Thursday, May 13, 2010

Cream of Tomato Soup

Today I overheard my veterinary assistant, Kamilla, imploring a caller to bring her cat into our hospital for an examination. From what I could gather on the phone, the caller was not yet a client at our hospital, and was just calling for advice about her cat. The caller was Japanese, and I could tell that there was a bit of a language barrier at play here. (We have a large Japanese clientele, and we get a lot of Japanese referrals, thanks to my technician Hiromi who serves as a translator, reducing the anxiety and uncertainty these clients feel when trying to explain to a non-Japanese veterinarian exactly what is wrong with their cat.) I asked Kamilla what was going on. Apparently, the cat was having trouble breathing. Breathing problems are something that need to be addressed promptly, and Kamilla wisely convinced the woman to come in.

About a half hour later, I find myself examining the cat. Pumpkin is a large cat. Very large. Okay, let’s not mince words. This cat is grossly obese. Small instruments in the room begin to orbit the cat’s body. But it is clear that indeed, the cat is having breathing problems. The chest is heaving, the abdomen is pumping, the nostrils are flaring. There’s a problem here.

There’s a second problem here, too. Hiromi is on vacation this week. I’m trying to explain to the client, using crude drawings scrawled on a paper towel, that I think that there is fluid between the lungs and the chest wall (pleural effusion), and that I need to take an x-ray to confirm this. She nods in agreement, but I can’t be sure she really understood. Hiromi did say, however, that if I need her for translating purposes, I can call her. So I call. Alas, it goes into voicemail. I leave a message asking her to call back. The client agrees to the x-ray.

The x-ray shows a chest completely full of fluid. I’m wondering how I can explain to the client that I need to stick a needle into the chest and draw this fluid off of the chest so that the lungs can expand, giving the cat some relief. As I try to figure out what to say, the phone rings. Yay! It’s Hiromi. I tell Hiromi what’s going on and what I need to do. Then I bring the client into the room, put Hiromi on speakerphone, and after five minutes and a couple of konichiwahs, we’re good to go.

Normally, when we “tap the chest” (remove the fluid from the chest cavity; the technical term is thoracocentesis) we use a standard butterfly needle. This is a ¾” needle with a long thin piece of tubing attached to it. The tubing allows you to see the fluid as its being drawn off. The problem here is: this cat is fat! Super fat. I try using our standard needle, but the needle does not penetrate into the chest. In fact, it barely reaches the cat’s ribs! I try again, but to no avail. My technician Rita then suggests that we hook a regular 1 inch needle, but hook a t-connector to it. A t-connector is a short piece of tubing that we use when placing an intravenous catheter. She’s right…this might work. So we rig the device. I call in Kamilla. This is going to be a three person job. Rita will hold the cat. Kamilla will keep the needle pressed firmly into the cat’s chest, and I’ll draw off the fluid. After scrubbing the skin again, I insert the new, longer needle in, and presto! Pay dirt. Out comes a torrent of fluid, the appearance of which can only be described as a cross between Pepto-bismol and cream-of-tomato soup. This, I’m certain, is blood-tinged lymphatic fluid, and this cat has a condition called chylothorax. I’ll need to send this fluid to the laboratory to confirm it, but this is my working diagnosis for now.

Twenty minutes and 300 milliliters later, the cat’s chest is emptied, and she is breathing like a normal cat. Relief all around.

Two days later, the laboratory confirms my suspicions. Chylothorax.

There are several possible causes for chylothorax in a cat. Lymphosarcoma in the chest is one reason. Heartworm disease is another. Cardiomyopathy (heart disease) is a third. Trauma (causing rupture of the thoracic duct) can cause chylothorax, although this is unlikely, as the cat is housed completely indoors. The most common cause is “idiopathic”, a fancy way of saying “no reason at all”. What we really need to do is an ultrasound of the chest. That one test will rule out heartworm, cardiomyopathy, and lymphosarcoma. Unfortunately, the owner cannot afford the ultrasound. More worrisome is the fact that if it turns out to be idiopathic (and I suspect that it will), the only real successful treatment is a surgical one, and that would be cost prohibitive for the client (we’re talking thousands). For now, the client will try to manage things medically, with a low-fat diet and a drug called rutin, which can be obtained in a vitamin or health food store. I know from experience, though, that medical management is rarely successful, and that this cat’s chest is going to fill back up with fluid. Exactly how quickly is impossible to say. I had Hiromi explain this to the client. All I can do now is wait and see what happens.
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