S1 E3: Double Tick Trouble

Welcome to Tales from the Lab, where an ever optimistic veterinarian and slightly salty technician entertain listeners with true stories and tall tales revolving around laboratory diagnostics.

Names have been changed to protect the innocent, but the lab work is real.

You can listen on your lunch break, on your commute, or when you’re hiding from your kids in the bathroom.

Each episode we hope to leave you a little smarter, a little brighter, and feeling more empowered in the lab.

And here’s today’s tale from the lab entitled Double Tick Trouble.

Just go.

I can’t. You keep making me laugh. So I’m Jessica. I’m the slightly salty technician.

And I’m Holly. I’m a clinical pathologist and we are a diagnostic team. We’ve worked together in the hospital for over nine years.

And really highlighting that sort of team aspect that diagnostics provides in the hospital. Right. That we get to be part of this team of finding the answers and helping the patients together.

And along the lines of team.

I just think it’s so important to tell the people that you care about that you care about them. I know that we have a really strong friendship. It went from doctor technician, and over the course of nine years has turned into a great friendship.

And I think it’s probably because of all the crying and laughing. You know, we’re in the trenches together and I think a lot of the friendships in vet Med are really, really strong because you see some stuff.

Yeah.

Some shared experiences right through the. Through the trenches. But through the highs as well. Correct, Right. Those successes. And you know, I’ve always felt we’ve all gone through the loss of a pet and there’s no better place to show up at work the next day than with your colleagues in the animal hospital where it’s totally fine to cry all day and that’s fine.

And they’ll talk about your pet and it’s. It’s okay. And you cry through it and that’s okay. Yeah, yeah. It’s like a safe space for that.

And people check on you four months later. Yeah. Are you still.

Are you okay?

Because they get it.

They get it.

Yeah, yeah, yeah.

So Sammy is one of my favorite patients at the animal hospital. He’s a seven year old male neutered Labrador retriever.

He originally presented to the hospital for suspected Lyme nephritis.

And we use stem cell therapy to treat some types of renal disease.

I think more commonly in veterinary medicine, it’s used to treat osteoarthritis. But he had been receiving stem cell therapy for several years now.

And his owners actually felt like the stem cells were really helping his osteoarthritis as well. And they kind of use that as their marker for when they brought him in for his stem CE cell therapy.

He received stem cells for his lyme nephritis years previously, right. And they had his kidneys had totally recovered.

And now his owners only come back as they need it for help with his osteoarthritis.

So stammy, Sammy came in for his stem cell therapy treatment.

Everything went really well. We had a stem cells delivered. It’s an IV injection.

Did great. We did some lab work.

Everything looked great.

We always run lab work before we give their stem cells, make sure everything looks normal, that we don’t have any issues going on.

And we sent him home. I said to his mom and dad, make sure you call me, you know, before you when he starts to have some symptoms and we’ll get the next stem cell therapy set up.

So I was shocked,

dismayed,

anxiety ridden. I don’t know what the best term is because I tend to err on the side of the I messed something up.

When I saw Sammy on the schedule several days later for ain’t doing right. So adr.

So I’m anxiously waiting.

They put Sammy in a room. I go in and I get him. I talk to his mom and dad. He was acutely not doing well, lethargic, he wasn’t eating.

His physical exam, he was febrile and he was really, really reluctant to stand.

So. So in my mind I’m like, ****. Did something happen with his stem cell administration?

Was there a mix up at the lab? Did he get someone else’s stem cells? Does he have some type of infection? I’m like spiraling out of control of what went wrong.

Yeah.

What did I do wrong?

What did I do wrong?

We’re pretty hard on ourselves. And, you know, I think this underscores the importance of the diagnostic process. Right. History alone does not tell us what’s going on.

Right.

We get these vague histories and the owners don’t even know what’s relevant medically versus behaviorally.

We don’t know how to interpret that.

And even physical exam, while it’s supposed to give us objective information,

like in this case, he did have a fever and he was, you know, reluctant to stand. There may have been an orthopedic issue, but again, if you had to jump to what was going on, you just wouldn’t know, right?

That we have to get objective data from our patients and we start with the lab work.

