Feline Medicine. Michael Lappin, DVM, PhD, DACVIM. Sponsored by

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1 Feline Medicine by Michael Lappin, DVM, PhD, DACVIM March 11, 2009 Sponsored by

2 UPDATE ON FELINE INFECTIOUS DISEASES Michael R. Lappin, DVM, PhD, DACVIM The Kenneth W. Smith Professor in Small Animal Clinical Veterinary Medicine College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins Colorado FELINE GASTROINTESTINAL DISEASES Clinical problem and differentials. Vomiting is the forceful ejection of stomach and proximal duodenal contents through the mouth. Vomiting can be induced by vestibular, vagal, chemoreceptor trigger zone, or direct input to the emetic center. Diarrhea is a characterized by increased frequency of defecation, increased fluid content of the stool, or increased volume of stool. Markedly increased frequency of defecation, small volume stools, tenesmus, urgency, hematochezia, and mucus are consistent with large bowel diarrhea. Slight increase in frequency of defecation, large volume, melena, steatorrhea, and polysystemic clinical signs are more consistent with small bowel diarrhea. Mixed bowel diarrhea is a combination of characteristics or clinical signs. Gastrointestinal (GI) signs can be the result of primary diseases of the GI system or secondary GI diseases. The secondary GI diseases are generally those of the kidneys, liver, pancreas (pancreatitis or exocrine pancreatic insufficiency), endocrine system (hypoadrenocorticism; diabetic ketoacidosis; hyperthyroidism), or central nervous system. Differential diagnoses for primary GI diseases are often grouped into obstruction (masses, foreign body, and intussusception), dietary intolerance, drugs/toxins (garbage gut), inflammatory gastric and bowel diseases, neoplasia, infectious diseases, and parasites. The primary bacteria associated with gastrointestinal tract disease in cats include Salmonella spp., Campylobacter jejuni, Clostridium perfringens, Helicobacter spp., bacterial overgrowth syndrome, bacterial peritonitis, and bacterial cholangiohepatitis. The primary viral agents include feline coronaviruses, feline leukemia virus, feline immunodeficiency virus, and feline panleukopenia virus. The primary nematodes are Ancylostoma/Uncinaria, Strongyloides cati, Dirofilaria immitis (vomiting), Toxocara cati, Toxascaris leonina, Ollulanus tricuspis, and Physaloptera spp. Enteric protozoans include Giardia spp., Cystoisospora spp., Cryptosporidium spp., Entamoeba histolytica, and Tritrichomonas foetus. The cestodes Taenia, Dipylidium, and Echinococcus generally cause subclinical infection. DIAGNOSTIC PROCEDURES FOR INFECTIOUS DISEASES Direct smear. Liquid feces or feces that contains large quantities of mucus should be microscopically examined immediately for the presence of protozoal trophozoites, including those of Giardia spp. and Tritrichomonas foetus. A direct saline smear can be made to potentiate observation of these motile organisms. The amount of feces required to cover the head of a match is mixed thoroughly with one drop of 0.9% NaCl. Following application of a coverslip, the smear is evaluated for motile organisms by examining it under 100X magnification. The sample should be fresh. The material for evaluation should be collected from the surface of the fecal material, preferably mucous if present. Alternately, a rectal scraping can be used. 1

3 Stained smear. A thin smear of feces should be made from all cats with large or small bowel diarrhea. Material should be collected by rectal swab if possible to increase chances of finding white blood cells. A cotton swab is gently introduced 3-4 cm through the anus into the terminal rectum, directed to the wall of the rectum, and gently rotated several times. Placing a drop of 0.9% NaCl on the cotton swab will facilitate passage through the anus, but not adversely affect cell morphology. The cotton swab is rolled on a microscope slide gently multiple times to give areas with varying smear thickness. Following air drying, the slide can be stained. White blood cells and bacteria morphologically consistent with Campylobacter jejuni or Clostridium perfringens can be observed after staining with Diff-Quick or Wright's-Giemsa stains. Histoplasma capsulatum or Prototheca may be observed in the cytoplasm of mononuclear cells. Methylene blue in acetate buffer (ph 3.6) stains trophozoites of the enteric protozoans. Iodine stains and acid methyl green are also used for the demonstration of protozoans. Acid-fast or monoclonal antibody staining of a fecal smear should be performed in cats with diarrhea to aid in the diagnosis of cryptosporidiosis. Cryptosporidium parvum is the only enteric organism of approximately 4 to 6 µ in diameter that will stain pink to red with acid-fast stain. Presence of neutrophils on rectal cytology can suggest inflammation induced by Salmonella spp., Campylobacter spp., or Clostridium perfringens; fecal culture is indicated in these cases. Fecal enterotoxin measurement should be considered for cats with spore-forming rods morphologically consistent with C. perfringens. Fecal flotation. Cysts, oocysts, and eggs in feces can be concentrated to increase sensitivity of detection. Most eggs, oocysts, and cysts are easily identified after sugar or zinc sulfate centrifugal flotation. These procedures are considered by many to be optimal for the demonstration of protozoan cysts, in particular, Giardia spp. and so is a good choice for a routine flotation technique in practice. Sugar centrifugation can be used for routine parasite evaluation and may be superior to many techniques for the demonstration of oocysts of Toxoplasma gondii and Cryptosporidium spp.. Giardia cysts are distorted by sugar centrifugation but can still be easily identified. Fecal sedimentation will recover most cysts and ova, but will also contain debris. This technique may be superior to flotation procedures for the documentation of Eurytrema procyonis, the pancreatic fluke. Strongyloides cati larva may be easier to identify after concentration using the Baerman funnel technique. Culture. Culture of feces for Salmonella spp., Campylobacter spp., and Clostridium perfringens is occasionally indicated in small animal practice. Approximately 2-3 grams of fresh feces should be submitted to the laboratory immediately for optimal results, however, Salmonella and Campylobacter are often viable in refrigerated fecal specimens for 3-7 days. Appropriate transport media should be available through your laboratory. The laboratory should be notified of the suspected pathogen so appropriate culture media can be used. More than 1 culture may be needed to prove infection. Tritrichomonas foetus can be cultured from feces of cats in general practice using a commercially available kit (InpouchTM, Biomed Diagnostics). Some Giardia spp. isolated from cats will grow on culture media, but this technique is not generally performed in small animal practice. Immunologic techniques. Parvovirus, Cryptosporidium parvum, and Giardia spp. antigen detection procedures are available for use with feces. Canine parvovirus antigen assays appear to detect feline parvovirus antigen. A fluorescein-labeled monoclonal antibody system is 2

