Erica': lymphoma or IBD? ultrasound tomorrow, consult with IM specialist was good

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Steph & Quintus & L & O

Steph & Quintus & L & O

Member Since 2017
Previous episode: http://www.felinediabetes.com/FDMB/...oma-bg-question-310mg-dl.190229/#post-2120535

Erica is doing better on the antibiotics. I cancelled the biopsy, seeing the vet tomorrow, who is still adamant it can't be pancreatitis. The jury is still out.

In the meantime I have monitored her BG. Here it is: https://docs.google.com/spreadsheets/d/1lji4XkT0UZ23z5xWRuQwgd9k-EXmCqwkdPoUhftaISo/edit?usp=sharing

Curious to have a bunch of eyes used to BG look at it. Clearly she's not diabetic, it's been going down. But what do you make of it? Antibiotics working on that (hypothetical) pancreatitis? Something else? What might cause BG to fluctuate like that, if that's not what is going on?
 
Here's the spreadsheet again: https://docs.google.com/spreadsheets/d/1lji4XkT0UZ23z5xWRuQwgd9k-EXmCqwkdPoUhftaISo/edit?usp=sharing

Yesterday we went to the vet and went through a horrendous blood draw experience. It lasted "forever", started with jugular, failed, switched to paw, we had to constrain her, she was growling and protesting the whole time. Stressful. Since we got back she's been hiding and avoiding me (we stopped some meds so can't be entirely sure this is just a stress reaction).

Anyway, I measured her BG last night and this morning (she didn't eat much during the night) and it was normal.

I am arguing that this BG variation doesn't look like "just" stress-related, but this is just my gut feeling. I'm sure many people on the board have had the opportunity to observe stress-related BG variation (with cats on insulin, granted, but still).

Any testimonials or info you could give me to help interpret these numbers would be welcome.

I will be checking for glucosuria today as her BG is back to "normal", as there is a pending diagnosis of tubulopathy (renal) due to "glucosuria without elevated BG" (the "198" being considered not elevated, just stress) and observation of fairly large kidneys. If no glucose in urine and normal BG at the time, that kind of invalidates the hypothesis.
 
An update and more info, just in case somebody thinks of something. Today she has really been "less well". Not eating, hiding, afraid of me. So, trauma from yesterday's vet visit, and certainly my repeated attempts to pill and medicate her. I'm leaving her alone 2-3 hours in hope she'll calm down and eat some.

Other stuff:
  • got detailed explanations from the vet who did the US on what she saw and her reasoning:
    • mesenteric (? translating, not sure of English term) lymph node, a long thing she drew for me, supposed to be <5mm wide, is 12mm, so suspicion of IBD/tumor
    • intestine wall, section normally shows two dark strips, the interior one wider and the exterior one thinner. here they are both wide => also suspicion of something nasty going on
    • kidneys, one is 4.5cm, the other 4.8 (upper normal limit is 4.5); added to glucosuria with "normal" BG => tubulopathy certain => infiltration of tumoral process
  • at 198 after a day of fasting, I'm thinking her BG was elevated for either stress or other reasons and the glucosuria is linked to that (I know renal threshold varies from cat to cat and we're roundabout where it starts); it was 310 the next morning. It's gone rather steadily down back to normal now.
  • FIV/FeLV came back negative, waiting on Spec fPL, B12, folates
  • her BG after the vet yesterday was 139, this morning 95. Can a cat have stress hyperglycemia after one stressful vet visit and not (to the point of nothing!) after another? Numbers for reference: https://docs.google.com/spreadsheets/d/1lji4XkT0UZ23z5xWRuQwgd9k-EXmCqwkdPoUhftaISo/edit#gid=0 -- I keep coming back to this because it bugs me and I think those numbers indicate something and chalking them down to stress is missing it.
  • I will be measuring her urine glucose tonight, hopefully, if she pees in the special litter. If her BG is normal and no glucosuria that puts a big question on the tubulopathy diagnosis.
  • she didn't have omeprazole yesterday morning, or metoclopramide last night. After discussion with vet (my main vet) I put her back on everything mid-morning.
 
I know for sure that I could have very high readings because of stress sometimes ( almost 150 more than at home ) or not sometimes Babu's BG wouldn't really change much, sometimes just looking at the vet would stress him, beats me if I know why, but that doesn't mean stress is the explanation to every high reading the vet gets.

