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A retrospective clinical and epidemiological study on felinecoronavirus (FCoV) in cats in Istanbul, Turkey

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UKa r t i c l e i n f oArticle history:Received 16 June 2014Received in revised form 6 January 2015Accepted 24 January 2015Keywords:AntibodyCatFeline coronavirusClinicalEpidemiologyIstanbulTurkeya b s t r a c tThe presence of antibodies to feline
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  Pleasecitethisarticleinpressas:Tekelioglu,B.K.,etal.,Aretrospectiveclinicalandepidemiologicalstudyonfelinecoronavirus(FCoV)incatsinIstanbul,Turkey.PREVET(2015),http://dx.doi.org/10.1016/j.prevetmed.2015.01.017 ARTICLE IN PRESS G Model PREVET-3735;No.ofPages7PreventiveVeterinaryMedicinexxx(2015)xxx–xxx ContentslistsavailableatScienceDirect Preventive   Veterinary   Medicine  journalhomepage:www.elsevier.com/locate/prevetmed A   retrospective   clinical   and   epidemiological   study   on   felinecoronavirus   (FCoV)   in   cats   in   Istanbul,   Turkey B.K.   Tekelioglu a ,   E.   Berriatua b , ∗ ,   N.   Turan c ,   C.R.   Helps d ,   M.   Kocak a ,   H.   Yilmaz c a MackaVeterinaryClinic,Besiktas,Istanbul,Turkey b  AnimalHealthDepartment,RegionalCampusofInternationalExcellence“CampusMareNostrum”,UniversidaddeMurcia,Murcia,Spain c UniversityofIstanbul,VeterinaryFaculty,DepartmentofVirology,Avcilar,Istanbul,Turkey d UniversityofBristol,LangfordVeterinaryServices,ChurchillBuilding,LangfordHouse,Langford,Bristol,UK  a   r   t   i   c   l   e   i   n   f   o  Articlehistory: Received16June2014Receivedinrevisedform6January2015Accepted24January2015 Keywords: AntibodyCatFelinecoronavirusClinicalEpidemiologyIstanbulTurkey a   b   s   t   r   a   c   t The   presence   of    antibodies   to   feline   coronavirus   (FCoV)   and   feline   immunodeficiencyvirus   (FIV),   together   with   feline   leukemia   virus   (FeLV)   antigen   was   investigated   in   169illhousehold   and   stray   cats   attending   aveterinary   surgery   in   Istanbul   in   2009–14.   The   esti-mated   FCoV   andFIV   seroprevalence   (95%   confidence   intervals)   were   37%   (30–45%)   and   11%(6–16%),respectively   and   FeLV   prevalence   was   1%   (0–3%).   FCoV   seroprevalence   increaseduntil   2years   of    age,   was   highest   in   2014   and   among   household   cats   living   with   other   catsandwith   outdoor   access,   and   was   lower   in   FIV   seropositive   compared   to   seronegative   cats.Symptoms   typically   associated   with   wet   feline   infectious   peritonitis   (FIP)   including   ascites,abdominal   distention   or   pleural   effusion,   coupled   in   manycases   with   non-antibiotic   respon-sive   fever,   were   observed   in19%   (32/169)   of    cats,   and   75%   (24/32)   of    these   cats   were   FCoVseropositive.   FCoV   seropositivity   was   also   associated   with   ahigh   white   blood   cell   count,high   plasma   globulin,   low   plasma   albumin   and   low   blood   urea   nitrogen.   The   percentage   of FCoV   seropositive   and   seronegative   cats   that   died   in   spite   of    supportive   veterinary   treat-ment   was   33%   (21/63)   and   12%   (13/106),   respectively.   