Dyspnoeic - grateful for ideas!

RE: Dyspnoeic - grateful for ideas!

Jenny Harris — Wed, 22 Mar 2017 16:37:57 GMT

Thanks for the reply- cat had a non investigated murmur previously and then presented acutely. Was pretty sick but seems to have turned the corner today. Seems sensible to recheck in a few weeks

thanks

RE: Dyspnoeic - grateful for ideas!

Kate Richardson — Wed, 22 Mar 2017 12:46:27 GMT

[quote user="Jenny Boyd"]

Hi Kate

just wondered if I could pick your brain slightly on a current case of mine given what you said above-

currently treating a 10yo cat with R and L sided CHF (unclassified cardiomyopathy). Cat currently not doing very well. I have checked a T4 and at 36 thought this ruled out hyperthyroidism- cat has no other signs, actually overweight and a bit on the young side . Would you have expected the T4 to be lower and should I think again?

many thanks

Jenny

[/quote]

hi Jenny Harris certainly a robust t4 in the face of CHF which always raises my suspicions but in the absence of other clinical signs probably not. Also depends on how sick the cat is just now.

has the cat only just presented with the heart disease or was the cardiomyopathy known about previously?

if cat does well clinically I would perhaps review the T4 in a few weeks?

RE: Dyspnoeic - grateful for ideas!

Kate Richardson — Wed, 22 Mar 2017 12:18:14 GMT

_{the fact he has chronic recurrent diarrhoea and he's on a high dose of of Vidalta with poss poor control does make me suspicious of poor absorption Due to IBD for example or even secondary to hyperthyroidism causing increased gut transit time, the response to erythromycin might just be treating secondary bacterial overgrowth as he shouldn't get recurrent campylobacter (which may or may not be causal anyway). So he might be better changing to a bid regimen, either felimazole as robin suggested or thyronorm liquid which might help if difficult to tablet. Be nice to check b 12 levels as might give you a clue there if low, or you could just supplement with a weekly injection regardless as will do no harm.}

RE: Dyspnoeic - grateful for ideas!

Robin Grimmer — Wed, 22 Mar 2017 10:44:22 GMT

I wouldn't go beyond 25mg. I'd switch to felimazole.

RE: Dyspnoeic - grateful for ideas!

Gillian Mostyn — Wed, 22 Mar 2017 08:54:04 GMT

Sorry for delay - day off yesterday (although I did ring the owner and Beau's doing well so far.)

[quote user="Beats"]then TP should be low also as rough rule of thumb[/quote][quote user="Beats"]You don't mention the hemoglobin being low[/quote][quote user="Beats"]If the hemoglobin is normal you can probably forget about any significant anemia here[/quote]

Hb (8) and TP (58) were both very low normal, so the anaemia is certainly marginal.

[quote user="Beats"]Was the patient sedated prior to getting blood sample taken[/quote]

No. Done very soon after admission.

[quote user="Beats"]Also low MCV doesn't really suggest hemorrhage[/quote]

No, but it can indicate iron deficiency so worried re ongoing haemorrhage.

[quote user="Kate Richardson"]With a T4 of 56 in the face of current symptoms I would suspect heart failure secondary to uncontrolled hyperthyroidism[/quote]

That was my assumption on admittance (inherited case) but, as I said, the radiographs weren't what I expected. Not sure now what I expected!

[quote user="Kate Richardson"]Compliance issues recently[/quote]

Not that I'm aware of, although pilling this cat isnt fun.

[quote user="nikki"]Cat that ill should have a low thyroid so worth treating that too. [/quote]

Generally I agree, but have concerns about his renal function. But I guess increasing to 30mg is sensible.

[quote user="robloxley"]With low MCV and MCH and chronic diarrhoea, might there be some GI bleeding?[/quote]

Not that the client has ever mentioned, but again, possible. He had issues with campylobacter for a while, hence the erythromycin, and although recent faecal results have been clear, at the first sign of diarrhoea the owner wants to reach for the erythromycin again - apparently he responds very quickly but I suspect it would clear on its own anyway. He had such major gut issues previously that I'm reluctant to risk withholding it though! (And he has it fairly rarely.) No melaena etc at any point though.

