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Date:   07 May, 2011  
Focus: Small animals - dogs, cats, hamsters, guinea pig & rabbits.

Toa Payoh Vets Clinical Research
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Mouth Ulcers In Cats
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS 
Updated:
07 May, 2011
Case written: 05 October, 2002
Toa Payoh Vets
Be Kind To Pets
Veterinary Education
Project 2010-0005
The drooling cat
Singapore cat 4 years old - tonsillitis, salivation  "This is a frightened cat," 65-year-old Groomer Ken said as he lifted the drooling cat out of the cage onto the examination table. "The hair along the back stands on end. Her ears are held up and back for protection. Her tail is wrapped round her body to prevent injury. Her eye pupils are dilated. Her body is arched and her whiskers are pulled back. She drools."

Groomer Ken was right. This five-year-old spayed cat was an indoor cat and had never left the condo. She must be frightened of the smells of dogs and other animals in the veterinary clinic.  Singapore does not have a cat-only veterinary clinic and barking dogs at the clinic could also frighten cats. 

 "Why is she drooling?" Nurse Ann asked me as viscous saliva oozed out continually from her mouth, below the protruding tip of a pink tongue. Gravity pulled down the drops onto the examination table. The cat seemed unable to keep her tongue inside her mouth as the tip of the tongue dangled out. 

Her front legs were stained with saliva and food debris for some weeks and she could not groom himself now. Ann was now used to the foul breadth of cats and dogs and did not complain.   

Ken said, "This cat must have a fish bone inside the mouth or throat for the past two or three months. She is now skin and bones because she cannot masticate properly."

Nurse Ann asked, "What is 'masticate'? It sounds like an obscene word!"  

Ken expected Ann to know medical words as she was in the veterinary profession. "It means chewing and crushing the cat feed pellets to small pieces."     

I said to Ken, "Singapore does not have a veterinary nursing college. Therefore, it will take some time for Nurse Ann to learn more about medical terms on the job."    

The cat pawed at me as she strongly objected to her mouth being opened. She swung her right paw out at my hand, claws unsheathed. Her hind legs were all stretched out,  ready to escape from Ken's iron grip on the scruff of her neck. 

She hissed and thrashed her tail from side to side as if she was a snake trying to intimidate me. She was now a fighting cat.

I boarded her after giving her an antibiotic injection and dextrose saline as she was too weak to be tranquilised for a proper examination of her mouth. 

In this case, a tranquiliser into her back muscle would relieve the cat's of intense mouth pain. Then I could examine her mouth without causing more stress to the patient. What could be the cause of drooling?

She was now very thin. Emaciated as if she was a street cat with infectious diseases. She wanted to eat but could not eat more than three pellets of cat food. Her mouth was excruciatingly painful as the food touched the tongue. Singapore cat 4 years old - stomatitis (infection and inflammation of the mouth)So, she would not eat much.   

The next day, she was feeling better.  I tranquilised her but she needed some gas anaesthesia as her tongue was painful.  She slept well when given the gas anaesthetic and this was a good sign that her pharynx was not obstructed.  

White plaques covered the back of the tongue. I could see a much larger rounded mass of tissue on the right side of the back of the tongue. The left side had a smaller lump. This would be the adenoid tissue which is part of the cat's tonsils.


This tissue filters out all the germs and toxic substances - the bacteria, viruses and toxins from entering the lungs and stomach. Like frontline soldiers. Only that the tonsillar tissues were overwhelmed.  The tissues increased in size and hardened. The cat could not swallow. Saliva could not be swallowed too and the cat drooled.
    
Was there a fish bone lodged deep inside the growth? The owner had said that the cat was given only dry cat feed and no fish.  

Was the cat suffering from cancer of the tonsils? I palpated the submandibular lymph nodes located at angle of the jaws under the skin. The cat was now anaesthesized by gas and she could be properly examined. The nodes were hard and enlarged but not considerably. A gritty feel as if the nodes had sand. 

The much enlarged tonsillar tissue areas were hard lumps. They obstructed the entry into the oesophagus by 50%. Ulcerated and painful. It was difficult for the cat to swallow food. She only ate dry feed pellets and the pain would be worse than if she ate liquid food. 

She did not even want to consider the crushed powdery feed or the canned feed.  It is not easy nor the time to change her eating preference.Singapore cat 4 years old - tonsillitis, salivation

Should I cut off the lumps or wait for them to reduce in size after antibiotic injections for the next few days?  Would the cat die if surgery was done? If it was not done, the cat would drool and the bad breadth would return in the next week. It would cost the owner more money for further treatment. 

