Heartworm disease in dogs and cats

In many areas of North America, April is the time of the year when veterinarians begin to check dogs and cats for exposure to heartworm organisms that may have occurred during the previous mosquito season. If your pet was infected last mosquito season, evidence of the disease may now begin to be detected. And like any other pathogenic situation, the earlier a diagnosis is made and treatment is begun, the better the chances are that the patient will recover properly. Give your veterinarian a call early in Spring about testing your pet for Heartworm.

Important facts About Heartworm:

  • Heartworms are a parasitic worm (about the diameter of thin spaghetti) that normally live free floating in the right ventricle of the heart and nearby blood vessels.
  • The parasites are transmitted from one individual to another by mosquitoes.
  • Heartworm is diagnosed with blood tests, and/or X-rays, along with other tests.
  • Heartworms are not detectable with the commonly used antigen blood test until they are sexually mature (about 6 months after entering the patient). Female worms must be present for accurate test results.
  • Heartworm has been diagnosed in all 50 states and also worldwide. In most areas of the country Heartworm is an important pet health care issue.
  • Heartworm is spread by the bites of infected mosquitoes.
  • In most areas of the USA, veterinarians recommend Heartworm prevention for dogs. Preventative measures in cats is also becoming more common as veterinarians continue to learn more about the parasite in cats and become skilled at recognizing the disease in cats. Previously it was thought that felines were not at a significant risk of getting Heartworm and that preventative was not needed. We are learning this is not necessarily true. The need for pre-exposure preventative medication in cats depends on the incidence of Heartworm in your area. Your local veterinarian is your best source of information.
  • Dogs should be tested FIRST? before starting heartworm preventatives unless they are less than 7 months old.
  • Dog?s over 7 months of age that are started on preventative without first testing for Heartworm are at an increased risk of developing severe reactions.
  • Puppies should be started on Heartworm preventative by 8 weeks of age (depending on the product being used) and then blood tested at 7 months of age.
  • Dogs should be tested on a regular basis, yearly if any doses of preventative have been missed and once every 2-3 years even if no doses were missed and preventative is given year around.
  • In the cat, the presence of Heartworm is difficult to detect with a blood test alone. Preventative medication is often started without testing unless signs of a Heartworm infection are noticed.
  • In cats, one worm can cause sudden death or sudden (acute) respiratory signs that are indistinguishable from asthma without a medical work up.
  • Any area where dogs can get Heartworm, cats can get them as well. The current rate of diagnosis ranges from 5 to 20% that of dogs in the same area.
  • The rate of cat Heartworm diagnosis varies by geographic area. As veterinarians continue to improve diagnostic techniques in cats, it is suspected there will be less variation from the canine incidence rate in the same area (5-20%). Until the last few years, it was thought that feline Heartworm disease was so rare that prevention was not needed in cats.
  • This view is changing as we learn that many cat Heartworm infections are overlooked since feline Heartworm disease does not commonly present with the same symptoms as dogs and the signs and symptoms look and act like other cat diseases.
  • The detection of adult Heartworms in cats can be difficult and tests are not 100% reliable.

Heart Worm Tests

There are several kinds of Heartworm tests performed on a blood sample. The most common ones are mentioned below.

  1. The most common one in practice is a Heartworm antigen test that looks for the presence of a protein given off by the sexually mature female worm actively producing microfilaria. There are several manufacturers that produce tests of variable sensitivity. They may miss infections if there are only 1-2 adult female worms present.
  2. Other types of tests look for the presence of microfilaria in the blood sample. One is a filter test that traps the tiny microfilaria in the filter. The treated blood is forced through a filter to trap the microfilaria for microscopic analysis. This test and the Knotts test treat the blood with a chemical to break down the blood cells. In the Knotts test, the solution is then spun in a centrifuge, the top part poured away, and the contents in the bottom portion of the test tube are examined under a microscope for the presence of Microfilaria. A positive diagnosis is made if microfilaria are present, however, Heartworm can be missed if there are very few microfilaria or the dog or cat has an Occult Heartworm infection.
  3. A third type of test looks for the presence of antibodies to the larval stage of the Heartworm. The down side of this test is that it only shows that the animal has had larval stages of Heartworm in its body at some time in the past. The antibodies persist for a while after all worms are dead. Therefore, a positive test is not proof of a current live Heartworm infection. This test just confirms exposure to Heartworms at some time in the pet?s life.

