Eosinophilic Granuloma Complex
Eosinophilic granuloma complex treatment
Question: I am a new subscriber, and would like your opinion. I have a 10 ½ mo old female short hair cat who developed lumps on her stomach after being spayed at 5 mo. She was given oral antibiotics for 60+ days with topical ointments such as Otomax and the lumps remained. After that she was given surgery to remove the lumps, and a biopsy revealed it was eosinophilic granuloma complex. She was given two injections of Depomedral which cleared up the lumps, but they started coming back. She has experienced considerable weight gain (1 ½ lb) in six weeks (total weight 10 ½ lb. small frame.) My local vet checked and said it was fat not fluid. He said that continuing to give steroids could result in her only living to four or five years of age. He referred her to a dermatologist who confirmed it was eosinophilic granuloma plaques. He had me treat her with Advantage (I am doubtful about fleas as she is a second story totally indoor cat), put her on Z/D food, and another shot of Depomedral as he felt it is most important to try and get the lesions under control. What I would like to know, is do you feel that the Depomedral will significantly shorten her life? I had another cat who took oral prednisone for over 10 years for a colon problem, but she didn't gain weight That cat lived to 17 years of age, but she was about 7 when she began taking the pred. Any other suggestions on treating this kitty?
Answer: Barbara- I really have no idea where the opinion that corticosteroids will dramatically shorten a pet's lifespan came from. It is mentioned by many people and it is a belief that seems to be held by many veterinarians, as well. The only thing that I can think of to support this argument is that we use corticosteroids very reluctantly on a long term basis and most of the time when we do, we're treating a pretty serious condition. So we probably do have a group of patients whose life expectancy is less than normal when we look at the group of patients who must have corticosteroids on a regular basis. There are some serious side effects of corticosteroids, such as a tendency to increase the chance for diabetes, infections and weight control problems. While we try not to use corticosteroids on a continuous basis long term we have done this with several patients and the ones whose conditions were not especially life threatening in the first place have lived normal life spans -- or have varied from normal by months, not years. The good news about this is that most cats with eosinophilic granuloma complex will not require corticosteroid use on a continuous basis. They do often require the use of corticosteroids on an intermittent basis, but that is less likely to cause side effects. In most cases, it is possible to get eosinophilic granulomas under control using 2 or 3 methylprednisolone acetate (DepoMedrol Rx) injections at two week intervals. Then it is usually possible to use the injections at much longer intervals, such as once every three months or to wait until the next episode and repeat the series of injections, if the remission interval gained by these injections is long enough to warrant this. Antihistamines (we use chlorpheniramine) and essential fatty acid supplementation (we use 3V Capsules tm) help to control eosinophilic granuloma complex. Some cats do have food allergies, which is why the z/d diet has been recommended. It is really important to treat for fleas, even if none are ever seen, for at least a few months, before ruling out flea related problems leading to the eosinophilic granuloma complex. Flea bite hypersensitivity is the major cause of this problem and since it only takes one or two fleas to induce the allergic reaction in a patient, there does not have to be a noticeable flea problem. Good luck with this. The odds are pretty high that you won't have to worry about the effects of continuous use of corticosteroids --- most of the time that isn't necessary. Mike Richards, DVM 2/10/2001
Eosinophilic granuloma complex with weight loss and breathing problems in Maine Coon Cat
Question: 10 yr old indoor white with black Maine Coon has "scabs" on the bridge of his nose and around the edge of his nose that will not heal. This all started last December, once we returned home from the holidays, he began having sneezing spells, where he would sneeze up to 20 times in a row. We took him to the vet for the sneezing/wheezing; nothing found. We moved from Seattle to Atlanta in May, where he continued to have occasional sneezing spells and spent more time outside. In June, we took him to the vet, where they ran a urinalysis, and gave him a shot of Depomedrol and put him on Clavamox. In September, another visit to the vet yielded a fecal test, his annual vaccines, and now Cefadrops. Another visit to a different vet in September proved he was negative for Diabetes, intestinal parasites and Feline Aids, and put on Baytril plus Panalog Ointment and some Triple-B Opht Ointment (his eyes started running). We moved from Atlanta to Virginia in October, and tried one of the top rated vets in Herndon. They started with a shot of Prednisone 5mg and then proceeded to take a "punch" or sample of the skin from his nose to test for cancer or SCC. Negative (whew!). Also did an xray of his nasal passages which yielded some sort of vague blockage, but not considered an issue at the time. Was put back on Clavamox, tablets this time, and followed with a shot of Dexamethasone SP 4mg, and tablets of Cyproheptadine 4mg - 1/2 tablet 2 times per day. Another shot of Depomedrol 2 weeks later. Per suggestion of the vet, we put 1 tablet of Omega 3V on his food, although he is not fond of it. He has an incredible