So what you’re saying is, calm down. Yeah, slow your roll.

Why don’t we get some objective data off Sammy and then we’ll figure out what’s going on.

So we brought him back to our treatment area. We drew lab work, CBC chemistry.

Luckily, we had that.

That data from several days ago to compare when everything looked normal. And that, that really is the importance of trending data. We want to get data on them when they’re, quote, unquote healthy so that when we have an episode like this, we can go back and compare for what’s normal for them.

Yes. So on one of my soapboxes and I always talk about the. How wide reference intervals are for healthy patients. Right. They’re established certainly from a variety of ages, whether they’re intact or neutered, male or female,

and inherently, within healthy animals, that reference interval of health will be so wide because of that. Right. But for an individual animal, they are far more narrow. Right. They are consistent in their hematocrit, often throughout their life.

They.

Their creatinine is often consistent through their life unless they lose muscle mass. Right. And so if we have this baseline data,

if we have information about wellness testing to know what’s normal in quotes for that patient,

then again, when they come back, adr, we have a much more sensitive indicator, you know, if there’s anything off.

So in Sammy’s case, when we get his CBC back, and again, we love the cbc, you’ll hear us say over and over again as a great screening test for overall health.

Right. It’s not specific to the process necessarily, but understanding in our anemic patients what might be going on, understanding, looking for inflammatory leukograms, stress response, all of those things.

We scan the CBC, it’s not one test. We get like 20 to 24 different variables that tell us so much about our patients.

You literally just took what I was going to say. I even raised my hand to be like, I have. I have something to add.

I was like, let me finish my thought. You’re like, that was my thought.

Dang it.

So insane. In Sammy’s case, we see somewhat, might initially seem subtle, but very significant changes.

No changes through his erythrogram,

but in the leukogram. And we’re looking at the white blood cells. He has reported lymphopenia, so low lymphocytes and eosinopenia, low eosinophils. And that pattern of both those cell types decreased, is what we call a glucocorticoid or stress response.

So his Cortisol levels are up in response to whatever his illness is. And that stress response tells us we have a sick.

So you don’t mean stressed like me.

Stressed and not excitement stress, like, what am I going to wear to the party? Right. But I’m going through something really difficult here. And in response to my cortisol levels building to withstand this, I’m suppressing the circulating numbers of lymphocytes and eosinophils.

So a great indicator of a, of a sick patient. Move forward with your diagnostics to find out what’s wrong. It’s real.

And then as we look through the platelet data, he does have a reported thrombocytopenia.

Do you want to speak to that?

So do we just ignore that?

Because I feel like sometimes on our automated hematology analyzers, we get reported thrombocytopenias and we assume that it’s related to platelet clumping.

But that’s not always the case. You can review in some cases your scattergrams or the histograms to determine if there’s platelets. But if you’re not comfortable doing that, you can very easily take a blood film and,

and find the platelet clumps.

On the blood film.

And I think that it’s just a really important point that I think we’re obligated. Not only can we, but like, we need to be looking at these reported thrombocytopenias and confirming whether that’s true or it’s spurious because of platelet clumps.

And clinicians, I think, have become desensitized to report thrombocytopenias for that reason.

And as the laboratorians, as you as the technician in the lab, or me overseeing the data coming out the lab as well, we need to verify that data before we give it to our doctors for interpretation.

So I was waiting by the printer for Sammy’s lab work because I’m like, oh, what is happening? I’m so anxious for his parents, for myself, for him as my patient.

I see, you know, the low eos, the low lymphs, and I also see this thrombocytopenia. So I’m going to look before anybody even asks for this review.

So I make a blood film out of Sammy’s blood,

you know, a nice little wedge or some print shaped film.

And I’m actually going to look at the feathered edge. I’m going to be able to scan that feathered edge and see platelet clumping.

And that’s the first thing I’m looking for when I have a reported thrombocytopenia are those present.

Because if there are platelet clumps, we can’t believe the reported thrombocytopenia. And more than likely there is probably adequate platelet volume because it was enough to clump on the feathered edge.

