Triple Immunosuppressive Therapy of Immune-mediated Hemolytic Anemia in a Dog: Case-report

Abstract

Immune mediated hemolytic anemia (IMHA) is a disease in which the body's own immune system attacks and destroys the erythrocytes causing anemia. This may be primary or secondary as the result of an underlying illness such as neoplasia or intracellular parasites like babesiosis. In most cases the underlying trigger of the anemia may never be found, in which case the disease is called idiopathic immune-mediated anemia. A double immunosuppressive therapy including prednisolone and cyclosporine as well as various blood transfusions has been administered to the patient, without any results. Mycophenolate mofetil was introduced as the third immunosuppressive drug on the eight day after admission (Park et al., 2012; Wang et al, 2013; West et al, 2014) The diagnosis of immune-mediated hemolytic anemia has been made after the auto-agglutination test of the patient was positive after three RBC washes and negative results for Ehrlichia, Babesia, Leishmania and Borrelia antibodies. Also, tumors have not been found. The patient received in the first eight days of treatment four type specific blood transfusions with erythrocyte concentrate and two immunosuppressive drugs, but still manifested post-transfusion reactions after each transfusion with the hematocrit (Hct) dropping back to initial levels after two days. After the addition of mycophenolate mofetil the Hct stayed stable at a higher level and the patient was discharged two weeks after with a stable Hct of 27%. Mycophenolate mofetil can be used in severe cases of IMHA when other immunosuppressive agents might not be enough. However due to the frequently encountered side effects it is recommended to be used mostly as a last resort therapeutic agent.