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Is a cure for IMHA near?

Veterinarians are making progress in researching the genetic and environmental factors putting dogs at risk

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The image of a straight line neatly sums up the frustration of treating dogs afflicted with immune-mediated hemolytic anemia (IMHA), according to Andrew Mackin, BVMS, DVSc, FANZCVSc, DACVIM, professor and head of the Department of Clinical Sciences at Mississippi State University College of Veterinary Medicine. Dr. Mackin is a member of the American College of Veterinary Internal Medicine’s (ACVIM) Small Animal Internal Medicine consensus committee, which will present recommendations for immunosuppressive therapy for treating IMHA at the ACVIM 2018 Forum this month.

A straight line is how a graph charting average mortality from the disease as presented in journal articles over the past four decades would look, said Mackin. The average mortality rate for dogs afflicted with IMHA within three to six months of diagnosis and treatment, has stubbornly hovered at about 50 percent, he said, even as veterinary medicine has advanced and outcomes for dogs with many other diseases have dramatically improved.

“Everything we do is chipping away, chipping away,” Mackin said. “We’re getting a little bit better and a little bit better.”

Keith Richter, DVM, DACVIM, chief applied science officer for Ethos Veterinary Health, which runs a network of specialty veterinary hospitals, also thinks that treatment is gradually, but perceptibly, improving.

“Our critical care skills are better; our transfusion skills are better,” said Dr. Richter.

The most common autoimmune disease

IMHA is the most common immune-mediated disease to affect dogs, and a busy specialty or emergency veterinary practice may see dozens of cases a year, said Richter.

Yet although it’s the most common autoimmune disease, it is still a rare condition, said James W. Swann, VetMB, DACVIM, DECVIM, MRCVS, who is researching the effect of systemic inflammatory disease on hematopoiesis at the University of Oxford’s Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences.

At large university-affiliated animal hospitals, dogs with IMHA represent about 1 percent of all dogs brought in for treatment, but that number may be lower for general veterinary practices. He recently worked on a project analyzing medical notes from 240,000 visits at veterinary practices in the U.K., which found that about 120 dogs, or 0.05 percent, had IMHA.

“These figures were difficult to verify, which is why this data has never been published, because we were not sure that all these dogs definitely had IMHA,” said Dr. Swann, who is also serving on the ACVIM consensus committee.

The precise interplay of genetics and environmental triggers that cause some dogs to get the disease is still not completely understood, according to IMHA experts.

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Genetics likely play a role in the development of IMHA because certain breeds are more likely to be affected than others, said Richter. Cocker spaniels and springer spaniels are among the breeds commonly affected. In fact, the prototypical IMHA patient would be is a “middle-aged, female cocker spaniel,”
he said.

But one of the many mysteries of IMHA is that breeds commonly affected vary geographically, said Mackin. For example, Old English sheepdogs are known in Australia as a breed that commonly develops IMHA, but in Mississippi, where Mackin resides, dachshunds are commonly affected.

“Every time we think we find a genetic trait that puts a dog at risk, another study doesn’t confirm it. We know there’s a genetic link, but we haven’t put our finger on it,” he said.

Steven Friedenberg, DVM, Ph.D., DACVECC, an assistant professor of small animal emergency and critical care medicine and genetics at the University of Minnesota College of Veterinary Medicine, is hoping to shed some light on the genetic mutations associated with IMHA. He and his research team published a study in 2015 demonstrating an association between a variant of the DLA-79 gene and four immune-mediated diseases in dogs, including IMHA. He’s now conducting a study comparing the genes of English cocker spaniels and clumber spaniels that develop IMHA with the genes of healthy English cocker spaniels and clumber spaniels, hoping to find genetic mutations associated with the disease.

According to Dr. Friedenberg, preliminary data from the two spaniel studies indicates that genetic predisposition to IMHA may be complex, instead of one “slam dunk” genetic mutation that causes the disorder.

Friedenberg is also starting a study to look at gene pathways that are differentially regulated in dogs with IMHA in hopes that it will help veterinarians better understand the IMHA disease process and possibly lead to more effective therapies.

“This study could potentially get us some quick answers in terms of what’s going on and explore the pathogenesis in a new way,” he said.

