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Goitre And Myelofibrosis

by mikemesley - July 11, 2009

A super interesting one from Down Under.
A young cat (2years old) was seen in Feb for F3 vaccine - Excellent condition.
Then progressed to become lethargic, have pica (licking dirt), losing weight etc.
At initial presentation our clinic - diff vet - HR200+ and palpable thyroid mass, T4 level mildly elevated. Full bloods not run at this stage.
Were speaking about progress from this point when over next few days the condition progressed and O also noted urinary incontinence. Urine - USG 1.021, proteinuria, haemoglobinuria - > full bloods run
PCV 9.3 (this cat did not look like a severely anaemic cat in general - only the paleness- maybe suggesting chronicity?) slightly low platelets, WBC counts in normal limits, hyperproteinaemia including very high globulin levels.
Referred to specialist centre who toom BMarrow aspirate with diagnosis of myelofibrosis. They suggested 2 common causes of this are FeLV and FIP - diagnosis poor and sent home on doxycycline and cortisone with poor prognosis.
Has gone exceptionally well and now, about 3 months later, looks like a cat that has had too much cortisone, but very well. Bloods taken about a month ago suggested all cell count normal and TP normal also.
Exam today = slippery but quite weak pulse (is this a spreading pulse?), tongue pink-red and moist. Owners call her a heat-seeker. HR - 140ish. No palpable thyroid felt. Abdomen feels flaccid. Pica has recently begun again - although is just starting to be let outside again, so unsure if it ever went away truly.
My assessment was probable SP Qi/Yang deficiency (weight loss, meakness, pica) - however with incontinence coming in maybe there was actually primarily a KID yang issue? From that has developed a damp heat issue (high HR) as well as Blood deficiency (anaemia).

Have been on pubmed researching myelofibrosis and found an autoimmune condition in huans that is seemingly not that uncommon - autoimmune myelofibrosis. Also have found a link between Grave's disease (autoimmune thyroiditis -> hyperthyroidism) and anaemia - and between other autoimmune thyroid disease (including Hashimoto's thyroiditis - which may itself be the same disease as Grave's - just different manifestation of the thyroiditis) and autoimmune myelofibrosis specifically.

Just wondered about a) my TCM diagnosis and Tx (I was considering BZYQT originally)
and b) If you'd had any success in humans treating any of the above diseases. My overall assessment is that it seems likely we are dealing with autoimmune disease (response to Tx) here of both thyroid and bone marrow which seems to mirror the description of these diseases in humans.
and c) how much of a role would you suspect the vaccine played in the pathogenesis?

I am looking forward to your expert opinion!

Mike

by naturevet

July 12, 2009

Hi Mike,

You're right, interesting case. I like your reasoning in suspecting this is either a Kidney or Spleen deficiency. The onset post-vaccination suggests the vaccine is acting as a Shao Yin pathogen. When this occurs, the main symptoms often are associated with Yang depletion.

Re-reading the case, I see lots of Kidney related symptoms - the bone marrow involvement (it is an extension of Kidney Essence); the incontinence; the chilliness; the loss of protein in the urine (representing a loss of Essence); the pred responsiveness; the pica; and the loss of condition.

In terms of treatment, I'd test the waters with a plain old Kidney tonic - Ba Wei Di Huang Wan (Rehmannia Eight) should be good for starters, and has a further bone marrow stimulating effect to support the cat as it comes off pred. The rapid HR is typical of a Shao Yin disorder. As the interior becomes severely cold, the Yang drifts to the body surface, creating sometimes agitation and sometimes tachycardia.

I have treated this in humans, or a variation on this theme, but every case is different. In humans, they often seem very deficient, as does this cat, but may need very strong aggressive formulas. This is because the humans actually have a Shao Yang syndrome going on. Your cat, I think, is more Shao Yin.

Autoimmune conditions in small animals probably develop the same way they do in humans - through cross-reaction of antibodies developed against gut flora with host tissues, including TSH receptors, etc. So a loss of bowel wall integrity facilitates this.

As for BZYQT, it's a definite option, but I would worry about the Astragalus ramping up the autoimmune response, so would hold off just yet. Rehmannia Eight should be safe.

Good luck treating the cat, whatever you do!

Steve

by naturevet

July 19, 2009

Hi Mike,

I've had a couple more thoughts on this.

The cold in the interior (Kidney deficiency) has probably allowed the Yang to 'float freely', creating the spreading pulse. Therapeutic goals would be to astringe the Yang back into the interior. A formula that does that is called Gui Zhi Jia Long Gu Mu Li Tang (Cinnamon Twig, Dragon Bone and Oyster shell combination), and has been useful for us in the management of critical anemia, among other things. It does not stimulate the bone marrow, however.

Another formula to consider, either alone or in tandem with it is Dang Gui Bu Xue Tang (Chinese Angelica Tonify the Blood Decoction), which is a 6:1 ratio of Huang Qi (Astragalus) and Dang Gui (Chinese Angelica). Astragalus is a powerful immune stimulant and would seem to be appropriate here where viruses are suspected and hemobartonella is being treated. Dang Gui is a potent bone marrow stimulant.

I think these two formulas are well indicated. If the cat is still quite convalescent, the latter formula is well indicated, and helps astringe the Yang by tonifying Wei Qi and closing the pores. That's how I'd approach this case I think, now I've had more time to think about it.

All the best,

Steve

by naturevet

July 19, 2009

Also, Mike, in hindsight, I expect the tachycardia was due to severe anemia that was either precipitated by the vaccine; triggered by an immune suppression reaction to the vaccine (which is common in the first week following immunization, I undersand); or just un-diagnosed at the time of the annual physical (although it would be hard to imagine the cat as presenting in good health).

Good luck with the cat. I'd love to hear how it goes!

S

by mikemesley

February 7, 2010

This cat went beautifully on good old BWDHW.
What I am most interested about is that for the first few days/weeks on preds, this cat showed no signs. However, after a while it began to have the Dampness/Heat signs in spades - PU/PD, weight gain, increased appetite etc.
My interpretation was that initially there was both KID yin and yang deficiency - and obviously Blood deficiency with PCv 9 ! - and that when this was rectified, the poor KID yang resulted in the accumulation of damp with excess yin tonification. Yes?

Anyway, when I last saw it it was a "normal" cat - that's what Os called it - although Damp. Deep and slightly wiry pulse, pale lavender tongue - I still felt BWDHW appropriate for it.

Have decided against vaccination in future and keep trying to convince Os about natural diets - they are in theory supporters of my ideas, but in practice too busy...

Anyway - a great result.

by naturevet

February 8, 2010

Hi Mike,

I suspect the diet is driving this. You can try and reduce the herb dose, but at this point, if the cat is on a typical canned or dry diet, that's what might need to change to resolve things.

If the Damp Heat signs grow, you might eventually move to ZBDHW. Damp Heat signs are metabolic syndrome signs, and Huang Bai has an anti-inflammatory and insulin sensitizing effect that can counter the deleterious effect of the diet of promoting insulin resistance.

I'd wait until the heat signs are prominent, though, as long as the cat is generally doing well.

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