My legacy to Pablo

This is probably the most heart wrenching thing I have ever had to write about, quite simply because every time I have had to put pen to paper it has pulled at every heart string and I have become overwhelmed with emotion. The truth is it has been the worst experience of my life and I would never want anyone else to go through what I have gone through. I struggle so much with the 'if only'....if only I had recognised the acute stage, if only Pablo had worn a collar etc. My father used to say 'Life is great in hindsight' and it is that that I want to give to you, if I can make a difference to just one other dog then Pablo's death will not have been in vein. But first let me tell you a little bit about Pablo so that you can get a 'feel' for him. In the summer of 2010 we brought home our most beautiful Pyrenean puppy. We had not long lost Marni (our rescue Guide dog) and both my son and myself felt that no dog could ever come up to 'our dog of a lifetime', how wrong we were! He exceeded all expectations! We called him Pablo after the Spanish side of the Pyrenean Mountains. Even from a puppy he exuded an inner calmness and gentleness that was almost spiritual in nature. Wherever he went he 'touched' a cord with people and radiated happiness. I remember going up to London for the Royal wedding and the impact he made on people was so overwhelming that I felt it had to be streamlined into something good and so we applied for Pets as Therapy. Pablo began working at the local hospice and hospital and soon it became obvious that he could reach out to people in a way that no human could. One particular event that comes to mind has to do with a patient (whom I shall call Eric) Eric was in his final stages of terminal care at the hospice and was unable to communicate or react with anyone. When I went into the ward his wife sat by his bedside and she told me how she wished that Eric could see Pablo for he was so fond of dogs. We sat and chatted, meanwhile Pablo gently rested his head by the top of the bed where Eric was lying. The next moment I don't think I will ever forget for the rest of my life....as we looked up Eric's face had a huge beam on it. I returned later to the hospice for a late shift (I am a nurse there) - Eric died four hours later. The reward in knowing that Pablo had given someone something to smile about before they passed away is indescribable. Visiting the local hospital 'stroke unit' also carried its own rewards. I recall going to my vets and the receptionist telling me how one of their client's had been in that morning having just come out of hospital. The client told the receptionist how she had had this amazing experience with a large beautiful white dog that had visited her on the ward. She recounted how she felt at the depths of despair and how on meeting Pablo he had given her a new lease of life. She said it was as though something had changed in her. This story meant a lot to me as the client had not realised that Pablo was at the same practice, for that reason the feedback carried much more impact.

Looking back now I recall Pablo intermittently going off his food for a few weeks and vomiting small amounts up on an infrequent basis. At times the vomit contained yellow phlegm. Every so often Pablo would appear to be clearing his throat and small amounts of phlegm would appear on the floor but there was no chest infection. He was always calm but he somewhat became quieter (I can remember thinking what a lovely subdued dog he was and mentioning this to the breeder, was this normal for a Pyrenean dog?) "Not usually in such a young dog" came the reply, but I never picked up on it. We tried different

foods and eventually after two or three weeks everything started to settle down and Pablo seemed to regain his appetite on James Well-beloved....of course that was what was wrong!

We had just missed the acute phase of Ehrlichia (a rickettsial bacteria spread by rhipecephalus ticks) the only opportunity to reverse the disease with doxycycline had tragically passed us by.

Outwardly everything now seemed to have settled down. We were in the subclinical phase of the disease.(This can last for months or years) The organism was hiding out in the spleen and the only hint that Ehrlichia was hiding out somewhere would have been a reduced platelet count and/or elevated globulin levels on a blood test. It was the lull before the 'chronic' and final cruel stage of the disease.

I can never remember the time scale between the acute and the chronic stage, quite simply because the 'acute' stage seemed so insignificant and after all, things had resolved themselves and we were now back to normal. What I can tell you is that we are dealing with months.

We have a white creamy floor in the kitchen and I can remember finding tiny specks of what looked like blood. I have three dogs so I checked their paws and gave them a quick once over but found nothing. It was so bizarre. They appeared every so often and then seemed to go away for a few weeks.

