Vet School 101 Ehrlichia, ticks and the case of the elusive Christmas Eve diagnosis

Christmas Eve is not the best day of the year to come down with any illness that eludes obvious diagnosis. That’s what happened to the eight year-old Rottweiler who arrived as a last-minute emergency before we closed for last week’s holiday.

When she arrived, Trixie had been restless and uncomfortable overnight. Her owners suspected a serious flare-up of her arthritis and were seeking some powerful pain relievers. But Trixie’s limbs seemed no more painful to me than usual. Her back, however, was more sensitive than I’d remembered, she had a low-grade fever, and the clincher…she howled when I palpated her abdomen.

Damn! Possibly the worst day of the year for abdominal pain.

X-rays showed a significant amount of gas in her intestines. But further evaluation and a definitive diagnosis were not likely to happen in my hospital. Not when one hour remained before the staff cleared out for the holiday. Not when any bloodwork would be unlikely to get turned around by the lab until after Christmas.

To make matters worse, the specialty hospital across the street had sent out a notice indicating a communal specialist vacation. No surgeons or internists until Monday? Sorry, Trixie, you’re traveling.

At the Animal Medical Center in Cooper City, Florida, a board-certified emergency doc was holding down the fort. That was more than good enough for me. There, Trixie could get an ultrasound along with an evaluation by a specialist ideally trained to handle “acute abdomens” (that’s what we call painful bellies with no clear diagnosis).

By the time she arrived, however, Trixie’s belly and fever had relaxed. The ultrasound was negative…nothing interesting or diagnostic revealed itself. Her osteoarthritis and seemed the worst of it, according to the ER specialist. So he hooked her up with corticosteroids and opiates and sent her home for the holiday.

Though most of the extensive labwork had revealed nothing of interest, her platelet count was significantly lower than it should have been. Although her owner swore up and down that he’d never seen a tick on her, the ER doc had tested for tick borne disease anyway. Negative.

But Trixie’s condition worsened over the next 24 hours. Though Trixie’s platelet count had gone up in this time (almost certainly the work of the steroids), her overall condition was worse than ever. Her restlessness had disappeared with the heavy doses of pain medication, but now she could hardly stand and her fever was back.

So you know, a painful dog with a fever and low platelets pretty much screams out to be tested for the wily bacteria spread by ticks. But these bugs have a way of hiding inside cells as they do their dirty work. It makes tham hard to find on some tests. That’s why I re-tested her with a more specific test (despite her owner’s protests over Trixie’s ticklessness).

Here's a pic of the ehrlichia organism hiding in a white blood cell:

And guess what? She was positive for an early case of Ehrlichiosis, one of a wide variety of potentially fatal tick-borne diseases and the one we see most commonly in South Florida.

That’s when we started giving her big doses of Doxycycline, a tetracycline-like antibiotic with a high rate of efficacy against these difficult-to-reach bacteria. Within 24 hours she’d improved enough that we could taper down her dose of steroids and pain medications. And after the weekend (three days later) she’d finally reached a pre-crisis state of relative comfort.

But Trixie’s not out of the woods yet. Her discomfort may have abated. Her platelet count may be normal. Her fever may have subsided. But she’ll remain on Doxycycline for at least a month. And the long-term effects of Ehrlichiosis are yet to be determined. That’s because some dogs respond beautifully to treatment while others do so only to relapse later with the “chronic form” of the disease. (Read more about the different forms of ehrlichiosis here.)

Most tick-borne diseases have a way of working insidiously. Not only are they hard to diagnose in cases like Trixie’s, they’re often hard to treat, too. Sometimes dogs will present with symptoms even more non-specific than Trixie’s. Sometimes the platelets will be normal and no pain or fever will be evident. Sometimes they just seem tired, leaving us to work them up for cardiac disease, thyroid malfunction and other red herrings.

