Well, hello everybody. Hopefully, you're not taking a break from the gorgeous sun to come inside and listen to this. I am, but I'd rather be with you guys.
Hopefully you can all remember back to the first part of this, two lecture series where I talked about the causes of feline pneumonia. And, how to diagnose it. Because in this one, we're going to be talking about, treatment.
And I thought I'd do it completely around cases. So I always think that's a good way of doing it. Apologies for the strange noise behind me.
That is my little 2 year old cat who's finally woken up and is eating some biscuits. She never eats more than very many, so she won't be there for long. OK, Rosie, this is Rosie.
She's a bit Rotund, as you can see, an eight year old, female neutered Burmese when I met her first, 3-year history of episodic bouts of coughing and some really severe dyspneic, episodes. She was in a cattery a week ago, which is a significant piece of history. Always look out for that sort of thing as a piece of history.
And now she's got severe dyspnea and coughing. Body condition score, I'm being very generous if I say 8 out of 9, to be honest, she's more like 10 out of 9. But you know, she's a Burmese, loves her food, and she's had lots of steroids in the past.
Yeah, that's a bad combination, not this lecture, but I'm hoping some of you will be thinking Burmese steroids and obesity. Yeah, she's a high risk for diabetes. So we really want to get to grips with this little cat so she can stop having systemic steroids.
Heart rate was 180, nothing to here there, doesn't rule out the heart as the cause, but she's got a lot of coughing. And really heart disease is, is not a cause of, of coughing in the cat. It's not a major cause at all.
But her respiratory rate is 48 beats of breaths per minute, which is kind of high, and she's got marked expiratory dyspnea. OK, so she's going. Really marked output.
And then when you listen to it with the stethoscope, you've got wheezes and crackles, but not good. Do you need more information at the moment? She's fully vaccinated, and she is not up to date with her worming, which might be important because one worm is something to consider, and she does go outside, so that is kind of important, or could be.
So most, most likely differentials for Rosie, what would you say? Do you think chronic bronchopulmonary disease? Do you think she's having another one of her asthma attacks, which is what the underlying concept is that's going on with her?
What about bacterial problems? Maybe she's picked something up in the cattery or more likely, her own bacteria or, viruses have come to a recrudesced because of the stress of being in a cattery. What about lung worm?
OK, she is not wormed and she does go outside. She's not a great eater of of worms and things of slugs and snails, but she's been known to play with the odd slug. I know why.
What about toxoplasmosis? It might be not likely, but she did hunt in her youth, so to be considered. And what about edoema?
Would be cardiac, not that anything points in that direction. If you're thinking, where you're going, what did I do? Well, get some bloods to start with, mostly, to be honest, because I wanted to make sure she wasn't becoming, diabetic.
Nothing much on her bloods. A few neutrophils extra. Ultrasound of the chest is obviously the next way to go.
In a case like this, respiratory cases, you really don't want to go to, X-ray until you get them out of the acute crisis because the risk of them dying when you put them, into lateral, it is really quite high. So chest ultrasound, no pleural fluid, so that rules that out, which is good. Left lung looks kind of consolidated, but there was so much fat, it was really hard to interpret.
She's just looking down the no, me fat, never. These are her radiographs. I know.
What a giggle. It's actually there's quite a small cat inside massive adiposity. Look at this, just appalling, and her heart looks rather round, but that is actually, whoopsy, that is pericardial fat.
So she's got a patchy broncho interstitial pattern and too much fun. We did a both, sins, neutrophils, macrophages. And PCR was positive for mycoplasma gai.
A reasonably high, amount. So, yeah, she's definitely got an infection. So we need to treat that infection.
What do we? So have a think. What would you do?
Would you give her azithromycin? That's very good at getting into lung macrophages, and it's got a liquid as well as a tablet version. What about doxycycline?
What about a refloxacin? What about no antibiotics, just controlled her asthma better. Well, the guidelines tell us for respiratory cases, we really need to be treating doxycycline first, upper and lower, acute acronic dog and cat.
So we should be going doxy. But I didn't do that until we were able to get this doxycycline monohydrate, paste from, bovalabs, simply because a reasonable course of doxycycline. The standard ones, so Reexam, generic, if you get the generic, that's got a pH of 2 to 3, pH, whereas this one is, is near and neutral.
So I really don't ever want to cause, esophageal inflammation or stricture, and obviously, I'm not gonna touch any refluxes in in a cat because of the risk of a very real risk of, retinal damage. Resulting in acute blindness. I wanted to say a little bit about the mycoplasmas in respiratory disease because I think this is an area that's moving forward quite quickly.
You've got mycoplasmaphilus, which is the most prevalent. Thengatii, which Rosy's got, then eliminutum, that's different from hemimutum and hemiellis, which are the blood hemoplasmas. And you've got my Jenny as well.