Keep in mind that for glucose to show in urine, it has to be high enough to be over the renal threshold but also it has to be like that for a while not just a few minutes

Hope she getts better sending you :bighug::bighug::bighug:
 
Another day, another Erica update! She still hasn't eaten since the traumatic vet visit 48 hours ago (I am aware of and worried about hepatic lipidosis). But her behavior is less "off" today, except for one moment when she desperately wanted to go out, couldn't, and then tried to hide.

I got and gave her Cerenia (tab) about an hour ago, I hope it will work. I have mirtazepam if needed.

Lab results in:
  • folic acid: 39 nmol/l [25.2-49]
  • B12: 289 pmol/l [199-984]
  • PLi: 3.6 ug/l (so, ultrasound-vet goes "see, no pancreatitis!" and I go "see, pancreatitis and she's almost over it!" -- dialog didn't happen in the open, but in subtext)
The vet had a free slot Monday for US + biopsy if necessary. I prebooked it but can cancel it Monday morning.

With the tubulopathy off the table (because no glucose in urine, what the vet told me indicated that pathology for sure), I feel the case for something tumoral is weaker. When she explained what she found on the US, it was clear the "tubulopathy finding" confirmed her lymphoma suspicions (because it would mean tumoral infiltration in the kidneys).

My gut tells me she has IBD (what is a gut worth?).

I'm trying to decide if it's worth putting her (and my wallet) through another US, and cut her open for a biopsy. Will it change the face of the world when it comes to her treatment? And depending on the findings and the treatment course, will that change the outcome?

I'm lost and not sure where to turn. I'm thinking of getting a second opinion but again, that means putting a stressed cat through more exams and tests. If she starts eating again this week-end, I'm tempted to leave her alone for a bit while I weigh my options.

Anybody with knowledge of IBD and lymphoma (the two likely contenders), please share your science. I know SCL seems quite treatable, I'm on the SCL group and what I understand is that this doesn't look like SCL.

I think she has an underlying condition (lymphoma/IBD based on ultrasound) and that she had an acute pancreatitis episode.

For those who like data, I made a curve of her BG over time since the vet visit last Friday. Check the graph tab: https://docs.google.com/spreadsheets/d/1lji4XkT0UZ23z5xWRuQwgd9k-EXmCqwkdPoUhftaISo/edit#gid=0
 
I have no data. What I can tell you is that we flipped from pancreatitis DX, to an IBD DX to a likely SCL and need biopsy DX. This was over a period of 3 months and him steadily losing weight. Then the whole FD dx came in. By that point he is around 4Kg and for a 5.5Kg cat that was very thin. He had no muscle left and he was very painful it seemed.

We did not do the biopsy as he was not in a state to have one. All we had to go on was an aspirate at the time of the original US which didn't show any abnormal cell changes. So we treated what we could.

@Wendy&Neko is someone with knowledge on both conditions.

Sending some vines for Erica. Hope she eats for you soon.
 
You are getting good advice on the Feline SCL boards. There is more collected experience there than here. It's not uncommon for SCL or IBD cats to have flares of pancreatitis. Aspirates are not a diagnositic mechnism for IBD/SCL. Did you discuss endoscopy vs. biopsy with the vet? Neko did not have a biopsy or endoscopy, because her heart condition meant she could not have anesthesia. I wish she could have. Because if it was only IBD, I could have avoided the nausea that chlorambucil brought. We treated as SCL without really knowing.
 
Wendy&Neko said:
You are getting good advice on the Feline SCL boards.
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Lately I feel as if I am mainly talking to myself :(
Wendy&Neko said:
It's not uncommon for SCL or IBD cats to have flares of pancreatitis.
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Makes perfect sense and I'm now pretty sure this is what happened.
Wendy&Neko said:
Did you discuss endoscopy vs. biopsy with the vet?
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Yup, briefly, asked ultrasound-vet if there was any way to do the biopsy without cutting the cat open, and she explained something about doing it with the ultrasound was really imprecise.

I will, however, be calling the new medical centre tomorrow to see what they offer.

Thanks, Wendy.
 
