Applications and Integrations

VM 540
Case #9 Wrap-Up
“Kyla” Owens

Michael O. Childress, DVM

Resident, Medical Oncology
 Outline
• Summary of case
• Case management strategies
• Topics for further discussion
– FeLV
– Feline myeloproliferative disease (myeloid
leukemia)
– Hemotrophic mycoplasmosis
 Case Presentation
• Signalment: 9-year-old F/S Tonkinese
• Presenting complaint: Anemia and lethargy
• Relevant history:
– Presented to RDVM for cough, lethargy, wt. loss of 3-
4 wks. duration.
– History of feline asthma
– Mucosal pallor noted by RDVM: PCV 18%
– Indoor cat, 2 other cats in house (both well)
– One cat has outdoor access
– Current on vaccines (FVRCP and rabies)
 Physical Exam
• Pale mucous membranes
• Tachycardia (HR 240)
• Tachypnea (42 bpm)/harsh lung sounds
• Skin tenting (dehydration)
 Initial Problem List
• Pale mucous membranes/
anemia (historic)
• Tachycardia
• Cough/harsh lung sounds/hx of asthma
• Weight loss
• Dehydration
• Lethargy/weakness
 Diagnostic Plan
• Minimum database
– CBC
– Blood chemistry profile
– Urinalysis
– FeLV/FIV serology
– Serum total thyroxine (T4)
• Thoracic radiographs
 Initial Diagnostic Results:
CBC
• Hct 22% (30-45)
• MCV 68 fl (40-55)
• MCHC 33 g/dl (30-36)
• WBC 87,400/µl (6,000-
18,000)
– Neut 3,500/µl (3,000-
12,000)
– Lymph 1,800/µl (1,500-
7,000)
– Mono 900/µl (50-850)
– Eos 0/µl (100-1,500)
– Baso 0/µl (0-100)
– Other 81,200/µl (ZERO!)
• Plt’s 185,000/µl (200,000-
700,000)
• Retic’s 0.2% (0-1%)
 Initial Diagnostic Results:
CBC
• Hct 22% (30-45)
• MCV 68 fl (40-55)
• MCHC 33 g/dl (30-36)
• WBC 87,400/µl (6,000-
18,000)
– Neut 3,500/µl (3,000-
12,000)
– Lymph 1,800/µl (1,500-
7,000)
– Mono 900/µl (50-850)
– Eos 0/µl (100-1,500)
– Baso 0/µl (0-100)
– Other 81,200/µl
(ZERO!)- OTHERS ARE
BLASTS
• Plt’s 185,000/µl (200,000-
700,000)
 Initial Diagnostic Results:
CBC
• Hct 22% (30-45)
• MCV 68 fl (40-55)-
MACROCYTIC ANEMIA
• MCHC 33 g/dl (30-36)
• WBC 87,400/µl (6,000-
18,000)
– Neut 3,500/µl (3,000-
12,000)
– Lymph 1,800/µl (1,500-
7,000)
– Mono 900/µl (50-850)
– Eos 0/µl (100-1,500)
– Baso 0/µl (0-100)
– Other 81,200/µl
(ZERO!)- OTHERS ARE
BLASTS
• Plt’s 185,000/µl (200,000-
700,000)
• Retic’s 0.2% (0-1%)
 Initial Diagnostic Results:
CBC
• Cats have two types of reticulocytes:
– Punctate
– Aggregate
• Which type is counted to assess a
regenerative response in the cat?
 Initial Diagnostic Results:
CBC
• Cats have two types of reticulocytes:
– Punctate
– Aggregate
• Which type is counted to assess a
regenerative response in the cat?
 Initial Diagnostic Results:
CBC
• Diagnoses
– Macrocytic, normochromic, non-regenerative
anemia
– Acute leukemia
– Mild thrombocytopenia
 More Initial Diagnostic Results
• Total Protein 7.9 g/dl (5.5-7.1)
• Albumin 3.5 g/dl (2.7-3.8)
• Globulin 4.4 g/dl (2.3-3.8)
• ALT 120 (20-108)
• FeLV +/FIV-
• T4 ?
 Now What?
• Mycoplasma serology
• Bone marrow aspirate (+/- core biopsy)
• +/- Abdominal imaging
Indications for Bone Marrow
Evaluation

