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Author Topic: New Hyperthyroid diagnosis  (Read 3062 times)
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rbauer
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« Reply #15 on: April 08, 2019, 05:11:37 AM »

Hi Mandycat, thanks again for all your kind help with all of this.  It is greatly appreciated and you are truly Mabel's hero!  Below are the lab results cut and pasted.  I could not figure out how to attach files or images.  Hope this is okay.  I emailed Penn with the questions about tailoring the dose and the scan.  Withheld Clavamox last evening and she is eating almost normally again this morning.  Did not start Felimazole yet.  I'd like to discuss the possibility of maybe not even starting it at all and going straight to I131 if the diagnosis is confirmed by other methods and the facility does not require a tapazole trial.  As far as the tooth is concerned, she has a history of crown and root FORLs and extractions.  I'm hoping that maybe this tooth is not a true "infection" but maybe just hurts when she chews on dry food and the clinicians will give us a pass on addressing it before I131 is offered.  I left a detailed message for her doctor and she will likely call this afternoon.


Laboratory:   Antech - Zoasis East
   Profile:   General Senior Profile
   Test   Results   Range
Superchem


Total Protein   6.5 g/dL   5.2 - 8.8
   Albumin   3.4 g/dL   2.5 - 3.9
   Globulin   3.1 g/dL   2.3 - 5.3
   Albumin/Globulin Rat   1.1   0.35 - 1.5
   AST (SGOT)   22 IU/L   10 - 100
   ALT (SGPT)   42 IU/L   10 - 100
   Alkaline Phosphatase   64 IU/L   6 - 102
   GGTP   1 IU/L   1 - 10
   Total Bilirubin   0.1 mg/dL   0.1 - 0.4
   Urea Nitrogen   23 mg/dL   14 - 36
   Creatinine   1.0 mg/dL   0.6 - 2.4
BUN/Creatinine Ratio   23   4 - 33
Phosphorus   4.2 mg/dL   2.4 - 8.2
GLUCOSE   136 mg/dL   64 - 170
Calcium   9.5 mg/dL   8.2 - 10.8
Magnesium   2.0 mEq/L   1.5 - 2.5
Sodium   155 mEq/L   145 - 158
Potassium   4.3 mEq/L   3.4 - 5.6
Na/K Ratio   36   32 - 41
Chloride   122 mEq/L   104 - 128
Cholesterol   137 mg/dL   75 - 220
Triglycerides   66 mg/dL   25 - 160
Amylase   1022 IU/L   100 - 1200  PrecisionPSL   24 U/L   8 - 26
Acute pancreatitis is unlikely. Chronic pancreatitis is not excluded by a normal PrecisionPSL.
CPK   120 IU/L   56 - 529
Complete Blood Count
WBC   7.4    3.5 - 16.0
RBC   8.8    5.92 - 9.93
Hemoglobin   13.6 g/dL   9.3 - 15.9
HEMATOCRIT   39 %   29 - 48
MCV   44 fL   37 - 61
MCH   15.5 pg   11 - 21
MCHC   35 g/dL   30 - 38
Platelet Count   318    200 - 500
Platelet EST   Adequate
Neutrophils   53 %   35 - 75
Bands   0 %   0 - 3
Lymphocytes   37 %   20 - 45
Monocytes   3 %   1 - 4
Eosinophils   7 %   2 - 12
Basophils   0 %   0 - 1
Absolute Neutrophils   3922    2500 - 8500
Absolute Lymphocytes   2738   1200 - 8000
Absolute Monocytes   222    0 - 600
Absolute Eosinophils   518    0 - 1000
Absolute Basophils   0    0 - 150 T4
T4   3.7    0.8 - 4.0
The Total T4 result is greater than 2.5 mcg/dl and less than or equal to 4.0 mcg/dl. A Free-T4 by equilibrium dialysis may aid the diagnosis of hyperthyroidism in cats with clinical signs of hyperthyroidism. Please contact Customer Service for this additional testing.

