Bumbly A.

Bumbly1Bumbly Aggarwal – Orlando, FloridaBumbly3
Female, Domestic short hair
Approx date of birth:  Feb, 1997 – January 10, 2012
Diagnosed with suspected IBD on March 21, 2007
Diagnosed with triaditis on February 16, 2011
Diagnosed with probable lymphoma on April 27, 2011

 

 

First Entry: May 18, 2009
We adopted Bumbly as a kitten in May, 1997. She joined two other cats in the house, eating Science Diet dry – under the commonly shared impression that it was the best food (must be, it’s in the vet’s waiting room, right?). She also received annual vaccines as recommended. Over time she would occasionally strain during bowel movements and pass blood-streaked stools, I would mention this to the vet at her annual exams and be reassured it was nothing.

On 7/31/06, now 9, she was constipated, though passing some bloody mucus, vomiting, and lethargic. I took her to our vet’s office, where she was seen by a fill-in vet.  Her weight was documented at 12.1 lbs, which was normal for her. She had an elevated white blood cell count and he did x-rays which he read as normal. She was given Clavamox for infection of unknown origin. The next day she was worse so I took her back in. Her weight was documented as 9.1 lbs, obviously impossible that she lost 3 lbs in 1 day. I wonder if she was actually weighed the day before. Her regular vet was back and reviewed the x-rays which he felt were not normal. He scheduled a barium upper GI study for the next day, started IV fluids and sent off an PLI, noting that pancreatitis was newly being recognized as a common problem in cats. This came back slightly elevated. The upper GI series was done the next day and was normal. On 8/3 she was sent home with a her weight at 9.4 lbs, she seemed fine for awhile after this. I have since learned that barium seems to coat the GI tract and settle down symptoms. Though not given a diagnosis of probable IBD until later, I consider this the start of her disease.

On 1/31/07 I took her in for diarrhea on and off for 1 month, was given Clavamox and told that if the diarrhea recurs I could just call for a refill at any time, no need to come in. I had started researching diarrhea in cats and asked if metronidazole (Flagyl) would be a better choice, but was told no, use the Clavamox.  My vet seemed to be sort of “running out of gas”, not as motivated to pursue diagnoses as before, and I had seriously been contemplating changing to a cat-only vet recommended by a friend. It was a big decision as we had been with our vet for over 10 years. I was also doing more and more research about diarrhea and IBD, learning a lot about diet and began changing foods, using canned foods and going to higher protein, better quality dry. This began over a year of challenges trying to find a food that would agree with her GI tract but also be palatable to our other 6 cats.

Finally on 3/21/07 I changed to the cat-only vet. On my own I had given her prednisone and Flagyl with improvement in her condition (the Clavamox didn’t help). But at this time other cats in the house were experiencing diarrhea and I brought in multiple fecal samples. Her weight at this time was 10.2 lbs and for the first time a senior blood panel, including thyroid testing, was done on her. It was normal, but one of the fecals came back positive for giardia. This began a brutal week of giving 7 cats Panacur and bleaching everything. The vet also started her on Hill’s i/d, which I was willing to try but with some skepticism, having learned to read labels. The other cats’ diarrhea cleared, but Bumbly persisted. And on 5/2/2007 she went back and received her “annual” vaccines (which will be the last time) with instructions to give her Flagyl as she usually responded to it. I was told she could get Depo-Medrol injections, this vet’s preferred method of steroid administration when needed chronically, if needed in the future.

On 5/30/07, her weight was down to 9.7 lbs when I brought her back in for continuing diarrhea. It responded to Flagyl, but she was getting very resistant to taking it and hiding under the bed all day. I had changed her diet from the i/d as I didn’t feel it was helping and didn’t like the idea of all my cats eating it. She received Depo-Medrol and her diarrhea cleared, with her normal personality returning now that the pill threat was gone.