4 available that contains monoclonal antibodies that react with Cryptosporidium spp. oocysts and Giardia spp. cysts. However, the assay was developed for detection of human isolates and it is possible that cat isolates may not always be detected. In addition, a fluorescence microscope is required and so the assay can only be performed in diagnostic laboratories. Antigens of Giardia spp. or Cryptosporidium spp. can be detected in feces by enzyme-linked immunosorbent assays. Most fecal antigen studies in cats have evaluated with kits developed for use with human feces and so it is possible that cat isolates may not always be detected. This appears to be true for Cryptosporidium spp. assays and they should not be used with cat feces. Recently, an in clinic Giardia spp. antigen test for use with dog and cat feces was released and seems to detect feline isolates. Serum antibodies against D. immitis can be measured in cat serum but positive test results do not prove current infection or disease induced by D. immitis. FeLV can cause lymphoma and induces the panleukopenia-like syndrome. FIV has been associated with lymphoma and can cause enteritis. Detection of FIV antibodies or FeLV antigen in serum documents exposure, but does not prove that clinical disease is due to the virus. The only way to document that gastrointestinal signs are due to FeLV or FIV is to exclude other known causes. Electron microscopy. Electron microscopy can be used to detect viral particles in feces of cats with gastrointestinal signs of disease. Approximately 1-3 grams of feces without fixative should be transported to the laboratory by overnight mail on cold packs. Endoscopy or exploratory laparotomy. Ollulanus and Physaloptera rarely pass ova in feces and so frequently are diagnosed only by endoscopy. Diagnosis of diffuse inflammatory diseases can be made by evaluation of endoscopy or surgically obtained tissue samples. Endoscopically obtained biopsies are small; I generally take at least 8-10 biopsies from stomach, duodenum, colon, and ileum if possible. Even if a lesion is present, endoscopically obtained biopsies can be falsely negative requiring full thickness biopsies. Gastric biopsies should be placed on urea slants to assess for urease which is found in the cell wall of Helicobacter spp.. The combination of inflammation, exclusion of other causes of inflammation, presence of gastric spiral bacteria, and positive urease testing can be used as a presumptive diagnosis of gastric helicobacteriosis. There is no benefit to performing duodenal aspirates for quantitative bacterial cultures or Giardia trophozoite evaluations in cats; the normal bacterial count range is very broad in cats and Giardia is found in the distal small intestine. Regional enteritis due to feline infectious peritonitis can be confirmed by documenting the organism in tissue after immunohistochemical staining. Polymerase chain reaction. Polymerase chain reaction (PCR) is currently available to detect Giardia spp., Cryptosporidium spp., and T. foetus in feline feces. For Cryptosporidium spp., PCR is 10 to 1,000 fold more sensitive than IFA. Reverse-transcriptase PCR can be used to detect coronavirus RNA in feces of cats but is not specific for feline infectious peritonitis. INFECTIOUS DISEASE TREATMENT OPTIONS There are multiple drugs used in the treatment of gastrointestinal parasitic infections. For all kittens, the strategic deworming recommendations for the control of hookworm and roundworm infections from the Centers for Disease Control and the American Association of Veterinary Parasitologists should be followed by veterinary practitioners. 3

5 ( Kittens should be administered an anthelmintic at 3, 5, 7, and 9 weeks of age and then periodically monitored or treated. If the kitten is not presented to the clinic until 6-8 weeks of age, administer the anthelmintic at least 2-3 times, 2-3 weeks apart. Pyrantel pamoate and fenbendazole are usually effective drugs for use in strategic deworming programs and for the treatment of nematodes causing gastrointestinal tract disease. Albendazole is more likely to cause hematologic sideeffects than fenbendazole and so should not be used in cats. Even if anthelmintics for hookworms and roundworms are administered, a fecal flotation should be performed to evaluate for other parasites. Monthly D. immitis preventatives can help control or eliminate some nematode infections as well as prevent heartworm infection. Ivemectin at heartworm preventative doses is effective for control of hookworms but not roundworms. Thus, selamectin or milbemycin should be used in regions where roundworm infections are common. Selamectin has the advantage of controlling fleas as well and so may lessen the potential for Bartonella spp., Rickettsia felis, and Haemobartonella (Mycoplasma) spp. infections. Dipylidium and T. taeniaformis infestations usually are eliminated by praziquantel or espiprantel; fenbendazole is effective for Taenia taeniaformis. Since Echinococcus multilocularis can be a significant zoonosis transmitted to cats by carnivorism, hunting cats in endemic areas should be treated up to monthly. Administration of a pyrantel/praziquantel combination may be effective in these cats since praziquantel is approved for the treatment of Echinococcus and roundworms are also transmitted by carnivorism. Withholding food for 24 to 48 hours is indicated in cats with acute vomiting or diarrhea. Highly digestible, bland diets are used most frequently if vomiting and small bowel diarrhea are the primary manifestations of disease. High fiber diets are generally indicated if large bowel diarrhea is occurring. Diarrhea associated with Giardia spp. generally resolves during or after administration of metronidazole. In a recent study, cyst shedding resolved in 26 cats after the administration of metronidazole benzoate at 25 mg/kg, PO, q12hr for 7 days. Metronidazole also helps correct the anaerobic bacterial overgrowth that commonly accompanies giardiasis. If inflammatory changes exist, metronidazole may also be beneficial due to inhibition of lymphocyte function. Central nervous system toxicity occasionally occurs with this drug; it is unlikely if no more than 50 mg/kg, PO, total daily dose is given. Fenbendazole has not been studied extensively for treatment of giardiasis in cats. In one experiment study of cats coinfected with Giardia spp. and Cryptosporidium spp., four of eight cats treated with fenbendazole at 50 mg/kg, PO, daily for 5 days stopped shedding Giardia cysts. The combination product of febantel, pyrantel, and praziquantel has been shown to have anti-giardia activity in dogs. When given at the febantel dose of approximately 56 mg/kg, PO, daily for 5 days, Giardia cyst shedding was eliminated in some cats. Albendazole has been evaluated for treatment of giardiasis in a limited number of dogs, but has been associated with neutropenia. Furazolidone (4 mg/kg, PO, q12hr, for 7 days) and paromomycin (appropriate dosing interval for cats is unknown) are other drugs with anti-giardia effects but have not been evaluated extensively in cats. Lastly, because use of the commercially available Giardia spp. vaccines as immunotherapy has given variable treatment responses in dogs and cats, the use of the feline product should be reserved for resistant infections in cats. 4

