Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Andrew Kent — Tue, 16 Feb 2016 19:10:48 GMT

[quote user="robloxley"]

[quote user="Andrew Kent"]colestyramine as a non-specific treatment[/quote]

I'd be interested in which cases and at what point and at what dose you might use Questran?

[/quote]

So the most common time I use it is in kittens (<6-8 months of age) with chronic diarrhoea which is unresponsive to dietary/antibiotic therapy and I want something to improve the diarrhoea whilst I suspect time will sort out the rest - because these cats are often too young to get true IBD and so there is suspicion we are seeing the after-effects of a previous infectious disease.

Anecdotally I have found it very effective in that setting, whether thats because these are true cases of bile acid malabsorption (what colestyramine is designed for) or whether it does something else I don't know.

In dogs I have occasionally used it in chronic enteropathy cases which seem not to respond to anything else - in those cases I suspect they do have true bile acid malabsorption (keep an eye on Vet Record Open over the next few months for more info on that - there is an excellent article due to be published - even if I do say so myself :-p I don't think we recognise the same difficult chronic diarrhoea cases in puppies that we see in kittens so less use in that context.

There is a massive range of reported doses, usually around 20-40mg/kg PO every 12 hours. Dosing can be difficult so lots of cats get started on 0.5 to 1g BID - the worst that tends to happen if you give too much is constipation so seems very safe.

I have seen it work wonders in some cases.

Andy

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Rob Loxley — Tue, 16 Feb 2016 18:23:03 GMT

[quote user="Andrew Kent"]colestyramine as a non-specific treatment[/quote]

I'd be interested in which cases and at what point and at what dose you might use Questran?

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Robin Grimmer — Tue, 16 Feb 2016 17:24:03 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Wanna maybe quote the whole post instead of just a snippet? Or preferably copy and paste the url of the post so we can look at it in context.[/quote]

There you go then:

Blood testing for a food allergy is a complete waste of time and money, and I don't think anyone is suggesting that. The only way to document a food allergy is to do an exclusion diet - either a single source novel protein diet or hydrolysed diet, which causes resolution - and then challenge with the offending protein and seeing a relapse of signs.

Which is what I've been banging on about?

[/quote]

Er , you just copied and pasted my post..

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Andrew Kent — Tue, 16 Feb 2016 16:20:55 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Wanna maybe quote the whole post instead of just a snippet? Or preferably copy and paste the url of the post so we can look at it in context.[/quote]

There you go then:

Which is what I've been banging on about?

[/quote]

There are very few people who advocate blood testing specifically for food allergies - as Robin says they are a waste of time, but often well marketed by diagnostic labs.

Andy

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Tue, 16 Feb 2016 16:14:46 GMT

[quote user="Robin Grimmer"]Wanna maybe quote the whole post instead of just a snippet? Or preferably copy and paste the url of the post so we can look at it in context.[/quote]

There you go then:

Which is what I've been banging on about?

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Andrew Kent — Tue, 16 Feb 2016 09:57:36 GMT

Hi Katie,

long time indeed - hope all is well with you!

Thanks for posting the histo, neutrophilic enteropathies are always a little tricky and its not typical of a 'classical' IBD picture (plus she is a bit young for that).

So with neutrophilic disease it suggests that there is, or has been, an infectious component. The difficulty here is that we know we have previously identified pathogens and so its possible that this is a reaction to a historic insult.

I think there are three possible options when neutrophilic inflammation is identified:

The first is to perform additional staining to see if we can identify organisms in the tissue. You can ask the pathologist to stain routinely but the best way to do this is to submit the fixed tissue blocks for fluorescence in-situ hybridisation (FISH) which is a way of staining for organisms in tissue. I usually use Bristol's lab for this (but there is another one in the USA) and I can send you a submission form if you are keen for this or you can get one from the Bristol diagnostic lab.

The second is to treat with antibiotics speculatively for possible infection - difficult to know what to pick in that context but perhaps a month of metronidazole.

The third is to give more time - lots of infectious agent cause changes in villus architecture which just takes a while to resolve and this seems to be quite common in young cats with chronic diarrhoea. So we often treat them symptomatically (diet +/- antibiotics +/- colestyramine as a non-specific treatment) and give them time to see if they improve (and they often do).

The lymphoplasmacytic component is interesting also - it could suggest an underlying chronic enteropathy (food related, IBD etc) but could also be normal. I wouldn't immunosuppress at this stage without considering possible infectious causes first, but I would start a hydrolysed diet trial as a component of what we do.

So in summary I would go hydrolysed diet +/- antibiotics +/- further analysis of biopsies +/- other symptomatic treatments.

