Monday, January 30, 2012

One heart-wrenching day after another

While there can really only be one more horrible day - yet to come and not even to be thought about - than the day that Scruffy was diagnosed with cancer (and a heart murmur and kidney failure, like one awful disease was not nearly enough...) - this morning was definitely in the running for Day I Never Wanted To Come.

It was clear that - only 3 months from the fourth anniversary of being officially OTJ (off the juice, in feline diabetes speak) - the introduction of dexamethasone by IV in the hospital and prednisone pills at home were going to wreak havoc with Scruffy's glucose levels.  His last official lab test glucose level - on January 17th - was a lovely 51. (Which was actually a smidge lower than I would have expected.  Maybe cancer does eat sugar?)   From the introduction of steroids, on January 23, 2012, Scruffy's been around 200-250 each time I tested him.  I bought urine test strips, and sure enough, there was glucose spilling into his urine.

It's been so long since I had to worry about any of this stuff, and my mind has definitely deteriorated in the last 4 years.  But, I clearly can't risk DKA or further kidney damage from lack of treatment of diabetes.  

I wanted to use Levemir again - a human insulin that produced the OTJ status the first time.  It was gentle, long-lasting, didn't sting when injected, and gave him good control.   My expectations and goals are totally different this time, though.  I simply want him to be under the renal threshold.  I'm not interested in doing a whole bunch of testing or fine-tuning dosages.  I don't know how long I will have him here, and I don't want to make him any more miserable with treatments than he already is.  He was such a good diabetic cat the first time around - more than 7,000 ear pokes and who knows how many shots, and he never protested.  Except for the time I bought ReliON syringes....  he could apparently tell the difference between them and the BD's that I usually used.   The most efficient way to purchase Levemir for use with a cat is in the form of a "pen,"  a measured cartridge that humans can use by dialing the size of the dosage they wish to give and allowing the pen needle that is attached to inject the insulin.  Since this doesn't permit the tiny doses that cats generally require, we still need to use a syringe to withdraw the insulin from the pen and inject it into the cat.  Levemir comes from the pharmacy in a box with five pens.  Given the usual small dosages needed for treating a cat, five pens would last a very long time, and it's sadly unlikely that Scruffy would even be here long enough to use up that many pens.

So, I "networked" - asked a few very good friends if they might have any extra Lev pens, and was kindly offered four different pens by Pamela, Vicky, Melissa, and Dian.  Two of them would require shipping, which makes it more difficult in the winter, but Melissa and Dian are within driving distance.  Yesterday, Melissa and I met - and had a nice lunch at Cracker Barrel and a good visit - and she gave me a partial pen of Lev, a box of syringes, and a box of Kleenex to mop the tears that seem to appear unexpectedly and often.  Tomorrow, I'll met Dian - more lunch and more understanding friendship! - and she has another partial pen.  Of all the many pleasures Scruffy has given me over the eight years he's belonged to me, meeting and loving the special people from the Feline Diabetes Message Board is right up there on the top of the list.  Crazy cat ladies - well, maybe.  But smart, caring, thoughtful, wonderful humans - for sure.  I have been so fortunate.

This morning, I tested Scruffy again.  I'm really kind of quivery about this whole thing - I can't see well enough to fill the syringe, my math skills are so minimal I can't even figure out the dosage by the lines on the syringe - oh, and I really DON'T want to have to do this.  But.....  He was at 200.  So, I fed him - and of course, today was the first day he wasn't determined to eat out of every plate on the floor.  he did finally eat a little Gourmet Chicken FF and drink some lactose free milk, so I figured he was good to go.  I oh-so-carefully drew just a tiny little bit of insulin into the syringe - as close as I could get to the first line on the barrel, which is some totally unknown amount, but presumably way less than a half unit.  I made the tent, and poked poor Scruffy.  He probably got next to no insulin, I don't know.  At least, it was a first step, I guess.

