Tibial osteomyelitis caused by Rhodococcus equi in a mature horse

A 7‐year‐old Paint mare presented for evaluation of a swollen right hindlimb of approximately 6 weeks' duration. Ultrasonography and radiography suggested a severe osteomyelitis and abscessation of the right tibia. Previous treatment included systemic antimicrobial therapy using procaine penicillin G (22,000 u/kg bwt, q. 12 h, i.m.) and gentamicin sulfate (6.6 mg/kg bwt, q. 24 h, i.v.) initially followed by oral doxycycline (10 mg/kg bwt, q. 12 h, per os) and rifampin (5 mg/kg bwt, q. 12 h, per os). Based on the poor prognosis the mare was subjected to euthanasia. Necropsy results subsequently revealed a severe, chronic, focal, necrotising osteomyelitis with localised cellulitis and abscessation. Rhodococcus equi was isolated from the tibia, subcutaneous abscess and from a pectoral abscess found at necropsy. Immunological testing of blood samples obtained ante mortem revealed normal blood lymphocyte phenotyping, but markedly increased IgG and IgM concentrations, indicating an active humoural response. While there have been reports of Rhodococcus equi infection in mature horses this is an area previously unreported in the literature.     

Vertebral osteomyelitis caused by Rhodococcus equi in a three-and-half-month-old Dutch Warmblood foal

Rhodococcus equi infection occurs worldwide and is especially a problem in foals, where it often causes colitis or pneumonia. Other organs are seldom affected, and their involvement is regarded as a complication of pneumonia and/or colitis. Vertebral osteomyelitis is one such rare complication and is probably caused by haematogenous spread from inflammatory lesions in the lungs and/or intestine. In rare cases, osteomyelitis can be caused by contamination of a wound. This case study describes a foal with vertebral osteomyelitis due to R. equi in which there were only minor inflammatory changes in a mesenteric lymph node.     

Two cases of equine abortion caused by Rhodococcus equi

Rhodococcus equi was isolated from lung, liver, spleen, and stomach content of two aborted equine fetuses of 7 and 8 months gestation from two different farms. Lesions included diffuse pyogranulomatous pneumonia with numerous Gram-positive coccobacilli within the cytoplasm of macrophages, multinucleated Langhans giant cells and neutrophils, and enhanced extramedullary hematopoiesis with megakaryocytosis within the liver and spleen. Detection of R. equi was made by bacteriology and immunohistochemistry for R. equi and VapA, the virulence factor of R. equi. R. equi and VapA were identified within the lungs of both fetuses, and its distribution correlated with lesions. Fetal lesions were similar to those observed in foals. We speculate that the fetuses contracted infection from the placenta by normal breathing movements or by swallowing of the amniotic fluid contaminated with R. equi.     

Intracranial abscess caused by Rhodococcus equi infection in a foal

CASE DESCRIPTION: A 4-month-old Missouri Fox Trotter colt was examined for a 5-week history of head tilt after treatment for suspected pulmonary Rhodococcus equi infection. CLINICAL FINDINGS: Computed tomography revealed osteolysis of the occipital, temporal, and caudal portion of the parietal bones of the left side of the cranium. A soft tissue mass compressing the occipital region of the cerebral cortex and cerebellum was associated with the osteolytic bone. TREATMENT AND OUTCOME: A rostrotentorial-suboccipital craniectomy approach was performed to remove fragmented occipital bone, debulk the intracranial mass, and obtain tissue samples for histologic examination and bacterial culture. All neurologic deficits improved substantially within 3 days after surgery. Bacterial culture of the resected soft tissue and bone fragments yielded R equi. CLINICAL RELEVANCE: Intracranial surgery in veterinary medicine has been limited to dogs and cats; however, in select cases, extrapolation of surgical techniques used in humans and small animals can assist with intracranial procedures in horses.     

