ERHLICHIOSIS By Deborah S. Harper
(First published in the Corgi Cryer, magazine of the Mayflower PWCC)
"Penny died -Cosi will survive".  As Dr. Kruesi told me the night she died, 'Penny had a purpose on earth.  She opened the door for others.'  Her death made me question all the learned vets involved, and I could not accept their explanations.  She was sick for a year and dying for six months of that year, and no one could help. A few minutes before she died she pulled her head up, her eyes were brilliant, her ears were stiff, and she demanded that I find out why.  She looked like a two-year-old puppy.  Then she died, and there was nothing but a sack of bones, very little flesh; but her spirit was in the air.  She wasn't finished yet.
Thus wrote Pat Dejan remembering the loss of her beloved Corgi from undiagnosed Ehrlichiosis described as "encephalitis of unknown origin and internal bleeding of the major organs."  At one point Penny was thought to have Cushing's Disease.  She spent nine days with a canine neurologist.  She had a CAT scan and other tests run.  She did have a high, active Western Blot score indicating Lyme Disease and a compromised immune system, but the CBC (complete blood count) values were within normal ranges. After the results of a Super Chem blood test were studied and her nutrition was adjusted to her needs, she had three months of relative health.  But she started bleeding from her nose and gums, her spleen was swollen, she had a urinary infection, and a test showed she had severe glomerulonephritis (a disease of the kidneys).  A new vet, Dr. Kruesi, finally ran an IFA (indirect fluorescent antibody) test that detects antibodies for tick-borne diseases.  That, plus her varied symptoms, pointed to Ehrlichiosis.  But it was too late.  She could not be put on the medication that could have saved her months earlier, because her organs could not handle the stress and she was dying.  Her autopsy showed her heart to have walls eight times as thick as normal and her other major organs in total disrepair.  Penny fought for her life with all her Corgi spunk, but lost.
And now Cosi has been diagnosed with the same killer disease.
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At this point it is a safe guess that most people in our area are all too familiar with Lyme Disease that is transmitted primarily through the bite of a tick.  Dog and man alike have suffered the ravages of this well-publicized illness.  Fortunately, these days diagnosis and treatment are relatively simple, and most patients recover fully with no lasting ill effects.
It is time to learn about the similar but much more deadly tick borne disease, Ehrlichiosis.  It is here.  It is spreading.  It is not being diagnosed.  Corgis have died from it. Those with Internet access are encouraged to read the most informative, 14 page article, Ehrlichiosis, A Silent and Deadly Killer, by Jan Hendricks and Bob Wilson, two Border Terrier people.  Much of the following is excerpted from this comprehensive paper along with other material gleaned from The Net and elsewhere by Pat Dejan.  Sources are listed at the end of the article.
SOME BACKGROUND
The disease is caused by an organism in the Rickettsiae family of the genus Ehrlichia that has features common to both viruses and bacteria, but is classified with bacteria.  It is related to Rocky Mountain Spotted Fever. Although there may be several Ehrlichia species responsible, for the most part it is E. canis and E. risticii, sometimes both at the same time, which are found in our dogs. Usually the organism is transmitted via a tick bite, but other insects, birds and even horse manure can be a vector. Creatures, such as mice, rats and certain mammals, can be carriers, but do not get the disease themselves. This is what happens with the deer and mice that are carriers for Lyme Disease, another tick-borne disease, caused by the spirochete Borrelia burgdorferi.  Again thanks to ticks, Babesia, a protozoa which infects red blood cells, is also found in our area. These organisms can be transmitted through the placenta or by contaminated blood.  (Item: The most dangerous time for tick bites in the Northeast is between May and September when the ticks are in the infectious nymphal stage.  Also, it takes about 24 hours before the tick transfers the organisms from its body to the host.)
 Ehrlichia were first described in 1935 in Algerian dogs, and in 1962 several dogs involved with the fighting in Vietnam were found to have died of Ehrlichiosis.  Spreading rapidly within the past few years, cases have been reported throughout the United States and in Canada, Europe, Asia, South America and Africa.  Florida and Texas are hotbeds of infection.  Closer to home, Dutchess County, New York, has reported over 100 diagnosed cases, and heavens knows how many have been undiagnosed. The Institute of Ecosystem Studies in Millbrook, NY, found 25% of the ticks collected carried Erhlichia!
Ehrlichiosis is an infectious disease of the blood.  The organisms live and reproduce in the white blood cells and wreak havoc with the body's immune system with a particularly disastrous effect on the lymphatic network.  The bone marrow is prevented from replacing the white blood cells fast enough.  With the compromised immune system, the body is prone to secondary infections.  Eventually the disease will destroy multiple organs, cells and the central nervous, respiratory and circulatory systems.  Total disaster!