And what you find is, yes, they are present in commensal in maybe 20% of cats. But what you find is that you find a heavier burden. And in places where you don't expect it, when you've got disease.
So if we're talking about microphilis, mycoplasma philus, this is where the data was here, upperspiric tract disease, prevalent presence of this in about 50%, conjunctivitis and gingivo stomatitis, which is quite interesting, about 40%, as I said, healthy 20%. The lower respiratory tract should be, sterile for standard bacteria, including mycoplasmas. And we find them in, lower respiratory tract disease in 15 to 20% of cases.
PCR is obviously far more sensitive than culture. And treatment doxycycline is your treatment choice, but if you have a situation where doxycycline can't be used or doxycycline has failed, then aquinolone would be the next one to go. But you can now see why azithromycin is one I reach for because it is good for this as well.
Remember, the beta lactams are gonna be no good at all, including obviously your convenient. Nebulized gentamicin is a way to go with resistant cases and you do need a month of treatment. Yeah, and that's just a shelter study that showed effervescent is of no use at all.
And then this is data from the VEPathth group, and I asked them to to add in Mycoplasma Gattii a few years ago. And so we've got data, so negative and positive. These are upper and lower respiratory cases.
So, elus is found in 50% of cases. GATI in about 11% and dual positive is in about 10%. So it is worth knowing because with a tinkling feeling that GATI might be a little bit more tricky to to treat.
And, strongylostrusis, so, lung worm, I think in about 3.5%, they added that the, the profile when I asked them to a few years ago. So all of you who are using IEX or any of the other respiratory profiles, you are not going to get mycoplasma Atii or lustroullus stosis.
So I do recommend you actually use the PETPath group because it gives you this much more data. No, I do not get any kind of cut at all. So how are you going to manage Little Rosie?
Do you think environmental control, weight loss, and antibiotics is a good way forward? What about environmental control inhaled bron steroids and bronchodilate. What do you think you need to start with systemic corticosteroids and antibiotics first and then move on to, environmental, etc.
Yeah, I'm with you. I'm gonna go for number 4. I want all of the above, really.
So environmental control first. This is really, really important. I have got some mild cases of feline asthma type cases that can be completely controlled with environmental management on its own.
So this means, a non-dusty cat litter, preferably, dust-free as you can get it, no lid because the lid allows the dust to gather up, no open fires, aerosols, potpourris, particularly there's ones that plug in the wall and puff, revolting things. washing the bed linen regularly anywhere they sleep to get out, house dust mites and house dust mite poke. So that really can make a huge difference.
Where we've got, too much adiposity, as in this little cat, then gentle weight loss is needed. These drugs aren't general ones you're gonna be using in this case. What about inhaled drugs?
Well, in human medicine, obviously we wouldn't go anywhere without them. So, certainly for my cases, now mine are obviously all referred cases, this is where I go every time because It's, it's so much more effective, you're getting a far, far more concentrated dose of the drug into the cat's lungs, you get it where you want it and you do not get the systemic side effects. Not the cheapest, and so if your practise can rent out an inhaler, you know, an inhaler chamber as a starting point, that can be a good way of getting your owners to consider trying this.
You want a bronchodilator in All cases as far as I'm concerned, and then you're gonna need, gonna need corticosteroid and fluticasone is one that's removed on first path. So it doesn't cause systemic effects. You introduce the the mask and chamber.
I'll show you in a second, slowly at home. And then once they're accepting it, just being put on their nose for 5 seconds or so, then you can add the drug to it. It ideally, you do want to use the Araca.
It does what it says on the tin. But if you're not gonna use it, then the only other chamber to consider is the baby haler. Anything else that has got a valve and cat's lungs are not big enough to push the valve open.
By way of getting owners to introduce it, there's a really good advice on the international cat care. If you look up international cat care and feline asthma, you'll get straight to it. So I've seen all sorts of weird things used world over, but Araca is the way to go.
Initially, introduced the mask with a little bit of a favoured food just to get them putting their nose into it and being happy to push their nose into it. Once they're happy with that, then obviously the food they need to have eaten. And then you can put the the mask on their nose.
Initially they'll push it off, just persevere with this, the owner to do it rather. Then you have the chamber to it as well. It looks a bit odd to the cat, so they need to have that done a few times until they're happy with that.
Then add the drug. Just a little bit of time, up to 2 weeks, and if a cat is the cat that will sit with the owners, then a cat is the cat that you can almost always be convinced. Mild cases in theory, you just use salbutamol.
I don't see mild cases and I guess you probably don't either. I think mostly we are going to be seeing moderate to severe. If you were using drugs the non-combination, so you've got two different inhalers, then you need to give the bronchodilators first to open the lungs before you give the steroid.
To me, that's an unnecessary faff. Use Seretide. All right?
It is albutamol, albuterol rather, which is the long acting version of salbutamol. So it acts for over 12 hours. With fluticasone at these different doses.
