Welcome to this talk on a practical approach to anaemia. And today we're gonna be looking at the case studies associated with that. My name's Claire Ottenbelt.

I'm an RCVS specialist in small animal medicine. But my background is that I worked in university for 18 years at the University of Glasgow, and then have subsequently set up to do freelance work within the field of oncology and medicine. So what I like to do is really give people a very practical approach to problems and help them to get the easiest way to to find out what's going on with, with their patient.

And anybody who knows me knows that I like to keep things nice and simple for myself as well as for everybody else. So So what we're going to be doing is following on really from the the overview of anaemia. We're going to be having a look at some cases that will demonstrate some of the things you've learned through the first lecture, and also, show you some new ways perhaps to think about some of the things that you've you've learned there as well.

So what are we going to be really focusing on? Well, I think one of the key questions, we have to ask ourselves whenever we're looking at a patient with anaemia, is, does the haematology fit the clinical picture? OK?

Because you've got to trust yourself, trust your own clinical skills far more than any lab result that you get through a machine. So it's really important that you think about, does it actually fit with what you're seeing? What mechanisms are responsible for the anaemia, and obviously we talked about that previously in the other lecture, and we'll go through some of the mechanisms that we talked about there and show perhaps in some cases where there might be more than one mechanism for the anaemia forming.

And then that allows us to work out in the case why they occurred, and that directs our treatment approach, our management approach, or our further investigations in the patient. So the first case we're gonna look at is one actually I had just a few weeks back, and it's a really, really good example. It was a little 8 year old, female neutered Jack Russell terrier who presented with a really large, plasma cytoma in the mouth.

It had been biopsied, by the referring vet, but it was really big, it extended right across to the midline. But everything else was completely unremarkable. And we, we kind of knew that we couldn't do surgery at this point.

So we were going to use some chemotherapy to try and shrink the tumour down with a view to do surgery. So I quite happily took bloods, really not expecting any abnormalities, and I got this result. And obviously we can see there's a, a, a big.

Asterisks marked up here, on the red cell, parameters, but quite shocking. Oh my goodness, hematocrit, when you first look at it, and actually it was a nurse who called me and said, the hematocrit's 40.6%, in a big panic.

And I was thinking, oh my God, has my, my clinical judgement gone so bad that I can't detect an anaemia that That severe in a patient that I examined. And then I just paused for a moment, and I was like, no, no. This isn't right, OK?

This is definitely not right. This dog did not have a hematocrit of that low amount, because it would have really been showing clinical signs and really, really unwell, and I would have seen it. So, immediately, I know that that's not correct.

So I followed it up and said, no, no, no. Can we run these again? I think something's gone wrong.

And one of the most common reasons for something going wrong like that is where someone's forgotten to mix the blood. OK? So they haven't mixed it adequately before it's gone through the machine.

So you can see these are the results that we have obtained after, we had done it again, different time later in the afternoon. And you can see much more what I was expecting a completely normal haematology results. So this is really just to remind you, trust your clinical findings.

Never ever doubt yourself, because that's much more likely to be accurate than the machine. So if the machine's giving you result that doesn't look right, run it again or double check it. And I have been seeing quite a few errors coming through on some machine counts in practise lately, people asking me for advice on cases that just don't fit together.

And if it doesn't fit together, just ask yourself, has something gone wrong with the way we've been running things? So next up, we're gonna look at a slightly different way of, of kind of trusting your clinical judgement. And this was actually my own dog from a number of years ago, and everyone knows that that vets dogs get a hard deal in life.

They don't get looked after, perhaps to the high standards that they would if they were one of our actual patients. And this poor dog, Huntley, had a history really of an ongoing problem for a number of years. And to be honest with you, I, I'd just been managing him very, symptomatically for a long, long time.

But he had presented with this very acute hotspot. He had had a poor appetite when I look back for about a week or so, and he'd also had intermittent diarrhoea, and he'd been vomiting bile for on and off. Not all the time, OK?

I just hasten to add, I wasn't that bad a parent. But it had been happening intermittently for about the last 2 years. And 2 years previously, he'd been diagnosed as hypothyroid.

So, obviously we'd had issues then as well. And on clinical examination, and I hasten to add, I, I actually did examine him, but I also took him to a vet, the vet who I lived next door to. And yeah, the poor vet was like, I can't tell you what's wrong with your dog.

And I said, Yes, you can. You're gonna have to because I'm in bits, I can't do it. So she also examined him, and he was dull and depressed.

He He was at least 10% dehydrated and had congested mucous membranes. He had a low grade heart murmur, and actually, he was quite slim. And I think I had really been thinking, Oh, this is great, because he was really fat when he had hyperthyroidism.