So in Sammy’s case, I review the feathered edge and I see no platelet clumps. So I’m like, sugar. Now I gotta, I gotta dig a little deeper on this because that I’m,

I’m leaning towards believing that value.

So I will go in at 100x and I start kind of looking around and I’m gonna look in the monolayer of the film just to make sure that they have adequate platelet mass.

So we’d say in a healthy patient we expect about 10 to 20 per 100x field.

So I’m looking my 100x fields, I’m not seeing platelets, not a ton of platelets.

And then I come across a neutrophil and I’m like, oh,

there’s something inside of there.

Right. So first we did, you did confirm a thrombocytopenia, correct?

Yes.

Right. And in our area that thrombocytopenias are commonly secondary to tick borne disease.

Correct.

It’s very hard to focus only on the platelets when you’re taking a walk around the blood film. But I do try to make it a systematic approach.

I will cheat a little bit when I find something like this because I don’t know how many organisms I’m going to see.

Right. You see something that looks like an infectious agent, you’re going to keep your eye on that.

I’m probably going to stop,

leave a note on the microscope that says do not touch this and page you to the lab. Or run to your microscope and be like, you need to come look at this.

If you’re not here and I find something that I’m not sure of what it is. How many blurry photos have you gotten of me, like holding my phone, like trying to get the perfect image with my cell phone.

And I know that everyone can relate to that. Right? We see something in lab and you’re afraid you’re never going to see it again. So nobody touched this. I need to get some more opinions or I’m going to try and take a picture.

Try it.

So inside the cytoplasm of any of our granulocytes.

So whether it’s neutrophil could be eosinophil or basophil. But in these cases where they have the stress response, they have so few eos or bezos that we see them almost exclusively in neutrophils.

There is a generally round inclusion and within that these DIT dots, these individual little cocci that stain like a gray blue that fill that round inclusion. And so the story there is that this bacteria, these cocci,

are engulfed in the phagosome of the neutrophil, one of its organelles. And within that phagosome, while it’s supposed to break down and kill that invading infectious agent, they’re able to evade that and they replicate.

And so you get a replication or numerous numbers of these small little cocci.

And the storybook description of it is that they look like mulberries. They look like a little bear. I don’t even actually know what a mulberry is.

You don’t?

No. You do?

Oh, yeah. We used to like throw them at one another as kids. They like stain your skin like a country girl.

Yeah, we didn’t have that in the city, but they have these. It looks like a berry.

Right.

With these multiple little dots in it. And indeed,

you know, when you said not get too excited when you see one, look for more. And I think that’s often a great way to understand if something’s, you know, an artifact or not.

Right. In truth, if you have an infection,

you won’t see just one.

Right.

You get a chance to look around the film, get an idea if there’s any stain precipitate in the background, you know, other things that could mimic that. Sometimes a platelet overlying a neutrophil, while that can happen occasionally, might mimic this appearance because the little stippling to it.

So now you’ve said, you come to me and you say, oh,

you’re excited.

I am, I’m excited.

I’m relieved. Yeah. Because now this is not related to the stem cells.

So which I think could have been something really bad.

This is something that I know that we can treat and make him feel much better.

So this look of this mulberry like inclusion within our granulocytes in neutrophils, specifically when we don’t have the other ones around,

is consistent with either. So it’s a tick borne disease. We know that. And it’s consistent with either Anaplasma phagocytophalum or Ehrlichia ewingi.

So we see a lot of anaplasmosis in our area because of the prevalence of ixodes ticks where we are and we rarely see Ehrlichia. So Sammy had a presumptive diagnosis of.

Acute anaplasmosis and they feel like ****.

Yeah. So Sami, typical of almost all of our dogs who present for clinical disease, which is a small percentage of those who get infected,

high fever, lethargy, inappetence,

some indication of their joint pain, whether it’s a lameness, reluctant to rise, stiffness,

and a variety of other clinical signs, but those are the main ones.

So we have screening tests for vector borne diseases. Right. And the tick borne diseases, we in our area don’t have a lot of heartworm disease. So in particular on these panels of tests, when we’re looking at vector borne disease, we’re looking at the tick borne diseases and antibodies to those.

