Homeopathic Treatment in a Puppy with Immune-Mediated Chronic Rheumatic Polyarthritis and Anemia due to Ehrlichia Sp. and Babesia Sp.

Hemoparasitoses are common in small animal clinics and cause serious, even life-threatening illnesses. They can be caused by protozoa or bacteria and are transmitted to animals through the bite of ectoparasites, such as fleas and ticks. Ehrlichia sp. and Babesia sp. are the pathogens that stand out most for the damage they cause to animal health [1].

Canine ehrlichiosis is caused by Ehrlichia canis, an obligate intracellular parasite of hematopoietic cells, transmitted by the tick Rhipicephalus sanguineus [2,3]. The agent multiplies in organs of the mononuclear phagocytic system (liver, spleen and lymph nodes) resulting in hyperplasia of this cell lineage and organomegaly [4].

In Brazil, E. canis can manifest itself clinically in three aspects: acute, subclinical and chronic. The acute phase is characterized by anorexia, apathy, hyperthermia, mucopurulent ocular-nasal secretion, epistaxis, pulmonary crepitus/wheezing, dyspnea, liver failure, renal failure, and also neurological signs such as convulsions and ataxia [5]. In the subclinical phase there are no clinical signs. Dogs unable to mount an effective immune response develop the chronic phase of the disease [6]. The most common symptoms of chronic disease are depression, apathy, chronic weight loss, emaciation, pale mucous membranes, pneumonia, polyuria/polydipsia, stomatitis, fever, peripheral edema (legs and scrotum), glomerulonephritis, polyarthritis (immune-mediated) and hemorrhagic diathesis [7]. Blood loss is usually evidenced in the form of epistaxis, melena, hematuria, hematemesis, hyphema and meningeal hemorrhage [8,9].

The diagnosis is based on the association of clinical, hematological signs, cytological and serological findings and Polymerase Chain Reaction (PCR) [10]. Canine babesiosis is a disease transmitted by the bite of ticks, such as Rhipicephalus sanguineus, vector of Babesia vogeli, a hemoprotozoan. This protozoan parasitizes erythrocytes, causing hemolysis. The infected animal may present fever, lethargy, anorexia, anemia, pale or jaundiced mucous membranes, hematuria and hepatosplenomegaly. The presumptive diagnosis of canine babesiosis can be based on history, anamnesis or physical examination, but confirmation is obtained through parasitological examination [11].

Although people cannot acquire hemoparasitosis by handling an infected canine, they can serve as a reservoir, transmitting vectors throughout the environment, with indirect participation in the disease in humans, with lesions being considered emerging zoonoses by the World Health Organization [12].

An animal of the canine species, SRD, female, eight months old, weighing 6kg (cachectic) was treated in Ribeirão Pires - SP, Brazil, five months after being rescued from the street.

In the anamnesis, a history of apathy, anorexia, locomotor difficulties, joint stiffness, decreased range of movement, claudication of the four limbs, inability to stand or walk, joint effusion and arthralgia, manifestations of pain throughout the body, secretion mucopuruoenta in moderate quantity in both eyeballs and epistaxis.

The animal was undergoing allopathic treatment due to chronic anemia for 4 months. They administered the antibiotic doxycycline, and it had no effect. Upon clinical examination, the patient was found to be debilitated, with tick infestation, moderate turgor deficit, pale mucous membranes, heart rate 160bpm (regular, without murmur), respiratory frequency 40mrpm increased respiratory amplitude, reactive lymph nodes and joint edema in all four limbs.

To confirm the suspected diagnosis, an immunoenzymatic ELISA assay was performed to detect anti-Ehrlichia canis antibodies, the result of which was negative. Therefore, PCR for Ehrlichia and PCR for distemper were performed, both of which were negative. In the serological analysis of antibodies, Babesia sp. (in the IgG serology test) and Ehrlichia canis (IgG - Titration score 4).

In addition, a control blood count was carried out weekly in the first month, spacing the intervals in the remaining months. Biochemical measurement of urea, creatinine, alanine aminotransferase and alkaline phosphatase at the beginning and end of treatment (Table 1); other tests consisted of cytological analysis of synovial fluid and radiography of the affected joint (Figure 1).

Figure 1:X-ray examination of the thigh (dorsal ventrum) and thoracic limbs (plantar dorsal) showing osteomyelitis and increased volume of soft tissues.

Table 1:Laboratory tests used to analyze the general picture.

Note: *Reference values of the factors evaluated: Erythrocytes (6.0 to 7.0million/mm³), Hemoglobin (14.0 to 17.0g/dl), Hematocrit (40 to 47%), Platelets (200 to 500 thousand/dl) mm³), Leukocytes (8.0 to 15.0 thousand/mm³), Alkaline phosphatase (up to 156.0U/L). Source: Barbosa, 2024.

