Case discussion - cat with anorexia and weight loss

RE: Case discussion - cat with anorexia and weight loss

Sarah Keir — Tue, 23 Apr 2019 17:12:49 GMT

It is perhaps an ethic debate we, as veterinary professionals, should have.

The treatment may work and cure the cat but I know that some are not cured and remain potential sources of infection and need extended treatment. What do we feel about this?

Is this cat going to be kept as indoor cat until it can be proven it is cured? Otherwise it would risk infecting the environment, as it sounds like it is in a mesenteric lymph node so potential for faecal contamination.

I understand that the risk of passing to the humans is low but there are cases of zoonotic transmission of M.bovis to humans. That could be a visiting child or elderly friend, not just the people living with the cat every day. How would the owner's feel if a friend become infected from their cat?

Are the owners committed for the full treatment? 6 months of multiple times a day pills and then more tests at the end (repeat imaging and interferon gamma) to check that it is 'cured'. A few weeks of pills are very different to every day for 6 months.

Should we be using human protected antibiotics in treating this? What do the medics that treat TB frequently feel about this?

There are no right or wrong answers but we need to discuss important topics such as this.

RE: Case discussion - cat with anorexia and weight loss

Thomas Johnson — Tue, 23 Apr 2019 16:41:16 GMT

[quote user="Sarah Keir"]

Thank you for posting this Thomas, definitely worth the CPD time!

Is it wise to treat M.bovis? Have you reported to the ministry?

[/quote]

The day I got the result I was going to phone APHA, but before I could I had a phone call from the TB centre in Birmingham who had already been notified by the lab, they then notified APHA and Public Health England, and I had phone calls from both organisations the following day. Public Health England have also spoken to the owners.

I was initially unsure about the wisdom of treating TB in cats, but I was advised that unless they've got open sores with a significant discharge the risk is very very low. I did discuss euthanasia with the clients but they wanted to try treatment.

RE: Case discussion - cat with anorexia and weight loss

Sarah Keir — Tue, 23 Apr 2019 15:42:38 GMT

Thank you for posting this Thomas, definitely worth the CPD time!

Is it wise to treat M.bovis? Have you reported to the ministry?

RE: Case discussion - cat with anorexia and weight loss

Thomas Johnson — Tue, 23 Apr 2019 08:32:28 GMT

[quote user="Louise6732"]Do you know if this case was one of the recently reported ones by Danielle et al of the raw diet and TB link or is this case in addition to the others? [/quote]

I first spoke to Danielle on 5 April so I would assume this is in addition to the ones she has reported.

[quote user="Virginia Campbell"]

Great case Thomas and the improvement is very interesting...do you know if this is unusual? What all had the cat had in the way of treatment by this point and do you think this helped or do you reckon it was mostly the cat's own cell mediated immunity kicking into gear?

[/quote]

[quote user="Kate Richardson"]

TB cases often have a really chronic presentation with waxing and waning symptoms, so it maybe the natural course of the disease

[/quote]

This was my assumption, the only treatment she had had at the point she started to improve was a Convenia injection given about 6 weeks previously.

RE: Case discussion - cat with anorexia and weight loss

Kate Richardson — Mon, 22 Apr 2019 09:00:41 GMT

[quote user="Virginia Campbell"]

[/quote]

TB cases often have a really chronic presentation with waxing and waning symptoms, so it maybe the natural course of the disease

RE: Case discussion - cat with anorexia and weight loss

Virginia Campbell — Sat, 20 Apr 2019 21:11:36 GMT

RE: Case discussion - cat with anorexia and weight loss

Julie Innes — Fri, 19 Apr 2019 19:04:02 GMT

Interesting case, Thomas, thanks for posting!

RE: Case discussion - cat with anorexia and weight loss

Louise6732 — Fri, 19 Apr 2019 14:06:00 GMT

Thank you for posting this case Thomas it’s really interesting. I was thinking FIP so the TB diagnosis was a surprise!

