Chylous Abdominal Effusion in a Cat

With Feline Infectious Peritonitis

A 10-year-old cat was diagnosed with chyloperitoneum based on the effusion characteristics.
Feline coronavirus serology was positive. The owner declined further evaluation and elected
euthanasia. Necropsy revealed vasculitis with multifocal areas of necrosis and lymphocytic-plas-
macytic inflammation in multiple solid organs, most likely due to feline infectious peritonitis (FIP).
Immunohistochemistry was negative for FIP antigen. Notwithstanding, the final diagnosis of FIP
was based on the characteristic histopathological lesions. Underlying causes of chyloperitoneum in
cats and humans are discussed, and possible pathogenesis of the chyloperitoneum in association
with a vasculitis such as FIP is discussed. J Am Anim Hosp Assoc 2001;37:35–40.

Karine C. M. Savary, DVM Introduction

Compared to chylothorax, chyloperitoneum is an uncommon condition in
Rance K. Sellon, DVM, PhD
cats.1,2 Chyloperitoneum in cats has been associated with intra-abdominal
J. McHugh Law, DVM, PhD neoplasia, biliary cirrhosis, and vitamin E deficiency-associated steatitis.2
The incidence of chyloperitoneum in dogs is also low. Underlying dis-
eases associated with canine chylous ascites include mediastinal lym-
phangiosarcoma,3 nontraumatic rupture of mesenteric lymphatic vessels,
C and lymphatic obstruction or inflammation.4 Chyloperitoneum in dogs
may also develop as a complication of thoracic duct ligation surgery.4
Feline infectious peritonitis (FIP) is a common and well-described
feline viral disease due to coronavirus infection (FIPV). The classical
forms of FIP are the effusive and the noneffusive. The effusive form is
characterized by a high protein effusion (i.e., exudate) in the pleural or
peritoneal cavities or both. This article reports the case of a cat that pre-
sented clinically with chyloperitoneum and was diagnosed with vasculitis,
most likely due to FIP, at necropsy. The possible associations between
FIP and chyloperitoneum are also discussed.

Case Report
A 10-year-old, castrated male domestic shorthair cat was referred to the
North Carolina State University Veterinary Teaching Hospital (NCSU-
From the Departments of Clinical Sciences VTH) for evaluation of partial inappetance, depression, and intermittent
(Savary, Sellon) and Microbiology, fever of two months’ duration. The cat had been previously treated with
Pathology, and Parasitology (Law),
College of Veterinary Medicine,
antibiotics including sulfonamide and penicillin, and he had also been
North Carolina State University, dewormed; however, no improvement in appetite or general attitude
4700 Hillsborough Street, occurred. Oral diazepam and prednisone administered prior to referral
Raleigh, North Carolina 27606. had resulted in some improvement in appetite. No previous medical con-
ditions were reported, and the cat was due for a rabies vaccine. His vacci-
Doctor Sellon’s current address is the
Department of Veterinary Clinical Sciences,
nation status against feline rhinotracheitis, calici, and panleukopenia
Washington State University, viruses was current. No FIP vaccine had ever been given. The cat was
Pullman, Washington 99164-7060. housed predominantly indoors, but he was allowed to go outside. He had

