Concurrent Ehrlichiosisand Babesiosis in A

Concurrent ehrlichiosis and babesiosis in a dog Alan R. Klag, Laurie E. Dunbar, Christine A. Girard A10-week-old intact male terrier-cross dog was pre- hemoglobinuria; and hyperbilirubinemia, bilirubinuria, sented to the Cote St. Luc Hospital for Animals on respectively) decreased our suspicion of its presence December 7, 1988 for routine examination. History in our case. The initial presence of regenerative revealed that the dog was a stray recently adopted in anemia, however, along with other clinical signs con- Greece. In accordance with Canadian regulations, the sistent with babesiosis, resulted in its inclusion as a dif- dog was examined and vaccinated by a veterinarian ferential diagnosis. A serum sample was sent to the in Greece prior to entering Canada one week before Laboratory of Veterinary Diagnostic Medicine of the presentation. Upon arrival in Canada, the owner had University of Illinois for determination ofE. canis and observed tapeworm segments in the stool but the B. canis antibody titers. Treatment with oral puppy was otherwise normal. oxytetracycline at 22 mg/kg (Apotetra, Apotex, On physical examination, the abnormal findings Toronto, Ontario) every eight hours was initiated. The were a poor hair coat, splenomegaly, pale mucous dog was also given oral metronidazole at 25 mg/kg membranes, a small pustule on the lateral maxillary (Apo-metronidazole, Apotex, Toronto, Ontario) every gingiva, and generalized gingivitis. The puppy was twelve hours for periodontal disease. bright, alert, and responsive. Initial diagnostic workup On day 2 of hospitalization, petechial hemorrhages included a complete blood count (CBC) (Table 1) and were observed on the gingiva and on the right pinna. fecal analysis which was negative. The dog was treated The stifle joints were swollen but were nonpainful. with oral praziquantel at 5 mg/kg (Droncit, Haver, Bilateral submandibular and right prescapular lym- Etobicoke, Ontario) and pyrantel pamoate at 5 mg/kg phadenopathy were now present. Urinalysis revealed (Pyr-a-Pam, rogar/STB, London, Ontario). The dog moderate proteinuria (3 +, 100 mg/dL) with no evidence was to be fed a nutritionally balanced commercial diet, of hematuria or pyuria, and a specific gravity of 1.045. and the owner was instructed to return the dog for Mucoid tubular casts were observed in the urine sedi- re-evaluation. ment. Prothrombin time, activated partial thrombo- Upon re-evaluation three weeks later, the owner plastin time, and fibrin/fibrinogen degradation prod- reported the dog to have an intermittent right hindlimb ucts were within normal limits. There was profound lameness of one-week duration, severe halitosis, and leukopenia, thrombocytopenia, and anemia (Table 1). occasional gingival bleeding. On physical examination, there was an elevated rectal temperature (39.7°C), splenomegaly, marked bilateral submandibular lymphadenopathy, and halitosis associated with general- Based on the patient's signalment and history, ized periodontal disease. Palpation of the caudal thigh a tentative diagnosis of ehrlichiosis was made muscle groups of the right hindlimb elicited pain. At this time, the patient was admitted to the hospital for further diagnostic workup (Table 1). Survey chest On day 3, little change was noted in the patient's and abdominal radiographs were obtained; marked condition. Oral prednisone therapy at 2 mg/kg (Apo- splenomegaly was found. A serum biochemical profile prednisone, Apotex, Toronto, Ontario) every 12 hours revealed a serum albumin concentration of 16 g/L was initiated in an effort to decrease peripheral cellular (normal, 24-44 g/L). A Giemsa-stained peripheral destruction of platelets (1,2). blood smear was negative for blood parasites. On day 5, the dog became hyperesthetic along the Differential diagnoses consisted of primary or sec- lumbosacral spine and was lame in both hindlimbs. ondary bone marrow suppression and/or peripheral Submandibular lymph nodes were enlarging progres- consumption or destruction of red blood cells, sively. In the afternoon, the dog became stuporous platelets, and leukocytes. Based on the patient's signal- with vertical nystagmus and intermittent opisthotonos ment and history, a tentative diagnosis of ehrlichiosis which spontaneously disappeared later that day. The was made. Although Babesia canis is also prevalent presence of intermittent neurological signs and spinal in Greece, the lack of clinical evidence of intravas- hyperesthesia were attributed to possible central ner- cular or extravascular hemolysis (hemoglobinemia, vous system hemorrhage and/or infection as a result of severe thrombocytopenia and leukopenia. Can Vet J 1991; 32: 305-307 On day 6, ecchymotic hemorrhages were observed on the left sclera. The dog was depressed. Oral prednisone