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Veterinary Journal
The Veterinary Journal 182 (2009) 125–130
www.elsevier.com/locate/tvjl

Short Communication

The role of acute phase proteins in diagnosis and management

of steroid-responsive meningitis arteritis in dogs
M. Lowrie a, J. Penderis a, P.D. Eckersall b, M. McLaughlin c, D. Mellor b, T.J. Anderson a,*
a
Division of Companion Animal Sciences, Faculty of Veterinary Medicine, Institute of Comparative Medicine, University of Glasgow,
Bearsden Road, Glasgow G61 1QH, UK
b
Division of Animal Production and Public Health, Faculty of Veterinary Medicine, Institute of Comparative Medicine, University of Glasgow,
Bearsden Road, Glasgow G61 1QH, UK
c
Division of Cell Sciences, Faculty of Veterinary Medicine, Institute of Comparative Medicine, University of Glasgow, Bearsden Road,
Glasgow G61 1QH, UK

Accepted 1 May 2008

Abstract

Acute phase proteins (APPs) have become an important tool in the diagnosis, management and prognosis of inflammatory diseases in
humans and are developing a similar utility in domestic species. Steroid-responsive meningitis arteritis (SRMA) is a well-recognised
inflammatory disease of the dog, the diagnosis of which remains unsatisfactory based on clinical criteria and non-specific laboratory
investigations. In this prospective pilot study the authors examined the acute phase response throughout the course of SRMA in serum
and cerebrospinal fluid (CSF) by evaluating three key stages in disease management: presentation, treatment response and putative
relapse.
Serum APPs were found to be of value in supporting the diagnosis of SRMA and monitoring its treatment. C-reactive protein (CRP),
serum amyloid-A (SAA), alpha-1-acid glycoprotein (AGP) and haptoglobin (Hp) all exhibited an increase above our laboratory refer-
ence range in nine patients at initial presentation. During treatment APPs decreased significantly compared to presentation except Hp
which increased (Wilcoxon–Signed–Rank-test: CRP, SAA and AGP P < 0.05). Serum CRP and SAA were also found to be of clinical
value in the identification of putative relapse (seven cases), particularly in the light of unperturbed CSF parameters where APP concen-
trations were elevated. CSF APPs were found to be less reliable markers in the management of this disease. The results indicate that
SRMA causes a significant APP response in dogs, which although not disease specific, is of value in supporting the diagnosis of SRMA.
Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Acute phase proteins; Central nervous system; Dog; Inflammation; Meningitis

Steroid-responsive meningitis arteritis (SRMA) is a well-
recognised disease in canine practice characterised by pro-
longed treatment and clinical relapse (Tipold and Jaggy,
1994; Cizinauskas et al., 2000). Diagnosis relies upon a
combination of suggestive clinical indices and exclusion
of other diseases. An inflammatory leucogram suggests
the presence of an inflammatory process hence supporting
a diagnosis (Hayes et al., 1989). A cerebrospinal fluid
(CSF) pleocytosis confirms inflammation within the sub-
*
Corresponding author. Tel.: +44 141 330 5808; fax: +44 141 330 5729.
E-mail address: t.j.anderson@vet.gla.ac.uk (T.J. Anderson).
arachnoid space. Finally, raised serum combined with
CSF IgA titres has been suggested to be a specific indicator
of SRMA (Tipold et al., 1994; Tipold and Jaggy, 1994).
The literature on IgA states that an increased concentra-
tion may be found in the CSF of SRMA patients, though
this feature is shared with other inflammatory CNS dis-
eases reducing specificity (Tipold and Jaggy, 1994; Tipold
et al., 1994, 1995). Serum IgA in SRMA has been reported
to be significantly elevated above the published reference
range (10.9–100.1 lg/mL) in comparison to other CNS
inflammatory diseases, where concentrations may be nor-
mal or only mildly increased (Tipold and Jaggy, 1994;

