Sunday, November 7, 2010

238. Integrity of the vet

"No general anaesthesia," the young man suggested local anaesthesia as he was worried that his cat might die on the operating table. His cat was weak as he had been sneezing blood and had runny noses for the past 2 months. He wanted my second opinion after Vet 1 advised a CT scan costing $1,500 excluding surgery for 2 lumps above the right nostril and below the right eye.

"Local anaesthetic cannot be applied to this area as there is not much space due to the large size of the growth," I said. "The cat would feel the pain of injections of the local anaesthetic and scratch me." I had a feeling that this cat was suffering from tumour as he had around 3 grey melanomas in the ear pinnae. Both ears and melanomas may have spread to this nose area.

The following was briefly how I handled this case with the least cost as required.

PROCEDURES
1. History & Palpation of the tumour. Firm but no pain. The cat had 10 days of vibravet 50 mg at 3/4 tablet per day from Vet 1. Now he had yellow runny nostril on the right side. "Did he get nose discharge on the left nostril?" I asked the young man. "No," he said. But I could see the brownish stain not completely wiped out, below the left nostril (see picture). His mum later confirmed that the cat had discharge of both nostrils.

2. Aspiration with 18G needle. The quiet cat was held by my assistant (without wrapping him in a towel as it should be done. My right wrist was scratched). I aspirated 0.02ml of red blood from the bigger of the two lumps.

3. Incision for biopsy. I used the scalpel to excise the lump to see what is inside. As I had promised the young man, I did not use general anaesthesia. The cat raised his front left paws weakly a few times. I got scratched once as I took out 2 pieces of the greyish maroon muscle-like mass below the skin, put in formalin and sent them to the Laboratory.

4. Anaerobic bacterial cultures and Gram stain were not done as the cat just had been on 10 days of antibiotics from Vet 1.

5. I had asked my assistant to clip the hairs of the forelegs so as to insert the IV catheter easily. This was done with no prolem. Blood test and an IV drip was done. In the IV saline drip to be given as 500 ml, I put in baytril antibiotic according to weight, a small 0.2 ml dexamethosone anti-inflammatory and metronidazole according to weight.

RESULTS
Least veterinary cost is what the young man's father wanted. With the above procedures, the cost was "affordable" as it was well below $1,000 since there was no general anaesthetic and surgery. And no possibility of death.

24 hours later, the cat had no runny left nostril. I did not expect such drastic improvement. He went home on Day 3 with Baytril antibiotics. He had no problem with runny nose and was eating well. Lab reports indicate he had cancer - malignant cellular infiltrate with a differential diagnosis including malignant melanoma. I advised surgical excision but the father wanted to wait and see.

LAB REPORT. Cat, M, 6 years. Soft tissue lesion, near muscle. MALIGNANT CELLULAR INFILTRATE. Different diagnosis includes malignant lymphoma, malignant melanoma, carcinoma or sarcoma. Immunostains needed to delineate and type the tumour.

CONCLUSION.
A biopsy is important in growths. A CT scan of $1,500 is too costly for most cat owners. In chronic sinusitis as suspected in this case, a gram stain, a fungal and anaerobic culture would be good but these were not done as the cat had been on antibiotic in the past 10 days. There was a budget from the owner.

Metronidazole IV may be effective in this case when combined with Baytril. As there was no bacterial culture done, it was hard to say what caused the blood sneezing and nose discharge. Metronidazole is effective against anaerobic bacteria (unique anaerobic bactericidal activity). It seldom cause the pseudomembranous colitis sometimes associated with the use of clindamycin. Metronidzole is said to be potentially mutagenic (likely to cause cancer), but short-term use has not been shown to cause cancer.

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