Thanks for all the help - I'm seeing him again later this morning so will let you know what is decided.

RE: Dyspnoeic - grateful for ideas!

Rob Loxley — Tue, 21 Mar 2017 23:31:51 GMT

With low MCV and MCH and chronic diarrhoea, might there be some GI bleeding?

RE: Dyspnoeic - grateful for ideas!

nikki — Tue, 21 Mar 2017 23:01:53 GMT

I'd probably scan him before sedating as can do with them sitting up and almost all cats will tolerate that. Then you can find out if any fluid worth sedating him for and also check size of left atrium and confirm if this is definitely heart failure and how bad. If left atrium is humongous and smoke present then not so great but if only mildly enlarged I'd be more positive. I've had several live a very surprising length of time after presenting in this kind of way, sometimes even years so usually try treating them. Find often they are anaemic to some degree, generally turns out just to be anaemia of chronic disease. Cat that ill should have a low thyroid so worth treating that too.

RE: Dyspnoeic - grateful for ideas!

Jenny Harris — Tue, 21 Mar 2017 22:05:39 GMT

Hi Kate

just wondered if I could pick your brain slightly on a current case of mine given what you said above-

many thanks

Jenny

RE: Dyspnoeic - grateful for ideas!

Kate Richardson — Tue, 21 Mar 2017 20:28:00 GMT

[quote user="Gillian Mostyn"]

Thanks Nikki. I also often tap first, think later, but this cat was unusual. Although putting more effort into breathing he was relaxed, nice colour, no open mouth breathing etc and chest compliance was subjectively normal. He also improved quite quickly with the IV dimazon, which, as you say, they don't usually do.

Bloods show a T4 of 56.8, Urea 15.9 and crea 133.

He is much brighter today, RR in the 20s and still eating well.

HOWEVER, he has a PCV of 27% with low MCV and MCH - hmm.. poss haemorrhage?

I've had a chat with the owner and she is having a think about her options. If she wants to investigate further, I'll sedate, scan and tap the chest tomorrow. Quite justifiably, she is reluctant to do too much if it makes no difference to prognosis, which certainly seems quite poor. While he is happy and breathing OK, we may just wait and see.

Thanks for all your help yesterday everyone.

[/quote]

With a T4 of 56 in the face of current symptoms I would suspect heart failure secondary to uncontrolled hyperthyroidism, and explains why so bright considering, otherwise I would expect T4 to be low. Good response to frusemide iv could be due to resolution of pulmonary oedema, which on looking at the rads again, I think is likely. So pleural fluid may have been present for a little while, certainly not as overt on the dv as the lateral. Compliance issues recently? poor gi absorption? PCV of 27% doesn't worry me too much, low end of normal, I wouldn't be thinking bleed I'd be thinking chronic disease, but would check a smear and repeat in a few days.

If its all due to hyperthyroidism then the prognosis is more favourable, but otherwise, sadly guarded

RE: Dyspnoeic - grateful for ideas!

Beats — Tue, 21 Mar 2017 13:51:14 GMT

[quote user="Gillian Mostyn"]he has a PCV of 27% with low MCV and MCH - hmm.. poss haemorrhage?[/quote]

If you're thinking hemorrhage into thorax acutely, then TP should be low also as rough rule of thumb.

Was this PCV a manually done one? You don't mention the hemoglobin being low but list MCV and MCH indicating automated analysis. If the hemoglobin is normal you can probably forget about any significant anemia here. Was the patient sedated prior to getting blood sample taken (can radically alter PCV in cats). Also low MCV doesn't really suggest hemorrhage.

RE: Dyspnoeic - grateful for ideas!

Gillian Mostyn — Tue, 21 Mar 2017 13:30:42 GMT

Bloods show a T4 of 56.8, Urea 15.9 and crea 133.

He is much brighter today, RR in the 20s and still eating well.

HOWEVER, he has a PCV of 27% with low MCV and MCH - hmm.. poss haemorrhage?

Thanks for all your help yesterday everyone.