And it's in, when we talk about Seretide, 125, we're talking about the fluticasone dose and the 125s will work in almost every case. 1 to 2 puffs twice a day. The mask can get a little bit grubby, and the drug can build up on it, so it needs to be washed out every now and again to stop it causing irritation of the muscle.
What about if you can't get the cat to take inhale drugs? Well, you can get bronchodilators in the form of salbutamol, obviously tebuylin. If you're going to go down the the theophylline route, then you need specific names because other formulations don't seem to work for cats.
But the phototonin works just as well. You've probably got that on the shelf. You need to reduce inflammation.
Corticosteroids, if you've got you're gonna need those in some way or other, and if it won't take them inhale then. Obviously, preferably daily steroids, prednisolone, for example. But yes, I have treated occasional cats, but in the springtime, they're disappearing for days on end.
Yeah, we gave them depo steroids. Better that than they die of an asthmatic crisis while they're out hunting. Always look for secondary infections because antibiotics will reduce the inflammation.
You can use anti-erritage, ne, acetinate, I can't even say it, suprapine. It makes them fat though, so not ideal, makes them hungry. I tend to use my next go to is chlorambuil, and I've, I use a lot of that.
By way of things that in the next 5 years you might see coming through, Mropoin may work on asthma, data still to be done. Immunotherapy, potentially stem cell therapy, potentially, ask me next time I might be able to tell you more. So overall, your plan alter lifestyle first.
Sometimes that's all that's needed. Then really try with inhale. If you're doing it in steps, go bronchodilator first.
Then if you need it, add in the prednisolone. That doesn't work, use a different bronchodilator because sometimes the cat will work to one and not to another, and always monitor these cats. They're very at risk of secondary infections, which can make them suddenly, oh, cats are on my face.
That's what happens when you've got two pussy cats. Yeah, you get, secondary infections, so acute deterioration always look for the secondary infection. Other things you can consider we have got, .
You've got all the secondary drugs you can go to. But Be considering that the cat might have developed idiopathic pulmonary fibrosis when you start seeing images like this coming up and then they can get pulmonary hypertension, in which case they're gonna need so Benafil, Viagra. Owners always want prescription so they can go into the chemist and go, Viagra for the cat, please.
Bit of fun. So what happened with the Rosie Posy? Oh, I better speed up.
We did all the environmental stuff, but remember how poorly she was. We started dieting her very slowly. We introduced her to the Araca with, erratite.
1 puff twice daily. Sorry, 2 puffs twice daily initially. And doxycycline.
To be honest, within a week of being on doxycycline, she was very much better, which really showed it was, it was the the mycoplasma that was causing the problem. She had regular checkups in our CT mouse trap. I think I've got a picture of, and I know I showed you a picture of in the previous lecture.
And she did have a couple more bouts of mycoplasma pneumonia, particularly when they put her in a cattery. Eventually I convinced them to get a a house sitter in, which was Rosie preferred that too, and she lived another 5 years. So 13 years for an asthmatic cat.
It's not cheap. Murphy's a little short case, but I want to, to show Murphy to really highlight, how bad, certain infections can be. Only 2, and he's been in a cattery until a week before the clinical sciences started.
He had 4 days of complete anorexia. Lethargy and dry cough, and now this has gone over to Disney and he's got a fever. His respiratory pattern was horrible.
This is obviously a picture of him afterwards once he was feeling better, mixed inspiratory and expiratory, so nothing happening up here. So that means we've got problems in our, trachea and primary bronchi, etc. So the asthma type pattern and then either a pneumonia or pleural disease.
Respiratory rate of 50 and paradoxical abdominal respiration. Really, really, I was very worried about him. So I can't really ask you your thoughts, but you'd be worrying, you would think I really need to do something fast.
And the fact he's been in a cattery, you're gonna be thinking infections. We did get bloods to start with, but certainly argue why that's kind of the things that happen in, in our hospital. It certainly, it wasn't, we needed other things first.
Obviously, he was already in oxygen. So the low potassium because he hasn't eaten, nothing really useful other than it showed his vasculitis. Soon as he tried to do anything with his veins, they were just bruising everywhere.
This is a very sick cat. He got vasculitis and a fever. That is worrying.
This is the mouse trap CT on him, which it's not, it's a real CT. Yes, it was a real CT. You can see he's got a very patchy, pneumonia, doesn't look hideous for how severely affected he is, but then all of these lungs are looking pretty rubbish.
So, increased lymph nodes as well, higher lymph nodes. So, you know, not good. So we've got a patchy pneumonia.
We did send off, faecal parasitology, . Just it was there and it was, yeah, run it. I wasn't worried, came back negative, woohoo.
More importantly, we initially, we just did tonsular swabs. I did these first because I didn't think he was going to be stable enough to do the anaesthesia and alveola lavage, but in fact, he was actually much better when he was anaesthetized. So maybe.
