Mr. A's Surgery

We know how everyone loves to hear about Mr. A and Mr. B, so we thought we would share with you something about what's been going on with Mr. A, lately. We had been monitoring some weight loss over the past few weeks. Then we started noticing that he was acting aggressive towards Mr. B. Suddenly, about three weeks ago, we noticed that his urine started smelling strangely like an un-neutered male cat's urine (if you have never smelled it, un-neutered male cat urine smells very distinct: VERY strong and stinky), and he started urinating inappropriately. We were concerned that he had circulating testosterone in his system, which a neutered cat should not have. This led us to believe that he had something wrong with his adrenal gland.

We took some x-rays and drew some blood, and then looked at his penis under anesthesia. Why would we do that? You may not know this but un-neutered male cats have tiny barbs on their penises, kind of like the barbs they have on their tongues. These barbs disappear when a cat is neutered (or never develop, if they are neutered before maturity). Sure enough, Mr. A had developed barbs on his penis. Since his neuter surgery was uncomplicated and straightforward, we knew that he should not have testosterone in his system to produce these symptoms, this suggested even more strongly that he had a malfunctioning adrenal gland. His testosterone test results were the same as an intact male cat's. We then performed an abdominal ultrasound and found a small mass near his kidney that should not have been there.

A week ago, we scheduled him for surgery. During the procedure, we found evidence of recent bleeding or hemorrhage in the retroperitoneal space (a pocket around the kidney and adrenal gland). The bleeding became active during the surgery, and to control the hemorrhage, we performed a blood transfusion and removed the kidney that was associated with the affected adrenal gland. This was done to remove all of the abnormal vessels and adrenal tissue associated with the mass. It appeared that Dr. Bailey was able to remove the entire mass. Now that Mr. A has had a transfusion, he has sadly been removed from the blood donor list because his blood has been sensitized to blood proteins from another cat. This means that his blood is likely to destroy the red cells of a blood recipient.

The pathologist at our reference lab examined the mass for us and reported an unusual result. He could not see any evidence of tumor, but reported that the mass displayed signs of infarction – dead tissue due to a loss of blood supply. This infarct may have destroyed any sign of a tumor, or there may be a problem elsewhere in the body. Certainly, we don’t know at this point what caused the infarct, which means the outlook on his health is unknown. Right now, he is doing well, and recovering. Our staff is impatiently waiting while the pathologist takes a closer look at his biopsy samples in the hopes that he can give us more information.

Meet Mr. October: Ahote

Ahote

Ahote has a very special story - we didn't just pick an orange cat because it is October and the leaves are changing colors. Ahote was brought to us in September as a stray cat that one of our clients had noticed hanging around for a number of weeks. She brought him in for a checkup and he had a microchip! We scanned the microchip and it was registered to a Michigan phone number but a Chicago address. We tried several times to contact the owner at the phone number, but we were unable to contact the owner, so suspect that the contact information is not current. It is VERY important to keep your microchip information current in case of situations like this one! We did learn that the cat's name was Ahote, which means "restless one" in the Hopi language.

Cloudy fluid from Ahote's abdomen

In the meantime, he did not seem to be feeling well. At first, it seemed like he might be coming down with an upper respiratory infection, but he didn't want to eat and seemed very uncomfortable, so we decided to take an x-ray. We were very surprised to see his x-ray when it was developed - there was a BB in him, and a large amount of fluid and debris (effusion) in his abdomen. We tapped his abdomen and found that he had evidence of inflammation in the abdomen (peritonitis) , but no obvious bacterial infection. However, the presence of the BB in him and the sheer number of white blood cells made us concerned that he may have had a perforation in his digestive tract. Other concerns were a condition called steatitis, which is an inflammation of the abdominal fat, and pancreatitis, which is an inflammation of the pancreas. 

