We've been to a pretty good vet. We know the symptoms, but we just can't figure out what might be going on, or a cause. The vet says its serious and possibly life threatening, but he's at a loss what else it might be as well. I'll write what we know - any ideas, insights, suggestions for uncommon causes, weird or exceptional toxins, ideas sparked by the information, or anything else, would be helpful, to prevent recurrence.
The cat is about 10 years old, spayed female rescue, lived with us 5+ years, 5kg, rude good health apart from occasional bouts of stress cystitis (urinary stress diet + extra soup/water + cistaid given to counter this). Also pathologically misanthropic - her general view on humans is that apart from opening doors and providing food, they should all go away. But we love her anyway :)
First episode & vet visit
About 2 months ago (25 April 2018) she had an acute episode of some kind of poisoning. She vomited a lot, but otherwise seemed fine all day. The next morning, over the course of 12 hours she went from "off her food" in the morning, to pretty much laid down and indifferent to everything waiting to die by afternoon, to the point of not even hissing, avoiding or clawing at human fingers near her face. Serious stuff for her.
We contacted the emergency vet hospital, who gave us some tips, and did some online research, and watched her a long time. She had no confusion, when pushed off the bed she didn't fail in co-ordination, no dilated pupils, tongue was very pale though.
We took her to the vet (well known to us, and competent). They identified a significant heart murmur (usual feline myopathy) in passing, did ultrasound and bloods, which confirmed no liver tumour or masses, no sign of internal bleeding, but general signs of gross insult/damage to the liver, some anaemia (25 on whatever scale is used in the UK) and off the scale for ALT (Alanine aminotransferase, an enzyme related to liver cell necrosis/toxicity: the level was 6000+ according to independent lab they asked to retest it. I gather usual is < 100 ish?). She was so gone that the vet could take a blood sample from the neck without protest or sedation (when she recovered next week, the same vet couldn't even palpitate her stomach without risk of injury!). The conclusion was liver toxicity, and indeed the next afternoon she noticeably regained her appetite, and suddenly began to recover, and the episode ended. She was put onto beta blockers and thinners (Atenolol + Plavix) for the heart condition, and tolerated them, and all was well. A retest a week later showed ALT level had dropped to ~ 600 and the anaemia had "resolved".
Today's episode & vet visit
This morning (2 June 2018) she was off her food. There hadn't been any vomiting, but she remained off food all day and by 4pm was once more showing the same signs as before - laid down, lethargic, and so on. We decided the risk was too great to leave overnight, and took her to the vet.
We arrived at 7pm, and he said at once it was serious and probably life-threatening. He expressed concern it might be internal haemorrhaging or a missed tumour, and redid the ultrasound, but there's no evidence of leakage or pooled liquid or other issues internally, and no masses in the liver or anywhere else he checked. Yet again ALT levels are sky-high - his machine goes up to 2000 and ALT is off the scale (he said done by a lab it could easily be 6000 or whatever), and anaemia is lower than last time, just 18 now, and the tongue is very pale. Most other levels are normal-ish, I gather. He didn't want to use a drip to address blood pressure as that would accentuate the anaemia issues, and said to stop giving the blood thinner until we know more, as well. We finally left about 9pm. In all, he saw her for almost 2 hours, compared to the usual 10-15 minute consultation.
We went through a bunch of possibilities but he said that the symptoms looks most like paracetamol poisoning - but that it doesn't fit that either. It could be an infection, except there's no other evidence and why would it go then return? It seems most likely she ate something - just inhaling even dust from a tablet wouldn't be enough, she would need to eat quite a lot to have this effect, and there just aren't any tablets around, and in 5 years we've never seen her scouring the floor for anything. She's in a flat (apartment) so she's isolated from any other cats and probably all/most pathogens they could carry. She has access to a terrace with some plants, but this doesn't resemble any plant poisoning he could suggest. The household products used aren't normally spilt, and those we do use he said would cause irritation, diahrrea, or vomiting, which we didn't see this time.
We're at a loss, and so is the vet. I'm staying up all night to watch her breathing, in case it worsens and she suddenly needs to go to the emergency hospital. I'm about 60/40 that she will be OK, but the fact it's happened twice and we can't think how, even after taking all the precautions we can think of against odd eventualities, is really a worry.
Like I said at the start - any thoughts, insights, suggestions or things missed, that this narrative sparks off, or that might be worth checking or considering, would be very welcome.
Below are the actual lab/test results, maybe they help suggest ideas. I've highlighted anything marked as outside "normal" ranges. All units are metric (we're in the UK).
First visit (25 April, weight 5kg): heart 190, total protein 58, alb 26, glob 32, A:G 0.8, Na 144, K 4.2, Na:K 34, Urea high 16.4, creat 146, ALT high 6462, alk phos 21, total bilirub 9, gluc high 7.2; red cells low 4.2, Hb low 6.3, Hcrit low 22%, MVC 52.3, MCH 15, MCHC low 28.6, Retic'cytes 55, platelets low 17, white cells 8.3, neutrophils 4.1, lymphoc 3, monocytes high 1.2, eosinoph 0, basoph 0.
Urine normal: LEU+NIT+KET+BIL+BLD (blood?)+GLU (glucose?) all negative, UBG/URO normal, Pro(tein?) +, pH 7.5, SG 1.005, refractometer s.g. 1.040, JG.
Lab additional comments: occasional reactive lymphocytes, occasional neutrophils have small dohle bodies, mild anisocytosis, occasional/mild polychromasia, mild echinocytosis, occasional Heinz, rare metarubicytes, occasional macroplatelets, minimum manually estimated platelet count 30, quality EDTA good, RBC agglutination RT neg @ 1.5 dilution, no azotemia, in saline agglutination included. Possible options include (for ALT): liver disease/trauma/neoplasia, (for anaemia) possible chronic disease? CBC: thrombocytopenia, anaemia - mild regeneration.
Followup to first visit (1 May, sedation): cardiac: HCM diagnosed. 3/6 gallop, thickening/enlargement, no thrombus though. Liver scan: no masses or cystic lesions, heterogynous echogenicity throughout, granular appearance. Options: diffuse inflammatory reaction? toxicity? infection? ALT down to 600s, anaemia resolved. Options: likely toxicity? Heart meds begun: Atenolol 6mg, Plavix 19mg, both in the form of 1/4 of a tablet once daily
Second visit (12 June, printout hard to read some letters, sorry for any typos): ALB 31, ALP 13, ALT high [off scale] >2000, AMY 365, TBIL 5, BUN high 11.2, Ca 2.1, Phos low 0.82, CRE high 192, gluc high 12.1, Na low 137, K 5, TP low 52, Glob 22, QC (quality?) OK, HEM 0, LIP 0, ICT 0, Hcrit low 18.5%, HGB low 5.6, MCHC borderline low 30.3, WBC 14.2, ?GRANS 11.7, %GRANS 82%, L/M 2.5, %L/M 18%, platelets "extremely low" 15, retics 2.7%. v pale mm, heart 200, very (vv) weak pulse, no respiratory distress, well hydrated, no free fluid in abdomen/chest, liver darker than normal/granular pattern, signs of regen(eration?) with reticulocytes, no reaction to jugular blood, concerned re depressed appearance. Plavix on hold due to anaemia.