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Family Pet Animal Care - Meet Ralph - May 2016


Family Pet Animal Care 
Meet Ralph

by Dr. Michael Trapani

Meet Ralph. He’s a hangin’ out, used to be feral, half an ear chopped off, cool cat kind of guy. Ralph lives with Carol and Tony, but he’s really his own cat. Ralph has friends, that’s all, friends with benefits (regular meals and a warm place to sleep). He’s a good boy, but kind of shy. Ralph gets along, an’ he don’t start no trouble with nobody. 

Ralph hasn’t been his usual dapper self lately. He’s lost weight and his coat is dull and sticky. Ralph has bad breath and he doesn’t feel like eating. He’s not cruising the neighborhood like he used to. In fact, Ralph feels so lousy that he allows himself to be picked up and driven to the hospital. We all know that isn’t good.

At the veterinary hospital, Ralph shows what a decent sort of guy he is. He deals with the doctor and technicians with resigned tolerance. He accepts all the poking and prodding, and even lets them stick something up his butt (which, for the life of him, he’ll never understand). Ralph knows people are weird, and he can’t pull together enough energy to resist. 

This is bad. There’s no way any dignified, used to be feral, half an ear chopped off kind of cat would sit on the exam table and put up with all this. It’s totally NOT Ralph’s style.

On physical exam Ralph’s breath is terrible and his teeth are rotten. His coat is sticky. He’s seriously dehydrated. His temperature is normal. He’s making urine. His heart and lung sounds are normal. Ralph purrs through the entire examination.

What to do? A blood panel and urinalysis, that’s what. While we wait for results we’ll give Ralph some subcutaneous fluid to start replacing his deficits and an antibiotic injection to suppress the infection of his teeth: Minimal and basic supportive care for someone in his condition. 

Ralph’s urine reveals no bacteria and is highly concentrated, but contains 50 mg/dl of glucose. Ralph’s blood parameters are entirely normal and his major organ function is good, but his blood sugar is way above normal at 241 mg/dl.

So what’s your diagnosis? What’s wrong with our Ralphie Boy?

It’s obvious, isn’t it? Just go to Google and type in the major lab findings: Glycosuria and hyperglycemia. Everything else is normal. Dr. Google is quick to return the answer: Ralph is diabetic. Obviously. What else could it be?

Diabetics often have bad teeth because their high blood sugar levels promote bacterial growth causing gingivitis and dental disease. Diabetic cats often have sticky coats because they apply tons of sugar to themselves while grooming. Out of control diabetics frequently lose weight. It makes so much sense. 

And it’s so wrong, wrong, wrong.

Take another look: Ralph is a LOUSY diabetic. His blood sugar is elevated, but not enough to make him terribly ill. His urine contains glucose, the diagnostic characteristic of diabetes, but only 50 mg/dl. Any self-respecting diabetic cat should have ten times this much sugar in their urine – and a blood glucose over 350, possibly over 500. Something is rotten in Denmark.

That something is Ralph’s teeth (although how they got to Denmark is another question) and the systemic disease they’ve caused.

There are ten answers to every question in medicine. All of those answers are correct, but they don’t apply to the same patients. Ralph isn’t diabetic. He is (spoiler alert!) SEPTIC.

Remember, Ralph has a bunch of really rotten teeth. Ralph also has several foxtails digging into his abscessed upper jaw, so we anesthetize and clean up the mess in Ralph’s mouth. When Ralph wakes up, he is ravenous and eats a can and a half of canned food.

Ralph’s disease goes together like this: Ralph has severe dental disease and chews on grass to get rid of his loose teeth but instead collects foxtails in his infected tooth roots. Ralph keeps grooming and covers his coat with rotten tooth stuff. Over time, his teeth get worse, so he can’t eat and loses weight. The foxtails dig in and bacteria invade Ralph’s bloodstream. When Ralph goes septic, he crashes. His blood sugar spikes, making him spill sugar into his urine. Ralph looks just like a diabetic, but his pathology is far more dire.

But, but, but… Dr. Google will protest, if he’s infected so badly, why didn’t Ralph have a fever? An elevated white blood cell count? An altered white cell distribution?

Because Ralph is Ralph and he does sepsis the Ralph way, not the Google way. Nothing is ever simple in medicine.