June 30, 2025

🔓Clinical: Feline Anaemia: What You’ve Been Missing — with Dr Rachel Korman

🔓Clinical: Feline Anaemia: What You’ve Been Missing — with Dr Rachel Korman
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Season 1

I’m never excited when I diagnose a cat with anaemia: vague signs, confusing diagnostics, and what feels like a not-so-great prognoses. But are they really that hopeless?

In this episode, feline medicine specialist Dr Rachel Korman joins us demystify the anaemic cat and offer a clear, practical diagnostic framework that will give you more confidence and better outcomes the next time you see a cat with a low PCV.

Some highlights from this conversation:

  • A step-by-step approach to categorising anaemia.
  • Regenerative vs. non-regenerative: what it actually means in cats, and how to interpret the data.
  • Why IMHA in cats doesn’t look like IMHA in dogs — and how to recognise it.
  • Haemoplasma infections (like Mycoplasma):  When to treat, how to treat, PCR testing, and what the results really tell you.
  • Age-specific differentials: what to prioritise in young vs. older cats.
  • Supportive care: what works, what’s myth.
  • Prognosis pitfalls: why PCV alone doesn’t predict survival.

 

This episode will help you approach feline anaemia with more clarity, structure, and - dare we say - optimism.

💡 Proudly supported by Vetnostics Pathology: Australia's largest network of veterinary pathologists and internal medicine consultants. Learn how Vetnostics can support your work-up of complex anaemia cases with comprehensive PCR panels and diagnostic expertise.

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Episode Topics and Timestamps05:14 – Categorising anaemia06:00 – Regenerative vs. non-regenerative07:42 – Haemolytic anaemias in cats17:17 – Clinical signs and first tests18:43 – PCV/TP interpretation27:48 – Common causes by age31:38 – Mycoplasma diagnosis and treatment35:04 – Recognising haemolysis39:38 – PCR and anaemia panels48:53 – Bone marrow biopsy tips54:52 – Supportive treatments

 

I don't know about you, but when I see a cat with significant anemia, I feel several things, and optimism isn't really one of them.Well, that isn't until I recorded this podcast with feline specialist doctor Rachel Corman.
See, my lack of optimism stemmed from a bunch of anemic cases early on in my career that didn't have what you'd call happy endings.And to be honest, I think this influenced how I've approached these cases over the years, perhaps with a little bit less drive to solve the problem.
Well, if you are nodding along going yeah, me too, here is Doctor Rachel to hit the reset button for you.One of the things that we found from that was that the severity of anemia for cats is not something that's predictive of survival.
And I think that's really important is he might have a cat with APCV of 8% or 10%, and that sounds terrifying, but that figure isn't the thing that's predicting whether the cat's gonna survive or not.And their prognosis can actually be pretty good.
So jump into this one with us.It is a complex topic.We are talking about cats after all, and they are nothing if not complex.But it's actually really interesting.And I think once you've done with this, you will have a much clearer plan and hopefully significantly more optimism the next time you look at that PCV tube and you go, oh, shoot.
This episode is one of our clinical episodes where I interview smart people like Doctor Rachel to ask them all of my dumb questions.You can find more than 600 other episodes like this one on all things small animal medicine, surgery and ECC at vvn.supercast.com.
That's VVN for vetvaultnetwork.supercast.com.Our friends at Vet Gnostics Pathology are bringing this one out of our subscriber only feed and into your ears because A, it's such a great episode and I know that I'm not the only one that struggles with these cases, so we really wanted to share it more widely.
And B, if you practice in Australia, then Vet Gnostics will almost certainly be the ones helping you with your advanced diagnostics for anemic cats and dogs for that matter, with their comprehensive PCR panels.In this episode you will hear Doctor Rachel discuss when she reaches for these in her anemia work up and how to interpret your results better.
If you're an Aussie vet, you already know the name Vagnostics Pathology.Australia's largest network of veterinary pathologists and internal medicine consultants, which means faster results, direct access to real experts and support that actually solves problems.Vagnostics offers one of the most comprehensive and highly specialized test ranges in the country, so you are never left guessing.
Supported by 4 core laboratories in Brisbane, Sydney, Melbourne and Perth, plus a network of over 50 regional labs, you'll get answers fast no matter where you are.And this isn't just a lab service, it's a diagnostic partnership.You'll collaborate with pathologists and internal medicine consultants who are there to help you deliver gold standard care.
Plus, with a strong focus on ongoing education, like their support of this podcast, Vetnostics helps you stay sharp, current and informed.So don't be left guessing.Visit vetnostics.com dot AU and experience first hand how Vetnostics Pathology can support you in delivering exceptional veterinary care.
OK, let's get more comfortable with anemic cats with Doctor Rachel Corman.Thank you so much for joining us on the Red Vault for this topic I've been looking forward to for a long time.
It's been on my wish list of topics for a while.I want to talk.We want to talk feline anemia, which I, I have to confess, and maybe you can help me.Hopefully this episode will change that.But I don't love anemic cats.Like, give me an anemic dog and I'm like, yeah, cool.
This is an interesting challenge.I have my sort of algorithmic process in my brain of how am I going to figure out what it is?And, and most of them I feel like, yeah, well, we'll sort this out versus I do a PCV on a sick cat or like, oh shit, this is going to be bad.Is that justified at all or am I just bad at managing it?
I think.It's often it's just that the whole aspect that, you know, cats are different to dogs.And so you just need to get your head around a little bit more, you know, what's normal, what's common, what's unusual, and how they kind of react to illnesses in in different ways.
And so for us, I think as sort of cat specialists, a lot of the cats that we're seeing are sick cats and many sick cats will have a degree of anemia because cats are very, very good at developing an anemia of chronic disease for very vague reasons.
So it's often something where you just, you need to have it on your clinical radar.And then with any of those sorts of disease processes, it's just trying to keep a level head and work through the steps of, you know, categorizing what type of anemia you have and then what your differential diagnosis might be, and then just to start working through what's more likely and what's not.