Just gave her the Mirtazapine. When I googled hepatic lipidosis the first thing that came up aside from anorexia was « hiding in strange places » — which she has been doing. So I freaked out and figured I’d throw that at her as well and call the new clinic at 8am (midnight now)
 
I've had two cats with IBD- one of whom also had intestinal lymphoma. I did not have a biopsy done on my 17 1/2 yr old due to her age. Her symptoms were extreme and her specialist was 99.9 % positive she had lymphoma due to the thickened intestines and swollen lymph nodes. She was treated with prednisilone and chlorambucil and also B-12 injections. My current cat was diagnosed with mild IBD by endoscopy but not an intestinal wall surgery. He gets treated with pepcid and metronidazole as needed for now. If he gets worse he may need to be put on Budesonide. Treatment for severe IBD can be the same as treatment for intestinal lymphoma- pred, chlorambucil, other immune modulators, cerenia, and other anti nausea meds. Unless there's a mass/tumor that can be seen on the ultrasound that can be excised I don't see the point of major intestinal surgery when/if treatments and outcomes are the same either way.
 
Thanks Lillie!

This morning update: of the smorgasbord on display she did eat my neighbours kibble last night, after I left her, and this morning. Small quantity so getting more.

Big nasty — part pudding, part liquid, half out of the box. She was not in her usual place and growled when I took her (growls these days, poor heart) but after eating what was left of the kibble she came to crouch on my lap.
 
Stephanie & Quintus said:
Thanks Lillie!

This morning update: of the smorgasbord on display she did eat my neighbours kibble last night, after I left her, and this morning. Small quantity so getting more.

Big nasty — part pudding, part liquid, half out of the box. She was not in her usual place and growled when I took her (growls these days, poor heart) but after eating what was left of the kibble she came to crouch on my lap.
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At least she came up on your lap, she still loves you :)
 
Aww- I hope things turn around soon. It gets so darn frustrating trying to figure out what's wrong with our cats sometimes, and trying to make a decision as to how to treat them can be nerve wracking.
 
Evening update: I went to the new vet clinic this morning, managed to get an appointment. I could see we weren't going to last the week-end without heading to the ER.

I had a good long chat with the vet there, taking the opportunity to get a "second assessment". Limited as I didn't have the ultrasound report, but still, it was good to go through everything again.

Short term: Erica has abdominal pain and has not been eating, so we decided it was best to hospitalise her to keep her stable and get her eating again. I am hugely relieved on a personal level to get a "break" and know she's in good hands. They have 24/7 care there, and I got to see their brand new facilities two weeks ago on their open house day.
Medium term: if she doesn't eat, a feeding tube might be a good idea. I think so too, but we're first trying to get her to eat, and I was told on the phone just a few minutes ago that she ate a good handful of the kibble I brought. That's good. Hopefully no need for a tube.
"Long" term: not really long term, but underlying issue. What the vet suggests is I book a consultation with their internal medicine specialist on Tuesday to see a) if there is other stuff to investigate before doing a biopsy (the vet I talked to told me she could think of a few things) and b) what the options are re biopsy/IBD/lymphoma.

So I now have two options to choose from, and how Erica evolves during the week-end will influence my decision, but I'm not sure in which way:

- I have a follow-up ultrasound with a slot for possible biopsy booked with my vet on Monday morning; it's understood I can cancel it
- I can wait until Tuesday to see the specialist at this other clinic and see what they recommend, knowing that if we end up deciding on the biopsy we will not be able to do it until the end of the week, probably.

I'll be calling tomorrow morning to see how she's doing and get an appointment to talk with the vet and maybe pick her up.
 
Sounds like a good idea to wait to see the specialist. (If possible) He may have other options before a surgery. I wish I had gone to a specialist first off- it would have saved me a lot of time for diagnosis.
 
I’m at the clinic to pick her up!

She’s doing “great”, eating like a hog, peed, had a NORMAL stool (wtf???!) and is lounging around seeming comfy.

All she had in her drip was cerenia, omeprazole and combiclav.

So we have stopped Metacam and metoclopramid. She had 1/4 Mirtazapine 36 hours ago.

Not sure what to make of all this! I think she likes clinics and drips, because last Friday at my vet’s similar happened.
 
It sounds like the meds they're giving her in the IV are helping her a lot. Is there any suggestion yet as to her ongoing treatment, or will she need to be seen by the specialist first?
 