And sometimes, as in Trixie’s case, they’ll come up negative on the ER doc’s SNAP test, too (this test looks for antibodies against Ehrlichia canis, one of several varieties of the organism). If the dog is tested very early on in the process the antibodies may not be present yet. And if the organism doesn’t exactly conform to the standard Ehrlichia canis bug but to another less common version of ehrlichia then it’s possible that no standard blood test will ever prove the presence of this bacteria.

Luckily, we have a new test for ehrlichia that’s closer to foolproof than any of the SNAPs and antibody titer measuring tests. It’s called PCR and it looks for minute quantities of the bacteria’s DNA in a blood sample. Trixie’s was positive. So was her antibody titer just one day after the ER’s SNAP.

The same can be true for humans who suffer Lyme and other tick-borne diseases (yes, humans can get ehrlichiosis, too, though not from their dogs). Varied symptoms like chronic fatigue, transient joint pain, flu-like symptoms and even nervous system effects can make diagnosis difficult in humans. In fact, I had one friend whose Lyme disease was first diagnosed as multiple sclerosis (!) before one smart, second-opinion neurologist caught the infection.

In Trixie’s case the confounding element was her historical lack of ticks. But we all know that just one tick has the capacity to spread disease. So here’s the message in this good news case:

Whether your dog gets ticks or not, whether you’ve actually seen a tick or not, whether your dog has obvious symptoms or not, tick disease IS possible. Letting your vet work up a suspicious finding as seemingly innocuous as a slight drop in her normal platelet level is always a good idea.

There may be a lot about tick-borne diseases we don’t understand. But one thing this South Floridian does know is that her dogs will keep getting tick meds…whether I see a tick or not.

PS: Here are the ticks that carry ehrlichia. The first is the "lone star" tick. The second is the brown dog tick.

January 2nd, 2009

Add Comment42 Comments

Ugh, they are so, so, so creepy! There are very few things that make me 'scream like a girl' but ticks are on that very short list. I hates them, and when I got my first one on me this past summer, oit was the most satisfying thing in the world to watch it smother under a giant glob of soap gel.

KateH January 2nd, 2009 11:16:18 AM

What an exciting column for me to read, Dr K. I've battled chronic neuro Lyme with one dog & chronic Lyme- like symptoms in yet another whose dam presented with Lyme symptoms after she received the old Lyme vaccine. When my present greyhound was only 7 months old his activity level alone told me we were probably dealing with something tick borne so I asked my vet to run an IDEXX Snap 4DX. Sure enough he was positive for what was previously known as Ehrlichia Equi now Anaplasma phagocytophilum. (How I wish the disease hadn't been shifted to an anaplasma just for name alone) To verify the Snap test I sent blood to ProtaTek Ref. Lab in AZ & again a positive. I treated him aggressively for 8 weeks & I suspect because I caught it so early he's been fine ever since. I do a Snap test at least yearly on both dogs as I'm in CT where ticks are also rampant. For those who might be interested there's a wonderful internet group that's comprised of many tick knowlegeable people. It's a Listserv discussion group called the Tick-L. Having been involved with racing bred greyhounds for so long, I was one of a number of people who were original Tick-L members because of the prevalance of both B & E. canis in racing dogs. It was a way adoption people all over the country could come together to share information about these diseases. Although PCR is surely the gold standard for identifying a tick disease, we've found if the bug isn't circulating in the blood but is sequestered somewhere in an organ, results will yield nothing. So numberous samples could be needed to find what you're suspecting. Forgive the length of this missile. I do tend to get carried away when TBDs are discussed.

Ellie January 2nd, 2009 12:20:58 PM

There's also the frustration of what to do with a dog who tests positive on a SNAP but shows no clinical signs. Since SNAP tests only indicate exposure, not active infection, do you treat if the dog shows no clinical signs? They are teaching us now that it's not justified to treat just because of a positive SNAP, but that a lot of vets will put them on a course of doxy anyway.

Lousy ticks!

