Indian Journal of Animal Research

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Clinico-diagnostic and Therapeutic Management of Ehrlichiosis in Dog

P.G. Gamit1, A.R. Patel1, S.A. Mehta1,*, S.V. Mavadiya1, M.D. Patel1, S.M. Parmar2, J.A. Vala2
1Department of Veterinary Medicine, College of Veterinary Science and Animal Husbandry, Kamdhenu University, Navsari Campus, Navsari-396 450, Gujarat, India.
2Clinical Complex, College of Veterinary Science and Animal Husbandry, Kamdhenu University, Navsari Campus, Navsari-396 450, Gujarat, India.

Background: The research work was undertaken to investigate the efficacy of various diagnostic tests by using conventional microscopic examination, rapid Ab detection test and molecular technique, haemato-biochemical changes, Abdominal organs changes using ultrasonography, and therapeutic efficacy of different treatment protocols on Canine Monocytic Ehrlichiosis (CME) infected dogs from in and around Navsari, Gujarat, India.

Methods: 69 dogs suspected of ehrlichiosis based on clinical signs and hematological values and then subjected to blood and buffy coat smear examination, rapid Ab detection test and PCR based assay targeting 16S rRNA gene. The pre and post-treatment haematology and biochemical analysis of treatment groups along with all the positive dogs were performed. Further, all the treatment group dogs were subjected to ultrasound for evaluating organ abnormalities. Modified Clinical Sign Grading (MCSG) score for CME-infected dogs was carried out to evaluate therapeutic responses based on minimizing the clinical score. Descriptive statistics along with Student t-test and One-way analysis of variance (ANOVA) followed by DMRT was performed to compare differences between means wherever applicable.

Result: CME incidence among the 69 suspected cases was 49.28%. Out of 69 suspected dogs, Ehrlichial inclusions or morulae in the monocytes could be identified in only 4.35% of blood smears and 10.14% of buffy coat smears examined by Giemsa and or Field-stained and 15.94% of dogs were found positive for Ehrlichia genus by PCR. 72.5 per cent of dogs were found positive for antibodies to E. canis, out of 40 dogs. The sensitivity of blood smear examination, buffy coat smear examination, and thrombocytopenia was 10.34%, 24.14% and 89.66%, respectively. The specificity of all the diagnostic tests was 100%. The anemia along with leucopenia, were the most significant hematological alteration recorded while ALP, creatinine, and BUN were elevated and albumin was significantly decreased in CME-infected dogs. Significant improvement of haemato-biochemical parameters towards normalcy in both treatment groups. However, a higher percentage of reduction was observed in the clinical score of imidocarb treated CME affected dogs than in the oxy-doxycycline therapy after 14 days.

Canine Monocytic Ehrlichiosis (CME) is an important vector-borne zoonotic disease of canines with a worldwide geographical distribution, observed particularly in tropical and subtropical areas. The main cause of canine monocytic ehrlichiosis (CME) is recognized as Ehrlichia canis (Sainz et al., 2015). Leukocytes are the main target of infection by Ehrlichia spp., which produce intracytoplasmic, membrane-bound bacterial aggregates known as morulae (Mylonakis and Theodorou, 2017).

The prevalence of E. canis is determined by the distribution of Rhipicephalus sanguineous tick, the vector that is prevalent in tropical and subtropical areas (Megat Abd Rani et al., 2010). Hematologic abnormalities observed in CME are moderate to severe thrombocytopenia, mild anemia and mild leukopenia during the acute stage, mild thrombocytopenia in the subclinical stage and pancytopenia in the severe chronic stage. Hypoalbuminemia, hyperglobulinemia, elevated level of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) is the promising biochemical alteration observed in CME (Mylonakis and Theodorou, 2017). Diagnosis of CME is based on anamnesis, clinical presentation and detection of morula in peripheral blood or buffy coat smear examination. The tetracyclines are the drug of choice for the treatment of canine ehrlichiosis and among all the tetracyclines, doxycycline is probably the most effective drug for use in dogs. Besides this, imidocarb is also another choice of treatment for rickettsial organisms. In view of this, the current study was undertaken to investigate the haemato-biochemical alterations, efficacy of various diagnostic techniques used for the identification of Ehrlichia infection in dogs along with the therapeutic efficacy of different protocols used for management of canine monocytic ehrlichiosis in dogs.
 