6 Multiple drugs have been evaluated for the treatment of cats with T. foetus infections; until recently no drug eliminated infection and diarrhea rarely resolves during the treatment period. Recently ronidazole at 30 mg/kg, PO, q24hr, for 14 days eliminated clinical signs of disease and trophozoites from cats infected with one strain of the organism. Ronidazole is more neurotoxic than metronidazole and so should be used carefully. In another one small study, administration of metronidazole and enrofloxacin lessened diarrhea in kittens but it is unknown if the organisms infecting those cats was T. foetus. It is possible that some cats with T. foetus have other enteric coinfections and so antihelmintics or drugs with activity against Giardia spp., Cryptosporidium spp., and enteric bacteria like Campylobacter spp. are often prescribed. Paromomycin should be avoided cats with bloody stools because of the potential for being absorbed and inducing renal disease or deafness. In one study, 23 of 26 cats with diarrhea and T. foetus infection had complete resolution of diarrhea a median of 9 months after initial diagnosis. Cryptosporidium spp. associated diarrhea sometimes resolves after administration of tylosin (10-15 mg/kg, PO, BID for at least 14 days) or azithromycin (10 mg/kg, PO, daily for at least 14 days). If the cat is responding to therapy, continue treatment for 1 week past clinical resolution. Some cats may require several weeks of treatment. The Toxoplasma gondii oocyst shedding period can be shortened by administration of clindamycin or sulfadimethoxine. Cystoisospora spp. generally responds to the administration of sulfadimethoxine or other sulfa-containing drugs. Clindamycin, trimethoprim-sulfa, or ponazuril are also options. Since many of the gastrointestinal parasites that infect cats are transmitted by carnivorism, cats should not be allowed to hunt or be fed raw meats. Additionally, infection of cats by many feline parasites results from ingestion of contaminated water. Clinical disease in some parasitized cats can be lessened by eliminating stress and providing a quality diet and clean environment. Clostridium perfringens and bacterial overgrowth generally respond to treatment with tylosin, metronidazole, ampicillin, amoxicillin, or tetracyclines. The drug of choice for campylobacteriosis is erythromycin; however, oral administration of quinolones is often less likely to potentiate vomiting. Salmonellosis should only be treated parenterally due to rapid resistance that occurs following oral administration of antibiotics. Appropriate antibiotics for the empirical treatment of salmonellosis while awaiting susceptibility testing results include chloramphenicol, trimethoprim-sulfa, amoxicillin; quinolones are also effective. Helicobacter spp. infections are usually treated with the combination of metronidazole and tetracycline or amoxicillin and metronidazole in dogs. Clarithromycin or azithromycin may be logical choices in cats since the species is often difficult to treat with multiple drugs. Whether to concurrently administer an antacid like famotidine is controversial but seems to lessen vomiting in some cats. Cats with apparent bacteremia due to enteric bacteria should be treated with parenteral antibiotics with a spectrum against anaerobic and gram negative organisms. The combination of enrofloxacin with a penicillin or first generation cephalosporin is generally effective. Second generation cephalosporins or imipenem are also appropriate choices. Cats that have hepatic infections and signs of bacteremia should be treated with antibiotics that kill gram positive, gram negative and anaerobic bacteria as discussed before. Non septic hepatic 5

7 infections generally respond to amoxicillin, amoxicillin-clavulanate, first-generation cephalosporins, or chloramphenicol. Decreasing numbers of enteric flora by oral administration of penicillins, metronidazole, or neomycin can lessen the clinical signs of hepatic encephalopathy. Panleukopenia virus, feline leukemia virus, feline immunodeficiency virus, and coronaviruses are the most common viral causes of gastrointestinal tract disease in cats. Viral diseases are managed by supportive treatment. Make sure to maintain hydration, correct hypoglycemia, and maintain normal potassium concentrations. Use of jugular catheters is superior to leg veins since blood samples can be drawn and CVP can be measured. Based on results in dogs with parvovirus infection, administration of plasma or serum (1 ml/kg) from your hyperimmune blood donor cat may lessen morbidity in cats with panleukopenia due to passive transfer of immunity. This is effective because parvoviruses induce a viremic state; virus particles are complexed by the antibodies transferred passively. Adminstration of interferon alpha at 10,000 U/kg, SQ, once daily may have anti-viral effects. Antibiotics effective against gram negative and anaerobic bacteria are commonly indicated. Vaccines are available for the prevention of parvovirus, coronaviruses, and feline leukemia virus infection. Zoonotic considerations. Infection of people by feline enteric agents is usually from contact with feces in the environment, by ingestion of contaminated food or water, or by ingestion of undercooked meat (T. gondii). Contact with infected cats is an unlikely way for humans to acquire infection. The following guidelines may lessen the risk of transfer of feline enteric zoonotic agents to people. Perform a thorough physical examination and zoonoses risk assessment on all new cats. Perform a physical examination and fecal examination at least once or twice yearly. Take all cats with vomiting or diarrhea to a veterinarian for evaluation. Fecal material produced in the home environment should be removed daily, preferably by someone other than an immunocompromised individualuse litterbox liners and periodically lean the litterbox with scalding water and detergent. Do not allow cats to drink from the toilet. Follow the CDC strategic deworming guidelines. Wear gloves when gardening and wash hands thoroughly when finished. Filter or boil water from sources in the environment. Wash your hands after handling cats. Maintain cats within the home environment to lessen exposure to other animals and their feces. Feed cats only commercially processed food. Do not share food utensils with cats. Avoid being licked by cats. Control potential transport hosts like flies, rodents, and cockroaches. Cook meat for human consumption to 80 C for 15 minutes minimum (medium-well). Wear gloves when handling meat and wash hands thoroughly with soap and water when finished. 6

