Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Bob Russell — Thu, 29 Oct 2020 16:03:16 GMT

Perhaps the anti 'droids' brigade have got to me but I treat PUO with meloxicam as long as kidney function is OK. Probably would even if kidney disease was a serious differential.

Fevers serve a purpose but can be counterproductive as well. I would rather have a recovering non-pyrexic patient that was eating than a pyrexic one that refused to eat.

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

David Mills — Thu, 29 Oct 2020 15:17:04 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/29434/live-case-discussion-young-adult-cat-acute-lethargy-over-night-lilies-or-not/226194#226194"]I think a one-off shot of amoxicillin to cats that you think may have a cat bite but haven't found one is low on the spectrum of antibiotic naughtiness, perhaps my second injection (and tomorrow will make three) is less acceptable though...[/quote]

The use in individual animals is rarely a huge problem, I agree, but that does not mean it is justifiable. The problem is in the multiplication of this through 1000s of PUO cats and I don't think "well its only one or two injections" is a strong enough defence.

What's more, it is illogical. Most bacterial causes of pyrexia will be systemic - that is, septicaemic or a severely ill animal. It wasn't the case here. The cat was unwell but apparently functional. I have a pet theory that in CBAs with pyrexia, these are likely mainly due to the inflammatory response rather than systemic bacteraemia.

Further to this, would people be treating CBAs with antibiotics anyway? There was a thread on this a while back...

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Beats — Thu, 29 Oct 2020 12:43:48 GMT

[quote userid="6386" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/29434/live-case-discussion-young-adult-cat-acute-lethargy-over-night-lilies-or-not/226233#226233"]I may have missed something but what was your justification for iv fluids? [/quote]

from above:

"the vague possibility that may have ingested lily pollen and my belief that maintaining on iv fluids may be helpful in reducing risk of serious consequences if had [perhaps by maintaining renal perfusion in anorexic/dehydrated cat or by diluting any toxin being excreted through renal tubules?]. "

Very happy to be corrected.

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Kate Richardson — Wed, 28 Oct 2020 22:04:22 GMT

I may have missed something but what was your justification for iv fluids?

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Beats — Sun, 25 Oct 2020 20:10:52 GMT

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/29434/live-case-discussion-young-adult-cat-acute-lethargy-over-night-lilies-or-not/226191#226191"]Re the OP, and it may not have been your decision, I really wish people would stop using antibiotics in PUO cases as first line! [/quote]

Was my decision on this occasion. Cat bite was featuring highly in my mind on presentation - I didn't find one, but I have been known to miss them before. While the cat was fine to take temperature, blood sample and drip without assistance, it was somewhat harder to check in detail for possible bite puncture or traces of lily pollen on coat - nothing obvious on either front though on brief solo exam.

I think a one-off shot of amoxicillin to cats that you think may have a cat bite but haven't found one is low on the spectrum of antibiotic naughtiness, perhaps my second injection (and tomorrow will make three) is less acceptable though...

CASE UPDATE: appears to have eaten few pieces of chicken and has urinated (on blanket that is hiding under).

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

David Mills — Sun, 25 Oct 2020 19:36:53 GMT

[quote userid="7002" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/29434/live-case-discussion-young-adult-cat-acute-lethargy-over-night-lilies-or-not/226181#226181"]I probably would have felt the need to "treat" (remove) the pyrexia, but I've just watched Ian Ramsey's BSAVA webinar on feline infectious disease and it's made me think twice about doing this.[/quote]

This argument comes and goes and there is quite a bit in the human literature. I don't think the "function" of pyrexia is completely understood to make any firm recommendations. On one hand it may be adaptive, and help, but in many diseases it is an unhelpful byproduct of pyrogens (esp in sepsis as it happens).

It is generally accepted that humans and animals with fever have increased morbidity however, and humans have a high preference for reducing this unpleasant sensation even if it extends the period of disease. Cats especially seem to be morbid with fever, and whilst letting it run its course may be laudable, is it in the cats bests interests? Or even owners? Likely to be more expensive not treating.