These   results   indicate   that   FCoV   iswidespread   andhas   asevere   clinical   impact   in   catsfrom   Istanbul.   Moreover,   the   incidenceofFCoV   infections   could   be   rising,   andinthe   absence   of    effective   vaccination   cat   ownersneed   to   be   made   aware   of    ways   to   minimize   the   spread   of    this   virus.©   2015   Elsevier   B.V.   All   rights   reserved. 1.Introduction Felinecoronaviruses(FCoVs)areenveloped,positive-sense,single-strandedRNAvirusesclassifiedas“subgroup1a”inthefamily Coronaviridae withintheorder Nidovirales (Vijaykrishnaetal.,2007).FCoVsconsistoftwobiotypes designatedasfelineentericcoronavirus(FECV)andfelineinfectiousperitonitisvirus(FIPV),whicharebothdividedintotwoserotypes,IandII.SerotypeIisoffelineorigin ∗ Correspondingauthor.Tel.:+34868883997;fax:+34868884147. E-mailaddress: berriatu@um.es(E.Berriatua). anddifficulttogrowincellculture.SerotypeIIappearstohavearisenfromtherecombinationofFCoVserotypeIwithcaninecoronavirusandgrowsrapidlyincellculturecaus-ingalyticcytopathiceffect(Benetkaetal.,2004;Hartmann, 2005;Pedersen,2009).ItisthoughtthattheFIPVbiotypemay   arisefromFECVsinindividualcatsbyinternalmuta-tion,ofteninimmunesuppressedcats(Polandetal.,1996;Vennema,1999).AnalternativehypothesisisthatFECVsandFIPVsformdistinctviralpopulationswithinfectionbyFIPVcausingFIP(Brownetal.,2009).FCoVsaretransmittedbythefecal–oralrouteandtheviruscanpersistonfomitesfor3–7weekswheretheyposeariskoftransmission(Hartmann,2005;Pedersen,2009; http://dx.doi.org/10.1016/j.prevetmed.2015.01.0170167-5877/©2015ElsevierB.V.Allrightsreserved.  Pleasecitethisarticleinpressas:Tekelioglu,B.K.,etal.,Aretrospectiveclinicalandepidemiologicalstudyonfelinecoronavirus(FCoV)incatsinIstanbul,Turkey.PREVET(2015),http://dx.doi.org/10.1016/j.prevetmed.2015.01.017 ARTICLE IN PRESS G Model PREVET-3735;No.ofPages72 B.K.Tekeliogluetal./PreventiveVeterinaryMedicinexxx(2015)xxx–xxx Kiparetal.,2010).FCoVsprimarilyinfectenterocytesandspreadfromtheintestinebymonocyte-associatedviremia(Gunn-Mooreetal.,1998;Kiparetal.,2005).Theyhave alsobeenshowntoreplicateinmonocytes/macrophagesof healthycats(Can-Sahnaetal.,2007;Dyeetal.,2008).Ver- ticaltransmissionhasnotbeendemonstrated(Foleyetal.,1997).Persistentlyinfected,asymptomaticcarriersspreadFCoVsincemostofthesecatsshedthevirusforaperiodof monthsoryears,eithercontinuouslyortransiently(Foleyetal.,1997;Caveetal.,2004;Dyeetal.,2008;Kiparetal.,2010;Sabshinetal.,2012).ThesymptomsofFCoVinfectionarehighlyvariable.MostFCoV-infectedcatslookhealthywiththeexceptionof amildenteritis(Pedersen,2009).Upto12%ofFCoVinfected catsdevelopfelineinfectiousperitonitis(FIP),whichisafatalformoftheinfection(Addieetal.,2009).Development