At +3, he's 180.  Not a lot of movement, lol. I'm not gonna keep poking his ear.  If he pees, I'll check and see what the strip says.  That's the best I can do for him, except to tell him again how sad and sorry I am that all this has happened to him.  It's really not fair.  I gotta go find Melissa's kleenex.

Tuesday, January 24, 2012

Glucose level - 243 :(

Scruffy's home.

Jan.23, 2012

I wasn't sure that I'd even get to write that.  This is Monday night.  This morning, Dr. E called from the Specialty Hospital and said that he thought that the Puffer could come home today.  His ionized calcium level this morning was 1.34 , down from 1.38 yesterday.  But - his creatinine was 3.3, up from 3.1 yesterday.  He weighed only 10 pounds, 2 ounces today, no surprise since he had eaten virtually nothing from Thursday afternoon until Saturday afternoon, when he began to voluntarily eat small amounts of Fancy Feast Gourmet Chicken.  (Which was his "go to" food when he began to eat again after being diagnosed with diabetes back in 2004.)  Speaking of which, his glucose level has climbed steadily since he was hospitalized and since he was being given dexamethasone by IV for the last three days.  It was 184 on Jan. 21,  210 on Jan. 22, and 251 today, Jan. 23.  The doctor thought that stress from the hospitalization could be impacting the glucose level.   Truthfully, I'm hesitant to even test him now that he's home, but I suppose I'm going to have to.

The official report, made on information gathered between Jan. 20 - Jan 23, 2012, after ultrasound and other assorted tests, includes the following information:

"Diagnosis:  Large cell lymphoma of liver and spleen; kidney failure, history of diabetes mellitis, history of urethral obstruction.

Radiographs:  Possible cardiomegaly, decreased detail within the cranial abdomen suggestive of mild effusion or inflammation.  Hepatomegaly was noted as well.

Ultrasound abdominal:  On the spleen, there were multiple large, hypoechoic, heterogenous masses up to -80mm to the right of the midline.  On the liver, there was a single 27x20mm mass similar in appearance to the liver mass.  The peritoneal cavity had mild/trace effusion.  Single small mass between stomach and liver of questionable origin.

Ultrasound-guided aspirate:  consistent with large cell lymphoma

Ascultation of the heart reveals grade II-III/VI systolic murmur.

Urinalysis:  SG: 1.014, remaining values WNL   (Because his kidney values - creatinine, etc - showed virtually no improvement even though the calcium level is approaching normal, they have added "kidney failure" to the diagnosis.)

We came home with:

Azopt drops for glaucoma (already prescribed since June, 2010.)
Prozac (already prescribed since August, 2010, discontinued for 4 months in 2011, restarted in December, 2011.)

Prednisone - 5mg - 1 tablet every 24 hours until evaluation at appointment on January 26, 2011.  May be tapered off at that time.

Cyproheptadine - 4mg - 1/2 tablet every 12 hours to stimulate appetite.

Famotidine  (Pepcid) 10mg  - 1/4 tablet every 24 hours until recheck.    For nausea.

Renakare:  1 2meQ capsule every 12 hours with food.  Potassium supplement.  (However, this is actually a huge white pill, not a capsule, and even broken into small pieces, was a real problem to get into Scruffy.  He's very difficult to pill, and we've now got a ton of pills to give him.) This will hopefully be discontinued at the Thursday appointment if his potassium level has normalized.

Buprenorphine - to be given if he appears to be uncomfortable, although they don't expect that he should be "overtly painful."

Next Thursday's appointment is to include bloodwork  to recheck CBC, and Chem 8 test, and IV cytoxan/lasix chemotherapy.  It makes me shudder to think of it.  I am not convinced/committed to completing the entire schedule of chemotherapy, which includes treatment virtually every week for six months.  I think at either four weeks or six weeks, they plan to do another ultrasound to see if there has been reduction in the tumors. If there does not appear to have been any progress toward remission at that time, the option seems to be to stop and do nothing further, or to change to another protocol.  Given that the predicted survival of my sweet cat was "four to 12 months", I'm not sure I want to waste six months of that time making him sicker, and I am sure that I would not want to start another kind of treatment.  They are insistent that cats don't suffer the distress that humans do with chemotherapy; I'm not sure how they know that, and we all know how expert cats are at hiding their pain.