Controversies in therapy of infections caused by Rhodococcus equi in foals

Pneumonia caused by Rhodococcus equi is one of the most important causes of disease and death in foals. R. equi can also be cultured from a large variety of extrapulmonary sites of infection. In the absence of an effective vaccine, ultrasonographic screening for early detection of pulmonary lesions has become routine practice at many farms endemic for pneumonia caused by R. equi. Consequently, the most frequently recognised form of R. equi infection at such farms is a subclinical form in which foals develop sonographic evidence of peripheral pulmonary consolidation or abscessation without necessarily manifesting clinical signs. Evidence exists that not all foals with ultrasonographic lesions will progress to develop clinical signs, and treating a large proportion of foals based on subclinical ultrasonographic findings has been linked to emergence of macrolide‐ and rifampin‐resistant R. equi at a horse farm. Selectively treating only those foals with larger lesion scores and monitoring foals with daily physical inspections and weekly thoracic ultrasonography offers an approach that could decrease antimicrobial drug use without significantly increasing mortality. Current evidence continues to support the combination of rifampin with a macrolide (azithromycin, clarithromycin or erythromycin) for treating clinical infections caused by R. equi despite recently described pharmacological interactions between these drugs. When infection with a macrolide‐resistant isolate is confirmed, limited effective alternatives exist.     

Rhodococcus equi

Rhodococcus equi is an important cause of subacute or chronic abscessating bronchopneumonia of foals up to 3-5 months of age. It shares the lipid-rich cell wall envelope characteristic of the mycolata, including Mycobacterium tuberculosis, as well as the ability of pathogenic members of this group to survive within macrophages. The possession of a large virulence plasmid in isolates recovered from pneumonic foals is crucial for virulence. The plasmid contains an 27 kb pathogenicity island (PI) that encodes seven related virulence-associated proteins (Vaps), including the immunodominant surface-expressed protein, VapA. Only PI genes are differentially expressed when the organism is grown in macrophages in vitro. Ten of the PI genes, including six Vap genes, have signal sequences, suggesting that they are exported from the cell to interact with the macrophage. Different PI genes are regulated by temperature, pH, iron, oxidative stress and probably also by magnesium, all environmental changes encountered after environmental R. equi are inhaled in dust and are ingested into macrophages in the lung. The basis of pathogenicity of R. equi is its ability to multiply in and eventually to destroy alveolar macrophages. Infectivity is largely or exclusively limited to cells of the monocyte-macrophage lineage. Current evidence suggests that infection of foals with virulent R. equi results in some foals in subversion of cell-mediated immunity and development of an ineffective and sometimes lethal Th2-based immune response. Significant progress has been made recently in the development of R. equi-E. coli shuttle vectors, transformation and random and site specific mutagenesis procedures, all of which will be important in molecular dissection of the mechanisms by which R. equi subverts normal macrophage killing mechanisms and cell-mediated immunity.     

Osteomyelitis of the pelvis caused by Rhodococcus equi in a two-year-old horse

A 2-year-old female Quarter Horse was evaluated for hind limb lameness, fever (40 degrees C [104 degrees F]), and lethargy of 2 weeks' duration. Hypoproteinemia characterized by hypoalbuminemia and hyperfibrinogenemia was detected. Abdominal ultrasonography revealed thickening of the right dorsal colon wall. Treatment was instituted for putative right dorsal coliis. Lameness evaluation localized signs of pain to the lumbar vertebrae or pelvis. Radiography performed with the horse standing and nuclear scintigraphy revealed no abnormalities. Ventrodorsal pelvic radiography revealed a focal area of bony lysis and proliferation involving the cranial portion of the pubic symphysis. Aspiration yielded purulent exudate containing Rhodococcus equi, which was susceptible to erythromycin. Treatment included surgical debridement of the abscess and oral administration of erythromycin and rifampin. The horse's hind limb lameness completely resolved within 20 days. Infections of the pubic symphysis should be considered when lameness localized to the pelvis is associated with fever and an inflammatory leukogram.     

Immunohistochemical observations on pneumonic lesions caused by Rhodococcus equi in foals.

