Diabetes in Cats: Symptoms, Causes, Treatment & Diet

Diabetes mellitus is one of the more common endocrine diseases seen in adult and senior cats. The typical patient is a middle-aged or older cat that has gradually started drinking more, producing larger amounts of urine, losing weight, or eating differently.

Sometimes the changes are obvious. More often, they are not.

In practice, owners will sometimes tell me that they first noticed something as simple as larger urine clumps in the litter box or that their cat had become unusually interested in the water bowl. Weight loss may be attributed to aging, while increased appetite can initially seem like a positive sign. These small changes can be the first clues that glucose metabolism is no longer normal.

The good news is that feline diabetes can often be managed successfully. Unlike diabetes in dogs, diabetes in cats may enter remission, particularly when treatment is started before prolonged metabolic disturbances have developed.

But remission should not be confused with a permanent cure. Some cats need lifelong treatment, and even cats that achieve remission can develop diabetes again.

What Is Diabetes in Cats?

Diabetes mellitus develops when a cat does not have enough effective insulin to keep blood glucose within an appropriate range.

Insulin is produced by specialized pancreatic beta cells. Its main role is to help the body’s tissues use glucose for energy and to regulate the amount of glucose circulating in the blood.

When insulin is insufficient or the tissues become resistant to its effects, glucose accumulates in the bloodstream. Once blood glucose becomes high enough, the kidneys begin excreting glucose into the urine.

This produces an important sequence:

impaired insulin action → high blood glucose → glucose in the urine → increased urine production → increased thirst

At the same time, the body’s cells may have difficulty using glucose normally. A cat can therefore lose weight even while eating normally or eating more than usual.

Feline diabetes is not a single uniform disease. In many cats, insulin resistance and progressive dysfunction of pancreatic beta cells occur together. The underlying cause and the remaining ability of the pancreas to produce insulin influence both treatment and the possibility of remission.

What Causes Diabetes in Cats?

There is usually no single cause of feline diabetes.

Instead, diabetes develops when several factors combine to produce persistent insulin resistance and/or loss of adequate pancreatic beta-cell function.

Important contributing factors include:

• obesity and excess body fat;
• insulin resistance;
• pancreatic disease, including pancreatitis;
• pancreatic beta-cell dysfunction;
• amyloid accumulation within pancreatic islets;
• glucocorticoid treatment;
• certain hormonal medications;
• other endocrine or systemic diseases;
• individual and genetic susceptibility.

This is why two cats of the same age and weight can have very different courses of disease.

Obesity and Diabetes in Cats

Obesity is one of the most important modifiable risk factors for feline diabetes.

Excess body fat is associated with insulin resistance. In a susceptible cat, the pancreas may initially compensate by producing more insulin. Over time, however, beta cells may no longer be able to compensate adequately.

This does not mean that every overweight cat will become diabetic. Diabetes can also occur in cats with a normal body condition.

Nevertheless, maintaining an appropriate body weight is one of the most useful things an owner can do to reduce metabolic risk.

Pancreatitis and Pancreatic Disease

The pancreas is central to glucose regulation because its beta cells produce insulin.

Pancreatitis and other pancreatic disorders can interfere with normal pancreatic function. Chronic or recurrent pancreatic injury may therefore contribute to diabetes in some cats.

Feline pancreatic disease can also be difficult to recognize because the clinical signs are sometimes nonspecific. A diabetic cat with poor appetite, vomiting, abdominal discomfort, or unexplained deterioration may need evaluation for concurrent pancreatic disease rather than simply having its diabetes medication increased.

Steroids and Diabetes in Cats

Glucocorticoids can increase insulin resistance.

This does not mean that steroids should never be prescribed to cats. They have legitimate and sometimes essential uses in veterinary medicine. However, the potential effect on glucose metabolism should be considered when a cat has risk factors for diabetes.

If a cat develops persistent hyperglycemia while receiving glucocorticoids, the veterinarian may need to reassess the medication, its dose, the reason for treatment, and the cat’s overall metabolic status.

Which Cats Are at Higher Risk?

Feline diabetes is most often diagnosed in adult and senior cats.