Heartworm Infection - versus - Heartworm Disease

Heartworm infection ? The host (dog, cat, or other animal) is parasitized by one or more stages of the Heartworm (Dirofilaria immitis). This does not mean that the host is sick, or has adults in the heart.

Heartworm Disease ? The host is sick. Heartworm infection is resulting in any number of problems caused by damage due to the presence of Heartworms in the heart and nearby blood vessels.

Signs - versus - Symptoms

Signs - A sign is any objective evidence of a disease that is perceptible to the examining doctor or person. Therefore it is what someone other than the patient observes about the patient and it may indicate a disease process. An example would be hearing another person cough or sneeze and thinking they may have a cold.

Symptoms - A symptom is what a patient perceives and communicates to someone what they perceive. Therefore a symptom is something experienced and felt by the patient and described by them.

Technically, signs and symptoms are used in human medicine and only signs in veterinary medicine. It is not unusual to see them used interchangeably even though technically they are completely different.

WHERE DO HEARTWORMS COME FROM?

We are not sure where they evolved originally but we do know they have been around for a long time. The first written canine documentation was in the ?Western Journal of Medicine? in 1847. The first documented cat infection was in the early 1900?s. We have learned much more about them and now know that in areas where dogs contract heartworm, cats can become infected too. Cats are simply less susceptible to becoming infected when exposed to the larvae deposited by a Heartworm-harboring mosquito.

The education of pet owners about Heartworms has increased significantly over the past twenty years. The spread of the disease has accelerated due to the trend of pets, and especially dogs, to travel everywhere with their owners. Pet owners often were unaware they were visiting Heartworm country, their pets became infected and the worm was brought back to their home environment unknowingly. Thus territories that never experienced Heartworm infections in the past started to see them. Heartworm disease is now wide spread and has been diagnosed in all 50 states in the USA as well as worldwide. Actually, cats have been found NOT to be a big factor in the spread of the heartworm disease.

WHAT ANIMALS ACQUIRE HEARTWORMS?

Most parasites have a specific host they prefer to infest. The normal host for Heartworm is the canine. Heartworms can live in animals other than canines but often have a shorter life, vary in size, or end up in odd locations due to aberrant migration. This is true of Heartworm infections in the feline. Some of the other animals that can acquire heartworm include the wolf, coyote, fox, bobcat, jaguar, tiger, muskrat, raccoon, ferret, otter, bear, horse, orangutan, gibbon, sea lion, and man.

IN THE DOG

THE LIFE CYCLE OF THE HEARTWORM

Mosquitoes zero in on the dog's nose!The key to understanding the importance of Heartworm to your pet?s health is to understand the life cycle of the worm and the damage that results due to its presence in your pet. Once this is understood then it will make sense why it is wiser to prevent a Heartworm infection than wait and treat the worm once it is present.

The fancy name for Heartworm in dogs and cats is Dirofilaria immitis. The heartworm goes through a total of four molts to mature into an adult worm. The first two occur inside the mosquito and the next two occur inside the final host. Heartworm disease begins with an infected animal that has circulating microfilaria in its blood. This infected animal is called the source. A mosquito stops by for a meal and inadvertently sucks up a number of circulating microfilaria in the blood. Once inside the mosquito?s body, the microfilaria go through two molts over 14 days or longer depending on the environment?s temperature. They go through their first two molts and change from an L1 to an L2 and then an L2 to an L3 (third stage of development of the larva). As an L3, they have migrated into the mosquito?s salivary glands and during the mosquito?s next meal they burrow into the victim through the mosquito's small bite wound.