8 References available on request Table 1. Common gastrointestinal parasites of cats. Classification 1 clinical signs Zoonoses Cestodes Taenia taeniaformis Subclinical No Dipylidium caninum Subclinical Yes (vector-associated) Echinococcus multilocularis Subclinical Yes Coccidians Cystoisospora spp. MBD, LBD No Cryptosporidium spp. SBD Yes Toxoplasma gondii Polysystemic Yes Flagellates Giardia spp. SBD Yes Tritrichomonas foetus MBD, LBD No Fluke Eurytrema procyonis V No Nematodes Ancylostoma tubaeforme V, MBD Yes Strongyloides cati V, MBD Yes Dirofilaria immitis V Yes (vector-associated) Toxocara cati V Yes Toxascaris leonina V No Ollulanus tricuspis V No Physaloptera spp. V No V = vomiting; SBD = small bowel diarrhea; MBD (mixed bowel diarrhea); LBD (large bowl diarrhea) 7

9 Table 2. Drugs commonly used in the management feline gastrointestinal diseases Generic drug name Common dosage Primary disease/organisms Amoxicillin 22 mg/kg, daily, for 5 days, PO C. perfringens, bacterial overgrowth, Salmonella Ampicillin 22 mg/kg, q8hr, for 3-7 days, IV Anaerobic sepsis Azithromycin 7-15 mg/kg, q12hr, for 5-7 days, PO C. parvum, T. gondii Cefazolin 22 mg/kg, q8hr, for 3-7 days, IV Gram positive and anaerobic sepsis Cefoxitin 22 mg/kg, q8hr, for 3-7 days, IV Gram positive, gram negative, and anaerobic sepsis Cephalexin mg/kg, q8-12hr, for 3-6 wks, PO Bacterial cholangiohepatitis Clarithromycin 5-10 mg/kg, q12hr, for 7 days, PO T. gondii, Helicobacter Clindamycin 12.5 mg/kg, q12hr, for 28 days PO, IM T. gondii Doxycycline 5-10 mg/kg, q12-24hr, 4 weeks, PO T. gondii, E. histolytica Erythromycin mg/kg, q12hr, for 7-10 days, PO C. jejuni Enrofloxacin 5-15 mg/kg, q8-12hr, for 3-7 days, IV, IM Gram negative sepsis Enrofloxacin 5-15 mg/kg, q8-12hr, for 3-7 days, PO Tritrichomonas foetus Epsiprantel 2.75 mg/kg, once, PO Dipylidium, Taenia Pyrantel/praziquantel < 6 months, 15 mg/kg (F) mg/kg (P), Helminths, cestodes daily for 3 days > 6 months, 10 mg/kg (F) mg/kg (P), Helminths, cestodes daily for 3 days Fenbendazole 50 mg/kg, q24hr, for 3-7 days, PO Nematodes, Giardia, 30 mg/kg, q24hr, for 6 days Eurytrema procyonis Furazolidone 4 mg/kg, q12hr, for 7 days, PO Giardia 8-20 mg/kg, q24hr, for 7 days, PO Cystoisospora spp. Ivermectin 24 micrograms/kg, monthly, PO D. immitis, hookworms Itraconazole 5-10 mg/kg, q12hr, for weeks, PO Histoplasma capsulatum Metronidazole mg/kg, q12hr, for 7 days, PO Giardia, E. histolytica, T. foetus, bacterial overgrowth, C. perfringens Milbemycin 2 mg/kg, monthly, PO D. immitis, hookworms, roundworms Neomycin mg/kg, q6-24hr, for < 14 days, PO Hepatic encephalpathy Paromomycin 150 mg/kg, q12-24hr, for 5 days, Cryptosporidium spp., Giardia, E. histolytica Praziquantel < 1.8 kg, 6.3 mg/kg, once, PO Cestodes > 1.8 kg, 5.0 mg/kg, once, PO Cestodes Pyrantel pamoate 5-20 mg/kg, q days, PO Nematodes Prednisolone 2-4 mg/kg, PO, divided q12hr Inflammatory bowel disease Pyrantel/praziquantel 1 tablet per 4 kg bodyweight Nematodes, cestodes Ronidazole 30 mg/kg, q24hr, PO T. foetus Selamectin 6 mg/kg, monthly, topically D. immitis, hookworms, roundworms, fleas, earmites Sulfadimethoxine mg/kg, daily, for 5-20 days, PO Cystoisospora spp. Trimethoprim-sulfa 15 mg/kg, q12hr, for 5 days, PO Cystoisospora spp., T. gondii Tylosin mg/kg, q8-12hr, for 21 days, PO Bacterial overgrowth, C. perfringens, C. parvum 8

