1216000 JFM Journal of Feline Medicine and SurgeryMüller et al

Original Article

Journal of Feline Medicine and Surgery

Abdominal ultrasonographic 1­–12

© The Author(s) 2023
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DOI: 10.1177/1098612X231216000
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Thiago R Müller1 , Dominique G Penninck1,

Cynthia RL Webster1 and Francisco O Conrado2

Abstract
Objectives The aim of this study was to describe the abdominal ultrasonographic findings in cats with confirmed
or presumed feline infectious peritonitis (FIP).
Methods This was a retrospective study performed in an academic veterinary hospital. The diagnosis of FIP
was reached on review of history, signalment, clinical presentation, complete blood count, biochemistry panel,
peritoneal fluid analysis, cytology and/or histopathology results from abnormal organs, and/or molecular testing
(immunohistochemical or FIP coronavirus [FCoV] RT-PCR). Cats with confirmed FIP by molecular testing or with a
highly suspicious diagnosis of FIP were included. Abdominal ultrasound examination findings were reviewed.
Results In total, 25 cats were included. Common clinical signs/pathology findings included hyperglobulinemia
(96%), anorexia/hyporexia (80%) and lethargy (56%). Abdominal ultrasound findings included effusion in 88% and
lymphadenopathy in 80%. Hepatic changes were noted in 80%, the most common being hepatomegaly (58%)
and a hypoechoic liver (48%). Intestinal changes were noted in 68% of cats, characterized by asymmetric wall
thickening and/or loss of wall layering, with 52% being ileocecocolic junction and/or colonic in location. Splenic
changes were present in 36% of cats, including splenomegaly, mottled parenchyma and hypoechoic nodules. Renal
changes were present in 32%, encompassing a hypoechoic subcapsular rim and/or cortical nodules. Mesenteric
and peritoneal abnormalities were seen in 28% and 16% of cats, respectively. Most cats (92%) had two or more
locations of abdominal abnormalities on ultrasound.
Conclusions and relevance The present study documents a wider range and distribution of ultrasonographic lesions
in cats with FIP than previously reported. The presence of effusion and lymph node, hepatic and/or gastrointestinal
tract changes were the most common findings, and most of the cats had a combination of two or more abdominal
abnormalities.

Keywords: Ultrasound; feline infectious peritonitis; abdomen; viral diseases

Accepted: 4 November 2023

Introduction diagnosis of FIP.7 In the absence of a definitive diagnosis,

Feline infectious peritonitis (FIP) has a high incidence background, clinical signs, routine laboratory tests and
in multi-cat populations and is most prevalent in young molecular analyses can be combined to establish a high
cats.1–3 The pathogenesis is still incompletely understood. index of suspicion of FIP.7,13
The FIP coronavirus (FCoV) is a monocyte/macrophage-
tropic mutant of the feline enteric coronavirus (FECoV).4,5
1Department of Clinical Sciences, Tufts University, Cummings
Two clinical manifestations are described; the effusive
School of Veterinary Medicine, North Grafton, MA, USA
and non-effusive forms.6 FIP is a systemic disease with 2Department of Comparative Pathobiology, Tufts University,

variable clinical and imaging presentations. Historically Cummings School of Veterinary Medicine, North Grafton, MA, USA
considered a fatal disease, recent research has revealed
Corresponding author:
efficacy of new antivirals in FIP treatment, making an
Dominique G Penninck DVM, PhD, DACVR, DECVDI, Department
early diagnosis even more critical.7–12 of Clinical Sciences, Tufts Cummings School of Veterinary
Immunohistochemistry (IHC) for the FCoV antigen in Medicine, 200 Westboro Road, North Grafton, MA 01536, USA
affected tissues is considered the gold standard for the Email: [email protected]

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2 Journal of Feline Medicine and Surgery 

