroid hunger mission.

Keep that open dialogue with your vet and remember this: No question or concern is dumb or stupid. It’s what we are here for. And you might just save your pet’s life.

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This pet health content was written by a veterinarian, Dr. Debora Lichtenberg, VMD. It was reviewed for accuracy by Dr. Pippa Elliott, BVMS, MRCVS, and was last updated Oct. 13, 2018.

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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10 Comments

  1. helloavatar
    January 29, 2017

    On Wednesday morning I noticed blood on carpet. I examined her and didn’t know where it was coming from. I saw bruising on her stomach. I took her outside and she peed blood and then all of a sudden blood in her gums. I rushed to the ER and her platelet is 14,000 (dangerously low), Red/White ok. Ultra Sound, X ray normal, urine sample normal. Started her on steroids and antibiotics that night. She has more bruises on her tummy after shaving.

    Next morning she had no energy to walk so back to ER. She was loosing too much blood and red blood count down to 25%. She was hospitalized and had to get 1st blood transfusion. Friday morning no improvement to red blood count. Noticed less red in urine but black stool. At night Red blood down to 21%. 2nd round of blood infusion.

    (today) Saturday its up to 35%. No red in urine (hint of pink), stomach bruise fading, no gum bleed, black stool. Red Blood went down to in afternoon 31%. Platelet results are tomorrow. Will not being doing 3rd transfusion today (fingers crossed)

    This has been 4 days of hell. My baby is everything to me.
    I continue to make her organic chicken, liver, eggs, salmon, sardines, spring water, no vaccines, use many Mercola holistic supplements. She is 11 ridgeback/shep. Very healthy, takes daily 1.5 hours of walks a day.

    Please help/advice anything. Thank you. I can’t loose my girl.

    Reply
    1. Melissa Smith
      January 30, 2017

      I’m so sorry!! How is she doing now?

      I don’t understand why the animal hospital is sending her home. I’m not a vet, but she seems awfully ill. Have they offered any type of answer?

      Reply
      1. helloavatar
        January 30, 2017

        Thank you Melissa.
        I responded but i just saw it wasn’t posted for some reason.

        She came home last night Her platelet was unreadable at the lab due to blood clotting which I was told is a good thing as it means she has platelets that are functioning to clot the blood. Her Red was 37%.

        Last night she didn’t want to eat but we left the food out and she eventually ate it a few hours later. This morning she ate her breakfast just fine.

        I noticed she was all wet where she was sleeping (twice) last night but I think that has to do withe meds she is on. Its clear but doesn’t smell like urine. Years ago I gave her antihistamine/cortisone prescription and the same thing happened but as soon as she stopped immediately, it didn’t happen.

        She drinks a lot because of the steroid meds so I am taking her outside every 3 hours.
        This morning I got a call from the Nurse and she said her platelets are now 118,000 which is insane considering just 5 days ago she was 0-14,000.

        We are scheduled to go back for more blood work in a few days.
        She is resting at home comfortably and we will take it day by day.

        Reply
        1. Melissa Smith
          January 30, 2017

          Sorry about that; I fixed it! It thought there was a random link in there for some reason….weird forum 😀

          Reply
    2. Dr. Pippa Elliott, BVMS, MRCVS
      Pippa Elliott
      January 30, 2017

      Hi Hello Avatar,
      It sounds as if your girl is in excellent hands, with all the important test run. It’s great that the vet has access to blood for transfusions. Bleeding disorders are scary, and sometimes it takes a few days to ‘switch off’ the inappropriate reaction that’s damaging the red cells. This means the blood from early transfusions can be attacked in just the same way as her original blood, so repeat transfusions can be needed whilst waiting for the drugs to kick in.
      Many, many dogs do respond well to immunosuppressive drugs to switch off that damaging attack on the red blood cells. She sounds very fit and the healthy diet means you’ve done everything possible to keep her well. Keep strong for her, and try not to worry too much – hard as that is. In the meantime lots and lots of TLC, and spoil her rotten.
      Best wishes,

      Reply
      1. helloavatar
        January 30, 2017

        Thank you so much for your kind words Pippa!

        I never knew about dogs donating blood and even with transfusions the body can attack as fast as it goes in. Our bodies and dogs bodies are such complex systems. We owe her life “twice” to the pups who donated their blood.

        Thank you again.
        We will take it day by day.

        Reply
  2. Tammy Robertson
    April 5, 2017

    This article hit home. I am so worried about my pug baby (10 1/2 yrs old) who has been diagnosed with IMT. She originally went to the vet for bleeding gums. IMT was suspected. She also has a history of mast cell tumors, the tumor they aspirated would not stop bleeding (due to the IMT). We started her on a high dose of steroids and vitamin K, as well as an antibiotic to rule out infection. One week later, blood cell count is worse, very high white blood cells and she’s practically lost 80% of her blood. Most recently she’s developed edema and is so swollen she can hardly walk at all. We are now on Lasix, a pill for her liver function, 40 mg of prednisone and azathioprine. I am terrified. The vet will recheck her blood on Friday and we are PRAYING for the best. My heart is breaking, she went from healthy to not able to function in a matter of days. I’m concerned about the medication, are we giving her too much? I just don’t know how to help her. Her protein levels were a little low and that is what they suspect is causing the edema. It’s all so scary and we just want to do the right thing for her. I just find it hard to believe she’s changed so dramatically in a few days. Any one who has input or experience with this I welcome your feedback. I’ve been researching night and day looking for answers.