Department of Medicine (Klag) and Department of Pathology was discontinued because of the lack of clinical and Microbiology (Girard), Faculty of Veterinary Medicine, response as well as the presence of University of Montreal, P.O. Box 5000, Saint-Hyacinthe, ongoing leukopenia Quebec J2S 7C6; Cote St. Luc Hospital for Animals, 5330 and increased susceptibility to opportunistic infection. Patricia Avenue, Montreal, Quebec H4V 1Z2 (Dunbar). On day 7, the right hock and elbow joint were Present address of Dr. A.R. Klag: Department of Medicine, markedly swollen and painful and, for the first time, Veterinary Hospital of the University of Pennsylvania, the submandibular lymph nodes were painful. A whole 3850 Spruce Street, Philadelphia, Pennsylvania, USA blood transfusion was given (30 mL/kg) over three 19104-6010. and one-half hours. Can Vet J Volume 32, May 1991 305 Table 1. Hematological results for a dog with concomitant ehrlichiosis and babesiosis Day of hospitalization Reference presentation 1 2 3 4 5 7 8 ranges Hematocrit (L/L) 0.24 0.17 0.16 0.16 0.14 0.18 0.13 0.17 37-55 Polychromasia, anisocytosis + + + - - - - - - Total protein (g/L) 58 60 70 68 80 ND 70 72 60-77 Leukocytes (xlO/L) 8.4 4.1 0.5 <0.5 0.5 0.8 0.7 <0.5 6.0-17.0 Platelets (x 109/L)a 120 40 40 <20 <20 <20 <20 <20 150-400 ND = Not done aEstimated count based on number of platelets observed per high power microscopic field. From day 3 of hospitalization onward, no platelets were visible in peripheral blood smears On the morning of day 9, the patient was in lateral Fibrinonecrotic foci, with the presence of small recumbency, was alert, and had extreme, generalized gram-positive cocci, were present in meninges, tonsils, myalgia and severe cervical neck pain suggestive of right submandibular and right scrotal lymph nodes, meningitis. A second blood transfusion using the same lungs, heart, and left kidney. Inflammatory cells were donor was initiated and intravenous ampicillin at totally absent from these foci. The bone marrow was 10 mg/kg (Ampicin, Bristol, Belleville, Ontario) was markedly hypocellular and primarily red cell precur- given due to suspicion of secondary bacterial menin- sors were present in the hemopoietic compartment. gitis and because of ongoing severe leukopenia. Unfor- Giemsa stains performed on liver, spleen, lung, lymph tunately, the patient died a few hours later. The E. canis nodes, bone marrow, and intestinal sections revealed and B. canis antibody titer results were received no Babesia or Ehrlichia organisms. postmortem and were 1:10,240 and 1:640, respectively, Canine ehrlichiosis and babesiosis are tick-borne confirming infection with these organisms. diseases which affect wild and domestic Canidae (2-4). At necropsy, the mucous membranes of the animal The causative agent of canine ehrlichiosis is Ehrlichia were pale. Petechiae and small hemorrhagic foci were canis, an intracellular rickettsial organism which observed in the bulbar conjunctivae, subcutaneous infects canine leukocytes, predominantly monocytes tissues, some muscles, pleura, renal cortices, and (1-3). Recently, several cases of ehrlichiosis in humans urinary bladder serosa. Generalized lymphadenopathy, have been reported (5). The causative agents of canine with severe hepatomegaly and splenomegaly, was also babesiosis are Babesia canis, B. gibsoni, and B. vogeli, present. intracellular protozoan parasites of canine erythrocytes (4). Only B. canis is found in Europe (4). Both E. canis and B. canis are transmitted primarily by the brown Anemia, thrombocytopenia, splenomegaly, dog tick, Rhipicephalus sanguineus (3,4). Concurrent canine ehrlichiosis and babesiosis is lymphadenopathy, and abnormal bleeding common. The incidence of simultaneous infection are commonly seen with both ehrlichiosis varies, according to several studies (4,6,7), and is prob- and babesiosis ably related to the geographic distribution of the agents. There have been no published reports of naturally occurring canine babesiosis in Canada. Evidence of secondary bacterial infection was char- Both canine ehrlichiosis and babesiosis can cause acterized by abscessation of the right submandibular many of the abnormalities observed in our case. and right scrotal lymph nodes, by the presence of two Anemia, thrombocytopenia, splenomegaly, lympha- small purulent subendocardial foci in the right ventricle, denopathy, and abnormal bleeding are commonly seen and by a large abscess which had destroyed the cranial with both diseases (1-4,6,8-11). The anemia present pole of the left kidney. Culture of submandibular in our dog showed initial qualitative indications of and scrotal lymph nodes and kidney yielded group regeneration; however, no evidence of regeneration G Streptococcus. was observed after

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