Then one day in April Pablo vomited up a large amount of yellow phlegm. I was in no doubt that he had a respiratory infection and so took him to the vets for some antibiotics. Later that day he started to vomit copious amounts of food several times within an hour. I was worried enough to return to the vets, instinctively I felt something else was wrong (if only I had had that same feeling during the acute stage of the disease) The vet this time did a more thorough examination and found Pablo to have a very large spleen. A blood test was undergone which showed that Pablo was anaemic (low white cell count)and a scan was arranged to look at the spleen. The scan was negative and showed no growths but confirmed a large spleen. Pablo continued with the antibiotic therapy but was not improving. After a few weeks the vet was just about to refer Pablo to the RVC(Royal Veterinary Hospital) when he did a further set of blood tests - an IFA (immunofluorescent antibody) and a PCR (identifies the DNA) test to see if Pablo had been exposed to any diseases. It was at this point that Ehrlichia was confirmed.......it shook the Veterinary practice to the core, Pablo had not left the UK and the disease was only known in the USA and the continent. (Subsequently they found it to have been reported in Sussex and the New Forest) I can remember hugging the vet when he told me it was a tick bite "Thank goodness" I said "I am so relieved it’s only a tick bite, for a moment I thought it was going to be serious"

As a result of dismissing the acute stage from my memory we thought we were treating Pablo for the acute stage of the disease and so we were hopeful of a recovery. Pablo was now on doxycycline 100mg three times a day (antibiotic) but there was no improvement with his bloods and those little red specks had now revealed themselves as nose bleeds, becoming more frequent in nature and amount. Countless evenings (always seemed to be worse in the evenings) were spent rushing him off to the emergency vets in an effort to stop the bleeding. On one particular occasion I recall a vet on call asking me if I knew what the cause of the nose bleeds were. When I mentioned Ehrlichia he bent down to me and said "Mrs Stacey, Ehrlichia is very, very rare, we do not have it in this country, there is no way it can be Ehrlichia" Even when my vet talked to him the next day it did little to convince him. Unfortunately the vet is not alone in thinking that Ehrlichia cannot occur in this country and I believe that Leukaemia is often mistakenly diagnosed instead. This is because the signs and symptoms of Ehrlichia are consistent with other more common diseases such as immune mediated blood disease and leukaemia. It is so easy to confuse the symptoms with other individual disease processes. Sadly Pablo's condition started to deteriorate within a few weeks,

nose bleeds became even more frequent and increased in their intensity, diarrhoea set in and his respirations were noticeably increased and he was breathless at times. He was then referred to the RVC. A bone marrow biopsy was performed which showed that he only had 15% of his bone marrow left. "Enjoy what time is left with him" we were told. Even now I have a huge lump in my throat; I cannot describe the pain and sorrow.

The final stages over the last few months were soul destroying. I found it so hard to cope that I went straight into denial and being a naturally optimistic person I lived in hope of some sort of 'magical cure' We tried Chinese medicine, (Yunnan Bai Yoa) and continued with doxcycline, (antibiotic) Prednisolone (steroid) and Fanotidine (anti acid) and together with my vets we were in touch with South Carolina (they lead the research into Ehrlichia) We went up to the RVC countless times with nose bleeds that didn't stop until finally one of the vets told us that it was time to manage them at home, "Learn not to panic and they usually resolve themselves" we were told. Finally on the evening of October 6th I was called in for a late shift. Pablo had a small nose bleed and so before I went to work I told my friend who came into feed the dogs 'not to panic' (biggest regret of my life) On my return from work I opened the kitchen door and what I saw then was absolutely horrific. My large cream kitchen floor had turned completely red and there were splashes of blood on work surfaces and all over the furniture, it was as though a massacre had taken place. Pablo showed so much courage, such dignity - he was lying in an upright position, all his legs and face had turned red and his big eyes just looked up at me. Miraculously he could still walk and I immediately took him in the car to the emergency vet who put him on a drip (he estimated that Pablo had lost 3-4 pints of blood) The bleeding did not stop. A plasma transfusion was started followed by a blood transfusion but the bleeding did not albeit. The vet contacted the RVC and a decision was made to put Pablo under general anaesthetic and pack his nasal cavity. I went home to change and get ready to take Pablo up to the ITU at the RVC but at 4.00 am the vet rang to say that Pablo had not come out of the anaesthetic. My world had just ended.

The post mortem report revealed diffuse haemorrhage in the nasal cavity, haemorrhaging at the base of the mitral valve and also in the small and large intestine. Lungs were oedematous.(full of fluid)

I write this now with a pounding heart and tears are streaming down my face, I would do anything in the world to wind that clock back and change things, but I can't. Pablo was just two years old and had so much to give. As a legacy to him I hope that I will be able to increase the awareness into Ehrlichia and emphasise the importance of wearing a tick repellent spot on collar. Recent research shows that gun dogs, terriers and the pastoral group are most susceptible and within these three groups long haired varieties are particularly at risk, as are German Shepherds.

