Coagulation abnormalities in 5 cats with naturally occurring cytauxzoonosis

Cytauxzoon felis: An Overview

Cytauxzoon felis is a tick-transmitted, obligate, hemoprotozoal, piroplasmid pathogen of felids and the causative agent of cytauxzoonosis. It has a complex life cycle which includes a tick as its definitive host and a felid as its intermediate host. Since its first description in 1976, C. felis infections of felids have been reported in several southeastern and south-central U.S. states, overlapping with the ranges of its two known biological vectors, Amblyomma americanum (Lone star tick) and Dermacentor variabilis (American dog tick). Infected felids demonstrate disease as either an acute, often-fatal, infection, or a subclinical carrier infection. To develop effective C. felis transmission control strategies, the incidence of acute cytauxzoonosis, patient risk factors, the role of domestic cat carriers, and ecological variabilities need to be investigated further. Of equal importance is communicating these strategies for high-risk cat populations, including recommending year-round use of an acaricide product for all cats that spend any time outdoors. More studies are needed to further identify factors affecting C. felis and other Cytauxzoon spp. infection, transmission, disease progression, and treatment options and outcomes within the U.S. and globally. Here we provide an overview of C. felis highlighting its lifecycle within its definitive host, transmission to its intermediate host, symptoms and signs providing evidence of transmission, definitive diagnosis, current treatment and prevention strategies, and future considerations regarding this condition.

Evaluation of various sample sources for the cytologic diagnosis of Cytauxzoon felis

Background

Cytauxzoon felis is a life‐threatening protozoan disease of cats. Identification of schizont‐laden macrophages is a point‐of‐care diagnostic test for acute cytauxzoonosis.

Hypothesis/Objectives

The primary objective determined cytologic agreement between sample types to diagnose acute cytauxzoonosis. The secondary objective evaluated novices' ability to identify cytauxzoon organisms in blood films and tissue aspirates.

Animals

Thirty‐eight cats with suspected acute cytauxzoonosis and 5 controls examined postmortem.

Methods

Cases were prospectively submitted and collected. Blood film, lymph node, and splenic aspirates were blindly reviewed for sample quality, presence of schizont‐laden macrophages, and agreement between sample types. A subset of cases and controls were evaluated by 12 blinded novice observers to determine sensitivity and specificity for identifying organisms in various sample types.

Results

Acute cytauxzoonosis diagnosis was made on at least 1 sample type in 28/38 cats. Schizont‐laden macrophages were seen on 33% (10/30) of blood films, 56% (19/34) lymph node aspirates, 77% (26/34) splenic aspirates. Schizont‐laden macrophages were more likely seen on splenic than lymph node aspirates (McNemar's, P = .03) or blood film (McNemar's, P = <.001). Novice observers were more likely to agree with experts when identifying schizont‐laden macrophages in splenic aspirates (sensitivity = 77.1%, specificity = 94.4%) versus lymph node aspirates (sensitivity = 52.8%, specificity = 96.4%) or blood films (sensitivity = 41.7%, specificity = 96.9%).

Conclusions and Clinical Importance

Schizont‐laden macrophages are most frequently identified in spleen, even by novice observers. If the diagnosis of acute cytauxzoonosis cannot be confirmed via blood film, then splenic, followed by peripheral lymph node aspirates can be considered.

Decreased antithrombin activity and inflammation in cats

OBJECTIVES

The objective of this study was to determine if inflammatory markers are associated with antithrombin activity in cats.

METHODS

For a retrospective population of 231 cats admitted to a referral hospital, antithrombin activity was classified as decreased (n = 77), intermediate (n = 97) or in the upper quartile (n = 57). Odds ratios (ORs) were calculated for an association between decreased or upper quartile activity and hypoalbuminemia, hyperfibrinogenemia, band neutrophilia and toxic change. Multiple logistic regression was performed to determine if an association between band neutrophilia and decreased antithrombin activity was independent of decreased hepatic synthesis, consumptive coagulopathy or protein loss.

RESULTS

Cats with decreased antithrombin activity were more likely than cats with intermediate-to-upper quartile activity to have band neutrophilia (OR 2.85, P = 0.0050), hypoalbuminemia (OR 12.1, P <0.0001) or toxic neutrophils (OR 4.47, P <0.0001). Cats with antithrombin activity in the upper quartile were less likely than those with intermediate-to-low activity to have hypoalbuminemia (OR 0.31, P = 0.0023) or toxic neutrophils (OR 0.44, P = 0.033). In a regression model that included other mechanisms for decreased antithrombin, band neutrophilia remained associated with decreased antithrombin activity (adjusted OR 2.62, P = 0.013).