1090-0233/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tvjl.2008.05.001
126 M. Lowrie et al. / The Veterinary Journal 182 (2009) 125–130
Tipold et al., 1994, 1995). However, the reported sensitivity
of this combination varies, for example, Tipold and Jaggy
(1994) report it to be 100% but in a later study Tipold and
others (1995) suggest a figure of 83%. A report of normal
serum IgA concentrations in four groups of healthy dogs
found a wide range of IgA values (from 6.1 to 973 lg/
mL) with 1/4 groups (a colony of beagles) exhibiting a
mean IgA concentration of 113.9 lg/mL (Griot-Wenk
et al., 1999). Consequently, serum IgA was not used as a
diagnostic criterion for SRMA in this study.
The acute phase response provides markers for diagnos-
ing and prognosticating inflammatory diseases in both
humans and dogs (Jergens et al., 2003; Vermeire et al.,
2004; Agrawal, 2005). A recent pilot study in dogs found
C-reactive protein (CRP) concentrations were elevated in
SRMA patients at initial examination in both the serum
and CSF (Bathen-Nöthen et al., 2006). Serum APP concen-
trations have been found to be eight times more sensitive to
inflammatory disease than white blood cells (Cerón et al.,
2005). As such, APPs may provide valuable information
in reaching an early diagnosis of SRMA and allow the cli-
nician to respond quickly to relapse. In this report, a panel
of APPs was evaluated in dogs at the time of diagnosis and
clinical remission during treatment of SRMA, and in dogs
with clinical signs consistent with suspected relapse of
SRMA. The aim of the investigation was to assess their
usefulness as biomarkers for diagnosis and monitoring of
therapy, particularly in relation to identifying potential
relapse.
A panel of four APPs was selected for this study: CRP,
serum amyloid-A (SAA), a1-acid glycoprotein (AGP) and
haptoglobin (Hp). CRP is the primary major canine APP
and has been shown to be immediately responsive to both
inflammation and its resolution. Serum amyloid A is also
considered as a ‘fast’ APP and Horadagoda et al. (1999)
demonstrated that SAA had a 100% clinical sensitivity in
detecting acute inflammation in cattle compared to 71%
for neutrophils. a1-Acid glycoprotein and Hp are more
moderate APPs, taking longer to increase and return to
normal, and therefore perhaps reflecting more chronic con-
ditions than CRP and SAA. In contrast to the other APPs,
Hp is thought to be induced by endogenous cortisol pro-
duced in response to any inflammatory stimulus and can
be induced by steroid therapy (Cerón et al., 2005; Marti-
nez-Subiela et al., 2004).
Samples were obtained from nine dogs with a clinical
diagnosis of SRMA presented to the small animal neurol-
ogy service at University of Glasgow Small Animal Hospi-
tal (UGSAH) between May 2006 and May 2007. Each dog
was subjected to a complete general and neurological
examination by a veterinary neurologist. A minimum data-
base for each dog consisted of the following: complete
blood count (CBC), serum biochemistry profile, cervical
radiographs and CSF analysis (collected from the cerebro-
medullary cistern) of cytology, differential count and total
protein. The diagnosis was based on signalment, clinical
signs, history, supportive CSF characteristics (increased
total white cell count and protein concentration), and
response to treatment. Dogs with a history of steroid
administration prior to accession were excluded from the
study. All dogs were treated with a standard protocol using
high immunosuppressive doses of prednisolone (2 mg/kg
prednisolone BID PO for 2 days reducing to 1 mg/kg
BID PO for 12 further days) in accordance with guidelines
from other studies (Tipold and Jaggy, 1994; Cizinauskas
et al., 2000; Tipold, 2000). Serum and CSF samples were
obtained at the point of diagnosis and 2 weeks into treat-
ment at which time all patients were in clinical remission.
In the second part of the study, samples were obtained
from seven dogs presenting to the neurology service at
UGSAH with clinical signs consistent with relapse of
SRMA (defined as the exhibition of clinical signs similar
to that at first diagnosis) during the same period. These
patients had all been diagnosed with SRMA by the neurol-
ogy service at UGSAH prior to the start of this study using
the stated inclusion criteria and were carefully re-evaluated
in the same manner. Serum and CSF samples were obtained
at the time of investigation of the suspected relapse.
CSF and serum samples were stored at 20 °C until
assayed. Values for CRP were obtained using an immuno-
turbidimetric assay (Eckersall et al., 1991). AGP was mea-
sured using a radial immunodiffusion assay (J-Path Inc)
and SAA was measured using a commercial canine ELISA
kit (Tridelta Development Ltd) (Martinez-Subiela et al.,
2005). Hp was assayed based on its haemoglobin binding
capacity (Eckersall et al., 1999; Martinez-Subiela et al.,
2005; Mischke et al., 2007). Assays for all the APPs above
were performed on both CSF and serum samples obtained
from dogs at initial assessment and remission, although in
the relapsing dogs only CRP and SAA assays were per-
formed, and only on serum samples. The reference range
in our laboratory for serum APP concentrations based on
previous studies was 0.46–9.6 mg/L for CRP, 0–1 mg/L
for SAA, 0.5–2.2 g/L for HP and 0.02–1 lg/L for AGP
concentration. A reference range has yet to be established
for APP concentrations in CSF.
Values of different groups are presented as modified box
plots (Figs. 1 and 2). The upper limit of reference ranges
was defined based on the 95% percentile. Statistical analy-
ses were performed using GraphPad Prism version 4
(GraphPad Software Inc.). Comparisons between the pre-
sentation and remission groups were performed on paired
samples using the Wilcoxon–Signed–Rank-test. The puta-
tive relapse group was compared with the laboratory refer-
ence values and statistical comparisons were performed
between the suspected relapse and the remission groups
using the Mann–Whitney-test. P values < 0.05 were consid-
ered as significant.
Serum and CSF samples were obtained from nine dogs
representing initial assessment and treatment. All nine
cases had a leucocytosis, with three exhibiting a left shift,
and hypoalbuminaemia was present in four cases. The
CSF cytology was markedly inflammatory in all nine cases
with cell counts ranging from 30 to 1800 white blood cells/
 M. Lowrie et al. / The Veterinary Journal 182 (2009) 125–130 127