A previous study has described the abdominal ultra- were evaluated. Evaluation of abdominal LNs included
sonographic (US) findings in 16 cats with FIP. 14 Cats thickness, echogenicity and margination. LNs >5 mm
had abdominal effusion (75%) or abnormalities in the thick were considered enlarged.16 Hepatobiliary assess-
kidneys (69%), lymph nodes (LNs) (56%) and/or liver ment included subjective liver size, echotexture and echo-
(37%). In 82% of the cats, the gastrointestinal (GI) tract genicity, focal lesions (number and size), common bile
was unremarkable.14 duct dilation (>4 mm), and gallbladder wall thickening
Our hypothesis was that FIP has a higher prevalence (>1 mm) and contents.17 GI tract evaluation included
of abdominal lesions, especially in the intestinal tract. The wall thickness, layering, and extent and distribution of
aim of our study was to describe abdominal US lesions lesion(s). Wall thickness was considered normal if it was
in cats with FIP and evaluate features that might support 2–4 mm for the stomach, up to 2.5 mm for the duodenum
its diagnosis. and jejunum, 2.8 mm for the ileum and 1.5 mm for the
colon.18 The splenic size was considered normal if the
Materials and methods mean thickness was ⩽1 cm, as previously described.19
Inclusion criteria Splenic echogenicity and echotexture were subjectively
The database of the Foster Animal Hospital for Small assessed. Renal evaluation included size, shape, echo-
Animals between 2013 and 2022 was searched for cats genicity, presence of focal lesions, subcapsular rim and
with a confirmed or highly suspicious diagnosis of FIP pyelectasia. Urinary bladder wall thickness and contents
and that had abdominal US performed within 7 days of were reported if abnormal.
admission. Historical and clinicopathologic information
was recorded, including sex, age, breed, presenting clini- Statistics
cal complaint, duration of clinical signs, complete blood Descriptive statistics were performed and data were pre-
count (CBC), serum biochemical findings, abdominal sented as median (range) for continuous variables and
fluid analysis, molecular testing, cyto/histopathologic frequency counts for categorical variables.
findings and outcome.
The diagnosis of FIP was established based on sig- Results
nalment, clinical presentation (fever, ascites, ocular A total of 25 cats met the inclusion criteria.7 Of them, 12
or neurologic signs), clinical pathology (low serum (48%) had a definitive diagnosis of FIP. These cats had
albumin:globulin ratio <0.6, lymphopenia <0.9 K/µ, supportive clinical presentation, clinical pathology, fluid
anemia [packed cell volume <30%]), highly proteina- analysis (8/12 cats), cytology (8/12 cats), histopathology
ceous effusion (>3.5 g/dl,13 reference interval [RI] <2.5 (4/12 cats) and either positive FCoV IHC on tissue or
g/dl; low to moderate cellularity, pyogranulomatous fluid (7/12 cats) or a positive FCoV RT-PCR test (5/12
inflammation, low albumin:globulin ratio <0.8), pyo- cats). In total, 13/25 cats were highly suspicious for FIP
granulomatous inflammation and vasculitis on tissue, based on supportive clinical presentation, clinical pathol-
positive FCoV antigen on immunohistochemistry (IHC) ogy, fluid analysis (7/13 cats) and/or cytology (7/13 cats)
on tissue or fluids or RT-PCR demonstrating FCoV mes- and/or histology (8/13 cats) consistent with pyogranu-
senger RNA (mRNA) in effusions.15 lomatous inflammation.
Cats with a definitive diagnosis of FIP had sup-
portive clinical presentation, and clinicopathologic Signalment and clinical presentation
and histopathologic findings, along with one of the The median age was 3.5 years (range 0.3–12.2 years). Of
following: (1) positive FCoV IHC on tissue or fluid; or the 25 cats, nine (36%) were aged <2 years and five (20%)
(2) positive FCoV RT-PCR mRNA on effusion. Highly were aged ⩾11 years. Most cats (n = 14) were domestic
suspicious cats had a supportive clinical presentation, shorthair cats. Other breeds included domestic longhair
low albumin:globulin ratio in serum, characteristic (n = 3), Siberian (n = 2) and one each of the following
fluid cytology (if effusion was present) and, if obtained, breeds: Ragdoll, Bengal, domestic medium hair, Maine
cyto/histopathology consistent with pyogranulomatous Coon, Egyptian Mau and Persian.
inflammation. Patients with known comorbidities were Of the 25 cats, 13 were spayed females, 11 were cas-
excluded. trated males and one was an intact male. Of the 25 cats,
seven were adopted from a shelter, seven were from a
Abdominal ultrasound multi-cat household, five were indoor-only with no other
Cats were scanned using an Epic 7G or an iU22, with a pets in the household and two were obtained from breed-
curvilinear 8–5 MHz, or linear 12–5 MHz or 18–5 MHz ers. Information about the environment was not available
transducer (Phillips). Images, video clips and reports for four cats.
were reviewed by a board-certified radiologist (DP) and The most common clinical signs in the 25 cats were
a diagnostic imaging resident (TM). anorexia/hyporexia (n = 20), lethargy (n = 14), vomiting
The presence, echogenicity, amount of peritoneal/ (n = 7), dehydration (n = 9), pyrexia (n = 9), diarrhea (n = 5)
retroperitoneal effusion and mesenteric fat echogenicity and weight loss (n = 5). Most cats (17/25) had a duration
Müller et al 3

