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18 CLINICAL FELINE

Veterinary Times

Degeneration of autonomic nervous


system in feline dysautonomia case
A five-year-old male neutered
British blue cross cat arrived
having become progressively
depressed and anorexic over
the past three days.
It had regurgitated twice that
morning and had appeared to be
straining to pass faeces indoors,
which was most out of character
as the cat usually defecated outdoors. For the past 24 hours the
third eyelids had become prominent, especially in the left eye.

Clinical examination
Temperature: 38.1C.
Pulse: 120 per minute.
Respiration: 36 per minute.
The cat was moderately dehydrated and the nose was slightly
dry. In addition to the third eyelids protruding, the pupils were
also dilated and had no pupillary
light reflex. Menace and palpebral
reflexes were intact, ophthalmic
examination revealed no abnormalities and vision was deemed
normal. The conjunctiva were
mildly hyperaemic.
Other mucous membranes
were a normal colour, and CRT
was two seconds. A Schirmer
tear test (STT) revealed reduced

VICKI BROWN

VetMB, BA, BSc, MRCVS

discusses the case study of a British blue cross


cat presenting with depression and anorexia
tear production in both eyes: the
left eye had a flow of 7mm per
minute and the right was 10mm
per minute. Peripheral lymph
nodes were normal and auscultation of the heart and lungs
revealed no abnormalities. Palpation of the abdomen revealed
constipation. Proprioceptive
responses appeared to be normal, although it was thought that
anal tone was reduced.

Hiatal disorder.
Oesophageal neoplasia.
Oesophageal diverticulum.
Constipation and
faecal tenesmus
Dietary: foreign
material in faeces.
Obstruction: extraluminal
perirectal/perianal tumour, peril

neal hernia and pelvic fracture;


intraluminal neoplasia, granuloma, diverticulum/prolapse and
foreign body.
Neuromuscular: lumbosacral
cord disease, bilateral pelvic
nerve injury, dysautonomia,
CNS disease (lead), idiopathic
megacolon and cauda equina
syndrome.
Dehydration.
Metabolic disorders:
hypokalaemia, hypercalcaemia,
hyperparathyroidism and phaechromocytoma.
Painful defection: anal sac
abscess, perianal fistula, anorec-

Problem list and


differential diagnosis
Regurgitation
Megaoesophagus:
idiopathic, myasthenia gravis,
polyneuropathy (such as FD),
systemic lupus erythematosus
or toxicosis.
Motility disorder.
Foreign body.
Stricture: intraluminal lesion
and extraluminal compression.
Oesophagitis.
l

From

tal stricture/tumour, proctitis,


spinal injury and pelvic injury.
l Keratoconjunctivitis sicca,
mydriasis and protruding
third eyelids
Dysautonomia.
Toxoplasmosis.
Hypocalcaemia.
Retrobulbar lesion/tumour.
Glaucoma.
Toxicosis.
Tetanus.
l Anorexia
Dietary/oral disorder
not applicable.
Systemic disease causing
inappetence.

Depression
GI tract disease as primary
cause for example, leading to
systemic infection.
Systemic disease with secondary GI disease for example,
dysautonomia.
l

Investigation
Initially, blood haematology and
biochemistry were performed
(Table 1). This revealed haemoconcentration and hyperproteinaemia, which reflected the
patients dehydration. FeLV and
FIV tests were negative and a
blood smear was unremarkable.

rr

gUrr

A healthy well fed British blue cat. Clinical signs of feline


dysautonomia are regurgitation, constipation, dilated pupils,
prolapsed third eyelids and reduced tear secretion.
Table 1. Blood haematology and biochemistry
Test

