Clostridial Enterocolitis in a Neonatal Foal - PowerPoint Presentation

Slide1

Clostridial Enterocolitis in a Neonatal Foal

Mallory Lehman, MS

Colorado State University

DVM Candidate, Class of 2020

Mentors: Gabrielle Landolt, DVM, DACVIM;

Yvette Nout-Lomas, DVM, DACVIM, DACVECCS

Slide2

Signalment and History

26 hours old, Quarter Horse Filly, 48

kgs

Chief complaint:

hematochezia

History:

Reported full term gestationFirst foal to be born on the property this yearNo complications with parturitionFilly has been BARSuckled immediately

Presented to primary veterinarian at approximately 18 hours old

Slide3

Diagnostic Results from Referring Veterinarian

Significant Parameters

Actual

Reference Range

PCV

47%

32-46%

WBC

3.15 x 10

3 /uL

5.5 - 10.5 x 10

3

/

uL

Lymph

0.52 x

103 /uL1.5 - 4.0 x 103 /uLNeuts2.59 x 103 /uL3.0 - 7.0 x 103 /uLFibrinogen230 mg/dL100 - 400 mg/dLTotal Protein7.2 g/dL6.0 – 8.0 g/dLIgG>800 mg/dL>800 mg/dLGlucose28 mg/dL67-136 mg/dLCreatinine3.1 mg/dL0.9-2.1 mg/dL

Hemoconcentration

Leukopenia with lymphopenia and neutropenia

Hypoglycemia

Azotemia

Slide4

Treatment from Referring Veterinarian

Administration of (unknown doses):

Amikacin IV

Procaine Penicillin G IM

Flunixin

meglumine

IV

2 doses of Bio-Sponge PO

No improvement with primary veterinarian within hours, recommended referral to local Veterinary Teaching Hospital

Slide5

Colorado State University: Initial Physical Examination

Quiet and lethargic but ambulatory

Good suckle reflex

Prolonged capillary refill time

Injected mucous membranes

Cold extremities

Hind end coated with red/brown liquid

Multiple episodes of hematochezia during examination

Grade 4/6 holosystolic murmur, L heart baseSepsis score: 10 (>12 correctly predicts sepsis) (Brewer 1988)

Temperature

(° F)

Pulse

(bpm)

Respiration

(bpm)

97.9 (99-102)

90 (80-120)36 (20-40)Borborygmi per quadrantL Upper: ↓R Upper: ↓L Lower: ↑R Lower: ↑

Slide6

Initial Problem List

Hematochezia

Hypothermia

Clinically dehydrated

estimated 8%

Hemoconcentration

↑

PCV/TP

LeukopeniaNeutropeniaLymphopeniaHypoglycemiaAzotemiaHeart murmur

Photo courtesy of CSU Internal Medicine Team

Slide7

CSU Diagnostic Plan

Neonatal foal exam:

Lungs: WNL

Joints: WNL

Umbilical structures: WNL

Venous Blood Gas

Urine Specific Gravity

Abdominal Ultrasound

Blood cultureEquine Diarrhea RealPCR™ PanelSalmonella spp. culture

Equine Diarrhea

RealPCR™ Pathogens

Equine rotavirus

Equine coronavirus

Cryptosporidium spp.

Clostridium perfringens

Enterotoxin A

Clostridium perfringens netEF ToxinClostridium difficile Toxin AClostridium difficile Toxin BNeorickettsia risticiiLawsonia intracellularisSalmonella spp.

Slide8

Diagnostic Test Results

Significant Parameters

Actual

Reference Range

pH

7.28

7.38-7.44

pCO2

49.2 mmHg

43-52 mmHgpO2

41.3 mmHg

35-45 mmHg

HCO3-

22.8

mEq

/L

28-35 mEq/LAnion Gap22.37-14Glucose19 mg/dL67-136 mg/dLLactate10.8 mMol/L1.11-1.78 mMol/LCreatinine3.4 mg/dL0.9-2.1 mg/dLUrine Specific Gravity1.0161.004High anion gap metabolic acidosisHypoglycemiaHyperlactatemiaAzotemia, suspect pre-renal with elevated urine specific gravity

Slide9

Diagnostic Ultrasound Findings

Multiple loops of hypomotile fluid-filled small intestine with minimal peritoneal fluid

No evidence of gastric distension

Umbilical structures WNL

Thoracic ultrasound WNL

Ultrasound image of a neonatal foal with Clostridial Enterocolitis. Note fluid filled small intestine with thickened walls. Image courtesy of CSU Diagnostic Radiology Team

Slide10

Updated Initial Problem List

Dehydration and hypovolemia:

Elevated PCV/TP

Azotemia, suspect pre-renal

Hyperlactatemia

Elevated Urine Specific Gravity

Hypoglycemia

High anion gap metabolic acidosis

Fluid loss through hematocheziaHypomotile GI tractLeukopenia (lymphopenia, neutropenia)Heart murmur

Refractometer image courtesy of Midwest Vet Supply

Slide11

Initial Differential Diagnoses

Infectious rule-outs for hematochezia:

Most Likely:

Intestinal

Clostridiosis

Fits with signalment and presentation

Salmonella spp.

enterocolitis

Culture due to biosecurity protocolsBleeding disorderLess likely due to normal hemogramTrauma to GIT tract (enema?)