Right.

So when we see a positive anaplasma case, then we know the body’s been exposed to the organism. Right. And they’ve mounted an antibody response.

So in those animals, they actually don’t show their acute disease. They were already infected weeks, at least weeks ago, if not months ago,

and mounted that antibody response that gives them the serologic titer to turn those tests positive.

So it’s actually can be very misleading as the majority of our cases where they have acute anaplasmosis, the vast majority are antibody negative because it’s an acute infection.

Right.

We don’t have the weeks to mount that antibody response that’s detectable.

So the serologic testing is a great survey test to let you know what this patient’s been exposed to because it lets you know what organisms are in the area and that their tick control is inadequate.

So Sammy did spend a night with us at the hospital for treatment of his acute anaplasmosis.

He received IV fluids, he was started on oral doxycycline, and we continued his NSAIDs that he was given at home for his joint pain.

By the next morning, Sammy had turned around, as we commonly see in these cases of acute anaplasmosis. He was brighter. He was standing in his cage, his tail was wagging,

he was happy to greet his owner and be discharged again with his course of oral doxycycline to treat the anaplasmosis and a continuation of his NSAIDs for his joint pain.

For us as laboratorians, that recheck was also reaffirming. Right. That when we saw him at the end of his antimicrobials,

he had been doing well clinically. We recheck his blood work and everything was back within the reference interval.

So that’s not always the case.

They don’t always bounce back, turn around. Yeah. The following day. And I think especially in our elderly patients, we had one very Recently, Toby,

who 14 years old,

already has some arthritis issues, presents really not feeling well and his mom’s concerned about his quality of life and he ended up having acute anaplasmosis.

It took several days and it was kind of a roller coaster for mom.

That is interesting and worth mentioning because in our geriatric dogs,

any or other comorbidities that they commonly will have at that older age,

it is not the 24 hour turnaround that we see in our younger ones. And sometimes it is a little more protracted nursing care.

Right. And hospitalization maybe to get them back on their feet to. I think their immune response isn’t as strong. Right. Given their older age. And it might take a few more days for them to clear.

We are really familiar with seeing anaplasmosis because we’ve been seeing it for years in our area. So we know the classic glucogram changes of that stress response, the thrombocytopenia that you confirm out of the lab and microscopically together with the clinical signs.

And then we can find the organism on the blood film making the diagnosis for those who are not or you suspect an organism, you’re not sure, you haven’t seen it before and you’re concerned you can send off for pcr.

So remember your serology test, your antibody test for your vector borne disease screening is most commonly still negative. But you can send off for PCR at the reference lab that will look specifically for parts of the organism to show that it is there now and it will speciate it as well.

So it’ll let us know not only yes, you do have an infection vector borne tick borne disease, but you can differentiate that anaplasma effects to from the Ehrlichia uae.

So our take homes.

Yep. You know we like our take homes.

So our take home messages from Sami’s case of acute anaplasmosis.

We are going to recognize this on lab work. Right. And again, the importance of running blood work to get objective information on our ADR patients.

A stress response which is low eosinophils and low lymphocytes,

a verified thrombocytopenia and recognizing those mulberry like inclusions inside neutrophils.

And PCR testing is available at the reference lab that can definitively distinguish between Anaplasma faxatophalum and Ehrlichia ewingi as they will appear similar as those rickettsiomoruli within neutrophils.

So we don’t want you to go numb to thrombocytopenias. We want you to investigate those things. They are not always just platelet clumps. So you want to verify the platelet counts on a blood film first by looking at the feathered edge for any platelet clumps and then you can always go back into the body to do your estimated counts.

And then again understanding that screening tests that are they’re serologic, meaning they look for antibodies in the cases of acute anaplasmosis. They’re almost always negative. They haven’t had enough time to seroconvert to turn those tests positive and PCR is a test that you could use in the face of acute infection to get a definitive diagnosis.

Tales from the Lab is a production of Antec Diagnostics.

The intent of this podcast is to provide education and guidance with the understanding that any diagnostic testing and treatment decisions are ultimately at the discretion of the attending veterinarian within the established veterinarian patient client relationship.