More research needed on triggers

More research is needed to understand the environmental factors that may trigger IMHA, said Mackin. Sometimes, the trigger is clear, such as reaction to a drug like a sulfonamide, but in many other cases, the cause is unknown or merely suspected, he added. Cancer, tick-borne infections like babeisosis, and bee stings all are associated with IMHA—but association doesn’t prove causality, he said.

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The limited amount of data on trigger factors makes it challenging to pinpoint them, noted Unity Jeffery, VetMB, Ph.D., DACVP, an assistant professor at Texas A&M University College of Veterinary Medicine and Biomedical Sciences. The many breeds of dogs that develop IMHA, combined with seasonal variations in disease frequency, point to environmental factors,
Dr. Jeffery said, but it’s still not clear what they may be exactly.

“Identifying these triggers is increasingly becoming a focus of veterinary research, but the limited availability of large epidemiological databases in veterinary medicine makes the discovery of environmental practices challenging,” said Jeffery.

At the June ACVIM Forum, anther consensus committee will review evidence for IMHA trigger factors. It won’t provide any groundbreaking information on triggers, “but will give an assessment on what has been published so far,” Swann said.

A complex soup

Once a dog is diagnosed with IMHA, the complexity of the disease makes it much more challenging to treat than a disease with a uniform presentation and one standardized treatment, such as transmissible venal tumors, said Mackin.

“IMHA is a complex soup of many different presentations,” he said. “Some versions destroy red blood cells by popping them and others eat the red blood cells; some dogs have the disease affecting their platelets and others don’t. You can’t expect one cookie cutter treatment to work.”

The foundation of treatment is steroids often combined with one or more immunosuppressant drugs such as cyclosporine, azathioprine, or mycophenolate.

Because blood clots frequently are a complication of IMHA and thrombosis is associated with higher mortality, aspirin, heparin, or clopidogrel also are often used to reduce the risk of blood clots, said Mackin.

However, there’s little evidence on which drug or combination of drugs is most effective, said Richter.

The upcoming consensus statement will provide recommendations for using immunosuppressants, said Mackin, adding that tailoring treatment to individual dogs is crucial and that more therapeutic drug monitoring tools are needed.

“Dogs have narrow therapeutic windows,” he said. “The gaps between effective, ineffective, and dangerous drug doses are really narrow.”

One such tool is an assay that was developed at the Pharmacodynamic Laboratory at Mississippi State University College of Veterinary Medicine
that can help gauge the immunosuppression activity of cyclosporine and provide dosage guidance to veterinarians who submit blood samples of dogs they are treating. Similar assays likely will be available soon for other drugs, said Mackin.

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Swann is working on a study analyzing blood samples from dogs with IMHA to measure biomarkers such as pro- and anti-inflammatory proteins and the expression of pro- and anti-inflammatory genes that might be able to be used to predict how dogs will respond to treatment, as well as whether they are likely to develop serious side effects.

“Our hypothesis is based on our opinion that there already are effective immunosuppressive drugs available, but that treatment should be individualized for each dog to control the disease while minimizing side effects,” said Swann.

They will study whether the biomarkers they measure correlate with treatment outcomes, he added.

Plasma exchange shows promise

One promising new treatment is plasmapherisis, also known as therapeutic plasma exchange.

Results from trials at Ethos hospitals have been promising, said Richter.

“We’ve had success with a few dogs that were dying and were not responsive to even aggressive immunotherapy,” he said.

Mackin said that while he, too, is cautiously optimistic that plasmapherisis may become another effective treatment option, it’s available only at a few facilities and is expensive and labor intensive.

“We’ll find the answer”

The experts agree that it’s frustrating that not more progress has been made in preventing and treating IMHA in dogs. However, it’s being made slowly, they said, and the upcoming consensus statements on trigger factors and the use of immunosuppressants will provide valuable guidance to veterinarians treating dogs with this very serious and complicated disease.

“We are doing a much better job of keeping dogs going long term without intolerable side effects,” said Mackin, adding that he is hopeful that someday IMHA might be a easily diagnosed and effectively treated disease.

“I firmly believe that some time in the future we are going to look back at this and recognize that this is a simple disease with a fairly simple diagnosis and a simple treatment,” he said. “One of these days we are definitely going to find the answer.”

