Feline Chronic Lymphocytic

Plasmacytic Stomatitis/Gingivitis

Feline chronic lymphocytic plasmacytic gingivitis and stomatitis (FGS) is a painful condition for the cat and a distressing condition for both the cat's care giver and for the veterinary surgeon because of its intractability. Feline calicivirus can be isolated from almost 100% of cases, but is not the sole cause of the problem. The incidence of feline leukaemia virus (FeLV) and feline immunodeficiency virus (FIV) in chronic gingivostomatitis is no greater than in the general population, although many papers have linked the condition with these viruses. The condition may also be partially caused by food additives. Some cats presenting with aggressive behavioral problems may, in fact, be suffering from this condition. This webpage is written for veterinarians.

I am very keen to find a cure for this condition. If you are a veterinary surgeon and would like to take part in an email discussion group, please email register@dr-addie.com and put "FGS email group" in the subject. I am especially keen right now to hear whether any of you have used cimetidine (Tagamet) in treatment of this condition and to learn which foods you have used successfully.

New to the website - an e-book called "My Cat Has Feline Chronic Gingivostomatitis - What Now?" written for cat guardians.

The chapters are:

1. What is feline chronic gingivostomatitis?
2. What causes feline chronic gingivostomatitis?
3. How is feline chronic gingivostomatitis treated?
4. What you can do to help your cat recover from feline chronic gingivostomatitis.
5. If your cat dies.
6. Feline chronic gingivostomatitis and the cat breeder.
7. Feline chronic gingivostomatitis and the cat rescuer.
8. Glossary of weird and technical terms.
9. What you can do in the fight against feline chronic gingivostomatitis.
10. Useful websites.
11. Information fact sheet to take to your veterinary surgeon.

To buy in UK pounds - £5.00 GBP:

To buy in US dollars - $9.00 :

To buy in Euros - €7.50 EUR:

Upper respiratory disease in cats e-books

Download an e-book on feline infectious upper respiratory disease and feline chronic lymphocytic plasmacytic gingivostomatitis (note this e-book is only for undergraduate and postgraduate veterinary surgeons, especially those studying for feline or small animal medicine certificates or for continuing professional development. The e-book is not worded for non-veterinarians). In addition to everything contained on this webpage, the e-book contains tables of differential diagnoses, a section about infectious respiratory disease control in catteries, details about feline vaccination and treatment, the truth about azithromycin, notes on less common upper respiratory infections of the cat and more extensive lists of references and websites for further reading.

Purchase feline upper respiratory infection and FGS e-book

Buy with UK pounds (cost £5.00):

To pay in US dollars (cost $9.00):

To buy in Euros (cost €7.50):

Cause
The exact aetiology of feline chronic lymphocytic plasmacytic gingivostomatitis (FGS) is unknown and likely to be multifactorial. However, it is probably caused by combination of feline calicivirus (FCV) infection and the cat's inappropriate immune reaction within the stomatitis lesions (shift from normal Th type 1 response (cellular) to a mixed Th type 1 and 2 (humoral) response. (Harley et al, 1999). Feline immunodeficiency virus (FIV) and feline leukemia virus (FeLV) have both been linked with the condition, but in my last two small studies, the incidence of these viruses was no more than in the general cat population in the UK.

In humans, chronic gingivostomatitis can be due to intolerance to food ingredients (e.g cinammon) or additives, especially those of chewing gum or the fizzy Scottish drink, Irn Bru. Just before Lucky, the cat described in the case report below, dramatically improved, his food had been changed to the additive-free Classic Cat Food. We believe that the food change aided his recovery and have several anecdotal reports from veterinary surgeons of similar responses to this food.

Diagnosis

Definitive diagnosis of feline chronic lymphocytic plasmacytic gingivostomatitis is by biopsy. Diagnosis of feline calicivirus can be performed with an oropharyngeal swab. Virus isolation is still the diagnostic test of choice for this virus because of genetic variability of the virus (so some reverse-transcriptase polymerase chain reaction (RT-PCR) tests will give false negative results). However, virus isolation is not available in all countries.

Recommended laboratories:

This list is unfortunately nowhere near complete and I apologise if your country is missed. Scandinavian countries usually send their samples to Companion Animal Diagnostics in Scotland, UK.

France - Scanelis laboratory, which is attached to the Ecole Nationale Veterinaire Toulouse - for quantitative RT-polymerase chain reaction to detect FCV.

UK - Companion Animal Diagnostics, University of Glasgow Veterinary School - who perform virus isolation. Telephone them on 0141 330 5777 or email Companion, to order viral transport media, swabs and sample submission forms. Their charge is £13.00 plus VAT. You may also wish to send a biopsy of the lesion in 10% formol saline (from £18.00 plus VAT).

