Wednesday, February 25, 2015

Myrna Has Her Two Week Cardio Visit to Remove Fluid Build-up-and Jimmy Stewart Tags Along for the Visit to the ER

Jimmy Stewart saw the vet on Friday for swollen chin acne.  We spent the weekend cleaning his sores.  He seemed otherwise fine until Sunday when he wasn't urinating the volume that he would usually.  And then late in the day he began to sit in the box.  We took him out and then he went back in.  He wasn't cleaning his genitals; he wasn't going frequently; he wasn't going tiny amounts.  So, I didn't think he had a UTI. But that didn't mean he couldn't suddenly have a blockage.  The antibiotic shot wasn't suppose to make him sick and he hadn't had any gastro upsets or diarrhea.  Since I was taking Myrna to see the cardiologist Monday and the regular vet can never see last minute patients on Mondays, I decided to take him to the ER in Novi that is in the same building as Myrna Loy's cardio.

Jimmy Stewart at ER
Xrays didn't show stones, most of which would show up on an xray. Urinalysis didn't reveal crystals-another cause of blockages-nor any bacteria.  Xrays did reveal that his colon system was full of bile that hadn't been expelled yet.  Exam didn't reveal that it was impacted but his anal glands were impacted.  The vet expressed them.  She hypothesized that packed glands may have made him feel unable to pass fecal matter and being uncomfortable made him lay in the litter box-which cats are known to do when trying to go and are unable to or when upset enough that the box is a safe place.  Blood work didn't reveal anything other than slight dehydration which would also lead to less water in the colon, lead to constipation.  His urine pH was 8.5.  With a lack of water and a high pH, he is susceptible to forming stones and getting a blockage.  I am to give him daily doses of Methigel-DL methionine, an acidifier-which should lower his pH.  They gave him sub-q fluids to rehydrate.   So, we are to give water by mouth, add fiber to his food, give Methigel, clean his chin acne, and continue to monitor.  

He came home smelling of vanilla which must be from the shampoo they used to clean him after expressing his glands.  His siblings didn't care for it.  "You stink!" they seemed to hiss.  He has been content to spend last night and all today upstairs in bed.  He could have come downstairs but never did until this evening. He has used the litter box twice during the day, going large amounts. He continues to eat very well.  

Myrna Loy
Myrna Loy is now seeing the cardio every two weeks since Christmas to have fluid withdrawn. We have regular two week appointments set up through April for now.  And we will go in sooner if needed.  Myrna had more fluid withdrawn from her pleural effusion.  She had 7 oz. last time and 8 oz. this time, despite high levels of torsemide and despite me giving her extra torsemide this past week as needed to lower her breathing rate.  The ONE good news: her afib-atrial fibrillation, has disappeared.  The cardio has never seen that before.  But that's how it goes with Myrna-she's always presenting with something other cats don't present with to the cardio. 

Her heart rate is steady at 160. 

Her weight is down now to 9.4 lbs, down from 9.8 just a few months ago and around 10 lbs a year ago.  While we wanted her weight to come down for her heart, she's now at the place where we want her to be.  To help her kidneys and her body function, she actually can't get below 9 lbs.  It's a bad sign when cats lose weight which they do because they don't feel like eating which can have many causes. But the result is a lack of water which leads to dehydration, which itself leads to a myriad of issues because of a lack of electrolytes.  And a lack of eating means a lack of protein which causes the body to waste away, and a lack of vitamins and minerals to supply the body with what it needs for energy which would allow the body to function from brain to heart to kidneys, etc.  We have had to give mirtazapine, an appetite stimulant, about once a week which helps her eat enough.  We will have to make sure she eats well every day and give more mirtazapine if needed. 

Her potassium is down to 3.2 from two weeks ago at 3.5.  Potassium is needed for kidney function and a decline in potassium means a decline in kidney function. So, we must increase her potassium levels by increasing the amount of supplements and sweet potato baby food we give her.  The BUN is 37 the same as two weeks ago; creatinine is 2.9, up from 2.7 two weeks ago.  Those are the kidney values that are analyzed the most for kidney function. An increase in values means a decrease in function which is crucial when you are asking the kidneys to process the diuretic medication for the diuresis process of removing extra fluid from the body.  

So, she's ok, stable enough, eating well enough, and for about three days a week still plays with toys and runs around before she runs out of energy.

