Most of the diseases that we see and treat in the ER can be pretty easily comprehended by non-medical folks: trauma, infection, cancer – all of these seem to make sense to pet owners when we discuss them. But there is one disease that almost always sends heads spinning and puts a look of blank incomprehension on the faces of pet owners. This disease is immune-mediated hemolytic anemia, or IMHA, and I will give you a little insight into its nefarious workings right now.
Your immune system keeps you safe and protected from all the zillions of things that try to kill you every day. Every minute of every day, viruses are trying to enter your sinuses, bacteria want to creep into your blood stream, and even your own cells decide what the heck – let’s mutate and try and cause cancer. Your immune system stands a post, grabs a gun and keeps all these hazards at bay so you can spend another day looking for just the right pair of jeggings at the Gap.
Your immune system is an amazingly choreographed and intricate machine with dozens of types of cells and hundreds of chemical messengers that allow it to determine what’s you, what’s not you, and what’s potentially trying to kill you. It doesn’t always work the way it is supposed to.
In some cases, it gets confused and decides that something totally harmless is worthy of note and launches a counteroffensive – this is what happens with most allergies. Your immune system decides that pollen, for example, is dreadful and must be eliminated at all costs and mounts an attack that leaves you with puffy eyes, a runny nose and a bad case of the sneezies. To my knowledge, pollen has never killed anyone – so, why the big fuss, immune system?
In other cases, your immune system gets even more confused and decides that little bits of you – important bits of you, like joints and blood – are the bad guy and takes them out. These are the so-called autoimmune diseases, many of which you have heard of: rheumatoid arthritis, lupus, Grave’s disease. There are many more. Even diabetes (Type I, in which the body stops making insulin) is an autoimmune disease at its core; the body attacks the cells of the pancreas that make insulin. No one knows why. I think it’s because the pancreas said something about the immune system’s mama once, and it all went downhill from there.
One of the more common autoimmune diseases that veterinarians see is IMHA, in which the immune system decides that red blood cells would make a tasty snack and goes after them like Chuck Norris after the bad guys. In most cases, the trigger is never known – one day, your immune system wakes up and says “yesterday – viruses and bacteria, today – red blood cells! Tomorrow – who knows?!” and starts destroying them with abandon. The ‘hemolytic’ in the name refers to the process of popping or lysing red blood cells. Incidentally, onions, mothballs and the zinc found in pennies minted after 1982 can all cause the same thing.
Some of the signs of IMHA include:
- Pale or yellow gums
- Extreme weakness and lethargy
- Loss of appetite
- Jaundice (yellow discoloration) of the whites of the eyes.
It can happen with remarkable speed – one day your dog is happily snoozing by the fire, the next day your veterinarian is telling you that he’s in a 50:50 battle for his life. The speed always amazes clients, and makes it one of those diseases that prompts people to use the old ‘but, doc he was fine yesterday’ line.
Your immune system moves fast – think of how fast you go from the depths of the flu to feeling fine; one or two days and you are back to normal, once it gets a toe-hold on the invading bugs. It moves at the same speed when it is confused. It is mercilessly efficient whether it is covering your butt or kicking it.
IMHA and its close cousin Evan’s syndrome (in which red blood cells and platelets are both consumed) are not easily treated. The odds we give pet owners are around 50:50, and some days even those poor odds seem a tad optimistic. Doing battle with the immune system is not for the faint of heart or lean of wallet. Many days in the hospital, multiple transfusions and, in some cases, medications costing thousands can all take their toll and many owners elect not to go ahead with therapy. Not all cases reach the financial limit for owners, but I have been involved in enough that have gone down that path that I always warn families of the potentially rocky road that may lay ahead. I never fault owners who decide not to even dip a toe in the pool and call it quits once the diagnosis is made. It is that bad.
One of the dreaded consequences of IMHA is a blood clot that can travel to the lungs and is often fatal – a pulmonary thromboembolism, or PTE. After treating several cases that seem to have dodged a bullet, enduring transfusion after transfusion, only to catch that bullet in the form of a massive PTE, I always let people know the worst than can happen.
Those that we do treat are on medication for months (steroids like prednisone are the cornerstone of therapy) and about one dog in five will have a relapse at some point. Cats, for some reason, are relatively resistant to IMHA; they can still get it, but I have treated hundreds of canine cases and only a handful of cats.
There is an association between recent vaccination and the onset of IMHA, but I don’t want to infer that vaccines cause IMHA. It’s just not that simple, although folks love to paint vaccines as the bad guy. The association between the two is tenuous and somewhat unproven, and vaccines are still one of the most important tools we have against dreaded diseases like parvo and distemper. We do, however, usually recommend that patients who have had IMHA not receive vaccinations ever again in the future, out of, as they say, an abundance of caution.
Since most cases of IMHA are seen in middle-aged to older pets (females are slightly more likely to get autoimmune diseases in general; Cocker spaniels are the poster dog for IMHA) and vaccines have the greatest protective effects in the young, this recommendation does not usually mean that skipping a vaccine will open the door to potential diseases. Whatever you do, don’t skip vaccines in the hopes of avoiding IMHA, especially in a younger dog. Parvo has killed millions more dogs than IMHA and the vaccines are proven and effective in preventing it. It is simply not worth the risk.
