WHAT IS YOUR DIAGNOSIS?

A 6 year old, neutered female crossbreed presented to the R(D)SVS Small Animal Medicine
Service with a 2 week history of reduced appetite, lethargy and pyrexia which was
unresponsive to amoxicillin. On physical examination, the dog was in good body condition
(score 5/9), quiet, responsive, and normally hydrated. The mucus membranes were pink
with capillary refill time of < 2 seconds. The heart rate was 110 beats per minute with
matched pulse of good quality. The rectal temperature was 40.2oC. The rest of the
examination was unremarkable.

The biochemistry and haematology results are shown below.

Haematology

Parameter Day 0 Reference Range

Packed Cell Volume 0.41 0.39-0.55l/l

Red Blood cells 6.29 5.5-8.5 x 1012/l

Haemoglobin 13.5 12-18g/l

Mean Cell Volume 66 60-77fl

MCHC 32.4 32-36%

Total WBC 4.8 6-15 x109/l

Neutrophils 0.24 3.6-12 x109/l

Lymphocytes 2.01 0.7-4.8 x109/l

Monocytes 2.44 0-1.5 x109/l

Eosinophils 0.1 0-1 x109/l

Basophils 0 0-0.2 x109/l

Platelets 277 200-500 x109/l

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Biochemistry

Total Protein 70.6 58-73 g/l

Albumin 26.5 26-35g/l

Globulin 44 18-37g/l

Bile Acids 6.6 0-7 umol/l

Bilirubin 1.6 0-6.8umol/l

Chloride 110 99-115 mmol/l

Creatinine 104 40-132umol/l

Glucose 3.7 3-5mmol/l

Urea 4.1 1.7-7.4mmol/l

AlKP 62 20-60IU/l

ALT 16 21-102IU/l

Calcium 2.35 2.3-3.0mmol/l

Phosphate 1.25 0.9-2.0mmol/l

Sodium 143 139-154mmol/l

Potassium 4.9 3.6 -5.6mmol/l

1) What are your differential diagnoses for the case?

2) What further investigations would you like to perform?

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 1) What are your differential diagnoses for the case?

The main problems in this case were the hyperthermia and neutropenia. Hyperthermia may
be due to fever related to pyrogens from infection, inflammation, necrosis, drugs or immune-
mediated disease. Alternatively increased body temperature may be due to a high
environmental temperature, increased muscle activity (strenuous exercise, muscle tremors,
seizures) or increased metabolic rate (e.g. hyperthyroidism). In this case, the elevated
temperature was thought to be true pyrexia as there was no history of exposure to high
temperatures, increased muscle activity or prior drug administration. This pyrexia may be
due to a severe infection which is resulting in the neutropenia (overwhelming demand for
tissue neutrophils), or the neutropenia may have predisposed to infection producing the
pyrexia.

Neutropenia may be due to decreased or ineffective production (myelodysplasia,

myelofibrosis, infiltrative bone marrow disease, cytotoxic or idiosyncratic drug reaction),
decreased survival (due to sepsis/endotoxaemia, extreme hyperthermia/pyrexia or immune
mediated destruction), temporary shift to marginating pool or overwhelming demand and
sequestration into the tissue pool. As the neutropenia was persistent, decreased production
or increased destruction was thought more likely as tissue sequestration or margination
would be expected to cause only a transient neutropenia until a compensatory increase in
marrow production occurred. Decreased production may be due to bone marrow disease
although it would be expected that other cell lines would also be affected. Increased
destruction may be due to immune-mediated process which may be idiopathic (i.e. primary)
or secondary (drug associated, paraneoplastic, infectious).

Additional abnormalities were the monocytosis which may be due to an inflammatory

response, as part of a stress leucogram or seen with monocytic leukaemia (although the
total count would have been expected to be higher). Hyperglobulinaemia may be monoclonal
due to; neoplasia (multiple myeloma, lymphoma, chronic or acute lymphocytic leukaemia),
certain infectious diseases (Ehrlichia, Leishmania, Dirofilaria; uncommon in the UK and the
dog had no prior travel history) or monoclonal gammopathy of unknown significance
(MGUS), or polyclonal due to; inflammation, infection or immune-mediated disease. The
increase in alkaline phosphate was mild and considered clinically insignificant.

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 2) What further investigations would you like to perform?

Although the dog was currently receiving antibiotics, making a positive culture less likely,
blood and urine culture and urinalysis were performed as sepsis or urinary tract infection
was a possible cause of the pyrexia and neutropenia. Both cultures were negative. Thoracic
ultrasonography and abdominal ultrasound were performed as a hidden septic focus could
not be completely excluded and also to investigate for underlying neoplasia. No
abnormalities were detected on diagnostic imaging. Serum protein electrophoresis was
carried out to define the hyperglobulinaemia which revealed a polyclonal gammopathy. Bone
marrow aspiration was performed to evaluate maturation of neutrophilic lineage and to
detect bone marrow disease. Although tick-borne disease is uncommon in the UK, whole
blood and bone marrow were submitted for Ehrlichia, Borrelia and Bartonella PCR. The
infectious disease screens were negative.