There is much more depressing information that I don't have the energy or desire to add right now, although I will post it maybe tomorrow, since it's potentially of interest to others who may be contemplating chemotherapy for their cat.

Here's a little more upbeat stuff:

It took FOREVER to get Scruffy sprung from the hospital. Although we had made what we thought was an "arrangement" to pick him up at 2:30 (and my husband had a doctor's appointment of his own at 3:30), it was almost 4:30 before I finally had poor Scruffy in my arms.  And then, we were taken to one of the exam rooms to get the medication and instructions and information sheets about the chemotherapy program - which is the Madison, Wisconsin protocol, by the way.  Then we waited a little longer for Dr. E to come and actually hand over the discharge papers, the buprenex, and Scruffy's kitty pi, which must have been left in his cage.

We finally got out of there about a quarter to five.  And by the time we'd gone a mile or two, it started to pour.  Tons of rain.  As we entered the area of Wexford, the most amazing thing happened:  an enormous, brilliantly colored, complete rainbow appeared in front of us, with a second rainbow forming to its left.  Stunning, defined stripes of color, and funniest of all, it looked like the end of it would be right in our back yard!  Well, of course, it wasn't, but it sure was close.  We decided that that was Scruffy's good luck rainbow, and hopefully, it means that he will survive whatever chemotherapy he ends up having, and that we will be allowed to have him for what will hopefully be a lot longer.

When we got home, I carried him upstairs and put him down in the living room.  There has been a sort of manic quality to his movements since being in the hospital - kind of jerky, unplanned-seeming movements, and his back legs aren't totally functional, which may be one of the side effects of the chemo.  Anyway, he looked around for a minute, and then headed immediately to the kitchen, where he climbed into one of the litter boxes and sat, looking kind of dazed, for the longest time.  When he got out of the box, I went to sit in my chair and he galloped over to assume his usual position on my right leg, with his little head cupped in my palm.  He had  trouble jumping up onto the table, and when I went to "help", I discovered that his whole bare-shaven little stomach was wet.  With chemo-infused urine, lol.  And we were instructed not to touch any of his "productions" for five days....  (He had what they thought might be a urinary tract blockage while in the hospital, although there was very little sediment when they catheterized him.  The catheter was removed just minutes before we got him, so I assume that it had caused some irritation and maybe lack of control.)   Anyway, he sat there, and purred mildly for about a half hour.  Then, he jumped down and headed for the kitchen again, to see what the other cats had left in their dishes.  He snuffled around, while I opened a can of Gourmet Chicken and gave him a little plate of lactose free milk.  He gobbled down half the can of FF, and I put the other half down for him and he ate that, too.  My poor cat that hadn't eaten a total of an entire can of food in two weeks!  He continued to make periodic food searches until around 9:30 or 10:00, when he got up and peed again, then climbed up on his window ledge and curled up in his kitty pi on the heated mat.

None of the other cats showed much interest in him.  He has a really odd smell to him, and I was a little concerned that maybe the others would reject him or not recognize him because of it, but it didn't seem to be a problem.  My little Milkshake was the only one to make any effort to "greet" Scruffy.  He jumped up beside The Puffer, and tried to lick his head, but all he got for his kindness was a whack with Scruffy's paw.

The one odd thing seemed to be that he didn't put his head down.  He just sat, eyes open and his head in the air, for nearly an hour.  I wondered if he was sleeping with his eyes open.  He didn't react to sound or noises, except for one unpleasant exchange between Minnie and Burble, when he turned his head toward the noise.  He got up twice to drink some water, and did a long, involved circling thing before laying down again, this time with his head down.  He's been generally napping now (although right this minute, his eyes are open halfway.)  It seems a little odd.