The disease has three stages.  The first is the acute stage of short duration that often mimics a mild viral infection and may even go unnoticed in a stoic dog like a Corgi.  If caught at this time, most of the destruction is reversible, and a dog can be returned to full health.  The second stage is subclinical, may last weeks, months or years, and is followed by the final, chronic stage.  Alas, at this juncture the organism is entrenched in the bone marrow and organs, and the damage done is irreversible.  In spite of heroic efforts, the victim may succumb to massive internal hemorrhage, severe, secondary autoimmune disease, stroke, seizures, heart attack, or failure of the kidneys, liver or spleen.  Often the end comes quite rapidly.  The pace is affected by the strength of the dog's immune system, level of stress, concurrent diseases/conditions, use of corticosteroids, and, of course, treatment.  Even if caught in time, it may take up to a year before blood values reveal the infection has passed completely.  What is more, past infection with Ehrlichiosis does not impart protective immunity. 
Obviously, early detection and treatment are imperative, but, unfortunately, not easy.  The biggest problem is that symptoms mimic many other diseases and/or are varied, mild and subtle.  It is confusing and vague, even misleading.  A veterinarian not considering Ehrlichiosis in the acute stage may prescribe a broad spectrum antibiotic or perhaps a steroid.  Almost any antibiotic not in the tetracycline group is totally useless, and steroids are contraindicated.  Once in the chronic stage, precious time and a great deal of effort and money are lost chasing down diseases with similar symptoms such as Lyme Disease,  Coomb's Disease, Cushing's Disease, Lymphoscarcoma, Leukemia, Lupus, or Endocarditis.  The list goes on and on.  Erhlichiosis should be ruled out before accepting any of these diagnoses.
SYMPTOMS
Early symptoms include general fatigue, loss of interest in play, a poor coat, bad breath, a cough, poor appetite, weight loss, diarrhea, vomiting bile, enlarged spleen or lymph nodes, red eyes, a glassy look, a "headache", trouble getting up on things, drinking lots of water and then having "accidents" and perhaps an intermittent fever.  The dog probably will have several of these complaints, but perhaps not all.  Ehrlichiosis is often misdiagnosed as a parvo or corona virus infection, or sometimes kennel cough.
Chronic symptoms come on gradually.  In addition to lethargy, loss of appetite, and poor general condition especially around the eyes and spine, other signs are: nosebleeds, bleeding gums or hemorrhaging even when the blood count looks normal, bleeding under the skin or rash, clotting problems, low platelet count (thrombocytopenia), pallor, anemia, low white blood cell count (leukopenia) , viral tumors on the face/mouth/muzzle, skin infections, low or high calcium levels, seizures, muscle wasting and weakness, lack of coordination, arthritis, neck or back pain, swelling of the joints, enlarged lymph nodes, bone marrow suppression, neurological signs, ocular lesions and inflammation, diarrhea, vomiting,  pneumonia, cough, breathing difficulties, increased thirst and urination, incontinence, alkaline urine, abdominal pain, glomerulonephritis and kidney failure.  Most patients have several of these ills, which indicates that several of the body's systems are affected.
DETECTION
The best and only way to cope with this devastating disease in through early detection and treatment.  There is a blood test, the indirect fluorescent antibody test (IFA) that detects exposure and is quite accurate, although there are some false negatives for three weeks at the onset of the disease when the immune system has not yet manufactured antibodies.  Another false negative, or a low titer, sometimes shows up when the immune system is overwhelmed during the chronic stage.  It is important to run the IFA test every  three weeks, because the titer level will rise four-fold if the dog is infected with Erhlichiosis. It is recommended that any dog with a positive result of the test be treated immediately and aggressively.  A dog testing negative, but with suspicious symptoms, should be treated anyway and re-checked later.   Another reason to treat right away is that the IFA test picks up antibodies to E. canis and E. risticii, but not any other Erhlichia species should they be causing the problem.  (Some labs will run a "rickettsial panel" and catch the other species.) Also, as IFA results take a while to come back, it is important not to wait before starting the antibiotics. Clinical assessment should dictate here.
Two labs that perform the IFA test are: Protatek Reference Lab, 574 E. Alamo   Street, Suite 90m, Chandler,  AZ85225 (602) 545-8499  and  Corning Clinical Lab, P.O.   Box 305125, Nashville, TN .  Also, the vet schools at the Universities of Illinois, Washington State, North   Carolina and Louisiana are experienced with this test.  Addresses can be found in the Internet article mentioned above.
The common complete blood count  (CBC) panels often are not specific enough for diagnosis of the very early stage of Ehrlichiosis.  Somewhat later indicative abnormalities will show a reduction of platelets, mild anemia, high WBC (white blood cells) in new infections or low WBC in chronic cases, high sedimentation rate, and a high alkaline/phosphatase ratio. Kidney function will indicate a high BUN and creatinine.  Liver enzymes have elevated transaminase.  Other initial lab tests would be a urinalysis, a Coomb?s test, a granulocyte stain to show clumps of bacteria in the cells, and a Western Blot test for Lyme Disease.  Further tests to monitor the status of the body, such as scans, ultrasound, thyroid panels, etc. may be called for and useful, as are repeated CBCs, biochemistry and urinalysis.  Tests for Lyme Disease and/or Babesiosis are wise, as these  frequently are concurrent infections with Ehrlichiosis.
