Meet, ‘Fluffy’ or as I like to refer to her ‘Miss Fluffball’.
She is a 17 year old domestic long haired female de-sexed cat with a big personality. She absolutely loves to chat and tell you all about her day.
This is Fluffy in action. She exhausted herself.
She first presented to me in November 2011 as her owner was concerned about a lump that had suddenly appeared on her head. I recommended doing a geriatric blood test and monitoring the lump closely. If it grew any bigger, the plan was to resect it given all her blood results were within normal. Most of Fluffy’s blood work returned as normal. However, we did discover her ALT (liver specific) enzyme was elevated and most likely secondary to her now diagnosed hyperthyroid condition. Her total thyroxin levels were twice the normal range.
I supplied her owners with a handout explaining what hyperthyroidism stood for and the various treatment recommendations available.
So what is hyperthyroidism?
It is a disease that results from an excess of thyroid hormone produced by the thyroid gland. It is the most common hormonal disorder in cats over 8 years of age. It usually results from a tumour in the thyroid gland.
The owners called me up after reading the handout as they were very concerned about one of the risks of treating hyperthyroidism that was listed; the risk of possibly unmasking underlying chronic kidney failure. These owners had recently tragically lost their cat to kidney failure and simply didn’t want to go down that road again. I emphasized the importance of treating her hyperthyroidism and explained that it outweighed the risk of kidney disease. However, her owners preferred to hold off on treating her hyperthyroidism as it wasn’t very severe at the time.
In all honesty, this is not the first time owners have turned down hyperthyroid treatment. I often find it very challenging to convince cat owners to accept the risk of unmasking kidney disease when treating hyperthyroidism. It is crucial for me to warn owners about all the possible complications associated with treating hyperthyroidism. Listing these complications namely kidney failure often puts pet owners off treating hyperthyroidism.
However, it is pertinent for me to explain why I still argue for treatment knowing that risk is present.
Many cats over 8 years of age often have some form of kidney disease.
Those cats that develop hyperthyroidism can often develop secondary hypertension (high blood pressure). The hypertension in that situation increases blood supply to the kidneys, which may improve their function. Hence, hyperthyroidism coupled with hypertension can actually ‘mask’ already existing kidney disease. When we start treating the hyperthyroidism and hypertension, normal blood pressure is restored and any pre-existing kidney disease will now become more apparent. Basically, treating the hyperthyroidism doesn’t directly cause kidney failure. The condition of kidney failure is simply ‘unmasked’.
Some of you may then speculate that it is still better to forgo treatment as the high blood pressure secondarily caused by hyperthyroidism has been shown to improve the kidney function to some extent. It is a very fair argument. After all chronic kidney failure is a non-reversible disease process. There is no black and white answer here. The fact remains that if hyperthyroidism is left untreated, your feline will suffer an array of secondary complications ranging from weight loss, vomiting, diarrhoea, liver damage, hypertension and even heart failure.
It literally causes your cat to fade away and even causes mood changes including aggression, hyperactivity and constant yowling for food.
In my personal experience, I have always had greater outcomes with treating hyperthyroid cases as opposed to untreated ones. For those hyperthyroid cases that are diagnosed in the early stages and immediately started on medication, they go really well. However, for those that have not been treated at all or treated much later in the disease process, they have often deteriorated rapidly and always presented to me in a very emaciated and unkempt horrific state.
Now back to ‘Fluffy’, the lump on her head was growing quickly so her owner booked her in for surgery. We removed the lump and she recovered really well from her anaesthetic and surgery.
‘Fluffy’ was going really well until she presented to my colleague in February 2012. She was very wonky in her back legs and was sore on palpation of her back. An x-ray of her thoracolumbar spine was taken. It was a bit difficult as ‘Fluffy’ was not sedated as she was too old and acutely unwell. She only cooperated enough for one view to be taken of her thoracolumbar spine.
Her x-ray is below.
If you pay close attention to the circled area, you may notice a narrowed intervertebral disc space between L1-L2.
Compare it to the intervertebral space right before it and the one right after it.
Based on the acuteness of her presentation and the x-ray findings, my colleague treated her as a patient with a partial disc prolapse. She was sent home on cortisone and strict rest. She responded really well to treatment.
On the 31st of July, ‘Fluffy’ came back as her owner was quite concerned about a severe respiratory wheeze that she had developed. She also informed me that ‘Fluffy’ had been coughing on and off since she was treated with cortisone in February. The reason the owner hadn’t brought her in for the coughing sooner was that it was waxing and waning and she thought ‘Fluffy’ was recovering from a bout of cat flu secondary to the immunosuppressive effects of cortisone.
‘Fluffy’ had a very distinct audible wheeze in her chest.
Auscultation of her chest was quite difficult as she was very vocal and quite active. She was a wiggle wart and couldn’t stand still for more than one second. I continued to ask leading questions while I examined ‘Fluffy’. I discovered that her owner had actually been recently using an air freshener in Fluffy’s sleeping quarters and this puts feline asthma on the differential list. I discussed treatment options and recommend taking chest radiographs.
The owner opted for medical management as a first step and if we didn’t get any response, we would proceed with further workup (chest x-rays etc.). I sent ‘Fluffy’ home on cortisone as that is the recommended treatment for asthma. I also sent her on an oral course of antibiotics to protect her from developing a chest infection secondary to the immunosuppressive effects of cortisone.
Only four days later, ‘Fluffy’ was brought back in. Her owner had even contacted my colleague afterhours over the weekend for advice on whether to bring her in then. The owner was pretty distressed as she explained to me the recent developments.
She described ‘Fluffy’ as having a few episodes of muscle twitching followed by collapse and an instant recovery from that state.
The muscle twitching seemed to mostly affect her back legs. Her examination showed she was tender on palpation of her thoracolumbar region and she had developed a very stiff hind limb gait.
I proceeded with more x-rays:
1. A chest x-ray which showed a bronchial pattern (commonly seen with cats with feline asthma):
2. A catagram as ‘Fluffy’ was starting to get stressed with being restrained. This x-ray showed no abnormalities in her intervertebral disc spaces. Basically, the previously suspect narrowed intervertebral disc space observed on the x-rays taken in February appeared normal on this x-ray.
I also collected blood from ‘Fluffy’ but only got enough to run biochemistry. As she was too stressed out with handling, I decided to abort a second attempt at blood collection. I ran a general health profile and discovered she had a very elevated liver enzyme.
I looked back at her history and realized she was an untreated hyperthyroid cat and so that would explain her abnormal blood results.
I sent her home on tramadol (a pain killer) for her suspect sore back and recommended we continue with her previous treatment. I also asked her owners to take video footage of her muscle twitching episodes since she didn’t display any of these symptoms at the clinic. In the back of my mind, I was worried that ‘Fluffy’ was actually having seizures and that was the last thing she needed given her breathing issues.
Only four days later, ‘Fluffy’ was back again but this time her owners had video surveillance of her movements at home.
This case definitely kept getting more and more interesting.
Stay tuned for Fluff ball’s continued twisted medical developments in part 2 next week.
Filed under: Cats, Medicine Cases  
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