appetite, yet still appears to be losing weight. Over the past year, he has gone from 16.5 lbs down to 11.8 lbs. He is still very affectionate and playful. The result of the skin sample reads: " Diagnosis: Ulcerative, Pyogranulomatous, Eosinophilic Dermatitis- There is extensive epidermal erosion and ulceration with a thick serocellular crust on the surface. Within the dermis are pyogranulomas with central aggregates of eoisinophils and a peripheral infiltrate by epithelioid macrophages. Numerous plasma cells, lymphocytes, and eosinophils were also present w/in the deeper tissues. No evidence of a neoplasm. Do not know underlying cause. May be part of the eosinophilic granuloma complex. (EGC)" We did some research on the web on the EGC and found it may be caused by either a 1) flea bite allergy or 2) a food or inhalant allergy. He has been on the same food for years (Fancy Feast) and we've changed his litter and moved 3 times so we know it's not the carpeting or our laundry detergent. To be sure it's not a food allergy, we put him on the ZD brand food, and he appears to like it (although without the Omega 3V on it) and has gained a few pounds. We've been through 4 sessions of Depomedrol total, and the nose scabs still are not healed. The right side of his nose is healed almost completely, and has regained its pinkish color, but the left side is not healed and has scabbed over his nasal passages so he has difficulty breathing. Has been very lethargic lately, not eating much, and his fur looks "greasy". Occasionally, he really goes after his tail, and bites at the very tip. It feels hard to the touch when I examined it and sort of bumpy. We are scheduled to go see a cat dermatologist next week in VA, but since he has had a great deal of difficulty breathing, our vet prescribed another round of Cyproheptadine 2mg every 12 hrs to help reduce the mucus and wheezing until our appointment time. Also, his left eye has recently began "running" again with an oily type substance. We are at a loss as to what to do next. This has been going on for almost a year now with the sneezing attacks and approx 5 month with the scabs. What we don't know is ....where do we go from here? W hat is the underlying cause of the scabs?He appears to have increased difficulty in breathing, and continues to lick the sores on his nose, occasionally ripping off the scabsand bleeding everywhere. How do we find out what is really the underlying reason for the sores? After 4 major doses of the steroid (plus other doses via pills) should the sores be almost gone? We are also very concerned about the high dosages of the steroids...what are the long term effects in cats? Will the skin on his nose ever be the same? or is the epidermal erosion permanent? Do cats need to be "weaned" off steroids like humans should? Any advice would be GREAT. Christina
Answer: Christina- I think that I would want to broaden the search at this time. Sometimes, it is easy to focus on one problem and not see other ones that are present at the same time that may or may not be contributing to this one. The things that you mention in your note are weight loss despite a good appetite, a non-healing sore on the nostrils and difficulty breathing that appears to be due to congestion or blockage of the nasal passages. You and your vets have done the right things for dealing with the non-healing sore on the nose and going to the dermatologist is a good step at this time. I hope that is productive in determining the cause of the sore. It may be necessary to biopsy this again, as there are times when having a pathologist examine biopsies who is very interested in skin disease can make a difference. That still leaves two other problems. While it seems logical that the nostril blockage/congestion would be related, it may not be. I think that I would be trying to find someone with an endoscope small enough to examine the nasal passages. I am pretty sure that one of the internal medicine specialists in the DC area and probably even several of the general practices probably have this capability. If it has not been done, it also seems like a good idea to check a routine blood chemistry exam and also a thyroxine (T4) level. The most common cause of normal to increased appetite with weight loss is hyperthyroidism and it may exist concurrently with many other problems. Hopefully, you will have a better idea about the nostril problem, at least, after the visit to the dermatologist and he or she will be capable of drawing blood for hyperthyroidism and possibly even have access to endoscopy, if that seems appropriate. While many cases of eosinophilic granuloma complex can be linked to allergies of some sort, not all are. This can be an extremely frustrating condition to treat, at times. The dermatologist will have lots of experience with it and should be a big help with a resistant case of eosinophilic granuloma complex. I hope this helps some. Mike Richards, DVM 1/23/2001
Eosinophilic granuloma complex in cats
