Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Kate Richardson — Wed, 09 Oct 2013 16:19:22 GMT

[quote user="Martin Atkinson"]

[quote user="Kate Richardson"]....it is worth just taking a moment to consider the worst case scenarios. For example, if the hypercalcaemia is due to hyperthyroidism say, there may well be significant subclinical cardiac pathology which may adversely affect the GA. Or an underlying neoplasm which is triggered by the stress of another GA into activity or triggers an immune mediated haemolytic crisis[/quote] Crikey Kate, its a wonder you get anything done if you worry about everything as much as this, you must have a lot of scared clients!

[/quote]

No, I have a lot of well informed happy clients with realistic expectations. I take them through all the options and possible outcomes so that they are aware of consequences of any decisions and the chances of them occurring and we make a decision together as what is best for the cat. In this case I would be telling them that these worst case scenarios are very unlikely and I would advise proceeding with the dental if I felt it was the appropriate action for the cat. Most of my clients appreciate my frankness and honesty. Don't yours?

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Rob Davis — Tue, 08 Oct 2013 20:02:58 GMT

[quote user="Graham Bilbrough"]

Hi, Rob

What haematology analyser did you use? Assuming it's a LaserCyte or ProCyte, can you share the dot plots with the group? I think it would be very interesting to see them.

Thanks

Graham

PS. If you don't know how to get these, send me a PM and I can walk you through it. It's super easy. Otherwise, assuming your analysers are connected via SmartService, let me know your practice and the dates the samples were run and I can 'pull' them for you.

[/quote]

Hi Graham, I'm afraid we're no longer with idexx The samples were run on a vetscan HM5, but thanks for offering to help!

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Martin Atkinson — Tue, 08 Oct 2013 18:27:21 GMT

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Graham Bilbrough — Tue, 08 Oct 2013 18:10:29 GMT

Hi, Rob

What haematology analyser did you use? Assuming it's a LaserCyte or ProCyte, can you share the dot plots with the group? I think it would be very interesting to see them.

Thanks

Graham

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Rob Davis — Tue, 08 Oct 2013 17:07:46 GMT

[quote user="Kate Richardson"]Cool, I would only add make sure the owners are fully informed of possible consequences of 'ignoring' the findings so far as they are potentially quite significant abnormalities. I totally agree with Martin and Evelyn that the dental treatment is likely the cats immediate priority, but it is worth just taking a moment to consider the worst case scenarios. For example, if the hypercalcaemia is due to hyperthyroidism say, there may well be significant subclinical cardiac pathology which may adversely affect the GA. Or an underlying neoplasm which is triggered by the stress of another GA into activity or triggers an immune mediated haemolytic crisis. Cue euthanasia a week or 2 post dental and unhappy, possibly angry owners. Okay, unlikely but not impossible, so make sure they go in with their eyes open. If you have had a good open discussion with them already, then I apologise if I sound patronising Keep us posted![/quote]

Not patronising at all! The owners are fully aware of my concerns, want copies of all lab reports and frantically google everything, so are probably more worried than I am! Unfortunately he has just finished the 40IU/ml PZI he brought over from the USA and has started the 100IU Hypurin PZI I have given him, so I would like to ensure that the DM is stabilised before booking in for another GA (isn't it great to have another layer of complication...). The owner is doing curves at home, so hopefully we can get the cat booked in soon.

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Kate Richardson — Tue, 08 Oct 2013 14:54:05 GMT

[quote user="Rob Davis"]

Update: Bile acid stimulation test results suggest normal hepatic function. Cat has recovered very well from liver biopsy.

Plan: book in for GA thorough oral examination and treatment as necessary - likely to require several extractions. I am intending to repeat the ionised Ca++ and haematology at an external lab in due course, although given how well the cat is I'd happy to leave this until her mouth is sorted out.

[/quote]

Cool, I would only add make sure the owners are fully informed of possible consequences of 'ignoring' the findings so far as they are potentially quite significant abnormalities. I totally agree with Martin and Evelyn that the dental treatment is likely the cats immediate priority, but it is worth just taking a moment to consider the worst case scenarios. For example, if the hypercalcaemia is due to hyperthyroidism say, there may well be significant subclinical cardiac pathology which may adversely affect the GA. Or an underlying neoplasm which is triggered by the stress of another GA into activity or triggers an immune mediated haemolytic crisis. Cue euthanasia a week or 2 post dental and unhappy, possibly angry owners. Okay, unlikely but not impossible, so make sure they go in with their eyes open. If you have had a good open discussion with them already, then I apologise if I sound patronising Keep us posted!