JOURNAL of the American Animal Hospital Association 35

36 JOURNAL of the American Animal Hospital Association January/February 2001, Vol. 37

been living with another cat that had died two months previ- erythrocytes/µl) attributed to cystocentesis collection, since
ously of unknown cause. there was no evidence of urinary tract inflammation on the
On physical examination, the cat was thin, depressed, sediment examination. Glucosuria (250 mg/dl), without
mildly dehydrated, and febrile (rectal temperature, 39.5˚ C). hyperglycemia or ketonuria, was also found. Prior stress-
Slight abdominal distention and slippery bowel loops, sug- induced hyperglycemia and tubular dysfunction were consid-
gestive of mild abdominal effusion, were detected during ered as possible explanations.
abdominal palpation. A small mass (approximately 1 cm in Results of feline leukemia virus (FeLV) antigena and
diameter) was felt in the abdomen. Thoracic auscultation feline immunodeficiency virus (FIV) antibodya tests were
was within normal limits. A fundic examination was normal. negative. The cat had a low antibody titer against a corona-
Complete blood count (CBC) abnormalities [Table 1] virus (1:320).b
included nonregenerative, normocytic anemia; a normal neu- Thoracic radiographs revealed a bronchial pattern
trophil count with a mild left shift and moderate toxic throughout the lung field, compatible with feline asthma or
changes; lymphopenia; and eosinopenia. Large blastic cells pulmonary infiltrative disease. There was severe degenera-
(91 cells/µl) with moderately vacuolated cytoplasm and reac- tive joint disease of both scapulohumeral joints. Abdominal
tive lymphocytes (91 cells/µl) were reported on the white ultrasonographic examination confirmed the presence of a
blood cell differential count. moderate amount of peritoneal effusion with slightly
A complete serum biochemical profile was performed. echogenic debris. A hyperechoic nodule, which was
Serum biochemical abnormalities [Table 2] included mild thought to be the mass palpated on physical examination,
hyperbilirubinemia, hypokalemia, and acidosis. The total was observed dorsal to and slightly medial to the left kid-
protein and albumin concentrations were within reference ney. Fine-needle aspiration of this mass was not attempted
ranges (7.9 g/dl; reference range, 6.3 to 8.7 g/dl; 2.8 g/dl; because it was surrounded by vascular structures. The kid-
reference range, 2.7 to 4.6 g/dl, respectively); however, the neys were mildly enlarged and had slightly hyperechoic
globulin concentration was increased (5.1 g/dl; reference cortices.
range, 3.5 to 4.2 g/dl). Due to the abnormalities seen on the urinalysis and the
Urinalysis showed a normal urine specific gravity (USG) ultrasonographic appearance of the kidneys, an ultrasound-
of 1.043 with proteinuria (500 mg/dl) and hematuria (250 guided, fine-needle aspirate from the right kidney was per-

Table 1

Hematological Abnormalities in a Cat With Chylous Effusion and Feline Infectious Peritonitis

Test* Result on Presentation Result on Day 2 Reference Range

RBC (106/µl) 4.76 3.94 7.10–11.10

PCV (%) 22 18 28–45
HGB (g/dl) 7.6 6.5 9.5–15.3
Hct (%) 22.3 18.5 31.1–50.7
MCV (fl) 46.8 46.9 38.9–48.9
Plasma protein (g/dl) 8.5 8.0 6.5–8.4
WBC (103/µl) 9.1 5.8 5.4–23.6
Seg neutrophils (103/µl) 8.463 4.988 1.600–15.600
Bands (103/µl) 0.273 0.638 0.000–0.100
Lymphocytes (103/µl) 0.091 0.116 1.000–7.400
Monocytes (103/µl) 0.091 0.058 0.000–0.700
Eosinophils (103/µl) 0.000 0.000 0.100–2.300
Basophils (103/µl) 0.000 0.000 0.000–0.300
Reactive lymphocytes (103/µl) 0.091 0.000 0.000–0.200
Blast (103/µl) 0.091 0 0–0
Punctate reticulocytes (%) 17.93 20.30 2.00–17.00
Aggregate reticulocytes (%) 0.31 0.60 0.10–0.50

* RBC=red blood cells; PCV=packed cell volume; HGB=hemoglobin; Hct=hematocrit; MCV=mean corpuscular volume; WBC=white
blood cells
January/February 2001, Vol. 37 Chylous Abdominal Effusion in a Cat With FIP 37