Abdominal fluid with WBC, RBC, plasma and fat -  layers from bottom to top

Ahote was upgraded to a critical case at 8pm that night (a Thursday) and we ran bloodwork and prepped him for surgery. His blood clotting times were prolonged, so we knew that he might require a

blood transfusion during surgery, and we were right to be prepared! Dr. Demos and Dr. Bailey quickly performed an exploration of the abdomen, found no leaks in the intestinal tract, but did find some firm lumps of necrotic (decomposing) fat. This confirmed that Ahote had a case of steatitis. We were able to flush the remaining debris from his abdominal cavity and complete the surgery, which was good, because the samples that we had collected from his abdomen earlier grew bacteria, as did the lumpy fatty material we collected from his abdomen. We started him on multiple antibiotics because both the white blood cell count in his blood stream and the cell count from his abdominal fluid were high. A normal white blood cell count in a cat his age should not be higher than 15,000 cells per deciliter of blood. His WBC count was 43,400 cells per deciliter! The white cell count from his abdominal fluid was 156,400 cells per deciliter. Ahote was losing a lot of blood and protein during this procedure, and his blood pressure was so low that it would not register on the blood pressure machine.

Ahote getting prepped for surgery

Once we knew he was going to need a transfusion, Mr. A was prepped for a donation. We needed fresh whole blood ASAP! In addition, while one of our technicians was in surgery with him and the surgeons, another technician was gathering blood from Mr. A, and a third was preparing to get blood on a second cat, as several of our staff members were contacted to bring donors from home on their days off! When the other cats arrived, we continued to use our teamwork to efficiently prepare donors and collect blood and transport it to surgery for administration.

He received two blood transfusion during surgery and several more post-surgery - a total of four whole-blood transfusions and 2 fresh frozen plasma transfusions, because his protein levels were still low after surgery. By 10pm, he was out of surgery, but the doctors were in disagreement as to whether he was going to pull through. He was on blood pressure support medications for 4 days post-surgery, and IV fluids for 6 days after surgery, but he started eating again, and we had hope that he would persevere.

Ahote rubs your legs for his ENTIRE length - even his toes!

As of the last week of September, his white count is almost normal, and he is active and affectionate, though his name, "restless one" definitely fits - he winds around our legs and head-butts and climbs all over us, but is definitely not a lap-sitting cat. He has a peculiar habit of rubbing against a person's leg and then sticking one leg out straight behind him, pointing his toes, and stretching.
It is an adorable thing to see!

He is still taking multiple antibiotics for his peritonitis, as well as Vitamin E and liver supplements for their free-radical scavenging and anti-oxidant properties, to treat the steatitits. We hope that when he is fully recovered, we will be able to find him a good home. We may never know why he developed steatitis, but generally the most common cause is a poor diet, deficient in Vitamin E.

Ahote's care was in-part funded by Foxy's Fund - made possible by generous donations from people like you! Without your help, care for cases like Ahote would not always be feasible for us to manage. Thus far, Ahote has received over $5000 worth of care and treatment. If his story moves you, we hope you would consider donating to his cause through Foxy's Fund and theVeterinary Care Foundation.

Ahote hopes that he can look forward to a bright and happy future!

Bladder stones: A Technician's Perspective

Can you tell which cat has bladder stones?

In light of the numerous cases of bladder stones, crystals and inappropriate urination issues we have seen in the last month, I thought that I would share my own experience with bladder stones, in the hopes that others will take away the same lessons that I learned.

Marley

For over a decade, I shared my life with two lovely cats who were brother and sister. Mina, the sister, is still with me, but I lost Marley to lung cancer in 2013. Both cats came from a rescue group in East Lansing, siblings from a litter of hand-raised kittens whose mother had died when they were 10 days old. Both cats were fairly healthy during their younger years - Marley had a congenital cataract, Mina had some foul diarrhea. Marley had chronic skin allergies. Both cats went through a period of time when they had adverse vaccine reactions. Mina occasionally has bouts of bronchitis. Together, they
kept my hands full!

In September of 2009, I noticed that Marley had stopped squatting to urinate. I was annoyed by the habit, because he would stand in the litterbox and a big stream of urine would splatter out onto the floor in front of the box. I watched this go on for two weeks, because he didn't seem to be in pain - he didn't vocalize or strain when he urinated, he didn't seem to be going all that frequently - maybe 2-3 times daily. He didn't seem to be drinking more water than usual, and the urine wasn't bloody. I wondered if he had developed some arthritis in his hips - after all he was 9 years old at the time. I brought him in to work with me and after a thorough exam, we took hip x-rays. Dr. Brooks looked at the x-ray and said, "Well, his hips are fine, but he has bladder stones." I thought she was teasing me. I couldn't believe it. I looked for myself. Sure enough, there they were - 7 stones (I would share the x-ray, but it is in attic storage, now, and I don't like attics). A few weeks later, I scheduled him for surgery - I forget now, why I waited. It might have been a busy surgery schedule. I might have been saving up money. Anyway, it was a dumb idea to wait, because I was on pins and needles the whole time, worrying that he might become obstructed with a stone. This was a little silly, not because it wasn't possible, but because it takes weeks to months for stones to form, so he could have become obstructed at any time prior to his diagnosis, and I had not been worried, before. Worrying wasn't going to help him. Surgery was the only option.