But that's just my thoughts - there are always lots of ways to approach these things :-)

Andy

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Robin Grimmer — Tue, 16 Feb 2016 09:32:54 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Blood testing for a food allergy is a complete waste of time and money, and I don't think anyone is suggesting that.[/quote]

Um. then why was that specific blood test done in the example I quoted, and others, if you want me to dig back?

[/quote]

Wanna maybe quote the whole post instead of just a snippet? Or preferably copy and paste the url of the post so we can look at it in context.

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Mon, 15 Feb 2016 23:18:14 GMT

[quote user="Katie Blackburn"]Can everyone stop bickering about diets please![/quote]

We only "bicker" about diets because diets cause more simple diarrhoeas in otherwise normal animals than all the other diseases of dogs, cats [and humans] combined!

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Mon, 15 Feb 2016 23:09:04 GMT

[quote user="Virginia Campbell"]Last FIP case I saw (kitten about this age) presented with chronic diarrhoea well before other signs showed up.[/quote]

Of course, so see below:

But this is a cat, bright/ish, eating /ish possible vomiting [ice cold food for instance?] Temp normal, physical and abdomen normal. ie not very ill, with D+.

The sort of symptoms seen commonly any day of the week.

Day 1 24 hours Water only, no food no milk Usually nothing passes. KEEP INDOORS

Kaolin or the modern equivalent if you like. I suppose neosulphentrin isn't around?

Day 2 boiled chicken and water, no milk! [Perhaps one more loose stool]

Day 3-4 D- keep on boiled chicken; D+ still? change to fish, water only

Day 5-10 D-; fish only

Day 11 add another protein source to fish and a carb source. Should KEEP INDOORS

etc etc.

BUT

Day 5 D+ still; interrogate owner re diet control, if watertight then bloods and a real careful palpation, temp, family history etc etc.

Hopefully then a definitive diagnosis, fortunately most shouldn't get to this stage.

So, from day one in this thread all I've been suggesting is around 5 days only of diet trials and, most would agree, I think, over 90% of cats [or dogs] would obviously respond and pass normal stools, if not then, and only then, start looking for the serious but fortunately not common.

I'll get my coat....

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Katie Limb — Mon, 15 Feb 2016 23:08:20 GMT

Hi Andy (long time since Bristol hey?!)

I will attempt to post the histo report and bloods below. Thank you for looking at this.

Can everyone stop bickering about diets please!

Standard profile
Sodium		150	mmol/l	140 - 157

Potassium		4.9	mmol/L	3.4 - 5.6

Sodium : Potassium		30.61		26.00 - 40.00

Chloride		115	mmol/L	111 - 129

Calcium		2.4	mmol/l	1.6 - 3.0

Phosphate	H	3.1	mmol/L	0.7 - 2.1

T Protein	L	53	g/l	56 - 81

Albumin		29	g/l	26 - 42

Globulin		24	g/L	15 - 57

A:G Ratio		1.2		0.6 - 1.4

Urea		8.6	mmol/l	6.1 - 12.5

Creatinine		58	umol/L	45 - 170

CK		279	u/l@37C	0 - 360

Bilirubin		3	umol/L	0 - 10

Cholesterol		3.2	mmol/L	0.9 - 6.5

Bile Acids		3	umol/L	0 - 15

ALT		43	u/l@37C	18 - 77

ALP	H	111	u/l@37C	11 - 67

Glucose		6.2	mmol/L	3.8 - 7.6

Feline TLI, B12, folate
External Test		Results to follow...
B12	H	699	pmol/L	220 - 500
Vitamin B12 General Comments: • Low vitamin B12 can be seen with pathology of the distal small intestine, bacterial overgrowth and exocrine pancreatic insufficiency (EPI). • Low B12 can be associated with generalised small intestinal disease (e.g. malabsorption conditions, IBD).

Folate		> 54.4	nmol/L	19.0 - 37.0
Folate General Comments: • Increases in Folate and/or decreased vitamin B12 can be associated with bacterial overgrowth and exocrine pancreatic insufficiency. • Low Folate is consistent with disease affecting the proximal small intestine, reflecting a state of chronic malabsorption. • EPI can be associated with an increase or decrease in Folate. • Low Folate can be associated with generalised small intestinal disease (e.g. malabsorption conditions, IBD). • Sample haemolysis may artefactually increase or mask subnormal folate values.