The study was carried out at Veterinary Clinical Complex, College of Veterinary Science and A.H., Navsari of south Gujarat region during October 2022 to June 2023. A total of 1040 were registered as fresh cases. Among them 69 dogs were suspected for ehrlichiosis based on clinical signs and hematological values and further subjected to Anigen Rapid CaniV-4 (Leish) test (Fig 1 and 2) (manufactured by BIONOTE Inc., Republic of Korea) and PCR assay. Out of these, 12 dogs found positive in rapid diagnostic test were randomly divided in two groups comprising 6 animals each for therapeutic trials. Group II was treated with Inj. Oxytetracycline @ 22 mg/kg body weight intravenously diluted with normal saline once a day for 3 days followed by Tab. Doxycycline @ 10 mg/kg body weight orally once a day for a period of 14 days along with supportive treatment. Group III was treated with Inj. Imidocarb dipropionate @ 6.6 mg/kg body weight subcutaneously (if required repeat after 14 days) along with supportive treatment.

Fig 1: Negative anigen rapid CaniV-4 (Leish) test.



Fig 2: Positive anigen rapid CaniV-4 (Leish) test.



The rapid test detects antibodies of Ehrlichia canis, Leishmania infantum, Anaplasma platys and Dirofilaria immitis antigen. The genomic DNA of the ehrlichiosis organism was isolated from whole blood by using the standard phenol/chloroform extraction method as per John et al., (1991) with necessary modifications. Purified DNA from the blood samples was subjected to molecular analysis with PCR using genus-specific primers EHR16SF (5'- GGTACCYACAGAAGAAGTCC-3') and EHR16SR (5'- TAGCACTCATCGTTTACAGC-3') which was amplified at 345 bp (Alhassan et al., 2021). The pre and post-treatment haematology and biochemical analysis of treatment were compared between and within groups along with healthy dogs.Besides this, the six healthy dogs presented for vaccination or regular health check-ups were also included in study as control after obtaining the owner’s consent. Modified Clinical Sign Grading (MCSG) score for CME-infected dogs was carried out based on the modification of 17- points scale clinical score of dogs (Table 1) for tick-borne diseases given by (Himalini et al., 2018). The same was used to evaluate therapeutic responses based on minimizing the clinical score from day 0 to day 14 where day 0 was pre-treatment and day 14 was post-treatment score. The finalresponse of treatment was determined based on the percentage of reduction which was calculated using the following formula:
 
 
The hematological and biochemical parameters were subjected to descriptive statistical analysis to obtain mean±SE. One-way analysis of variance (ANOVA) followed by DMRT was performed to determine differences in means. Student t-test was also used to compare differences between means wherever applicable. The criterion for statistical significance was considered both for p≤0.05 as well as p≤0.01.

Table 1: Modified 17-points scale clinical sign grading score of dogs with CME.

The overall incidence of canine monocytic ehrlichiosis was 3.26% in and around the Navsari district whereas hospital based incidence among the suspected cases was found 49.28% (34/69). The result was in accordance with Senthil et al., (2020) who also reported an overall incidence of ehrlichiosis in 36% and 56.43% cases of dogs, respectively. On the contrary, a higher incidence of CME was detected by Bhadesiya and Raval (2015) and Kottadamane et al., (2017) in 62.07% and 86.90% of the dogs, respectively might be due to the large size of the population studied. While very low prevalence (1.33% and 0.63%) of E. canis in cases in dogs was reported by Roopali et al., (2019) and Prajapati et al., (2023), respectively. The variation in the incidence rate of CME might be attributed to distribution of the vector, geographical area, climatic condition, sample size and time of the sample collection (Selim et al., 2020). Among 69 suspected cases, 34 (Thirty-four) dogs were found positive Anigen Rapid CaniV-4(Leish) test and 15.94% (11) dogs were found positive for Ehrlichia genus using primers of 16S rRNA gene which produced an amplicon at 345 bp (Fig 3). Similarly, Sarawade et al., (2023) also found 16.66% dogs positive for E.canis among 60 suspected dogs. The 72.5 per cent of dogs were found positive for antibodies to E. canis. The serological prevalence for CME found in our study was similar to the findings of Sosa-Gutierrez et al., (2013) who reported 74.5% cases positive for E. canis antibodies using the IDEXX snap 4Dx test.

