Drh.

Siti Winda Kusumawardhani

Update on Diagnosing & Treatment

for Feline Infectious Peritonitis
Estimasi sekitar 0.3% - 1.4% kematian pasien
kucing disebabkan oleh Feline Infectious
Peritonitis. Hampir setiap dokter hewan praktek
pernah berhadapan dengan pasien terinfeksi FIP

FIP is one of the most important infectious disease in cats

What is FIP?
• Penyakit fatal yang disebabkan oleh feline coronavirus (FCoV)
• Penyebaran infeksi FCoV sangat tinggi di lingkungan multi-cat
(shelter, cattery, rumah dengan kucing lebih dari 2 ekor).

Namun hanya sebagian kecil kucing yang terinfeksi FCoV

ini akan berkembang menjadi FIP!!!
 Diag i G ideli e

Why?
Fecal- al T a i i f FC V
Fecal-oral Transmission of FCoV

• Penularan FCoV umumnya terjadi di

rumah dengan banyak kucing melalui
jalur fecal-oral.
• Sebagian kecil kucing cukup kebal
(resisten) terhadap infeksi less-virulent
FCoV
• Namun, sebagian besar kucing yang
terpapar less-virulent FCoV rentan
terhadap infeksi dan mereka sering
shedding virus untuk sementara waktu
melalui kotorannya selama beberapa
bulan.
• Kucing yang sebelumnya pernah
terinfeksi FCoV, setelah sembuh dari
infeksinya, dapat terinfeksi kembali
dengan FCoV.
• Hanya sebagian kecil kucing yang
terinfeksi FCoV akan berkembang FIP.
FIP-a cia ed FC V

How?
(a) Beberapa kucing yang terinfeksi akan
menjadi long-term persistent atau
intermittent shedders ketika sel epitel
kolumnar di colon mengandung infeksi
FCoV yang persisten

(b) Peralihan tropisme FCoV dari epitel

gastrointestinal ke monosit/ makrofag
memungkinkan penyebaran virus secara
sistemik, namun peralihan tropisme ini
tidak serta merta menyebabkan FIP

(c) Mutasi tambahan (belum teridentifikasi)

diperlukan sebelum FIP-associated FCoV
muncul.

(d) FIP-associated FCoV bisa

menyebabkan pyogranulomatous vasculitis,
yang berkontribusi terhadap munculnya efusi,
dan atau menyebabkan pyogranuloma pada
jaringan/organ. Kucing dengan FIP bisa
memiliki efusi dan pyogranuloma bersamaan.
SUPPLEMENTAL FIGURE 4: Pa h ge e i Pa h a f Le - i e FC V
 rounded by a broad band of lymphocytes or plasma cells ffusive FI uid wave can be felt upon palpation, but it is necessary to consider the
can lead to the formation of pyogranulomas covered with virus-loaded differential diagnosis of pregnancy in cats or other circumstances that

How?
macrophages and scattered neutrophils and lymphocytes edersen, cause abdominal swelling Sometimes uveitis and neurological

Fig. 3. Schematic representation of the pathogenesis of effusive and noneffusive FI edersen,

H I e Re e FC V I fec i

How?
• Host immune response terhadap infeksi
FCoV adalah salah satu penentu
keparahan penyakit FIP yang
ditimbulkan
• Kucing yang terinfeksi low-virulent
FCoV dengan strong cell-mediated
immunity (CMI) response: tidak
berkembang menjadi FIP-associated
FCoV.
• Kucing dengan poor CMI response:
develop FIP-associated FCoV dengan
efusi
• Kucing dengan partial CMI response:
develop FIP-associated FCoV tanpa
efusi
• Namun, seiring perkembangan
penyakit, efusi dapat terjadi pada
kucing dengan primary FIP-associated
FCoV tanpa efusi dan sebaliknya.
 Clinical sign & lesions
01 02 03
Infeksi FCoV biasanya Pada kucing dengan FCoV Efusi:
bersifat subklinis, yang baru mulai • Ascites
• efusi thorax
walaupun ada beberapa berkembang menjadi FIP • efusi pericardium
kucing (terutama kitten) biasanya akan muncul • Sebagian kecil pasien
yang menunjukan gejala fluctuating fever, weight mix ascites dengan
diare (usually self limiting) loss, anoreksia, & lethargy efusi thorax

04 05 06
Lesi granulomatous di Ocular: uveitis and/or Lesi di Central Nervous
organ abdomen maupun chorioretinitis terlihat sebagai System yang disebabkan
granulomatous “mutton-fat” encephalitis and/or myelitis,
thorax: biasanya multifocal & slow
• Renomegaly keratic precipitates, fibrin di progress: ataxia,
• Chronic diarrhea anterior chamber, aqueous flare hyperaesthesia, nystagmus,
• Lymph node enlargement tebal, retinal perivascular cuffing seizure, paralysis dll
 The many faces of FIP

Non-specific manifestations

Many Figure 2 Kitten from a rescue

group showing lethargy
(listlessness), a common early sign
of FIP. LIkewise, failure to thrive or

faces of
unthriftiness is a frequent complaint
in a kitten or young cat with FIP.
This kitten eventually developed
seizures from neurological FIP.
Courtesy of Julie Jacobs

FIP:

Figure 3 Male Ragdoll

with a history of
anorexia, fever and
weight loss of 2 lb (0.9 kg)
over 2 weeks, as well as
effusion, caused by FIP. Figure 4 Female Oriental Shorthair from a cattery,
Courtesy of Stacey showing significant weight loss. Jaundice and
DeVaney effusion were also present. Courtesy of Lisa Callaway

Neurological manifestations
 Neurological manifestations

Many
faces of
FIP: Figure 6 Cortical blindness in a male Bengal
manifesting as bilateral dilated pupils. Courtesy of
Glenn Olah

Figure 7 Five-
year-old male
castrated
domestic
shorthair cat with
non-effusive FIP
presenting as
a progressive
weight loss,
anemia and
Figure 5 (a) Female spayed Persian development of
showing depression, weakness and blindness. The
tremors (see supplemental video 10, cat was PCR
which shows this patient’s neurological positive on FNAs
signs). (b) Same cat with progression of kidney, liver,
of neurological signs to decreased spleen and MLNs.
consciousness, weakness and focal b Courtesy of
seizures. Images courtesy of Tammy Evans Matthew Kornya

Continued on page 912

 Courtesy of Glenn Olah

Ocular manifestations Abdominal effusion

Many
faces of Figure 8 Oriental a b
Shorthair with anterior
uveitis, and corneal Figure 10 (a,b) Two cats demonstrating subtle differences in the clinical

FIP: edema due to

development of
glaucoma. Courtesy
of Lisa Callaway
presentation of anterior uveitis caused by FIP: iris color changes, haziness
in the anterior chamber (hypopyon or hyphema) and lesion(s) (keratic
precipitates) in the cornea. The young cat in (b) has additional evidence of
irregular pupils, which can occur with anterior uveitis caused by FIP. Repeated
ophthalmoscopic
a examinations are indicated in difficult-to-diagnose FIP cases.
Images courtesy of Marybeth Rymer (a) and Haley Batemen (b)

Figure 12 (a,b) Cat

a with abdominal b
effusion (ascites)
presenting with
abdominal distension,
weight loss and
decreased muscle
mass. This patient
Figure 9 Weight loss is shown in
and progression of supplemental video
Figure 11 (a) Uveitis
neurological signs 11.aImages courtesy of
and leakage of fibrin
accompanied the Stephanie Newton
into the anterior
presence of chamber of the eye.
anisocoria in this (b) Rubeosis iridis
12-year-old male and a clump of fibrin.
neutered domestic Images courtesy of
shorthair cat. Jessica Meekins
Courtesy of Glenn Olah b
 Abdominal effusion Dermatological manifestations
Figure 13 Ventral
inguinal area of an

