Don't Ignore that Cough

I recently had a bummer of a case.  A 12 year old cat who presented to our clinic for itching.  The cat had generalized hair loss all over the abdomen, extending to the inner thighs.  It also had hair loss on the inner forearms, and  some scabs on the head and neck.  The owner said that  the cat was also coughing about two weeks ago, but that  the cough had resolved.

She was worried  that the cat would be stressed out by traveling to the vet, so she had a housecall vet come to her house to evaluate the cat. 

Whenever a cat is losing hair, the first thing I wanna know is:  Is the hair falling out, or is the cat pulling it out?  Clearly, this cat was pulling it out.  She was grooming her abdomen and legs non-stop.  The  next question I ask is:  Does it itch?  Some cats will overgroom for psychological reasons, rather than for dermatological reasons.  Grooming is a comfort behavior, and when cats are stressed or upset, they will often overgroom.  The abdomen is a favorite spot, but other areas, such as the flanks and the forearms are also common areas.  

The owner told me that the vet thought the cat might have ear mites, because the cat was scratching at the head.  She didn’t actually check for ear mites.  I guess a house call vet doesn’t travel with a microscope.  Still… where would a 12 year-old, totally indoor cat get ear mites?  Anyway, to cover all of her bases, the housecall vet threw the kitchen sink at the cat:  Revolution to treat ear mites, antibiotics to treat an infection, and a steroid shot to treat allergic or inflammatory conditions.  Grrrr….  vets like this give the rest of us a bad name.  The owner said that the skin didn’t improve all that much… maybe there was a tiny decrease in the scratching, but interestingly, the coughing resolved.  About three weeks later, the cat was scratching badly again, so she called the housecall vet, and she prescribed antihistamines this time.  Needless to say, this had minimal effect as well, so she brought it to see me. 

I saw the cat and yes, there was definitely a lot of self-induced hair loss.  What had me more concerned was the cough, though.   When the owner described the cough getting better after the first housecall vet treatment, I thought that the cat could have asthma, and the cat responded to the steroids, or it could have been some kind of infectious bronchitis and the cat maybe responded to the antibiotics.  Either way, if a cat is coughing, it’s prudent to take an x-ray of the chest to get more information about the cough.  I couldn’t tell by looking at the skin exactly why the cat was so itchy.  Before discussing the diagnostics we’d need to consider to diagnose the skin condition, I suggested x-rays.  The owner consented.

I took the x-rays, and unfortunately, I saw what I believe was a nodule in one of the lung fields.  It was pretty clear on the lateral view, and also visible (but maybe not as clear) on the ventro-dorsal view.  This is a pretty bad finding.   Sometimes, tumors can cause inflammation in the tissue surrounding them, and steroids will reduce the inflammation and cause temporary improvement.  I suspect this is why the coughing improved after the steroid injection. 

I offered to e-mail the radiographs to a board-certified veterinary radiologist at Blue Pearl Veterinary Partners, for a second opinion on the radiographs.  The radiologist reads hundreds of x-rays a month and his opinion carries a lot of weight.  She agreed to let me do this.  As far as the skin condition, we put that on the back burner.   We had bigger fish to fry.

I sent the films, and the radiologist called a few minutes later and said, “well, there’s a nodule in the lungs”.  Sigh. 

The nodule is almost certainly some type of tumor.  The next question we would want to ask ourselves is whether this is the primary tumor, and whether it is a single solitary nodule.  If so, then theoretically, it could be removed surgically and the cat would be cured.  If, however, this is a metastatic nodule, i.e. the primary tumor is somewhere else in the body, and this nodule is evidence of spread to the lungs, then the prognosis is grave.  I recommended referral to a specialty center for a CT scan of the lungs to see if any further nodules were present.   The owner was distraught.  She had four cats, and this was her favorite of the bunch.  She was a really sweet cat in the exam room, too.  I felt terrible. 

The owner did go to a referral center a few days later.  A place out on Long Island, close to where her son was living.  At the referral center, they repeated the radiographs, only this time, they did three views:  TWO lateral views and a ventro-dorsal view.  Taking two lateral views, one with the cat’s right  side down, and the other with the cat’s left side down,  was a good idea.  We call this a “met check”, or a “metastasis check”, and is probably something I should have offered at my own hospital.   The left lateral view apparently revealed a second nodule.  These were probably metastatic nodules.  The owner declined abdominal ultrasound to possibly look for the primary tumor, since treatment would likely be futile regardless.  She took the cat home and will let the cat live out her life as comfortably as possible.  So far, the cat is doing well; she’s eating and drinking okay, and there’s no coughing, no vomiting, no diarrhea, minimal weight loss.  Just itching.  We’re going to try to control that with a short course of anti-inflammatory medication, omega-3 fatty acids, and medicated baths using an anti-itch shampoo.  It’s really amazing how much cancer I see in my practice.

But it’s not all bad news.  I'm about to see a favorite cat of mine, Faye Clementine.  I'll post her story next.  Stay tuned.

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