Rule-outs for heart murmur:Most likely: Normal for neonate

Ductus Arteriosus closure usually occurs in 1

st

week of life

Continue to monitor for any changes

Ventricular Septal Defect

Clostridium perfringens

bacteria, courtesy of Pathogen Profile Dictionary

Slide12

Treatment Goals 1: Fluid Resuscitation, Hypoglycemia Support

Over the wire IV catheter placement

Correct hypovolemia:

½ shock dose

2 L

PlasmaLyte

™ bolus IV (~40 mL/kg)

After bolus: improved perfusion, warm extremities, urination

Clostridial enteritis foal receiving fluid therapy. Note complete separation of foal and dam to prevent nursing and tangle of fluid lines.

Correct hypoglycemia:

2 mgs/kg/minute glucose therapy

5% dextrose in water IV 2 mLs/kg/hr

(Administer while other fluids are being prepared)

Slide13

Treatment Goals 2: Fluid Therapy + Nutritional Support

Fluids:

Isotonic crystalloid therapy (

PlasmaLyte

™)

Run at Total Fluid Rate –

Nutritional Therapy

Continue 12-24 hours and reassess

Monitor PCV/TP, Lactate, Blood Gas

(q 6 hours)

Nutritional therapy

Partial Parenteral Nutrition

50% dextrose + 8.5% amino acids

Target: 50-100

kCal

/kg/d (200

kCal/hour) Rest GI tract for 18 hoursFeeding for trophic support of the GI Tract, 10 mLs milk q 1-2 hours, otherwise NPO

Slide14

Treatment Goals 3: Antibiotic therapy, combat possible septicemia, and endotoxemia

Combat Top Rule out:

Intestinal

Clostridiosis

Gram (+) Spectrum

Metronidazole 10 mg/kg PO q 12

hrs

Combat septicemia

Provide Gram (+) and Gram (-) spectrumPotassium Penicillin 22,000 IU/kg IV q 6 hrs

Amikacin 21 mg/kg IV q 24 hrs

Combat endotoxemia:

Bind endotoxins with:

Biosponge

1

Tbsp

in water PO q 12

hrsC. perf C&D antitoxin 10 mLs PO q 24 hrsFlunixin meglumine 1 mg/kg IV q 12 hrs*After normalization of creatininePhoto courtesy of PBS Animal Health

Slide15

Treatment Goals 4: Gastroprotection

Protect

GI tract:

Neonatal foals highly susceptible to gastric ulcers

Ranitidine 6 mg/kg PO q 8 hours

Proton pump inhibitors may be associated with

C. diff

infection in humans, therefore H2 antagonist was chosen

Parietal Cell of Gastric Mucosa

Gastric Lumen

Cl

-

Cl

-

Cl

-Cl-Cl-Cl-Cl-H+H+H+H+H+H+H2

H

+

Histamine

Acetylcholine

Gastrin

Ranitidine

Slide16

Treatment Goals 5: Provide immune support

Immune support

Already a

dequate passive transfer of antibodies

Concern for developing sepsis from bacterial translocation through compromised intestinal barrier and increased IgG consumption

Sepsis score of 10 = 88% likely to be non-sepsis, however this score was performed early in the course of disease

1 L IgG Hyperimmune plasma IV

Volume added to total fluid rate

Image courtesy of PlasmaLife.it

Slide17

Overnight Update

Filly is BAR

Hematochezia resolving

Hemoconcentration and azotemia are improved

Lactate is still slightly elevated

Normoglycemic

Acidosis has improved

Significant Parameters

On Presentation

After Overnight

Reference Range

PCV

47%

35%

32-46%

Total Protein

7.2g/dL5.6g/dL6.0 – 8.0 g/dLGlucose19mg/dL155mg/dL67-136 mg/dLLactate10.8mMol/L2.8mMol/L1.11-1.78 mMol/LpH7.287.397.38-7.44Creatinine3.4mg/dL2.0mg/dL0.9-2.1 mg/dLUrine Specific Gravity1.0161.0061.004

Slide18

Updated therapeutic plan

Decrease fluid rate to maintenance + ongoing losses

Pan feeding milk by 18

hrs

after hospitalization

2.5% BW divided into hourly feedings

Discontinue

Biosponge

and Clostridial Antitoxin ~36 hrs after presentationAllow hourly nursing from mare by 36 hours after presentation