Question: Dear Dr. Richards, Beauty had been diagnosed with eosinophilic granuloma on her abdomen and the Internist she is seeing believes that she also has eosiniphils in her lungs. She has hypertension in her lungs from what the vet has said was long term lung disease and also has some damage to the right side of her heart. Since I last wrote to you the plaques on the cats stomach have disappeared. I gave the cat dexamethasone 25mg for five days in a row and then every other day after that along with amoxicillin twice daily to clear up her infected skin. I gave the cat the amoxi for seven days a couple of different times before her skin finally cleared up. I really think that some how the amoxi really helped to rid her of the plaques. Between the initial steroid shots the cat received and the dexamethasone pills, it took almost two months to clear up her skin. Right after the granuloma dissapeared on her stomach she got a rodent ulcer on her upper and lower lip which she still has. We tried the dexamethasone every day for 4 days and the ulcer improved somewhat but did not clear up. I told the vet that I was worried about giving her too much dexamthasone because it seemed when I gave it to her every day that she would start looking ragged and she would lose her appetite. On the other hand I also thought that when I gave it to her every other day that on the day she did't get the pill she would start to feel bad again - itchy skin, breathing rapidly, etc. The vet then suggested switching her to prednisone 20 mg - 1/4 of a pill daily for 5 days and then increase it to 1/2 a pill daily if she had no side effects. She said that prednisone isn't as long lasting as dexamethasone so that we might be able to give it to her everyday without side effects so that the cat would not back slide as she did every other day on the dexamethasone. I have been giving the cat the prednisone for two weeks but I still have not increased her dosage to 1/2 a pill a day because I thought it would be too much for her. Her food intake has decreased and I thought if I increased her dosage, she might eat even less. Although it may be that she is eating less because she is getting less medication. It is hard for me to know what to do. The last couple of days she has gotten really sick. Yesterday she did not eat all day long and just slept most of the day. I gave her her 1/4 of a pill at night and she ate her food in the middle of the night. When she is at rest I watch how fast her stomach moves up and down to see how she is breathing and to me it seems a little rapid and shallow. Her mouth sore seems to be worse. Do you think I should increase her dosage to a 1/2 a pill? Should I give her 1/4 of a pill in the morning and a 1/4 of a pill at night or all of it at once? I read in my "Cat Owners Manual" that some cases of Eosinophilic Granuloma Complex respond to antibiotics (especially Trimethoprin-sulfa). Do you think I should try this drug? I tried to give the cat a special diet food that contained duck, rabbit, or vension and rice but she wouldn't eat it. She has eaten Fancy Feast canned food her whole life and is very picky. I made her food using recipes that my vet gave me. One day I made her rabbit and she really liked it but it gave her really bad diarhea. I didn't think it was a good idea to change her diet when she was already feeling so bad, so I am still feeding her Fancy Feast. The vet is leaving it up to me to decide on how much of the prednisone to give her and I don't know what to do. I am really worried because she seems to have really gone down hill in the last few days. Any advice you can give me would be greatly appreciated.
Answer: A- There are a number of different methods of treatment for eosinophilic granuloma complex in cats which have been advocated. This is probably because none of them are consistently successful. When using corticosteroids for eosinophilic granuloma complex, the recommended dosages in "Small Animal Dermatology, 6th ed." by Scott, et al are; dexamethasone (Azium Rx) 0.4mg/kg per day, triamcinolone (Vetalog Rx) 0.8mg/kg/day or prednisone 4.4mg/kg/day. I am thinking that you are probably using 0.25mg tablets (rather than 25mg) of dexamethasone, which would be a low dose for almost any cat if you are giving one per day. The prednisone dosage is lower than is usually necessary for this condition, as well. Since a kilogram is 2.2 lbs, most cats are about 4 to 6 kg, which means that it is likely to take up to 25mg per day of prednisone to control eosinophilic granuloma complex. These are much higher dosages than the usual anti-inflammatory dosages of the corticosteroids and most vets are reluctant to use dosages in this range. Fortunately, lower dosages do often seem to work and some cases of eosinophilic granuloma complex resolve spontaneously. We find that injectable methylprednisolone workes better than oral medications when we treat eosinophilic granulomas but it is likely that is because we use higher injectable dosages than we use oral dosages, just like most vets. We do see some cats who respond well to antibiotic therapy when they have eosinophilic granuloma lesions. We have used clindamycin (Antirobe Rx), cephalexin (Keflex Rx), cefadroxil (CefaTabs Rx) and enrofloxaxin (Baytril Rx) with success. I don't use trimethoprim-sulfa combinations in cats unless I absolutely have to because this combination makes a lot of cats foam at the mouth really badly -- badly enough that even when I warn owners many of them call me to tell me how bad the experience was. There are cats that appear to have eosinophilic granuloma complex that have something else. Herpes virus, feline leukemia virus, ringworm and skin cancer can all cause lesions that resemble eosinophilic lesions. When we are not having any success treating a cat we usually do skin biopsies. This isn't commonly necessary but we have had to do skin biopsies more than once in a couple of patients to find an underlying cause. Using a novel protein diet or the new z/d (tm) diet from Hill's to try to eliminate food allergy is a good thing to consider for non-responsive or recurrent cases of eosinophilic granulomas, too. It may be a good idea to try this again but to make a slower change to the new diet. Our experience has been that this doesn't result in a clinical improvement in many cats but it sure helps the ones that do have food allergies. Some cats respond to the combination of essential fatty acid supplementation and antihistamine use. We have used products like DermCaps (tm) or 3V Capsules (tm) in combination with chlorpheniramine (Chlortrimeton tm) effectively in some patients. We recommend using imidocloprid (Advantage tm) or fipronil (Frontline Topspot tm) on a monthly basis for almost all patients with eosinophilic granulomas or plaques, because there is a strong correlation between flea allery and this condition. These products work very well to control fleas and eliminating this one source of irritation is beneficial even when it is not the sole underlying cause. Hope this helps some. Mike Richards, DVM 1/13/2001