?
 Indications for Bone Marrow
Evaluation
• Unexplained and persistent increases or
decreases in one or more hematopoietic
cell lines
• Abnormal cells in circulation
• Atypical cell morphologies/reactions (e.g.
nucleated RBC’s w/o polychromasia)
• Unexplained physical exam findings (e.g.
fever of unknown origin)
 Indications for Bone Marrow
Evaluation
• Hypercalcemia
– #1 cause in dogs = CANCER!
– #1 or #2 cause in cats = CANCER!
• Hyperglobulinemia (monoclonal gammopathy)
• Staging of malignant neoplasia
– Lymphoma
– Mast cell tumor
– Multiple myeloma
– Histiocytic malignancies
Bone Marrow Cytology

Myeloid hyperplasia
Photo courtesy of Dr. Craig Thompson
Bone Marrow Cytology

Erythroid hyperplasia

Photo courtesy of Dr. Craig Thompson

Bone Marrow Cytology

Acute myeloid leukemia

Photo courtesy of Dr. Craig Thompson
 Diagnostic Test Results
• Bone Marrow Aspirate- Acute leukemia
– 95% blasts
– Immunophenotyping: CD3 and CD79a
negative (i.e. non-lymphoid)
– Cytochemical staining: stained positive for
non-specific esterase (monocytic lineage)
• Mycoplasma serology
– M. haemofelis- negative
– M. haemominutum- positive
 Diagnostic Test Results
• Bone Marrow Aspirate- Acute leukemia
– 95% blasts (myelophthisis)
– Immunophenotyping: CD3 and CD79a
negative (i.e. non-lymphoid)
– Cytochemical staining: stained positive for
non-specific esterase (monocytic lineage)
• Mycoplasma serology
– M. haemofelis- negative
– M. haemominutum- positive
 Further Discussion

• FeLV

• Myeloid leukemia

• Hemotrophic mycoplasmosis
 Feline Leukemia Virus (FeLV)
• Family Retroviridae
– Retrovirus possessing reverse transcriptase
• Subfamily Oncovirinae
– i.e. “tumor-causing”
• First characterized in 1964
• Major cause of morbidity and mortality in
cats although prevalence seems to be
decreasing
 FeLV: Viral Structure
• RNA virus
• Inner core
– p27 protein- present in high levels in cytoplasm of
infected cells (WBC’s, plt’s) and serum of viremic cats
• Outer envelope
– gp70 protein- used to attach to T-lymphocytes,
neutralizing Ab’s are protective
– p15e protein- interferes with host cell immune
responses (i.e. immunosuppressive), facilitates viral
persistence
 FeLV: Subgroups
• Subgroup A- only contagious form of the
virus. Others formed by recombinations of
FeLV-A and host DNA and require FeLV-A
for replication.
• Subgroup B- associated with cancer
development
• Subgroup C- rare; mostly associated with
non-regenerative anemia
 FeLV: Epidemiology
• Worldwide prevalence 1-8%
– Prevalence in sick cats up to 21%
• Originally ~70% of feline lymphoid neoplasia
was attributed to FeLV
– More recent estimate is 20%
– RR of LSA for FeLV+ cats is 62 (i.e. 62 X more likely
to get LSA than non-infected)
• Test and removal as well as vaccination have
decreased prevalence by as much as 50% over
past 20 yrs.
 FeLV: Transmission
• Usually oronasal - “intimate, moist contact”
• Wimpy virus- dies rapidly outside host or
on exposure to disinfectants
• Very high concentrations in saliva
– Licking
– Biting
– Mutual grooming
– Sharing food and water dishes
• Multi-cat households, catteries
 FeLV: Transmission
• Vertical transmission possible
• Young cats much more susceptible to
infection
– CMI, antibody titers increase with age
– Young also more susceptible to neoplasia if
infected
 FeLV: Pathogenesis
• Initially replicates in local lymphoid tissue in
oropharynx
• Enters systemic circulation in mononuclear cells
(lymphocytes, monocytes)- transient viremia
(INFECTIOUS)