So I was quite pleased that he'd slimmed down, but the vet was actually, mm, I think he's maybe a little bit too skinny. And he also had this really nasty hot spot on his, his thigh, but his anal sacs were completely normal. So, we took some bloods.

And the key thing, I think here is to notice really how normal these bloods look. They really do look normal. You know, there isn't an anaemia present in this dog.

But what we have is something that's not really expected. This dog should have a high. Hematocrit, not a, a sort of middle of the range, normal.

It should be high because he's dehydrated, and it's not. He's also a very sick dog, you know, he's, he's really not well. He's very dull, he's very lethargic.

He's, you know, dehydrated, he's not right. And yet, everything looks remarkably normal. We don't have evidence of Of a normal stress leukogram, as in a response to a disease process.

OK? So it's, it's not how it should be. OK?

But we can infer some things from this. We can say, OK, we know he's dehydrated. So we know the hematocrit is going to fall when we rehydrate him.

So we know that that is definitely going to happen. So, it's worth just remembering that, that again, this doesn't fit the clinical picture. I would expect if he's dehydrated for the hematocrit to be higher, and it's not.

So that probably suggests there is a degree of anaemia there that we're kind of not exactly picking up at this point in time because of his severe dehydration. So once we've given him IV fluids, this is what happened, and this was a big shock, a really big shock to see how much his hematocrit fell following administration of IV fluids. That is, is massive, OK?

And what we can say there is, OK, he's he's maybe a lot more than 10% dehydrated. But even with a say, 20% dehydrated, we wouldn't necessarily expect the PCB to fall quite so dramatically. OK.

The, the bloods are non-regenerative. Now, we know obviously that a non-regenerative anaemia can occur in the early stages, potentially, of an anaemia of other reasons. So we could either have a chronic non-regenerative situation, or we could have an acute non-regenerative situation.

It's also just worth pointing out the remembering to use the RDW, that's the red cell distribution width down here. You can see that that's quite wide, OK? So that means that there's a wide range of sizes of red cells.

It doesn't tell us where they're placed, but we can then use the MCV, which is the mean cell volume, to work. Where the kind of middle of that spread is. And you can see here it's just below the reference range.

So they are slightly on the smaller side, but there's quite a, a range across, a wider field than we would expect. OK? So, that kind of fits with the poorly regenerative.

They're they're probably more on the smaller side rather than the larger side. Now, I'm gonna show you the biochemistry results, and obviously, when we handled this case, we had day one biochemistry at the same time as we had day one haematology. But what is interesting here is actually that, the key kind of jump out findings, if you like, are this low album.

The albumin was low, OK? And you'll remember from the first talk, we talked about low albummen potentially occurring in a blood loss situation. OK, it can also obviously occur where there's problems with liver pathology, and kidney loss and so forth.

All the globulins are actually bang on normal. OK, but nothing really going on of any excitement down in the initial liver, and nothing kind of hugely exciting going on down here in day one. Whereas in day two, we actually start to see something which may point us in a particular direction.

So we've seen that the sodium potassium ratio is, is dropping. And that's quite interesting, because that's after IV fluids as well. So we've been giving IV fluids a supportive treatment over the last few days.

In addition, the albumen's dropping further, suggesting that the cause of whatever the low albumin is, is actually getting worse, so that's still ongoing. And that ties in quite nicely with that fall in PCV I think. So, obviously, from these results, the fact that there was no stress leukogram present, the fact that there was a disturbed sodium potassium ratio, we did an ACH stimulation test.

And this was diagnostic for Addison's disease. I think I must be one of the most unlucky people in the world to have a hypothyroid and an Addisonian in the same dog. The only plus was, of course, it's nice and cheap to treat both of these.

So then I had to ask myself, does this explain the fall, in the hematocrit from the 41.5% to the 26.3%?

And the quick answer here is, OK, can we say it's just fluids? So probably not, because that would be a really significant degree of dehydration. So we have to then ask ourselves what other possible mechanisms are there.

We have, the, the consideration of taking into account something like anaemia of chronic disease, OK, which we talked about in the first lecture. And that would obviously mean that he's not regenerating, which is what we're seeing on the picture. So we would see a loss of regenerating capacity, and that can occur in both hypothyroidism, although he's controlled with that, and in Addison's disease as well.

So we could see that inability to form red blood cells. But that's gonna take quite a long time, because the, the red cell lifespan in the dog is around about the 90 day mark. So you can imagine, you're, you're only losing a small proportion of your red cells over those days.

So over a kind of 3 month period. So that really means that something else is, is probably also happening. So we may have, the anaemia of chronic disease as associated with some of these other conditions.

But what else is potentially going on? Yes, he was dehydrated. That's also potentially going on.