Many
8-year-old male
neutered domestic
shorthair cat with
significant dermal
vasculitis and

faces of
neutrophilic splenitis
a b that later developed
effusion and was
Figure 8 Oriental diagnosed with FIP. Cats
Figure
Shorthair with10 (a,b) Two cats demonstrating subtle differences in the clinical
anterior
with skin changes can
uveitis, and corneal of anterior uveitis caused by FIP: iris color changes, haziness
presentation

FIP:
edemaindue be difficult-to-diagnose
thetoanterior chamber (hypopyon or hyphema) and lesion(s) (keratic FIP cases. These images
development of
precipitates) in the cornea. The young cat in (b) has additional evidence of show the initial (a) and
glaucoma. Courtesy
of Lisairregular
Callaway pupils, which can occur with anterior uveitis caused by FIP. Repeated later (b) presentation of
ophthalmoscopic examinations are indicated in difficult-to-diagnose FIP cases. the vasculitis. Courtesy
a
Images courtesy of Marybeth Rymer (a) and Haley Batemen (b) of Matthew Kornya
Figure 12 (a,b) Cat
with abdominal a
a effusion (ascites)
b
presenting with
abdominal distension,
weight loss and
decreased muscle
mass. This patient
Figure 9 Weight loss is shown in
and progression of supplemental video
neurological signs 11. Images courtesy of
accompaniedathe Stephanie Newton Figure 11 (a) Uveitis
presence of and leakage of fibrin
anisocoria in this into the anterior
12-year-old male chamber of the eye.
neutered domestic (b) Rubeosis iridis
shorthair cat.
b and a clump of fibrin.
Courtesy of Glenn Olah
Images courtesy of b
Jessica Meekins

Dermatological manifestations
Diagnosing
FIP
 What is the challenge?
Laboratory work up Spesifik
Clinical Diagnostic Testing
presentation • Walaupun ada beberapa • Deteksi antigen virus pada
• Pasien dengan efusi hasil laboratorium yang khas makrofag yang terdapat di
dan dengan untuk pasien FIP (seperti jaringan yg terifeksi dengan
signalement yang ratio a/g, hyperbilirubinemia, metode IHC
tipical FIP anemia non regenerative) (immunohistochemistry)
mempermudah namun tidak pathognomonic menjadi gold standard
peneguhan diagnosa. hanya untuk kasus FIP. diagnosis
• Namun jika pasien • Beberapa kasus disertai • Deteksi RNA virus dengan
tanpa efusi peneguhan dengan penyakit lain yang metode Real Time RT-PCR
diagnosa akan lebih membuat hasil darah menjadi (RT-qPCR) memiliki nilai
sulit mengingat gejala bias. diagnostic yang baik.
klinis FIP bervariasi dan • Keduanya belum available
non spesifik di Indonesia
Da cW - FIP ‘B c b B c ’

k - u p
t ic Wor
n o s
ia g r F IP ’
D fo ric k
b y B
c k
‘Bri

SUPPLEMENTAL FIGURE 8: D a cW - FIP ‘B c b B c ’

The eterinarian m st consider the patient s histor , signalment and ph sical e amination findings, and then select diagnostic tests and
Dokter hewan harus mempertimbangkan riwayat pasien, singnalement dan temuan
sample t pes based on these, in order to b ild the inde of s spicion 'brick b brick'. ADR = ain t doing right . For e planation of other
abbre iations, see bo on page 906 of the G idelines.
pemeriksaan fisik, i,dan
G a hic de ig ed b Vic i Tha e a d S a G g ba ed
kemudian
Me i a Ke ed
memilih
diag ic b ic a
tes diagnostik dan jenis sampel
berdasarkan
F e hal a ini, untuk
, ca membangun
e .c / &e e indeks
ca . kecurigaan
/aa - - de 'brick
e . by brick'
©C 2022. A e ca A ca f Fe e P ac e & E e Ca Hea F da .A e e ed.
45
In the afore-
Table 1 Risk factors influencing the development of FIP
and after being
a, FCoV shed-

History &
Risk factor Examples/comments
n-fold in some
elter.36 Origin < From environment with high FCoV load
nce of FCoV in Background < FIP diagnosed in the same litter/family lineage9
ority is to pre- < Immunosuppressive therapy9

Signalement:
s the potential < Adoption or acquisition from a cattery, shelter, rescue
nerable kittens or rehoming center62,63
< Recent stressful event:17,26,54,55,62,64,65
by identifying – Surgery (spay, neuter or other)
To detect FCoV – Vaccination
ach cat should – Gastrointestinal disease
hree fecal RT- – Upper respiratory tract disease ” Susceptibility to FIP in a cat involves the
– Travel, boarding, attending cat shows
ls of 1 week to – New household member (eg, new baby or pet), moving house interplay between virus virulence factors,
Signalment < Age at exposure to FCoV (less-virulent biotype): <2 years
host factors (eg, genetic characteristics,
th less-virulent
do not require old66–69 age), concurrent diseases and/or other
< Sex: intact (male) cats3,4,5,70,71
gastrointestinal < Breed: certain purebred cats (eg, Bengals, Birmans;3,68 stressors at the time of FCoV infection ”
or diarrhea).46,49 see supplemental file 7)
lly self-limiting Health status < Coinfection (eg, FIV, FeLV) or concurrent disease9,23,72
ever, in a small < Immunosuppression9
st for weeks to
Housing < Multi-cat household45,48
ooking at feline conditions < Frequent introductions and reintroductions to new cats73–75
ter cats found < Variable lengths of stay in multi-cat environments76
ut of 12 enteric < Mingling of different age groups77
< Overcrowding (>5 cats)63
s significantly
iarrhea than in
ectively).51

Given that FIP different cats with FIP in the same household
show mostly unique genetic characteristics,
 Physical Examination
• Given that the clinical presentation of FIP is so highly variable, a comprehensive physical examination is
essential.
• Demam menjadi gejala non specific yang paling awal terdeteksi pada kasus FIP. Pemeriksaan suhu badan
pasien saat visit rutin dilakukan “cat friendly manner”: contohnya dengan menggunakan ear thermometer
(termometer rectal digunakan untuk konfimasi jika ada demam)
 Table 3 Potential differential diagnoses for FIP85,120

Disease/condition Comparison and clinical considerations

Septic peritonitis/pleuritis Often these cats are sick, depressed and have fever. Septic effusions are yellow to tan in color and sometimes
foul-smelling. Effusions contain high cell counts, and cytology is characterized by degenerative neutrophils and
intracellular bacteria. Culture can reveal bacterial infection
Dikarenakan gejala klinis Neoplasia Lymphoma can involve multiple organs or lymph nodes (like FIP, also affecting younger cats). Other neoplasms are
(eg, lymphoma) predominantly present in older cats. Cytology can reveal neoplastic cells. Ultrasound-guided aspirates or biopsies
dan manifestasi patologis of affected tissues may be needed for diagnosis

