Hi, I'm Doctor Kathy Johnson Delaney, and I'm going to be presenting a lecture on the collapsed ferret. There are more causes than insulinoma. I've been working with ferrets for over 45 years, and I have a little bit different, take on some of the more common things that we see.
The learning objectives for this course are basically to understand basic ferret anatomy and physiology as it pertains to metabolism and disease because these are not little dogs or little cats and make an appropriate differential diagnosis list when you are presented with a collapsing ferret. Obtain appropriate diagnostics including the imaging or at least what I think are appropriate diagnostics and then of course the immediate treatment of that ferret and based on the diagnosis, the development of a treatment plan including instruction of the owners on what to look for and what to do for their ferret. Some important points is that ferrets have a very short GI tract, with no cecum and, a very rapid transit time, 1.75 to 3 hours from mouth to faeces.
They can't digest fibre over 4%. Therefore, most dog and cat foods are inappropriate. They require high protein, high fat, and not carbohydrates.
Ideally you want a diet that is 40 to 45% protein and 30 to 40% fat, or at least a ratio of protein to fat that's fairly different than dog or cat foods. You only want to feed diets that actually have feeding trial data, not boutique diets. The raw diets are not proven right now, and we've had some problems with introduction of Campylobacter and salmonella, and homemade raw diets.
There are frequently we find problems with consistency and, owners supplementing or, Changing, items if they become available or if they become too pricey, so there's some inconsistency and they're not proven. And then there are those who feed a whole prey diet, and you just have to remember that domestic prey items such as mice are higher in fat and carbohydrates than a wild prey mouse would be. And again, prey items depending on the colony where they're raised, .
It may carry some bacteria that you really don't want to introduce into your ferrets like again the Campylobacter and salmonella, and even some of the clostridial organisms, and remember that ferrets are a man-made animal. These guys are all one blood type worldwide. There are no wild fitch ferrets.
Mustella putorius furrow. It is a man-made domestic animal, so to say what their wild diets are, we are basing that on what their ancestor, the European polecat, is. And even then we can't really, get all the things that a wild polecat would eat, including birds and birds' nests and You know, rodents, whatever they can find.
So, the diet that we're feeding our domestic ferret is different than the wild European polecat. The stomach is spontaneously produces acid and proteolytic enzymes, you know, it has to be ready to take food at any given time. It also has a lot of histamine, which is under vagal stimulation, and it's, so that the histamine promotes more acid.
The stomach itself is innervated by parasympathetic fibres of the vagus and, comes out of the ceo celiaccom mesenteric plexus. That histamine stimulates that acid, and there's a low concentration of free histamine because they, they don't have a lot of the histamine forming enzyme, so. It, it's a little bit different than again your dog or cat, which doesn't have that huge histamine response, .
The receptor antagonists will abolish that secretion, so that's why we, Give famotidine or omeprazole or, or any of the histamine agonist antagonists while we have a ferret with any kind of a GI problem. And remember atropine given only reduces the response about 30%, so, acid secretion will continue even under anaesthesia even with fairly high doses of atropine, which is again a little different. The duodenum has 3 sections, but you're not gonna be able to see that grossly externally.
They do not have really a distinguishing mark between the jejunum and the ileum, so they call it a jejuno ileum. And it ends in the ascending colon. It can be seen on histopath, but, again, just looking at the ferret gut, it looks like one continuous tube.
It is innervated by the vagus nerve, and, that is something to always keep in mind when you are manipulating the throat and neck, not only triggering the vagus reflex in the heart, but you also could be stimulating more acid production. The colon has, mucous substances that are very similar to humans, and, the motility of the colon is. Very similar to the dog's ileum.
So there again you can see that even the colon moves faster, more like a small intestine. The vagus nerve, again, that is, mediating the entire GI tract, and it's interesting that the sacral innervation to the GI tract, i.e., into the colon, is excitatory.
So the actual genesis of vomiting and retroperistalsis in ferrets. Begins with the sacral nerve excitatory, so you can, you can actually stimulate retroperistalsis if you get too energetic with an enema or even a thermometer. Ferrets are used as emetic models, so they can vomit quite easily and, do so, so.
Just a kind of a look, you may have seen this diagram before that appears in Fox, and it just shows that the entire GI tract pretty much looks the same. And when you actually look at a ferret, one thing to note is there is a large lymph node in the curvature of the stomach. The stomach is attached to the spleen.
This ferret had a relatively small spleen. But the GI tract is pretty much looks the same diameter all the way. Till you get to the colon, the pancreas in the ferret is not as, nice in some ways to find, especially on ultra sound as you do with a dog or cat.
It can be very variable. It lays starting on. The curve of the stomach, but it also will come around here and form a C-section, C, it, it is a different shape in different ferrets.
It's not the same. So, finding it on ultrasound is a real challenge unless there are nodules or something wrong. The pancreas itself is under vagal stimulation and it has a lot of capillary connections with the islets and the exocrine tissue.
It does produce a bile salt dependent lipase, and adult angels in the mammary tissue have a 10 to 20% higher, lipase levels, in ferret milk than in human milk. But so when you do a blood work and you see lipase elevations, should we be thinking about the pancreas? Probably.
