The Canadian Veterinary Journal La Revue Vétérinaire Canadienne All in the Family: a Comparative Look at Coronaviruses

August/Août 2021 The Canadian Veterinary Journal

Vol. 62, No. 08 La Revue vétérinaire canadienne

August/Août 2021 Volume 62, No. 08 The Canadian Veterinary Journal La Revue vétérinaire canadienne All in the family: A comparative look at coronaviruses

Cryotherapy provides transient analgesia in an induced lameness model in horses

Indications and outcomes for puppies undergoing mechanical ventilation: 59 cases (2006 to 2020)

Obstipation in pet pigs: 24 cases

Multiple myeloma and primary erythrocytosis in a dog

Subcutaneous and cardiopulmonary dirofilariasis in a dog

Intramuscular Grade 1 fibrosarcoma: Magnetic resonance imaging findings in 2 dogs

Medial malleolus fragmentation following talocalcaneal arthrodesis by a dorsomedial approach in a horse

Fungal osteitis of the axial aspect of the mid body of the medial proximal sesamoid bone in a horse

Surgical treatment of a double aortic arch in a dog

Hematuria in a 3-month-old filly with an internal umbilical abscess and internal iliac artery aneurysm FOR PERSONAL USE ONLY

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AUGUST/AOÛT 2021 Contents Table des matières

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

REVIEW ARTICLE 857 Intramuscular Grade 1 fibrosarcoma: COMPTE RENDU Magnetic resonance imaging findings 825 All in the family: A comparative look at in 2 dogs coronaviruses Karine P. Gendron, Elizabeth W. Howerth, Koichi Nagata, Michael Perlini, Nicole Northrup John Ellis 861 Medial malleolus fragmentation following ARTICLES talocalcaneal arthrodesis by a dorsomedial 834 Cryotherapy provides transient analgesia approach in a horse in an induced lameness model in horses Pablo Espinosa-Mur, Mathieu Spriet, Vivian Quam, Jonathan Yardley, Mikkel Quam, Marcos Perez Nogues, Thomas Cullen, Cahuê Paz, James Belknap Larry D. Galuppo 839 Indications and outcomes for puppies 867 Fungal osteitis of the axial aspect of the undergoing mechanical ventilation: mid body of the medial proximal sesamoid 59 cases (2006 to 2020) bone in a horse Elyzabeth Lemieux, Elizabeth Rozanski, Alejandro Merchán, Jana K. Voss, Gareth Buckley, Nolan Chalifoux, Marie-Soleil Dubois Christopher Kennedy, Alex Lynch, Chrissie Rutter, 872 Surgical treatment of a double aortic arch Alyx Tracy, Deborah C. Silverstein in a dog 843 Obstipation in pet pigs: 24 cases Maya Sekhar, Katherine Meyers, Susan W. Volk, Kallie J. Hobbs, SallyAnne L. DeNotta, David E. Holt Aitor Gallastegui, George L. Elane, Luis A. Rivero, 877 Hematuria in a 3-month-old filly with an Pamela Adkins, Diego E. Gomez internal umbilical abscess and internal iliac artery aneurysm CASE REPORTS RAPPORTS DE CAS Luiza Zakia, Sarah Shaw, Natacha Bonomelli, Siobhan O’Sullivan, Alex zur Linden, Marie Dubois, 849 Multiple myeloma and primary John Baird, Bruce Guest erythrocytosis in a dog Marianna Ricci, Giulia De Feo, Martin Konar, 809 QUIZ CORNER George Lubas TEST ÉCLAIR 854 Subcutaneous and cardiopulmonary dirofilariasis in a dog Leticia B. Oliveira, Brittany J. McHale, Guilherme G. Verocai, Daniel R. Rissi

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AUGUST/AOÛT 2021 Contents Table des matières

FEATURES RUBRIQUES

EDITORIAL ÉDITORIAL NEWS | NOUVELLES 801 How is our profession doing?/Comment se porte notre profession? 811 NEWS John Kastelic, Tim Ogilvie NOUVELLES Heather Broughton, Sophie Perreault 805 VETERINARY MEDICAL ETHICS DÉONTOLOGIE VÉTÉRINAIRE

ONE HEALTH UNE SANTÉ 883 The origins and lineage of One Health, Part I Justin Ancheta, Raad Fadaak, R. Michele Anholt, Danielle Julien, Herman W. Barkema, Myles Leslie

NOTICES ANNONCES

866 Erratum 871 Index of Advertisers Index des annonceurs 887 Classifieds Petites annonces

Contributors

“Instructions for authors” are available online (www.canadianveterinarians.net).

Les « Directives à l’intention des auteurs » sont disponibles en ligne (www.veterinairesaucanada.net).

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The Canadian Veterinary Journal Editorial policy: All published articles including editorials and letters reflect the La Revue vétérinaire canadienne opinions of the authors and do not necessarily reflect the opinion of the publisher. Publication of an advertisement does not necessarily imply that the publisher agrees 339 rue Booth Street with or supports the claims therein. Ottawa, Ontario K1R 7K1 The Canadian Veterinary Medical Association holds complete copyright of all articles Telephone: 613-236-1162 within this issue. Fax: 613-236-9681 Politique de la Rédaction : Tous les articles publiés, y compris les éditoriaux et les E-mail: [email protected] lettres, représentent l’opinion de l’auteur et non pas nécessairement la position de Website/Site Web: www.canadianveterinarians.net l’éditeur. www.veterinairesaucanada.net La publication d’une annonce ne signifie pas nécessairement que l’éditeur est d’accord avec son contenu ou qu’il l’appuie. © C anadian Veterinary Medical Association 2021 L’Association canadienne des médecins vétérinaires détient le droit d’auteur complet L’Association canadienne des médecins vétérinaires 2021 sur tous les articles contenus dans le présent numéro.

The Canadian Veterinary Journal is indexed or abstracted in: Co-Editors-in-Chief/Co-rédacteurs en chef La Revue vétérinaire canadienne est indexée ou ses articles sont Dr. John Kastelic, Calgary, Alberta résumés dans : Dr. Tim Ogilvie, Springbrook, Prince Edward Island AGRICOL, Biological Abstracts, Capsule Report, Current Contents — Agriculture, Derwent Veterinary Drug File, EMBASE/Excerpta Medica, Associate Editors/Rédacteurs en chef adjoints Index Veterinarius, Index Medicus, Quarterly Index, Science Citation Index, Small Dr. Murray Jelinski, Saskatoon, Saskatchewan Animal Practice, Veterinary Bulletin, Veterinary Reference Service, Veterinary Update. Dr. Wayne McDonell, Guelph, Ontario Feature Editors/Rédacteurs des chroniques Dr. Jangi Bajwa, Burnaby, British Columbia Photo by/Photo de : Shutterstock Dr. Tim Blackwell, Fergus, Ontario Dr. Myrna Milani, Charlestown, New Hampshire Typesetting/Typographie Dr. Lynne Sandmeyer, Saskatoon, Saskatchewan AN Design Communications Dr. Debbie Stoewen, Ayr, Ontario Printed by/Imprimé par Assistant Editors/Rédacteurs adjoints Dollco Print Solutions Group Dr. Aylin Atilla, Calgary, Alberta Ottawa, Ontario Dr. Marcio Costa, Saint-Hyacinthe, Quebec ISSN 0008-5286 Dr. Robert Friendship, Guelph, Ontario Dr. Luis Gaitero, Guelph, Ontario Dr. Emily John, Charlottetown, Prince Edward Island Report undeliverable Canadian addresses to: Dr. Ron Johnson, Guelph, Ontario e-mail: [email protected] Dr. Shawn McKenna, Charlottetown, Prince Edward Island Dr. Shannon Martinson, Charlottetown, Prince Edward Island Subscriptions (2021). Annual: Canada $225 + applicable GST or HST; foreign Dr. Javier Sanchez, Charlottetown, Prince Edwad Island $240 US; institutional $295. Express subscriptions available. Single issue/back issue: Managing Editor/Directrice de la rédaction $25 each, institutional single issue = $50.00 + GST or HST, if applicable. (All prices Heather Broughton, Ottawa, Ontario subject to change.) Missing issues will be replaced if the Subscriptions Office is Assistant Managing Editor/Directrice adjointe de la rédaction notified within 6 months (for requests within Canada) and 1 year (for requests from Stella Wheatley, Ottawa, Ontario abroad) of the issue date. The publisher expects to supply missing issues only when Editorial Coordinator/Coordonnatrice de la rédaction losses have been sustained in transit and when the reserve stock will permit. Telephone Kelly Gray-Sabourin, Ottawa, Ontario (613-236-1162) or (1-800-567-2862) and fax (613-236-9681) orders accepted with a valid Visa or MasterCard number. Please advise the publisher of address changes Advertising and Sponsorship Consultant/Consultante, publicité et commandites promptly. Laima Laffitte, Prescott, Ontario Abonnements (2021). Annuel : Canada 225 $ + TPS ou TVH en vigueur; pays étranger 240 $ É-U; prix d’une institution 295 $. Abonnement express disponible. Published monthly by/ Anciens numéros (chacun) : 25 $, ancien numéro d’institution 50 $ + TPS ou TVH Publication mensuelle de en vigueur. Les prix sont sujets à changement sans préavis. Les numéros qui ne sont pas Canadian Veterinary Medical Association reçus seront remplacés si l’éditeur en est informée dans les 6 mois (pour les demandes venant du Canada) et 1 an (pour les demandes venant de l’étranger) suivant la date de parution. L’éditeur s’engage à remplacer les numéros manquants seulement lorsque les pertes ont été subies en transit et lorsque ses réserves le permettent. On peut payer son abonnement par téléphone (613-236-1162) ou (1-800-567-2862), par télécopieur (613-236-9681) ou par carte de crédit (Visa ou MasterCard). Veuillez aviser le bureau de l’éditeur de tout changement d’adresse.

798 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Whatever and wherever you practice, the CVMA is with you every step of your way.

We speak for you on veterinary issues of We provide resources to help you achieve a national importance and protect the integrity meaningful career and personal wellness. of our profession.

As a CVMA member, you benefit from… As a CVMA member, you benefit from… • Engagement with Government and stakeholders to influence • The Canadian Veterinary Journal policy decisions • The Canadian Journal of Veterinary Research • International relations to provide the Canadian veterinary • CVMA Source Guide perspective • Bi-monthly e-newsletter ‘Online from 339’ • Media/public relations to provide trustworthy information and • CVMA Online Education Portal promote veterinary professionals • CVMA National Issues Forum • Position statements addressing animal welfare and national CVMA Summit veterinary issues • • Emerging Leaders Program • Member consultations on key veterinary issues • CVMA Canadian Veterinary Reserve • Leadership initiatives on antimicrobial stewardship and surveillance, cannabinoids, telemedicine • MyVetStore.ca™ CVMA web store solution for clinics • Administration of national veterinary exams to ensure uniform • Practice Owner’s Economic Survey certification of professional credentials • Individual Practice Diagnostic Report and Practice Value Estimate • Accreditation of veterinary colleges and veterinary technician programs • Provincial Suggested Fee Guides • Associate Compensation and Benefits Report We put money in your pocket to increase • Compensation for Non-DVM Report your profitability. • Report on Veterinarians in Government, Industry and Academe • Practice management articles and career/business resources As a CVMA member, you benefit from… • CVMA specialized group insurance program • GoodLife Fitness (discount) • CVMA Mentoring Program • CVMA Petcard™ Program – financing options for your clients • VetLaw Online™ legal advice column • Moneris™ payment processing services (preferred pricing) • Practical Veterinary Tools and Resources • HRdownloads™ (discount) • Veterinarian Health and Wellness Resources • Mont Tremblant SkiMax/GolfMax (discount) • Early Career DVM Resource Hub • Hotels worldwide discount program • CVMA Guidelines for Veterinary Antimicrobial Use (online • The Personal Insurance for home/auto/travel (preferred pricing) database) • National and Enterprise car rental (discount) • Therapeutic decision cascade poster • Scotiabank® business banking and lending solutions • Animal abuse resources for practitioners • Classified ads in The CVJ (discount) • Preventive healthcare, nutritional assessment and client • Plumb’s Veterinary Drugs™ (subscription discount) education tools and resources • Staples Advantage™ business products • Animal Health Week, National Tick Awareness Month and Mental • Adtel® telephone hold service and digital signage (preferred Health in Vet Med Awareness Week campaigns pricing) Visit our website or contact us to learn how to • Petro-Canada SuperPass™ fuel/diesel discount get more value from your membership. • CVMA Annual Convention (registration discount) • WSAVA World Congress and WVA Congress (registration discount)

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How is our profession doing? Comment se porte notre profession?

Dr./Dr John Kastelic Dr./Dr Tim Ogilvie

t has been more than 3 decades since Dr. William R. ela fait plus de trois décennies que le Dr William R. I Pritchard authored The Future Directions for Veterinary C Pritchard a écrit The Future Directions for Veterinary Medicine (1). Also known as The Pew Report, this was the Medicine (1). Aussi appelé « The Pew Report », ce rapport author’s view of the state of the profession, veterinary practice, donnait le point de vue de l’auteur sur l’état de la profession, and veterinary education in the USA and Canada in 1988. la pratique vétérinaire et la formation des médecins vétérinaires The context was to assess “the relevant social, economic and aux États-Unis et au Canada en 1988. Le contexte consistait à technological environment in which veterinary medicine func- évaluer l’environnement social, économique et technologique tions and how it is changing.” Excerpts from the report and entourant la médecine vétérinaire et comment il évolue. Des its recommendations were published in our journal (2). The extraits du rapport et de ses recommandations ont été publiés recommendations were the following: dans notre revue (2). Les recommandations étaient les suivantes : 1. Change the focus of the veterinary medical profession from 1. Changer l’orientation de la profession médicale vétérinaire, animal disease to animal health in all its dimensions. en déplaçant l’accent mis sur la maladie animale vers la 2. Abandon the unrealistic concept of the universal veterinar- santé animale dans toutes ses dimensions. ian who can minister to the health needs of all creatures 2. Abandonner le concept irréaliste du vétérinaire universel great and small. qui peut répondre aux besoins de santé de tous les animaux, 3. Restructure veterinary practice to better serve the needs of peu importe l’espèce. society and the veterinary profession in the future. 3. Restructurer la pratique vétérinaire pour mieux répondre 4. Make research a higher priority for individual veterinar- aux besoins de la société et de la profession vétérinaire à ians, the veterinary medical profession, and for veterinary l’avenir. medical colleges. 4. Faire de la recherche une plus grande priorité pour les 5. Establish a more rational system of funding for veterinary médecins vétérinaires individuels, la profession médicale medical research. vétérinaire dans son ensemble, et les facultés de médecine 6. Improve the quality of veterinary services delivered to all vétérinaire. species of animals in response to the escalating expectations 5. Mettre en place un système de financement plus rationnel of the public as to the health care of all of the animals de la recherche médicale vétérinaire. important to people. 6. Améliorer la qualité des services vétérinaires fournis à toutes 7. Strengthen the general education of veterinarians. les espèces animales en réponse aux attentes croissantes 8. Focus the professional educational process and the practice du public quant aux soins de santé de tous les animaux of veterinary medicine on the ability to find and use infor- importants pour les humains. mation rather than the accumulation of facts. 7. Renforcer la formation générale des médecins vétérinaires. 9. Strengthen the basic biological science content of the vet- 8. Axer le processus de formation professionnelle et la pra- erinary medical curriculum. tique de la médecine vétérinaire sur la capacité de trouver

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

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10. Make the achievement of educational, experiential, and et d’utiliser de l’information plutôt que sur l’accumulation cultural, racial, and ethnic, diversity among veterinarians de faits. a goal of veterinary education. 9. Étoffer le contenu de base en sciences biologiques du pro- 11. Reorient clinical veterinary education to enable a student gramme de médecine vétérinaire. to elect in-depth instruction and clinical experience with a 10. Viser une plus grande diversité parmi les diplômés du pro- practice theme (class of animals or a single species), rather gramme de médecine vétérinaire, tant sur le plan culturel, than require all students to obtain clinical experience with racial et ethnique que sur le plan de la formation et de numerus species. l’expérience. 12. Change the emphasis in the veterinary curriculum from 11. Réorienter la formation vétérinaire clinique pour permettre almost total concentration on clinical practice to include ÉDITORIAL aux étudiants de choisir et d’acquérir une expérience cli- important public sector needs for veterinarians. nique approfondie ciblée (groupe d’animaux ou espèce 13. Move toward a national perspective or strategy of veterinary unique), au lieu d’exiger que tous les étudiants aient une medical education (2). certaine expérience clinique avec de nombreuses espèces. Associated with (and arguably because of) these recom- 12. Modifier le programme d’études vétérinaires de façon à mendations, there have been many numerous advancements in réduire la concentration presque totale sur la pratique cli- education, clinical veterinary practice, and the profession. Some nique et à inclure les besoins importants du secteur public. examples include: 13. Évoluer vers une perspective ou stratégie nationale en Regarding education: matière de formation vétérinaire (2). • Student recruitment, application and selection for veterinary À la suite de (et sans doute à cause de) ces recommandations, schools have been modified and reflect a more comprehensive il y a eu de nombreux progrès dans la formation, la pratique approach to selecting future veterinarians. clinique et la profession vétérinaire. En voici quelques exemples. • Best educational practices are developed, collected, and Concernant la formation : shared more widely, e.g., by the CVMA, American Veterinary • Le processus d’admission dans les programmes de médecine Medical Association (AVMA) and the Association of vétérinaire a été modifié et reflète une approche plus globale American Veterinary Medical Colleges (AAVMC), spurred de la sélection des futurs vétérinaires. on by far-reaching studies such as the the North American • Des pratiques exemplaires sont élaborées, obtenues et diffu- Veterinary Medical Education Consortium (NAVMEC) sées plus largement, par exemple, par l’ACMV, l’American Roadmap Report (3). Veterinary Medical Association (AVMA) et l’Association • Competency based programming and outcomes assessments of American Veterinary Medical Colleges (AAVMC), et have been adopted by veterinary colleges (4). alimentées par des études de grande envergure telles que le • Recruitment, recognition, and support for a more diverse North American Veterinary Medical Education Consortium student population is becoming a priority. (NAVMEC) Roadmap Report (3). Regarding clinical practice: • Des programmes fondés sur l’évaluation des compétences • There is increasing demand for clinical veterinary services. et des résultats ont été adoptés par des facultés de médecine • Many practices are larger and offer more services. vétérinaire (4). • There is more group and corporate ownership of clinics. • Le recrutement, la reconnaissance et le soutien d’une popu- • There is integration of general and referral practices. lation étudiante plus diversifiée deviennent des priorités. • Animal welfare, the human/animal bond and animals as fam- Concernant la pratique clinique : ily members have altered practice focus. • La demande pour les services vétérinaires cliniques est Regarding the profession: croissante. • Regulatory bodies and professional associations are providing • Les pratiques sont plus grandes et offrent plus de services. more and more contemporary services. • Il y a plus d’établissements vétérinaires en propriété collective • Veterinarians are generally well-regarded by the public, and et corporative. demands for high-quality service require veterinarians to • Il y a intégration des pratiques générales et de référence. sustain clinical competence. • Le bien-être animal, le lien humain/animal et les animaux • One Health is gaining traction; veterinarians have taken lead en tant que membres de la famille ont modifié le contexte roles, not only in animal health, but also in public health de la pratique. and environmental health, e.g., the veterinary response to Concernant la profession : the COVID crisis. • Les organismes de réglementation et les associations pro- • Personal health, well-being and wellness of veterinarians and fessionnelles fournissent de plus en plus de services actuels. veterinary staff are increasingly priorities of practitioners and • Les médecins vétérinaires sont généralement bien perçus par professional associations. le public, et la demande pour un service de grande qualité As a profession, have we done well with our responses to the exige qu’ils maintiennent leurs compétences cliniques. 13 challenges? Could we have done more? Can we do better in • Le concept « Une santé » gagne du terrain; les médecins the future? The answer to all is an unequivocal YES! vétérinaires ont pris un rôle de premier plan, non seulement