Maybe what I should have been giving him was a bit of gabapentin or something just to settle him. He looked like a really friendly cat, but I think he was very anxious about his breathing, which was making his breathing worse. So that is something to factor in.
You do not want to heavily sedate a cat with breathing problems because that can start making them very hypoxic. But just taking the edge off can help these guys. So I started with the tonsilar swab because I thought that's all I would get.
And what we've got is mycoplasma files, the more common one. And this is copy threshold. I don't know why the labs insist on doing a CT, and it's inverse.
So this is a high copy number, so it means there's not that much of the bug there, whereas from his alveola Lavage, it's a low copy number, hence there's a lot of bug. I don't see why they can't just flip this and report it as, you know, moderate level. At a high level.
It seems crazy to me. But yeah, he is a mycoplasmic pussycat. His, lungs were just so friable.
They're just not pussy, but just dry. I, I went to find a, one of the pictures and, and I can drag it down. I'll try that the next time, I promise.
So we got a diagnosis. You always need some, potassium. Before his alveolar lavage, he was given tebutyin.
So, I was very worried all my cats are given tebutyin before we do alveola lavage because cats get a bronchospasm much, much quicker than in the dog. And even if a dog does get bronchospasm, you're starting with a bigger airway. Whereas croissant law is if you reduce, I don't get I never get this quite right, but it's basically for a small reduction in the diameter of a tube gives you a 4 fourfold sorry, reduction in air flow.
Important thing is small reduction in diameter, big reduction in flow, whether it's blood, whether it's the blood for blood pressure, whether it's airways, you know. It's the same thing. So really important before you do alveola lavage, give them bun.
And then he still went into spasm despite that, so more tobutyle and dexamethasone. Now, in theory, for pneumonia, severe pneumonia pending your cultural and sensitivity, we should be going Quinolone plus penicillin or er or metronidazole, pending cultural sensitivity. He actually was, we at this point we've given him, mirtazapine and he wanted to eat.
So I figured I could start straight away with azithromycin. It's a liquid. Well, there is a liquid version, because he was just coming out of a cattery, I suspected it might be mycoplasma.
So that's what I started on, and then I just kept going once we'd got the diagnosis. You could argue, maybe I should have changed to, doxycycline. But I was on azithromycin.
It's got a really good lung penetration profile. So that's where I stayed. Also, once you've done the loading dose for, daily dose anyway, for 3 to 5 days, you can then go to every other day, which makes medication that bit easier.
Within 24 hours, he was a much, much happier cat. You do need to make sure these cats have airway irritant control for home because they've got a very high risk that they're going to develop asthma. So you need to warn the owners that this is a high probability and watch out for it.
And then would you have done things differently? Probably used a different antibiotic, but have a think. What would you have done differently?
Well, we go into a really funky case. OK, this is Harvey. Oh, Harvey, Harvey and then his brother just about did my head in.
Like, while you're thinking what you might have done differently with Murphy, I'm gonna take a quick look. Mm. This is gorgeous Harvey, 12 year old, British shorthair, as you can see, British blue.
I love the way his, his owner coordinated his, his eyes with the sofa. I suspect it wasn't that, but his eyes on the sofa match beautifully, don't you think? Indoor, outdoor a little bit, not majorly, with full brother.
Now, because he was a big fluffy cat, he's not long-haired, but he was fluffy and he was a bit overweight. Nobody noticed him losing weight. Until suddenly they thought, hey, Harvey's looking skinny.
He lost 20%, 20% of his body mass in nine months. That's a terrifying amount. More than 5% requires investigation, whether it's in a week or in a year.
Adult animals, adult mammals, shouldn't be changing weight significantly unless there's significant weather changes or if you're a hibernating animal. But certainly, you know, cats and dogs, shouldn't be changing weight significantly. He's had occasional bouts of coughing, but they weren't particularly worried.
But its respiratory rate had kind of crept up there, and with the weight loss, the vet took some pictures and went there and sent them to me. So. I want you to think seriously, look at these radiographs.
What would you describe those changes are? Do you think it's broncho interstitial nodules? Do you think it's broncho alveola nodules?
Is there a difference? Is it a milly interstitial pattern? Most important, whatever it is, there's dystrophic mineralization.
So if I get my pointer, what we've got, we've definitely got millry nodular sort of pattern going on here. Away kind of associated. So actually, oh, I've written it wrong.
I should say, bronchi bronchi bronchi. No, it is bronchial. I'm having a moment.
Just ignore, just ignore me. But the important thing is, yeah, bronchi are involved, it looks like, and then we've got these little bits of. Mineral.
So this is dystrophic mineralization, so it's associated with whatever's going on. So we've got generalised milly interstitial lung pattern with dystrophic mineralization. Like causes, what do you think?
Are you gonna plump for lung worm? Metastatic mammary carcinoma? Oh, Mycobacterium bovis, so we're not talking mycoplasmas now, we're talking mycobacteria, so we're TB group in this case, or are we talking toxoplasmosis?