“I firmly believe that some time in the future we are going to look back at this and recognize that this is a simple disease with a simple diagnosis and a simple treatment. One of these days we are going to find the answer.”—Andrew Mackin, BVMS, DVSc, FANZCVSc, DACVIM, professor and head of the Department of Clinical Sciences at Mississippi State University College of Veterinary Medicine

45 thoughts on “Is a cure for IMHA near?

  1. It’s good to know people are interested in finding ways to better manage this disease. My standard poodle was diagnosed at three years old in Feb 2018
    My biggest struggle seems to be managing the side effects of prednisolone and azathioprine he is also on Zantac. His diesel are tapering off but still diarrhoea on and off is a major factor. Thank you

    1. Hi Mary – I know this post is almost a year but thought I might share my story…. I have a dog that was over vaccinated, 13 vaccines in 6 days on top of a spay in the same time frame. This has caused her to get immune mediated polyarthropathy. She is currently on prednisone and aziathioprine…. I worked really hard for a year to get her on a lower dose of steroids. Finally at 5mg pred every other day and 10mg aziathioprine every other day. The only way I was able to get her to this point was through feeding a raw diet and a naturopath vet. Her name is Dr. Angela Casey in North Phx. You may want to check her out. Dr Casey has put her on Chinese herbs that have gotten her side effects way down and given the ability to lower all the steroids! The goal is to get her off the meds completely. I know you have a bit of a different situation but I hope this helps point you in a good direction if you haven’t already gotten there. Wishing you and your poodle all the best!

  2. My 6 yr old Irish Setter was diagnosed with IMHA in April 2018. We have been battling it ever since–4 months later, she haa improved, but not in the normal range on her CBCs yet. She just developed a raging case of Demodex that my vet and I assume developed because she has been on Prednison and Azathioprine. It’s a battle, but she’s a warrior–we’ll keep fighting. I hope one day soon a cause and cure will be found.

  3. I’ve had 2 back-to-back dogs that have contracted IMHA and both where Corgis. My first Corgi was 11 years old and contracted it in November of 2005. Despite treatment, she passed a clot and died a month later.

    We got another Corgi in 2006 and she contracted it around 2009. She was young enough to fight it off but because she was prescribed prednisone as part of the treatment, the side effect of it deteriorated her joints and she eventually couldn’t walk properly. We effectively had to carry her around for the rest of her life which ended last Saturday, August 25, 2018.

    I truly hope they can finally find a cure for this horrible disease and as pointed out, I think any dog is vulnerable.

  4. Very informative article. It’s been tough to find good and current information on IMHA. My Jack Russell Terrier (female, 6.5 years old) was diagnosed with IMHA last week, two days after a teeth cleaning. After her PCV went down to 9, she had a transfusion which raised it to 18 where it has hovered for 3 days. She’s on Prednisone and Cyclosporine. I’m hopeful she’ll survive long enough for it to be effective but really don’t know what to expect long term.

    1. I almost lost my dog to IMHA thee years ago. He had two blood transfusion at our local vet clinic but was still declining. I rushed him to a Vet Hospital 50 miles away and they ran all kinds of tests to find out what caused the IMHA. The first Vet told me the tests were a waste of money but I wanted to try since he was always healthy. They gave him a different type of transfusion and kept him for five days. They couldn’t get him to eat and wasn’t doing well. We decided to bring him home and try on our own. They sent us home with 4 different medications to give him. Within two months, we had our old dog back. He was doing really well, so our local Vet wanted to cut the dose of Cyclosporine from twice to once daily. However, he relapsed and we started back up on the two. It was a long battle and well worth it. I know there are dangers with this drug but it does make a big difference. I also found the Cyclosporine online for $60 for a months supply.

    2. Hi how is she doing on cyclosporine. my bella is on prednisone ever other day and vet nw wants her on cyclosporine. Im so nermouse giving her this new drug. have you done blood work since your dog is on this.

  5. My 19 month old black lab from South Carolina was diagnosed and we had to put her down that same day. We took her to the vet on Wednesday and she was gone by Sunday. She had 3 blood transfusions within 5 days and by the last one early Sunday morning, her blood cells were attacking faster then the transfusions coming into her. She was already so weak, she never would of made it through any chemo drugs. I couldn’t do that to my baby. So we made the hardest decision to put her down. She was our first pet. We need to find faster testing, so no one has to go through this too. It’s heart breaking. She was only 19 months old, we thought we would have her for at least 10 years.