Urinalysis-Complete
COLLECTION METHOD
Natural Voiding
COLOR   Yellow
Appearance   Cloudy
Specific Gravity   1.046   1.015 - 1.060
PH   8.0   H   5.5 - 7.0
PROTEIN   2+   H   Negative -
Urine protein:creatinine ratio testing is recommended (if the sediment is inactive) to help determine the clinical significance of proteinuria.
GLUCOSE   Negative   Negative -
Ketone   Negative   Negative -
BILIRUBIN   Negative   Negative -
BLOOD   3+   H   Negative -
WBC   0-1 HPF   0 - 3
RBC   11-20 HPF   H   0 - 3
CASTS   None Seen LPF   Hyaline 0 - 3
Triple Phosphate Cry   4-10 HPF

Free T4 By Equilibri
Free T4 (Dialysis)   53.0 pmol/L   H   10 - 50

« Last Edit: April 08, 2019, 05:20:28 AM by rbauer » Logged
GKit
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« Reply #16 on: April 09, 2019, 11:14:31 AM »

rbauer, I hope you were able to get some satisfactory answers from your vet call yesterday. I’m glad Mabel is eating normally again.
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rbauer
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« Reply #17 on: April 09, 2019, 04:04:05 PM »

Thank you Gkit.  The vet wants to do some more testing and check a couple more things.  If those are okay she can then get her dental.  I asked for some testing besides the free.and total T4 because I’m not convinced yet she’s really hyper t.
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Mandycat
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« Reply #18 on: April 09, 2019, 08:53:27 PM »

rbauer,
Sorry for being late replying.  I was not able to be on-line on Monday to see the labs.  Now that I have seen them, I think that the results are so borderline that you might want to wait to treat at all.  If you read the article I send by Dr. Peterson that discussed whether an elevated T4 and/or Free T4 is always diagnostic for hyper-t, you will see that Mabel's result fall in the category of the T4 being at the upper end of the reference range which is the gray area for a definite diagnosis.  Dr. Peterson's advice in that case is to wait and not treat, but to retest in 2-3 months to see if the T4 has increased above the reference range, palpate for the enlarged thyroid nodule, and observe for additional symptoms of hyper-t.  It will not be  harmful to wait with the results being so borderline.  It would be far more harmful to treat when it is not needed.  Treating with the medication may cause hypo-t, which would make Mabel sick, but can be reversed.  However, even that should be avoided if possible.  In the case of doing the I131 treatment, that would totally destroy her thyroid if she were not really hyper-t and would make her permanently hypo-t and cause other adverse effects.  You definitely want to avoid that.  It is your decision to make about treatment, but, IMO, it would be best to wait and see if the diagnosis becomes clearer before treating.  If she is truly hyper-t, you will see additional symptoms and the vet will also observe additional symptoms that you cannot see like increased heart rate,  heart murmur, elevated BP, and the enlarged thyroid nodule.  And, more important, the T4 will increase above the reference range to help confirm the diagnosis.  The most common symptoms you can observe are weight loss despite a ravenous appetite, increased thirst, increased urination, increased vocalization, poor haircoat, overgrooming.  Also, there are some clues that can be seen in the lab results that I do not see at this time.  I think I mentioned that the liver enzymes, especially the ALT, can be elevated, but not indicate any true liver disease.  It returns to normal when the T4 is controlled.  There can be a decrease in the Creatinine due to the increased metabolism caused by  hyper-t increasing filtration through the kidneys.  Mabel's Creatinine is very good, but I would not really know if it is decreased unless it could be compared to a previous test result.  There are some other clues as well, but I don't see any of them on these lab results.  The urinalysis shows blood in the urine. Since a cystocentesis was not done, which can ususally be the cause of blood due to the vet hitting small blood vessel during the procedure, you might want to ask the vet if any follow-up is needed to find the root cause of this blood.  The other abnormalities on the U/A are most likely due to the presence of the blood, with the exception of the crystals.  Nothing in the U/A is due to hyper-t.

