Chest fluid, steroid

Thank you for doing this forum.  Liz, I am concerned at my deceased cat’s veterinary treatment and would appreciate your views please.  My almost 15 year old indoors 5.5 kilo cat had stopped eating, although she was drinking.  The vet said her weight had gone from 6.2 kilo to 5.5 kilo in six months, before this she was always 6.2 kilo, and found her to be breathing ‘really really quickly’ and so gave her dexadreson (which I understand is dexamethasone) and synulox - I was told to come back the next day for an ultrasound.  Three hours later my beautiful loving cat started to open mouth breathe and I was wondering whether to call the emergency vet but then she lay on her left side and was breathing in through flared nostrils and the open mouth breathing had stopped.  I reported this to the vet the next day and explained I wouldn’t want her to have the steroid or antibiotic again as it had appeared to of given her a breathing problem, she looked concerned as if she knew what had happened and she did an ultrasound after receiving oxygen.  She came running towards me in the car park shrieking ‘she has a pocket of fluid’ quickly followed by ‘but we can’t get to it where it is’.  I think this steroid that was given the previous day caused my cat damage.  She took blood also, gave her the opposite medicine to a steroid (a diuretic) and I was told I would get the results the next day.  Another vet called me and the blood results revealed all normal but elevated white blood cells (two were high, one normal and one low).  I have since read dexamethasone can affect white blood cell count and laboratory tests and that this steroid stays in the system for two to two and a half days.  Even though my cat was still not eating I was encouraged to come back four days later for an echocardiogram (results revealed that her heart was fine) and cytology was taken.  Cytology revealed ‘different size cells that looked like they were dividing which could indicate a mass or tumour in the chest as this can cause fluid there but difficult to tell if it was benign or malignant'.  I have since read that in cytology inflammatory cells can mimic cancel cells.  Before the cytology results were given x ray was mentioned as the next step but as her breathing was not good, breathing in through flared nostrils, I did not think that she would survive being under anaesthetic.  As it looked like a cancer diagnosis, due to her age I said that I didn’t want her to go under an operation and so I was told going forward it was palliative care which I was told was best for her also.  She was therefore at home with me.  Of the four reasons given for fluid in the chest all of them were ruled out apart from possible cancer.  She did not eat the whole two weeks she was ill but would drink and take the diuretic tablet crushed into soft liquid yoghurt for cats and would have the cat soup brand.  Her records went back to 2012 and she had never been ill apart from a dental in 2016.  I had her in 2016. I would appreciate your thoughts.  I feel ultrasound, blood test and blood pressure test should have been performed first before medication.  The vet said that she was breathing quickly, a cause of this is fluid.  I feel the steroid being an anti-inflammatory may have damaged her trachea or lungs if the fluid was in there or maybe it was in her chest which is why her breathing deteriorated, maybe ultrasound showed damage.  Her breathing never improved and she continued to breathe in with flared nostrils, she breathed out fine and she was always better lying down on her left side.  She looked fine when I took her in for her first appointment apart from not eating.  She had never had a blood pressure test, I never knew this could be tested on cats and that in senior cats it is common.  I had mentioned on a previous visit that she had been meowing at night and I was told it was due to age.  I have since read high blood pressure can cause nocturnal vocalisation.  I said that in the mornings when she was first ill her eyes were dilated.  On her last morning she had temporary anisocoria but the vet when I wrote to them afterwards about my concerns that she had high blood pressure said that this would have been the cancer spreading and that her blood pressure was not taken because her primary symptoms of ‘difficulty breathing and weight loss are not typical for hypertension’, I have since read they can be.  Their response was very brief and dismissive.  She was not offered hospitalisation or put on a drip, I kept having to go back – three appointments in seven days and then her final one the following week.  She was found on her visit to have rapid breathing and from three hours after the antibiotic and steroid had difficulty breathing (breathing in through flared nostrils).  I have read antibiotics rarely cause side effects but with steroids there are many. I did ask at her heart scan appointment if the vet could check to see that the fluid was less so the medication was working as it had been five days of the diuretic but when the vet came back out said that as another vet did the scan before she did not know.  Well surely there is a copy on the file but I was too upset at the time to say much and just listened. She did not meow or purr for the two weeks of her illness, inflammation leads to fluid, which if in her trachea or lungs or chest and the steroid being a strong anti inflammatory may have condensed her trachea/lungs with the fluid being in it and damaged it and/or her lungs causing the fluid in her chest.  It did not enter my mind to seek a second opinion, they said they could not get to the fluid so I believed this.  I feel dexamethasone is so strong and would have been too much for her to cope with being a senior cat and her heart, blood results, blood pressure and ultrasound could have been checked first before medication.  I have read that dexamethasone is for not eating and respiratory illness but an almost 15 year old indoor cat that has never been ill is not suddenly going to become asthmatic or have bronchitis.  I do not wish to blame and realise it may have been cancer and being elderly maybe it was 'her time', but something feels wrong and I would just like thoughts from another vet like yourself please. Her heart was fine, her blood results were fine, she had no lumps, maybe she had inflammation and high blood pressure.  Apologies for the long post.  