But it's not really consistent. We haven't really decided what makes for a true lipase elevation. It varies depending on when the ferret ate tremendously.
OK, so the gallbladder, contracts via cholecystokinin. Which, unlike other animals, is found throughout the entire GI tract. So the cholecystokinin inhibits gastric emptying, but it stimulates the small intestine and colonic motility.
So essentially that means that any time there is food anywhere in the GI tract, it is stimulating. Cholecystokinin, it is stimulating the gallbladder to release, and it basically makes the whole GI tract very modal. And that's kind of, kind of interesting because it is a highly modal secretory system designed to have very fast transit time.
So our food must be highly digestible, something to keep in mind. Ferrets are basically designed to be kind of mucousy and soft. So, hypoglycemia, OK, this is a differential for a ferret who comes in who is collapsed or collapses intermittently.
You have to think islet cell endocrinopathy. That's what everybody jumps to immediately, but I'm gonna go through a bunch of other things that will also give you a quote unquote hypoglycemia on a blood test. Just inappotence and anorexia from whatever reason will give you low blood glucose, so that could be any systemic illness.
Ferret doesn't feel like eating. It hurts. It's, you know, it's sick to its stomach.
It's got, dental disease which makes everything taste horrible and its teeth hurt. Just pain, generalised pain. The ferret just fell off the stair landing and got hurt.
The ferret has a blown disc. The ferret is older and has osteoarthritis. Gastroenteritis in any shape or form causes some malabsorption, and you get that with, scarring from a, from a coccidia infection when they were young.
That's one of the things that we see, inflammatory bowel disease going on to neoplasia. Neoplasia, any place can make a ferret not want to eat much. A poor diet, an inappropriate diet at a ferret-fed dog food, for instance, or one of these boutique diets where it's really not getting the nutrients it needs, or the, the, the protein is way out of whack with the, with the, fat, and there are some commercial diets that have like 70% protein, and that's way too much.
It's just not working. Feeding irregularities, OK. The owner doesn't leave food in there all the time or has a weird work schedule and feeds just once a day or puts food in there.
There's a whole bunch of ferrets in there. There's competition, stress at the food bowl. The ferrets are pretty good about sharing things, but sometimes the smaller ferret, especially if you've got a bunch of big boys and then you've got a little girl, may not push her way in and may have less food.
What we call a grostriosis, i.e., not getting the groceries.
So one low blood sugar result on a collapsed ferret in the exam room is not a definitive reason to diagnose this ferret as insulinnoma. You can't do it. It's just not correct.
Remember that a ferret can normal can be 66 to 69 in between periods of eating. And again, think of the mustelid metabolism, and it's a, it's a hunter, so it'll be feast or famine, and, the blood glucose goes all over the place. It is lower normally than a dog or a cat postprandial.
So what should you be asking? Oh, there's a whole bunch of things you should be asking. First thing is what diet is the ferret eating.
When was the last meal? Is food always available for the ferret? Can the ferret get to the food easily?
I had a little old ferret who's got splenomegaly, so the belly's so light, and the food is fed up on the third level of the condo. Can the ferret get up there easily? No, it can't.
Does the ferret pot its mouth? Does it have pain in the mouth? Does it have dental disease, or is it just nauseated?
Is it hyper salivating? And again, look at those teeth. Does it have hindquarter weakness prior to going flat ferret or speed bump, or does it do that and actually have a seizure?
What other signs of nausea or pain, and again, nausea and pain, squinting eyes, maybe hypersalivation, licking its chops a whole bunch, or acting like it's swallowing, that can be nausea. Does it show inactivity, or lack of playing, or other limitations? Just not, just sort of randomly?
Is it keeping up with the other ferrets, or is it just kind of taking three steps and going pelt? We gotta think about all those things. So, 11 thing that's kind of a problem for us though is the inclinic blood gluse analyzers.
You want an immediate reading, but is an immediate reading good? Years ago, Cheryl Greenacre, did a study looking at, the, at the time, the human glucometers, and we had alpha-rac 2, C, alpha track 1 and 2. And the canine overestimated by 15%, what was the closest, but all the regular human ones indicated severe hypoglycemia in all the ferrets, and it wasn't.
These ferrets had 66 to 69 on a regular lab, and yes, these are US, the, . Numbers, but I think you can get the idea. We found that Alpha Track on the canine setting was fairly good, at least for trends.
I mean, it doesn't give you the absolute, but we've been using the Alpha Track 2 for years and years and years, and they quit making it. And so now we've got Alpha Track 3, and so far we're having a heck of a time, as we've heard from everybody else too. Getting it to correlate with anything.
We ran a whole bunch of, bloods on alphaTrac 2 and alpha track 3 simultaneously and got way different numbers, which was ridiculous, and then we tied them to the, in-house. Analyzer at the time and again that alphatrac 2 on canine was fairly close, but the alphatrac 3 was ridiculous, just didn't work. So if you send it out, you need to spin it immediately and separate that serum, but realise there's gonna be some degradation.
OK, so, you want symptoms versus aetiology, right? You need that history. OK, so is this a collapsed ferret, or does it always lay around very exercising intolerance, i.e., flat ferret, we call them speed bumps, call them pelting.