USA - In America, the feline calicivirus RT-qPCR test which I would recommend you use is available from Dr Christian Leutenneger's laboratory, the Lucy Whittier Molecular and Diagnostic Core Facility. You can download a sample submission form from his website.

Treatment

The treatment with the highest reported success rate for this condition remains complete removal of all teeth and especially the roots by a specialised veterinary dentist. A good veterinary dentist can achieve cure rates as high as 80%. However, this procedure is not without risk: Smith et al (2003) report penetration of the eyeball in 3 cats and 2 dogs following dentistry, with subsequent loss of the eye. And of course general anesthetics always carry a risk too. Not surprisingly, many owners would prefer to try conservative treatment first.

Conservative treatment is aimed at using a non-allergenic food, restoring normal mouth flora (healthy cat's mouths have predominantly Pasteurella multocida, 50% of cats with stomatitis have spirochaetes), trying to eliminate FCV, and shifting the immune response back to type 1. For the latter, it is not a good idea to use corticosteroids, but a non-steroidal anti-inflammatory safe for use in the cat (e.g. Metacam). Thalidomide is ideal, since it is safe, anti-inflammatory, and shifts the immune response from Th1 to Th2, but it is now virtually impossible for veterinary surgeons to source it. Cimetidine is being recognized to stimulate the Th1 response, and may be worth trying, it certainly shouldn't do any harm. To my knowledge, it has never yet been used to treat this condition.

Corticosteroids are absolutely contraindicated because of the high rate of diabetes mellitus development following long term therapy, the risk of obesity and because whilst they appear to help the cat initially, there is a bounce-back effect - with the cat re-presenting with worse clinical signs than initially and requiring higher and higher doses just to maintain. Corticosteroids suppress both humoral and cell-mediated immunity, reducing the cat's chance of clearing the infection, and cause thinning of the epithelium.

The treatment I currently recommend is as follows: Metacam (continually, or until complete healing), Antirobe for 6 weeks (or on alternative weeks - week on, week off), Classic cat food (continually or until complete healing), 1MU Virbagen Omega per kg every other day subcutaneously for 5 injections, thereafter monitor clinical progress and give injections as required. Individual cats require differing regimes of Virbagen Omega injections - some every other day, others only once a week, others recover completely and no longer require injections. Submucosal injections of Virbagen Omega are reported to give good results. See below for more details.

Antibiotics


Antirobe (clindamycin) 5mg/kg bid for 6 weeks

NOT Metronidazole 4-6 weeks (metronidazole has a suppressant effect on cell mediated immunity in mice, and may be less desirable in this condition where CMI is preferable to the humoral response).

Interferon

Feline interferon: Virbac make feline recombinant interferon (Virbagen Omega). Note that feline interferon omega should always be stored in the fridge and will remain viable once reconstituted for up to 21 days at 4oC.

Subgingival use: A dose of 1 million units (0.2ml of a 5 million unit vial, 0.1ml of a 10 million unit vial) locally into the junction between healthy gum and diseased gum given when the cat is anaesthetised has been reported to have excellent results (Camy 2004, Mihaljevic 2004). However, some cats require more than one treatment and if they are poor anaesthetic risks an alternative may be preferable.

Case study by Dr Guy Camy

Subcutaneous injections: 1 MU/kg, or 0.1 ml/kg of the reconstituted solution, once every other day for 5 treatments. Thereafter attempt to reduce dosage to twice a week, provided the cat is still doing well. Discontinue treatment only after three attempts to isolate calicivirus have been negative (these can be at weekly intervals). We find monitoring the cat's weight a useful objective way of assessing response to treatment.

Suppliers: NVS, Abbeyvet

Virbagen Omega website

Case studies of Virbagen Omega

Human interferons: - (feline interferon is preferable if available) - Intron A (human recombinant interferon) obtained as 3M I.U. from local pharmacist (write a prescription). Dilute in one litre of saline, aliquot into 1ml volumes, freeze for up to a year. Defrost as required, dilute 1:100 to get 30 I.U. per millilitre, keep refrigerated for up to a week. Treat continually, until FCV shedding ceases.

Dose: 30 I.U. per day orally

Anti-inflammatories

Corticosteroids should be AVOIDED because although the cat may improve initially, ultimately the condition will worsen or become more chronic. For preference, use non-steroidal anti-inflammatories.

Metacam
Meloxicam (Metacam, Boehringer Ingelheim) is preferable to steroids in the control of this condition. In our study, both controls and the IFN omega group were put onto Metacam.

Dose:
Day 1: 0.3mg/kg sid with food
Days 2-7: 0.1mg/kg sid with food

Thereafter reduce the dose until you find the minimum that keeps the cat comfortable: most cats will maintain on 1-2 drops per cat per day.