Here are the vet's notes: "We removed 130ml of chylous effusion from the right side of Myrna's chest today.  Only a small pocket of fluid remained after the procedure was performed. Myrna's kidney values are stable compared to her last visit earlier this month. However, her potassium level is on the decline again. Myrna's is developing pleural effusion at a more rapid rate despite our incredibly aggressive medical efforts.  I see no benefit to increasing her torsemide dose further. Rather, it is very likely that this will be a detriment to her health.  Sadly, we have maxed out on all of her cardiac medications.  We are left with no other great options other than to periodically drain her pleural effusion as her symptoms dictate." 

Tuesday, February 24, 2015

Jimmy Develops Horrible Case of Chin Acne

Two weeks ago, Jimmy developed chin acne.  I cleaned it with chlorhexidine pads and the next day it seemed to clear up.  But last Thursday, I noticed his face was misshapened but couldn't figure out why.  He just seemed to have taken on a new longer, pointer shape. Then I realized that his chin and bottom lip were swollen. Upon closer examination, the entire area of his bottom lip, chin, and underneath were horribly red and swollen.  Friday, he saw the vet who gave him an antibiotic shot of Convenia so that we didn't have to pill him each day.  The shot also helps avoid gastro upset such as vomiting and diarrhea.  I have to clean his chin each day with the chlorhexidine.  The area is a mess of dirt and blackheads.
I thought they were bugs but thankfully, just horrible blackheads covering the area that unfortunately are infected.  

Wednesday, February 11, 2015

Myrna Visits Cardio for Pleural Effusion Fluid Withdrawal for Feline HCM

Posted to Facebook 2/10/15
At cardio-even though she wasn't and then she was better this a.m. and about noon, I brought her in. They took out 6oz which explains the roller coaster breathing rate and difficulty. The torsemide took out the extra fluid that must have existed in addition to the 6oz they withdrew which is why her breathing would go up and down.  
No word on why she was sick Sunday unless kidneys are not well or the effusion

lymphatic fluid was involved. But we could have come in yesterday but definitely today. We are waiting to see blood results. There's no scarring in lungs so this must be due to Rutin supplement!
Torsemide should take care of the fluid but it's not and we need to give more as needed or maybe more regular daily doses.

Myrna came home feeling better, more alert, breathing well. 
Myrna's potassium is up to 3.5 from 3 on 1/22 which is good. Not great news but not really bad is that BUN is up to 37 from 33; creatinine is 2.7 from 2.3 so not bad.
She will get extra 2.5mg of torsemide and extra potassium.
We will schedule a vet visit for every two weeks in case she needs fluids withdrawn.
But the cardio wanted me to understand that Myrna is in the end stages of her disease. You know it's bad when the cardio is using her calm, serious voice and not the one I've heard for over five years that was hopeful, optimistic, and laughing. We had the beginnings of the talk in January. And there have been times in the past-as Myrna developed increased heart size, clots, other incidents-that the serious voice was used. But Myrna always bounced back and surprised us all.
That her kidneys still function must be due to the vitamins and supplements we give. The cardio is surprised that she needs such a high level of torsemide and that her kidneys are still functioning. We will keep up all that we've been doing , pushing extra meds as needed, etc.

Myrna's sixth birthday is March 22. My goal is to celebrate it with her.

Monday, February 9, 2015

Myrna's Breathing Rate Ramps Up Middle of the Night Due to Feline HCM

Posted to Facebook 2/9/15

Myrna had a rough day yesterday. Breathing was ok until after midnight. But in the am she vomited and wouldn't eat or drink. She vomited her meds so I waited until 1pm to give torsemide again. She kept it down so we resumes normal med schedule and gave supplements. She wasn't drinking so wasn't going. Knowing that water is necessary for kidneys to process diuresis of torsemide, we gave water by mouth, (sugar water , tuna juice also for protein) constantly. Eventually I gave mirtazapine appetite stimulant. Finally she began eating at. 9 pm but very little. She did finally start drinking on her own by then. And using the box. But then her breathing went up to 48 after midnight and then 60 around 2am. I fought it with lasix and more torsemide. At 7 am she was 48 and by noon 40. The cardio said to watch, do meds , and wait to see if she needs to go in Tuesday if breathing increases again. This not eating , giving mirtazapine, breathing increase, and more meds has been happening weekly for three weeks. I don't know why she went from fine Saturday night to being sick Sunday am. But it's upset her system and made recovery from congestion more difficult.

By 3:30 p.m. today, her breathing rate increased again suddenly. She stopped eating treats and food. I waited to see if it would calm down but it didn't so by 5 p.m. I gave 5mg of lasix.  Then at 6 p.m. 2.5mg of Torsemide.  At 8 p.m. she had the rest of her meds.  Finally, by 8:30 p.m. she was breathing 44 bpm; by 9:30 9bpm.  She began eating again.  Everything seemed back to normal. 