They just flat out on the ground. They may walk a little and play a little and then collapse again, or sometimes they hypersalivate a little bit and they don't even seem to collapse. Sometimes there's some pawing at the mouth with some ruxism and some grinding and some swallowing, and sometimes you may even see gagging or tremors.
And I may not be progressive in frequency and duration, and then again, the, the, it may not have changed very much over time. So most of the ferrets you see presented with these collapsing episodes or who are just not as active or who are doing these weird gagging things are older ferrets, i.e., over the age of 4, and when you talk to the owners, a lot of the collapsing episodes and even the hypersalivation don't seem to be directly correlated to when they ate.
Many of these ferrets have concurrent diseases and are on other medical treatments or maybe after you get done working them up, and some of these have a pattern. The owner may report that. It happens when they just wake them up and put them outside the cage for their play and then they go into this whole collapsing and, you know, salivating and whatever, or it just can be an activity rather than the activity itself that seems to prompt it and so there, there may be a pattern, but a lot of times there isn't a pattern, so the true testing.
In my book anyway for determining islet cell endochronopathy and let's just call it that and not insulinoma or islet cell carcinoma because it hasn't progressed that far yet, but let's just call it islet cell endochronopathy for the time being. So the true testing. Again, that I use as a diagnostic indicator is you feed the ferret at you get a baseline blood.
It helps to have a catheter in, but you can also just be really good at drawing blood from the ferret. And so you feed the ferret a meal and then at 2 hours you draw blood and separate the serum. At 3 hours you draw it and separate the serum and 4 hours, and this is where having the in-house blood glucose, .
I will say the monitor that we used to use the alpha tracks, but we can't really use that anymore. So when you had that immediate and you knew what the blood glucose was at each of those time points, you can, look at it a little bit differently than if you have to send all of it out and then, look at, the, the glucose at those different time points. When you could do it in-house, if the blood glucose is below 50 at 2 hours, boy, that's highly suspicious in my book.
If the blood glucose is below 40 at 3 hours, yeah, it's pretty likely you got an islet cell problem. But if the blood glucose is over 70 at 4 hours, it's very unlikely. A blood glucose of say 78 at 6 hours, ah, it's fine.
When the blood glucose drops below 60, that's when I send in that serum for the insulin levels. University of Tennessee endocrinology lab has a validated ferret insulin assay. If you send it into other companies, they often send those off to the University of Tennessee anyway for, testing, but that, that will give you pretty good indication.
So to interpret it, . The insulin level, if it's elevated or within normal limits, it makes it kind of hard sometimes to figure this out, but you can. So you compare it with when the low blood glucose level happens.
So if you have a normal blood glucose, say at 2 to 3 hours and it's 60 or 70, but the insulin is elevated. You're gonna put those in the suspicious category. If the blood glucose is less than 50 at 2 hours and you got a high insulin, yeah, that's, you pretty much can diagnose that.
You've got it going. That's pretty significant. But sometimes they'll, it, it'll be a little iffy and again, watching the ferret, really getting the owner to take the observations as to when it ate and when the problem began.
Is, is kind of how you start ruling out if this truly is, ins insulinoma, insulin carcinoma, islet cell carcinoma, islet cell endocrinopathy, whatever you wanna call it, but don't stop there. Do a full workup. Assess other organ systems.
Many of these guys have concurrent GI, liver, kidney, and other endocrinopathies. Remember, most ferrets have some degree of adrenal disease, and all of them should have an Israelellin implant in for life. In my, that's a whole other lecture.
Do your CBC, your chemistries, your urinalysis, your radiographs, and for me, the abdominal ultrasound, and you may find a whole bunch of other things when you start looking at the ultrasounds. That's my diagnostic go to. So the imaging, large nodules may be seen with, with, ultrasound.
Sometimes there's evidence of gastritis, gastroenteritis, gallstones, and changes in the liver. If a ferret is a good candidate for surgery and you have found a nodule that you're, you know, is really obvious, then surgery probably to remove any neoplastic islet cell masses is a good idea. However, you gotta remember that not all of them are nice visual nodules.
Some of this tissue can be very diffuse throughout the pancreas, and you can't tell. The nice, the nice ideal nodules kind of peel out, unless they are adherent to adjacent organs like the duodenum. And there's invagination into the, the gut wall, that's a problem.
Do look at the neovascularization and you can see that with Doppler and ultrasound and then metastasis and Metastasis through the, the, pancreas, but also up the bile duct. It can, they can spread into the liver, and it isn't usually just that nice simple peel out a nodule and you're cured. Just doesn't work like that, .
A lot of people, their suggestion is to remove part of the pancreas because of those diffuse changes, but you can't tell if it's already metastasized in the liver with that, and then you can set up some problems with creating diabetes, which I have seen. And creating exocrine pancreas insufficiency. That's pretty drastic to be removing part of the pancreas, but if you can feel, you know, tonnes of little nodules, maybe that's what you're gonna have to do, but you're gonna have to realise that the side effects are diabetes and exocrine pancreas insufficiency.
IV fluids during post-surgery should contain glucose. There may be an, a rebound insulin surge after all the pancreatic and the surgical manipulation, so you're gonna need to monitor it for several days post-op. And there again is, is kind of this problem keeping the, the ferret hospitalised for a few more days.