If the dog survives, a Super Chem test, that tracks the immune system, will show that the gamma globulin levels decrease with the elimination of the disease.  Repeated IFA tests reveal a persistent titer for nine months while in a carrier state, but will revert to negative three to nine months after resolution.
TREATMENT
The most important thing is to recognize the severity of the disease, run an IFA test and CBC, and put the dog on Doxycycline immediately.  If the titers return as negative, but the dog is responding to the treatment, he should remain on the drug and be re-tested in three weeks, because it may take the body time to produce detectable antibodies.   Actually, the drug becomes a diagnostic tool as well as the treatment and does not skew the test.   If Lyme Disease is suspected as well, use Doxycycline to treat it.  Do not use steroids except when absolutely necessary, perhaps to treat the drop in platelets, and then only in conjunction with Doxycycline.  Corticocosteroids should be discontinued as soon as possible to avoid their immunosuppressive effects. When more than one disease is suspected, treat Erhlichiosis first.  Do not vaccinate nor give injectable antibiotics, as the overstressed immune system may react badly or even fatally.
Ehrlichias are normally susceptible to tetracycline antibiotics, of which Doxycycline is preferred.  However, in some cases (such as pregnancy, a very young age, or when diagnosis has been delayed to the point where the organs are so compromised they cannot cope) this drug cannot be used.  In this case it is reported that Cloramphenicol can be tried.  Extensive supportive care in the hospital may be needed for the critically ill.  This would include IV fluids, transfusions and other protocol.
As per the article by Lynda Adame (see Sources), the recommended dose of Doxycycline is 11 mg per kg body weight twice a day for two to four weeks. (If using Tetracycline, the dose is 22-23 mg three times a day.) Others say the length of treatment should be for at least 6 weeks.  The Border Terrier people recommended 5 to 10 mg per day per kg body weight.  Cosi Dejan, an average sized Corgi bitch now in the chronic stage, is receiving 100 mg per day.  Her vet gives 50 mg per day while a dog is still in the acute stage, and will up the dose as high as 200 mg in the later stage if no response is noted and that amount is tolerated. During this period supplementation with vitamins B and K is suggested.  Other antibiotics may be needed for secondary infections. 
Our holistic veterinarians will set up an individually designed regime to support the body during illness.  Supplements could include multi vitamins/minerals, enzymes, glandulars, acidophilus, homeopathic remedies, immune system enhancers, and perhaps acupuncture, for example.  The specifics would be based in finely tuned readings of the Super Chem blood test results.  Consultations can even be handled by phone once all the tests have been compiled by the attending veterinarian.  The men we have used are Dr. Martin Goldstein at the SmithRidgeVeterinaryCenter, South   Salem, NY (914-533-6066), Dr. Robert Goldstein at the Northern Skies Veterinary Clinic, Westport,  CT (203-622-0260) or Dr. Conrad Kruesi,  87 E. Clarendon Road, Clarendion,  VT  05759.  Of course, optimum nutrition is also very important. A good quality kibble with dark green veggies, squash, carrots, some raw meat, brown rice and maybe fruit would help, but dairy products, according to Dr. Kruesi, are not compatible with Doxycycline.
CONCLUSIONS 
The good news is that, when caught in time, the treatment can be dramatically effective.  Scientists are working on new DNA-type tests for better diagnosis and alternate drugs for treatment.  ImizolŪ is reported to be an excellent choice but is not yet approved for animals by the FDA.  As yet, no vaccine is available.  Dr. Ibulaimu Kakoma, DVM, PhD, at the University  of Illinois in Urbana, is currently at the forefront of research on Ehrlichiosis.
The more attention and publicity Erlichiosis receives, the sooner our vets will become familiar with the syndrome.  We need to be aware of the prospect of this dreadful disease.  Knowledge is a critical step in the prevention of any further heartbreaking deaths of our beloved Corgis from lack of understanding, recognition and proper treatment.  We owe it to Penny and the others.  Just think what a difference $30 worth of Doxy and a few simple tests can make.  A dead dog is a compromised dog, isn't it??
 
SOURCES
* From the Internet:
* Ehrlichiosis, A Silent and Deadly Killer by Jan Hendricks and Bob Wilson, 1996
Canine Ehrlichiosis by Amy D. Shojal, as printed in Kennel Healthline (no date          available or other information on the printout given)
* Enclycopedia of Canine Veterinary Medical Information: Ehrlichiosis by Michael Richards, DVM, 1997
* Canine Tick Diseases by Lynda Adame, 1996
Antech News: Ehrlichiosis a publication of Antech Diagonistics Laboratory(no date)
Coinfection of Blacklegged Ticks (Acari:Ixodidae) in Dutchess County, New York, with the Agents of Lyme Disease and Human Granulocytic Ehrlichiosis by Eric M. Schauber, Shira J. Gertz, William T. Maple and Richard S. Ostfeld, 1998
By Deborah S. Harper