    1. Yesterday my golden retriever collie mix 6 years old was diagnosed with ihma and her onset of symptoms was so quick and so severe she was suffocating we made the decision to euthanize. I had never heard of this and looking back at all her behavior and living life I am wondering if imha was also evident in brain development…She would sometimes lay with her head pressed against a wall. Her behaviors we sometimes odd but endearing although she also had a fight or flight reaction that was not warranted. I am now understand that this was all she had to express certain reactive symptoms. Reading father in the net tells me this might have been a sign of brain tumor or other neurological disease…Pretty was a rescue from the shelter who was still lactating when her pups were taken and She was abandoned. Writing this is all I can do for her now. She was my best friend. How can I help other dogs and owners?

  6. I had a 8 month old Mastiff that we had to put down after he was diagnosed with IMHA.
    He got sick out of no where but was in the hospital for about a week then came home with a lot of medication. Unfortunately July 3rd we had to rush him back to hospital and we had to make the decision on Huly 4th to put him to aleep.

  7. My10yr old skily was recently hospitalized for 7 days and diagnosed w IMHA. He got sick out of nowhere with vomiting first and then came the diarrhea.His RBC count was at 23 and when released from hospital it was at 27, and no more vomiting or diarrhea. My concern thou is that his RBC still seems low.

  8. My dog maple, a bluetick coonhound was diagnosed with this nasty disease. She had 2 transfusions, this disease ravaged her, I had to put her down.

    1. IMHA is a terrifying disease. My Cavalier King Charles was given a 50/50 shot survive the weekend. He lived 18 months with IMHA until the meds stopped working. Every single time we tried to wean him off them he relapsed. Those 18 months of caring for him were the hardest of my life. He had a good quality of life most of that time however I knew the disease was there, waiting to kill my fragile, sweet boy. IMHA is brutal. It is merciless. I hate it so much. As a last ditch effort we took him to UC Davis. They had no answer. Our hail mary pass was IVIG and that didn’t work either. Putting him down crushed me. We all fought so hard. I love you Pip.

  9. This is an interesting article. I know in the hospital I work at, we see quite a few IMHA patients of many different breeds, so we’ll definitely look into the genetic testing study being run at University of Minnesota. Great info!

  10. Our 9 yr old cocker spaniel was diagnosed with imha on Monday. She had a blood transfusion on Monday which raised her pv from 10_25. She’s on steroids. We’re hoping that she’ll eventually start remake her own blood cells while she’ll have to take it easy we’re trying to be positive that she’ll make a recovery in order to lead a happy life for the reminder of her time.

  11. I have no more time. My 18 mo samoyed succumbed to sterile meningitus, then imha plus itp, then switching from dexamethasone & leflunomide to prednisone and mycofenolate, then they said she had a disease of the spine and brain stem. Then she would die from stopping breathing. Really?
    We are in 2018 guys! 8,000 later not to mention the suffrage plus interns ignoring my calls and what i had to say about her symptoms? In and out of er and neurologist that was so overworked. It is simple. I know. I got her at 8 wks old. Symptoms started then. Itching, facial swelling signs if impa then. That was at 8 mos. RIGHT AFTER PUPPY VACCINATIONS. THERE IS A REAL-POSSIBLE TRIGGER! HMMMMM. ALSO AFTER HER HEAT BOTH IST AND 2ND TIME. HELP! I GAVE UP MY LIFE FOR THIS DOG FOR 1.5 YRS. WATCHING TALKING TO 3-4 DIFF VETS. VRCC AN ER AND CLOSE ONLY BOARD CERTIFIED NEURO. POURING OVER SCIENTIFIC DATA. THE COMMUNITY NEEDS YOUR HELP. I CANNOT FAITHFULLY WATCH ANOTHER VERY SMART samoyed begging me telling me that mom, these drugs are not working and an intern responding to me saying all owners are experiencing the same thing, lethargy, distant etc. NO! She was dyeing slowly and losing her footing, and taking 3 steps at 2 and 4 AM at a time, looking for a place to die in the yard until i realized it was the meningitis coming back not that she substantiated yet another immune mediated disease of the spianalcord and brain stem in which she now had paralysis on all four legs, what? This was a healthy 8 wk old when she came home with me? Symptims start at 8 mos, dead at 1.5 years, heat and vaccine induced triggers? Please re look at your data. Both parent no problems.