Taper PPN

Continue to monitor PCV/TP/Lactate and glucose q 6

hrs

Goal to taper measurements to q 12 hours

Slide19

Blood culture: no aerobic growth

Salmonella spp.

culture: negative

Equine RealPCR™ Panel Results:

Positive for

Clostridium perfringens

alpha toxin gene

Negative for

C. perf netEF toxin gene

Day 5 Diagnostic Update

Clostridium

perfringens

common

exotoxins

Actions

Clinical associationsAlpha toxinEnzymatic with phospholipase activityBreakdown of cell membranes, necrotizing effectsBeta toxin*Forms pores in cellular membranesAssociated with necrotizing enterocolitis*Note: the Equine RealPCR ™ Panel does not test for C. perf beta toxin DIAGNOSIS ALERT: PCR Panel suggestive of Clostridium perfringens enterocolitis

Slide20

Day 5 Diagnostic Update

Significant Parameters

On Presentation

After 3 days hospitalization

Reference Range

PCV

47%

35%

32-46%

WBC

3.15 x 10

3

/

uL

4.1x 10

3

/uL5.5 - 10.5 x 103 /uLLymph.52 x 103 /uL1.7 x 103 /uL1.5 - 4.0 x 103 /uLNeutrophils2.59 x 103 /uL1.9 x 103 /uL3.0 - 7.0 x 103 /uLFibrinogen230 mg/dL300 mg/dL100 - 400 mg/dLTotal Protein7.2 g/dL5.8 g/dL6.0 – 8.0 g/dL

Glucose

19 mg/

dL

125 mg/

dL

67-136 mg/

dL

Lactate

10.8

mMol

/L

1.3 mg/

dL

1.11 – 1.78

mMol

/L

pH

7.28

7.43

7.38-7.44

Creatinine

3.4 mg/

dL

1.0 mg/

dL

0.9 – 2.1 mg/

dL

Slide21

Day 5 Clinical Update

Able to maintain normoglycemia while PPN was tapered

Transitioned to nursing well

Comfortable, no signs of colic

Progression to yellow pasty feces

Weight gain from 48

kgs

 51 kgs

Continues to be slightly neutropenic

Improvement of heart murmur

Ready to go home with continued monitoring and care

Slide22

C. perfringens

Types A & C are the most common enteric pathogens of neonatal foals

High fecal shedding of

C. perfringens

by foals < 3 days old

Exotoxins are usually broken down by trypsin, but mare’s milk contains trypsin inhibitors

Overview:

Clostridium perfringens

enterocolitis

Slide23

Previous Clostridial enteritis reports at this facility

(East 1998)

84% of foals presented before 6 days of age

Median age 3 days

Fatality reports in neonates: 54

%

Updated reports at this facility

(Lehman, 2018)

45% Fatality

Incidence rate in neonates: 31%

Overview:

Clostridium perfringens

enterocolitis

Necrohemorrhagic enteritis in a foal with Clostridial enteritis, photo courtesy of CSU Veterinary Diagnostic Laboratory

Slide24

Further Steps:

Mare and filly discharged after 5 days of hospitalization

Concern for future sepsis due to compromised GI barrier

Recheck neutropenia with RDVM in 1-2 days

Monitor temperature

Continue to monitor appetite, diarrhea, and lethargy

Consider hygiene of foaling area and monitor further foals closely for similar signs

Slide25

Update:

Filly recovered uneventfully and has had no problems since her hospitalization.

Breeding operation had no other complications with Clostridial enteritis in their foals following this event.

Breeding facility implemented Clostridial vaccination program of their mares following this event (C. perf Type C&D Toxoid, for livestock use)

Filly as a yearling. Photo credits and permissions from client.

Slide26

References and Further Reading:

Brewer,

B.d

.,

Koterba

, A.M. Development of a scoring system for the early diagnosis of equine neonatal sepsis. Equine Vet J. 1988; 20(1): 18-22.

East, L.M., Savage, C.J., et al. Enterocolitis associated with

Clostridium perfringens

infection in neonatal foals: 54 cases (1988-1997). JAVMA 1998; 212(11): 1751-1756.Lehman, M., Nout-Lomas, Y. (2018, January).

Incidence and outcome of clostridial enterocolitis in neonatal foals presented to the Colorado State University Veterinary Teaching Hospital between 2007-2017. Abstract Presented at CSU College of Veterinary Medicine and Biomedical Sciences 19th

Annual Research Day, Fort Collins, CO.

Jones, R.L. Clostridial Enterocolitis. Veterinary Clinics of North America: Equine Practice: Emerging Infectious Diseases 2000. 16(3): 471-485.

Weese

, J.S.,

Toxopeus

, L., Arroyo, L.

Clostridium difficile associated diarrhea in horses within the community: predictors, clinical presentation and outcome. Equine Veterinary Journal 2006; 38(2): 185-188.