That in-house glucometer issue, comes into play. We do use some dexamethasone and fluids post-op because some of these guys just crash on you, and some of them don't. Some of them do just really great.
So you just, you know, you can't really tell, but I can tell you that a lot of times what you'll see is just the pancreas and it's nice little C-shaped. Form and you can't really find those nodules. It may feel thickened, it may look a little bit hyperemic, but what do you do with that?
Well, You remove part of it and hope, or do you find a nodule and another nodule that has invaginated into the duodenal wall, that becomes problematic. Are you gonna resect the duodenum? No, because where the pancreas frequently where the duct opens is right opposite of the, bile duct, and this happened to be right across from the bile duct.
And so, you, you know, surgically it can cause kind of a problem. Ultrasound again can help you sort that out before you go to surgery, so could CT, so do you wanna think about chemotherapy? Well, years and years and years ago, we tried Doxorubicin, which is an IV treatment, and, it did help slow the progression on a number of them.
This is a picture showing a nodule and with the, with it, but also with, some neovascularization. The doxorubicin did eliminate the symptoms for months and a lot of ferrets. However, it had serious cardiotoxic effects and when closely monitored with ECG and echocardiography, don't use if there's concurrent cardiac disease, and there is the big bugaboo because most of these are older ferrets with some degree of cardiac disease before you start.
That is kind of an option, especially if you have a younger ferret, and, maybe you did surgery and removed some of the pancreas, some of the nodules, and you wanna do a little follow-up, that might be an option, but just remember you gotta closely monitor the heart while you're doing this. You need to recognise nausea and pain if they do have, islet cell endocrinopathy. You know, people with pancreas problems say it hurts, so, they also say if you have hypoglycemic episodes, you have a heck of a headache.
So I kind of cover for all that. Pepcid, famotidine, or omeprazole, yep, Neopetin has helped, seems to have helped with gut pain at that dosage of 1 mg per kg. Q24, buprenorphine, the long-acting, 72 hour brand Ithaca, one shot and it really helps for, for 72 hours without really sedation or anything.
And then gabapentin, we also cover with that because remember you've got the vagus nerve stimulated with all of this too, and it's got pain and gabapentin can help, and then you make sure the ferret eats every 4 to 6 hours. You even can teach the owners how to give fluids as part of it, and you get the owner involved in the treatment because chances are even if you took a nodule out, it's gonna have more. So, another medical therapy, is diazoxide, which in my experience does work depending on the formulation.
It seems to need to be higher than the published doses which I got started years and years ago, but depending on how it is compounded really affects how well it is absorbed. So I can tell you that, that the compounder that we have used that and It seems to be pretty bioavailable, and palatable. We've gone up to 30 megs per kidQ 12 hours for, pretty good control, but it, it really depends and then.
You can use some people do use dexamethasone orally Q 12 hours. But some reach for the prednisone right away. And remember this, 2 mgs per gig is kind of the lymphoma dose, so, you know, think about that.
Start low, realise all the side effects that prednisone, you can add it. If diazoxide up at a really high level doesn't seem to be working, you can add it to the diaoxide and you can increase it till you get effects. But the prednisone side effects may be worse than actually the periodic low blood glucose.
So you definitely are gonna create fatty liver. Some iatrogenic Cushing's disease does happen. GI bleeding is the big problem that we have with prednisone along with that fatty liver.
Some ferrets get hyperactive, some of them get hypertension, back to that already. They may have some cardiac disease. They will get some alopecia.
Now, is it adrenal or is it due to the prednisone? That is the question. It is definitely contraindicated with cardiomyopathy, with renal disease, and any pre-existing liver disease, which we all know a lot of older ferrets already have those things.
So just think about that before you reach from prednisone. You got to monitor, and again, CBC chems imaging, faecal occult blood, yes, watch for that because GI bleeding is so common. Cytology of the faeces can tell you if you're getting blood through there, and monitor the blood pressure and the urinalysis with specific gravity.
You've got to watch for those things in older ferrets. Along with anything else you decide to do, I've been using Apple Cas now for 20 years since I worked with the person of the veterinarian who started developing it. We use the large dog size.
It's the cheapest way to buy it. They're capsules you can get it on Amazon. It's a nutraceutical that contains, Several extracts from green tea is one of them that helps to inhibit neovascularization to some level.
Don't know it exactly. It's totally anecdotal, but I use about a half capsule per day for ferret mixed into their food, . It can't hurt and I really do think it helps on these solid tumours.
It, it doesn't work on lymphoma and leukemias, but it does on solid tumours and remember a lot of these may already be carcinomas, you don't know. So remember that. Blood glucose under 90 may not mean much.
It can be unknown what glucometer was used, and again, and we see a lot of these that you that, that they'll come into a clinic, they'll have that, and they put them on prednisone. In fact, the ferret, it's not resolved, it gets worse. That's what I hear most of the time.
Just don't reach for that pred first thing without working up the ferret. Cardiac insufficiency is probably The largest cause for collapsing ferrets, they all seem to develop some level of cardiomyopathy by the time they're 4 or 5 years old. It's usually dilated, but I've seen hypertrophic and I've seen restrictive, which is kind.