One other matter of interest, I suppose, is the cost so far.  (No one has mentioned the cost of the chemotherapy itself.)  I did say that I didn't think we could afford another regular charge of $900 for the several scheduled ultrasounds, and Dr. E said that it would likely be more in the range of $300 or $400; the original one include the aspiration and a ton of lab work.  Somewhat comforting.

The two page bill, which included the information that the charge for the "Hospital Level 2" is $90 for weekdays and $108 for weekends - summarized the charge for all of things that had been done to/for Scruffy on Friday, Saturday, Sunday, and Monday as $2,264.00.  A fairly shocking amount.  (It was my intent to tell the person doing the money collecting NOT to say all that financial stuff out loud, but unfortunately, just as she started reciting all of the gruesome and expensive details, my husband wandered over to the desk and, of course, was regaled with all of the numbers.  It was even more shocking to him, I guess.....

At any rate - with the exception of the fact that I don't know how I'm gonna get the potassium pills into Scruffy twice a day, and that I'm not convinced that Pepcid/famotidine is going to control nausea sufficiently now that he's eating again - my sweet kitty is home again.     I have cried practically non-stop for four days, and now, to be able to hold him and pet him and just have him here is wonderful.  He's such an odd little guy, with probably the most interesting personality of any cat I've ever had.  I'm going to concentrate on treasuring however many more days we have.

Scruffy's Rainbow

First meal at home

Milkshake's greeting

Saturday, January 21, 2012

Scruffy has lymphoma.

It hurts my heart to write that.  In his liver and spleen.  And the hypercalcemia is causing kidney failure.

I thought this post would be a report of the results of the second bloodwork, and the arrival of the results of the fPLI test.  (He got a 14; normal is 1.0 to 3.5.) And to mention that I weighed him again this morning and he was down to 10 pounds, 5 ounces.  And that there is a sort of odd, squishy quality to his abdomen when I pick him up.

To summarize the second bloodwork, AST and ALT were elevated more, although not horrifically.  Amylase was high/higher.  Glucose was 51.  I wish I could laugh about that.  Total calcium was significantly higher, and his creatinine and whatever the other kidney thing is were both abnormal this time, although they had been fine just a week ago.  The vet sent a referral for an ultrasound.  When I called them, they said two weeks.  It was becoming apparent that we didn't HAVE two weeks.  I flung everything I could think of into the conversation with the receptionist, including Dr. B, the ophthalmologist.  And somehow, she discovered an appointment she hadn't seen before for this Friday, only two days away.

In the meantime, although Scruffy would turn up in the kitchen every time I put food down for the cats, he couldn't seem to bring himself to eat.  I started putting a whole handful of kitten chow on his plate, and carrying it around to wherever he ended up sitting down.  He also would still wander out to the living room where Milkshake eats, but instead of inching up closer and closer to sneak a bite of Milk's food, Scruffy would just meatloaf down a couple inches from Milk and watch him eat.  I picked up a couple of cans of AD because even the ham baby food wasn't enticing him, and I was getting worried about taurine and all the other neutrients he wasn't getting enough of.  The one thing he wanted and ate eagerly - and which was probably a terrible thing to give a cat with calcium in his blood that was killing him - was lactose-free milk.  I never give any of the cats milk, although Black Kitty started every morning of his life inside with a nice dish of regular old milk and we never thought a thing about it.

