Need help with diagnosis, interpreting blood test results

Hi all,

I have a very sick kitty who we've taken to the vet twice over the past week. They've done a number of bloodwork tests, but seem hesitant to make a diagnosis. Tomorrow we're taking him to a teaching vet hospital (Auburn University) for more extensive testing, but I'd like to get feedback from anyone who might have recommendations about what I should mention to the vet, or specific diseases I should followup and ask about.

I have some specific info about his bloodwork.. unfortunately only the numbers that were abnormal, but I've included them below with his overall list of symptoms.

He's tested negative for FelV (feline leukemia) and FIV.

His symptoms are:

-weightloss (skin and bones on his back)
-anemia (low red blood cell count)
-high white blood cell count

6 days ago bloodwork:
-PCV was 22% with T.P. of 7.0
-post hydrate PCV = 16% / TP = 5.9
-BW (or BUW? can't read the writing) is low
-Bilirubin is high
-WBC = 18,800 with neutrophilia, left shift

Bloodwork today:
-PCV = 20
-TP = 6.0


Treatment to date:
6 days ago he received
- Stanazdol
- Kenalog
- fluids and antibiotics

For the past few days we've been giving him:
- Panacure (for worms)
- Doxycycline (in case he has blood parasites)
- Lixotinic (vitamins)

He doesn't seem to be any worse, but also not much better. He is eating and drinking by himself, and going to the litterbox, but is lethargic and doesn't groom himself. His anemia has improved somewhat as indicated by the numbers above, but this may be related to us putting Frontline on him, which killed off some fleas (we've been using Advantage, but the vet told us to switch since the fleas may have built up an immunity). So I'm hesitant to say his overall condition is improved just because the anemia is less severe. He may be suffering from flea-related anemia and some other completely different disease.

Blood parasites sound like a likely candidate, but I don't know how quickly he would improve once on the doxycycline (it's been 5 days). Should he be noticeably better now? He has lost a ton of weight, so he may be feeling weak from that.

He is a 3 yr old, male, neutered cat, who is indoors 99% of the time. He did escape a couple times over a year ago, so it's not impossible he picked up something outside, but it would have to have been dormant for a while since then.

If anyone has past experience with something that sounds similar, or has veterinary experience and can make any recommendations about what I could talk to the vet about tomorrow I would -really- appreciate it.


So far I've been considering:

FIP - not ruled out, especially since he has a somewhat pouchy tummy.. but it hasn't gotten any bigger in the past 5 days, and it seems to be a family trait (several of his siblings have it and are not sick). May be less likely since I read this causes a low WBC, and his is high, but I heard in the late stages of the disease it could cause the WBC to become high.

Pancreatitis - not ruled out. It's not clear he is in any pain in his stomach area. The vet palpated it and he didn't resist or seem to be upset, so I'm not sure this is likely.

Feline heartworm - he doesn't have any upper respiratory symptoms which I've read go hand in hand with this diagnosis.

Toxoplasmosis - Again, no upper respiratory symptoms.

Cancer - I'm not sure what to make of this - there are so many different kinds of cancer and each of their effects are different. Not ruled out. What should I look for?

Apathetic hyperthyroidism - possible, but seems hugely unlikely considering his relatively young age.

Well, only the vet can ake a true diagnosis, but it *could* be FIP - again you hopefully Auburn will be able to make a true diagnosis. I am giving you this website, as it is has helpful info about FIP.
http://www.dr-addie.com/WhatIsFIP.htm
(Keep in mind when looking at lab values that the measurements may be different from you cat's tests. (i.e. g/L is different from ug/L, there are online converters for scientific measurement values.))
The problem with FIP is that there is no clear diagnostic lab value. (Cats may only have some of the symptoms and the test results vary from cat to cat.)
It is important that you kitty keeps eating food and water. That is critical!!!
I would definitely look for values like HCT<30%, neutrophilia (lots of neutrophils) Serum globulin >/= 40 g/L, serum Albumin/Globulin ratio <0.8. If it is 0.4 or less, that is considered likely that it is FIP. Note that if the A:G ratio is 0.8 or higher, FIP is NOT indicated. Two other tests that should be considered are FCoV tests to measure the amount of corona virus in the blood (a FIP positive cat typically has values of 1280 or greater) and 1-alpha glycoprotein test (1-AGP) many FIP cats test with levels of 1500 mg/mL. (A normal cat has levels of 500 mg/mL). It is really difficult to diagnose, but if your kitty develops fluid in the stomach or chest cavities, it would suggest wet FIP. (There are two forms - wet and dry.) Please let us know what happens after you visit Auburn. that you're boy does not have FIP and recovers!