The blood count showed significant thrombocytopenia 42,000 platelets, mild normochromic normocytic anemia, hypoalbuminemia and leukocytosis with left shift, moderately increased alkaline phostase. In the cytology of the synovial fluid, moderate cellularity was observed, represented by some large mononuclear cells, which sometimes present vacuolated cytoplasm, some neutrophils, rare lymphocytes, some red blood cells and amphophilic dense amorphous material at the bottom of the slide, sometimes the cellular components are present lined up horizontally. Synovial fluid consistent with inflammatory joint disease. The radiographic examination showed an increase in soft tissue volume in the bilateral femurotibiopatellar joint, suggestive of joint edema, in the right and left thoracic limbs: radio/ulna/ carpals showing irregular periosteal proliferation in the cortical region of both ulnas on the cranial and caudal surfaces, suggestive of bacterial osteomyelitis.

Given these laboratory parameters, it is concluded that the patient has chronic rheumatoid immune-mediated arthritis secondary to ehrlichiosis and hemolytic anemia secondary to babesiosis and ehrlichiosis.

Initially in the emergency clinic, episodic homeopathic medicines were used: Arnica montana 200cH, five globules in a single dose, then Arnica montana 30cH, three globules twice a day and Lachesis muta 100cH five globules in a single dose, Phosphorus 12cH three globules twice a day for ninety days, Pyrogenium 30cH three globules twice a day for forty-five days, Symphytum officinale complex 6cH + Rhus toxicodendron 6cH, three globules twice a day for sixty days. The electrolyte balance was restored with fluid therapy and food was offered to the animal.

Through the repertorization of the main symptoms: anemia, leukocytosis, arthritis, physical pain, weakness, inflammation, we had the most scored medications, considered simillium: Phosphorus and the Calcarea Complex (Calcarea Carbonica, Calcarea Flourica and Calcarea Phosphorica).
A. Episodic: Symphytum officinale 6cH + Rhus toxicodendron 6cH, Pyrogenium
B. Simillium: Phosphorus; Biotherapeutic: 30cH blood (Figure 2).

Figure 2:Homeopathic treatment.

On the first three days of homeopathic treatment, a plus of the Symphytum + Rhus 6cH complex and Calcarea 6cH complex were administered (five globules diluted in 100ml of water, with 10ml of the dilution being administered every ten minutes for one hour). The pathology was exonerated by generalized muscle tremors, a maximum fever of 40.5 °C and intermittent vocalization. Patients avoided walking and spent most of the time withdrawn. Eating a high-calorie diet to gain weight, drinking water from a syringe.

On the tenth day, blood biotherapy 30cH was administered once a day for thirty days. On the twelfth day of treatment, the patient developed anterior uveitis of the left eyeball (Figure 3). Moxibustion therapy in the ocular region with isolation of the area with walnut shells after infusion of barba timão inhibited the symptom after being applied once a day for three days.

Figure 3:Uveitis in the left eyeball due to deposition of the ehrlichia bacteria immune complex.

On the twenty-fifth day of treatment, when the laboratory results were within normal limits, the patient had weakness in her hind limbs, compromising her mobility until physiotherapy and acupuncture were introduced. The improvement was evident after the first session. Hemopuncture was carried out for appropriate purposes in VG14, and three more acupuncture and physiotherapy sessions every fifteen days.

During the second month of treatment, the patient again presented paralysis of the pelvic limbs, this time with greater severity, selective appetite and oligodipsia, hemochesia. In the third month of treatment, the animal had an episode of hematochesia. After these events, the animal was stable, with mobility, appetite and preserved blood markers returning.

There is enormous difficulty in confirming a diagnosis when the clinic matches a certain disease, but laboratory tests considered key cases (PCR) are negative. During the study period by Lopes et al. [1], Ehrlichiosis was the main hemoparasitosis that affected dogs treated at the Veterinary Hospital -FIMCA, in Porto Velho, state of Rondônia, Brazil.

PCR allows the detection of all Ehrlichia sp. sequences, however, during the chronic phase of the disease, there is less sensitivity due to the reduction of the agent in the blood sample. An important percentage of dogs with pancytopenia are serologically positive and present negative PCR in chronic cases, when the cells are reduced due to damage to the bone marrow and the presence of E. canis in the tissue [10].

As a differential diagnosis of the reported case, distemper (negative) and babesia (positive) were investigated. Normally, the presentation of thrombocytopenia in conjunction with anemia characterizes Ehrlichia sp. infection associated with Babesia sp., even without finding traces of the protozoan on slides [11]. The chronic phase of Ehrlichia resulted in uveitis. In a study in dogs with positive serology for Ehrlichia canis, there were reports of uveitis, distributed in iridocyclitis, posterior uveitis and panuveitis; uveitis and secondary glaucoma [13]. Therapy with moxibustion in walnut shells for eye disease was reported to be effective in 3 days of treatment, as described in the literature regarding its applicability [14] and there were no secondary conditions (glaucoma, hyphema, intense pain) to uveitis.