An immunohistochemical analysis of Rhodococcus equi-induced pneumonia in 10 foals was performed by biotin-streptavidin system. The detection of R. equi was more sensitive in immuno-stain using anti-R. equi serum than in Gram's stain. This bacteria also reacted to anti-BCG serum. Lysozyme and alpha 1-antitrypsin were detectable in macrophages. A particularly intense staining was observed in association with intracellular bacteria. Though a degree of reaction for alpha 1-antichymotrypsin was very low in comparison with lysozyme and alpha 1-antitrypsin, it was also demonstrated in macrophages ingesting R. equi. These bacteria were almost intact under an electron microscope. Therefore, the surface components of R. equi may play important roles of protection from intracellular enzymes of macrophages. The cells containing intracytoplasmic IgM, IgG or IgA were a few in number and scattered predominantly around the pneumonic lesion. It is considered that the bactericidal activity by immunoglobulins may be weak in comparison with phagocytosis by macrophages.     

Pyogranulomatous skin disease and cellulitis in a cat caused by Rhodococcus equi

This report describes a case of Rhodococcus equi infection causing pyogranulomatous skin disease and cellulitis in a two-year-old female domestic shorthaired cat. The case differed from previously reported cases in cats in its clinical presentation and in the locations of the lesions, which were similar to those seen in horses. The presence of an intracellular organism was confirmed by cytology and on histopathology. The aetiological diagnosis was confirmed by routine biochemical tests specific for R. equi on a pure isolate obtained from a biopsy specimen. The report also reviews the literature of the documented feline cases and discusses the common pitfalls in the diagnosis of such infections.     

Cellulitis and subcutaneous abscesses caused by Rhodococcus equi infection in a foal

Cellulitis and subcutaneous abscess formation was diagnosed in a 3-month-old Thoroughbred filly. Clinical signs consisted of a large ulcerated plaque, with satellite pustules on the medial aspect of the right hock and subcutaneous abscesses in the right inguinal and mammary gland areas. Laboratory analysis revealed mature neutrophilia. Rhodococcus equi was isolated from the cellulitis and the subcutaneous abscess. Oral administration of erythromycin and rifampin for 35 days resulted in a clinical cure.     

Septic pleuritis and abdominal abscess formation caused by Rhodococcus equi in a foal

A 3-month-old female Arabian horse was evaluated because of fever, respiratory distress, lethargy, and decreased appetite of 5 days' duration. Pleural effusion was diagnosed on the basis of ultrasonographic and radiographic examinations. Cytologic examination of pleural fluid collected via thoracocentesis revealed septic inflammation; bacteriologic culture of a sample of that fluid yielded Rhodococcus equi. A large intra-abdominal mass adjacent to the body wall was identified ultrasonographically. A specimen of the mass was collected via aspiration; the specimen was identified cytologically as purulent exudate that contained large numbers of rod-shaped bacteria, which confirmed abdominal abscess formation. Bacteriologic culture of a sample of the exudate also yielded R. equi. The foal was treated with azithromycin (10 mg/kg [4.5 mg/lb], PO, q 24 h for 5 days then q 48 h) and rifampin (5 mg/kg [2.3 mg/lb], PO, q 12 h) for 8 weeks and metronidazole (15 mg/kg [6.8 mg/lb], PO, q 8 h) for 3 weeks. Clinically, the foal responded to antimicrobial treatment within 2 weeks. At 8 weeks after the initial evaluation, ultrasonographic examination of the foal revealed resolution of the pleural effusion and abdominal abscess. In foals, R. equi infection typically results in pyogranulomatous pneumonia, and pleural effusion is an uncommon clinical sign. The combination of azithromycin and rifampin appears to be an effective treatment for R. equi infection in foals.     

Association of pneumonia in foals caused by Rhodococcus equi with farm soil geochemistry

OBJECTIVE: To quantify and compare geochemical factors in surface soils from horse-breeding farms with horses with pneumonia caused by Rhodococcus equi (affected farms) and horse-breeding farms with no history of pneumonia caused by R equi (unaffected farms). SAMPLE POPULATION: Soil from 24 R equi-affected farms and 21 unaffected farms. PROCEDURE: Equine veterinary practitioners throughout Texas submitted surface soil samples from areas most frequented by foals, on R equi-affected and unaffected horse-breeding farms in their practice. Soil samples were assayed for the following factors: pH, salinity, nitrate, phosphorus, potassium, calcium, magnesium, sodium, sulfur, zinc, iron, manganese, and copper. Median values for all factors were recorded, and differences between affected and unaffected farms were compared. RESULTS: Significant differences in soil factors were not detected between affected and unaffected farms; hence, there was no association between those factors and R equi disease status of the farms. CONCLUSIONS AND CLINICAL RELEVANCE: The surface soil factors monitored in this study were not significant risk factors for pneumonia caused by R equi. As such, it is not possible to determine whether foals on a given farm are at increased risk of developing disease caused by R equi on the basis of these factors. Data do not support altering surface soil for factors examined, such as alkalinization by applying lime, as viable control strategies for R equi.     