CONCLUSIONS AND RELEVANCE

Contrary to previous studies suggesting antithrombin is a feline positive acute phase protein, this study demonstrates an association between decreased antithrombin activity and inflammation. Further studies are needed to determine the mechanistic basis of this association.

Thromboelastography in cats with cholestatic liver disease

OBJECTIVES

While thromboelastography (TEG) has helped define a complex state of hemostasis in dogs and humans with hepatobiliary disease, it has not been explored in cats with cholestatic liver disease (CLD). The objective of this study was to describe TEG parameters in cats with CLD and to compare these parameters with conventional plasma-based coagulation tests, white blood cell (WBC) count and biochemical indicators of liver disease grade and severity.

METHODS

Eighteen cats with CLD, defined by a serum bilirubin ⩾3 mg/dl and a greater than two-fold increase in serum alanine aminotransferase (ALT) and/or alkaline phosphatase (ALP) activity, were prospectively enrolled. All cats received vitamin K1 subcutaneously for 24-36 h prior to acquisition of blood for kaolin-activated TEG analysis, prothrombin time (PT) and activated partial thromboplastin time (aPTT). Patient total solids, packed cell volume, platelet count, WBC count, and serum liver enzymes and bilirubin were extracted from the medical record and correlated with coagulation test results.

RESULTS

TEG global clot strength (TEG G) values defined 9/18 (50%), 5/18 (28%) and 4/18 (22%) cats as hypercoagulable, normocoagulable or hypocoagulable, respectively. TEG G was significantly negatively correlated with PT, aPTT and serum ALP activity and positively correlated with total solids. Five cats (5/18, 28%) were hyperfibrinolytic with clot lysis at 60 mins (LY 60) >15.3%. LY 60 was significantly positively correlated with PT.

CONCLUSIONS AND RELEVANCE

By TEG analysis, cholestatic cats replete with vitamin K1 display a variety of coagulation profiles. Indications of synthetic failure (prolonged PT and aPTT) were associated with hypocoagulable and hyperfibrinolytic TEG parameters. High disease activity (serum ALP) was associated with a hypocoagulable state.

Acute Cytauxzoon felis Cases in Domestic Cats from Eastern Kansas, a Retrospective Case-Control Study (2006-2019)

Cytauxzoon felis, a tick-borne hemoprotozoal pathogen of felids, causes an acute, often-fatal disease in domestic cats. While public awareness of the disease has increased, few studies have evaluated the incidence of acute cytauxzoonosis cases and their associated risk factors. The objective of this study was to retrospectively review records of cats diagnosed with acute cytauxzoonosis in eastern Kansas from 2006–2019 using clinic records and determine: (i) feline cytauxzoonosis risk factors; and (ii) if cytauxzoonosis case incidence is increasing. Although inter-annual variation of acute cytauxzoonosis diagnosis was observed in the eastern Kansas domestic cat population, the overall incidence trend remained largely unchanged over the 14-year case review period. In comparison to ill (C. felis-unrelated) control cases, more acute cytauxzoonosis cases were diagnosed in spring and summer, suggesting a seasonal fluctuation of infection, with samples most commonly submitted from ≥1 year old, owned, male cats. Although cytauxzoonosis case submissions remained consistent over the broad study period, increasing tick vector and domestic cat reservoir populations may contribute to additional cytauxzoonosis case expansion in endemic areas. Investigating the incidence of acute cytauxzoonosis, patient risk factors, and ecological variables that influence disease transmission are important steps towards developing and communicating the need for effective cytauxzoonosis control strategies for high-risk cat populations.