Do you know if this case was one of the recently reported ones by Danielle et al of the raw diet and TB link or is this case in addition to the others?

Louise

RE: Case discussion - cat with anorexia and weight loss

Thomas Johnson — Thu, 18 Apr 2019 09:45:54 GMT

[quote user="Virginia Campbell"]

[quote user="Joyce Whitehead"]TB might have climbed the list in my mind[/quote]

I thought this too. I'd be on the phone to the lab asking what samples they want to check for this...and probably asking the doyenne of feline internal med too :-)

[/quote]

For those thinking TB, yes, this was high on my list as well. Though interestingly between taking the FNAs and skin biopsy she improved significantly, the owner reported that her behaviour was back to normal, her appetite returned and she re-gained weight. The mass in her abdomen was palpably smaller and the skin lesion on her head resolved. However she developed another skin lesion on her right fore leg and I took biopsies for aerobic, anearobic, fungal and mycobacterial culture.

The aerobic, anaerobic and fungal cultures came back negative after a few days, and after a long two months the final results came through, a positive culture for Mycobacteria bovis. Apart from the biopsy site taking the full 2 months to heal the cat has remained very well in herself and has re-gained all of the weight she lost, and no further skin lesions have appeared.

Since then I have taken thoracic radiographs and consulted Danielle Gunn-Moore, and we are planning to treat, though I would have understood if the owner's had decided on euthanasia. I have also taken blood samples from the in contact dog and cat for interferon gamma testing, the owners are being tested as well (though not by me!). The radiographs are below:

RE: Case discussion - cat with anorexia and weight loss

Virginia Campbell — Wed, 17 Apr 2019 14:32:34 GMT

[quote user="Thomas Johnson"]commercial raw diet.[/quote][quote user="Thomas Johnson"]pyogranulomatous inflammation[/quote][quote user="Thomas Johnson"] skin lesions [/quote][quote user="Joyce Whitehead"]TB might have climbed the list in my mind[/quote]

I thought this too. I'd be on the phone to the lab asking what samples they want to check for this...and probably asking the doyenne of feline internal med too :-)

RE: Case discussion - cat with anorexia and weight loss

Julian Earl — Wed, 17 Apr 2019 10:24:34 GMT

I would humbly suggest looking for a source of pain. Not necessarily of the major traumatic type, but chronic pain. Spinal or joint pain, even subtle oral pain somewhere. I have used NSAIDs in similar cases and sometimes the effect is dramatic. It is a case of If Only they could talk to tell us about aches and pains!

I hope this helps. Both the cat, and you!

RE: Case discussion - cat with anorexia and weight loss

Kate Richardson — Tue, 16 Apr 2019 19:33:46 GMT

I’d want some imaging of the thorax, and sampling if indicated, and a biopsy of the lymph node for histology, culture, ZN staining and immunocytochemistry/histochemistry looking for FCOV. Assuming one could do all they want to Any of skin biopsy available for culture?

and would be considering supportive treatments such as appetite stimulants, feeding tube, depending on how the cat was doing in itself, prob nsaids to help with pyrexia if happy cat hydrated etc

RE: Case discussion - cat with anorexia and weight loss

Joyce Whitehead — Tue, 16 Apr 2019 19:03:54 GMT

I think TB might have climbed the list in my mind, don‘t some of them get skin lesions? I think I’d be tempted to ex lap and have a look in the abdomen. I assume chest clear?

RE: Case discussion - cat with anorexia and weight loss

Thomas Johnson — Tue, 16 Apr 2019 18:18:39 GMT

My thoughts at the time were that there was something inflammatory going on, and I was concerned about FIP. I didn't think pyelonephritis was that likely as my experience has been that they generally have some elevation of renal parameters and a higher white cell count, I probably should have done urine tests to be sure, however the final diagnosis wasn't a urinary problem. I didn't want to look at other trial treatments as she had been unwell for several months, and the owner was keen to get an answer as well. I didn't repeat haematology, but took blood for FeLV, FIV, FCoV, toxoplama (only because it was in the combined package of tests from the lab) and serum protein electropheresis.