ofFIPisstronglyassociatedwithstress,immunity,multi-cathouseholdsandmainlyoccursinyoungcatsbetween3and16monthsofage(Caveetal.,2004;Hartmann,2005;Belletal.,2006;Addieetal.,2009;Vogeletal.,2010).Clin-ically,twoformsofFIParewelldocumented:a‘wet’oreffusiveform(polyserositisandvasculitis)anda‘dry’ornon-effusiveform(pyogranulomatouslesionsinorgans)(Kiparetal.,2005).Ascitesisthemostprominentmani- festationof‘wetform’FIPwhilelethargy,anorexia,weightlossandfeverrefractorytoantibioticsarecommonandnon-specificsignsofFIP(Kiparetal.,2005;Addieetal.,2009).DiagnosisofFIPiscomplicatedandthecat’sclinicalhis-torytogetherwithresultsfromseveralanalysesincludingserology,PCRandpostmortemanalysesareoftenrequiredbeforeadefinitediagnosiscanbereached(Shellyetal.,1988;Hartmannetal.,2003;Addieetal.,2004,2009;Pratelli,2008;Sharifetal.,2010;Tayloretal.,2010).HematologicalandbiochemicalchangesinFIPcasesarenotveryspecific,butascites,increaseinserumproteinlevel,increaseinbilirubin,decreaseinhematocritanddecreaseinA:Gratioareprominent(Addieetal.,2009).Serologicaltestsmay   failtodetectrecentinfectionsandcross-reactionsoccurbetweenFIPVandlowpathogenicFECVstrains(Hartmann,2005,Sharifetal.,2010).Molecu- lardetectionsystemslikestandardandrealtimereversetranscriptionpolymerasechainreaction(PCR)havecer-tainadvantagesastheyarerapidandsensitive,particularlywhenusingabdominalorpleuralfluidortissuebiopsyoraspirates(Pedersen,2009;Sharifetal.,2010).ArecentPCR  testthatiscommerciallyavailable(FIPVirusRealPCR  TM Test,IDEXX)allowsdifferentiatingFIPVandlowpathogenicFECVbiotypes,andaccordingtothemanufacturers,thetestwas99.4%accurateinsamplesfrom88%infectedcatswithapositivePCRresult.PCRresultsshouldbeevaluatedtogetherwithclinicalfindingsandpostmortemsamplesshouldbeanalyzedbymolecularmethods(Sparkesetal.,1994;Hartmannetal.,2003;Pratelli,2008;Addieetal.,2009;Pedersen,2009;Sharifetal.,2010).WorldwidetheprevalenceofFCoVinfectionsmay   beupto90%inmulti-catenvironmentsand10–60%inhouse-holdcats(Herreweghetal.,1997;Pedersenetal.,2004;Belletal.,2006;Addieetal.,2009;Sharifetal.,2009;Taharaguchietal.,2012).DetectionofFCoVantibodiesintheearlystageofinfectioncanbeusefultominimizethespreadofFCoVsinabreedingcattery,multi-cathouseholdandFCoV-freehousehold(Caveetal.,2004;Dyeetal.,2008;Drechsleretal.,2011).Therefore,itisimportanttomoni-torcatslivinginmulti-catenvironmentsinordertoreduceandcontrolFCoVinfection.TheaimofthisstudywastoinvestigateFCoVseropreva-lenceanditsrelationshipwiththeanimal’ssignalment,habitat,hematologicalandbiochemicalparametersandsymptomsincatsfromIstanbul. 2.Materialsandmethods  2.1.Studypopulationandsampling  During5years,fromJanuary2009toApril2014,atotalof169catswithsymptomscompatiblewithfelineviralinfectionswereincludedinthestudypopulation.Theyincludedindividualswithfever,depression,dullnessand/orweightloss.Theywereexaminedbytwo   differ-entveterinariansworkingataprivateVeterinaryClinicinIstanbul.Theanimals’gender,breed,ageandhábi-tatwhetherhousehold,shelterorstreet(straycats)wasrecorded.Otherdatafromhouseholdcatsincludediftheywereadoptedorhomeraisedfrombirth,theycohabitatedwithothercatsandhadoutdooraccess.Catswereclinicallyexaminedtodetectfever,skinlesions,behavioralchanges(insidiousonset,depression)andsymptomsrelatedtoorgansystemswererecorded;specifically,cardiorespiratory(dyspnea,abnormalheartandlungsounds),gastrointestinal(anorexia,weightloss,stomatitis,enteritis,abdominaldistension,vomication,ascites),urinary,circulatory(lymphoadenopathy,ane-mia,icterus),ocularlesions(keraticprecipitates,uveitis,hyphema,iridocyclitis,chorioretinitis)andcentralnervoussystem(epilepticseizures,ataxia)symptoms.BloodsamplesweretakenfromthecephalicveinbytheveterinariansexaminingthecatsforhematologicalandbiochemicalanalysesandtodetectantibodiesagainstFCoVandfelineimmunodeficiencyvirus(FIV)togetherwithfelineleukemiavirus(FeLV)antigenasdescribedbelow.AllanalysisexceptFCoVIFATantibodieswerecarriedoutattheveterinaryclinicwithinanhouroftakingthebloodsample.IFATtestsandproteinelectrophoresiswerecarriedoutatanexternalprivateveterinarylaboratory.Diseaseprogressionofthestudycatswasevaluateddur-ingrepeatvisitstotheclinicandmortalitywasconsideredtobeassociatedtothecurrentinfectionwhenthecatdidnotrespondtostandardtreatmentswhichincludedfluidandantibiotictherapy.  2.2.AnalysisofserumsamplesforantibodiestoFCoV andFIVandforFeLVantigen Allserumsamples( n =169)wereanalyzedbyrapidtestsforthepresenceofantibodiestoFCoV(Bionote,Ani-gen,FCoV)andFIV(Bionote,AnigenFIVAb),andFeLVantigen(Bionote,FeLVAg)followingkits’instructions.Accordingtothemanufacturers,thesensitivity(Se)andspecificity(Sp)oftheFCoVtestcomparedtothereferenceimmunofluorescenceantibodytest(IFA)were96.0%and97.9%,respectively,SeandSPoftheFeLVtestversusvirus  Pleasecitethisarticleinpressas:Tekelioglu,B.K.,etal.,Aretrospectiveclinicalandepidemiologicalstudyonfelinecoronavirus(FCoV)incatsinIstanbul,Turkey.PREVET(2015),http://dx.doi.org/10.1016/j.prevetmed.2015.01.017 ARTICLE IN PRESS G Model PREVET-3735;No.ofPages7 B.K.Tekeliogluetal./PreventiveVeterinaryMedicinexxx(2015)xxx–xxx 3  Table   1a PercentageofFCoVseropositivecatsaccordingtoexaminationyear,gender,breed,andage.VariablesLevel N  No.seropositive%seropositive95%CI  p valueLowerUpperStudyyear200913931656<0.00012010201525644201119171102420123524311647201352363118432014305837097GenderFemale70424029510.6499Male   9964352645BreedCrossbreed 142883830460.8062Pure   breed2718331651Age   (years)0.1–0.42520204360.20310.6–0.81383812651   38224226582   24125030703   24125030704–5   1613190386–914102955210–15159401565 isolationwere94.7%and99.7%,respectively,andthatof theFIVtestsversusWesternBlotwere96.8%and99.6%,respectively.SerafoundtobepositiveforantibodiestoFCoVbytherapidtestwereanalyzedbyIFAinanexternalprivatelaboratorytoconfirmtheresult.Serumgivingflu-orescenceatadilutionabove1:20wasconsideredpositiveforantibodiesagainstthisvirus.  2.3.Hematologicalandbiochemicalanalyses Allbloodsampleswereanalyzedforacompletebloodhemogram–histogram(18parameters)usingaVeterinarySpecificMindraybloodanalyzingkitandtheHemogramInstrument(Mindray).Sampleswerealsoanalyzedforcomprehensivebloodbiochemistry(14parameters);60sampleswereanalyzedusingtheVet-Scan(Abaxis)kitandtheremainingsampleswereanalyzedusingReflotron(Roche)kit.SerumproteinelectrophoresiswasperformedforserumsamplespositiveforantibodiestoFCoV.Asciticfluidfrom14catswasanalyzedforalbumin/globulin(A:G)ratio.Hematologicalandbiochemicaltestsincludedtotalwhitebloodcellcount(WBC),lymphocyteandredbloodcellcounts,hematocrit,hemoglobin,totalprotein,albumin(alb.),globulin(glob.),alkalinephosphatase(ALP),alaninetransaminase(ALT),amylase,totalbilirubin,bloodureanitrogen(BUN),creatinine,glucose,calcium,phosphorus,sodiumandpotassium.  