Lymphoma diagnosis

[paschat]

Edited to say: she has not yet been diagnozed with Lymphoma, I am just worried about her symptoms. She does not have dyspnea, coughing or wheezing.

Moche cat is 17 years old and indoors only. There are no plants in our house, and no toxins/chemicals she could get into. We have been doing a 6 monthly senior wellness check for the last 5 years, which includes bloodwork, UA, physical exam and blood pressure exam. She has feline hypertension, which she's had for a few years and is on 0.5 ml Amlodipine for the last 18 months.
In August 2011 she had her last Senior Wellness Exam and her bloodwork, urinalysis etc was normal. Vet says she is in excellent health for a 17 yr old. Moche is a small kitty and although she gets plenty of food, she never weighs more than 6 pounds. She has not lost weight at all, except on the days she was sick (see below), she had lost about 3 ounces and the vet said it was probably due to the nausea and vomiting. She gained the weight back after the tummy upset.

Here is the timeline since her senior wellness exam:
1. On Oct 29 2011 she vomited 5 times over the course of 7 hours - from 4am until 11am. The vomit was spit and water, she was obviously nauseous and had no food in her tummy. No sign of diarreah. I took her to the vet that day, he examined her and said it was probably just a tummy bug and gave her sub q fluids and a Famatodine injection. She was fine about 5 hours later, playing, eating and behaving normally.

2. On November 9 2011 she started vomiting up spit and water again,she cried when I picked her up and her tummy seemed sore. Took her straight to the vet.
Vet gave her Sub Q fluids and a Famatodine injection. Moche was fine 5 hours later, playing, eating etc.
Vet also did full bloodwork including the Pancreatitis test (Spec fpl). Got tests back on 10 November and everything was normal and her pancreas levels were 1.5 so she did not appear to have pancreatitis.
We thought she may have a food allergy. Our 3 cats are on Hill's c/d canned (chicken flavor) for the past 5 years as they tend to get struvites easily, and since they've been on canned Hill's c/d they've been doing very well. Vet suggested we feed Moche Hill's canned I/D, a bland food that should help her tummy. So far so good, she was eating very normally, no vomiting, and she even gained some weight.
In addition doctor said that we should add Famatodine to her Amplodipine daily as it would help her tummy, and it was not harmful to use long term. We had the Amlodipine and Famatodine compounded togther from the pharmacy into a suspension so I only have to medicate her once a day instead of giving her two different meds a day which would stress her.

3. This morning, 25 November, Moche started vomiting up spit and water again. I gave her the Famatodine/Amplodipine suspension as usual, but she vomited it up. In addition I found 3 small puddles of watery spit in the room. Took her straight to the vet, they gave her famatodine injection + sub q fluids again.

I'm very worried now and I'm not sure what the next step is. Our usual vet is away until Monday. Do you think it is possible Moche has gastrointestinal Lymphoma? Is there anything else you think we should test for?

Edited to add her exact medication: (suspension form)
AMLODIPINE/FAMOTIDINE (C) 1.2MG/2.4MG/MI
GIVE 0.5ML BY MOUTH ONCE DAILY

[Traci]

Has Moche been tested for hyperthyroidism, IBD, or diabetes? Hypertension can be associated with more commonly kidney or heart disease, but hyperthyroidism is an equal concern. IBD should be considered a ruleout. Additionally, a complete heart workup may be in order, especially given her age. An ECG and ultrasound could be useful at this point (hopefully with a board-certified feline cardiologist).

Are you still feeding the I/D or only at those times she has vomiting episodes? If you are currently feeding something else, please state what it is, it could be that she has developed an intolerance to it.

I'm a bit concerned that three times now, the vet has only given famotidine and sub-q fluids but hasn't pursued additional rule-outs/testing. It sounds like Moche is relatively very healthy for her age, although I do feel she should be tested for hyperthyroidism, IBD as rule-outs, and consider that complete heart workup, particularly when hypertension is, I assume, primary and no underlying cause has yet been detected. If you feel the vet isn't looking far enough, perhaps a second opinion with a feline-only or more experienced vet is in order.