So you talk about the categorizing of what type of anemia and again, I have a very clear picture in my head for dogs, but it's the same for cats, right?So it's either you are losing red blood cells somewhere, so you're bleeding or you are not producing red blood cells.
So bone marrow or chronic disease or you are breaking down red blood cells.Yeah, correct.I mean, I just decided.Yes, I guess there's a couple of different ways that you can look at trying to classify the manias that way.And one of the simplest ways is just to say, you know, is it haemorrhage, is it reduced production or is it increased destruction?
And starting with that is often and just the, the nice basic kind of approach.So we tend to look at is it regenerative or not regenerative?And then further splitting it into one of those 3 categories.
Then you can also look at the DAB net VE is what I would call it.There's probably other types of names for it, but that's where you go through and you look at the, you know, degenerative diseases, anatomical or anomalous metabolic, you know, neoplastic infection.
So that's when you're getting more into the nitty gritty specific disease processes at that way and that that can come sort of a little bit later once you've got more information about the patient.OK, so your algorithm is regenerative, non regenerative which will help you put it into one of those 3 buckets.
And then from there, once you're in the right bucket, then you go, OK, here's the list of potential T DS.Yeah, yeah, that's right.So, and, but I guess as with anything, there's always parts that are grey and I think cats are just so good at doing grey, which is what makes it so difficult for for everybody.
So most of the time, I guess if you think about the hemorrhage, you know, you would expect that to be a regenerative anemia unless you're in that time frame where it's pre regenerative.So you know that might be something where if you're really confident that this is about a hemorrhagic process that you still seeing a non regenerative process, then recheck it in another couple of days and you'll probably start to see evidence of regeneration.
And I guess on that note, we'll need to talk about how you differentiate non regenerative from regenerative.But if we think about the hemolytic anemias as well, so cats do that a little bit differently too.So you know, they're also pretty good at developing a non regenerative hemolytic anemia, which is where that destructive process of the immune system is actually targeting the precursors of red cells in the bone marrow.
So you don't get any signs of regeneration.And that's typically something that's occurring in in younger cats.So that can be what gives you the clue there.So it's thinking about the different buckets that you need to put things into you, but just remembering that there's exceptions to the rule at times as well.
Yeah, that's right.Cats live in that Gray zone in in most diseases.Did you if you decide to become a feline specialist, were you just like, oh, normal medicine's too easy.I want to make a vagina for myself.I love that's quite.Difficult for myself so.
So I just want to clarify what you said there about the hemolytic anemias being different in cats.So we're talking about IMHA.Any other diseases in that bucket or is that's basically what it?Comes to So look I guess with the hemolytic anemias in cats, there's different causes as to why that might develop and immune mediated hemolytic anemias would be 1 type, but you will get drug induced hemolytic anemia.
You can get Heinz body anemia in cats as well.And you know they're very prone to developing that because of the extra sulfur hydro groups that their red cells have compared to humans and dogs.So it's really easy for their cells to become damaged and have oxidative damage.
And then because their spleens are non sinusoidal, the spleen is not very efficient at getting rid of sort of these cells.So a lot of them do get destroyed quite quickly.So with the hemolytic anemias, there's immune mediated, but then there's other causes and I guess the infectious 'cause as well.
So the hemoplasma species in there as well.Just keeping ahead, should we get back to regenerative?So step one, regenerative versus non regenerative.So in my mind that means I'm looking for your CVC and look for reticular sites basically different size red cells and different colour red cells and that or send it off to the lab and say that that's.
Exactly right.And so I would say it's so 100% send stuff off to the lab.Like I'm a huge fan of getting an external CBC done and the the clinical pathologists are so great at looking at everything and giving you really useful information.
But I would say don't lose the art of looking at a smear in house because where it becomes incredibly important is those Friday night cases, you know, or log weekends where you've got to manage a cat for three or four days until you can get sort of something back in that report.
So being confident with your ability to look at a smear just comes with repetition.And so ideally, you take blood, you make 2 smears, look at one in house yourself, send one externally, and then compare the information that you're getting with what you're seeing.
And so when we're trying to look at whether they're regenerative or not, like you said, you look at the reticular side count and that's normally it'll sort of spit out a percentage or an absolute count.And so I always just look at the absolute account and obviously if they're regenerating, that should be, you know, above reference interval.
And if they're not regenerating or they're pre regenerative, it'll be within the reference interval.And then you can also look at the appearance, so the morphology of your red cells.So obviously, if you're regenerating, you'll have cells of different sizes because you'll have cells that are younger cells in different ages.
And you might also see things like a nucleated red blood cell where it's sort of younger cells much, much faster.So same as dogs, there's nothing specifically unique to looking at regenerative cat smear versus a dog one.No, that, yeah, that's it.So similar similar sort of process.
Great.So, but then you said cats will trick us because if they are humanizing sometimes they won't, they're well, the immune systems will will be destroying those reticulus.Yeah, so I'll.Target the.So the cytological appearance of an immune mediated hemolytic processing cats will be different to dogs.
So cats start to produce ferocites the same way that dogs do.So in dogs it's much easier to see spherocytes on the the smear of a dog with IMHA.But often you don't see them in cats, and so the absence of spherocytes doesn't exclude A hemolytic process in a cat.
And sometimes you'll see ghost cells in cats, which is where they have sort of very pale cells, and that can be sometimes a marker of a hemolytic process in a cat.But typically you'd also be looking for a glutenation.So there's probably another thing to talk about is cats, again, because of the difference in structure of their red blood cells and the nature of their red blood cells, they're very good at sort of sticking together.
And typically you'll see what we call Rulo, which is like a stack of coins.So you've got, you know, lots of cells on top of each other, whereas agglutination is pathological typically, and it looks like a bunch of grapes kind of altogether rather than stepped on top of each other.
And that's where doing your saline and glutenation test is helpful for differentiating lots pathological and lots not.Because when you wash those cells, if it's not pathological, they'll stay separated.