Once inside an animal (host) where it continues development, the worm takes at least 6 to 7 months to go through the last two molts and to become sexually mature before the infection can be detected by a Heartworm test. The L3 larva goes through its first molt to the L4 within the first 15 days and as early as 2-5 days after infection. The second molt from the L4 to the L5 occurs within the next 2 months. The L5 larva is considered a juvenile adult and works it?s way through the host?s tissues all the way to the heart as early as 70 days after first entering the host. The majority of L5 larvae arrive in the heart by 90 days. They stay here and grow rapidly in length and size. The worm is home and will live here until it dies in 5-7 years.

Sexual maturity is achieved about three months after arrival in the heart. The worms actually continue to grow in size after reaching sexual maturity and the females start to pass microfilaria into the blood. Adult female worms have been known to grow up to 14 inches long and males are generally shorter. Some pets are infected with numerous worms, all traveling from the site of the mosquito bite to their preferred home in the heart. This mass of twisted and intertwined worms can serve as a significant mechanical blockage to the normal flow of blood. Think of a garden hose. If pieces of debris block the hose, pressure builds up due to the obstruction of the flow of water. This is what happens to the heart and blood vessels when more and more worms congregate within the right ventricle. The smaller the host the fewer worms it takes to cause a problem.

Once the worm becomes an adult it will continue to produce young for many years in the dog, and a shorter time in cats and other animals that are not the usual host for the worm. The adults have been documented to live around 7 years in the dog and 2-3 years in the cat. This completes the normal life cycle of the Heartworm.

Another factor to consider is that an animal can act as a source for future additional infesting mosquito bites, so over time unprotected dogs can develop a large number of adult worms in the heart. Also, some animals develop something similar to an allergy to the worms, or to the microfilaria, which results in the Occult Heartworm infections and can cause varying signs similar to allergies. This more elusive kind of infestation occurs most often in the cat. Cats seem to harbor only small numbers of adult worms, the worms are usually males only, microfilaria are rarely found in circulation, and signs of Heartworm infection can present as an allergic condition similar to asthma. It is not uncommon for infected cats to suddenly die from the effects of just a few worms.

SIGNS OF HEARTWORM DISEASE- IN THE DOG

Two major mechanisms result in the signs of Heartworm disease seen in dogs. The first is due to the damage the worms cause to the arteries in the lungs (called the Pulmonary arteries). The second is the mechanical obstruction of blood flow that results from the inflammation and the number of worms present.

When a dog is first infested with Heartworm there are no visible or detectable signs. The infection cannot be detected even with a blood test. The changes in the victim start to occur when the final molt of the Heartworm larvae occurs and the immature L5 larvae arrive in the right ventricle and neighboring blood vessels. The arteries do not do well with worms living inside them. The artery lining is damaged within days, the body responds by inducing inflammation of the artery, called endarteritis, and other inflammation in the area to try to heal the damage. Unfortunately, the worms cause damage at a rate faster than the body can heal. The arteries over time develop certain characteristics that are typical of Heartworm disease, often these changes can be seen on x-rays. The vessels become tortuous and dilated. Blood clots and aneurysms are a common side effect, and complete blockage of small blood vessels can occur. The blood re-routes to non-worm burdened arteries. The result is complete and partial blockage of blood vessels and fluid begins to accumulate around these blood vessels in the lungs. This results in a loss of useful lung tissue and reduces the effective area of the lungs to oxygenate the blood for the body?s needs. As a result of the inflammation, blood vessel obstruction, and fluid accumulation, coughing results. The dog or cat displays exercise intolerance, nosebleeds, shortness of breath and a type of pneumonia may occur secondary to the increase in lung inflammation (called pulmonary eosinophilic granulomatosis).

