Problem-oriented Approach

to Anemia in the Horse

What is anemia?

Objective 1.

What is anemia?
Decreased proportion of RBC in blood
Decreased oxygen-carrying capacity

How do you know anemia is present?

Objective 2.

Objective 2.

RECOGNITION OF ANEMIA

How do you know anemia is

present?

1.
1.
2.

2.
3.

Mucous membrane color

pallor
Icterus (look in sclera)
Exercise intolerance
Decreased PCV, Hb, RBC count

Objective 2.

LABORATORY DEFINITION

Packed cell volume < 30%

6
RBC count
< 6 x 10 /uL
Hemoglobin
< 10.0 g/dl
1/3 of PCV
Objective 2.

How can you tell Mechanisms of

your patient is anemia?

WHAT CAUSES ANEMIA IN HORSES?

If you can determine the mechanism, you can

rule out most of the causes
(blood loss, hemolysis, inadequate production)
Objectives 3.

MECHANISMS OF ANEMIA

Blood loss (regenerative)

Hemolysis (regenerative)
Inadequate production (non-regen
Regenerative vs. non-regenerative
Horses are different.. do a bone
marrow evaluation (dont have retics
released from BM)

Objective 3.

APPROACH TO DIAGNOSIS

Take history
Perform physical exam
Perform CBC
Evaluate leukogram & proteins
Evaluate biochemical panel
Objective 5.

APPROACH TO DIAGNOSIS (CONT)

Perform bone marrow analysis (if not obvious you have

anemia)
Analyze urine (if chronic renal dz, glomerulonephritis w/
protein loss)
Test feces for occult blood
Measure serum iron and TIBC
Perform Coggins test
Perform Coombs test
Do other things
Objective 5.

What are the causes of anemia in horse?

1) INFECTIOUS CAUSES OF ANEMIA

Piroplasmosis
Trypanosomiasis
Equine infectious anemia

Objectives 3 and 4.

Piroplasmosis
biliary fever
Babesia caballi and Babesia equi
intra-erythrocyte protoza
tick-borne
certain species of ticks
not airborne and not direct contact
B. equi causes more severe disease

Piroplasmosis
Clinical signs
vague generalized signs

fever, depression
icterus, anemia (d/t hemolysis from parasitemia)
Edema (in distal limbs)
hepatomegaly, splenomegaly
colic
ecchymosis of 3rd eyelid

Piroplasmosis

Diagnosis

o
o

serology (complement fixation test is approved test

in US)
C-ELISA and PCR better than complement fixation
tests
visualization of organism in erythrocytes

Piroplasmosis

Treatment

variable success
repeated treatment often required
imidocarb
Berenil, Ganaseg
phenamidine isethionate

12 HR OLD MULE FOAL

One differential is piroplasmosis not most likely in LA, but on your listcan do
serology, look at smears, send sample in for PCR

Trypanosomiasis
several species produce disease in horses;
Vague signs - fever, cachexia, anemia, CNS signs
and death
Dx based on observation of organism in blood
smear or serology

EQUINE INFECTIOUS ANEMIA

"swamp fever"
retrovirus similar to AIDS
limited to horses, donkey, mules
persistent viral infection for life
virus infects macrophages
new variants repeatedly emerge

Objective 3.

2) TOXIC CAUSES OF ANEMIA

Wild onion
Phenothiazine drug not really available
Red maple
Water
Drugs
All tend to cause hemolysis

Wild Onion Intoxication

Allium canadense

n-propyl disulfide = toxic principle

usually unpalatable = but if not much else to eat or

if randomly like

Wild Onion Intoxication

Clinical signs:

Tend to cause hemolysis

Pallor/icterus, hemoglobinemia (pink serum),

hemoglobinuria
petechia
pigment nephrosis (if lots of blood going through urine)
anemia
Heinz bodies

Wild Onion Intoxication

Diagnosis:
plant identification and evidence of ingestion
typical clinical signs
Heinz bodies
absence of other erythro oxidants

Heinz bodies

NMB heinz bodies look

like blue dots and RBC look
clear

Phenothiazine Toxicity
anthelmintic drug rarely used
toxicity idiosyncratic toxic dose varies
debilitated animals more susceptible

Phenothiazine Toxicity

Clinical signs (same as wild onion):

anemia,
hemoglobinemia,
hemoglobinuria
Heinz bodies

Phenothiazine Toxicity

Treatment:
no specific antidote
transfusion
supportive treatment
avoid future exposure
hematincs not necessary or beneficial all lysed

hemoglobin still in body so more blood really not very useful

Red Maple Toxicity

Acer rubrum

leaves and bark contain toxic principal

wilted leaves

Red Maple Toxicity

Two clinical syndromes

marked methemoglobinemia and few Heinz

bodies
high mortality
large numbers of Heinz bodies and no
methemoglobinemia
low mortality

