Feline Gastrointestinal Eosinophilic Sclerosing Fibroplasia Interview with Dr. Michael Linton of Eastside Veterinary Emergency and Specialists

Feline Gastrointestinal Eosinophilic Sclerosing Fibroplasia Interview with Dr. Michael Linton of Eastside Veterinary Emergency and Specialists and Jenny and Amy Dean of Floppycats.com

A sincere thank you to Dr. Michael Linton for hopping on an international call with us to discuss Feline Eosinophilic Sclerosing Fibroplasia, a disease Amy’s cat, Addie has recently been diagnosed with.  This is a rare disease in cats with the first diagnosed cat in 2009 and Dr. Linton is known as the world expert in the disease.  He was a complete delight to talk to – so if you live in Sydney, I would certainly suggest checking him out.

You can learn more about Dr. Michael Linton at Eastside Veterinary Emergency and Specialists’ website.  Dr. Linton is based in Sydney, Australia and is known as the world expert in the disease.  You can read Dr. Linton’s 2015 study (with several other vets – Michael Linton (BVSc MACVSc), Judith S Nimmo (BSc BVSc DipPath MSc DipACVP PhD MRCVS, Jacqueline M Norris (BVSc MVS PhD MASM GradCertEd), Richard Churcher (BVSc FANZCVS), Sophia Haynes (BVSc FANZCVS), Agnieszka Zoltowska, (BVSc MRCVS), Sunishka Hughes (BVSc), Naomi S Lessels (BVSc), Miranda Wright (VetMB CertSAM MACVSc MRCVS), and Richard Malik (DVSc DipVetAn MVetClinStud PhD FACVSc FASM) here: Feline gastrointestinal eosinophilic sclerosing fibroplasia: 13 cases and review of an emerging clinical entity.

You can listen to the recorded version here: Feline Eosinophilic Sclerosing Fibroplasia Interview with Dr. Michael Linton of Eastside Veterinary Emergency and Specialists or just click play on the YouTube video below (which is not really a video, but rather a stagnant photo with the audio of the interview).

[youtube]https://youtu.be/KHdXMk1lWhM[/youtube]

Here is a transcription of our conversation, if you’d prefer to read it:

Jenny Dean: Hello, Floppycatters. Today, we are interviewing Dr. Michael Linton of Eastside Veterinarian Emergency and Specialists in Sydney Australia about… Dr. Linton, I can’t even pronounce the disease. Can you pronounce it for me please?

Dr. Linton: Good morning or good afternoon, Floppycatters. The disease we’re going to talk about is Feline Eosinophilic Gastrointestinal Sclerosing Fibroplasia.

Jenny: Right, exactly, and thank you for being here.

Dr. Linton: Not a problem at all. Happy to be here.

Jenny: Okay. So, what is it exactly? And I’m looking at layman’s terms not…

Dr. Linton: Yeah, sure, sure, sure. What the disease is is essentially it’s an inflammatory reaction where in effect, these little cats, we’re seeing an increased percentage of ragdolls specifically are getting these growths in their intestines and sometimes in what’s called the lymph nodes around the intestines, which when vets are feeling them, they’re feeling like they’re tumors. But in fact, the growths are actually not tumors. They’re just a big inflammatory response.

Jenny: Okay. That’s interesting just because my sister’s cat, Addie, has been diagnosed with it. So we were told it was tumor, so I kind of got thrown of there for a minute.

Dr. Linton: Yeah, sure. It’s an interesting comment that you made there because that’s, I guess for me, how I got involved with the disease. Because the first patient that I diagnosed with the disease was actually unfortunately misdiagnosed with having a tumor because we didn’t really know, well, and we still don’t know that much about the condition. And when the pathologist first had a look, they thought it was a cancerous process. And only after time and repeats of I guess evaluations and so forth, we realized that it isn’t in fact a tumor but it’s something that we can generally treat medically. Sometimes we have to do surgery, but generally we can treat them medically and they can do okay.