As immature L5 worms continue to arrive and mature in the heart and lungs, the total number of worms at various stages of maturity increase and as they grow in size and number the above conditions take their toll. The host?s reactions become more significant and the signs worsen. More and more blood vessels and the surrounding lung tissue are damaged and not useful to the dog and this results in an increased resistance to blood flow through the lungs. This ?backup? increases the blood pressure (hypertension) in the right side of the heart and Vena Cava due to the obstruction of blood flow. With accumulation of even more fluid in the lungs, the end result is the signs of actual heart failure. The severity depends on the number of worms present and the dog?s reaction to the worms. The failing, weakened, stretched heart muscle results in rhythm abnormalities, fluid accumulation in the lungs (called pulmonary edema) and exercise intolerance.

Over time, the immune system becomes ?turned on? at a rate higher than normal. This puts extra proteins (in the form of antibodies) into circulation and they can settle out in the various organs of the body that are delicate in nature such as the eye, kidney, blood vessels, and joints. This causes inflammation, more tissue damage, and pain.

One of the most severe signs of heartworm is called Caval Syndrome or Vena Cava Syndrome. This is seen when there are large numbers of adult worms (usually around 100 or more) in the heart. There is almost complete blockage of all blood flow. Many times there will be no signs of heart disease prior to the animal?s collapse. When fainting and collapse does occurred it is accompanied by severe shock, red blood cell destruction, and often death within 1-2 days. Sometimes the only chance for survival in these cases is for the veterinarian to surgically remove the worms from the heart through the jugular vein. If enough worms can be removed to re-establish sufficient blood flow, there is some chance of survival.

DIAGNOSIS OF HEARTWORM IN THE DOG

Any patient presented because of the suspicion of Heartworm Disease will have a thorough medical history taken, a complete physical exam performed, x-rays of the chest taken and routine blood chemistry tests done to evaluate the entire patient. The definitive diagnosis (proof of diagnosis) is usually made through the use of a Heartworm antigen test. Whole blood is drawn from the dog, stabilized so it will not clot, and tested for the presence of a protein shed by the female worm as she passes microfilaria. This test is very reliable and will detect worm burdens of 2-3 worms or higher.

The University of Illinois, College of Veterinary Medicine, Diagnostic LaboratoryAnother common test that can be used in conjunction with the antigen test is the Knotts test or Modified Knotts test. This is where whole blood is drawn and treated to cause the blood cells to break open. Then the sample is spun in a centrifuge, the top portion is poured off, and the bottom sediment is looked at under the microscope for the presence of microfilaria.

Usually once a diagnosis is made via a blood test, then X-rays, CBC (complete blood count), Chemistry profile (evaluates the function of the body?s organs), and Urinalysis are evaluated to determine the impact of the Heartworm infection on the dog?s health. Animals displaying signs of heart disease side effects may have a complete cardiac evaluation, or evaluation of any other area of the body that is indicated by the initial test results.

Canine patients will be staged for Heartworm Disease as part of the evaluation. This helps the practitioner decide which method of treatment would be best for the elimination of the Heartworms:

Stage I

Lowest risk... young healthy dogs with minimal Heartworm disease evident on X-rays and all other tests are normal.

Stage II

Moderately affected dogs... some coughing is noticed, some difficulty breathing, changes are seen on X-rays, and blood work may reveal some kidney and/or liver damage.

Stage III

Severely affected dogs... the patient has weight loss, coughing, difficulty breathing, more damage visible on x-rays, and blood tests shows kidney and/or liver damage.

Stage IV

Vena Cava Syndrome or Caval Syndrome... the dog is collapsing in shock, all of the above abnormalities are more intense and the dog is dying. They are initially treated with surgical jugular removal of some worms if possible. There is no guarantee this treatment will be successful and many patients with Caval Syndrome die in spite of attempts to treat.

