Elevated Pancreatic Enzymes - The Spec fPL is 3.5x the max reference value. To me that doesn't seem "mild." But as
@Marje and Gracie pointed out, a high Spec fPL does not necessarily equate to pancreatitis. While I understand that there's not one clear diagnosis for this, it's unclear if Jenks exhibits the usual symptoms.
Weighing in favor of a finding of pancreatitis: A recent bout of vomiting and diarrhea, followed by continuing inappetance. Lethargy.
Weighing against a finding of pancreatitis: He had two nights of acute vomiting and diarrhea 10 days ago, but nothing since and nothing similar in the last 5 years. He's not dehydrated. The doctor did not indicate that he felt anything abnormal in the abdomen during the physical exam. Jenks shows no signs of pain or discomfort. Temperature was normal. BG is not elevated, in fact, it's better than ever.
Vet recommendation: He said that even if it was pancreatitis, all he'd do is give fluids in the office and send him home, which seemed unnecessary because Jenks was drinking normally at home and didn't show any signs of dehydration.
The challenge is that inappetence, vomiting and diarrhea, lethargy can all be caused by things other than pancreatitis. While I am a proponent of “if you hear hooves, think horses, not zebras”, cats are complicated. Considering the diabetes and his specfPL, treating it as if it is pancreatitis given his normal liver values, is probably just fine at this stage. However, giving fluids to a cat with pancreatitis is a great support even if the cat is not officially dehydrated. If he bounced back pretty quickly, I’d not worry about it but if he had ongoing symptoms, fluids might help him.
Elevated White Cell Count - Innate immune cells up, adaptive immune cells down. According to IDEXX, the common causes for ______ are:
Decreased lymphocytes: Stress, acute systemic inflammation
Increased neutrophils: Inflammatory response (infection, immune related disease, tissue necrosis)
Increased monocytes: Inflammatory response (infection, immune related disease, tissue necrosis)
My thoughts: I'm not sure these are very indicative of anything by themselves, and may be a result of something else that's going on. The least concerning of the out-of-whack values, especially if the stress of the office can be a causative factor.
Typically, I try not to get too wrapped up in mild changes to white cell count. As you’ve seen, it can be due to many things. As long as they are fairly mild changes, I usually watch them. It’s when there are massive changes that you need to take action. When you have a parameter that the range is from 2620 to 15,000+, then an elevation of 2,000 is not dramatic. An elevation of 15,000 would be.
Creatine Kinase - 10x the max reference value and didn't even warrant a mention by the vet. But this is the one that concerns me the most. It was apparently worth a re-test by IDEXX, who noted "RESULT VERIFIED BY REPEAT ANALYSIS". I'm afraid there's no baseline number to compare to, so this is the only result we have to work with.
If it's heart involvement, what do we do and who do we see???? Is it clinically relevant that he's lost 3 pounds in the last year? What if some of that was from muscle?
According to IDEXX, "Significant elevations in CK are usually the result of skeletal muscle damage." Not sure how he would have that, but ok....
Common causes include (I have used a strike out on ones that can reasonably be ruled out as an issue):
Muscle trauma
RestraintDifficult venipunctureHit by car/other traumaProlonged recumbencySurgical proceduresMuscle biopsy- Intramuscular injections
My notes: I shoot his insulin with an 8mm needle into a tented flap of skin along his belly just in front of his right rear leg. There shouldn't be any muscle there (right???), and this is the only injection he receives.
Muscle inflammation
- Ischemia (Post-infarct ischemia, Aortic thromboembolism, Disseminated intravascular coagulation [DIC])
Necrosis (Snake/spider envenomation, Heatstroke)- Infectious (Toxoplasma sp. Neospora sp. Pyogenic bacterial infections Endocarditis Systemic infections (septicemia) Parasitic)
- Inflammatory non-infectious myositis (Immune-mediated polymyositis, Eosinophilic myositis)
My notes: I'm not educated enough on these topics to exclude anything other than venomous bites.
Exertional disorders
Exertional rhabdomyolysisSeizures
Uncommon Causes include:
- Congenital/inherited degenerative myopathies (Muscular dystrophy, Myotonia, Hyperkalemic periodic paralysis)
Nutritional myopathies (Hypokalemia, Taurine deficiency)
Toxic
Ionophores (e.g. monensin)Castor bean (ricin)Gossypol (cotton seed meal)
My notes: He's definitely not poisoned.