I hope this helps a little.
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rbauer
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« Reply #19 on: April 11, 2019, 02:21:58 PM »

Hi Mandycat, thank you for looking at Mabel’s labs and helping us navigate through  all of this information.  I’m so grateful for your help and really glad that we waited and that no medication was started.  I will just recheck the levels in 2-3 months as you suggested to see if the diagnosis becomes clearer. Mabel’s appetite has fully recovered and her stool is pretty much back to normal.  She still has that bad tooth but is doing okay on wet food only now.  At this point the vet still does not want to do her dental yet despite very good lab work.  Now they want me to get an ultrasound of her belly to follow up on something from 5 years ago.  Back then Mabel had  a minor bout of pancreatitis I think was caused by a drug reaction to high dose gaba pentin. The ultrasound said her intestine had minor  thickening, and lymphoma was suggested because of low b12 status.  She did b12 shots for awhile but I never followed up with biopsy.  She’s been perfectly healthy all this time though, so I don’t think it’s lymphoma and is  more likely just IBS/IBD. They might be linking her weight loss with this other condition perhaps.   Then again, she could have lost weight from dropping food and not eating full servings due to tooth pain. At this point I just would like her to have a dental and get that bad tooth out so that she can enjoy eating again.  I believe that the tooth is an acute situation that needs immediate attention.  I’d be happy to do ultrasounds and what not after the tooth is taken care of, but the vet doesn’t want to do things in that order.  They want to do the ultrasound, test TLI, PLI, cobalamin, and folate and then refer to a specialist if needed.  Mabel just got her appetite back, diarrhea is resolving and she’s happy and playing again.  I would have to fast her and put her through all this. Feeling a little frustrated.  I don’t think she’s very hyper t and there’s nothing really in her labs that says she can’t handle anesthesia for a dental.  Her blood pressure was 140 / 140 / 140.  What do you think if I go get the dental done elsewhere?  And then come back and follow up with the abdominal  workup when she’s pain free? Or are they really right and I should just follow the plan?  I could let them do the abdominal work up on Monday but am just concerned if I would be jumping the gun and chasing another non emergency again (like the hyper t) and delaying the bad tooth.  The only thing that’s absolutely certain right now is there’s a bad tooth and Mabel is in pain.  I don’t know what to do.  What do you think? Im really grateful for all your help Mandycat.  Thanks.  
« Last Edit: April 11, 2019, 06:16:26 PM by rbauer » Logged
rbauer
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« Reply #20 on: April 12, 2019, 10:49:49 AM »

I emailed with Mabel’s doctor and she was very kind and understanding of my concerns and explained why we need to go in the order that she wants.  I decided to just follow her plan and do the ultrasound, blood work, and b12 on Monday.  Hopefully the dental can follow soon after. In the meantime Mabel is eating canned food okay.
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Fizzy1
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« Reply #21 on: April 12, 2019, 12:22:07 PM »

Rich, I'm glad you've had your questions answered by your vet.  It's so hard to know what to do!  Please keep us posted on Mabel's tests on Monday.  It's great to hear she's eating the canned food.  Hang in there!  Kiss
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I once asked a four year old what the secret of life was.  "Feed the kitties," she said, "Feed the kitties."--Ellis Felker
Mandycat
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« Reply #22 on: April 12, 2019, 08:52:02 PM »

I don't quite understand why your vet wants to do the GI work-up, but I will have to just accept that she knows more about Mabel than I do when it comes to that.  As for the tooth, IMO, it would probably be safe to get it taken care of.  I personally prefer using a veterinary dentist to do all dental work except simple cleanings.  With Mabel's dental history, that is what I would suggest doing.  In any event, I think you need a second opinion on how to handle the dental issue.  I'm not understanding why your vet would just allow Mabel to remain in pain.
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rbauer
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« Reply #23 on: April 13, 2019, 03:22:12 PM »

Hi Mandycat.  Thanks for your reply.  I had been taking Mabel to the University of Pennsylvania dental clinic for many years and they did her extractions and even a root canal on a canine tooth but it was getting a little pricey.  She was getting one FORL after another.  Penn is still an option, and a very good one.   I am not completely on board with this ultrasound idea myself, but I will go through with it.  Mabel gets the poops a lot and I think it’s just chronic IBD but who knows.   I don’t think it will hurt to get the scan and labs and it may give me some peace of mind about what ever went on before with the pancreas and thickened bowel.
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rbauer
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« Reply #24 on: April 15, 2019, 12:22:38 PM »