But if it is pathological, then they'll clump together and you'll see that macroscopical microscopic glutenation under the.So just to clarify, ruler, will you see ruler on a stand smear versus a?Because again, when I'm working up my anemic patient, I will do the agglutination, the saline agglutination test.
So once you've put saline in it, it the ruler will disappear.So if they're sticky, then if they're making those little clumps of grapes versus if you just look at a smear and you go, oh, why are these red cells all sticky together?Yeah.Yeah, that's just.Big cats being cats.Yeah, that's right.
So if it looks like a stack of coins, sort of one on top of the other, then that's a very normal thing that cats will cats will do.And that's not a pathological process.But if it looks like a bunch of grapes all stuck together and then you do, you know, a saline and glutenation test and it's still looking like that, then that would definitely be, you know, a, a marker for an amine mediate or for a hemolytic process.
Sorry, I should say not necessarily Amine mediate.Sorry I keep coming back into the nitty gritty of amine mediated disease.So in dogs, I know agglutination is a is a great indicator that it is, but the absence of by no means rules it out.Same thing in can.
Yeah, that's right.So ruler is certainly not associated with any kind of pathological process.Sometimes, again, this is sort of the, there's exceptions to every rule.If you've got a cat who's got a really high protein level, so maybe a cat with FIP or a cat with the multiple myeloma or something like that where they've got a lot of huge amounts of plasma proteins, you'll see more rule O and everything's sticking together that way.
But typically rule O is is not a pathological process, whereas A glutenation certainly is.But an anemic cat that does not have a glutenation on a saline agglutination test doesn't mean that it's not immune mediated, just like in dogs, right?
If it's there, it's relevant, but if it's not there, it doesn't mean you can.You can take it off the table, correct?Yeah, but it probably drops down the list a bit if you're not seeing it.Hey Neds, I just need to interrupt you to tell you about more learning with Yvette Vault, but this time not online or alone in your car.
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But if you've missed out on this one.And we do still have about 9 more tickets left by the way, for Wanaka, so it's not too late or even if you're already coming.But you need more snow and more fun with an epic group of attendees while you are sharpening your clinical knowledge.Our Japan's Snow conference is now on sale.
We're heading to a fabulous little mountain village called Nazawa Onsen.And if you didn't know, Onsen means hot spring.Yes, there's a hot spring at the conference venue.No, it's not one of those you have to be naked ones.Bathing suits are allowed, in fact encouraged.So this one is a week of deep powder.
Amazing traditional food in these tiny little snow covered eateries.Great company, world class continuing education.We would love you to join us there.Both of these events are live at Vets on tour.com.We can't wait to see you there.OK, back to Doctor Rachel.Maybe right back to the start and we just say you've got a cat that comes in and often the clinical signs of, you know, cats are really not inventive with the symptoms that they show.
So like the different diseases, they do the same thing.It's just they're they're not coming out, they're not interacting, they're off their food, they're a bit more lethargic.And that could be anyone of a million different disease processes, right.Not himself.Yeah, that's.Normally that at that point when?You know, something like that.
And so then you sort of start, you know, your physical exam and some cats may look pale, you know, you know, some cats maybe don't.Some cats might sort of have a thready hyperdynamic pulse that gives you a clue that there's something cardiovascularly the instability happening.
Some cats will be tachycardic, you know, some cats will be severely bradycardic if they're sort of very on the on the edge of the rest potentially.So physical exam can give you some of those clues, temperature, you know, cats with FYP, for example, or maybe anorexic.
And we see a lot of anemia for different causes in caps with FIP.And then when we start to get into the laboratory testing, I guess the first thing that you're going to do is grab a blood sample for biochemistry, you know, CBC in house or or out house and two smears, one to look at yourself, one to send out and then your PCVTP.
So if we talk a little bit about just the PCV first, the information that you can get from that is it just guides you on the severity of your anemia.But one of the things many years ago, and I sound so ancient now, but we looked at a big group of cats, you know, referral population that came in for anemia and we looked at the different causes of their anemia.
But one of the things that we found from that was that the severity of anemia for cats when they're presenting to us initially is not something that's predictive of survival.And I think that's really important, particularly for the for the emergency guys is he might have a cat with APCV of 8% or 10%.
And that sounds terrifying, but that figure isn't the thing that's predicting whether the cat's going to survive or not.And that's probably because when we have young cats with amine mediated anemias, for example, their prognosis can actually be pretty good and they can do quite well.
And so, you know, it's just an important thing to realize that that severity of anemia is not predictive of survival.That's a very, very good point because I in my head it it is if I see a cat with a.Sub 10 and e-mail like oh.
I'm saying you don't lose sleep over it.Like it's yeah, but it's just, it's not the thing where, you know, you would then say all you need to put this cat to sleep because what a really severe edemia, like the cat, particularly if it's young, may still have a very good prognosis.You know, if you've got a super elderly cat, your diseases are going to be slightly different.
You're thinking more along the lines of neoplasia or, you know, bone marrow disorders, then that population of cats would be different.But across the board, as far as prognosis goes, don't make it on the sort of severity of your PCV.
And the other thing to look at with the PCV is just the colour.Is it clear?Is it yellow?You know, So then if you're seeing yellow, you'd start to think is there a hemolytic process happening or not?And then we obviously start getting into the nitty gritty of cytology, looking at red cell appearance, you know, looking at your white cell line, looking at your platelets and then a reticular site count, OK.
Can I ask you about the PCBTP?Does how low it goes, does that give you any clues as to deities and and basically what I'm getting to is I if it's an anemia of chronic disease.Yeah, yeah.Do they go super low or do they tend to be like high 20?
Typically anemias of chronic disease.There's no specific cut off, I guess is the short answer to your question, but it would be unusual to get an anemia of chronic disease in a single digit number.You know, if it's eight or nine, you know, something that would be unusual where it might happen is if you've got multiple disease processes sort of happening together.
