Equine proliferative enteropathy caused by Lawsonia intracellularis

Equine proliferative enteropathy (EPE) is a disease of foals caused by the obligate intracellular organism Lawsonia intracellularis. This emerging disease affects mainly weanling foals and causes fever, lethargy, peripheral oedema, diarrhoea, colic and weight loss. The diagnosis of EPE may be challenging and relies on the presence of hypoproteinaemia, thickening of segments of the small intestinal wall observed on abdominal ultrasonography, positive serology and molecular detection of L. intracellularis in faeces. Although the clinical entity, diagnostic work-up and treatment of EPE are well established and described, the epidemiology for this disease has remained largely unaddressed. This article reviews the aetiology, epidemiology, clinical signs, diagnosis, treatment and prevention of EPE.     

Oral Infection of Weanling Foals with an Equine Isolate of Lawsonia intracellularis,Agent of Equine Proliferative Enteropathy

Background: Equine proliferative enteropathy (EPE) is an emerging disease of weanling foals. Objectives: Describe clinical, hematologic, biochemical, serologic, molecular, and ultrasonographic findings in foals experimentally infected with Lawsonia intracellularis. Animals: Eight foals. Methods: Recently weaned foals were assigned to either the challenge (n = 3), the sentinel (n = 3), or the control (n = 2) group. Foals were experimentally challenged via intragastric inoculation of 3 × 10¹⁰L. intracellularis organisms grown in culture. Each experimentally infected foal was housed with a sentinel foal in order to assess feco‐oral transmission. All foals were monitored daily for the development of clinical abnormalities and were weighed once weekly for the duration of the study (90 days). Abdominal ultrasound examination was performed weekly. Feces were collected every other day for 60 days, then weekly for an additional 30 days for the quantitative molecular detection of L. intracellularis. Blood was collected weekly for hematologic, biochemical, and serologic analysis. Results: Only challenged foals developed transient clinical signs of EPE consisting of anorexia, lethargy, fever, loose feces, and peripheral edema. Two challenged foals developed transient hypoalbuminemia. Fecal shedding of L. intracellularis was first detected in the challenged foals between days 12 and 18 postinoculation and lasted for 7–21 days. Seroconversion was documented in all challenged foals and in 1 sentinel foal. The remaining sentinel and control foals remained unaffected. Conclusions and Clinical Importance: Clinical EPE of variable severity was induced in all foals infected with L. intracellularis. Furthermore, L. intracellularis can be transmitted via the feco‐oral route to susceptible herdmates.     

Demographic and Environmental Risk Factors for Exposure to Lawsonia intracellularis in Horses in Israel

Equine proliferative enteropathy (EPE) is an enteric disease of foals that is caused by Lawsonia intracellularis. Clinical cases have been reported worldwide; however, data regarding the epidemiology of L. intracellularis in horses are scarce. Thus far, L. intracellularis has not been reported in the Middle East. The objectives of this study were to determine whether the causative agent of EPE exists in horses in Israel and in the Palestinian Authority and to define environmental and demographic risk factors for exposure. Fecal and serum samples were collected from horses from various regions of the country. The presence of L. intracellularis in horses in Israel was determined by real-time polymerase chain reaction (PCR), and seroprevalence was determined by enzyme-linked immunosorbent assay. One fecal sample of 136 tested (0.7%), was PCR positive. Sixty-seven sera samples (30.5%) of 220 horses in sentinel farms had anti-L. intracellularis antibodies. Low seroprevalence was found in foals both from Israel and from the Palestinian Authority (4.2% and 13.3%, respectively). In logistic regression models, geographical locations, management type, and age were found to be significant risk factors associated with seroprevlaence to L. intracellularis. No significant correlation was found between environmental variables and L. intracellularis seroprevalence after controlling for management type. These results support the existence of L. intracellularis in horses in both Israel and the Palestinian Authority. The reasons for the relatively low prevalence are currently not known and may be the result of different management, low exposure to free-living animals, and differences in environmental variables affecting the bacterial burden.     

