Canine Ehrlichiosis in Six Dogs with

Persistently Increased Antibody Titers

Amy L. Perille, DVM, and Robert E. Matus, DVM, MS

Chronic ehrlichiosis was diagnosed in six dogs on the basis of increased immunofluorescent antibody
titers to Ehrfichiu cunis. Although clinical signs varied, all six dogs were anemic, hyperglobulinemic, and
an IgG monoclonal gammopathy was documented in five dogs in which serum protein electrophoreses
were performed. All dogs were treated with tetracycline for at least 14 days; four dogs also received
immunosuppressive drugs. Clinical signs resolved within 1 week, hematologic abnormalities resolved in
I to 5 months, and increased globulin concentrations normalized in 1 to 15 months; however, E. cunis
antibody titers remained increased for 15 to 31 months after initiation of treatment. Results of this study
show that increased E. canis titers can persist in dogs with ehrlichiosis for many months after clinical
recovery. (Journal of Veterinary Internal Medicine 1991; 5195-198)

CANINE EHRLICHIOSIS is a tick-borne rickettsia1 dis-
ease caused by Ehrlichia canis, an obligate intracellular
parasite of canine mononuclear cells. Infection produces
a wide variety of clinical and hematologic abnormalities
that may be influenced by the strain of E. canis, the
breed of dog, the immune response of the dog, and the
coexistence of other diseases.’-7 Chronic infection leads
to plasma-cell proliferation, hyperglobulinemia, and the
infiltration of plasma cells into Abnormal
findings including hyperglobulinemia, lymphadenopa-
thy, pancytopenia, Coombs positive anemia, and infil-
tration of plasma cells into tissues have led investigators
to conclude that immune mechanisms are important in
the pathophysiology of the The cellular
immune response of the host may be important in elimi-
nating the organism and maintaining remission after
treatment with appropriate antibiotics (tetracycline,
doxycycline, or imidocarb dipropri~nate).’,~,~,~’-~~ T reat-
ment is considered successful when dogs recover clini-
cally and hematologically with concurrent declines in
serum globulin concentrations and antibody titers.’.’
Treatment becomes controversial when immunosup-
pressive drug therapy is necessary to treat immune-me-
diated complications of the disease. Although poorly
substantiated, this may lead to persistent infection.’
In this retrospective study, we evaluated six dogs with
~ ~ ~~
From the Department of Medicine and the Donaldson-Atwood Cancer
Clinic, The Animal Medical Center, 5 10 East 62nd Street, New York,
New York.
Reprint requests: Amy L. Perille, DVM, the Animal Medical Center.
510 East 62nd Street, New York, NY 10021.
chronic ehrlichiosis whose antibody titers remained per-
sistently increased during the post-treatment follow-up
period ( 1 5-3 1 mo). Two of six dogs received tetracy-
cline, and four dogs were treated with tetracycline and
immunosuppressive drugs.
Materials and Methods
Six dogs with chronic ehrlichiosis were diagnosed and
treated at the Animal Medical Center from 1984 to 1988
(five dogs) and Angel1 Memorial Animal Hospital from
1986 to 1988 (one dog). All six dogs lived in the north-
eastern states (New York, New Jersey, and New Hamp-
shire) at the time of diagnosis and treatment; four dogs
had travelled to areas that are considered to be endemic
for E. Canis before onset of disease.
Diagnosis of ehrlichiosis was made on the basis of in-
creased immunofluorescent (IFA) antibody titers to E.
canis. l 6 Other diagnostic tests included complete blood
count, serum biochemical analysis, heartworm test
(Knott’s), Coombs test, antinuclear antibody test, serum
protein electrophoresis using cellulose acetate strips with
densitometer analysis, and immunoelectrophoresis or
quantitative radial immunodiffusion. The heat precipita-
tion method was used to screen for light-chain protein
(Bence Jones) in the urine. Serum viscosity was assessed
by comparing the rate of serum flow down a capillary
tube to that of water at 37°C.
All dogs were treated with tetracycline (22 mg/kg,
orally, three times daily) for at least 14 days. Four of six
dogs had immune-mediated complications and received
prednisone ( 1 mg/kg, slowly tapering to 0.5 mg/kg,