But typically anemia of chronic disease will be sort of the 15 to 25, something around that range.And am I right?I get the feeling that cats handle anemia better, probably because it's more chronic often, But you could if you say 8, if I said dog with eight, I'm like, yeah, you're pretty much dead.
Whereas you see cats sometimes come in in a single digit that looks, that doesn't even really show transfusion triggers.They're still.Cruising, yeah.And I, I guess for young players as well, that's probably a really important thing to have a think about where you need to relate the number back to what your patient is doing as well.
And what I mean by that is if you look at, if you've got a cat who's wandering around the consult room, you know, still relatively bright and it has a, a PCV of eight or a PCV of 12, that anemia hasn't developed suddenly, right?
That anemia has taken a long time to develop because the cat's been able to adjust to it.And so that immediately tells you that disease processes like hemorrhage are going to be pretty unlikely in that patient.And it's far more likely to be a slow degenerative process like a bone marrow disorder.
And the same with some of the hemolytic diseases, you know, they tend to be relatively fast in their in their progression.Whereas if you've got a cat who's collapsed, it's tachycardic, it's got bounding peripheral pulses, and it's got a PCV of 20, then you know, you've got to be worried that it's going to get worse probably before it gets better from APCV and patient perspective, and that there's something there that's happened relatively quickly so the patient hasn't been able to adjust to that reduced oxygen carrying capacity.
Right.One more question on the PCV, you mentioned serum colour.I feel like I heard somewhere that that cats, well you mentioned earlier, they breakdown red blood cells differently.So again, to me, the clear serum in a dog makes it way less likely that you're hemolytic.
Yeah, but it's not the case with cats, am I?Right.Yeah, that's right.It's not quite the same in cats.So they tend to not really produce quite as much of so the bilirubin in hemolysis.And so if you've got severe kind of acute hemolysis, then they might have a significant increase in bilirubin, but not seeing it doesn't necessarily exclude A hemolytic process.
And you know, that's there's lots of different reasons sort of for that, but it's mainly to do with sort of the way that liver can handle hem and the way that they're spleen and sort of adjusts to the red blood cells and things as well.So we would only expect to see very mild increase in bilirubin and the absence of it doesn't exclude the hemolytic process necessarily either.
I'm right in saying cats are.Complicated.Oh yeah.Welcome.Welcome to live world.Never threat.That's the problem.Way earlier when he talked about looking at a smear to try and differentiate regenerative from non regenerative.So he said sometimes they're non regenerative because they've just started bleeding.
How long is that window?How long between sort?Of two to three days before you'll start to see some erection.And in older cats it can sometimes be a little bit longer as well because their bone marrow kind of can be a little bit, a little bit sluggish and then they'll start to start to regenerate.
So it can be a little bit of a long time in older patients.On the other end of the time scale, if you had a slow bleed so you've got AGI bleed or something like that, do do you get to the point where the regeneration disappears because they've run out of iron or?Yeah, it certainly, Yeah, it certainly can.
And I guess we recognize that a little bit more in cats with other sort of processes happening.So there was a recent paper looking at cats with subcutaneous seridor bypass catheters.So and a lot of those cats can have a very mild cystitis and hematuria associated with the hardware that they have in their kidney and their bladder.
And and we're starting to recognize that some of those cats can get an iron deficiency anemia are associated with the presence of the sub.OK, so we're trying to differentiate regenerative to non regenerative, those grey areas, the ones that don't quite, let's say I do a smear and there's no obvious regener.
Oh, other way I, I look at it, I go, yes, there's obvious regeneration, then I can put you in the bucket of haemorrhage or hemolysis, Am I right?That's, that's right.If I don't see regeneration, then you're likely in the other bucket.
But with those couple of caveats in the back of your head going, you could still be but to help me decide, it sounds like history and clinical science are going to help me just be more suspicious of as you said, if if you are non regenerative but you are very sick with a modest we're relatively with A20 PCV, then I think I'm still thinking, well you just started bleeding or you just started hemolyzing, correct?
Yeah, correct.Or you've got one of the non regenerative hemolytic anemias that we see in cats where it's the the precursors in the bone marrow that the immune system is targeting or so they're destroying the baby cells before they can get released into the circulation.
So they look non regenerative.They are non regenerative, but it's still a hemolytic process.And are they fairly acute as well to be a dog with IMHA, is a they get sick really quickly because it's an acute change in cats or are they, are they going to be more chronic?
A little bit.Well, probably a week or so of being not quite right, yeah.All right, all right.So that doesn't really help.So again, that's where you're going to look for agglutination and and other things to try and decide.OK, cool.Is it an appropriate place to give me an indication of most common causes, you know, the horses versus zebras of what are we thinking of in different age groups in cats, the anemic cats, especially if we have these vague ones, We do the initial tests and it hasn't given us much direction.
What do you see fairly commonly as causes for anemia?So I guess my brain tends to separate the diseases by kind of signaling of the patient, for example.So in young cats we would tend to think about trauma, so haemorrhage, radenicide, toxicity, you know, if they're outdoor cats, for example, we would think about Haemoplasma infections if they're male outdoor cats as well.
So that's your Mycoplasma haemophilus infection.We would think about potentially FIP, you know, in young cats as well.A lot of those cats have either an anemia of chronic disease or a hemolytic anemia potentially too.
And then the immune mediated processes also tend to affect the younger cats in that sort of two to four or five year age bracket.That's the primary IMHA.Secondary IMHA's that are triggered by neaplasia or other infectious processes can happen in any age, but the true primary ones tend to be in the in the younger cats in the older age group population.
You know, most of those cats are probably going to be anemia of chronic disease.So you know, do you have a grumbling liver disorder?Do you have small cell lymphoma or large cell lymphoma or do you have chronic kidney disease?
And you know, they tend to be sort of the more common processes.And then we also I guess, get the leukemias a little bit too, which can kind of happen in any age group.So you say Hemoplasma, is that the new name for Michael?That's just kind of the the group.And so then within that you've got mycoplasma.