By 6/20/07 I had joined the Yahoo IBD group and reviewed tons of information including a recommendation to do B12 and folate testing. My vet agreed and Bumbly tested normal. I also asked about limited ingredient diets and we started venison and pea dry by IVD and canned by Natural Balance. We used this for about 5 months, but she was still requiring frequent courses of Flagyl and occasional injections of Depo-Medrol while her weight was gradually decreasing.  Despite all this, she always acted fine, playing like a kitten.

On 9/18/07, she went in for another semi-annual exam and her weight had decreased to 8.65 lbs despite eating, acting well and having no diarrhea. Her vet said she was at ideal weight, not underweight. Her labs were again normal, including thyroid, and the vet discussed possibly doing an ultrasound or even exploratory surgery with biopsies. After being threatened with the possibility of surgery, Bumbly, who is very smart, decided to gain 5 oz in the next week, so we held off on any further work-up. She continued to require Flagyl almost continuously and Depo-Medrol about every other month.

I started experimenting with various treatments that I had read about. These included Gastriplex, which she wouldn’t eat; digestive enzymes, which helped slightly, if at all; pumpkin and Metamucil without obvious success; and probiotics, which I believe may have caused diarrhea in both her and a couple of our other cats. I also continued to experiment with various foods. It was all very tedious and nerve-wracking, changing one thing at a time and waiting for a response. I also began giving her B12 shots.

On 4/29/08 she went in for her semi-annual exam. She had been taking Flagyl and had a Depo-Medrol shot 2 weeks before (I was giving them myself at home). She had no diarrhea, was very active and playful, yet her weight was down to 8.20 lbs. Blood work was again done, including free T4 as I felt she must have hyperthyroidism, but it was all negative, so again an ultrasound was discussed.

By 6/2/08, her weight was stable, but she was requiring Depo-Medrol every 3-4 weeks to control her diarrhea in addition to the Flagyl, and I was worrying about long-term side effects from the steroid injections. I had researched budesonide (Entocort EC) and wanted to try it to reduce the risks, feeling she was likely to be on steroids for life. She had started having diarrhea again for a few days prior which rapidly progressed to being pure water. The vet agreed with starting the budesonide. Though shocked at the price of $7 per capsule, I went ahead and filled it, then devised a system to split them into 1/3rds.  By 6/5 she had improved to pudding consistency, and continued to improve over the next week to mostly normal stools.  Since over the next few weeks she would fairly often have soft stools early in the morning, I began to include ¼ of a Flagyl tablet in the capsule with her budesonide. After a month, when it was clear it was working for her, I had the vet write a prescription for 100 capsules, as they are only $1.85 each from Canadadrugs.com, but they did require you buy 100 (now it’s 90) at a time. She rapidly gained 2 pounds.

She has continued to take this combination ever since, now approaching a year on the same treatment. I have tried to reduce the Flagyl, but she seems to have bacterial overgrowth and begins to have soft, smelly stools, so it appears she is on it for the duration, though at just 1/8 to ¼ pill a day, which is very low risk for toxicity. Every morning she walks out with me to the kitchen and waits for me to put the capsule in her mouth and swallows it – I can’t believe how easy her treatment is now after all we went through, though I know at some point it will probably lose effectiveness and I’ll be experimenting again, as is the nature of this disease. She and the rest of our cats, are eating 4 flavors of Natural Balance canned food and Wellness Core dry – she starts to lose weight if I remove the dry, even though she doesn’t eat very much of it, and the dry doesn’t seem to bother her GI tract. She gets a B12 shot every 3 weeks – that is just what seems to work best for her. She had her semi-annual exam 5/12/2009 and the vet feels she is doing well and her labs were satisfactory.