I wish I could have you vote. Because the answer is actually all of them. All of those things that could be lung worm, definitely could look like one lung worm.
It could be metastatic carcinoma, it could be TB, it could be toxin. So when you see this generalised millary interstitial type patterns, you've got the certain types of cancers. So the metastatic mammary is the one that I see most of presenting like this.
And I just thought it could be unlikely for lymphoma, but in theory it could. Mycoback, absolutely, definitely, particularly the TB rather than the non-tuberculous ones. Toxo, yeah, lung worm.
And then you go to the weird, say weird, very unusual, infections. So noardia could definitely look like this and potentially, rhodococcus, actually it was a nice group of papers, quite a nice group of cases recently, which showed that Rhodococcus can can look just like this. Severe asthma.
I have seen severe asthma look just like this with mineralization. Now, That all those cases I've seen haven't been worked up for mycoplasma. So I think when you see this severe asthma with this type of pattern, it's because there is mycoplasma, not mycobacteria, mycoplasma on top of asthma.
But the problem is, if you've got these as a differential, you want to investigate this case. It's potentially TB. So, you know, I wouldn't be jumping in there to do an alveola lavage until I've ruled out that it's not TB because for our sins, Britain.
Britain is the world capital of tuberculosis in dogs and cats. Oh brilliant, yep. And for my sins.
I'm apparently the global lead on it. See if you pick a small enough puddle, it can be your puddle. Thankfully, I have trained up a few people who are gonna take on my mantle cause I don't want it forever.
So yeah, we need to rule out TB. So we could do some things looking at the cat to try and get a hint of what might be happening. We had a good look at the respiratory rate.
Which too mild expiratory abdominal effort, but not particularly anything. You wouldn't look at him and go, oh, he's a respiratory case. You could look at him and go, he's a little bit anxious after the journey in.
Retinal exam was boring, so that makes toxoplasma plasma less likely, doesn't rule it out. Biochemistry, haematology, boring. Maybe ask me you might have expected to see ears in the fills in the blood.
But we have got ionised hypercalcemia. So you immediately going, ah, it's cancer, it's a mammary cancer. It could be, but TB does this thing.
So we still have TV on the table. So what we need to do is, I did, I did some more work here. I'm still thinking I'm going to rule out TB it's always in my mind, faecal parasites.
NA, so that means nothing abnormal, normal detected. So certainly lung worm. Not ruled out.
The problem is this has been going for what, 9 months? So it could have been that he had lung worm 9 months ago, and it caused loads and loads of damage and then has moved on. So the fact that the faeces are negative does not rule out lungworth.
Toxoplasma serology was negative. IGM and IgG always look for both. There is zero point for looking for combined, which some labs do.
Best lab for this is bioest up near me, up in, up, up in Edinburgh. Aptoscan, boring. OK, and we looked long and hard for any mammary carcinoma.
I know he's a boy, but it does happen, we couldn't find any. And we did a pharyngeal swab. See, I'm trying to find out what might be happening anything short of doing an alveolar lavage in this cat.
And he, he's another mycoplasma. You're going, what more mycoplasma, Daniel? You've got mycoplasma on the brain or mycoplasma on the lungs, which, to be honest, I did have, I caught mycoplasma felus from one of, actually, sorry, Gattii from one of my patients.
She was in ICU with pneumonia and pleurisy. She gave me pneumonia and pleurisy. She was one of those little Burmese that likes to head bump.
I know, I'm stupid. I shouldn't have that, but we both did fine and that's. So pharyngeal swab is high level for mycoplasmaphilis.
Does that mean that's what's happening in his lungs? No, because 20% of cats have got it in their pharynx anyway, but not normally at a high level, so I'm a bit suspicious that mycoplasma may be playing a role, but they don't cause, hypercalcemia, so. Still not sure.
If you think about hypercalcemia, first thing you want to do is repeat the, the test because you can get spurious. There you go, there's the S is spurious means false. Particularly in hemolyzed or lipemic samples.
So make sure you've run it on a non-healed, non-lipemic sample. Recheck and you can check for ionised calcium. Then you're looking at PTH PTHRP related peptide from cancers, and vitamin D metabolites.
The problem is just to get those three things they're done is gonna cost, I don't know what, 5, 600 pounds. So Let's go through the lightly, because sometimes you find the cause. So idiopathic, oh, dragon dragonspit is the acronym that I use, plenty others out there, but I like dragons.
So I is there, but ionised is now the most common cause in the Western world and was 30%, it's now much higher than that. Whereas neoplasia is reducing. And in cats, lymphoma producing calc calcium but only occurs in 2% of cases, whereas in the dog, it's about.
20% of cases. I've got that wrong. A dog it's something like 20%, it's a lot more.