195
 Journal of Veterinary
196 PERILLE AND MATUS Internal Medicine

orally, once daily for 2- 15 mo); two of four dogs were
also treated with melphalan (0.1 mg/kg, orally, once
daily for 1*/2 mo); and one dog received plasmapheresis,
cytoxan (7 mg/kg, IV, once), prednisone for 2 months,
and melphalan for 1 month (the subject of a case report
by RE Matus). ' '
Results
Signalment, clinical abnormalities, and response to
treatment are summarized in Table 1. Dogs 2 and 6 were
treated with tetracycline and supportive therapy. Dog 6
relapsed clinically whenever the tetracycline was ta-
pered, so the tetracycline was continued once daily for
the entire 19-month follow-up period. The remaining
four dogs were treated with immunosuppressive therapy
in addition to tetracycline to control what was consid-
ered to be secondary immune-mediated complications
of infection (epistaxis, Coombs positive anemia, and
serum hyperviscosity). All four had epistaxis with nor-
mal platelet counts (Table 2). Dogs I and 4 had Coombs
positive anemia, and dog 3 also had serum hypervisco-
sity (Table 2). The E. canis titer remained increased
( 21 :640) for the entire 15- to 3 1 -month follow-up period
after initiation of treatment in all six dogs (Fig. 1).
All six dogs had a normocytic normochromic anemia
(Table 2). Reactive plasmacytosis was found by cytologic
examination of bone marrow in all six dogs; three dogs
had erythroid hypoplasia. Hematologic abnormalities
resolved in 1 to 5 months after initiation of treatment in
all dogs.
All dogs had hyperglobulinemia and hypoalbumin-
emia with no evidence of proteinuria (Table 2). Five of
five dogs tested had IgG monoclonal gammopathy. Dog
3 had high serum viscosity (3.4 seconds, normal <2 sec-
onds). The five dogs with monoclonal gammopathies
had no evidence of Bence Jones protein in their urine.
High globulin concentrations normalized in 1 to 15
months after initiation of treatment in all dogs (Fig. I).
Discussion
IgG antibodies to E. canis normally increase within 3
weeks of exposure and remain increased for the duration
of infection.2' Antibody titers are expected to decline
within 3 to 9 months after treatment, although the titer
can remain increased up to 17 months after treat-
ment.',22,23Sequential measurement of post-treatment
serum antibody concentrations in dogs with E. canis in-
fection has not been reported. In this study, titers in all
six dogs never decreased below 1:640 for the entire fol-
low-up period ( 15-3 1 mo). Reinfection is a possible but
unlikely cause of persistent antibody titers in these dogs,
because none lived in areas that are considered endemic
for ehrlichiosis during the treatment and follow-up pe-
riod. The most likely explanation for this finding is a
failure to completely eliminate the infection. Treatment
did lead to clinical recovery, but persistent antigen may
have chronically stimulated plasma cells to produce
anti-E. canis antibodies. Monocyte cultures for E. canis
or subinoculation studies could be done to identify oc-
cult infection in these dogs; however, negative results
would not rule out infection due to low numbers of or-
ganisms that may be sequestered in noncirculating
mononuclear cells.
The most common clinical finding in this group of
dogs was epistaxis. Epistaxis was considered a classic sign
of E. canis infection in German Shepherd dogs during

TABLEI . Signalment, Historical Findings, and Response to Treatment in Six Dogs with Chronic Ehrlichiosis

Post-Treatment
Dog Age Resolution of Post-Treatment
## (yr) Breed Sex Clinical Signs Treatment Clinical Signs Follow-Up Titers

I 3 Collie Male Intermittent sneezing Tetracycline X 1 mo 24 hr 1: 1280 or greater for

and epistaxis prednisone X 6'12 mo 20 mo
x 1'12 mo
2 8 Collie mixed Male castrate Partial Anorexia and Tetracycline X 3 mo I wk 15120 for I8 mo
breed weight loss X 6 mo
3 9 German Female Epistaxis and Tetracycline X I mo 24 hr 15120 for 31 mo
Shepherd spayed sneezing X 2 wk plasmaphoresis
m-lphalan X I mo
prednisone X 2 mo
4 6 Mixed breed Male Epistaxis and Tetracycline X 1 mo 24 hr 1:5120for 15 mo
sneezing X 24 h prednisone X 3 mo
5 13 Mixed breed Male Epistaxis, sneezing Tetracycline X 2 wk 24 hr 1:5120 for I5 mo
and nasal lesions melphalan X 2'/2 mo
X 2 yr prednisone X 15 mo
6 10 Dachshund Male Progressive spastic Tetracycline X 19 mo I wk 15120 for 7 mo
mixed tetraparesis and then fell to 1:640
breed cerebellar ataxia by 19 mo
X3mo
VOI. 5 . NO. 3, 1991 CANINE EHRLlCHlOSlS 197

2. Selected Laboratory Findings in Six Dogs with Chronic Ehrlichiosis

TABLE

Total Gamma Serum Initial

Dog PCV Reticulocytes WBC Platelets Coombs Protein Albumin Globulin Globulin Viscosity E canis
No. (%) (%) (cells/mm3) (cells/mm') Test ANA (g/dL) (g/dL) (g/dL) (g/dL) W ) Titer

1 26 3.8 6,200 250,000 + NA 10.1 3.0 7.1 4.4 (MC) NA 1:1280

2 33 NA 8,900 119,000 NA NA 11.2 2.18 9.02 6.26 (MC) 2.18 15120
3 26 0.1 7,000 264,000 NA NA 12 1.64 10 7.08(MC) 3.4 15120
4 26.9 NA 14,700 27 5,000 + - 9.9 1.75 8.15 6.65 (MC) 2.0 15120
5 24 1.2 12,400 180,000 NA NA 11.1 1.6 9.3 8.30 (MC) NA 15120
6 20.5 3.2 23,909 55,000 - - 6.4 1.o 5.4 NA NA 15120
Reference 37-52 0- 1 6,000- 200,000- ~
- 5.4-7.2 3.0-4.9 3.0-4.9 0.4-1.2 1-2
14,000 400,000

