Knowledge Lab

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.

So welcome today’s case entitled not off the Hook.

We’re back.

We’re back.

Hi, Mom.

You’re back.

I am back.

You were gone.

I feel like we haven’t seen each other.

Yeah.

Forever.

At least a week.

No, it’s been over a week.

It’s been over a week.

Lots going on. I’m tired. I lost my mind last night. As a. As a dog owner.

Why is it when it’s our own dogs, do we lose our absolute minds?

Insane.

Yeah, it’s bad.

Yeah.

We go to the darkest places.

Oh, the darkest. Knowing way too much. So I have a three year old lab. His name is Ruger. His birthday is coming up. He’ll be four. He’s super happy. Wiggly. Just the best boy ever.

Yeah.

And last night we were eating dinner, he walked through the living room and just screamed and then went in his crate.

And I got him out, he screamed again, went back in his crate, started shaking, panting. And I was like, oh, my God, he has a splenic torsion.

He’s bloating.

Gdv. Yeah.

And so I got him back, back out of his crate.

Did a quote unquote physical exam in my panic, which was basically like, are you limping? Can I bend your neck? All sorts of different directions. Do you have a ruptured **** gland?

Like, I don’t. What is happening? And no stick in his mouth. His. You know, I was just trying to touch all the bases. And then.

Gum color.

Yeah, I did check his gum color because I was like, oh, yeah.

And some deep abdominal palpation. Right. If something’s in there, just like presta.

I don’t. I don’t. How doctors consistently palpate abdomens. Like, are you all just pretending?

I. I am when I do it. Yes, I am.

You’re like, yes, I can definitely feel kidneys.

No, I am. Right.

I am definitely pretending you can feel bladders.

Pretty good, though, in a cat.

Yeah.

That’s not fat and stretched on its side. I got it. Yeah. Really, really well.

So I called my hospital and said, hey,

sorry, are you guys super busy? Because I’m Pretty sure Ruger is dying.

They’re very nice. That is one of the really great things about being a veteran veterinary professional is when something is wrong with one of our dogs, we all just help as much as we can.

And so I brought him in on emergency,

did lab work of course, and that was completely normal. But he ended up having some back pain. So he was not dying. He did not have a splenic torsion and he’s resting comfortably in his crate now on his medication.

And you’re resting?

I am, but I went to bed at like, I don’t know, I got like five hours of sleep last night, so. Which is not my normal nine to ten hours of sleep.

So I am a little bit tired. But I’m glad that he’s feeling better. But I literally lost my mind that 45 minute drive from my home to here. I just kept turning the light on like in the car because it was.

Am I losing him?

Yeah. Like I actually was like in my mind creating a scenario because I have to drive past your house that if he had like arrested that I was just going to your house so that you could drive and I could do cpr.

Like it was just ridiculous.

Yeah. Covering all your braces.

But I think that now, I think it was his presentation and that he was scared and stressed. Right, right. And they’re our kids, so we are instantly scared and stressed.

And he’s a, he’s a bit of a baby. Yeah. But he’s good. So that’s my, my dog died.

Yeah.

Okay.

But we’re good.

Back on track. I’m glad we caught up.

Yeah.

Yeah.

I mean there’s other stuff too. We could just talk forever. But we should talk about our case of the.

Our patient today is paxton. Paxton’s a 1 year old male intact boxer. And do you remember when Paxton came in the first time?

I. I do remember when Paxton came in. He came into to the animal hospital as a puppy.

He was non ambulatory,

really non responsive. He was really, really sick when he presented. And what he actually ended up having was meningitis. And so through a CSF tap we diagnosed him with meningitis.

But he did really well with supportive care. Steroids I believe, because it was steroid responsive meningitis.

Exactly.

And his owners were just all in like such great owners. They brought him in for rehab. Like he became one of our favorite patients because he’s so stinking cute. He was so little and all the know technicians.

We just loved him so much and really enjoyed his parents because they Were such wonderful. They are such wonderful pet owners.

And it was just one of those feel good cases. Right. We saw him turn around and we all need to celebrate those highs in veterinary medicine.

Right.

Because we get both of them.

Yeah, both ways. So he actually came in for vaccines.