Megan January 2nd, 2009 12:53:04 PM

Here in Western New York we don't really deal with ticks much - pets get flea & tick and heartworm preventative and that's about it. Reading this made me wonder what to look out for in different parts of the country - for example, my friends in Arizona have to be careful their pets don't get out unsupervised (even in their own yard) because of coyotes. It'd be interesting to know what the major dangers are in different regions.

Shirley January 2nd, 2009 12:57:43 PM

We found PopCorn Christmas Eve about 6 yrs ago. We'd seen her several times and she kept getting skinnier. The owners of the house where she was seen the most said she'd just showed up. It was 20F with wind chill of much less that night so we brought her home. A few weeks later, we assumed she was very pregnant and took her to the vet. No, it was her spleen that was so large. It took up a huge space in the chest cavity and most of the belly. Blood tests showed she was Ehrlichia positive. She was on Doxycycline for a month and the spleen shrunk to normal size by the end of that. Funny thing is that she has tested higher for Ehrlichia since then but the spleen has been normal sized.

Four weeks ago, she stopped eating. She was anemic and had a huge mass on her spleen. The next morning, the spleen and the mass were removed (for a combined 5+lbs). The mass was fibrous-something-nodules, a slow growing cancer. We had assumed the round belly was just the Ehrlichia.

Here in the mountains of western NC, ticks are more numerous than fleas. Some dogs seem to be tick magnets and others rarely have one. All our dogs are tested each year but she's the only one that's got any tick disease.

PaulaO January 2nd, 2009 01:13:11 PM

Megan: OK so I know it's not always justified to treat on a positive SNAP, but I will if I get a follow-up titer and that's positive, too. PCR is a good idea in these cases, too, but sometimes visualizing the organism on a blood smear will justify your course of Doxy as well. In fact, that's the best test in some ways--cheap, quick and unmistakably positive--but unfortunately you won't often find the nasty bugs on a simple smear.

Dr. Patty Khuly January 2nd, 2009 02:01:21 PM

Ellie: Thanks for the mention of the groups. I've seen a lot of great information come out of them. I'll bet you know more about Lyme than I do.

Dr. Patty Khuly January 2nd, 2009 02:03:08 PM

But I'll bet, Dr Patty, that you know a whole lot more about E.canis than I'd even care to know. I was looking at a US map the other day showing the distribution of tick diseases across the country. CT, where I live, still has a higher % of Lyme than A. phagocytophilum but the Anaplasma is quickly catching up. Lots of co-infections here. Here's a great paper created by one of the most informed member of the Tick-L for a comprehensive review of Tick Borne Diseases: http://dogsandtickdisease.googlepages.com/home

Ellie January 2nd, 2009 02:13:35 PM

Yikes. hope she gets well soon.

We are fighting E.canis with Goodman right now. Apprently those buggers where actaully seen in his blood at the lab.

Poor Goodman is taking Prednisone and Doxycycline, and suffering from multiple side effects from the Pred: loose stool, increased apetite and PU/PD.

Next Friday we will be taking his blood again, and will see if his plateltes are up or not. Keeping my fingers crossed...

Xslf January 2nd, 2009 02:51:52 PM

Ellie: Thanks for the map idea. Here's one for ehrlichiosis cases:

Dr. Patty Khuly January 2nd, 2009 04:35:57 PM

Oops. the map says it's for Lyme, Anaplasma and Heartworm, too, but I only clicked on the Ehrilichia color. If you want to see the results for these other cases go here.

Dr. Patty Khuly January 2nd, 2009 04:37:55 PM

Oh just great, now I see it officially--another tick disease in my area! Actually, my niece was diagnosed with erlichia not too long ago.

I have 3 lyme positive dogs (almost converted sero-neg). All were occasionally slightly lethargic, intermittent feverish, reluctant to go out in the morning, and one was off food. NO serious lameness or leg joint swelling. It was the yearly test that brought the diagnosis, not the symptoms!

And, it took several "repeat" treatments, to get that titer dropping to within reason!!

