Tuesday, April 3, 2012

Just another Manic Monday - Part 2

(Continued from part 1) After that crazy morning I had a little break, or so I thought.   I was hoping to cram a little food in my face, but my technician Hiromi was doing a dental cleaning, and she informed me that I had a tooth to extract.  It was a carnassial tooth (the third upper premolar), and that’s a three-root tooth.  The gums around the largest root were very diseased, and there was a very deep pocket between the gum and tooth, indicating that the periodontal ligament (which attaches to tooth to the gum) was diseased.  However, the gums around the other two roots  were okay.  Trying  to extract a tooth with one diseased root and two healthy roots is NOT easy.  It took me a good 20 minutes, but I got the tooth out intact, leaving me 10 minutes to scarf down my salad.

Next, I looked at Jack,

FeLV and FIV positive (yes, positive for BOTH viruses. Sigh.) with an absolutely horrendous ear condition. Jack was rescued from Animal Care and Control by the good folks at Empty Cages Collective.  Jack deserves a blog post all to himself, which I may or may not ever get to.

After looking at Jack, I had what was probably the easiest case of the day:  Fanny, here for a blood pressure measurement.  Fanny was recently diagnosed with chronic renal failure, very early stage.  There’s not much you can do to improve a cat’s kidney function, but there are lots of things you can do to slow the progression of the disease, and that becomes the focus of our management of cats with chronic renal failure.  Twenty percent of cats with CRF have high blood pressure, and this can accelerate the progression of the kidney disease if not treated.   It can also affect the eyes, the heart, and the central nervous system.   Whether or not cats have high blood pressure is unrelated to the severity of the CRF.  Cats with severe disease can have normal blood pressure, while cats with mild CRF can be seriously hypertensive.  Thankfully, Fanny was a mellow little angel, and we easily obtained our five blood pressure measurements.  They were all perfectly normal.  So, that’s one less variable we had to worry about in terms of her kidneys.  We sent Fanny’s owner home with our famous “kidney variety pack”, a bag containing all of the available prescription diets currently  manufactured for cats with CRF.  We almost always find one that the cat likes, even the most finicky feline.  Studies have proven without a doubt that feeding a low-protein, low-phosphorus diet extends the lives of these cats.  I’ll see Fanny back in six months.

Next came Lola.  Lola is a Bengal kitten that I spayed four days before.  Her owner was concerned that the incision was open.  Well, things tend to come in threes, and Lola completed the trifecta of spitfire cats.  Sharkey, Harley Davidson, and now this little maniac.  Lola wasn’t really aggressive, but she was a screamer.  As in blood-curdling shatter-your-ear-drums Friday-the-13th –horror-movie scream.  It took two technicians to hold this little kitten down just so I could peek at her incision, the edges of which had separated slightly.  Normally we use surgical adhesive on our spays rather than sutures. It allows us to avoid dispensing the dreaded, feline-despised Elizabethan collars.  We rarely ever have a problem.  I particularly wanted to avoid sutures in this kitty, because of her temperament. There is no way this hyperactive little spitfire would tolerate a collar.  I therefore deliberately placed a few subcuticular sutures.  These sutures were right under the skin, pulling the edges of the incision closer together so they are under less tension, allowing for more reliable gluing.  Alas, to no avail.  Lola’s owner confirmed that she spent the last few days running around like a total nutjob (her prompt recovery either being evidence of my surgical skill, or evidence of her having  the kitten version of ADHD. I suspect the latter), and the skin incision did separate a tiny bit.  The subcuticular sutures were holding fine, though.  So we cleaned and dried the incision and applied a little additional adhesive.  Lola screamed her way back into her carrier, and then screamed her way out the front door.

Val arrived next.  Val  is an 11 month-old kitten who also got into lilies!  Her owner caught her nibbling on a lily plant and brought her into Blue Pearl Veterinary Specialists on Sunday evening.  Bloodwork showed no kidney damage at the time of admission, and she was put on intravenous fluids throughout the night as a precaution.  Monday morning, she was transferred to us.  She looked fine on physical examination.  We admitted her to our hospital for another 24 hours of fluid therapy, and another check of her kidney function.  (She ended up doing fine).  (Later that afternoon, when I logged onto my computer, a reminder popped up that said “Don’t forget to post the warning about lily toxicity on your website”.  Timely, no?)