Thanks for the reply!

I have a question - is the serum albumin/globulin levels something that would be done in a standard blood test, or would we need to wait till tomorrow for these values? I can call the vet and check if those were included, but unfortunately they only gave me the ones they considered abnormal when I took him in for a recheck today.

did they fax the records over to Auburn? If not, I would ask them for a copy of everything to take with you. It gives them a point to start from.

A shift to the left indicates inflammation or infection.

No, as far as I know they didn't - I asked for a copy of everything to take with me, and I got a poorly-written synopsis of his blood values. Unfortunately I didnt look at it till I got home and I didn't have time to go back, but I will probably call them in the morning and ask them to send everything.

I want to make sure they don't need to duplicate any tests... this has already cost a few hundred dollars, and though I want to make sure we find out everything we can, until I start my new job later this month I am scratching the bottom of the barrel.

Was he tested for Bartonella? If it is, the doxy should help.

Our kitty had the same thing. Anemia combined with high wbc - but VERY low reticulocytes (no new blood cells). He lost half his body weight and his hematocrit (basically the same as PCV, though a hematocrit is more accurate as the PCV can contain small amounts of blood plasma trapped between the red cells) got as low as 7%. FYI, a PCV or hematocrit of 24% or below is considered anemic. Normal is 30% - 45% (totally depends upon the cat). At 17% - 18% they can live - but will be lethargic. Below that they really start acting out of it). He needed a blood transfusion. After eliminating cancer and blood parasites, they treated it as if it were feline hemolytic anemia, which it technically wasn't, but to which treatment it responded. Our vet was on vacation when we first went in, and the idiot vet we first saw put him on Leukeran (for leukemia - before even testing for it). This depleted his white blood cell count, so when our regular vet got back and we had him tested for everything, he ended up having to give him shots of nupogen and epogen, to boost both his RBC and WBC. He needed a transfusion along the way - but that should be a LAST resort, because cats have very complicated blood structure, and can often receive only one transfusion in their lifetime - it's too difficult to match exactly, and after that their body gets "smart" and attacks the invader (the blood to be transfused) by coagulating, thus preventing any further transfusions.

We then did the blood parasite route - and it was Doxy they used to treat it. This is standard.

They then did steroids - and this worked. For about a year. Then it stopped. Our vet said "I'm out of bullets." He'd contacted every feline blood specialist in the country. He'd been reading about feline hemolytic anemia because of our boy, and decided to give Depomedrol a try instead of the prednisone. That was all it took. He's been on the mend ever since. And from a vet visit EVERY DAY to every-other-day to every week - for a year - it became every three weeks, then every three months - and now, we appear to be up to every four months before he has to get his Depo shot.

Without the low reticulocytes, it sounds like a blood parasite, but I'm no expert. If he does have fleas, it could just be that - though I don't know if that explains the high WBC. Getting rid of the fleas often improves an otherwise "unexplained" anemia. And being anemic, he'd be lethargic. When Tuxie was anemic, he'd just stare at his food bowl - it looked like he would forget why he was standing there. We basically had to force feed him at times.

Given that his PCV improved with the use of steroids, it may be an autoimmune problem.

I'm just not familiar enough with any of the other diseases.

I don't get the Kenalog - isn't that topical????????

I'm sure they'll figure it out at Auburn. I sure hope it isn't FIP - though I'm pretty sure that in addition to the above information, high neutrophils would be combined with low reticulocytes and a low platelet count.

Vibes to your baby boy that it's easy to treat and he completely recovers quickly!

Laurie

If you had a serum chemistry panel done, you should have a readout that shows both the albumin and globulin levels, so take your albumin value and divide by the globulin value.
i.e.
Albumin - 4.1 g/dL
Globulin - 3.2 g/dL
A:G = 4.1/3.2 = 1.28

Do you have these values for your kitty?

