Hello and welcome, I am Dr. B and would like to help you today.
What signs did he have before eating the litter?
What signs does he have now? Any vomiting, appetite loss, belly pain,etc.?
Are his gums pink, pale, or yellow tinted?
No worries, Helen.
Let me have a wee read and I will post in full afterwards.
Hi again Helen,
First, I have to say that you have been very thorough and sound to be helping him as much as you can do so. Though I do have a few questions for you to just give me a bit more information on this situation:
What direction does he circle? Which side is he tilting his head to?
Does his vet think the Mirtazapine is causing these?
Did his vet check bloods? Any anemia, liver abnormalities, or kidney ones (since he had the Metacam)? Was he every tested for FIV or FeLV?
As I have not heard back from you, I have started trying to tease out what is going on with your poorly lad and thought I would post my thoughts thus far (especially as I'd hate to miss you when I go to see my own patients this afternoon).
First, I do just want to touch on your initial question about the litter ingestion and Pennyroyal. It is a concern if he is eating litter with this in it as it is known to cause vomiting, diarrhea, and can damage the liver. As well, litter eating is always risky, since it can cause gut blockages. And this can appear with the same GI upset signs along with gut damage, paling gums, black stools or lack of stools, and sometimes need to be addressed surgically. So, his eating this is quite serious and if we were seeing those signs then we’d really want to consider having a check (perhaps with an alternative local vet if you aren’t happy with your current vet) for this situation at this stage.
That said, we also need to question why he is eating litter in the first place. For a cat that has to have appetite stimulants and steroids to eat a bit, this is a red flag that something is being missed. This is because litter eating is a pica behavior. Its often triggered by anemia (often related to low iron), so we’d want to review bloods done or consider a recheck of this (while looking at the liver values with the pennyroyal concern). Otherwise, I do have to warn that we could also see this –as well as the seizure activity, circling, head turn, and wobbliness – with brain based issues. The main ones we’d have to be concerned about would be Toxoplasma but also brain based bleeds, inflammation, masses, or diffuse viral/bacterial meningitis. Furthermore, considering all of his signs together (the skin included), this also raises worries of possible underlying FIV or FeLV. So, if these have not been checked for, we’d want to do so at this stage. And again since owners and their local vets do need to be a good team working together for a pet’s health, if you have lost faith in your vet, it would be ideal to see an alternative one (even if it means a wee trek).
Overall,m the pennyroyal could cause gut upset and could damage the liver. So, it is a concern. Though given his other signs, I suspect his litter eating behavior is a sign of a bigger issue. So, the above would be our main concerns here and what we’d need to look into for
Please take care,
If you have any other questions, please ask me – I’ll be happy to respond. **Afterwards, please don’t forget to rate my service by clicking on the "Rate my Expert' button at the top of the page as this is the only way I am credited for helping you. Thank you for your feedback!: )
No, no worries.
I will need to be away shortly to see my own wee patients but our chat will remain open as long as needed ( leaving feedback won't close it either so no worries there). So it's fine to post when you can and I will check back for that this evening after I return. :)
Good morning to you too,
I do apologize for already being asleep and away from my computer when you posted last night. As well, I cannot offer a phone call service via the website, but am happy to discuss your lad here as needed. And while this isn’t the original question, I would say it is part of the original discussion since as I noted initially this sounded to be a much deeper situation then a simple pennyroyal exposure. And I am actually in the midst of reviewing everything you have posted, so I will be a wee bit but then will post all my thoughts in full. :)
Actually, it isn't raining yet, which is a surprise since it was pouring yesterday. :S
Anyway, I appreciate that costs are an issue, but if he were my patient, I ‘d be thinking about rechecking those bloods. If he had a mild anemia then and is showing pica behavior now, I’d just be worried that that has worsened. As well, it would give us a chance to check the liver values after his litter ingestion and recheck the FIV if he goes outside (since infection can occur at any point and the test only represents that point in time). And just to note, the mildly elevated glucose isn’t often significant since glucose levels increase in cats that are stressed (which being poked with needles for blood tests certainly will elevate that).
Further to that, I would suggest considering seeing an alternative vet, either at that practice or another one. I didn’t take what you said as negative at all. Its just I am concerned that Tam’s situation is a challenging one –potentially with more than one issue afoot. Therefore, it may just be better to have a vet that listens, has worked with cases like this before, and therefore will have a better grasp on this situation and thus able to treat more effectively. And you may even want to see if home visits are an option, since that would get around the stress he has had with this whole situation.