10 GIARDIA SPP. INFECTION UPDATE Michael R. Lappin, DVM, PhD, DACVIM The Kenneth W. Smith Professor in Small Animal Clinical Veterinary Medicine College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins Colorado Are most Giardia spp. infections shared between animals and man? The genus Giardia contains multiple species of flagellated protozoans that are indistinguishable morphologically (1). Infection in dogs and cats are common (2-4). Host specificity was thought to be minimal for Giardia spp., but not all small animal isolates cause disease in human beings. There have been varying results concerning cross-infection potential of Giardia spp.. Human Giardia isolates usually grow in cell culture, animal isolates often do not. Recent genetic analysis has revealed 2 major genotypes in people. Assemblage A (G. duodenalis) has been found in infected humans and many other mammals including dogs and cats. Assemblage B (G. enterica) has been found in infected humans and dogs, but not cats. It appears that there are specific genotypes of Giardia that infect dogs (G. canis; Assemblages C and D). cats (G. felis; Assemblage F) but not people. Accordingly, healthy pets are not considered significant human health risks for HIV infected people by the Centers for Disease Control ( The majority of dogs and cats with Giardia spp. infections are infected with animal specific genotypes (5). Assemblage A is occasionally found in pets, especially cats (6). What are the optimal diagnostic tests? The primary diagnostic tests that are available to document Giardia spp. in dog and cat feces include direct smear of feces, direct saline preparation, fecal flotation, fecal antigen testing, fecal immunofluorescent antibody assay, and fecal PCR assay (7,8). These tests can be used alone or in combination in the diagnosis of Giardia spp. infection in dogs or cats with diarrhea. How should I evaluate fresh feces from animals with diarrhea? Fresh, liquid feces or feces that contain large quantities of mucus should be microscopically examined immediately in the clinic for the presence of protozoal trophozoites of Giardia spp. (small bowel diarrhea), Tritrichomonas foetus (large bowel diarrhea), and Pentatrichomonas hominus (large bowel diarrhea). A direct saline smear can be made to potentiate observation of these motile organisms. A 2mm X 2mm X 2mm quantity of fresh feces is mixed thoroughly with one drop of 0.9% NaCl or water. The surface of the feces or mucus coating the feces should be used as the trophozoites are most common in these areas. After application of a coverslip, the smear is evaluated for motile organisms by examining it under 100 magnification. Culture (T. foetus), antigen testing (Giardia) or PCR (T. foetus or Giardia) can be used to distinguish between specific organisms. What are my options for fecal flotation? Fecal flotation with zinc sulfate centrifugal flotation technique (specific gravity ) is one of the optimal techniques for the demonstration of cysts ( and is more sensitive for detection of Giardia spp. cysts than cup flotation. Sugar and other salt solutions lead to distortion of cysts but are also sensitive tests. Cysts are shed intermittently and their presence does not correlate to clinical signs of disease. Evaluation of a single fecal flotation has a sensitivity of approximately 70%. Sensitivity increases to > 90% if at least 3 stool specimens are examined. 9

11 Do currently available antigen ELISA detect dog and cat strains of Giardia? Multiple ELISAs for detection of Giardia antigens in stool are available. In experiments performed in our laboratory, all human and veterinary assays assessed to date have detected G. canis and G. felis. In one of our dog studies (5), all 17 Giardia assemblage C and D isolates were detected by the commercially available ELISA labeled for use with dog and cat feces (SNAP Giardia, IDEXX Laboratories, Portland, ME). In other studies where we have compared different Giardia antigen assays results to IFA, there can be up to a 5% false positive and 5% false negative rate. Thus, some animals that are Giardia spp. cyst negative on fecal flotation but Giardia antigen positive may have a false positive antigen test. Does the IFA produced for human feces detect Cryptosporidium spp. and Giardia spp. in dog and cat feces. The IFA for simultaneous detection of Giardia spp. cysts and Cryptosporidium oocysts is currently available in most commercial veterinary laboratories and has been shown in our laboratory to identify C. felis, C. canis, G. felis, and G. canis. I use this assay as a first wave diagnostic test in dogs and cats with diarrhea (combined with a fecal float, a wet mount examination, and a rectal or fecal cytology) instead of Giardia antigen tests because it detects two important agents with zoonotic potential and because Cryptosporidium spp. are usually not detected on fecal flotation in small animals. When should I use PCR for amplification of Giardia spp. DNA from feces? The sensitivity of the currently available PCR assays are low and should not be used in lieu of fecal flotation or other tests. These assays should only be used if genotyping of the previously detected Giardia spp. is desired. Genotyping is available at Colorado State University; call concerning sample submission. Which dogs and cats should be screened for Giardia spp. infections and what tests should I use? In healthy dogs and cats, a fecal flotation should be performed at least once or twice yearly. In dogs and cats with diarrhea, the combination of the direct saline preparation with fecal flotation should be used as the minimum initial screening tests for Giardia infection. Antigen tests or IFA test can be used to increase sensitivity but should not be used in lieu of the other assays. What are the best drugs for Giardia spp. infection? Giardia spp. have specific antimicrobial sensitivity patterns like bacteria and so it is currently impossible to predict which anti-giardia drug will be effective. Because G. canis and G. felis can be difficult to cultivate and there is little in vitro susceptibility test results available. While there have been multiple drugs used for the treatment of giardiasis in dogs and cats, there are few studies that utilized dose titrations and evaluation of drugs in experimentally infected animals (9-18). In most studies, fecal samples were only assessed for short periods of time after treatment and immune suppression was not induced to evaluate whether infection was eliminated or merely suppressed. Infection with Giardia does not appear to cause permanent immunity and so reinfection can occur, a finding that also hampers assessment of treatment studies. Treatment options currently available or used historically include metronidazole, tinidazole, ipronidazole, ronidazole, fenbendazole, albendazole, pyrantel/praziquantel/febantel, quinacrine, and furozolidone (Table 1). Newer drugs being studied include paromomycin and nitazoxanide. 10