Can I interject?

Yeah.

So for some background, as I understand it, we were not his regular vet when he was a puppy.

Correct.

He developed these neurologic signs, inappropriate mentation. He was referred to us and then he sort of became our patient.

Right.

I don’t think he went back to his referring vet for any of his routine puppy visits. He was certainly not going to get vaccinated in the face of a steroid responsive meningitis.

And while we had him immunosuppressed and I don’t think we had thought about his puppy wellness either.

Right.

We are treating him for his meningitis, which he responded to well. But we were seeing him monthly. Right. Clinically well, at each visit, tapering off his steroids. Now he’s been off his steroids.

He’s clinically healthy, per mom.

As I’m talking to mom, you know, I’m on the floor with Paxton and I lift up his gum to look at his mucus. Mem. Or his lip. Yes. I lift up his flop chop to look at his gum and they are white.

I mean, like, not just like, oh, like, are you, are you white? Like, could that be a little pink? No, they’re like paper white.

I’m like, oh, red flag.

Something is not right.

Which was shocking.

Yeah.

Given that he’s so happy bouncing around the room. And we have a picture of him from when we brought him back to treatment and made this diagnosis. And while he appears bright, I do now appreciate looking at the picture.

His ear, pinna on the inside, it’s pale.

His muzzle where it should be, a bright pink. He just looks pale. But we didn’t realize it until you lift the flap shop.

Yep. So I very,

I guess kindly say to nonchalant, like, hey, I’m just gonna take Paxton to the back. And then I come back to the, the treatment area. I’m like, oh, my God, look at, look at Paxton’s gums.

Like, what is going on? So we, of course, are going to draw some blood because, I mean, presumably we have a very anemic patient.

And you obviously, I’m sure you did the blood draw. I’m sure you’re processing it in the lab and I don’t get a chance to peek at it until the blood film is made, till the Results come off the printer.

However, the doctors already. I already hear his verbiage around this, right? So his mentality is a little doom and gloom, right. A Paxton’s a white boxer, right? So like, anything can happen, Right.

All bets are off. It doesn’t.

He already had meningitis.

He already had meningitis and he’s only a year old. Right. All bets are off. He is thinking maybe imha, immune mediated hemolytic anemia, given that he’s so apparently anemic, given how pale his gums are and that he’s already had one immune mediated disease.

Right?

His meningitis. And the thought is he’s now off all his meds. Here’s the other shoe has dropped. That was one of his thoughts that he wanted me to investigate. And I think pretty soon after the blood was processing in the lab, he was put on the ultrasound table.

Right.

Because his other thought is, does he have internal bleeding? What else is leading to a hematocrit Solo as we look through the erythrogram. So we said he was really pale, right?

And indeed his hematocrit was 11%. Just like those. I’d only seen it before, like in a kitten.

Right.

There’s those kittens with a hematocrit of seven and they’re on the exam room table meowing, perfectly happy, and you’re like, oh, oh, oh, not good. But he’s like a 50 pound dog, right, who’s bouncing around with a hematocrit of 11.

So the first thing that tells us from a clinical perspective is that this is not new. Yeah, right. That we have to tie together what we know about the history and the physical exam with the lab work to understand that 11%.

If we had a fast drop in hematocrit down to 11%, he’d be clinical for the anemia.

Right?

Yeah, I think that’s a really good point that I don’t know whether I’ve ever really thought about that. Like chronically anemic. He’s kind of. His body’s kind of learned how to live with that.

Exactly right. Exactly right. And why mom sees no problems at home. Right. Okay, so then as we characterize an anemia, right, so we have red cell indices that are reported. So in addition to looking at red cell mass, whether that’s the RBC count, the, the hematocrit or the hemoglobin levels,

we have red cell indices that describe the red cells to us. Tell us about morphology changes, in particular the MCV or the mean cell volume and the mchc, or the mean corpuscular hemoglobin concentration.

I noticed that you skipped over mch.

Yeah, I hate it. It adds no additional information to the mcv. Yeah, right.

Needle you a little bit.

I was very intentional. I said, well, I mean, what’s the point?