    Reply
    1. Melissa Smith
      April 5, 2017

      I’m so sorry Tammy, what a terrible situation you’re facing! I don’t have experience with this disease, but I wanted to offer my support. It’s so hard to see our fur babies go through things like this. 🙁 My advice is to keep loving her and to call the vet whenever you have questions, even if it’s ten times a day. That’s what they’re there for!

      Reply
      1. Tammy Robertson
        April 5, 2017

        Thank you so much. The vet has been very kind. Even texted today to check on her. It’s just so heartbreaking and hard to know what to do or what to believe. Very torn. Thank you for your kind words and support. We are very hopeful Friday’s labs will show some improvement.

        Reply
  3. Tammy H.
    September 2, 2017

    My sister has a very sick Biewer Yorkie, Gizmo, a little over a year old male.
    Entire panel of platelets and white blood count critically low.
    Recently vaccinated(6-7 weeks ago) and recently sick (2- weeks ago)with a bacterial infection either from a tooth abscess or other unknown cause, but bacteria (campylobacteria) was found in his fecal sample and was given antibiotics. And apparently not only was Gizmo sick but 4 other members of her household got nausea and severe diarrhea. All this has never been taken seriously by the ICU vet.

    August 23, 2017-Initial symptoms: severe dehydration, lethargy, no eating, diarrhea, vomiting, fever and very orange urine. Then she noticed sores on gums and found the abscessed baby tooth.
    The below blood test was taken about a week after first symptoms. Gizmo has been seen by a regular clinic and under care in ICU, and no one up to this point has taken a urinalysis. Was told it’s too late in treatment and would not add any value in diagnostics, really? But they want to do a bone marrow needle and aspirate. Isn’t Gizmo too sick for this type of surgical procedure with so many unknowns? Ultrasound indicated severely inflamed pancreas, but snap was negative, so too was heartworm. So far the only treatment he is receiving is antibiotics and IV fluids. They wont treat for IMT or any other auto immune until the bone marrow biopsy. Isn’t there another way to determine if he can have immunosuppressants?
    I am certainly no vet, but I am a very proactive pet parent and I’m just trying to help out with my 20 years experience (AIHA, CHF, Lymphoma, Chemo, Rickettsia, chronic pancreatitis)with my own fur family. It seems to me that if Gizmo has an auto immune disease that it is likely secondary to the infection/s had or triggered by the vaccinations and then the infection was too much for him to fight off. But the doctor discounts (not eliminate, but discounts) the role the vaccinations or even the previous infection could be playing. They want to go straight to the bone marrow biopsy…and it just seems her dog is awfully sick for this.
    the hopeful news is that after a week of antibiotics and fluids, he’s clinically improved with slight increase in eating, drinking, no vomiting, and more solid pooping and his mood is slightly elevated. It’s just the bloodwork is still so bad.
    Parvo tested 2x both negative. Erichlea also negative

    Blood test taken August 29
    ALB = 2.0 g/dL L 2.3 – 4.0
    ALKP – –.– U/L 23 – 212
    ALT = 30 U/L 10 – 125
    BUN/UREA = 10 mg/dL 7 – 27
    Ca = 8.1 mg/dL 7.9 – 12.0
    CHOL = 402 mg/dL H 110 – 320
    CREA = 0.5 mg/dL 0.5 – 1.8
    GLU = 118 mg/dL 74 – 143
    PHOS = 3.9 mg/dL 2.5 – 6.8
    TBIL = 2.7 mg/dL H 0.0 – 0.9
    TP = 6.3 g/dL 5.2 – 8.2
    GLOB = 4.3 g/dL 2.5 – 4.5
    Sodium = 153 mmol/L 144 – 160
    Potassium = 3.5 mmol/L 3.5 – 5.8
    Chloride = 110 mmol/L 109 – 122
    GGT = 2 U/L 0 – 11
    ALB/GLOB = 0.5
    BUN/CREA = 21
    Na/K = 43
    OSM calc = 302 mmol/kg

    HCT = 24.8 % L 37.3 – 61.7
    HGB = 9.3 g/dL L 13.1 – 20.5
    MCHC = 37.5 g/dL 32.0 – 37.9
    WBC = 0.41 K/uL L* 5.05 – 16.76
    NEUT * * 0.03 K/uL L* 2.95 – 11.64
    %NEUT * * 7.3 %
    EOS * * 0.00 K/uL L 0.06 – 1.23
    %EOS * * 0.0 %
    PLT = 20 K/uL L* 148 – 484
    Retics = 2.5 K/uL L 10.0 – 110.0
    %Retics = 0.1 %
    RBC = 4.15 M/uL L 5.65 – 8.87
    MCV = 59.8 fL L 61.6 – 73.5
    MCH = 22.4 pg 21.2 – 25.9
    RDW = 14.4 % 13.6 – 21.7
    MPV = 16.3 fL H 8.7 – 13.2
    PDW – –.– fL 9.1 – 19.4
    PCT = 0.03 % L 0.14 – 0.46
    LYMPHS * * 0.28 K/uL L 1.05 – 5.10
    %LYMPHS * * 68.3 %
    MONOS * * 0.10 K/uL L 0.16 – 1.12

    My sister has very little resources so we’re trying to figure out the best options for them.
    She’s spent $3500 so far and has no means for much more and it’s a terrible thing to choose between her dogs life and her rent. Any guidance or direction would be greatly appreciated.

    Reply

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