Routine haematology with profile
Full Blood Count
WBC		11.6	x10⁹/L	4.0 - 15.0

RBC		8.49	x10¹²/L	5.50 - 10.00

Haemoglobin		11.0	g/dl	8.0 - 15.0

PCV		36.0	%	27.0 - 50.0

MCV		42.4	fl	40.0 - 55.0

MCH		13.0	pg	13.0 - 17.0

MCHC	L	30.6	g/dl	31.0 - 34.0

Platelets		477	x10⁹/L	200 - 600


Differential		%	Abs	Interval

Neutrophils		63 %	7.3 x10⁹/L	2.5 - 12.5


Lymphocytes		24 %	2.8 x10⁹/L	1.5 - 7.0


Monocytes		4 %	0.5 x10⁹/L	0.0 - 0.8


Eosinophils		9 %	1.1 x10⁹/L	0.0 - 1.5


Basophils		0 %	0.0 x10⁹/L

FIP package

External Test
. AGP analysis (g/l) by RIDA:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.541 FCoV Ab titre by IFA:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640 (Referral laboratory) . COMMENT : Alpha-1-acid glycoprotein (AGP) : AGP is an acute phase protein produced by the liver in response to a wide range of inflammatory stimuli, including infectious (viral, bacterial) and non-infectious diseases. Increased concentrations are not specific for FIP but can be a useful diagnostic marker for the disease, when combined with other findings. . Greater than or equal to 1.5 g/l - Increased index of suspicion for FIP Less than 1.5 g/l - Reduced index of suspicion for FIP Less than 0.5 g/l - Most normal cats are in this range . FCoV Ab titre : Titres 100 - 3200 - Diagnosis of FIP is possible (titre for non-effusive forms of FIP should be 640 or higher), but some cats that have come into contact with FCoV and contained the infection (i.e., do not have FIP) will have antibodies at this level. Titres therefore must be interpreted carefully with other parameters such as clinical signs, plasma proteins, and the nature of any pleural or ascitic fluid.


Pancreatic Lipase (Top-up)		Results to follow...
Staff Pet		Discounted


Histology upto 3 sites
DESCRIPTION: Biopsies of Ileum, jejunum and mesentric lymph node x 4. Ileum, jejunum - The villi are mildly blunted (approximately 75% of normal length) with varying sizes and widths. The Villous epithelial injury is mild. The epithelium exhibits focal areas of attenuation and degeneration. Villous intraepithelial lymphocytes are moderately increased, approximately 50-70 per 40x objective stretch of epithelium. The central lacteals are within normal limits and represent up to approximately 25% of the villous lamina propria when sectioned longitudinally. There is a mild increase in lamina propria lymphocytes and plasma cells. Within the villous lamina propria the cells occupy approximately 25-50% of the area of one 40x objective field. There are up to 5 lymphocytes and plasma cells between the crypts. Eosinophils within the lamina propria are within normal limits. There are 2-3 cells per 40x objective field. Neutrophilic infiltration is mild (5-10 per 40x objective field) and macrophage infiltrates are are mild to moderately increased . Crypt distension is mild. Up to 10% of the crypts are dilated, distorted or present as crypt abscesses. The mucosal stroma is within normal limits, with narrow bands of stromal tissue, up to 1-2 fibroblasts in width, separating the crypts. (These samples were evaluated utilising criteria proposed by the WSAVA Gastrointestinal Standardization Group, J. Comp. Path. 2008, Vol. 138, S1 - S43.) . Mesenteric lymph node - a single small wedge of tissue was examined. The tissue comprises lymph node tissue featuring large lymphoid follicles with germinal centres, mildly hyperplastic paracortical areas and medullary histiocytosis and lymphocytosis. . DIAGNOSIS: Moderate mixed lymphohistiocytic and neutrophilic enteritis with mild reactive lymphadenitis. . COMMENT: The appearance is consistent with a moderate mixed lymphohistiocytic and neutrophilic enteritis in these samples. There are both lymphohistiocytic and neutrophilic components to the inflammation. No clear underlying cause is evident in the samples examined. The presence of appreciable numbers of neutrophils suggests possible bacterial involvement. Differential diagnosis includes post-viral enteropathy (e.g. panleukopenia) and idiopathic enteritis. Diagnosis of the latter requires exclusion of other known causes of lympho-plasmacytic enteritis including bacterial infection and bacterial overgrowth (which may be segmental), certain parasites and dietary sensitivity. . Nick Woodger BSc BVetMed FRCPath MRCVS 11:28:54 12/02/2016

Comment

Sample appearance: Slightly lipaemic.

10/02/2016

The increases in phosphate and ALP may be attributable to the young age of the patient.

Haematology appears essentially unremarkable.