2.4.Statisticalanalyses DatawereanalyzedusingR(http://cran.r-project.org/)software.ApproximatelyunbiasedestimatesofprevalencewerecalculatedassumingknownvaluesoftestSeandSpusingtheRogan–Gladenstatistic(GreinerandGardner,2000).Yates-correctedchisquaredtest,orwhenappro-priateFisher’sexacttest(KirwoodandSterne,2003),was usedtocomparetheproportionofFCoVseropositivecatsaccordingtocatdemographicandhabitatexplanatoryvari-ablesandtheproportionofsignsinFCoVseropositiveandseronegativecats.Biochemicalandhematologicalresultswerecategorizedasbeingwithin(normal),above(high)orbelow(low)referencevalues(VilliersandBlackwood,2005).TheindependentrelationshipbetweenFCoVserolog-icalstatus,andacat’sdemographic,habitatandFIVserologicalstatuswasfurtherinvestigatedusinglogisticregressionanalysis(KleinbaumandKlein,2010).FCoVwas thebinaryoutcomevariable(seropositiveorseronega-tive).Theexplanatoryvariablesincludedthoseassociatedat  p <0.05withFCoVserologicalstatusintheunivariableanalysis;theywereFIVserologicalstatus,age,examinationyearandthevariablereflectinglivingplace,outdooraccessandcontactwithothercats(Tables1aand1b).Allvari- ableswereincludedinthemodelascategoricalvariablesasshowninTables1aand1b,exceptage,whichincluded sevenlevelsaftercombiningdatafrom4to15yearoldcatsintoasinglelevel.Modelparameterswereestimatedusingthemaximumlikelihoodestimationmethodandsignifi-cancewastakenforalphalessthan5%foradoublesidedtest. 3.Results  3.1.EstimatedFCoVandFIVseroprevalenceandFeLV  prevalence AntibodiestoFCoVandFIVweredetectedin63/169and19/169cats.Twooutof169catswerepositiveforFeLVantigen.TheestimatedFCoVandFIVseroprevalenceandFeLVprevalence(95%CI)adjustedfortestsSeandSp,were37%(30–45%),11%(6–16%)and1%(0–3%),respectively.AllcatstestingFCoVantibodypositivetotherapidtestwerealsoIFATantibodypositive.  Pleasecitethisarticleinpressas:Tekelioglu,B.K.,etal.,Aretrospectiveclinicalandepidemiologicalstudyonfelinecoronavirus(FCoV)incatsinIstanbul,Turkey.PREVET(2015),http://dx.doi.org/10.1016/j.prevetmed.2015.01.017 ARTICLE IN PRESS G Model PREVET-3735;No.ofPages74 B.K.Tekeliogluetal./PreventiveVeterinaryMedicinexxx(2015)xxx–xxx  Table   1b PercentageofFCoVseropositivecatsaccordingtoorigin,habitatandFIVstatus.VariablesLevel N  No.seropositive%seropositive95%CI  p valueLowerUpperHomeHousehold122734031490.2835Street4733301743OriginHomeraised5023544068<0.0001Pet   shop166633986Shelteradopted30100100100Streetadopted 10077261834OutdooraccessNo75532919400.0805Yes   9453443454CohabitatingwithothercatsNo3712142250.0014Yes   13294443552Home;outdooraccess;cohabitatingwithothercatsStreet,yes;yes47333017430.0002House;no;no373214225House;no;yes3721432759House;yes;yes 4720574372  3.2.RelationshipbetweenFCoVserologicalstatus,year,demographicandhabitatvariables FCoVseroprevalencevariedsignificantlybystudyyear,originandhabitatvariables(  p <0.05)(Tables1aand1b). Furthermore,FCoVseroprevalencewas5%(1/19)and41%(62/150)amongFIVseropositiveandseronegativecats,respectively(  p <0.05).Logisticregressionanalysiscon-firmedtheindependentrelationshipofFCoVserologicalstatuswithexaminationyear,age,FIVstatus,habitatandcontactwithothercats(Table2).  