There is a limit to veterinary spending on the cat as most Singapore owners do not wish to spend much on a cat. Fees add up when there are laboratory tests and repeat visits. 

The cat had been given dextrose saline and antibiotic injection twenty four hours before tranquiliser and anaesthesia to make her stronger.

Surgery to remove the enlarged tonsillar tissues might cause bleeding. The bacteria and fungal micro-organisms that populated in large numbers in her mouth would then spread all over the body through the blood stream. 

This might be the only opportunity for this cat to get cured as many time-pressed Singapore cat owners don't return for repeat visits. A reluctance to spend money could be a reason.

I cut off the top part of the lump. There was little bleeding.  The cat recovered in the next three days and she meowed to greet me. There was  some drooling from the right side for the first two days. The tongue no longer prolapsed out.

The cat would not want to eat the crushed powdery pellets. She just looked at them and smelled them but no, she was not going to eat such powdery stuff which I thought would be appropriate since she had a sore throat and could not swallow well.  She was able to groom herself after Ken bathed her and scrubbed all her dirty stains on the front legs at the end of anaesthesia. 

Singapore cat 4 years old - tonsillitis, salivation On the third day, I gave her the dry pellets on the floor of the cage as she would not eat canned feed nor the powdery pellets.

Nowadays, the pet companies sell small packets of meat cubes in gravy so that there was no need to buy a big can. The cubes looked appetising to me but this cat was not interested. She was really hungry and ate very fast. Suddenly she made a gagging sound as she choked and felt the pain in the back of the mouth. She recovered quickly.  She choked another time as she swallowed too fast.

Cat, Singapore. Little drooling 3 days after treatment. "She is as thin as ever for the last four years and friends think I mis-treat my cat," the owner complained to me when I asked about the cat's feeding habits.  

He and his wife had bought all kinds of feed, consulted a vet and had given deworming medicine. But the cat was still as thin as a rake.  Could it be due to the fact that this cat would not eat sufficient amounts.

This condition happens to pre-teen girls and boys in affluent families in Singapore too. They just do not eat much and are very fussy with the kind of food they will eat. Doctors will diagnose as nothing wrong with them. 

The bacterial infections in her mouth produced toxins. These toxins spread via the blood and now had affected her whole body system. She became toxic and lost her appetite. It was a surprise that she was still alive. The cause of his tonsillitis was unknown but the mouth ulcerations could be due toxic substances.  

Antibiotics did reduce the infections in her  swollen tonsils and her submandibular lymph nodes were less gritty when checked 7 days later. There was a little drooling even after ten days.  However the cat could eat her pellets. 

Why did this cat drool?  Many questions have no answers. One possible cause of this tonsil infection could be the environment. The cat was the only one of the three that loved to sleep in the place where the dog passed his excrement and urine. 

Over the months, the waste products of the dog could have contaminated this cat and she could be licking off the toxic products during grooming. In time, the tonsils just could not cope and enlarged much more. Bacteria and fungal infections came in and cause ulcerations and mouth infections known as stomatitis.  The solution might be simple - remove the cat from the area.  

There could be other causes such as autoimmune diseases where the cat's immune system had produced antibodies to attack its tonsils. Or a cat virus such as herpes virus could be present although there were no signs of runny nose or lung diseases. This cat did not suffer from the usual chronic gingivitis or inflammation and infection of the gums as her teeth and gums were in good condition.

Two weeks after going home, the cat drooled again. If there was no cure, it would be euthanasia for this cat.  

This was the real world in which there was a limit to the amount of veterinary fees, laboratory tests for viral infections and drug costs to be paid by a cat owner. Singapore just had an increase in bus fares. Now, the medical and hospitalisation charges for people would be increased soon. Therefore, the cat would be euthanased if there was no guarantee of success.      
 
The lower part of her gums on both sides were blood red and swollen around the teeth.  An anti-inflammatory injection was given in the muscles. An antibiotic injection was given under the skin.  There was no drooling the next day and the cat continued eating. Drooling stopped for the next 14 days. 

The swollen tissues had shrunk. The cat Cat stopped drooling after anti-inflam and antibiotic injections 14 days ago meowed when she saw Nurse Ann and groomed herself well. She liked to rub her face against the cage bars to mark her territory. She ate the dry feed well and had gained weight.  

This was most likely an auto immune disease.  Fortunately, the cat did not suffer from oral tumours. The swollen tonsillar tissues would reduce after treatment. There was no complaint from the owner for the next sixty days. The cat's tongue no longer protrude from the mouth. It was great to see her back to normal.