Hopefully, it is just a simple GI tract issue, perhaps a food issue, but testing should be done regardless. Vomiting water is rather uncommon for healthy cats, and could be due to a number of issues like drinking too much too fast (sometimes due to dehydration), or due to diabetes, etc.

Typically, with any type of lymphoma, particularly intestinal, cats will vomit frequently, suffer diarrhea and lethargy, be anorexic and will lose weight (sometimes rapidly and/or steadily). It doesn't sound like Moche has signs of lymphoma, but an ultrasound (plus or minus xrays) could help rule that out.

Please get a second opinion just to ensure you have all your bases covered. Let us know how this goes, ok?

[paschat]

Has Moche been tested for hyperthyroidism, IBD, or diabetes? Hypertension can be associated with more commonly kidney or heart disease, but hyperthyroidism is an equal concern. IBD should be considered a ruleout. Additionally, a complete heart workup may be in order, especially given her age. An ECG and ultrasound could be useful at this point (hopefully with a board-certified feline cardiologist).

Are you still feeding the I/D or only at those times she has vomiting episodes? If you are currently feeding something else, please state what it is, it could be that she has developed an intolerance to it.

I'm a bit concerned that three times now, the vet has only given famotidine and sub-q fluids but hasn't pursued additional rule-outs/testing. It sounds like Moche is relatively very healthy for her age, although I do feel she should be tested for hyperthyroidism, IBD as rule-outs, and consider that complete heart workup, particularly when hypertension is, I assume, primary and no underlying cause has yet been detected. If you feel the vet isn't looking far enough, perhaps a second opinion with a feline-only or more experienced vet is in order.

Hopefully, it is just a simple GI tract issue, perhaps a food issue, but testing should be done regardless. Vomiting water is rather uncommon for healthy cats, and could be due to a number of issues like drinking too much too fast (sometimes due to dehydration), or due to diabetes, etc.

Typically, with any type of lymphoma, particularly intestinal, cats will vomit frequently, suffer diarrhea and lethargy, be anorexic and will lose weight (sometimes rapidly and/or steadily). It doesn't sound like Moche has signs of lymphoma, but an ultrasound (plus or minus xrays) could help rule that out.

Please get a second opinion just to ensure you have all your bases covered. Let us know how this goes, ok?

Thank you Traci. Yes, Moche has had full bloodwork done to test for hyperthyroisim and diabetes - they are negative. I can scan all her bloodwork for the last year + her U/A and send you a link if that will help? 7 years ago in 2004 our previous vet had said she may have IBD and we put her on Prednisone for a year. However she would still throw up occasionally. When we moved to a new state we took her to a Feline Only clinic who advised us to wean her off the prednisone in 2005, and said it was unlikely she had IBD (no biopsies were done). We had an ECG+ blood pressure test along with her bi annual bloodwork/U/A + Senior Wellness Exam in 2007 and that is when she was discovered to have mild feline hypertension. In 2009 the vet said she felt it would be prudent to place her on Amplodipine, as her hypertension was escalating from mild. She said that the ECG was normal, and said a cardio ultrasound was not necessary. Since then her blood pressure has been quite normal from the Amlodipine, we have her BP tested every 6 months.

Moche has ONLY been on Hill's canned I/D since November 9 2011.
This evening she looks much better, has perked up and is eating again.

The first time, vet thought it was tummy upset and gave her the sub q fluids and famotidine. It helped for 2 weeks.

****Second time vet gave her sub q + famotodine as well as a full bloodwork up including a test for pancreatitis.
Came back all clear.

Then today Moche had the same issue as the 1st two times, and she seemed to have stomach pain and was all hunched over. Our usual vet is away, so the local vet gave her sub q + famotodine and said it would be good to wait until Monday when our usual vet is back to ask about an ultrasound and further tests, unless she gets worse and then we must take her to the ER immediately.

Thank goodness she is ok tonight. But it is very worrying that this has occurred three times over a 4 week period.

So you think we should test for IBD with biopsies, and also do a series of ultrasounds? Is a biopsy the best way to get a definitive answer for IBD?

I will let you know what happens with her.

