Tiger, a 3-year-old spayed female Persian cat, was presented to the Veterinary Medical Center at the Ohio State University
College of Veterinary Medicine for evaluation of straining in her litter box and blood-tinged urine of three days' duration.
The owners reported that they had observed straining behavior on a number of occasions, but had assumed it was related to
constipation until they noticed the blood in the urine.
Tiger, upon initial presentation.
History and diagnostic findings
The owners had adopted Tiger as an orphaned kitten. She was their only pet and was housed exclusively indoors. The owners
described Tiger as "kind of a scaredy-cat"—she was easily startled by sounds and hid whenever guests were present in the home.
Tiger was at home alone much of the time because the owners, a husband and wife (no one else lived in the home), were professionals
who worked long, irregular hours. They reported no recent changes in the home, although they mentioned that they had observed
Tiger "fighting" with an outdoor cat through a window.
The owners reported that Tiger sometimes ate quickly and then regurgitated her food and that she expelled a hairball once
or twice a month. Tiger was fed one-half cup (200 kcal) of a diet formulated to help prevent hairballs, which the owner concluded
must be working because of the regular expulsion of hairballs.
Physical examination findings included her being overweight (9.9 lb [4.5 kg]; a body condition score of 4/5), and barbering
of the caudal abdomen and proximal inner thighs. Urinalysis of urine obtained by cystocentesis revealed too-numerous-to-count
red blood cells, 3+ protein, and a pH of 7.6, but no white blood cells or crystals. The rather high pH in the absence of evidence
of a common alternative cause (bacterial urinary tract infection, vomiting, alkalinizing diet), hematuria, and proteinuria
in the absence of inflammatory infiltrate is consistent with stress-associated hyperventilation, as well as bladder vasodilatation
and vascular leakage.1 Results of imaging of the urinary tract were unremarkable.
Tentative diagnosis and treatment
Because of the reported chronicity of the lower urinary tract signs, the history of adverse early life experience, and the
presence of anxious behavior and multiple organ system involvement (upper gastrointestinal, endocrine [excess body weight],
and dermatologic), Pandora syndrome was provisionally diagnosed. The diagnosis was explained to the owners as a chronic medical
condition that, somewhat like migraines in people, can be managed but not cured.
Initial treatment included in-hospital administration of buprenorphine at a dosage of 15 µg/kg given intramuscularly. The
owners were then instructed to give buprenorphine at 15 µg/kg orally three times daily for five days. And a trained technician
conducted an extended environmental interview with the owners, including a review of resources available to the cat. The review
revealed that a scented clay litter was used in the litter box, which was in the basement, and that no climbing structures
or toys were present in the home.
Based on these findings, the goals of environmental enrichment included provision of
- An additional litter box—containing unscented, clumping litter—placed in another part of the house
- A climbing structure, preferably placed so Tiger could observe from an elevated position the area in which the outside cat
had been seen
- A food puzzle to provide an intrinsically motivating resource toy that also might reduce the frequency of food regurgitation.
After discussing the plan with the owners, we decided to implement the new litter box first, followed by the climbing structure,
and then the food puzzle. We gave the owners explicit instructions about presentation of each of the three enrichments, and
we told them that the technician would follow up to help guide them through the changes.