And I always get this wrong because it changes quite a bit, but there's Mycoplasma hemophilus, there's hemominutium, and then there's chiricensis as well.So there's sort of the three different species or the one that is more pathological is Hemophilus and Hemo mynetium and chiracensis.
They can still not Chiracensis doesn't cause disease necessarily, but Hemo Mynetium, if you get that on PCR in a cat, you really need to be looking for another cause of that cat's anemia because it doesn't often cause clinically significant anemia that we in a long time ago sort of trapped it in cats.
And we found that it did drop their PCV a little bit, but still it stayed within reference interval.So if you've got a cat with a pretty severe anemia, you run a Hemoplasma PCR and you get my UTM or Chira sensors, you need to look for another cause of that cat's anemia.
If you get that Hemophilus, that's probably your answer.You know, it's probably that that's causing the disease and then you treat that as you need.To OK, in your list of deities you you didn't mention mycoplasma.For the older cats, they can't obviously still get it depending on lifestyle.
Yeah, exactly right.It's still on the list.It's probably it's just that we would see more cats in that age group presenting with cancer or with kidney disease or or something like that.They're often the cats where you will see the the other species that are sort of non pathological if you like.
So you'll you might get a, you know, my eating or a cherosensors in those cats.OK, I want to ask a little bit of detail about mycoplasma.Is this a good place or?I think that's a good place yet.So so that's one that's I often think of it that if if I have an anemic cat and I don't find any other causes a is it common?
Is it common?I feel like there's variation in regional prevalence.And so when I worked in the UK we saw a lot, you know and we would see a lot of cats with severe anaemias with hemophilus.I feel like I don't see that many now that I'm working in Brisbane.
And we certainly do isolate sort of the non pathological species on PCR and we routinely sort of PCR our blood donors for example.So we will sometimes see them sort of pop up on that.But I see a lot less in significant infections with Hemophilus in Brisbane compared to when I worked in the UK.
So I suspect there's a regional distribution for it.But you you get it globally.Yeah, you do.So I think it's here like you, you've absolutely the appropriate thing is to is to look for it and test for it.And so I guess if we talk about testing a little bit with that, we've got 2 main ways that we can test for it. 1 is looking for the Organism cytologically, and one is doing APCR.
And hands down, without a doubt, PCR is the most sensitive and specific way to identify the Organism because there's just such an issue with false negative and false positive results looking cytologically.So it's very, very difficult to be confident with the diagnosis cytologically.
Right.That was going to be my question.So if it's a if it's the Friday 6:00 PM anemic cat and age fits and everything else fits and you do a blood smear and you go, I'm pretty sure that's that.Is that enough?For you to treat on or.Would you still say?Yeah.So I guess in that circumstance, if we role play that a little bit out.
So I would say you still send the PCR, right?If your owner can afford the cost of the PCR.So you send that out, but it might be a couple of days or a week until we get that back.But in front of you is a sick cat that's probably a younger cat that has a, a pretty severe anemia.
And so you're not going to withhold treatment in that patient while you're waiting for that test result to come back.And if we talk about treatment a little bit, there's probably 2 main parts of treatment that we're looking at.But the biggest thing is doxycycline.
You can also use fluoroplonolones as well.So marvofloxacin or prior tofloxacin.But certainly the the first go to is going to be doxycycline.And it's such a safe drug, right, that even if the cat doesn't have that infection, you're really not going to rock the boat clinically by putting that cat onto doxycycline.
So it's 100% the correct approach on a Friday night.Where it gets a little bit more tricky is does the cat need a steroid?And so we certainly see a lot of cats with haemoplasma infection.Doxycycline alone will be sufficient to treat that infection and get everything under control, and they may not necessarily need the immunosuppression that comes with Prednisolone.
Immunosuppression is because these are, by definition, they're actually hemolytic anemias, right?Yeah.The the parasite sits on the red blood cells, and the immune system's the thing that that destroys.The red blood cells, what there probably is, it is a degree of variation between the body being able to recognize that the parasite is there, it's foreign and it's going to get rid of it.
So appropriate hemolysis of an abnormal cell versus the haemoplasmas then triggering a sort of severely mediated process that then just starts destroying cells regardless of what they're producing.
And, and so when that process is happening there the caps that probably need the steroids in addition to the doxycycline.But telling the difference between the two, it can be quite difficult.And so in an ideal world, what you'd probably do would be maybe base it on, you know, a Coombs test or the degree of agglutination that you're seeing, or maybe even just how severely affected the cat is.
And you're just trying to cover all of your bases.But if your cat is kind of mildly affected and you want to just start with doxycycline and see how things go, then that would be appropriate.If your cat's severely affected, so, you know, maybe has a severely low PCV, has transfusion triggers, has marked a glutenation on a smear, maybe you've got the time to get a positive to send off the comb.
So it's positive.They're the cats that you'd probably be reaching for Prednisolone for sooner rather than later.Yeah.The doxy dose for this is that just labeled dose or do you have a specific recipes that you because you've got the you know those paste Yeah, yeah.Did you just use?
Basically just sort of 10 milligrams per kilo per day for the doxy dose.And then it's just whether you give that as a single dose or whether you divide it is kind of based on probably how easy the cat is to, to administer medications to.So if it's super tricky then I'd do the 10 Mig once daily dosage.
If they're relatively easy to medicate then I split it because I think the the big doses of doxy in one hit can make them feel a bit nauseous.And I'd also try and make sure they have a bit of food with it as well, because if you're giving it on an empty stomach it'll definitely make them feel pretty crummy.
OK.And bread, standard immunosuppressive bread doses if you do decide to, Yeah.And again, you don't want to shortcut things.But if you're in a situation where you, for whatever reason, either cost or convenience, can't do all the things diagnostically that you want at the start.