Calcium oxalate stones

Surgery went smoothly, and 7 large stones (and two smaller stones that were not visible on the x-ray) were removed. We sent off the stones for analysis at the Minnesota Urolith Center and the report stated that they were 70% Calcium Oxalate Monohydrate and 30% Ammonium Acid Urate stones. After surgery, Marley didn't like using the clay litter we use here in the hospital, so he urinated bloody urine on the floor and towel until we switched him back to scoopable clumping litter. At home, he resumed urinating in the box normally, squatting like a good boy.

After that, he switched to a canned stone-prevention diet. Calcium oxalate stones do not dissolve with a dietary change, but they can be prevented from re-forming in many cases. Marley had bladder radiographs and urine rechecks every 6 months until 2012. I had a baby and went on maternity leave around the time that he was due for a recheck. In retrospect, I should have brought him in for a recheck early, but I was caught up in my own medical issues at the end of my pregnancy, and I figured a few months' delay was not that important.

But it was. In May of 2012, four months after the birth of my daughter, I was scheduling Marley for a

One large stone that required surgery to remove, and the many smaller stones we expressed.

repeat cystotomy. He had a bladder full of stones again. They were smaller, this time, but one stone was large enough that it could not be expressed. Marley recovered well from his second cystotomy and continued to do well until July 2013, when cancer took its toll.

Mina

Shortly after I lost Marley, his biological sister, Mina, started vomiting. She has had occasional bouts of acute vomiting, and was empirically
diagnosed with inflammatory bowel disease in 2005. In August 2012, she had a bout of vomiting that lasted about a week, and I brought her in for abdominal x-rays. At that time, she was having no issues urinating in the litterbox. She did not have any intestinal abnormalities, but there was a shadow in her bladder, which turned out to be a "puddle" of small stones. Fortunately, since she is a female, we were able to express all the small stones out of her bladder, and surgery was avoided. We sent in the stones to the Minnesota Urolith Center and they were 100% Calcium Oxalate stones. She has also been eating a crystal prevention diet and so far, she has had no further sign of stones on any of her followup xrays or urine samples.

If I had taken my own advice, many years ago, and fed canned food to my cats more often, I might

Sometimes, a lot of small stones look like one large stone

never have had to deal with this issue, as their urine might have been more dilute and less likely to form stones. I was very fortunate that neither of my cats decided to start urinating outside the litterbox due to discomfort - in fact, they are both very good examples of the fact that cats hide their problems from their owners. As a technician, I should be more attuned to signs and symptoms of illness, and I was unaware of the issues my own cats had. They are also a good testament to the importance of follow-up. Even if your cat seems fine after a treatment or procedure, it is important to follow-up on schedule. If I had brought Marley back 3 months earlier for a recheck, he might have been able to avoid the second cystotomy surgery. It may be that Mina will be one of the lucky few cats that never re-forms stones after a cystotomy, but you can be sure that I will continue to check her every 6 months!

Mina would rather nap than have a bladder recheck

How could my cat be sick? He acts like a kitten! - Hyperthyroid disease and your cat

THE MANY FELINE FACES OF HYPERTHYROIDISM 

What is hyperthyroidism?

The thyroid is a gland located in the neck. It plays a very important role in regulating the body's rate of metabolism. Hyperthyroidism is a disorder characterized by the overproduction of thyroid hormone (thyrotoxicosis). When excessive amounts of thyroid hormone are in the circulation, the body's metabolism speeds up greatly.