Common risk factors include:

Risk factor	Clinical significance
Obesity	Promotes insulin resistance
Increasing age	Diabetes becomes more common with age
Previous glucocorticoid exposure	Can increase insulin resistance
Pancreatic disease	May impair insulin production
Reduced physical activity	Can contribute to obesity and metabolic dysfunction
Concurrent endocrine disease	May interfere with glucose regulation

Male cats may also be overrepresented in some feline diabetes populations, although sex alone does not determine whether an individual cat will develop the disease.

Breed differences have been reported, but diabetes can occur in any cat.

Diabetes Symptoms in Cats

The classic signs of diabetes in cats are:

• increased thirst;
• increased urination;
• weight loss;
• increased appetite.

However, not every cat develops all four.

The severity of the signs depends on how long the disease has been present, how high the blood glucose is, whether the cat has concurrent disease, and whether complications have developed.

Increased Thirst

A diabetic cat may begin drinking noticeably more water.

Some owners notice the change because the cat repeatedly returns to the water bowl. Others notice that the water level in a bowl or fountain is dropping much faster than before.

Increased thirst occurs because glucose in the urine causes increased water loss.

Increased Urination

Large urine clumps in the litter box can be an early clue.

Because glucose draws water into the urine, diabetic cats can produce substantially more urine than they did previously.

Increased urination is not specific to diabetes, however. Kidney disease, hyperthyroidism, urinary tract disorders, and several other conditions can produce similar changes.

Weight Loss

Unexplained weight loss is an important sign.

A diabetic cat may continue eating normally or even become hungrier while losing body weight. This happens because glucose is not being utilized normally by tissues and the body begins relying more heavily on other energy stores.

Any unexplained weight loss in an adult or senior cat deserves veterinary attention.

Increased Appetite

Some diabetic cats develop polyphagia, meaning an increased appetite.

This can be particularly noticeable when weight loss occurs at the same time.

However, lack of increased appetite does not rule out diabetes. A cat with another illness or a diabetic complication may eat poorly instead.

Lethargy and Reduced Activity

Cats often hide illness remarkably well.

Instead of appearing obviously sick, a diabetic cat may simply sleep more, play less, or stop jumping onto furniture.

This type of subtle behavioral change is easy to overlook, especially in an older cat.

Hind-Leg Weakness and Diabetic Neuropathy

Some cats with diabetes develop peripheral neuropathy.

The characteristic presentation is weakness of the hind limbs and a plantigrade stance, in which the cat appears to walk with the hocks lower than normal.

This complication can be alarming for owners, but improvement is possible when diabetic control is restored.

If a cat suddenly develops weakness or difficulty walking, however, diabetes should not automatically be assumed to be the cause. Other neurological, orthopedic, metabolic, and spinal conditions can produce similar signs.

Poor Coat Condition

Some diabetic cats develop a dull or unkempt coat.

This is usually a nonspecific sign and should not be used to diagnose diabetes. It becomes more meaningful when it occurs together with weight loss, increased thirst, increased urination, or changes in appetite.

Early Signs of Diabetes in Cats: What Owners Often Miss

The earliest changes can be surprisingly easy to overlook.

A cat may:

• drink slightly more than usual;
• produce larger litter-box clumps;
• lose a small amount of weight;
• become less active;
• appear hungrier;
• stop grooming as carefully as before.

None of these signs proves that a cat has diabetes.

What matters is a pattern of change.

For example, an older cat that has lost weight while drinking more and producing larger amounts of urine should not simply be put on a different diet without first investigating the cause.

When Should a Diabetic Cat See a Veterinarian?

Arrange a veterinary examination if your cat has persistent:

• increased thirst;
• increased urination;
• unexplained weight loss;
• appetite changes;
• lethargy;
• hind-limb weakness;
• repeated urinary problems.

Urgent assessment is needed if a diabetic or suspected diabetic cat:

• stops eating;
• vomits repeatedly;
• becomes markedly weak;
• becomes dehydrated;
• has difficulty breathing;
• collapses;
• appears severely depressed or disoriented.

These signs can occur with serious metabolic complications, including diabetic ketoacidosis.

How Is Diabetes Diagnosed in Cats?

Diagnosing diabetes in cats requires more than looking at one blood glucose result.

A veterinarian considers the entire picture, including:

1. clinical signs;
2. blood glucose concentration;
3. urine glucose;
4. repeated or persistent hyperglycemia;
5. fructosamine when appropriate;
6. other blood and urine abnormalities;
7. concurrent diseases.

