Strangles and its complications

Strangles, caused by the Gram‐positive bacteria Streptococcus equi subspecies equi (S. equi), is a highly contagious upper respiratory infection in horses. The infection is transmitted by inhalation or direct contact with mucopurulent discharge from an infected animal, resulting in fever, depression, and submandibular and retropharyngeal lymph node enlargement that can lead to respiratory distress. Complications include secondary cellulitis at external abscessation sites, guttural pouch empyema and its persistence into the carrier state, purpura haemorrhagica, metastatic abscessation, emergency tracheostomies and rarely secondary S. equi pneumonia or myositis. Control of outbreaks requires strict isolation protocols and hygiene measures. Detection methods of the index case and carrier state are constantly being refined to assist in the identification and prevention of disease perpetuation.     

Sequelae and complications of Streptococcus equi subspecies equi infections in the horse

Streptococcus equi ssp. equi infection in the horse, or strangles, commonly results in abscessation of the submandibular, submaxillary or retropharyngeal lymph nodes. Although this classical presentation of strangles is associated with a low mortality rate, complications and sequlae may worsen the prognosis and increase mortality rates. This article reviews sequelae and complictions of S. equi ssp. equi infection in the horse, including guttural pouch empyema, bastard strangles and immune mediated diseases such as purpura haemorrhagica, myopathies and myocarditis.     

Lessons learned from a strangles outbreak on a large Standardbred farm

Streptococcus equi subspecies (ssp.) equi infection (strangles) remains one of the most frequently diagnosed and costly infectious diseases of horses. Large breeding herds, where a disease outbreak competes for personnel and financial resources needed for foaling management, present a special challenge for equine practitioners. A 15‐month outbreak involving 62 clinical cases of strangles occurred on a large Standardbred breeding farm (average population of 1400 horses). Sixteen asymptomatic horses were found to be PCR (polymerase chain reaction)‐positive for S. equi ssp. equi. During the outbreak, serological samples from 48 clinically normal horses were found to be seropositive for S. equi ssp. equi, confirming herd‐wide exposure. After several clinical cases of strangles had been diagnosed, an intranasal S. equi ssp. equi vaccine was administered to clinically normal horses (n = 558) considered to be at risk of exposure. Strangles complications included 7 fatalities (none in vaccinated horses) and 6 cases of purpura haemorrhagica (4 in vaccinated horses). Midway through the outbreak, injectable, sustained release ceftiofur crystalline free acid (CCFA), given as an initial dose followed by a second dose 4 days later, was used exclusively for systemic antimicrobial treatment of clinically affected and PCR‐positive horses. This antimicrobial regimen coincided with a reduction in disease incidence and eventual resolution of the outbreak. Two horses with persistent guttural pouch infection were endoscopically confirmed as carrier horses. The herd history demonstrated that a strangles outbreak will often result in asymptomatic carrier horses and that identification and treatment of these horses are necessary to eliminate long‐term sources of infection. Ceftiofur crystalline free acid was found to be a suitable antimicrobial due to its activity against S. equi ssp. equi and the efficiencies associated with twice parenteral dosing during a 10‐day treatment period. Occurrence of purpura in 4 vaccinated horses suggests that vaccination should be reserved for healthy seronegative horses and avoided during an active outbreak.     

Identification of Corynebacterium pseudotuberculosis isolated from muscular abscesses in two horses: First report in Mexico

Two Quarter Horse stallions from the same region in Mexico presented with pectoral abscesses and lameness. Exudate samples were taken from drained muscular abscesses and Corynebacterium pseudotuberculosis, identified by bacteriological techniques and multiplex polymerase chain reaction, was obtained in a pure isolation culture from both samples. The sequences of a hypervariable region of the rpoB gene showed 100% and 99% identity to C. pseudotuberculosis 316 biovar equi (CP003077.1) isolated from a horse. Both strains' sequences were located in the same phylogenetic cluster as other biovar equi strain sequences obtained from GenBank. Both horses responded satisfactorily to treatment, which included surgical procedures and wound management. These study cases proved the infection of Mexican horses with C. pseudotuberculosis; however, the prevalence of this pathogen remains unknown.     

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.     

Review of Equine Piroplasmosis

Equine piroplasmosis is caused by one of 2 erythrocytic parasites Babesia caballi or Theileria equi. Although the genus of the latter remains controversial, the most recent designation, Theileria, is utilized in this review. Shared pathogenesis includes tick‐borne transmission and erythrolysis leading to anemia as the primary clinical outcome. Although both parasites are able to persist indefinitely in their equid hosts, thus far, only B. caballi transmits across tick generations. Pathogenesis further diverges after transmission to equids in that B. caballi immediately infects erythrocytes, whereas T. equi infects peripheral blood mononuclear cells. The recent re‐emergence of T. equi in the United States has increased awareness of these tick‐borne pathogens, especially in terms of diagnosis and control. This review focuses in part on factors leading to the re‐emergence of infection and disease of these globally important pathogens.     