12 How do I choose which of these drugs to use? If spore-forming rods, morphologically consistent with Clostridium perfringens are concurrently detected with Giardia, use of metronidazole is indicated as this drug is an antibiotic. If there is clinical evidence to suggest concurrent infection with a nematode, like eosinophilia or eosinophils on fecal cytology, fenbendazole or febantel are indicated. Some clinician s currently recommend the combination of metronidazole and fenbendazole. What are the goals of Giardia spp. treatment? The primary goal of treatment is to stop diarrhea. Because healthy pets are not considered human health risks, elimination of infection (which is difficult) is a secondary goal. What do I do if diarrhea continues and Giardia infection is still detected? Giardia spp. can have resistant patterns and so if the first drug fails to clear the infection (cysts or antigen) or resolve the diarrhea, a second drug from an alternate class is indicated. The addition of fiber to the diet may help control clinical signs of giardiasis in some animals by helping with bacterial overgrowth or by inhibiting organism attachment to the microvillus. Immunotherapy with the Giardia vaccine has aided in the elimination of cyst shedding and diarrhea in some infected dogs. However, in a controlled study in 16 experimentally infected cats, vaccination as immunotherapy was ineffective with one strain of Giardia. Probiotic administration may also be beneficial in some animals. In one study, bathing the dog was a beneficial adjunct therapy. In dogs and cats with persistent diarrhea and Giardia spp. infection, a more extensive workup to attempt to diagnoses other underlying diseases is indicated if several therapeutic trials fail. Common underlying disorders include cryptosporidiosis, inflammatory bowel disease, bacterial overgrowth, exocrine pancreatic insufficiency, and immunodeficiencies. Should healthy dogs and cats with Giardia infection be treated? Healthy pets are not considered significant human health risks by the Centers for Disease Control ( However, because clinical signs induced by Giardia spp. can be intermittent and since some Giardia spp. may be zoonotic, treatment of healthy infected animals should be considered with each owner. Treatment of healthy animals is controversial because all of the drugs have side-effects, animals with normal stools are not considered human health risks, treatment is unlikely to eliminate infection, and re-infection can occur within days. For example, in a recent study of naturally infected healthy dogs, we induced clinical side-effects in 50% of the dogs treated with nitazoxanide or fenbendazole and of the dogs that the treatment protocol was completed successfully, 62.5% were still infected on recheck evaluation (9). Should healthy housemates of Giardia infected dogs and cats be tested? Whether to test all housemates of infected dogs and cats is controversial because all Giardia tests can give false negative results. It may be more financially viable to treat all animals in lieu of testing. Should healthy housemates of Giardia infected dogs and cats be treated? Whether to treat all healthy housemates of infected dogs or cats is controversial because all of the drugs have sideeffects, animals with normal stools are not considered human health risks, treatment is unlikely to eliminate infection, and re-infection can occur within days. However, the safety margin of fenbendazole is very wide and so if treatment chosen, this drug seems to be a reasonable choice. 11

13 Should I follow Giardia test results after treatment? It is currently unknown how long Giardia antigens will persist in feces after successful treatment (resolution of diarrhea). In one of our small studies on treated healthy dogs, four of eight dogs treated with nitazoxanide or fenbendazole were still SNAP Giardia positive on day 34 after treatment. The AAFP Advisory Panel on Zoonoses recommends attempting to remove the source of infection during the treatment period and performing a fecal flotation (not an antigen test) after Giardia treatment one time, within 2-4 weeks after the end of the treatment period ( If the animal is healthy and negative for cysts, retesting is not indicated again until the next scheduled fecal flotation. What should I do with dogs or cats that have normal stool and are Giardia antigen positive, Giardia cyst negative? These animals have either a low grade infection or have false positive antigen test results. To further evaluate the case, the veterinarian can perform an IFA test, 2 additional fecal flotations, or an antigen test from a different manufacturer; if these other test results are negative, the antigen test was likely falsely positive. What can I do to prevent re-infection with Giardia spp. Prevention involves boiling or filtering of water collected from the environment prior to drinking and disinfection of premises contaminated with infected feces with quaternary ammonium compounds (1 minute contact time). Transport hosts should be controlled and treatment of all animals in the environment could be considered. To date, no study has shown the Giardia spp. vaccines licensed for dogs and cats to have lessened Giardia spp. infections in the field and so both vaccines have been classified by AAHA and AAFP as generally not recommended as preventatives. The feline Giardia spp. vaccine was recently discontinued by the manufacturer. Table 1. Drugs used for the treatment of Giardia spp. infections. Drug Species Dose Metronidazole B mg/kg, PO, q12-24 hr, for 5-7 days Tinidazole C 44 mg/kg, PO, q24hr for 3 days Ipronidazole C 126 mg/liter of water, PO, ad libitum for 7 days Fenbendazole B 50 mg/kg, PO, daily for 3-5 days. Albendazole B 15 mg/kg, PO, q12hr for 2 days (less commonly used because of bone marrow toxicity) Pyrantel, praziquantel, febantel C Label dose for 3 days F Feline dose-56 mg/kg (based on the febantel component), PO, daily for 5 days. Quinacrine: C 9 mg/kg, PO, q24hr for 6 days F 11 mg/kg, PO, q24hr for 12 days. Furazolidone: F 4 mg/kg, PO, q12hr for 7-10 days. C = canine; F = feline; B = canine and feline 12