Bone marrow analysis was consistent with myeloid hypoplasia and maturation arrest at the
neutrophilic promyelocyte stage. Although this could have been consistent with an early
marrow response to increased consumption, the fact that no underlying septic focus was
identified on imaging and the neutropenia was persistent, made this unlikely. Immune-
mediated destruction was thought most likely at this stage. As no underlying cause had
been identified, an idiopathic possibly primary immune-mediated neutropenia was the
presumptive diagnosis.

The profound neutropenia meant that the dog was at risk of sepsis. As a result, antibiotic
cover was increased with 12.5mg/kg potentiated amoxicillin every 8 hours and 2mg/kg
marbofloxacin every 24 hours administered. As the dog appeared stable, these medications
were given orally to avoid the risk of introducing infection with intravenous catheter
placement. Although the highest risk of sepsis is via translocation from the gastro-intestinal
tract, reverse barrier nursing was instituted to reduce the risk of noscomial infection.
Twenty-four hours after increasing antibiotic cover the dog appeared brighter, ate small
amounts of food and the rectal temperature reduced to 39.5oC.

Antibiotic cover was continued and oral prednisolone was administered at a dose of 1mg/kg
twice daily. Forty-eight hours after starting immunosupression (Day 4), the dog appeared
bright, alert responsive and had a good appetite. Rectal temperature was within reference
range. Routine haematology was repeated which demonstrated that the neutrophil count
was within the reference range.

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The dog was discharged on oral medication. Twelve days after discharge, the dog was
reported behaving normally aside from polyuria/polydipsia (PUPD) which was thought to be
most likely due to steroid administration. Clinical examination was unremarkable and the
dog was normothermic. Haematology revealed a normal neutrophil count, the monocytosis
was less pronounced. Antibiotic cover was withdrawn after 5 days. Twenty-three days after
discharge the owners only concern was PUPD. Prednisolone was slowly tapered over the
following 4 months.

Discussion:

The diagnosis was steroid-responsive idiopathic neutropenia as no underlying cause could

be found and a prompt response was seen to prednisolone. It is suspected that immune-
mediated destruction was the cause of the neutropenia. Immune-mediated neutropenia is
well described in humans and anti-neutrophil antibody tests are recommended to reach a
diagnosis. Although direct and indirect testing for anti-neutrophil antibodies have been
described in dogs, these are not commercially available and not available for this case. It
has been suggested that until these tests are available, the diagnosis of immune-mediated
neutropenia be based on fulfilment of three of four criteria; 1) Exclusion of other known
causes of neutropenia, 2) Presence of concurrent immune-mediated disease, 3) Bone
marrow cytology supportive of immune-mediated destruction of neutrophils and 4) Prompt
response to corticosteroid administration. Although this case had no other concurrent
immune-mediated disease, it did fulfil the other 3 criteria and, as a result on this basis could
be classified as immune-mediated neutropenia.

In dogs, immune-mediated attack has been reported the level of mature neutrophils, in which
case the myeloid series may appear normal or increased on bone marrow examination.
Alternatively, destruction of neutrophil precursors may occur and an absence of neutrophil
precursors may be seen. This case demonstrated apparent maturation arrest at the level of
neutrophilic promyelocyte, suggesting that immune-mediated attack was at the precursor
stage.

Monocytosis and hyperglobulinaemia as seen in this case, are reported in human and
canine IMN, and suspected canine IMN cases. These increases are assumed to be a
compensatory response to the neutropenia.

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Consistent with previously reported cases of canine IMN and suspected IMN, this case
showed a rapid response to immunosuppressive medication. Spontaneous remission is
reported in human cases and canine cases have been reported to have good prognoses.

References:

Brown, C.D., Parnell, N.K., Schulman, R.L., Brown, C.G., Glickman, N.W., Glickman, L.,
2006, Evaluation of clinicopathologic features, response to treatment, and risk factors
associated with idiopathic neutropenia in dogs: 11 cases (1990-2002). J Am Vet Med
Assoc 229, 87-91.

Bux, J., Kissel, K., Nowak, K., Spengel, U., Mueller-Eckhardt, C., 1991, Autoimmune
neutropenia: clinical and laboratory studies in 143 patients. Ann Hematol 63, 249-
252.

McManus, P.M., Litwin, C., Barber, L., 1999, Immune-mediated neutropenia in 2 dogs. J Vet
Intern Med 13, 372-374.

Perkins, M.C., Canfield, P., Churcher, R.K., Malik, R., 2004, Immune-mediated neutropenia
suspected in five dogs. Aust Vet J 82, 52-57.

Weiss, D.J., 2007a, Evaluation of antineutrophil IgG antibodies in persistently neutropenic

dogs. J Vet Intern Med 21, 440-444.

Weiss, D.J., 2007b, An indirect flow cytometric test for detection of anti-neutrophil antibodies
in dogs. Am J Vet Res 68, 464-467.

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