Case of the Month - Charlie
Charlie McCarthy was first referred to us in June by Amy Coulson of Deane Vets in Taunton, after tests concluded that Charlie was suffering from Acromegaly.
Acromegaly is a condition in which overproduction of growth hormone from the pituitary gland occurs, due to a tumour in this gland. This results in proliferation of cartilage, soft tissues and bone and increases in organ size. These changes occur both directly and indirectly via IGF-1 (synthesized in the liver). Acromegaly is diagnosed by measurement of IGF-1 in a blood sample and imaging of the brain to detect a pituitary tumour. One of the effects of this condition is insulin resistance resulting in diabetes mellitus, which is the main reason cats are presented to veterinary practices. This condition can result in difficulty stabilising a diabetic cat with insulin. It is thought that this condition in diabetic cats could have a prevalence of ~ 25%.
Potential treatment options in cats for this disease include medical treatment (with a somatostatin analogue), radiation treatment and removal of the pituitary tumour (hypophysectomy). Hypophysectomy can be curative for acromegaly and the good news is that with control of acromegaly, cats can potentially go into remission from their diabetes mellitus. However, as the pituitary gland is removed with this surgery, cats do require lifelong hormone supplementation (steroid and thyroid hormones).
Firstly, tests were taken with Amy at Deane Vets after Charlie’s owners first noticed he was drinking more than usual. Unfortunately, blood tests showed that Charlie had developed diabetes. However, even after injecting him twice a day, after four months blood tests were still showing a steady increase in glucose levels despite the increase in insulin. This concluded that Charlie was insulin resistant and his diabetes was subsequently uncontrolled.
The IGF-1 test was taken to check his pituitary hormone to confirm whether or not Charlie had the condition Acromegaly. Test results diagnosed that Charlie was suffering with acromegaly, which had resulted in poor control of his diabetes mellitus and referral to ourselves, here at Cave Veterinary Specialists. Following discussion with us, his owners elected to pursue the option of Hypophysectomy and his operation went well. Not only has his pituitary tumour been removed but we have already seen an improvement in his diabetic control as he is on ~ 1/6th of the insulin dose he was previously receiving. Charlie will be coming back to us for monitoring of his diabetes mellitus to see if he goes into complete remission. Following a check-up Charlie has also now gone into diabetic remission and is enjoying his insulin free life!
CHARLIE AFTER HIS HYPOPHYSECTOMY
CHARLIE ON THE POND
Here is a lovely story from Charlie’s owners…
Charlie has always been a big cat. Even when he first showed up in the garden ten years ago as a wandering entire tom, half-starved and covered in fleas, we could see a big cat waiting to fill out. And fill out he did. Over the last decade Charlie has fully earned his nickname of Big Charlie and, at his most splendid, he weighed nearly twice as much as his fellow resident black and white tom cat, Little Ed.
Then in January this year we noticed he was drinking more…not a huge amount admittedly, but more than he used to. We took Charlie to visit our local vet, Amy, and a blood test later we learned the bad news – Charlie had developed diabetes.
It’s at times like this that you realise that giving up isn’t an option. We had great support and advice from Amy and the team at Deane Vets in Taunton and soon got into the routine of injecting Charlie twice a day with insulin, and testing his blood frequently to see what his glucose levels were. I’d read about diabetic remission and hoped we’d be in that fortunate group of pet owners whose diabetic animals recover sufficient pancreatic function to be able to come off insulin for good. Unfortunately, over a period of around four months, Charlie’s blood tests showed steadily increasing glucose levels, levels which were getting higher in spite of his being given increasing amounts of insulin. The situation was clear: Charlie was insulin resistant and his diabetes, rather than heading for remission, was uncontrolled.
Amy suggested another test to check Charlie’s levels of a pituitary hormone called IGF-1. She explained that a percentage of cats presenting like Charlie can have an underlying condition that can cause uncontrolled diabetes - a condition that is much more serious and, if untreated, is inevitably fatal. It’s called Acromegaly and is caused by a tumour on the pituitary gland at the base of the brain. The affected gland secretes excessive amounts of the IGF-1 growth hormone and one effect of this is uncontrolled diabetes. Other symptoms include skeletal changes such as a broadening of the face and enlargement of the paws and feet. Other changes, more insidious and hidden, take place in important internal organs. Amy wouldn’t confirm her suspicions until the test results came back, but we were aware that a couple of weeks previously we’d taken Charlie in to see her after he developed a limp. Bizarrely his claws had grown so much one had curved almost full circle and was digging into a pad. Excessive claw growth is a symptom too…
The positive test result for high levels of IGF-1 came as no big surprise. Charlie was confirmed as acromegalic and we were given the news. Over the next year or two Charlie’s internal organs would continue to grow. Even a big cat like Charlie doesn’t have the internal room to accommodate an enlarged heart, liver and kidneys and these changes, in conjunction with his uncontrolled diabetes, would likely prove fatal before too long. Adding to Charlie’s woes was his insatiable appetite which drove him to ask for food throughout the day and night, his endless thirst, and his desperate listless fatigue which, when he wasn’t eating, saw him flopped down on his side, eyes open, slowly twitching his tail. Charlie was most definitely not a happy cat.