Result

High/
low

Normal value

Units

Haemaglobin
Haematocrit

18
0.56

H
H

8-15
0.24-0.45

G/dl
L/l

MCHC

32

30-36

G/dl

White blood cells

16.5

5-18

x109/l

Neutrophils

10.2

3-14

x109/l

Lymphocytes

6.3

1.5-7

x109/l

Eosinophils

<1.0

x109/l

Monocytes

<0.5

x109/l

Platelets

434

175-500

x109/l

ALKP

135

0-193

IU

ALT

67

0-100

IU

Urea

6.6

5-12.85

Mmol/l

Creatinine

80

71-212

Umol/l

Glucose

5.8

3-8.06

Mmol/l

Total protein

88

57-89

G/l

Albumin

42

29-39

G/l

Globulin

46

24-44

G/l

Cholesterol

3.2

1.68-5.81

Mmol/l

Amylase

891

456-1,376

IU

Total bilirubin

0-9

Umol/l

Calcium

2.4

2.03-2.9

Mmol/l

Phosphate

1.9

1.0-2.42

Mmol/l

Sodium

138

135-155

Mmol/l

Potassium

5.0

3.3-5.5

Mmol/l

VT38.08 master.indd 18

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29/2/08 10:49:22

CLINICAL FELINE 19

March 10, 2008


After 24 hours of intravenous
fluids, the cat was hydrated and
brighter and had passed faeces.
A test meal was fed to the cat
but was regurgitated within five
minutes of consumption.
The cat was then anaesthetised with propofol and maintained with isoflurane carried in
oxygen. A stomach tube administered 10ml of barium paste,
and a lateral thoracic radiograph was taken. This revealed
oesophageal dilation and no sign
of aspiration pneumonia. As cost
was of concern to the owner, no
further radiographs were taken.
The ocular response to 0.1
per cent pilocarpine and the third
eyelid response to 1:10,000
epinephrine was assessed
comparing the results with a control cat (Table 2). These revealed
denervation hypersensitivity.
Following these investigations,
feline dysautonomia was sus-

pected and so a clinical scoring


system was drawn up. Following this, the patient scored 11.
Diagnosis: feline dysautonomia.
Prognosis: guarded.

Treatment
The patient was given intravenous
Hartmanns solution (Aquapharm
number 11, Animalcare) at a rate
of 10ml/kg/hour for two hours.
The drip rate was then slowed
to 4ml/kg/hour. Hypromellose
0.3 per cent (non-proprietary)
eye drops were given every two
hours. Pilocarpine one per cent
(non-proprietary) eye drops
were given every eight hours
to aid oronasal and lacrimal
secretion.
A dose of 3mg metoclopramide hydrochloride (Emequell,
Pfizer) was given by intravenous infusion to improve gastric emptying. A liquid paraffin enema was administered.

Food and water were withheld.


After 24 hours the cat had
defecated successfully. Intravenous fluids were ceased and the
patient was started on cisapride
tablets (Prepulsid, Janssen-Cilag)
at a dose rate of 5mg BID (100g/
kg). A test meal was regurgitated.
A naso-oesophageal tube was
placed to prevent aspiration of
oesophageal contents.

Follow-up
Regular small meals per os were
offered from a raised platform
from the third day of treatment.
Regurgitation was significantly
reduced with the aid of cisapride,
although not entirely eliminated.
The cat was discharged
on cisapride, pilocarpine and
hypromellose (as above). Two
weeks later the cat was doing
well and gaining weight. Constipation was present intermittently
and the owner was provided

back to

with white soft paraffin 475mg/g


(Katalax, C-Vet VP) to administer
as necessary (half to one inch of
paste one to two times daily).
Six weeks later the cat re-presented in a very depressed state,
with severe dyspnoea and crusting around the nose. The owner
had not re-ordered cisapride
when the supply had finished
and the cat was regurgitating
after every meal.
For the past two days it had
been anorexic, and was severely
dehydrated on presentation.
Constipation was marked, the
coat was very poor, and the eyes
were crusted. Auscultation of
the lungs revealed consolidation
of the ventral lobes and aspiration pneumonia was strongly
suspected. Although emergency
treatment was offered, the owner
declined and the cat was euthanised. Permission for postmortem examination was refused.