My next appointment was Jasper, an elderly cat that was sent to me for a second opinion.  The doctor is a very good vet, so when he sends me a case, it’s going to be frustrating for me, because undoubtedly, he’s worked it up pretty thoroughly and I’ll end up being stumped.  But that’s okay. Sometimes, a doctor just wants a new set of hands and eyes on a case, partly to see if there’s something you might have missed, and partly to just have someone validate that you indeed worked things up to their logical conclusion and that there’s no clear diagnosis or answer.  Jasper is a diabetic cat who was losing weight despite having the diabetes pretty well controlled.  The cat is not hyperthyroid and does not have renal disease, two other common causes of weight loss in an older cat.  He had abdominal ultrasound performed by Dr. Patrick Hopper, and the liver looked a “hyperechoic”, meaning that there might be some kind of cellular infiltrate in the liver.  The pancreas also looked inflamed, and the intestines looked thickened.   Dr. Hopper got a needle biopsy of the liver, which turned out to be normal.  He also did a PLI test to see if there was pancreatitis, and the test came back elevated, indicating that there is indeed pancreatitis going on.  Peter also did a TLI test, and a B12 and folate level.  No need to elaborate too much on this, except to say that his workup was very thorough indeed, leaving me with little to add, in terms of commentary.   The big kicker in this case is that the cat has a dramatic, large, firm mass on the right flank. Specimens were sent to the lab for cytology, but the results came back as “reactive”, i.e. no cancer cells seen.

After thinking about this case for a while, my take on it is this:

The presence of thickened intestines on the ultrasound suggests that there is something infiltrating the intestinal tract, the most likely culprits being inflammatory cells, in which case the cat has inflammatory bowel disease (IBD), or cancerous lymphocytes, in which case the cat has lymphoma.   Often, if a cat has IBD, it will be accompanied by inflammation of the pancreas and the liver.  All three organs are anatomically linked in the cat.  When all three are affected, we call this “triad disease” or “triaditis”. We know the pancreas is affected, because it looks swollen on the ultrasound, and the PLI test has come back elevated.  The liver, surprisingly, is normal (confirmed by biopsy).  Whether the cat has primary pancreatitis, or pancreatitis secondary to IBD is really immaterial here.  The cat is not showing clinical signs of pancreatitis, i.e. vomiting, poor appetite, abdominal pain, etc.  Some might argue that the diabetes could be a sign that the pancreas in inflamed; the pancreas makes insulin, and when it is inflamed and not working properly, it won’t release insulin properly and the cat becomes diabetic. But Jasper has been diabetic for years, so I think the pancreatitis we’re seeing in Jasper is mild and is likely secondary to presumed IBD. 

The mass on the flank is dramatic.  The nice thing about an aspirate is that it is a non-invasive procedure. The potential disadvantage of an aspirate is that the results might not be fully reflective of what’s going on.  Sometimes the mass doesn’t exfoliate its cells into the needle very well, leading to a misleading diagnosis, or even a non-diagnosis.  A biopsy specimen is much more accurate, but this requires anesthesia and surgery. 

My recommendation would be to have the cat undergo endoscopy so that we can see if the cat has IBD or lymphoma.  While the cat is asleep for endoscopy, remove the mass on the leg and send it to the laboratory.  If the mass is benign, fine.  It would be good to have this big mass off the leg regardless. If the mass turns out to be malignant, it definitely would be good to have it off, and we can deal with post-operative management based on what the biopsy reveals.  The big question we’re going to have to address later on, if the cat does undergo endoscopy, is:  how would we manage the IBD or lymphoma?  Treatment of either illness involves administration of prednisolone, a steroid that should not be used on a diabetic animal, since steroids can mess up the regulation of the diabetes.  There are other ways to treat IBD or lymphoma that might not involve the use of prednisolone, but cats respond very nicely to good ol’ pred, the tried and true treatment.