Of a combination of the two. Mostly it's dilated, which is back to taurine, maybe, who knows, but it may just be that this very fast metabolism isn't designed to live hew long time, you know, by 5. They're geriatric, so there you go.
Cardiomegaly, yes, on radiographs, they may seem like the heart is enlarged, but an enlarged heart on a spinal score or just because it looks too big, or you can get your hand all the way around it and it's way too big. Does that tell you if it's dilated, hypertrophic, or restrictive? No, it just tells you that the heart is enlarged.
They do get hypotension and poor perfusion, and that can certainly cause collapsing. Pulmonary edoema, yeah, we do see that with left-sided and we do see ascites. We do see fluid buildup with right-sided.
Or congestive heart failure and you get the combination of all of this. Arrhythmias are very common. Grade 2 or 3 heart block is seen very commonly.
Atrial fibrillation, I'm picking up more and more frequently. I'm not sure why. Grade 1 heart block, yeah, that can just be an irritable ferret, scared ferret.
On your exam, I'm not too sure how to interpret always a, a first-degree heart block that you get in the office when you're doing stuff, but certainly just listening to the heart, you can't tell if it's heart block or afib or anything on the arrhythmias. You can just tell it's an irregular beat. So.
I'm not gonna turn you into a cardiologist cause I'm not one, but you can sure do a whole lot to determine if the ferret has heart disease. Weakness, exercise intolerance, and collapse, it's kind of like the number one thing that you will see. Arrhythmia, bradycardia, or tachycardia, yeah, you can pick up all of those things.
Do you, they have murmurs? Well, not as frequently as dogs or cats. The valve regurgitation and mitral valve disease can be confirmed on an audio Doppler, but just regular auscultation, they just don't have as many heart murmurs in my experience as, other animals.
Do as a way to tell if they've got cardiac disease. Even if they have really bad teeth, they don't seem to get that vegetated mitral valve level that like a dog will, and so just not having a murmur doesn't tell you that they don't have a heart disease. Poor profusion, and I.
You do the femoral pulses, but I also look at their feet and how warm their feet are. Look at the pads. Look at if there's hair over the knuckles.
Cool paws and loss of hair over the knuckles. For some reason, this is kind of a tip off the ferret's got heart disease. I don't exactly know why it is, but it has come true so many times.
A chest that doesn't compress. Remember, these guys are designed to compress both ventral dorsal and lateral lateral, and if the chest doesn't compress much cause that heart's enlarged, yeah, there's a problem there. Dyspnea, yeah, they'll have rapid breathing, but ferrets with heart disease, again, in my experience, coughing is not the thing that you're gonna get like you do in a dog with heart disease.
The ferrets just aren't coughing that much, mainly because I think. When they start to get in trouble, they just go flat ferret and wait it out, and they don't get all excited and cough, but you can palpate the size of that heart. And again, ferrets over 4 years of age and they're collapsing and have some exercise intolerance, boy, I'm jumping on the cardiac.
But a cardiac workup is more than just plain auscultation. I use, an electronic stethoscope where I can record the audio, which is really helpful and it's really great to be able to play back and for the owner to hear. I use a regular audio Doppler, which you can listen to each heart valve and each heart sound and really get, you can move it all around the heart in the ferret.
I do a blood pressure off the tail with a small cuff and an audio Doppler. It's very easy to do, ECG and then imaging. And imaging takes radiographs, yeah, for your general size, but the echocardiogram is like my go to.
But I don't just do the heart. I have a systematic way of starting in at the bladder and the abdomen, and I do the entire ferret because there's a lot of things that will show you. Additional things going on with the cardiovascular system.
You look at vascularization. You look to see if there's, the renal vessels have a pulse. Look at the caudal vena cava as it goes through the diaphragm and how well it collapses.
Look at the portal veins and all the liver vessels. Is there presence of ascites? Is there a presence of pulmonary fusion, or ultrasound of the lungs themselves, you can tell whether there is pulmonary edoema or not.
And it, it really will help you out. Don't just do the heart, do the rest of the ferret. Obviously, a CT scan of the abdomen and thoracic will really help too, but a lot of us don't have those readily available.
Start with this stuff that is a little more affordable and then move on to this if you're seeing some things that just are not making sense to you whatsoever. ECG. Whatever unit you use, and most of the small animal units now will do over 250 beats a minute, but there's still a lot of them out there that won't.
A lot of them have a traumatic clips, but now I use a system on the VCheck that has these loops. Oh, that they're so wonderful. You just slip these loops around the legs, use a little electrode contract gel, and the ferret just sits there.
So do hamsters, so do birds. I mean, the stuff, the little loops are great, . It's best to run it with the ferret relaxed, but they can be scruffed and restrained if you have to, if they're really wiggly.
Midazolam doesn't seem to interfere with the arrhythmias for the ECGs, at least in my experience, and sometimes it will help you to get a better, reading on everything. And then you download to the computer for the analysis, and then you can take all of your measurements and you can do everything. You know, measure your, your QRS, look at your P waves, look at everything.
You don't have to do it necessarily with the ferret right there. You may take your traces, record them, and then go back and look at them, because let's face it, ferrets have an attention span of a minute and a half, and about that long is all you can get them to hold still for your trace. We do see a lot of.