With all that in mind, we’d hope to get a better grasp on his situation. If the anemia is worse, they may need to alter his steroid dose (which we may need to do for the continual itching signs) or consider an anabolic steroid (as this stimulates marrow production of red blood cells) instead. As well, since he isn’t responding to their treatment, if a skin based irritation is suspect, we may need to think about Atopica (an immune modulating drug). Though I have to say that the more you tell me about him, the more the skin signs and twitching sound hyperaesthesia syndrome (http://www.vet.cornell.edu/fhc/Health_Information/HyperesthesiaSyndrome.cfm) . It is not a very common condition in cats, so it may be something not even on this young vet’s radar. So, it may be worth speaking to them about this or having a senior vet assess him. And if that is suspect with what they have found on exam, then he may be best trialed on Gabapentin to see if we can reduce these signs for him. You may even be able to have his vet dispense either of these based on their concerns from previous exams when you speak to them next (since they have recently seen him for this issue).
Finally, just in regards ***** ***** mention of euthanasia, we'd hope that we aren't at that point but it is always s a difficult choice that needs much thought. We do use it in veterinary medicine to allay suffering and give our pets mercy when we cannot treat their illnesses. And I have to say that while it is a difficult choice to make it is a very good one to have access to, especially as we cannot even offer that final peace to people in similar situations. So, it is something to keep in mind and just to note if we did go down that route, you can request a home visit from his vet and request sedation (so just one intramuscular injection) to make him sleepy so that he does pass without any stress or worry when the final IV injection is given.
You are very welcome, my dear.
I think that is absolutely fine to do. Perhaps even see if Tam can be seen by both together (that way the senior is getting the whole picture and the younger vet is still part of the process, and able to learn from it). And see how you go, but if your gut says this isn't the right place then I would trust that. Because again you need to be working as a team (listening to one another, working together, etc) to ensure you are able to do the best possible for Tam. :)
What a lovely lad, though he has the same impressed face my own cat has when I take photos of her. ;)
Though he looks like he could use a bit more weight, so further to what we have discussed it may be worth offering a calorie rich diets (ie Hills A/D, Royal Canin Recovery diet, even canned kitten food) or supplementing with a liquid diet (ie Clinicare, Catsure) or paste supplement (ie Nutrical) to just get more into him per bite even if we cannot get much in. And as well these will all be easy on his mouth if he has any discomfort there (just since dental issues can sometimes effect appetite in cats his age).
All the best,
I am not quite sure what you mean by the throat condition’s term. Rhinotracheitis? Since you mentioned stomatitis, did you mean gingivostomatitis? Had they mentioned viral agents with this like herpes of calicivirus? Both viruses could give us gum issues and herpes can inflame the throat (though swallowing issues can also be related to nausea in kitties as well).
Now its rare to see B vitamin allergies, but if they intubated him while he was under that could irritate the trachea. As could the litter irritate the esophagus.Though the pupil dilation doesn’t fit with the litter ingestion unless he is quite stressed or in discomfort with it. Otherwise, we’d be thinking that the dilation is due to the other underlying issues.
In regards ***** ***** our approach will depend on how he is doing generally. If he hasn’t really responded to them, then we may need to have his vet decide the next plan of attack before we make any changes. Or if you found the antihistamines useful, you could use them as he is being weaned down from the steroids. You can use Piriton as instructed or half the dose if he is very sedate. Otherwise the Cetirizine is fine to use in cats (I tend to lean to it myself since it’s a once daily treatment of 5mg; thus reduces the amount of tableting for them). So, they are options if they help and may balance the weaning of the steroids.
First, I would note that if you are going to provide your vet with our discussion, you may be best to just send along the medical discussions we had or make a list of those issues we discussed. Otherwise, she may misinterpret your feelings on her experience as a young vet and be hurt. So, you may want to copy/paste what we have discussed into a word document and cut it down to the important issues we need to consider for Tam.
Anyway, if he doe shave feline gingivostomatitis but not the dental disease to support the level of inflammation, then those 2 viruses I noted would be concerns. And if he does have this, it would be another reason for pain relief (like Gabapentin or Temgesic) since sore mouthed kitties tend to eat poorly and have weight loss issues too. So, that is a base we’d want to cover.