Fig 3: Positive PCR.



However, Roopali et al., (2020) and Van Hai and Khuong, (2021) detected E. canis antibodies in 100% and 95.7% cases, respectively through a dot-ELISA kit. The difference in sero-prevalence might be due to regional variations, different climates, sample sizes, sampling periods, methodology and the differences in the dog populations (outdoor, indoor, stray, or owned dog) (Cetinkaya et al., 2016). This rapid test detects IgM produced by the body against the ehrlichial organism, hence, the presence of adaptive immunity suggests the presence of acute infection. Therefore, the dogs were found positive in rapid antibody tests and if showing clinical signs and other defined laboratory findings, then such dogs might be infected with E. canis infection. Further, a low number of E. canis infections detected using PCR technique might be due to E. canis being captured in tissues such as bone marrow and spleen resulting in low concentrations of DNA of organism in systemic circulation which was inadequate for PCR amplification (Cetinkaya et al., 2016). Looking at the literature, it was found that Nested PCR is a more efficient technique in the detection of CME rather than conventional PCR because Nested PCR is a modification of conventional PCR which increases the specificity of any reaction. Besides this, Kalaivanan et al., (2020) stated that any previous treatment of the clinically suspected cases and prevalence of transmitting ticks in local regions could also be a cause for the variation in the results of Ehrlichia canis detection using various techniques.

In the current study, tick infestation was noticed in 23 (67.65%) dogs which were found positive for CME and the significant (p£0.05) difference was observed between the tick-infested and non-infected dogs (Table 2). Moreover, the relative risk of owning ticks on the body was found >1 (Carneiro, 2011) in the present study which suggests that harbouring the ticks is relatively more prone to be affected by CME. Game et al., (2019); Rao et al., (2020) and Singh et al., (2021) also reported similar results in their studies.

Table 2: Relative risk of tick infestation in CME infected dogs.


 
Hematological alterations in ehrlichia affected dogs
 
There was a significant (p≤0.05) decrease in Hb level, TEC count and PCV in the infected dogs on the day of presentation compared to healthy dogs. These results suggested anemia in dogs infected with CME. The results of the present studies were in accordance with Dhavalagi et al., (2021b) and Singh et al., (2021). Anaemia found in dogs with CME could be due to loss of blood on account of thrombocytopaenia and immune-mediated destruction of red blood cells as well as suppression in production of colony forming erythroid cells resulting in decreased RBC production under the effect of bone marrow suppression by Ehrlichia organism (Game et al., 2019).

The platelet count of CME-infected dogs of the present study was significantly (p≤0.01) decreased in comparison with healthy dogs. The thrombocytopaenia in Ehrlichia infected dogs corroborates with the earlier reports of Dhavalagi et al., (2021b) and Singh et al., (2021). Thrombocytopaenia in CME might be observed due to decreased platelet production by bone marrow, increased platelet destruction and the presence of antiplatelet antibodies reduces adhesiveness of platelets because of immune-mediated response stimulated by Ehrlichia organism. Besides, platelet consumption was increased and inversely platelet half-life was decreased due to immune-mediated splenic sequestration (Dhavalagi et al., 2021b).

The mean TLC count of CME-infected dogs significantly (p≤0.01) decreased when compared with healthy control dogs. Game et al., (2019) also similarly reported leucopenia in their studies. While Rao et al., (2020) and Singh et al., (2021) observed leucocytosis in ehrlichiosis infected dogs as result of a hypersensitized immune system in the acute phase of infection. The variation in the same parameters among the authors could be associated with the presentation of dogs in various stages of CME (acute, sub-clinical and chronic) during blood sample collection. It has been reported that in the acute or subclinical phase there will be leucocytosis as a result of body defence whereas leukopenia is observed in chronic stage due to myelosuppression (Rao et al., 2020).