I have a young cat.It's anemic up even if I make a smear and I don't see parasites.Is it very wrong to go?I'm going to cover you with a bit of doxy just in case.Not at all.Not at all, no.I think that would be entirely appropriate.OK so while you are trying to keep this cat alive saying well let's see if we hit something that's causing this if I can't find another obvious cause.
Because it's, it's a safe drug, isn't it?Like it doesn't have a really bad side effect profile.So you you're really not going to rock the boat by putting it onto doxycycline?And because they're emalytic, they'll do they go, they go quite anemic, right?They can get very anemic.Yeah, absolutely they can.Yeah, absolutely.
Are they going to show you regeneration?Based on what we talked about earlier, they should show you.Regeneration.Yeah, correct.Because that's not the immune mediated that's targeting the the reticular sites that's going to be killing.So they should show regeneration.So young cat regenerative anemia, do they?
Are they pyretic or anything else like that typically?Yeah, they can be.So it certainly, but I guess as well absence of pyrexia doesn't exclude it.OK.Does that cover mycoplasma or is there anything else we.I think that, I think that covers it.I, I guess the main thing probably just that PCR is really the most important thing.
That treatment length I guess would be another thing because no one really knows the appropriate time for treatment length, but it's probably going to be at least two to four weeks on the doxin cyclin.And then some cats, you know, they can still become carriers potentially in the in the longer term.
There's some research that suggests that following up with Martha Floxacin after the doxycycline may reduce that, that load of of carrier status afterwards.But I think if you just did a two to four week course of doxycycline, track the anemia and if that's getting better, then great, great.
OK.You mentioned the PCRS a few times, so we have those.I'm not sure about the rest of the world, but I'm sure they have similar things.Your feline anemia profiles typically, what are they checking for?Yeah.So they would be testing probably for the the hemoplasma species, so hemophilus, hemomanetium and churicensis.
So for the the three, but again it's the Hemophilus which is the most pathological one we'd be looking at and as far as kind of other.Organisms and things that they would be looking for.I guess it depends on the regional laboratory.
There is a, I don't know too much about it because we, we don't have it here, but cytosine species that I think they're mainly in Europe and I think they're another one that you can see cytologically.
I don't know for sure whether there is a, a PCR or not.If there is, it's probably in America, I think, which is where, you know, this Organism is a bit more prevalent.Other panels might include things like some of the the Bezier species.So we can see sort of species that do you infect domestic, domestic cats.
Again, it's not very common in Australia.I think this is something that you'd see more in sort of countries like South Africa and and Europe and it's been recorded in Asia as well.And also I guess the other one would be the retrovirus viruses.So FIV and FPLV actually as well.
And I probably should have included actually FPLV in that differential list for the younger cats as well as a possibility for for infection.So so FLV will typically cause a fairly significant anemia.It can, yeah, it can do.
And but it's also more I guess just associated with development of potentially lymphoma or bone marrow leukaemias and things like that.So it's all definitely worthwhile screening in the younger cats that are presenting with anemia.
OK, so those profiles, so PCR part of your work up if you unless you have a very obvious, you know, cat comes in and Oh yeah, I can see you're bleeding.But if it's a non obvious diagnosis, worthwhile setting off, yeah.So I guess where we would be running it would be.
So let's say for example, we have a cat that is middle 8, let's call it 8, where it's the age where it can kind of be anything.And you know, we've got a PCV that is 15.So again, in that kind of bracket where it could be anything, it's kind of poorly regenerative.
So that cat, we're going to be doing some screening work essentially on it.So we'd probably be looking at chest X-rays, abdominal ultrasound, looking for neoplasia, looking for abnormal organ appearance.And if we don't find anything at all there, then we'd be looking at sending off a off APCR at that point potentially too.
OK.And the PCRS in terms of sensitivity and specificity, could we trust what we see there?If it's, you know, it's relevant if it's.Positive, it's probably not that straightforward.Again, with all things sort of cat related, depends on the laboratory, depends on the PCR primer that they're using and it's very difficult to get that information often when you need it.
So that's where it becomes important to just look at the result and sort of tie it back to your patient.So say for example, you know you get a positive result for cytosine, but you know, you live in Brisbane, then you think actually that's really doesn't really fit with what I'm seeing.
So I'm just not sure that this is correct.Most of the tests though for the hemoplasma species, you know they're going to be pretty reliable.Most of the tests for FIV are going to be reliable.FELV, the PCR I guess is going to be pretty good.
Where you've got to be a little bit careful is with the in house testing just because the prevalence in some areas of FELP infection is quite low and so you're more likely to sort of get a false positive.And so then just backing that test up.
If you get a in house positive then make sure you back it up with either a second ELISA test and or APCR at an external laboratory.OK.And in terms of the just to recap to the haemoplasmas comes back mycoplasma HEMA feel is yes significant.
That's likely to be why you can't anemic versus the others.It's there.Do you treat them if you see them at all?Would you still go on Doxy or not?Not.Really good question.And the, the answer is probably not necessarily because they're probably not really doing anything.
And that you'd be so say for example, you've got your cat with the PCV of 15 and it comes back and it's got your senses.That's not the answer.And so you need to be looking for another, another cause.And so, you know, you follow, you follow that pathway.
Great.That helps a lot.Thank you, trying to think of this anything else diagnostically?Some of the other things would be just check your platelet count and that's something that is so easy to do in house and so many people don't do it.And in house lab analyzers are inherently rubbish at getting the numbers right for cat platelets.
So so often you'll see really low numbers, but you absolutely just need to have a look at a blood smear and double check that their platelet counts are real.We certainly do see amine mediated throbocytopenia in cats.
It's less common probably than in dogs, but we absolutely see it.We treated a number of them here and so it can definitely be a cause for haemorrhage in cats.So they'll often bleed from the nose, you know, they might have some internal bleeding, but it's a real disease.
Interestingly, we see less Evans syndrome, you know, in cats.So in dogs it seems to be pretty common to get both IMHA and IMTP.In cats it's much less common, but we do see IMHA and then we do see IMTP in cats as well.