Otherwise, with the concerns of bacterial contamination with feces, I am not sure edible litter would be the way forward. Though you could try shredded newspaper as a safe alternative that he perhaps won’t be so keen to eat.
In regards ***** ***** hyperaesthesia suspicion, he does sound like one of these kitties; especially with the unexplained skin signs that aren’t responding to steroids (as often true itchy skin conditions tend to). And it may be that the light pressure of the vest calms that discomfort. And his biting you when handling could certainly be related to this or to underlying joint discomfort. So, if Tam were my patient, it is an angle I would really be trying to cover for him; especially since the conventional treatments for skin itchiness haven’t managed to soothe his signs for him.
The chronic and relapsing pancreatitis is an interesting addition to his history. I had been under the impression that he had had a full recovery, but it sounds that isn't the case. Now it is a condition reported to be excruciating in people and is known to cause poor appetites, belly discomfort, sometimes vomiting in cats. So, I am glad he responds to the steroids, but if pancreatitis is still though to be grumbling along, then we’d really want him on stronger pain relief (ie Gabapentin or even Buprenorphine). Furthermore and especially if he relapses when off the steroids, we do usually need these cats on an easily digestible/low fat diet; so that may need to be considered if he isn’t on one already. As well, while I don’t like mentioning more testing, if he has a persistent pancreatitis, we’d want to be having his vet scan the pancreas (potentially a job for a senior vet since it is tricky to do) with teir ultrasound since we can see pancreatic abscesses and tumors cause pancreatitis like signs that wont’ settle.
And as I noted its interesting to have a chronic relapsing pancreatitis added to Tam’s situation. The reason is because as I noted it tends to be an uncomfortable condition. And it is quite possible that if he is sore with that, his skin/itching behavior could be related to a displacement behavior. This is a behavior where cats target another site because they cannot address or remove pain elsewhere (its an odd pattern of irritation here but I'd still be a wee bit suspicious). Its akin to cats with cat bite abscesses on their back ends or anal gland issues hissing at their bums. So, it is possible that his general discomfort/agitation is related to underlying pain or the pancreas issues may just be lowering his general pain tolerance threshold. So, since we have this and he cannot tell us it is causing no bother, I’d be leaning to our pain relief trial even more.
In regards ***** ***** Metacam, I do think it was a red herring. If we are going to see sensitivities to that drug, it tends to be GI upset (vomiting, diarrhea, stomach ulcers in overdose cases) and not skin issues. And if there was already irritation and the shaving left razor burn, then that is more of a fit for the signs.
As for summary of what we’d like to do, a basic blood test (CBC/chemistry) would let us check the anemia, liver, and kidney functions. FIV/FeLV tend to be tested together and usually can be done at the same time. We could also check for herpes/calicivirus (ideally with virus isolation for calicivirus and PCR testing for herpes) but I would delay testing for those if his mouth is better just now (just since herpes is intermittently shed and testing is best done when they are in the early stages of an acute flare up). That way we avoid false negatives and needing to retest in the future.
Though further to all of that or if you wish to take a slower approach, we’d want to discuss hyperaesthesia and a potential trial on the Gabapentin (which he can have with the steroids and is well tolerated if needed for the long term, only potentially causing a bit of sedation initially) with his vet. And I do think that is a worthwhile avenue for him since the biting you sounds to be him telling you that you were causing him discomfort (which could be related to his joints, pancreatitis –which is very sore for them, or the hyperaesthesia we are concerned about). As well, if they have just seen him recently, they may even be willing to dispense the drug and let you trial it first before bringing him back in.
Finally, the travel situation is a difficult one and truly our best option will be what you think will cause him the least stress. If he can be kept in (ie cat flap shut) while the friend is watching that may be best. Though if he isn’t too put out by travelling and you can restrict him to a room, en suite bathroom, or even a big dog kennel where you are staying; then he may be best with you.But it is very much a decision that needs to based on what you think he’d tolerate best.
You are very welcome, Helen.
I am glad that I can be of aid for Tam.