PCV = packed cell volume; WBC = white blood cells; ANA = antinuclear antibodies: MC = monoclonal gammopathy; NA = not assessed.

the Vietnam War,7,'7but anorexia and weight loss are
more common according to more recent studies.6J8In
this series, only one dog had a history of anorexia and
weight loss. Neurologic signs are uncommon in dogs
with ehrlichiosi~.~ Dog 6 had progressive neurologic defi-
cits, which were clinically localized to the brainstem and
cerebellum. Histopathologic examinations of dogs exper-
imentally infected with E. canis disclose nonsuppurative
encephalomyelitis involving the brain stem, midbrain,
~ * ~5 had persistent cutaneous
and cerebral ~ o r t e x .Dog
lymphocytic-plasmacytic rhinitis responsive to low
doses of prednisone; presumably the lesion was of im-
mune-mediated origin.
Consistent with results of a recent study by Kuehn, the
most common hematologic abnormality was anemia, af-
fecting all six dogs in this group. Thrombocytopenia
was not a common complication (30%),contrary to the
findings of Troy et al., Kuehn et al., and Breitswerdt et
al., who reported thrombocytopenia in loo%, 64%,and
86%, respectively of the dogs in their s t u d i e ~ . ~ * ' ~ ~ ' ~
An I,G monoclonal gammopathy with hypoalbumin-
emia was documented in all five dogs who were tested.
Monoclonal gammopathy has been described in dogs
with ehrlichiosis,' but, historically, polyclonal gam-
' ~ ~ 3 ~ '
mopathy with concurrent hypoalbuminemia has been
more commonly associated with E. canis i n f e ~ t i o n . ' , ~ , ~ , ~
Increased serum globulin concentrations usually de-
crease within 3 to 9 months after initiation of tetracy-
cline, although concentrations can remain increased
from 6 to 18 months after elimination of the ~rganism.~
Of the five dogs who were monitored, all had increased
globulin concentrations that returned to normal within
15 months of treatment.
The clinical and laboratory signs that were associated
with the chronic phase of ehrlichiosis may be caused by
prolonged antigenic stimulation of plasma cells, result-
ing in their multiplication and in the production of im-
munoglobulins.'~'O~l' Monoclonal gammopathy may be
caused by stimulation of a single clone of plasma cell^.'^
Globulin (Q/dl)
12
10

RECIPROCOL TITER
10000 1 1
6

+ DOG2 2

-
-
DOG3
-S D O G 4
DOG5
DOG6
0
100 I I

0 5 10 15 20 25 30 35
MONTH POST TREATMENT Month Post Treatment
FIG. 1. Sequential Ehrlichiu canis titers in six dogs after treatment of FIG.2. Sequential changes in serum globulin concentrations aRer treat-
chronic ehrlichiosis. ment of chronic canine ehrlichiosis.

198 PERILLE AND MATUS
As in patients with multiple myeloma, many ofthe clini-
cal and hematologic abnormalities seen in dogs with E.
canis infection may be the result of increased concentra-
tions of globulins and their effects on circulating blood
cells and blood viscosity rather than a direct effect of the
organism itself." Four of six dogs in this study had epi-
staxis develop with normal platelet counts. It is believed
that increased globulin concentrations inhibit platelet
function by coating the platelets, thereby interfering with
platelet migration and adhesiveness.10,11~18,20,24,25 Two
dogs had Coombs positive anemia develop, which has
previously been associated with ehrlichiosis and is be-
lieved to be caused by nonspecific coating of red blood
cells by globulins or by a specific immune response to
surface red blood cell antigen^.^,",'^
Because of these immune-mediated complications,
the use of immunosuppressive drugs in conjunction with
tetracycline administration has been suggested.2*10z1 ',I4
Immunosuppressive therapy is controversial because E.
canis causes pancytopenia in some dogs, and additional
immunosuppression may worsen their ~ o n d i t i o nFur-
.~
thermore, because tetracycline is a rickettsiostatic drug
and clearance of E. canis is dependent on a competent
cell-mediated immune system, suppression of this de-
fense system may hinder clearance of the organism and
lead to a camer ~ t a t e . ~Although
.'~ the four dogs in this
study that received immunosuppressive therapy fully re-
covered, specific titers remained increased during the en-
tire follow-up period, so the possibility of relapse exists.
The two dogs that did not receive immunosuppressive
therapy also manifested prolonged increase in titers.
Further studies are needed to compare the clinical re-
sponse in dogs treated with tetracycline versus those
treated with tetracycline and immunosuppressive ther-
apy. Considering the possibility of persistent infection,
the use of immunosuppressive therapy should be ju-
dicious, and all dogs with ehrlichiosis should have their
titers'monitored after treatment.
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