• MOST CATS WILL CLEAR THE INFECTION

DURING THESE EARLY STAGES. THEY
DEVELOP VERY EFFECTIVE IMMUNITY
AFTERWARDS.
 FeLV: Pathogenesis
• If viremia persists, other organs become infected
(thymus, spleen, LN’s, salivary glands).
• After 3 weeks of viremia, infection of bone
marrow occurs.
– Complete viral clearance no longer possible
– Proviral DNA now part of host DNA in BM stem cells
– Viremia can still be terminated (latent infection)
 FeLV: Pathogenesis
• Latent infection
– No production of viral proteins
– No viral shedding (non-infectious)
– Usually no clinical disease
– Undetectable by standard diagnostics (PCR
will detect)
– Can be reactivated to viremia by stress (e.g.
glucocorticoids, pregnancy).
 FeLV: Pathogenesis
• Viremia >16 wks likely to result in lifelong
viremia and viral shedding (persistent
viremia)
– Young and immunosuppressed cats at high
risk
– Most will die within 3 years
 FeLV: Clinical Syndromes
• Most infected cats seen by DVM’s for
signs related to anemia or immune
suppression
• MANY diseases in cats are caused or
complicated by FeLV
 FeLV: Clinical Syndromes
• Neoplasia
– Hematopoietic
– Sarcomas (coinfection with FeSV)
– Multiple cartilaginous exostoses (osteochondromas)
– Olfactory neuroblastomas
• Non-neoplastic hematopoietic dysfunction
– Anemia
• Occurs in majority of FeLV+ cats
• Usually non-regenerative, macrocytic due to bone marrow
dysfunction
 FeLV: Clinical Syndromes
• Non-neoplastic hematopoietic dysfunction
(cont’d)
– Pancytopenia
– Platelet abnormalities
• Immunosuppression/Opportunistic infections
– FIP
– URI
– FIV
– Hemotrophic mycoplasmas
– Stomatitis
 FeLV: Clinical Syndromes
• Immune-mediated disease
– AIHA, GN, uveitis, polyarthritis
• FeLV-associated enteritis
– Parvo-like
• Reproductive disorders
– Fetal resorption, abortion, neonatal death
• Fading kitten syndrome
• Neuropathies