Cats are cats are only 2%. Dogs might even be 60%. I'm sorry, I've blanked my doggy data.
I apologise, but yeah, lymphoma in the, in the cat really doesn't cause high calcium very often. The cancers that do it more frequently are things like squamous cell carcinoma of the mouth, so always have a good look in the mouth, and we have a good look in Harvey's mouth. But lung cancers, kidney cancers, etc.
Can all do it too. Chronic kidney disease, it causes total, high total calcium, rarely changes the ionised. Granulomas as by way of TB, yeah, the data from the US, they don't see much, well, they don't see TB, but they see granulomatous disease with some of the fungal diseases.
It's not that common. Vitamin D, intoxication, plants, so, jasmine plants. So if the cat is a house cat and eats plants, then that's a good one to, to look for because if they have got, house plants that have been munched, and particularly if they've got jasmine, then, ask the owners to move those plants out of the way and see if the cat's calcium falls.
The other one that's always a nice find. I always look at the my owner's elbows to see if they've got psoriasis. And then if they have, I ask them if they use anti-psoriasis cream.
With dogs, it tends to be a Labrador pup that comes in with acute calcium intoxication. High calcium because of vitamin D intoxication because it chews the whole tube. But with cats, the owners are putting on the cream at night and cuddling the cat.
It's getting from their arms, hands onto the cat's coat, the cat grooms their coat, and it's a slow chronic poisoning. So again, easily then dealt with. Osteolytic disease, this could obviously be a non-healing, fractures, calcium, cancers in the bone, that sort of thing.
I've already mentioned, fake ones and then P for parathyroid, . Neoplasia, and then, Addison's disease is incredibly rare in the cat. So we've got to the point we need to know, is this, could this be TB or not?
Because the other mycobacteria, we don't mind because we're not likely to get infected by them. So we really want to know, is it TB group? We might like to know if it's mycobacterium avium because with significant immune suppression, particularly AIDS, not just not HIV AIDS, like when you've got a long way down the line, they, they're at risk.
So you've got AR, that's the TB blood test. This is at Bioest, same lab that you do the, toxo test at. Serology and skin tests don't really work in cats.
Culture, yes, if you've got something to culture, fresh tissue or spit could go to Weybridge, but it could take. Mycobacteria microti, which is the second, you've got Mbovis and, and microte. They're the, TB, mycobacteria and microte is the, the old one.
It, it can take. 34 months to grow. You want to answer before then.
So, the Leeds reference lab, contact me or just look up the Leeds human, reference lab. It's the Leeds, Leeds General Hospital for humans. So they can do culture, but more importantly, they do PCR.
They can do PCR of swabs, they all fresh tissue, they used to use glass slides which were really good, got a lot of positives from those, but then I understood why they stopped wanting to take the glass slides that could have TB on it. Yeah. And Liverpool were offering a PCR.
It's been withdrawn. I don't know if it's coming back, but when it was running, it generated some, results that were quite different from the reference lab. So I think that might have been why it was withdrawn.
So this is Harvey's result. So when you run a An IGRA test, you need 2 mLs of heparin. Blood, don't spin it.
Don't let it get cold. And it's set up for culture in a negative culture system, positive culture system. So that should grow, it's, sorry, it, the lab extracts, lymphocytes and cultures the lymphocytes for 5 days.
So in culture media, and you've got a positive control and a negative control. So the positive means they've put stuff in there that should get, memory, T cells to produce interferon gamma, regardless of whatever they've met. And then we want to know have they met the TB, antigen?
Have they met Mycobacterium avium? And then have they met the virulence protein, which is on Mycobacterium bogavi. So then I can tell if this one is positive, that means it's TB.
And this one is positive, that means it's bovis. If I've got this one, it's TB, but this one's negative, then that's usually going to be my crote because my crote is not particularly virulent in people. And if B is negative but A is positive, then it's AB.
And Harvey is negative for all of them, so at least I've now ruled out the TBs and the things I might catch. We did send one off to Liverpool. This is when it was running, and we got the witness weird response, you know, not sure what it is.
You don't want to bother reading it. Basically they said there was a band, but it's not mycobacteria. It's probably one of these other ones.
So I was thinking hotococcus, nocardia, etc. I really, really, well, we really, really need a system where we can identify these, more unusual infections. I don't think they're that unusual.
I think we just don't have a system to recognise. So, oops, long lady, . Pending the results, we treated him for his mycoplasma, Pradafloxacin 4 weeks, treated him for his lung worm.
And we always say, observe closely, give it in the morning and observe closely in case there are lung worms, and they might get acutely sick, and then return for reassessment. This is him on his reassessment. His lungs are looking a whole lot cleaner, and what you can actually see he's got his tree in bud.
This means it's bronchiola disease. It doesn't indicate what, but what we've got is something is causing his bronchioles not to work. They are not clearing the infections, and we know mycoplasma can paralyse the mucociliary cascade such that anything that's inhaled just gets stuck in there.