I have the dates all confused in my head.  I need to get a calendar, I guess.  The Sunday after the second bloodwork was done - and there was an error that delayed the testing and the return of the results, so it was right after we got the report - Dr. G. said he thought that we should start doing fluids.  It has been one of my fondest desires NEVER to have to do fluids with one of my cats.  I have been needle phobic forever; it took me months to be even moderately comfortable with insulin needles, and they were 31 gauge.  But - it had to be done.  We took Scruffy down to the office and got a quick demonstration of how to do it.  I thought Rege was intending to help, but the next day, he announced that he was NOT going to.  I managed to do it myself, and my sweet cat never fussed at all.  Not a move, not a peep out of him.  I expected, though, that it would make him feel so much better.  It didn't seem to.  And he wasn't peeing any more than usual, which also surprised me.    I discovered that Costco sells/will order Lactated Ringers - a case for $26.19 or there abouts.  Dian gave me a website that sells the needles - Terumo's, too! - Dr. G. gave me disgusting Monojects that stuck to Scruffy's skin like glue; they were horrible to use.  And I bought sets of tubing.  All set to go.  Scruffy and I got through five days of "giving fluids" without much trauma, and without his making the least protest.  I took pictures, for no particular reason.  I guess I wanted to prove that I was able to do it, no matter how I hated it, and what a good cat I had for tolerating it when he felt so lousy.  As you can tell from his fur, he felt crummy, and he was still purring when I rubbed his ears at the end.

Another installment of this nightmare tomorrow.......I'm too weepy and exhausted to do any more tonight.  And I miss my Puffer terribly already and it's only been 13 hours.  

Wednesday, January 11, 2012

10 pounds, 11 ounces. :(

Scruffy's not doing very well.

Tuesday, January 10, 2012

He's been licking his lips for two weeks or so, and doing some throwing up.  Nothing very major, nothing particularly unusual.  His teeth are again in need of a dental, so I made an appointment for him to have bloodwork.  He's never, in all his years, had any bloodwork results that were abnormal except for glucose and cholesterol.

But, this one came back with:

ALT   154 (high)   ref. range  10-100
AST   106 (high)   ref. range  10-100

Calcium   12.8  (high)  ref. range  8.2 - 10.8

Amylase - 1407  (high)  ref range 100 - 1200


Neutrophils  (high)  9225   ref range  2500 - 8500  75%

When Dr. G. called with the bloodwork results, I was shocked that there was something wrong, and even more by what it appears to possibly be.  Hypercalcemia.  Excess calcium.  Most often an indicator of lymphoma, or also of parathyroid adenoma, or kidney disease/failure, or hyperthyroidism.  Only, his kidney values were just fine, as was his Total T4.

Also, he's lost somewhere in the range of at least a  half pound.  His little face is tiny, suddenly.  And then I realized that his fur is horrible - getting dandruffy and sticking up all spiky in every direction.  When he lays down, meatloaf-style, the fur on the tops of his back legs sticks out like clumpy batwings.  He's never had nice fur, but this reminds me of all those months of uncontrolled glucose levels in the 300's and 400's......

Spiky hair from his ears to his feet.  :(

Poor Scruffy's been very sniffly for several weeks.  He did finish a course of zeniquen for herpes in early December, successfully.  I had thought maybe the lip-licking might have had something to do with his ears, actually; he has a history of ear infections, and if I rub in front of his ears, he shakes and scratches at them in a fairly frantic manner.  He's been sleeping significantly more than usual for the last week. One night, he didn't even show up to sleep with me for the first time in months, although he's always tucked away with his little head in my hand in the morning.   For the last two days, he's been throwing up foam once or twice a day, usually when his stomach is empty.  And he's drinking  water very frequently, although he doesn't seem to be spending any more time in the litter box than usual.  (Unless, of course, he's wandering downstairs to pee on the rug when I'm not around. )  I was consoling myself by thinking that at least he was still eating in Scruffy fashion.  Scruffy never not eats.  Until this morning, when he ate only a few bites, sniffed and wandered slowly away.  (And the final blow - the melanosis in his right eye - I can't see it totally clearly and I haven't been able to get a picture of it - seems to have a second area of discoloration suddenly.)