of clinical signs of over 1 week and 8/25 cats had clinical Wall thickening affecting the ileum, cecum and colonic
signs for less than 1 week. Neurologic signs were noted in walls was seen in 5/6 cats, and loss of wall layering in
2/25 cats: one had seizures and the other had non-ambula- 2/5 cats. An ICJ marked thickening was seen in 1/6 cats
tory tetraparesis. Ocular signs were reported in 2/25 cats: (Figure 4). This lesion was heterogeneously hypoechoic,
one cat had anisocoria and the other had uveitis. with faint, ill-defined and irregular hyperechoic areas,
extending to the ascending and transverse colon with loss
Ultrasonographic findings of wall layering, extending approximately over 3.5 cm in
Individual US findings are presented in Table 1. All 25 length (case 10).
cats had ultrasonographic abnormalities. The jejunum had changes in 4/17 cats, with segmental
Abdominal effusion (peritoneal or retroperitoneal) muscular layer thickening in 3/4 cats. A long asymmetri-
was present in 22/25 cats (scant in seven cats, mild in cal thickened segment of jejunum (>15 cm) with altered
six cats, moderate in three cats and severe in six cats). to lost wall layering (up to 3.8 mm) was seen in 1/4 cats.
Effusion was anechoic in 13 cats and mildly echogenic The stomach and duodenum were unremarkable.
in nine cats. The spleen was abnormal in 9/25 (36%) cats; spleno-
The mesentery was abnormal in 7/25 cats. A hyper- megaly was observed in 7/9 cats and a mottled paren-
echoic/lobular mesentery was seen in 4/7 cats, and 3/7 chyma in 3/9 cats. Two small hypoechoic splenic nodules
cats had hypoechoic nodules. The peritoneum was thick- (up to 5 mm in diameter) were identified in another cat.
ened in 3/25 cats (Figure 1) and 1/25 cats had a parietal One cat had multiple small (up to 4.3 mm) hyperechoic
peritoneal nodule. nodules, thought to represent myelolipomas.
A total of 20/25 cats had LN changes. Multifocal Abnormal renal findings were seen in 8/25 cats:
abdominal lymphadenopathy (two or more LNs) was decreased corticomedullary distinction in five cats; a
identified in 13/20 cats and perinodal hyperechoic fat hypoechoic subcapsular rim in five cats (bilateral in three
was noted in 4/20 cats. The jejunal LNs were enlarged cats and unilateral in two cats) (Figure 5); and pyelecta-
and hypoechoic in 11/20 cats. Markedly enlarged (up to sia (up to 7 mm) in three cats. Of the eight cats, two had
20 mm), lobulated, hypoechoic jejunal LNs were noted bilateral renomegaly and two had unilateral renomegaly
in 1/11 cats (Figure 2). The ileocecal LNs were enlarged (up to 4.9 cm in length). Hyperechoic cortical nodules
(thickness up to 8.4 mm) and hypoechoic in 8/20 cats. were seen bilaterally in three cats and unilaterally in four
The colic LNs were enlarged and hypoechoic in 7/20 cats, cats (Figure 5).
measuring up to 18 mm. The hepatic LN was enlarged, The abdominal lesions had a predominantly multifo-
measuring up to 14 mm, and hypoechoic in 7/20 cats; 6/7 cal distribution with involvement of two or more organ/
cats had hepatic changes. The gastric LN was enlarged structures in 92% of cats.
(6 mm) in one cat. The pancreaticoduodenal LN was
enlarged and hypoechoic in 5/20 cats (thickness up to Clinical pathology and fluid analysis
10 mm). The medial iliac LNs were hypoechoic in 2/20 The serum albumin:globulin ratio was <0.77 in 24/25
cats. LN images were not available in 3/25 cats. (96%) cases. Of the 25 cats, 15 had anemia (hemato-
The liver was abnormal in 20/25 (80%) cats. Of them, crit <35); in 13/15 cats, this was non-regenerative.
hepatomegaly was noted in 13 cats. The liver was dif- Lymphopenia was present in 12/25 cats.
fusely hypoechogenic in 12 cats and diffusely hyperecho- Increased total serum bilirubin was seen in 10/25 cats
genic in five cats. Of the 20 cats, one had multiple small (median 2 mg/dl; range 0.5–8.3 mg/dl; RI <0.3 mg/dl).
(up to 2.4 mm) hyperechoic nodules, some distorting the Serum alkaline phosphatase (188 U/l, RI <79 U/l) or
capsule (Figure 3). One cat had gallbladder wall thicken- serum alanine aminotransferase (224 U/l; RI <145 U/l)
ing (3 mm) and a mildly distended common bile duct was increased in only one cat. Of the 25 cats, nine had
(5 mm). The pancreas was unremarkable in all cats in an increase in serum aspartate aminotransferase, which
which it was imaged (20/25 cats). was typically very mild (median 78 U/l; range 61–232
Intestinal abnormalities were found in 17/25 cats, U/l; RI <42 U/l). All of these cats also had increased
with 13/17 being ICJ and/or colonic changes. Of these serum bilirubin. In 4/9 cats with increased serum aspar-
13 cats, in six, primarily ICJ lesions were noted, and in tate transaminase (AST), there was a concurrent increase
nine, colonic lesions were noted. Of the nine cats with in creatinine kinase activity, suggesting a muscle source
colonic lesions, two had a mass-like lesion marked by for the serum AST. Two cats had an elevated serum cre-
eccentric, mixed echogenicity and colonic wall thicken- atinine concentration.
ing, measuring up to 3 cm in width. The remaining 7/9 The results of the fluid analysis are summarized in
cats showed colonic wall thickening (up to 6 mm; range Table 2.
2.6–6 mm). An abdominal fluid analysis was performed in 15/25
Ileal wall thickening (up to 6 mm) with altered layer- cats and revealed high protein content most consist-
ing (thickened muscular layer) was noted in 2/17 cats. A ent with FIP. Results included exudates with mixed
total of 6/17 cats had ileocecocolic junction (ICJ) lesions. inflammation in five cats, exudates with neutrophilic
 4

Table 1 Summary of abdominal ultrasonographic findings in 25 cats with confirmed or presumed feline infectious peritonitis (FIP): cases 1–12 are confirmed; cases
13–25 are highly suspicious for FIP

Case Effusion Mesentery Lymphadenopathy Liver Intestinal tract Spleen Kidneys

1 Mild NA Jejunal, colic NA NA Two small LK: hyperechoic nodule and

(retroperitoneal) hypoechoic pyelectasia
nodules
2 Scant NA PD Hypoechoic Thickening with lost wall layering NA NA
hepatomegaly of the ICJ and transverse and
proximal descending colon
3 Severe Hyperechoic, Ileocecal Hypoechoic Diffuse SI muscularis thickening NA NA
lobulated
4 Severe Hyperechoic, NI Hepatomegaly NA NA NA
lobulated*
5 Mild NA Hepatic, PD, Hypoechoic ICJ thickening with altered Mottled NA
jejunal, ileocecal, hepatomegaly layering and focal lost layering
colic
6 Severe Hyperechoic, NI Hypoechoic NA Splenomegaly NA
lobulated* hepatomegaly
7 Severe Hypoechoic nodules PD, jejunal Hyperechoic NA Splenomegaly NA
hepatomegaly
8 Moderate Hypoechoic nodules Jejunal, ileocecal Hepatomegaly Thickened, layered ileum NA NA
9 Severe Hyperechoic, NI Hyperechoic NA Splenomegaly, NA
hypoechoic nodules* hyperechoic
nodules
10 No NA Ileocecal, colic NA ICJ mass. Descending colonic NA NA
wall thickening
11 Mild NA Ileocecal Hypoechoic Descending colon thickening NA NA
12 Scant NA Hepatic, jejunal, Hypoechoic ICJ thickening with altered NA NA
ileocecal hepatomegaly layering
13 Scant NA Hepatic, PD, medial Hyperechoic Focal colonic wall thickening, Mottled RK: renomegaly,
iliac hepatomegaly altered to lost layering splenomegaly subcapsular rim
14 Moderate Peritoneal nodule Jejunal, colic Hepatomegaly, Thickened descending colon with Splenomegaly NA
hyperechoic reactive lymphoid nodules
nodules
15 Scant NA Hepatic, colic NA Eccentric thickening of NA NA
descending colon, altered layering

(Continued)
Journal of Feline Medicine and Surgery 
 Müller et al

Table 1 (Continued)