And then you can't cough it up and it's just gonna sit in there and get concreted. So, so that reference goes to the tree but. So I worried that I was missing a rhotococcus.
I added arafampicin. He improved initially. I really thought, yeah, this is, hotococcus, but then he got one of the horrible skin reactions that that that rifampicin causes, so I had to stop the rifampicin.
At this point, he's obviously very much better other than his skin, and his calcium's normal. Oh. Would you have done that?
Probably not. It was a slightly crazy thing for me to do, but the previous lab test saying that it, it, that there was a band which could be consistent with Rocco. So, He had a two-month course of radifloxacin.
He clearly doesn't cough up all the rubbish, so he had to go onto bronchodilators, and corticosteroids to try and reduce the inflammation that was occurring. We were getting a granulomatous response to mycoplasma, which really shouldn't happen, but it showed it could, and environmental control, really important, and then monitoring. What we really found helped was nebulization and coupon, which makes sense.
So there's a number of different nebulizers available. You can get these cheap ones from Boots, we can get more expensive, more effective ones from the Breathe Easy system, which is the Araca people. And then once you've got the airway nice and moist, you put the cat on your knee and Make cups and you start at the back of the ribs and move forward.
And these pictures, yeah, this is Bailey Ellis being, looked after by Sarah Ellis's mom. Thank you for this. Harvey continued to do great, but then his brother presented identically.
Identically, 8 months later. Also loads of mycoplasma. So, what was my diagnosis?
I think they probably had some congenital inability to clear rubbish from their lungs. It could have been made a chronic mycoplasma infection and because the house wasn't particularly dusty, it didn't cause the coughing you might expect, and that ultimately caused the problem with the bronchioles, and the cats couldn't cough up the rubbish, it became mineralized, and we got that tree in bud pattern. I want to skip through the best bits of the next two because there's some highlights I want you to take home.
This is Bailey, it's a rag doll. And this is day 2. The referring vet, took a picture the day before and it just had part of the cranial part of the left lung.
Looked a bit solid and he thought it might be a foreign body and sentimental. This is the following day. So you've got 3 days in a row.
You look at the progression. Within 3 days, we've now gone with the whole, the whole right side, the whole right side has gone down. And I clipped them up because, let me go back again.
So I figured that lung is solid. I want to stick a needle in it so I can get multiple lung aspirates to send for culture. For cytology and for the respiratory PCR panel.
But when I clipped him up, this is actually his neck that I clipped up at the same time because I figured he needed an O tube. He wasn't going to eat. So this is me placing an O tube and you've got all of these circular raised patches.
These are beautiful, if you like weird pathology. These are pots. Hunter.
This is autumn time. So likely differentials where I've already told you, yes, it could be asthma and is in ahilic granuloma, but they're not quite right, are they? They are classic pox.
Virulent cholei, no, that wouldn't be quite like this. That would be more patchy and mushy. Carcinoma, yeah, metastatic carcinoma could look exactly like that, and believe it or not, cutaneous toxo or cutaneous FIP.
Could look a bit similar, but it's shouting poxo or sorry, it's shouting. Pro or cancer to me. I've seen a, a lymphoma of the skin look like this.
So your differentials, where you've got cute necrotizing pneumonia with skin lesions and we've really, discussed this all my cell absolutely could be a ma. Cowpox is the wrong name. They come from voles.
They, they're in a vole population and All over Europe and Soviet Union, all the way across to there. So most commonly see signs in autumn. Initially, it's a bite that then becomes ulcerated and they can get these secondary bacterial infections, pork.
Secondary infections, pox, it's not very circular pox, blood should be on. Poxx, but then secondary infections. There's a pot that's been clicked up.
So they usually resolve within a couple of months. But sometimes they don't. In immunosuppressed cats, then they can become systemic and they can, and these are not obvious immunosuppression.
Yes, sometimes they are FLV or FIV, but often we can't tell. You see it on their feet, on their feet, they can look a lot more like virulent calllei. That looks like virulent Calei.
Every time we've seen them go to lungs, there's been something else in the infection, either mycoplasma or herpes or orella pseudomonas. This is a ho, this is Pussycat's tummy, and this was the original pot was here and that skins died. Yeah, it was solid and this obviously I didn't win.
This is a pluck, this is the heart, and we've got pock lesions all over the plaque. Diagnosis, tighter, you haven't got time. The crusts, yeah, send them to Langford.
They'll do a PCR for you or do a fine needle aspirate of the lung or of the skin lamp and tell the lab you want them to look for pot lesions and then if they know what they're looking for, then they should be able to find them. And then, you know, quickly. And the treatment, if it's not in the lungs, they should get better on their own.
If it is severe in the lungs or you've got those horrible lesions where the whole feet are involved, then you want, high dose interferon. So interferon omega, about 11 million international units per kilo, sub-Q or IV daily for 3 days, and then we always say dead or better. Analgesia, covering antibiotics.