Fig. 1. Serum acute phase protein response in nine canine steroid responsive-meningitis arteritis patients at diagnosis and 2 weeks into treatment. The box
represents the 25–75th percentile range, the line through represents the median, the range lines correspond to the highest and lowest values, outliers are
represented by *, and the highest and lowest values of the laboratory normal reference range is represented by dashed lines. Extreme outliers are presented
as censored data. C-reactive protein (CRP); serum amyloid-A (SAA); alpha-1-acid glycoprotein (AGP); haptoglobin (Hp).

Fig. 2. Cerebrospinal fluid acute phase protein response in nine canine steroid responsive-meningitis arteritis patients at initial diagnosis and 2 weeks into
treatment. The box represents the 25–75th percentile range, the line through represents the median, the range lines correspond to the highest and lowest
values and outliers are represented by *. Extreme outliers are presented as censored data. C-reactive protein (CRP); serum amyloid-A (SAA).

lL (median: 400 white blood cells/lL; reference range: < 5
white blood cells/lL). There was no red blood cell contam-
ination in any of the samples collected. Protein concentra-
tion was elevated in six cases with a range of 170–1680 mg/
L (median: 400 mg/L; reference range: < 250 mg/L). 6/9
dogs had a mononuclear pleocytosis (>80%) and had suf-
fered clinical signs for >7days. 3/9 dogs had a polymorpho-
nuclear (>80%) predominance and presented within 7 days
of onset of clinical signs. At presentation, all nine dogs had
CRP, SAA and Hp serum concentrations above the refer-
ence range. Only the 6/9 dogs with more chronic clinical
signs demonstrated an elevated serum AGP concentration.
There was a significant difference in the CRP, SAA and
AGP concentrations at initial assessment compared to
treatment (CRP P = 0.0195; SAA P = 0.0039; AGP
P = 0.0078) (Fig. 1). Serum Hp concentration increased
in five out of the nine cases during treatment although this
change was not statistically significant (P = 0.1641) (Tables
1 and 2 and Fig. 1).
AGP and Hp were undetectable in any of the CSF
samples collected, however CRP and SAA were detect-
able both at initial diagnosis (CRP median = 0.499 mg/L,
128 M. Lowrie et al. / The Veterinary Journal 182 (2009) 125–130

Table 1
Serum and cerebrospinal fluid acute phase protein concentrations in steroid-responsive meningitis arteritis dogs at presentation
Signalment CRP (mg/L) SAA (mg/L) Serum AGP (g/L) Serum Hp (g/L)
Serum CSF Serum CSF
1 year old ME Saluki 93 0.35 1450 0.13 2.31 23.8
9 month old FN Labrador 22 0.54 68 1.06 1.66 21
1 year old FN Golden Retriever 206 0.32 240 0.9 1.51 11.6
16 month old MN Boxer 329 9.1 1400 74 1.63 14.6
9 month old ME Jack Russell terrier 73 0.24 240 0.48 0.63 4.6
18 month old FN Springer Spaniel 140 2.37 6100 38.2 1.74 21.2
9 month old FN Boxer 32 0.25 283 26.05 1.26 17.2
13 month old ME Boxer 53 0.53 149 18.2 0.54 10.7
1 year old ME Weimaraner 77 0.50 179 0.24 1 6.9
AGP, alpha-1-acid glycoprotein; CRP, C-reactive protein; CSF, cerebrospinal fluid; FE, female entire; FN, female neutered; Hp, haptoglobin; ME, male
entire; MN, male neutered; SAA, serum amyloid-A.

