Autoimmune thrombocytopenia in dogs and cats

ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but there are no evidence-based guidelines to assist clinicians with treatment decisions. Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include secondary immunosuppressive drugs such as azathioprine, modified cyclosporine, and mycophenolate mofetil, usually selected based on clinician preference. Vincristine, human IV immunoglobulin (hIVIg), and transfusion of platelet or red blood cell-containing products are often used in more severe cases. Splenectomy and thrombopoietin receptor agonists are usually reserved for refractory cases, but when and in which patient these modalities should be employed is under debate. To develop evidence-based guidelines for individualized treatment of ITP patients, we asked 20 Population Intervention Comparison Outcome (PICO) format questions. These were addressed by 17 evidence evaluators using a literature pool of 288 articles identified by a structured search strategy. Evidence evaluators, using panel-designed templates and data extraction tools, summarized evidence and created guideline recommendations. These were integrated by treatment domain chairs and then refined by iterative Delphi survey review to reach consensus on the final guidelines. In addition, 19 non-PICO questions covering scenarios in which evidence was lacking or of low quality were answered by expert opinion using iterative Delphi surveys with panelist integration and refinement. Commentary was solicited from multiple relevant professional organizations before finalizing the consensus. The rigorous consensus process identified few comparative treatment studies, highlighting many areas of ITP treatment requiring additional studies. This statement is a companion manuscript to the ACVIM Consensus Statement on the Diagnosis of Immune Thrombocytopenia in Dogs and Cats.

Excitement-Induced Cutaneous Bleeding (Haematidrosis-like) in a Dog

A 15-month-old intact female Pitbull was referred because of recurrent, episodic, self-limiting, excitement-induced bleeding from nontraumatised skin. No abnormalities were detected upon physical examination. Subsequently, the dog went for a walk under the direct supervision of one of the authors, became overexcited and, after approximately five minutes, bloody liquid, with a patchy distribution, appeared along the hair shafts of the face and neck. The affected skin was congested, partially blanching on diascopy and bloody liquid was oozing from the follicular openings. Urticaria, dermographism and hypertension were excluded, the complete blood count and coagulation profile were within the reference ranges and an analysis of the bloody exudate confirmed its blood components. The cutaneous bleeding of the dog followed a self-limited course, with no episodes during the last two years. Clinical and laboratory findings and the long-term evolution of this dog bear striking similarities to haematidrosis, a rare human disease of multifactorial aetiology and equivocal pathogenesis.

Primary immune-mediated thrombocytopenia and immune-mediated neutropenia suspected in a 21-week-old Maine Coon cat

CASE REPORT

A 21-week-old Maine Coon cat presented with an acute-onset coagulopathy. Severe concurrent thrombocytopenia and neutropenia were identified on peripheral blood smears and bone marrow cytology supported a peripheral consumptive process. Other than mild superficial haemorrhage, the cat was clinically well and screening for retroviral diseases, abdominal ultrasound examination, thoracic radiography, haematology and biochemistry panels did not identify an underlying disease. There was no historical pharmaceutical or toxicological trigger noted and the cat was from an area without endemic Ehrlichia spp. There was a rapid resolution of both cytopenias following treatment with immunosuppressive doses of prednisolone, though a mild relapse occurred during gradual prednisolone withdrawal and was responsive to a dose increase.

CONCLUSIONS

This report describes this combination of diseases for the first time in a cat and presents a younger patient than previously described with feline primary immune-mediated haematological disease.

Animal models of immune thrombocytopenia (ITP)

With regards to research animal models related to immune thrombocytopenia (ITP), there is an extensive literature of over 300 publications published since 1959. It appears that many of these models either confirm what has been found in human ITP or, in some instances, are the first to describe a phenomenon related to ITP that is still of relevance today in human medicine. These models will undoubtedly play a significant role in the future research of human ITP particularly related to understanding of the pathogenesis of the disorder and the development of novel therapeutics. This review will highlight some of the major animal models utilized for ITP research and will present a somewhat historical aspect of the subject.

Primary Immune-Mediated Thrombocytopenia in Cats

Feline primary immune-mediated thrombocytopenia (pIMT) is a rare condition, and only a few cases have been described in veterinary literature. Five cats with severe thrombocytopenia most likely due to pIMT are described. A flow cytometry platelet-bound antibody test was positive in all cats; underlying diseases or triggering factors causing thrombocytopenia were not detected. Three cats were transfused with blood type-compatible fresh whole blood; one cat received Oxyglobin as well. All cats were treated with prednisolone; one cat received chlorambucil in addition. Four cats responded to treatment and were discharged from the hospital. One cat was euthanized due to dyspnea. Primary immune-mediated thrombocytopenia is rarely diagnosed in cats, but it is important as a differential diagnosis in cats presented with surface bleeding.

