Cases

•  8 week old F DSH •  1 of 4 kittens born in rescue centre •  3 day ago: 1 died, 2 developed v+ + d+ → died •  Emma → severe watery blood-stained d+ •  Depressed, dehydrated, very weak •  Abdominal pain + gas / fluid-filled GIT

Q. Most likely causes of severe d+ in a kitten of this age?

Emma

Q. Most likely causes of severe d+ in a kitten of this age? A. FPV (CPV), FeLV, FCoV, FIV

Campylobacter, Salmonella

Giardia, Cryptosporidium, Coccidia,

Tritrichomonas foetus, Toxoplasmosis, etc.

Haematology → ↓PCV 18% + panleukopenia (2.1x109/l) (Neuts. 0.9x109/l; Lymphs. 1.2x109/l; eos. 0.2x109/l)

Q. Most likely causes of d+ in this kitten?

Emma

Q. Most likely causes of d+ in this kitten? FPV (CPV), FeLV, FIV, Salmonella, Toxoplasmosis

Q. How would you try to confirm a diagnosis?

Emma

•  Diagnosis of FPV (CPV)

Clinical findings Detect virus in faeces (ELISA / PCR), or tissue (VI / EM) Serology PM examination

•  FeLV - antigen/virus/PCR; FIV - antibody/PCR; Toxo - antibody; Salmonella - faecal culture; Giardia,

Cryptosporidium, Coccidia, Tritrichomonas foetus - feacal analysis/PCR

Q.  How would you try to treat this kitten?

Emma

Q. How would you treat this kitten? •  Supportive care •  Fluid therapy

?Intraosseous route

Andrew Brown, U of Penn

Emma

IV fluids

Q. How would you treat this kitten? •  Supportive care •  Fluid therapy •  Broad spectrum antibiotics •  Anti-emetics •  Gut protectants •  B-vitamins •  Warm clean environment •  Good nursing •  Micro-enteral feeding

Emma

Q. How would you treat this kitten? •  Blood transfusion •  G-CSF SQ q12-24h, ~£250 •  rFeIFNω (Virbagen Omega)

Licensed to treat CPV: 2.5 M IU/kg IV q24h, for 3 days 92 dogs: over 9 days 4x more of the controls died, cf Tx IV, IM, SQ, PO?

Side effects - ‘flu’-like, GI upset, transient fever ↓ platelets, ↓ wbc, ↓PCV

Emma

•  ?12h starvation → small frequent bland meals (chicken) •  Hospitalisation - severe diarrhoea → dehydration •  Oral water ± oral electrolyte/glutamine solution

•  Microenteral nutrition - water, electrolytes, glucose, amino acids (glutamine) - helps preserve mucosa + ↓ bacterial translocation

•  Antibiotics - not indicated unless specific bacterial agent or GI ulceration

Treatment

•  Corticosteroids - not unless IBD •  Adsorbents - bind bacteria + toxins, protect mucosa •  Motility modifiers - opiates (e.g.diphenoxylate, loperamide) ↓

secretions + ↑ segmental contractions – ok short term but not in young kittens or if obstructive or infectious; anticholinergics (e.g. hysocine) risk ileus

•  Prebiotics - promote growth of beneficial bacteria •  Probiotics - help repopulate with beneficial bacteria

Treatment

Questions?

Candy

Candy

•  12 year old •  FN •  DSH

Candy

•  Very bright and well •  Good appetite •  Occasional vomiting and

diarrhoea •  Weight loss, 3 months duration

Candy

•  Physical Examination –  BCS 5/9 –  Well hydrated –  MM-Pink –  CRT<2secs –  HR 220, Grade III/VI systolic murmur –  RR 32 –  Abdominal palpation; soft faeces in colon –  All peripheral LN; normal –  Bilateral palpable goitre

Candy

•  Problem List – Vomiting – Diarrhoea – Weight loss – Heart murmur – Bilateral palpable goitre

Candy

•  Differential Diagnosis –  Vomiting

•  Gastric disorders •  Metabolic Disorders •  Small intestinal disorders •  Sympathetic stimulation

–  Diarrhoea •  Food allergy •  IBD

–  lymphocytic plasmacytic –  Eosinophilic –  Granulomatous

•  Neoplasia •  Partial obstruction (FB,

intussusception) •  ??SIBO •  Chronic infection

–  Giardia –  Toxoplasmosis –  Bacterial

–  Goitre •  Cystic adenoma •  Carcinoma •  Cyst •  Lymphoma

–  Weight Loss •  Metabolic disorders

–  -organ failure (CHF, CRF, hepatic failure, hypoadrenocorticism)