Re the OP, and it may not have been your decision, I really wish people would stop using antibiotics in PUO cases as first line!

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Beats — Sun, 25 Oct 2020 12:58:49 GMT

8am - had not eaten; urinated and with full bladder. Had 300ml hartmanns iv. T=38.6'C, HR144/min; RR36/min. Hiding under blanket and probably had been since admitted other than urination in litter tray. Had an amoxicillin injection on admission and another this morning. Syringed 20ml of Royal Canin "recovery" food. Kidneys feel a little large, but I wouldn't place to much weight on that very subjective feeling. Mild skin tent (again subjective and of highly questionable significance), drip restarted in morning at 25ml/hr. 1/8th of 15mg mirtazapine given PO.

12pm - syringed another 20ml Royal Canine "recovery" food.

Plan: keep on iv fluids until tomorrow morning (given possibility of lily pollen ingestion), with couple more syringe feeds today given judged unlikely to eat. Give some SC fluids in morning + amox injection +/- dex injection and send home to see if normal enough (unless anything untoward on assessment tomorrow); possibly repeat creatinine first.

Thoughts:

1) Had the owner not mentioned was worried had ingested lily pollen, would have had metacam and amoxicillin injections yesterday from me and been told only to come back if wasn't better next day.

2) A temperature of 39.5'C is borderline for pyrexia (versus stress) for me, and was 38.8 and 38.6 on only 2 subsequent readings after admission. Neutrophilia and increased bands adds little weight to this being inflammatory/pyrexic cat rather than toxicity, but I'm pretty open-minded either way.

3) I would send this can home today for certain to see how was at home other than the vague possibility that may have ingested lily pollen and my belief that maintaining on iv fluids may be helpful in reducing risk of serious consequences if had [perhaps by maintaining renal perfusion in anorexic/dehydrated cat or by diluting any toxin being excreted through renal tubules?]. I don't think being on drip for another 24hours will set back too much otherwise, so seemed worth it.

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/29434/live-case-discussion-young-adult-cat-acute-lethargy-over-night-lilies-or-not/226185#226185"]Think the pcv bit low[/quote]

likely inaccurate on lasercyte; as rule of thumb should be about 3 x Hb level. Hb level is fine and I didn't do PCV manually as wasn't going to change my assessment presently.

not that I identified.

Thanks to everyone for all the thoughts :-)

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Richard Carter — Sun, 25 Oct 2020 11:39:26 GMT

Think the pcv bit low with reticulocytes- never trust cat blood results from blood machine but can do a good blood smear- infectious anaemia on smear?

flea bite anaemia with borrlia is my wild guess

onions/ garlic...

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Sara Ramsey — Sat, 24 Oct 2020 23:09:24 GMT

I probably would have felt the need to "treat" (remove) the pyrexia, but I've just watched Ian Ramsey's BSAVA webinar on feline infectious disease and it's made me think twice about doing this.

I Would monitor renal parameters/urine output/bladder size but at this stage wouldn't be putting AKI due to lillies at the top of the list.

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

David Mills — Sat, 24 Oct 2020 22:40:51 GMT

Shot of dex. Most of these aren't bacterial. If you think about how bacteria cause pyrexia, almost all these IME are nowhere near septicaemia. PUO. Cats often tachypnoeic with a high temperature. Dex is very harmless at anti inflam doses for most conditions.

Thorax xray or scan (don't call it something silly like POCUS or TFAST please) if you are feeling worried but I'd be dex and fluids and reassess tomorrow.

I wouldn't have done bloods.