Yes, if they do spend a lot of time away from home, it is easy to miss health issues. Especially since cats (as prey species despite being the bane of wildlife) are notorious for hiding ailments until they are too advanced to do so. And arthritis and joint discomfort are commonly missed in cats. In fact,there was actually a study that found so many elderly cats have underlying arthritis when examined via autopsy, yet so many are missed clinically because cats cope or change their life styles to it instead of running about like usual and ending up lame like dogs do. So, it could play a role here on its own or be part of a hyperaesthesia situation. And if he still has residual pancreatic pain that too can accumulate with the rest to make him feel sore and unwell.
So, a pain relief trial with out be ideal and again Gabapentin is good for nerve pain so ideal with our concerns but they could also use the Ketogesic (Ketoprofen, in the same family as the Metacam) in place of steroids as an anti-inflammatory. And I’d note that the neither would be of harm to use if we did have any type of brain lesion and could reduce its effects if we did have one. Plus it isn’t a medication where we need to monitor dosing levels or organ function with bloods when using. So, hopefully if they have just seen him recently for this they will be flexible with you.
As for the pancreatic scan, I am glad it has been done and they have hopefully ruled out abscesses and masses on it. They are right that it isn’t an easy organ to scan but it is good if they have been able to do so confidently and rule out problems there (hopefully also ruling out any of the nearby organs being overly large and squashing the pancreas –another way the organ can get upset and not settle). And I agree that my number one rule on cat feeding is that it has to be something they will eat. From there low fat is ideal for pancreas kitties and I do find that many do like the Royal Canin Sensitivity Control food (even my healthy cat used to steal it from my poorly one) if you did want to try one.
In regards ***** ***** stinky stuff, I will have to look into it as I’ve not used it myself. Though if it smells like and could have garlic, we may need to avoid it since garlic is quite harmful for cats. Otherwise, I am sure he’d be fine on his own during the day and if he would be less stressed with you then that may be the way forward. And I cannot say what he was doing with his leg, he may have been a bit stiff but if he does it again and you can video that to post on youtube I am happy to have a look and see if I can decipher it for you.
Best wishes and a peaceful evening,
I must be brief as I am about to pop away from the weekend.
Now that is good that she doesn’t feel that he is sore with his pancreas, but with his signs I’d not just assume it. In fact, since he cannot clearly tell us what is bothering him and since cats often hide pain, if he were my patient I would be of the mind to use a pain relief treatment trial to make sure that isn’t the case. If he had no change, we’ve not lost anything but if we do find a positive response then we will all be relieved for that. So, I would still lean to doing so even if he may have been stoic when she examined him.
Furthermore, I’d note she could use Amitryptiline but since he has so many possible focuses of discomfort, I do feel that Gabapentin would be a better option. As well, since you had asked, our cats do tolerate Gabapentin quite well with again the initial sleepiness being the only side effect I have seen with my own patients. It tends to be fairly quick acting (though I cringe for you to mention Paracetamol since it is so toxic to cats it rings my alarm bells just to see it there ;)), so while I’d not expect a 100% response in a day, we’d hope to see some response over a week of treatment. Furthermore, while high doses could harm the liver, if they have done bloods before and know his liver is fine, we’d not be overly worried about that.
And since her colleagues and she haven’t heard of its use (it is a recent addition to our treatment options for this so perhaps they are not up to date), I would suggest a peek @ Cornell Vet School’s information on the topic : @ http://www.vet.cornell.edu/fhc/Health_Information/HyperesthesiaSyndrome.cfm
Though if she will meet you half way, it is worth trying to see if we can get him more comfortable (since that is our #1 goal).
Otherwise, I appreciate she hasn’t seen signs of hyperaesthesia when examining him but as you will be aware it flares-up and is intermittent. So, unless she was with him 24 hours a day, she may not be seeing what you are. Therefore, we may need to think about videoing what he is doing (his odd postures/gaits too). That way we can all see what you are seeing and be on the same page. And that would be the best option if she can only base her clinical opinions on what he is doing when she sees him (which could be masked by his stress).
In regards ***** ***** throat, he does sound sore. If it is when he is having the steroids, we may need to consider having them swap to a long acting injectable steroid to continue to treat but allow the throat to settle. Or you can crush the tablets to mix with water and syringe (you can pop the tip between the cheek and teeth to give) if it will be easier for you both.
As for YouTube, I believe there is an option to restrict viewing and then the website should give a link for you to then give to me. After we have discussed it, you can then delete the video if you wish to.