But remember that in Addison's, we also see hemorrhagic gastroenteritis. So maybe there was also some bleeding. And this would explain quite nicely, why we were seeing this.

Dramatic fall, if you like, as we rehydrated. It wasn't just the the hydration. It wasn't just dilution of blood.

That's, that's something that people often talk about, dilution. Actually, you can't dilute blood very effectively. You can dilute it in the short term, but it's not, it's not really a mechanism, for getting an anaemia per se.

So I suspect that this dramatic fall wasn't just those two things, the dehydration and the anaemia or chronic disease. There was also probably some blood loss, which ties in nicely with the low albummen as well. So we're going to move on to the next case now, and this one is Malibu, a 16 year old female neuter domestic short hair, and hopefully she's quite a straightforward one in terms of why she might have developed anaemia.

But we'll have a little chat about some of the things we need to consider in this because, common things are the things you guys are going to see most. And so therefore you can get the most out of understanding some of the mechanisms. So she presented with PUPD.

She was vomiting bile once or twice a day over the last week or so and had a very poor appetite. And on clinical examination, again, she was a dehydrated cat. She seemed a little bit underweight, couldn't feel a goitre when I palpated her neck, and she had pale mucous membranes and her capillary refill time was fine, and her heart rate was a bit elevated.

And both kidneys and abdominal palpation felt quite small. So I think we all know where this is kind of going. But let's have a look at her haematology first.

So, on the haematology, we can see we've got a pretty dramatic anaemia. And as you'll remember from the previous lecture, the cats can tolerate anaemia quite well. So she wasn't really showing a lot of signs of her anaemia.

Her heart rate was a bit elevated, but not much else, to kind of really show that. And that's because cats are really good at adjusting their lifestyle, and tolerating it because of their specific red cell physiology. We can see, an elevated white cell count, a neutrophilia, which is kind of to be expected, a mild lymphoenia to be expected.

She's got an ongoing chronic disease. We can also see that we have a non-regenerative blood picture present on the smear report, which again, is probably to be expected. And interestingly, her platelet numbers were increased.

And this actually came from a lab that don't put a count on the list when you have a cat blood, they put it in the smear report. OK. So it is quite important if you are sending samples away to a lab that you do send an air dried smear at the same time, so that they can actually have a really accurate smear assessment.

And you can see the MCVs on the low side as well. OK, so we're not seeing evidence of the MCV going up, which is supportive more of a regenerative picture. So fairly predictably, Malibu's bloods showed that she has problems, renal problems, elevations in urea and creatinine and phosphate, and also her urine SG is on the low side.

So the cutoff for cats, remember, they're very good at concentrating, so their cutoff is is higher than it would be in a dog for a diagnosis of of renal disease. So we were pretty confident that we had a renal disease picture in this cat. So this just gives me an opportunity to talk to you a little bit about anaemia or chronic renal failure and really understanding that it's about a lot more than just the problem with erythropoietin production.

You know, it's quite easy to think, oh, yeah, kidneys produce erythropoietin, therefore, that's gonna fall off, and therefore, we're gonna have issues associated. With it. OK.

And that is true, that does occur. But we do also see some other things taking place. We see a reduction in red cell survival associated with azotemia.

So in other words, the red cells are more easily damaged and therefore more likely to be removed from the system. So there's there's a faster process, if you like, for the anaemia of chronic Disease. We know we've got anaemia of chronic disease.

We're locking away iron stores and preventing the body accessing them. So the reduction in erythropowe in the reduced red cell survival, the locking away of iron stores, all of these factors mean that we're not producing as many red cells, and we're losing them perhaps a little bit faster than we might in another disease process. We also see problems with platelet function.

So they, the platelets become affected by the azotemia and can't function as normally. So that results in ongoing blood loss, and that is exacerbated by the, the gastritis that you get. You know, that gastric ulceration that you see associated with chronic renal failure.

So, it's a kind of horrible, vicious cycle that we're trying to deal with. So, what we I don't want to do is just jump for the urethra per eatin. That's, that's all well and good in certain situations, but we need to look at some of the other mechanisms, like the loss of blood and the gastric ulceration, and try and fix those as well.

So this is a really good example here of how the mechanisms will direct your treatment options. So next one, OK, is Suzie, who's a one year old female neutered springer spaniel. And you can see in the pictures here just how yellow this this poor dog was when she presented.

And she had a history of 7 days of anorexia, a couple of episodes of vomiting. She was dull. The owner thought maybe she was a bit uncomfortable in her tummy, you know, the way she was lying and so forth.

She had, for the last 24 hours, had hyperapnea, and her urine had been very dark as well. Fiona had noticed that when she went out to the toilet. On clinical examination, she was dull, depressed, recumbent.