802 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY

What are next steps? Should there be another Pew Report? 2. Future directions for veterinary medicine: The Pew report Pew National More specifically, what can The CVJ do to advance the veteri- Veterinary Education Program. Can Vet J 1989;30:472–476. 3. Association of American Veterinary Medical Colleges. [Internet] Available nary profession in terms of education, professional service, and from: https://www.aavmc.org/assets/data-new/files/NAVMEC/navmec_ research? We look forward to presenting thoughts and ideas in roadmapreport_web_single.pdf Last accessed June 24, 2021. future editorials. Please share with us your comments and ideas. 4. Association of American Veterinary Medical Colleges. [Internet] Available from: http://www.aavmc.org/cbve Last accessed June 24, 2021. ■

References EDITORIAL John Kastelic 1. Pritchard WR. Future Directions for Veterinary Medicine. Pew National ([email protected]) Veterinary Education Program, Institute of Policy Sciences and Public Tim Ogilvie ([email protected]) Affairs, Duke University, Durham, North Carolina, USA, 1988.

en santé animale, mais aussi en santé publique et en santé environnementale (la réponse vétérinaire à la crise de la COVID-19 en a été un exemple). 2021 • La santé personnelle et le mieux-être des médecins vétérinaires et du personnel vétérinaire sont de plus en plus des priorités EMERGING des praticiens et des associations professionnelles. En tant que profession, avons-nous bien réussi à suivre LE DERS les treize recommandations? Aurions-nous pu en faire plus? Pouvons-nous faire mieux à l’avenir? La réponse à toutes ces PROGRAM questions est un OUI catégorique! Quelles sont les prochaines étapes? Devrait-il y avoir un autre rapport du même genre? Plus précisément, que peut faire La RVC pour faire progresser la profession vétérinaire sur PART 1 Emerging Leaders Workshop les plans de la formation, des services professionnels, et de la PART 2 Leadership Outreach recherche? Nous avons hâte de présenter des réflexions et des PART 3 Virtual Leadership Webinars idées dans de futurs éditoriaux. N’hésitez pas à nous transmettre vos suggestions et commentaires. TO LEARN MORE VISIT Références www.canadianveterinarians.net 1. Pritchard WR. Future Directions for Veterinary Medicine. Pew National Veterinary Education Program, Institute of Policy Sciences and Public Affairs, Duke University, Durham, Caroline du Nord, États-Unis, 1988. 2. Future directions for veterinary medicine: The Pew report Pew National SPONSORED BY Veterinary Education Program. Can Vet J 1989;30:472-476. PRESENTED BY 3. Association of American Veterinary Medical Colleges. [Internet] Disponible au : https://www.aavmc.org/assets/data-new/files/NAVMEC/navmec_ roadmapreport_web_single.pdf (dernière consultation le 24 juin 2021). 4. Association of American Veterinary Medical Colleges. [Internet] Disponible au : http://www.aavmc.org/cbve (dernière consultation le 24 juin 2021). ■

John Kastelic ([email protected]) Tim Ogilvie ([email protected])

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Ethical question of the month — Question de déontologie du mois — May 2021 Mai 2021 A retired farmer keeps a few cattle, sheep, and poultry on his En Ontario, un agriculteur à la retraite garde quelques bovins, farm in part to keep himself mentally and physically engaged. moutons et volailles sur sa ferme, en partie pour rester actif These animals are kept in basic unheated shelters with outside mentalement et physiquement. Ces animaux sont logés dans access. He also has 2 dogs that are tied up most of the time des abris rudimentaires non chauffés ayant accès à l’extérieur. Il and each has a doghouse. All the animals are in good physi- a également deux chiens qui sont attachés la plupart du temps cal condition. A passerby who sees the animals outside in the et qui ont chacun une niche. Tous les animaux sont en bonne winter makes a complaint under the Ontario Provincial Animal condition physique. Un passant qui voit les animaux dehors Welfare Services Act. Investigators under this Act announce a en hiver dépose une plainte en vertu de la Loi sur les services farm inspection. You are asked to accompany the investigators provinciaux visant le bien-être des animaux de l’Ontario. Une (who are not veterinarians) as a third-party veterinarian on inspection à la ferme a lieu. On vous demande d’accompagner behalf of 1 commodity group. The investigators are trained les inspecteurs (qui ne sont pas des médecins vétérinaires) on the legal requirements of the Act but have little to no farm en tant que vétérinaire indépendant à titre de représentant experience. You point out that the housing, feeding, watering, de l’industrie. Les inspecteurs ont reçu une formation sur les and veterinary care of all species are acceptable in your profes- exigences de la Loi mais ont peu ou pas d’expérience dans le sional opinion. The farm veterinarian who has worked with the domaine agricole. Vous affirmez que, selon votre jugement retired farmer for years and who regularly attends to the needs professionnel, le logement, l’alimentation, l’abreuvement et of the animals, has never doubted the quality of the husbandry. les soins vétérinaires de toutes les espèces présentes sont accep- Nevertheless, the investigators write up a number of orders for tables. La vétérinaire de la ferme qui travaille avec l’agriculteur the farmer to implement, none of which you believe are required depuis des années et qui s’occupe régulièrement de ses animaux nor will improve the welfare of the animals. The retired farmer n’a jamais douté de la qualité des soins. Néanmoins, le rapport is extremely upset to be accused of sub-standard animal care des inspecteurs recommande un certain nombre de mesures à and is considering getting rid of all his animals. The farm vet- mettre en œuvre par l’agriculteur, et vous êtes d’avis que ces erinarian who was never consulted likewise feels her expertise in mesures ne sont pas nécessaires et qu’elles n’amélioreront pas animal husbandry is being disregarded. Should the law place le bien-être des animaux. L’agriculteur à la retraite est extrême- the interpretation of the Provincial Animal Welfare Services ment contrarié d’être accusé de négliger ses animaux et envisage Act by the provincial investigators above that of experienced, de s’en débarrasser. La vétérinaire de la ferme, qui n’a pas été licensed veterinarians? consultée, estime que son expertise n’est pas prise en compte. Submitted by Sue Burlatschenko, L’interprétation de la Loi sur les services provinciaux visant Goshen Ridge Veterinary Services and Joel Rumney, le bien-être des animaux par les inspecteurs provinciaux North Simcoe Veterinary Services devrait-elle avoir préséance sur l’interprétation qu’en font les médecins vétérinaires expérimentés? Question soumise par Sue Burlatschenko, Goshen Ridge Veterinary Services, et Joel Rumney, North Simcoe Veterinary Services Comments on investigations into standards of care under the Provincial Animal Welfare Services Act I have been involved in many such cases over my career as the and provide a timeline for completion of any remediation. Never third-party veterinarian. In all those cases, it was made clear to once were my findings and recommendations challenged or dis- me by the provincial investigators that my responsibility was to missed by the investigators. In fact, the opposite was true. Have determine if there was abuse or neglect and assess whether the things changed since these investigations were discontinued by basic needs of the animals were being addressed. I was instructed the provincial Society for the Prevention of Cruelty to Animals? to produce a report outlining my findings and recommendations Submitted by Dr. Henry Ceelen, Rideau-St. Lawrence for remediation (if in my professional opinion, any was required) Veterinary Services, Kemptville, Ontario

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Interpretation of the law is not a competition between the Given the specific education and experience of the 2 veterinar- inspector and the veterinarian. Inspectors must take all avail- ians and the producer involved, it appears that the Provincial able information into account, including veterinary advice. Animal Welfare Services Act is being used ahead of such educated Respective knowledge and experience of animal welfare is and experienced individuals. Prior to any such action, consulta- expected to be applied collaboratively. Accepted references such tion should take place; that would include opinions from the as the National Codes of Practice for the Care and Handling of Provincial Veterinary Association and the Provincial Veterinary Farm Animals (1) should be consulted to help resolve conflict- Licensing Body (Public Interest). It appears in this case that ani- ing interpretations. mal welfare is being interpreted by individuals unfamiliar with Submitted by Dr. Gord Doonan, Ottawa, Ontario accepted farm animal conditions. Hopefully, consultation would produce a result that is understood and acceptable to all parties. Reference Submitted by Dr. Clayton Mackay, 1. National Farm Animal Care Council. Codes of practice for the care MacKay Veterinary Consulting, Guelph, Ontario and handling of farm animals. Available from: http://www.nfacc.ca/ codes-of-practice Last accessed June 15, 2021. DÉONTOLOGIEVÉTÉRINAIRE

Ethicists’ commentary on investigations into standards of care under the Provincial Animal Welfare Services Act Hermeneutics is the philosophical theory of interpretation and of the regulations can be reached. An animal welfare inspection is classically applied to the interpretation of religious texts. This is productive when it discerns what the potential welfare con- theory can also be applied pragmatically in situations such as the cerns mean for those who are directly involved in them, both case before us. Hermeneutics calls us to practice within the con- human and animal. text of the present situation and avoid seeking to apply ahistori- When a citizen makes a complaint about animal welfare, they cal interpretations of principles and procedures. Animal welfare do this from a place of genuine concern. Although the complaint inspectors and veterinarians alike will both know through their may originate from a place of ignorance, it is well-intentioned, experiences that ethical challenges on farm are often complex, and we must not discourage the interest of the public in the and unique to each scenario. well-being of animals. With that said, when responding to the When inspectors are called to respond to the concerns of concerns of the public we must remember that the impetus for the public, they bring their expertise of the Ontario Provincial the investigation is to promote the positive welfare of animals. Animal Welfare Services Act, and the intention behind the regula- A negative experience that pushes a conscientious and caring tions within the act itself. Alone, this knowledge is abstract and farmer to consider getting rid of their animals does not promote cannot be practically implemented as a process to determine welfare and fails to fulfill the motivation behind the inspection the correct course of action. No set of fixed criteria, principles, itself. While producing abstract orders in response to public or regulations can be universally applied to produce a satisfying complaints produces a political deliverable, it risks a grave irony: answer for the correct moral path. For the act to be functional, the public concern for animal welfare may dictate contextless it must be coupled with the intricacies of the context at hand. responses at the expense of welfare for all involved. This requires the narratives of the farmer, the attending veterinarian, and the third-party veterinarian, in order to complete the Megan Allore, Master’s Candidate, Biomedical Ethics Unit, picture. When these 3 sides interact, a contextual understanding McGill University and Bernard E. Rollin, PhD

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Ethical question of the month — Question de déontologie du mois — August 2021 Août 2021 You are an employee of a veterinary hospital with strict billing Vous travaillez dans un établissement vétérinaire ayant des pro- ETHICS MEDICAL VETERINARY protocols. If treatment is deemed necessary to avoid unnecessary tocoles de facturation stricts. Si un traitement est jugé nécessaire suffering or death, an estimate is provided, a 50% deposit is pour éviter à un animal des souffrances inutiles ou la mort, un required, and the balance is payable upon completion. If a client devis est fourni au client – un acompte de 50 % est exigé et is unable to afford the treatment, either surrender or euthanasia le solde est payable au moment où le traitement est effectué. is recommended. Your client is an elderly gentleman with a Si le client n’a pas les moyens de payer le traitement, on lui 10-year-old toy poodle, his only companion. The dog presents recommande de donner son animal en adoption ou de le faire with recent anorexia. You diagnose severe dental disease with euthanasier. Votre client est un homme âgé qui est propriétaire no suspicion of any other issues. Given the breed, the dog could d’un caniche nain de 10 ans, son seul compagnon. Le chien pré- live for several more years after the necessary dental surgery. sente une anorexie d’apparition récente. Vous diagnostiquez une The estimate is several thousand dollars. Your client is unable maladie dentaire grave et ne soupçonnez aucun autre problème. to afford treatment and leaves. He obtains a lower-priced pallia- Compte tenu de la race, le chien pourrait vivre encore plusieurs tive care option at another facility and later advises you of his années après la chirurgie dentaire dont il a besoin. action and that the dog is “doing well.” If you believe the care Le devis s’élève à plusieurs milliers de dollars. Votre client n’a to be substandard, should you report it and if so, to whom? pas les moyens de payer le traitement et s’en va. Il vous informe Submitted by Dr. Mary Jane Bowie, plus tard qu’il s’est fait offrir une option de soins palliatifs moins British Columbia chère dans un autre établissement et que son chien « va bien ». Si vous pensez que les soins sont de qualité inférieure, devez- vous le signaler et, si oui, à qui? Question soumise par la Dre Mary Jane Bowie, Colombie-Britannique

Responses to the case presented are welcome. Please limit your Les réponses au cas présenté sont les bienvenues. Veuillez limiter reply to approximately 50 words and forward along with your votre réponse à environ 50 mots et nous la faire parvenir par la poste name and address to: Ethical Choices, c/o Dr. Bettina Bobsien, avec vos nom et adresse à l’adresse suivante : Choix déontologiques, 4353 Yellowpoint Road, Ladysmith, British Columbia V9G 1G5; a/s de la Dre Bettina Bobsien, 4353 rue Yellowpoint, Ladysmith e-mail: [email protected] (Colombie-Britannique) V9G 1G5; courriel : [email protected] Suggested ethical questions of the month are also welcome! All ethical Les propositions de questions déontologiques sont toujours bienvenues! questions or scenarios in the ethics column are based on actual events, Toutes les questions et situations présentées dans cette chronique which are changed, including names, locations, species, etc., to protect s’inspirent d’événements réels dont nous modifions certains éléments, the confidentiality of the parties involved. comme les noms, les endroits ou les espèces, pour protéger l’anonymat des personnes en cause.

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Quiz Corner Test éclair

1. In urinary sediment, the presence of renal epithelial casts 1. Dans un sédiment urinaire, la présence de cylindres épithé- suggests which of the following as a cause? liaux rénaux suggère laquelle des causes suivantes? A. Fever A. Fièvre B. Lower urinary tract infection B. Infection du tractus urinaire inférieur C. Diabetes mellitus C. Diabète sucré D. Acute tubular necrosis D. Nécrose tubulaire aiguë E. Hemolysis E. Hémolyse 2. In reptiles, gout can be caused by diets high in which of the 2. Chez les reptiles, la goutte peut-être causée par une diète following? riche en quel élément suivant? A. Fat A. Gras B. Fiber B. Fibres C. Protein C. Protéines D. Vitamin A D. Vitamine A E. Biotin E. Biotine 3. Medical management of canine insulinoma may include all 3. Le traitement médical de l’insulinome canin peut com- except which of the following? prendre toutes les thérapies suivantes, excepté laquelle? A. Prednisone therapy A. Traitement à la prednisone B. Diazoxide B. Diazoxide C. Streptozocin C. Streptozocine D. Limit feeding to one large meal D. Limitation de l’alimentation à un gros repas E. Limiting exercise E. Limitation de l’exercice 4. Which of the following is NOT a typical clinical sign of 4. Lequel des signes suivants N’EST PAS un signe clinique Johne’s disease in small ruminants? caractéristique de la paratuberculose (maladie de Johne) A. Depression chez les petits ruminants? B. Chronic weight loss A. Abattement C. Diarrhea B. Perte de poids chronique D. Hypoproteinemia C. Diarrhée D. Hypoprotéinémie 5. A 14-year-old gray Thoroughbred mare has multiple smooth masses under her tail and surrounding her perineal region. 5. Une jument Thoroughbred âgée de 14 ans, de couleur grise, The most likely diagnosis is which of the following? possède plusieurs masses lisses sous la queue et dans la A. Squamous cell carcinoma région périnéale. Lequel des diagnostics suivants est le plus B. Exuberant granulation tissue probable? C. Habronemiasis A. Carcinome spinocellulaire D. Melanoma B Tissu de granulation exubérant C. Habronémiase D. Mélanome

(See p. 885 for answers./Voir les réponses à la page 885.)

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2021 CANWEST VETERINARY CONFERENCE GOES VIRTUAL! OCT. 16-19, 2021

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In addition to the daily keynote sessions, Sunday, Oct. 17 the affordable, all-inclusive conference Too Stubborn to Quit? registration also includes access to: Dr. Sarah Boston • Daily scientific CE in your chosen Lucky Dog: Veterinary Oncologist, bestselling author of “ learning track: Companion Animal, How Being a Veterinarian Saved my Life” and co-founder of The CageLiner, a satirical newspaper for veterinary peeps. Equine, Food Animal, Veterinary Team, Veterinary Technologist • numerous wellness offerings including yoga and meditation Monday, Oct. 18 • network with your industry partners by visiting the virtual exhibit hall It’s time thrive, not just survive! Dr. Dave Nichol • enter for numerous great prizes Veterinary Speaker, Author and Podcaster. Founder of • CanWest is pleased to partner with VetX International and 2019 VMX Speaker of the Year. JAM Events to bring you Survey Says or Escape the Haunted House Virtual Escape Room! A great chance to form a team or meet new colleagues for an hour Tuesday, Oct. 19 of gaming fun at the end of each day Delivering Healthcare to Bonded Families • access to additional CE on demand Dr. Michael Blackwell • access to the virtual platform for eight Director of the Program for Pet Health Equity, College of Social weeks following the event Work, University of Tennessee. Distinguished Service Medal Winner, U.S. Public Health Service and two time recipient of *Program is tentative and subject to change. the US Surgeon General’s Exemplary Service Medal. RACE application ongoing*

CanWest also welcomes back the ABVTA events include: CE Session: RVT Utilization and Advocating for Yourself! ABVTA who will be offering CE Speaker: Senani Ratnayake, BSc, RVT, Chief Motivator – Motivatum Consulting. and AGM on Saturday, Oct. 16. Followed by the 2021 ABVTA Virtual Annual General Meeting

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NEWS | NOUVELLES

Alberta Veterinarian Appointed 73rd President of the Canadian Veterinary Medical Association Un vétérinaire de l’Alberta nommé 73e président de l’Association canadienne des médecins vétérinaires orn in Michigan and raised in Japan, Dr. Louis Kwantes é au Michigan et élevé au Japon, le Dr Louis Kwantes s’est Bnow hails from Sherwood Park, Alberta, where he has lived Nétabli à Sherwood Park, en Alberta, où il vit depuis 28 ans. Il a for the past 28 years. His educational background includes fréquenté l’école primaire au Japon, un collège d’arts libéraux aux grade school in Japan, liberal arts college in the United States, États-Unis, puis une faculté de médecine vétérinaire au Canada veterinary college in Canada (Ontario Veterinary College, ’87) (Ontario Veterinary College, promotion de 1987), et il a fait études and post-DVM studies in the United Kingdom (MSc in Tropical postdoctorales au Royaume-Uni (il a obtenu une maîtrise en méde- Veterinary Medicine, University of Edinburgh, ’89). cine vétérinaire tropicale de l’Université d’Édimbourg en 1989). Dr. Kwantes’ professional background includes mixed-animal Son parcours professionnel tout aussi diversifié comprend practice in Ontario, short and long overseas veterinary post- la pratique mixte en Ontario, ainsi que de courts et de longs ings in Haiti, Uzbekistan, and the Middle East, mostly in mandats de vétérinaire à l’étranger en Haïti, en Ouzbékistan et the Sultanate of Oman as a senior staff veterinarian for the au Moyen-Orient (principalement au Sultanat d’Oman en tant University of Durham’s Centre for Overseas Research and que médecin vétérinaire au Centre for Overseas Research and Development. Development de l’Université de Durham). He is presently employed as a veterinarian for National Le Dr Kwantes est actuellement employé par National Veterinary Associates (NVA) at Park Veterinary Centre, a com- Veterinary Associates en tant que médecin vétérinaire au Park panion and exotic animal veterinary clinic he founded with his Veterinary Center, un établissement vétérinaire pour animaux de business partner in 1997. compagnie et animaux exotiques qu’il a cofondé en 1997. Dr. Kwantes is a past-board member of the Edmonton Il a été membre du conseil d’administration de l’Edmonton Veterinary Emergency Clinic and Past-president of the Veterinary Emergency Clinic et président de l’Edmonton Area Small Edmonton Area Small Animal Veterinarians group. He has Animal Veterinarians Association. Il s’est également impliqué au also served the Alberta Veterinary Medical Association for over sein de l’Alberta Veterinary Medical Association pendant plus de 12 years in a variety of capacities, including a term as President 12 ans à divers postes, dont un mandat de président en 2015. Il in 2015. He received a Canadian Veterinary Medical Association a reçu le Prix du leadership étudiant de l’Association canadienne (CVMA) award for scholarship and leadership in 1987, shared des médecins vétérinaires (ACMV) et la bourse d’études qui l’ac- the CVMA Hill’s Public Relations Award in 2006, and was compagne en 1987, il a été l’un des corécipiendaires du Prix des awarded a Rotary Integrity Award in 2015. relations publiques Hill’s de l’ACMV en 2006, et il a reçu un prix Dr. Kwantes enjoyed teaching a reptile and amphibian du club Rotary soulignant son intégrité en 2015. class for the Animal Health Technology Le Dr Kwantes a eu le plaisir de don- course at the Northern Alberta Institute ner, une fois par année pendant 10 ans, un of Technology once annually for 10 years cours sur les reptiles et les amphibiens dans and, based on experiences he has been for- le cadre du programme de techniques de tunate to have in the veterinary profession, santé animale au Northern Alberta Institute of he wrote a book of short stories entitled, Technology. Il est également l’auteur d’un livre Catfight in the Kitchen. He is a passionate de courtes histoires inspirées de ses expé- promoter of veterinary medicine and has a riences dans la profession vétérinaire intitulé history of regular contributions to media in Catfight in the Kitchen. Le Dr Kwantes est un print, radio, and television. grand passionné de la médecine vétérinaire Together with Janet, his youthful, lov- et un collaborateur régulier des médias dans ing, and patient wife of 31 years, he is now la presse écrite, à la radio et à la télévision. an empty nester, save for a spoiled cat. Their Il partage son quotidien avec Janet, son eldest daughter Katrina is a musician (obo- épouse aimante et patiente des 31 dernières ist) in Boston; her twin brother Derrick is années, et leur chat qu’ils gâtent énormé- a dentist in Australia; and their youngest ment. Leur fille aînée Katrina est musicienne daughter Allison is studying veterinary med- (hautboïste) à Boston, son frère jumeau icine at the University of Calgary Faculty of Derrick est dentiste en Australie, et leur Veterinary Medicine! Dr./Dr Louis Kwantes plus jeune fille Allison étudie la médecine

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N Dr. Kwantes still loves working with animals and with people vétérinaire à la Faculté de médecine vétérinaire de l’Université as much as ever and feels honored to share in the bond of trust de Calgary! between pets and their caretakers. He is grateful for the oppor- Le Dr Kwantes aime toujours autant travailler avec les ani- tunity to have represented and served fellow veterinarians as a maux et avec les gens, et il se sent honoré de partager le lien de CVMA Executive Member the past few years and is excited to confiance qui unit les animaux et leurs gardiens. Il est reconnais- serve as the 2021–2022 CVMA President. sant d’avoir eu le privilège de représenter et de servir ses collègues vétérinaires en tant que membre du Comité exécutif de l’ACMV au cours des dernières années, et il est heureux d’occuper le poste de président de l’ACMV pour l’année 2021-2022.