Eosinophilic granuloma complex in lungs
Question: Dr. Mike, This is a follow up to my first correspondence with you shown below. Thank you so much for your very helpful answers to my questions. I called my vet about my cat, Beauty,after she had been on Methylprednisolone (an injection) for three weeks because this large patch of red, hard skin on her abdomen still looked very bad. She told me to give her Amoxi liquid because it was probably infected from her licking it all the time. I did this for a week and it seemed to improve and start to become drier and less red. My vet, suggessted that I bring Beauty in to see a new vet that had just started at the hospital. She is an Internist who had just finished her residency at Cornell. I bought the cat in to see the Internist and explained her history. I asked her about doing the tests you had suggested in your email, which were the T4 test for hyperthyroidism and the x - rays to check her heart as well as a skin test to find out what the patch on her stomach is. She said the T4 test had already been done and it was negative. She agreed that an x-ray of the heart should be done as well as other blood tests and a skin test. She wanted to wait two weeks to do the tests because she wanted to see if the skin on her stomach would clear up further. It was looking a lot better. After less than a week after seeing the Internist, the cat had started to scratch her head a lot. She actually scratched a big chunk of hair and skin off right under her eye and scratched herself really bad over her other eye, which swelled up. Then I noticed that she was licking her stomach and a new red patch had developed on her stomach. It was my opinion that the Methyprednisolone had worn off because before she would keep her distance from me and did not seem like herself, know she wanted attention like she used to and was becoming more affectionate again. In additon to being very itchy she also seemed like she was very tired and weak. She would sometimes lay on the floor with her head out in front of her with her chin on the floor. One time she was laying next to me and her head started to shake for like 10 seconds. During this time her eyes were half closed and after it stopped, she started to scratch her head. I only saw this happen one time. I decided to call the Internist and move up her appointment for the tests. The Internist agreed to do the tests right away. I brought her in yesterday and these were the results: The skin test showed that she had eosinophilic cells on her stomach, the patch over her eye did not show eosinophilic cells but the Dr. said it was infected and perhaps there are cells there that did not show up. The x-rays showed an infiltrate through out the lungs that she beleives is also eosinophilic cells. She said that she has bronchitis and that the long standing lung disease has caused hypertension in the lungs. She said the cat's heart has had to work harder because of the hypertension in the lungs and this has enlarged the heart and damaged the right side of it. I'm not sure if I have everything she said right because it was hard for me to follow. When I asked her how long standing the lung disease was she said probaby several months or more. She said that she had also done an electocardiogram and an ultrasound of the lungs. I asked her if the infiltrate in her lungs showed up on the x-rays she had in September and she said those were done for her abdomen and even though they showed the lungs the view of them wasn't good enough to tell. The Dr. also said that she thought that prednisone should hopefully clear up the eosinophils in her lungs and on her skin since the drug did seem to work on her abdomen so far. She thinks that she may also have these cells in her bowels based on the symptoms I had described to her - ie. soft, foul smelling stool that come and go, weight loss, apparent pain after she eats, etc. I asked about a possible food allergy and she said if she had a food allergy, she would not have improved on the prednisone. She said that it has not been proven that eosinphils are caused by allergies and it would be almost impossible to find out what she is allergic to, if that is indeed the reason she has this problem. It is so aggravating to me to know that there might be something I could eliminate from her environment that could make this all go away and I don't know what it is. She gave the cat another injection of Methlyprednisone but only gave her half the dosage she had last time because of the bad side effects she had with the last shot and because of her heart condition. She gave me Dexamethasone 25mg to give her every other day starting in two weeks. She also gave me more Amoxi liquid to give her to clear up the infection over her eye and on her stomach. She said if she is right about the eosinophils in her bowel and lungs, she should start to feel better and gain weight on the prednisone. She said the prednisone should clear up the eosinophils but she may have to stay on a low dose of prednisone forever because there will be no easy way to know if it returns to her bowels or lungs. She said her