Particular escape traces, we do see that atria, you know, with one rhythm and the ventricles another, again, that first-degree heart block is very common, but it has few clinical signs associated with it. But when they get on the 2nd and 3rd degree or the atrial fib, then we need to think treatment, and complete heart block, which I have seen and atrial fib as well require a pacemaker. The pacemakers now, we can get them that will go over 180 beats per minute, at least over 160.
I do know that Oregon State University has done them, and they've worked really well with a really good outcome. Certainly if the ferret is younger, that is an option for you. A lot of owners will go for it.
We all know that with ferrets, you are very attached to them. There are medical treatments for heart block that were, you know, Doctor, Bob Wagner came up with a good, article on it back in 2009, and he looked at some different drugs that are, Said to work for heart block, but they didn't work in the ferret. We've had a lot of 1st degrees that are regular 1st degrees.
I mean, they're throwing them all the time, just resolved with that cardiac formula which I'll talk about and again, 2nd and 3rd degrees may resolve with terbutyline in my experience, and we haven't had to go on to a pacemaker, but, it just depends. That terbutyline, we've gone up to 5 mgs per kg every 8 to 12 hours, and it has worked and then sometimes you can, slowly decrease that dosage and it may stay fine, but you gotta look at the underlying cardiomyopathy because you may still be dealing with dilated. Hypertrophic or restricted even with heart blocks.
So, we take a look. Again, dilated is the most common. Pimobendin is the heavy duty drug, but enalapril or benazepril are also used sometimes to start and then we add pimobendin.
If the ferret is obviously got ascites and pulmonary edoema and is having congestive heart failure, you're definitely gonna start putting pimobendin on right away. But I use a lot of enalapril or benazepril, as the ferret shelter calls it, bananapril, to get the owners to take it, but. The now I'm gonna call it bananapril.
Either one of those, depending if, if you've got an owner that prefers to give twice a day medications and you think that'll be a better combo, then use benazepril. I think benazepril has less side effects, but enalapril works fine and it's a once a day treatment. And I, it, if I was giving a geriatric medicine course, I would talk a lot more about all the other things that enalapril and benazepril do, but they are mainstays.
You may need to use furosemide, hopefully not long term, but initially. And then I use my nutraceutical, which has these very cardiac specific ingredients, the L-carnitine, tarine, CoQ10, vitamin E, and I use an omega 369. I use that omega, which we seem to feel that ferrets can use the, plant-based omegas.
We know that cats and mice can't. But ferrets seem to do fine. If you don't want to use V Omega, which I, I really like, it's very stable.
You can keep it frozen, and, we keep it frozen until we're going to use it, and then we mix it up in one, ounce little bottle, so it comes in, it's pretty handy. Sometimes we use Hawthorne 4 400 milligrammes added to that, . You can use the other favourite omega oil if you want to use it that ferrets like is a salmon oil.
Trader Joe's is a favourite. Some people use sardine oil, but oh boy, they really smell like sardines afterwards. And so, that's not my favourite, but ferrets do like salmon oil, and it does work too.
Can ferrets have heart attacks? Absolutely. And I've had ferrets presented that are having a heart attack and they're having an ischemic episode and they're dropping and they're in severe bradycardia plus or minus the arrhythmias, and they have this glazed look and they're irregular breathing.
They're having a heart attack. Some of them may be scrambling around and they're uncomfortable. They're paddling, and they're intermittently frantic, and we're, you know, it's all hands on deck getting the IV in, getting the ECG hooked up.
And you can do CPR, cardiac arrest. There are really sensitive to epinephrine, so hold off on that if you can. Heat, oxygen, get that IV going, get the fluids, you can do subcu while you're doing it, and then get that dobutamine in very slow IV and it'll increase the heart rate and stabilise the rhythm while you get the catheter in and you get everything going.
And then you may need to keep the ferret on a continuous rate infusion for 24 to 72 hours on dobutamine and slowly wean it off. And I will tell you at necropsy, you find those ischemic, they, they have white streaks. It's pretty definitive.
Now, ferrets also have been linked to an L-carnitine metabolism abnormality. That is linked to skeletal muscle weakness, and I really think this happens fairly frequently, you know, you get the paxial muscles kind of wasting. You get just kind of poor muscle mass all over.
I mean, they bulk up for the winter, but when they slim down for the summer. Their muscles are just really not so great, but we don't have a good way of diagnosing it other than they have some paresis and collapse and it's in older ferrets, and we start supplementing them with L-carnitine and gosh, they get better and the, and the muscle mass starts building, . They don't, .
They don't show any, any definite things with L-carnitine, so it's kind of anecdotal, and I don't know how you would diagnose it. Anyhow, Another big differential is just pain, and it can be spinal, it can be osteoarthritis, it can be neoplasia anywhere. GI, especially spleen, splenomegaly, big spleens can definitely feel uncomfortable.
Chordomas can hurt, gallstones, oh yes, urolithiasis. I mean, the list goes on and on and on of causes of pain. So don't rule that out.