The tissues from the tonsils could be sent for laboratory examination for tumour but in private practice. However, the cat owner would like minimal veterinary costs and so this was not done.

A few follow-ups with your vet if your cat has oral problems are essential if you want the cat to live longer lives. One visit to the veterinarian is not sufficient.  Seek a second opinion but it is obviously better to work with one veterinarian rather than doctor-hopping as the progress of the disease can be monitored by your first veterinarian.

Sadly, many Singaporean owners either do not have the time nor knowledge to follow up in time as in this case. Surprising this cat, though emaciated, could survive the tranquilisation and anesthesia without dying, as she was a very high anaesthetic risk.

Owners never forgive the veterinarian if the cat dies under anaesthesia. They never forget if they forgive and seldom want to consult the vet again. Sometimes they bad-mouth the veterinarian to their friends. This is the real world!   


REFERENCES:

1.  A well researched reference by a cat lover: Steatites in the Cat & useful references (the hyperlink to Geocities is dead. The webpage is published below. Geocities has closed down and so the link has been archived somewhere.).

2.  RABIES IN CATS:
Singapore does not have rabies for more than 50 years. The U.S State law requires any animal that is suspected of rabies to be quarantined for 10 days. Rabies symptoms are usually manifested within 4 days after infection. The animal, if infected, usually dies within 10 - 12 days. 

An infected cat will have clinical signs that are divided into three phases. The first 2-3 days post exposure there will be mild behavioral changes that may go unnoticed. A mild fever, dilation of the eyes, and extreme pain around the bite wound will usually be present. The next phase is known as the "furious phase". For 2-5 days cats will be excitable, aggressive and may attack without any provocation. 

Staggering, salivation and muscle tremors may also be present during this phase. The last phase is known as the paralytic phase and lasts only a few days until the cat dies. For the final 2-4 days of the infection, the cat may seizure, a general paralysis will overtake the feline and death will occur after the patient falls into a coma.

Diagnosis is based on clinical signs and a special IFA test performed on brain tissue from the dead animal. If a cat bites a human, it will be quarantined for about 10 days for observation. If no signs are present, all involved can rest easily. Cats showing clinical symptoms or animals otherwise killed after a bite must have their brain examined by this Immuno-fluorescent antibody test for rabies. 

3. RODENT ULCERS IN CATS (feline eosinophilic granulomatosis). Salivation and ulcers are signs. 

Eosinophilic Granuloma Complex - 

Three distinct but related clinical syndromes comprise the granuloma complex:

3.1 Eosinophilic (or rodent) Ulcer. This may occur on the skin or in the mouth but usually affects the upper lips. The lesions are well-demarcated ulcers.

3.2 Eosinophilic Plaque. These are raised, moist, red eroded or ulcerated areas with a well demarcated border. Pruritus is usually severe. lesions usually occur on the underside of the cat (abdomen, brisket or inside the thighs.)

3.3 Linear Granulomata. These can occur at most sites, especially behind the hind legs and within the mouth. They are well-demarcated lesions which are raised and yellow to 
yellowish-pink in colour. They are often thin, hence the name *linear* granuloma.

The mechanisms leading to the onset of this group of symptoms is unclear. However it is known that cats with flea allergy, food allergy or atopic dermatitis may have ECG. It is probable that the underlying causes of ECG are similar to those of Miliary Dermatitis (Parasites, Hypersensitivity, Infections and Essential Fatty Acid deficiency).

Treatment is based on identification of the underlying cause or the use of anti-inflammatory drugs (gluco-corticoids, essential fatty acids and anti-histamines) in undiagnosed cases.

 

432. Blog: A cat owner's cat mouth ulcers posting in Geocities
Steatites in the Cat & useful references
Geocities webpages are no more. The following detailed website of cat mouth ulcers was previously published by a cat owner. After Geocities closed down, the webpage was gone. I managed to track it down to an archive and publish here for references

Boot's Story:
Lymphocytic-Plasmacytic Stomatitis.
Feline Viruses, Auto Immune Diseases
& Interferon

"You Are The Wind Beneath My Wings"
from the movie Beaches


Sept 1996. Boots, shortly after he came home with us. Weighing about 7 lbs, and waiting for his boiled chicken.

Lymphocytic plasmacytic stomatitis (LPS) is thought to be an auto immune disease of the gums and lining of the mouth and throat, although the exact cause is unknown. It can only be confirmed through biopsy. Although the symptoms may appear the same, do not mistake this disease with chronic gingivitis which is almost always due to tartar buildup.