Case Effusion Mesentery Lymphadenopathy Liver Intestinal tract Spleen Kidneys

16 Scant NA NA Hyperechoic NA NA NA
17 Moderate NA Jejunal NA Jejunal thickening, altered to lost NA Bilateral subcapsular rim and
layering hyperechoic nodules
18 Scant NA NA NA NA NA Bilateral renomegaly,
(retroperitoneal) subcapsular rim, pyelectasia,
hyperechoic nodules
19 Severe Hyperechoic and PD Hypoechoic Thickened descending colon, Splenomegaly RK: hyperechoic nodule and
lobulated altered to lost layering subcapsular rim
20 Mild NA Hepatic, ileocecal, Hypoechoic Jejunal thickening. ICJ thickening NA LK: renal nodule
colic
21 Mild NA Jejunal Hypoechoic NA NA NA
22 No NA Jejunal, ileocecal Hyperechoic ICJ thickening with altered to lost NA NA
hepatomegaly layering
23 Mild NA Hepatic, gastric Hypoechoic Jejunal wall thickening, altered Mottled NA
hepatomegaly layering. Descending colon: splenomegaly
eccentric thickening
24 Scant NA Jejunal Hypoechoic Thickened ileum with altered to NA Bilateral renomegaly,
hepatomegaly loss of layering subcapsular rim, pyelectasia,
cortical nodules
25 No NA Hepatic, jejunal, Hypoechoic Thickened colonic wall, lost NA LK: cortical nodules
colic, medial iliac hepatomegaly layering

*Also showed a thickened parietal peritoneum

ICJ = ileocecocolic junction; LK = left kidney; NA = no abnormalities detected; NI = not identified; PD = pancreaticoduodenal lymph node; RK = right kidney; SI = small intestine
5
6 Journal of Feline Medicine and Surgery 

Figure 1 Longitudinal ultrasonographic (US) image of the abdomen in a 12-year-old female cat with feline infectious
peritoniris (case 9). (a) Part of the moderately thickened parietal peritoneum is seen between the calipers (2.6 mm). (b) The
hyperechoic mesentery appears nodular (between the calipers: 1.2 cm) and irregular. Anechoic peritoneal effusion (asterisk)
was also present.

Figure 2 Jejunal suppurative lymphadenitis in a 7-month-old

female cat (case 21). Longitudinal ultrasound image of the Figure 3 Longitudinal ultrasound image of the liver in an
enlarged jejunal lymph nodes. Note the cranial mesenteric 8-year-old male neutered cat with feline infectious peritonitis
vein (asterisk). The most dorsally located jejunal lymph (case 14). A 2.4 mm ellipsoid hyperechoic nodule (cursors)
node is markedly enlarged, hypoechoic, with an ill-defined is noted within the periphery of the liver, bulging along the
anechoic cranial pole (white arrow) and slightly lobulated. hepatic capsule. Serosal granuloma was diagnosed by
Regional perinodal fat is hyperechoic, supportive of steatitis histopathology. Slightly echogenic peritoneal effusion is also
(white arrowhead) noted (asterisk)

inflammation in three cats, high-protein transudate with US-guided fine-needle aspiration of abdominal struc-
mixed inflammation in six cats and with neutrophilic tures was performed in 15/25 cases. Histopathology was
inflammation in one cat. In all 15 cases, neutrophils were available in 12/25 cats: on post-mortem (n = 9); US-guided
non-degenerate, and no infectious organisms were iden- tissue biopsies of liver (n = 1 [case 11]); colonic wall/
tified. Bacterial culture was not performed on any of the mass and LNs (n = 2 [cases 10 and 11]); and enucleated
abdominal fluid samples. eye (n = 1). Case 11 had a liver biopsy and post-mortem
evaluation. The post-mortem evaluation revealed lesions
Cytology and necropsy typical of FIP13 in all nine cats.
Individual cytologic and histopathologic findings are pre- Hepatic abnormalities were noted in 8/12 cats with
sented in Table 2. histopathology, including granulomatous hepatitis
Müller et al 7

Figure 4 Transverse ultrasound image of (a) the ascending colon and (b) ileocolic junction in a 3-year-old female cat with feline
infectious peritonitis (case 10). (a) The ascending colon is thickened with lost wall layering (between the calipers: 8.5 mm).
(b) An ileocecocolic junction-centered colonic wall thickening with loss of wall layering (between the calipers: 8 mm). The ileum
is also seen (asterisk)

Figure 5 (a) Parasagittal ultrasound image of the right kidney in an 8-month-old cat with feline infectious peritonitis (case 19)
showing a 1 cm hyperechoic cortical nodule (cursors). There is concurrent retroperitoneal anechoic effusion (asterisks). (b)
Pyogranulomatous nephritis in a 1-year-old cat with feline infectious peritonitis (case 18). Longitudinal ultrasound image of the
enlarged (4.7 cm long) right kidney with heterogeneous parenchyma and slightly irregular margination. A thin hypoechoic rim
is also noted at the outer cortical (white arrow). The perirenal fat is hyperechoic. The asterisk indicates a scant amount of urine
in the renal pelvis. Pyogranulomatous nephritis was diagnosed on necropsy