Some lessons learned so far from this experience:
1.  Every case of IBD is different and there will be a lot of trial and error that will test your nerves.
2.  Most vets don’t have extensive knowledge of the disease, so it is vital for you to do research on your own. As long as your vet is willing to work with you and try different suggestions, you should be OK. If not, consider finding a new one.
3.  A baby scale is invaluable for monitoring.
4.  Learn to read and understand food labels. Don’t count on your vet for nutrition info.
5.  Either check B12 blood levels or just give the injections, or do both – might help, can’t hurt, and is easy and cheap to do.
6.  If you are using metronidazole/Flagyl, it is best given broken up and placed into a gelcap to eliminate the possibility of your cat tasting it.
7.  Consider a holistic vet – I have had great results with another (non-IBD) cat and will probably try this route if/when Bumbly starts having trouble again.
8.  Learn the AAFP vaccination protocols and insist your vet follow them: catvets.
http://www.catvets.com/guidelines/practice-guidelines/feline-vaccination-guidelines

October 5, 2009: Bumbly has been generally stable as far as her IBD is concerned. She’s still on Entocort, Flagyl and B12 injections. With mostly normal stools. Her appetite is good, but her weight has drifted downwards to 9# 1oz. While she is still about ½ pound above her ideal weight, I like to have a buffer in case she has a flare-up. She has a lot of obsessions and compulsions, which to some degree make her personality special. But they had been worsening and she was peeing out of the litter box with increased frequency, so her vet agreed to start her on Prozac. She told me that it can cause constipation as a side effect, so I may need to reduce her IBD meds.  Initially I slightly reduced the Flagyl dose, but then read where Prozac can increase the systemic absorption of Entocort, so instead I reduced that to ¼ cap per day from 1/3rd. She seemed fine for a couple weeks, but then had diarrhea in the morning for 3 days in a row, so she is back on her original Entocort/Flagyl dose and doing well. Her Prozac is squeezed into the #3 gel caps with her other two meds, for a real power pill. The Prozac has worked well, she has mellowed out and the spraying has decreased dramatically.

November 20, 2009: Bumbly went for her semi-annual vet exam 11/16 and was judged to be doing well. Her lab work was essentially normal except for an elevated white blood cell count, which can be caused by stress, and she was very stressed at the visit, as usual. We are going to continue her Budesonide, Flagyl, Prozac, and B12, and the vet consented to trying Adequan injections for possible arthritis, so I will order that online.

May 18, 2010: Bumbly went for her semiannual vet visit yesterday. Her weight is stable at 9#1oz and she has been on the same meds for about 2 years and doing well. The vet remarked that it is unusual for a kitty to respond so well to Flagyl and to require it long-term. She heard a very localized murmur which she has heard intermittently in the past. She does not feel that it’s likely a problem and has never pushed for an echocardiogram. She was intrigued with how faded Bumbly has become, her head is still jet black but her body becomes progressively reddish-brown. I remarked that she has actually darkened some over the winter, by the end of last summer she was really faded. Other than fading from laying in the sun, she had no other explanation. Her labs came back today and everything was normal, except an elevated white blood count which she always has and the vet feels is due to stress and steroids (called a stress leukogram). There are no changes in her treatment.

September 26, 2010: It’s been quite an eventful summer.In June, 2010, Bumbly began having worsening diarrhea. She always seems to flare-up in June, maybe some allergy, so I began wiping her down with a dust cloth and increased her Flagyl to twice a day, which instantly controlled her symptoms. After 10 days I went back to once a day, but the symptoms returned, so her vet said to just keep her on twice a day until the end of the month. But when I went back up, it didn’t control her diarrhea and her appetite decreased, so I went back to once a day and increased her budesonide to 1.5mg daily. This helped some, but there were still pudding poops in the boxes. I also switched their dry food (I have 7 cats) from Before Grain to California Natural to minimize ingredients, but didn’t notice much difference and one of my cats had trouble with the larger pieces so I went back to the Before Grain.

