On Mar 5th, 2009, a 14-year-old tortoise shell indoor-outdoor domestic short hair cat had presented excessively vocal, somewhat inappetant, underweight with full body muscular atrophy, and tachycardic with a new III/VI left systolic heart murmur. Normally a fastidious groomer, the patient had ceased self-care. Bloodwork had been run [T4 5.1 ug/dL (0.8-4.0)], and a diagnosis of hyperthyroidism had been made. She had been started on methimazole 2.5 mg BID for the first month, with an increase to 5.0 mg BID for the past 2 months.
Physical Examination: BAR, yowling loudly throughout PE. HR 200, RR 30, III/VI left systolic murmur. Good body condition, shedding prolifically. The tongue was red, and pulses were rapid and thin with a weaker pulse on the left side. Pinnae, back, and paws were warm to the touch.
Assessment: The patient was hyperthyroid, tactile-defensive, tachycardic with a persistent left systolic heart murmur, and shedding excessively. Weight and body condition had improved since initial diagnosis. Ddx included unmasked kidney disease, uncontrolled hyperthyroidism, and other chronic disease processes, such as neoplasia. Naturally aloof, the cat was a Metal Constitution. Her red tongue, warm ears/back/paws, and thin rapid pulse with a weaker pulse on the left indicated a Kidney Yin Deficiency. Her excessive shedding was likely due to Kidney Qi Deficiency. Her increased vocalization reflected a Shen Disturbance, due to a Heart Yin Deficiency.
Diagnostic Plan: CBC/Chemistry/T4/UA (via cystocentesis).
Results: The patient was azotemic [BUN 42 mg/dL (14-36) creatinine 2.8 mg/dL (0.6-2.4)], iatrogenically hypothyroid [T4<0.2 ug/dL (0.8-4.0)], mildly immunosuppressed [WBC 3.2 X 103/uL (3.5-16.0), neutrophils 2016/uL (2500-8500), lymphocytes 768/uL (1200-8000)], and borderline isosthenuric [SG=1.016].
Treatment Plan: The patient’s dose of methimazole was reduced to 2.5 mg BID, and she was started on Liu Wei Di Huang Wan, 1/8 tsp BID, with a gradual increase to a goal dose of ¼ tsp BID. The owner declined subcutaneous fluid therapy and treatment with acupuncture.
Follow-up and Case Summary: The patient was maintained on Liu Wei Di Huang Wan ¼ tsp BID for 2 ½ years. The owner provided regular email and phone updates. The patient was rechecked every 3-6 months, and her blood work was rechecked once a year. She maintained an active lifestyle, mostly good appetite, normal grooming habits, a normal sleeping schedule, and she had normal stools with no vomiting. Unfortunately she was attacked and killed by a neighborhood dog in Nov. 2011 at 16 ½ years of age. She was still very busy and energetic at the time of her death.
Discussion: Hyperthyroidism in cats can be described by four different TCVM Diagnoses:
1. Stagnant Liver Qi with Stagnation of Blood and Phlegm. These patients are irritable, anxious, and depressed. They resent being touched on the cranial abdomen (hypochondriac region). Tongues are deep purplish red with a thin white coating. Pulses are wiry and slippery.
2. Qi Deficiency. These patients are emaciated, lethargic, with vomiting and loose stools. Tongues are pale and wet. Pulses are deep and weak.
3. Yin Deficiency with Yang Floating. These patients are emaciated, irritable, restless, hyperactive, polyphagic, polydipsic, with vomiting and loose stool. Tongues are red and dry. Pulses are wiry, rapid, floating, and thin.
4. Qi and Yin Deficiency. These patients are emaciated, with waxing and waning appetites, variable stools, reduced grooming behavior, dry dull haircoat, weak painful back and stifles, cool-seeking, depressed and irritable, and restless at night. Tongues are red and dry or pale to light purple, swollen, with a light white coating. Pulses are rapid, thready, weak, and deep.
This patient’s presentation contained many of the hallmarks of Qi and Yin Deficiency: she was thin, with rare, periodic episodes of waxing/waning appetite and reduced self-care behavior. She did not like to be picked up, which may have reflected discomfort and/or may have been in keeping with her Metal Constitution. She exhibited irritable behavior at times. Her tongue was red, and her pulses were consistently rapid, and thin. This patient was treated with Liu Wei Di Huang Wan (Rehmannia 6).
Herbal Formula Used and Rationale: Liu Wei Di Huang Wan was a good formula for this cat, because she needed the Shu Di Huang (Rehmannia), Ze Xia (Alisma), and Shan Zhu Yu (Cornus) to Nourish Kidney Yin and to reduce False Heat in the body. Shan Zhu Yu (Cornus) and Shan Yao (Dioscorea) helped to Tonify Qi. The Fu Ling (Poria) was good for her appetite and GI function, and the Mu Dan Pi (Moutan) helped balance her emotions by Resolving Stagnation.
Ingredients and Actions of Liu Wei Di Huang Wan (Rehmannia 6)
Shu Di Huang (Rehmannia) Nourish Kidney and Liver Yin, Nourish Blood
Shan Zhu Yu (Cornus) Nourish Kidney and Liver Yin, Tonify Blood and Qi
Shan Yao (Dioscorea) Tonify Yang and Qi, Nourish Kidney Jing
Ze Xia (Alisma) Drain Damp, Clear Kidney False Fire
Fu Ling (Poria) Drain Damp, Strengthen Spleen
Mu Dan Pi (Moutan) Cool Blood, Resolve Stagnation, Cool Liver
Lecture Notes, TCVM Clinical Approach: Renal/Geriatric/Urinary/Reproductive Disorders/Herbology, Dec 4-7, 2008.
Lecture Notes, TCVM Clinical Approach: Liver/Endocrinology Disorders/Herbology, February 26-March 1, 2009.
Xie, Huisheng. Chinese Veterinary Herbal Handbook, 2nd Edition, 2008 by the Author.
Xie, Huisheng. Preast, Vanessa. Xie’s Chinese Veterinary Herbology, 2010, Blackwell Publishing, Ames, Iowa.