[paschat]

Following up to my last post, I don't know if any of this is relevant but this is a very brief medical history for Moche:
I have had her from the day she was born on 3 January 1995 in South Africa. She is turning 17 in 1 month's time.
She was a plump, healthy little kitten. She was spayed and vaccinated, then when she was about 1 year old she got feline hepatitis. We thought she was going to die and she spent 2 weeks in the ER. Thank goodness she pulled through. After that she never gained weight and remained thin. At that time I had the vet specialist (the vets in South Africa are not good like the ones in the US, they were basic at best) do bloodwork and a phsyical exam to determine why she was so thin, but he said she was healthy and that some cats are just 'skinny'.
When I moved to the US I brought her and Ozwald with me in November 2000 and took her to a vet in 2001 just for a general check up, bloodwork and a dental. The new vet said she was very skinny and wanted to do tests to determine why. Again, the tests he did came back normal. In November of 2001 he put her on a course of Megestrol Acetate - he said it would increase her appetite and she would gain weight. A month later she began acting strangely - gained weight, very affectionate, making nests in the house and my husband and I were petting her and I found 6 lumps on her stomach. I got the fright of my life because I thought it was breast cancer. I rushed her to a new feline only vet, and he said the Megestrol Acetate had caused a phantom pregnancy, and she had teats filled with milk. We took her off the Megesterole Acetate, she recovered from the phantom pregnancy and the new feline only vet did bloodwork, tests, and an abdominal ultrasound to see if she had any issues with her intestines. All was normal. During this time, she would throw up hairballs - she is a long haired kitty and I brush her daily, but sometimes she threw up a hairball, or would eat very quickly then throw up. This occurred about every 8 to 10 days. She never had diarreah. New feline vet said she was normal and some kitties just vomit sometimes as they have sensitive tummies. 2 years later I was worried because she was still under 6 pounds and the feline vet said we should put her on Prednisone as he thought it might be IBD. I was very naive at that time and believed everything he said, and didn't even know to ask about doing any further tests to see if he was correct about IBD. He did not change her diet at all, and said the Prednisone would not only make her gain weight, she'd stop throwing up. She ate a little more and gained 1/2 a pound, that's it. She weighed 6.5 pounds on the Prednisone.

Anyway, to cut a long story short, we moved to a new state, I got a new vet. She was due for a dental, bloodwork, U/A and physical exam. And that is when we were told to wean her off the Prednisone. We did, and she remained a skinny kitty but has always been healthy, very active, playful and all her bloodwork, Urinalaysis, physical exams have come back normal. The only hiccup has been mild hypertension and that is why she is on Amlodipine.

Then as you know, she started throwing up about a month ago, and the timelines are all in my previous posts. What I find odd, is that about 5 hours after she has the sub q fluids and the Famotodine injection she is happy and normal, her abdominal discomfort is gone, she's eating, playing and behaving normally.

The only other thing that has changed in her behavior is that she has recently become EXTREMELY loving towards my husband and won't leave him alone. We work from home, and before she started this lastest vomiting issue she was a mommy's girl. Now she cuddles on my husband's lap all the time and chases her brothers' away. I thought it may be due to old age.

I'm sorry for rambling here. I just want to give you as much info as possible in case any of it is relevant. I have also told this to Moche's Primary Care Physician.

[Traci]

Actually, I do NOT recommend any biopsy unless an absolute last resort. Even though she may be relatively healthy, I would definitely only consider non-invasive tests at this point. A biopsy to rule out IBD would require anesthesia, something you don't want to subject her to right now. I think a good starting point is xrays and an ultrasound. You don't need a "series" of ultrasounds, one ultrasound of any suspect areas should be enough.

A more conservative method of ruling out IBD would be perhaps getting her on a tolerable diet. But, if she doesn't have bouts of diarrhea, or constipation, or vomiting/regurgitating food, it's likely she does not have IBD. Some other type of inflammation could be present, however, which the ultrasound might be helpful in ruling out.

In the meantime, continue the I/D, unless your vet recommends otherwise.

Do you feed her treats or other types of snacks/foods? Sometimes, cats can develop an intolerance to these just as much as they can a particular cat food. If you feed treats, try ceasing them for a few weeks to rule that out.