Annual Awards Recognize CVMA Members for Outstanding Contributions to Veterinary Medicine Remise des prix annuels récompensant des membres de l’ACMV pour leurs contributions exceptionnelles à la médecine vétérinaire he Canadian Veterinary Medical Association (CVMA) has Association canadienne des médecins vétérinaires (ACMV) est Tproudly recognized its members’ exceptional contributions L’ fière de reconnaître les contributions exceptionnelles de ses to the veterinary profession and animal health and welfare for membres à la profession vétérinaire et à la santé et au bien-être over 35 years. This year is no exception, despite the unique des animaux depuis plus de 35 ans. Cette année ne fait pas situation we find ourselves in collectively. Even though we were exception, même si nous vivons collectivement des circonstances unable to honor award recipients in person again this year due sans précédent. Nous n’avons pas pu honorer les récipiendaires en to the ongoing pandemic, the CVMA Awards Gala commemo- personne en raison de la pandémie, mais nous les avons salués lors rated recipients during the CVMA’s first virtual Convention in du gala des prix de l’ACMV qui a eu lieu durant le premier Congrès July. The CVMA also featured recipients and highlighted their virtuel de l’ACMV, en juillet dernier. L’ACMV a également présenté outstanding achievements through our social media channels, les récipiendaires et souligné leurs réalisations remarquables dans eNewsletters, and web news. We invite you to read more about nos réseaux sociaux, notre infolettre et les actualités de notre site these exceptional recipients below. Web. Nous vous invitons à en découvrir plus sur ces personnes The Small Animal Practitioner extraordinaires ci-dessous. Award, sponsored by Petsecure Le Prix du praticien des petits animaux, commandité par Pet Health Insurance, is presented Petsecure assurance maladie pour animaux de compagnie, to a CVMA member whose work est décerné à un membre de l’ACMV dont le travail en pratique in small animal practice, clini- des animaux de compagnie, en recherche clinique ou en sciences cal research, or basic sciences has fondamentales représente une contribution importante à l’avan- significantly contributed to the cement de la médecine ou de la chirurgie des petits animaux ou advancement of small animal medi- à la gestion d’une pratique pour petits animaux. Le lauréat de cine, surgery, or the management of 2021 est diplômé de l’Atlantic Veterinary College et a effectué a small animal practice. The 2021 une résidence en chirurgie à l’Ontario Veterinary College, où il est r Dr./D Ameet Singh recipient graduated from the Atlantic maintenant professeur de chirurgie des animaux de compagnie. Veterinary College and completed his surgical residency at the Ses intérêts cliniques et de recherche comprennent la chirurgie Ontario Veterinary College where he is now a Professor of Small minimalement invasive et les infections du site opératoire. Président Animal Surgery. His clinical and research interests include mini- de la Veterinary Endoscopy Society et membre fondateur de mally invasive surgery and surgical site infections. In addition, he l’American College of Veterinary Surgeons of Minimally Invasive is currently the President of the Veterinary Endoscopy Society, Surgery, il a publié plus de 100 articles et a donné de nombreux is an American College of Veterinary Surgeons Founding Fellow ateliers et cours de chirurgie à l’échelle internationale. Félicitations of Minimally Invasive Surgery, has published over 100 journal au récipiendaire du Prix du praticien des petits animaux de 2021, articles, and taught numerous workshops and surgical courses le Dr Ameet Singh! internationally. Congratulations to the recipient of the 2021 Le Prix de la présidente de l’ACMV, décerné par la présidente Small Animal Practitioner Award, Dr. Ameet Singh! et le Comité exécutif de l’ACMV, félicite une personne pour ses The CVMA President’s Award, selected by the CVMA contributions et son dévouement exceptionnels à l’Association. Le President and Executive Committee, recognizes an individ- lauréat de 2021 a été sélectionné pour ses nombreuses années ual for their exceptional contributions and devotion to the de service et d’engagement envers la profession vétérinaire. Après

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association. The 2021 recipient was avoir obtenu son diplôme de l’Ontario Veterinary College (OVC) en N selected for his long and dedicated 1964, il a terminé un doctorat en 1968 et a effectué des études service to the veterinary profession. postdoctorales au Royaume-Uni et au Danemark avant de revenir à After graduating from the Ontario l’OVC en tant que membre du corps professoral en 1969. Au cours Veterinary College (OVC) in 1964, des 36 années suivantes, il a enseigné aux étudiants en médecine he earned his PhD in 1968 and vétérinaire et aux étudiants diplômés des cycles supérieurs, a fait conducted postdoctoral studies in de la recherche, et a occupé des postes administratifs dont celui de the United Kingdom and Denmark directeur de département, doyen des études supérieures et doyen before returning to the OVC as a par intérim de l’OVC. Il a représenté la profession vétérinaire en faculty member in 1969. For the tant que membre fondateur de l’Académie canadienne des sciences r Dr./D Carlton Gyles next 36 years, he taught DVM and de la santé en 2005, siégeant à son conseil d’administration graduate students, conducted research, and held administra- pendant plusieurs années. Il offre son aide à l’école de médecine tive positions, including Department Chair, Dean of Graduate vétérinaire de l’Université des Antilles à Trinidad depuis 1990, et Studies, and Interim Dean of OVC. He represented veterinary il a été rédacteur en chef de La Revue vétérinaire canadienne de medicine as a founding Fellow of the Canadian Academy 2008 à 2020. Il considère ce prix comme étant très spécial, car le of Health Sciences in 2005, serving on its board for several récipiendaire est sélectionné par la présidence de l’ACMV et a été years; has assisted the University of the West Indies’ School of décerné dans le passé à divers leaders exceptionnels de la pro- Veterinary Medicine in Trinidad since 1990; and was Editor-in- fession vétérinaire canadienne. L’ACMV est heureuse de remettre Chief of The Canadian Veterinary Journal from 2008 to 2020. He le Prix de la présidente de l’ACMV de 2021 au Dr Carlton Gyles! considers this award very special because the recipient is selected Le Prix de l’industrie de l’ACMV a été créé en 1996 pour by CVMA Presidents and has previously been awarded to many reconnaître et saluer le rôle de l’industrie en médecine vétéri- outstanding leaders in the Canadian veterinary profession. The naire et pour féliciter un membre de l’ACMV pour sa contribution CVMA is pleased to award Dr. Carlton Gyles the 2021 CVMA à l’avancement de la médecine vétérinaire. Le récipiendaire de President’s Award! cette année a obtenu son diplôme de l’Ontario Veterinary College The CVMA Industry Award was en 1982. Il y a ensuite effectué un internat et une résidence en instituted in 1996 to acknowledge médecine interne des petits animaux, ce qui a mené à l’obtention and celebrate industry’s role in vet- d’un doctorat en sciences vétérinaires et d’une certification de erinary medicine and recognize a spécialiste en médecine interne de l’American College of Veterinary CVMA member for their contribu- Internal Medicine. De 1987 à 1998, il a été chef du département tions to the advancement of vet- de médecine interne dans une pratique vétérinaire générale et spé- erinary medicine. This year’s recipi- cialisée située dans l’est de Toronto, dont il est devenu le directeur ent graduated from the Ontario général en 1993. En 1998, il a réorienté sa carrière et est devenu Veterinary College in 1982 before le premier rédacteur en chef canadien du Journal of the American returning to complete a small ani- Animal Hospital Association. r Dr./D Walt Ingwersen mal internal medicine internship and Il offre des services de consultation dans l’industrie de la santé residency resulting in his post-graduate Doctor of Veterinary des animaux de compagnie, dans les domaines du micropuçage, de Science degree and his veterinary internal medicine specialist l’assurance maladie pour animaux de compagnie et de la patholo- certification from the American College of Veterinary Internal gie clinique. Il a agi comme consultant pour l’équipe de la division Medicine. From 1987 to 1998, he was chief of veterinary inter- des animaux de compagnie Vetmedica de Boehringer Ingelheim nal medicine at a multi-person, general and specialty veterinary Canada Ltée à partir de juin 2002 avant de s’y joindre à temps clinic on the east side of Toronto, becoming its hospital director plein en janvier 2004. Il continue de fournir des services de consul- in 1993. In 1998, he changed career directions by becoming tation en médecine interne et d’aider les médecins vétérinaires de the first Canadian Editor of the Journal of the American Animal partout au Canada à prendre des décisions en matière de soins de Hospital Association. santé et à recommander des traitements aux patients. Activement He also provides consulting services to the pet health indus- impliqué au sein d’associations médicales vétérinaires provinciales, try, in the areas of microchipping, pet health insurance, and nationales et internationales, il est un ancien président de la World clinical pathology laboratory medicine. Since June 2002, he Small Animal Veterinary Association et il a récemment joint le has been a consultant to the Boehringer Ingelheim Canada Ltd. groupe consultatif de Pawzy, dont la mission est de permettre aux Vetmedica Companion Animal team, joining them full-time in propriétaires d’animaux de trouver les meilleurs conseils et services. January 2004. He continues to provide internal medicine con- Il a eu l’honneur de recevoir le Prix du président de l’ACMV en sultative advice and assist veterinarians across Canada in making 2000 et le Prix du vétérinaire exceptionnel de l’Ontario Veterinary healthcare decisions and patient treatment recommendations. As Medical Association en 2020. Félicitations au récipiendaire du Prix an active volunteer for provincial, national, and international de l’industrie de l’ACMV de 2021, le Dr Walt Ingwersen! veterinary medical associations, he is a Past-president of the Le titre de membre à vie de l’ACMV est conféré à un membre World Small Animal Veterinary Association, and recently joined de l’ACMV pour des services exceptionnels et de longue date au the advisory group of Pawzy, focusing on connecting pet par- sein du Conseil, du Comité exécutif ou des autres comités de ents to the best advice and services. He was honored to receive l’ACMV ou pour des contributions remarquables à la profession

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N the CVMA President’s Award in 2000 and the 2020 Ontario vétérinaire. Le récipiendaire de cette année a reçu son D.M.V. de Veterinary Medical Association’s Outstanding Veterinarian l’Ontario Veterinary College (OVC) en 1965 et, après un an en Award. Congratulations to the 2021 CVMA Industry Award pratique privée, a été embauché par l’OVC en tant que membre recipient, Dr. Walt Ingwersen! du corps professoral pour établir la première spécialisation en CVMA Life Membership is anesthésie dans une école vétérinaire canadienne. Sa formation presented to a CVMA member for dans sa discipline vétérinaire était en grande partie « autodidacte », long and outstanding service on mais il a participé au programme de résidence en médecine de CVMA Council, Executive, Boards, l’Université de Toronto. Il a obtenu une maîtrise en sciences en and Committees or for outstand- 1969 à l’Université de Guelph et un doctorat en 1974 à l’Université ing contributions to the veterinary de Cambridge. Il a été l’un des diplômés fondateurs de l’American profession. This year’s recipient College of Veterinary Anesthesia en 1976, dont il a plus tard été received his DVM from the Ontario directeur du comité d’examen et président. Au cours de sa carrière Veterinary College (OVC) in 1965, universitaire à l’Université de Guelph, il a été coordonnateur du and after a year in private practice département des études supérieures, coordonnateur de secteur r Dr./D Wayne McDonell was hired by the OVC as a junior pour la clinique des petits animaux et plus tard celle des grands faculty member to establish anesthesia as a specialization — the animaux, directeur d’hôpital pendant trois ans, et vice-doyen à la first in a Canadian veterinary school. His veterinary disci- recherche et aux études supérieures durant les sept dernières pline training was largely “self-taught,” but he did partici- années de sa carrière. pate in the University of Toronto medical residency program. Alors qu’il était directeur d’hôpital, il a joué un rôle déterminant He completed a Master of Science (MSc) in 1969 from the dans la création du fonds de recherche sur les animaux de com- University of Guelph, and a PhD in 1974 from the University pagnie Pet Trust, le plus fructueux du genre en Amérique du Nord. of Cambridge. He was a Charter Diplomate of the American Plus tard, alors qu’il était vice-doyen à la recherche et aux études College of Veterinary Anesthesia in 1976, later serving as supérieures, il a aidé à élaborer et à mettre en œuvre une propo- the Exam Committee Chair and President. During his aca- sition de recherche de la Fondation canadienne pour l’innovation demic career at the University of Guelph, he served as the consacrée à la médecine comparée. Sa passion a toujours été la Departmental Graduate Coordinator, as Area Coordinator for recherche et la formation aux cycles supérieurs, et il a supervisé the small animal, and then the large animal clinic, a 3-year term ou cosupervisé 7 internes en anesthésie vétérinaire, 6 résidents, as Hospital Director, and as the College Assistant Dean for 10 résidents/candidats au doctorat en sciences cliniques, 5 étu- Research and Graduate Affairs for the final 7 years of his career. diants à la maîtrise et 3 étudiants au doctorat en recherche. Il a While serving as Hospital Director, he was instrumental également publié ou copublié 120 articles scientifiques et 13 chain establishing the Pet Trust companion animal research fund, pitres de manuels et d’ouvrages de référence. Il a pris sa retraite en the most successful fund of its kind in North America. Later, 2004 après 38 ans en tant que membre du corps professoral de while serving as the Assistant Dean for Research and Graduate l’OVC et a obtenu le statut de professeur émérite. Après sa retraite, Affairs, he helped develop and implement a successful Canadian en 2005, il a aidé à établir l’organisation caritative vétérinaire Foundation for Innovation research proposal devoted to compar- internationale canadienne Vétérinaires sans frontières – Canada, ative medicine. His passion has always been research and gradu- dont il a été membre du conseil d’administration pendant plusieurs ate training and he has supervised or co-supervised 7 veterinary années. Il est membre de l’ACMV depuis l’obtention de son diplôme anesthesia interns, 6 residents, 10 residents/clinical doctorates, de D.M.V. et rédacteur en chef adjoint de La Revue vétérinaire 5 MSc students, and 3 research doctorate students. He has also canadienne depuis six ans. L’ACMV est fière de décerner le titre published, or co-published, 120 referenced scientific articles de membre à vie au Dr Wayne McDonell! and 13 chapters in monographs and textbooks. He retired in Le Prix de la pratique de l’année de l’ACMV, commandité par 2004 after 38 years as an OVC faculty member and was granted la Banque Scotia, a été créé en 2013 pour récompenser l’équipe University Professor Emeritus status. After retirement, he helped d’une pratique vétérinaire pour ses réalisations exceptionnelles establish the Canadian international veterinary charity organi- au sein de sa communauté locale. La pratique lauréate de cette zation, Vets Without Borders — Canada in 2005, serving as année est un établissement vétérinaire certifié « Fear Free » offrant board member for years. He has been a CVMA member since des services complets aux communautés de Langley, de Surrey, his DVM graduation and has served as an Associate Editor de White Rock et de la vallée du Fraser en Colombie-Britannique. for The Canadian Veterinary Journal for the past 6 years. The Fondée en 2013, la pratique a récemment inauguré un nouvel CVMA is proud to award Dr. Wayne McDonell with CVMA emplacement agrandi doté des dernières technologies vétérinaires Life Membership! où on applique l’approche sans peur. La vraie force de la pratique, The CVMA Practice of the Year Award, sponsored by cependant, est son équipe expérimentée, sympathique et haute- Scotiabank, was established in 2013 to recognize a veterinary ment qualifiée qui s’affaire à fournir d’excellents soins aux animaux practice team for outstanding achievement within their local et à créer un environnement de travail enrichissant. En plus d’aider community. This year’s recipient is a full service, Certified les clients et les animaux de compagnie, la pratique travaille avec Fear Free veterinary practice serving the British Columbia plusieurs organisations de sauvetage, telles que TinyKittens, pour communities of Langley, Surrey, White Rock, and the Fraser créer de nouvelles normes de soins pour les animaux secourus Valley. Established in 2013, it recently opened a new, expanded ou féraux, notamment en faisant de la recherche lors de cas rares