Jenny: Oh, okay. So you can treat it and it will go down in size?

Dr. Linton: Yeah, very much so. Yeah. Treatment is sort of multifactorial. In the majority of times, we can treat it medically with medications to just reduce inflammation. Sometimes you also have to give them antibiotics and things like that because there’s an infectious process going on. If the growth is in an area that we can’t safely remove surgically, we often do like to cut it out because we find these animals get better a little bit quicker. But there are some areas where the lesion can occur where it’s actually better not to do surgery on these guys because surgery can be dangerous in itself.

Jenny: Yes. Does the disease itself have a shorter common name?

Dr. Linton: No, that’s something I guess that we all need to work on a little bit because there isn’t a common name, and it’s very much a bit of a tongue twister and it doesn’t really roll off the tongue that well. We haven’t thought of a common name just yet, but I’m sure with time some smart, intelligent person will work something out which is a little bit more catchy and easier to say.

Jenny: Okay. Well if you want to name it the “Addie Dean Disease”, we understand.

Dr. Linton: Absolutely, yeah. That was my first preference.

Jenny: What are some of the common signs of the disease before it was discovered?

Dr. Linton: The common signs of disease are actually reasonably non-specific. And what that means is there’s nothing which is really diagnostic to say that this is the disease. But what we see is we see weight loss. That can be over a period of time, usually a couple of months. We also see vomiting and diarrhea. And what’s actually interesting is we see a lot of these cats, especially Ragdolls, have a history of over grooming as well.

Jenny: Interesting. What do you think the link is there with the over grooming?

Dr. Linton: Yeah. I’m not too sure, and it’s sort of only speculative, but our feeling is that these cats are getting these inflammatory reactions because, to be honest, their immune system is going a little bit mad and almost out of control or having a little bit of what’s called dysregulation. I guess I hypothesize that anything that can cause the immune system to start overworking can potentially cause these lesions. For example, if these guys get really big thick hairballs, that can cause inflammation. The immune system says, hey, or the gastrointestinal tract says, hey, what’s going on here, and starts having this strange reaction to it, and the tissue starts thickening up a little bit. So, that’s what I suspect. But at the same time, we’ve done a whole lot of studies where we’ve looked at various viruses and bacteria which could potentially trigger the immune system. And we are finding that there are viruses and bacteria in these cases. But we’re not seeing an actual common link, so there’s not one common bug or anything like that which is causing these problems. So, it is more, I think, the body’s reaction to a variety of different causes. Why Ragdolls are affected specifically, maybe there’s something in their genes or an abnormality which is causing their immune system to be set off. Again, that’s a study down that track, and that’s something that we’re looking into now.

Jenny: Okay. That was a question that I had later on, so I’ll address it now.

Dr. Linton: Yeah, sure.

Jenny: When the surgeon came in for Addie’s, he mentioned your study and said is there a larger Ragdoll population in Australia. And I had said, well, I wouldn’t think so given the fact that the breed started in the US. But he was wondering why it was so Ragdoll focused.

Dr. Linton: Yeah, well it’s interesting. I’m not sure compared to the US what the percentage of Ragdolls we’ve got here. But compared to our general population, Ragdolls were significantly over represented. What’s also interesting as well is since the paper was published, I’m getting a lot of emails from around the world. And I would say maybe two out of every three cats that people are contacting me are Ragdolls.

Jenny: Oh.

Dr. Linton: So I think that there’s definitely something with the breed. Maybe one out of two or two out of three, but yeah there’s definitely an over-representation of Ragdolls compared to the rest of the feline population. So, there has to be some sort of link to be found there.

Jenny: Right. And what about the comparison between males and females, are you seeing any difference there?

Dr. Linton: Statistically in our study, we’re not seeing any differences, and I think it’s too early to say if there is or there’s not at this point there. Is your kitty a male or a female?

Jenny: Female.

Amy Dean: She’s two years old. She just turned two in May.