Stress Hyperglycemia in Cats

This is particularly important in feline patients.

Cats can develop a temporary rise in blood glucose when they are frightened or stressed. Transport, restraint, blood collection, unfamiliar surroundings, and even the presence of a veterinary team can influence glucose levels.

Therefore, one elevated blood glucose measurement does not automatically diagnose diabetes in a cat.

If the clinical signs are not convincing, the veterinarian may repeat testing or use additional investigations such as fructosamine.

Fructosamine in Cats

Fructosamine reflects average blood glucose over a longer period than a single glucose measurement.

It can therefore help distinguish persistent hyperglycemia from a temporary stress response.

Fructosamine is not a standalone test either. It should be interpreted in combination with the cat’s clinical signs and other laboratory findings.

Urine Glucose

Persistent hyperglycemia can cause glucose to appear in urine.

Glucosuria supports a diagnosis of diabetes when it occurs together with compatible clinical findings and elevated blood glucose.

Urine testing can also provide additional information about hydration, urinary tract disease, ketones, and other abnormalities.

What Blood Glucose Level Is Considered Diabetic in Cats?

There is no single blood glucose value that should be used in isolation to diagnose feline diabetes.

Cats can develop substantial stress-related hyperglycemia, particularly in a clinic.

The veterinarian therefore looks for persistent hyperglycemia together with glucosuria and compatible clinical signs.

When the diagnosis is uncertain, repeat blood glucose measurements and fructosamine testing can be particularly useful.

This approach is safer than labeling a cat diabetic based on one stressful blood draw.

Feline Diabetes Treatment

The goals of diabetes treatment are broader than simply lowering blood glucose.

Treatment aims to:

• control excessive thirst and urination;
• prevent clinically important hyperglycemia;
• avoid hypoglycemia;
• maintain an appropriate body weight;
• preserve quality of life;
• identify and treat concurrent disease;
• and, when realistic, achieve remission.

Depending on the individual cat, treatment may involve:

• insulin;
• an SGLT2 inhibitor;
• dietary modification;
• weight management;
• home glucose monitoring;
• ketone monitoring;
• treatment of concurrent disease.

The choice should be based on the cat’s clinical status rather than a one-size-fits-all protocol.

Insulin for Diabetic Cats

Insulin remains an important treatment for feline diabetes.

Long-acting insulin preparations are commonly used because they can provide more consistent glucose control over the day.

The insulin product, concentration, dose, and administration schedule must be selected for the individual patient.

Some cats need insulin temporarily and later achieve remission. Others continue to require insulin for long-term control.

Giving Insulin to a Cat

Insulin is administered subcutaneously.

Most owners can learn to give injections at home, and many cats tolerate them surprisingly well.

The practical details matter:

• use the correct insulin and syringe;
• follow the prescribed schedule;
• store insulin according to the manufacturer’s instructions;
• do not change the dose based on one isolated glucose reading;
• know the signs of hypoglycemia;
• keep a written record of glucose measurements and medication when requested by the veterinarian.

Never give an extra dose because a cat’s glucose appears high unless the veterinarian has specifically instructed you to do so.

Insulin requirements can change as a cat loses weight, becomes healthier, develops another illness, or moves toward remission.

SGLT2 Inhibitors for Diabetic Cats

SGLT2 inhibitors are now an important part of the feline diabetes treatment discussion.

These medications reduce renal glucose reabsorption, allowing more glucose to leave the body through urine.

Examples used in feline medicine include bexagliflozin and velagliflozin.

They can be appropriate for selected newly diagnosed cats, but they are not simply a replacement for insulin in every patient.

Before an SGLT2 inhibitor is considered, the cat needs appropriate clinical assessment. Cats with significant insulin deficiency, ketones, serious concurrent illness, dehydration, or other contraindications may require a different approach.

This distinction is important because SGLT2 inhibitors can lower blood glucose while the underlying metabolic situation still needs careful monitoring.

The 2025 iCatCare consensus guidelines provide updated recommendations for diagnosis and management of feline diabetes, including newer treatment options.

Best Food for Diabetic Cats

Nutrition is an important component of feline diabetes management.

Many diabetic cats benefit from a diet that is:

• nutritionally complete and balanced;
• relatively low in carbohydrates;
• appropriately high in animal-based protein;
• suitable for the cat’s body condition and concurrent diseases.