Biochemical alterations in ehrlichia affected dogs
 
The elevation of total protein value could be due to either dehydration or increased gamma globulin response after Ehrlichia organism infection (Smitha and Vijayakumar, 2014). Similar findings were alsonoted by Mondal et al., (2019). Further, the albumin value was significantly (p≤0.01) lower in CME-infected dogs than in healthy control dogs. This finding was in accordance with the study of (Smitha and Vijayakumar, 2014); Dhavalagi et al., (2021a) and Singh et al., (2021). The hypoalbuminemia in CME-infected dogs might be due to anorexia and reduced protein intake, loss of protein into the oedematous inflammatory fluid as a result of vasculitis which increases vascular permeability as well as protein excretion in urine because of glomerulopathy, or decreased production of protein due to liver damage in some cases (Smitha and Vijayakumar, 2014) (Dhavalagi et al., 2021a).

In the present study, SGPT was non-significantly higher in CME-infected dogs as compared to healthy control dogs. This was in agreement with the earlier reports of Singh et al., (2021). Besides, Dhavalagi et al., (2021a) reported significantly higher levels of SGPT in Ehrlichia-infected dogs. Additionally, the SGOT values were found non-significantly higher in CME-infected dogs as compared to healthy control dogs. This finding was in accordance with Parashar et al., (2015) who also reported same results.

The ALP value was significantly (p≤0.01) higher in CME-infected dogs of the present study in comparison with healthy control. (Smitha and Vijayakumar, 2014); Dhavalagi et al., (2021a) and Singh et al., (2021) also reported the same results in their study. Hepatocytes were compressed and injured by development of many expanding foci of reticuloendothelial cells in the hepatic sinusoids which compressed the function of hepatocytes leading to their necrosis and rise in the levels of serum SGPT, SGOT and ALP but this might be found for transient period, hence, the liver associated enzymes could not significantly altered in all the presented cases (Smitha and Vijayakumar, 2014). Further, infiltration of perivascular mononuclear cells because of hepato-biliary dysfunction might also contribute to the elevation of these enzymes (Nair et al., 2016).

The elevated values of BUN and creatinine found in the present study were similar to Rao et al., (2020) and Singh et al., (2021) but in contrast with the study of Kottadamane et al., (2017) and Mondal et al., (2019) who noted non-significantly increased value of BUN in CME infected dogs. The increased creatinine and BUN values in ehrlichiosis infected dogs might be due to immune complex-mediated glomerulonephritis which affect the GFR of nephron and resulted into renal pathology (Roopali et al., 2018).

A significant improvement towards normalcy was observed in platelet count, TLC and blood glucose before and after treatment values in both the treatment groups (Table 3). Likewise, a significant regression was also observed in albumin, ALP, BUN and Creatinine values while comparing before and after treatment data of both the treatment groups (Table 4). However, looking at Table 5, a significant percentage of reduction was observed in the clinical score of group III CME-affected dogs than group II after 14 days of treatment. The better efficacy of imidocarb was reported by Xaxa and Kumar, (2018), Roopali et al., (2018) and Game et al., (2020) which was similar to the present study. In contrary to present findings, Rao et al., (2022) stated that doxycycline was far greater in the normalcy of clinical signs in comparison with imidocarb, whereas Sainz et al., (2000) reported equal efficacy of both the drugs in returned to normal clinical signs. The better efficacy of imidocarb recorded in the present study might be due to the persistence of the drug for a longer period in plasma and tissue and therefore produces highly active concentration to destroy the intracellular Ehrlichia organism (Game et al., 2020).

Table 3: Haematological assessment in therapeutic groups of CME affected dogs.



Table 4: Biochemical assessment in therapeutic groups of CME affected dogs.

It may be concluded that owing ticks on the body of dogs might have more probability of being found positive for CME. The Rapid Antibody-based serological assay can be used as primary screening for ehrlichiosis. Further, the thrombocytopenia was a good prognostic marker for suspecting disease. The anemia along with leucopenia were the most significant hematological alteration recorded while ALP, creatinine and BUN were elevated and albumin was significantly decreased in CME-infected dogs. Based on therapeutic trials, imidocarb was found more effective in minimizing the clinical signs of CME rather than oxy-doxycycline therapy.
The authors were thankful to the Principal, College of Veterinary Science and A.H., Heads of Department namely Veterinary Clinical Complex, Animal Biotechnology and Veterinary Biochemistry, Kamdhenu University, Navsari for providing necessary facilities to carry out the research work.
The authors have no conflict of interest for said article.

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