Dr. Linton: Yeah, we saw a slightly over-representation of males in our study. But that being said, I wouldn’t be saying anything on that. Did you say two years old, pardon me?

Amy: Yes, two years old. She turned two in May.

Dr. Linton: Yeah, so the average age in our study was seven years old. But we’ve had patients from as young as a year up to eleven years old. So again, there are a lot of different ages that appear to be affected, which I think is important though as well because you’ve got a very, very young cat there, and it’s important because I guess… And it’s not always the case, but when you do have a young cat with a lump or a growth or even a seven-year-old which is still a reasonably young cat as well, it’s very easy when you first feel it to say, oh this is likely a tumor, this isn’t good, etcetera-etcetera. But at the same, it’s really important that all the various tests are performed to actually confirm the exact origin of the lesion because this is potentially a very treatable condition which is good.

Jenny: So what are the ways in which the disease is found? In Addie’s case, she would have died had she not had the emergency surgery.

Dr. Linton: Yeah, absolutely and exactly. So the way to diagnose the disease, I think it’s obviously you guys come in and say, my cat’s unwell. And then your veterinarian will have a look and they’ll do a physical examination. The majority of times, a good eighty or ninety percent, most veterinarians would be able to palpate a lump or a growth when they’re doing their physical examination. And then from that, they’ll usually recommend some sort of imaging to determine where that lump or growth is exactly. So that can be anything from an ultrasound, which is probably the best test, but X-rays would be sufficient. Some vets might even do things like CT scans which would also give more of an indication about where the lesion is. And then the approach from there is really up to you and your own veterinarian. But some veterinarian’s might suggest to take a sample from that lesion and send it away to the lab so they can get a diagnosis before they go to surgery or before they treat medically. But for other animals that are coming in acutely like it sounds like with your cat, sometimes surgery needs to be performed then and there because although this is a very treatable long term disease, if it’s not treated in the short term, it can be devastating. So sometimes surgery is required immediately.

Jenny: Okay. So it’s an immune disease. Is it auto-immune or?

Dr. Linton: Well, that’s it. I guess it comes down to the fact that what’s triggering the immune system and triggering this what we term inflammatory response where we’re getting a rush of a specific type of cells to the area [inaudible 00:10:41]. That’s the big question. So, what I would be suggesting to anyone whose cat has been diagnosed with this illness is to make sure that there actually isn’t another disease going on which could have triggered this in the first place. So we spoke about hairballs initially. But other things that we need to consider are parasites. What’s interesting, there was a case of a [pumer 00:11:05]. So obviously not a domestic cat, but a cat [inaudible 00:11:10] which had some specific parasites which then led to this disease occurring. Various fungal diseases can do it, inflammatory bowel disease could potentially do it. There was one case of an older cat which actually ended up having a cancer, but the cancer triggered this type of lesion to occur. So, any condition or anything that can really cause inflammation can set this condition off.

Jenny: Okay. Okay.

Amy: Acts as a trigger?

Dr. Linton: Yeah, exactly, acts as a trigger, exactly. And so I think it’s important when this is diagnosed make sure a [inaudible 00:11:49] test is performed where parasites are checked for, various bugs are checked for, a blood test is performed just to make sure there’s nothing else going on which can trigger this off.

Jenny: Okay. So, it’s typically found in the intestines and stuff?

Dr. Linton: Yeah, it is. It’s mainly found in the stomach and a little bit further down at the junction between the large intestine and the small intestine. Occasionally, we do see some cases where we get the lymph nodes which are surrounding the intestines, which may be infected as well or only infected. About fifteen years ago, there was an interesting journal article which came out of Japan where [finally 00:12:40] enough, they actually identified similar lesions in the neck region of some of these cats which had very similar pathology. We’re not quite sure if it’s exactly the same condition, but the lesions look very similar when we look under a microscope.

Jenny: Okay. Addie’s tumor was growing over her cecum.

Dr. Linton: Yes, exactly, and that’s really the junction between the large and the small intestine. So that’s the second most common place for this to be found.