Empyema of the guttural pouch (auditory tube diverticulum) in horses: 91 cases (1977-1997)

OBJECTIVE: To identify features of guttural pouch (auditory tube diverticulum) empyema in horses and compare findings of uncomplicated guttural pouch empyema with guttural pouch empyema complicated by chondroids. DESIGN: Retrospective study. ANIMALS: 91 horses with guttural pouch empyema. PROCEDURE: Medical records of horses with guttural pouch empyema were reviewed. RESULTS: The most common owner complaint and abnormal finding was persistent nasal discharge. Chondroids were detected in 21% (19/91) of affected horses. Streptococcus equi was isolated from the guttural pouch in 14 of 44 horses; for Streptococcus spp, in vitro resistance to sulfadimethoxine and trimethoprim-sulfamethoxazole was detected. Retropharyngeal swelling and pharyngeal narrowing were significantly more prevalent in horses with chondroids, compared with horses with uncomplicated empyema. Ninety-three percent of affected horses were discharged from the hospital; at time of discharge, 66% had complete resolution of disease, 19% had improvement without resolution, and 15% did not have improvement. CONCLUSIONS AND CLINICAL RELEVANCE: Horses with persistent nasal discharge should be examined endoscopically for guttural pouch empyema. Treatment with lavage offers a good prognosis for resolution of uncomplicated guttural pouch empyema. Aggressive treatment with lavage and endoscopic snare removal of chondroids offers a good prognosis and may make surgical intervention unnecessary.     

Soft tissue sarcomas in the pharyngeal region of a 5‐year‐old Quarter Horse mare

This case report describes the identification of multiple soft tissue sarcomas in the pharyngeal region of a 5‐year‐old Quarter Horse mare. Diagnostic work‐up included physical examination, radiography, ultrasonography, endoscopic examination of upper airways and guttural pouch, and post mortem examination with histopathology. Humane euthanasia was indicated due to the chronicity of the condition, prognosis and financial constraints.     

Pasteurella multocida isolation in a horse with retropharyngeal infection

Retropharyngeal infections in horses normally induce local painful swelling of the retropharyngeal area, which may lead to dyspnea, dysphagia, and systemic manifestations. Differential diagnosis of local painful swelling of the retropharyngeal area includes retropharyngeal lymph node infection, neoplasm, cellulitis, hematoma, guttural pouch empyema, parotiditis, and jugular thrombosis. Apart from Streptococcus equi ssp. equi, other bacteria are rarely reported as a cause of retropharyngeal abscesses. The reason for this might be a lack of specific sampling to identify the causative agent. This work deals with a case of retropharyngeal infection in an 11-year-old Standardbred stallion with acute depression, fever, tachycardia, asymmetric painful swelling in the throat area, ptyalism, and respiratory distress. Endoscopy, radiography, ultrasonography, blood analysis, and cytological examination of a puncture sample taken from the throat mass were consistent with a pyogenic to pyogranulomatous retropharyngeal inflammation. The clinical evolution was initially satisfactory in response to treatment with nonsteroidal anti-inflammatory drugs and antibiotics, but clinical signs relapsed twice, each time a few weeks after cessation of antibiotic therapy. The bacteriologic finding in this case was unusual and consisted of the isolation of a Pasteurella multocida strain that was obtained after the second relapse (ie, 79 days after initial admission), using a brain heart infusion (BHI) medium, and after two successive negative bacteriological cultures performed on day one of clinical signs and at the first relapse of clinical signs, respectively.     

Genetic Susceptibility to Rhodococcus equi

Rhodococcus equi pneumonia is a major cause of morbidity and mortality in neonatal foals. Much effort has been made to identify preventative measures and new treatments for R. equi with limited success. With a growing focus in the medical community on understanding the genetic basis of disease susceptibility, investigators have begun to evaluate the interaction of the genetics of the foal with R. equi. This review describes past efforts to understand the genetic basis underlying R. equi susceptibility and tolerance. It also highlights the genetic technology available to study horses and describes the use of this technology in investigating R. equi. This review provides readers with a foundational understanding of candidate gene approaches, single nucleotide polymorphism‐based, and copy number variant‐based genome‐wide association studies, and next generation sequencing (both DNA and RNA).     