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Rob Davis — Tue, 08 Oct 2013 12:48:39 GMT

Update: Bile acid stimulation test results suggest normal hepatic function. Cat has recovered very well from liver biopsy.

I will post further details in due course. Thanks again for the input so far.

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Evelyn Barbour-Hill — Sat, 05 Oct 2013 19:31:57 GMT

[quote user="Martin Atkinson"] but would say that this cat will now benefit more from getting its painful teeth sorted out than worrying about problems that may not exist,[/quote]

Seconded

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Kate Richardson — Fri, 04 Oct 2013 21:13:50 GMT

[quote user="Rob Davis"]Hypercalcaemia and neutropaenia have both been checked twice using in-house equipment and the samples were taken three weeks apart with the ex-lap in between. Ionised calcium was run on an istat. The cat is not insured, and the owners are happilly paying so far, but are keen to keep costs as reasonable as possible, hence not confirming results with an external lab so far. I can see the logic in doing this (particularly getting a pathologist to look at the neutrophil morphology), but I think that spurious results are very unlikely given the similarity between the two samples and we have run multiple other samples on other animals in the meantime with no other comparible results.[/quote]

I can't emphasise how important it is to get a pathologist to assess WBCs. I have had numerous samples tested in house showing wbc changes only to find completely normal on external assessment. The in house machines are notoriously unreliable. Doesn't mean the cat doesn't have a neotropaenia but I would want to be certain. Istats are pretty good as you are assessing samples immediately and sending samples away can result in errors. But nothing compares to an blood smear assessment by someone who knows what they are looking at. No offence intended. I am rubbish at cytology. And neutropaenia (how low?) could be potentially serious.

Good work so far though

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Rob Davis — Fri, 04 Oct 2013 18:23:33 GMT

[quote user="Martin Atkinson"]has anyone examined a stained blood smear to look for abnormal cells?[/quote]

I have examined a smear and they look normal to me (but I'm no pathologist!).

[quote user="Martin Atkinson"]However ask the owner if they give any vitamin supplements or if anyone uses skin creams that the cat could lick off[/quote]

I will check this with the owner.

[quote user="Martin Atkinson"]

I wonder how zinc (in the PZI) affects calcium levels, it rings some bells but is really just thinking out loud while I go to Dr Google to find out!

[/quote]

I'm not aware of any issues, but if you find something out I would be keen to know!

[quote user="Kate Richardson"]Were there any other changes on biochem? [/quote]

Rest of biochem unremarkable.

[quote user="Kate Richardson"] assume remainder of abdomen within normal limits on ultrasound[/quote]

It becomes more odd here... The scan was done by a colleague as I'm not great with ultrasound. In addition to the liver changes, she thought she could see a spherical mass in the abdomen. At ex-lap, I could find nothing to correspond with this - everything apart from the liver looked normal. When I told the owner about this he said the cat was diagnosed with a "benign abdominal mass" from x-rays taken in USA a couple of years ago; he is sure no other testing was done and had no other information. No idea what that's all about, but as I couldn't see anything grossly I've chosen to assume there's nothing there.

[quote user="Kate Richardson"]I guess you have to ask yourself firstly what is bothering the cat[/quote]

At present the cat seems totally unbothered about any of it! Being a cat, that clearly doesn't rule out dental pain, and with RLs and a complicated canine fracture, there is likely to be pain there.

[quote user="Kate Richardson"]As long as you are happy you got a representative sample from the liver, and you have confirmation of the hypercalcaemia and neutropaenia (with an external lab if you haven't done already (check your labs protocol for ionised Calcium as many variables with collection/pH/sample tubes and ensure no artefacts such as lipaemia, haemolysis or hyperbilirubinaemia, no EDTA contamination, also make sure a fasted sample is tested) [/quote]

Liver biopsy definitely representative from gross appearance, though I guess there could be different histological pathology elsewhere. Hypercalcaemia and neutropaenia have both been checked twice using in-house equipment and the samples were taken three weeks apart with the ex-lap in between. Ionised calcium was run on an istat. The cat is not insured, and the owners are happilly paying so far, but are keen to keep costs as reasonable as possible, hence not confirming results with an external lab so far. I can see the logic in doing this (particularly getting a pathologist to look at the neutrophil morphology), but I think that spurious results are very unlikely given the similarity between the two samples and we have run multiple other samples on other animals in the meantime with no other comparible results.