•  Excessive nutrient loss –  -PLE –  PLN –  DM

•  Malabsorptive disorders •  Excessive use of calories

–  increased physical activity –  extremely cold environment –  Hyperthyroidism –  pregnancy or lactation –  increased catabolism (fever/

inflammation) –  Systolic Heart Murmur

•  Specific Cardiomyopathy –  Hyperthyroidism –  Hypertension

•  HCM •  RCM •  DCM •  Myocarditis •  Congenital heart disease

Candy: Haematology

RBC - PCV 37.0 (24-45 %) Haemoglobin 12.2 (8.0-14.0 g/dl) MCV - (39-55 fl) WBC 8.2 (7.0-20.0 109/l) Neutrophils 7.2 (2.5-12.8 109/l) Band neuts. 0.0 (0.0-0.3 109/l) Lymphocytes 0.8 (1.5-7.5 109/l) Monocytes 0.08 (0.07-0.85 109/l) Eosinophils 0.18 (0.0-1.0 109/l) Platelets - (300-600 109/l)

Candy: Biochemistry

Total Protein 67.1 (69-79 g/l) Albumin 26.0 (28-39 g/l) Globulin 41.1 (23-50 g/l) ALT 37 (15-60 u/l) Bile acids 4.3 (0.0-7.0 umol/l) Urea 9.7 (2.8-9.8 mmol/l) Creatinine 127 (40-177 umol/l) ALP 48 (10-100 u/l) Glucose 6.7 (3.3-5.0 mmol/l) Ca 2.33 (2.1-2.9 mmol/l) PO4 1.17 (1.4-2.5 mmol/l) K 3.3 (4.0-5.0 mmol/l) Na 154 (145-156 mmol/l) Cl 119 (117-140 mmol/l) T4 63.1 (13-48 nmol/l)

Candy

•  BP: 160mmHg •  Urinalysis

– SG 1.028 – pH 6.0 – Otherwise NAD

Diagnosis: Hyperthyroidism

Candy

•  Re-homed, on Neomercazole 5mg bid and Atenolol 6.25mg sid

•  3 wks, Diarrhoea (severe) •  Occasional vomiting

•  Ex-lap: IBD (L/P) •  Pred, 1mg/kg bid

Candy

•  5 weeks later –  Loosing weight –  Polyphagic –  Polyuria/

Polydipsia

–  No more GI signs

•  Physical Exam –  BCS 4/9 –  Poor coat quality –  MM’s are pink –  CRT<2secs –  Heart rate is

180bpm –  RR 28bpm. –  Grd III/VI systolic

murmur –  Mild

hepatomegaly

Candy

•  BP 172mmHg •  Haematology RBC Not possible, due to agglutination PCV 28.0 (24-45 %) Haemoglobin 10.2 (8.0-14.0 g/dl) MCV - (39-55 fl) WBC 9.2 (7.0-20.0 109/l) Neutrophils 8.5 (2.5-12.8 109/l) Band neuts. 0.0 (0.0-0.3 109/l) Lymphocytes 0.1 (1.5-7.5 109/l) Monocytes 0.28 (0.07-0.85 109/l) Eosinophils 0.18 (0.0-1.0 109/l) Platelets - (300-600 109/l)

Candy •  Biochemistry Total Protein 80.1 (69-79 g/l) Albumin 28.0 (28-39 g/l) Globulin 52.1 (23-50 g/l) Bile acids 5.3 (0.0-7.0 umol/l) ALT 57 (15-60 u/l) Urea 13.7 (2.8-9.8 mmol/l) Creatinine 238 (40-177 umol/l) ALP 49 (10-100 u/l) Glucose 19.7 (3.3-5.0 mmol/l) Ca 2.6 (2.1-2.9 mmol/l) PO4 1.4 (1.4-2.5 mmol/l) K 3.6 (4.0-5.0 mmol/l) Na 152 (145-156 mmol/l) Cl 116 (117-140 mmol/l) T4 <5 (13-48 nmol/l)

Candy

•  Treatment –  Decrease neomercazole to 2.5mg once

daily –  m/d: Diarrhoea worsened –  Whiskas only –  Stop Prednisolone –  Caninsulin 2IU bid –  Tumil-K –  Famotidine –  Benazepril

Candy

Throughout the next 12 months, Candy is stable, with mild CRI. Her blood pressure is monitored, throughout this period. It is initially 180-190mmHg, but gradually increases to 210mmHg.