It'll cause those same symptoms that you think that have to do with pilot cell disease. OK, so I'm gonna present some cases and we'll just, you know, just talk briefly about these just kind of to give you an idea of some of these things and how I kinda look at them and work them. Up or don't work them up, six year old neutered male ferret got over a year ago from a rescue, yay, adopted from a rescue.
It's on a good diet, gets lots of attention, and it started having episodes of collapse, exercise intolerance, lethargy, and intermittent inhapotence, and it was taken to a local vet. Using an in-house glucometer, it was 78 milligrammes per deciliter. Yay, that was pretty good.
The ferret hadn't eaten for over 6 hours, but hey, 78's pretty good. However, OK. There was no heart murmur, but again, that's not really high on my list of ways to diagnose cardiac disease in a ferret.
The radiograph showed mild heart enlargement. OK, mild splenomegaly. Yeah, OK, it's an older ferret.
That's not too worrisome. CBC's chems had a mild anaemia. Mm, OK.
Slight liver enzyme elevations, but nothing too bizarre. On ultrasound, it had kidney cysts. It had confirmed splenomegaly, and there was no free fluid.
There was no ascites. So the ferret was prescribed in America, which are syllabins, and I'll just throw this out there real quick. In humans and even some others, excessive syllivins can lower blood glucose.
So always think about that when you put a ferret on milk thistle, which are the syllabins. And then prednisone as a diagnosis was hypoglycemia and insulinoma and hmm, the owner was a really experienced ferret owner, I mean, really experienced and didn't think 78 was a, a very low glucose since it had been at least 6 hours since it ate. So she started prednisone for one day and the ferret got markedly worse and stopped the medication because the ferret just collapsed.
So what would you do next? You're all thinking answers. I'm sure ultrasound, yes, of course, ultrasound, ultrasound, yay, so I happened to be passing her way en route to a consulting job and she contacted me cause we've been long time ferret friends.
And so I went to visit the old ferret, and the first thing I did when I just was, I set my machine on just to kind of make sure that all my greys are, you know, my focal distance is right. And I noticed this great big vessel through the liver, and I thought, hmm, OK. So, first thing she said, he, he kinda needs to urinate a lot and, and he kinda, sometimes he whines when he pees.
And I'm like, OK, well, we'll check the bladder and make sure he doesn't have prostate enlargement and he doesn't have any stones, which he didn't, but he had this big spleen pushing right on the bladder. So that probably was a cause for some of that problem she was seeing. OK, so scanning a little bit more, it was like, oh yeah, we definitely have some cysts in that old spleen.
OK, well, we can deal with that. And then we also have these renal cysts, which In itself, renal cysts and ferrets are kind of incidental unless they get so huge. Ferrets adrenal gland was also enlarged, but hey, he's 6 years old.
He has a deser and implant in, so that wasn't too concerning, and then I went up to the heart. And he's dilated. His left atrium is big, but what I really saw was this aortic outflow.
This should be parallel lines, and it almost totally collapses. This is aortic, outflow stenosis and could explain almost all of his collapsing symptoms just then. He's just not getting blood, so.
You can see that it just, the aortic outflow is just not a parallel. It, it, it contracts. So that's kind of an, an anomaly.
Normally, don't see that every day. There were cysts in the spleen, yeah, OK, congested liver, yeah, OK. Left adrenal enlargement, OK.
Splenomega pushing on the bladder. The, prostate looked fine. That wasn't causing the problem.
An incidental renal cyst, so we started enalapril with famotidine cause again, I insist that most critters who have all this stuff congesting probably have some, . Excess stomach acid and upset stomach periodically cause we know that he was already on mopetent for appetite and gut pain, which was great. And so the appetite and the activity have way improved, and so they did a follow-up timed meal with the glucose and it was 80 at 4 hours, which is considered within normal limits.
So basically, this ferret has a cardiac problem and he's doing fine now, except that he, he has some chronic diarrhoea issues which we found he has Clostridium perfringens, but hey, that's another story. This is a 5 year old neutered male ferret, presented because the prednisone wasn't working. In fact, the owner reported that he was collapsing more since he was on prednisone, and we did a blood glucose in the clinic using the, alpha-trac 2, and it was 90 after 3 hours, so it was like, yeah, I don't think low blood glucose is the reason for this, but he was on pred, so maybe it was masking it.
I don't know at this point. But he had a real noted arrhythmia on just auscultation and running lead two, you can see that, you know, we're, we're throwing ventricular escape beats here. We have a P wave and it's not catching up.
We've got some kind of a heart block going, and then we have these episodes of the tachycardia. So there's, you know, you can figure right there, you're going, hmm, OK, that's a little interesting. You can run all this, you can do your actual measurements.
There's premature contractions, overriding some missing ones, and the RR intervals vary, which, you know, our, our intervals are not supposed to vary. They're supposed to stay. You know, pretty regular and this ferret definitely doesn't, so we're, we're kind of looking at, hm, OK, so what would you do next with this guy?
You do ultrasound, of course you would. This is an older machine, so I, I can, I mean, the newer machines, this stuff looks way better than it did on our older ones, but hey, we had years ago, this is what we had. And what you watch when you watch this heart, what strikes you?
OK, this is all working at a different speed than, than this, right? Your, your left atrium is like, you know, a round ball. You can see the right heart, which you shouldn't, so you can figure this is pretty dilated.