Thanks for the help so far, always grateful for more thoughts or opinions. I will update once I get the BAST results back.

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Kate Richardson — Fri, 04 Oct 2013 15:18:28 GMT

[quote user="Thomas Johnson"]'m sure I read somewhere recently that exposure to some human skin creams containing Vitamin D can be a cause of hypercalcaemia in cats.[/quote]

There is a cream prescribed for psoriasis in humans which has anecdotally resulted in toxicity after the cats had licked their owners skin. Not sure if thats the one you were thinking of? Always worth questioning the owner re any potential toxins. Vitamin D toxicity can also occur secondary to some rat poisons, some plants, but more worryingly due to some commercial diets (has been seen overseas esp in fish containing foods, but I have also heard of UK cases)

Some other causes of hypercalcaemia are granulomatous disease (mycobacterial infection, histoplasmosis and nocardiosis)

By the way didn't mean to imply that the diet may be a USA diet, more that if they moved here recently they may had fed things unfamiliar to them!

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Thomas Johnson — Fri, 04 Oct 2013 14:51:16 GMT

[quote user="Kate Richardson"]

hypervitaminosis D (check diet history very carefully esp as from the USA

[/quote]

I'm sure I read somewhere recently that exposure to some human skin creams containing Vitamin D can be a cause of hypercalcaemia in cats.

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Kate Richardson — Fri, 04 Oct 2013 14:46:13 GMT

Gosh, interesting one! Were there any other changes on biochem? Was the neutropaenia confirmed on smear examination? Assume no other rbc/wbc changes such as anaemia and assume remainder of abdomen within normal limits on ultrasound. Did you perform a urinalysis? Any weight loss or other symptoms?

I guess you have to ask yourself firstly what is bothering the cat? If it has significant dental pain, then that's got to be a priority, however would be good to know that nothing more sinister going on prior to the procedure. So if you think you can defer the dental procedure for a bit, then I would; plus or minus some pain relief if you feel it is necessary (buprenorphine orally?) or at least trial it on pain relief to assess the degree of discomfort if you are unsure re pain.

As long as you are happy you got a representative sample from the liver, and you have confirmation of the hypercalcaemia and neutropaenia (with an external lab if you haven't done already (check your labs protocol for ionised Calcium as many variables with collection/pH/sample tubes and ensure no artefacts such as lipaemia, haemolysis or hyperbilirubinaemia, no EDTA contamination, also make sure a fasted sample is tested) then I would go back to first principles and draw up a list of differentials for hypercalcaemia (renal disease, neoplasia, hyperparathyroidism, idiopathic hypercalcaemia, hypervitaminosis D (check diet history very carefully esp as from the USA), hyperthyroidism can cause mild hypercalacaemia, so definitely one to check for especially if eating well in the face of dental disease? and hypoadrenocorticism. Do same for neutropaenia (decreased production or life span, increased use eg inflammatory focus) and tick things off the list.

Interesting one

Re: Hepatic fibrosis, hypercalcaemia and neutopaenia in cat

Martin Atkinson — Fri, 04 Oct 2013 14:10:19 GMT

Given the most common cause of hypercalcaemia in older animals with normal renal function will be neoplasia I would have a closer look at your neutropaenia - has anyone examined a stained blood smear to look for abnormal cells? Maybe then a bone marrow biopsy if it doesn't improve. However some normal cats do seem to have a stubborn idiopathic hypercalcaemia (I have a number with higher values than that) and if there are no symptoms related to that I wouldn't get overly blinkered by it. I also suspect that if you investigated the liver of all old animals you may well find similar (not clinically significant) pathology in quite a number. I think you're right to step back and investigate this initially but would say that this cat will now benefit more from getting its painful teeth sorted out than worrying about problems that may not exist, a well managed GA with some IV fluids isn't going to cause any other problems and its dental disease may be part of the problem. However ask the owner if they give any vitamin supplements or if anyone uses skin creams that the cat could lick off.

Finally: I wonder how zinc (in the PZI) affects calcium levels, it rings some bells but is really just thinking out loud while I go to Dr Google to find out!