Investigation of the Usefulness of Serum Amyloid A in Supporting the Diagnosis of Equine Proliferative Enteropathy

The objective of this study was to determine if serum amyloid A (SAA), a major acute-phase protein, could help support the diagnosis of equine proliferative enteropathy (EPE) caused by Lawsonia intracellularis infection in foals. Archived serum samples from 101 foals with enteric signs and hypoproteinemia were available for SAA testing. Based on immunodiagnostics for L. intracellularis, the foals were divided into EPE-suspect (67) and non–EPE-suspect cases (34). Serum amyloid A values ranged from 0 to 2,761 μg/mL (median 466 μg/mL) and from 0 to 2,555 μg/mL (median 192 μg/mL) for the EPE-suspect and the non–EPE-suspect cases, respectively. Although SAA can be measured patient-side and help determine the severity of the underlying inflammatory condition, SAA was unable to consistently support the diagnosis of EPE in hypoproteinemic foals with enteric signs.     

Lawsonia intracellularis-associated proliferative enteritis in weanling foals in the Netherlands

Equine proliferative enteropathy (EPE) is an emerging infectious enteric disease caused by the obligate intracellular gram-negative bacterium Lawsonia intracellularis. EPE was tentatively diagnosed in six weanling foals, aged between 5 and 7 months. Clinical signs included depression, anorexia, ventral oedema, and weight loss. Plasma biochemistry consistently revealed severe hypoproteinaemia. The ante-mortem diagnosis of EPE was based on clinical signs, hypoproteinaemia (6/6), the detection of moderate-to-high titres of L. intracellularis antibody (6/6), and severe thickening of the small intestinal wall on ultrasonography (2/2), or L. intracellularis detected in faeces by PCR (I/2). The first foal died despite treatment and at post-mortem examination the tentative diagnosis was EPE. Three foals from the same farm, which showed similar clinical symptoms were treated with azithromycin and rifampicin; two survived. Post-mortem examination of the foal that died confirmed the tentative clinical diagnosis of EPE on the basis of the lesions found and the detection of L. intracellularis--DNA in the ileum and jejunum. The fifth foal died despite intensive treatment and the post-mortem examination revealed lymphohistiocytic enteritis, typhlitis, and widespread thrombosis in several organs. The sixth foal recovered completely after treatment. This report confirms the presence of clinical L. intracellularis infection in weanling foals in the Netherlands and shows the difficulty in reaching a definitive ante-mortem diagnosis.     

Efficacy of gallium maltolate against Lawsonia intracellularis infection in a rabbit model

Antimicrobial efficacy against Lawsonia intracellularis is difficult to evaluate in vitro, thus, the effects of gallium maltolate's (GaM) were investigated in a rabbit model for equine proliferative enteropathy (EPE). Juvenile (5–6‐week‐old) does were infected with 3.0 × 10⁸ L. intracellularis/rabbit and allocated into three groups (n = 8). One week postinfection, one group was treated with GaM, 50 mg/kg; one, with doxycycline, 5 mg/kg; and one with a sham‐treatment (control). Feces and blood were collected daily and weekly, respectively, to verify presence of L. intracellularis fecal shedding using qPCR, and seroconversion using immunoperoxidase monolayer assay. Rabbits were sacrificed after 1 week of treatment to collect intestinal tissues focusing on EPE‐affected sections. Intestinal lesions were confirmed via immunohistochemistry. No difference was noted between treatments regarding EPE‐lesions in jejunum (P = 0.51), ileum (P = 0.74), and cecum (P = 0.35), or in L. intracellularis fecal shedding (P = 0.64). GaM and doxycycline appear to have similar efficacy against EPE in infected rabbits.     

Transmission of Lawsonia intracellularis to weanling foals using feces from experimentally infected rabbits

The aim of this study was to investigate whether feces from rabbits experimentally infected with Lawsonia intracellularis were infectious to foals. Two rabbits were infected with L. intracellularis, while two rabbits served as controls. Eight foals received daily feces from either the infected or the control rabbits. All rabbits and foals were monitored daily for clinical signs for the entire study period (21 days for rabbits, 42 days for foals). Feces and blood were collected for the PCR detection of L. intracellularis and serologic analysis, respectively. None of the infected rabbits or foals developed clinical signs compatible with proliferative enteropathy. All infected rabbits and foals shed L. intracellularis in their feces and all seroconverted. The results support the role of rabbits as asymptomatic amplifiers of L. intracellularis and their role as sources of infection for susceptible foals.     