Wet food is often a practical choice for diabetic cats because it can provide high moisture and may make carbohydrate control easier.

However, there is no single commercial food that is automatically the “best diabetic cat food” for every patient.

A cat with diabetes and chronic kidney disease, for example, may need a different nutritional strategy from an otherwise healthy overweight diabetic cat.

Can a Diabetic Cat Eat Dry Food?

Some diabetic cats can be managed while eating dry food, depending on its nutritional composition and the individual patient’s treatment plan.

The important issue is not simply whether the food is dry or wet.

The veterinarian should consider:

• carbohydrate content;
• calorie density;
• protein content;
• body condition;
• concurrent disease;
• appetite;
• insulin or other medication.

If a cat is already receiving insulin, a major change to a lower-carbohydrate diet can alter glucose control. Dietary changes should therefore be coordinated with glucose monitoring and treatment adjustments.

Weight Loss and Diet for Diabetic Cats

If an overweight cat has diabetes, gradual weight reduction can improve insulin sensitivity.

But weight loss must be controlled.

A diabetic cat should never be deliberately starved.

Cats that stop eating are at risk of hepatic lipidosis, and the risk is particularly important in overweight cats.

A safe weight-management plan should include an appropriate calorie target, regular weight checks, and adjustments based on the cat’s response.

If a diabetic cat suddenly refuses food, contact your veterinarian rather than trying to force a rapid weight-loss plan.

Feeding Schedule for a Diabetic Cat

The correct feeding schedule depends on the medication being used, the cat’s appetite, the type of food, and the owner’s routine.

Consistency is useful, but there is no universal rule that every diabetic cat must eat at exactly the same time every day.

Cats receiving insulin should have their feeding schedule coordinated with the prescribed treatment plan.

For cats receiving newer non-insulin treatments, the feeding strategy may be different.

The important point is that diet and diabetes medication should be treated as one management plan rather than two unrelated decisions.

Monitoring Diabetes in Cats at Home

Home monitoring can provide information that is difficult to obtain during a short veterinary visit.

Depending on the treatment plan, monitoring may include:

• blood glucose;
• body weight;
• appetite;
• water consumption;
• urine production;
• activity;
• urine ketones when indicated.

Home blood glucose measurements can be particularly useful because some cats experience marked stress hyperglycemia at the clinic.

Continuous glucose monitoring systems may also be used in selected patients to provide information about glucose trends over time.

The numbers should never be interpreted without considering how the cat is actually doing.

A cat with an apparently “good” glucose value that is not eating, vomiting, or becoming weak needs veterinary attention.

Ketone Monitoring in Diabetic Cats

Ketones develop when the body begins relying heavily on fat for energy.

Their presence can be clinically important in a diabetic cat, particularly when the cat is not eating or appears unwell.

Owners may be advised to check urine or blood ketones in certain situations.

Ketones accompanied by:

• vomiting;
• poor appetite;
• dehydration;
• marked lethargy;
• weakness;
• weight loss;

are a reason for prompt veterinary assessment.

This is particularly important for cats receiving SGLT2 inhibitors, because serious metabolic complications can occur without extremely high blood glucose concentrations.

Hypoglycemia in Diabetic Cats

Hypoglycemia means that blood glucose has fallen too low.

It is one of the most important potential complications of diabetes treatment.

Possible signs include:

• weakness;
• unusual sleepiness;
• trembling;
• poor coordination;
• abnormal behavior;
• disorientation;
• seizures;
• collapse.

Severe hypoglycemia is an emergency.

Owners of diabetic cats should receive clear instructions from their veterinary team about what to do if hypoglycemia is suspected.

Do not attempt to compensate for a high glucose value by giving extra insulin. A dose that is appropriate at one point in the disease may become excessive after weight loss or improvement in insulin sensitivity.

Diabetic Ketoacidosis in Cats

Diabetic ketoacidosis (DKA) is a serious metabolic complication.

It occurs when insulin deficiency is severe enough for the body to produce excessive ketones and develop significant metabolic disturbances.

A cat with DKA may show:

• loss of appetite;
• vomiting;
• dehydration;
• profound lethargy;
• weakness;
• weight loss;
• abnormal breathing;
• collapse.

DKA requires veterinary treatment and should never be managed by adjusting insulin at home without professional guidance.