FeLV, FIV and toxoplasma were negative, FCoV titre 2,560 so very high, and the SPE report was: There is a marked alpha 2 elevation consistent with acute phase proteins, acute phase proteins may also account for the marginal beta elevation. The gammaglobulins only appear marginally elevated and this is a broad based elevation suggestive of a polyclonal response. These findings are non specific and could be seen with infection; to include FIP amongst others, inflammation and neoplasia amongst other causes.

She was booked in for an abdominal ultrasound, though there was a 3 week delay at this point as the owner went on holiday. When she came in for the scan she was still pyrexic and had lost further weight, clinical examination also revealed a 25mm diameter mass in the mid-abdomen and skin lesions on the left side of her head and on her ventrum, they were about 6mm in diameter and looked like non-healing wounds.

The mass in her abdomen appeared to be an enlarged mesenteric lymph node and no other abnormalities were noted, FNAs were taken from the mass and one of the skin lesions was removed and sent for histopathology.

The cytology results form the abdominal mass came back as inconclusive due to low cellularity, but suggestive of pyogranulomatous inflammation. The histopath report on the skin mass was: epidermal ulceration with extensive inflammation and multifocal necrosis in the dermis and subcutis. Large numbers of neutrophils are intermixed with macrophages, lymphocytes and plasma cells. Reactive fibroplasia is observed. Histological evaluation is diagnostic for ulcerative necrogranulomatous dermatitis.

What would you have done next?

RE: Case discussion - cat with anorexia and weight loss

Kate Richardson — Mon, 15 Apr 2019 21:23:18 GMT

I would be suspecting an inflammatory focus somewhere and FIP would be high on the radar given age/breed. So I would either give a course of nsaids and a different antibiotic such as amoxyclav or clindamycin and assess response, or I would investigate further depending on owners wishes/funds available. Low urea would also make me slightly concerned about liver functon and a PSS so would ideally do dynamic bile acids as well. I would check urine although rare in my experience for a uti to cause pyrexia, and pyelonephritis I would expect to cause azotaemia, however, cats don't read the book, so I wouldn't rule it out. I would advise imaging of chest and abdomen. I would run coronoavirus titres to see of exposed or not, predominantly because the more ticks in the box I get for support of FIP the more I can guide the owners as to value of spending more money. Sample fluid/masses if found on imaging. Is the raw diet a red herring? Have to consider bacterial infection secondary to this, especially given recent reports of TB in a few indoor cats fed a raw diet

RE: Case discussion - cat with anorexia and weight loss

Sara Ramsey — Mon, 15 Apr 2019 17:49:39 GMT

I would considrr: urine culture and ultra kidneys for signs of pyelonephritis.

Also re-palpate peripheral lymph nodes and joints for subtle changes.

If I was happy with kidneys and o wanted conservative approach then I would trial nsaid and re-assess in 5 days

RE: Case discussion - cat with anorexia and weight loss

Richard Carter — Mon, 15 Apr 2019 16:23:58 GMT

think it has chronic inflammatory changes, the low urea relates to anorexia. Rule in/ out FIP, FeLV/FIV, start looking for source of inflammation/ infection. Presume the convenia did nothing for WBCC?

RE: Case discussion - cat with anorexia and weight loss

Anthony Dennison — Mon, 15 Apr 2019 15:57:48 GMT

If it wasn't done at the time of the original bloods, blood smear to check red and white blood cell morphology. Look for any toxic changes and examine morphology of RBCs in case raised TBil was due to intravascular haemolysis.

Suspicion of FIP given how high the globulins are and the fact that it's a purebreed, though I wouldn't go down the route of coronavirus titre just yet as it's not the most useful of tests.

Abdominal ultrasound to look for an effusion to sample, see if there are any changes to the gastrointestinal tract, check liver and pancreas for any changes.