Table 2

Select Serum Biochemical Abnormalities in a Cat

With Chylous Effusion and Feline Infectious Peritonitis

Test Result on Presentation Reference Range

Bilirubin (mg/dl) 0.4 0.1–0.2

Potassium (mmol/L) 3.2 4.0–4.8
Total CO2 (mmol/L) 11 16–26

formed. Cytopathology of the renal aspirate showed a few A diagnostic abdominocentesis was performed. Approxi-
renal tubular epithelial cells and did not reveal any neoplastic mately 3 ml of an opaque, milky-pink fluid was obtained.
cells (e.g., lymphoblasts) or a specific etiological agent. After standing, the fluid supernate was grossly lipemic and
Cytopathology of a bone-marrow aspirate showed a plasma- could not be cleared with centrifugation [Figure 1]. How-
cytosis, compatible with chronic antigenic stimulation. No ever, the sample cleared when ether was added. Triglyceride
abnormalities in the cell lines or neoplastic cells were seen. and cholesterol concentrations in the effusion were 3,140
mg/dl and 238 mg/dl, respectively, compared with 415 mg/dl
triglyceride and 204 mg/dl cholesterol in the serum. The pro-
tein level by refractometry was high (6.8 g/dl) but may have
been artificially elevated because lipids interfere with protein
evaluation by refractometry. The total cell count and specific
gravity were 1,760 cells/µl and 1.025, respectively. The pre-
dominant cells in the peritoneal effusion were moderately
degenerate neutrophils (57%). Plasma cells (15%),
macrophages (15%), and small, mature lymphocytes (11%)
were also seen, along with a few, large, round cells sugges-
tive of lymphoblasts (2%). Bacteria or neoplastic cells were
not seen. Based on these findings, the effusion was deter-
mined to be chyle.
Serum protein electrophoresis, performed because of the
increased serum globulins, revealed a polyclonal gam-
mopathy with mild elevations in gamma globulins (1.9
g/dl; reference range, 0.5 to 1 g/dl) and alpha-2 globulins
(1.5 g/dl; reference range, 0.3 to 1.3 g/dl), consistent with
chronic inflammation or chronic antigenic stimulation due
to an infectious disease, such as FIP, or neoplasia. A CBC
performed on day two of hospitalization [Table 1] docu-
mented worsening anemia or possibly hemodilution related
to rehydration, as total protein decreased from 8.5 g/dl to
8.0 g/dl.
Supportive care consisting of fluid therapy (lactated
Ringer’s solution, 100 ml per day subcutaneously), liquid
enteral nutritionc (30 ml four times a day for the first day,
then 60 ml the second day, then 90 ml the third day, given
through a nasoesophageal tube), and oral potassium supple-
mentation (potassium gluconate powder,d 2 mEq twice daily,
through the nasoesophageal tube) was instituted. The fever
(39.1˚ C to 40˚ C) persisted over the three-day hospitaliza-
Figure 1—Chylous abdominal effusion in a 10-year-old cat tion time. The cat’s clinical status worsened, and mild dysp-
diagnosed with feline infectious peritonitis (FIP). Macroscopic
appearance of the chylous abdominal effusion: before nea developed. The owner declined further treatment and
(opaque, on the right) and after (clear, on the left) the diagnostic tests. The owner requested euthanasia and
addition of ether. allowed necropsy.
38 JOURNAL of the American Animal Hospital Association January/February 2001, Vol. 37

At necropsy, the thorax contained approximately 50 ml of

a thick, gelatinous, and fibrinous pleural effusion. The
abdomen contained approximately 50 ml of a pink, opaque
fluid consistent with the chyle obtained by abdominocente-
sis. Analysis of the pleural fluid revealed 560 cells/µl, which
might have been artificially low due to a postmortem clot in
the sample; a protein concentration of 3.8 g/dl; and a spe-
cific gravity of 1.025. Cytopathology of the pleural fluid
was consistent with suppurative inflammation, with 98%
nondegenerate neutrophils and 2% macrophages. Rare clus-
ters of densely basophilic epithelioid cells, most consistent
with mesothelial cells, and rare plasma cells were seen. The
liver and lungs contained multifocal to coalescing, white to