heart and lungs will never return to normal and she may feel tired at times. The Dr. also sent out blood to the lab to test for heartworm. She said her liver looked normal in the x-ray or ultrasound ( I don't remeber which) so she did not asperate it as she had planned to. She also did a urinalysis which was fine. She did FeLV and FIV tests which were negative. I had brought in a stool sample last week which she tested for specific things but didn't find anything there either. The Dr. said her diagnosis - eosiniphils in the lung and abdomen - is the diagnosis that best fits with the syptoms I have described to her. She said if the cat begins to gain weight and look and feel better, we know that the predinisone was effective in ridding her of the eosinophils. Is there a way to know for sure if the infiltrate in her lungs is eosinophilic cells? Could it be lymphoma? The Dr. said there is no effective way to treat hypertension when it is just in the lungs. Is there any way to improve her lung and heart condition? What affect will the long term use of Dexamethasone have on the cat? When I was going through chemotherapy for cancer I was given Dexamethasone and it caused me to have very bad anxiety and depression. Is there evidence of this in cats. I know that my cat is not herself when she is on the Methylprednisolone. Is it true that she will need to be on the Dexamethasone her whole life? Thank you
Answer: A- Your vet has done a pretty thorough work-up of this case. It is actually a little unusual for cats to have eosinophilic granuloma complex affecting their skin and eosinophilia in the lungs at the same time. I am not sure, but I think there is a stronger correlation between eosinophilic gastrointestinal problems and skin problems but that in these cases, food allergy has to be high on the list of possible underlying causes. I disagree with the argument that an eosinophilic skin or gastrointestinal problem that responds to the administration of corticosteroids such as methylprednisolone (DepoMedrol Rx) or dexamethasone (Azium Rx) is not likely to be due to food allergy. I think that food allergy does respond to these medications, although the response may not be as good as for other causes. The "standard" treatment for eosinophilic granuloma lesions that don't respond to a single injection of methylprednisolone is to give three injections at two week intervals using 20mg of methylprednisolone ----- however, this may not be possible since there was an early reaction to the DepoMedrol. There are lots of recommended alternatives, including the dexamethasone. One non-cortisone alternative is an antihistamine, ceterizine (Zyrtec), which has been used at dosages varying from 2.5mg/cat/day to 5mg/cat per 12 hours without seeming to cause problems -- but there are no published dosages based on good scientific studies that I am aware of. This antihistamine is supposed to have very good anti-eosinophilic effects. Food allergies are not the most common cause of eosinophilic granulomas in cats but they are nice to find because they can be eliminated just by avoiding offending dietary ingredients. There is a new food z/d (tm), made by Hill's, that should be good for doing food trials with to see if food allergies are the problem. The most common cause of eosinphilic granuloma complex in cats is flea bite hypersensitivity. It can also be caused by mosquito bites, inhalant allergies (pollens, etc.) and by contact allergies (plastic, wool, etc.). It can be mimicked by herpes virus dermatitis, feline leukemia virus and ringworm (dermatophytosis) --- and probably other things that aren't coming to mind right now. Cats are resistant to the side effects of corticosteroids, including dexamethasone. But that doesn't mean they can't occur, so there is some potential for personality changes when using these medications. If you see this occurring, you should bring it to your vet's attention. Some cats do have to stay on corticosteroids their whole life to control eosinophilic granuloma, inflammatory bowel disease or pulmonary disease associated with asthma or allergies (which can cause eosinophils to congregate in the lungs or airways) but there are lots of cats who only need these medications intermittently or who recover from bout of problems and then can be controlled just by using good flea control, with antihistamines, or with other medications. It is too early to worry about whether this will require lifelong therapy but your vet was probably just being cautious and making sure you knew that was a possibility. It can take some time to work through all the potential problems that might be present. Your vet is doing a good work-up. I disagree some with her thinking regarding food allergies and response to cortisones and I also would be hopeful for some improvement in heart function if underlying problems for it can be treated --- but that doesn't mean that she isn't right and it doesn't mean that you have to do anything different right now. Time is on your side as long as the response to dexamethasone is good. If not, you may have to consider further testing, such as a trial of the z/d diet, skin biopsy, bronchoalveolar lavage, fine needle aspirate of lung tissue or other testing that seems more appropriate to your vet, who can actually evaluate the overall situation better than I can. Good luck with this. Please feel free to ask for clarification of anything you didn't really understand in this, or future notes. Mike Richards, DVM 11/19/2000
Eosinophilic granuloma (rodent ulcers type) treatment