And Bailey actually did really well, Moxie cloud and all of the above, and he recovered anyway. And then I want to tell you very quickly, quickly, quickly about LT because he definitely sends you a message. So he's a Maine Coon, beautiful outdoor in a pen, only came in, this is a cat we handled so badly, which is also fun to show.
Coughing really in a bad way, respiratory rate is 60. Blood's just said toxic changes, this all shouts bacterial, doesn't it? And what was the point of running FELV and FIV in a pedigree cat that had only ever been in an indoor bin?
Yeah, exactly. Yeah, he came in at night. This is about 5 years ago, thankfully.
Everything has been changed since and intern didn't know to not take radiographs. So this poor cat in respiratory distress got sandbagged. Yeah.
If this was a case report that I was marking, you fail on that. I'd have to fail you on that. However much the rest of the case was handled brilliantly, just on that.
You know, if you Most of you are gonna have an ultrasound, an ultrasound of the chest will tell you whether it's lung or whether it's airway or not, not a needle in it. But don't sound back on, please. But as you can see, he's got pleural fluid.
Yeah, we've got loads of pleural fluid. It just breaks my heart to see this and know that we did it. Yeah, radiographs, and they took out pus.
They got mycoplasma and some light. That's nothing, you know, that's not the cause. You just look at that, that's not the cause of this problem.
He had chest drains and he had amoxiclav and clindamycin for 4 weeks. This is done by the book, other than the radiographs. Appropriate choices, I would say no because I don't believe that this is that pastorrella and a light and anaerobbe is the answer.
Initially he did a little bit better, but then he got very much worse, and then he came in and got these radiographs done. And we've got very patchy, so this is a mediastinal lymph node. So that says something's going on in his abdomen.
And we've got patchiness. They're not the worst lungs on the planet, but they're, they're not great. At this point, I got them and it was like, what could this be?
OK, we've got patchy bronchialveola pulmonary pattern. But he's already on moxylanov and clindamycin. Well, this isn't mycoplasma.
It hadn't been looked for, but Clindamycin should have treated it. Any bacteria would have to be resistant to a pretty impressive cover. He's got no upper respiratory signs, which would suggest the respiratory viruses, toxoplasma, the clindamycin dose isn't high enough, but he had had a retinal check by me and his retina was normal.
You could argue this wouldn't be this wouldn't be recrudescent toxoplasma taxoplasma toxoplasma though, because, he's only, like a youngster. So then you start looking at the weird ones and you think, oh, what else could it be? So I said, OK, let's do the pharyngeal swab, let's send it off, in case we've missed some mycoplasma, etc.
And, it'll get us whether or not we've got lung worm. Continued with those. Benbendazole.
I figured if there were any lung worm, at least that would kill them slowly. No, no, it didn't. You would think it would kill one more slowly than the spot-ons, not a dot of it.
It put him straight into acute deterioration and he was really dismick and ended up in the ICU, which was pretty diagnostic, but it's 11. I. Not the ideal way of diagnosing it, and it, it was confirmed on the PCR when it came back.
So really quickly, these are the lung worm in Britain, it's lustroullus and capillary aerophola. There are biggies prevalence in the UK. Well, in theory at 2%, but you saw in the other study, 3.5% of our respiratory cases are presenting with it.
Yeah. It causes respiratory disease, can cause anything from snots and sniffles to sneezes and wheezes, you know, they're not very specific, these worms. Remember they come up the lungs up here, cause inflammation around the pharynx and then go into the GI tract.
The bath is not always the xenophilic. And yeah, you can get really bad lung change. This little kitten was 11 weeks old when it died and you can see his lungs.
This is a different cat, just wall to wall, horrible. The diagnosis is the Berman test or the PCR, but we've only got PCR for a strongullus at the moment, not for cap capillaria treatment. You can use Fambendazole.
Personally, mostly nowadays, I'm using a broadline, Profender, or Advocate, which all have the licence, and I treat one and then a month later. LT post-treatment, he rattled a bit, but then he got very much better. Look at the weight gain in 10 days.
And he did brilliantly. But I've understood very recently that something happened. I think it was his lungs again, and he had to be put to sleep.
But at least they got him at least a few years of good quality life, but he did suffer. His lungs were never perfect again. So please don't forget lung worm, and even in a cat that's never been outside, beyond and, a pen because slugs and snails will crawl into pens, and particularly cats in pens, get bored.
So they'll pat them and play with them. And it only takes one slug or snail that's got a lot of lung worm larvae in it to, or, infect a pussy cat. So, I hope.
Rosie and her friends helped you with a few, interesting cases of, respiratory tract disease. I hope that allowed you to put into practise some of the things we had covered when we were talking about the causes and the, the, the diagnostics. .
And I will happily pick up questions if there are questions at some point. Thank you.