A bit of research showed that there did exist a possible cure: the surgical removal of the diseased pituitary gland in a procedure called a Hypophysectomy would stop any further release of the IGF-1 hormone that was causing the trouble. The surgery came with considerable surgical risk, required extensive post-operative medical care and apparently would require Charlie travelling to either the Royal Veterinary College in London, or Bristol University’s Langford Hospital to have it performed.
Charlie has never enjoyed travelling and putting an unwell cat through several hours of driving seemed unacceptably cruel. That said, the prospect of a cure had to be worth pursuing, especially as the alternative was watching our dear cat become increasingly unwell and unhappy until illness or euthanasia brought things to an end.
We live only a few miles from Cave Veterinary Specialists, and I have yet to fully comprehend what impulse made me send an email off to them in May this year asking if they knew of the hypopyhsectomies being performed by the RVC and Langford, and whether such a procedure was available at their hospital in Somerset.
While I thought I might get a reply I doubted I would get a very positive one, and I most certainly didn’t expect to get a reply within half an hour of sending my email from Dr Nicolas Granger – a recently appointed neurosurgeon at Cave. Nicolas said he had experience of pituitary surgery in cats, and would be prepared to offer the surgery and that it would be useful to have a chat.
Needless to say I picked up the phone and had the first of many detailed conversations with Nicolas. I don’t need to list here Nicolas’ considerable qualifications or his extensive surgical experience as a quick look at his profile on Cave’s website will explain all of that. What you won’t find listed in his CV however is the ability he has to instil confidence when he modestly explains how he performs these surgeries. Nicolas was quick to point out that even a successful hypophysectomy was only the start of a long and complicated treatment that might see Charlie cured. Removing the pituitary would stop the further production of IGF-1, but would also mean that other, essential, hormones would no longer be produced and Charlie would need both short and long term management with steroid and thyroid medications to ensure his continued survival. Nicolas explained that if we went ahead, he would perform the surgery and his colleague, Emma Roberts, would be in charge of the medical aspects of Charlie’s recovery.
We made an appointment to bring Charlie to Cave Veterinary Specialists in early June. Charlie spent the day having tests and on our return to Cave that afternoon we had a long discussion with Nicolas and Emma and the full implications of the proposed surgery were explained. Nicolas makes brain surgery sound almost routine but he left us in no doubt that things can and sometimes do go wrong, with catastrophic results. Emma would be monitoring Charlie in the immediate period following his surgery until he would be stable enough to be discharged and for us to take over his care. She detailed the extensive daily drug regime that Charlie would need to be on following the surgery, but allowed us some small hope by mentioning the possibility of a full or partial diabetic remission.
Ultimately the decision to proceed was ours. I don’t know how people can reasonably balance the risks and benefits of such a choice… surely two years of declining health is better than irreversible brain damage or sudden death? Then again, surely complete diabetic remission and a couple of pills a day for the rest of a, hopefully, long and comfortable life has to be a future worth pursuing? In the end, we placed our trust in Nicolas and Emma and agreed to the surgery. Charlie was booked in for his operation on Monday 26th June.
I’m not a fan of Mondays at the best of times, and that particular Monday was worse than most. We decided that there was no point calling for news and so we spent hours pretending to be busy while waiting for the phone to ring. Every hour brought a renewed consideration of the risks we’d taken and a gnawing worry that by aiming too high we’d caused harm to our cat. Thankfully Nicolas phoned just before the guilt became unbearable and with his characteristic understatement said it had all gone very well and that Charlie was recovering nicely. Were we relieved? A bit…
There followed a few nervous days while the excellent team at Cave looked after Charlie, and him becoming a favourite with the nurses. Daily updates from vets Nicolas, Emma and Chiara were always half-dreaded, but the news was predominately good, and then finally, on Friday and five days after his operation, we collected a very happy Charlie who, apart from lots of shaved patches in the oddest places, looked remarkably untroubled by his recent experience.
He’s on a lot of drugs at the moment: pain relief, antibiotics, eye drops to concentrate his urine, and the steroids and thyroid medication he’ll be on for the rest of his life. He’s also on insulin, although much less than before which suggests that diabetic remission may have already begun. These are early days yet and we still have a cat in a very fragile state of health, but we feel he’s getting better every day and we believe that our faith in the skills of Nicolas and Emma and the rest of the team at Cave has been rewarded. We’re now looking forward to Charlie regaining full health and spending many more happy years with us.
It goes without saying that we, and of course Charlie, have been blessed with great good fortune. We were lucky to have Charlie first seen by Amy, our primary care vet, who was sufficiently knowledgeable and thorough to suspect a rarely diagnosed condition. We were lucky to have good pet insurance that provided sufficient cover to take the sting out of the bills. We are lucky to live within twenty minutes of the amazing facilities at Cave Veterinary Specialists at West Buckland. But our biggest stroke of luck came when we managed to get Charlie treated by Nicolas and Emma – outstanding clinicians both, and two of the nicest people we have ever met!
Charlie at the beginning of August - Charlie is now in complete diabetic remission