Hello!  So let me recap: you had an older cat who had lost a significant portion of bodyweight and was found to be breathing too quickly before any drugs were given.  Breathing deteriorated at the vets (as stressful an environment for a cat as a hospital can be for people, so sometimes this happens, despite best efforts) and an ultrasound showed a pocket of fluid in the chest.  Cytology revealed cells with a potentially high mitotic index (cells that looked as though they were dividing quickly).  So far, this reads fairly convincingly for a cancer diagnosis.

Before I go any further, however, let me say I'm sorry to hear about the outcome of this case.  There is never a right time to lose a 15 year old cat and it's a stressful time under even the best of circumstances, but this sounds as though it happened quickly and suddenly, with lots of technical words and explanations which would be difficult to follow at the best of times.    Obviously I wasn't there and can't tell you what happened, but you have asked me to clarify some technical points and I can help with that.  I would also point you to the RALPH site which was set up by an awesome vet named Shailen Jasseni who I had the privilege to know, and who struggled considerably after the death if his own cat.  The Ralph Site is very Googleable and I believe that people in your position have benefited a lot from their help and advice, so you might want to contact them, too.

There are some technical points that I can put you right about; one is I'd that I wouldn't want to handle a dyspnoeic cat more than necessary, including to measure blood pressure which cannot be done in a hurry, but rather repeatedly over time in a calm room.  If a cat is struggling to breathe, it extremely likely that their blood pressure would be high anyway; think what would happen to your own blood pressure if every time you breathed in, you met resistance.  Hypertension is simply a posh word for 'high blood pressure,' which goes hand in hand with stress in cats, and while high blood pressure can be important to know about in cats with chronic illness, it is usually secondary to something else (kidneys / heart / some cancers even, thyroid disease) rather than a diagnosis in its own right.

I wouldn't put a cat with hypertension or dyspnoea on a drip if I didn't need to - sometimes it can be indicated, but excessive fluid (resulting from high blood pressure) often ends up sitting on cats' lungs, worsening their breathing.  Sometimes fluid is needed eg if the cat themselves is dehyrated, but in these cases fluids have to be given extremely carefully.  It also has to be weighed up against the chances of the drip stressing the cat out.  Fluids tend to treat hypotension, toxicities, blood loss and so on, which haven't been mentioned here.

Steroids are a relatively strong, fast acting anti-inflammatory drugs, which thereby help to receive pain and sometimes stimulate appetite.  They can also cause a rapid reduction in inflammation, which may be why they were chosen here, and have provided short lived releif in lymphoma cases.  Steroids do have their dangers, but I wouldn't particularly associate them with early sudden death in acute-stage cats.

(relieve, not receive!)

Sorry, that's a lot of rambling and has possibly further muddied the water at this stage.  Concisely, cancer is a relatively common cause of dyspnoea in older cats and could explain the signs as I understand them so far.   However, this is not a second opinion; I have insufficient information to judge your vets' treatment of this case and if you are unsure, then it is always best to ask them, again, for explanations.  No one can be expected to take everything in when their cat presents as an emergency at the hospital - and your vets should understand this.  It can help to try to satisfy yourself later what was done and why.  We are available for general, technical questions and the Ralph Site may help you with this and also with the emotional side.  Your vets can answer questions specific to your own beloved cat.  I hope that some of this brings you some level of peace but in the event of concern, the RCVS do operate an investigation and complaints procedure should you need it.   Wishing you all the best; you know where we are.

Thank you very much for your responses to my post.  It has clarified my thoughts and as you say it did seem like a cancer diagnosis.  I should add that I did take her in to be put to sleep at the vets as I did not want her to die a painful death.  I was hoping she would eat again (the vet did prescribe Mirtazapine tablet to increase her appetite, and I tried to hide it in a soft treat, but sadly I could not get her to take it), and I hoped that the diuretic would help her to breathe normally again but again sadly her breathing remained the same and she was still not eating after two weeks (she would drink water and have soft cat yoghurt and cat soup).  She had used her litter tray less, she was getting weaker so I took her in.  Thank you for mentioning The Ralph Site and thank you again for running this forum.  Best wishes.

And you too - Wishing you all the best with whatever happens next.