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Julie Turner — Sat, 24 Oct 2020 22:14:02 GMT

I’ve never seen a lily poisoning with a high temp - it’s usually lower than normal, if anything.
I’m a young cat with those results o would be searching for a cat bite wound for starters and would give something like amox/clav preemptively. The elevated WBC would add to that suspicion.
I am not a specialist, but am long in the tooth (=old) and no longer dish our antibiotics like sweeties: however, common causes are common.
let us know how you get on Beats

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Beats — Sat, 24 Oct 2020 18:25:40 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/29434/live-case-discussion-young-adult-cat-acute-lethargy-over-night-lilies-or-not/226171#226171"] bloods for renal function[/quote]

creatinine is 79 (lower end of reference interval).

Breathing noticeably a little rapid on presentation also - I forgot to mention that.

EDIT: Full blood results:

Idexx Lasercyte (samples with asterisk deemed unreliable by machine) and Idexx VetTest

RBC	* 6.51 5.30 - 10.60 x10^12/L
Haematocrit	* 0.263 0.297 - 0.445 L/L
Haemoglobin	120 92 - 154 g/L
MCV	* 40.5 38.1 - 53.9 fL
MCH	18.5 11.5 - 19.2 pg
MCHC	- --.-- 29.9 - 38.6 g/dL
RDW	18.4 17.3 - 22.0 %
% Reticulocyte	1.2 %
Reticulocytes	76.7 3.0 - 50.0 K/µL
WBC	21.14 5.50 - 19.50 x10^9/L
% Neutrophils	* 87.2 %
% Lymphocytes	5.4 %
% Monocytes	* 5.0 %
% Eosinophils	2.2 %
% Basophils	0.2 %
Neutrophils	* 18.43 2.50 - 12.50 x10^9/L
Lymphocytes	1.15 0.40 - 6.80 x10^9/L
Monocytes	* 1.05 0.15 - 1.70 x10^9/L
Eosinophils	0.47 0.10 - 0.79 x10^9/L
Basophils	0.05 0.00 - 0.10 x10^9/L
Platelets	* 228 175 - 600 x10^9/L
PDW	20.3 %
MPV	* 20.3 fL
Plateletcrit	* 0.46 %

Glucose	9.07 4.11 - 8.83 mmol/L
Creatinine	79 71 - 212 µmol/L
Urea	5.9 5.7 - 12.9 mmol/L
Phosphorus	1.47 1.00 - 2.42 mmol/L
Total Protein	70 57 - 89 g/L
Albumin	32 22 - 40 g/L
Globulin	38 28 - 51 g/L
ALP	24 14 - 111 U/L
Bilirubin - Total	< 2 0 - 15 µmol/L
Cholesterol	2.32 1.68 - 5.81 mmol/L
Amylase	398 500 - 1,500 U/L

Temperature after few hours in quiet kennel on 3 x maintenance iv fluids was 38.9'C; remained subdued - quite fearful also.

Checking blood smear, lots of platelets and wbcs, with manual count of 200 wbcs giving:

neutrophils 89% (18.8 x 10^9/L)

lymphocytes 6.5% (1.37 x 10^9/L)

Monocytes 1% (0.2 x 10^9/L)

Band neutrophils 3.5% (0.7 x 10^9/L)

Idexx Snap for FeLV/FIV was negative also.

After 200ml of fluid, breathing seemed settled and has not eaten - hiding in hide in cage, probably slightly more normal looking. Has not urinated.

RE: Live Case discussion: Young adult cat acute lethargy over night; lilies or not?

Neil Wheadon — Sat, 24 Oct 2020 17:13:07 GMT

Bizarre as had one of these 2 days ago. A 5 month old kitten that was covered in pollen, 10 minutes prior

Aneasthetised

2 x 10 gauge tubes placed, one in, one out and we stomach pumped it (2 tubes work well)

Fluids at 2 x maintanance

Coat extensively washed

15ml liquid charcoal placed in the tubes

Bloods not taken at the time, but left to the OOH centre to do a little later.

In this case, bloods for renal function (you need to do that), however that temperature could make the lillies a red herring

Neil