Well, I feel pretty good about those yearly CBC's, I'm looking for the 'abnormal' platelet increase (that hints the big C, along with the alk phos) and now I'll be eyeing any decrease too.

Great update, hope Trixie does well. Barbara A. Albright

Pocket's Story from NH January 2nd, 2009 05:43:08 PM

Tick borne illness scare the crud out of me.. I've seen my share of them with humans.. Besides using Heargard, and Frontine, what other precautions can be taken? I haven't seen ticks on Socks in a couple of years.. Once was more than enough... I picked him up at my brothers, and pulled four off.. and that was it.. I give him a body rub at night.. and his hair is very fine, so I can feel his body..

barri January 2nd, 2009 06:12:13 PM

Thanks for the timely post. I'm busy researching what to do about the faint positive anaplasmosis my dog got on his snap test. His CBC was normal, but I'm not comfortable waiting 6 months to a year for retest. I think I'm headed back to ask about IFAs and other options. I'm not sure I want to take chances, given what I've read.

Jean January 2nd, 2009 11:42:23 PM

Dr. Kuhly: I guess I am thinking less about ehrlichiosis and more about lyme- in MN, there is a 50/50 chance that a deer tick carries lyme, but only about a 5% chance that a deer tick carrying lyme will cause clinical disease if it attaches to a dog for the appropriate amount of time. So, there is a much greater likelihood that a dog will have a positive SNAP (indicating exposure to lyme) than will have actual clinical disease caused by lyme. It doesn't help that the darn disease is one of the "nebulopathies", with no great list of classical presentations.

Having thought I might have had lyme once (developed a bullseye lesion while I was researching white-footed mice in deer country... yikes!), I have a particular dislike of it amongst the tick-borne diseases. :-/

Megan January 3rd, 2009 07:58:30 AM

Megan: Did your physician automatically initiate Doxyxyline therapy in your case? What lab test were run? Just curious.

Dr. Patty Khuly January 3rd, 2009 08:32:07 AM

My physician looked at the bulls-eye, said it didn't look like a lyme lesion, and sent me home. :-/ I went back to the clinic six months later and asked that a lyme titer be taken in addition to the rabies titer that I was due for. Sometimes I wish I could just go to the vet!

Megan January 3rd, 2009 02:19:24 PM

Megan, The thing that scares me about the "5% statistic of clinical disease" is if the profession poopoos or opts not to treat. Non-specific symptoms are often explained away or overlooked. At the very least, initiate treatment or insist on a follow-up titer for positive snap.

All I think back to was the widespread report , us Scottie folks received, on the young Scottie misdiagnosed in PA. for his "lameness", put on Rimadyl and went into liver/kidney failure within 10dys, (died)& it was learned, too late, that he had advanced lyme.

I'd rather treat than let a disease silently advance. B. Albright

Pocket's Story from NH January 3rd, 2009 04:51:19 PM

I'd rather treat than let a disease silently advance.

But where do you draw the line? Doxycycline is an antibiotic, and with all the concerns of resistance and overuse, is it justifiable to treat every dog with a positive SNAP? I very much agree on insisting on a follow-up titer, but not on initiating treatment. If the dog isn't clinical, the SNAP test might just be telling you that the dog was exposed to a tick carrying lyme, generated antibodies, and cleared the infection on its own. The SNAP only tells you about exposure, not about disease status.

I think the case you point out is a sad story of a misdiagnosis, but doesn't support the use of doxy for every dog that tests positive for lyme. That scottie wasn't tested, so the appropriate course of action wasn't followed.

Megan January 3rd, 2009 05:04:59 PM

Megan ~ Do join the Tick-L because the questions you raise have been addressed & responses are in the list archives.

Ellie January 3rd, 2009 06:48:30 PM

It's hardly surprising that an animal could be exposed to tick-borne diseases without the owner noticing a tick -- those are sneaky little critters! Last fall one of my cats had one tucked away in the crook of his hind leg (not armpit but legpit or whatever you call it). How often do you run your hands over your pets back there? By the time I found it, it was hugely fat and could have been on for days.