The first thing to understand about this condition is that this disease is generally a secondary symptom of a greater underlying viral infection such as Feline Immunodeficiency Virus, Feline Leukemia, Feline Herpes (aka Rhinotracheitis) or Calicivirus. Always, always have your kitty tested for FeLV and FIV if faced with this condition. Fortunately Boots tested negative, both at the shelter, and by our own veterinarian, however our vet did conclude that Boots was chronically infected with Feline Herpes.

These viruses may cause other symptoms besides the stomatitis. You may notice your cat is more susceptible to upper respiratory infections and eye problems. As this condition is also thought to be associated with auto immune deficiency, you are also dealing with a disease that is triggered by stress. The stress of being in a shelter for two years had eroded Boots' mouth and gums to the point where he couldn't swallow. He weighed seven pounds when we brought him home in August of 1996.

The single biggest thing we have found to make a difference in the management of this disease is Interferon, an anti-viral medication developed for use in humans. We now have three years experience with it, and we have seen a dramatic improvement with Boots.

Boots' stomatitis was very severe with involvement down the throat and into the larynx and the loss of 3 teeth, but we have managed to stabilize it to the point where he's now eating boiled chicken (spoiled cat) and has almost doubled his weight since we began this protocol.

Our initial routine with him was teeth and gum cleaning and cortisone if necessary every 3 months, Antirobe (Clindamycin) antibiotic 1 cc X2 daily, and 1 cc of diluted (30 units per 1 cc of sterile water) Interferon a day. Cortisone (Depo-Medrol) is also common therapy for this disease. But you want to try to minimize the amount you have to give as it has long term side effects. Used judiciously it helps to control the inflammation and pain. Some cats require cortisone on a monthly basis, however we have found that the Interferon has significantly reduced the progress of the disease, therefore we are giving it less often. Our doctor mixes the Interferon in the correct diluted dosage and freezes it in 10 cc syringes. Interferon has a very short shelf life and cannot be kept in the refrigerator over an extended period of time. We thaw one syringe and use it for 10 days. It is given orally, and is mostly water, so there's no taste. You can either syringe it directly into the mouth or mix it into food.

Regular teeth cleaning is necessary to control tartar buildup which can make the mouth and gum ulcers worse and also open the body up to serious infection, so its important that you monitor this closely.

Interferon is a drug that was originally developed for human cancer intervention, and is also being used in human AIDS treatment. It is the only known anti-viral medication mankind has developed. It has mixed success in humans, but veterinarians are having greater success with cats. Consequently it is being used to treat or manage many feline viral infections including Calicivirus, herpes (both of which have stomatitis as a complication), Feline Leukemia, Feline Immunodeficiency Virus and even Feline Infectious Peritonitis.

If all else fails, removal of all the back teeth seems to provide relief. While this might seem extreme, cats can do very, very well without teeth as long as you feed them canned food, and the quality of their lives can be excellent.

I was reluctant to take home a sick cat, so soon after having lost my beautiful Tardy. But Boots caught my eye, and I know without a doubt it was Tardy who had pointed him in my direction. Boots was so pathetic looking, scrawny and haggard. I knew the wonderful volunteers at the shelter were doing everything they could to help him, but I also knew Boots was slowly failing, and that he would be hard to place. I couldn't leave him there, even though I thought at the time I was opening my heart to eventual grief. The shelter had been very, very careful to be sure I understood this was a lifetime problem. I took him on a foster basis, not yet ready to deal with what I thought was a terminal illness which would lead me to more grief. But after the first few hours of having him in a real home and watching him bound delightedly from empty room to empty room, I knew Boots was home, and I called to say he wasn't leaving. The shelter waved the adoption fee.

Not knowing anything about stomatitis, I had no idea how much could be done to manage this disease. Two years later Boots now weighs over 14 lbs. He purrs now, and he plays with the other cats. He rules the house. I know that God and my rainbow Tardy are watching over us, but I also know the real difference in these animal's lives has been the experience and the unbelievable knowledge of our vet. It has been the deciding factor in our ability to maintain their health.

If, for any reason you feel that your vet isn't dealing with this properly, I urge you to seek a second opinion. The key to our success lay in the fact that our doctor keeps up with current trends, and with the published literature, and we are the beneficiaries of his dedication to his profession.

I leave you with one final thought. Don't lose hope! Boots has taught me that although you might face the pain of losing an animal, it is always worth the risk to open up your heart, to love and to try. The reward is indescribable. I often wake up in the middle of the night to find Boots nuzzled against my face, purring.