Candy

•  Amlodipine 6.25mg sid added – Neomercazole to 2.5mg sid – Whiskas only – Atenolol 6.25mg sid – Caninsulin 2IU bid – Tumil-K – Famotidine – Benazepril

Candy Day 1 Day 60 Day 90 Day 150 Day 220 Reference

Total Protein 67.1 80.1 81.2 80.0 78.5 (69-79 g/l)

Albumin 26.0 28.0 29.5 28.9 31 (28-39g/l) Globulin 41.1 52.1 51.7 51.1 47.5 (23-50g/l)

ALT 37 57 44.0 42 - (15-60u/l) Bile acids 4.3 5.3 6.9 5.1 - (0.0-7.0umol/l)

Urea 9.7 13.7 14.9 12.8 13.8 (2.8-9.8mmol/l) Creatinine 127 238 187 209 189 (40-177umol/l)

ALP 48 49 56 51 - (10-100u/l) Glucose 6.7 19.7 21.4 14.0 6.7 (3.3-5.0mmol/l)

Ca 2.33 2.6 2.69 2.54 2.74 (2.1-2.9mmol/l) PO4 1.17 1.4 1.72 1.8 1.6 (1.4-2.5mmol/l) K 3.3 3.6 3.7 3.2 3.3 (4.0-5.0mmol/l) Na 154 152 152 156 163 (145-156mmol/l) Cl 119 116 115 116 114 (117-140mmol/l) T4 63.1 <5 15.5 13.5 16.3 (13-48nmol/l)

Candy

•  Abdominal Ultrasound – R Adrenal mass: 8mm – Aldosterone: 2000 pmol/l

(150-430pmol/l)

Candy: Outcome

•  Gradual enlargement over the following 18 months

•  Treatment: –  Spironolactone –  Amlodipine 6.25mg sid –  Neomercazole to 2.5mg sid –  Whiskas only –  Atenolol 6.25mg sid –  Caninsulin 2IU bid (temporarily) –  Tumil-K –  Famotidine –  Benazepril

Outcome

•  Euthanised 2 yrs after initial presentation for CRI. – PM performed: Adenocarcinoma of

R adrenal gland

Questions?

Pushkin

•  14 yr old •  FN •  DSH •  Previous hx:

–  HCM –  No other problems

•  Presented for PU/PD/PP (3 weeks) •  Occasional vomiting & diarrhoea

Pushkin

•  Physical Examination – Poor coat quality – Overweight BCS 6/9 – Lame LF – Weak – Grade III/VI systolic heart murmur – Mild hepatomegaly – T: 38.5˚C

Pushkin

•  Differential Diagnosis –  Diabetes Mellitus –  Hyperthyroidism –  EPI –  Renal insufficiency/failure –  Hypercalcaemia –  Infection

•  Pylonephritis •  Sepsis •  Pyrexia

–  Hepatic insufficiency –  Hyperadrenocorticism –  Hypoadrenocorticism –  Drugs/diet

Pushkin

•  Investigations – Blood Pressure: 210mmHg – Bloods:

•  Lymphopenia: 0.425x109/l (1.5-7.0) •  Cholesterol: 7.97 mmol/l (2.2-3.4) •  Glucose: 24.4 mmol/l (2.8-9.8) •  AP: 110 IU/l (10-100) •  T4: 13.6 nmol/l (13-48) •  Albumin: 36.0 g/l (28-39) •  Calcium: 2.39mmol/l (2.1-2.9)

Pushkin

•  Further Investigations – Fructosamine 346umol/l (100-350)

Pushkin

Further investigations?

Pushkin

•  History – 6 weeks PU/PD/PP – Weight loss – Hair Loss: Ventral abdomen – Painful abdomen esp. cranially – Lame LF with muscle fasciculation's – Poor coat – BCS 5/9, but very little muscle

Pushkin

•  Further investigations – Repeat blood pressure – Repeat Bloods – Urinalysis – Ultrasound Abdomen – Radiograph Thorax & Abdomen

Pushkin

•  Blood Pressure: 164mmHg •  Bloods:

•  Lymphopenia: 0.11x109/l (1.5-7.0) •  Chloride: 105 mmol/l (117-140) •  Glucose: 20.7 mmol/l (2.8-9.8) •  Urea: 17.6 mmol/l (2.8-9.8) •  AP: 135 IU/l (10-100) •  T4: 11.3 nmol/l (13-48) •  Albumin: 35.4 g/l (28-39) •  Calcium: 2.1mmol/l (2.1-2.9)

Pushkin

•  Bloods Cont: –  Fructosamine 334umol/l (100-350)

•  Ultrasonography: –  Painful, with poor detail especially right

cranial quadrant –  Hyperechoic omental fat –  Hyperechoic hepatic parenchyma –  Poor GI motility