For me there is one event that particularly hurts. When my friend came in to feed the dogs on that last fateful evening Pablo had tried to block her way out of the kitchen by standing in her way as she was about to leave. Sadly she failed to read him and went home. I think Pablo knew he was dying and needed someone there by his side. This for me is excruciatingly painful to bear. He reached out to dying patients and yet we as humans can unknowingly fail in always being there for our animals. By sharing my experience with you I hope that I will give you an insight into a disease that cleverly mimics other blood borne diseases. Perhaps together we can then be one step ahead in anticipating and above all preventing such a devastating disease gripping hold of those we hold so close to our hearts.

"Pablo, we miss you so much and we will always love you. May you rest in peace"

Vets reports on next page.

From Katie’s Vets Newsletter:

We have recently seen our first case of Erlichiosis at the practice. We have been treating Pablo who is a gorgeous 2 year old Pyrenean Mountain Dog for this disease. He has been very poorly indeed but is gradually improving. Erlichiosis is a disease which is very rarely seen in the UK. It is more common in the Mediterranean and USA and it can be fatal. It is caused by rickettsial bacteria which are spread by rhipicephalus ticks. These ticks are not normally seen in the UK but have recently been reported in Kent and the New Forest.

Initial signs of the disease include coughing, weakness and spontaneous bleeding and this can progress to lameness and paralysis and in severe cases the disease can’t be treated. If caught early enough the disease can be treated and we are hoping Pablo will make a full recovery. There is no vaccine to protect your pets against this disease, the most important thing you can do is protect them from ticks by using an effective tick repellent spot-on or collar.

The article below is the one from Katie’s Vet for our newsletter.

For some time we have been worried about the possible emergence of exotic or novel diseases being imported into the country. There has been some recent research by a drug company that has revealed that indeed some tick borne diseases usually only found on the continent or in the USA, are now present in the UK . It is spread by a specific tick, rhipicephalus (the Brown Dog tick). These ticks are not normally seen in the UK but have recently been reported in Kent and the New Forest. One such disease is Ehrlichia, also known as canine rickettsiosis, canine typhus or tracker dog disease. There are three stages of the disease, the acute, subclinical and chronic. The incubation period is 8-20 days after which the acute phase is entered, and this lasts for 2-4 weeks. During the acute phase the organism enters and multiplies in the circulating white blood cells and in the liver and spleen’s immune cells. The circulating cells can enter many different organs, and can be the cause of a wide range of clinical signs. Enlarged spleen, lethargy, high temperature, cough weight loss, eye and nose discharges, breathlessness, enlarged lymph nodes, vomiting and various neurological signs (twitches, tremors etc.) can be seen, in combination or on their own. These signs often resolve on their own after 1-2 weeks.

The subclinical phase occurs 6-9 weeks after infection. The signs seen in this phase are mainly related to the anaemia and low white cell count including the cells involved with blood clotting. There can however commonly be no clinical signs in this phase. Spontaneous bleeding in this phase is unusual.

The chronic phase in some dogs is very severe and in others very mild. Spontaneous bleeding can be severe and life threatening. The other signs are associated with the anaemia, debilitation, painful abdomen, eye damage, and further neurological signs. At this stage it is common to see a massive reduction in all of the circulating blood cells (pancytopaenia) and also bone marrow biopsies reveal marked damage to the blood cell factories.

It is very easy for the disease to mimic other diseases in any of its phases. There are signs of the disease that would easily be consistent with other more common disease such as immune- mediated blood cell disease and leukaemia. Some of the many symptoms can be confused with an individual disease processes.

Ehrlichiosis is a very worrying disease, but if it is diagnosed at an early stage it should be able to be managed successfully. It is sensitive to a widely available veterinary antibiotic (doxycycline).

Testing for the disease is relatively straightforward. A blood test (sometimes two) is needed to confirm whether a patient has been exposed to the disease.

We still consider the disease very unusual in dogs that have never travelled outside the UK. However, due to its ability to mimic other more common diseases it is easily over looked.

There is no vaccine to protect your pets against this disease, the most important thing you can do is protect them from ticks by using an effective tick repellent spot-on or collar.

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