Hematologic abnormalities and flow cytometric immunophenotyping results in dogs with hematopoietic neoplasia: 210 cases (2002-2006)

BACKGROUND

Growing interest in veterinary oncohematology has facilitated the recent development and advancement of new techniques, such as flow cytometry, for immunophenotyping hematopoietic neoplasia in animals.

OBJECTIVE

The aim of this retrospective study was to characterize hematologic abnormalities and flow cytometric immunophenotyping (FCI) results in cases of hematopoietic neoplasia in dogs.

METHODS

Signalment, CBC data, and FCI results were obtained for 210 dogs with blood samples submitted to our laboratory. Immunophenotyping was carried out using an Epics XL-MCL flow cytometer and a panel of 10 antibodies (CD45, CD3, CD4, CD8, CD79, CD21, CD14, CD34, CD41/61, CD61). The prevalence and severity of hematologic abnormalities was determined for the different types of hematopoietic neoplasms.

RESULTS

Based on cell morphology and phenotype, cases were classified as: acute lymphoblastic leukemia (ALL, n=51), acute myeloid leukemia (AML, n=33), chronic lymphocytic leukemia (CLL, n=61), and leukemic high-grade lymphoma (L-HGL, n=65). Most cases of ALL (47/51) and L-HGL (41/65) had a B-cell phenotype, while most cases of CLL (54/61) had a T-cell phenotype, with a high prevalence of the large granular lymphocyte subtype (49/61). Anemia was found in 85% of all cases and was significantly more severe in ALL and AML compared with CLL and L-HGL. Neutropenia was seen in 64-78% of acute leukemias (AML and ALL) in contrast to no cases of CLL and 11% of L-HGL. Thrombocytopenia was seen in 88-90% of acute leukemias in contrast to 15% of CLL and 40% of L-HGL. Thrombocytopenia was more prevalent (71% vs 22%) and significantly more severe in T-cell vs B-cell L-HGL.

CONCLUSION

A standard CBC is useful in suggesting the type of hemoproliferative disorder and may also help to predict the phenotype, especially in cases of L-HGL.

Primary immune-mediated thrombocytopenia in 30 dogs (1997-2003)

During a 6-year period, primary (idiopathic) immune-mediated thrombocytopenia was retrospectively evaluated in 30 dogs. Ages of the dogs ranged from 3 months to 10 years (median 4 years); female dogs were markedly overrepresented with 73%. Clinical examination revealed hemorrhages in 70% of the dogs. Platelet counts ranged from 0 to 111,000/microL (median 8000/microL); 77% of the dogs had platelet counts <30,000/microL. Seventeen dogs were anemic (hematocrit 9% to 36%; median 31%). Immunosuppressive therapy was performed in all but one dog. The recurrence rate of 19 dogs that were followed over an extended period (112 to 1684 days; median 340 days) was 26%. Twenty-nine (97%) dogs survived 14 days after initial presentation, and 27 (93%) dogs survived at least the following 15 to 1684 days (median 220 days).

Detection of antiplatelet antibody: comparison of platelet immunofluorescence, agglutination, and immunoinjury tests using rabbit antiequine platelet serum

Immunofluorescence, tube agglutination, and platelet factor-3 immunoinjury tests for detecting antiplatelet antibody were compared using a heterologous system of equine platelets and rabbit antiequine platelet serum. Platelet immunofluorescence tests were performed using paratormaldehyde-fixed platelets in suspension as well as in air-dried smears on glass slides (solid phase). Bright homogeneous, membranous, specific fluorescence was seen in both assays with anti-immunoglobulin G (IgG) and protein G fluorescein isothiocynate conjugates (FITC-conjugates). Protein A conjugate gave nonspecific fluorescence irrespective of normal or antiserum treatment. Anti-IgG and protein G conjugates in suspension immunofluorescence tests with the same antiserum yielded antibody titers of 1:1024 and 1:128, respectively. Similarly, respective titers of 1:512 and 1:64 were obtained with solid phase immunoassay. Platelet suspension assay was slightly better than the solid phase assay. These observations indicated that anti-IgG was more sensitive than protein G in detecting antiplatelet antibody by fluorescence microscopy, while protein A was ineffective because of its nonspecificity. Chloroquine treatment of platelets failed to reduce the nonspecific fluorescence. Platelet agglutination and platelet factor-3 tests were relatively less sensitive to detect equine antiplatelet antibody.