Below you will find a number of links I have collected regarding Stomatitis, Viral diseases for which stomatitis is an opportunistic symptom, and some info on Interferon. If you have any more questions, or comments never hesitate to e-mail me.


Boots today, at 15 lbs, healthy and happy.

Postscript: I have always believed that Tardy led us to Boots. On June 4, 1997 I finally trapped and took in a stray that had been visiting us for several weeks. The first thing our doctor did was look at his mouth. We now have two cats with this disease, and two cats who are thriving because of our vet's skill and Interferon. Sammy lives indoors with us now, and Tardy watches over us still.

September, 1999 Update: Boots continues to thrive. He is still on 30 units of Interferon daily and has been since August, 1996. Just recently I received an unexpected e-mail from the wonderful woman who worked with us on adopting Boots. One of her shelter co-workers had found Boots' Story on the web and printed out the information to help with one of their shelter cats. Jo sent me an e-mail asking if this was possibly the same Boots. We traded e-mails, and finally Jo came to visit us. I was so proud to show her how well he is doing, and we both shed a few tears of happiness. Life takes unexpected turns, and it is so fulfilling to have a circle completed.

November, 1999 Update: Sammy has developed a Herpes eye infection. We are treating it with two human Herpes medications - Viroptic and Chloroptic eyedrops 4 times a day, and 250 moms of L-lysine amino acid twice a day. The Viroptic drops seem to sting, so I give him the Chloroptic drops first to water down the Viroptic side effect. This seems to work. After 4 weeks, the medication is having a noticeable effect. There is no more squinting and Sammy seems to have regained all his old habits and appears to feel no more discomfort.

February 28, 2000: Our vet has just returned from a conference and is hearing wonderful things about L-lysine and viral infections. I have continued Sammy on 250 mgms of L-lysine twice a day since his Herpes eye infection, even though that has resolved. I am convinced it is helping him stave off URI's when we take vet trips. Today our vet recommended we begin Boots on the same dosage.


Stomatitis Links

About Stomatitis:

Feline Stomatitis - site includes good photos of what this condition looks like.
Oral Ulcerations - Includes diagnostic procedures and drugs of choice for treatment
Feline Stomatitis - More on Stomatitis from Dental Vet
Mouth Problems in the Cat - from the Feline Advisory Board in the UK
Stomatitis - From the Cat Fancier's Association
Veterinary Dental Care & Problems of the Mouth
Understanding Your Pet's Immune System - a good basic explanation of how the immune system works. Warning! Its a little technical!!


About Herpes and Calici Viruses:

Feline Herpes Virus - A veterinarian's explanation.
Herpes Virus, Stomatitis and Interferon - Dr. Mike Richards continues with an explanation of treatment
Herpes Virus: Symptoms and Treatment - Another good explanation of the relationship between Herpes and stomatitis.
Use of Interferon in Feline Herpetic Keratitis - corneal ulcers are another complication of Herpes virus
Calici Virus, Upper Respiratory Infections & Mouth Ulcers - Not so common a virus, but complications can include stomatitis. Excellent info on dealing with Chronic Reparatory problems!
Chronic Nasal Disease - Causes and Treatment
Upper Respiratory Infections - What to do when Kitty has a cold
Cat Colds - Causes and Treatment


About Interferon and its use in treating other viruses:

Interferon and FeLV / FIV - Using Interferon to combat leukemia & immunodeficiency viruses.
Newer Methods for Treating FeLV - Includes a link to an company manufacturing Interferon, and protocols for use.
Smudge's Story - Smudge has Feline Leukemia, and he is truly an Interferon success story.
Chloe's Story - An excellent site for info on FeLV, including Interferon treatment.
Dr. Mike Richards - using Interferon for FeLV
Dr. Richard C. Weiss - developer of the FeLV vaccine. A list of published articles on the use of Interferon in treating FeLV
Colorado State University - Study on the use of Interferon in treating FeLV

Living with the FeLV+ or FIV+ Cat. - How viruses affect the cat, False Positives, Treatment, Information and Support. See the treatment section.

Pyewacket's Story - FIV and Interferon. A genuine success story.
Felix's Story: FIV and Interferon

FIP and Interferon - The use of Interferon in managing Feline Infectious Peritonitis

What is Interferon? - This site is for Human Hepatitis, but does a good job of explaining how Interferon works.
Interferon: Patent claims

Resources:

Dr. Camuti Memorial Feline Consultation & Diagnostic Service - a wonderful resource for either you or your vet. For a $35 consultation fee you can talk to a vet at Cornell about diagnosis, treatment and the protocols involving Interferon.
 
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