She was very jaundiced, as you can see. So you can see here, when you look at her sclera and her third eyelid, you can see that it's yellow, but underneath, it's pale. I, and that is really as opposed to a situation where underneath it's pink, which might indicate a jaundice for another reason other than anaemia.

Where it's very pale underneath the jaundice, that really points me towards anaemia plus jaundice. They could be related, they could be unrelated. OK?

So, really important to make that distinction and look beneath. You can even see it, actually, on her skin as well. You know, her skin looks pale, and then she's got this hue of yellow.

OK. She had a normal capillary refill time. OK.

Remember, that's a really good way of kind of differentiating heart disease, you know, heart failure from anaemia. Her heart rate was elevated at 140, and she had a grade 2 out of 6 pansastolic murmur. And these were her bloods, and no surprise, she's got a really, really significant anaemia.

We could see that when we looked at her membrane, just how pale it was underneath the yellow area. And other things to kind of note here, we have an elevated mean cell volume, OK? So that's going up, which could support regenerative picture, because obviously, remember, our reticular sites and our immature red cells tend to be bigger than our normal ones.

OK? But we haven't got here. The RDW.

So we don't know how spread out that is. We just know that the average is above. OK?

And so that, that may point us towards saying it's more regenerative. She has got a slightly low platelet count, but that count is not low enough to suggest that that's the cause of the bleeding, at least spontaneously. Bleeding.

Remember that spontaneous bleeding only occurs when it's under 30, and then the kind of induced bleeding worry zone for me is where it's under 50. So this suggests more that they're being used up currently, rather than they're the cause for the bleeding at the present time, or the, you know, the cause of the anaemia that's, that's present. And this is an example where, because we don't know what's going on, we know there's something strange going on.

We want to have a look and see if there is any regeneration and work that out. It's really important to look at a blood smear. OK?

So we look at the blood smear, and what we can see here are tonnes of red cells without their central pallor. And red Cells without their central palate are called spherocytes, OK? And for those of you who had to sit through lectures of mine in the past, you'll know that I have my particular way of remembering the difference between a spherosy and a schisto site.

We have the spherocyte, which is circular, like a sphere, and we have the schita site, which is like the mark of Zora. So schistocyte, and that means the red cells have been cut up. OK?

And I can't see looking at this smear here, I can't see any evidence of schistocytes, which would indicate cell destruction, say, going through clots, hemangiosarcoma, that sort of thing. I can only see spherocytes, which are nice and round and have lost their central pallor. And you can see there are some darker staining, red cells kicking about.

They, there's lots and lots of spherocytes, and they are kind of sticking a little bit together in places. OK. So this really indicates that there is probably an immune mediated process going on.

And we also did a slide agglutination test, so we added a drop of blood. A drop of saline and just mixed it together. And you can see in this case, just by looking at the slide, you can see this granular texture, which shows that the, the cells are clumping together.

If you don't see that granular texture, it's really worthwhile just popping that under a microscope, because you may actually see the red cells kind of sticking together in little clumps under the microscope. They're just not big enough clumps. So, what about her biochemistry?

Does this give us any kind of pointers towards the anaemia? I think we're pretty confident, we know we're dealing with an immune mediated, problem here. But obviously, we need to just check, is there anything else going on, that may give us a reason, like a secondary cause.

So, we're going to be having a look for any secondary causes, not just assuming it's autoimmune at this point. So we can see how Almen is a little on the low side. It's slightly down.

It's not massively down. So this to me isn't, could be, could be a bit of blood loss, could also just be a sort of negative acute phase protein situation where the body doesn't produce so much albumen because of inflammation in the body. We can see we have an elevation in our urea, OK?

That can obviously indicate potentially a bleeding problem if we're seeing it, it going into the gut. But also, one of the key things with a, such a low PCV in this case, we know that there is going to be organ damage, and we can see that here in the kidneys and also in down in the liver results as well. OK?

No surprise, bilirubin is through the roof. We can see that. We, we I knew that was going to be there.

It is, however, worth remembering that bilirubin can sit in the skin. So you can get jaundice skin that hasn't released. So your blood can normalise, but your skin will still look a little bit yellow.

So there is an advantage in, in not just going, Oh, yeah, jaundiced body, jaundiced blood, I'm not going to bother checking it. There is, it is important to see that it's coming down, and that the skin and the sclera and so forth may just reflect old jaundice. She's also got a slight reduction in her calcium, but that is probably most likely is going to be associated with the album.

So, I'm not too concerned about that. OK, so what we can say with this case is that we know so far that she has an immune-mediated hemolytic process. And to make a diagnosis of primary autoimmune, you'll remember, we need to rule out the other causes, potential causes.