I texted the cardio who said to bring her in Tuesday if needed.  And that's where we are at 11:27 p.m. Except Myrna just seemed to begin to suddenly breathe hard again and seemed bothered by it.  I'm waiting to see if it's momentary of sudden onset of something again.  This time, if it's something, I may take her to the ER connected to the cardio's office.  I'll monitor for a short while and see how she does.  It's always difficult to tell now what is the best course of action now that the disease has progressed. 

Update 2/10/15:  Myrna needed extra Torsemide overnight but by 2 a.m was breathing more comfortably.  I will call the cardio in the later a.m. to see if need to bring her in Tuesday or make an appointment for Thursday.  They are closed on Wednesdays.

Sunday, February 1, 2015

Updates to January 2015 Care of Myrna's Feline HCM

Posted to Facebook January 4, 2015

If your HCM cat is on Flovent, discuss with your vet about moving to albuterol. Flovent is for asthma but is a steroid which HCM cats cannot have because it increases fluid retention, the oppposite of what we want for our HCM cats.

Posted to Facebook January 5, 2015

Myrna at cardio and having more fluid drained. We spent last night fighting congestion as she was restless, crying, likely due to pain from fluid. There was a snow storm last night and I was grateful she didn't need to go to the ER.  Blood work normal so will increase torsemide.

Myrna very happy to be home (we were home by two p.m. EST) and bouncing around.

Doctor's notes: "We drained 2.5oz of fluid out of the right side of Myrna's chest...character of the fluid is chylous...pleural effusion (in time may become) pocketed, which will make it more difficult to drain her...kidney values are back up (BUN 30, creatinine 2.8)..."

Posted to Facebook January, 8, 2015

So it's cold in almost every state in the US. Wherever you are, keep your HCM cat warm. Turn up the heat. Put blankets on floors under their beds, and on the furniture, even the bed, places where they like to sleep. Drape blankets over chairs to make tents (will keep in heat) and put rugs or towels underneath the chair for them to lay on. A diseased heart shouldn't work harder to keep a body warm. And keep them indoors, which should be done at all times.

To update you on Myrna, this is what the vet said she had on Monday: lymphatic fluid in the pleural cavity of her lungs, unlike the previous fluid they withdrew before Christmas. Yes, a new complication.

We need to prevent the accumulation of lymphatic fluid in the pleural cavity because it can lead to scarring-fibrosis. There's a supplement we can try called rutin. And I found Canadian studies such as this one that describes how rutin works and why it is necessary.

We are trying rutin for Myrna's lymphatic fluid. Found some at Whole Foods. Round large tabs, and I'll cut into halves. She gets four halves or more a day. I'll start with four and increase as I can. I say halves only because I think the size is too big as a whole to give so I'll cut it in half. Each whole tab is 250mg and we'll give a total of 500mg a day or more.

Posted to Facebook January 22, 2015

Myrna had less than 2 oz of fluid removed today. The cardio said she may not have had to come in, that meds may have continued to work well enough. She was breathing better but since the cardio was off Friday, and since we had to fight yesterday to get her breathing rate low by giving extra meds, I wanted to make sure she was doing well. And I'm glad we did. Her potassium is low at 3.0 from two weeks ago around 3.2 so now we need to push more potassium, possibly begin Tumil-k (a potassium source for cats.) But now we have two examples to go by to compare against in the future when deciding when to take her to the cardio for needle aspiration of fluid: when she's not breathing well, is in pain and won't settle, not responding well to meds; and when she's not breathing well but responding to meds-eventually-but not in pain and not crying.

Doctor's notes: "We drained 1.7oz of fluid...kidney values improved (BUN 33 from 1/5/15 @39; creatinine 2.3 from 1/5/15 @2.8)...potassium is hovering lower (3.0 down from earlier in January 3.2)...begin Tumil-k to better support her potassium..."