Species-specificity of equine and porcine Lawsonia intracellularis isolates in laboratory animals

Lawsonia intracellularis infection causes proliferative enteropathy (PE) in many mammalian species, with porcine and equine proliferative enteropathy (PPE and EPE) known worldwide. Hamsters are a well-published animal model for PPE infection studies in pigs. There is no laboratory animal model for EPE infection studies and it is not known whether there is species-specificity for equine or porcine isolates of L. intracellularis in animal models. The objective of this study was to determine whether it is possible to generate typical EPE lesions in hamsters after inoculation with an equine strain of L. intracellularis (EPE strain) and whether it is comparatively possible to generate PPE lesions in rabbits after inoculation with a porcine strain of L. intracellularis (PPE strain). In 2 separate trials, 4-week-old and 3-week-old weanling golden Syrian hamsters were challenged with EPE strains and compared to uninfected (both trials) and PPE-infected controls (Trial 2 only). Concurrently, 6 female New Zealand white juvenile rabbits were infected with PPE strain and observed concomitantly to 8 similar rabbits infected with EPE strain for a different experiment. Hamsters and rabbits were observed for 21 to 24 days post-infection (DPI), depending on the experiment. Neither infected species developed clinical signs. The presence of disease was assessed with diagnostic techniques classically used for pigs and horses: immune-peroxidase monolayer assay on sera; quantitative polymerase chain reaction (qPCR) detection of molecular DNA in feces; and hematoxylin and eosin (H&E) stain and immunohistochemistry (IHC) on intestinal tissues. Our results showed that EPE-challenged hamsters do not develop infection when compared with PPE controls (IHC, P = 0.009; qPCR, P = 0.0003). Conversely, PPE-challenged rabbits do not develop typical intestinal lesions in comparison to EPE-challenged rabbits, with serological response at 14 DPI being significantly lower (P = 0.0023). In conclusion, PPE and EPE strains appear to have different host-specificities for hamsters and rabbits, respectively.     

Outbreak of Lawsonia intracellularis on a Standardbred breeding farm in North Carolina

Lawsonia intracellularis is a cause of protein‐losing enteropathy in weanling foals commonly causing signs including diarrhoea, oedema and unthrifty appearance. It has previously been reported as sporadic cases throughout the USA, Canada and Europe. Only recently have outbreaks on a single farm location been reported. The cases reported here are an example of multiple foals on a single farm testing serologically positive for L. intracellularis. These foals ranged in severity from asymptomatic to severely hypoproteinaemic and septic; however, none of the foals ever displayed diarrhoea, which is the most common presenting sign of this disease process.     

Evidence of host adaptation in Lawsonia intracellularis infections

Background

Lawsonia intracellularis is the causative agent of proliferative enteropathy, an endemic disease in pigs and an emerging concern in horses. Enterocyte hyperplasia is a common lesion in every case but there are differences regarding clinical and pathological presentations among affected species. We hypothesize that host susceptibility to L. intracellularis infection depends on the species of origin of the bacterial isolate. The objective of this study was to evaluate the susceptibilities of pigs and horses to L. intracellularis infection using either a porcine or an equine isolate.

Materials and methods

Twelve foals and eighteen pigs were equally divided into three groups and infected with either a porcine or an equine isolate (10⁹L. Intracellularis/challenged animal), and a saline solution (negative control group). The animals were monitored regarding clinical signs, average of daily weight gain, fecal shedding of the bacteria by PCR and humoral serological response.

Results

Foals infected with the equine isolate developed moderate to severe clinical signs and maintained a lower average of weight gain compared to control foals. Fecal quantitative PCR in equine isolate-infected foals revealed higher amounts of bacterial DNA associated with longer duration of shedding compared with porcine isolate-infected foals. All four foals infected with the equine isolate demonstrated higher IgG titers in the serum compared with porcine isolate-infected foals. In the pig trial, diarrhea and seroconversion were only observed in animals infected with the porcine isolate. Pathological changes typical of proliferative enteropathy were observed in the necropsied foal infected with equine isolate and in the two necropsied pigs infected with the porcine isolate.