  12. My 20 month old 6 lb. Maltese was diagnosed last Thursday and has been hospitalized since, She has had 5 blood transfusions in 5 days. Today she seemed more alert than she was last week, but they have told us it is an up and down disease. We are praying that her numbers stabilize and she can come home. Such a crazy out of nowhere disease…

  13. There are many causes of IMHA including vaccines, tick diseases, drugs, predisposition, hormones (females more likely to get it) & poisons. Reading the article, I am shocked at the figures for survival rates, which in my experience are total rubbish when the correct treatment protocol is used – no cure in this article either. I’m sorry to say vets are often ignorant, closed minded & slow to act. I am so sorry for all the owners who have lost their precious pups. For support from fellow IMHA owners, go to w ww.secondchanceimhadogs.com

  14. My dog Lucy was diagnosed with IMHA a year ago this very day. I am so greatful that my husband and I got her to our vet in time to save her life. I love her dearly, she is like my child. On that same day we also found out that she has lyme disease. She was put on Atopica and high doses of Prednisone, it was awful watching her go through all that. 11 months she was on these meds. It was hard financially and emotionally. We were paying over $600.00 a month for her medications and that’s not including vet visits weekly/ monthly. In the spa. Of this year she had a rough road, her lyme disease made her unable to walk, we had to carry our 90 pound dog up and down the stairs to use the bathroom, she had several bladder infections, skin discoloring from the atop a, lost of fur and a bit of kidney damage from the prednisone. Now that she is off all of these medications we are now dealing with demodectic mange. This poor girl can’t catch a break. I’m so scared the Imha will come back

  15. Our 10 year old female cocker spaniel was diagnosed with IMHA and IMTP on Nov 5. She was started on pred and Atopica. Happy to say we started weaning 4 weeks ago. It was a horrible first 2 weeks! Keep up the research.

  16. I lost my 9 year old maltese..my sweet Fred to this ugly disease 2 weeks ago. I had taken him in to vet starting in October with various ailments. I knew something was terribly wrong. He fainted on a Thursday night…diagnosed then and there and dead by Sunday…not without a blood transfusion, hospitalization and being ravaged by IMHA. I’m so mad…sad…and I miss my boy.

  17. Get your pets on BHT right away. It protects the lining of the red blood cell so they don’t die off prematurely. Our dog was diagnosed with IMHA 10 years ago and she is with us today because of BHT!

  18. My chihuahua was almost 10. Fine one day the next day lethargic and not eating. Vet emergency visit showed IMHA. Meds and to a different vet. Blood transfusion done. Slightly better but blood work still off the charts. Passed away after 2 days. Still devastated. She didn’t deserve to die like this. I hope they find answers

  19. Please do not give up hope. We adopted a dog from a neighbor when he could no longer care for her. She is s Japanese Vhin and was 7 1/2 years old when we got her. We updated her vaccines and she checked out fine at our vet. Three weeks later she collapsed. We were in FL and after two visits to a vet in one day, she was rushed to UFL in Gainesville. She had a blood transfusion and was there 10 nights. Once she was released we had to take her back daily, then every other day, finally weekly. She is now 11 1/2 years old and has been in remission for the last 3 years. She is now fighting bladder cancer and we will be saying goodbye to her within days. But the IMHA was under control. She ended up taking Atopica for the IMHA. She has had reactions to flea medications and can only take Nexguard. She has had wonderful vet care and even survived two dental Durham’s one eye surgery. It is so hard to say goodbye but we will not let her suffer. Tonight is the first time she has whimpered. We jooecwe can make it through the weekend so our regular vet can help us say goodbye. But if we see she is hurting more, we will go to the ER vet.

  20. My 3 1/2 yr old little girl died from IMHA on Christmas day (2018). It was vaccine induced, 100% confirmed by the doctors. I am devastated, and frustrated at the BIG PHARM.
    This totally unacceptable.

    1. Hi there, my baby passed away two nights ago from imha. It seemed to occur overnight and I rushed her to the ER last week the meds did not help and she became jaundiced so I put her down. May I ask which vaccine did the doctors tell you caused your baby’s death? Because I have a feeling that may be the case for mine Thank You Kindly.