I discussed switching from Flagyl to tylosin with her vet who agreed it was worth a try. I decreased her budesonide back to 1.2 mg daily (using 2 Entocorts to make 5 capsules), and added the tylosin twice a day. This gave reasonably good control of her diarrhea, but I was still seeing pudding poops in the box and began to wonder if there was some other problem as it would seem to happen for a day then be cleared for one or two days. In order to keep their interest in canned food up, I had added several new varieties, Wellness Turkey and Salmon, Precise Turkey, and Best Feline Friends. When I add a new food, I give a can and see if they like it and if it “likes” them by what comes out in the litter boxes before adding it to the rotation. Despite that, something was upsetting several of my cats, so I went back to just the Natural Balance line, 5 different flavors, and things have improved. With the food issue hopefully resolved, I decided to see if I could get Bumbly back on the Flagyl for the once a day dosing convenience.

She did well on Flagyl with 1.2mg budesonide, so I then tapered that back down and we are right back to the doses of IBD meds she was on prior to all this: budesonide 1 mg and Flagyl 62.5mg once a day. I did reduce her Prozac to 1/8 tab (1.25mg) because she was starting to act like a zombie, spending a lot of time staring into space, and she has done well with that adjustment – I’m glad to see her sometimes playing like a kitten again. Her weight actually increased during all this by ¾#, most likely because I stopped putting dry food away at night and leaving just canned out. Hoping she stays stable on this dose, and dreading next June!

November 14, 2010: Bumbly had her semi-annual exam and seemed well to the vet. Her weight is up 3/4#. Labs were drawn and showed a very high white blood count, 30,000. Previously, it has always been elevated due to stress, but this time it was so much higher that the vet was concerned this could be a sign of cancer. Since our doorbell rang an hour before the appointment and we were tearing up the house trying to find the cat who actually had the appointment that day, and, failing that, took Bumbly in instead a week before hers was scheduled, it was a higher stress situation than normal so we are just going to recheck it in a month instead of doing any sort of cancer work-up at this time.

December 29, 2010: Bumbly’s repeat white blood count was unchanged. The vet said it is not uncommon for this situation to indicate cancer, so we did x-rays, which were negative. Originally she had said that unless the x-rays showed cancer in the chest that either an ultrasound or exploratory laparoscopy (latter preferred for better biopsy ability) would be the next step, but since Bumbly had gained 1 1/2 ounces between blood draws and was having no IBD symptoms, she suggested we wait another month and repeat the WBC.

February 16, 2011: Bumbly’s recheck WBC was increased to 32K so we scheduled an ultrasound. Her vet was highly suspicious for cancer, though said that chronic pyelonephritis was a possible infectious cause. She had seemed to be drinking and peeing more, I dip-sticked her urine worried about diabetes, but it was negative for glucose. However it looked more dilute so I thought this was a definite possibility as chronic pyelo causes dilute urine. The radiologist let me watch the ultrasound and explained her findings as she did it. Bumbly has a small area of mild thickening in the small intestine that appeared to be the only part of her bowel affected by IBD. The architecture of the bowel wall was normal meaning cancer was very unlikely so no biopsies were taken there. Her pancreas looked somewhat abnormal and she had a hypoechoic area in her liver which was biopsied. She is now considered to have triaditis due to having IBD along with pancreatic and liver abnormalities. Her kidneys looked normal.

The radiologist drew urine from her bladder for culture and a blood chemistry profile was drawn at her request. The pathology report for the biopsy showed “hepatocellular fatty change and anisonucleosis with subacute, neutrophilic, lymphoplasmacytic hepatitis and bile ductular proliferation”. The fatty change can be from the IBD as can the hepatitis, but bacterial infection may also cause the latter. The bile duct changes can rarely be caused by a liver fluke (parasite) that cats that live here in the deep south get from eating lizards. But Bumbly is my only cat that never bothers with the lizards we get. Nevertheless, I’ll treat her with 3 days of high dose Droncit, just in case. Her urine culture was negative, but her chemistry showed her BUN increased to 30 and creatinine to 2.0, a big increase from just 3 months ago when they were 20/1. 3, the cause of which is unknown, unless the urine culture was a false negative. Her liver function tests were all normal. We started her on Clavamox which led to some diarrhea, so I had to increase her Flagyl to twice a day. If the diarrhea persists we will use Orbax instead. She may require several months of this treatment. She is also to take Denamarin and got her first dose today, and ursodiol which she will start tomorrow. The plan is to recheck a blood count, chemistry, and urinalysis at 1 month. We’ve also stopped her Prozac about 8 weeks ago and we’re increasing her B12 to 1 cc weekly for now.