When do you normally give Moche's meds? Morning or eve? Do you feed her at the same time? Does she vomit any time near the time the meds are given?

The hunched over and pain issue: when she vomits, do you think she is actually retching a lot prior to actually vomiting? This can indeed, cause a slightly painful abdomen during retching, especially if dehydrated. The stomach lining gets rather irritated and sometimes, during a great deal of retching, blood is present (which is usually irritation of the stomach lining).

No, it's not necessary to post her lab results, when the vet said the levels were normal, I'll take his word for it. He would definitely point out any enzymes to you that may not have been normal, particularly given Moche's age.

As for the ECG, (this can be confusing sometimes) - generally, an "electrocardiogram" involves leads attached to the body and measures electrical waves and pulses and the vet records on a graph, it is NOT a sonogram of the heart, that is the "echocardiogram" (which is an ultrasound of the heart) - did your vet do the echocardiogram? This should be done in conjunction with the electrocardiogram (as well as a chest xray), when hypertension is present, as a diagnostic to monitor heart health in patients with potential or current heart disease. A feline cardiologist is generally the better choice to use when monitoring heart disease. Not saying Moche has heart disease, but her age and the hypertension are factors to consider that may require that complete heart workup.

Do you know how many times/readings the vet takes when he measures Moche's blood pressure? This should ideally be done at least 3-5 times at each appointment. Stress at the clinic can alter the results, therefore, the 3-5 readings will allow the vet to get a fairly accurate median reading. If only one blood pressure reading is taken, this could misrepresent her true blood pressure measurement.

I think ultimately, an xray and ultrasound might be useful at this point in time, at least to rule out some hidden form of inflammation. Talk to the vet about the following:

How long to keep Moche on the I/D? (indefinitely?)

Should a feeding schedule be implemented or not? (for example, she vomits a certain time of day or near feeding time - if she is on a scheduled meal time, maybe consider small amounts more frequently throughout the day - consider leaving dry I/D out for her during the day if you're currently only feeding her canned I/D)

Upon palpation, are Moche's kidneys normal size?

Should the dose of amlodipine be re-evaluated, and perhaps adjusted? (in the event it could possibly be lowered - but here's where that heart workup might be handy before adjusting her amlodipine!)

To my knowledge, there shouldn't be any harm in the use of long-term famotidine, but if there is renal or liver disease present, this should be used with caution, ask the vet about that.

Again, it could be something as mild as stomach upset (that causes the vomiting, like excess acid in the stomach, but the famotidine should be addressing that). However, express your concern that these episodes have emerged rather suddenly and seem persistent. That she responds to fluids and the famotidine is a good thing, but there could be some inflammation present somewhere that is going undetected. That ultrasound (and/or accompanying xray) could be useful in ruling that out.

Just to rule out: Is Moche unnecessarily stressed at home for some reason? Anything changed in her environment in the last few months?

[Traci]

Just read your last post, we were posting at the same time

Try not to fret too much about her weight. I have a few cats who have always been small and thin, despite my attempts to get them to gain more. I find that these cats tend to be more high-strung, (and sometimes, more nervous than the others) - one of them is a very petite female and she is extremely high strung.

Not to mention, she's been through an awful lot since you adopted her.

As for which human Moche prefers, this can change for any cat. For some, it's a trust issue, for some it's a bond from the beginning, and for some, it changes frequently depending on the cat's moods! You are right to be concerned about the seemingly sudden change, since we always want to pay attention to behavioral changes, but as long as she is eating, drinking, has normal elimination habits, is sleeping normally, and otherwise active and normal as she usually is, I don't think you should worry too much about her new found desire to be around your husband more. Remember, you're the one poking and prodding, and giving meds and taking her to the vet, like most cats, they eventually learn the other "parent" is more likeable in that regard since they aren't poking/prodding/medicating, etc! My cats do that too, and sometimes my feelings get hurt something fierce, but eventually, they forgive me In that regard though, do keep an eagle eye on her, or any other unusual behavioral change.

