Resolution of Canine Acute Bilirubin Encephalopathy and Immune-Mediated Hemolytic Anemia Following Four Plasmapheresis Treatments

An 8 mo old spayed female mixed-breed dog was presented for pale mucous membranes. The dog was diagnosed with intravascular immune-mediated hemolytic anemia (IMHA) and was started on medical management including corticosteroids, thromboprophylaxis, a packed red blood cell transfusion, and IV immunoglobulin. The dog developed severe hyperbilirubinemia (total bilirubin 48.1 mg/dL) and was referred for centrifugal plasmapheresis. Before treatment, the dog was stuporous to comatose, had intermittent opisthotonos, forelimb extension, and an absent menace consistent with acute bilirubin encephalopathy (ABE). The dog underwent a previously reported protocol of three therapeutic plasma exchange (TPE) treatments 24 hr apart. Moderate improvement was noted in her neurological status, although autoagglutination and hemolysis persisted, and the protocol was deemed inadequate. A fourth TPE treatment was performed on day 6. The following morning, the dog was autoagglutination negative. Her neurological status gradually improved, and she was discharged from the hospital on day 12. The dog remains neurologically normal and continues to do well at home on monotherapy with mycophenolate. Continued plasmapheresis treatments should be offered as a treatment option for severe cases of IMHA in the face of persistent disease, because TPE is able to provide ongoing support and stabilization, particularly in the face of ABE.