(n = 3), moderate to severe lipidosis (n = 2), lympho­ lymphoplasmacytic nephritis in one cat (case 16) with an
plasmacytic portal hepatitis (n = 1) and peliosis hepatis unremarkable kidney on US.
(n = 1). A total of 11 cats had cytologic (n = 6) or histopatho-
Intestinal histopathology was abnormal in 5/12 cats. logic (n = 5) evidence of pyogranulomatous (n = 8) or
Multifocal pyogranulomatous or lymphohistiocytic suppurative inflammation (n = 3) in one or more abdomi-
lesions (vasculitis or enterocolitis) were seen in five cats nal LNs; all these LNs were abnormal on US.
(cases 10, 11, 21, 22 and 24). Cat 22 had inflammatory
lesions confined to the intestinal lymphatic vessels. Outcome
Pyogranulomatous splenitis (in 2/12 cats) and acute Of the 25 cats, 12 were euthanized during the first week
fibrino-necrotizing capsulitis (in 1/12 cats) were diag- of presentation. Three were euthanized after 1, 3 and 5
nosed on splenic cytology or histopathology. The cats months of supportive care treatment, owing to worsen-
with pyogranulomatous splenitis had either hypoechoic ing of clinical signs. Of the 25 cats, eight were discharged
nodules or mottled splenomegaly on US, while the cat with supportive care and lost to follow-up. Two cats
with capsulitis had a normal spleen on US. (cases 5 and 12) treated with a trial drug for FIP (GS-
Abnormal renal histopathology was noted in 5/12 cats 441524)20 showed improvement of the clinical signs and
and revealed pyogranulomatous nephritis and vasculitis resolution of abdominal effusion. Case 5 had an ultra-
in four cats (cases 1, 18, 20 and 24), and neutrophilic and sound 10 weeks after therapy, which showed resolution
 8
Table 2 Summary of clinical signs, histopathology, necropsy, cytology, abdominal fluid analysis and molecular testing in 25 cats with confirmed or presumed feline
infectious peritonitis (FIP): cases 1–12 are confirmed; cases 13–25 are highly suspicious for FIP

Case Clinical signs Histopathology and necropsy Cytology Abdominal fluid analysis PCR or IHC
positive

1* Fever, lethargy Necropsy: lymphoplasmacytic portal Kidney: possible neutrophilic None IHC
hepatitis. Pyogranulomatous lymphadenitis, inflammation
nephritis, splenitis, meningoencephalitis and
pleuropneumonia
2 Diarrhea, lethargy Ocular signs: uveitis and pyogranulomatous None None IHC
perineuritis
3 Fever, emesis, None None High-protein transudate (mixed IHC
anorexia inflammation)
4 Fever, lethargy, None Mesentery: mixed neutrophilic/ None PCR
emesis. macrophagic inflammation
5 Fever, lethargy, None None Exudate (neutrophilic PCR
weight loss inflammation)
6 Fever, lethargy, None Possible mild neutrophilic hepatitis Exudate (neutrophilic PCR
anorexia inflammation)
7 Emesis, anorexia None Liver: possible neutrophilic inflammation Exudate (mixed inflammation) PCR
Jejunal LN: neutrophilic/macrophagic
inflammation
8 Chronic diarrhea, None Mesenteric nodule: necrosis with mixed Exudate (neutrophilic IHC
hyporexia, lethargy inflammation inflammation)
9 Fever, hyporexia, None None High-protein transudate IHC
lethargy (neutrophilic inflammation)
10 Fever, lethargy, Biopsy: ICJ: pyogranulomatous enterocolitis and Colon: neutrophilic inflammation None IHC
emesis lymphadenitis Jejunal LN: reactive
11 Chronic diarrhea, Biopsy: pyogranulomatous lymphoplasmacytic Colon: mixed inflammation High-protein transudate (mixed IHC
lethargy, anorexia hepatitis, colitis and peritonitis Colic LN: non-diagnostic inflammation)
Necropsy: diffuse severe peritonitis
Pyogranulomatous vasculitis and enterocolitis
12 Weight loss, None Jejunal lymph node: moderate High-protein transudate (mixed PCR
hyporexia neutrophilic/macrophagic inflammation inflammation)
Scant heterogeneous lymphoid
population
13 Hyporexia Biopsy: hepatic pyogranulomas Spleen and liver: moderate neutrophilic/ None
macrophagic inflammation
14 Hyporexia Necropsy: pyogranulomatous serositis and None High-protein transudate (mixed
vasculitis (diffuse) inflammation)
15 Constipation, None Non-diagnostic Exudate (mixed inflammation)
hyporexia

(Continued)
Journal of Feline Medicine and Surgery 
Table 2 (Continued)

Case Clinical signs Histopathology and necropsy Cytology Abdominal fluid analysis PCR or IHC
Müller et al

positive

16* Fever, hyporexia, Necropsy: fibrinous peritonitis and pleuritis None None
weight loss Hepatic lipidosis with lymphoplasmacytic portal
infiltrate. Neutrophilic and lymphoplasmacytic
interstitial nephritis. Meningoencephalitis
17 Fever, anorexia None Kidney: mild neutrophilic inflammation High-protein transudate (mixed
Liver: neutrophilic inflammation; mild inflammation)
hepatocellular lipid vacuolation
Spleen: no evidence of inflammation or
neoplasia
18 Weakness, Necropsy: pyogranulomatous and None None
hyporexia lymphoplasmacytic nephritis and vasculitis
Multifocal telangiectasis (peliosis hepatis)
19 Anorexia, weight None None High-protein transudate (mixed
loss inflammation)
20 Fever, hyporexia Necropsy: bicavitary serofibrinous effusion None Exudate (mixed inflammation)
weight loss Pyogranulomatous to suppurative lymphadenitis
and nephritis. Fibrino-necrotizing splenic
capsulitis cholestasis; multifocal, acute hepatic
necrosis
21 Fever, hyporexia, Necropsy: omentum, small intestine, lymph Jejunal LN: neutrophilic inflammation Exudate (mixed inflammation)
lethargy node: lymphohistiocytic vasculitis with fibrinoid
necrosis. Suppurative lymphadenitis with
fibrinous peritonitis. Acute pulmonary edema
22 Fever, hyporexia, Necropsy: pyogranulomatous and necrotizing Marked hepatocellular distinct None
lethargy lymphadenitis. Hepatic lipidosis; neutrophilic vacuolation (lipid), possible neutrophilic
cholangitis; lymphoplasmacytic periportal inflammation. Lymph node: neutrophilic/
hepatitis. Small intestine (Peyer’s patches): macrophagic inflammation, possible
pyogranulomatous lymphadenitis necrosis
23 Fever, hyporexia, None ICJ mass: neutrophilic inflammation Exudate (mixed inflammation)
lethargy
24 Anorexia, lethargy Necropsy: pyogranulomatous nephritis, None None
enterocolitis, lymphadenitis, hepatitis and
vasculitis
25 Anorexia, lethargy None Hepatic and medial iliac LN: None
pyogranulomatous lymphadenitis