So we need to rule out infectious issues like Babesiosis, if there's any history of travel. She hadn't travelled anywhere. And we need to And also eliminate other toxic causes very uncommon, to be honest, the reality is also means much more common in dogs, and make sure we've taken chest X-rays, abdominal ultrasound or done some form of imaging in both cavities to look for any underlying reasons.

It's important as well to just remember, we might need to look at drug history. Has she been on something in the past? Anything like that.

I kind of feel like going all through all of that is a bit beyond today's scope. We're really just focusing on getting to that diagnosis. But it's just important.

I want you to remember that this isn't the end of the story. We do have to do some other things before we confirm that she has, an autoimmune. And she did.

She was clear on everything. And she was very well controlled with a combination of transfusions and, immunosuppressive agents. So, the next case, is Emma, who was a 5 year old female neutered cocker spaniel, who presented with a very acute onset of epistaxis.

And when we examined her, we discovered that she had some particular haemorrhages. It's pretty tiny here, but honestly, I didn't draw that in. It is a real picture.

It does look a little bit unrealistic, but it does make you, really understand how carefully you have to look. You know, it's that easy to just go, Oh, yep, fine, fine, fine. In this sort of situation, whenever you're dealing with an animal with a bleeding problem, really important to to look hard for any evidence of, petiation.

And actually, she also had it on her vulva as well. So when I just diverted the vulval lips, you could have a look. And it's, you know, it's quite useful to do that, particularly if you've got very, dogs with lots of dark gums, it can be difficult to see them.

So think about all the mucous membranes in the body when you're having a wee look for that. Her temperature was a little bit elevated, respirate a little bit elevated, although she was quite stressy. And on abdominal palpation, her spleen just felt a little bit prominent, you know, I think you'll know what I mean when I say that.

You know, there's one of those ones where you just go, Oh my God, massive spleen. Others, when you go, Ah, is that a big spleen? Mm, feels a bit more than I should do.

So let's have a look first at her blood results, her haematology results. And I, I haven't put all the white blood cells in. They were all within reference range, OK?

Which is fine. There's no evidence for stress leukogram, but all within reference range. And she has, fairly mild anaemia.

It's not a, a big anaemia. And there's a non-regenerative blood picture. Which I guess is what we expect, because this is an acute epistaxis situation.

So it's not going to very quickly become regenerative. And what we can see straight away is an extremely worrying platelet count, OK? And this explains the tication, this explains the blood, and it explains the anaemia, because at 8, you're gonna get spontaneous bleeding, for 100% certain.

So that makes that one relatively straightforward. So we're gonna move on to Ziggy. And Ziggy is a 9 month old male neutered domestic short hair.

And he presented with 10 days of just being lethargic. And that always worries me in a cat because cats can tolerate their anaemia extremely well. So if they start to show any lethargy associated with it, that's a big worry.

He was also hyponeic, again, a big sign that things are problematic if this cat is anaemic. And actually on the history, he was castrated at around 6 months of age, and there was a note on the history that just said he was a little bit pale, but no further investigation was was taken. And the owner was concerned that maybe this was related to fleas because she'd seen a lot of fleas on the cat, and yes, external parasites can cause an anaemia, but.

When we see this cat's anaemia, and the fact that he's got quite dramatic clinical signs already really worries me. On clinical examination, heart rate was, was elevated. There was a normal CRT but very pale mucous membranes, and he did have a grade 2 out of 6 murmur.

It's important to remember that anaemia will give you a murmur, and that's where some of the problems comes when you're trying to differentiate a cardiac problem from an anaemia, because both can have a murmur, OK? Both can have pale mucus membranes. So the key, and both can have a high heart rate.

So the key is what's going on with the CRT? Is the CRT doing well or are we having an output failure? OK, taking place.

And You know, really, really think about that other differential when you've got something with a murmur. Is it? Is there an anaemia situation taking place?

And you can see, when we have a look at the haematology here, oh my God. And this is real. I didn't make this up.

I was absolutely appalled to see that we have a Hematocrit of 6%. And that really goes to show how well cats can super adapt to anaemia. So really, really, really important to remember that.

When we have a look at the, the biochemistry side of things, we can see that the urea is elevated, and we have a, an elevation in ALT. And these don't massively excite me in terms of reasons for The anaemia, what they do worry me is that they are probably as a result of the anaemia. So these organs are starting to, to really feel the burn.

OK? The burn of having 6%. Cats are remarkably good at tolerating anaemia, because remember that they release, their oxygen from their red cells at lower oxygen.

Concentrations. So it means they can get more peripherally out before they release oxygen. And that's part of the reason why they present so late.

You know, they relax, they chill. Dogs are stupid, they run around and fall over and they go, Oh, why did I fall over? Oh, I think I'll run around again.