Jenny: Okay. Hers somehow…

Amy: Ruptured.

Jenny: Ruptured is what they used.

Dr. Linton: Oh, my.

Jenny: So the contents of her colon and intestines were out swimming around in her organs.

Amy: In her abdominal cavity.

Dr. Linton: Wow, wow, yeah.

Jenny: So she was pretty sick.

Dr. Linton: Yeah. Is she doing okay now?

Amy: Yeah, she’s on three different meds. Two are antibiotics and one is a steroid now.

Dr. Linton: Yes.

Amy: She seems to be responding to them okay. She’s not completely herself, but as figured with how much trauma I guess she’s been through in the last couple weeks.

Dr. Linton: Yes, absolutely.

Amy: Yeah, no, otherwise she’s eating. Her poop has gotten a lot more solid from the liquid state it was.

Dr. Linton: Yeah.

Amy: And so I’ve been pleased with that improvement. She’s been peeing, and so she’s been doing all normal activities, just not necessarily her lovey-dovey self that she was prior to being sick.

Dr. Linton: Yeah. Sure. Sure. Yeah.

Amy: So she’s on Prednisolone, Clavamox.

Dr. Linton: Yep. Yep.

Jenny: Metronidazole

Amy: And Metronidazole.

Dr. Linton: And Metronidazole, yeah. I think they’re all very, very suitable and appropriate medications, which is obviously good. The reason why she’s on the Prednisolone it’s to reduce the inflammation because as we discussed, it’s a lot of this sort of secondary inflammation which causes the process. We do find that the majority of cats need to be on this lifelong at a reasonably low dose. The antibiotics are important. Your specific cat, it’s important for a couple of reasons – one because there was what’s called a peritonitis. So when the intestinal contents spilt into the abdomen, we need to be on antibiotics for that because that’s life threatening in itself. We find that about 50% of these lesions, when we have a look at them under the microscope, there seem to be various bacteria invading the lesions itself. Now, we don’t know if they’re a primary process or are they that trigger or are they secondary. So then certainly a reasonable course of antibiotics for I would probably say at least a month or two is appropriate.

Amy: Okay. We go back in a month to meet with an internist to kind of discuss how she’s doing. She is going to have an ultrasound to have a baseline of where things are now, and then kind of go from there. Yeah, she’s doing pretty well considering her odds. We’re quite happy.

Dr. Linton: Yeah. It sounds like they did a really good job there, and it’s fantastic she’s gotten here now because hopefully now she’s passed that acute process. She should have, I’m hoping, a good long-term outcome.

Amy: Yeah, it was about the size of a golf ball. Jenny and I actually saw it. The surgeon brought it out to us, and it was pretty big for a 9-pound cat. I do have a photo of it which we could send you if you’d be curious to look at it.

Dr. Linton: Yeah, please, I’d love to see.

Amy: And what happened, the reason why, I don’t know if you’re curious, but I had come downstairs and I had found two huge piles of throw up, and it was her cat food but a lot of water surrounding that throw up. And I had seen hair balls before here and there but never throw up. And she wasn’t interested in her food, just completely her eyes looked like crud. She didn’t look very good. And over a couple of hours, I let it sit to see if her condition changed, and then it didn’t. Man, am I glad that I brought her in.

Dr. Linton: Yeah, absolutely.

Amy: Because I wouldn’t have had a live cat the following morning.

Dr. Linton: No, it sounds that way. I think, to be honest, the presentation that you described of the vomiting, the going off food, is very typical of this condition. Unfortunately, that can be typical of many different things as well. So it’s not specific, but they are definitely the signs that we see.

Amy: Okay.

Jenny: What are the treatment options once it’s discovered? You’ve mentioned what we’ve discussed on the antibiotics and the steroids for a month or two. But then what happens after that?