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location featuring the latest veterinary technology and Fear Free et compliqués pour trouver des solutions de traitement et en N principles. The hospital’s real strength, however, is its experi- établissant de nouveaux protocoles pour augmenter l’efficacité et enced, fun, and highly qualified team dedicated to providing diminuer les coûts, et elle offre du temps et ses installations pour excellent pet care and creating a supportive work environment. des journées de « capture, stérilisation, remise en liberté ». In addition to helping clients and pets, this recipient works En utilisant la portée mondiale de TinyKittens, la pratique dif- with several rescue organizations, such as TinyKittens, to cre- fuse en direct des vidéos éducatives sur diverses procédures, des ate new care standards for rescued and feral animals including sessions de questions-réponses, et des événements de stérilisation researching rare and complicated cases to create new treatment d’animaux féraux. Depuis son ouverture, la pratique a fourni plus solutions, establishing new protocols to increase efficiencies and de 350 000 $ en soins gratuits pour les animaux secourus par la decrease costs, and regularly donating their time and hospital for Langley Animal Protection Society (LAPS), qu’elle soutient par des “Trap, Neuter/Spay, and Release Days.” collectes de fonds annuelles et avec laquelle elle s’associe pour Using TinyKittens global reach, this recipient livestreams edu- organiser des cliniques de soins sans frais pour les animaux de cational procedure webcasts, Q&A sessions, and feral spay/neuter sans-abri et de personnes à faible revenu. Elle a également mis events. Since opening, they have provided over $350 000 in free sur pied un programme de dons visant à remettre des ensembles animal rescue care for the Langley Animal Protection Society de masques à oxygène pour animaux de compagnie aux services (LAPS), which they also partner with to provide free animal d’incendie locaux, ce qui a inspiré d’autres intervenants à organiser care clinics for homeless and low-income people and support leurs propres campagnes. La pratique lauréate amasse des fonds through annual fundraisers. They have an ongoing donation pro- pouvant servir à offrir des soins aux animaux de familles dans le gram providing pet oxygen mask kits to local fire departments, besoin et aux organisations de secours d’animaux touchées par des which has inspired others to organize their own campaigns. This catastrophes naturelles. Depuis 2013, la pratique a donné plus de recipient also has an “Angel Fund” providing pet care for families 92 000 $ en services et produits, et elle a remis 1200 $ à la SPCA in financial need and animal rescue organizations affected by de Fort McMurray et 1300 $ à la SPCA de la Colombie-Britannique natural disasters. Since 2013, they have donated over $92 000 lors des feux de forêt de 2016 et de 2017, respectivement. in services and products and have given $1300 to the BC SPCA La pratique organise une campagne de sensibilisation en Emergency Appeal for the 2017 wildfires, and $1200 to the Fort remettant gratuitement des autocollants pour fenêtres « Sauvez McMurray SPCA in aid of the 2016 wildfires. nos animaux » ainsi que des listes de préparation aux urgences They run a campaign increasing awareness by providing free aux propriétaires d’animaux dans le cadre de la Semaine de la “Save Our Pets” window clings and “Emergency Preparedness sécurité civile du Canada, et participe chaque été à la campagne for Pets Checklists” to the public as part of Canada’s annual « Keep Pets Cool » en offrant des autocollants de fenêtre gratuits Emergency Preparedness Week. Their “Keep Pets Cool” cam- aux entreprises locales qui invitent leurs clients à emmener leurs paign runs every summer, providing free window clings to local animaux à l’intérieur au lieu de les laisser dans leur voiture par businesses, informing customers they are welcome to bring their temps chaud. Elle a également organisé deux séances de bien-être pets inside and not leave them in hot cars. This recipient has also en santé mentale, a demandé à un physiothérapeute d’élaborer hosted 2 mental health wellness sessions, has had a physiothera- un programme d’entraînement et d’étirements pour son équipe, et pist develop a training/stretching program for their team, and dispose d’un espace dédié à l’exercice et au mieux-être. Tous les has a dedicated exercise and wellness area. Each team member is membres de l’équipe sont activement encouragés à poursuivre actively encouraged to pursue their professional passions through leurs passions professionnelles grâce à une formation continue paid continuing education, and volunteer initiatives, within and rémunérée et à des initiatives de bénévolat, tant au sein qu’en

Mountain View Veterinary Hospital team/Équipe du Mountain View Veterinary Hospital

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N outside the veterinary profession. Every year, members of this dehors de la profession vétérinaire. Chaque année, les membres team mentors RVTs and students through school practicums and de cette équipe mentorent des techniciens en santé animale et paid work experiences, and currently employs 3 former students des étudiants en médecine vétérinaire dans le cadre d’expériences and 2 aspiring veterinarians. They have created a respectful, de travail et de stages rémunérés, et la pratique emploie actuel- inclusive, and diverse workplace through their hiring practices, lement trois anciens étudiants et deux aspirants vétérinaires. Elle clearly articulated anti-racism/bullying policies, and conflict offre un milieu de travail respectueux, inclusif et diversifié grâce à resolution mentoring. ses pratiques d’embauche, à ses politiques clairement articulées Their staff diversity is a business strength, with team mem- contre le racisme et l’intimidation, et à du mentorat pour la réso- bers from several ethnic groups, the LGBTQ21 community, lution des conflits. and living with Autism Spectrum Disorder. Over the last 7 years, La diversité de son personnel est d’ailleurs une de ses they have earned several awards including: 2020 Employer of forces – plusieurs groupes ethniques, la communauté LGBTQ21 the Year from the Greater Langley Chamber of Commerce et les personnes vivant avec un trouble du spectre de l’autisme y Business Excellence Awards; 2019 Readers Choice from the sont représentés. Au cours des sept dernières années, cet établis- Langley Times Newspaper; 2017 and 2018 “Got a Pet, Get a sement vétérinaire a remporté plusieurs prix, notamment le prix de Vet” Award; 2017 and 2018 Best of Langley Award from the l’employeur de l’année 2020 décerné par la Chambre de commerce Langley Advance Newspaper; and 2017 Small Business of the du Grand Langley; le Choix des lecteurs du journal Langley Times Year from the Greater Langley Chamber of Commerce Business en 2019; le prix « Got a Pet, Get a Vet » en 2017 et en 2018; le Excellence Awards. In addition, the owner was nominated for prix « Best of Langley » du journal Langley Advance en 2017 et en her work keeping staff and clients safe during the COVID-19 2018; et le prix de la petite entreprise de l’année 2017 remis par pandemic. The CVMA extends heartfelt congratulations to la Chambre de commerce du Grand Langley. De plus, la proprié- Dr. Renée Ferguson and her veterinary care team at Mountain taire a été louangée pour son travail visant à assurer la sécurité View Veterinary Hospital for being awarded the 2021 CVMA du personnel et des clients pendant la pandémie de COVID-19. Practice of the Year Award! Their work and commitment to the L’ACMV félicite chaleureusement la Dre Renée Ferguson et veterinary profession and well-being is an inspiration for all. tous les membres de son équipe du Mountain View Veterinary The R.V.L. Walker Award has Hospital pour avoir mérité le Prix de la pratique de l’année 2021 de 2 recipients; a plaque is presented l’ACMV! Leur dévouement et leur engagement envers la profession annually to the Students of the vétérinaire et le mieux-être sont une source d’inspiration pour tous. CVMA (SCVMA) President in rec- Le Prix R.V.L. Walker a deux récipiendaires; une plaque est ognition of his/her contributions to remise annuellement au président du Comité des étudiants de promoting student interest in the l’ACMV (ÉACMV) en reconnaissance de sa contribution à la promo- CVMA, and a monetary award is tion de l’intérêt des étudiants auprès de l’ACMV et une bourse est presented to a student in financial décernée à un étudiant dans le besoin qui fréquente la même école need who attends the same college vétérinaire que le président des ÉACMV. La présidente des ÉACMV as the current SCVMA President. de l’année 2020-2021 s’est familiarisée avec l’agriculture en gran- me Ms./M Svetlana Ponsin The 2020–2021 SCVMA President dissant dans la ferme familiale de céréales et de pommes de terre gained an appreciation for agriculture while growing up on her à St. Eustache, au Manitoba, et s’est découvert une passion durant family’s grain and potato farm in St. Eustache, Manitoba and sa formation en productions animales à la Faculté d’agriculture de developed a passion for animal production while pursuing an l’Université du Manitoba. Elle a d’ailleurs profité de cette période Animal Systems degree at the University of Manitoba’s Faculty pour travailler et faire du bénévolat dans plusieurs fermes et éta- of Agriculture. While in university, she worked at veterinary blissements vétérinaires pour acquérir de l’expérience et élargir clinics and volunteered on various livestock operations where ses connaissances sur les animaux et la médecine vétérinaire. En she gained experience and broadened her knowledge of animals 2018, elle a franchi une étape importante vers la concrétisation de and veterinary medicine. In 2018, she realized her childhood son rêve d’enfance de devenir vétérinaire lorsqu’elle a été admise dream of pursuing veterinary medicine when she was accepted au Western College of Veterinary Medicine (WCVM). Elle est la to the Western College of Veterinary Medicine (WCVM). She représentante de VetPrep pour sa promotion et elle fait partie de is the current VetPrep Representative for her DVM class and divers groupes, y compris le club équin et le comité des articles participates in a variety of clubs, including the equine club and promotionnels de sa classe. Elle est également membre étudiante her class merchandise committee. She is also a student member de l’American Association of Swine Veterinarians et de l’Association of the American Association of Swine Veterinarians and the canadienne des vétérinaires porcins. Pendant ses temps libres, Canadian Association of Swine Veterinarians. In her free time, elle aime jouer de la flûte (elle est d’ailleurs joueuse de piccolo au she enjoys playing the flute, is a piccolo player in the WCVM sein de l’orchestre de chambre du WCVM) et passer ses vacances Chamber Orchestra, and enjoys spending time with horses, bar- d’été avec des chevaux en faisant de la randonnée et en participant rel racing, and trail riding over her summer breaks. She gained à des courses de barils. Elle a acquis une expérience précieuse valuable experience over the last 2 summers working for an au cours des deux derniers étés en travaillant pour une pratique all-swine veterinary practice and more recently, a mixed-animal vétérinaire exclusivement porcine, et plus récemment, une pratique practice. After graduation, she plans to return to Manitoba to mixte. Après l’obtention de son diplôme, elle prévoit retourner au work in mixed-animal practice, providing access to veterinary Manitoba pour travailler dans une pratique mixte offrant un accès

816 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY care for rural communities. She was honored to be the SCVMA aux soins vétérinaires dans les communautés rurales. Elle se dit N President, representing veterinary students on the CVMA honorée d’avoir été la présidente des ÉACMV et d’avoir représenté Council for the 2020–2021 school year. The CVMA congratu- les étudiants en médecine vétérinaire au Conseil de l’ACMV durant lates the 2021 R.V.L. Walker Award recipient, Ms. Svetlana l’année scolaire 2020-2021. L’ACMV est heureuse de féliciter la Ponsin, and thanks her for her service to the veterinary profes- récipiendaire du prix R.V.L. Walker de 2021, Mme Svetlana Ponsin, sion and her national veterinary association. et la remercie d’avoir servi la profession vétérinaire et son associa- The Merck Veterinary Award, tion vétérinaire nationale. established in 1985 and sponsored Le Prix vétérinaire Merck, créé en 1985 et parrainé par Merck by Merck Animal Health, is pre- Santé animale, est remis à un membre de l’ACMV dont le travail sented to a CVMA member whose en productions animales, en recherche clinique ou en sciences work in food animal production fondamentales a contribué de manière importante à l’avancement practice, clinical research, or basic de la médecine et de la chirurgie des animaux destinés à la pro- sciences is judged to have contrib- duction d’aliments, y compris la régie de la santé des troupeaux. La uted significantly to the advance- récipiendaire de 2021 a fréquenté l’Université de Guelph où elle ment of food animal medicine a obtenu un baccalauréat en biologie animale, puis son D.M.V. à and surgery, including herd health l’Ontario Veterinary College (OVC). Elle s’est ensuite tournée vers re Dr./D Claire Windeyer management. The 2021 recipient la pratique mixte rurale dans le sud de l’Alberta, avant de retourner attended the University of Guelph where she completed her BSc à l’OVC pour faire un doctorat en régie de la santé des ruminants in Animal Biology followed by her DVM degree at the Ontario axé sur le complexe respiratoire bovin chez les génisses laitières. Veterinary College (OVC). After graduation, she went into rural La lauréate s’est jointe au Département de la santé des animaux mixed practice in southern Alberta. She then returned to OVC de production de la Faculté de médecine vétérinaire de l’Université for a DVSc in Ruminant Health Management, with a focus on de Calgary (UCVM) en 2011. Ses recherches portent sur la régie bovine respiratory disease in dairy heifer calves. The recipient de la santé dans les élevages vache-veau, y compris les soins joined the Department of Production Animal Health at the périnataux du veau nouveau-né, les pratiques de régie avant le University of Calgary Faculty of Veterinary Medicine (UCVM) sevrage, l’épidémiologie des maladies infectieuses du veau avant in 2011. Her research focuses on cow-calf health management, le sevrage, ainsi que la douleur et le bien-être animal. Elle enseigne including perinatal care of the newborn calf, pre-weaning l’épidémiologie, la régie de la santé, l’investigation lors d’éclosions management practices, epidemiology of infectious diseases of de maladies infectieuses et la médecine des animaux de production the pre-weaned calf, and pain and animal welfare. She teaches dans le programme de D.M.V. de l’UCVM, ainsi que la régie avancée epidemiology, health management, outbreak investigation, and de la santé des bovins dans le programme d’études supérieures. production animal medicine in UCVM’s DVM program, as well Elle vit sur une petite ferme près de Dogpound, en Alberta, avec as advanced beef health management in the graduate program. son mari Bruce ainsi que leurs cinq chevaux, huit poules, deux She lives on a small acreage near Dogpound, Alberta, with her chiens et plusieurs chats. Félicitations à la récipiendaire du Prix husband Bruce, their 5 horses, 8 chickens, 2 dogs, and too vétérinaire Merck de 2021, la Dre Claire Windeyer! many cats. Congratulations to the 2021 recipient of the Merck Le Prix humanitaire de l’ACMV, commandité par Merck Santé Veterinary Award, Dr. Claire Windeyer! animale, a été créé en 1986 et reconnaît le leadership dans The CVMA Humane Award, sponsored by Merck Animal le domaine des soins et du bien-être des animaux. Ce prix est Health, was established in 1986 and recognizes leadership in présenté à un membre de l’ACMV dont le travail est réputé avoir the care and well-being of animals. This award is presented to a grandement contribué au bien-être des animaux. La récipiendaire CVMA member whose work is judged to have contributed signif- de cette année occupe le poste de directrice principale de la icantly to the welfare and well-being of animals. This year’s recipi- santé animale pour la Société de prévention de la cruauté envers ent serves as the Senior Manager, Animal Health for the British les animaux de la Colombie-Britannique, et offre du soutien, de Columbia Society for the Prevention of Cruelty to Animals la formation et une surveillance en matière de santé animale à providing animal health support, training, and oversight to 36 refuges dans toute la province. Elle enseigne aux étudiants en 36 sheltering branches province wide. She also teaches veterinary médecine vétérinaire, participe à des partenariats communautaires students, participates in community partnerships and outreach, et à des activités de sensibilisation, et fait du bénévolat auprès and volunteers with several animal welfare, One Health, diversity, de divers groupes axés sur le bien-être animal, le concept « Une equity, and inclusion in veterinary medicine groups, including the santé », ainsi que la diversité, l’équité et l’inclusion en médecine CVMA-SBCV Chapter Animal Welfare Committee. Her clinical vétérinaire, notamment le Comité du bien-être animal de la section interests include infectious disease, community medicine, internal ACMV-SBCV. Ses intérêts cliniques comprennent les maladies medicine, and behavior. She has co-authored several publications infectieuses, la médecine communautaire, la médecine interne et on shelter infectious disease, and was the lead veterinarian investi- le comportement. Elle est co-auteure de plusieurs publications gating a multi-facility feline gastroenteritis outbreak in 2018 that sur les maladies infectieuses dans les refuges, et a été la vété- led to the discovery of a novel feline virus, feline chaphamapar- rinaire principale enquêtant sur une épidémie de gastro-entérite vovirus. Her other research interests and areas of active col- féline touchant plusieurs établissements en 2018 qui a conduit laboration include animal welfare epidemiology, particularly à la découverte d’un nouveau virus, le chaphamaparvovirus félin. factors leading to animal relinquishment and their relationship Ses autres intérêts de recherche et domaines de collaboration

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N with human social vulnerability, and active incluent l’épidémiologie appliquée au bien-être animal, shelter feline behavior and welfare. en particulier les facteurs qui mènent à l’abandon des animaux Originally from the United States, et leur relation avec la vulnérabilité sociale humaine, ainsi que she holds veterinary licenses in le comportement et le bien-être des chats en refuge. Originaire California and British Columbia and des États-Unis, elle détient des permis d’exercice en Californie in 2020, became the first veterinarian et en Colombie-Britannique et, en 2020, elle est devenue la pre- in Canada to become Board-certified mière vétérinaire au Canada à être reconnue comme spécialiste in Shelter Medicine Practice through de la pratique de la médecine de refuge par l’American Board the American Board of Veterinary of Veterinary Practitioners. Au cours des 20 dernières années, Practitioners. For the past 20 years, elle a fait du bénévolat auprès d’organismes qui soutiennent les re Dr./D Emilia Wong Gordon she has volunteered with organiza- sans-abri et leurs animaux de compagnie. Elle pense qu’une tions supporting people experiencing homelessness and their collaboration intersectorielle axée sur l’approche « Une santé » companion animals. She believes that cross-sector collaboration est essentielle à l’atteinte des objectifs communs des profession- with a One Health emphasis is essential to the shared goals of the nels du bien-être animal, de la santé des animaux et de la santé animal welfare, veterinary, and human health professions. These humaine. Ces objectifs comprennent notamment la prestation goals include the provision of accessible, culturally competent, de soins accessibles dans la communauté et adaptés sur le plan community-based care that meets human-animal families’ needs. culturel qui répondent aux besoins des animaux et de leurs familles. The CVMA is pleased to present the 2021 CVMA Humane L’ACMV est heureuse de présenter le Prix humanitaire de l’ACMV Award to Dr. Emilia Wong Gordon! de 2021 à la Dre Emilia Wong Gordon!

National Check the Chip Day Check the Chip Day is August 15, 2021 Journée nationale de vérification de la micropuce 15 août 2021 icrochips greatly increase the chances of pets being reunited es micropuces augmentent considérablement les chances Mwith their families if they are lost or stolen, but a micro- Lque les animaux de compagnie soient réunis avec leur famille chip only works if its registration information is accurate. s’ils sont perdus ou volés, mais elles ne sont efficaces que si les Encourage clients to microchip their pets and register the renseignements qu’elles contiennent sont exacts. chip number immediately. Remind clients to ensure their pet’s Encouragez les clients à faire installer une micropuce à leurs information is updated in the manufacturers database with animaux de compagnie et à enregistrer le numéro de puce immé- accurate phone number(s) and address. diatement. Rappelez aux clients qu’ils doivent s’assurer que les A microchip also allows accurate identification of a pet in données concernant leur animal soient mises à jour dans la base cases where ownership is in question. de données du fabricant, avec leur adresse et un ou des numéros Microchips have distinct advantages over tattoos and collars de téléphone qui permettent de les joindre. as collars can be easily removed or lost and tattoos can become Une micropuce permet également d’identifier de façon précise illegible and information retrieval can be slow or impossible due un animal de compagnie dans les cas où la propriété est en cause. to incomplete record keeping. Encourage your clients to use Les micropuces ont des avantages par rapport aux tatouages microchips in addition to collars and tattoos. et aux colliers, car les colliers peuvent être retirés ou perdus et Remind clients that microchip implants should even be les tatouages peuvent devenir illisibles, et la récupération de considered for pets that never leave the home, as they can acci- l’information peut être lente ou impossible en raison de données dentally get out of the house and are particularly susceptible to incomplètes. Encouragez vos clients à utiliser une micropuce en disorientation when they do escape. plus des colliers et des tatouages. A review process has been established by the National Rappelez aux clients que la micropuce devrait aussi être envi- Companion Animal Coalition (NCAC) to assess the conformity sagée même pour les animaux qui ne quittent jamais la maison, car of radio frequency identification (RFID) products and processes ils pourraient s’échapper accidentellement et sont particulièrement with the revised Canadian standard for electronic (microchip) susceptibles de se perdre s’ils se retrouvent à l’extérieur. identification of companion animals. The revised Canadian Un processus d’examen a été établi par la Coalition nationale sur standard came into effect December 1, 2004 and is based on ISO les animaux de compagnie (CNAC) afin d’évaluer la conformité des microchips, accompanying databases, and compatible readers to produits et des processus d’identification par radiofréquence (IRF)

818 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY promote maximum long- par rapport à la norme canadienne révisée pour l’identification élec- N term recovery potential of tronique (par puce) des animaux de compagnie. La norme canadienne companion animals. Only révisée est entrée en vigueur le 1er décembre 2004 et respecte la those RFID products norme des puces de l’ISO, des bases de données correspondantes that have been submitted et des lecteurs compatibles afin de faciliter le potentiel de récupé- for review and deemed ration à long terme des animaux de compagnie. Seuls les produits in conformity with the IRF qui ont été soumis aux fins d’examen et ont été jugés conformes Canadian standard will à la norme canadienne seront reconnus comme étant acceptables be recognized as suitable pour l’identification des animaux de compagnie. Seules les puces de for companion animal identification. Only ISO microchips are l’ISO sont acceptables en vertu de la norme canadienne. De plus, la acceptable under the Canadian standard. In addition, the NCAC CNAC autorise les utilisateurs à employer des puces standard non permits users to apply non-Canadian standard microchips only canadiennes seulement en cas de besoin et uniquement si elles font if required and specially requested for export purposes. l’objet d’une demande spéciale aux fins d’exportation. Visit the Guides & Information/Animal Owners subcate- Visitez la page Guides et ressources de la section Propriétaires gory under the Public Resources section of (www.canadian d’animaux sous l’onglet Ressources publiques du site de l’ACMV veterinarians.net) to access a list of NCAC Recognized RFID (www.veterinairesaucanada.net) pour accéder à une liste de pro- Products. duits d’IRF reconnus par la CNAC.