      1. I wis h I would have read this soon my 2 year old mini goldendoodle was put thro hell took her to the best hospital got one transfusion and went down hill more infections I didn’t no what to do I live her so much they put a tube down her thr oart nothing helped I looked in her sweet eyes told her I loved her so much. We put her to sleep the doctor said she was to sick. How do you have a great dog energy to dying in 6 days. I hope they find a cure I cry everyday and scared to get another dog that she will get it. Help

    2. I totally agree. I lost my baby boy to IMHA – again vaccine related and 100% confirmed. Broke my heart. It’s been 3.5 years and I miss him every day. That’s why I am overly cautious now. Unnecessary vaccinations are unacceptable in our house now.

  21. My standard poidle developed immune mediated meiningitis 24 hours after receiving a rabies vaccine. He has recovered completely but it took about 7 months, and at least 4 near-death episodes.

  22. Please Have Confidence,our ten yer old cocker maddie was struck down in november with imha,she had to have a blood transfusion and was treated with Prednisone only, now in March Maddies blood count is back to normal and she is back to her active self we do know it may return but we are remaining Positive.

    1. Thanks so much for this. Our precious dog was just diagnosed and has been hard reading through all of these bad outcomes. Nice to hear something hopeful.

  23. Our Boykin Spaniel was diagnosed in June of last year. She was four at the time. She was treated with antibiotics (in case there may have been a primary undetected infection going on) & prednisone.
    It was a long road, but as of December she was fully weaned off of the prednisone and has returned to her old self. The only visible effect at this time is the hair loss and weight gain she suffered as a result of being on the steroid that long.
    I will say though, we were fortunate to have caught it early, she did not need transfusions and her bone marrow never stopped producing red blood cells.
    I researched everything I could to be sure I was making informed decisions with my vet about her care and recovery. Fortunately for us, this treatment plan has worked – she responded well. It can always come back- which makes me very anxious and she can never have another vaccination…. but she is here and is herself.
    If your dog has been diagnosed, please collaborate with your vet; read vet studies (not just blog posts etc); and ask questions… do what feels right… there are no guarantees but positive outcomes do happen.
    For those of you that have lost pets to this disease, I am so sorry for your loss. Clearly, more needs to be done to determine triggers and causes as well as treatment. This article gives me hope for that…. as it may return to our baby girl at any time.

    1. Hi Melissa, Can you tell me why you decided to stick with prednisone only? My vet is recommending Atopica now. Lucy is currently on low dose prednisone, famotidine, sucralfate and b12 shots. Has been since December. I hate all the medications but know she needs them. Just afraid to now introduce Atopica. Lucy is a 9lb Pomeranian. 6 years old. My angel.

  24. I’ve got 2 dogs with these horrible diseases… one is a Great Dane with IMT. We don’t know what triggered it…. knock on wood but he is currently in remission and off all drugs. We have tried to get him off drugs in the passed and failed but are succeeding right now…. please hope it continues…

    My other dog is a pittie. I agreed to foster him after he was diagnosed with Vanessa and had signs of IMHA… we got him through the babesia but he now has Evan’s syndrome- IMHA and IMT… we have not been successful weaning him off of the drugs although he is down to a low dose of pred… he was only one when diagnosed and is now 3… I am thankful for every day with these two…

  25. My 4yr old English bulldog was diagnosed with this Saturday. She has had a blood transfusion and it has brought her count up. She is still very jaundice and she is still battling an upset stomach. This came out of nowhere, she has been in hospital for 3 days now. I’m a mess, shes a mess. Hardest thing to leave her there. Any advice on this disease? I’m scared and reading everything I can find. Our vet is wonderful, he specializes in Bulldogs and is over an hour away from our home. I would drive to the end of the world for my baby girl

    1. Darlene – my baby’s doctor worked and researched this in her efforts to help my baby. She’s no slouch. When things took a turn for the worst with my boy she was there. I told her I wanted to know that she learned something from all this because I needed to believe there would be some good in all of it. She said take the spleen, Always take the spleen. (She removed his after a lot of research) Please look into it. It’s been over 3.5 years but I remember it like yesterday. We couldn’t save him but I wouldn’t trade one day of the 11 months he survived with the condition for anything.

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