3.3.Clinicalsymptoms,prognosisandrelationshipwithFCoVserologicalstatus Clinicalexaminationrevealeddepressionordullness,feverandlowbodyweightin81%(137/169),76%(128/169)and70%(119/169)ofstudycats,respectively,and57%(96/169)ofcatshadallthreesigns.Thepercentageofcatswithascites,abdominaldistensionandpleuraleffusionwas10%(17/169),14%(24/169)and5%(8/169),respectively.Allthreesymptomswerepresentinonlyonecat,nocatshadpleuraleffusionandascitesorabdominalenlargementalone;incontrast,ascitesandabdominalenlargementwithoutpleuraleffusionwereobservedin9%(15/169)ofcatsand19%(32/169)ofcatspresentedoneofthesethreeconditions.ThecatwithallthreesymptomswasFCoVseronegativeinstead;FCoVseroprevalencewas   93%(14/15)incatswithascitesandabdominalenlargementand75%(24/32)incatswithatleastoneofthethreesymp-toms,and94%(30/32)oftheseweredullordepressed,hadfeverand/orlowbodyweight.Thepercentageofsomeclinicalsignsdifferedaccord-ingtothecat’sFCoVserologicalstatus(Table3a).Other symptomsfoundincludeddyspnea(20/169),stomatitis(13/169),ocularsigns(12/169),urinarytractsigns(12/169)andepilepsy(2/169)(notshownintableformat).Theprevalenceofthesesymptomswasnotsignificantlydif-ferentbetweenFCoVseropositiveandseronegativecats.Thirty-threepercentofFCoVseropositivecats(21/63)and12%(13/106)ofseronegativecatsdiedfromtheconditionforwhichtheywereadmittedinspiteofreceiv-ingtreatment(  p <0.05).  3.4.HematologicalandbiochemicalparametersandrelationshipwithFCoVserologicalstatus ResultsofthehematologyandclinicalchemistryareshowninTable3b.Abnormalitieswereparticularlyfre- quentincatswithascitesandpleuraleffusionand72%(23/32)and76%(24/29)ofcatswiththesesignshadhighWBCandlowA:Gratio,respectively(nottabulated). 4.Discussion ThisstudyshowsthatFCoVinfectionsarewidespreadincatsfromIstanbulandthisisinagreementwithotherstudieselsewhere(Sparkesetal.,1992;Pedersenetal.,2004;Pesteanu-Somogyietal.,2006;Sharifetal.,2009;Taharaguchietal.,2012;Parisetal.,2014).Moreover,FCoVseroprevalenceincreasedin2014comparedtopreviousyearsandthismay   suggestthatFCoVinfectionsareanincreasinghealthproblemincatsinIstanbul.HighFCoVseroprevalence(upto84%)hasbeenreportedinmanycountries(Sparkesetal.,1992;Holstetal.,2006;Pratelli,2008;Pratellietal.,2009;Sabshinetal.,2012;Taharaguchietal.,2012).Incontrast,FCoVseroprevalencewascom-parativelylowinchronicallyill(19.3%)andevenlowerinhealthycats(10.1%)inKorea(Dong-Junetal.,2011).Preva- lencemay   varydependingontheinclusioncriteriaused(normalversusillcats)andestimatesmay   beaffectedbyselectionbias,analyticalerrorsandimperfectdiagnostictests.SeveralriskfactorshavebeenreportedtobeassociatedwithFCoVinfectionandwithFIPdevelopment,includ-ingage,breed,gender,multi-catenvironmentandstress(Belletal.,2006;Pesteanu-Somogyietal.,2006;Addieetal.,2009;Sharifetal.,2009;Worthingetal.,2012).Inthepresentstudy,FCoVserologicalstatuswas   signifi-cantlyassociatedwithyear,age,FIPserologicalstatusandhabitatvariables.Theriskofinfectionwouldbeexpectedtoriseduringthefirstmonthsoryearsoflifedueto  Pleasecitethisarticleinpressas:Tekelioglu,B.K.,etal.,Aretrospectiveclinicalandepidemiologicalstudyonfelinecoronavirus(FCoV)incatsinIstanbul,Turkey.PREVET(2015),http://dx.doi.org/10.1016/j.prevetmed.2015.01.017 ARTICLE IN PRESS G Model PREVET-3735;No.ofPages7 B.K.Tekeliogluetal./PreventiveVeterinaryMedicinexxx(2015)xxx–xxx 5  Table   2 Estimatesfromthelogistic-regressionmodelofFCoVserologicalstatusconversion.AstudyofcatsfromIstanbulin2009–14.VariableLevelOR95%CI  p valueLowerHighExaminationyear20091–––20100.540.083.540.52282011   0.140.011.350.08962012   0.570.113.010.50882013   0.720.153.550.69162014   7.57 1.25 45.83 0.0275Age(years)0.1–0.41–––0.6–0.81.550.2210.860.65871   