Diabetic Neuropathy in Cats

Diabetic neuropathy is one of the better-recognized complications of chronic feline diabetes.

The classic sign is a plantigrade stance caused by weakness of the hind limbs.

Some cats appear to walk with their heels closer to the ground or have difficulty jumping.

Fortunately, diabetic neuropathy can improve when metabolic control is restored, although recovery takes time and depends on the severity and duration of the nerve damage.

Urinary Tract Problems in Diabetic Cats

Diabetic cats may be more susceptible to urinary tract problems.

If a diabetic cat begins urinating outside the litter box, straining, vocalizing while urinating, or producing unusually small amounts of urine, do not automatically assume that the diabetes is simply “getting worse.”

Urinary tract infection, bladder disease, and urethral obstruction are different problems and require appropriate investigation.

A male cat that is straining and unable to pass urine requires emergency veterinary care.

What If a Diabetic Cat Stops Eating?

This deserves special attention.

A diabetic cat that refuses food should not simply be monitored at home for several days.

Loss of appetite can occur with pancreatitis, infection, gastrointestinal disease, metabolic complications, or other serious conditions.

The appropriate medication decision also depends on what treatment the cat is receiving.

Do not automatically give the usual insulin dose, skip insulin, or change an SGLT2 inhibitor without veterinary advice.

Contact the veterinary team and explain:

• when the cat last ate;
• what medication was given;
• whether vomiting is present;
• whether the cat is drinking;
• whether ketones have been detected;
• and how the cat is behaving.

Can Diabetes in Cats Go Into Remission?

Yes. Feline diabetes can go into remission.

Remission means that the cat can maintain adequate glucose regulation without ongoing insulin treatment.

It is more likely in some cats than others and is influenced by factors such as:

• how early treatment begins;
• the degree of pancreatic beta-cell function remaining;
• the severity and duration of hyperglycemia;
• body condition;
• dietary management;
• concurrent disease;
• the response to treatment.

Not every diabetic cat will achieve remission.

Importantly, remission is not the same as a permanent cure.

Can a Cat Stop Insulin After Remission?

Some cats can eventually stop insulin.

This should happen only as part of a veterinary treatment plan.

As glucose control improves, the cat’s insulin requirement may decrease. If the original insulin dose is continued unchanged, hypoglycemia can occur.

A veterinarian will use the cat’s clinical signs and glucose data to determine whether treatment can be reduced or discontinued.

The FelineVMA remission strategy also emphasizes monitoring during this process rather than simply stopping insulin because the cat appears clinically better.

Can Diabetes Come Back After Remission?

Yes.

A cat that has achieved remission can relapse.

Possible contributors include renewed insulin resistance, weight gain, pancreatic disease, or other concurrent illness.

This is why remission should be thought of as a period of stable glucose regulation rather than a guarantee that diabetes has disappeared permanently.

Owners should continue to pay attention to:

• body weight;
• thirst;
• urination;
• appetite;
• activity;
• and any recurrence of previous diabetic signs.

Prognosis for Cats With Diabetes

The prognosis varies considerably.

A cat with uncomplicated diabetes that responds well to treatment can have a good quality of life for years.

The outlook becomes more guarded when diabetes is accompanied by severe pancreatic disease, recurrent ketoacidosis, uncontrolled concurrent illness, or other significant complications.

The most useful prognostic factors are often not the initial glucose value alone but the cat’s overall health, ability to eat, remaining pancreatic function, response to treatment, and the owner’s ability to maintain a consistent management plan.

Factor	Effect on long-term management
Early diagnosis	Allows treatment before severe metabolic complications develop
Appropriate glucose control	Reduces the effects of prolonged hyperglycemia
Healthy body condition	Can improve insulin sensitivity
Remaining beta-cell function	Influences treatment requirements and remission potential
Concurrent disease	May make glucose control more difficult
Consistent home care	Helps maintain stable treatment and detect changes early

How Long Can a Cat Live With Diabetes?

There is no reliable single life-expectancy number for diabetic cats.

Some cats live for many years after diagnosis.

The outcome depends on the severity of diabetes, concurrent diseases, treatment response, complications, and quality of diabetic control.

A diagnosis of diabetes does not automatically mean that a cat has a poor quality of life.

In many cases, once the initial treatment routine is established, owners find that diabetes becomes a manageable part of everyday care.