Vitamin B12 is elevated, - has the patient received any supplementation? Folate is also increased. TLI will follow as soon as possible and may provide further information.

fPLI is also to follow. Please do not hesitate to contact us if you wish to discuss this case.

Simone Knudsen DVM MRCVS

Additional results for this submission are to follow...

END OF REPORT

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Virginia Campbell — Mon, 15 Feb 2016 20:36:41 GMT

[quote user="Anthony Todd"]why bloods etc at this stage? what does a blood test tell you that a formed stool doesn't?[/quote]

Last FIP case I saw (kitten about this age) presented with chronic diarrhoea well before other signs showed up. I know there is no definitive blood test for it, and some owners prefer to sit tight on the suspicion and just euth if the D+ gets too bad in the face of symptomatic treatment or if other signs eg neuro problems show up - but others may like to have as much evidence as we can gather - for example, if this was my kitten and I'd found anaemia and raised globulins, low albumin on bloods, I wouldn't euthanase right now but I wouldn't be buying a big bag of cat food (or a job lot of cheap chicken for the freezer- whatever you're into).

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Mon, 15 Feb 2016 17:51:29 GMT

[quote user="Robin Grimmer"]Blood testing for a food allergy is a complete waste of time and money, and I don't think anyone is suggesting that.[/quote]

Um. then why was that specific blood test done in the example I quoted, and others, if you want me to dig back?

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Robin Grimmer — Mon, 15 Feb 2016 17:20:56 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]But how common is this? I know there are individual examples of dogs with acute diarrhoea having blood taken, but I really don't think there are many people recommending anything other than straightforward conservative treatment in these cases.[/quote]

This for one, and, if you want me to find others, I'll go back [this is a recurring thread]

Only anecdotal but I have a feline patient that is sensitive to both chicken and beef. Rechallenge brought back the d+ and vomiting, but on bloods came back as borderline

and the suggestion or implication that the challenge was wrong and the bloods were more reliable....??

[/quote]

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Mon, 15 Feb 2016 16:27:22 GMT

This for one, and, if you want me to find others, I'll go back [this is a recurring thread]

Only anecdotal but I have a feline patient that is sensitive to both chicken and beef. Rechallenge brought back the d+ and vomiting, but on bloods came back as borderline

and the suggestion or implication that the challenge was wrong and the bloods were more reliable....??

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Thomas Johnson — Mon, 15 Feb 2016 15:26:32 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]I suspect there is some confusion about the group of patients we are talking about. My experience of animals presenting with diarrhoea is that most vets will switch them onto a bland diet for a few days, whether this is something like Royal Canin Sensitivity (which is duck or chicken and rice), or a home-cooked equivalent, probably alongside a kaolin based treatment. And most of them get better.[/quote]

Exactly! But why bloods etc at this stage? what does a blood test tell you that a formed stool doesn't?

[/quote]

But how common is this? I know there are individual examples of dogs with acute diarrhoea having blood taken, but I really don't think there are many people recommending anything other than straightforward conservative treatment in these cases.

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Mon, 15 Feb 2016 11:23:39 GMT

Exactly! But why bloods etc at this stage? what does a blood test tell you that a formed stool doesn't?

[quote user="Thomas Johnson"]Then you come to the chronic cases where this approach has been tried, and you'd probably want to rule out infections and parasites, [/quote]

Of course! [perhaps one more trial to pick up the cat that's sensitive to beef and chicken??]

Not sure that you ever need 4-6 weeks, perhaps 4-6 days for an obvious response.

Haven't got my head round the hydrolysed diets in that it seems to me that, if you have a cat sensitive to chicken, hydrolysed chicken breaks the protein down so it is not recognised and therefore doesn't give D+. Why doesn't the D+ recur when the cat is back on normal chicken?

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Thomas Johnson — Mon, 15 Feb 2016 10:22:20 GMT

[quote user="Anthony Todd"]

I can never understand why a simple diet trial for a couple of days isn't done first before bloods and biopsies etc., and one US specialist agrees with me.

[/quote]

I suspect there is some confusion about the group of patients we are talking about. My experience of animals presenting with diarrhoea is that most vets will switch them onto a bland diet for a few days, whether this is something like Royal Canin Sensitivity (which is duck or chicken and rice), or a home-cooked equivalent, probably alongside a kaolin based treatment. And most of them get better.

Then you come to the chronic cases where this approach has been tried, and you'd probably want to rule out infections and parasites, but then you might do a more extended diet trial, which might take 4-6 weeks to make a difference, so a properly balanced manufactured diet such as one of the hydrolysed diets is a much better idea.