14 References 1. Thompson, RCA: The zoonotic significance and molecular epidemiology of Giardia and Giardiasis, Vet Parasitol 126:15, Carlin EP, Bowman DD, Scarlet JM: Prevalence of Giardia in symptomatic dogs and cats in the United States, Comp Contin Educ Vet 28:1, Hill S, Lappin MR, Cheney J, et al. Prevalence of enteric zoonotic agents in cats. J Am Vet Med Assoc. 2000;216; Nutter FB, Dubey JP, Levine JF, et al: Seroprevalence of antibodies against Bartonella henselae and Toxoplasma gondii and fecal shedding of Cryptosporidium spp., Giardia spp., and Toxocara cati in feral and pet domestic cats, J Vet Med Assoc 225:1394, Clark M, Scorza AV, Lappin MR. A commercially available Giardia spp. antigen assay detects the assemblages isolated from dogs. In the Proceedings of the American College of Veterinary Internal Medicine Forum, Vasilopulos RJ, Mackin AJ, Rickard LG, et al: Prevalence and factors associated with fecal shedding of Giardia spp. in domestic cats, J Am An Hosp Assoc 42:424, Dryden MW, Payne PA, Smith V: Accurate diagnosis of Giardia spp. and proper fecal examination procedures, Vet Ther 7:4, Mekaru SR, Marks SL, Felley AJ, et al: Comparison of direct immunofluorescence, immunoassays, and fecal flotation for detection of Cryptosporidium spp. and Giardia spp. in naturally exposed cats in 4 northern California animal shelters, J Vet Intern Med 21:959, Lappin MR, Clark M, Scorza AV. Treatment of healthy Giardia spp. positive dogs with fenbendazole or nitazoxanide. In the Proceedings of the American College of Veterinary Internal Medicine Annual Forum, Barr SC, Bowman DD, Frongillo MR, et al. Efficacy of a drug combination of praziquantel, pyrantel pamoate, and febantel against giardiasis in dogs. Am J Vet Res 59:1134, 998;. 11. Barr SC, Bowman DD, Heller RL, et al. Efficacy of albendazole against giardiasis in dogs. Am J Vet Res 54:926, Caylor KB, Cassimatis MK. Metronidazole neurotoxicosis in two cats. J Am Anim Hosp Assoc 37:258,

15 13. Keith CL, Radecki SV, Lappin MR: Evaluation of fenbendazole for treatment of Giardia infection in cats concurrently infected with Cryptosporidium parvum, Am J Vet Res 64:1027, Olson ME, Hannigan C, Gaviller R, et al. The use of a Giardia vaccine as an immunotherapeutic agent in dogs. Canadian Vet J 42:865, Efficacy of a combination febantel-praziquantel-pyrantel product, with or without vaccination with a commercial Giardia vaccine, for treatment of dogs with naturally occurring giardiasis. J Am Vet Med Assoc 220:330, Rossignol JF, Ayoub A, Ayers MS. Treatment of diarrhea caused by Giardia intestinalis and Entamoeba histolytica or E. dispar: a randomized, double-blind placebo-controlled study of nitazoxanide. J Inf Dis 184:381, Scorza AV, Lappin MR: Metronidazole for the treatment of feline giardiasis, J Fel Med Surg 6:157, Stokol T, Randoph JF, Nachbar S, et al. Development of bone marrow toxicosis after albendazole administration in a dog and cat. J Am Vet Med Assoc 210:1753,

16 FELINE INFECTIOUS RHINITIS Michael R. Lappin, DVM, PhD, DACVIM The Kenneth W. Smith Professor in Small Animal Clinical Veterinary Medicine College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins Colorado Viral diseases. Herpesvirus 1 (rhinotracheitis; FHV-1) and calicivirus (FCV) are the most common viral causes of sneezing and nasal discharge in the cat. If oral ulcers are present, calicivirus is most likely. If corneal ulcers are present, herpesvirus 1 is most likely. FHV-1 has now also been associated with chronic stomatitis, facial dermatitis, and endogenous uveitis. Viral rhinitis with or without secondary bacterial infection can be recurrent. FHV-1 can be documented by direct fluorescent staining of conjunctival scrapings, virus isolation, or polymerase chain reaction. Since FHV-1 DNA can be detected in conjunctival cells of approximately 25% of healthy cats, the positive predictive value of these tests in diseased cats is low. Quantitative PCR may ultimately prove to correlate to the presence or absence of disease. Currently used PCR assays also detect vaccine strains of FHV-1. RT-PCR assays can be used to amplify the RNA of FCV. However, these assays have the same problems with predictive value as those to detect DNA of FHV-1. Feline viral rhinitis with or without secondary bacterial infection can be recurrent. There are no consistently effective primary therapies. I generally only use the following therapies if chronic disease is present. Lysine at mg, PO, BID may be helpful in some cats and has been shown to be safe. Administration of alpha interferon at 30 U, PO, daily may help some cats with suspected chronic calicivirus or FHV-1 infection. Topical administration of alpha interferon in saline to the eyes of cats with conjunctivitis or the nose may aid in the management of some cats. Lysine and alpha interferon are unlikely to lead to a cure, but hopefully will lessen clinical signs of disease. Intranasal administration of modified live, intranasal FHV-1 and FCV vaccines may lessen disease in some chronically infected cats. If there is a positive response to intranasal vaccination in a cat with chronic disease, I will use this form of immunotherapy up to 3 times per year. The intranasal vaccine has been shown to potentiate cell-mediated immunity to FHV-1 better than parenteral vaccination. In kittens with acute life-threatening infection, use of alpha interferon at 10,000 U/kg, SQ, daily for up to 3 weeks can be beneficial. Acyclovir is an antiherpesvirus drug for use in people but can be toxic to cats. Famcyclovir seems to be safer and more effective than acyclovir and is now being used for long-term therapy. One dose that has been used is ¼ tablet (31.25 mg) q12 hr for 14 days. Topical cidofovir (product for humans) can be used for the treatment of FHV-1 conjunctivitis twice daily and was effective in a controlled research project. The drug was easier to administer (twice daily) than idoxuridine or other anti- FHV-1 ocular therapies and does not cause as much irritation. Feline leukemia virus and feline immunodeficiency virus can induce immunosuppression predisposing to bacterial rhinitis. However, there is no universally effective treatment. Bacterial diseases. Almost all cats with mucopurulent or purulent nasal discharge have a bacterial component to their disease. Primary bacterial disease is rare but may be associated with Bordetella bronchiseptica, Mycoplasma spp. and Chlamydophila felis. Recently it was shown that Bartonella spp. are not causes of rhinitis in cats. Both B. bronchiseptica and Mycoplasma 15