Table 2
Serum and cerebrospinal fluid acute phase protein concentrations in steroid-responsive meningitis arteritis dogs at clinical remission after 2 weeks of
immunosuppressive steroid treatment
Signalment CRP (mg/L) SAA (mg/L) Serum AGP (g/L) Serum Hp (g/L)
Serum CSF Serum CSF
1 year old ME Saluki 6 0.262 0.2 0.08 0.5 19
9 month old FN Labrador 7 0.357 0.2 0.07 0.78 15.8
1 year old FN Golden Retriever 86 0.051 0.4 0.59 1.14 29
16 month old MN Boxer 13 0.419 0.8 2.92 0.33 29
9 month old ME Jack Russell terrier 17 0.351 0.8 0.35 0.24 15.2
18 month old FN Springer Spaniel 14 0.276 0.5 0.10 0.29 20.2
9 month old FN Boxer 10 0.212 0.1 0.37 0.15 15
13 month old ME Boxer 14 0.267 0.4 0.3 0.78 17.6
1 year old ME Weimaraner 7 0.126 2.4 0.05 0.46 27.6
AGP, alpha-1-acid glycoprotein; CRP, C-reactive protein; CSF, cerebrospinal fluid; FE, female entire; FN, female neutered; Hp, haptoglobin; ME, male
entire; MN, male neutered; SAA, serum amyloid-A.