FIP sangat luas dan Toxoplasmosis Less commonly seen than FIP in cats. Can involve multiple organs and cause signs such as gastrointestinal
(diarrhea), ocular, pancreatic, liver and neurological disease. Diagnosis is obtained by finding tachyzoites in
bervariasi, RU diagnosa samples, or by demonstration of antibodies with high immunoglobulin (Ig)M or rising IgG titers
Pancreatitis Cats with pancreatitis can exhibit anorexia, jaundice, fever and weight loss. Abdominal effusion can be present
banding menjadi bagian as a non-septic exudate, often with a high cell count of non-degenerate neutrophils. Abdominal ultrasound
and/or measurement of feline pancreatic lipase immunoreactivity can detect pancreatitis
penting dalam proses
Lymphocytic cholangitis Generally this is more chronic in nature than FIP. Liver enzymes (such as alkaline phosphatase [ALP] and alanine
mendiagnosa. aminotransferase [ALT]) are more likely elevated. Jaundice/hyperbilirubinemia can be present. Lymphocytic
cholangitis can be associated with inflammatory bowel disease and/or pancreatitis. Aspirates of bile or liver
and/or histopathology of liver tissue samples can be diagnostic
Saat FIP menjadi diagnosa Congestive heart failure Can lead to effusion, most commonly a modified transudate. Cats with congestive heart failure do not typically
have a fever. Heart murmur and/or gallop rhythm can be present. Cytology shows a very low cell count.
banding dari suatu kasus, Echocardiography can confirm the diagnosis

beberapa pemeriksaan Mycobacteriosis Fever, lymphadenopathy, respiratory signs, abdominal masses and uveitis can occur with Mycobacteria species
infections. Mycobacterial cases do not usually present with severe hyperglobulinemia or a reduced A:G ratio, as
rutin yang bisa dilakukan: seen with FIP. Cytology can demonstrate (acid-fast) bacteria in tissue samples. PCR and culture can be diagnostic

hematologi, serum Trauma Effusions caused by trauma are usually hemorrhagic and can be differentiated from FIP effusions by cytological analysis

biochemistry, urinalysis
914
dan test FIV/FeLV
Differential
JFMS CLINICAL PRACTICE

diagnoses
 ed as supplemental file 12; the veterinarian nosed with FIP.
was concerned about FIP, until cytology
confirmed Mycobacteria species.

Diagnostic testing Common statistical terms used when describing

Diagnostic
A good understanding of each
various diagnostic tests for FIP121,122
diagnostic test’s sensitivity, speci-
ficity, predictive value, likelihood Sensitivity Test’s ability to recognize cats with FIP
ratio (LR) and diagnostic accuracy

Testing
is important when diagnosing FIP;
these are common statistical terms Specificity Test’s ability to recognize cats without FIP
used to describe how accurately a
diagnostic test can determine
Likelihood ratio (With FIP)/(Do not have FIP)
whether a cat has FIP (see box). (LR) or expected test Not influenced by disease prevalence
Sensitivity, specificity and LRs are result in cats Good diagnostic tests have LR+ >10 or LR– <0.1
not influenced by the prevalence of
disease in the test
Pemahaman terhadap diagnostic studied population,
yang akan (True positives + True negatives)/
while positive (PPVs) and negative Overall test accuracy
Total number of test results
dilakukan (meliputi sensitity, specivity,
predictive predictive
values (NPVs) are influ-
121
enced
value, likehood ratio (LR) dan byakurasi)
prevalence.sangat
PPVs will Positive predictive Probability cat with positive test result has FIP
be higher when the prevalence of value (PPV) based on disease prevalence in population examined
penting dalam mendiagnosadisease FIP.
is high and lower when
prevalence is low,123 and predictive Negative predictive Probability cat with negative test result does not have FIP
values should not be applied to dif- value (NPV) based on disease prevalence in population examined
In highly fatal disease such as FIP, the specifity
ferent populations of cats unless it
of the diagnostic test is more important than the
test sensitivity since it will help prevent
Table 3
euthanasia of cats misdiagnosed Potential
with FIP.differential diagnoses for FIP85,120

Disease/condition Comparison and clinical considerations

Septic peritonitis/pleuritis Often these cats are sick, depressed and have fever. Septic effusions are yellow to tan in color and sometimes
foul-smelling. Effusions contain high cell counts, and cytology is characterized by degenerative neutrophils and
intracellular bacteria. Culture can reveal bacterial infection
 Beberapa penelitian menggunakan modal pengujian yang berbeda
menyimpulkan bahwa akurasi diagnostik tertinggi adalah analisis efusi,
jadi ketika mendapatkan sampel cairan harus dilakukan analisa
• khas konsistensinya berwarna kuning dan lengket. Beberapa kucing
memiliki efusi yang lebih merah muda serta lebih encer/tidak lengket.
• Eksudat non septic dengan high protein level (rasio A:G rendah)
dan low cell count (typically <5 x109/l cells, mainly neutrofil dan
B 26/08/2022 20:54 Page 917
makrofag)
• Rivalta tes, hasil negatif bisa menyatakan FIP unlikely
• Alpha 1-acid glycoprotein jika tersedia, nilai > 1.5 mg/ml menyatakan
SPECIAL ARticle / FIP
2022 AAFP/EveryCat FIP more
diagnosis likely
guidelines

tein tH e l p f u l t i p s
e if
ou- How to perform the Rivalta’s test*
ion
atio < Mix 8 ml of distilled water at room temperature and 20 µl (1 drop)
the of 100% acetic acid in a plastic test tube (volume 10 ml).
550 < Carefully layer 20 µl (1 drop) of the effusion on the surface of this solution.
y of < Observe the behavior of this drop:
on- – A positive test is indicated by the drop precipitating and either staying

Effusion analysis
olo- attached to the surface of the solution, retaining its shape with a
cell connection to the surface, or floating slowly to the bottom of the tube
vity, as a drop or jellyfish-like.
lse- – A negative test is indicated by the drop dissipating (disappearing)
cus- and the solution remaining clear.

an *Supplemental video 13 shows the Rivalta’s test being performed

The information in this box is based on references 78, 96 and 132
 eC -C c (CC) e , a d f a e He a -Re a U b ca (HRU) e . If e ca aced ef
aea ec be c , e AFAST d aga beg a e DH e , b ead f e SR e be g e ,
e be d be aced a e HRU e f ed b e CC e , a d f g a e SR e (See
Fg e 1). S ce a ca d a e e a ceab e abd a f d a e e d ea e

Diagnostic Imaging Abdominal focused assessment with sonogra-

a f be g a -eff e eff e (2 5), e a AFAST e a a a e a e ce e
d ag c de f e e ca e . M e d e a e de a ed a ce a d ag c e
ef ed eff a e a e a e a g e d ag c acc ac a de f g e e e phy for trauma, triage and tracking (AFAST)
c ca e e a e e FIP a e a e c d (6).
is a first-line screening test that allows the
attending clinician to quickly identify
whether free fluid and soft tissue abnormali-
A Aties
F P / Eofethe
r C arelevant
F e l i n e Itarget
n f e c i oorgan
s P e rare
i o npresent.
i is
Diagnosis G idelines
Ins r c ions for AFAST and TFAST (con in ed)
AFAST membantu menemukan cairan efusi
pada pasien yang cairan efusinya belum
terlihat
Fig e 2 e e e
jelas.
a DH- i i e AFAST i age de a i g a ech ic f ee f id ha , if f di a ca
ec ed f ha i g FIP, h d be i edia e a ed a d a a ed.

F g e 1: F e f e AFAST f d c g e a ca e a ge ga .A
e a e ega e f f ee f d a b f- e ab a e .T e de
a a d be g f 1 g 4. T e e a - e a 5 b e a d e f c ed ee
e ae . T e ca e e a eda ed a d a ed f a a e ec a d
g a ed f d dac c e ; eda a d a gae ef ed a e .
CC, C -C c; DH, D a ag a c -He a c; HRU, He a -Re a U b ca ; SR, S e -
Re a .

F e 2: P i i e AFAST a he b i h id Dia h ag a ic -He a ic ie de ai g a ica

c ed...
a ech ic acc ai f f ee f id be ee he dia h ag a d i e . B ki g c a ia he
dia h ag , e a a d e ica dia eff i a d g ah g a a be de ec ed.
F , . / & . / - - .
©C 2022. A e ca A ca f Fe e P ac e & E e Ca Hea F da .A e e ed. I he e e ge a aa d - a a fe i e a ie ha i i ia e ia e e i h f ee f id i he
to the skin surface without hair in between the probe head and the patient's
trapping in wetted hair while optimizing the image quality).

Diagnostic Imaging
How to Perform TFAST - Its 5 Acoustic Windows
In cases where there is not obvious
respiratory distress, but fluid is still
suspected, thoracic-focused
assessment with sonography for trauma,
triage, and tracking (TFAST) should be
performed, since like with
abdominal effusions, ultrasound is more
likely to be able to detect small amounts
of fluid

TFAST3 - Its 5 Acoustic Windows.