Cutaneous Vasculopathy and Pulmonary Thromboembolism in an Unstable Diabetic Cat

A 6-year-old, male-neutered, domestic short-haired cat was referred for further management of a 3-month history of uncontrolled diabetes mellitus. The cat visited the hospital on 3 occasions during a 3-week time period. Hyperglycemia was documented at all visits. The cat initially presented with evidence of hypovolemia, cranial abdominal pain, and dehydration. Moderate hyperglycemia, mild ketonemia, and severe hypokalemia were documented. A 3 × 2 cm skin lesion with associated alopecia and erythema was first noticed at a routine follow-up examination (visit 2) 1 week later. A diagnosis of diabetic ketoacidosis was made 6 days later. The previously identified skin lesion now measured 6 × 2.5 cm. Two episodes of respiratory distress were identified at this visit, with no evidence of cardiac or pulmonary pathology. The cat developed a moderate anemia (packed cell volume 16 %, total solids 7.9 g/dL) on the fifth day of hospitalization. Fluid therapy, electrolyte supplementation, regular insulin, anti-emetic, and analgesia medications were administered during visits 1 and 3. Due to development of anemia, suspected pulmonary thromboembolism events and progression of skin lesions, euthanasia was elected. A diagnosis of cutaneous vasculopathy with secondary ischemic necrosis was made postmortem and pulmonary thromboembolism was confirmed. To the authors' knowledge, this is the first report of cutaneous vasculopathy and pulmonary thromboembolism in a cat with confirmed diabetes mellitus, warranting further research to assess if hypercoagulability is common in this patient population, as routine thromboprophylaxis and anticoagulation may be potentially indicated.

Prevalence of Cytauxzoon felis Infection-Carriers in Eastern Kansas Domestic Cats

Cytauxzoon felis is a hemoprotozoal tick-transmitted pathogen of felids. Felids that survive acute disease often remain infected and serve as reservoirs for subsequent tick transmission to other susceptible felines. States adjacent to Kansas have identified C. felis-domestic cat carriers while statewide awareness and concern of cytauxzoonosis have increased. The objective of this study was to determine the prevalence of C. felis-carriers in the eastern Kansas domestic cat population using a sensitive quantitative PCR assay targeting the C. felis Cox3 mitochondrial gene. An overall C. felis infection prevalence of 25.8% was determined for asymptomatic domestic cats in eastern Kansas. Significantly more C. felis-carrier cats were identified in spring and fall, suggesting a seasonal fluctuation of survivors. Additionally, a greater percentage of feral and owned cats were positive for C. felis compared to rescue/rescinded cats. This study demonstrates that C. felis-domestic cat carriers are common among cats that spend at least a portion of time outdoors in eastern Kansas, and that more cats likely survive cytauxzoonosis than expected. Understanding the role of domestic cat carriers of C. felis is essential in developing cytauxzoonosis mitigation strategies, including recommending year-round use of acaricide products for all cats that spend any time outdoors.

Preliminary study of Cytauxzoon felis infection in outdoor cats in Mashhad, Iran

The objectives of the current study were to assess the preliminary status of Cytauxzoon felis (C. felis) infection among outdoor cats in Mashhad, Iran and also to compare clinicopathological findings between C. felis infected and non-infected cats. Blood samples were collected from 100 outdoor domestic cats between April and September in 2019. Infection with C. felis was determined using microscopic observation of giemsa-stained blood smears and molecular analysis. The piroplasms was microscopically detected in 5 (5%) of the blood smears with low parasitemia. The presence of C. felis was confirmed in one positive microscopy sample by PCR. The molecular assay revealed that 19 cats (19%) were infected with C. felis. Hematological and some serum biochemical factors were evaluated in both of the infected and non-infected cats. There was no association between C. felis infection and age, gender, and laboratory findings except for hematocrit (Hct) and concentration of total protein and globulin. Clinical signs such as fever, dehydration, lethargy, and icterus were observed only in 15.78% (3/19) of the infected cats, while 84.22% (16/19) were asymptomatic. Laboratory findings such as non-regenerative anemia, thrombocytopenia, neutrophilic leukocytosis hyperproteinemia, hypoalbuminemia, and hyperbilirubinemia were detected in the clinically infected cats. This study revealed the relatively high frequency of C. felis infection in outdoor domestic cats in Mashahd, Iran. The predominance of asymptomatic infection likely indicates that these cats may be infected with low-virulent strains of C. felis.

Two Tales of Cytauxzoon felis Infections in Domestic Cats

Cytauxzoonosis is an emerging infectious disease that affects wild felids as well as the domestic cat; it is caused by the apicomplexan protozoan parasites belonging to the genus Cytauxzoon. Cytauxzoonfelis is the species of major concern, whose transmission occurs via the bite of an infected tick. Cytauxzoonosis of the domestic cat has historically been considered uniformly fatal, with a short course of illness, and most domestic cats die within 9 to 15 days postinfection. However, increasing evidence of domestic cats surviving C. felis infection suggests the existence of different strains with various levels of pathogenicity. Although wild felids are considered natural reservoirs for this parasite, a number of studies suggest that domestic cats that have survived nonlethal infections may serve as an additional reservoir. The current article comprehensively reviews the parasite and its life cycle, geographic distribution, genetic variability, and pathogenesis, as well as host immunology and the diagnosis, treatment, and prevention of infection in the domestic cat. This information should provide a basis for better understanding the parasite as well as the pathogenesis of the disease.