Cats don't, they just adapt and adjust, but they also have this very clever physiology that means they can tolerate quite severe levels of anaemia without showing very many clinical signs at all. But eventually, the organs are gonna start to feel the burn. When we looked at the smear for this, patient, we can see we had a non-regenerative blood picture.

There were no parasites or aberrant cells present. And obviously, as part of the investigation, we needed to eliminate mycoplasma species infections. So that's gonna be one of your most common reasons for cats becoming anaemic in the first place.

Although this cat, Hasn't really got anything to point us more towards a kind of hemolytic process, nothing on the blood smear, or anything like that. But do remember, you're not gonna see your beautiful spherocytes in a cat because they don't have that central pallor that dogs do. It was FELV positive, OK?

But FIV negative and, as I say, mycoplasma PCR negative as well. OK. So, what we have here is a really severe anaemia.

No kind of real evidence of bleeding anywhere. I don't think the fleas would have been sufficient to take this down to 6%. Honestly and truthfully, and it should be regenerating, you know, even at the start, it should have started regenerating.

So we really have to move on to thinking about, is there a non-regenerative process here? And in this cat, we thought, right, we need to do, a bone marrow sample. Obviously, this is not the same cat in the picture, but.

Take a bone marrow sample. I particularly like, the humerus or the femur, for cats. Those are my kind of favourite sites.

So, and I'm somebody who doesn't really like metal on bones. So you guys out there, you'll be so much better at that than me. I'm like, Oh, I hate that.

Which is why I do medicine. And it was a bit of a shock to discover when I chose medicine that I had to still do metal on bone. But there you go.

So what we found here is when we did a bone marrow, we had a myelodysplasia, which is a known complication of FELV and this poor cat had a really severe, inability to form red cells, basically. So, that wasn't really going to be much hope. The only way we could have.

Tim going would be a, you know, really regular transfusions. Unfortunately, the owner agreed that that was, was just not feasible. You know, how difficult it is to to get cat blood and get matching cat blood and all of that.

So, unfortunately, Ziggy was no more fairly quickly after this result. OK. So, the next case we're doing is a really interesting one, and I hope it's gonna show you why sometimes we have to consider multiple factors, OK?

And not just jump to the obvious, conclusion. So, this is C, who was an 11 year old female neutered Kerry Blue. And she presented with 5 months of nasal discharge.

And over the last month, they've noticed a mass in her mouth that appeared to be bleeding. And particularly like when she was playing ball or when she was eating. And, you know, she'd become quite picky with her food.

And I think you can see why that might have happened, because that's pretty horrendous, what's going on. Mouth. There were multiple masses in the front part of her upper jaw, and before she was referred across to us, she had had a blood sample taken which showed a hematocrit 32%.

So a mild anaemia, not a massive anaemia. On clinical examination, there were multiple masses in the mouth. The largest was just behind the left incisors, and, you know, it was a sizable mass for this kind of size of dog.

And the heart rate was normal, but she did have a grade 2 murmur. So this case was really being referred for an oncological workup with a view to doing some radiotherapy. So had full staging performed obviously, before we go forward to radiotherapy and spend large sums of money treating a single site.

And they picked up some incidental liver and kidney cysts, and she'd had a CT of her nose for the radiotherapy planning process and also a biopsy taken at the same time. And that revealed an acanthomatous amioblastoma. So, what about her blood results?

Well, let's take a look at them. So by the time she came to us, we can see immediately that the hematocrit has fallen down to 26%, which is now becoming a sort of moderate anaemia process. OK?

The MCV is, is normal, so No kind of clues there about whether it's regenerating or not regenerating. And the RDW is on the low side. OK.

So there's a narrower width, if you like. So it means perhaps that they're all much more the same size. OK?

And that also supports that there's no evidence of regeneration. And on a smear, again, no evidence of regenerative process taking place. OK?

On her biochemistry, we've got elevations in her liver enzymes, OK? We could see these cysts in her liver, but they were Incidental, as we now know, obviously we might not have known that at this point. The urea is elevated and the most likely reason for that is because the masses in her mouth are bleeding.

She's swallowing the blood down, and that's creating the effect of a high. Meals. So we do commonly see elevated urea where we've got blood loss in either the airway, where they're coughing up and then swallowing it in the GI tract, or in the mouth if they're swallowing down blood in their mouths because it's basically just the same as eating a high protein meal.

We can also see that the albumen is a little bit low, which would support what's blood loss being one of the reasons. OK? Remember that, your albummen will normalise much faster than your hematocrit.

So you're much more likely to see an abnormal hematocrit with a normal albummen. So if your albumin is low, there may be a reason for that. And obviously, we have to be slightly concerned that a low albumin combined with liver enzymes could reflect something going on.