I have one patient at a time. I am going to work to omit that MCH reporting. Okay, so his mean red cell volume is very, very small. So we say that’s a microcytosis, and then the MCHC is saying it’s about the hemoglobin concentration of the red cells, Right?

The mean of them. So of all of the red blood cells, regardless of their cell size, is their hemoglobin concentration appropriate? Were they made with the appropriate amount of iron?

Because iron binds hemoglobin. Right. So this pattern of having a microcytosis, low mcv, he also has a low mchc. That’s the mean corpuscular hemoglobin concentration. So that’s saying in all of the red cells, what is the mean?

Regardless of their cell size, what is the mean of their hemoglobin concentration?

So when that is low, we’re saying his hemoglobin content or his concentration in his red cells is low, which we call hypochromia.

So the trick on that name, right, hypo, we know, means low, and it means low color, right? Because it’s hemoglobin that adds the pink color.

Right?

And so if there’s less hemoglobin, there’s less color. Hypochromia sound good.

And microcytic and hypochromic, that combination, low mcv, low MCHC is classic for iron deficiency.

So while the clinician on the case was saying, you know, do you think this is imha? I said, I haven’t looked at the blood film, but this pattern of microcytic hypochromic anemia should be iron deficiency.

And we’re going to look at the blood film to see if that’s true.

So another thing we should talk about is when we assess anemias, we talk about whether they’re regenerative or not, right? So some of it’s. It’s always great to sort of bucket our information, right?

So if we’re going through our differential list and we’re trying to work through an algorithm of why our red cells are low, it might be that we’re not making them.

We are making them. They’re being destroyed or making them, and they’re being lost from the body.

Production, loss, lysis production, lysis loss.

You Love to say it, I do.

And because I think it really helps us to work through again, sort of a diagnostic algorithm. Right. And so if you, depending on where you run your blood work, you may have an automated reticulocyte count.

And so that’s an automated count of those young red blood cells to assess regene. So if that’s increased, then you have a regenerative response. And obviously it’s not a production problem.

Right. If you don’t have an automated retic count reported,

some things that you can do, one is look at a blood film. Right. So looking for polychromatophils, those bigger, bluer red blood cells.

Right.

On a routinely stained blood film, those would be evidence of a regenerative response. Or using the new methylene blue stain that we talked about in Sally’s episode, New Methylene Blue, it identifies the Heinz bodies.

That’s how we use that for Sally’s case. But it also will cause aggregation of ribosomes or RNA in the young red blood cells, meaning it will show you reticulocytes.

And the polychromatophils and the reticulocytes, they are in essence the same things, it’s just different stains.

You got it.

So when we use our diffquick, we have to call them polychromatophils. When we use pneumethylene blue, we can then call them reticulocytes.

Correct. And it’s more objective when we put new methylene blue on, because that aggregation of the ribosomes is that chunky bl, which is a little easier than the more subtle changes between pink and blue on the polychromatophils.

Helps with the enumeration.

Right.

If you’re going to. And in Paxton’s case, what’s interesting on these iron deficiency cases, right. So he’s sort of classic in his erythrogram, is that initially they’ll be regenerative, but as the iron stores are depleted, they’ll become less and less and become non regenerative eventually.

Right.

So really, in these iron deficiency cases, they can be anywhere in that continuum.

So let’s talk about Paxton’s blood film. So in a case like this, where I know that you’re going to want to review the blood film, I’m going to just make it as the rest of the lab work is running, just so that that way I can get it dried.

A nice little tip that we have is we have a nail dryer that has an on off switch. There’s also hot and cold setting, but it’s really nice because we can stick our microscope slides in there and dry them on the cool setting.

So that’s kind of the standard protocol. You make blood film and then stick it underneath the nail dryer so that. That way it gets dry.

And the faster they dry, the less artifact we see as well. So they can also just get a small fan that they could put over them. What’s nice about the nail dryer is that it’s enclosed a little, because labs are often super dusty.

And so if you just have a fan over your slides, often, it puts a lot of lint and debris on them as well. So in health, when we look at canine red blood cells that have generally central pallor, they have an area of paleness in the center when we look at them sort of top down because they’re biconcave discs.

So almost like a lifesaver, except it’s not a hole in the middle.

