Tomten - Where do you go when your cat has stumped all the vets?

A: a cat specialist - case solved by Dr Plotnick! http://manhattancats.com/
The first blog post on I wrote on his case was the Winter Tomten "Yuletide " the midpoint of winter - the cosmic balance between life and death". I feel like we are poised on such a tipping point - and i cant help thinking being in the southern hemisphere the december solstice signals the descent." If you want to follow his story in graphic detail use the labels to find the other posts but now for the news i should have updated months ago! Tomten was originally thought to have FIP around the same time as Mishka. He had already started feline interferon so I drew a lot of strength from the kindness of Cassie answering my emails 2 years ago. For Cassie the drug was a really really big ask as it is hard to import to the USA as well as super expensive. 

"He who asks a question is a fool for five minutes; he who does not ask a question remains a fool forever." - Chinese proverb

 So glad her persitence paid off: June 2014 Cassie posted -

Finally a possible explanation for Tomten's illness. Ok I have truly crossed over to crazy cat lady. While making Tomten's next appointment for his Cardio check up I began feeling frustrated that he still has no diagnosis. So I broke down and submitted an e-mail to Cat Fancy magazine's ask the doctor. I felt a bit silly but figured what could it hurt? 

My 7 year old Devon Rex has stumped all the vets he has seen. 2 years ago he stopped eating, started throwing up and was hiding. An emergency trip to the local ER showed that he hadgranulomatous tumor in his intestines. An aspiration of the tumor ruled out lymphoma and based on his blood work he was diagnosed with dry FIP. He was put on feline interferon and methyl prednisone and sent home to die. Only a “miracle” happened and he appeared to get better over the course of two months. Three months after diagnoses scans showed that his tumors had disappeared through his lymph nodes remained swollen and abnormal. 12 months after the first tumor appeared he stopped eating again. Scans showed 3 new granulomatous tumors one of which was in danger of perforating his bowel. At this point his vet moved him to an excellent large regional vet hospital. They consensus was that he didn’t have FIP (based on his longevity). Since he was no longer responding to the feline interferon the thought was to do surgery to remove the tumors. All 3 tumors where removed in a double bowel resection and subsequent gram staining of the tissue was negative for FIP. He appeared to recover for a bit and then went into a tail spin hiding and not eating. He was placed back on the methyl prednisone and within a week was recovering once again. 3 months later he developed an ear polyp and infection and lost his balance. A month of antibiotics and dedicated ear cleaning and he recovered much of his balance but his counter surfing days where behind him. When he was being evaluated to remove the ear polyps it was discovered that his heart had become greatly enlarged and he was in heart failure. We made the decision to leave the ear polyps and focus on managing his failing heart.

Tomten has been lucky to have better care than many human beings and we are very grateful to his vet teams, who have given him an additional two years of life. The vets have all been unanimous that what ever is causing his health problems is an unknown and perhaps is some sort of an autoimmune disease? While we have tried to make peace with the fact that we will probably never know what is wrong with him its hard not to wonder if we took him somewhere else would someone know what is causing his condition? And could we do anything to stop it other than to treat each symptom as it comes up.

Dr Plotnick's Reply:

I think the ear polyps and the heart disease are separate issues. Devon Rexes are at increased risk of developing hypertrophic cardiomyopathy, which is the heart disease I suspect he has. As for the intestinal disorder, it sounds like your cat has granulomatous enteritis. This is a mysterious illness. Inflammatory bowel disease is a common disorder in cats. With IBD, most cases are due to infiltration of the intestines with either lymphocytes and plasma cells, or with eosinophils. These are types of inflammatory cells. Every now and then, we see a case that doesn’t fit into this pattern. We see what they call granulomatous inflammation. In these cases, the intestines are infiltrated with lymphocytes, plasma cells, macrophages, neutrophils..a whole mishmash of inflammatory cells. It often affects a discrete region of the intestine, rather than diffusely infiltrating the intestines. (Diffuse infiltration is the more common scenario.) (The disease has sometimes been called “regional enteritis” because it affects a discrete region of the intestine). FIP likes to cause granulomatous inflammation, but not all cases of granulomatous inflammation are due to FIP. When granulomatous inflammation is seen on an intestinal biopsy, the specimen should be stained with a special stain that detects coronavirus in the tissue. If the stain comes back positive, the cat has FIP, and the prognosis is terrible. If the stain comes back negative, it rules out FIP. However, the prognosis for granulomatous inflammation in the intestine is unknown. It’s a mysterious disease that no one has really figured out. Some people try steroids, and they work for some cats, in some cases. Other people suggest surgically removing the affected area. There are no big case studies of cats with this type of enteritis, so we don’t really know what the best treatment is. Unfortunately, I think the best approach is the one you’ve been doing, i.e. treat the symptoms as they come up. With him having heart disease, steroids are not recommended because steroids expand your cat’s blood volume, which can put a strain on the heart. I’m not sure how you would treat another bout of granulomatous enteritis if it were to develop again. Good luck with him. I hope he does well.

Dr. Arnold Plotnick

I've asked Cassie for an update - i know some on the facebook group had reccomended the raw diet as she was investigating IBD - Irritable Bowel Disease.  

PS. I love Dr Plotnick's idea of a cat only vet - cats hate the fuss and stress of a regular clinic full of dogs. Poor Mishka's worst moments were not from FIP so much as the 'system' - I won't spoil this feelgood post with the details of that - contact Dr Plotnick http://manhattancats.com/

Pikachu - a wobbly cat

Pikachu does not seem to have FIP although one vet he was taken to made this diagnosis. He was a wobbler (ataxia) because his brain or inner ear ( vestibular system responsible for balance) had damage after a viral illness but is getting better on PI (polyprenyl immunostimmulant) since early Nov 2012 " For the first few months, his ataxia waxed and waned, but now all that remains is a head tilt and the deafness. The head tilt seems to get worse/more exaggerated when he has a UTI or some other issue affecting his general health. He is doing really well now, although it took months to recover, and he still has a few neurological deficits. My only worry is that the virus may reactivate in his system and he won't be able to fight it off again"

"He was first diagnosed in September/October 2012. We took him to an emergency vet because he was ataxic (wobbly) and had nystagmus (shaking eyes). They originally diagnosed him with Idiopathic Vestibular Disease and said it would resolve within two weeks. When he didn't get better, we got a referral to a neurologist who did an MRI, Spinal Tap, FIP titer, toxoplasmosis test, etc., and said it was in his central nervous system and diagnosed dry FIP. After he became ill, we noticed he had lost his hearing completely. We were basically told to say goodbye to him, but you can't give up as long as you have hope. 

The neuro was ready to give up on Pika and really had no interest in PI or Dr. Legendre. I found the information on Dr. Legendre's success with PI and PUSHED the neuro to contact him and write the rx for the PI. Even after he contacted the university, he called me back and told me it was too costly and I should just put Pika down. It was unbelievably frustrating! I'm soo glad I didn't follow his advice. Even if the PI didn't help his situation, it certainly must have boosted his immune system in general and definitely didn't hurt him. " Kathleen Maki Potts

 She sent his results to the FIP fighters for opinions.

 "Pika's A/G ratio is 0.9. Anything above 0.8 almost always rules out FIP. A positive titer for FIP only means exposure to FCoV. It is not predictive of FIP. An extremely high titer, along with other suspicious lab results would make me think different. Also the 7b ELISA was negative. I would definitely explore some of the CNS stuff and it looks like your vet is doing a good job and looking at other things. You can always print out Dr. Addie's flowchart and provide to your vet if they start to explore the possible diagnosis of FIP again. The slightly elevated liver values can just be dehydration or a low grade infection."

Moki is a 'famous' facebook cat who seems to have a similar mystery wobbly problem but which didn't resolve, also initially diagnosed as FIP.