Liver side of things as well. So we need to consider the possibility here that there's something going on in the liver, that maybe that is contributing to the bleeding through, an inability to make coagulation factors and so forth. So, something, you know, yes, blood loss, and yes, this is the obvious site.

But let's double check that there's nothing else kind of going on there. OK. So, to summarise what we found, we've got the multiple bleeding masses.

We've got a murmur that we think is probably hemic, but we can't be 100% certain. We can do a scan to check that out. 26 is probably low enough that you would start to get potentially a hemic murmur, but there may be other factors.

And obviously, she's going to have multiple radiation, so we need to bear that in mind. The, we have a moderate ongoing non-regenerative anaemia. And that is a little bit weird because she's been bleeding for a month now.

So why is that? Not regenerating. And even if she's swallowing it down, she should be, you know, yes, there's some external blood loss, but she's got plenty of opportunity down a GI tract to reabsorb some of the, the lost iron and so forth.

So, yeah, a little bit weird. Her platelet count is slightly elevated, so it's not the cause of any blood loss. There's no low platelet count resulting in there.

But her, it's the elevation often is associated with blood loss. So you'll get a rebound elevation and platelets when you've got ongoing bleeding. You'll see the platelets try and bounce back in between the bleeding episodes.

Obviously, they're being used up during the bleed, but afterwards, they'll, they'll bounce back as the bone marrow tries to do its funky stuff. The urea is elevated, the albummen's low. So, as I said in the previous slides, you know, we can tie some of these things.

Together, we can say, OK, maybe there's some blood loss as a result that's causing the anaemia, and but that should be regenerating by now. It's not down to platelet count. So, I should probably also say that we did check the coagulation premises as well.

So your APTT and your PT, just to make sure that there wasn't anything problematic there. And that was. Not a problem.

They were all fine as well. So there wasn't really anything to suggest that there was something additional causing the bleeding other than the masses. So we then have to think to ourselves, why is the anaemia non-regenerative?

She's been bleeding for a long time. We should be seeing some evidence, OK? Could be an acute bleed.

Yes. Remember that there's that delay in the reticular site coming up when you have an acute bleed. But we have been bleeding for a long time, and to get to a PCV of 26, we need to have been doing a reasonable amount of bleeding over a long period.

So, whilst we would expect to see some regeneration in a chronic one, we might not, if it's a very cute one. So, have we got acute on chronic here? Or is there something else going on.

And we had a big discussion about this because it was a little bit strange. OK. So we were really thinking about the recent haemorrhage.

Is that why it's not regenerative? Is there an iron deficiency occurring because she's losing blood out through the back end in the GI tract? Or are there bone marrow issues?

And, you know, it's this big dilemma, what do you do? You know, if you're assuming that it's recent haemorrhage, then obviously, stopping the bleeding will help. If you're assuming it's iron deficiency, stopping the bleeding will help.

We haven't got anything on our bloods to suggest iron deficiency. So we're not really able to take that forward. We haven't found anything on the smear to support it.

So, Like, kind of left us with, well, what do we do? Do we just treat it? It's going to take a number of weeks for these bleeding situations to stop.

But we decided, no, this was more than, than we really needed to, to kind of, we need to kind of dive down a little bit more. And then two days later, just before we're about to start radiation, oh my goodness, her PCVs dropped further. OK?

So, again, we're like, well, Because this recent haemorrhage should be regenerating, it's still not regenerating in this situation. And the iron deficiency theory is not really appropriate. OK?

I realise I've, I've highlighted MCHC here, and I shouldn't have done because that's completely normal. So we can see that the MCH and the MCHC are normal, and we would expect those to start falling in an iron deficiency anaemia. And we'd expect to see something on the smear, and there's just nothing on the smear, OK?

So we'd expect to see hypochromasia, and, You know, changes, microcytic cells, small cells, OK? Our red cell distribution width is just bang on normal. It's not narrowed down.

Our mean cell volume is bang on normal. It's not narrowed down. So all of these factors really fit in with what we're seeing on the smear as well.

There is some relo formation, and that may be significant, it's very not significant in cats, cats are very prone to relo formation, but it's a bit weird in the dog. You sometimes see it when you've got high globulins and so forth. So that really pointed us towards performing a bone marrow aspirate, and we did it using a rib, because we were able to do it after we performed the radiation treatment.

So it wasn't a big invasive procedure. It's a relatively easy procedure to do. And we just thought, you know, we've got to eliminate what's something going on in the bone marrow here, because the, it's the jigsaw's not fitting together.

You know, it's a bit like, if you've got, if you're trying to sit and do a jigsaw, that's great, and you get the outside and you put the inside and then the picture all fits, OK? And you can imagine what the picture is. If there's a few bits missing, you can say, Yeah, that is definitely a picture of a cat.