17 spp. can be associated with bronchitis in cats. Chlamydiosis in general, is a mild infection resulting only in conjunctivitis. If primary infections are suspected, doxycycline 10 mg/kg, PO, once daily or topical administration of tetracyclines are usually effective. Cats with acute disease only need to be treated for 7 to 10 days. Most cases of bacterial rhinitis are secondary to other diseases including trauma, neoplasia, inflammation induced by viral infection, foreign bodies, inflammatory polyps, and tooth root abscessation. Thus, if routine antibiotic therapy fails, a diagnostic workup should be performed. Since bacterial rhinitis leads to chondritis and osteomyelitis, antibiotic therapy should be continued for weeks in cats with chronic disease. I generally use drugs with an anaerobic spectrum that also penetrate bone and cartilage. Clindamycin, amoxicillin, amoxicillinclavulanate, or metronidazole. Amoxicillin-clavulanate has the advantage of killing most Bordetella isoloates. Clindamycin has the advantage of effective against Mycoplasma spp. and the drug can be used once daily for routine bacterial infections in cats. Doxycycline and metronidazole may be superior to other drugs for the treatment of chronic infections since they may modulate the immune reaction, lessening inflammation. Azithromycin (10 mg/kg, PO, q hr) or fluoroquinolones can be used for cats with chronic disease. Fungal diseases. Cryptococcus neoformans and Aspergillus spp. are the most common causes of fungal infection in cats. Cryptococcosis is the most common systemic fungal infection of cats and should be considered a differential diagnosis for cats with respiratory tract disease, subcutaneous nodules, lymphadenopathy, intraocular inflammation, fever, and CNS disease. Infected cats range from 6 months to 16 years of age, and male cats are over represented in most studies. Infection of the nasal cavity is reported most frequently (56.3 to 83.0% of cases) and commonly results in sneezing and nasal discharge. The nasal discharge can be unilateral or bilateral, ranges from serous to mucopurulent, and often contains blood. Granulomatous lesions extruding from the external nares, facial deformity over the bridge of the nose, and ulcerative lesions on the nasal planum are common. Submandibular lymphadenopathy is detected in most cats with rhinitis. Definitive diagnosis of cryptococcosis is based on antigen testing or cytologic, histopathologic, or culture demonstration of the organism. Cats with cryptococcosis have been treated with amphotericin B, ketoconazole, itraconazole, fluconazole, and 5-flucytosine alone and in varying combinations. Good to excellent treatment responses in cats were seen with fluconazole (96.6%), itraconazole (57.1%), and ketoconazole (34.6%). Because of toxicity, I no longer use ketoconazole. I generally use fluconazole at 50 mg/cat per day because it has the least side-effects and or the azoles, has the best penetration across the blood-brain and blood-ocular barriers. If life-threatening infection is occurring or the cat is failing to respond to the azole, drugs liposomal amphotericin B should be used. Nasal and cutaneous cryptococcosis generally resolve with treatment; CNS and ocular disease are less likely to respond to treatment. Treatment should be continued for at least 1 to 2 months past resolution of clinical disease. People and animals can have the same environmental exposure to Cryptococcus neoformans but zoonotic transfer from contact with infected animals is unlikely. Parasitic diseases. While nasal mites (Pneumonyssoides) and a nasal worm (Eucoleus) occur in dogs in the United States, there are no significant nasal parasites in cats of the USA. 16

18 FELINE INFECTIOUS DISEASE CONTROL STRATEGIES Michael R. Lappin, DVM, PhD, DACVIM The Kenneth W. Smith Professor in Small Animal Clinical Veterinary Medicine College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins Colorado Introduction. Infectious diseases are extremely common in cats. Most are acquired by direct contact with other cats, by contact with contaminated vehicles, or by contact with vectors. Thus, cats allowed outdoors seem to be more likely to be exposed to infectious disease agents than cats housed exclusively indoors. Some owners believe that housing cats indoors alone is adequate for infectious disease control. However, this is untrue in most situations. For example, indoor cats may occasionally escape and if not recently vaccinated may develop significant illness if they contact many of the common infectious agents. Many owners with cats housed indoors have multiple cats, increasing the likelihood of shared infectious agents with latent or subclinical phases like feline herpesvirus 1 (FHV-1). Many homes have cats housed indoors that live with indoor/outdoor dogs that can bring ectoparasites indoors to the cats. Finally, transport hosts (or intermediate hosts in some infectious agents) like flies, beetles, cockroaches, and mice can come indoors. Thus, I believe the cat that is well vaccinated, housed as an individual cat indoors, fed processed foods, and maintained on routine parasite control is least likely to acquire an infectious disease agent. Parasitic infections. Overall, the most common parasitic infections of cats are those that involve the gastrointestinal system, the respiratory tract, and the skin. Some parasites like Dirofilaria immitis can result in significant clinical illness, including death, in infected cats. Many internal parasites and ectoparasites also cause illness in people and so are zoonotic. Suggestions for avoided cat-associated illness in people are listed in Tables 1 and 2. Ancylostoma tubaeforme (cutaneous larva migrans) and Toxocara cati (visceral and ocular larva migrans) are classic examples. Infections with these nematodes are extremely common in many parts of the USA and the organisms are shed by both healthy and ill cats as well as both kittens and adults. For example, in one of my studies of cats in north-central Colorado, which is a hot, dry state in the summer and a cold state in the winter, 3.8% of adult cats were shedding T. cati into the human environment. Some ectoparasites, like Ctenocephalides felis, also serve as vectors for other infectious agents that can result in clinical illness in the cat and for some agents, the owner. For example, many C. felis are infected by Mycoplasma haemofelis and Candidatus M. haemominutum, common causes of hemolytic anemia in cats (Previously called Haemobartonella felis; now collectively known as hemoplasmas). Bartonella henselae, the most common cause of cat scratch disease in people, is found in C. felis feces on the skin of infected cats and fleas are responsible for transmission of B. henselae between cats. Flea-associated illnesses are important in almost all of the USA. For example, while Colorado is considered a low flea state, over 5% of the cats in one of my studies were infected by a hemoplasma and 9% of the cats in another study had B. henselae antibodies in serum. 17

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