Right.

It’s just a thinner part of the red blood cell. Less hemoglobin in there, so less pink staining. So the. The pink stain is all around the periphery.

Right.

The outer, maybe third of the red blood cell with the pallor in the middle.

Right.

So you’d asked before about how we recognize hypochromia in our red blood cells, because dogs normally have some degree of central pallor. And for Paxton’s case, almost all of his red blood cells have a significantly expanded central pallor.

The vast majority look like ghosts. I mean, they’re open cells.

Right.

With just sort of a thin rim of hemoglobin.

Right.

So markedly increased central pallor, which is our hypochromia.

Right.

Decreased color. And again, that’s hemoglobin that’s staining there. The reason there’s less hemoglobin in the cells is there’s less iron around when those cells were made, and it’s iron that binds hemoglobin.

So this is the look of iron deficiency.

Now, as far as assessing whether they’re microcytic.

Right.

It can be really challenging without a reference point. Platelets are a great one on Paxton’s case because his. Many of his red cells are the same size as his platelets.

It’s really quite sad.

Those are really, really small.

Right.

So canine red blood cells should be significantly bigger than their platelets. And in Paxton’s case, they are definitely not. So we can appreciate on the blood film, it confirms microcytic hypochromic anemia.

And we can see actually a lot of polychromatophils.

Right.

To Support that this is regenerative.

And so those are going to be the more like purpley dark staining ones that are on there. Purple, blue.

You got it. So I’m looking at the film at my microscope, which is in the ultrasound room, and Paxton’s on the ultrasound table and the clinician says, I don’t see anything wrong in here.

I don’t see any internal bleeding, no hemoabdomen, no hemothorax, no hemopericardium.

What do you see? Is it.

I. Yeah, Come on, Holly, give me an answer.

Is it imha? I said no, I don’t see any support for imha. This really looks classic for iron deficiency, which I think, you know, in his mind he was a little incredulous because he had gone to far more nefarious things.

Like it was doom and gloom, Right. It was going to be something bad. I’m like, this is iron deficiency. And in a young dog, that should be because of GI parasitism.

Right.

So it’s actually, I wouldn’t say innocuous because this is actually life threatening, obviously, with a hematocrit of 11 and we can lose puppies to iron deficiency and kittens to iron deficiency.

Right.

But it is absolutely something treatable. Right. And so we ran the fecal.

Yep.

And indeed he was loaded with hookromova. Yeah.

Like loaded to the point where we were like, oh, my goodness.

Yeah.

And it was a mixed bag response. Right. Because I think for the most part, we were all delighted. A. As a diagnostician, Paxton read the book. Right. Microcytic hyperchromic anemia with this blood film in a young dog should be GI parasitism.

With the idea that we were looking for some cause of a chronic, continuous slow bleed such that he could adapt and not show his clinical signs of anemia.

Right.

With a hematocrit of 11, in an older dog, this is more likely to be a bleeding GI tumor.

Right.

Again, something that’s allowing a slow bleed. If you had more significant hemolysis or blood loss, you’d be presenting for that clinical syndrome. Right.

So. But the mixed bag of the response was then also like, oh. Because all of a sudden all sort of came clear that Paxton start stopped his routine puppy care when he came to us for his meningitis.

Right.

So we weren’t. It is recommended, I think, by the CAPS group that they do like three or four fecals in that first year of life.

Right.

So they stop fecal testing, they stop routine deworming. We knew we weren’t going to be vaccinating in the face of his immune made disease. But think about the fact that we didn’t go through his fecal testing, we didn’t deworm him routinely, and then we immunosuppressed him to boot.

Right.

So I think they really got a toehold. So when I think about from a parasitologist standpoint, right. Which I’m not. When we see that many ova in his feces and I think about him shedding that much in the environment.

Right. Because he could be getting reinfected.

Right.

The larval stages that hatch out of those ova are infective to dogs, to cats. I mean, hook rooms are one of the most common GI parasites of dogs, especially in our young dogs.

And they can kill puppies, Right. Their mouth parts, when they get into the intestinal tract of the worms, you know, they adhere or they grab onto the GI mucosa and they just suck their blood.

Right.