Quantification of thrombopoietic activity in bone marrow aspirates of dogs

The aims of the study were to investigate possible influences of different numbers of counted fields on slides, and different slides on the counting of platelet precursors, and to establish guidelines for bone marrow examination in dogs. The study was based on bone marrow slides of 131 healthy dogs. The slides were prepared by a squash technique. On each slide the number of thrombopoietic cells at different levels of maturation were counted in all fragment-containing fields. The results of a variance component model revealed no influence of different slides, in contrast to a high variance related to different fields. Between 20 and 25 low power fields (100x magnification) had to be examined to achieve an imprecision of 20%. An imprecision of 10% required the counting of 100 fields. The lowest thrombopoietic activity was seen in the bone marrow of dogs aged one to six years. The total number of platelet percursors per field was significantly higher in adult female (10.4 +/- 2.67) than in male dogs (7.84 +/- 2.04, P = 0.0008) as was the number of megakaryocytes. We recommend assessment of thrombopoiesis on the basis of 20-25 fragment-containing low power fields and that age- and sex-related differences should be considered.

Cytologic evaluation of primary and secondary myelodysplastic syndromes in the dog

Myelodysplastic syndromes are a heterogeneous group of acquired primary and secondary alterations of hematopoietic stem cells that result in cytopenias in blood and cytologic features of dysplasia in blood and/or bone marrow. To better understand the cytologic features that would permit differentiation of primary and secondary forms of myelodysplasia, we reviewed 267 consecutive bone marrow reports from dogs. These reports indicated that 34 dogs (12.7%) had dysgranulopoiesis, dyserythropoiesis, and/or dysthrombopoiesis in >10% of granulopoietic cells, erythroid cells, and/or megakaryocytes, respectively. Thirteen dogs had primary myelodysplastic syndromes, and 21 had secondary myelodysplastic syndromes. Of the 13 dogs with primary myelodysplasia, 4 were subclassified as myelodysplastic syndrome with refractory anemia (MDS-RA), and 9 were subclassified as myelodysplastic syndrome with excess blasts (MDS-EB). Secondary conditions associated with dysplasia in the bone marrow included malignant lymphoma (n = 5), myelofibrosis (n = 3), immune-mediated thrombocytopenia (n = 4), immune-mediated hemolytic anemia (n = 5), multiple myeloma with melphalan administration (n = 1), pyometra with estrogen administration (n = 1), polycythemia vera (n = 1), and thrombopathia (n = 1). MDS-RA was characterized by <5% myeloblasts in bone marrow, normal granulocyte maturation ratio, increased erythroid maturation ratio, and dysplastic changes in >15% of erythroid cells. MSD-EB was characterized by >/=5% myeloblasts in bone marrow, high granulocyte maturation and erythroid maturation ratios, >/=32% dysplastic granulocytes, and the presence of small atypical immature myeloid cells. Secondary myelodysplastic syndromes were characterized by <5% myeloblasts in bone marrow, variable granulocyte maturation and erythroid maturation ratios, and variable dysplastic features. These results indicate that morphology alone cannot be used to distinguish primary and secondary myelodysplastic syndromes in dogs.

The role of blood component therapy in the management of canine and feline patients with cancer

Blood component therapy may be required for a variety of pathologic reasons in the cancer patient. The tumor itself not only affects various cell lines, but treatment with chemotherapeutic agents can induce cytopenias. In addition, chronic and acute hemorrhage can be caused by tumor erosion and rupture or by paraneoplastic coagulopathies. Component replacement will depend on the underlying hematologic deficiencies and should be performed in conjunction with treating the cause of the deficiency.

Immune-mediated disease as a risk factor for canine lymphoma

BACKGROUND

Autoimmune diseases and neoplasia have been associated as occurring simultaneously in individuals. This study evaluated the association between the simultaneous occurrence of canine lymphoma and various immune-mediated diseases.