Ok, I definitely don't have those values, but I'll call the vet and see if they did the serum panel test.

Also I have no clue about the Kenalog.. they gave it to him when he spent the night there after we brought him in 6 days ago. They actually didn't tell us they were giving him that or the Stanazol (I first found out when I was looking over the case history they gave me!).

I'm not that sure about our vets.... they seem very well-intentioned, but not much for explaining what they're doing or why.

The vet said they only did a general protein test, but don't have the albumin or globulin levels specifically... so I guess we'll find out tomorrow. She did say when I called that FIP was very possible.

Sending lots of that the folks at Auburn will make an accurate determination of what's wrong --- and that it's NOT FIP.

Originally Posted by sapling

I'm not that sure about our vets.... they seem very well-intentioned, but not much for explaining what they're doing or why.

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That's really unfortunate, especially when you're trying to deal with something as seemingly complex as this situation. But I guess that's a complaint of doctors in general. I say, always ask as many questions as you need to in order to fully understand what they're doing and thinking, and why. Sometimes you need to be persistent, unfortunately. Remember, it's your cat and it's your money.

Do keep us posted.

It could unfortunately be FIP, possibly the dry form if there is no fluid build-up. You may want to consider an ultrasound. Ultrasound was part of Willow's diagnostic process, along with a needle biopsy from an enlarged lymph node that they found during the ultrasound. Unfortunately, there is no single test that can confirm FIP short of a tissue biopsy perfomed during surgery. Other things to look at would include testing (or possibly just treating if you and your vet are comfortable with that) for Toxoplasmosis, Haemobartonella, Bartonella, and Ehrlichia. Some of those things should be knocked out by doxycycline, but it may take longer or higher doses--14 to 21 days of treatment may be needed (http://www.vin.com/VINDBPub/SearchPB...00/PR00111.htm). Some, like haemobart (also called Mycoplasma haemofelis), aren't always visible through tests since the organism goes through phases and tests can't always detect its presence.

It's possible the cause is not infection but inflammation of some sort, which is why the ultrasound may be helpful in pinning down the area(s) where the problem is occuring. Another possibility includes an auto-immune disorder, such as immune-mediated hemolytic anemia (http://www.vin.com/VINDBPub/SearchPB...00/PR00043.htm).

I would strongly suggest getting copies of all the recent blood tests performed so that you can monitor and research the results. Sometimes we are more adept and spotting patterns than a vet with a high caseload.

Im sending that its not FIP!!
When you go in, try to have everything written down so you can ask them the questions off a list instead of off the back of your head! I always forget to ask something when I dont write it down! I must get nervous or something!!

Good luck and please let us know whats going on!!

Let us know how the vet appointment goes....

Any news yet from Auburn?

Keeping up the good vibes....

Laurie

Hey guys,

Ok, a lot went on today and I just heard from the vet, but I don't have the hard numbers down - so far, they still don't know what's wrong.

Major findings:
He is still anemic, and the anemia is non-regenerative.

While the previous vet found that he had neutrophilia with left shift, Auburn says they did not find any signs of neutrophilia. This I find very confusing ?? Did someone screw up the test? Would it be likely to change that quickly?

They did some imaging of his chest and stomach - his left ventricle is somewhat enlarged but they said that is likely due to the anemia. One of his kidneys is smaller than the other and "looks odd" but the creatinin and BUN levels are all completely normal, so they don't think the problem is kidney related. They did do a urinalysis and are still waiting on the results.

His overall proteins are still low, but none of the individual numbers are significant.

Soooo, with non-regenerative anemia, I don't think FIP is indicated, right? I haven't had time to do more research since we got back.

Tomorrow they're going to do a bone marrow aspiration and try to find the source of the anemia, but so far the word is still pretty much "we don't know what's going on".

So expensive too... the total bill right now is about $700 and they don't even know what the problem is.

This is exactly what happened with Tuxie. They did the bone aspiration - and it came back negative too. His heart and liver were also enlarged - but we didn't catch the problem as early as you did.

They ended up calling it "an autoimmune problem." Apart from the Epogen and Nupogen he needed, the Depomedrol was what worked for Tuxie.