Neoplastic
Artifact
- Hemolysis interferes with some CK assays
My notes:
@Marje and Gracie asked me to check the report for any mention of this. There are no additional notations for this test.
Miscellaneous disorders
Urinary obstruction- Vomiting
Shivering/tremblingMalignant hyperthermiaHypothermia
My notes: Vomiting is what precipitated this visit, but I can't find any info about how this factor would affect the numbers.
I love that you took the time to do this and let us know what is really not a consideration. Not that we can diagnose anything here but I know it helps to run through the list and perhaps we can give you other ideas. Thanks for letting me know there was no hemolysis of the sample. Even if there had been, I would not expect to see that much of an elevation.
Just an interesting observation in humans about CK (and this actually happened to my mom). If one falls and is not able to get up and lies there for a time before being found, the tissue damage from lying there undetected can cause the CK to go up and result in a condition called rhabdomyolysis (you listed it above as an external disorder). If it’s treated promptly, it can fully resolve and the CK can come down quite fast. I don’t know if he has a kitty buddy, but no chance they could have been playing roughly while you were gone or no chance that he could have fallen from a high spot and landed uncatlike (e.g. not on four feet).
If you were shooting into muscle, you would know it because he would likely screech. It’s painful. Think about when you receive an IM injection. So Jenks would let you know. It seems to me it would take repeated and violent vomiting to cause muscle damage to this extent.
One thing I will say about Doodles is that his BG literally went off the rails when his CK went up. I don’t know if that is ECID or not but Jenks is still looking really great. If he lost 3 lbs slowly in a year, it depends on his normal weight. If he weighs 17 lbs and he loses 3 in a year, it’s not likely too significant but if he weighs 8 lbs and loses 3, it is especially if he has muscle wasting which is really easy to tell as the hip bones will stick out as will the shoulder blades. Sudden weight loss can be attributable to many things including heart issues. However, conversely, Doodles also did not lose a lot of weight so I wouldn’t use weight loss as a specific indicator of heart disease across the board. You may or may not “see” anything if it is heart disease. Cats can compensate a very long time until they get to a tipping point. Karen didn’t really see any symptoms until Doodles was a bit further along and then she would see open mouthed breathing and inflated RR. Because cardiomyopathy is so easily hidden in the cat, one might not see anything at all until it is quite advanced.
The fact that your vet did not remark upon that elevation concerns me. I’ve had cats for more years than I’d like to admit and I’ve never once seen a CK elevation on any of their labs and I believe the only other cat I’ve seen with a marked elevation is Doodles (and you know how many labs I look at on the board) so it’s not a common thing to see elevated. If you had just had his heart completely checked out and everything was fine, I’d be less concerned that it be addressed right away and would likely think a recheck could be done in a week. You might want to do that anyway especially if you are waiting to get him into a specialist.
As I indicated yesterday, you could get the CardioPet ProBNP done to give you an initial indication of heart disease. If it comes back elevated, then an echo would be in order, for certain. That test will indicate cardiomyopathy but it doesn’t indicate all heart issues. For example, my Tobey has a left fascicular bundle branch block and, under stress, has premature ventricular contractions. His CardioPet ProBNP came back beautifully normal and his CK is always normal; CK would not be elevated unless there was heart muscle damage. But I have him echoed every two years to be sure his bundle branch block is not causing any other issues (it’s not expected to do so; a bundle branch block is synonymous to a detour in a road when you are driving. You still get there, you just go a different way).
I hope this has helped you a bit as you think about it and decide how to discuss with your vet. If you decide to just go see a cardiologist, as Karen said, Dr. Church is in Phoenix (he’s Tobey’s cardiologist) and he is the absolute best. I don’t know where you are in northern AZ and what specialists you have access to. I have found that while IM vets can do echoes, they don’t really know what they are looking at to the extent a cardiologist would.
Hugs for you.....I know this is stressful news along with him being not quite himself. One thing I will add is I don’t know if there is a situation where the CK is elevated that much and it has absolutely no significance. I did not find this to be the case in the reading I’ve done on it, but obviously, I don’t have access to veterinary journals that might have addressed it more.