Your immune system is something you absolutely can’t live without, but when it gets off track and sets its sights on some vital part of you – look out. It is hard to get the genie back in the bottle. It can happen, but not without a fight, and with IMHA we are up against a formidable foe.
384 Comments
Bev
February 18, 2024
We lost our 3.8 year old Corgi boy Cooper to IMHA. End of January took Cooper to Vet as we saw the back area have small tremors. Vet checked Cooper and said thought it was a muscle spasm and gave us medication for spasm. The on Feb 8 we took Cooper back as he was having more back tremors, breathing heavy and licking everything non stop. We asked Vet to do blood work, check stools and urine. He came back and said a small amount of blood in urine so gave antibiotic and said white cell a little elevated but nothing to worry about. (What we found out later that Vet did not tell us his palettes were like 1,000 should be like in 150,000 or more.). So this was Friday. By Sunday night we were at Urgent Care Vet as Cooper was starting to fall, breathing heavy and licking everything. They did additional tests and said they felt it was muscle spasms again, gave pain pills and said if got worse take to Emergency Neurologist as possible slip disk. Well by Tuesday morning poor Cooper could not even stand up to pee and now the tremors were happening in back and neck. Drove hour to Emergency got there at 9:30 am. Tuesday. They did a short exam and said Neurologist can look at Cooper but be like around 12 pm. So about 12:00 pm Neurologist talked to us who they got Cooper records from our Vet and said did they tell you how low the palettes were and we said no. Well now the Emergency said they were at zero. Neurologist said he did not have a slip disc in back but she believes he was bleeding from his back spine and brain. Poor Cooper eyes when you lift the lid had blood in them and his mouth had blisters and bleeding in mouth, even his nails some had blood in them and his tummy was bruised alot. They said turning him to Internal Medicine Dr but could not see us till 2:30 pm. By the time that Dr looked at Cooper he has gotten worse. They wanted to keep Cooper for at least 4 days maybe more, do blood transfuse and many different medications in hoping to get him stable. Because they felt he was bleeding from Brain and spine they said he may have a 50/50 chance of making it but could not promise the out come. Then proceeded to tell us how he would have to be checked weekly for several months and need get of medication with a good chance of it coming back and have to get treated again. The bill for the 4 days was going be $9,000 but could be more days and $$$. MRI that they would maybe have to do be $5,000. Wasn't so much the money but by the time we saw the last Dr poor Cooper could not even lift his head. We made the decision to put him to sleep so he did not have to suffer any more. We are so angry at our Vet back on the 8th that he did not tell us how low the palettes were, maybe we could had prevented the bleeding in the brain and out come would be so much better. Our Vet and Urgent Care looked at Cooper as a Corgi with long back so if not muscle has to be slip disk without looking at all the test. We will never know why our Vet never told us about the low reading but feel Cooper could had been saved. We are grieving the loss of our sweet boy who left us way to early. Never heard of IMHA before this such a terrible disease.
Bee
December 27, 2023
My heart breaks reading all these comments. I had to say goodbye to my beautiful baby girl - a seven year old white and gray Maltese Poodle mix - just a few days ago on Christmas Eve. We celebrated her birthday on December 16th, and I would’ve never imagined it would one of our lasts moments together.
Her death was so sudden and unexpected that we were left with more questions than answers. Looking up information to try and understand what happened, I came upon this post. We might never know for sure what happened to our sweet girl, unfortunately we live in a small town in an underdeveloped country where veterinarian services are not very advanced.
Almost three months ago she suffered what appeared to be a sprained muscle in one of her back legs, when we took her to the vet they told us that nothing seemed to be wrong with her spine or her joints, so it must be just a sprained muscle. They also did some blood work and various parasites screening, but everything was normal. Overall she was a very healthy dog except for this pain on her leg so they sent her home with analgesics. We were relieved and happy. It took some time but she did a full recovery, in a couple of weeks she was running and jumping like her usual playful self.
Our girl was fine. Up until Wednesday night she was running and playing and eating normally. On Thursday, close to noon, she vomited so I decided to cook her some plain chicken thinking she might have an upset stomach, she refused to eat it and this was a red flag for me since she LOVED her chicken. We took her to the vet in the afternoon where they noticed that her pee was turning a little dark so they suspected a UTI and gave her some antibiotics, told us to keep her hydrated and to come back the next day if she was still vomiting or refusing to eat.