They ingest their blood and then drain the dog of their blood and their iron stores, as is the case here. And so not only do we need to think about Paxton being reinfected, their other dog in the household, but there’s also zoonotic potential too, Right.

So that’s really awful.

Right.

And so it’s called cutaneous larval migrans. It is not common, of course, fairly rarely seen here in the US but it’s our obligations, we think about these ova being shed into the environment that we need to be treating this as effectively as possible because we really are putting that risk out there.

Right.

For something zoonotic. And as we think about treatment for Paxton.

Right.

So I think that historically in we’ve dewormed dogs and not rechecked fecals.

Right.

Assuming that our deworming protocols are effective, parasitologists have become increasingly aware of multidrug resistance and hookworms specifically.

So they’ve fortunately identified some of the markers for the genes that confer this resistance. This adaptation that they’ve developed to multiple drugs are routinely used in Telementix. And last year Antec released their key screen GI parasite PCR panel.

It’s done at the reference lab. It’s a very sensitive PCR test. So it tests for 20 different GI parasites very sensitively, again using PCR technology.

But in addition to that, it will be able to assess an ancelostoma or the hookworm infections if they have the marker for drug resistance they’ve identified. Even new ones have been identified even within the past year.

So they’re going to keep updating that test.

Right.

To include these new markers. But that’s really important in Paxton’s case that we make sure that we’re treating these effectively. A because it’s life threatening to him with a hematocrit of 11 and he’s shedding so many ova in the environment, which has a zoonotic potential as well.

So Paxton was routinely dewormed.

We did put him on a multivitamin that had iron.

He didn’t warrant a blood transfusion even at a hematocrit of 11 because he wasn’t clinical. Right. And again, the clinician on the case was doubtful that this was going to fix him.

I think he had just wrapped his mind around the fact that this was going to be something far worse because we had a recheck at 10 days, maybe with mom to come in sooner if he wasn’t doing well.

But after just routine deworming and a multivitamin and he had already turned the corner, his hematocrite already come up about 10%, I think, and it was a slow recovery. If you think about us having to,

obviously we can kill off the worm burden with our repeated regular deworming.

Right.

Given the lifecycle of these.

But also we need to replenish his iron stores. Right.

The whole process for his erythrogram to normalize. You know, we. His hematocrit came back within a few weeks. But his red cell indices. Right. We looked at the mean cell volume and the mean vascular hemoglobin concentration, the mchc, they took months to normalize.

Because if you think about it, it’s looking at a mean of all of those red blood cells.

Right.

The ones that were made over the past several months.

Right.

They’re also going to be included in that mean. So even though he was making them more normal size and more hemoglobin concentration, they were a mean of the previous ones that were hypochromic and microcytic.

And I think it actually took four months for his erythrogram to normalize.

So our take homes, yes,

my first take home is recognizing iron deficiency anemia as being obviously a low hematocrit for the anemia that is microcytic, meaning low MCV and hypochromic, low mchc. So that combination is classic for iron deficiency.

And when you look on the blood film, the cells will indeed be smaller and use maybe a platelet as an indicator of how small they are. And they’re staining, there’ll be increased central pallor.

So the cells will look relatively see through because there’s less hemoglobin, less iron.

My take home point is to make sure that you’re vigilant about preventative care. And that goes for both the doctors and the technician nurses, assistants that we’re all double checking and making sure that the, you know, very basics of preventative medicine are complete because things like this can happen.

We’re so focused on this disease process that we kind of forgot about the basic stuff.

Yeah.

And it’s, it’s super important to make sure we get all of, all of those things covered.

And my last take home is around Antech’s key screen GI parasite PCR panel. And that we are not only able to very sensitively identify the GI parasites, there are 20 on that panel currently much more sensitive than fecal flotation because a lot of times ova are shed intermittently.

Right.

You have to wait till the infection is advanced enough to have a high parasite burden to detect them. But also, especially around hookworms is that we’re seeing these multi drug resistant worms and so being able to use PCR to identify the markers of drug resistance and that that landscape is going to continue to change.

And so it’s really nice that technology and the science behind it will keep Antech vigilant and flexible around continuing to develop those diagnostics.

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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.