T.T. January 3rd, 2009 08:59:04 PM

Thanks for the website, Dr. K! When I looked at that, I see that Michigan had more positive heartworm cases reported than Florida in that time period! That will be a good talking point with the clients we get in who think that Michigan doesn't have heartworm!

Sassy January 4th, 2009 08:52:36 AM

Sassy: I completely agree. The reason Florida sees less HW cases than you might expect it to comes down to how compliant our clients are with our prevention reommendations. And yes, I'm proud of that.

Dr. Patty Khuly January 4th, 2009 09:52:58 AM

I learned long ago that given a reprieve from winter weather - a January thaw, if you will - mosquitoes can appear here in CT. Perhaps in colder climates like that of MI, folks don't use heartworm preventative all year round as you must in more moderate climes.

Ellie January 4th, 2009 05:15:13 PM

My beagle has chronic ehrlichia (diagnosed over 2 years ago, treated with Doxy for 6 weeks and has had maybe 6 flare-ups, we moved on to amoxicillin after doxy stopped working, no major flare-ups in over a year)and although he has not had a flare up of lameness (his symptom) He has started gettting very aggressive at times with our old dog who has been his companion for about 6 years. when this happens he looks like he has lost touch with reality. Can ehrlichia affect the brain and cause aggression? Has anyone else had this kind of behavior?

Penny January 21st, 2009 07:12:56 PM

thank you for asking that question Penny! My 2.5 year old bassett hound resently showed some aggression. It was sudden and inconsistent so i took him to the vet after extensive tests and b/w he was tested for this disease. When the vet cytologist looked at his blood under the microscope, he saw something indicative of the disease. We are still waiting for final test results but we were told that its a strong possibility that he has been infected with ehrlichia! We live in RI and its rare here i'm told but my dog was rescued from down south were its far more common. Unfortunatly this has gone undiagnosed because he has not exhibited any of the "classic" symptoms in the year he's been with us.

jen March 13th, 2009 03:13:36 PM

My baby, Fox, did not have almost any of the severe symptoms that Trixy had. However, since she's sleeping next to me, every night, and since I really o know her well, I senses that something was wrong.

After numerous test, blood samples, and a very heavy bill, Fox was finally diagnosed with the same disease. The vet told me that everything should be fine, the worse that could happens, if Fox does not respond to the treatment, is that she'll need steroids for live.

Well, thats okay.

Nevertheless, Fox showed great improvement, and actually, she was improving day by day. She got her steroids everyday, as well as he Doxycycline .

Since she was diagnosed, until date, is about 6 weeks, I guess.

I took Fox for a checkup (full blood count) every single week. And results shown that she's really getting better. Last week, I had Fox at the vet, for her normal checkup.

So 2 days ago, I got the following email(s) from my Vet.

I have just received Fox's latest blood results and am very sorry to report that things are not looking good and she has deteriorated again. The fact that she is not eating or drinking is also very worrying. I think you are seeing patches of blood as she is haemorhaging again because she is not making enough platelets (which clot the blood) as the disease is affecting her bone marrow. We hoped that the steroids (white tablets) would counter the disease in her bone marrow and stimulate her to make more platelets and white blood cells, however the treatment is not working and both counts have fallen dramatically since her last tests. We can try increasing the dose of steroids however I no longer think that this will be in Fox's best interests as the prognosis for full recovery is now very poor and although it is heart breaking it may be kindest to have her euthanased. I know that Fox means the world to you and you will be devastated at this sad news but I don't think either of us want to watch her deteriorate anymore. I have spoken to a specialist at a referal centre about her disease progression and they agree that we have treated her correctly and done everything we could for her but sadly on some occasions when the disease is effecting the bone marrow then recovery is not always possible.

So, I took Fox back, and apparently there's just nothing to be done. I can't let my baby go, and I'm supposed to put her to sleep today, but I'm convinced there must be SOMETHING to be done.