The pathophysiological mechanisms by which systemic infections can lead to uveitis are through direct destruction of uveal tissues by infectious agents or the presence of immune-mediated events by infectious agents, including classic hypersensitivity responses I, II, III and IV [15]. Many endogenous causes of uveitis have been recognized such as bacterial, fungal, parasitic, protozoal, viral, idiopathic, neoplastic and paraneoplastic, metabolic disorders, coagulopathy and immune-mediated disorders [16].

Chronic anemia caused by hemolysis requires blood transfusion and the patient can often progress to hemolytic anemia, requiring corticosteroids to regularize the red blood series. In the reported animal, Phosphorus acted in this potential, where laboratory tests prove that the homeopathic therapy adopted was effective for anemia and thrombocytopenia (Table 1). Phosphorus is used in several pathologies where nausea, vomiting (mainly hematemesis), epistaxis, diarrhea, hepatomegaly, hematuria, lymphadenopathy and anemia occur, therefore, it was the reason for choice [17].

The patient’s four limbs had edema in the joints, consistent with polyarthritis (Figure 1) caused by Ehrlichia sp., the result of synovial fluid cytology describes an inflammatory/infectious process. Arnica Montana 200 cH is well used in cases of trauma due to mistreatment of animals rescued from the street, in addition to working as a systemic analgesic. Arnica 30cH better targets physical pain, which together with the medications Symphytum and Rhus 6cH were effective in controlling joint pain, reducing edema and local inflammation.

To eliminate the agent from circulation, some homeopathic medicines were used. The first in this potential was Lachesis muta in a single dose, followed by Pyrugenium. Like all snake venoms, Lachesis breaks down the blood, making it more fluid; therefore, it exonerates the parasite from red blood cells leading to the hematuria characteristic of Phosphorus, producing an image of destructive metabolism (exoneration hyperthermia for the evolution of the healing process). It causes yellow atrophy of the liver and subacute hepatitis, consistent with the presence of the agent Erlichia sp. In addition to leaving the individual prostrate, it deposits immune complexes in the synovial fluid and compromises bone irrigation, potentially causing osteomyelitis, as well as the polyarthritis experienced by the patient.

Some signs presented by the patient were identified with the matéria médica, where Torro [18] mentions: Lachesis muta no desire to mix with the world; Calcarea carbonica: swelling of the joints, especially the knee and elbow. swelling of glands, scrofulous and rickety conditions; Calcarea phosphorica: patient is thin, edematous, thin and never gains weight. Joint pain, anemia, intense pain in the bones during the growth period, prominent eyeball; Calcarea phosphorica: osteolysis.

The results obtained in a dog with babesiosis, diagnosed at an early stage of the infection, with allopathic treatment instituted, were positive. After sixty days of care, all exams were repeated and no changes were found [11]. To eliminate the agent from circulation, some homeopathic medicines were used. The first in this potential was Lachesis muta in a single dose, followed by Pyrugenium. The homeopathic treatment lasted ninety days, considered long when compared to allopathic therapy, because the more chronic the disease, the longer the treatment time with homeopathic medicines will be required.

A study with an experiment on homeopathic medicines associated with isotherapy took place in dogs positive for Ehrlichia canis using the SNAP 4Dx (IDEXX) test. The dogs were treated with blood nosode, at 30CH potency, from a dog with clinical-laboratory modifications compatible with canine Ehrlichiosis in association with the drug Phosphorus 6CH. Based on the results, means and standard deviations were obtained for all treatment times. Between five and eighteen weeks of treatment, they were cured, their data were compared to normal hematological values for healthy dogs [17].

Hemoparasitoses are complex diseases and pose a risk to the animal’s life. The report describes characteristics of the chronic phase of ehrlichiosis associated with babesiosis. As signs and symptoms, the canine patient presented apathy, anorexia, anemia, thrombocytopenia, leukocytosis, elevated alkaline phosphatase, polyarthritis, uveitis, hyperthermia, hematochesia. Polyarthritis and uveitis are symptoms found less frequently in clinical routine. This is a condition where the preferred treatment with antibiotics was not enough, requiring homeopathy to eliminate the agent. In association with traditional Chinese medicine therapies through the modality of moxibustion, it offered support to the climatic complaint of uveitis and acupuncture helped in the animal’s locomotor return. As the only choice, the medicine Phosphorus is selected as a homeopathic epidemic genius for infections generated by Ehrlichia sp. and Babesia sp.

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