Question: Dear Dr. Richards, Have a female 12 year old cat with rodent ulcers on her upper lip, that only Depo has alleviated in all these years. This has produced Depo induced diabetes, and I do not want to give her any more of this steroid since now her BG is normal. Don't want to get into all the history of her problems, but have read all dialogue my vet has been able to pull off her "network" about treatments besides the steroids, and wonder what experience you have had treating this condition. (By the way this is a new veterinarian. We moved to SC from MD where our vet there only treated her with Depo.) From reading this documentation, I have seen a wide use of two new methods to me of treating this condition other than the Depo shots every 4-6 weeks. These are very briefly: 1. Depo shots, 3 in a short interval coupled with or without antibiotic treatment. 2. Antibiotic treatment for 4-6 weeks coupled with a antihistamine. While thinking back about when her ulcer episodes are greatest, they are always coupled with sneezing and runny eyes, which leads me to believe there is some allergy there other than fleas. She has been treated with Advantage for that condition, as have the other 3 cats and 2 dogs in our household, all of which are indoor/ outdoor family members. Would love to hear from you back. Anita
Answer: Anita- Methylprednisolone injection (DepoMedrol Rx) is the most consistently successful treatment for eosinophilic granulomas (rodent ulcers are one form of eosinophilic granuloma complex). Some cats will respond to one injection and not have recurrences for some time. Other cats require three injections at two week intervals to control the problem and we see some cats who need injections on a regular basis to keep oral eosinophilic lesions under control. A variation on the use of cortisones is to inject triamcinilone (Vetalog Rx) directly into the sore and the subcutaneous tissue around it. This seems to help in some cases and allows the use of lower total dosages of a corticosteroid when it does work. However, there are a lot of other treatments that have been tried and that sometimes seem to help. We try, whenever possible, to eliminate food allergies as a possible cause of the eosinophilic granuloma. It is necessary to feed the cat a diet that contains a protein source that the cat has not eaten before for at least three weeks and six to eight weeks is better. There are special diets made for this food trial period. No other food or treats should be fed during the trial period. If the ulcer clears up during this time and stays away, it is possible that food allergy is a problem. If adding other foods back into the diet leads to a return of the ulcer, that would make it much more likely. Even though food allergies do occur, they are not especially common. Still, considering the types of medications necessary to control rodent ulcers it is definitely worth trying to see if a food allergy is present. Good flea control is also very important, since flea allergies can be an inciting cause for eosinophilic granulomas. Advantage (Rx) is a good flea control product. Antihistamines in combination with essential fatty acid supplementation seems to help some cats. We use chlorpheniramine, usually 2mg every 12 hours and 3V capsules (tm) currently when we try this combination. We have used DermCaps (tm) in the past and it seemed to work sometimes, too. Due to the possibility of random remission with this condition it is hard to be sure if this treatment works but it seems to at times. Megestrol acetate (Ovaban Rx) will control eosinophilic granulomas in many cats. However, it is even more likely to cause problems with diabetes than methylprednisolone and can cause other side effects, including mammary cancer. We view this as an absolutely last resort medication. We have used bovine lactoferrin for a couple of oral eosinophilic lesions in which it seemed to help and a number more that it did not seem to help. One of the cats that it did help had the typical rodent ulcer, though. Due to a low rate of success, it is hard to tell if this medication is actually working, too. An apparent cure may be due to a natural remission. But lactoferrin seems pretty safe and so we use it sometimes. Antibiotics are reported to help some cats with rodent ulcers. We have several cats that seem to respond to clindamycin in our practice and other vets have reported success with trimethoprim/sulfa combinations (although these medications can cause profuse salivation). In desperate situations people have tried chemotherapy medications, cyclosporin, interferon, gold salt therapy, niaciniamide and tetracyclines and probably most other medications. Surgical excision is sometimes recommended. Acupuncture has been tried, as have homeopathic medications. In our practice, we have the best luck with DepoMedrol, followed by antibiotics and/or antihistamine and fatty acid supplementation. We have seen a few food allergies we could confirm. We seem to see a smaller number of these ulcers since Program (Rx), Advantage (Rx) and Frontline Topspot (Rx) have become available. Herpes virus infections in cats can cause skin sores. Since you see this in conjunction with runny eyes and sneezing, this seems like a possible contributing factor. If that is the case, administration of l-lysine, 250 to 500mg/day, may also help. I wish I could help more. Mike Richards, DVM 8/13/2000
Eosinophilic Granuloma Complex therapy and loss of smell