Lillie said:
It sounds like the meds they're giving her in the IV are helping her a lot. Is there any suggestion yet as to her ongoing treatment, or will she need to be seen by the specialist first?
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Yes, definitely seems the important stuff was in the IV! So I'm sticking to that (actually didn't give the cerenia, they were planning on seeing how she ate first before deciding for tonight, and I did the same -- she's eating well enough that I'm trying without).

In the drip she got last week there was cerenia, omeprazole, bupe, metacam, metoclopramid and maybe some other thing I'm forgetting. This was before starting the antibiotics (she crashed the next morning and improved over the next few days once we started ABs).

I also really think there is a "feline psychology" aspect to this. Once when trying to switch her kibble, she went on a proper food strike and lost 1kg in a month. When I first brought her in she would hide and come out and eat only when we were there. So I really think the panic at the vet Wednesday evening set her off not eating for a bit, and then she started feeling crummier because she wasn't eating, and it went downhill. And clearly some food aversion as she was eating one kibble heartily but not the other.

So now until we see the specialist I am keeping her on the two foods she had at the vet's. We'll see if I get the honour of normal stools.

Tonight she maybe feels a bit warm (can't take her temperature) and her tummy is clearly sore. But she's still eating so she just got her antibiotic.

Thinking of it, I did give her Fortiflora when she got home (she loves it) -- hoping that doesn't have the potential to bring on a GI upset!

For the moment we're just treating the symptoms and trying to keep her stable until we see the specialist on Tuesday.
 
Cats can be really stubborn when it comes to food they just don't want. Wish they could talk and tell us why after loving a certain food they all of a sudden hate it. It baffles me.
Good luck on Tuesday! My cat loves the Forti Flora too but if I overdo it he gets some runny stools- which is odd because they advertise that it's good for diarrhea. Oh well. He has IBD though so his digestive system is not like a normal cat.
 
A quick note post-IM-specialist. There are two issues here, that may or may not be linked: nasty poo and digestive issues that she's had since I got her, and the acute episode from ten days ago. That episode looks like it could have been something infectious that responded to the antibiotics. She agrees that the "relapse" after the scary consultation on Wednesday can be a combination of still being a bit fragile, stress, and then a vicious circle of not eating. After all it looks like it just took a few cerenia, mirtazapine and an overnight drip at the vet's to turn her into an eating machine again. Caveat: mirtazapine could still be having an effect.

She suggested getting a follow-up ultrasound done by a specialist now that she seems over the acute issue. If they find the same stuff in that second ultrasound, then probably what was seen is due to the chronic condition. Otherwise, it is to be linked to the acute condition. That will help in figuring out what the chronic condition is and how to deal with it.

Stroke of luck, I got an ultrasound appointment tomorrow morning, as they had a cancellation! We won't be waiting long.
 
A quick update after this morning's ultrasound (I'll get the report later).

The mesenteric lymph nodes are not enlarged anymore. Her heart is fine (checked as she has a murmur). Pretty much everything is fine aside from her intestines, where there is clearly signs of unhappy digestion. The wall is a little enlarged, but not alarmingly so. This seems to indicate that the enlarged lymph nodes were linked to the acute condition and not the chronic one.

According to this US specialist, no reason to think of lymphoma or do a biopsy based on what she is seeing.

I'll head back to the IM specialist for interpretation and follow-up regarding the chronic condition (which might lead us to endoscopy or other exams). The US specialist asked if I'd tried hypoallergenic food, and that was indeed something I had in my mind to try before all this mess happened.

Relief! And thanks again for following me through these trials. But it looks like lymphoma and biopsy are off the table at this stage (pending confirmation by the IM specialist, but she was already very doubtful initially).
 
So, now that we're out of the emergency, we're trying stuff:

- try HA food (but she's having very liquid diarrhea, calling vet tomorrow to see if I should persevere or switch back)
- test for parasites (giardia, trichonomias)
- if that doesn't give us anything to go on with, discuss endoscopy/biopsy -- endoscopy probably not possible given it's the jejunum, biopsy could be surgical or laparoscopic
 
I tried a lot of hypo allergenic foods on Leo. It took me quite a while to find one that he would eat and do well on. I found the limited ingredient single protein worked the best. He didn't like any of the prescription ones and I've ended up with Canidae Pure canned. I hope they gave you something for the diarrhea- ? Metronidazole works well. Well, at least for my Leo it does.
 
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