PUrrrrr

Table 2. Ocular pharmacological tests (after Cave, 2003)


Pupillary response to
0.1 per cent
pilocarpine solution

Membrana nictitans
response to 1:10,000
adrenaline solution

Feline
dysautonomia

Miosis within
12 minutes

Retraction

Control

No response

No response

Discussion
Feline dysautonomia is a disease
of domestic cats characterised
by extensive degeneration of
the autonomic nervous system
(Cave, 2003). Within a few days,
clinical signs develop, characterised by regurgitation, constipation, dilated pupils (which are
unresponsive to light) prolapsed
third eyelids and reduced tear
secretion (Sharp et al, 1984).
Feline dysautonomia was first
reported in 1982 in the UK but
has now also been seen sporadically in the US, other European
countries, New Zealand and the
United Arab Emirates (Sharp et
al, 1984). Feline dysautonomia
appears to be one of a group of
primary dysautonomias affecting
dogs, hares, rabbits and horses.
These diseases have very similar
pathophysiology. To date, the
causes of this group of diseases
remains unknown (Cave, 2003).
Although differential diagnoses
are few in cats with multiple
cardinal clinical signs, definitive
diagnosis requires histopathological examination of autonomic ganglia at postmortem.
It is not known how sensitive
and specific the clinical scoring
system for antemortem diagnosis is (Table 3). Ideally, thoracic
radiology should be performed
with the cat conscious as sedation and anaesthesia can cause
megaoesophagus. However,
adequate restraint of the patient
in the conscious state was not
possible in this case.
As the aetiology of feline dysautonomia is unknown, treatment is symptomatic. Pilocarpine
is an autonomic stimulant; poten-

tial side effects (abdominal cramps


and muscle fasciculations) were
not seen in this case. Metoclopramide improves gastric emptying in feline dysautonomia (Sharp
and Gookin, 1995).
In a study by Cave et al (2003),
no improvement in oesophageal
motility was detected by fluoroscopy in cats treated with cisapride
(1mg/kg every eight hours per
os) but increased rates of regurgitation were noted when it was
withdrawn seven days during
chronic management.
Original reports described
survival in less than 30 per cent of
cases (Sharp et al, 1984). However, more recent studies show
that in less severely affected
cats survival rates are higher
(Blaxter and Gruffydd-Jones,
1987). Heart rate measurement
may be a prognositic indicator;
heart rates in surviving cats were
higher (Cave et al, 2003). In this
case the heart rate was at the low
end of the reference range.
References
Blaxter A and Gruffydd-Jones, T
(1987). Feline dysautonomia, In
Practice 9: 58-61.
Cave T A, Knottenbelt C et al (2003).
An outbreak of feline dysautonomia
(Key-Gaskell syndrome) in a closed
colony of pet cats, The Veterinary
Record 153: (13) 387-392.
Sharp N J H, Nash, A S et al (1984).
Feline dysautonomia (the Key-Gaskell
syndrome): a clinical and pathological
study of 40 cases, Journal of Small
Animal Practice 25: 599-615.
Sharp N J H, and Gookin j l (1995).
Visceral and bladder dysfunction
and dysautonomia. In Wheeler S J
(ed), Manual of Small Animal Neurology (2nd edn), BSAVA publications,
London: 179-188. n

Table 3. Clinical scoring system for feline dysautonomia


(after Sharp and Gookin, 1995)
Group A clinical features

Score

Patient

Dry, crusty nose

Reduced tear secretion (STT less than 5mm/min)

Mydriasis or reduced pupillary light response

Bradycardia (heart rate less than 120bpm)

Regurgitation and demonstration of oesophageal


dysfunction by radiography

Constipation

Proprioceptive deficits

Dry oral mucosae

Prolapsed membrana nictitans

Dysuria or bladder atony

Anal reflexia

Group B clinical features

... comINg

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VT38.08 master.indd 19

Score

Clinical grade

Clinical diagnosis

1-4

Inconclusive

5-8

Probable

9-12

Positive

13-16

Positive

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