Location of the thyroid gland

 

1: Normal thyroid gland. 2, 3: parathyroid glands. 4: enlarged thyroid gland

Hyperthyroidism is a fairly common disease of older cats. It is estimated that about 5-10% of cats will develop hyperthyroidism in their lifetimes. Although the thyroid gland enlarges, it is usually a non-malignant (benign) change.  Less than 2% of hyperthyroid cases involve a malignant change in the gland.

What does this do to the cat?

The typical cat with hyperthyroidism is middle aged or older; on the average, affected cats are about 13 years of age. The rapid rate of metabolism causes 95-98% of cats with this disease to lose weight. The cat tries to compensate for this with an increased appetite. In fact, 67-81% of these cats have a ravenous appetite and will literally eat anything in sight! Despite the increased intake of food, most cats gradually lose weight. The weight loss may be so gradual that some owners will not even realize it has occurred.  Affected cats usually drink a lot of water and urinate frequently. There may be periodic diarrhea or vomiting, and the hair coat may be unkempt. As the disease progresses, the cat's appetite may decline to the point of anorexia.

In addition to:

• weight loss
• increased appetite
• vomiting
• diarrhea
• unkempt coat

other signs of hyperthyroidism that may be noticed include:

• increased thirst
• increased or more frequent urination, larger clumps in the litterbox, or inappropriate urination outside the litterbox
• increased activity
• increased vocalizations 
• pacing or restlessness
• anxiety
• panting or rapid breathing

How is hyperthyroidism diagnosed?

The disease is most commonly diagnosed by determining the blood level of one of the thyroid hormones; the hormone most frequently measured is T4. Usually, the T4 level is so high that there is no question as to the diagnosis. Occasionally, a cat suspected of having hyperthyroidism will have T4 levels within the range of normal cats. In this case, a second test, called a T3 Suppression Test, is performed. If this is not diagnostic, a thyroid scan can be performed at a veterinary referral center.

Hyperthyroid cat before becoming hyperthyroid, and again at the time of I131 treatment

Is this disease treatable?

Because less than 2% of these cats have cancerous growths of the thyroid gland, treatment is usually very successful.  There are three choices for treatment; any one of them could be the best choice in certain situations.  Many factors must come into consideration when choosing the therapeutic option for a particular cat.

What would happen if I chose not to treat my cat's hyperthyroidism?

Hyperthyroid is a deadly disease if left untreated. The effects that hyperactive metabolism has on the body are progressive, and this is a disease that will not resolve on its own. Over time, a cat that is hyperthyroid will develop problems associated with malnutrition because the overactive metabolism is using up calories and nutrients more quickly than usual. Add to that the likely side effects of vomiting and diarrhea, and an untreated cat will also become severely dehydrated.

The increased heart rate of a hyperthyroid cat will cause the heart muscle to thicken, and many will develop cardiomyopathy (poor muscle contractions) and eventual congestive heart failure. The high blood pressure that often goes hand in hand with hyperthyroid disease can cause damage to many sensitive organs in the body, including the kidneys, the eyes and the brain - as these blood vessels rupture from constant high pressure, blood supply is lost and tissues become unhealthy. This can cause kidney disease, neurologic effects due to damaged brain tissue, and blindness if the eyes are affected.

1) Radioactive iodine.  Probably the safest, and definitely the most effective way to destroy the abnormal tissue is with radioactive iodine (I131) therapy. In 95% of cats treated with I131, the cure is complete and permanent. Radioactive iodine treatment for cats requires one to three weeks of hospitalization at a veterinary clinic licensed to administer radiation therapy, and involves administration of the iodine via injection or oral capsule. The iodine is concentrated in the thyroid gland and destroys the overactive cells. At Exclusively Cats Veterinary Hospital Cats RadioIodine Treatment Center, the cats are treated with an oral dose and isolated for one week at the hospital followed by one to two weeks of isolation within the home.

Here is a vivid demonstration of a cat before and 3 months after treatment.