Animal Health Week 2021 — Semaine de la santé animale – October 3 to 9, 2021 du 3 au 9 octobre 2021 Animal Health 1 Human Health 1 Planet Santé animale 1 santé humaine 1 Health = One Health santé de la planète = Une seule santé nimal Health Week (AHW) is an annual national public a Semaine de la santé animale est une campagne nationale Aawareness campaign organized by the Canadian Veterinary Lannuelle de sensibilisation du public organisée par l’Association Medical Association (CVMA) and hosted by veterinarians across canadienne des médecins vétérinaires (ACMV) et mise en œuvre Canada. Each year, through AHW, the veterinary community par les médecins vétérinaires du Canada. Chaque année, dans le draws attention to an important health-related message. cadre de la Semaine de la santé animale, la communauté vété- From October 3–9, 2021, the CVMA will celebrate the rinaire attire l’attention sur un important message lié à la santé. 36th annual Animal Health Week by raising awareness of Du 3 au 9 octobre 2021, l’ACMV célébrera la 36e Semaine de One Health — the collaborative effort of multiple disciplines to la santé animale en mettant l’accent sur le concept « Une santé », attain optimal health for people, animals, and the environment. soit l’effort de collaboration de professionnels de multiples disci- This year’s theme, Animal Health 1 Human Health 1 Planet plines qui travaillent ensemble en ayant pour objectif une santé Health = One Health, will showcase how Canada’s veterinary optimale pour les gens, les animaux et l’environnement. Le slogan professionals occupy unique positions within the national One de cette année, Santé animale 1 santé humaine 1 santé de la Health community in protecting animal health which, in turn, planète = Une seule santé, met en évidence la position unique protects everyone’s health. de la profession vétérinaire au sein de la communauté nationale Promotional tools, including a social media campaign, edu- « Une santé » pour protéger la santé animale et, ainsi, protéger la cational information, and articles will be available to promote santé de tous. Animal Health Week across the country. A free Animal Health Des outils promotionnels, y compris une campagne sur les Week poster was included in July’s issue of The Canadian médias sociaux, de l’information et des articles, seront offerts pour Veterinary Journal and a 2nd poster will arrive at veterinary promouvoir la Semaine de la santé animale d’un bout à l’autre du pays. Une affiche gratuite de la Semaine de la santé animale était incluse dans le numéro de juillet de La Revue vétérinaire canadienne, et une autre affiche sera envoyée par la poste aux établissements vétérinaires du pays en août. L’ACMV ne vendra pas de marchandise cette année, car nous faisons la transition des célébrations de la Semaine de la santé animale vers une campagne de sensibilisation en ligne seulement. À l’approche du mois d’octobre, visitez la section Semaine de la santé animale sous l’onglet Pratique et finances du site Web de l’ACMV (www.veterinairesaucanada.net) pour obtenir des conseils et des outils qui vous aideront à planifier vos célébrations. Commanditaires La campagne de la Semaine de la santé animale de 2021 est généreusement soutenue par iFinance Canada (Petcard) et

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N hospitals and clinics across the country in August. The CVMA Petsecure assurance maladie pour animaux de compagnie. will not be selling merchandise this year as we are transition- Ce mois-ci, nous saluons Petsecure. ing Animal Health Week celebrations to an online awareness Petsecure assurance maladie pour animaux de compa- campaign only. As Animal Health Week nears, visit the Animal gnie souligne l’apport des équipes de soins vétérinaires à titre Health Week section under the Practice & Economics tab of the de champions « Une santé » pendant la Semaine de la santé CVMA website (www.canadianveterinarians.net) to find tips animale célébrée partout au Canada. Les vétérinaires ont des and tools to help plan your celebrations. perspectives intéressantes et utiles en tant que leaders du savoir Sponsors dans le développement et le maintien d’une société en santé. L’expertise médicale combinée à la compréhension de la relation Generous support of the 2021 Animal Health Week campaign humain-animal permet des stratégies d’action intégrées en matière is provided by Program Sponsors, iFinance Canada (Petcard) de santé publique, de protection de l’environnement et d’innocuité and Petsecure Pet Health Insurance. This month we highlight des aliments. Les chats et les chiens sont de plus en plus perçus Petsecure. comme des membres de la famille à part entière, ce qui crée une Petsecure Pet Health Insurance celebrates veterinary care énorme opportunité pour les médecins vétérinaires d’intégrer la teams as One Health champions across Canada during Animal philosophie « Une santé » dans leurs pratiques quotidiennes. Health Week. Veterinarians have valuable perspectives as knowl- En tant qu’entreprise canadienne, Petsecure s’engage à sou- edge leaders in the development and maintenance of a healthy tenir les équipes vétérinaires et leurs patients canins et félins. Ses society. Medical expertise combined with understanding of the produits d’assurance pour animaux de compagnie permettent aux human-animal relationship allows for integrated action strategies médecins vétérinaires d’examiner et de traiter les animaux en fonc- in public health, environmental protection, and food safety. Cats tion de leurs besoins individuels et d’assurer la tranquillité d’esprit and dogs are increasingly identified as close family members, financière des clients*. Petsecure couvre les frais d’examen et les which creates a huge opportunity for veterinarians to incorporate taxes contrairement à certaines autres compagnies d’assurance the One Health philosophy into daily practices. pour animaux de compagnie, de sorte que les clients n’ont jamais As a Canadian company, Petsecure is committed to support- à hésiter avant de contacter leur médecin vétérinaire pour obtenir ing veterinary teams and their canine and feline patients. Its pet les meilleurs conseils et soins médicaux. insurance products allow veterinarians to examine, diagnose, and Les équipes vétérinaires jouent un rôle crucial dans le concept treat pets according to individual needs with financial peace of « Une santé » du bien-être collectif selon la Dre Colleen Fisher, mind for clients.* Petsecure covers examination fees and taxes, directrice médicale vétérinaire de Petsecure. « Une approche unlike some pet insurance companies, so clients never have to réussie tient compte de la santé des animaux, des personnes et worry about reaching out to you for the best medical advice de l’environnement dans lequel nous vivons, explique-t-elle. Pour and care. souligner cet engagement, Petsecure fait régulièrement des dons “Veterinary team roles are critical to the One Health concept à des organismes de bienfaisance et à des refuges pour animaux of community wellness,” says Dr. Colleen Fisher, Veterinary partout au Canada, et soutient le personnel en télétravail pour aider Medical Director of Petsecure. “A successful approach consid- à freiner la propagation de la COVID-19. » ers the health of animals, people, and the environment we live Petsecure améliore l’assurance en offrant une couverture com- in. To highlight that commitment, Petsecure regularly donates plète contre les accidents et les maladies, y compris les problèmes to charitable organizations and animal shelters across Canada, dentaires et les troubles du comportement, dans tous ses régimes. and supports staff working from home to help stop the spread Le programme de bons en clinique Petsecure est une politique of COVID-19.” d’essai de 6 semaines offrant aux nouveaux propriétaires d’ani- Petsecure makes insurance better with comprehensive acci- maux une protection financière en cas de dépenses vétérinaires dent and illness coverage, including dental and behavior benefits imprévues. Renseignez-vous sur les régimes qui incluent une on all Secure plans. The Petsecure in-clinic voucher program is a couverture pour les examens annuels, les vaccinations, la maîtrise 6-week trial policy that offers new pet owners financial protec- des parasites et les tests de santé de routine. tion for unexpected veterinary expenses. Ask us about wellness Les médecins vétérinaires sont les experts lorsqu’il s’agit de plans that include coverage for annual examinations, vaccines, promouvoir la philosophie « Une santé » auprès des propriétaires parasite control, and routine health testing. d’animaux de compagnie. Donnez à vos patients la possibilité Veterinarians are experts when it comes to promoting the de recevoir des soins de santé optimaux durant toute leur vie One Health philosophy with pet families. Set up your clients en offrant à vos clients une assurance maladie pour animaux for a lifetime of great pet health care by offering Petsecure Pet de compagnie Petsecure. Des représentants de Petsecure sont Health Insurance. Local Territory Managers are available across disponibles partout au pays pour soutenir les équipes vétérinaires Canada to support clinic care teams with educational semi- avec des séminaires et du matériel d’information. Les membres nars and information materials. CVMA members may contact de l’ACMV peuvent communiquer avec leur représentant ou le their local Territory Manager or reach out to our Vetline at personnel du service vétérinaire de Petsecure au 1-877-202-5813 1-877-202-5813 for information about our products. pour obtenir de plus amples renseignements sur leurs produits.

Underwriting and designated waiting periods may apply; see policy for full * La souscription et des périodes d’attente peuvent s’appliquer; voir le libellé des details. * polices pour plus de détails.

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Six Things Veterinary Teams Can Do with the All-New Plumb’s N Six choses que les équipes vétérinaires peuvent faire avec le nouveau Plumb’s Veterinary Drugs s a member of the Canadian Veterinary Medical Association n tant que membre de l’Association canadienne des méde- A(CVMA), you have access to many practical veterinary tools Ecins vétérinaires (ACMV), vous avez accès à plusieurs outils and resources to support you, your healthcare team, and your et ressources vétérinaires pratiques pour vous soutenir, vous, practice. This assistance also contributes to satisfying one of the votre équipe et votre pratique. Ce soutien contribue également à CVMA’s top priorities, improving animal welfare in Canada. répondre à l’une des principales priorités de l’ACMV, soit l’amélio- One of the resources the CVMA offers is through our val- ration du bien-être animal au Canada. ued partner, Plumb’s Veterinary Drugs, granting access to an L’une des ressources offertes par l’ACMV et son partenaire improved drug reference that will change the way you practice. Plumb’s Veterinary Drugs est l’accès à un outil de référence sur The all-new Plumb’s Veterinary Drugs is built with the lat- les médicaments qui changera votre façon de pratiquer. est technology and a slate of new features and functionality so Le nouveau Plumb’s Veterinary Drugs, conçu avec les dernières veterinary teams can rely on a faster, more intuitive, and more technologies, est doté de nouvelles caractéristiques et fonctionna- robust digital drug reference. lités afin que les équipes vétérinaires puissent s’appuyer sur une The new Plumb’s sports a fresh look and much more, référence numérique plus rapide, intuitive et robuste. including: En plus de sa présentation renouvelée, Plumb’s Veterinary • A first-of-its-kind drug interaction checker Drugs propose notamment : • Lightning-fast search that gives you results as you type • un vérificateur d’interaction médicamenteuse unique en son • Easy-to-use notes and favorites so you can make Plumb’s genre; your own • une fonction de recherche ultrarapide qui vous suggère des • Plus, details on more than 20 new drugs you won’t find in the résultats à mesure que vous tapez; most recent edition of the Plumb’s Veterinary Drug Handbook. • des fonctions de notes et de favoris faciles à utiliser pour per- In short, it’s a better way to find up-to-date veterinary drug sonnaliser votre outil de référence; information and make informed decisions for your patients — in • des détails sur plus de 20 nouveaux médicaments que vous ne clinic or on the go. trouverez pas dans la plus récente édition imprimée du manuel Here are 6 things you and your team can do with the new Plumb’s Veterinary Drug Handbook. Plumb’s: Autrement dit, c’est un meilleur moyen de trouver de l’information à jour sur les médicaments vétérinaires et de prendre des 1. Evaluate your patient’s drug list for potential interactions* décisions éclairées pour vos patients, en clinique ou sur la route. Introducing the first-of-its-kind drug interaction checker: a Voici 6 choses que vous et votre équipe pouvez faire avec le robust, easy-to-use tool that lets you enter multiple drugs to nouveau Plumb’s Veterinary Drugs : check for potential drug-to-drug interactions — from minor additive effects to major absorption concerns. 1. Évaluez la liste de médicaments que prend votre patient Interactions are assigned a color-coded risk classification pour connaître les interactions possibles* and include animal-specific information based on current evi- Le vérificateur d’interaction médicamenteuse est unique en son dence. Classifications range from contraindicated (i.e., don’t genre : il s’agit d’une fonctionnalité fiable et facile à utiliser qui vous permet d’entrer plusieurs médicaments pour connaître les interactions médicamenteuses possibles – des effets additifs mineurs aux problèmes d’absorption majeurs. Les interactions se voient attribuer un code de couleur selon le risque, et sont appuyées par de l’information spécifique aux animaux basée sur les preuves actuelles. Les classifications vont de la contre-indication (autrement dit, à éviter!) à l’absence d’interaction connue, avec trois niveaux de risque entre les deux : majeur, modéré et mineur. Ce nouvel outil couvre actuellement plus de 25 000 interactions médicamenteuses potentielles et est continuellement mis à jour avec de nouvelles données.

2. Trouvez de l’information sur les médicaments plus rapidement Avec la fonction de recherche à partir de mots partiels et la navigation améliorée, il est encore plus facile de trouver l’information dont vous avez besoin. Vous ne vous souvenez pas de l’orthographe d’un médicament ou d’un nom commercial? Tapez

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N do it!) to no known interaction, with 3 levels of caution in quelques lettres et la nouvelle fonction de recherche fournira between: major, moderate, and minor. des suggestions. This new tool currently covers more than 25 000 potential 3. Naviguez plus facilement drug interactions and is continually updated with new data. À la lumière des commentaires des abonnés (et de ceux de 2. Find drug information faster près de 100 professionnels vétérinaires qui testent la nouvelle With partial word search and enhanced navigation, it’s even plateforme dans leurs pratiques), le nouveau Plumb’s Veterinary easier to find the information you need. Can’t recall the spell- Drugs a été conçu avec une interface renouvelée facile à utili- ing of a drug or trade name? Type in a few letters and the new ser et une apparence améliorée. search will provide suggestions. La plateforme propose une navigation simplifiée, un espace- ment accru pour faciliter la lecture, ainsi que des icônes simples 3. Navigate Plumb’s more easily et des codes de couleurs qui permettent de trouver encore plus Armed with feedback from subscribers — as well as nearly facilement ce dont vous avez besoin. 100 veterinary professionals who are testing the new platform De plus, dans chaque monographie de médicament, la table in their practices — the new Plumb’s was designed with an des matières défile avec le contenu et vous permet de passer easy-to-use new interface and an enhanced look. rapidement à n’importe quelle section. The new platform features simplified navigation, increased spacing for ease of reading, and simple icons and color-coded 4. Accédez à l’information la plus récente labels that make it even easier to find what you need. Le nouveau Plumb’s Veterinary Drugs contient de l’infor- Plus, in each drug monograph, the table of contents scrolls mation que vous ne trouverez pas dans le manuel imprimé, with you and can jump you to any section. y compris des dizaines de monographies de nouveaux médi- 4. Access the most up-to-date Plumb’s yet caments – comme celle du ropinirole, un nouvel émétique – et The new Plumb’s comes with information you won’t find in les versions mises à jour de centaines d’autres. the book, including dozens of new drug monographs — like Comme chaque nouveau renseignement a fait l’objet de the new emetic ropinirole — and updates to hundreds of plusieurs cycles d’examen et de révision par des spécia- others. listes vétérinaires, des pharmaciens vétérinaires et des méde- Every piece of new information has been through several cins vétérinaires en pratique, vous pouvez donc être assuré rounds of review and revision by veterinary specialists, vet- d’obtenir les renseignements les plus pertinents et à jour erinary pharmacists, and practicing veterinarians, so you can disponibles. be confident that you’re getting the most relevant, up-to-date 5. Épinglez des notes n’importe où† information available. Vous avez probablement l’habitude de prendre des notes un 5. Pin notes anywhere† peu partout, que ce soit dans les marges de votre ouvrage de You’re probably accustomed to jotting down notes every- référence préféré ou sur les feuillets autocollants qui recouvrent where, whether in the margins of your favorite reference votre bureau. Plumb’s Veterinary Drugs a été conçu pour que book or on the sticky notes that cover your desk. Plumb’s was vous puissiez avoir accès à tous ces rappels, perles et proto- built so you can take all those tidbits, pearls, and preferred coles préférés en tout temps. protocols on the go. 6. Faites les conversions et les calculs directement dans la 6. Convert and calculate from the new app‡ nouvelle application‡ They have built all-new Plumb’s apps for iOS and Android. Une nouvelle application a été créée pour iOS et Android. Fast, sleek, and reliable, the new app puts the features you Rapide et fiable, la nouvelle application propose les fonctionna- need in a clean new interface. Search drug monographs, lités dont vous avez besoin dans une nouvelle interface épurée. check for drug interactions, make quick conversions, and Faites des recherches dans les monographies des médica- even e-mail medication guides to pet owners (without reveal- ments, vérifiez les interactions médicamenteuses, effectuez des ing your e-mail address) right from the app. conversions rapides et envoyez même des fiches d’information sur les médicaments par courriel aux propriétaires d’animaux Meet the team building the new Plumb’s (sans dévoiler votre propre adresse courriel) directement à partir From the content to the technology, the new Plumb’s is the result de l’application. of ongoing work by an extensive team of veterinarians, veterinary pharmacists, software developers, and content editors. Rencontrez l’équipe derrière le nouveau At the core of these changes is a commitment to helping Plumb’s Veterinary Drugs veterinary teams worldwide make informed decisions for the Du contenu à la technologie, le nouveau Plumb’s Veterinary Drugs animals in their care. The new Plumb’s digital drug reference is est le résultat du travail continu d’une vaste équipe de médecins fast, efficient, and easy to use. vétérinaires, de pharmaciens vétérinaires, de développeurs de CVMA members enjoy a 30% discount on the Individual logiciels et d’éditeurs de contenu. or Practice online subscription of Plumb’s Veterinary Drugs. Au cœur de ces changements se trouve un engagement à aider Contact the CVMA ([email protected]) to obtain the les équipes vétérinaires du monde entier à prendre des décisions CVMA discount code needed. Plumb’s Veterinary Drugs is éclairées pour les animaux dont elles s’occupent. Le nouveau

822 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY a CVMA benefit that can help position your practice on the Plumb’s Veterinary Drugs est une référence numérique en matière N forefront of veterinary medicine. de médicaments qui est rapide, efficace et facile à utiliser. Les membres de l’ACMV profitent d’un rabais de 30 % sur * The drug interaction checker is a beta version that is undergoing continual l’abonnement en ligne individuel ou de pratique à Plumb’s Veterinary medical review and content updates. Results generated by the interaction checker Drugs. Communiquez avec l’ACMV ([email protected]) pour represent one-to-one drug interactions only, and they are intended to supplement obtenir le code de réduction de l’ACMV requis. L’accès à Plumb’s the knowledge and clinical judgment of veterinarians using this tool. Veterinary Drugs est un avantage offert aux membres de l’ACMV † This feature is not available for users on custom IP-authenticated accounts or accounts using shared credentials. qui peut aider à positionner votre pratique à l’avant-garde de la ‡ The iOS and Android apps are not available for users on custom IP-authenticated médecine vétérinaire. accounts or accounts using shared credentials. * Le vérificateur d’interaction médicamenteuse est actuellement une version bêta qui fait l’objet d’un examen médical en cours et de mises à jour de contenu. Les résultats générés par le vérificateur d’interaction représentent uniquement les interactions médicamenteuses individuelles, et ils sont destinés à complémenter les connaissances et le jugement clinique des médecins vétérinaires qui utilisent cette fonctionnalité. † Cette fonctionnalité n’est pas disponible pour les utilisateurs de comptes authentifiés par IP personnalisés ou de comptes utilisant des informations d’identification partagées. ‡ Les applications pour iOS et Android ne sont pas disponibles pour les utilisateurs de comptes authentifiés par IP personnalisés ou de comptes utilisant des informations d’identification partagées.