Conclusions

Evident clinical signs, longer periods of bacterial shedding and stronger serologic immune responses were observed in animals infected with species-specific isolates. These results show that host susceptibility is driven by the origin of the isolated L. intracellularis strain.     

Lawsonia intracellularis-associated ulcerative and necro-hemorrhagic enteritis in 5 weanling foals

This report describes 5 cases of fatal Lawsonia intracellularis-associated ulcerative and necro-hemorrhagic enteritis in weanling Thoroughbred and Standardbred foals. The lesions are similar to those of the L. intracellularis-associated ulcerative and necro-hemorrhagic enteritis syndrome in pigs. Two foals had concurrent severe typhlo-colitis as a result of a large burden of encysted cyathostomes. The clinical, diagnostic, and therapeutic challenges, and the potential complications encountered during the management of such cases are discussed.     

Lawsonia intracellularis proliferative enteropathy in a weanling foal,with a tentative histological diagnosis of lymphocytic plasmacytic enteritis

This Case Report describes a weanling filly with protein-losing enteropathy associated with Lawsonia intracellularis infection. This was diagnosed on the basis of a significant antibody response and a positive faecal PCR result. The histopathological lesion observed in proliferative enteropathy is mucosal hyperplasia, commonly affecting the ileum and colon in foals. Duodenal biopsies obtained from this filly revealed a lymphocytic plasmacytic infiltrate. The filly recovered completely following treatment with erythromycin and no additional medication was administered to treat the lymphocytic plasmacytic infiltrate. This Case Report suggests that lymphocytic plasmacytic infiltrates observed on duodenal biopsies may represent a nonspecific intestinal immune response.     

Review of methods for the detection of Lawsonia intracellularis infection in pigs

Lawsonia intracellularis is an obligate intracellular bacterium associated with enteric disease in pigs. Clinical signs include weight loss, diarrhea, and, in some cases, sudden death. The hallmark lesion is the thickening of the intestinal mucosa caused by increased epithelial cell replication, known as proliferative enteropathy. The immune response to L. intracellularis is not well defined, and detection of the infection, especially in the early stages, is still a significant challenge. We review here the main approaches used to identify this important but poorly understood pathogen. Detection of L. intracellularis infection as the cause of clinical disease is confounded by the high prevalence of the pathogen in many countries and that several other pathogens can produce similar clinical signs. A single L. intracellularis–specific ELISA and several amplification assays are available commercially to aid detection and surveillance, although histopathology remains the primary way to reach a conclusive diagnosis. There are major gaps in our understanding of L. intracellularis pathogenesis, especially how the host responds to infection and the factors that drive infection toward different clinical outcomes. Knowledge of pathogenesis will increase the predictive value of antemortem tests to guide appropriate interventions, including identification and treatment of subclinically affected pigs in the early stages of disease, given that this important manifestation reduces pig productivity and contributes to the economic burden of L. intracellularis worldwide.     

Rhodococcus equi foal pneumonia: Update on epidemiology,immunity, treatment and prevention

Pneumonia in foals caused by the bacterium Rhodococcus equi has a worldwide distribution and is a common cause of disease and death for foals. The purpose of this narrative review was to summarise recent developments pertaining to the epidemiology, immune responses, treatment, and prevention of rhodococcal pneumonia of foals. Screening tests have been used to implement earlier detection and treatment of foals with presumed subclinical R. equi pneumonia to reduce mortality and severity of disease. Unfortunately, this practice has been linked to the emergence of antimicrobial-resistant R. equi in North America. Correlates of protective immunity for R. equi infections of foals remain elusive, but recent evidence indicates that innate immune responses are important both for mediating killing and orchestrating adaptive immune responses. A macrolide antimicrobial in combination with rifampin remains the recommended treatment for foals with R. equi pneumonia. Great need exists to identify which antimicrobial combination is most effective for treating foals with R. equi pneumonia and to limit emergence of antimicrobial-resistant strains. In the absence of an effective vaccine against R. equi, passive immunisation remains the only commercially available method for effectively reducing the incidence of R. equi pneumonia. Because passive immunisation is expensive, labour-intensive and carries risks for foals, great need exists to develop alternative approaches for passive and active immunisation.     