Extensive and invasive guttural pouch granuloma in a 2-year-old gelding

This report describes a case of an unusually extensive and invasive fungal granuloma within the right guttural pouch and its surrounding area of a 2-year-old Noriker gelding, causing diverse neurogenic deficits and tissue destruction. The gelding was initially presented with cachexia, unilateral nasal discharge, intermittent fever, swelling of the right side of the head, facial nerve paralysis and dysphagia. The right guttural pouch was not accessible to endoscopic examination initially, but after anti-inflammatory medical management, empyema and an extensive, solid mass appeared within the guttural pouch. Surgical exploration and excision were attempted but were unsuccessful. Histopathological examination identified Aspergillus fumigatus as the causative infective agent of the extensive fungal granuloma, and the consequent invasion and destruction of surrounding bone and soft tissue structures.     

Dysphagia caused by focal guttural pouch mycosis: mononeuropathy of the pharyngeal ramus of the vagal nerve in a 20-year-old pony mare

A 20-year-old pony mare was presented to the equine hospital with a ten-day history of dysphagia, regurgitation and coughing. An obstruction of the oesophagus was excluded via endoscopy, but the proximal oesophagus appeared to be distended and circular contractions were missing. A guttural pouch endoscopy revealed a single, black-mottled plaque on the pharyngeal ramus of the vagus nerve in the left guttural pouch, causing a local swelling of this nerve. The pharyngeal ramus seemed to be atrophic distal to the lesion. A biopsy was taken from the lesion and histopathological findings proved the reasonable suspicion of a guttural pouch mycosis with a high degree of purulent-necrotic inflammation and invasion of fungal hyphae. There were no signs of neoplasia, such as melanoma. Daily guttural pouch irrigations with a clotrimazole emulsion (20 g Canesten^® Gyn⁴ solved in 500 ml water), led to a good recovery of the mucosa above the nerve. Periodic endoscopic examination of the left guttural pouch showed that local thickening and distal atrophy of this pharyngeal ramus did not improve, neither did the clinical symptoms. Due to progressive weight loss, acute respiratory distress and aspiration pneumonia, the 20-year-old pony mare unfortunately had to be euthanized three weeks after discharge. This case report emphasizes the enormous importance of a single nerve for the realization of the swallowing process. The one-sided loss of function of the pharyngeal branch of the vagal nerve cannot be compensated neither by the remaining ipsilateral nerves nor by the contralateral normal functioning glossopharyngeal and vagal nerves and thus inevitably leads to severe dysphagia.     

Guttural pouch empyema secondary to a periocular foreign body

This report describes a 3‐year‐old gelding presenting with signs of injury to its left eye following an accident in which the horse crashed into a hedge. The first treatment attempted to treat infections in the eye and respiratory tract due to secretions identified in the trachea. The horse did not improve and further clinical and radiographic evaluations detected a guttural pouch empyema. Surgical drainage was performed and antimicrobial treatment continued. However, the horse presented with severe epistaxis and euthanasia was elected due to suspected arterial rupture. At necropsy, a round and stiff branch plant was found creating a fistula from the left orbit to the left guttural pouch. Another branch was found inside the pouch, confirming the origin of the persistent infection and severity of the tissue lesion.     

Progression of mycosis of the auditory tube diverticulum (guttural pouch) after arterial occlusion in a horse with contralateral temporohyoid osteoarthropathy

CASE DESCRIPTION: A 6-year-old Appaloosa mare was examined because of inappetance, difficulty eating, and swelling and mucopurulent discharge in the right eye. CLINICAL FINDINGS: Results of a CBC and serum bio-chemical analysis revealed no important findings. Ophthalmologic examination revealed scarring and ulceration of the superficial layers of the cornea. Endoscopic examination of the upper portion of the respiratory tract and auditory tube diverticula (guttural pouches) revealed abnormal thickness of the right stylohyoid bone and a plaque suggestive of mycotic growth on the left internal carotid artery. Radiographic examination revealed right-sided otitis media. Temporohyoid osteoarthropathy in the right guttural pouch and mycosis in the left guttural pouch were diagnosed. TREATMENT AND OUTCOME: Ceratohyoidectomy of the right stylohyoid bone was performed, and the left internal carotid artery was occluded via placement of stainless steel spring embolization coils. The mare regained the ability to eat without difficulty and improved clinically for approximately 4 weeks. However, the mare returned to the medical center 53 days after surgery with left-sided Horner syndrome, atrophy of the right side of the tongue, and a 3-week history of dysphagia and weight loss. Endoscopic evaluation revealed progression of mycotic growth in the left guttural pouch. The mare was euthanatized. CLINICAL RELEVANCE: Although the mycotic lesion in the left guttural pouch was an incidental finding at the time of initial examination, the lesion progressed to cause dysphagia and Horner syndrome after occlusion of the left internal carotid artery, a treatment that is typically associated with resolution of guttural pouch mycosis. Arterial occlusion is not necessarily a reliable method of resolving guttural pouch mycosis.     