I know that you did, but its one of those ingrained "buzz words" that send vets into a tizzy. ;)
In regards ***** ***** further replies, you are welcome to post and I will reply when I can. Though if you needed a reply quicker you can choose to open a new question for a colleague.
Best wishes and a peaceful weekend,
I am just now (like to have a quick check when I can to make sure all is well with everyone) ;)
A lovely weekend to you too,
I am sorry to hear that he has signs of seizure activity. It is possible that his ongoing issues are overstimulating him as much as stressors at home. Though it does again mean we have to be wary of brain based issues. Still while I understand your reluctance,I would be keen for you to start the Gabapentin now especially. As we have discussed it is a medication for nerve pain but it is also used to help reduce seizures in animals (its multi-purpose use is why you are seeing such a dose range variation). Though 3mg/kg is the base dose for seizure treatment, were 1.25mg/kg is the low dose for pain issues. So, I would defer to the dose his vet has prescribed but you could try the lower one (5mg) first if you are worried about adverse signs despite this being even more a proper option for Tam.
You are very welcome,
That sounds like a good place to start and hopefully we can get Tam a bit more comfortable and stable for us.
A lovely and peaceful evening for you both,
Good afternoon Helen,
I am glad to hear that he is perking up. If he is stillirritated a bit, I would suggest ringing his vet about any wiggle room on hissteroid dose (though that may be making him a bit more thirsty); just sincegiving Piriton with Gabapentin can make them dizzy/wobbly/etc and thus bestavoided since we are making some progress. Otherwise, you could also speak tothem about using a hydrocortisone spray on the flank skin as his vest willprevent him licking it off
Keep up the good work,
Dr. B. :)
Good morning, my dear.
I am very sorry to hear that things have been so difficult at home with your mother.
In regards ***** ***** I am glad to hear that his appetite and walking have responded so well, but that itchy skin despite a large of steroids is understandably frustrating. Especially since its quite odd for the Piriton to help but not the steroids (since its usually the other way around). If you did wish to do so, you could try him on a low dose of the Piriton (2mg) to see if he settles. Of course, if he becomes wobbly/dizzy, we’d have to stop that since that is our concern with using it alongside the Gabapentin.
Otherwise, it does depend how long ago that hair was shaved but if he has been struggling to keep weight on and eating poorly, then that is likely why the coat hasn’t regrown. Especially since in times of nutritional compromise, the body redirects nutrition to critical organs and the coat often suffers.
Finally, with the Gabapentin, the drugged up/sedation signs do tend to pass once they get a bit of a tolerance. Though you could give it every 8 hours at the lower dose first to see if we at least keep him comfortable stably at the lower dose.
Good morning Helen,
It does sound like a mixed bag of good and a bit of frustration. To start, Gaba doesn’t usually cause diarrhea. So, I’d be more suspicious that the steroids (with their immune dampening effects would be playing a role with this). In regards ***** ***** to reduce this for him, you can try adding probiotics (ie Fortiflora), and fiber (ie 0.25tsp of unflavored Metamucil or canned pumpkin) into his diet to see if we can reduce this for him. There are also OTC probiotics/kaolin products for pets that can be used to slow diarrhea (ie Protexin Prokolin, Propectalin, etc). And these can be bought OTC at vets or even sites like Amazon. So, those are worth using here.
Otherwise, in regards ***** ***** it is tricky and we are trying to do so via his treatment response (which being more of a handful and jumping on the counter now is definitely positive ). Because otherwise, diagnosis of brain lesions require MRIs and hyperaesthesia tends to be a diagnosis of exclusion (when you have ruled all else out). So, that can mean a lot of testing to then assume it is. So, we have cut to the chase with the Gaba but do have to appreciate that we are treating on the basis of clinical suspicion in the hopes of avoiding all those tests. Still, again while the diarrhea is an annoyance and we may need them to tweak his steroids if he is still that itchy, his mobility actually sounds improved (which we’d hope it continues to as he regains muscle mass in his back end) and that Gaba is making a positive difference even at this early stage.
Therefore, testing-wise, we have 2 options. We can do everything like I noted for a diagnosis. Or you can have a heart to heart with his vet about his positive response and continuing the treatment to see if he continues to improve. At the same time, they can work with you on the steroids side and if the diarrhea doesn’t settle with the aforementioned supportive care a stool sample could be tested or they could try broad spectrum antibiotic treatment to see if they can get that blip settled for him.
Have a lovely day,