She was lethargic, but still, she got up and walked to her plate to drink some water, we were optimistic. She kept refusing to eat however, so we decided to take her back early in the morning on Friday. As I was getting her ready to leave I noticed that the skin on her belly - usually pink - had turned pale, then i checked her mouth and her tongue and her gums had turned white as a paper. I knew something was terribly wrong, I cried all the way as we rushed to the vet. They did all the testing and informed us that she had 18% RBC, her platelets had decreased significantly, she had liver and kidney failure, her pancreatic enzymes were also high. We were devastated. The vets suspected a tick borne infection but the tests for those were all negative. They told us she needed a blood transfusion but that they didn’t do that here. So they gave her corticosteroids and other support medicines but there was nothing else they could do. The next day my family spent desperately trying to find a hospital we could transfer her. But it was all too complicated, some places didn’t have donors or the type of blood she needed, all while we watched our beloved baby get worse and worse. When we finally seemed to get the blood, she was in such a deteriorated state that she wouldn’t make the 4 hour car ride there. My poor baby, she was strong until the very end, still sitting up to drink. But eventually she got so weak she no longer could lift her head. She started breathing faster and faster and even had a seizure. It was breaking my heart to see her like that. It is an image that will never leave my brain.
Her temperature started to drop, we were doing everything we could. We tried to keep her comfortable. Never leaving her side. Finally, at 2 am on Sunday, her heart stopped beating putting an end to her suffering.
It is still hard for me to believe that my baby girl who was running around just 3 days before, had left us. She didn’t get to open her Christmas presents. I keep thinking that maybe if we got the blood sooner, she could’ve survived.
My sweet sweet girl, I hope we made you as happy as you made us. You were my emotional support on my darkest days. Thank you for all the love. I miss you terribly. And I will love you forever.
Libby
November 12, 2023
My husband and I got our little mini Goldendoodle puppy, Pepper, just before covid hit. Little did we know how important that little guy would be to us. He gave us such joy and purpose as we worked our way through lockdown. He was the happiest little dog. And, as my husband’s health declined, Pepper kept joy in the house. After the passing of my husband, he gave me a reason to keep going. But then IMHA hit. He had just turned four years old. On Tuesday night he was his normal self, barking at the squirrels. On Wednesday morning he was lethargic, not interested in food. I observed him in the morning and decided something was off. I took Pepper to the vet on Wednesday afternoon. He vomited on the way to the vet. Pepper loved to pull all the stuffing out of his toys and because he had worked all through Tuesday unstuffing a toy, we thought he might have ingested some stuffing though he was always good about not eating the toy insides. His symptoms of vomiting and not eating led us down the wrong path. Everything else was normal. The vet did x-rays and results were questionable. Vet said to take him home, hopefully if some stuffing was in there, it would pass. Bring him back tomorrow if not better. I took him back Thursday morning. They performed a barium procedure and though everything was flowing through the small intestines, there was some cloudiness in the stomach. I agreed to have him opened up and stomach cleared. We also decided not to draw blood since he was such a young, healthy dog. Big mistake. Immediately upon opening him up, the vet realized he was very jaundiced inside. They drew blood during the surgery and his PCV was 11. She did clear some stuffing out but not enough to cause a blockage. He was put on IV with high dose meds hoping to turn him around. His Thursday evening blood draw showed improvement to 20. I took him home and returned for more IV treatment on Friday morning. He spent all Friday on IV. I took him home Friday night and was to return Saturday morning for more IV treatment. Wherever I placed him Friday evening, he did not move. Refused all food and water. At this point he had not eaten since Tuesday. I spent all Thursday and Friday researching this dreaded disease. The vet said that even if he turned around, there would be a strong possibility he would relapse. I made the decision to let him go on Saturday morning before taking him in. He had spent the entire night snuggled up next to me. He did not move all night. This happy little dog was in such misery. Before agreeing to my decision, the vet wanted to do one more draw to see the Friday results. His numbers went backwards to 17. The vet agreed it was time to let him go. This little light in my life is now gone. It’s as if a switch was flipped and nothing could un-flip it.
Val
October 12, 2023
Like so many other heartbreaking comments, I am here writing after not sleeping a single minute after making the decision to put our beautiful, beautiful, black lab mix Rylee girl down on Friday. Our battle started a little over a month ago. With what appeared to be a strained back leg muscle, took her to the vet who diagnosed her with a strained muscle and ibuprofen. I should have known, and in hindsight, I did in my gut that something was seriously wrong. This dog is a survivor - she should have died multiple times and despite having a hard life, has been the absolute best dog for our family. After surviving 2 cancers in 2022, here she is at 9 years old being taken by Evan’s Syndrome.
After taking her to the vet twice for this “pulled muscle” (I am placing no blame on the vet - but just, in my gut, I knew.) I took her back the 3rd time because she looked like she was on her death bed. Diagnosed with Evan’s Syndrome, we left with 60mg/day prednisone and prayers. She has survived a month. She has lost 20 lbs and has been doing ok up until 2 days ago when vomiting, lethargy, and lack of appetite started happening. Took her back to the vet and her lab work has gotten worse. Liver enzymes up, platelets and rbc critically low, wbc up, heart murmur.
We’ve elected to (please God) spend one last day with her. Even if this means holding her. We just cannot continue watching her not be her old self - chasing her ball, eating everything in sight, playing with her 2 favorite little human children. It’s honestly the worst thing I could imagine watching a dog go through. At this point, even if we have the financial means, our goal through this whole thing was quality over quantity.
She will forever be in our hearts, and I don’t think a day will go past that I will think of her and not shed a tear. My beautiful, sweet pup. Rest in pure peace now and keep us safe while you watch over us.
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