I hope your kitty's mystery ends up being cleared up easily, and that he doesn't have to go through the two years Tuxie did before finally hitting on the right thing....

Laurie

From the Merck Veterinary Manual (an excellent source of information):
Cause of nonregenerative anemia:
Nutritional deficiency anemias develop when micronutrients needed for RBC formation are not present in adequate amounts. Anemia develops gradually and may initially be regenerative, but ultimately becomes nonregenerative. Starvation causes anemia by a combination of vitamin and mineral deficiencies as well as a negative energy and protein balance. Deficiencies most likely to cause anemia are: iron, copper, cobalamin (B12), B6, riboflavin, niacin, vitamin E, and vitamin C (only important in primates and guinea pigs).
Iron deficiency is the most common deficiency seen in dogs and piglets, but occurs less commonly in horses, cats, and ruminants. Iron deficiency is rarely nutritional in origin—it most commonly occurs secondary to blood loss (see blood loss anemia, Blood Loss Anemia). Young animals have minimal iron stores, and milk contains very little iron. This can be especially important for piglets that grow rapidly and are often raised indoors with no access to iron. Oral iron supplementation is indicated as treatment for iron deficiency; any source of blood loss must be removed.
Copper deficiency can develop in ruminants fed forage grown in copper-deficient soil. Copper is necessary for the metabolism of iron. Copper deficiency may occur secondary to high dietary molybdenum or sulfate in cattle and can develop in pigs fed whey diets. Low blood copper concentrations or low copper concentrations in liver biopsies (more definitive) are diagnostic. Treatment is oral or injectable copper supplementation.
B vitamin deficiencies are rare. Certain drugs (anticonvulsants, drugs that interfere with folate metabolism) have been associated with the development of folate or cobalamin deficiency, leading to a normocytic, normochromic, nonregenerative anemia. Cobalamin malabsorption has been reported in Giant Schnauzers (their enterocytes are unable to absorb cobalamin). These dogs respond to parenteral supplementation with cobalamin. Ruminants also develop a secondary cobalamin deficiency when grazing on cobalt-deficient pasture. Treatment with oral cobalt or parenteral cobalamin is indicated.
Anemia of chronic disease can be characterized as mild to moderate, nonregenerative, normochromic, and normocytic. It is the most common form of anemia seen in animals. The anemia can be secondary to chronic inflammation or infection, neoplasia, liver disease, hyper- or hypoadrenocorticism, or hypothyroidism. The anemia is mediated by cytokines produced by inflammatory cells, which lead to decreases in iron availability, RBC survival, and the marrowâ€[emoji]8482[/emoji]s ability to regenerate. Treatment of the underlying disease results in resolution of the anemia. The anemia may be reduced by treatment with recombinant human erythropoietin, but the risk of antibody formation to endogenous erythropoietin probably outweighs any potential benefit.
Chronic renal disease is a common cause of nonregenerative anemia in animals. Erythropoietin is normally produced by the peritubular endothelial cells in the renal cortex. Animals with renal disease produce less erythropoietin, leading to anemia. Recombinant human erythropoietin (44-132 U/kg, 3 times/wk, with most animals starting at 88 U/kg) has been used for treatment. PCV is monitored weekly until the desired improvement is reached (this will vary with the initial degree of anemia), after which the dose is decreased. Animals receiving recombinant human erythropoietin require supplemental iron to support RBC production.
Primary bone marrow disease or failure from any cause can lead to nonregenerative anemia and pancytopenia. With diffuse marrow involvement, granulocytes are affected first, followed by platelets and finally RBC.
Aplastic anemia has been reported in dogs, cats, ruminants, horses, and pigs with pancytopenia and a hypoplastic marrow, replaced by fat. Most cases are idiopathic, but known causes include infections (feline leukemia virus, Ehrlichia ), drug therapy, toxin ingestion, and total body irradiation (see Table:Toxic Causes of Anemia and Table: Infectious Causes of Anemia). Treatment consists of eliminating the underlying cause and providing supportive measures such as broad-spectrum antibiotics, (amoxicillin/clavulanic acid, 20 mg/kg, bid) and transfusions. Recombinant human erythropoietin and granulocyte colony-stimulating factor (5 µg/kg, PO, sid) can be used until the marrow recovers. If the disease is idiopathic or if marrow recovery is unlikely (eg, phenylbutazone toxicity in dogs), bone marrow transplantation is beneficial if a suitable donor is available.
In pure red cell aplasia (PRCA), only the erythroid line is affected. It is characterized by a nonregenerative anemia with severe depletion of red cell precursors in the bone marrow. It has been reported in dogs and cats and may be primary or secondary. Primary cases are most commonly immune mediated and often respond to immunosuppressive therapy. Feline leukemia-positive cats can have PRCA. Recombinant human erythropoietin has been reported to cause PRCA in dogs and horses. Discontinuation of therapy may eventually lead to RBC recovery in some animals.
Myelodysplasia (myelodysplastic syndrome, MDS) is considered a preleukemic syndrome characterized by ineffective hematopoiesis, resulting in a nonregenerative anemia or other cytopenias. MDS has been described in dogs, cats, and humans. The disease can be primary or secondary and is commonly seen in cats with feline leukemia. Primary syndromes probably arise from mutations in stem cells. Secondary syndromes are caused by other neoplasia or drug therapy. Some cats and dogs respond to treatment with recombinant human erythropoietin and prednisone. Supportive care with transfusions may be helpful. Survival is variable because MDS can progress to leukemia; many animals are euthanized or die of sepsis, bleeding, or anemia.
Myelofibrosis causes bone marrow failure secondary to replacement of normal marrow elements with fibrous tissue. It has been observed in dogs, cats, humans, and goats. It can be a primary disorder or secondary to malignancies, immune-mediated hemolytic anemia, whole body irradiation, and congenital anemias (eg, pyruvate kinase deficiency). Diagnosis can be made by bone marrow biopsy. Treatment varies with the underlying cause but usually consists of immunosuppressive therapy.