PROPOSAL AND APPLICATION OF A NOVEL DISSEMINATED INTRAVASCULAR COAGULATION SCORING SYSTEM IN THE FLORIDA MANATEE (TRICHECHUS MANATUS LATIROSTRIS)

  Disseminated intravascular coagulopathy (DIC) is an acquired disorder of hemostasis resulting in activation of the coagulation and fibrinolytic pathways. It is reported secondarily to multiple disease processes and can be associated with increased mortality. Previous research at Tampa's Lowry Park Zoo (LPZ) demonstrated that Florida manatees ( Trichechus manatus latirostris) with cold stress syndrome (CSS) demonstrated thromboembolic disease. The object of this retrospective study was to establish the presence and clinical relevance of DIC in Florida manatees admitted to LPZ for rehabilitation from 07 March 2010 to 15 August 2015. A coagulation panel, including prothrombin time, partial thromboplastin time, platelet count, fibrinogen level, and D-dimer level was used to diagnose DIC. There were 100 cases identified in the study period: 35 trauma, 43 CSS, 17 secondary to harmful algae blooms (HAB), and five miscellaneous. Manatees with CSS had the highest incidence of DIC with 24 of 43 cases (56%) affected, followed by trauma with 18 of 35 cases (52%) affected. None of the manatees with HAB were found to have DIC. Manatees that developed DIC during rehabilitation or when DIC progressed did not survive. Due to the clinical implications of DIC, identifying its presence and recognizing its severity could improve clinical outcomes by enabling more intensive treatment protocols.

PCR amplification of a multi-copy mitochondrial gene (cox3) improves detection of Cytauxzoon felis infection as compared to a ribosomal gene (18S)

Cytauxzoon felis is a tick-transmitted protozoan parasite that infects felids. Clinical disease caused by acute C. felis infection rapidly progresses in domestic cats, leading to high morbidity and mortality. Accurately diagnosing cytauxzoonosis as soon as possible during acute infection would allow for earlier initiation of antiprotozoal therapy which could lead to higher survival rates. Molecular detection of parasite rRNA genes (18S) by PCR has previously been shown to be a sensitive method of diagnosing C. felis infections. Based on evidence from related apicomplexan species, we hypothesized that C. felis mitochondrial genes would exist at higher copy numbers than 18S and would be a more sensitive diagnostic target. In this study we have designed a PCR assay targeting the C. felis mitochondrial gene cytochrome c oxidase subunit III (cox3). Herein we demonstrate that (1) the cox3 PCR can detect as low as 1 copy of DNA target and can detect C. felis in samples with known mitochondrial sequence heterogeneity, (2) cox3 copy number is increased relative to 18S in blood and tissue samples from acutely infected cats, and (3) the cox3 PCR is more sensitive than 18S PCR for detection of C. felis during early infections.

Cytauxzoonosis: Diagnosis and treatment of an emerging disease

PRACTICAL RELEVANCE

Cytauxzoonosis is a life-threatening hematoprotozoal disease with a rapidly progressive clinical course. Once considered a rare disease only relevant to a small geographic area, it is now recognized in more than about a third of the United States. The geographic range seems likely to increase with expansion of the range of the vector tick.

CLINICAL CHALLENGES

Both disease diagnosis and treatment offer challenges. The acute illness is often recognized by characteristic parasitic cellular inclusions, but illness may occur before parasites can be identified, and parasitic inclusions may persist long after illness has resolved. Also, while infection was once considered nearly uniformly fatal, subclinical infections are now recognized. Disease prognosis has improved for many cats through implementation of new therapies, but some pathogens are resistant to these therapies and death from disease is still common. Currently, prevention strategies are limited to ectoparasite control.

GLOBAL IMPORTANCE

Cytauxzoonosis caused by Cytauxzoon felis is limited to the Americas, and is especially problematic in southeastern and south central USA. However, other Cytauxzoon species have been recognized in Europe and Asia.

AUDIENCE

This review is aimed at veterinary practitioners and focuses on the diagnosis and treatment of cytauxzoonosis. Disease management is of crucial importance in endemic regions. Furthermore, the expanding geographic range of infection, and the possibility of parasite identification in chronically infected cats with a travel history, make understanding cytauxzoonosis relevant in non-endemic regions as well.

EVIDENCE BASE

The authors draw on evidence from prospective clinical trials, experimental infections, retrospective clinical studies and case reports, as well as their own personal experience with the diagnosis and treatment of cytauxzoonosis.