• Bilaterally applied Chest Tube Site views Pada setiap sisi 1/3 dorsal thorax (antara intercostae
space 7-9) dilakukan secara horizontal. Untuk RI/RO pneumothorax.
• Bilateral pericardial Site views Pada setiap sisi 1/3 ventral thorax (antara intercostae space 5-6)
• Single applied Diaphragmatico-Hepatic view
• Histopatologi lesi cukup spesifik untuk mendiagnosa FIP, tetapi pengambilan sampel bersifat invasif
atau hanya dapat dilakukan post mortem.
• Pengambilan sampel beberapa jaringan lebih disukai meningkatkan sensitivitas dan dapat mencakup
MLN, usus kecil dan besar, omentum, limpa, ginjal dan hati.
• Gambaran patologi yang khas vaskulitis dengan nekrosis perivaskular
• Lesi pyogranulomatous dapat ditemukan disekitar pembulug darah, terutama pada permukaan serosa
• IHC (Immunohistochemistry) bisa mendeteksi keberadaan antigen FCoV di makrofag lesi jaringan. IHC
menjadi gold standard untuk diagnosa FIP
• Sampel bisa diambil dengan metode FNA dan Tru-cut biopsy (TCB) untuk dilanjutkan analisa histologi,
IHC, RT-nPCR.

Histopathology
 later studies also been positive in cats without FIP.
indicate the
Different types of FCoV RT-PCR tests are available, based on test design
< RT-PCR – conventional and semiquantitative. presence
< Real-time RT-PCR (also referred to as RT-qPCR) – quantitative and diagnostically more accurate than A positive
of FCoV, and
RT-PCR.*† RT-qPCR
< RT nPCR – two-step PCR reaction that first amplifies larger segment in cDNA; product is purified and not specifically
then smaller segment is amplified. This assay is used only if there is an issue with sensitivity/specificity
result
with the RT-qPCR, and it is not very useful diagnostically if the first-round cDNA needs to be purified.
the mutated
with high viral
< 7b-RT-qPCR – this RT-qPCR was developed to quantify the level of FIPV through specific targeting virusload
that moves
leads
of the 7b accessory gene. Typically, it is run first to verify FCoV presence and then followed by another
RT-qPCR to detect mutations. to FIP
FIP up. the list
< Real-time RT-PCR for M gene.† of differential
< Real-time RT-PCR detecting S gene mutations using specific hydrolysis probes.†
< Real-time RT-PCR followed by sanger sequencing for S gene mutations – more specific for detection
diagnoses.
of S gene mutations than special real-time RT-PCR detecting S gene mutations using specific primers.

*Preferred for most situations. †Available in commercial laboratories

The information in this box is based on references 50, 60, 88, 92 and 143–145

• RT-PCR & Realtime RT-PCR yang tersedia saat ini belum bisa membedakan antara mutated
and after
sequencing non mutated form FCoV
real-time RT-PCR. 60,79,153
For < FCoV RT-qPCR–/spike mutant RT-qPCR+
the •mutation-specific
Di IndonesiaRT-qPCRs,
baru tersedia RT-PCR
these typical- A positive (eg, something is wrong with the assay).
ly will be combined into one assay, referred to In a recent study, FCoV containing S gene
as multiplexed, for interpretation of results. RT-qPCR result mutations was found in at least one body
The assay will involve one PCR amplicon set fluid or tissue in all cats with FIP, but the
targeting a conserved region that will detect
all FCoV species, and a second set where one
Detection of Viral Nucleic Acid
with high viral
load moves
distribution varied from cat to cat, hence a
recommendation that multiple samples be
of the primers (forward or reverse) is specific analyzed to increase sensitivity.58 The speci-
at the 3 end for the mutation being looked for, FIP up the list ficity of detection of S gene mutations for FIP
• Antigen FCoV dapat dideteksi dengan pewarnaan antigen dalam sel targetnya, cairan atau makrofag
jaringan, menggunakan metode pewarnaan untuk mewarnai antigen.
• Pengikatan antibodi dengan antigen host cell-associated FCoV kemudian divisualisasikan (oleh IHC, ICC
atau imunofluoresensi [IF]), menghasilkan warna perubahan atau fluoresensi.

NOT AVAILABLE IN INDONESIA

Detection of Viral Antigen

• Measurement of anti-FCoV antibodies can be used to detect FCoV infection; however, the presence of
antibodies is not useful for diagnosing FIP, since antibodies are not only present in cats with FIP, but also
in healthy FCoV-infected cats or FCoV-infected cats with other diseases
• Although cats with FIP tend to have higher anti-FCoV antibody titersthan cats without FIP, there is often
no difference in median anti-FCoV antibody titers between healthy cats and cats with FIP
• Negative antibody test results do not rule out FIP, since up to 10% of cats with FIP do not have anti-FCoV
antibodies. This percentage was even higher in cats with neurological FIP without effusion.

Tes ini paling luas penggunaannya di Indonesia, gunakan dengan bijak

tidak sebagai satu-satunya atau alur pertama dalam proses diagnosa FIP

Detection of anti-FCoV antibodies

 FIP: diagnostic approach I
Evidence contributing to being highly suspicious of a diagnosis of feline infectious peritonitis

Modified from: Barker E & Tasker S. (2020). Advances in Molecular Diagnostics and Treatment of Feline Infectious Peritonitis. Advances
ABCD TOOL Clinical examination NOTE: - slightly less likely + slightly more likely History
Fever (typically <40 C) +++
o
The + & - symbols indicate how likely or unlikely -- moderately less likely ++ moderately more likely Weight loss/failure to thrive /stunted growth +++
Mucous membranes: --- far less likely +++ far more likely Swollen abdomen ++++
Icterus/jaundice ++
factors listed are to make a diagnosis of FIP ---- extremely unlikely ++++ extremely likely Persistent/fluctuating fever non-responsive to antibiotics +++
Pallor + Lethargy/dullness ++
Abdominal palpation: Signalment Inappetence ++
Fluid thrill due to ascites ++++
Irregular organomegaly (e.g. kidneys, lymph nodes) +++
Signalment & history <2 years ++++
>5 years –
Dyspnoea ++
Vision or ocular abnormalities incl. iris colour change &/or
Masses (e.g. abdominal lymph nodes, intestinal) ++ nystagmus ++
Male +
Auscultation: Pedigree + (breeds vary geographically) Jaundiced mucous membranes ++
Absence or dullness of heart sounds ++ Dietary history compatible with thiamine Ataxia/paresis (para- or tetra-), hyperaesthesia, seizures ++
Heart murmur / arrhythmia – deficiency – Sibling (or in-contact) with FIP ++
Absence of lung sounds ++ Multi-cat household +++
Increased lung sounds with crackles – Serum biochemistry Pale mucous membranes +
Percussion of chest dull ventrally ++
Tachypnoea or dyspnoea ++
Clinical examination Hyperbilirubinaemia +++
Diarrhoea, vomiting &/or constipation +
Recent stress (e.g. vaccination, rehoming, neutering) ++
including looking for any evidence of an effusion Hyperglobulinaemia +++
Otoscopic examination : Outdoor only/feral cat – –
Hyperproteinaemia (or total solids) ++ History of fighting –
Evidence of ear disease (e.g. polyps, otitis externa /media) –
Hypoalbuminaemia +
Ocular examination (unilateral or bilateral changes):
Albumin to globulin [A:G] ratio
Change in iris colour ++++
Dyscoria/anisocoria +++
A:G ratio < 0.4 + Analyse any effusion
A:G ratio > 0.6 – Typically, high protein low cell count effusions in
Hyphaema ++
Alpha1-acid glycoprotein, if available: abdomen ± thorax ± pericardium
Aqueous or vitreous flare ++
Other signs of uveitis ++ Y
Serum biochemistry >1. 5 g/L ++
>3.0 g/L +++
Biochemistry:
Perivascular cuffing of retinal vessels ++ High protein (or total solids) >35 g/L ++++
<1. 5 g/L – Low protein (or total solids) < 25 g/L – –
Nystagmus ++
Serum protein electrophoresis, if performed: A:G ratio < 0.4 ++
Retinal detachment +
Polyclonal gammopathy + A:G ratio > 0.8 –
Neurological examination:
Marked elevation in ALT & ALP – Yellow ++++ Effusion cytology &
Ataxia +++
Only mild or moderate elevation in ALT & Rivalta’s test positive ++ biochemistry
Seizures +++
ALP with hyperbilirubinaemia + Rivalta’s test negative – – – consistent with FIP?
Mental state or behaviour changes +++
FCoV antibody test with high titre + Cell count: Go to diagram
Head tilt ++
Priapism ++
Scrotal enlargement ++
Locate & analyse effusion FCoV antibody test negative – Low cell count <5 x10 /L ++++
9

