Visiting Veterinarian : Stuffed up
When Snuffy, the 18-year-old cat, arrived with a complaint of chronic nasal discharge, I have to admit I wasn't thrilled. My own geriatric kitty had this same problem for years and I had never been able to fix it completely. "Eeeuuuuwww," my kids would shout. "Baby Buck got buggers on me!" I took to leaving boxes of tissues strategically around the house and cultivating an attitude of maternal acceptance of snot. I hoped to do better for Snuffy's family.
I started by examining Snuffy's face. Was the discharge from one side or both? Unilateral discharge often indicates a foreign body, tumor, tooth root abscess, or trauma. Bilateral discharge is more typical of infection. Snuffy was dripping from both nostrils. What about the nature of the discharge? Clear or opaque? Any blood?
Several months back, Snuffy had presented with a clear, watery discharge, but now it was a thicker yellowish-green. Holding her head in my hands, I gazed at her. Was her face symmetrical or were there any bulges? Tumors can cause facial distortion, as can certain types of infections. Everything looked even and she was blowing little bubbles from each nostril. That was good. It meant air was flowing on both sides. Tumors often completely obstruct one nasal passage so it is a worrisome sign if an animal is not moving any air through one side. I opened Snuffy's mouth, looked down her ears, pressed lightly on her eyeballs, checked her temperature. All normal.
"Well, Snuffy has a nasal discharge," I reported sagely, stalling for time as I collected my thoughts about how best to present our next steps. Full evaluation of persistent nasal discharge in cats requires general anesthesia, skull X-rays, or maybe CT-scan, then rhinoscopy, which means looking up the nose with a teensy-weensy fiberoptic endoscope. Then, if indicated, biopsy, culture, and/or flushing of the passages.
Before doing any of this, a panel of blood tests is advisable to be sure a patient doesn't have an immuno-suppressive virus such as Feline Leukemia or Feline Immunodeficiency Virus and that there are no serious metabolic or clotting problems. The last thing we want to do is stick an instrument up the nose of a cat with a bleeding disorder and cause massive hemorrhage. The initial tests could be done at my office, but CT-scans and rhinoscopy? That would require referral to a specialist. Would Snuffy's owners want to pursue definitive diagnosis, considering that she was 18 and her symptoms were not severe? What else could I offer?
Empirical treatment. "Empirical - adj. 1. Relying upon or derived from observation or experiment; 2. Guided by practical experience and not theory, especially in medicine." Great. My observation was that Snuffy had a stuffy nose. My practical experience suggested her owners should buy stock in Kleenex. I had to do better than that. At the very least, I needed to thoroughly explain the differential diagnosis, treatment options, and prognosis.
One of the most common causes of acute bilateral nasal discharge in cats is upper respiratory tract infection (UTI), especially herpes and calici viruses. Other organisms such as Bordatella, Chlamydia, or Mycoplasma can also be implicated. A sneezing kitten or young cat with a runny nose is a no-brainer. It's almost always a UTI, which is usually a mild, self-limiting disease. Animals may also exhibit fever, loss of appetite, dehydration, drooling due to oral ulcers, conjunctivitis, and general malaise. Treatment is primarily supportive and most animals recover uneventfully. Many, however, become chronic asymptomatic carriers of the viruses and clinical disease may flair up when an individual is stressed or has other illnesses.
Cats like Snuffy are often referred to as "snufflers." No one knows for sure what role chronic UTI plays in creating or perpetuating their problems, but most have irreversible damage deep in their nasal passages, with secondary bacterial infection and inflammation. Taking a culture often isn't helpful because clinically normal cats may have many of these organisms in their nasal passages. Identifying an organism doesn't mean it's causing the snotty nose. (One exception is a fungus called cryptococcus. If you find this little bug in a patient's buggers, you've got a diagnosis, but it's not very common.)
I told Snuffy's owners that based on her history and presenting signs, the most likely diagnosis by far was chronic rhinitis/sinusitis syndrome, an evasive moniker that describes the problem in an official-sounding way without pinpointing an underlying cause. "If we want to rule out a tumor or fungal infection, we would need to do more testing," I said. We discussed the situation. If it was a tumor, they felt Snuffy was too old to put her through surgery and possible chemotherapy. I concurred. In time, we would know if it was cancer. The tumor would grow and the clinical presentation would change. Fungal infection seemed unlikely considering her lifestyle. The option of anesthetizing her and flushing her nasal passages seemed unnecessarily risky, expensive, and uncomfortable in light of her age and the mildness of her disease.
Long-term use of antibiotics to control secondary bacterial infection is the usual first line of treatment for snufflers. Other options include anti-inflammatory medications, oral lysine to inhibit herpes virus replication, and saline or antibiotic nasal sprays. We opted to start with oral antibiotics. "If this doesn't help, we can try some other empirical treatments," I said, easing Snuffy into her carrier. "But even if she responds, you need to know the odds of a permanent cure are remote."
Remembering my late Baby Buck fondly, I thought to myself that there are worse things than an old cat with a snotty nose. I hoped the antibiotics would help Snuffy, but I knew her owners loved her dearly and that, once they understood the chronic nature of her condition, they would adjust. Please pass the tissues.