Dr. Linton: Yeah, sure. So yeah, we’ve the initial period, which some patients may or may not require surgery. Then we’ve got a period of antibiotics and steroids or antifungal agents or whatever it might be. What we’re finding with the majority of cases is they’re not needing long-term antibiotics but the majority of cases are still needing steroids to control the body’s ongoing response. What happens is generally with time, people are tapering off the medication, and some people are able to completely taper off, so reduce the dose of steroids to nothing, and the lesion doesn’t come back and it can be monitored from clinical signs that you guys are seeing at home through repeat ultrasounds, through blood tests. But some patients, what we’re finding is that when these medications are reduced, then we’re seeing evidence that the lesions are coming back again. And hence those medications need to be, the dose, increased again.

Jenny: Got it. Have you had any success or seen any success with kind of eastern medicine type practices of herbal stuff?

Dr. Linton: Yeah, that’s a good question. Unfortunately, because there hasn’t actually been that many case reports, there maybe 50 or 60 cases now reported, a total of 50 cases, no studies have been performed using herbal or eastern medicine. I definitely think there would be opportunity to do it and perhaps now because we know a little bit more about the disease we could start looking into it a bit more. But as yet, I haven’t actually seen any cases treated without medicine at the moment.

Jenny: Okay. My concern is the long-term steroid things, so that’s why.

Dr. Linton: Yeah, absolutely. You know steroids long-term in cats isn’t good. It increases the risk for a variety of conditions such as heart disease, diabetes are probably the two that really spring to mind which would be most concerning. I think there are alternative medications that could potentially be used. But it just comes down to a risk sort of benefit. Ideally, we all do our best to get them off the medications, to be honest, as quick as possible as long as the signs can be controlled. Because the last thing we want is for the signs to reoccur and then we’re all back at square one.

Jenny: Right.

Amy: Yeah.

Dr. Linton: There certainly are other medications, and to be honest other types of immunosuppressive medications. But sadly, all of these tend to have side effects. It’s just about monitoring closely and having a good chat with your vet about what those signs or those side effects are so when they occur, they can be managed appropriately and quickly. Often those side effects are very reversible as well.

Jenny: Got it. What are your feelings about vaccines for a diagnosed cat, cause it’s my understanding that vaccines can trigger inflammation?

Dr. Linton: Yeah. We haven’t seen a link with vaccines and this condition in our case series that we certainly did. But I guess in reality, any inflammation could potentially trigger these infections. That being said, I think all the speculative links that we’ve found have been some sort of inflammation in the gastrointestinal tract, whether it be worms, bacteria, foreign body, or a localized tumor or something along the lines that way.

Jenny: Okay.

Dr. Linton: And again, I think it’s a whole new kettle of fish discussing vaccines because again the benefits versus the risks, I think vaccines are extremely important because there are some of these conditions that we don’t see any more, and we’ve sort of become a little bit I guess blasé about it because we don’t see them anymore. And vets who sort of practiced 50 or 60 years ago had some real terrible times with some of these diseases that we vaccinate against. That being said, we’ve also got to be very, very careful that we’re not over vaccinating as well because that can have problems in itself.

Jenny: Right. Right. Well, it was just a suggestion from a friend of mine who thinks very eastern medicine wise about vaccines. And she’s two, so she could be tittered for certain things.

Dr. Linton: Yeah. Again, the titers that can be performed, even those tests themselves have got limitations.

Jenny: Right.

Dr. Linton: I guess my own opinion is it’s all about balance. I think we have to be very sensible on these conditions. As long as we try to stick to very specific scientific principles and things like that and we’re careful not to overdo things but at the same time we also have to remember why vaccines were brought out in the first place as well. And some of these conditions can potentially be horrible. So it’s all about balancing enough, balancing things. That’s my opinion at least.

Jenny: I fully agree with an equal balance of both, so yes. So how did you get involved in this? It sounds like you’re pretty interested in it.

Dr. Linton: Yeah, absolutely.

Jenny: Can you tell me a little bit personally about that?