1.410.306.680.66412   3.98 0.8319.120.08443   7.571.3442.860.02224–15   1.320.286.230.7258Home;   outdooraccessHouse;no;no1–––CohabitatingwithcatsHouse;no;yes6.091.4825.030.0122House;yes;yes 12.87 3.15 52.570.0004Street;yes;yes3.120.7712.630.1111FIV   statusSeronegative1–––Seropositive0.050.010.500.0106  Table3a PercentageofcatswithclinicalsignsaccordingtotheirFCoVserologicalstatus.AstudyofcatsfromIstanbulin2009–14.VariableFCoV  p valueSeropositivesSeronegatives N  No.affected%(95CI) N  No.affected%(95CI)Fever634165(53–77)1068782(75–89)0.0211Depressionordullness634978(68–88)1068883(76–90)0.5235Weightloss633759(47–71)1068277(69–85)0.0144Vomiting63711(3–19)1063533(24–42)0.0027Abdominaldistention631727(16–38)10677(2–11)0.0006Ascites631524(13–34)10622(0–4)<0.0001Diarrhea63914(6–23)10644(0–7)<0.0001Pleural   effusion63610(2–17)10622(0–4)0.0532 increasingcat-to-catcontact.However,itispossiblethatinfectionprevalenceamong0.1–0.4year-oldsmay   havebeenunderestimatedasseveralweekswouldbeneededforanti-FCoVantibodiestodevelopfollowinginfection.OtherstudieshavereportedgreaterFCoVprevalenceincats3–11monthsofage(Belletal.,2006;Pedersen,2009;Taharaguchietal.,2012).Instead,astudyinAustraliaandMalaysiafoundnoassociationbetweenageandFCoVinfec-tionincats(Belletal.,2006;Sharifetal.,2009).HouseholdcatslivingalonehadthelowestriskofbeingFCoVseropositive,asreportedinotherstudies(Addieetal.,2009;Drechsleretal.,2011).Incontrast,thisstudyfoundthathouseholdcatsthatcohabitatedwithothercatshadahighriskofbeingFCoVseropositive,ashasbeenprevi-ouslyshown(Foleyetal.,1997;Herreweghetal.,1997;Pedersenetal.,2004;Pesteanu-Somogyietal.,2006;Sharif etal.,2009;Sabshinetal.,2012).Moreover,inthepresentstudy,FCoVseroprevalencewaslowerinstraycats(30%)comparedtocatslivingathome(57%).ItispossiblethatstraycatshavepoorerhealthandincreasedriskofdyingfromFCoVinfectionscomparedtohouseholdcats.Alterna-tively,straycatscouldbeexposedtolessFCoVcomparedtohouseholdcats,whocommonlysharethesamelitterboxandeatfromthesamefoodbowlasothercatsinthehousehold.Furthermore,immunologicaldifferencescouldexistbetweenstrayandhouseholdcats,withthelatterbeingnaturallyselectedforaprotectiveTh-1mediatedratherthanaTh-2antibodymediatedresponse.This,how-ever,hasnotbeeninvestigatedandremainsspeculative.Interestingly,FIVseroprevalencewas   negativelyassoci-atedwithFCoVinfectioninthisstudy.Thereasonforthisisunclear.ItcouldbebecausehouseholdcatsarevaccinatedforFIVinIstanbul.ItisalsopossiblethatcoinfectedcatsareatgreaterriskofdyingasaresultofFIVimmunosuppres-sioncomparedtocatsthatareonlyFCoVseropositive.Inthepresentstudy,nodifferenceinFCoVseropreva-lencewas   foundbetweenfemalesandmales.Similarresultshavebeenfoundbyothers(Caveetal.,2004;Belletal.,2006;Holstetal.,2006;Sharifetal.,2009;Taharaguchietal.,2012).Instead,inAustraliaandtheUSA,malecatswerefoundtobemorefrequentlyinfectedwithFCoV(Pesteanu-Somogyietal.,2006;Worthingetal.,2012).Thereisnoknownbiologicalreasonsupportinggender-associatedsusceptibilityandresistancetoFCoV,anddifferencesbetweenstudiescouldberelatedtomalesandfemaleshavingdifferentlifestylesandFCoVexposure.Breedwas   notassociatedwithFCoVseropositivityinthepresentstudy.Incontrast,higherFCoVseroprevalencehas
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