Red Maple Toxicity

Clinical signs (same as other toxic causes) :

icterus, hemoglobinemia, hemoglobinuria

petechia
pigment nephrosis
anemia
Heinz bodies

Red Maple Toxicity

Treatment

remove toxic agent

blood transfusions (some become v. anemic 10-15%)
sodium ascorbate IV
new methylene blue NOT effective (used in cattle,

but not effective in horses)

supportive therapy (fluids, corticosteroids)

stall rest

Red Maple Toxicity

Prognosis

(can base on lab work)

no methemoglobinemia -- favorable
methemoglobinemia -- poor

3) IMHA

Often idiopathic
Internal abscesses and other chronic infections such as EIA
Often Coombs test positive

reagents are equine specific

Neonatal isoerythrolysis

BLOOD LOSS ANEMIA

2) Chronic draining wounds

granulating wounds
venous fistulas
gastric ulcers, colonic ulcers - occult blood
urethral defects - urethroscopy
GI neoplasia

GI ULCERATION

PHENYLBUTAZONE TOXICITY

BLOOD LOSS ANEMIA

(3) Parasitism
internal parasites - strongyles - fecal exam
external parasites - lice, mosquitoes, ticks

BLOOD LOSS ANEMIA

(4) Bleeding defects

hemophilia A
idiopathic thrombocytopenia
coumarin toxicity
DIC

PRODUCTION
FAILURE/SUPPRESSION
1.

2.
3.
4.
5.
6.
7.
8.

Iron deficiency
Chronic blood loss
Chronic malabsorption syndrome
Copper deficiency
B12/cobalt deficiency
Protein deficiency
Over supplementation (Vitamin A, others)
Anemia of chronic disorders
Drug induced

Bone marrow suppression

Neoplasia

IRON DEFICIENCY ANEMIA

Microcytic, hypochromic anemia

decreased marrow iron stores
decreased serum iron
GI problem - prevents absorption
chronic external blood loss

IRON DEFICIENCY ANEMIA

Uncommon
injectable iron compounds usu. not indicated
Somewhat hazardous b/c anaphylactic rxns
molybdenum can interfere w/ iron and copper
metabolism

IRON DEFICIENCY ANEMIA

Decreased serum iron

Decreased serum ferritin content best indicator of
iron status
Normal or increased iron binding capacity

COPPER DEFICIENCY

affects iron metabolism

molybdenum can interfere w/ Cu metabolism
too much copper can produce anemia (similar to
Wilsons disease)
Cu, iron, molybdenum can all be measured in feed and
blood to see if imbalanced

B12/COBALT DEFICIENCY

Cobalt needed for GI flora to make B12

synthesized in LI
malabsorption can cause deficiency
too much cobalt can lead to anemia
Horses hardly ever cobalt deficient, but given to
stimulate appetite

PROTEIN DEFICIENCY

Proteins needed to form hemoglobin and

other structures of RBCs
starvation or other systemic disease can
interfere with availability of substrates

5) ANEMIA OF CHRONIC
DISORDERS/INFECTION

secondary to chronic (1 mo +) purulent

infections or parasitism
neutrophilia
hyperfibrinogenemia
marrow iron stores increased
serum iron decreased all iron goes to BMjust
cant recycle it

6) DRUG-INDUCED BM SUPPRESSION
drugs reported to cause
suppression
chloramphenicol

phenylbutazone
Dipyrone NSAID
not on market anymore
sulfonamides

estrogens
Arsenicals
streptomycin
erythropoietin

7) MYELOGENOUS LEUKEMIA

neoplastic cells replace normal BM

compete for substrates
RBCs more fragile and susceptible to lysis

OTHER NEOPLASIA

May result from any of the mechanisms

discussed.
Search for site/type of tumor

CASE STUDIES

APPROACH TO DIAGNOSIS

Take history
Perform physical exam
Perform CBC
Evaluate leukogram & proteins
Evaluate biochemical panel

Objective 5.

APPROACH TO DIAGNOSIS (CONT)

Perform bone marrow analysis

Analyze urine
Test feces for occult blood
Measure serum iron and TIBC
Perform Coggins test
Perform Coombs test
Do other things
Objective 5.

Objective 5.

Whiskey, 12 yo FE QH

HISTORY

Age/signalment
Diet/nutrition
Anthelmintic program
EIA status
Trauma/hemorrhage

Recent transport/import
Medications
Recent disease
Cohort disease

HISTORY

Age/signalment
Diet/nutrition
Anthelmintic program
EIA status
Trauma/hemorrhage

Recent
transport/import
Medications
Recent disease
Cohort disease

PHYSICAL EXAM

icterus
ectoparasites
hemorrhages
epistaxis
swollen joints
fever

weight loss
musculoskeletal or
neurologic deficits
urine color
edema

PHYSICAL RESTRAINT:

Always at least some minimum

form of restraint required.
Minimum restraint required: halter
and lead rope
A PE should never be attempted
without a halter and lead rope in
place with someone holding the
horse.
Never wrap lead around your hand,
arm or any other body part
Never tie a horse unless you know it
is accustomed to being tied.