tan nodules or plaques, ranging in size from 0.5 to 3 cm.
These foci were slightly raised above the capsular and pleu-
ral surfaces and extended into the parenchyma. The surfaces
Figure 2—Photomicrograph of a section of lung from the cat
of both kidneys had multifocal, 1- to 2-mm diameter, raised, of this report. The pulmonary blood vessel in the center is
white to tan areas that extended to the corticomedullary infiltrated and surrounded by numerous degenerate and non-
junction. An approximately 1-cm diameter, fibrous mass degenerate neutrophils, lymphocytes, and plasma cells. The
was present near the pancreas and was believed to be the vessel wall is fragmented and contains granular eosinophilic
mass palpated on initial physical examination as well as the material and nuclear debris (i.e., fibrinoid, leukocytoclastic
vasculitis) (Hematoxylin and eosin stain, 66X magnification).
mass seen on ultrasonography. The gross morphological
diagnosis was severe fibrinous peritonitis and pleuritis.
Histopathological lesions consisted of widespread vas-
culitis and perivasculitis with random, multifocal areas of
necrosis in solid organs. Many arterioles and venules had
multifocal endothelial cell loss, and infiltrations of neu-
trophils (degenerate and nondegenerate), lymphocytes, and
plasma cells were both within and around the vessel wall
[Figures 2, 3]. The normal architecture of vessel walls was
often disrupted by granular, eosinophilic material and frag-
mented nuclear debris [Figure 2]. Thus, the vasculitis could
be classified as fibrinoid and leukocytoclastic.5 The necrotic
areas (due to thrombophlebitis and infarction) were accom-
panied by heavy infiltrates of lymphocytes and plasma cells
in the liver, lung, spleen, and kidney [Figure 3]. In the brain,
the meninges were moderately thickened by infiltrates of
lymphocytes and plasma cells, and many meningeal vessels
Figure 3—Photomicrograph of a section of kidney from the
had fibrinoid vasculitis. The mass near the pancreas con-
cat of this report. Around the stellate vein are focal infiltrates
sisted of fibrous connective tissue with a necrotic core of lymphocytes, plasma cells, and neutrophils. The vessel is
(probably an infarcted mass of adherent omentum), infil- partially occluded by a fibrin thrombus (T) (Hematoxylin and
trated by lymphocytes and plasma cells. No lesions were eosin stain, 40X magnification).
found in the bone marrow. Other findings included moder-
ate renal tubular mineralization and pancreatic nodular
hyperplasia, both of which are common age-related changes
in cats. The histopathological lesions of vasculitis were Discussion
characteristic of FIP virus infection. Other causes of vas- Chyloperitoneum results from extravasation of chyle into the
culitis, such as drugs or toxins, seemed unlikely due to lack peritoneal cavity. It is an infrequent condition recognized in
of exposure. However, an immune-mediated vasculitis sec- veterinary medicine and is not considered a specific entity; it
ondary to sepsis or septic peritonitis could not be defini- usually occurs secondary to another disease process. How-
tively ruled out, because bacterial blood and effusion ever, as for chylothorax, there are cases in which no underly-
cultures were not performed. Additional paraffin sections of ing cause is found, and a diagnosis of idiopathic chylous
liver, kidney, and lung were dewaxed, rehydrated, and incu- ascites is made.6 The described causes of chylous ascites in
bated with a monoclonal antibody against the coronaviral cats are predominantly neoplastic. In a series of nine cats,
nucleocapsid proteine using the avidin-biotin complex chylous ascites was associated with nonresectable abdominal
method. Immunohistochemistry of the tissues from this cat neoplasia in four cases (i.e., hemangiosarcoma and paragan-
was negative for coronaviral antigen. glioma), with intestinal and mesenteric lymphoma in two
January/February 2001, Vol. 37 Chylous Abdominal Effusion in a Cat With FIP 39