My question is this;

Fox did not had any of the common severe symptoms. She's acting okay, well yeah, she is not as she used to be, but I even took her for her daily walk this morning.

I cannot just accept that nothing can be done. I might accept that I have to let her go, but, how is it possible that she cannot survive, after she just improved???

I would appreciate ANY recommendations and advice. And do you think I should take her for a second oppinion?

Right now she is sleeping on my lap. I've given her all my love and everything lin life.

I don't doubt my vet's diagnoses, not at all.

Here's a picture of Fox.

Fox

Derek March 18th, 2009 04:43:06 AM

Well, thats okay.

Nevertheless, Fox showed great improvement, and actually, she was improving day by day. She got her steroids everyday, as well as he Doxycycline .

Since she was diagnosed, until date, is about 6 weeks, I guess.

I took Fox for a checkup (full blood count) every single week. And results shown that she's really getting better. Last week, I had Fox at the vet, for her normal checkup.

So 2 days ago, I got the following email(s) from my Vet.

...she has seemed to respond so well to treatment initially but her white blood cell count never reached a normal level back from the first diagnosis (the other cells did seem to repond at fisrt) and I think she has completely depleted her reserves now and the fact that her bone marrow is not producing any more cells is the cause of her deterioration-in simple terms she has run out of white blood cells and can't make any more as her bone marrow is so badly damaged.

So, I took Fox back, and apparently there's just nothing to be done. I can't let my baby go, and I'm supposed to put her to sleep today, but I'm convinced there must be SOMETHING to be done. And just a note, Fox IS eating now.

My question is this;

Fox did not had any of the common severe symptoms. She's acting okay, well yeah, she is not as she used to be, but I even took her for her daily walk this morning.

I cannot just accept that nothing can be done. I might accept that I have to let her go, but, how is it possible that she cannot survive, after she just improved???

I would appreciate ANY recommendations and advice. And do you think I should take her for a second oppinion?

Right now she is sleeping on my lap. I've given her all my love and everything lin life.

I don't doubt my vet's diagnoses, not at all.

Here's a picture of Fox.

Fox

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Vet School 101 Ehrlichia, ticks and the case of the elusive Christmas Eve diagnosis

January 2nd, 2009

Add Comment42 Comments

KateH January 2nd, 2009 11:16:18 AM

Ellie January 2nd, 2009 12:20:58 PM

Megan January 2nd, 2009 12:53:04 PM

Shirley January 2nd, 2009 12:57:43 PM

PaulaO January 2nd, 2009 01:13:11 PM

Dr. Patty Khuly January 2nd, 2009 02:01:21 PM

Dr. Patty Khuly January 2nd, 2009 02:03:08 PM

Ellie January 2nd, 2009 02:13:35 PM

Xslf January 2nd, 2009 02:51:52 PM

Dr. Patty Khuly January 2nd, 2009 04:35:57 PM

Dr. Patty Khuly January 2nd, 2009 04:37:55 PM

Pocket's Story from NH January 2nd, 2009 05:43:08 PM

barri January 2nd, 2009 06:12:13 PM

Jean January 2nd, 2009 11:42:23 PM

Megan January 3rd, 2009 07:58:30 AM

Dr. Patty Khuly January 3rd, 2009 08:32:07 AM

Megan January 3rd, 2009 02:19:24 PM

Pocket's Story from NH January 3rd, 2009 04:51:19 PM

Megan January 3rd, 2009 05:04:59 PM

Ellie January 3rd, 2009 06:48:30 PM

T.T. January 3rd, 2009 08:59:04 PM

Sassy January 4th, 2009 08:52:36 AM

Dr. Patty Khuly January 4th, 2009 09:52:58 AM

Ellie January 4th, 2009 05:15:13 PM

Penny January 21st, 2009 07:12:56 PM

jen March 13th, 2009 03:13:36 PM

Derek March 18th, 2009 04:43:06 AM

Derek March 18th, 2009 04:45:13 AM

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