Medical management of Rhodococcus equi infections: A clinical epidemiology perspective

Rhodococcus equi infections cause severe pulmonary disease in foals, affecting animal welfare and increasing production costs in horse-breeding farms. Extra-pulmonary disorders (EPD) are relatively common and can occur independently of pulmonary disease; foals with EPD have a more guarded prognosis. The accompanying paper by Shaw et al. (2021) reports the successful diagnosis and medical treatment of a large abdominal abscess caused by R. equi infection. The authors report on the benefits of using gallium maltolate, a semimetal compound with antimicrobial activity, in combination with traditional R. equi infection antimicrobial treatment (combination of a macrolide and rifampicin). Experimental studies are needed to understand further the benefits of this combined therapy, to evaluate the synergistic effects and if it improves the concentration of antimicrobial drugs into infected tissues. The publication of this case report in Equine Veterinary Education is of clinical importance to equine practitioners when diagnosing and treating R. equi infected foals with or without EPD.     

Evaluation of the humoral immune response and fecal shedding in weanling foals following oral and intra-rectal administration of an avirulent live vaccine of Lawsonia intracellularis

Equine proliferative enteropathy (EPE) caused by Lawsonia intracellularis has recently been recognized as an emerging disease in foals. Whilst the clinical entity, diagnostic evaluation and treatment of affected foals have been well established and described, preventive measures for EPE have remained largely unaddressed. The objectives of this study were to investigate the humoral immune response and onset and duration of fecal shedding in foals after oral and intra-rectal administration of a modified-live vaccine of L. intracellularis. Foals were vaccinated twice, 3 weeks apart, via oral drenching after pre-medication with a proton-pump inhibitor (omeprazole; group 1), intra-rectally (group 2) or orally without any pre-medication (group 3). The health status of the foals was monitored daily, with feces and serum collected at regular intervals for Polymerase Chain Reaction (PCR) and serology. All foals remained healthy and no adverse vaccine reactions were observed. Fecal shedding lasted from 1 to 12 days and was mainly detected in foals receiving the intra-rectal vaccine 11-15 days following the first vaccine administration. Serological responses were measured in the majority of the vaccinated foals. All foals vaccinated intra-rectally seroconverted after the first vaccine, compared to 50% and 0% of foals in groups 1 and 3, respectively. Pre-medication with omeprazole prior to oral vaccination in group 1 foals led to an earlier and stronger detectable humoral response compared to non pre-medicated foals.     

Acute kidney injury due to Leptospira interrogans in 4 foals and use of renal replacement therapy with intermittent hemodiafiltration in 1 foal

Four 2-month-old foals were presented to an equine hospital with acute kidney injury caused by Leptospira interrogans infection. Clinical signs were nonspecific and included lethargy, fever, and unwillingness to nurse. The most important hematologic and clinicopathologic findings were azotemia, anemia, thrombocytopenia, hyponatremia, and hypochloremia. The diagnosis was based on urinary real-time PCR, serology using a microscopic agglutination test, or both. The most important serovars involved were L. interrogans serogroup australis serovar Bratislava and Australis. Treatment consisted of IV fluid therapy and antimicrobial treatment. Renal replacement therapy with hemodiafiltration was performed in 1 of the foals. All foals survived to discharge. This report highlights the importance of early diagnosis and treatment in foals with acute kidney injury caused by L. interrogans infection.     