Moderate cell count ≤20 x109/L ++

1
Locate any effusion
if present* High cell count > 20 x109/L –

in Small Animal Care 1: 161–188

Multiple skin nodules or papules +
Body condition score < 5/9 ++ Ultrasonography is most useful Alpha1-acid glycoprotein, if available:
Bicavity effusion +++ >1.5 mg/mL ++
to locate/direct fluid sampling
Cytology:
Bicavity effusion +++
Haematology Abdominal ultrasonography:
Non-degenerate neutrophils & macrophages ++++
Non-degenerate neutrophils, macrophages & a few
Mild non-regenerative anaemia ++
Severe non-regenerative anaemia + Haematology Peritoneal (or retroperitoneal) fluid +++
Thoracic ultrasonography:
lymphocytes ++++
Toxic neutrophils ± bacteria visible –
Regenerative anaemia +
Pleural (or pericardial) fluid ++ Neoplastic cells – – –
Microcytosis ++ *Absence of effusion & presence of
Thoracic radiography:
Neutrophilia (mild ± left shift) ++ nonspecific clinical signs? Go to diagram 2 Pleural fluid ++
Marked lymphocytosis –
Marked neutrophilia –
Lymphopenia ++ Neurological findings consistent with FIP? Go to diagram 3
Lymphocytosis – –
Ocular findings consistent with FIP? Go to diagram 4 For differential diagnoses of FIP, see box 5
 FIP: diagnostic approach IIa
Looking for evidence that confirms FIP as a diagnosis following a high suspicion:
ABCD TOOL 1 2
Effusion sample cytology & biochemistry Absence of an effusion & presence of

Adapted from: Felten S & Hartmann K. (2019). Diagnosis of Feline Infectious Peritonitis: A Review of the Current Literature. Viruses 11(11)
consistent with FIP nonspecific clinical signs: perform diagnostic imaging*
Findings that could be consistent with FIP:
Ultrasonography: abnormalities e.g. in lymph nodes (abdominal lymphadenopathy), liver, spleen (variable echogenicity), kidney (variable
Effusion sample analysis: echogenicity, medullary rim sign)
FCoV RT-PCR &/or immunocytochemistry for FCoV antigen Radiography: abnormalities e.g. lymphadenopathy, alveolar pattern consistent with pneumonia

negative FNA sample of any abnormal organ/tissue

either test positive (e.g. mesenteric lymph node) with consistent cytology (neutrophilic or pyogranulomatous):
FIP less likely FCoV RT-PCR &/or immunocytochemistry for FCoV antigen
negative
either positive
If still suspicious of FIP,
either positive
take FNA of accessible organs FIP unlikely
(e.g. liver, mesenteric lymph node, kidney, spleen), Positive FCoV RT-PCR
then FCoV RT-PCR &/or with high FCoV RNA loads
Positive FCoV RT-PCR immunocytochemistry for FCoV antigen &/or If still suspicious of FIP, continue monitoring as
with high FCoV RNA loads positive abnormalities can develop over time, which can then be
negative
&/or immunocytochemistry sampled for diagnosis by either FNA, trucut or full biopsy
positive Look for causes other than FIP for FCoV antigen
(cytology, immunocytochemistry for FCoV antigen, RT-PCR, histopathology,
immunohistochemistry for FCoV antigen)
immunocytochemistry &/or
for FCoV antigen laparotomy / laparoscopy / trucut to not consistent,
negative
biopsy for histopathology &
immunohistochemistry for FCoV antigen if FIP very unlikely
FIP very likely1 still suspicious of FIP Positive FCoV RT-PCR
FIP very likely2 with high FCoV RNA loads
&/or

*
Histopathology Histopathology not positive immunocytochemistry Histopathology
Note for IIa & IIb: consistent with FIP & consistent with FIP & In absence of any obvious for FCoV antigen with cytology consistent with FIP &
If you are submitting fluid or cytology immunohistochemistry negative localising signs or consistent for FIP immunohistochemistry
samples for FCoV antigen positive for FCoV immunohistochemistry abnormalities that allow positive for FCoV
immunostaining, it is wise to contact the antigen sampling, ultrasonography
laboratory first to ask for preferred indicated to evaluate antigen
samples &/or preparation methods. abdominal & thoracic organs
for any abnormalities & to
Confirms FIP FIP very unlikely direct sampling of tissue. FIP very likely2 Confirms FIP

1.Some authors regard a positive immunocytochemistry test for FCoV antigen on an 2.Some authors regard a positive immunocytochemistry test for FCoV antigen on an FNA sample
effusion (with biochemistry & cytology consistent with FIP) adequate to confirm FIP (with cytology consistent with FIP) adequate to confirm a diagnosis of FIP
 FIP: diagnostic approach IIb
Looking for evidence that confirms FIP as a diagnosis following a high suspicion:
ABCD TOOL 3 4

Adapted from: Felten S & Hartmann K. (2019). Diagnosis of Feline Infectious Peritonitis: A Review of the Current Literature. Viruses 11(11)
Neurological findings consistent with FIP* Aqueous humor cytology consistent with FIP*
MRI: Obstructive hydrocephalus, syringomyelia, foramen magnum herniation, marked contrast enhancement of the meninges, (neutrophilic or pyogranulomatous)
third ventricle, mesencephalic aqueduct & brainstem reported with FIP
CT: hydrocephalus &/or syringohydromyelia
CSF: high protein (>0.3 g/L cisternal samples, >0.46 g/L lumbar samples), Aqueous humor sample analysis:
high cell count (>0.008 x 109/L cisternal or lumbar samples),
cytology predominantly neutrophilic, mononuclear, mixed or pyogranulomatous FCoV RT-PCR &/or immunocytochemistry for FCoV antigen
either positive negative

CSF sample analysis: FCoV RT-PCR &/or immunocytochemistry for FCoV antigen
Positive FCoV RT-PCR FIP unlikely
either positive negative with high FCoV RNA loads
&/or
Positive FCoV RT-PCR FIP unlikely positive If still suspicious of FIP, continue monitoring for non-
with high FCoV RNA loads immunocytochemistry ocular changes as abnormalities can develop over
&/or for FCoV antigen time, which can then be sampled for diagnosis by either
positive If still suspicious of FIP, continue monitoring for non- FNA, trucut or full biopsy
immunocytochemistry neurological changes as abnormalities can develop (cytology, immunocytochemistry for FCoV antigen, RT-PCR, histopathology,
immunohistopathology for FCoV antigen).
for FCoV antigen over time, which can then be sampled for diagnosis by If enucleation is performed due to severe
either FNA, trucut or full biopsy uveitis/glaucoma, eye can be submitted for
(cytology, immunocytochemistry for FCoV antigen, RT-PCR, histopathology,
immunohistochemistry for FCoV antigen) histopathology & immunohistochemistry
not consistent, FIP very likely2 not consistent,
negative negative
FIP very likely1 Positive FCoV RT-PCR Positive FCoV RT-PCR
with high FCoV RNA loads FIP very unlikely
* with high FCoV RNA loads FIP very unlikely