Greetings from the RVTTC! Salutations des TTVAC! hat a year it has been! While the rest of the world has uelle année nous avons eue! Alors que le monde entier a Wbeen turned upside down by the COVID-19 Pandemic, Qété bouleversé par la pandémie de COVID-19, la profession the veterinary profession has seen immense change and growth. vétérinaire a connu de profonds changements et une croissance The Registered Veterinary Technicians and Technologists of immense. L’association Techniciens et technologues vétérinaires Canada (RVTTC) is pleased to announce that it has welcomed agréés du Canada (TTVAC) est heureuse d’annoncer qu’elle a the Association des techniciens en santé animale du Québec accueilli l’Association des techniciens en santé animale du Québec (ATSAQ) to the organization making it once again a truly (ATSAQ) au sein de son organisation, ce qui en fait encore une fois national body. un véritable groupe national. There is strength in numbers, and with pride the RVTTC L’union fait la force, et c’est avec fierté que l’association TTVAC represents approximately 10 000 RVTs across Canada on représente environ 10 000 professionnels de partout au Canada national and international issues; supporting member provincial et se prononce en leur nom sur des enjeux nationaux et inter veterinary technician and technologist associations in its mis- nationaux, et qu’elle soutient les associations provinciales membres sion to unite, advance and strengthen the registered veterinary conformément à sa mission d’unir, de faire progresser et de valo- technician/technologist profession. riser la profession de technicien/technologue vétérinaire agréé. As people across Canada got used to working from home, Tandis que les Canadiens s’adaptaient au télétravail, l’industrie the veterinary industry saw an influx of new pet owners and vétérinaire a dû composer avec un afflux de nouveaux clients ayant current pet owners adding to their furry families. The ongo- adopté un animal ou de clients existants ayant agrandi leur famille ing shortage of veterinarians and RVTs across the country à quatre pattes. La pénurie actuelle de médecins vétérinaires et became worse; many practices are feeling stressed, with burn de techniciens en santé animale s’est aggravée, le personnel de out and compassion fatigue on the rise. Mental health support nombreuses pratiques se sent stressé, et les cas d’épuisement and encouragement through these difficult times has been a professionnel et de fatigue compassionnelle sont à la hausse. Le priority for the RVTTC. One element of support includes the soutien en matière de santé mentale et l’encouragement en ces joint production of a video between RVTTC and Motivatum temps difficiles ont été une priorité pour TTVAC. Nous avons pro- Consulting to help educate clients regarding the behind-the- duit conjointement une vidéo avec Motivatum Consulting, intitulée scenes veterinary team process during COVID-19. With more « An Open Letter to Pet Owners », pour informer les clients sur ce

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N than 6500 views, An Open Letter to Pet Owners provides a vital que fait l’équipe vétérinaire en coulisses pendant la pandémie de share while acknowledging the extreme efforts of the veterinary COVID-19. Avec plus de 6500 vues, elle fait part de notre point community (https://youtu.be/KlXghiU7_II). This video is avail- de vue tout en reconnaissant les efforts extrêmes de la com- able to veterinary teams and their clients. munauté vétérinaire (https://youtu.be/KlXghiU7_II). Cette vidéo In May 2021, RVTTC announced receiving funding from (disponible en anglais seulement) est à la disposition des équipes Ontario Labour Market Partnerships for creation of a career vétérinaires et de leurs clients. pathway website to support and empower registered veterinary En mai 2021, l’association TTVAC a annoncé avoir reçu un technologists and technicians, and to position the profession as financement du programme Partenariats du marché du travail de a career with limitless opportunities. l’Ontario pour la création d’un site Web sur le cheminement de This national and bilingual Career Ladder website will help carrière afin de soutenir et de valoriser les technologues et tech- inform prospective and current RVTs of the varied options niciens vétérinaires agréés, et de positionner la profession comme within the profession. The website will also empower existing une carrière aux possibilités illimitées. RVTs by increasing their understanding of the breadth of options Ce site Web national et bilingue aidera à informer les RVT/TSA they have with their credentials. The RVT Career Ladder will potentiels et actuels des diverses options offertes au sein de highlight expanded career options with specific steps, informa- la profession. Il permettra aux RVT/TSA de mieux comprendre tion, and tools to advance in their chosen career pathway. The l’étendue des possibilités qui s’offrent à eux grâce à leur formation, full media release can be found here (https://rvttcanada.ca/ en mettant en évidence des options de carrière élargies avec les rvttc-announces-funding-for-the -creation-of-a-career-pathway- étapes requises, de l’information utile et des outils pour progresser website/) dans le cheminement de carrière choisi. Le communiqué de presse Stay tuned for more updates! complet (en anglais seulement) peut être consulté sur le site Web de TTVAC (https://rvttcanada.ca/rvttc-announces-funding-for -the- (by Cally Merritt RVT, CEMT, RVTTC Vice President) creation-of-a-career-pathway-website/). À la prochaine pour d’autres mises à jour! (par Cally Merritt, RVT, CEMT, vice-présidente de TTVAC)

824 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Review Article Compte rendu

All in the family: A comparative look at coronaviruses

John Ellis

Abstract — Coronaviruses, members of the order Nidovirales, the largest and most complex of the positive-stranded RNA viruses, have been recognized as important causes of disease in veterinary medicine for nearly a century. In contrast, in human medicine, especially until the recent SARS-CoV-2 pandemic, they were unimportant viruses associated with the common cold. This is a brief comparative review of the biology of coronaviral infections emphasizing the commonalities among the various members of the family and considering how the veterinary experience with coronaviruses can inform the response to SARS-CoV-2. Coronaviruses are perhaps best viewed as mutation machines whose genetic sequences can readily change through genetic drift, recombination, and deletions from a large genome. However, to be of clinical concern, variants must have the perfect set of amino acids in the S protein receptor binding domain and in their replication-mediating nonstructural proteins. Extensive experience with veterinary coronaviral vaccines suggests that optimal clinical immunity is a tandem of mucosal and systemic responses induced by a combination of mucosal and parenteral vaccines.

Résumé — Quelle famille : un regard comparatif sur les coronavirus. Les coronavirus, membres de l’ordre des Nidovirales, le plus grand et le plus complexe groupe de virus à ARN à brin positif, sont reconnus comme des causes importantes de maladie en médecine vétérinaire depuis près d’un siècle. Contrairement à la médecine humaine, en particulier jusqu’à la récente pandémie de SRAS-CoV-2, il s’agissait de virus sans importance associés au rhume. Nous décrivons ici un bref examen comparatif de la biologie des infections coronavirales mettant l’accent sur les points communs entre les différents membres de la famille et considérant comment l’expérience vétérinaire avec les coronavirus peut éclairer la réponse au SRAS-CoV-2. Les coronavirus sont peut-être mieux considérés comme des machines à mutation dont les séquences génétiques peuvent facilement changer par dérive génétique, recombinaison et suppression d’un grand génome. Cependant, pour être une préoccupation clinique, les variants doivent avoir l’ensemble parfait d’acides aminés dans le domaine de liaison au récepteur de la protéine S et dans leurs protéines non structurelles induisant la réplication. Une vaste expérience avec les vaccins coronaviraux vétérinaires suggère que l’immunité clinique optimale est un tandem de réponses mucosale et systémique induites par une combinaison de vaccins administrés par voies mucosale et parentérale. (Traduit par Dr Serge Messier) Can Vet J 2021;62:825–833

Introduction literally determined the course of history. The latest grim reaper is coronavirus disease-19 (COVID-19), caused by Severe Acute n the words of Siegfried Farnon, James Herriot’s eccentric, Respiratory Syndrome (SARS) coronavirus-2 (SARS-CoV-2). but wise, mentor and partner, “There’s nothing that brings I In human medicine, aside from the dramatic blips of mortal- people to their senses like a dead animal.” Bleak, perhaps, but one ity with SARS, and then Middle East Respiratory Syndrome of the truisms of life. Dead piles of both bipedal and quadripedal (MERS), in the last 2 decades, coronaviruses have generally animals, accumulated as a result of microbial incursions, have been relegated to the realm of sniffles; several of them being put the hominid capabilities for carnage to shame and have causally implicated in the common cold. In contrast, in veterinary medicine, members of this family of viruses have long Department of Veterinary Microbiology, Western College of been recognized as bona fide pathogens, including, for example, Veterinary Medicine, University of Saskatchewan, 52 Campus poultry infectious bronchitis virus (IBV) and mouse hepatitis Drive, Saskatoon, Saskatchewan S7N 5B4. virus (MHV), the 2 prototypical coronaviruses (1) that were Address all correspondence to Dr. John Ellis; e-mail: identified and studied in the 1930s and 1940s respectively, [email protected] before they were officially designated as coronaviruses. Use of this article is limited to a single copy for personal study. This is a current snapshot of the coronavirus family, the Anyone interested in obtaining reprints should contact the subject of a rapidly burgeoning literature. It focuses on familial CVMA office ([email protected]) for additional similarities and differences, the basis and likelihood for inter- copies or permission to use this material elsewhere. species infection, and the possibility of cross-reactive immune

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responses, as these relate to vaccine application in veterinary “backcrosses” (through recombination) of TGEV with CCoV and human medicine. type II circulate in dogs (14). More than 30 y ago, mutation, by way of a few deletions in TGEV, gave rise to porcine respiratory The coronaviral family tree: What are coronavirus (PRCoV), a less virulent variant than the “parent” the relationships? virus with a different tropism, respiratory versus enteric (15). Earlier on, when genomic sequencing was tedious if possible Porcine epidemic diarrhea virus (PEDV) (15), first identified in at all, viruses were grouped and named primarily on the basis the 1970s in Europe (16), is now an emergent concern in North of the way they looked under the electron microscope. The America. Looking at the “molecular clock” of sequence disparity coronavirus family got its name in the 1960s because members among PEDV isolates suggests that all derived from bats, the looked like a sun and its corona to some imaginative microbi- North American ones originating within the last decade from ologists (2). Since that time 2 major sequence-based taxonomic bats in southern China (17). The latest bat-derived entrant in COMPTERENDU reorganizations of the Coronaviridae have been done. The the alpha coronaviral enteric sweepstakes, swine acute diarrhea most recent re-organization was driven largely by the dramatic syndrome virus (SADS-CoV), is clinically and pathologically emergence of SARS-CoVs and subsequent investigation of indistinguishable from its cousins, TGEV and PEDV (17), and coronaviruses in bats. In fact, the emergence of SARS, and now, in a clade all its own (18). COVID-19, has led to a chiropteran revolution of sorts; before In the Betacoronavirus genus, long before COVID-19, even that the study of bat coronaviruses was largely an arcane aca- before coronaviruses were recognized as a separate family, some demic pursuit in search of funding. Now, some have even mused of the first viruses studied in the early 1960s were human that all coronaviruses derived from ancestors in bats, since that cold viruses (19). Many isolates only grew in organ cultures; host has the oldest and most genetically diverse representatives their study was supplemented with the experimental inocu- of the family (3). lation of human volunteers. One of those culture-adapted Currently, the coronaviral family tree comprises 4 main prototypical beta-coronaviruses is HCoV-OC43. In the early branches or genera: alpha, beta, gamma, and delta, with the 1970s, bovine coronavirus (BoCV) was discovered serendipi- alpha- and beta-groups containing the most mammalian patho- tously during a vaccine trial for prophylaxis against rotaviral gens (1) (Table 1). Splitting off from these are smaller branches diarrhea in calves (20). Molecular clock analyses indicate that or dendrites. A cluster of these dendrites originating from the HCoV-OC43 descended from BCoV, or a common ancestor same ancestral branch forms a “clade” (4), a group of related around the turn of the 20th century (21). Another likely spawn “subspecies” or genotypes. The lengths of the branches between of BCoV is the canine respiratory coronavirus (CRCoV), which individual variants or genotypes represent the genetic distances, was discovered in outbreaks of “kennel cough” in England in or degree of disparity, simply differences in sequence, or base the early 2000s (22,23), but apparently had been circulating in composition of the RNA. It is within these clades, among the Canada before that time (24). smaller branches where the most interesting and clinically rel- Preeminent in the genus Gammacoronavirus is IBV, first rec- evant evolution has occurred, a branching process that is ongo- ognized in the 1930s as a respiratory virus (25), and still a bane ing as the viruses continue to mutate and add to the family tree. in poultry production as a polytropic multisystemic pathogen; Within the Alphacoronavirus genus, canine coronaviruses not just another “cold virus” as its name implies (1,25). There (CCoV) and feline coronaviruses (FCoV) are endemic enteric was a war of words concerning the classification and naming agents, first recognized in the 1970s (5,6). Each of these of IBV-like viruses, since they infect gallinaceous birds other has been subdivided into 2 major genotypes, and 2 sero- than just chickens, notably turkeys and pheasants (26). Based types, I and II (7,8). There is some persistent confusion in the on cross-infectability amongst galliforms and ducks, IBV and nomenclature around FCoVs. It is acknowledged that feline IBV-like viruses are now named “Avian CoV” (26). infectious peritonitis viruses (FIPVs) are mutants of the feline The genus Deltacoronavirus is unique; its members infect enteric coronaviruses (FECoVs), the ones that are endemic avian and mammalian species (27). For example, porcine delta- and horizontally spread. These are 2 biotypes of FCoVs; the coronaviruses, cause of a recent diarrheic scourge of baby piglets latter virulent and the former mostly benign (9). Mustelids, in North America, probably originated in sparrows and leapt mink and ferrets, have their own enteric coronaviruses, causally into pigs, where it continues to mutate and defy vaccination. associated with diarrhea, that are closely related to FCoV (1). Type I CCoVs and FCoVs are thought to be the progeny of What are some clinical implications a common unidentified ancestor, and the type II viruses are of coronaviral virology? the products of multiple recombinational events involving By taxonomic definition, coronaviruses share common features unidentified viruses (10). The notorious FIPVs arise con- of bio-physicality and replication strategy with varying degrees tinuously in FECoV-infected cats by virtue of mutations in of conservation amongst the proteins encoded by their very the non-structural protein gene 3c (11) and the S gene (12). similar genomes (1). Details of coronaviral characteristics are In dogs and ferrets, less well-studied variants of their enteric reported in recent textbooks (1) and review articles (28); these CoVs are causally associated with multi-systemic diseases that are beyond the scope of this review. In brief, coronaviruses are have clinical and pathologic similarities to FIP (1,13). To make pleomorphic enveloped viruses, and the envelope renders the things even more incestuous, CCoV type II is the progenitor of viruses potentially labile to adversities outside the host, such as transmissible gastroenterovirus virus (TGEV) of swine (10), and detergents, desiccation, UV light, or anything else that disrupts

826 CVJ / VOL 62 / AUGUST 2021 FIPV — Feline infectious peritonitis virus FOR PERSONAL USE ONLY

Table 1. Coronaviruses of veterinary importance in Canada and coronaviral vaccines currently licensed in North America.a Virus Disease syndrome Vaccine Comments Alphacoronavirus Canine CoV (CCoV) Enteric Inactivated; SQ, IM Used infrequently

Feline CoV Enteric, multisystemic (FIPV) Modified-live; IN Used infrequently ARTICLE REVIEW Transmissible gastroenteritis virus (TGEV) Enteric Inactivated; IM, oral Use declining; decreased prevalence of virus Porcine respiratory CoV Respiratory None Deletion mutant TGEV; TGEV vaccines cross-protect? Porcine epidemic diarrhea virus Enteric Inactivated; IM Strain variation affects vaccine efficacy Betacoronavirus Bovine CoV Enteric, respiratory Modified-live; IN, oral Scant published data on efficacy Inactivated; SQ, IM Canine respiratory CoV Respiratory None CCoV vaccine unlikely to cross-protect Gammacoronavirus Infectious bronchitis virus Respiratory, multi-systemic Inactivated; SQ, IM Strain variation markedly affects Modified-live; aerosol, vaccine efficacy spray, IN, intraocular, oral Deltacoronavirus Porcine delta CoV Enteric None Strain variation likely to affect efficacy

a Adapted from reference (62). CoV — Coronavirus; SQ — Subcutaneous; IM — Intramuscular; FIPV — Feline infectious peritonitis virus; IN — Intranasal.

lipid membranes. This has important practical implications the larger part of the genome, which flanks and is interspersed for assessment of the role of fomites in transmission, as exem- between the open reading frames for the structural proteins. plified in the case of SARS-CoV-2. Testing methods applied This array of less glamorous genes encodes for a “toolkit” of up can dramatically impact the conclusions that can be drawn to 19 nonstructural proteins (NSP) that assist in, and control from the results. Unfortunately, much of current testing for replication (1,28). For a clinically relevant example, one of the SARS-CoV-2 and other coronaviruses is done, not with tedious tools in this kit is the essential RNA-directed RNA polymerase, cell culture, but with reverse-transcription polymerase chain which is being targeted with adenosine nucleoside analogues. reaction (RT-PCR), which is sensitive, but incapable of deter- Insertion of these analogues into the enzyme cripples it, prevent- mining whether the detected RNA is “dead,” or in a viable and ing viral replication (31). One of these drugs, Remdesivir (6) potentially transmissible virion. Indeed, early in 2021, the most is being applied therapeutically in SARS-CoV-2 infections in recent data indicate that the initial, PCR-driven concern over humans. It is only occasionally noted that the seminal work fomite transmission of SARS-CoV-2, complete with televised validating this approach was first conducted in feline infectious instructions for disinfection of plastic grocery bags, was exagger- peritonitis virus-infected cats (32). ated (29). It is now acknowledged that airborne transmission is the primary means of spread of this virus (30). Those data would How do coronaviruses change over be viewed as neither novel, nor unexpected by most veterinar- time and space? ians. A high incidence of respiratory coronaviral infections has Coronaviruses, like other single-stranded RNA viruses, exist as long been recognized in venues from hen houses to calf barns “quasi-species” (1). What this means is that a “species” of virus, to kennels (1); venues with high population densities and often SARS-CoV-2, for example, is really a population of related poor ventilation. These venues are predisposed to aerosolization viruses (1,33). What dictates this mode of existence is an error- of particulates, including viruses. The bottom line is that a posi- prone replication scheme. In coronaviruses, and other members tive PCR test should be taken as 1, sample-dependent, grain of of the order Nidovirales (nidus, Latin for nest) replication of the salt in the epidemiologic shaker. viral RNA is mediated by the virally encoded error-prone RNA The approximately 30 Kb genome is the largest of the polymerase, followed by the transcription of sub-genomic “nests” positive-stranded RNA viruses and encodes for 4 or 5 struc- of mRNAs which are then translated by the cell machinery tural proteins, including spike (S), envelope (E), membrane into cleavable polyproteins or individual proteins (1,28). It has (M), nucleocapsid (N) and, in some beta-coronaviruses, the been proposed (34) that there are 3 properties of this replica- hemagglutinin esterase (HE). These proteins, most notably tion strategy that contribute to the quasi-specific diversity of the S protein, which is the viral ligand for host receptors, and these viruses: the primary target for vaccine development (1), have been the i) Genetic drift. The toolkit of coronaviral NSPs contains traditional centers of attention. Increasingly, there is focus on a unique exoribonuclease RNA proofreading apparatus that