2) Surgery.  Surgical removal of the affected thyroid lobe(s) (thyroidectomy) is also very effective.  Because hyperthyroid cats are usually over 10 years of age, there is a degree of anesthetic risk involved, but not necessarily any more risk than for other cats of similar age.  However, the risk is much less than most people think, as long as the cat is otherwise healthy.  Tests are done before surgery to evaluate the cat and predict the chances for complications. If the disease involves both lobes of the thyroid gland, two surgeries may be required, depending on the surgeon’s choice of procedures.  In many cats, only one thyroid lobe is abnormal, so only one surgery is needed. Possible side effects include possible damage to the parathyroid gland, which is intimately associated with the thyroid gland, possible post-surgical hypothyroidism (under-functioning of the remaining thyroid gland, or as a result of bilateral thyroid removal).

3) Oral medication.  Administration of an oral drug, methimazole, can control the effects of the overactive thyroid gland.  After starting the medication, results can be seen in just 2-3 weeks. Some cats have reactions to the drug, but that number is fairly small (less than 20%). However, the side effects may begin as many as six months after the beginning of treatment and can include vomiting, lethargy, anorexia, fever, and anemia. Less frequently, cats may develop facial itching, clotting disorders and liver malfunctions. Methimazole does not destroy the abnormal thyroid tissue, but rather prevents the production of excess thyroid hormone.  Therefore, the drug must be given for the remainder of the cat's life. If the medication is stopped, hormone production will return to high levels again and the cat's symptoms will return.

Some cats can be particularly difficult to regulate, or may be poorly sensitive to this medication, which can be a downside to choosing this method of treatment. Other cats are difficult to medicate and would be better served by I131 treatment. Methimazole is a medication that some cats metabolize well in a transdermal form, but this option is not tolerated by all cat, and there is some risk to the owner in applying a thyroid-inhibiting medication that is absorbed through the skin, so appropriate handling of the medication is important, and transdermal medication may not be an appropriate choice for cats living in a home with small children. Periodic blood tests must be done to keep the dosage regulated. This type of treatment is appropriate for the cat that is a poor surgical risk due to other health problems.

4) Hill's Y/D diet.  Because the thyroid gland needs iodine to make thyroid hormone, feeding a diet with minimal iodine content should decrease the thyroid hormone levels of the cat. Feeding trials have indicated that after 3 weeks of feeding ONLY this diet - no treats, no human foods - thyroid levels are significantly reduced in most cats. Cats will not become hypothyroid while eating this diet, and a two year study suggests that cats that are NOT hyperthyroid that eat this diet will not suffer adverse effects. However, in practice, we have had a very difficult time getting cats to eat this diet, so while it is an option, it is a pricy (4 pounds of food is about $25 dollars and lasts about 3 weeks for a 7 pound cat) experiment that may not always pan out. There are many people who have had excellent results with this diet change, however, so it is definitely a viable treatment option. This treatment is not curative and the cat will need to remain on this diet for the rest of its life.

How Y/D diet works

If I elect to have surgery for my cat, what is the procedure?

If surgery is the treatment method chosen, the cat is put on methimazole for one to four weeks before surgery. This treatment should cause the ravenous appetite to subside, and your cat will probably gain weight. Some cats also have a very fast heart rate and may be medicated before surgery with another drug, such as Atenolol. After one to two weeks, another T4 level in the blood is measured.

The operation is performed in a sterile operating room and your cat is under general anesthesia. An incision is made along the neck just below the throat and the enlarged thyroid gland is removed. The skin is sutured together.

Your cat is generally hospitalized for one night following surgery and returns home feeling quite well. He or she should eat normally after returning home. 

Can hyperthyroidism occur again?

Recurrence is a possibility in some cats. Recurrence is uncommon after radioactive iodine therapy.  When surgery is performed, the chance of recurrence is slightly greater. It is usually not possible to surgically remove all of the cells from the abnormal thyroid gland. If those remaining cells grow, the disease may recur. However, this occurs less than 10% of the time and usually after 2-4 years.  Another possibility is that one side of the thyroid gland appeared normal at the time of surgery so it was not removed. Then, months or years later, it may become abnormal.

I think my cat is too old for anything but treatment with the oral medication or diet change.  Do you agree?

Many owners of cats with hyperthyroidism are hesitant to have radiation therapy or surgery because of their cat's advanced age. But remember, old age is not a disease. The outcomes following both surgery and radiation therapy are usually very positive, and most cats have a very good chance of returning to an excellent state of health. Some of the cats referred to our hospital in Waterford, Michigan, for radioactive iodine treatment have been as old as 20 years of age, and have done very well!