Thalidomide

At present, we are unable to source thalidomide in the UK and are putting all of our cases onto Metacam.

Thalidomide is a good anti-inflammatory to use in this condition but is difficult to obtain. If you do manage to get it, remember to explain to the owner that thalidomide is not licensed for the cat.

Dose: 1-2 x 50 mg capsules per day given in the evening

NOT to be used in pregnant queens

Ketofen

1mg/kg sid per os for 5 days

Aspirin

10-25 mg/kg every 48 hours

Food

Food is a very important feature in this condition. Most affected cats improve on Classic Cat Food (a tinned and pouch food made by Butcher's, available in Safeway, Pets at Home and other supermarkets and British pet food shops) and metacam alone. Lucky, the cat in the case study reported below, had just been changed to Classic Cat Food prior to his recovery. In addition, after dentistry, cats fed on Hills a/d diet gained more weight and had smaller lesions than those fed on a control diet (Theyse et al, 2003). We currently recommend a change to either of these foods for cats suffering from this condition. Unfortunately, we know of no food outside the UK with similar properties to Classic, other than Hill's a/d.

For local suppliers of Classic food or for buying in bulk, phone Butchers on 01788 823711.

I am often asked what can people use in countries which do not have Classic food, or for cats who do not like Classic. Other foods which MAY be all right, but I have no actual experience of using them in these cases, are:

1. Applaws natural cat food. Phone Roger Coleman on 08707 508 606 for a sample. Their website is still under construction, but should be www.applaws.co.uk

2. Royal Canin hypoallergenic diet.

I would be keen to hear from any veterinarians who have experience of using these foods to control feline chronic gingivostomatitis.

Antioxidants

Antioxidants such as vitamins A, C and E and zinc improve mucous membrane health and possibly have anti-viral and/or immune stimulant activities. One has to be careful of using vitamin A in the cat for 2 reasons: first the cat can't absorb or convert well the beta-carotene forms (i.e. those found in plant foods), so it must be given in the form of liver or fish oil (halibut or cod), secondly, vitamin A SHOULD NOT be used for more than 6 weeks or there is a risk of hypervitaminosis A and bone deposition. Also be aware that long term use of vitamin C in the cat can predispose to oxalate crystalluria.

Doses:
vitamin A: 200-400 i.u./kg/day for less than 6 weeks
vitamin C: 125mg/cat bid
vitamin E: 25-75 i.u./cat/bid
zinc: 7-10mg/cat/sid

Slippery elm in honey

UK vet, David Leicester, reports some response to slippery elm in honey applied directly to the lesions. This herb is used widely by humans with inflammatory bowel disease and has been shown to have antioxidant effects on mucosae in vitro.

Dave writes the following:

"The product I have been using is:

"Phytoplex Slippery Elm" produced by: Animal Alternatives, PO Box 289, Richmond, Surrey, TW10 7HX, England, UK. I must stress that I have no association whatsoever with this company and am not on a commision (though perhaps I should be!! ;-))

Each tablet contains: 400.0mg Slippery Elm Bark; 0.001ml Cinnamon Oil BP; 0.001ml Clove Oil BP; 0.001ml Peppermint Oil BP.

This formulation is actually sold as a digestive remedy for a plethora of GIT problems in dogs and cats.

The recommended dose for GIT indications for cats is 1/2 tablet TID

The manufacturers claim no contraindications and the further research I have done appears to support this.

For the topical treatment of oral inflammation and ulcers I have been grinding up a single tablet and mixing with c5ml of honey. This pasty mixture is then syringe directly onto the affected areas at regular intervals throughout the day. It is very well tolerated and as I reported previously seems to work wonders in a very short period of time. I postulate that at least part of the response is due to the local anesthetic effect of the oil components and possibly also the antiseptic effects of the honey, I'd be interested to hear if anyone has any thoughts on this matter.

I have seen 2 cats in the last 3 years develop diabetes mellitus from the chronic use of long acting steroid preparations for this problem and will not use them unless it's going to be euthanized otherwise. I have always tried to get them onto tablets in the past to allow alternate day therapy but with limited success. I am now using a combination of occasional steroid +/- antibiotic courses (usu Antirobe- clindamycin but sometimes Stomorgyl- metronidazole/spiramycin), xrays/dental and root extractions, lysine for viral related cases, chlorhexidine mouth washes and slippery elm in honey. If anyone is still trying to find Slippery Elm then try health food shops or over the internet, or you could always give Animal Alternatives a call as that's where I get mine. There must be plenty of other companies making it though as its widely recommended in human herbalist books for gut problems."

Dave's email is: beacon@MADASAFISH.COM
Telephone: (UK) 0208 940 3725



 

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