METHODS

The Veterinary Medical Data Program, a national disease data registry for veterinary schools, was examined. The following immune-mediated disease categories were evaluated: lupus disorders, pemphigus disorders, autoimmune polyarthritis, immune-mediated hemolytic anemia, and immune-mediated thrombocytopenia. Odds ratios with 99% confidence intervals were calculated for the occurrence of lymphoma and each of the immune-mediated disorder categories.

RESULTS

Only dogs with immune-mediated thrombocytopenia had a statistically significantly increased odds ratio (5.61; 99% confidence interval, 4.16-7.57) for the occurrence of lymphoma versus the general population. This association still was observed for immune-mediated thrombocytopenia when stratified by age, sex, and neutering status.

CONCLUSION

Dogs with immune-mediated thrombocytopenia had a greater occurrence of lymphoma than dogs without immune-mediated thrombocytopenia.

Bone marrow biopsy and evaluation

Bone marrow evaluation provides valuable diagnostic and prognostic information about neoplastic, metabolic, and inflammatory diseases. Bone marrow biopsies should be done only after examination of peripheral blood, to avoid performing unnecessary biopsies. A blood sample should be taken at the time of the bone marrow biopsy, for complete hematopoietic evaluation. It is preferable to take both an aspiration and core biopsy simultaneously. A good sample is mandatory for accurate evaluation and interpretation. The method of evaluation should be systematic, complete, and cover the following points: adequacy of specimens; estimation of cellularity; identification of number, maturation pattern, and morphology of megakaryocytes, myeloid cells, and erythroid cells; estimation of M:E ratio; and identification of abnormal cells, cellular reactions, infectious agents, or abnormal stromal reactions. Bone marrow findings should be interpreted in conjunction with signalment, history, physical findings, and laboratory results. Reference or institutional laboratories should be contacted for proper handling of bone marrow specimens for special procedures, such as histopathology, cytochemistry, immunopathology, and electron microscopy.

Platelets and neoplasia

Numerous platelet abnormalities have been recognized in animals with malignancy. Because platelets play a key role in hemostasis, it is vital that clinicians recognize those neoplastic conditions that are associated with platelet disorders. A review of these platelet abnormalities, their underlying pathophysiology, and treatment is presented in this article.

Quantitative platelet disorders

Thrombocytopenia may be caused by abnormal platelet production, accelerated removal owing to immunologic or nonimmunologic reasons, or sequestration of platelets in the spleen. Bleeding associated with thrombocytopenia usually presents as petechial or ecchymotic hemorrhages or epistaxis. Immunologic and nonimmunologic cases of thrombocytopenia may be diagnosed with routine hematology, bone marrow cytology, and platelet specific tests. Thrombocythemia may also be associated with platelet functional abnormalities, contrasting the normal platelet function noted in reactive thrombocytosis.

Immune-mediated diseases of the dog and cat. III. Immune-mediated diseases of the integumentary, urogenital, endocrine and vascular systems

The first two articles in this series have covered the basis of the immune mediated diseases, systemic immune-mediated diseases and those that involve the haemolymphatic and musculoskeletal system. The purpose of this article is to cover the immune-mediated diseases that involve the integumentary, urogenital, endocrine and vascular systems.

Gold-induced immune thrombocytopenia in the dog

In two seven-year studies with gold compounds in dogs of both sexes, thrombocytopenia was observed after 45 to 72 months of dosing in three of 14 and two of 14 dogs in high-dose groups that received 2.4 to 3.6 mg/kg of auranofin per day orally or 0.5 to 2.0 mg/kg of gold sodium thiomalate intramuscularly once every three days, respectively. An immune basis for the disorder was suggested by the apparent consumptive nature of the thrombocytopenia (increased bone marrow megakaryocytes and large peripheral blood platelets), the response to corticosteroid therapy and the demonstration of increased platelet-associated immunoglobulin. The latter was demonstrated with a solid phase radioimmunoassay and by electron microscopy using a staphylococcal protein A-colloidal gold conjugate. Platelet-associated immunoglobulin decreased as the platelet counts rose, and in one dog monitored over periods of steroid-induced remissions and subsequent relapses, the amount of platelet-associated immunoglobulin G correlated inversely with the platelet count (r = 0.82). These findings suggest that the long-term administration of gold compounds in dogs is associated with a dose-dependent incidence of thrombocytopenia, which is immune-mediated and similar to that associated with parenteral chrysotherapy in man. The application of tests for platelet-associated immunoglobulin to canine patients with immune thrombocytopenia should be useful in the diagnosis of the disorder in clinical practice.