It was the vet's suggestion that we wait two weeks or so and then retest the calcium level, and add in testing on a bunch of the other possibilities.  And an ultrasound -  which would be interesting, I guess, solely because everyone who has ever examined his abdomen has thought that there was Something Wrong In There.  (That was the reason that the Emergency Hospital thought that he had FIP, way back when I first brought him home in 2003.)  He did have xrays with the last dental, about a year ago, that included his lungs and the area around them, and his hips and spine; there didn't appear to be anything abnormal then.

Anyway, with today's rare and frightening lack of interest in food, I called the vet and asked about cerenia, which he had mentioned the last time I talked to him a couple days ago.  We have never resolved our definition of "vomiting" and "regurgitating" - I think Scruffy's throwing up his whole life has been "regurgitating" - the food never hits his stomach; he just gobbles it down, and within seconds, it comes right back up, untouched by teeth or digestive process.  The vet says that cats don't "regurgitate", and that it's vomiting.  Not that all of that is of any particular import, it's just an issue that has come up repeatedly.  Anyway, I thought I would try pepcid, but after thinking about it, I realized that, with all of the other stuff that seems to be going on, maybe it would be better to just start out with the Big Gun instead.  Turns out cerenia, which I know people on FDMB have had very good experiences with, is an injectible.  Dr. G. says it stings.  And that it can be given with an insulin syringe, sub q.  Thank God, I guess.  It took me forever to get used to giving Scruffy insulin, and the only other time I ever had to inject anything, they gave me four HUGE syringes full of Reglan to inject into my little 3 pound kitten, Burble.  With one of those enormous thick syringes and needles that are NOT insulin equipment.  I could only bring myself to do that once, and it was horrible.  I just don't know if I can do injectible cerenia, and I have mixed feelings about doing something that will cause him more pain and discomfort.  So, anyway, there's a pill form, which may or may not last 24 hours, like the injectible does.  I picked up 4 pills - I don't know why that number, since it's Tuesday and the fifth day is Sunday, when the vet's not open.  I guess to see if it works or not.  I came right home and gave him the first pill, with his prozac, because he's really difficult to pill, unfortunately.  Another reason to consider the injectible, I guess.  Waited three or four hours for the pill to start circulating, and then got out the food.  He did come out to the kitchen and wait in his usual place for his dish, but he didn't really eat any of it.  He likes to wait until I fix the dishes for Tootie and Milk - adding a little dry kitten food for them, and I always put three or four pieces on his plate at the same time; he did eat that dry, and a couple of snuffling bites of the canned.  And then he went back to sleep for three or four hours.

Dr. G. said today that 12.8 isn't exactly the level of calcium that is considered an alarm sign for hypercalcemia/lymphoma.  That's closer to 15, apparently.  And he says that electrolytes can vary - we might have just caught him at a time when it was unusually high.  But it's high enough to need to be checked, because high calcium can cause kidney disease, among other awful things.  An elderly cat who had totally uncontrolled glucose levels for more than two years and still manages to have well-functioning kidneys doesn't need anything to damage them.  I spent a long time reading stuff I didn't really understand about hypercalcemia today; everything that I thought might be an explanation for his level seemed to be negated by all the other stuff that's suddenly going wrong with him all at once.  The weight loss is worrying and sudden.  What if he's working up to hepatic lipidosis and that's why his liver values are screwy?  See, why didn't I ask the vet that?  Should I call him and ask him tomorrow?  Wouldn't he have mentioned it if he thought it was a problem?

I have literally spent every minute that this poor cat has lived with me keeping him alive.  He had a urinary blockage a half hour after I brought him home - the first of three that required surgery in the first two months I had him.  And then the "FIP scare", and the "sinus infection" that turned out to be herpes, and the diabetes and DKA, and the iris melanoma and subsequent laser surgery, and then the glaucoma, and now - after worrying for 3 years about the possibility of melanoma metastasis - now lymphoma, maybe?  Not fair.  I am so weepy I can hardly look at him.  The poor thing, none of this should have happened to him.