RE: Dyspnoeic - grateful for ideas!

nikki — Tue, 21 Mar 2017 00:02:16 GMT

I would definitely tap that chest based on those xrays. Quick ultrasound to confirm location of largest pocket of fluid. Quick whiff of ketamine/midazolam IV for a fidgety cat and be sorted. Frusemide is not great for shifting pleural effusions and won't be doing the already challenged kidneys much good so I'd go straight for tapping as the xrays are diagnostic for pleural effusion. I never usually xray these cases as can get all the initial info you need from a quick scan with a lot less stress.

RE: Dyspnoeic - grateful for ideas!

Kate Richardson — Mon, 20 Mar 2017 15:38:17 GMT

Oh and keep an eye on those kidneys and potassium levels on the frusemide- not got much choice, but consider adding spironolactone

RE: Dyspnoeic - grateful for ideas!

Kate Richardson — Mon, 20 Mar 2017 15:34:57 GMT

[quote user="Beats"] tap of fluid (+/- NT-proBNP on it) might increase confidence also[/quote]

Only thing to remember is that a negative means it isn't cardiac, but a positive means it could be, but could be due to other causes so caution interpreting BNP if run on pleural fluid

Be interesting to know what it T4 is Gillian Mostyn when you get the results

RE: Dyspnoeic - grateful for ideas!

Gillian Mostyn — Mon, 20 Mar 2017 15:28:18 GMT

Thanks - it was what I first thought but I think I'd been staring at the radiographs so long I'd started to see zebras!

Actually doing well on IV frusemide - RR now approx 35 and eaten a large bowl of food! Pretty wriggly cat so reluctant to tap chest without sedation and would rather wait for bloods. (Minor issue with in-house bloods so need to wait till tomorrow for results.)

RE: Dyspnoeic - grateful for ideas!

Robin Grimmer — Mon, 20 Mar 2017 14:50:57 GMT

Another vote for cardiac failure causing pleural fluid and ascites. If the hyperthyroidism is not controlled then if you can control it then the heart failure may improve, but ascites is generally a poor prognostic indicator.

RE: Dyspnoeic - grateful for ideas!

Beats — Mon, 20 Mar 2017 14:19:21 GMT

2nd (non-expert) vote for likely cardiac pleural effusion.

I think it's reasonable to treat with more furosemide on that basis, or assume a poor prognosis and euthanase.

basic check of atrial size with ultrasound and tap of fluid (+/- NT-proBNP on it) might increase confidence also - can combine with bloods (to include albumin/globulin) if wanted.

RE: Dyspnoeic - grateful for ideas!

Gillian Mostyn — Mon, 20 Mar 2017 13:44:32 GMT

RE: Dyspnoeic - grateful for ideas!

Gillian Mostyn — Mon, 20 Mar 2017 13:40:53 GMT

Last T4 was last year - 65 but with a urea of 18 and a crea of 139 the vet looking after Beau decided to leave the vidalta at 25mg sid. I've taken more blood today - results to follow. (Not insured so spending money as efficiently as possible...

I was also convinced the cause was cardiac but managed to convince myself that there looked to be another issue with the integrity of the diaphragm - am I overanalysing??? I'll post the right lateral too.....

RE: Dyspnoeic - grateful for ideas!

Kate Richardson — Mon, 20 Mar 2017 13:25:38 GMT

pleural effusion on lateral so that plus ascites points to cardiac cause most likely. Difficult to analyse dv on my phone but poss some bronchial lung changes as well? Cardiac disease doesn't usually cause coughing so could there be 2 things going on at once? Aerophagia sec to dyspnoea.

I would drain pleural fluid for symptomatic relief plus fluid analysis, check LA size if you can, pro BNP on bloods would be useful but not a quick turn around time unless you have snap test. I might give doxycycljane as well in case underlying infection

what is cats t4 currently?

RE: Dyspnoeic - grateful for ideas!

Gillian Mostyn — Mon, 20 Mar 2017 12:52:46 GMT

Oh...Should say that they were concious pictures and on film, so not ideal for reproducing here!