Question: We have been consulting our vets (one GP, one Oncologist) but neither has an answer. Our 5-yr old male (neutered) Maine Coon is undergoing treatment for an eosinophilic granuloma on the roof of his mouth. First appearance of the sore was in July, 1999. It was removed for biopsy (benign) down to the bone in the center; healed over 3-4 months, then granulama began growing back. We saw several vets till we found one who referred us to the Veterinary Oncologist. The current treatment includes one dose of Strontium radiation therapy (just under 1 month ago), prednisolone (was 10 mg per day, then reduced to 5 mg per day, back up to 10 mg per day today), and Leukeran (1 mg, currently every three days). The cat has developed an oral-nasal fistula. Noisy breathing, etc. We discovered this about 10 days ago. We started him on Clavamox (2x daily) 10 days ago. Seven days ago the cat stopped eating. He _wants_ to eat but doesn't seem to be able to smell anything. (Not only food; normally he hates banana; his reaction to a very ripe banana was "is it a toy or what?") We're giving him cyproheptidine as an appetite enhancer; the appetite is enhanced but the sense of smell isn't so now he's crying and appears anxious and has tried to devour a toy mouse but he's still not eating unless I force feed. Today our oncologist sedated the cat and checked his nose. There is no indication of the granuloma in the nose. Nothing up there but a little blood. She doesn't want to close the fistula until the traces of the granuloma are completely gone. But he's not eating on his own. Any suggestions or ideas of where I can turn would be appreciated. - Vicki (for Warrl)
Answer: Vicki- I have seen recommendations to try radiation therapy for stubborn eosinophilic granuloma lesions but have not had reason to resort to this therapy, yet, in our practice. I think I would hesitate to do that, due to the potential for complications such as those your cat is experiencing. However, this decision has already been made. I hesitate to make the only suggestion I can think of, since your cat has already been through a lot, but this is a time when it may be necessary to consider placement of an esophageal or gastric feeding tube to support your kitty until surgery can be performed and perhaps during the post-surgical recovery period. I am not an expert on chemotherapy or radiation therapy, by any means, but I have been to a couple of seminars on oncology at which the speakers said that cats that stop eating during radiation or chemotherapy do much better if feeding tubes are used to provide nutrition. Esophageal feeding tube are pretty easy to place and to maintain, so they are becoming more popular in cats than stomach tubes implanted directly into the stomach (gastrostomy tubes). Feeding tubes are a scary proposition but they can improve the quality of a sick cat's life very much. We have been able to control eosinophilic granulomas, so far, in all of our patients, using oral or injectable corticosteroids (such as prednisone or methylprednisilone) or megestrol acetate. We try not to use megestrol acetate until we are desperate, due to side effects associated with it, such as a tendency to induce diabetes. Chlorambucil (Leukeran Rx) is one of the medications also recommended for this condition. We have not used it, yet, either. We have two patients whose eosinophilic granulomas return within a few weeks to a few months of stopping therapy for them and have done so for years. These can be a very frustrating problem. You may have to figure out a long term strategy after getting through the immediate problems. I hope that your guy does better soon. Mike Richards, DVM 1/31/2000
Eosinophilic granuloma complex and Ringworm
Question: Dear Dr. Richards, A skin biopsy on our 1 year old male cat performed by the animal shelter we adopted him from 6 months ago was suggestive of eosinophilic granuloma complex. At the time, it manifested itself primarily by patches of hair loss on his face. He was given three steroid shots---one shortly before we adopted him and two shortly thereafter by my vet. The underlying cause for the EGC has not been determined. He does not have (and did not have ) fleas. I have never seen him scratch; his face does not ever appear to be itchy. The shelter put him on a hypoallergenic diet. Although it was interrupted after an estimated 4 weeks (b/c he got very sick), he did not improve during the time he was on it. He always eats on, and drinks from, a ceramic dish--not plastic. (He got very sick when he was exposed to some virus or bacteria ( the cause could not be determined) at the same time his immune system was apparently suppressed presumably as a result of the steroid shots (he had 106-107+ degree temperature for 4 days and was in the hospital for 7 days)). In the meantime, we realized he had ringworm, which we fought over four months primarily with griseofulvin (supplemented by a bath once a week for five weeks). (I should note he had CBCs every two weeks during the griseofulvin regimen and the results were always normal.) While I suspected the EGC was really ringworm, toward the end of the ringworm battle, he began to show some hairloss under his whiskers and his skin where the hair loss was somewhat crusty and plaque-like; my vet said that she thought that it was a manifestation of EGC. Now, a month later, his lower left lip has become swollen, red and looks crusty, and there has been some hair loss in the patch of skin just under his mouth . My vet said she thinks that it is another manifestation of EGC. We do not want to give him steroids (because of his past immune system suppression problems and ringworm). Given that he doesn't seem affected by the swollen lip in any way (he continues to have a healthy appetite and eat with ease), is there any problem in not giving him any treatment? That is, could he be harmed if he does not receive treatment? Will it ever go away by itself? If so, how long does it usually take to run its course? Should I expect it to always reoccur? (I should note that he is otherwise a tremendously healthy, happy, playful indoor cat.) Many many thanks for any advice you can give. R.R.