PHYSICAL RESTRAINT:

PHYSICAL RESTRAINT:

PHYSICAL RESTRAINT:

The general examination should

start with the observation of the
horse from a distance in order to
detect abnormalities that might be
obscured by handling and restraint.

Mucous membranes are examined for moistness,

icterus, hyperemia, cyanosis, pallor, ulceration, and
petechia. Capillary refill time is also evaluated at
this time by blanching the mucous membranes.

The retropharyngeal lymph nodes are

not readily palpated in the normal
animal but may be if enlarged. The
facial artery is palpated at the ventral
aspect of the mandible.

 The thyroid gland is frequently

palpable in older horses and
should not be confused for a
lymph node (P). The left jugular
vein is then occluded and palpated
to evaluate jugular fill and to
examine for thrombophlebitis.

 The heart is then ausculted in

three locations on the left
cranial ventral thorax: over the
pulmonic, aortic, and mitral
valves.
The normal resting heart rate
of the horse is 28-42 BPM.
The hand is then run down the
forelimb to evaluate
temperature of the distal
extremities if cardiovascular
shock is a concern and also to
palpate temperature of the
hoof and evaluate digital pulses
if laminitis is a concern .

FIRM, UPWARD PRESSURE IS THEN PLACED ON THE VENTRAL

THORAX ON MIDLINE TO EVALUATE FOR VENTRAL EDEMA.

A discussion of auscultation of the thorax and abdomen is included in

the focused examination of the respiratory and gastrointestinal tracts
respectively.

TEMPERATURE

THE HEALTHY HORSE

Sign

Normal

Temperature

99.5oF to 101.5oF

Heart rate

30-45 bpm

Respiratory rate

8-20 breaths per minute

Mucous membranes

Pink

Capillary refill time

1-2 seconds

Most resting horses have rectal temperatures of 98.0-101.5 F.

Examination is then continued on the left side for visual
inspection of the integument and auscultation of the abdomen
and thorax, as noted in the focused physical examination.
In the general examination, the right side of the heart is then
ausculted, the right jugular vein is occluded, and the right side
of the head and neck are visually examined.
As one can see, this general physical examination can be easily
performed in just a few minutes, yet it can provide important
information that would otherwise be easily missed.

THE LATERAL THORACIC VEIN

AND CEPHALIC VEIN (ARROWS)
ARE PROMINENT ON THIS
BELGIUM MARE, BUT FOR SOME
HORSES, THE LATERAL
THORACIC VEIN IS DIFFICULT TO
FIND.

TO COLLECT A SMALL AMOUNT OF

BLOOD FROM THE TRANSVERSE
FACIAL VEIN, A NEEDLE IS INSERTED
THROUGH SKIN, JUST BELOW THE
FACIAL CREST, ON A LINE
PERPENDICULAR TO THE FACIAL
CREST DRAWN FROM THE MEDIAL
CANTHUS OF THE EYE.

TO COLLECT A LARGE AMOUNT OF BLOOD FROM THE TRANSVERSE

FACIAL VEIN, 20-GA, 1.5 IN NEEDLE WITH A SYRINGE ATTACHED IS
INSERTED BELOW THE FACIAL CREST UNTIL THE POINT OF THE
NEEDLE STRIKES BONE. THE PLUNGER OF THE SYRINGE IS GENTLY
RETRACTED, AS THE NEEDLE IS SLOWLY WITHDRAWN, UNTIL THE
SYRINGE BEGINS TO FILL WITH BLOOD.

PHYSICAL EXAM

icterus
ectoparasites
hemorrhages
epistaxis
swollen joints
fever

weight loss
musculoskeletal or
neurologic deficits
urine color
edema

LABORATORY EXAM (MDB)

CBC
Serum biochemistry
Urinalysis
Feces for occult blood
Coggins test

Bone marrow analysis

Iron, TIBC
Coombs test
others

LAB ABNORMALITIES

PCV = 22%, Hb = 7 g/dl

TPP = 4.2 g/dl
WBC = 11,000 / uL
Segs = 9,500 / uL

LABORATORY EXAM (MDB)

CBC
Serum biochemistry
Urinalysis
Feces for occult blood
Coggins test

Bone marrow analysis

Iron, TIBC
Coombs test
others

PROBLEMS IDENTIFIED:

Weight loss
Chronic draining wound
Anemia
Hypoproteinemia
Neutrophilia

???

ANEMIA

Blood loss anemia

2 Iron deficiency
[2 Protein deficiency ?]