Btw, your second vet was very wise to get Moche off the pred. While pred is often used in confirmed cases of IBD (and it is very helpful in those cases), the fact that an endoscopy was not done at the time for confirmation didn't exactly lead to a conscientious decision. That said, sometimes we have to do what we think is necessary to help relieve symptoms (even based on presumptions) - if nothing else, it should have been a temporary approach and re-evaluated later to get her off the pred anyway (or at the very least, on a very low-dose maintenance). I don't think this has caused her any great harm, though - if anything, her kidneys or liver would have been compromised at some point, and that doesn't seem to be the case, which is a good thing.

[paschat]

Actually, I do NOT recommend any biopsy unless an absolute last resort. Even though she may be relatively healthy, I would definitely only consider non-invasive tests at this point. A biopsy to rule out IBD would require anesthesia, something you don't want to subject her to right now. I think a good starting point is xrays and an ultrasound. You don't need a "series" of ultrasounds, one ultrasound of any suspect areas should be enough.

A more conservative method of ruling out IBD would be perhaps getting her on a tolerable diet. But, if she doesn't have bouts of diarrhea, or constipation, or vomiting/regurgitating food, it's likely she does not have IBD. Some other type of inflammation could be present, however, which the ultrasound might be helpful in ruling out.

In the meantime, continue the I/D, unless your vet recommends otherwise.

Do you feed her treats or other types of snacks/foods? Sometimes, cats can develop an intolerance to these just as much as they can a particular cat food. If you feed treats, try ceasing them for a few weeks to rule that out.

When do you normally give Moche's meds? Morning or eve? Do you feed her at the same time? Does she vomit any time near the time the meds are given?

The hunched over and pain issue: when she vomits, do you think she is actually retching a lot prior to actually vomiting? This can indeed, cause a slightly painful abdomen during retching, especially if dehydrated. The stomach lining gets rather irritated and sometimes, during a great deal of retching, blood is present (which is usually irritation of the stomach lining).

No, it's not necessary to post her lab results, when the vet said the levels were normal, I'll take his word for it. He would definitely point out any enzymes to you that may not have been normal, particularly given Moche's age.

As for the ECG, (this can be confusing sometimes) - generally, an "electrocardiogram" involves leads attached to the body and measures electrical waves and pulses and the vet records on a graph, it is NOT a sonogram of the heart, that is the "echocardiogram" (which is an ultrasound of the heart) - did your vet do the echocardiogram? This should be done in conjunction with the electrocardiogram (as well as a chest xray), when hypertension is present, as a diagnostic to monitor heart health in patients with potential or current heart disease. A feline cardiologist is generally the better choice to use when monitoring heart disease. Not saying Moche has heart disease, but her age and the hypertension are factors to consider that may require that complete heart workup.

Do you know how many times/readings the vet takes when he measures Moche's blood pressure? This should ideally be done at least 3-5 times at each appointment. Stress at the clinic can alter the results, therefore, the 3-5 readings will allow the vet to get a fairly accurate median reading. If only one blood pressure reading is taken, this could misrepresent her true blood pressure measurement.

I think ultimately, an xray and ultrasound might be useful at this point in time, at least to rule out some hidden form of inflammation. Talk to the vet about the following:

How long to keep Moche on the I/D? (indefinitely?)

Should a feeding schedule be implemented or not? (for example, she vomits a certain time of day or near feeding time - if she is on a scheduled meal time, maybe consider small amounts more frequently throughout the day - consider leaving dry I/D out for her during the day if you're currently only feeding her canned I/D)

Upon palpation, are Moche's kidneys normal size?

Should the dose of amlodipine be re-evaluated, and perhaps adjusted? (in the event it could possibly be lowered - but here's where that heart workup might be handy before adjusting her amlodipine!)

To my knowledge, there shouldn't be any harm in the use of long-term famotidine, but if there is renal or liver disease present, this should be used with caution, ask the vet about that.

Again, it could be something as mild as stomach upset (that causes the vomiting, like excess acid in the stomach, but the famotidine should be addressing that). However, express your concern that these episodes have emerged rather suddenly and seem persistent. That she responds to fluids and the famotidine is a good thing, but there could be some inflammation present somewhere that is going undetected. That ultrasound (and/or accompanying xray) could be useful in ruling that out.