Rhodococcus equi pneumonia in an adult horse

A 20‐year‐old, Thoroughbred mare in the fifth month of gestation was examined for weight loss, pyrexia and lethargy. Physical examination, ultrasonography and radiography revealed a severe abscessing pneumonia and a dead fetus. The mare did not respond to symptomatic treatment and died suddenly. Necropsy revealed multifocal pulmonary abscessation. Rhodococcus equi was isolated from the lungs, liver and kidneys. Specific immune function of the mare and presence of the virulence associated protein A (VapA) of the R. equi isolated was not determined. It is likely that immunosuppression is required for systemic R. equi infections in adult horses; however, it is unknown if VapA is necessary to produce disease in adult horses.     

Standing surgical removal of inspissated guttural pouch exudate (chondroids) in ten horses

OBJECTIVE: To report use of a modified Whitehouse approach in standing horses for management of inspissated guttural pouch empyema. STUDY DESIGN: Retrospective study. ANIMALS: Adult horses (n=10) with guttural pouch empyema. METHODS: Inspissated exudate in 1 or both guttural pouches was removed surgically through a modified Whitehouse approach, with the horses standing and sedated. Medical records of affected horses were reviewed to determine history; physical, endoscopic, and radiological examination findings; surgical technique; complications, and outcome. RESULTS: All horses had purulent nasal discharge; 3 horses had dysphagia, 2 had recurrent laryngeal neuropathy on the side affected by guttural pouch empyema, and 1 had persistent soft palate displacement. Inspissated exudate was removed safely without causing apparent discomfort. Eight horses returned to their previous level of athletic activity after surgery; 1 horse dysphagic before surgery, was euthanatized because of persistent dysphagia after surgery, and 1 horse died 1 week after surgery for unknown reasons. Streptococcus equi subsp equi was isolated from the affected guttural pouch of 3 horses. CONCLUSIONS: Inspissated exudate can be removed surgically from the guttural pouch in standing horses through a modified Whitehouse approach. CLINICAL RELEVANCE: To eliminate risks associated with general anesthesia and avoid surgical suite contamination, removal of chondroids can be performed in standing sedated horses through a modified Whitehouse approach.     

Long-term successful outcome of a Streptococcus equi subspecies equi brain abscess

We previously described successful treatment, including surgical drainage, of a Streptococcus equi subspecies equi brain abscess that caused severe neurological deficits in a 7-year-old Quarter Horse mare. This report details the long-term successful outcome of the case, findings of a magnetic resonance imaging (MRI) study performed 14 years after surgery and necropsy findings 18 years after initial treatment. Despite persistent cerebral and midbrain lesions detected by MRI and at necropsy, the mare returned to serviceable function within a year of initial treatment and had a successful performance career for over 10 years until carpal arthritis prompted retirement. This case demonstrates that brain abscess in horses can be successfully managed by combined medical and surgical treatment.     

Fistulation of the auditory tube diverticulum (guttural pouch) with a neodymium:yttrium-aluminum-garnet laser for treatment of chronic empyema in two horses

Two horses with chronic empyema of the auditory tube diverticulum (guttural pouch) were refractory to medical treatment; empyema was bilateral in 1 horse and unilateral in the other. Both horses were treated by fistulation of the cartilage of the pharyngeal orifice by use of a neodymium:yttrium-aluminum-garnet laser in a noncontact manner. To maintain patency of the fistulae, indwelling catheters were placed into the openings created by the laser. For both horses, long-term follow-up did not reveal complications, and both owners were satisfied with results of the procedure. The authors recommend this procedure for horses that are unresponsive to medical treatment for chronic guttural pouch empyema.     

Successful management of multiple extrapulmonary complications associated with Rhodococcus equi pneumonia in a foal

This report describes the diagnosis and successful treatment of multiple extrapulmonary sequelae of Rhodococcus equi (R. equi) pneumonia in a 3‐month‐old filly. Bilateral uveitis and hyphaema, haemolytic anaemia and polysynovitis developed in this foal and were likely due to immune‐mediated mechanisms. The challenges associated with diagnosis and treatments of these extrapulmonary disorders are discussed. The filly was treated initially with clarithromycin and rifampin; however, a blood transfusion and immunosuppressive therapy with dexamethasone were required due to progressive haemolysis and for treatment of uveitis and polysynovitis. Bilateral hyphaema was successfully treated with intracameral injections of a recombinant tissue plasminogen activator. The development of antimicrobial resistance in R. equi was an additional challenge encountered in the management of this case and emphasises the importance of culture and in vitro antimicrobial susceptibility testing of isolates from foals with R. equi pneumonia. Extrapulmonary disorders associated with R. equi pneumonia are likely underdiagnosed and associated with a poor prognosis. This case highlights the importance of thorough and ongoing diagnostic assessment of foals with R. equi pneumonia and demonstrates that a successful outcome can be achieved with appropriate and directed treatment.