'Candidatus Mycoplasma Haemominutum' in a Cat with Immune-Mediated Hemolytic Anem
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224Case report Vlaams Diergeneeskundig Tijdschrift, 2012, 81 Coinfection with Mycoplasma haemofelis and ‘Candidatus Mycoplasma haemominutum’ in a cat with immune-mediated hemolytic anemia in Belgium Co-infectie met Mycoplasma haemofelis en ‘Candidatus Mycoplasma haemominutum’ bij een kat met immuungemedieerde hemolytische anemie in België C. van Geffen Algemene Dierenkliniek Randstad Frans Beirenslaan 155, B-2150 Borsbeek [email protected] ABSTRACT A young male domestic Shorthair was presented with weakness and anorexia of two days’ du- ration. Physical examination showed pale mucous membranes, caused by severe, regenerative, Coombs’ positive, hemolytic anemia. A blood smear revealed epicellular organisms compatible with Mycoplasma spp. Real-time polymerase chain reaction (RT-PCR) on EDTA blood identified these or- ganisms as Mycoplasma haemofelis and ‘Candidatus Mycoplasma haemominutum’. Despite the lack of clearance of the organism from the blood, the cat responded well to antibiotic treatment with doxycycline, together with immunosuppressive doses of corticosteroids. SAMENVATTING Een jonge, mannelijke huiskat werd aangeboden voor zwakte en anorexia die reeds twee dagen aan- hielden. Op klinisch onderzoek werden bleke slijmvliezen gezien, veroorzaakt door erge, regeneratieve, Coombs’ positieve, hemolytische anemie. Een bloeduitstrijkje toonde epicellulaire organismen aan, com- patibel met Mycoplasma (vroeger bekend als Haemobartonella felis). Real-time polymerase chain reac- tion (RT-PCR) op EDTA-bloed identificeerde deze organismen als Mycoplasma haemofelis en ‘Candida- tus Mycoplasma haemominutum’. Ondanks de blijvende aanwezigheid van de organismen in het bloed, reageerde de kat goed op antibioticatherapie met doxycycline, samen met een immunosuppressieve dosis corticosteroïden. INTRODUCTION this infection to be present in cats worldwide (Duin et al., 2009, Fujihara et al., 2007; Gentilini et al., 2009; Hemobartonellosis or feline infectious anemia is Willi et al., 2006). caused by gram-negative bacteria that attach to the The incubation period after infection with Myco - outer surface of host erythrocytes. Previously, they plasma haemofelis varies from weeks to months, and were classified into genus Haemobartonella, family is followed by cycles of bacteremia which may last for Anaplasmataceae, order Rickettsiales. Recently, mo- months. Infected erythrocytes are less deformable in lecular techniques have resulted in a reclassification of circulation and elicit an immune response with subse- these organisms. Phylogenetically, they seem to be quent phagocytosis in lymphoid organs. Massive in- more closely related to organisms of the genus My- fection or severe anemia may result in death. Other an- coplasma. Two closely related species have been de- imals will recover but remain carriers despite their tected, and they have recently been renamed again. immune response to the organism (Giger, 2005). Treat- Haemobartonella felis ‘Ohio strain’ or ‘large form’ is ment includes antibiotics, such as doxycycline, sup- currently called Mycoplasma haemofelis (Neimark et portive treatment with blood products in severely ane- al., 2001). Haemobartonella felis ‘California strain’ or mic animals, and possibly corticosteroids to halt ‘small form’, which seems to be a low-virulence bac- immune-mediated destruction of erythrocytes (Har- terium, has been given a candidate species name ‘Can- vey, 2006). didatus Mycoplasma haemominutum’ (Foley and Ped- ersen, 2001). Some years ago, a third feline CASE REPORT hemoplasma species was identified in Switzerland, and was named Candidatus Mycoplasma turicencis A 1.5-year-old, male, castrated domestic Shorthair (Willi et al., 2005). Recent studies have documented was presented with weakness and anorexia of 2 days’ Vlaams Diergeneeskundig Tijdschrift, 2012, 81 225 Figure 1. Blood smear from a cat infected with Myco - Figure 2. Blood smear from a cat infected with Myco - plasma organisms (Diff-Quick, magnification 1000 x). plasma organisms (Diff-Quick, magnification 1000x). Several Mycoplasma organisms are attached in an epi- Howell-Jolly bodies (black arrow), nuclear remnants, cellular location on erythrocytes (white arrows). A nu- should not be confused with red blood cell parasites. cleated red blood cell or normoblast (black arrow) is also Epicellular Mycoplasma organisms are indicated by present. white arrows. duration. The cat was mainly kept indoors and was cur- PCR, and revealed the presence of both Mycoplasma rently on vaccinations. There was no history of recent haemofelis (organism load of 2.4 x 106/mL of blood) drug administration or ectoparasite control. Recently, and ‘Candidatus Mycoplasma haemominutum’ (or- a young stray cat has also been adopted in the house- ganism load of 1.5 x 106/mL of blood). hold. Physical examination revealed a lethargic cat The cat tested negative for feline leukemia virus with pale and mildly icteric mucous membranes, mild (FeLV) antigen (ELISA) and feline immunodeficiency tachycardia (180 beats/minute) and a low-grade sys- virus (FIV) antibodies (immunofluorescence antibody tolic murmur. Femoral pulses were bounding. Respi- test). Lateral and ventrodorsal chest radiographs were ratory rate and rectal temperature were normal (36 within normal limits. Abdominal ultrasound revealed breaths/minute and 38.6°C, respectively). The right mild diffuse splenomegaly with normal echogenicity. prescapular lymph node was mildly enlarged. Ab- Fine needle aspirates of the right prescapular lymph dominal palpation was unremarkable. node had a normal cellular distribution with the pre- A complete blood count (CBC) revealed a severe dominance of small lymphocytes. normochromic (mean corpuscular hemoglobin con- Intravenous fluid therapy (Hartmann®) was given at centration / MCHC 36.0 g/dL [reference 30-36 g/dL]), maintenance rate. A fresh blood transfusion was con- macrocytic (mean corpuscular volume / MCV 62 fl sidered but postponed until absolutely necessary, be- [reference 37-55 fl]), regenerative anemia (hematocrit cause of financial concerns of the owner. Despite the 8.1% [reference 24-45%] with an absolute reticulocyte severe anemia, the clinical and cardiorespiratory pa- count of 338000/µL [reference < 40000/µL]). Leuko- rameters remained stable during the following days. cytes were within normal limits. The biochemistry Medical treatment included doxycycline (Vi- profile showed normal total protein (7.5 g/L [reference bramycine® 5 mg/kg twice daily) combined with an im- 5.4-8.2 g/L]) and albumin concentrations (3.6 g/L [ref- munosuppressive dose of parenteral dexamethasone erence 2.7-4.5 g/L]), as well as normal renal parame- (Rapidexon® 0.4 mg/kg once daily) initially, and oral ters, liver enzymes and electrolytes. However, the prednisolone (Prednisolone® 1 mg/kg twice daily) af- bilirubin concentration was increased (2.8 mg/dL [ref- ter the cat regained his appetite. A repeat blood smear erence 0.1-0.6 mg/dL]). Urinalysis was normal except on the second day of hospitalization no longer re- for bilirubinuria. A direct polyvalent Coombs’ test vealed Mycoplasma organisms. Signs of regeneration (Nordic, Tilburg, the Netherlands) was found strongly became more prominent (polychromasia, anisocytosis positive (titer 1:4096). A fresh blood smear was stained together with the presence of many normoblasts). A with Diff-Quick. A regenerative response was clearly CBC on the 6th day revealed a rising hematocrit demonstrated by the presence of polychromasia, aniso- (22.9%), with a MCV of 76.6 fl, the latter indicating the cytosis and a moderate number of normoblasts and presence of larger sized reticulocytes and thus an on- Howell-Jolly bodies (Figures 1 and 2). Heinz bodies going regenerative response. At that time, the systolic were absent. Several erythrocytes showed one or more murmur was no longer audible, suggesting that it was epicellular organisms resembling Mycoplasma spp. most likely caused by altered blood viscosity during the (Figures 1 and 2). An EDTA-blood sample was sent by severely anemic state. regular mail to a veterinary laboratory specialized in The cat was sent home with oral doxycycline (Vi- molecular diagnostics for confirmation, characteriza- bramycine®) 5 mg/kg twice daily for three weeks and tion and quantification of the organisms by real-time tapering doses of oral prednisolone (Prednisolone®, 1 226 Vlaams Diergeneeskundig Tijdschrift, 2012, 81 mg/kg twice daily starting dose). Furthermore, a result in exposure of hidden antigens or changes in ex- monthly flea prevention with fipronil (Frontline®) was isting antigens, thereby activating the production of prescribed. Four weeks later (and five days after dis- host anti-erythrocyte antibodies. The anemia mostly re- continuation of prednisolone), the physical examina- sults from extravascular erythrophagocytosis by tion, blood work, fresh blood smear, Coombs’ test and macrophages in the spleen, liver, lungs and bone mar- PCR for both Mycoplasma organisms were repeated. row (Harvey, 2006). Other conditions, such as inflam- According to the owner, the cat made full recovery and matory, infectious and neoplastic diseases, may result in was again alert and playful. The mucous membranes the immune-mediated destruction of erythrocytes in cir- were pink and the cardiac auscultation was normal, as culation or lymphoid organs. A thorough work-up, in- was the rest of the physical examination. The hemat- cluding retroviral testing, chest radiographs and ab- ocrit and red cell indices had returned within