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provides a certain level of fidelity of RNA replication (35), of canine parvovirus, or yearly point mutational changes in or less genetic drift, at least in vitro. Other RNA viruses, such influenza viruses that require vaccine reformulation to achieve as influenza virus, do not have this. But this fidelity is com- better efficacy. The phenomenon of “minor” changes and their promised in vivo when it comes to demographic changes in phenotypic sequelae, well studied in “animal” coronaviruses such the quasi-species in the presence of host factors, notably the as IBV, MHV, and FCoV, is now the subject of news alerts in immune response. It is well-documented that the immunological SARS-CoV-2 reportage. “pressure” of antibodies drives the evolution of antibody escape mutants of IBV in poultry (36). This process favors S protein What are the determinants of the host variants that are more fit and can outcompete the neutralizing range of coronaviral infections? capabilities of a slower moving antibody response. The emergent Generically, productive virus infection of cells depends on concern over the effects of escape mutation on the efficacy of both extra- and intra-cellular processes, each of which may COMPTERENDU SARS-CoV-2 vaccines and therapy with monoclonal antibod- contribute to species specificity and target cell tropism. The ies (37) was predicted in the hen house. first step in all viral infections is the interaction between viral ii) Recombination. The dynamics of coronaviral RNA repli- capsid or envelope proteins and receptors on the host cell. cation concocts a cytoplasmic “soup” of different forms of RNA, Like all receptor-ligand interactions that orchestrate life, this is including full-length strands and variously sized bits, the sub- dependent on compositional and conformational arrangements genomic transcripts. In cells that are co-infected homologously of viral amino acids that favor electrostatic attractions to host with another coronavirus, or heterologously with another species cell membrane motifs, peptide or carbohydrate, that constitute of virus, this enhances the chances for recombination and the a bond (1,28,34). Many cellular receptors for viruses have been generation of new variants through genetic shift. Indeed, beyond recognized and molecularly characterized. Some are biochemical theory, recombination frequencies as high as 25% have been motifs with no apparent specific function, such as sialic acid, observed in MHV-infected cells (38). that may be widespread among host cells, or present on only a iii) “Space” for mutations. The relatively large genome of subset of cells. Others are cell membrane molecules that per- coronaviruses, compared to most other RNA viruses, means form a specific task and are subverted by a virus. Angiotensin that there is more room for mutational errors in progeny viral converting enzyme-2 (ACE-2), the already infamous receptor RNAs without the generation of deleterious or lethal changes. for the SARS-CoVs, and aminopeptidase-N, a cell surface Exemplary of this plasticity is a naturally occurring viable variant metalloprotease and the probable primary receptor for FIPV and of PRCoV that derived from an over 600 nucleotide deletion TGEV, are exemplary of these (1,28,34). The coronaviruses use mutation from the S gene of another PRCoV (39); this gene is both types of receptors, and there is no predictable pattern of usually made up of 4000 bases in toto! The bottom line is that receptor usage among or within the genera to aid in remember- coronaviruses are perhaps best viewed as mutation machines ing the details. The spike or “S” envelope glycoprotein is the with rheostats. They crank along slowly in controlled mono- major ligand on coronaviruses. It exists as a trimer, each with an cultures of cells in the laboratory but can speed up considerably S1 and an S2 subunit. The S1 subunit is involved in binding to to fill niches in the multifactorial environment in often dense the host cell; the S2 in fusion with the cell membrane. As with vertebrate host populations, becoming of Darwin in real time. all proteins, there are N-terminal and C-terminal regions or This concept, well-supported in the veterinary literature, is now ends, and to further complicate things, both can contain (dif- “breaking news” in COVID-19 coverage. ferent) receptor binding domains (RBD), providing for many possibilities in initial virus/host interactions. Seemingly minor Noise in the (mutation) machine: differences in the amino acid composition of the RBDs can When does a genetic variant become affect binding affinity to the S protein, manifesting in differ- a (new) strain? ences in host species proclivity, or intra-species transmissibility, The word “strain” inevitably appears in any discussion of viruses the current concern in SARS-CoV-2 infections (1,28,34,37). and other pathogens. It is especially tossed about in the RNA It is generally thought that interactions between the S pro- virus space where it adds confusion to the biology of corona- tein and cellular receptors play the major role in determining virus infections. Unfortunately, strain means different things the host specificity of coronaviruses (34). However, inside the to different people (33). For many molecular virologists and cell, NSP-mediated modulation of viral replication also plays Internet sources, it means “a stable genetic variant,” with no a determinative, but less well-understood role. One of the best mention of phenotype. Such molecular entities are common in studied of these processes is the interplay between the virus quasi-species populations, and now, relatively easily and cheaply and the innate immune system, primarily involving the type-1 detected with high-throughput sequencing (33). A better clini- interferons (IFN) (40). Like all viruses, the coronaviruses have cal definition is a stable genetic variant with some measurable biochemical motifs that they do not share with their vertebrate phenotypic difference, for example, a difference in transmissibil- hosts. These are called pathogen-associated molecular patterns ity, a recent concern with SARS-CoV-2 (33). Importantly, the (PAMPs), or “danger signals,” because the cell recognizes them change in behavior is not necessarily directly related to number as trouble. Double-stranded RNA, formed during replication of nucleotides (bases), or even amino acids, that are different of corona- and other RNA viruses, is prototypical of these. The between 2 variants (33). Few changes can result in big differ- danger signals are ligands for another series of receptors, the ences in behavior, as famously recognized in the emergence pattern recognition receptors (PRRs), including TLRs, RIG-1,

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and MDA5. Engagement of the PAMPs with the PRRs in virtu- Altogether, the ongoing examination of a wide variety of ally any infected nucleated cell, initiates various kinase-driven animals for evidence of SARS-CoV-2 infection or infectability phosphorylation pathways with the final common pathway illustrates constraints on viral fitness in real time. Just because a being production of type-1 interferons. Interferons upregulate coronavirus, or any virus, for that matter, is capable of “infect- hundreds of genes involved in the control of cellular metabo- ing” a species is not necessarily indicative of a clinical concern; REVIEW ARTICLE REVIEW lism, many of which affect viral replication, often inhibitively. it is more biologically complicated than that. The bottom line But, not to be outdone, many viruses including the coronavi- is that, as far as variants within a coronaviral quasi-species go, ruses have evolved mechanisms to inhibit the innate immune only those with just the right set of amino acids in the S protein response comprising 3 general modi operandi: inhibition of IFN RBD and in their replication-mediating NSPs are going to be induction, inhibition of IFN signaling, and sequestration of fit enough to replicate enough in a new host and, may, in the PAMPs (40). These involve 1, or often, more of the “tools” in context of enabling host genetic and environmental cofactors, the coronaviral NSP tool kit. be a cause for clinical concern. Host-species “jumping:” Is this a cause What are the correlates of protective for clinical concern? immunity in coronaviral infections? Long before the emergence of SARS-CoV-2, cross-infection Before the COVID-19 era, family doctors probably considered of beta-coronaviruses was studied within the BCoV cluster of corona-viral infections (a cold) mostly an annoyance unworthy viruses. At least experimentally, BCoV can infect dogs (41) and of a clinical consult; the immunology of human coronaviral a human enteric coronavirus can infect calves (42). However, infections was little studied. Not so in veterinary medicine, in there is no indication that those variants routinely wander which coronaviral immunity has been extensively examined for into, and effectively transmit in the aberrant hosts. Similarly, decades. experimentally, MHV can infect rats, and rat coronaviruses At least for the epitheliotropic coronaviruses, such as TGEV, can infect mice, but natural cross-infection does not appear BCoV, CCoV, that cause diarrhea and/or respiratory disease, to happen even when these rodent hosts are housed in the disease-sparing immune responses fit an overall pattern common same facilities (1). Whether or not the alphacoronaviruses, to most viral infections: neutralizing antibodies reduce the pos- CCoVs and FECoVs, cross-infect to any large extent among sibility of infection, whereas cell-mediated responses enhance carnivore hosts is unclear (43). However, in 1 dramatic epi- the chances for recovery (1). In mammals, before SARS-CoV-2, sode in the mid-1980s a newly released CCoV vaccine appar- coronaviral immunity was most studied in pigs (1,49). Innate ently actually contained FCoV. Its use was associated with immune responses involving primarily interferons I and III the death of hundreds of dogs with neurologic and pancreatic are implicated as rapid “first responders” in enteric porcine lesions (44). coronaviral infections. Predictably, the primary targets of neu- Early in the SARS-CoV-2 pandemic, questions arose about tralizing lactogenic immunity, first IgG in colostrum, then IgA the susceptibility of domestic animals, notably household pets, in milk, and later systemic antibody responses are epitopes to the virus (45). Initial studies of the ACE-2 receptor indicated on the S protein, primarily in the receptor binding domain variable sequence identity with the human version among vari- (RBD). The S protein is also the target of cytotoxic T-cells, ous potential host species. Co-incident epidemiologic studies both intraepithelial and systemic CD81 T-cells. In addition, documented rare, isolated PCR-positivity and rarer disease in epitopes on the nuclear protein are also targets for cell-mediated cats and dogs, notwithstanding a highly publicized outbreak immune responses. A similar constellation of viral epitope tar- in captive tigers; the conclusion being that cases in animals gets and active and passive responses can modulate disease in were anthropogenic (45). There have been a few prospective less-extensively studied, bovine and canine corona-viral infec- experimental SARS-CoV-2 infections in cats and dogs, with tions (1). the consensus being that cats can develop productive infections of , 14-day duration, transmissible among cats, with minimal, Are immune responses against if any, clinical signs, minimal virus-containing lesions in the coronaviruses cross-protective? upper respiratory tract, and seroconversion. Dogs appear to have The common occurrence of coronaviral infections raises the non-productive, abortive infections without signs or lesions, but question: is there cross-protective immunity among related with seroconversion (46,47). Ferrets are similar to cats in their coronaviruses? The simple answer, based mainly on the outcome overall response to experimental SARS-CoV-2 infection and of primary infections in the laboratory and the field and the are a model in vaccine development (46). First in Europe and examination of neutralizing antibodies targeting the S protein, then in Canada, SARS-CoV-2 infections resulting in moderate is no. This specificity of protective antibody responses was to severe disease were reported in farmed mink. Whole genomic documented, large-scale, in pig barns following the emergence sequencing indicated anthropogenic transmission, followed of PEDV in North America in the 2010s. Neutralizing antibod- by mutation, and then zoonotic re-transmission (48). It is ies against TGEV, its alpha-corona-viral cousin, conferred no unresolved whether wild mink, not subjected to the inbreed- disease-sparing effect on PEDV (49). Long ago, on the coming, stress, and population densities of farms, would react to panion animal side, attempts to immunize cats against FIPV SARS-CoV-2 in the same way. Livestock and mice seem not to with its alpha-coronaviral sibling CCoV ended in failure (43), support infection at all (46). as did attempts to immunize with another relative, TGEV (50).

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Even considering responses to infections with different strains disease. Then, it was shown that antibodies against the S proof the same coronavirus, work conducted more than 30 y ago tein, even neutralizing ones, enhanced the infection of feline with MHV infections in mice, the natural host of the virus, macrophages in vitro (52). Tropism for subsets of monocyte/ demonstrated protective immunity, that, unfortunately, was macrophage lineage cells is now viewed as the primary pheno- “strain-specific” presumably related to disparity in the S (then typic marker of strain virulence among FCoVs, even though called E2) proteins among strains (51) typical of genetic drift the genetic basis of this remains elusive. In other words, strains in a quasi-species. A similar strain-dependent phenomenon is of FCoVs, mutants of FECoVs onboard in the intestines, that operant in FCoV infections in cats (52) and IBV infections in are likely to cause FIP, are macrophage-tropic. Their entry into chickens (36,53). In contrast, there is some evidence of cross those cells is enhanced via antibody and/or complement binding “strain” protection among rat coronaviruses, although, there, to the Fc receptors on those cells. From a pathophysiological the viral genetics are less well-characterized (54). standpoint this property is important in at least 2 ways. First, COMPTERENDU One by-product of the urgency to control COVID-19 is a the FIPV-infected macrophages are “Trojan horses” that ferry more nuanced answer to the question of cross-protective immu- the viruses from the gut to other organs. Second, macrophages nity. Trying to explain the heterogeneity of clinical outcomes normally play a central role in cytokine-mediated inflamma- to SARS-CoV-2 infections, several studies in human population. Feline infectious peritonitis viruses (FIPVs) hijack this tions documented that 20 to 50% of unexposed individuals function and put it into overdrive, the result being a version of have circulating CD41 (and to a lesser extent CD81 T-cell) a cytokine storm. Similarly, MHV (58) and IBV (53) are long responses to SARS-CoV-2 (55). Furthermore, these responses recognized as being polytropic and immunomodulatory and are equally cross-reactive with responses to several coronaviral can cause multisystemic disease. SARS-CoV-2 is not novel in common cold viruses, in both alpha and beta genera (55). this regard. However, the role of ADE is less well-established In other words, there are memory responses from previous in MHV and IBV-mediated diseases compared to its central exposure to common cold viruses. These observations have role in FIP; perhaps because FIPVs are primarily macrophage- several clinically relevant implications that are being further tropic, whereas the others, including SARS-CoV-2, are not. investigated (55). Cross-reactive T-cell memory responses could Alternatively, the explosion of SARS-CoV-2-related research is explain enhanced clinical immunity and amelioration of disease reiterating the probable role of a dysregulated innate immune in some SARS-CoV-2-infected individuals, and relatedly, a response, a big part of the cytokine storm, in pathogene- potential for anamnestic responses to SARS-CoV-2 vaccines sis (55). This NSP-mediated dysregulation is likely operant in in human populations. Conversely, this immunological déjà all polytropic coronaviral infections — a double-edged sword, vu could effectuate immune-mediated enhancement of disease indeed. following SARS-CoV-2 infection in some individuals, although this possibility is currently considered less likely (55). Great expectations: What is the best approach to coronaviral A double-edged sword: How does immunoprophylaxis? the immune response enhance In veterinary medicine, control of coronaviral diseases through coronaviral disease? vaccination spans more than 75 y. In the 1950s, one of the first For coronaviruses that have a cellular tropism beyond just attempts used dead piglets (“feedback”) for successful prophy- epithelial cells and a tendency to produce multi-systemic dis- laxis against TGEV (59). This technique has been more recently ease, such as FIPV, MHV and IBV, and, now, SARS-CoV-2, applied to PEDV (49). It is fitting, then, that from the mamma- immune responses are more of a double-edged sword. An lian perspective, most success and mechanistic understanding of “elephant-in-the-room” in the now ubiquitous discussions con- vaccine-induced immunity to coronaviral infections derives from cerning COVID-19 is the ominous possibility that the immune experiences in swine. Virtually all of this is related to successful response to SARS-CoV-2 is the purveyor of pathology rather reduction of enteric diseases, most notably due to TGEV, with than protection. This concept that immune-mediated disease is a spectrum of platforms from conventional to “high tech” (49). a feature of coronaviral infections is not new to veterinarians, Certainly, working with large numbers in confined populations, especially the cat-healing ones. The role of immunopathology, with usually defined genetics, and operating on the cusp of notably antibody-dependent enhancement (ADE), in FIP is tight financial margins over a short feeding/finishing period, well-documented, even if still somewhat enigmatic, and, maybe, has fostered this effort. Similar conditions have applied in the more pronounced in experimentally induced versus naturally assessment of IBV vaccines in poultry, albeit with the observa- occurring disease (56). In the early days of FIPV research tion of less efficacy due to the strain variation of the virus (53). in the late 1970s, it was observed that cats with preexisting In cattle, commercial, combination modified-live oral or FCoV-specific antibodies not only did not have disease-sparing intranasal (IN) vaccines, and inactivated parenteral BCoV effects after experimental challenge, but experienced more severe vaccines have been available for decades and used to control disease (57). Initially, from a mechanistic standpoint, antigen- neonatal diarrhea and enhance colostral antibody produc- antibody complexes and a resultant classic Arthus reaction or tion, respectively (1). However, there are few published data type III hypersensitivity reaction were considered the main substantiating their efficacy, especially with regard to current culprit (52). The resulting vaso-centric inflammatory response circulating strains. One study provides circumstantial evidence certainly explained the ascites typical of the “wet form” of the that application of IN vaccines can reduce respiratory disease in

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feedlot calves, even though BCoV vaccines do not have a label to mucosally delivered porcine, bovine, and feline coronaviral claim for that use (1). The correlates of immunity to respira- vaccines (1,62). However, arguably, it is never-televised IBV tory coronaviral infections in cattle, pigs, and dogs remain to be immunoprophylaxis that began in the 1940s with “planned fully characterized. To date, IBV vaccines stand alone in having exposure” (63) that is most data-rich and instructive in the a legal claim for vaccination against respiratory disease (1,53). nascent SARS-CoV-2 vaccine rollout (53). Notwithstanding REVIEW ARTICLE REVIEW Mucosal (IN) vaccination has also been used as a means strain-dependent immunity and application of numerous vaccine of stimulating IgA and of side-stepping immune-mediated technologies, it is a relatively low-tech protocol, heterologous enhancement of disease that can result from parenteral vac- prime-boosting, first with aerosolized modified-live followed cination and resultant systemic (IgG) responses. In the 1990s by injectable inactivated whole-virus vaccines that remains the a modified-live FCoV IN vaccine demonstrated reasonable best approach to the control of IBV infections and is therefore efficacy in a robust FIP challenge model without inducing ADE the industry standard (53). The bottom line is that extensive that had previously been observed after parenteral administra- experience with veterinary coronaviral vaccines (1,62) suggests tion (60). However, its efficacy and utility were controver- that optimal clinical immunity is a tandem of mucosal and sial (52) and, even though it is still commercially licensed in systemic responses induced by the combination mucosal and some countries, it is little used. Nevertheless, this experience parenteral vaccines. with IN vaccination in cats is relevant, should disease enhance- Although talk of the relationships among the coronavirus ment result from injectable SARS-CoV-2 vaccines. family usually summons fears of zoonotic infections, the other The development of vaccines for SARS-CoV-2 using a range side of the coin is the potential for cross-protective immunity. of formats from conventional whole-virus formulations to novel Especially in view of the recent documentation of cross-reactive mRNA constructs has proceeded at record speed. Reviews of this T-cell responses (55), the close relationship among the human effort are already available (61). Implicit in the application of cold viruses, HCoV-OC43 and HCoV-HKU1, and BCoV and SARS-CoV-2 vaccines is the assumption that induced immune CRCoV, all Betacoronaviruses, or the relatedness among other responses will be protective. Indeed, that hope evokes the suc- cold viruses HCoV-NL63 and HCoV-229E, and FECoV, PEDV, cess of veterinary coronaviral vaccines, mostly those targeting TGEV, and CCoV, all Alphacoronaviruses, raises the possibility the epithelial-tropic viruses (62). However, in contrast to many that repetitive (natural) exposure to corona-viral-infected live- veterinary coronaviral vaccines (62), the leading candidates stock or companion animals could also engender cross-reactive for SARS-CoV-2 immunogens are mRNA, viral-vectored, memory T-cell responses that could affect human owners’ and subunit constructs that reductively target the S protein, responses to SARS-CoV-2 infection or vaccination. Preferential or regions thereof. A major advantage of the mRNA, viral- stimulation of cell-mediated versus antibody responses takes on vectored, or even lower tech modified-live vaccines, versus S additional gravitas should ADE be a limiting factor in more subunit or, simpler whole-virus inactivated vaccines is a function conventional approaches to vaccination with, for example, of antigen presentation (61). The former approaches present S protein (inactivated) subunit vaccines (55,61). Although the antigen via both endogenous and exogenous pathways and can “free vaccination” of natural exposure is difficult to model in the more broadly stimulate CMI and antibody, whereas the latter laboratory, the Jennerian approach, effectively using a related stimulate little if any cytotoxic T-cell responses. However, it is pathogen as the (free) vaccine against another, could be discern- currently unresolved whether the reductionist approach of tar- able in populations if someone bothers to look. This would be geting 1 region of 1 protein will stimulate “mutation-proof” and a new and profound take on the human-animal bond and is durable responses. There are already televised data suggesting worthy of investigation. the contrary, but little acknowledgment or apparent awareness that this is really another déjà vu for veterinarians; it has all been Like déjà vu all over again? experienced before in the long history of IBV vaccines (53). In conclusion, the coronaviruses comprise a family of related Regrettably, the reductionist approach to vaccination and agents with similarities and differences; the expression of a (monoclonal antibody) therapy (61) with very limited epitopic defining genomic blueprint. There is a pattern of diseases among targeting may be a main driver of SARS-CoV-2 evolution going infected hosts. Generally, they have been associated with enteric forward. There is already some preliminary evidence for this and respiratory diseases. But, there can be systemic manifesta- epiphenomenon. tions of coronaviral infections that are mostly associated with Beyond disease-sparing clinical protection, there is much an overwrought immune response. SARS-CoV-2 has really discussion in the SARS-CoV-2 vaccine space about the pot- awakened the world to coronaviruses, agents that veterinarians of-gold possibility of vaccine-conferred sterilizing immunity, have been dealing with clinically for nearly a century. Minimally, i.e., prevention of infection. Again, the veterinary experience some comparative knowledge of the coronaviral family, and with coronaviral vaccines indicates that the likelihood of achiev- infections in animals can prevent reinvention of the wheel when ing this with injectable vaccines alone is low, as some level of it comes to control and prophylaxis of SARS-CoV-2. mucosal immunity in the form of immune-exclusionary IgA, is required to at least partially effectuate sterility. Relatedly, Acknowledgments the current news that re-infection with SARS-CoV-2 is pos- The author thanks Drs. G. Allan, S. Krakowka, S. Mahan, sible should not be newsworthy; immune exclusion is transient M. Thompson, and J. Wu for critical review of the manuscript. and less than complete. There are data examining responses CVJ

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Cryotherapy provides transient analgesia in an induced lameness model in horses

Vivian Quam, Jonathan Yardley, Mikkel Quam, Cahuê Paz, James Belknap

Abstract — The analgesic effect of cryotherapy in an induced lameness model was evaluated. Lameness was induced with solar pressure from a custom-made shoe in a 10-horse, cross-over study. The degree of lameness was recorded with a commercial non-invasive inertial sensor. The distal limbs were maintained in an ice and water slurry (cryotherapy) or at ambient temperature (control) for 1 hour. Lameness was assessed serially over the following hour. Lameness at each time point was compared to the baseline induced lameness, within and between groups. Lameness had improved significantly in all horses 5 minutes after treatment but remained improved 10 minutes after treatment for the cryotherapy group only. Fifteen minutes after treatment, lameness in the cryotherapy group was improved relative to the control. Cryotherapy produced moderate, transient analgesia. Additional research is required to determine if altering the method, duration, or temperature of cryotherapy, as well as the targeted pathology and anatomy, alters the analgesic effect.