Just to rule out: Is Moche unnecessarily stressed at home for some reason? Anything changed in her environment in the last few months?

Thanks so much for all your help Traci. I think that while you were replying to me 2nd post, I was typing out this third post with some medical history up to the present time for her.
I will ask my vet about ALL the items you have recommended above. There has not been any change in the house, or anything I can think of that has caused undue stress EXCEPT her 3 visits to the vet this month.
a) I agree about non invasive tests right now. We will make an appt. for a cardio ultrasound + heart workup with Teddie's Cardiologist Dr R. I would also like them to do a stomach ultrasound or xray.
b) Moche has litter boxes in my office so I can monitor all three of them, and her stool is always solid, never soft. She does not have constipation that I have noticed, not does she throw up immediately after eating (she used to years ago when she ate too fast, but not in the last few years).
c) Moche gets small pieces of organic turkey breast as a treat, usually around noon. She loves it and begs at the fridge. She never throws up aftewards. Moche, Ozwald and Teddie are free-fed as none of them have obesity issues. We had tried giving them canned food twice a day but the restricted feeding caused them stress.
d) Moche gets her meds at noon. After her meds she is given a small piece of organic turkey breast as a treat.
e) I have not found any blood in her vomit or stool and she doesn't retch a lot before vomiting. In her episodes over the past 30 days she starts vomiting early in the morning - around 4am. I am a very light sleeper and can hear her. Her tummy seems empty as no food comes up - it is foamy, watery spit.
f) Moche's ECG was not a sonogram of the heart, it was a hookup with wires.
g) The vet takes about 4 readings of Moche's BP and she also said stress at the clinic can cause her BP to go higher than normal.
h) The vet did a manual palpation of all Moche's organs, kidneys, liver, tummy and said she could not feel anything abnormal.

[Traci]

Thanks for that information, it's very helpful.

I wonder if you might consider ceasing giving the turkey with her meds. Give her I/D instead, and the turkey later, when the meds have had enough time to absorb (a few hours). I realize the timing here, when you say she vomits in the early morning hours, but try her meds with her regular food for a while and see if it helps. Turkey is a rather "rich" meat, and shouldn't be given too often, nor in excess. Not saying you're giving it in excess, but chicken would probably be better if you feel you must give her meat as a treat. Just make sure the meat is fully cooked.

Do you know what she's doing in those early morning hours? Is she playing, active, drinking a lot or?

[paschat]

Thanks for that information, it's very helpful.

I wonder if you might consider ceasing giving the turkey with her meds. Give her I/D instead, and the turkey later, when the meds have had enough time to absorb (a few hours). I realize the timing here, when you say she vomits in the early morning hours, but try her meds with her regular food for a while and see if it helps. Turkey is a rather "rich" meat, and shouldn't be given too often, nor in excess. Not saying you're giving it in excess, but chicken would probably be better if you feel you must give her meat as a treat. Just make sure the meat is fully cooked.

Do you know what she's doing in those early morning hours? Is she playing, active, drinking a lot or?

Thanks Traci. I WILL stop the turkey for now until we do further testing. An hour ago I fed her a little turkey and was so relieved when she ate it and kept it down. The turkey we give her is fully cooked from Whole Foods, it is the one my husband eats. I think it's a good idea to stop all treats until we can diagnose what is wrong with her.

I don't know what she is doing in those early hours - I'm asleep and the sound of her puking wakes me up. However I have gone over how she behaves the night before these puking episodes and she is playful, loving and acting normally. Yesterday she was eating normally and then this morning she was ill again.

I will keep you posted next week. I just hope to goondess we will get to the bottom of this and that she doesn't have any incurable illness like Lymphoma.

Thank you so much for all your time and help, Traci.

[paschat]

Moche had a good day today. She ate her cat food, sniped some grilled salmon off my dinner plate when I went to the answer the phone, and had lap time cuddles with my husband. Tomorrow, her PCP will give me referrals for the ultrasound and xrays. Please wish us luck, Traci. This is a photo of Moche:
http://img.makeupalley.com/3/7/2/3/2125344.JPG