Failure of hyperimmune plasma to prevent pneumonia caused by Rhodococcus equi in foals

SUMMARY A trial was conducted on a Thoroughbred stud to determine whether or not the administration of anti-Rhodococcus equi hyperimmune plasma would reduce the prevalence of R equi pneumonia (rattles) in foals born in the 1992 horse breeding season. Hyperimmune plasma was administered to 34 foals; another 57 foals were untreated. There was no significant difference in the number of transfused foals developing R equi pneumonia compared with the untreated foals. The time required for recovery from pneumonia between the 2 groups was not significantly different.     

Ecology of Rhodococcus equi

A selective broth enrichment technique was used to study the distribution of Rhodococcus equi in soil and grazing animals. Rhodococcus equi was isolated from 54% of soils examined and from the gut contents, rectal faeces and dung of all grazing herbivorous species examined. Rhodococcus equi was not isolated from the faeces or dung of penned animals which did not have access to grazing. The isolation rate from dung was much higher than from other samples and this was found to be due to the ability of R. equi to multiply more readily in dung. Delayed hypersensitivity tests were carried out on horses, sheep and cattle, but only horses reacted significantly. The physiological characteristics of R. equi and the nature of its distribution in the environment suggested that R. equi is a soil organism.     

Medical management of a large intra-abdominal mass caused by Rhodococcus equi in a foal

A 4-month-old Thoroughbred filly presented with pyrexia, inappetence and diarrhoea. Abdominal ultrasonography revealed a multilobulated abdominal mass that was determined to be associated with the caecum using computed tomography. Computed tomography also identified mesenteric lymphadenopathy and a pulmonary mass in the left caudal lung lobe. Percutaneous aspiration of the abdominal mass yielded pure growth of Rhodococcus equi. The filly responded in a positive fashion to the administration of clarithromycin, rifampin and gallium maltolate. Follow-up computed tomography revealed complete resolution of the abdominal mass and lymphadenopathy. Extrapulmonary disorders associated with R. equi should be considered even when thoracic ultrasonography reveals no evidence of pulmonary pathology. Although intra-abdominal abscesses have a grave prognosis, successful treatment is possible. Gallium maltolate can be safely administered to foals and may improve patient outcomes.     

Rhodococcus equi occipital bone osteomyelitis,septic arthritis and meningitis in a neurological foal

This case report describes a 3‐month‐old female Thoroughbred foal that presented following the acute onset of apparent respiratory distress, abnormal head carriage and severe neurological deficits referable to the brainstem or cranial cervical spinal cord. Ultrasonography revealed an abscessing pneumonia. Radiographs did not show evidence of bony pathology at the atlanto‐occipital region, an area consistent with the observed neurological deficits. With magnetic resonance imaging, atlantal and occipital osteomyelitis, atlanto‐occipital septic arthritis, and atlanto‐axial synovitis were diagnosed. Brainstem meningitis and extradural compression were also revealed. Culture of the right occipitoatlantal joint and cerebrospinal fluid yielded a pure culture of Rhodococcus equi. These findings and multifocal R. equi abscessation were confirmed at necropsy.     

Rhodococcus equi infection of cats

Six cases of Rhodococcus equi infection in cats are described. One cat had pneumonia and died. The remaining five cats had cutaneous lesions affecting the feet in four of the cats and the metacarpus in one cat, and all these cats recovered with the aid of antibiotics. All the Rhodococcus equi isolates were sensitive to amoxycillin/clavulanic acid and, where used, at least 14–16 days of treatment was needed to help eliminate the infection. Histologically and cytologically the reaction was pyogranulomatous and many macrophages in the lesions contained large numbers of Gram-positive bacteria.