*Cases that had concurrent neurologic signs

ICJ = ileocecocolic junction; IHC = immunohistochemistry; LN = lymph node
9
10 Journal of Feline Medicine and Surgery 

of the pretreatment hepatic and intestinal lesions. Case 12 effusion, we speculate that the presence of fluid facilitates
received antiviral treatment for 5 weeks and had resolu- the identification of these lesions on US.
tion of the previously seen ICJ-centered thickening at a Out of 25 cats, 20 had evidence of lymphadenopathy,
2-month US recheck, though hypoechoic hepatomegaly which is often reported with FIP.28,32 Differential diagno-
persisted. ses for abdominal lymphadenopathy in cats include infec-
tious diseases (eg, fungal, protozoal, bacterial), round cell
Discussion neoplasia (RCN) and reactive lymphadenomegaly.33–36
The present study supports our hypothesis that FIP has The liver is frequently affected in FIP.37–40 In our study,
a high prevalence of abdominal US lesions, more than 20/25 (80%) cats had diffuse or focal hepatic ultrasono-
previously described.14 Abdominal effusion was the most graphic changes. The most common US abnormalities
common finding on US (88%). Ultrasound lesions in the in our study were hepatomegaly (13/25, 52%) and dif-
LNs (80%), liver (80%) and intestines (68%) were also fuse hypoechogenicity (12/25, 48%). Too few cats had
common. In addition, all cats had two or more affected histopathologic evaluation of the liver to draw any con-
areas on ultrasound. clusions about typical US changes. In terms of clinical
In the present study, US lesions affecting the intestines pathology, 9/10 cats with hyperbilirubinemia had ultra-
were seen in 68% (17/25) of cats, compared with 13% in sound abnormalities of the liver, with the most common
a previous publication.14 Ileocecocolic and ICJ/colonic findings being hepatomegaly (n = 6) and a hypoechoic
changes were most common, with an incidence of 52% echotexture (n = 7). Likewise, a high percentage of cats
(13/25 cats). The most common abnormalities were wall with elevated serum AST (n = 8) had an abnormal liver on
thickening (11/17 cats) and altered to lost wall layer- US, with the most common finding being a hypoechoic
ing (11/17 cats). Three cats had marked thickening in liver (n = 6). The one cat with an increased serum ALT
the colon (n = 2) or at the ICJ (n = 1). Differential diagno- had a normal US.
ses for these lesions would include neoplasia (eg, lym- The spleen showed US abnormalities in 9/25 (36%)
phoma, mast cell tumor, carcinoma), fungal disease and cats, while a previous study reported splenic changes
feline gastrointestinal eosinophilic sclerosing fibroplasia in only 12% of cats.14 Splenomegaly was the most com-
(FGESF). Neoplastic lesions tend to be poorly echogenic mon abnormality; however, it is difficult to assess the
with more extensive loss of wall layering than seen in clinical relevance of this finding as only 3/9 cases had
this study.21–23 The mixed echogenicity within the lesions histopathological confirmation. Pyogranulomatous
in our study likely corresponded to fibrotic regions. This necrotizing splenitis and acute fibrino-necrotizing splenic
change can also be seen in sclerosing mast cell tumors or capsulitis, seen in our study, have been reported in FIP.28
FGESF.24–26 Therefore, cytologic or histopathologic evalu- A mottled spleen was seen in three cats in our study pop-
ation of intestinal lesions remain necessary to confirm ulation. This is a non-specific US finding and has been
the diagnosis. reported with extramedullary hematopoiesis, lymphoid
The effusive form is the most common presentation of hyperplasia, passive congestion, round cell neoplasia,
FIP27 and acquisition of fluid from these cats for analysis carcinoma, histiocytic sarcoma, as well as granulomatous
is important in establishing a diagnosis of this viral dis- splenitis.23,41–43
ease. Ultrasound was able to identify abdominal effusion Renal lesions in our population included renomeg-
in 22/25 (88%) cats, with seven (28%) cats having only a aly in 4/25 (16%) cats and the presence of a subcapsular
scant amount. Thus, US evaluation permits the identifica- hypoechoic rim in 5/25 (20%) cats. A higher prevalence
tion and acquisition of fluid even in cats with no obvious of these lesions (31%) was previously reported.14 The
effusion on physical examination, including those with hypoechoic rim in FIP may be due to cellular infiltration
neuro/ocular changes. in the outer renal cortex,37 similar to renal lymphoma.44
Of the 25 cats, 11 had US abnormalities of the mes- Hyperechoic cortical nodules were seen in 4/5 cats in
entery or parietal peritoneum. These US findings had our study and, histopathologically, pyogranulomatous
not been previously reported in cats with FIP and may inflammation typical of FIP lesions was documented.14
be secondary to granulomatous-necrotizing processes.28 Only one cat with renal ultrasound changes had ele-
Differential diagnoses for the mesenteric changes would vations in serum urea nitrogen or creatinine, indicating
include carcinomatosis, lymphomatosis, sarcomatosis, the likely presence of subclinical disease in some cats
mesothelioma or chronic peritonitis.29,30 Thickened pari- with FIP.
etal peritoneum (3/25 cats) and parietal peritoneal nod- Two cats in this study received a novel antiviral ther-
ule (1/3 cats) were not previously reported in FIP. The apy8,9,12,13,20 and follow-up US showed partial to com-
thickened peritoneum likely corresponds to the fibrin- plete resolution of changes, suggesting that US may be
ous serositis/peritonitis described in FIP.31 Since all cats a valuable tool in assessing response to treatment with
with these changes had moderate to severe abdominal this trial drug. Persistent US changes despite curative
Müller et al 11