Source: Gelatt KN, Essentials of Veterinary Ophthalmology, 2000

 FeLV: Diagnosis
• ELISA- detects soluble p27 in serum of
VIREMIC cats (transient or permanent)
– Standard test in routine practice
• IFA- detects p27 in cytoplasm of infected
cells (WBC’s and platelets)
• PCR- technically more difficult but can
detect latent infection
 FeLV: Diagnosis
• WHICH CATS SHOULD BE TESTED?
 FeLV: Diagnosis
• WHICH CATS SHOULD BE TESTED?
– ANY cat of uncertain status?
– ANY sick cat (regardless of previous test
results or vaccination status)
• ESPECIALLY in presence of non-regenerative
anemia
– High risk cats (e.g. outdoor intact males)
– Newly obtained cats (esp. before introduction
to multi-cat environment)
– Recently exposed cats (esp. if young)
 FeLV: Treatment
• Incurable
– Eradication of all cells into which proviral DNA is incorporated
would be needed to clear virus.
• Largely supportive
– Fluids, nutrition, blood transfusions
• Appropriate treatment for malignancies
• Immune suppression of immune-mediated diseases
• Protect from opportunistic infections
– Antimicrobial therapy when indicated
• Antiviral chemotherapy, immune stimulation
– Largely unrewarding
 FeLV: Prevention
• Vaccination
– Aimed at inducing neutralizing antibodies against
gp70.
• Will prior vaccination interfere with testing?
– Recommended for high-risk cats
– Not 100% protective!
– Risk of sarcomas with killed vaccines
• Odds of sarcoma about 1:1,000 to 1:10,000
• Odds of FeLV infection in exposed high risk cat about 1:25
• FeLV vax in L hind leg, distal
 FeLV: Prevention
• Test and removal
– Best way to prevent new infections in catteries
or multi-cat households
– Close facility to new cats
– Test remaining cats every 3 months, remove
all who test positive
– When all cats test negative for 2 consecutive
sessions, assume facility is FeLV-free
– New cats enter facility only after 3-month
quarantine and 2 negative FeLV tests
 Hematopoietic Neoplasia
• Most common malignancies of cats
• Represent approximately 1/3 of all feline
malignancies
– Vast majority are lymphomas
• The cat has the highest incidence of
hematopoietic neoplasia of any known
animal species (including humans!)
 Hematopoietic Neoplasia
• Basic definitions
– Lymphoid- of or relating to lymphocytes
– Myeloid- of or relating to other hematopoietic
cells of the bone marrow (erythrocytes,
granulocytes, monocytes, megakaryocytes)
– Lymphoma- neoplastic proliferation of
lymphocytes within parenchymal organs
– Leukemia- circulating neoplastic WBC’s,
usually due to a bone marrow-derived
malignancy
 Hematopoietic Neoplasia
• Definitions (cont’d)
– Acute leukemia- characterized by rapid onset,
short survival time, and proliferation of
immature, undifferentiated cells (“-blastic”)
• Blasts may be difficult to assign to a specific
lineage without special staining techniques
– Chronic leukemia- characterized by prolonged
clinical course, longer survival, and
proliferation of well-differentiated cells more
easily assigned to a specific lineage (“-cytic”)
 Hematopoietic Neoplasia
• Lymphoproliferative disease
– Lymphoma (LSA)
– Lymphoid leukemia
• Acute lymphoblastic leukemia (ALL)
• Chronic lymphocytic leukemia (CLL)
• Myeloproliferative disease (MPD)
– Acute myeloid leukemias (AML)
– Chronic myelogenous leukemias (CML)
– Myelodysplastic syndromes (MDS)
 Myeloproliferative Neoplasia-
French-American-British (FAB) Classification
• Acute Leukemias • Chronic Leukemias
– AUL- Acute undifferentiated – CML- Chronic myelogenous
leukemia leukemia
– M1- Myeloblastic leukemia without – CMML- Chronic myelomonocytic
differentiation leukemia
– M2- Myeloblastic leukemia with – CMoL- Chronic monocytic
some neutrophilic differentiation leukemia
– M3- Promyelocytic leukemia (not • Hematopoietic dysplasia
recognized in animals) – MDS- Myelodysplastic syndrome
– M4- Myelomonocytic leukemia – MDS-Er- Myelodysplastic
– M5a- Monocytic leukemia without syndrome with erythroid
differentiation predominance
– M5b- Monocytic leukemia with
some differentiation
– M6- Erythroleukemia
– M6Er- Variant of M6 with
erythroblasts composing erythroid
component
– M7- Megakaryocytic leukemia
 Myeloproliferative Neoplasia-
French-American-British (FAB) Classification
• Acute Leukemias • Chronic Leukemias
– AUL- Acute undifferentiated – CML- Chronic myelogenous
leukemia leukemia
– M1- Myeloblastic leukemia without – CMML- Chronic myelomonocytic
differentiation leukemia
– M2- Myeloblastic leukemia with – CMoL- Chronic monocytic
some neutrophilic differentiation leukemia
– M3- Promyelocytic leukemia (not • Hematopoietic dysplasia
recognized in animals) – MDS- Myelodysplastic syndrome
– M4- Myelomonocytic leukemia – MDS-Er- Myelodysplastic
– M5a- Monocytic leukemia syndrome with erythroid
without differentiation (Kyla) predominance
– M5b- Monocytic leukemia with
some differentiation
– M6- Erythroleukemia
– M6Er- Variant of M6 with
erythroblasts composing erythroid
component
– M7- Megakaryocytic leukemia
 Myeloproliferative Neoplasia
• ALL myeloproliferative neoplasia in cats is
highly correlated with FeLV infection.
– Approximately 70-90% will test positive
• Clinical signs usually referable to anemia
(tachycardia, pallor, weakness) or
potentially other organ failure due to
neoplastic infiltration
 Myeloproliferative Disease
• Distinguishing AML from MDS/CML
– AML will have >30% blasts in bone marrow
– AML very likely to have secondary organ
infiltration (liver, spleen, LN’s)
– Both anemic, but usually more severe in AML
– AML more likely to have circulating blasts
 Myeloproliferative Disease
• Prognosis
– >80% dead or euthanized within a few days of
diagnosis
– Theoretically better for MDS/CML
• May have prolonged periods of myelodysplasia
with relatively symptom-free life
• Clearance of FeLV may reverse dysplasia?
• May progress to AML
– Utterly dismal for AML
• Longest reported survival 14 weeks
Preferred treatment for AML
 Hemotrophic Mycoplasma
• Mycoplasma haemofelis and Mycoplasma
haemominutum
– Formerly Haemobartonella felis
– Obligate epicellular parasites
– M. haemofelis more likely to produce clinical
disease
– M. haemominutum usually results in
inapparent infections unless complicated by
FeLV infection.
 Hemotrophic Mycoplasma
• Transmission likely via blood-sucking arthropods
– Blood transfusion, vertical transmission also possible
• Parasitemia may be cyclical with concomitant
rise and fall in hematocrit
• Splenic phagocytosis of affected RBC’s appears
essential to clearance of organisms
• Recovered cats may remain chronically infected
for months to years (carrier cats)
– Balance between parasite production and splenic
phagocytosis
 Hemotrophic Mycoplasma
• Anemia due to AIHA or direct RBC damage by
parasite
• Anemia usually regenerative
• Clinical signs usually referable to anemia
– Weight loss
– Anorexia
– Lethargy/weakness
– Pallor
– Icterus
– Splenomegaly