cases, and with lymphangiosarcoma of the abdominal wall in prognosis is usually good.6 The acute pain is believed to be
one case.2 The last two cats had nonneoplastic disorders such related to the irritant characteristic of chyle to the serosal
as severe biliary cirrhosis with an extrahepatic portosystemic surfaces. Acute chylous ascites has been associated with
shunt and steatitis caused by vitamin E deficiency.2 In this external blunt trauma, retroperitoneal surgery, abnormalities
case, no underlying disease process known to cause chy- in the lymphatic vessels (e.g., congenital atresia, acquired
loperitoneum was diagnosed at necropsy. In the cat of this spontaneous rupture of a mesenteric cyst, or a ruptured
report, chylous ascites might have been idiopathic or possi- lacteal due to tuberculosis), intestinal obstruction (related to
bly associated with the FIP infection diagnosed at necropsy. volvulus, hernia, or intra-abdominal mass), and acute pan-
The diagnosis of chylous ascites relies on gross examina- creatitis.6 Intra- or extraluminal obstruction of the lymphat-
tion, biochemical analysis (triglyceride and cholesterol lev- ics from lymph node fibrosis, infiltration by a malignancy, or
els), and cytopathological examination of the peritoneal venous thrombosis can also cause leakage of chyle into the
fluid. The diagnostic criteria for chylous effusions are well peritoneal cavity.
established.7–11 It is important to note that while chyle is Chronic chylous ascites is classified as either primary or
routinely classified as an exudate, the physical characteris- secondary. Primary chyloperitoneum is due to a congenital
tics of chyle can be consistent with a modified transudate dysplasia of the lymphatic system and is usually seen in chil-
(protein content between 2.5 and 4 g/dl).7,8 The high protein dren or young adults.14 Congenital retroperitoneal megalym-
content (6.8 g/dl) in the effusion from the cat of this report phatics is also described as a cause of chylous ascites in
may have been due to lipid interference or may have children.14,15 The most frequent cause of chronic secondary
reflected protein leakage secondary to vasculitis. Cytopathol- chylous ascites is neoplasia, but infectious and inflammatory
ogy of chylous effusions typically shows a predominance of diseases such as tuberculosis, syphilis, filariasis, pancreatitis,
small lymphocytes, but with chronicity or repetitive cente- and mesenteric adenitis have been associated with chylous
sis, nondegenerate neutrophils can become the predominant ascites.15 Malignancies associated with chyloperitoneum
cell type. In the series of cats with chyloperitoneum, include lymphoma, acute leukemia, and diverse neoplasms
cytopathology revealed many nondegenerate neutrophils. of the pancreas, stomach, colon, ovaries, and AIDS-associ-
Vacuolated macrophages, small lymphocytes, and some ated Kaposi’s sarcoma.15,16 Other diseases associated with
eosinophils may also be seen.2 chylous ascites in humans include protein-losing enteropa-
The effusion seen with the wet form of FIP is typically a thy, liver cirrhosis, vascular disorders (i.e., bilateral subcla-
nonseptic exudate of high total protein and low cellularity vian vein thrombosis, iatrogenic thoracic duct obstruction,
(i.e., total protein greater than 3.5 g/dl; 1,000 to 2,000 nucle- and heart failure), and lymphatic damage postradiation treat-
ated cells/µl), consisting principally of nondegenerate neu- ment for intra-abdominal neoplasia.14–16 Another disease
trophils as well as lymphocytes and macrophages.12,13 The that has been anecdotally associated with chyloperitoneum
effusion observed in this case was chylous, with some of the in humans is Behçet’s disease, a chronic, multisystemic vas-
characteristics of the more classic FIP effusions (i.e., non- culitis of unknown etiology. In one case report, the proposed
septic exudate). The cytopathology of the abdominal fluid pathophysiology of chylous effusion in Behçet’s disease was
was, however, unusual, as the predominant cells in the peri- inflammation of the lymphatics, since no intra-abdominal or
toneal effusion were moderately degenerate neutrophils thoracic masses were found.17
(57%). Degenerate neutrophils are usually seen in septic In this case, chylous effusion might have been an inciden-
peritonitis, but no etiological agent such as bacteria was tal finding or associated with FIP. Infection by the FIPV is
seen. However, aseptic inflammation with tissue necrosis, classically characterized by vasculitis and inflammation of
such as that seen in this case, may also produce degenerate the peritoneal cavity, pleural cavity, or both. In the present
neutrophils. Plasma cells, macrophages, and small mature case, there was fibrinoid vasculitis in the liver, lungs, kid-
lymphocytes were also seen on cytopathology, which can be neys, and spleen, with resultant thrombophlebitis, infarction,
seen in both FIP and chylous ascites due to another cause, and necrosis. The widespread vascular damage, possibly
such as neoplasia. The fluid also contained 2% large round similar to that proposed for Behçet’s disease, might have
cells compatible with lymphoblasts, and the blood showed contributed to the formation of chylous ascites. In addition,
few circulating blasts, presumably of lymphoid origin; there- heavy inflammatory infiltrates composed of neutrophils,
fore lymphoma, which has been associated with chylous lymphocytes, plasma cells, and macrophages could have cre-
effusion in cats, was included in the differential diagnosis. ated an intraluminal obstruction of the lymphatics, further
However, lymphoma was ruled out based on a bone-marrow contributing to the extravasation of chyle. The contribution
aspirate as well as at necropsy, and the presence of the low of the fibrous mass found near the pancreas to the formation
number of blasts might have been a result of the chronic of chyle was not discerned, but it may have added further to
inflammation in this cat. the mechanical obstruction of lymphatic drainage. Contrast
In humans, the list of underlying diseases associated with lymphangiography may have helped determine the exact
chyloperitoneum is long, even if this condition is rare. Chy- pathophysiology of chyle extravasation in this cat. However,
lous ascites is divided into acute and chronic chylous effu- a direct causal relationship to the development of chylous
sion. Acute chylous peritonitis occurs as an acute abdomen. effusion could not be established. It would be an unusual
The diagnosis is usually not made before surgery, and the complication of FIP.
40 JOURNAL of the American Animal Hospital Association January/February 2001, Vol. 37

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a FeLV antigen and FIV antibody, ELISA, Snap Combo Test; Idexx,
Westbrook, ME
b Feline coronavirus (FeCoV) antibody test, IFA; North Carolina State
University—Virology Laboratory, Raleigh, NC
c Feline Clinicare; Abbott Laboratories—Animal Health, North Chicago,
IL
d Tumil K; Daniels Pharmaceuticals, St. Petersburg, FL
e FIPV-UCD1, 1:1500 dilution; School of Veterinary Medicine, University
of California, Davis, CA