treatment with antiviral therapy have been documented ORCID iD Thiago R Müller https://orcid.org/0000-0002-
in cats with FIP.9,12 Hence, a better understanding of FIP 7494-8588
lesions that are detectable with ultrasound pretreatment
Francisco O Conrado https://orcid.org/0000-0001-5055-2637
is beneficial.
The present study has some limitations. These include a
References
lack of the gold standard diagnosis in 13 cats, the collection
1 Riemer F, Kuehner KA, Ritz S, et al. Clinical and laboratory
of data from ultrasonographic examinations performed features of cats with feline infectious peritonitis – a retro-
by different operators and ultrasound machines, which spective study of 231 confirmed cases (2000–2010). J Feline
may have led to inconsistency in documenting findings, Med Surg 2016; 18: 348–356.
a lack of histopathologic or cytologic correlates to all the 2 Felten S and Hartmann K. Diagnosis of feline infectious
US changes detected, and a small sample size, especially peritonitis: a review of the current literature. Viruses 2019;
when evaluating imaging findings for a multi-organ dis- 11. DOI: 10.3390/v11111068.
tributed disease. Larger prospective multi-institutional 3 Rohrbach BW, Legendre AM, Baldwin CA, et al. Epidemi-
studies focused on in-depth correlation between imaging ology of feline infectious peritonitis among cats exam-
and histopathologic features are encouraged, especially ined at veterinary medical teaching hospitals. J Am Vet
Med Assoc 2001; 218: 1111–1115.
in the light of promising antiviral treatment.
4 Foley JE, Lapointe JM, Koblik P, et al. Diagnostic features
of clinical neurologic feline infectious peritonitis. J Vet
Conclusions Intern Med 1998; 12: 415–423.
We report a high incidence of ultrasonographic abnormal- 5 Pedersen NC. An update on feline infectious peritonitis:
ities in the liver, LNs, GI tract, mesentery/peritoneum, virology and immunopathogenesis. Vet J 2014; 201: 123–132.
spleen and kidney in cats with FIP. All cats had two or 6 Pedersen NC. A review of feline infectious peritoni-
more abnormalities on abdominal US, likely reflecting tis virus infection: 1963–2008. J Feline Med Surg 2009;
the multisystemic nature of this infection, despite non- 11: 225–258.
specific signs and neuro/ocular abnormalities. 7 Thayer V, Gogolski S, Felten S, et al. 2022 AAFP/EveryCat
feline infectious peritonitis diagnosis guidelines. J Feline
Although the US imaging features were not specific,
Med Surg 2022; 24: 905–933.
the combined presence of effusion and involvement of
8 Krentz D, Zenger K, Alberer M, et al. Curing cats with
several organs, along with the signalment, history, clinical feline infectious peritonitis with an oral multi-compo-
signs and clinicopathologic data, assist in prioritizing FIP nent drug containing GS-441524. Viruses 2021; 13. DOI:
as a diagnosis. In addition, US facilitates the sampling of 10.3390/v13112228.
abdominal fluid and/or affected organs for histopathol- 9 Zwicklbauer K, Krentz D, Bergmann M, et al. Long-term
ogy, immunohistochemistry or molecular testing, which follow-up of cats in complete remission after treatment of
are critical in making a definitive diagnosis of FIP. feline infectious peritonitis with oral GS-441524. J Feline
Med Surg 2023; 25. DOI: 10.1177/1098612X231183250.
Conflict of interest The authors declared no potential 10 Green J, Syme H and Tayler S. Thirty-two cats with effu-
conflicts of interest with respect to the research, authorship, sive or non-effusive feline infectious peritonitis treated
and/or publication of this article. with a combination of remdesivir and GS-441524. J Vet
Intern Med 2023; 37: 1784–1793.
Funding The authors received no financial support for the 11 Coggins SJ, Norris JM, Malik R, et al. Outcomes of treat-
research, authorship, and/or publication of this article. ment of cats with feline infectious peritonitis using
parenterally administered remdesivir, with or without
Ethical approval The work described in this manuscript transition to orally administered GS-441524. J Vet Intern
involved the use of non-experimental (owned or unowned) Med 2023; 37: 1772–1783.
animals. Established internationally recognized high standards 12 Taylor SS, Coggins S, Barker EN, et al. Retrospective study
(‘best practice’) of veterinary clinical care for the individual and outcome of 307 cats with feline infectious peritonitis
patient were always followed and/or this work involved the treated with legally sourced veterinary compounded prep-
use of cadavers. Ethical approval from a committee was there- arations of remdesivir and GS-441524 (2020–2022). J Feline
fore not specifically required for publication in JFMS. Although Med Surg 2023; 25. DOI: 10.1177/1098612X231194460.
not required, where ethical approval was still obtained, it is 13 Tasker S. Diagnosis of feline infectious peritonitis: update
stated in the manuscript. on evidence supporting available tests. J Feline Med Surg
2018; 20: 228–243.
Informed consent Informed consent (verbal or written) 14 Lewis KM and O’Brien RT. Abdominal ultrasonographic
was obtained from the owner or legal custodian of all animal(s) findings associated with feline infectious peritonitis:
described in this work (experimental or non-experimental a retrospective review of 16 cases. J Am Anim Hosp Assoc
animals, including cadavers) for all procedure(s) undertaken 2010; 46: 152–160.
(prospective or retrospective studies). No animals or people are 15 Simons FA, Vennema H, Rofina JE, et al. A mRNA PCR for
identifiable within this publication, and therefore additional the diagnosis of feline infectious peritonitis. J Virol Meth-
informed consent for publication was not required. ods 2005; 124: 111–116.
12 Journal of Feline Medicine and Surgery 