Photo courtesy of Dr. Craig Thompson

 Hemotrophic Mycoplasma
• Mycoplasma/FeLV co-infection
– About 40-50% of cats with M. haemeofelis are
FeLV positive (due to immune suppression?)
– Co-infection generally results in more severe
clinical signs
– While M. haemominutum produces minimal
clinical signs as a sole infectious agent, co-
infection with FeLV can lead to severe anemia
and possibly MPD.
 Hemotrophic Mycoplasma
• Diagnosis
– Demonstration of organisms on RBC
• Thin blood smear or feathered edge of thick blood
smear.
• Fresh blood smear (EDTA can cause organisms to
shed from RBC)
• Free of artifacts (e.g. stain precipitate)
– Organism-specific PCR
 Hemotrophic Mycoplasma
• Treatment
– Doxycycline 5-10 mg/kg PO BID x 3 wks
• May cause GI signs, esophageal strictures
– Enrofloxacin 5-10 mg/kg PO QD x 3 wks
• May cause serious retinopathy and blindness at
>5 mg/kg/day
– Immunosuppressive doses of glucocorticoids
for AIHA.
 Hemotrophic Mycoplasma
• Prognosis
– Up to 1/3 of cats with uncomplicated M.
haemofelis die from anemia without therapy.
– Antibiotics eliminate parasitemia but do not
entirely clear it from the body.
– Concurrent FeLV worsens overall prognosis
 Final Learning Issues
• Mrs. Owens is concerned about her other
two cats and 2 dogs. What will you tell
her?
• Should the other cats be tested for FeLV
and mycoplasma infections?
• Would you treat mycoplasma infection in
Kyla or in the other cats if positive?
• Is there any zoonotic risk for mycoplasma
or FeLV?
 References
• Blue JT, et al. Non-lymphoid hematopoietic neoplasia in cats: A retrospective study of
60 cases. Cornell Vet 1988;78:21-42.
• Grindem CB, et al. Cytology of bone marrow. Vet Clin North Am Small Anim Pract
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• Hartmann K. Feline leukemia virus infection. In: Greene CE, ed. Infectious Diseases
of the Dog and Cat 3rd edn. St. Louis: Saunders-Elsevier, 2006;105-131.
• Harvey JW. Hemotrophic mycoplasmosis (Hemobartonellosis). In: Greene CE, ed.
Infectious Diseases of the Dog and Cat 3rd edn. St. Louis: Saunders-Elsevier, 2006;
252-260.
• Mashita T, et al. A cat with acute myeloblastic leukemia without maturation (M1)
treated with combination chemotherapy. J Vet Med Sci 2006;68(1):97-101.
• Raskin RE. Myelopoiesis and myeloproliferative disorders. Vet Clin North Am Small
Anim Pract 1996;26:1023-1042.
• Shelton GH, et al. Feline immunodeficiency virus and feline leukemia virus infections
and their relationships to lymphoid malignancies in cats: A retrospective study (1968-
1988). J Acquir Immuno Defic Syndr Hum Retrovirol 1990;3:623-630.
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Animal Clinical Oncology 4th edn. St. Louis: Saunders-Elsevier 2007;733-756.