So with those with I'm TPS you should find evidence of bleeding somewhere.So you're going to see OK my cats a bit anemic.It's also has low platelets, which I've confirmed on a sphere and and you got it could be because IMTP I always struggle with to pull the trigger on treatment because you got slow, but is it low because you're bleeding or are you yeah, consuming them?
Are you?Are you killing?Them yeah, you've hit the nail on the head.It's really, really hard and I've 100% got it wrong.You know, I can think of 1 cat in particular where the cat came in with the history of being diagnosed as as IMTP.
And I thought, no, I think this cat actually just had a bleed for XYZ reason.And we pulled her off her steroids, but we tracked it and we were looking closely at her platelets and then lo and behold, her platelet count started sort of plummeting.
And then we could actually see, no, actually this truly was about an immune mediated process with the platelets.And she went back onto her steroids before there was any sort of catastrophic bleeding.But it 100% can be really difficult to tell that are they, is the platelet low because it's sitting in a big or is it low because the body's destroying it.
And what I would say is that the immune system is just so efficient at destroying platelets that if you see a cat or a dog probably for that matter, and the platelets are negligible, you know, to maybe, you know, 0 per high-powered field or one per high-powered field.
That's the immune system until proven otherwise, because it's just so efficient at getting rid of things it doesn't like.But in those cats and you should be able to find evidence of of bleeding somewhere.So it's gonna be can be blood in the feces or.Yeah, very likely.
But in sometimes it can be really.It can be really.Oh yeah.So I wouldn't necessarily like if they're sitting with a platelet count between, I don't know, I'm sort of pulling a bit of a roughy here, like between 100 and 150, you know, something like that.I'd be watching them really carefully that I wouldn't necessarily be assuming that's an IMTP or anything at that point.
If I'm getting a platelet count of 10 or 15 or 20, you know, less than 50 is kind of the the line for spontaneous bleeding.I think you can see some cats that will spontaneously bleed with a slightly higher platelet count.And then there's others that are running around perfectly happy with a platelet count of 15 and, you know, seem good.
Haven't bled yet?Exactly.OK.Do you do you ever need to go all the way down to bone marrow biopsies?Yeah.Is that is that something that happens or do you usually get your answer before you reach for those sort of things?
It's a really good question and I would say we probably there's we do them, we hate doing them.It's the almost I'm sure and it but it's definitely something where particularly for the non regenerative processes, you know that's how you identify them because you can see the arrest of the cell lines in the bone marrow.
There's definitely some leukemic and troid leukemia processes where that's how you identify them.You should be looking for Felv potentially within the bone marrow itself, but often it's really hard to get good samples from the cat's marrow histologically, like so cytology you can often get, but getting a really good core sample be difficult.
And that can be because of pathology.You know, if you've got severe fibrosis, you know, myelopsis in the bone marrow, that'll affect your sample.So I guess the short answer is that yes, it is definitely a test that is appropriate in certain circumstances and most of them will be the non regenerative anemias.
Often though, practically by the time you get to that point, you've gone through a lot of testing.So you've done a lot of diagnostic imaging.You've probably done a lot of laboratory work, you know, looking for infectious diseases, Coombs, you know, various different bits and pieces.
And you know, you may have had a cat that's already had a blood transfusion or you know, the cost is kind of mounting, mounting, mounting.And you've got to think about what are the treatable diseases that you're looking for?And the treatable diseases that we're looking for in the bone marrow will be the non regenerative hemolytic anemias.
So all the sort of precursor hemolytic anemias.And so sometimes you take a little bit of a leap of faith that if you like and you say to the owners, look, we can do this bone marrow test that will cost you probably another $1500 by the time you've anesthetized the cat, done the sample, sent it off to the lab.
Or we can treat for the treatable disease, which is a non regenerative IMHA.And we put them on Prednisolone plus or minus other immunosuppressives.If they get better, we're on the right track.If they're not, still could have been, it's probably bad disease.
Exactly.And so I would say in my experience, most people go down that pathway.OK, all right.And that makes sense.That's, that's pragmatic, which I, I love the ones that that I well, I struggle a little bit with decision making are the ones that I think are secondary.
So anemia of chronic disease.So my so let's say I have an old cat, it's anemic.I do my diagnostics and I go, yeah, you have kidney failure or, you know, some other disease.Am I OK to stop at that point?And as far as the anemia goes and says, well that's managed the disease and hopefully the anemia comes right or do you still need to skip digging to check or is there something else going?
On as well.It probably that's kind of a case by case basis I think and it would depend on the severity of the anemia as well.So if you've got a cat where you know, it's an older cat, you've found that it's, you know, got chronic kidney disease, maybe it's creatinine is 300, something like that.
And it's got a PCB of 19/20/21 that's poorly regenerative or non regenerative.That's probably your answer.And we should probably talk about erythropoietin or darbapoietin sort of treatment for that population of cats.
But if you've got a cat where it's PCB is sort of 1819 and it's creatinine is 182 hundred, you know, it's only very mildly kind of a asytemic, then that may not necessarily be your answer because most of the anemias of renal disease are occurring late in the stage of that kidney disease.
And so for those cats, you might then say, well, you know, we also see inflammatory bowel disease and small cell lymphoma in that population of cats.And so let's do a belly ultrasound.Let's, you know, double check your intestinal wall layering.
Let's look at AB12 level for example, and just maybe do a little bit more digging to see if you can get to the bottom of it.OK, great.All right, let's talk about it.Well, let's talk about all other things.So obviously in terms of treatment, we're not going to go into the individual diseases that cause anemia, but treat the disease.
We can treat the disease, give it steroids if it's hemolytic doxy, all those things.But in terms of other things that help to address the anemia directly beyond transfusion, which again we won't go down the transfusion route today, it's a whole different.I actually have a good episode on that.What I will just quickly Plumbo is that we wrote a really nice.
So it's a free access public access transfusion guidelines with international, so the Journal of Feline Medicine and Surgery.So if you just Google journal of Feline medicine and surgery transfusion guidelines and then you can download download that for free.