HEARTWORM TREATMENT - DOGS

The bottom line: Heartworm is a significant disease in dogs and cats. The treatment involves managing the heart, vascular and systemic disease present as well as eliminating the parasites. The goal of treatment is to eliminate the worms one way or another so the animal?s body can rebuild itself and return to the best possible post-infection health. This sounds simple but it can be very complicated depending upon the number of worms present, the dog?s reaction to their presence, the patient?s general state of health, handling the side effects from the medication and the effects on the patient of the dead worms within the circulatory system.

By now, it is clear that the treatment varies from dog to dog. Each animal?s personal condition is evaluated and the treatment protocol tailored to best effect a full recovery with the least side effects. Therefore, this discussion of heartworm treatment will be very general regarding the medications used and the more common side effects. The specific treatment protocol for your pet will be left up to your veterinarian since there is no way to predict how each animal will react to Heartworm treatment.

Treatment involves two basic areas:
1st) Patient evaluation and stabilizing for treatment procedure.
2nd) Elimination of all forms (adult, larvae, and microfilaria) of the Heartworm parasite.

Patient evaluation and stabilization

This involves X-rays, blood tests, heart evaluation, and any other tests indicated to completely evaluate the pet. The veterinarian evaluates the over-all health of the animal, then determines how to best proceed with treatment. Part of this evaluation is staging the severity of the Heartworm Disease in the dog. Some animals need to have certain conditions stabilized before Heartworm treatment can proceed. Those in third stage Heartworm disease may require deliberation to decide if it is best to try surgical removal of some worms through the jugular vein before any other steps of parasite elimination are considered.

THE CAT AND HEARTWORM DISEASE

DIFFERENCES IN THE HEARTWORM LIFE CYCLE IN THE CAT

The cat is not the normal host for the Heartworm parasite. Since they are not the normal host, it is less common for cats to become infested. When Heartworm in the cat is seen, aberrant migration of the larvae is more common than in the dog and a Let's see... I hope that's not a mosquito! lower percentage of the worms actually end up in the heart. It is known that more of the larval worms die before they can mature in the cat than in the dog. Those worms that do reach adulthood live a shorter time as adults, 2-3 years in the cat versus 7 years in the dog. Also, for some reason, male cats seem to be more susceptible to getting Heartworm disease than female cats.

Those worms that do complete a normal migration to the heart can cause many problems since the cat?s heart and blood vessels are much smaller than comparative structures in the dog. The adult worms reach a shorter adult length of 5-8 inches versus approximately 14 inches in the dog. The other feature not unusual in cats is single sex Heartworm infections. This means no microfilaria can be produced which makes identification of Heartworm disease more difficult. These single sex infections are commonly male worms only. In those cats that do have microfilaria present in the circulation the numbers of microfilaria are fewer and the production much shorter in duration than in the dog. Cats often will have 1-2 worms when infected. Larger numbers have been seen and sometimes cats have similar signs as the dog, but this is not common.

Those worms that do complete a normal migration to the heart can cause many problems since the cat?s heart and blood vessels are much smaller than comparative structures in the dog. The adult worms reach a shorter adult length of 5-8 inches versus approximately 14 inches in the dog. The other feature not unusual in cats is single sex Heartworm infections. This means no microfilaria can be produced which makes identification of Heartworm disease more difficult. These single sex infections are commonly male worms only. In those cats that do have microfilaria present in the circulation the numbers of microfilaria are fewer and the production much shorter in duration than in the dog. Cats often will have 1-2 worms when infected. Larger numbers have been seen and sometimes cats have similar signs as the dog, but this is not common.

SIGNS OF HEARTWORM DISEASE IN THE CAT

The signs of Heartworm in the cat are usually much different than in the dog. A cat?s immune system is readily activated against Heartworms. So the signs of a cat with a heartworm infestation display more immune system responses than a similar infestation in the dog.