*
&/or In absence of any non- &/or
In absence of any non-neurological positive ophthalmological signs or positive
abnormalities that allow immunocytochemistry
signs or abnormalities that allow immunocytochemistry Histopathology sampling of alternative Histopathology
sampling of alternative sites, advanced for FCoV antigen with consistent with FIP & for FCoV antigen with
sites, collection of an consistent with FIP &
imaging via CT, or preferably MRI, is cytology consistent for FIP immunohistochemistry aqueous humour sample cytology consistent for FIP immunohistochemistry
indicated. Imaging allows for evaluation for
neurological system abnormalities & to positive for FCoV may be indicated. positive for FCoV
assess for any potential risk of herniation if antigen Referral may be indicated for this antigen
subsequent CSF collection is planned. procedure if veterinarian is
unfamiliar with ophthalmological
Referral may be needed for these procedures if
investigations.
vet is unfamiliar with neurological investigations. FIP very likely1 Confirms FIP FIP very likely2 Confirms FIP

1.Some authors regard a positive immunocytochemistry test for FCoV antigen on a CSF sample 2.Some authors regard a positive immunocytochemistry test for FCoV antigen on an aqueous
(with biochemistry & cytology consistent with FIP) adequate to confirm a diagnosis of FIP humor sample (with cytology consistent with FIP) adequate to confirm a diagnosis of FIP
 FIP Differential diagnoses

ABCD TOOL 5
FIP: differential diagnoses to be considered

Modified from: Barker E & Tasker S. (2020). Advances in Molecular Diagnostics and Treatment of Feline Infectious Peritonitis.
geography/lifestyle dependent
Lymphocytic cholangitis or cholangiohepatitis: young, especially pedigree cats, jaundice ± abdominal
effusion, on biochemistry elevated ALP & GGT; histopathology
Pyothorax: outdoor cats, history of fighting, fever, leucocytosis with neutrophilia (± left shift) on
haematology, pleural effusion with high cell count & degenerative neutrophils (septic)
Toxoplasmosis: hunters &/or those fed raw meat diet, neurological/muscular/pulmonary/ocular signs all
possible, effusions, jaundice; serology (antibody); PCR; cytology or histopathology, responds to
clindamycin
Neoplasia: lymphoma in young cats with lymphadenopathy &/or organomegaly, carcinoma/other in older
cats, range of signs depending on type of neoplasia, can have bicavity effusions; cytology, histopathology
Septic peritonitis: fever, leucocytosis with neutrophilia (± left shift) on haematology, abdominal effusion
with high cell count & degenerative neutrophils (septic)
Pancreatitis: mainly middle-aged to older cats, reduced appetite, jaundice, weight loss, abdominal
effusion all possible, fever not prominent; ultrasonography & feline pancreatic lipase immunoreactivity
Mycobacterial infection: hunters &/or those fed raw meat diet: skin, abdominal, thoracic signs all
possible with lymphadenopathy, fever not prominent; Ziehl-Neelsen stain, interferon-gamma release blood
test assay, PCR (tissue samples), culture
Haemoplasmosis: cats with outdoor access, pallor, lethargy, fever, regenerative anaemia; PCR Effusion consistent
with FIP?
Congestive heart failure: pleural effusion more common but bicavity effusion possible, rare to see

Advances in Small Animal Care 1: 161–188

Go to diagram
abdominal effusion alone, heart murmur/gallop/arrhythmia, jugular vein distension possible, no fever,
effusion low protein, elevated serum N-terminal pro-B-type natriuretic peptide (NT-proBNP),
echocardiography for aetiology
Retroviral infection: feline immunodeficiency virus in middle-aged to older esp. male cats with outdoor
access & history of fighting: FIV serology (antibody) test, or feline leukaemia virus in cats with outdoor
access & history of fighting: FeLV serology (antigen). Note that when clinical signs are seen in retrovirus
infected cats, there is usually an associated infection or morbidity present in addition to the retrovirus In young cats with outdoor access, pyothorax, toxoplasmosis and
infection per se, resulting in clinical signs mycobacterial infection can be differential diagnoses for FIP.

If you found this ABCD information valuable, please tell a colleague. To download the ABCD tools, fact sheets, or the full disease guidelines, please visit our website: www.abcdcatsvets.org
The ABCD Europe is an association with an independent panel of experts in feline health. This tool was supported by Boehringer Ingelheim (founding sponsor) and Virbac. December 2021.
 FIP: diagnostic approach I
Evidence contributing to being highly suspicious of a diagnosis of feline infectious peritonitis

Modified from: Barker E & Tasker S. (2020). Advances in Molecular Diagnostics and Treatment of Feline Infectious Peritonitis. Advances
OL Clinical examination NOTE: - slightly less likely + slightly more likely History
-- moderately less likely Weight loss/failure to thrive /stunted growth +++
Fever (typically <40oC) +++
Mucous membranes:
The + & - symbols indicate how likely or unlikely
factors listed are to make a diagnosis of FIP
--- far less likely
---- extremely unlikely
++ moderately more likely
+++ far more likely
++++ extremely likely
Swollen abdomen ++++
Persistent/fluctuating fever non-responsive to antibiotics +++
Jika tidak khas
Icterus/jaundice ++
Pallor +
Abdominal palpation: Signalment
Lethargy/dullness ++
Inappetence ++
terutama non
Fluid thrill due to ascites ++++
Irregular organomegaly (e.g. kidneys, lymph nodes) +++
Signalment & history <2 years ++++
>5 years –
Dyspnoea ++
Vision or ocular abnormalities incl. iris colour change &/or effusion suspect FIP
Masses (e.g. abdominal lymph nodes, intestinal) ++ nystagmus ++
Male +
Auscultation: Pedigree + (breeds vary geographically) Jaundiced mucous membranes ++
Absence or dullness of heart sounds ++ Dietary history compatible with thiamine Ataxia/paresis (para- or tetra-), hyperaesthesia, seizures ++
Heart murmur / arrhythmia – deficiency – Sibling (or in-contact) with FIP ++
Absence of lung sounds ++ Multi-cat household +++
Increased lung sounds with crackles – Serum biochemistry Pale mucous membranes +
Percussion of chest dull ventrally ++
Tachypnoea or dyspnoea ++
Clinical examination Hyperbilirubinaemia +++
Diarrhoea, vomiting &/or constipation +
Recent stress (e.g. vaccination, rehoming, neutering) ++
including looking for any evidence of an effusion Hyperglobulinaemia +++
Otoscopic examination : Outdoor only/feral cat – –
Hyperproteinaemia (or total solids) ++ History of fighting –
Evidence of ear disease (e.g. polyps, otitis externa /media) –
Hypoalbuminaemia +
Ocular examination (unilateral or bilateral changes):
Albumin to globulin [A:G] ratio
Change in iris colour ++++
Dyscoria/anisocoria +++
A:G ratio < 0.4 + Analyse any effusion
A:G ratio > 0.6 – Typically, high protein low cell count effusions in
Hyphaema ++
Aqueous or vitreous flare ++
Y
Alpha1-acid glycoprotein, if available: abdomen ± thorax ± pericardium
Rule Out DDx yang memiliki
Other signs of uveitis ++ Serum biochemistry >1. 5 g/L ++
>3.0 g/L +++
Biochemistry:
High protein (or total solids) >35 g/L ++++
Perivascular cuffing of retinal vessels ++
Nystagmus ++
Retinal detachment +
<1. 5 g/L –
Serum protein electrophoresis, if performed:
Low protein (or total solids) < 25 g/L – –
A:G ratio < 0.4 ++
gambaran klinis dan hasil
Polyclonal gammopathy +
Neurological examination:
Ataxia +++
Marked elevation in ALT & ALP –
Only mild or moderate elevation in ALT &
A:G ratio > 0.8 –
Yellow ++++ Effusion cytology &
biochemistry
laboratorium mirip.
Seizures +++ Rivalta’s test positive ++
ALP with hyperbilirubinaemia + Rivalta’s test negative – – – consistent with FIP?
Mental state or behaviour changes +++
FCoV antibody test with high titre + Cell count: Go to diagram
Head tilt ++
Priapism ++
Scrotal enlargement ++
Locate & analyse effusion FCoV antibody test negative – Low cell count <5 x109/L ++++
Moderate cell count ≤20 x109/L ++
1
Locate any effusion
if present* High cell count > 20 x109/L –