16 d’Anjou MA and Carmel EN. Abdominal cavity, lymph 30 Morgan KRS, North CE and Thompson DJ. Sonographic
nodes, and great vessels. In: Penninck D and d’Anjou MA features of peritoneal lymphomatosis in 4 cats. J Vet Intern
(eds). Atlas of small animal ultrasonography. 2nd ed. Iowa: Med 2018; 32: 1178–1184.
John Wiley & Sons, 2015, pp 455–480. 31 Weiss RC and Scott FW. Pathogenesis of feline infectious
17 d’Anjou MA and Penninck D. Liver. In: Penninck D and peritonitis: pathologic changes and immunofluorescence.
d’Anjou MA (eds). Atlas of small animal ultrasonography Am J Vet Res 1981; 42: 2036–2048.
2nd ed. Iowa: John Wiley & Sons, 2015, pp 183–238. 32 Kipar A, Koehler K, Bellmann S, et al. Feline infectious
18 Di Donato P, Penninck D, Pietra M, et al. Ultrasonographic peritonitis presenting as a tumour in the abdominal cav-
measurement of the relative thickness of intestinal wall ity. Vet Rec 1999; 144: 115–118.
layers in clinically healthy cats. J Feline Med Surg 2014; 33 Gabor LJ, Malik R and Canfield PJ. Clinical and anatomi-
16: 333–339. cal features of lymphosarcoma in 118 cats. Aust Vet J 1998;
19 Sayre RS and Spaulding KA. Formulation of a standard- 76: 725–732.
ized protocol and determination of the size and appear- 34 Hittmair K, Krebitz Gressl E, Kubber Heiss AK, et al. Feline
ance of the spleen in healthy cats. J Feline Med Surg 2014; alimentary lymphosarcoma: radiographical, ultrasono-
16: 326–332. graphical, histological and virological findings. Eur J
20 Jones S, Novicoff W, Nadeau J, et al. Unlicensed GS- Companion Anim Pract 2001; 11: 119–128.
441524-like antiviral therapy can be effective for at-home 35 Zwingenberger AL, Marks SL, Baker TW, et al. Ultraso-
treatment of feline infectious peritonitis. Animals 2021; nographic evaluation of the muscularis propria in cats
11. DOI: 10.3390/ani11082257. with diffuse small intestinal lymphoma or inflammatory
21 Grooters AM, Biller DS, Ward H, et al. Ultrasonographic bowel disease. J Vet Intern Med 2010; 24: 289–292.
appearance of feline alimentary lymphoma. Vet Radiol 36 Daniaux LA, Laurenson MP, Marks SL, et al. Ultrasono-
Ultrasound 1994; 35: 468–472. graphic thickening of the muscularis propria in feline
22 Rivers BJ, Walter PA, Feeney DA, et al. Ultrasonographic small intestinal small cell T-cell lymphoma and inflam-
features of intestinal adenocarcinoma in five cats. Vet matory bowel disease. J Feline Med Surg 2014; 16: 89–98.
Radiol Ultrasound 1997; 38: 300–306. 37 Kipar A, May H, Menger S, et al. Morphologic features and
23 Sato AF and Solano M. Ultrasonographic findings in development of granulomatous vasculitis in feline infec-
abdominal mast cell disease: a retrospective study of 19 tious peritonitis. Vet Pathol 2005; 42: 321–330.
patients. Vet Radiol Ultrasound 2004; 45: 51–57. 38 Wang YT, Su BL, Hsieh LE, et al. An outbreak of feline
24 Weissman A, Penninck D, Webster C, et al. Ultrasono- infectious peritonitis in a Taiwanese shelter: epidemio-
graphic and clinicopathological features of feline gastro- logic and molecular evidence for horizontal transmission
intestinal eosinophilic sclerosing fibroplasia in four cats. of a novel type II feline coronavirus. Vet Res 2013; 44. DOI:
J Feline Med Surg 2013; 15: 148–154. 10.1186/1297-9716-44-57.
25 Munday JS, Martinez AW and Soo M. A case of feline gas- 39 Hartmann K. Feline infectious peritonitis. Vet Clin North
trointestinal eosinophilic sclerosing fibroplasia mimick- Am Small Anim Pract 2005; 35: 39–79.
ing metastatic neoplasia. N Z Vet J 2014; 62: 356–360. 40 Giordano A, Paltrinieri S, Bertazzolo W, et al. Sensitivity
26 Linton M, Nimmo JS, Norris JM, et al. Feline gastrointes- of Tru-cut and fine-needle aspiration biopsies of liver
tinal eosinophilic sclerosing fibroplasia: 13 cases and and kidney for diagnosis of feline infectious peritonitis.
review of an emerging clinical entity. J Feline Med Surg Vet Clin Pathol 2005; 34: 368–374.
2015; 17: 392–404. 41 Hanson JA, Papageorges M, Girard E, et al. Ultra­
27 Pedersen NC. A review of feline infectious peritoni- sonographic appearance of splenic disease in 101 cats.
tis virus infection: 1963–2008. J Feline Med Surg 2009; 11: Vet Radiol Ultrasound 2001; 42: 441–445.
225–258. 42 Quinci M, Sabattini S, Agnoli C, et al. Ultrasonographic honey-
28 Kipar A, Köhler K, Leukert W, et al. A comparison comb pattern of the spleen in cats: correlation with patholog-
of lymphatic tissues from cats with spontaneous feline ical diagnosis in 33 cases. J Feline Med Surg 2020; 22: 800–804.
infectious peritonitis (FIP), cats with FIP virus infection 43 Allan R, Thompson KG and Halsey TR. Splenic mast cell
but no FIP, and cats with no infection. J Comp Pathol 2001; tumour and mastocytaemia in a cat: case study and litera-
125: 182–191. ture review. N Z Vet J 2000; 48: 117–121.
29 Monteiro CB and O’Brien RT. A retrospective study on the 44 Valdés-Martínez A, Cianciolo R and Mai W. Association
sonographic findings of abdominal carcinomatosis in 14 between renal hypoechoic subcapsular thickening and lym-
cats. Vet Radiol Ultrasound 2004; 45: 559–564. phosarcoma in cats. Vet Radiol Ultrasound 2007; 48: 357–360.