Posted to Facebook January 26, 2015
On Sunday night, we had to give extra torsemide and extra lasix to Myrna because her breathing rate was up to 10/15 (normal for your cat should be 6/15 at rest, for Myrna it should be 8/15 at rest or 32 per minute.) It took two extra 2.5mg doses over five hours before the rate came down to an uneasy 9/15. She did well overnight, continued to drink a lot and use the box frequently, and of course, wake me to tell me about it. This a.m. she was fine and then the breathing became more labored even as it seemed to still be 9/15. So I gave 3mg lasix, 1.25 Torsemide and two hours later she was an easy 8/15. The cardiologist thinks her lung walls may be irritated due to the pleural effusion in the pleural cavity. All I know is that when I give meds and if she responds, there must be some congestion that is making breathing difficult. I think the cardio means that some congestion may not be easily tolerated if the pleural cavity is irritated and that she may not need more meds when she seems to have breathing difficulty. All I know is that I must work on what I see-high, labored breathing rate which calls for more meds (and I still give a touch of lasix with Torsemide just in case the fluid is in the lungs and not around them.) Then I wait to see if she responds. If she does not improve, then at some point she needs the cardio. So far, she's better still tonight. And with each additional Torsemide, I've been giving potassium supplement. We've increased her potassium-and I must still update the Med list-to about 1000mg of Tumil K (approx 485mg each), and two 595mg Sundown potassium, and Gerber baby sweet potatoes of 6ml daily. With a level of only 3.0 in the blood stream as of last week, she's in no danger of getting hyperkalemia.

Posted to Facebook January 29, 2015

We have given Myrna extra Torsemide, lasix, and potassium today because her breathing rate is up again to 9-10/15. She's responding but not using her litter box as much, not going as often as she had I think because as her potassium level declines, the kidneys have trouble processing the med because they need potassium in order to work, so this means she goes less often. But it also means the med isn't working as well as it should, which leads to the increase of breathing rate. We need to give some water by mouth if we think she's not drinking enough. The kidneys also need water in order to process the med and kick out the fluid in the pleural cavity.

The Necropsy on Cooper's Feline Moderator Band Cardiomyopathy Heart

We received the necropsy in September of Cooper's (who died August 2014) kidneys and heart we donated for research to MSU.

From the notes:

"...within the left ventricle of the heart there are excessive amounts of loose fibrous connective tissue lined by endothelium that span the interventricular septum to the left ventricular free wall and papillary muscles.  Subgrossly, sections of kidney have mild undulation of the capsular surface, with mild interstitial fibrosis of the subjacent cortical parenchyma.  Glomeruli have mild diffuse membranous glomerulonephropathy and there is multifocal thickening of basement membranes of Bowman's capsule, proximal convoluted tubules, and vessels. Proximal tubular epithelial cells are swollen with finely vacuolated cytoplasm and occasionally faded nuclei. There are mild, multifocal lymphoplasmacytic interstitial infiltrates.  Gross examination of the heart finds excessive number of small, fine moderator bands towards the apex of the heart, extending from papillary muscles to the interventricular septum. There is an increased amount of white fibrous connective tissue along the endocardial surface of the left ventricle. Excessive moderator bands are considered under the heading of cardiomyopathies although it is considered a congenital defect that manifests later in life.  In this case, these moderator bands are visible grossly and histologically within the distal apex of the left ventricle.  The kidney lesions  suggest a mild nephritis of some chronicity, and these changes, in conjunction with reduced cardiac output and therapies to enhance diuresis in the animal, likely contributed to the reported azotemia prior to death."

Definitions: I tried to find definitions and explanations for what the notes mean.  These are not the best but this is what the above refers to.  Basically, damage was done to the kidneys, preventing them from processing the diuretic properly. The diuresis process could not keep congestion from the lungs.  In addition, of course, were the complications of the heart disease.  We believe he needed more potassium and supplements for kidney support while in the ER and every day.  There had been a slight improvement in his kidney values prior to his death but we only had had a month when we were giving extra supplements.  Given more time, I think we could have helped his kidneys improve their function and the diuresis process.  We see it working currently for Myrna, who, despite now on Torsemide, has normal kidney values (see January 2015 posts):

Left ventricle-The left ventricle is one of four chambers of the heart. It is located in the bottom left portion of the heart below the left atrium, separated by the mitral valve. The thickest of all the chambers, the left ventricle pumps oxygenated blood to tissues all over the body. After flowing into the left atrium and through the mitral valve, blood enters the left ventricle before it is pumped out through the aortic valve into the aortic arch and onward to the rest of the body.

fibrous connective tissue- bands of tissue in the heart that normally serve a purpose

endothelium-thin layer of simple squamous cells that lines the interior surface of blood vessels and lymphatic vessels forming an interface between circulating blood or lymph in the lumen and the rest of the vessel wall.

interventricular septum-is the stout wall separating the lower chambers (the ventricles) of the heart from one another.

left ventricular free wall-The left ventricle free wall is composed of the area of the left ventricular wall not in contact with the interventricular septum and is not part of the apex.

