Page 4 - Clinical Connections - Summer 2024

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Emergency case
COMPLEX IMMUNO-MEDIATED HAEMOLYTIC
ANAEMIA CASE

Clara Mattavelli, Emergency and Critical Care Resident

ollowing a stick ingestion, Daphne, We suspect the IMHA may have been
a four-month-old whippet puppy, triggered by the penicillin-based antibiotic
F had a gastrotomy at her local vets. and/or systemic inflammatory response
A few hours later she was referred to RVC syndrome (SIRS) associated with the
Small Animal Referrals due suspected post- recent sepsis. As a consequence, Daphne’s
operative pyothorax. antibiotic was changed to marbofloxacin.
On her first admission to the RVC, Daphne Given that her packed cell volume (PCV)
was presented to our Emergency Referral remained static, and Daphne was clinically
Service with lethargy and dyspnoea. She stable, we decided to monitor her rather
was diagnosed with a diaphragmatic than commence immunosuppression at that
tear, causing a septic abdomen and point.
concurrent pyothorax, with evidence of Daphne rapidly improved, appeared
pneumoperitoneum and pneumothorax bright and demonstrated a good appetite.
and the presence of a gastric foreign body A very mild positive in-saline agglutination
(Figure 1). was still present at the point of discharge
three days later. However, the anaemia
was strongly regenerative and there was a
progressive increase in Daphne’s PCV.
In the following weeks, Daphne went for
Figure 2: Daphne’s severely pale mucous periodical rechecks at her local practice.
membranes, due to her anaemia on
readmission Blood tests showed a progressive resolution
of her anaemia and normalisation of her
Second RVC admission white blood cell count and morphology. She
Haematology showed marked anaemia completely recovered (Figure 3) and never
Figure 1: Transversal CT image (post-contrast with positive in saline agglutination and mild required immunosuppressive treatment.
lung window) showing mild pneumothorax and
pneumoperitoneum, pleural and peritoneal evidence of intravascular and extravascular
effusion and gastric foreign material haemolysis, suggestive of immune-
mediated destruction (IMHA). Point-of-care
Daphne successfully underwent emergency ultrasound excluded severe
exploratory laparotomy, gastrotomy and post-operative haemorrhage.
diaphragmatic tear repair. She recovered Daphne received an emergency
well from the procedure and was initially packed red blood cell transfusion upon
discharged. However, Daphne represented her readmission. Due to her recent
the next day critically ill (Figure 2) as she history of bicavitary sepsis and major
had developed severe anaemia. surgery, the team opted not to commence
immunosuppressive steroid treatment.

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4 Summer 2024