May 4, 2011: Bumbly had her semi-annual exam and blood work recheck April 27th. She’s lost about a pound, partly due to decreasing the amount of dry food and providing more canned food, her appetite is great but the weight loss is more than it should be. Her exam was remarkable only for having 2-3 teeth that have resorptive lesions and should be pulled. She has never needed a dental in her life prior to this and it is possible her current dental problems may relate to her recently increased BUN and creatinine. Her blood work came back the next day, and her WBC was up to 42,000, a dramatic increase from last month when it was still around 30,000. Her vet feels strongly she has lymphoma given the high WBC, with increased neutrophils and monocytes, along with the weight loss. It is probably the diffuse infiltrative type as her ultrasound was negative for a mass. We discussed doing laparotomy with biopsies, but don’t see much likelihood of that giving information that would change her treatment plan so decided not to do it. We are stopping her budesonide and starting her on prednisolone 5mg daily and Leukeran 2mg twice a week, with recheck CBC in 1 week.  She got her first dose of Leukeran today and tolerated it well. I pre-medicated her with Pepcid a/c to help prevent nausea. For now the dental is on hold until we see how she does with the pred/leukeran.

June 8, 2011: Since there seemed to be some uncertainty about Bumbly’s diagnosis and I didn’t want to do an exploratory laparotomy, for peace of mind I decided to take her for a second opinion from an internal medicine specialist. The one I wanted to see is a mobile vet so he goes to the referring vet’s office, but my cat vets don’t normally use him. On May 13, the day I was sure I wanted a second opinion, I made a same day appointment with another vet who does use that internist in order to get the referral started, and it was a good thing. That day Bumbly had low energy and didn’t seem to be feeling well. I brought copies of all her records and her story from IBDkitties for review. The vet felt she was dehydrated and gave her 75ml subq. Her temp was 102.9, slightly higher than the maximum for a stressed cat, and along with her high white count he gave her a Convenia antibiotic shot. She really perked up after this, was playing the next morning, and the vet wanted me to continue giving her subq fluids over the weekend then twice a week after that. Unfortunately the Convenia gave her diarrhea, which is a known side effect, though not that common.

Her appointment with the internist was set-up for May 18th. I had to pay $150 extra to be in the room with him, but wanted to make sure I could give her entire history and answer and ask questions. He reviewed her records, did a thorough exam, and repeated the ultrasound. It showed mild lymph node enlargement and nothing more. The spot on her liver has resolved. His conclusion was the same, possible lymphoma vs severe IBD. He also said that cholangitis and hepatitis cannot be diagnosed with cytology from needle biopsy; it requires histopathology, ie a larger piece of tissue that would require surgery to obtain. He said to continue the Leukeran, consider increasing the prednisolone to 10mg per day, continue giving B12, but stop the Marin and ursodiol.

Labs were repeated, which again showed the high WBC, but her hematocrit had dropped and I was concerned about anemia from the Leukeran. Her BUN was also lower, though, due to better hydration from the subqs, meaning that blood was more dilute, which would also lower the HCT, so we decided to repeat in 1 week. I returned to her cat vet for that, and the HCT was back up in the previous range, but her WBC had increased even further to 45,000. The vet wanted to increase her prednisolone to 7.5mg per day (she did consider 10mg per day), with recheck CBC in 2-4 weeks. Meanwhile, I posted a question about her needle aspiration of the liver and the internist’s statements about its inadequacy to diagnose to a vet group on Yahoo, and a pathologist did agree with him that you can’t make the diagnosis by cytology. I said that I understand you can’t rule it in based on that, but it doesn’t rule it out, either, and since the spot on her liver cleared and the Marin and ursodiol have very few side effects, wouldn’t it be OK to continue them? She agreed it would. My cat vet said I could go either way and if they are easy to give, which they are, may as well continue them. Bumbly seems to be stable for about a week, now. Her weight loss has slowed considerably, though I wish she would gain. Hoping the pred and Leukeran will work, the internist said when weight loss is the primary symptom, it can take a couple months to see a gain if it is working. We are giving her subqs twice a week. She hates it but is clearly feeling better for the next couple days.