And that gives you all the information that you need about, you know, getting donors, screening, how to administer risks, all those sorts of things as well.So it's just a really great document.So take.Amazing.OK.So that's that's transfusion.Beyond that, supplemental things that can help with the anemia, what's proven, what's rubbish, what helps.
Yeah, sure.So from it, it depends on the disease process.So I guess would be the the first thing.OK, B12, vitamin B12 in cats, I feel like I scatter it around like chicken feed, like it's, I use so much of it in so many cats.
The more we find out about B12 deficiency in cats, the more we realize it's kind of involved in lots of different processes.And absolutely there's reports of cats with pancytopenia and various different bits and pieces.
I think it can cause a, I'm pulling this out of some ether of my brain that like a macrocytosis as well.So big red cells in cats that have a very low big well, it's a very safe vitamin to give.It's a water soluble vitamin.
You're not going to overdose them if their B12 levels are normal and you give them an injection and it absolutely can just make them feel a bit better and, you know, get those processes back online.In an ideal world, you'd do AB12 assay and then follow it up with the series of injections, but a single B12 injection is probably gonna be helpful.
But would that normally be some GI disease that's gonna cause a big.Yeah, So exactly, Yeah, exactly.Right.So that'll be your inflammatory bowel disease, all cell lymphomas, exocrine pancreatic insufficiency is another one that we see, you know, cats that have really low B12.
So that's sort of that population of cats, iron deficiency, that's a bit of a tricky one because a lot of the cats that we see, they may have a functional iron disorder where their iron amount is appropriate, but their body's just not using it appropriately.
And so there's all sorts of different fancy tests that you can do to look at iron body stores and functionality.But pragmatically, giving them half a mil of iron, dextran, intramuscular probably isn't going to hurt.
And so, you know, that would be a reasonable thing in most cases to do.And then for the cats with chronic kidney disease or for the elderly, anemic cats, and even to be honest, some people use DARPA Coeten.
So like the EPO in young cats with diseases like feline infectious peritonitis, you know, where they do have a severe anemia and we're just trying to kind of kick start their bone marrow as quickly as we can so they will regenerate at some point.
But the EPO just kind of helps them get there a bit sooner.How much B12 and how much Darba perheton is it?A is it?A textbook, yeah.So, Well, yeah.So the B12 would just be half a milk per cap, basically.
Yeah.And the Darba per Wheaton is and look, it's really hard because there's been very little work done on Darba per Wheaton publishing wise for a long time.But essentially it's A1 microgram per kilo dosage and you do that sort of once a week and it's a sub cut injection.
You have to dilute it down into an appropriate fashion because it's the human syringe.It's pretty expensive depending on where in the world you are, but it's certainly something that makes a big difference to a lot of the cats when you start them on it.
So it generally takes a couple of weeks for them to show a response.So you need to see them every week, check their blood pressure because they can develop hypertension on it, check their PCVTP and and then administer the darbacoitant.
And then eventually you'll find that some of them will respond to it and their PCV will come up to, you know within normal limits.And then you can increase the time between injections.So you might go to every sort of two to three weeks depending on the the individual cut.
So those are those old kidney cats.Yeah, exactly.OK.The kidneys are hanging in there, but there were anemia.Yeah, exactly.And the other place that I use it sometimes is just in older cats that probably do have an anemia of chronic disease and they're, you know, they've got a mild non regenerative anemia that's just not really going anywhere.
And so we start the non darbapoietin and some of them you give them one injection and bam, you know their PCV comes up.But others need it for a little bit longer.OK, Rachel, it's a big topic.When I went into this, I, I, I've got to, unless there's anything that I've obviously missed, I think we should stop there because there's all these little rabbit holes that you could go down.
But I think as you, you kept saying, probably some of these are, are separate episodes.I think it was a really nice overview.Are you happy with that or are you missing anything obviously?No, no, I'm happy with that.I, I think it's, you know, just the main thing, I guess is just to, to not be scared of anemic cats.
Stop panicking, you know, put your thinking hat on and just think about the process.You know, get a book out that gives you your differential lists and just start kind of working through.And just remember that the PCV at presentation isn't prognostic and a lot of these cats can do well.
I think, and again, that's important because I I've had maybe in my early career because I didn't know what I was doing.I had bad experiences with anemic cats that didn't go well.And maybe it's because I tell.You that I have bad experiences with anemic cats now.Like I don't, I don't hate.
Now it goes away.I think I sort of got into the mindset of visit one, I see your cat sick, I see severe anemia.And I'm like, as you said earlier, maybe lean towards, yeah, this isn't going to go well, but it's important to hear you say that no, they can't.
Just.Just be systematic and figure it out or refer it to Rachel if if you're near Brisbane.Yeah, she she likes the challenge.I do.Yeah, absolutely.Particularly in that young cat population, you know that that's where these guys really, you know, can come out the other side and and do incredibly well.
I think probably what's what scares me because the transfusion thing is so much more of a pain than a dog, so much more complicated.So you go if you're very sick as you got transfusion triggers.I almost, I'm tempted to want to give up because I'm like well even just keep getting you through the next 402448 hours is going to be hard before I even get to diagnosis.
I've got to save your life, which is intimidating if you're not doing it all the time.Yeah, absolutely.And that's where, you know, I mean having the processes or some sort of a plan and for feline transfusion is great.In different parts of the world, you know, there are feline blood banks and things like that that are available, you know, checking with your local referral hospital if they've got a donation program and things like that.
Or there's, you know, obviously xenotransfusions with the use of dog blood that can, you know, get patients out of trouble.But it's not a perfect soul.It you know, it comes with its own bag of trouble sometimes.Rachel, thank you so, so much for your generous time.
I know you're busy, you are, but I think that was fantastic.I love that.Before you disappear.I wanted to tell you about my weekly newsletter.I speak to so many interesting people and learn so many new things while making the clinical podcast.
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Dr Rachel Korman