I hope this helps. I vote for a simple, but not common in cats, iron-deficiency.

Hey, that's a really good list, thanks!

I've been going through, and all the different kinds of lymphoma/neoplasia are making my head spin a bit. Mostly I just try to read up on it before I go to the vet so when we talk I know the implications of something they may just throw out there without explaining. But I don't think I can remember all this.

The odd thing.. he seems to fit the symptoms for hyperadrenocortisol (or feline Cushing's disease) to a T... including very odd, patchy hair loss with no signs of irritation around it. But it would be a 1 in a million shot - I can't believe that's it. He'd be the youngest cat by about 2 years ever diagnosed with an incredibly rare disease. :/

All the lymphomas.. it's so hard to know. They're doing the bone marrow aspiration tomorrow but the results won't come back for 1-2 days. So possibly not till next Monday?? Ug. I dont know what to do in the meantime. We're staying in a hotel about 4 hours from home, and can't afford to stay all weekend. I'm hoping we can just take him home for the weekend? He is eating and drinking by himself so I'm not sure there's any reason for him to be there if they're not doing tests.

Oh, also they said his spleen looked completely normal...

I am so glad to hear it is not FIP!!!!

Originally Posted by sapling

Hey guys,

Ok, a lot went on today and I just heard from the vet, but I don't have the hard numbers down - so far, they still don't know what's wrong.

Major findings:
He is still anemic, and the anemia is non-regenerative.

While the previous vet found that he had neutrophilia with left shift, Auburn says they did not find any signs of neutrophilia. This I find very confusing ?? Did someone screw up the test? Would it be likely to change that quickly?

They did some imaging of his chest and stomach - his left ventricle is somewhat enlarged but they said that is likely due to the anemia. One of his kidneys is smaller than the other and "looks odd" but the creatinin and BUN levels are all completely normal, so they don't think the problem is kidney related. They did do a urinalysis and are still waiting on the results.

His overall proteins are still low, but none of the individual numbers are significant.

Soooo, with non-regenerative anemia, I don't think FIP is indicated, right? I haven't had time to do more research since we got back.

Tomorrow they're going to do a bone marrow aspiration and try to find the source of the anemia, but so far the word is still pretty much "we don't know what's going on".

So expensive too... the total bill right now is about $700 and they don't even know what the problem is.

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