July 31, 2011: Bumbly had another CBC on 6/16/11, and finally had a slight decrease in her WBC to 41.6K. The office has a new vet who has practiced cat-only for years and she called the result to me. She wanted to start Bumbly on azithromycin, daily for 3 days then every other day for 6 weeks, saying she has seen good results with using that in kitties with very high WBC. I had doubts about this given the 3 months of Orbax and Clavamox that we already tried without success, I asked about that, especially in view of Orbax having a similar anti-bacterial spectrum as azithromycin. She still wanted to go ahead, and it was easy enough for me to just add it to her #3 capsules. She had been slowly gaining weight and continued to do so for the next couple weeks, but then started losing it again and by a month later was down again to 7# 12 oz, her lowest which she has hit a couple times. Meanwhile, I noticed a lump near her right shoulder, and she just didn’t seem to feel well, so made an appointment on 7/12 with the vet who’s seen her for years. She also felt Bumbly wasn’t looking good but that the lump was a lipoma, which is benign and doesn’t require any further work-up.

I mentioned she was having some nasty, smelly diarrhea and had just gone before we came in, so she had me bring a sample for an extensive diarrhea study at the lab, as she was concerned something, particularly Giardia, had activated due to the immunosuppressive drugs. I asked about changing from Flagyl to Tylan as I was worried that she may be getting toxicity and feeling poorly after 5 years of Flagyl, the last few months dosed twice a day. She said I could go ahead and experiment, but since Tylan is the same family as azithromycin, may be best to wait until completing the latter. The next day I talked with the new vet, Bumbly’s WBC had come down a little more, to 39K, but such a small response indicated that the azithromycin wasn’t making a difference and she said I could stop it and try Tylan now. The diarrhea panel only came back positive for coronavirus, which she has probably had her entire life as most cats from shelters and catteries do and there is nothing to do for it.

I stopped Flagyl and started Tylan and on the first day it was clear she felt better, she was brighter and had a better appetite. Initially her diarrhea was worse, though the smell wasn’t so putrid, but after a week or so, it became more sporadic and I am suspecting it is occurring as a side effect from the Leukeran, or, possibly, one of the foods may be upsetting her. I’ve removed that food from the rotation and will note if the diarrhea primarily occurs after the Leukeran. She has since gained back the weight she lost, but I just can’t get her over 8# 2oz. She is still requiring subq’s twice a week, and I give her B12 and B-complex with each one. She is to recheck her CBC in 1-2 months. Another concern developing is anemia, her HCT continues to slowly drop, a reticulocyte count showed non-regenerative anemia, a common finding with chronic diseases and also could be due to bone marrow suppression from Leukeran.

September 23, 2011: Bumbly’s WBC is up to 70,000, the cancer is worsening. In addition, she has rapidly lost 1/2# and she is now on comfort measures only. She still seems to feel OK and we will continue her meds, with a slight increase in the dose of pred and cypro, until she tells us it is time.

January 26, 2012: Bumbly had a remarkable response to the increase in pred, she rapidly gained 3/4# and seemed to feel good. In the literature, average survival with her WBC of 70,000 is about 4 weeks, but she was doing very well at that point and her vet said every day with her is a miracle. At Thanksgiving we had family visiting, which has always been a stress for her, and she started losing weight, whether the company visiting was causative or coincidental, I don’t know. She stabilized for a little while afterwards, but then began losing weight rapidly at the end of December. Her diarrhea worsened and she began to get weak in her hind legs, so on January 10th her vet came to the house and helped her pass peacefully.

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