Mabel had her ultrasound today.  She has active pancreatitis (again) and her intestine has inflammation but it doesn’t look like the kind of inflammation that requires biopsy.  Kidneys have changes consistent with an older age cat and need to be watched.  She got her b12 shot and the other lab results for pancreas and gi should be back in a day or two.  Hoping for a dental in a couple weeks if the medical director feels that all these other things are under control.  Treatment plan is buprenorphine for comfort, Pepcid for early morning vomits, oral b12, royal canine gastrointestinal high energy food, and repeating t4 labs in a few weeks with possible 1.25 mg felimazole.  Any new diarrhea might be treated with metronidazole and we also talked about using it to calm the intestines down.  I feel relieved and am grateful that Mabel is mostly okay.  Also am very grateful for all of the support from everyone here.  Thanks so much.
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Mandycat
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« Reply #25 on: April 15, 2019, 05:00:22 PM »

It appears that perhaps the pancreatitis is mild and will resolve pretty quickly.  The lab results will help to verify that.  I hope that she will be able to get the dental done sooner rather than later.  Let us know the results of the GI tests, and also the retest of the T4 when you do that.  Did you ever ask your vet about the urinalysis results?  I do think that the root cause of the blood in the urine needs to be explored since the urine was not collected by cystocentesis.  It could just be due to idiopathic cystitis, which is believed to be caused by stress.  You probably should repeat the urinalysis when you retest for the hyper-t to see if there is still blood in the urine.  You might consider doing a culture & sensitivity along with the U/A to rule out any infection also.  Just suggestions.  Discuss it with your vet. 
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alek0
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« Reply #26 on: April 15, 2019, 05:53:02 PM »

No experience with hyperthyroidism, but I would just like to add that vit B supplements do wonders for an older cat. My Mitzie is on oral vit. B complex and vit. B 12 (I use human supplements and just cut them), she was mildly anaemic before we started regular vit B supplementation but this has completely resolved after the supplements. With age the absorption of vit. B from food becomes less efficient, and since it is water soluble no harm done if there is excess.

Also, since we ask the vet for vit. B shots when we have to travel to reduce number of pills that pet sitter needs to give so Mitzie and Max would be less stressed out, there seem to be some new formulation of vit. B injections which doesn't sting. Not sure if that has been available on your side of Pacific for a while, for us is new, but wanted to mention it just in case you don;t know that there are different ones, some which are apparently painful and some which are not.
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rbauer
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« Reply #27 on: April 16, 2019, 03:16:35 PM »

The lab results did not come back yet but they emailed the full ultrasound report.  Mabel’s vet also said that we can definitely repeat the U/A with cytocentesis when we recheck the T4.  Thank you so much for catching that Mandycat.  You’re Mabel’s hero again Smiley  

Alek0 thank’s for sharing about Mitzie’s vitamin regimen.  I will ask about that too.  I think the plan is for me to use an oral b12 because I had expressed some discomfort with the idea of injecting Mabel. Not sure what we’ll be doing.

There is a vitamin Mabel sometimes uses for runny eyes.  Lysine.  Either powdered on wet food or the Viralys gel brand.  
« Last Edit: April 18, 2019, 05:48:10 AM by rbauer » Logged
rbauer
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« Reply #28 on: April 18, 2019, 05:55:52 AM »

Mabel’s lab work came back yesterday and her folate and pancreatic function was normal.  Her cobalamin was <150 and the normal range is 200-1500.  She received one B 12 injection on Monday. The plan is to give her one tablet of cobalaquin per day.  The early morning vomits have stopped since initiating 1/4 tablet of Pepcid at bedtime. My only question about it is if it is safe for long term nightly administration.  She seems to be enjoying the Royal Canin gastrointestinal high energy diet and her stools have been normal for several days since initiating it. I soak it in water for 45 minutes before serving it because of her tooth sensitivity.  We’ll recheck all labs and do a cytocentesis urinalysis in about 3 weeks.  Pending those we’ll schedule her dental and make decisions about the thyroid treatment if the levels still looks high.  I’m concerned about the kidney findings on ultrasound now that I’ve seen the report.  Her labs are still good in that regard however, so I’m not sure that we can really do much right now except continue observing them.  Thanks again for everyone’s help and support.
« Last Edit: April 18, 2019, 06:51:35 AM by rbauer » Logged
Fizzy1
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« Reply #29 on: April 18, 2019, 06:41:01 AM »

Thanks for the update.  I don’t think there is any problem with giving the Pepcid nightly.  It’s good to hear Mabel is eating better.   Smiley
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I once asked a four year old what the secret of life was.  "Feed the kitties," she said, "Feed the kitties."--Ellis Felker
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