But notice that wonderful aortic outflow in this guy. It's just nice and straight. And you look here in this very dilated left atrium, going on, but the heart is not.
Contracting and beating. You know, the atriums. Are going and not necessarily the ventricles, so.
We had dilated cardiomyopathy, so what did we do? We cleaned his teeth, which we thought would help. we did Pimobendon and terbutyline, put him on the cardiac formula, weaned off the prednis prednisone over a couple of weeks.
Ferret stabilised, stayed on Pepcid and the heart meds, and I believe we were able to take this ferret off the terbutyline and it just stayed on Pimabbend and cardiac, and Pepcid did fine. Six year old neutered male ferret collapsing frequently, hypersalivation, pawing at the mouse, mouth, which is just classic for a true hypoglycemic episode, but it was put on a fairly high dose of prednisone, and the owner reported it didn't do anything. OK.
So this is another one where you started just doing a little bit of cardiac work, but, you know, just kind of normal. Put your, put your hand on the heart and you find out that, you know, the atrium's going at one beat and the ventricles are going fairly slow. And you know, here is your atrium overriding there, overriding, overriding, overriding.
There's a venture beat, here's where it overrides again, you know, and you just look at that and you go, yeah, it's heart block. This is a mess. OK, so you look at it.
And Yeah, it's dilated. Nice straight aortic outflow though. Dilateated actually it may be a little of the restrictive in here, but if you watch this heart.
The Atria, and I'm sorry it moves, but sometimes ferrets move. The atrium, this part of the heart is beating at a totally different rhythm than that part of the heart. And you don't have to be a cardiologist to diagnose heart disease when you see that.
So, what would you do next? This sounds like a broken record, doesn't it? Famotidine, pima beendon, herbutyline, weaned off the prednisone, went on the nutraceutical formula, rechecked it in 30 days.
Make sure the ferret is eating regularly and staying hydrated. And guess what, the ferret did just fine. OK.
Like I said, I'm seeing more and more afib, and I don't know if I'm just getting better at identifying it or if we're actually seeing more of it. And if we are, I don't. Know why, really.
This is very dilated. You can, this is the left, atrium. There's the mitral valve.
Here's your nice straight aortic outflow. This is the left ventricle, this is the right atrium, with the way this is positioned, and you can see this, this mitral valve is, you know, working pretty good, but it's way over here and it should be kind of over here. But the heart is beating at You can see this is quivering at one movement and this is quivering at another, and in this view, it looks like there's a hole here, but there isn't.
I don't see, . Atrial, Fistulas, I don't really see very many, you know, of the changes that they usually associate with afib in humans, but I don't know, maybe I just need to look more on them. We might find them.
But I don't know. Here's another one. This is a different ferret.
Fairly recently, again, I think you can see that the mitral valve, the mitral the left atrium is rather enlarged, . But again, we have that nice aortic outflow, but, but look at this. I mean, the, the heart is beating at different rhythms and so the ferret collapses, you know, hey, I collapsed too if that was what was happening.
So we got another 15 year old spayed female, collapsing. It was referred for atrial tachycardia without an ECG. Diagnosed with congestive heart failure and insulinoma, and it was prescribed prednisone, which is contraindicated with congestive heart failure.
Owner discontinued Pred after only a few days because the hyperactivity seemed to be just causing the ferret a lot of problems. Blood glucose was 120 in the office. That was again using a, that was actually using, I believe in a Bis system, 4 hours after a meal.
So obviously, that's not a problem. That's before the pred. We took a look at this.
Anytime you get this huge amplification of the QRS, you gotta think, cardiomegaly and probably dilated, ventricles. The rate was 173 for your ventricular beats, which was considered. Within normal.
So, of course, what do you do next? You get out the ultrasound and there you see the atria and the ventricles are not working together. They're not beating at the same rate.
So, We did. We got the atrium weren't contracting well. You got dilation of the ventricles, you're in different rhythms, and lo and behold, you do that kind of formula, and guess what?
They do much better. So our differentials for collapsing ferrets number one, do full evaluations. Islet cell endocrinopathy.
You really do need to do a controlled feeding blood draw to confirm and assess. Look for the trends. Don't start prednisone.
Cover with famotidine. Watch for side effects. Start with, I would say start with diazoxide, then add in the corticosteroid if you really need to get, get things controlled, but I don't start with the prednisone.
But treat the entire ferret cause again, these are usually older ferrets, and being a ferret, there's more than one thing going wrong. Remember they all got adrenal disease, so they all should have an implant in. Look at cardiac disease, consider that L-carnitine metabolism disruption in these older ferrets with this kind of poor muscles, and then pain anywhere.
Pain will do it. So, I'd like to acknowledge all my vendors and people that I've worked with in the ferret rescue and, webinar vet for inviting me. And with that, I will invite you to join the exotic DVM if you're not already on the forum.
It's free. And also, if you are not already a member of the Exotic Association of Exotic Mammal Veterinarians, I would invite you to join that. We try to keep up with the latest in ferret medicine, and that's a view from my desk of Puget Sound, the Olympic Mountains, and an October sunset.
So, That's why I've never moved, so if