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Monday, September 6, 2010
Case 18

A 12 year old male neutered DSH feline was presented to the AcaseAweek Clinic. The cat had two episodes of vomiting and is lethargic for one week. Owner reports that the cat is also PU/PD and inappropriately urinates on the counter and bed. He has been vocalizing more than normal and is showing signs of generalized weakness.

Physical Exam:

Weight:  4 kg
Temperature:  102.1 o F
HR/Pulse:  135 beats/m
RR:  24 breaths/m
CRT:  = <2 sec
MM:  pink but slightly tacky
BCS: 3/9

ENT: Normal
Oral: Putrid stench from oral cavity
LNN: Normal
Thorax & Abdomen: Normal
U/G: Normal
Skin Turgor: Reduced
MSk: Normal
Neuro: Normal

CBC and  Biochemistry:


Platelets:  647 x 109/L [RR:  175 – 500 109/L]
BUN = 51 mg/dL [RR: 16-36]
CREA = 2.8 mg/dL [RR: 0.8-2.4]
ALT = 138 U/L [RR: 12-130]
Total  protein = 9 g/dl [RR: 6.6-8.4 g/dl]
GLU = 588 mg/dL [RR: 71-159]
All other parameters within normal limits
Urinalysis:

Sample obtain via cystocentesis
Apparence: Straw colored and cloudy
Glucose = +++
SG = 1.024 (from refractrometer)
Blood = trace
pH = 6.0
Protein = ++
Leukocytes = +++


What will be your tentative and differential diagnosis?
What further diagnostic test(s) you will perform to confirm your diagnosis?
What will be your treatment plan(s)?


Solution to this case
posted by Dr Banga's Websites @ 12:00 AM  
4 Comments:
  • At September 6, 2010 at 12:55 AM, Blogger K9F9VET said…

    Hello Dr. Banga,

    After observing the physical exam report abd blood values my top differentian diagnosis are:
    1.Diabetes Mellitus
    2.Chronic renal failure
    3.Ongoing Urinary Tract Infection
    4. Hyperthyroidism

    A history of PU,PD and accidents in house indicate diabetic cat. But it also indiacte renal failure.
    BUN and Cr values are high but they may be relative high due to dehydration.Glucose in Urine again indicate Diabetes and specific gravity of Urine 1.024..I donot know the normal range the refractometer you are using but it indicate normal specific gravity it means kidneys are able to concentrate urine.
    Sometime when the urine is collected in hospital enviornment it shows stress hyperglycemia in cats. So I re-eveluation of blood glucose and urine analysis is very important.
    When glucose is persistent in urine it act as a substrate for bacteria and Urinary tract infection take place and we can see protein and leukocytes.
    I would like to go for Serum fructosamine test which tell us about the previous three to six month history of serum glucose and help us to differentite truly diabetic to pseudodiabetic. Also after hydration I will recheck serum Creatine levels as it is more reliable indicator of kidney function.
    I would urine for Culture and sensitivity.I would also like to do serum T4 levels too.

    The treatment portion consist of Intravenus fluids( Ringers lactate in this case,Insulin( if diabetes confirmed),(Insulin Glargine is preferred in cats),Antibiotics and diet management.
    But In case Serum creatine level remain high...Vomiting continues and also blood pressure readings higher and serum sugar and urine sugar level comes normal The cat would be treated for chronic renal failure.