Next up, Nairobi. Nairobi is a black cat with a similar scenario as Jasper.  Here’s a little background:  He was hospitalized with us for a few days with a fever and poor appetite.  His fever was stubborn.  It varied from 103 to 104.7 over the course of a few days, but it never broke.  Exactly why he had the fever was a mystery.  He had a high white count and bacteria in his urine, so pyelonephritis (a kidney infection) was on our list.  I was leaning against this because he was put on very good antibiotics, and yet his fever did not break, and most cases of pyelonephritis respond to antibiotics pretty readily.  Nairobi also had a low calcium and moderately high blood sugar.  There aren’t too many reasons for a low calcium in cats.  Pancreatitis is on the list of causes of low calcium, and the fever, high white count, and high blood sugar did fit.  The pancreas makes insulin.  When the pancreas is inflamed, it may not secrete insulin properly. Insulin lowers your blood sugar.  If the pancreas is inflamed and not secreting insulin properly, you’ll often have high blood sugar.  To complicate matters further: Nairobi also had a low folate and low vitamin B12 level.  Folate and B12 are vitamins that are absorbed into the bloodstream from the gastrointestinal tract.  If the folate and B12 level are low, it’s because the intestinal tract cannot absorb the vitamins properly. The most common reasons for this are inflammatory bowel disease, or low-grade gastrointestinal lymphoma (a type of cancer).  Often, when a cat has inflammatory bowel disease, they will have concurrent pancreatitis and liver inflammation.  Two of Nairobi’s liver values were elevated, suggesting that there could be an issue with the liver.  So, to summarize:  Nairobi could have a kidney infection; he could have pancreatitis as a primary disorder;  or he could have inflammatory bowel disease with concurrent inflammation of the pancreas and liver, the so called “triad” disease.  Or any combination of these.   To figure out exactly which of these scenarios might be the cause of Nairobi’s illness would require additional diagnostic tests.  Additional tests would be cost prohibitive for the owner, as the case was already taking a significant financial toll, (not to mention the emotional toll of having a very sick cat.)    After much discussion, we decided to send Nairobi home.  I don’t like to send a cat home if he still has a fever and is not eating, but given the cost of the additional supportive care, the owner elected to try him at home.  Some cats will rally when they’re back in their home environment, with their favorite bed, food bowl, litter box, etc.  We sent him home with a variety of medications to treat a variety of presumptive illnesses, and we had her come back in three days for us to re-evaluate him.  This is why he’s here today.

Nairobi’s owner tells me that he’s done poorly since arriving at home.  Lethargic, not eating a thing, not responding to appetite stimulants, and his abdomen looked distended to her.  I examined him, and yes indeed, his abdomen was distended with fluid.  A fever was still present.  These findings led me to put another illness on our list: the dreaded Feline Infectious Peritonitis (FIP).  This is a viral disease that is invariably fatal, and only adds more gloom to his poor prognosis.   Poor Nairobi.  I could see on the exam table that he was miserable.

With his persistent fever, enlarging abdomen filled with fluid, zero appetite, and loss of muscle mass, his owner elected to euthanize him.  She got no argument from me.  Clearly something dreadful was going on with him, and even if we could do all of the diagnostics we’d want to, I feel we would end up diagnosing something that would not be treatable.  Sigh. 

Pandora was next, and was probably the easiest case of my day.  Pandora’s owner brought her in because she saw a worm “crawling out of her cat’s butt”.  She described the worm as small, white, and wriggling, expanding and contracting as it tried to move.  This description leaves no doubt as to the identity of this creepy critter:  this is a tapeworm

Pandora’s owner was concerned for her three other cats.  I told her not to worry.  Cats get tapeworms from swallowing a flea that is carrying tapeworm eggs. That’s how the life cycle works.  You cannot get tapeworms from eating a tapeworm segment.  You can only get them from eating a flea.  Pandora must’ve had an infected flea on her, and as she zealously groomed herself, she swallowed it. 

Pandora is indoors only, though.  So where did she get the flea?  Well, not only are there three other cats in the house, there’s a dog.  I suspect the dog brought in some fleas (even though he supposedly is given a monthly flea preventative.) In any event, we treated Pandora with Profender, a topical once-a-month anti-parasitic drug.  This would take care of the tapeworms easily.  I also dispensed four doses of a topical flea-control medicine.  This would kill any fleas on any of the cats in the house.  An easy appointment.

The last appointment of the day was Princess.  She came in because the owner noticed one of her canine teeth on the floor.  A while back, we examined Princess and discovered pretty significant periodontal disease.  I recommended that we do some bloodwork, and then schedule a dental cleaning.  We did the bloodwork, but life sometimes gets in the way, and somehow the dental cleaning never got scheduled.  Finding a diseased canine tooth on the floor was a big wake-up call for the owner. 

I examined Princess and as expected, her mouth was a mess.  Several other teeth were diseased and would probably need to be extracted.  We repeated the pre-anesthetic bloodwork (the previous bloodwork was now out-of-date), and were ready to schedule the dental cleaning.  But there was a little catch: Princess had a prominent heart murmur.  Before anesthetizing a cat with a murmur, it would be ideal to discover the reason for the murmur, since heart disease could affect whether or not we could anesthetize her safely.  I recommended that we have the cardiologist evaluate her before the dental, and she agreed.  As it turned out, Princess’s murmur was physiologic, not pathologic, and there would be no problem anesthetizing.  We cleaned her teeth, extracted a few diseased ones, and sent her home, where she’s doing great. 

And that was my day.  Now home for dinner, a movie (courtesy of Netflix), and a magazine in bed before hitting the sack.  Tomorrow it starts all over again.  Crazy and stressful? Yes. But I wouldn’t have it any other way.

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