Dr. Linton: Yeah. I guess when I was doing some training, I came across a cat which presented to me, which was really, really unwell. And the long or the short of it is from the top of my head I think it was a nine-year-old ragdoll, and the cat presented, and we could feel a big gritty stiff mass in its belly. The cat was really, really sick, and we took some biopsies of that specific mass and we sent it away to the lab. And when the results came back, it came back with a pretty nasty, nasty tumor. And the cat wasn’t doing any well or anything like that. Because the cat wasn’t doing well, we ended up putting the cat to sleep. It was a very strange tumor. Over the next few months, we got some more opinions and had a look at it again and then we found out that it was actually potentially this condition which could have possibly been treated. Now, I don’t know if that would’ve helped our cat because it was so unwell at the time. But it just really I guess intrigued me that this specific tumor was identified and to a degree initially… I don’t know if the term misdiagnosis because it’s so new, but I guess inappropriately diagnosed. And then when I had a bit more of a look in the literature, there was a very good study which came out from the United States as well by a lovely vet, Dr. Craig. I think in his paper, between 25% and 40% of cats, I can’t remember off the top of my head, were also misdiagnosed initially. That really intrigued me, and I just thought well we need to know a little bit more about this disease so then we can educate as many vets as possible about it and to a degree owners as well that this condition is out there, that potentially it’s not a death sentence as long as we can get on to it as soon as possible and manage it as quickly as possible.

Jenny: Well, I’m glad you did.

Amy: Yes.

Jenny: When the surgeon got the results and ran into my sister, she actually just had gone in to get something. He said, oh, I got the results and it’s something I have never seen before.

Dr. Linton: Yeah. That’s it, and that’s a lot of people’s reaction to be honest because it’s new. There are not that many cases about it. There’s no information about this disease in textbooks yet, for example. It’s all in journal articles. Hopefully down that track, there’ll be more information about it in textbooks. But it’s not easy to find information about this at the moment.

Jenny: So this might be an ignorant sounding question, but it’s even odd that the pathologist would know what it was?

Dr. Linton: Well, that’s it. And again, I think it’s just because of lack of exposure to it. And I think now you would probably find with the various journal articles that have come out, there would be a lot lower misdiagnosis or false diagnoses because obviously with the benefit of people seen with cases over time. But, yeah, that was one of the things that intrigued me. You’d see cats were getting misdiagnosed just on the examination and then misdiagnosed when looking at through a microscope. It can be complicated. The pathology is very, very complex and it can look similar to other conditions. And to be honest, cancers as well, and there are some papers where people are debating whether a specific lesion is this or it’s this. Sadly, unfortunately, it’s not always black and white. And I think it’s just important to take the whole picture together to look at how the cat is, what it’s presented for, what the vet’s feeling and seeing on their examination, where the lesion is, and so forth that way. Then hopefully once we’ve got the whole picture, that can really help point in the direction of the appropriate diagnosis.

Jenny: Okay. I think that is it that I have for general questions unless you had something written down that I should have asked.

Dr. Linton: No, no, I think you’ve covered a lot of information really well.

Jenny: You’ve done a better job than I did.

Dr. Linton: I don’t think so. Thank you very much.

Jenny: So tell me, it’s Eastside Veterinarian Emergency and Specialists – you’re a specialist vet. In other words, someone would have their regular that and then come see you for weirdo conditions like this one?

Dr. Linton: Exactly that. So we see referrals from general practitioner vets who will send cases like this over to us during the daytime. At night time, obviously we see emergencies, and during the daytime of course any emergencies or anything like that as well.

Jenny: Okay. I know that there are quite a few readers in Sydney.

Dr. Linton: Oh, good stuff.

Jenny: I wanted to give you a shout out if that would help.

Dr. Linton: Oh, that’s very [inaudible 00:28:20]. Thank you very much.

Jenny: You’re welcome. So thank you again, and then if you don’t mind talking to us a little bit about Addie, we would love it as well.

Dr. Linton: Absolutely. Thank you very much, guys. Cheers.

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