papillary muscles-muscles located in the ventricles of the heart. They attach to the cusps of the atrioventricular valves (a.k.a. the mitral and tricuspid valves) via the chordae tendineae and contract to prevent inversion or prolapse of these valves on systole (or ventricular contraction).

undulation-marks that appear on the surface of the kidneys that appear to be up and down

capsular surface-thin membranous sheath that covers the outer surface of each kidney. The capsule is composed of tough fibres, chiefly collagen and elastin (fibrous proteins), that help to support the kidney mass and protect the vital tissue from injury.

interstitial fibrosis- characterized by the destruction of renal tubules and interstitial capillaries as well as by the accumulation of extracellular matrix proteins. The severity of tubulointerstitial fibrosis has long been considered as a crucial determinant of progressive renal injury in both human and experimental glomerulonephritis.

subjacent cortical parenchyma-The parenchyma are the functional parts of an organ in the body. This is in contrast to the stroma, which refers to the structural tissue of organs, namely, the connective tissues.

glomeruli- A tuft of capillaries situated within a Bowman's capsule at the end of a renal tubule in the vertebrate kidney that filters wasteproducts from the blood and thus initiates urine formation.

glomerulonephropathy-any noninflammatory disease of the renal glomeruli.

Bowman's capsule-a cup-like sac at the beginning of the tubular component of a nephron in the mammalian kidney that performs the first step in the filtration of blood to form urine.

proximal convoluted tubules and vessels-is the portion of the duct system of the nephron of the kidney which leads from Bowman's capsule to the loop of Henle.

Proximal tubular epithelial cells-Epithelium is one of the four basic types of animal tissue

vacuolated cytoplasm-A membrane bound organelle in the cytoplasm of most cells, especially plant cells, containing water and dissolved substances suchas salts, sugars, enzymes, and amino acids.

faded nuclei-nucleus or nuculeus, meaning kernel) is a membrane-enclosedorganelle found in eukaryotic cells. It contains most of the cell's genetic material, organized as multiple long linearDNA molecules in complex with a large variety of proteins, such as histones, to form chromosomes. The genes within these chromosomes are the cell's nuclear genome. The function of the nucleus is to maintain the integrity of these genes and to control the activities of the cell by regulating gene expression—the nucleus is, therefore, the control center of the cell. 

lymphoplasmacytic interstitial infiltrates-of, relating to, or consisting of lymphocytes and plasma cells.  Interstitial Infiltrates occur within the connective tissue surrounding the air spaces.

papillary muscles- muscles located in the ventricles of the heart. They attach to the cusps of the atrioventricular valves (a.k.a. the mitral and tricuspid valves) via the chordae tendineae and contract to prevent inversion or prolapse of these valves on systole (or ventricular contraction).

interventricular septum-stout wall separating the lower chambers (the ventricles) of the heart from one another.

endocardial surface of the left ventricle-endocardium is the innermost layer of tissue that lines the chambers of the heart. Its cells are embryologically and biologicallysimilar to the endothelial cells that line blood vessels. The endocardium also provides protection to the valves and heart chamber

Saturday, January 31, 2015

Update on Jimmy Stewart and Possible Pre-Diabetic Condition

Refer to blog posts from September 1 and September 8, 2014: Jimmy had dental surgery at MSU in September.  A blood test at the cardio, for a pre-surgical cardio echo (he was fine), showed higher than normal glucose levels. His follow-up fructosamine test proved negative (a test to determine if higher than normal levels of glucose have been present in the blood over the last 30 days.)

MSU tests showed high glucose and high fructosamine before surgery and normal levels while sedated.  So, we believe stress causes high glucose but that still is not good for his system. MSU believed that this could lead to eventual diabetes which brings on all other sorts of complications and medical risks.  MSU also thought high glucose levels were the cause of his out of box incidences for which he has been on Prozac since 2010.  Once the glucose gets too high for the body to handle-due to stress or diabetes-cats will feel the need to urgently go and often dump their urine where they are at the moment.  While this could be one reason for Jimmy's need for Prozac, we know that without Prozac he would have a difficult time using his litter box.

In October, 2014, he had follow up tests which were normal.  BUT the dental surgeon suggested we reduce his carbohydrate and sugar intake and feed him diabetic diet.  The regular dentist disagreed BUT in researching, I found that carbs are present in gravy and gravy cat food is one type that diabetic cats cannot eat.  Pate types of food are better.  So, we began in October to feed him pate and we believe we have not had any out of the box incidents from him since then.