Cat owners must be aware that even a small number of Heartworms can cause sudden, serious, and even fatal disease in the cat. The main effect in cats is inflammation of the arteries (called endarteritis) and the surrounding tissues in the lungs. The amount of inflammation is much more exaggerated than what commonly occurs in dogs. The inflammation alone can result in partial to complete blocking of blood vessels. In cats, when worms die, complete blood vessel blockage often occurs. Depending upon where these blockages are located and the amount of inflammation, large portions of the lungs can be affected which results in a significant, often sudden breathing difficulty for the cat. The severity is also affected by the magnitude of the cat?s immune This little kitty should live into it's twenties with proper health care. system response. A single blocked blood vessel with a large inflammatory response can result in an emergency situation for the cat.

The cat?s highly reactive immune response to heartworms may be the reason we see some of the following signs in Feline Heartworm Disease?It is rare to find circulating microfilaria in the cat.

Cats acquire Heartworms at a lower rate than dogs.

Fewer worms cause much more severe reactions.

Often the preferred treatment is controlling the symptoms and allowing the worms to die naturally rather than risking treatment. Severe reactions may still occur when the adult worms die.

Worms live a much shorter time than in the dog? 2 to 3 years in the cat, 7 years in the dog.

One worm can cause a severe medical emergency.

Common signs associated with a Feline Heartworm Disease include lung disease associated with respiratory stress (difficulty breathing or rapid shallow breathing), gagging or vomiting, lethargy, loss of appetite, and weight loss. Some of the signs are difficult to distinguish from feline asthma. Sudden death may occur in cats, as well as it does in the dog, however only a few worms in the lungs of a cat can trigger a fatal outcome. In the average size dog a large number are generally required to cause a sudden fatality. Other signs indicating lung obstruction are a loss of coordination, seizures, blood from the nose, or collapse. If collapse does occur the cat may die despite treatment even if you are able to visit your veterinarian for treatment.

DIAGNOSING FELINE HEARTWORM

Diagnosing Heartworm in the cat is a bit more challenging than making the diagnosis in the dog. Since many infestations in Cats are beautiful... when they are healthy. cats are single sex (usually male worms) and therefore sterile with only a few adult worms, the typical antigen Heartworm test is not always successful in diagnosing the presence of adult Heartworms. The antibody Heartworm test does not distinguish between an old, resolved infestation and a currently active Heartworm case. Since blood tests are very simple and are test is positive, you do have your answer because that indicates live worms are present. Usually these tests are only done when a Heartworm infection needs to be ruled out as a cause of the cat?s abnormal signs. Since circulating microfilaria are so rare in the cat, the Knotts test and filter tests are not very useful. Once Heartworm disease in the cat is positively identified, the Knotts test may be done to see if microfilaria are present, but this test method is not performed on a routine basis to make a diagnosis. Most Feline Heartworm infections are diagnosed by presenting signs and history and by using ultrasound instrumentation, x-rays, non-specific angiograms, and other blood work to positively identify the presence of Dirofilaria immitis.

TREATMENT OF FELINE HEARTWORM DISEASE

In the cat, the treatment of choice may be no treatment at all! Certainly supportive therapy is utilized if a patient requires help. Supportive therapy is using medication to reduce the side effects of inflammation in the lungs. The usual choice is prednisone since aspirin can be toxic to cats. The need for supportive therapy, length of therapy, and use of other medications varies widely from cat to cat. Since the need for supportive treatment can be intermittent, and existing parasites may die suddenly creating an emergency, your understanding of what is going on and working closely with your veterinarian is very important to your cat?s survival and long-term health.

Intravenous injection only... for Heartworm treatment.

Usually adulticide treatment is only used on those cats in stable condition that do not respond well to the supportive care. Of the few cats that are treated, at least one third will have life-threatening complications due to the effects of dying worms. Currently, the adulticide used in cats is thiacetarsamide (Caparsolate). The other adulticide, Melarsomine dihydrochloride (Immiticide), is very toxic to cats. Occasionally worms that can be seen via ultrasound or some other reliable method may be surgically extracted. This is not a common procedure in the cat, though.