in Small Animal Care 1: 161–188

Multiple skin nodules or papules +
Body condition score < 5/9 ++ Ultrasonography is most useful Alpha1-acid glycoprotein, if available:
Bicavity effusion +++ >1.5 mg/mL ++
to locate/direct fluid sampling
Cytology:
Bicavity effusion +++
Haematology Abdominal ultrasonography:
Non-degenerate neutrophils & macrophages ++++
Non-degenerate neutrophils, macrophages & a few
Mild non-regenerative anaemia ++
Severe non-regenerative anaemia + Haematology Peritoneal (or retroperitoneal) fluid +++ lymphocytes ++++
Regenerative anaemia +
Microcytosis ++ *Absence of effusion & presence of
Thoracic ultrasonography:
Pleural (or pericardial) fluid ++
Toxic neutrophils ± bacteria visible –
Neoplastic cells – – –
Jika semua sudah di rule
Thoracic radiography:
2 Marked lymphocytosis –
Neutrophilia (mild ± left shift) ++
Lymphopenia ++
nonspecific clinical signs? Go to diagram
Neurological findings consistent with FIP? Go to diagram 3
Pleural fluid ++ Marked neutrophilia – out, bisa tes FCoV ab, jika
Lymphocytosis – –
Ocular findings consistent with FIP? Go to diagram 4 For differential diagnoses of FIP, see box 5
positif >> trial treatment
If you found this ABCD information valuable, please tell a colleague. To download the ABCD tools, fact sheets, or the full disease guidelines, please visit our website: www.abcdcatsvets.org
The ABCD Europe is an association with an independent panel of experts in feline health. This tool was supported by Boehringer Ingelheim (founding sponsor) and Virbac. December 2021.

Apa yang bisa dilakukan di Indonesia untuk peneguhan diagnosa FIP?

• ABON, tinggal di rumah dengan banyak kucing,
umur 4 tahun, jantan sudah steril, full vaksin.
• URTI berulang
• Datang dengan gejala: Ataxia, Nystagmus Vertical,
Headtilt, pilek
• Hasil lab: leukositosis, rasio A/G 0.42

• Next step: rule out disease possibility, central

vestibular syndrome, mengarah ke infeksi.
• Test Toxoplasmosis NEGATIVE
• Test FIV NEGATIVE
• FeLV POSITIF

• Trial pengobatan dengan antiretroviral: kondisi

membaik dalam 2 hari.

STUDI KASUS
• Without new, potentially curative, anti-coronaviral drugs (e.g. GC376, GS-441524 - not yet licensed),
FIP has a very poor prognosis.
• Veterinarians in many countries are not allowed to obtain or prescribe these unlicensed drugs but
many clients are sourcing the drugs themselves online.
• In some countries vets are supplying diagnostic and treatment monitoring support, without providing or
prescribing the drugs, to help support cat welfare.
• An accurate diagnosis is important to prevent unnecessary use of these drugs.
• Successful treatment indicators include improvement of clinical signs (e.g. reduced effusion, weight
increase) and laboratory parameters (e.g. decreasing globulin, bilirubin and AGP levels).
• Supportive treatment can include appetite stimulants for anorexia, effusion drainage (e.g.
thoracocentesis if dyspnoeic), anti-pyretic drugs.

Antiviral Drugs :
• GS 441524: not yet licensed
• Remdesivir (GS-5734): sudah ada produk legal di UK & Australia (injeksi dan oral). Di
Indonesia masih menggunakan human licensed injection
• Molnupiravir (EIDD-2801): belum ada scientific proved
• Mefloquine: anti malaria drugs Treatment
 Severe disease (anorexic, dehydrated, cat
Less severe disease (normal hydration, eating)
usually will be hospitalised)
Oral only treatment protocol:
An oral GS-441524 treatment only protocol is
1. Initial treatment with once daily intravenous
recommended if injectable not tolerated/
remdesivir (Table 1) for 3-4 days i.e. on days 1, 2, 3
possible financially:
± 4. This
dosageprovides a loading
needed) dailydose
oral of the drug. On
GS-441524 (Table 1) on 1. Once (or twice if very high neurological dosage
s each day, dilute the remdesivir dose required to a needed) daily oral GS-441524 (Table 1) until at
total volume of 10ml with saline and administer least day 84.
of slowly over 20-30 minutes manually or with a
NOTE ON WEIGHING CATS: It is very important to
syringe driver. Options for cost limited clients – please note
2. Follow with once daily subcutaneous remdesivir at that, ideally, therapy should be given using the
the same dosage (Table 1) up to day 7-14 recommended formulations and dosages for as long
3. Change to once (or twice) daily oral GS-441524 as possible (up to 84 days) to increase likelihood of
cure. Only take the options below if absolutely
(Table 1) on day 8-15, and continue until at least
necessary, as relapse may occur, which then requires
day 84. longer treatment, increasing costs;
tions for remdesivir and GS-441524
• Give oral GS-441524 treatment only for 84 days, as
Less severe disease (normal hydration, eating) outlined above;
1. Initial treatment with once daily subcutaneous • Give injectable remdesivir or oral GS-441524 for as
remdesivir (Table 1) up to day 7-14 many days as the owner can afford before switching
2. Change to once (or twice if very high neurological to oral mefloquine 62.5mg 2-3 times weekly (large
dosage needed) daily oral GS-441524 (Table 1) on cat, give 3 times a week) or 20-25mg orally once daily
day 8-15, and continue until at least day 84. (if reformulation of tablets is possible e.g. PCCA Ltd)
for completion of an 84-day treatment protocol;
mefloquine is cheaper than remdesivir and
GS-441524 but more research is needed to judge its
effectiveness in this situation;
• If an increase in remdesivir dosage is required (e.g.

Treatment Protocol due to neurological disease appearing during

treatment) but cannot be afforded, mefloquine
treatment can be added as adjunct treatment, as this
is cheaper than remdesivir, although more research is
needed to judge the effect of this combination;
• Feline interferon omega has also been used in the
 Table 1: Summary of dosage recommendations for remdesivir and GS-441524
Clinical presenta on Remdesivir – by injec on GS-441524 – oral
Cats with e usions and 10 mg/kg once daily 10-12 mg/kg once daily
without ocular or neurological
signs
No e usion and without 12 mg/kg once daily 10-12 mg/kg once daily
ocular or neurological signs
Ocular signs present (e usive 15 mg/kg once daily 15 mg/kg once daily
and non-e usive)
Neurological signs present 20 mg/kg once daily 10 mg/kg twice daily (i.e. 20
(e usive and non-e usive) mg/kg given as a divided dose)

ss severe disease (normal hydration, eating) Oral only treatment protocol:

Treatment Protocol
What should I expect during treatment? What do I need to monitor during treatment?
• In the first 2-5 days you should see an improvement • Ideally, serum biochemistry and haematology after 2
in demeanour, appetite, resolution of pyrexia and weeks and then monthly;
reduction in abdominal (Figure 3) or pleural fluid if • For cost limited clients, monitor
an effusion is present (note that in some cases weight/demeanour/effusions (e.g. by in-house
pleural fluid can transiently worsen in the first scanning)/neurological signs/key biochemical
couple of days– if the cat is at home, advise owner abnormalities only (e.g. measuring just globulin,
to measure resting respiratory rate, plus respiratory bilirubin or spinning microhaematocrit tube for
effort) – effusion typically resolves by 2 weeks; PCV/TP/colour of plasma);
• If an effusion is still present at 2 weeks, consider • NB. ALT enzyme activity may increase – it is not
increasing dosage to one that is greater than that clear if this is due to FIP pathology vs. drug reaction,
being used e.g increasing the dosage from that and it is not usually a reason to stop therapy. It is not
used for cats with effusions only; known if the addition of hepatoprotective therapy
• Serum albumin increases and globulin decreases (e.g.SAMe) is helpful in these cases;
(i.e. they normalise) over 1-3 weeks, but note that • Point-of-care ultrasonography (POCUS) to monitor
for effusion resolution and/or lymph node size.
globulins can initially increase when a large volume
effusion is absorbed;
• Lymphopenia and anaemia may take longer to If I am seeing a positive response to treatment,
resolve, up to 10 weeks; when do I stop treatment?
• Not before 84 days (12 weeks);
• Mild peripheral eosinophilia is a common finding
and may be a favourable marker for disease • Confirm resolution of previous abnormalities
resolution, as it is in COVID patients; (clinically, POCUS, serum biochemistry, and
haematology);
• Lymph node size reduces over a few weeks;
• Only stop treatment once cat has been normal
• If progress is not as expected, consider reviewing (clinically and on serum biochemistry and
the diagnosis (see below) and/or increasing dosage. haematology) for at least 2 weeks (ideally 4 weeks).

If I am seeing no response or only a partial

Treatment Protocol
 Article
pathogens
Unlicensed Molnupiravir
Article
is an Effective Rescue Treatment
Following Failure
Unlicensedof Unlicensed
MolnupiravirGS-441524-like Therapy
is an Effective Rescue for
Treatment
Cats with Suspected
Following Feline Infectious
Failure of UnlicensedPeritonitis
GS-441524-like Therapy for
Cats with Suspected Feline Infectious Peritonitis
Meagan Roy 1, Nicole Jacque 2 , Wendy Novicoff 3 , Emma Li 1 , Rosa Negash 1 and Samantha J. M. Evans 1, *
Meagan Roy 1 , Nicole Jacque 2 , Wendy Novicoff 3 , Emma Li 1 , Rosa Negash 1 and Samantha J. M. Evans 1, *

1 Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University,
1 Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University,
Columbus, OH 43210, USA OH 43210, USA
Columbus,
2 Independent Researcher,
2 San Jose, CA 95123, USACA 95123, USA
Independent Researcher, San Jose,
3 3 Departments of Orthopaedic Surgery and Public HealthSchool
Sciences,
Departments of Orthopaedic Surgery and Public Health Sciences, ofSchool of Medicine,
Medicine, University
University of Virginia,
of Virginia,
Charlottesville, VA 22903, USA
Charlottesville, VA 22903, USA
* Correspondence: [email protected]
* Correspondence: [email protected]
Abstract: Feline infectious peritonitis (FIP) is a complex and historically fatal disease, though recent
Abstract: Feline infectious
advancesperitonitis (FIP) ishave
in antiviral therapy a complex
uncovered and historically
potential fatal Adisease,
treatments. though recent
newer therapeutic option,
• NO scientific research yet advances in antiviral unlicensed
therapy molnupiravir, is being used
have uncovered as a first-line
potential therapy forAsuspect
treatments. newerFIPtherapeutic
and as a rescue therapy
option,
to treat cats who have persistent or relapsed clinical signs of FIP after GS-441524 and/or GC376
• Dosage range 10-15mg/kg BID PO unlicensed molnupiravir,
to treat cats who have
is being used as a first-line therapy for suspect FIP and as a rescue therapy
therapy. Using owner-reported data, treatment protocols for 30 cats were documented. The 26 cats
persistent or relapsed clinical signs of FIP after GS-441524 and/or GC376
treated with unlicensed molnupiravir as a rescue therapy were treated with an average starting
• 12 weeks treatment therapy. Using owner-reported data, treatment
dosage of 12.8 mg/kg and an averageprotocols
ending for 30 cats
dosage of 14.7were documented.
mg/kg The
twice daily for 26 catsof
a median

• Adverse effect: nausea/vomiting, muscle treated with unlicensed

Citation: Roy, M.; Jacque, N.;
dosage of 12.8 mg/kg
12 weeks
One cat
molnupiravir
and
(IQR = 10–15). as
wasaneuthanized
In a
average after
ending
rescue
total, 24 of therapy
completing
26 cats were
dosagetreatment
were
still treated
of 14.7 duemg/kg
with an at
living disease-free
to a prolonged
average
the time starting
seizure,
twice daily forand
of writing.
the otherof
a median cat
Novicoff, W.; Li, E.; Negash, R.;
wasting, leukopenia Evans, S.J.M.12
underwent retreatment for relapsed clinical signs. Few adverse effects were reported, with the most
weeks (IQR = 10–15). In total, 24 of 26 cats were still living disease-free at the time of writing.
Unlicensed
notable—folded ears (1), broken whiskers (1), and severe leukopenia (1)—seen at dosages above
Citation: Roy, M.; Jacque, N.; Molnupiravir is an Effective Rescue
One cat was euthanized 23 mg/kgafter completing
twice treatment
daily. This study providesdue to a of
a proof prolonged
principle forseizure,
the use ofand the otherincat
molnupiravir cats
Novicoff, W.; Li, E.; Negash, R.; Treatment Following Failure of
underwent retreatment
Unlicensed GS-441524-like Therapy
for relapsed
and supports clinical
the need signs.
for future Few
studies adverse
to further effectsmolnupiravir
evaluate were reported, with thesafe
as a potentially mostand
Evans, S.J.M. Unlicensed
for Cats withnotable—folded
Suspected Feline effective
ears therapy for
(1), broken FIP.
whiskers (1), and severe leukopenia (1)—seen at dosages above
Molnupiravir is an Effective Rescue
Infectious Peritonitis. Pathogens 2022,
23 mg/kg twice daily. This study provides a proof of principle for the use of molnupiravir in cats
Treatment Following Failure of 11, 1209. https://doi.org/10.3390/ Keywords: FIP; coronavirus; antiviral; EIDD-2801; black market

Molnupiravir EIDD-2801 Unlicensed GS-441524-like Therapy

and supports the
pathogens11101209
need for future studies to further evaluate molnupiravir as a potentially safe and
effective therapy for FIP.
for Cats with Suspected Feline Academic Editors: Alessia Giordano
Infectious Peritonitis. Pathogens 2022,
and Stefania Lauzi
1. Introduction
11, 1209. https://doi.org/10.3390/ Keywords: FIP; coronavirus; antiviral; EIDD-2801; black market
Received: 19 September 2022 Feline infectious peritonitis (FIP) is a complex and historically fatal disease caused
What new???
Control
! FCoV infection risk can be reduced by keeping cats in small (£3),
well-adapted groups (to reduce stress) with strict hygiene (sufficient,
frequently cleaned litter trays with clumping cat litter or outdoor

© Hannah Dewerchin, Ghent University, Belgium

access for toileting).
! In multi-cat households, where separation of cats is feasible, faeces
(free of cat litter) or rectal swabs can be tested by quantitative RT-
PCR for FCoV RNA to identify shedders and separate them from non-
shedders. In case of a negative result the possibility of intermittent
shedding has to be considered. To check this, multiple sampling
(ideally at least 3 x each 1-4 weeks apart) is necessary.

Prevention
! FCoV-infected cats should be kept in a low-stress environment.
! An intranasal FIP vaccine is available in some countries for cats over
16 weeks. However its efficacy is doubtful and it is ineffective in cats
previously infected by FCoV. ! Fluid accumulation in a Sphinx cat with FIP.

Control & Prevention

Thank you!
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