•  Radiography: –  Cardiomegaly, otherwise NAD

Pushkin

•  Urinalysis: – SG 1.035 – Glucose: +++ – Culture: +ve for Enterococcus

•  Further Bloods: – TLI: 92.1 ug/l (12-82) – PLI: 21.7 ug/l (2-6.8) – Cobalamin: 241 ng/l (290-1499) – Folate: 15.2 ug/l (9.7-21.6)

Puskin

•  LDDS: 83.7 nmol/l 4 hrs: 18.1(<30nmol/l or 50%) 8 hrs: 16.0

•  Urine Cortisol: Creatinine: 4.07 (<3.6x105 suggestive of HAC)

Pushkin

•  Differential Diagnosis –  Diabetes Mellitus –  Hyperthyroidism –  EPI –  Renal insufficiency/failure –  Hypercalcaemia –  Infection

•  Pylonephritis •  Sepsis •  Pyrexia

–  Hepatic insufficiency –  Hyperadrenocorticism –  Hypoadrenocorticism –  Drugs/diet

Pushkin

Pushkin

•  Home on: – Synulox 50mg bid – Ranitidine (Zantac) 3mg/kg bid – Buprenorphine 0.01mg/kg bid – Cobalamin inj once wk – Owner to measure blood glucose at

home – Measure water intake – Start on m/d diet

Blood Glucose Monitoring

Blood Glucose Monitoring

•  Blood Glucose: – Low 12.2mmol/l – High 21.0mmol/l

•  Water consumption~750ml/day

Pushkin

•  Start on Caninsulin 0.5 IU bid – BGC Flatline~20mmol/l – Cont m/d –  Increased Caninsulin slowly to 2 IU

bid

Pushkin

•  Bloods: •  Lymphopenia: 0.36x109/l (1.5-7.0) •  Bile Acids: 8.6 umol/l (<7.0) •  TBil 18.9 umol/l (0-6.8) •  ALT 109 IU/l (6-83) •  Chloride: 101 mmol/l (117-140) •  Glucose: 19.7 mmol/l (2.8-9.8) •  Urea: 20.3 mmol/l (2.8-9.8) •  AP: 169 IU/l (10-100) •  Potassium: 3.4 mmol/l (4.0-5.0)

Pushkin

•  Hepatosyl added@ 1 Capsule sid •  Sucralphate 1ml bid •  Pancrex 1tsp/100g food

Pushkin

•  Plan: – Fructosamine – Reassess re: HAC –  IGF-1

Pushkin

•  ACTH Stimulation: – Baseline: 241nmol/l (10-250) – 30 mins: 711nmol/l (210-330) – 60 mins: 790 nmol/l

•  Fructosamine: – 373 umol/l (100-350)

•  Ultrasound adrenal glands: – R 7mm, L 6mm (normal<4.5mm)

Pushkin

Pushkin

•  LDDS –  Cortisol pre: 169nmol/l –  4 hours post: 65.4nmol/l (<30 or

less than 50% pre dex. value) –  8 hours post: 68.5nmol/l

•  IGF-1: 140 IU/l

Pushkin

•  Summary: – DM – Pancreatitis – HAC – Hypokalaemia

Pushkin

•  Ranitidine •  Sucralphate •  Synulox •  Tumil-K •  Pancrex •  Cobalamin

•  Hepatosyl •  Caninsulin •  m/d •  Trilostane (30mg

sid)

Feline HAC

•  LDDS – Good screening test (few false

positives), but 30% of cats with HAC will suppress

•  UC:Cr – Good sensitivity, poor specificity

•  ACTH Stimulation: – 30-40% false negatives, can get

false positives

Feline HAC

•  Other screening methods: –  Imaging

•  Ultrasonography, CT & MRI – HDDS/At home HDDS: Cats with

PDH may or may not suppress, cats with adrenal dependant HAC will not.

– Endogenous Corticotrophin: PDH>15pg/ml

Pushkin

•  Outcome – 18 months later – Repeated UTI – Chronic pancreatitis – Single skin tear – Healed well, over 2 weeks

Current Medications

•  m/d •  Caninsulin 3 IU bid •  Hepatosyl •  Kaminox •  Pancrex •  Trilostane •  Ranitidine •  Sucralphate

Insulin Resistance •  Check for infection

–  UTI –  Skin disease –  Dental disease

•  Check for inflammatory/neoplastic disease –  Pancreatitis –  IBD

•  Check for endocrine disease –  Hyperthyroidism –  Hyperadrenocorticism –  Acromegaly

Questions