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Virginia Campbell — Sun, 14 Feb 2016 19:37:50 GMT

[quote user="Anthony Todd"]I wasn't worried about a balanced diet;[/quote]

In a six month old moggy I wouldn't mind so much; a Maine Coon I'd still want as balanced as possible at this age. Of course a single protein source and nice poo has [quote user="Anthony Todd"]got to be better than D+[/quote] but I'd use hydrolysed protein if it was mine. The OP didn't say cost was an issue. I usually offer both options and explain the advantages and drawbacks of each including cost; mind you if people have paid for a pedigree kitten often cost isn't top of their list of concerns.

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Sun, 14 Feb 2016 17:26:18 GMT

[quote user="Andrew Kent"]did anybody dismiss it? [/quote]

Point taken... I need constant adoration....

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Andrew Kent — Sun, 14 Feb 2016 15:10:31 GMT

[quote user="Anthony Todd"]Geez, why is the obvious, simplest and cheapest solution always dismissed and without contra argument.[/quote]

did anybody dismiss it? I said in my reply it's another perfectly valid option, it's just not the one that I use routinely as most clients want something off the shelf.

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Sun, 14 Feb 2016 00:08:02 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Anthony Todd"]protein sources you know are OK. Then pick a commercial diet with only one of those.[/quote]

[quote user="Anthony Todd"]with commercial diets you have so many ingredients, and they vary depending on supply [elephant meat??][/quote]

[/quote]

Point taken, so there may be more trials and errors involved. [particularly when they change the protein source or add the D+ one without changing the name....]

But usually they nominate the main protein source so you've got a fighting chance.

And there may be some animals that only cope with a single source of protein, no milk and a single carb.

Geez, why is the obvious, simplest and cheapest solution always dismissed and without contra argument.

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Emily Rainbow — Sat, 13 Feb 2016 22:26:38 GMT

Only anecdotal but I have a feline patient that is sensitive to both chicken and beef. Rechallenge brought back the d+ and vomiting, but on bloods came back as borderline. Owner is continuing on salmon and potato based generic food with good results.

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Evelyn Barbour-Hill — Sat, 13 Feb 2016 19:31:38 GMT

[quote user="Anthony Todd"]protein sources you know are OK. Then pick a commercial diet with only one of those.[/quote]

[quote user="Anthony Todd"]with commercial diets you have so many ingredients, and they vary depending on supply [elephant meat??][/quote]

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Anthony Todd — Sat, 13 Feb 2016 17:14:06 GMT

[quote user="Andrew Kent"]So, through trial and error you have to either gradually add things to the protein source (aware that you are not feeding a nutritionally balanced diet) or you have to try a different commercial diet.[/quote]

And of course, I forget my initial spiel viz: 24 hours on water only and not off the lead or outside....

No, normally I added a protein source, or changed the protein source, so hopefully you had a variety of protein sources you know are OK. Then pick a commercial diet with only one of those.

If you get D+ you know it's probably not your tested protein so you can go looking for the carbohydrate source, again by trial and error.

Fortunately it's usually the protein [or the fat] which is the problem.

As I said, with commercial diets you have so many ingredients, and they vary depending on supply [elephant meat??] so it's harder to pick the culprit.

I realise that this may be harder than the hydrolysed shortcut [which wasn't around in my day] so many will go for that option but usually the owner gets the message and the full-cream treat, which they never "remember" is stopped!

As cats lived purely on "cats' meat from the butcher, and dogs on porridge all winter I wasn't worried about a balanced diet; got to be better than D+!

I can never understand why a simple diet trial for a couple of days isn't done first before bloods and biopsies etc., and one US specialist agrees with me.

As it's now OK, sort of, to quote age and experience I can't count the number of animals that this approach has worked with of course if it doesn't and there will be some, then start your tests etc. but 99/100 it will.

PS Go home or have a drink Andrew, it's after 5 and it'll be better than receiving geriatric tosh from me, and/or you'll cope with it better.....

RE: Lymphoplasmacytic neutrophilic enteritis in Maine Coon kitten

Andrew Kent — Sat, 13 Feb 2016 16:01:17 GMT

[quote user="Anthony Todd"]Er, then they'll be back to square one, 'cos commercial diets have many components, sometimes not even mentioned, and if the cat goes out all bets are off anyway![/quote]

I'm obviously not understanding your approach - surely if you have had them on a single protein source you are faced with the same situation? i.e. you have proved that there is a dietary cause but you have no idea what element of the diet was responsible.

So, through trial and error you have to either gradually add things to the protein source (aware that you are not feeding a nutritionally balanced diet) or you have to try a different commercial diet.

Or am I missing something?