     
  • At September 6, 2010 at 2:52 AM, Anonymous Martina said…

    Dear Dr. Banga

    After your physical exam report and the blood values, my diff diagnosis would be:
    1. Chronic kidney failure (CKF)
    2. Longer ongoing cystitis (with urolits ?!)
    3. Diabetis mellitus
    4. Thyroideal problems

    As the cat is older, male and neutered tomcat, I presume first a CKF, or UTI, eventual with cystitis and stones.
    As already mentioned by K9F9VET the glucose can be high due to stress in cats. For verifying a blood fructose test could give more information.
    But for me, the information we already have show more directing a Kidney problem. The cat has tacky mm, elevated TP and platelets which indicate a dehydration ( I would like to know how the skin turgor was, but the RBC was in normal range -> that shows an anemia when the hydration would be back to normal.
    The cat showed nausea and urination problems.
    The dehydration should lead to higher condensed urine than normal, but the result of the SG was even in the lower range of cat urine. That shows a reduced ability to concentrate urine.
    I would like to have Urine sediment to check it for bacteria, cristalls, kidney cells, casts etc. Also I would like to have an US or RX of the Kidneys and bladder. The Leukocytes and Protein in the urine show already an infection, now is the question, if the infection is cause or result of the disease?
    Also the slight relative anemia shows direction of a CKF, I would like to know the blood pressure of the cat, as it normally is elevated in cats with CKF. The retina should be checked too, as minor bleedings show up there first. Also Diabetis mellitus can show some ocular problems.
    The CA, P and K level would also give information about the stage of the kidneys, a blood test would help.
    Also the bad stage of the oral cavity and the smell might indicate a kidney problem.
    The vocalizing during urination indicates pain while urinating. The general weakness could be due to dehydration, autointoxication ( if the cats don`t eat some time, the kidney parameters go down again a bit, but the cat stays weak).
    Like already mentioned diabetes could be checked out by blood fructose, and the T4 level should be checked too.

    As a treatment I would like to know if bact. are present in the sediment and Antibiogram should be done, while a broad spectrum AB is given till the results are present.
    If the blood results indicate a CKF, a cortison injection could be given together with exp. Laurabolin, to help to built up the lost muscles. Further on I would recommend a long term treatment with Fortekor 2,5 (Benazepril) and a kidney diet with reduced potassium, salt, and protein.
    In case of urolites, depending on the composition of them, (as the pH is acidic oxalate is more likely)the treatment involves, a flush of the bladder for sand, for bigger stones operation, in both cases combined with a live long diet.

    There is a possibility that a mixed problem is there, like diabetes and CKF, or Hyperthyroidosis and CKF, which can mask the original disease.

    Thanks for presenting that interesting case.

     
  • At September 6, 2010 at 7:14 AM, Blogger Dr Swarupmay Majumdar said…

    Dear Doc, thanks a lot for bringing cases back.
    glucose is high both on urine as well as on blood! there is higher serum creatinine level noticed..plat no is normal. what about total count?
    My tentatives will be
    1. diabetes melitus: loss of body weight, PUPD. Confirm by serial blood sugars post feed orby testing c-Hb level. and search for some more specifics signs of DM.
    2. Liver diseases too cum with PUPD , weight loss and higher blood sugar. I find total protein is good. so rule out kidney and liver involvement. Can any way think about hepatomegaly, albuminuria!!!need to rule out.
    3. uti- can be, even idiopathic cystitis is so common...but this is a smaller chance

    further diagnostics:
    Liver , kidney functions
    usg abd for abdominal organs

    would be eager to know the outcomes and would be enjoying the comments posted before me and after me!!!now

     
  • At September 6, 2010 at 3:59 PM, Anonymous Anonymous said…

    Dear Doc,
    I think from the glucoseuria and hyperglycaemia, it appears to be case of DM
    R/o Renal failure, addison (the great imposter), cushing, hyperthyroid, Gastritis, cystitis, urinary stones, HCM (because of weaknes and old age)

    Diagnostic plan will be to do both chest and abdominal X-rays, urine culture and serum T4 assay
    to rehydrate, my choice of fluid will be 0.9% Sod Cloride and when glucose comes to around 250-300 mg/dl, then switch to 5% Dextrose
    Repeat CBC and Blood chemistry after 6 hrs to see how the kidney and liver health indicators are doing

    Thanks Dr Banga for this mind teasing case. i liked it

     
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