Answer: R.R.- While this condition is very very likely to actually be eosinophilic granuloma complex, it might be worthwhile to have another biopsy examined and to make certain that the pathologist who examines it is good at dermatopathology (examination of skin lesions). Just in case there is something else that can be identified and treated. Ringworm does sometimes get misdiagnosed as eosinophilic granuloma complex, because they produce similar skin lesions, sometimes. So checking another ringworm culture isn't a bad idea, either. You and your vet can determine if these suggestions really seem necessary. It would be especially useful to know if the biopsy was examined by a dermatopathologist while making this decision. It is OK to ignore minor eosinophilic granuloma lesions that are not causing any apparent pain or discomfort. You do have to keep a very close eye on these lesions, though. They can change pretty quickly and if they are getting worse, treatment may be necessary. Also, be sure to open your cat's mouth at least once a month and look at the roof of the mouth and tongue to be sure there are no lesions there. These are spots that eosinophilic granuloma lesions spread to that are uncomfortable and may not be noticed without looking for them. It may be possible to use a lower dosage of cortisone but give it directly into the area of the eosiniphilic sores using triamcinilone (Vetalog Rx). This works well for some cats. Also, it is safer, when it works, to use oral prednisone. Our experience has been that it doesn't work as well to use oral corticosteroids in a lot of cats but it is worth a try if corticosteroid treatment does become necessary. You have doing the right things controlling fleas and staying away from plastic food bowls. If there is anything else that might induce allergies that your cat likes to rub its face on, such as a wool blanket, consider removing it from the environment for a few weeks, too. Flea allergy can cause eosinophilic granuloma lesions so keep up good flea control even if you are not seeing fleas. Lots of times eosinophilic lesions clear up on their own for a while. Usually they do return, although not always in exactly the same place. Other times, they won't go away without treatment. They seem to vary in how much they bother the cat, too. The ones that aren't causing problems probably are safe to take a "wait and see" approach to. Ones that are causing pain or discomfort should probably be treated. Hope this helps some. Mike Richards, DVM 12/8/99
Eosinophilic granuloma complex
Q: My question is about my Siamese cat, Mrs. Ming. Many years ago she was diagnosed with eosinophilic granuloma complex. She was at first put on prednisone on a prn basis. Eventually, she was on a qod dose of 5mg. About a year or so ago, megestrol acetate was added to the prednisone. This did wonders at first but now her lip continues to be large-at best it is not red. My doctor tells me that this is the best we can do now. I cannot afford the suggested radiation therapy and fear that surgery will put her through so much pain. She does not seem to suffer at present. She eats very well and goes about her business as she always has. I know that time will eventually run out. Do you have any suggestions? If it helps, plaques and rodent ulcer has been used in her diagnosis. Any help would be greatly appreciated. Thank you! Lana
A: Lana- At the present time the prevailing opinion among veterinary dermatologists appears to be that eosinophilic granuloma complex is usually a reaction to allergic stimulus in the cat. This has changed the approach taken to this disorder by many veterinarians. Food allergies appear to cause a higher percentage of allergic reactions in cats than in dogs, although I am not sure this has been confirmed. In any case, testing for food allergy should be considered in a cat with any chronic allergic signs including miliary dermatitis (small scabs in clusters, esp. around the neck) and eosinophilic granuloma complex. To test for food allergies it is necessary to feed a single protein source that the cat has not eaten previously. There are number of hypoallergenic diets on the market at the current time and it is also possible to choose a protein source such as lamb, rabbit, venison or other meats that are not commonly found in cat food and feed it to the cat for 8 weeks. It is usually possible to feed an all meat diet to a cat for this long without causing nutritional imbalances. If the condition responds well to the diet then a food allergy is very likely. In that case a more complete diet has to be worked out, using ingredients that do not cause allergic reactions. Inhalant allergies also occur in cats. At present the best way to test for these conditions is intradermal skin testing. It is often necessary to go to a dermatology specialist to get this sort of testing done but that is a good thing to do in a chronic non-responsive skin disease situation anyway. If an allergy can be identified it is possible to use hyposensitization shots in cats or to adjust the medications towards resolving an underlying allergy problem. This can be a good change for a cat that is on prednisone and megestrol acetate (Ovaban Rx) because many cats will respond to antihistamines combined with omega fatty acid supplementation as an alternative therapy. Skin biopsy can also be a useful test. Once in a while the problem isn't an eosinophilic granuloma even though it looks like one. It is sometimes possible to identify the underlying cause with skin biopsy and it can support a diagnosis of allergic skin disease in some cases as well. Contact allergies can occur. Plastic food bowls have been incriminated as a contact allergen that causes problems in some cats. Contact allergies can also occur to natural fibers such as wool or even to some dyes in synthetic fibers. Mosquito bite and flea allergies are also possible causes of eosinophilic ulcers. Eliminating fleas with the use of the new monthly flea control products or oral or injectable lufenuron (Program Rx) can be very helpful. Keeping a cat indoors when mosquitoes are most prevalent can be useful. Dawn and dusk are the worst times for mosquitoes. Sometimes it is not possible to identify an underlying allergic cause. In these cases it is still reasonable to try the antihistamine/omega fatty acid supplementation combination. Many antihistamines have been tried but chlorpheniramine, centerizine (Zyertec Rx) and clemastine fumarate (Tavist TM) are often recommended. There are many fatty acid supplements as well. DermCaps (TM) and EFA-Z (TM) are two that I can remember the names of. In addition, there have been reports of successful resolution of eosinophilic granulomas with chlorambucil (Leukeran Rx) and gold salt therapy. I think that gold salts have to be considered as a last resort because they seem to have a higher chance for toxic effects based on the literature. I can help with doses for these medications if your vet has a hard time finding them. When all of this doesn't work, some vets recommend radiation therapy, but I don't have any idea how well it works. Surgery has been tried by many veterinarians and doesn't seem to work very well. I have seen recommendations for acupuncture in the treatment of this condition as well but again do not know of literature support for this and have no personal experience. Hope this helps. Mike Richards, DVM Last edited 09/17/02
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...