How to Care for a Diabetic Cat at Home

Successful diabetes management is usually based on routine rather than complicated procedures.

Keep a simple record of:

• medication;
• glucose readings when monitoring is prescribed;
• body weight;
• appetite;
• water intake;
• urine output;
• unusual behavior.

This information can be surprisingly useful during follow-up visits.

In practice, I often find that the owner’s observations provide information that a single laboratory result cannot. A glucose value may look acceptable, but a cat that has stopped grooming, lost weight, or started drinking again is telling us that something has changed.

For this reason, treat the cat, not just the number.

Can Feline Diabetes Be Prevented?

Not every case can be prevented.

Some risk factors, including age, individual susceptibility, pancreatic disease, and genetics, cannot be eliminated.

There are nevertheless several practical measures that can reduce modifiable risk:

• maintain a healthy body condition;
• avoid chronic overfeeding;
• provide a complete and balanced diet;
• encourage normal activity;
• monitor body weight;
• review long-term medication use with a veterinarian;
• investigate persistent changes in thirst, urination, appetite, or weight.

For an overweight cat, prevention is not about rapid dieting. It is about achieving and maintaining an appropriate body condition safely.

Final Takeaway

Diabetes in cats is a serious disease, but it is not automatically a poor-prognosis diagnosis.

The signs owners are most likely to notice are increased thirst, increased urination, weight loss, and changes in appetite. Because cats can develop stress hyperglycemia, diagnosis should be based on the overall clinical picture rather than one elevated glucose measurement.

Treatment may involve insulin, an SGLT2 inhibitor in an appropriate patient, dietary management, weight control, and home monitoring.

Some cats achieve remission. Others require long-term treatment. Both situations can be managed successfully when the disease is monitored carefully.

If your cat is drinking more, producing larger amounts of urine, losing weight, or showing a persistent change in appetite, do not wait for the signs to become severe. Early veterinary assessment gives us the best opportunity to identify the cause, begin appropriate treatment, and protect the cat’s long-term health.

Frequently Asked Questions

What are the first signs of diabetes in cats?

The most common early signs are increased thirst, increased urination, unexplained weight loss, and changes in appetite. Some cats also become less active, develop a poorly groomed coat, or show hind-limb weakness.

What causes diabetes in cats?

Feline diabetes usually develops from a combination of insulin resistance and progressive pancreatic beta-cell dysfunction. Obesity, pancreatic disease, certain medications, hormonal influences, and individual susceptibility can contribute.

What blood glucose level indicates diabetes in a cat?

A single high blood glucose measurement does not automatically diagnose diabetes because cats can develop stress hyperglycemia. Veterinarians generally consider persistent hyperglycemia together with glucosuria and compatible clinical signs. Fructosamine may help when the diagnosis is uncertain.

What is the best food for a diabetic cat?

Many diabetic cats benefit from a nutritionally complete diet that is relatively low in carbohydrates and appropriately high in protein. Wet food is often useful, but the ideal diet depends on the cat’s body condition, concurrent diseases, and treatment plan.

Can a diabetic cat stop insulin?

Some cats can stop insulin after achieving diabetic remission. Insulin should only be reduced or discontinued under veterinary supervision because insulin requirements can change as glucose control improves.

Can diabetes come back after remission in cats?

Yes. A cat that has achieved remission can develop diabetes again. Maintaining a healthy body weight and monitoring for renewed thirst, increased urination, weight loss, or appetite changes can help identify relapse early.

What should I do if my diabetic cat stops eating?

Contact your veterinarian promptly. Loss of appetite can be a sign of another illness or a diabetic complication, and cats that stop eating are at risk of hepatic lipidosis. The appropriate medication plan depends on the treatment the cat is receiving.

Are SGLT2 inhibitors safe for diabetic cats?

SGLT2 inhibitors can be appropriate for selected cats, particularly some newly diagnosed patients, but they are not suitable for every diabetic cat. A veterinarian should assess the cat for factors such as ketones, insulin deficiency, concurrent illness, hydration status, and other contraindications before treatment.

Can diabetic neuropathy in cats get better?

Yes. Diabetic neuropathy can improve when diabetes is brought under better control. Recovery may take time, and other causes of hind-limb weakness should be ruled out if the clinical picture is not typical.