range = 0.252–9.192 mg/L; SAA median = 1.06 mg/L, ian = 0.3 mg/L, range = 0.05–2.92 mg/L). There was a
range = 0.13–74 mg/L) and during treatment (CRP med- significant decrease in CRP and SAA concentration in
ian = 0.267 mg/L, range = 0.051–0.419 mg/L; SAA med- CSF between diagnosis and remission (CRP P = 0.0195,
SAA P = 0.0039) (Tables 1 and 2 and Fig. 2).
In the dogs with putative relapse of SRMA, 3/7 dogs
had a leucocytosis, though only one of these cases demon-
Table 3
Serum C-reactive protein and serum amyloid-A concentrations in seven strated a left shift. CSF was obtained in all cases and the
putative relapsing dogs cytology was within normal limits in six cases (Table 3).
Signalment CRP SAA CSF WBC CSF protein Protein concentration was within the reference range in
(mg/L) (mg/L) (cells/lL) (mg/L) 6/7 (Table 3). However, the serum concentrations of
19 month old ME 33 481 0 180 CRP and SAA in dogs with suspected relapse were at least
Springer Spaniel 7 and up to 10 times greater than the reference range,
13 month old FN 83 117 0 200 respectively (Table 3). Comparison of the putative relapse
Labrador group with the remission group demonstrated a significant
15 month old FE Corgi 341 744 0 50
elevation of the CRP and SAA (CRP P = 0.0012, SAA
12 month old ME Jack 84 409 0 120
Russell terrier P = 0.0007).
12 month old ME 142 56 0 180 The hypoalbuminaemia observed in 4/9 presenting cases
Weimaraner of SRMA reflects albumin’s role as a negative APP (Gruys
18 month old MN 402 11.6 96 380 et al., 1994) and hence hypoalbuminaemia is a familiar fea-
Weimaraner
ture of inflammatory disease. CSF was markedly inflam-
18 month old FN 247 475 0 70
Labrador matory in all nine initial presentation cases, whereas in
the putative relapsing dogs only one had an inflammatory
CRP, C-reactive protein; CSF, cerebrospinal fluid; FE, female entire; FN,
female neutered; ME, male entire; MN, male neutered; SAA, serum CSF sample.
amyloid-A; WBC, white blood cell. The results of CSF analysis are also The findings demonstrate that the selected panel of
included. APPs are elevated at initial presentation of SRMA and
 M. Lowrie et al. / The Veterinary Journal 182 (2009) 125–130
the initial remission of clinical signs by immunosuppressive
therapy reduces, but does not eliminate, this increase in
serum concentrations. CRP and SAA in CSF also exhib-
ited this same general trend but to a lesser magnitude.
All putatively relapsing patients were found to have raised
serum CRP and SAA concentrations even in the absence of
haematological and CSF changes. CRP and SAA are
described as fast APPs responding rapidly to inflammation
and its resolution (Cerón et al., 2005). In all nine cases of
SRMA CRP was found to be at least five times greater
and SAA was over 60 times greater than the reference
range. Comparably, the relapse cases all demonstrated
increased CRP and SAA concentrations with values over
7 times greater and 11 times greater than the reference
range, respectively.
Hp and AGP are considered more moderate APPs and
as such they are considered responsive to more chronic
conditions. AGP concentrations were above the reference
range at initial presentation in 6/9 dogs and all had shown
clinical signs for >7 days. These six patients also had a pre-
dominance of monocytes (>80%) in the CSF. A monocytic
pleocytosis is consistent with the protracted form of
SRMA described by Tipold and Jaggy (1994) though these
cases did not feature neurological deficits. Therefore the
raised AGP in 6/9 dogs correlates with the more chronic
disease (of weeks to 1 month in duration) and this would
agree with findings in other species where AGP has found
to be particularly associated with chronic conditions
(Horadagoda et al., 1999; Eckersall et al., 2007). All nine
patients had increased Hp, although the magnitude was
modest at twice the reference range. Serum Hp was found
to increase during treatment in keeping with previous stud-
ies that found Hp was induced by steroid medication (Cer-
ón et al., 2005; Martinez-Subiela et al., 2004), but also
supports its use in investigation prior to steroid administra-
tion. In some cases Hp concentrations decreased during
therapy, and this probably reflects a greater decrease in
Hp due to disease resolution than increase resulting from
steroid induction in these patients. The CSF CRP and
SAA concentrations were found to be very variable with
a large range of values at presentation that all decreased
to negligible concentrations with treatment. Although this
decrease in CSF concentration was statistically significant,
the magnitude of the response was small making CSF APP
concentrations of lesser value in disease management than
serum APPs.
APPs have certain advantages over the leucogram as
they are not subject to fluctuation due to extravasation
and are therefore a more stable parameter to monitor
throughout disease (Cerón et al., 2005). The acute phase
response is eight times more sensitive to inflammation than
the immune response with a wider dynamic range when
compared to neutrophils (Cerón et al., 2005). This implies
that APPs should be more responsive and better markers of
early inflammation than neutrophils. This study demon-
strates that serum APPs increase in the early stages of pre-
sumptive SRMA relapse giving them a potential role in the
129
monitoring of SRMA patients, as they are more readily
collected than CSF.
Indeed in the presence of unperturbed CSF parameters
(6/7 putative relapsing cases) and a normal leucogram (4/
7 putative relapsing cases), CRP and SAA were found to
be elevated in all patients exhibiting clinical signs consistent
with SRMA relapse. The literature demonstrates that 1/32
dogs (Tipold and Jaggy, 1994) and 1/6 dogs (Cizinauskas
et al., 2000) with suspected SRMA relapse did not show
an elevated CSF cell count. The elevated APP concentra-
tions in these cases, though unspecific for SRMA, sug-
gested the presence of an inflammatory disease, which in
the clinical context was considered to support the diagnosis
of relapse. Re-starting or increasing the dose of predniso-
lone in these patients resulted in remission with a full
recovery in all cases. All putative relapse cases had a min-
imum follow-up of 12 months and did not develop any
concurrent diseases.
The limitations of this study are the small case series and
the lack of a specific disease marker to confirm the diagno-
sis. However, the study has shown that CRP, SAA, AGP
and Hp are a useful panel of serum biomarkers to support
the diagnosis of SRMA and CRP and SAA are of value in
the face of suspected relapse.
Conflict of interest statement
Professor P.D. Eckersall is a Director and shareholder
in ReactivLab Ltd., a spinout company established by
the University of Glasgow to provide diagnostic assays
for acute phase proteins in animals. None of the other
authors of this paper has a financial or personal relation-
ship with other people or organisations that could inappro-
priately influence or bias the content of the paper.
Acknowledgements
This study was funded by a grant from the Faculty of
Veterinary Medicine, University of Glasgow. We thank
Mary Waterston at The Acute Phase Protein Research
Group for processing the samples and our colleagues in
the Neurology Service of the Small Animal Hospital for
assisting in the collection of case material.
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