Faecal shedding and serological cross‐sectional study of Lawsonia intracellularis in horses in the state of Minas Gerais,Brazil

Reason for performing the study: Proliferative enteropathy, caused by the intracellular bacterium Lawsonia intracellularis, has been described in horses in Australia, the USA, Canada and European countries but has not been reported in Latin America. The prevalence of the disease in horses worldwide is unknown. Objective: To evaluate the presence of subclinical L. intracellularis infection in horses in the state of Minas Gerais, Brazil. Methods: A longitudinal study using serology and PCR for detecting antibodies (IgG) and shedding of L. intracellularis in faecal samples, respectively, was conducted using a total of 223 horses from 14 different horse farms in Minas Gerais, and from the Veterinary School of UFMG equine herds in Minas Gerais. The immunoperoxidase technique in glass slides was used as the serological test. Results: Twenty‐one horse sera had immunoglobulin G titres of 1:60 and were considered positive. The PCR technique in faeces for L. intracellularis DNA identified 7 horses as faecal shedders. Horses shedding the organism appeared healthy, indicating that subclinical infection of L. intracellularis occurred in the horses. Conclusion: Seropositivity and detection of faecal shedding of L. intracellularis indicates the presence of the agent in the equine population in Minas Gerais. Potential relevance: Results of this study should alert clinicians in countries where proliferative enteropthy in horses has not been reported to consider this disease as a possible cause of enteric disease.     

Prevalence of antibodies to Lawsonia intracellularis in pig herds in Australia

Objective Proliferative enteropathy (PE) of pigs is caused by Lawsonia intracellularis. Clinical severity appears to depend, at least partly, on the infective dose and strain of L. intracellularis. Serological tests are able to detect subclinical disease. The Bioscreen ELISA for detecting L. intracellularis-specific antibodies is widely used to monitor the circulating antibody status of pigs in Australia, but its sensitivity and specificity have not been reported. The aim of the present study was to measure the seroprevalence of antibodies to L. intracellularis in growing pigs in Australia. Methods Test sera were sourced from 1817 serum samples collected from finisher pigs from 63 herds across Australia in 2001, selected from a larger sample of 180 herds to represent the contribution that each herd size makes to the number of pigs produced. The test sera were the most recent collection of pig sera from all states and samples had been stored at −80°C from 2001 until testing was conducted in 2008. Sera were tested using the BioScreen ELISA. Results All herds tested positive for L. intracellularis-specific antibodies. The mean percentage of positive samples within each herd was 84.2% (range 31.3–100%). Conclusions Lawsonia intracellularis is endemic in pig herds in Australia and cost-effective strategies to reduce reliance on antibiotics, such as vaccination and/or all-in/all-out pig flow coupled with cleaning and disinfection of pens, are warranted.     

Efficacy of Mass Antimicrobial Treatment of Foals with Subclinical Pulmonary Abscesses Associated with Rhodococcus equi

Background

Mass antimicrobial treatment of foals with small subclinical ultrasonographic pulmonary lesions is empirical practice on many farms with endemic disease caused by Rhodococcus equi.

Hypothesis

Mass antimicrobial treatment of foals with subclinical ultrasonographic pulmonary lesions is unnecessary.

Animals

One hundred and eight foals on a farm endemic for infections caused by R. equi.

Methods

Controlled, randomized, and double‐blinded prospective study. Foals with ultrasonographic evidence of pulmonary abscesses 5.0–10 cm in diameter (n = 108) were randomly allocated in 5 treatment groups: (1) tulathromycin IM; (2) doxycycline monotherapy PO; (3) doxycycline with rifampin PO; (4) azithromycin with rifampin PO, and (5) saline IM as a placebo. Physical examination and thoracic ultrasonography were performed by individuals unaware of treatment group assignment. Foals with evidence of disease progression were removed from the study and treated with azithromycin‐rifampin.

Results

Overall, 22/25 (88%) foals in the placebo group recovered without the need for treatment. The proportion of foals that had evidence of disease progression did not differ significantly between the treatment groups (P > .05). Although the median duration of treatment was significantly (P < .05) shorter in foals treated with azithromycin‐rifampin (46 days) compared with foals treated with the placebo (73 days), the time frame of ultrasonographic lesion resolution did not differ significantly between the treatment groups.

Conclusions and Clinical Importance

The majority of foals with subclinical pulmonary abscesses <10 cm in diameter recover without antimicrobial treatment and treatment of affected foals does not provide a clear benefit over administration of a placebo.