It's fine. OK? But if someone gives you two boxes of jigsaws and mixes them all together, and then you're trying to create a picture out of it, You're never gonna create a picture until you realise there are two pictures, OK?

One's a cat and one's a dolphin. OK? So trying to put those together is never gonna work.

And so even if you haven't got all the pieces for the dolphin, or all the pieces for the cat. You'll still be able to tell it's a cat and a dolphin. OK?

So that's my analogy for trying to be a vet sometimes. You know, it's nice when the jigsaw all matches, that makes us very happy. Every piece fits in.

But if a piece really doesn't fit in, maybe it's a different jigsaw. OK. So, what did we find?

Well, when we did the bone marrow aspirate up from the rib, we found that actually, there was evidence of immune mediated red cell destruction taking place in the bone marrow. OK? And maybe the roule was a little hint of what was going on there.

but we found it quite readily in the bone marrow. So, So we started this dog on prednisolone at 2 milligrammes per kilogramme, and immediately the mag rate started to rise. And this was we were doing this whilst we're trying to continue the radiation therapy.

So you can see the change from her mouth at the start to the end after she'd had her radiotherapy treatment. So a significant improvement in the mass and the bleeding from the mass. So we were thinking, oh, well, maybe this was associated in some way with the bleeding.

And maybe we can now that she's no longer getting blood loss, we can wean things out. But immediately, as soon as we start to wean things out after the radiotherapy, the anaemia occurred. So that was clearly a separate problem.

OK? So, the anaemia that we got so excited about associated with the blood loss around the face and in the mouth mass. Wasn't actually the main problem for this dog.

It was probably causing a much lower effect on, you know, maybe enhancing the anaemia, but actually, it was an immune-mediated destruction that was taking place. OK? So, this is a classic cat, a dolphin jigsaw thing.

OK? We were assuming that it was going to be the blood loss that had caused the anaemia, when in fact, It was an a process taking place that was causing it. OK.

So this is a little bit unusual and I'm, I'm not asking you for every case to go out and assume everything is weird, OK, that everything's going to be that weird dolphin picture. But just bear in mind and really think about, do the results reflect what we were expecting? You know, is this correct?

Is this what it should be doing? OK. And I think that really helps me to remind you of the take home messages from today's talk, which is that, although anaemia is classically split into these really nice simple categories, that's why I love anaemia, cause I love things where you can just categorise, left, right, and centre.

You can get combinations. OK, so just because something has clear evidence of blood loss as in that last case doesn't mean it hasn't got something else going on that's also contributing to the anaemia. OK.

In that case, it might also be an anaemia of chronic disease as well on top. Remember as well, normal results aren't always appropriate. So remember that case, my dog that had a normal PCV, even though it was actually quite an unwell dog.

So, that's not appropriate. OK. So, I tend to talk about results being appropriate.

I think in today's days where we have our little red highlights on our machines or our little stars or whatever that says high or low, it's very easy to skim down and go abnormals and just pick those out. But, To do it well, you're much better if you think, Well, is that what it should be? What was I expecting to see on these bloods from the clinical picture?

And because of that, you need to trust your clinical findings. OK? Your skills and your ability to just lay your hands on something and feel something and look at something goes way beyond what any machine can do.

The machine can tell you things that will help support that, but you need to trust your clinical judgement. And I know that that's harder. Now, where we're stuck in a sort of coronavirus crazy situation because you may not, you may be trying to do teleconsults and so forth, but really think about that process, you know, if it's got pale mucus membrane, is that what I expect on the bloods?

And use your knowledge, OK? Books are great, but you guys have knowledge in your heads. You know, you've, you've gone through vet school, but you've also got clinical experience.

So trust yourself, trust your instincts. If it doesn't feel quite right, if it doesn't all piece together, maybe you've got those double jigsaws, OK? And And if you really feel that, trust your instincts and go for it.

Don't feel that anyone's going to judge you for doing an extra test that turns out it was negative, because actually, sometimes your instincts will tell you there's just something not right about this case, OK? And that will help you to work out if there's concurrent things going on and get you better management. You know, we talked about the cats, with the chronic renal failure.

Yes, erythropoietin loss is a proportion of that problem, but there are other things, and we can help manage those patients better if we remember that. So I hope you've all enjoyed, today's talk and learn some more about anaemia and how we can tie things together. And good luck using this in real cases.

And at any time you want to ask me something or you just want to share something that you've done, I'd be really delighted. I'm excited to hear how this has helped you, manage your case and see what's best for the patients, which is why I'm here, right? I just love helping vets out there do the best job that they can and getting owners the best care for their pets.

So thank you for your time and enjoy the rest of your day. Goodbye.