Résumé — La cryothérapie fournit une analgésie transitoire dans un modèle de boiterie induite chez le cheval. L’effet analgésique de la cryothérapie dans un modèle de boiterie induite a été évalué. La boiterie a été induite par une pression sur la sole à l’aide d’un fer sur mesure dans une étude croisée de 10 chevaux. Le degré de boiterie a été enregistré avec un capteur inertiel non invasif du commerce. Les membres distaux ont été maintenus dans une bouillie de glace et d’eau (cryothérapie) ou à température ambiante (témoin) pendant 1 heure. La boiterie a été évaluée en série au cours de l’heure suivante. La boiterie à chaque moment a été comparée à la boiterie induite au départ, au sein et entre les groupes. La boiterie s’était améliorée de manière significative chez tous les chevaux 5 minutes après le traitement mais restait améliorée 10 minutes après le traitement pour le groupe cryothérapie uniquement. Quinze minutes après le traitement, la boiterie dans le groupe cryothérapie était améliorée par rapport au témoin. La cryothérapie a produit une analgésie modérée et transitoire. Des recherches supplémentaires sont nécessaires pour déterminer si la modification de la méthode, de la durée ou de la température de la cryothérapie, ainsi que la pathologie et l’anatomie ciblées, modifient l’effet analgésique. (Traduit par Dr Serge Messier) Can Vet J 2021;62:834–838

Introduction such as injured ligaments or tendons or degenerative joint dis- quine musculoskeletal lameness produces substantial ease (2,3). Lameness also has safety implications as it increases E economic losses for owners and is a welfare concern for the chance of horses stumbling (2,4). Options for managing the equine athlete (1). Severe musculoskeletal injuries halt the low-grade pain are limited in events sanctioned by organizations athletic career of some horses, whereas others compete with including the Fédération Equestre Internationale (FEI) and The low-grade pain and reduced performance caused by conditions United States Jockey Club (5,6), based on pharmacokinetic

Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, 601 Vernon L. Tharp Street, Columbus, Ohio 43210, USA (V Quam, Yardley, Belknap); Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, Umeå 901 87, Sweden (M Quam); Department of Veterinary Clinics and Surgery, College of Veterinary, Universidade Federal de Minas Gerais (UFMG), 6627 Av. Antônio Carlos, Belo Horizonte, Minas Gerais 31270-901 Brazil (Paz). Address all correspondence to Dr. Vivian Quam; e-mail address: [email protected] Funding was provided to The Ohio State University Equine Research Fund by the Ohio State Racing Commission. Soft-Ride, Inc. provided the 2 ice boot prototypes used in the study. Neither the funders nor Soft-Ride, Inc. played any role in the study design, the collection, analysis, or interpretation of data, or the decision to submit the article for publication(s). None of the authors has any financial or personal relationship that could inappropriately influence or bias the contents of the paper. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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properties of non-steroidal anti-inflammatory drugs (NSAIDs) and their influence on soundness and performance (7,8). Ligament and tendon injuries are most common in the palmar metacarpus and digit, anatomical regions amenable to cryotherapy (3,9). Cryotherapy is used as an analgesic in humans and often as an alternative therapy for elite athletes that face

drug screening (10–13). Owners and trainers seek permissible ARTICLE therapeutics, including cryotherapy, to improve performance in the equine athlete. Understanding effects of cryotherapy on lameness and performance is essential for determining guidelines for its use in competition. Studies on cryotherapy in horses are largely limited to the treatment of laminitis, for which anti-inflammatory effects are reported (14). Cryotherapy prevents tissue injury when digital hypothermia is initiated early in the disease process, decreasing inflammatory mediators and the progression of digital lamellar tissue injury (15). However, effects of cryotherapy on digital pain were not reported in those studies. Cryotherapy was effective at cooling the deep structures in the distal limb and was safe up to 48 h (9,16). The commercial marketplace offers several equine cryotherapy products, including those marketed for sport horse management and those used in laminitis cases (17). The Figure 1. Custom shoe with screw placed for lameness goal of this study was to assess analgesic effects of cryotherapy induction. in a framework that could be applied in the future to the sport horse in competition or the hospitalized patient. To avoid confounding from an anti-inflammatory effect, a method of Each horse was assigned to a treatment group, cryotherapy or lameness induction with minimal inflammatory stimulus was control, during the first experiment period by a random number selected. We hypothesized that horses are less lame 1 h after generator. All horses had a 2-week washout period before the cryotherapy compared to horses in the control group, demon- second experiment period, when horses crossed over to the other strating an analgesic effect of cryotherapy. treatment group. Each horse, therefore, acted as both control and cryotherapy subjects. Materials and methods Subjects Baseline assessment and lameness induction All procedures were approved by the university’s Institutional Horses were trotted in the same straight line on the same grass Animal Care and Use committee. Ten mature horses from the surface for all lameness assessments. A grass surface was selected university research herd were selected for inclusion, based on to prevent excessive solar pressure and pain from the screw. normal physical examination and minimal observed lameness A baseline assessment was performed with the CNIS before at the time of initial examination, defined as lameness grade lameness induction. For all assessments, horses were trotted a , 3/5 on the American Association of Equine Practitioners’ distance to achieve a minimum of 25 strides for interpretation (AAEP) scale (18). The horses were aged 10 to 22 y and as stipulated by the CNIS manufacturer. Despite having selected weighed 468 to 615 kg. Breeds represented were Standardbred horses with lameness grade , 3/5 on the AAEP scale, in some (n = 3), Thoroughbred (n = 3), Warmblood (n = 2), Quarter cases a mild lameness was identified by the CNIS (Table 1). Horse (n = 1), and Arabian (n = 1). Horses were housed in When lameness was identified, the screw was applied to the stalls for the duration of the study and offered free choice grass contralateral limb to minimize confounding (19). The screw hay and water. Ten subjects were selected for the study, based was placed in the medial or lateral branch of the shoe on the on a review of the existing literature, in which similar studies treatment forelimb. Selection of the medial or lateral branch evaluated analgesia in a lameness model employing the same was based on which provided the best contact between the screw commercial non-invasive inertial sensor (CNIS) (Lameness and the sole. The screw was tightened or loosened as needed to Locator; Equinosis, Columbia, Missouri, USA) (19,20). A obtain a consistent grade 3/5 lameness on the AAEP scale, a pre- certified journeyman farrier applied steel keg shoes to both viously described criterion for adequate experimental lameness forefeet with modifications designed to create solar pressure, induction in context of using the same CNIS (18–20). After a proven model for experimental lameness induction (21). In recording the degree of lameness via CNIS, horses began the all shoes, the medial and lateral shoe branches had pre-drilled, treatment hour in cryotherapy or control conditions. threaded holes for lameness induction via screw application (Figure 1). Shoes were set 1 wk before the first treatment and Treatment and subsequent lameness assessment left on for the duration of the study. Due to loosening of the After induction of lameness, those in the cryotherapy group shoe, 2 horses required resetting of 1 shoe each during the study. stood for 1 h with the treatment forelimb in a gel orthotic

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Table 1. Vector sum (VS) for all horses and separately for 6 g (1 g = 9.8 m/s2) accelerometer sensors on the poll and the cryotherapy and control groups before and after lameness induction (range and median).a dorsum on the pelvis. Data were collected and measured by the CNIS, as described (24). The vector sum (VS) is a general mea- Cryotherapy Control All surement of the asymmetry of head movement defined by the (median) (median) (median) CNIS manufacturer (25). As outputs from the CNIS, the mean Before lameness 3.24 to 19.86 4.57 to 23.02 3.24 to 23.02 difference in maximum head height (in mm) after the stance induction (9.35) (11.94) (9.84) phases of the right and left forelimb (HDMax) and the mean After lameness 23.33 to 75.78 16.57 to 97.05 16.57 to 97.05 difference in minimum head height (in mm) during the stance induction (38.65)b (39.59)b (39.44)b phases of the right and left forelimb (HDMin) were obtained a

ARTICLE The VS was based on lameness determination using a non-invasive inertial sensor. b Indicates vector sum (VS) was higher (P # 0.05) for all horses and within both and used to calculate the VS, where: groups following lameness induction, as determined by the Wilcoxon signed-rank  2 2 test. There was no significant difference between cryotherapy and control groups’ VS = ((HDMax) + (HDMin) ) (25). VS before or after lameness induction. The VS was compared between treatment groups to ensure degree of lameness did not differ between the treatment groups cryotherapy boot (Soft-Ride, Bacliff, Texas, USA). A slurry before or after lameness induction. The change in degree of composed of ice and water was maintained to the level of the lameness at each point following treatment (5, 10, 15, 20, proximal metacarpus. Immersion of the complete distal limb 30, 45, and 60 min post-treatment) was calculated based on in an ice water slurry was selected for this study as it has been relative improvement in the induced asymmetry measured by reported to achieve a hoof wall surface temperature of , 10°C the inertial sensor. For example, at 5 min post-treatment, the in less than 1 h (17). The treatment forelimb for those in the lameness improvement score would equal: control group was maintained in a standard gel orthotic boot 1 2 [(VS at 5 min post-treatment)/(VS at baseline screw (Soft-Ride) at ambient temperature. In both cases, the non- placement)]. treatment forelimb was kept in a standard gel orthotic boot. Horses were kept in stocks with free choice access to hay and The lameness improvement score was used to compare lame- water. The temperature of the ice and water slurry was moni- ness within and between treatment groups at each time point, tored for those in a gel orthotic cryotherapy boot, and heart where higher scores indicated greater reduction in asymmetry rate was monitored in all horses every 10 min. Ice was added corresponding with lessened lameness. This method accounted to maintain the ice and water slurry temperature below 6°C, for variation in individual lameness (19). Wilcoxon signed-rank a temperature that is achievable with commercial boots with tests were performed for all analyses using commercial software circulating cooled water and has been shown to achieve deep (Stata 14; StataCorp, College Station, Texas, USA) as the data structure temperatures of 10°C in the equine distal limb (9). were non-parametric per the Shapiro-Wilk test. One-tailed The degree of lameness was assessed with the CNIS at pre- assumptions were based on the hypothesis that the lameness determined intervals: 5, 10, 15, 20, 30, 45, and 60 min post- is reduced by the treatment of interest. Statistical significance treatment. Following the 60-minute post-treatment assessment, was set at P # 0.05. the screw was removed. Starting with the 4th horse, lameness was also assessed following removal of the screw (n = 17/20). Results The additional assessment was added to ensure that the method Baseline assessment and lameness induction of lameness induction was not causing excessive solar pressure The baseline lameness, measured by the VS before application and that pain would not persist following removal of the screw. of the screw, did not differ significantly between the cryotherapy Heart rate, although an indicator of pain, was not included and control groups (Table 1). After lameness was induced with during the lameness evaluation, due to the confounding effect screw placement, horses were assessed to confirm appropriate of exercise. degree of lameness (grade 3/5 AAEP scale) for evaluation (18). Horses were sedated intravenously with acepromazine For all horses, the median VS was significantly increased relative (VetOne, MWI Animal Health, Boise, Idaho, USA) twice to to the baseline before lameness induction (Table 1). Again, the facilitate the lameness examinations and the time in stocks. The degree of lameness induced did not differ between treatment first dose, 0.045 mg/kg body weight (BW), was given before the groups (Table 1). first baseline jog, and the second dose, 0.025 mg/kg BW was The efficacy of this method of lameness induction was fur- given halfway, 30 min, through the treatment hour in stocks. ther substantiated by the lameness improvement score obtained Use of acepromazine was based on previous research indicating immediately after removal of the screw. To measure the change minimal effect on detection of lameness and in 1 case, improve- in lameness following screw removal from the shoe, the VS from ment in consistent lameness detection using the same CNIS the post-screw removal assessment was compared to the VS at device used in the current study (22,23). the 60-minute post-treatment assessment. The median [interquartile range (IQR)] VS values were 11.51 (8.21 to 19.03) Analysis and 35.28 (21.12 to 54.97), respectively (n = 17). Thus, there Objective lameness assessment with the CNIS relies on was an improvement (P # 0.01) in lameness following screw 3 body-mounted sensors: a gyroscopic sensor on the dor- removal from the shoe, supporting the technique for transient sum of the right forelimb pastern, and 2 uni-axial (vertical) lameness induction.

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Time post-treatment (minutes) Table 2. The median lameness improvement score for cryotherapy 1 and control groups. 5 10 15 20 30 45 60 0.75 Lameness improvement score Time (min) Cryotherapy Control 0.5 5 0.67a 0.44a b 0.25 10 0.46 0.27 c 15 0.49 0.35 ARTICLE 0 20 0.45 0.36 30 0.37 0.07 2 20.25 45 0.19 0.04 60 0.23 0.17 Lameness improvement score Lameness improvement 20.5 Time is in minutes post-treatment hour. a and b indicate improvement in lameness score (P # 0.05 and P # 0.01, respectively) at the given time point relative to the 20.75 baseline induced lameness as determined by the Wilcoxon signed-rank test within treatment groups. c indicates greater lameness improvement score (P # 0.05) in the Figure 2. Cryotherapy (black line) and control (gray line) median cryotherapy group relative to the control group at the given time point, as lameness improvement score with interquartile ranges (IQR) at determined by the Wilcoxon signed-rank test. each time point post-treatment. Black circles = cryotherapy IQR. White circles = control IQR. limb, as was used in the current study, was effective at maintaining hoof wall surface temperature below 10°C, the current therapeutic target protecting the submural lamellar tissue in Treatment and subsequent lameness laminitis (17). However, perhaps the duration of cryotherapy assessment used in the current study was too short to obtain maximal effects Both groups, cryotherapy and control, were maintained without of hypothermia on the submural soft tissues. Previous studies difficulty in stocks for the duration of the treatment hour. The have demonstrated that wet ice boot application has resulted in target temperature of 6°C was maintained easily with the appli- hoof wall surface temperature decreasing to equal the water ice cation of ice to the gel orthotic cryotherapy boot. No changes temperature (17). However, hoof wall temperature only reaches in heart rate, an indication of pain, were observed during the steady state temperature after 2 h (14). Since horses in this treatment hour for either group. study only received cryotherapy for 1 h, and hoof wall surface The median lameness improvement score at 5, 10, 15, 20, temperature was not directly measured, the deeper structures 30, 45, and 60 min following treatment for each group is pre- of the foot may not have reached the steady state temperature. sented in Figure 2, with interquartile ranges. Both treatment A longer duration of hypothermia may be more efficacious in groups experienced a reduction in lameness following the treat- reducing lameness due to solar pressure. In addition, the requi- ment hour. However, the cryotherapy group had a significant site method and duration of cryotherapy for analgesic purposes lameness improvement score 5 and 10 min after the treatment will likely vary with the target tissues within the distal limb. In period, indicating that the degree of lameness assessed at these 1 study evaluating the effect of cryotherapy on soft tissues of time points was significantly less than the degree of lameness the distal limb, 1 h of cold therapy was effective in lowering the initially following screw placement. The ambient group only temperature of the superficial digital flexor tendon to 10°C (9). had a significant lameness improvement score 5 min after the There was a brief significant but waning lameness improve- treatment period (Table 2). No significant lameness improvement for all horses, cryotherapy and control treatment groups, ment was noted for either group 15 min post-treatment or in following the treatment hour, compared to the initial induced subsequent assessments. lameness. Although this observed improvement was slightly When the lameness improvement score between treatment longer in duration in the cryotherapy treatment group, all horses groups was compared, there was a significantly greater lameness may have had significantly reduced lameness due to the gel improvement for the cryotherapy group 15 min post-treatment orthotic boots that all horses stood in for sole support during relative to the control group (Table 2), but this significance was the treatment hour. There was no negative control for the gel not maintained throughout the post-treatment hour. orthotic boots, so it is impossible to determine if the improvement can be attributed to the boots. Since the commercially Discussion designed boots provided for the study included gel orthotics, After 1 h of cryotherapy, horses in the cryotherapy treatment the control group had to be maintained in gel orthotics as well group had longer duration of lameness improvement relative to examine the effect of ice. If the heel screws were in constant to control horses, 10 versus 5 min. A difference in lameness contact with the hard ground, additional pain above the baseline improvement between the 2 groups was only significant at jog may have been elicited in those horses. However, regardless 15 min after treatment. Reports from studies on humans suggest of the reason for the transient improvement in lameness in both there is potential for longer effects (11,12). Due to variation treatment groups, improvement in lameness after the 5-minute among horses and the low number of subjects, this improve- time point for the cryotherapy group indicated that there is ment may not be reflected statistically. It is unlikely that the some potential for cryotherapy analgesia in equine athletes and lack of longer effect was due to an ineffective method of cooling. hospitalized patients. Further investigation into the use of cryo- Using an ice water immersion boot covering the hoof and distal therapy for analgesia in distal limb lameness may benefit from

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longer intervals of treatment for foot lameness models, or pos- 7. Foreman J, Grubb T, Inoue O, Banner SE, Ball KT. Efficacy of single- sibly the induction of lameness in joint or tendinous structures dose intravenous phenylbutazone and flunixin meglumine before, during and after exercise in an experimental reversible model of foot lameness proximal to the foot, as these structures may reach the target in horses. Equine Vet J 2010;42:601–605. temperature more rapidly. The model of lameness induction 8. Meucci V, Luci G, Vanni M, Sgoorbini M, Intorre L. Withdrawal time used in this study was designed to produce limited inflamma- of phenylbutazone administered to healthy horses. J Equine Vet Sci 2015;35:901–906. tion to isolate the effect of cryotherapy on pain from its effect 9. Petrov R, MacDonald MH, Tesch AM, Van Hoogmoed LM. Influence on inflammation. We deemed this method successful given that of topically applied cold treatment on core temperature and cell viabil- the lameness noted immediately following screw placement ity in equine superficial digital flexor tendons. Am J Vet Res 2003; 64:835–844. (median: 35.28), did not differ from that observed at 60 min 10. Bleakley CM, McDonough SM, MacAuley DC. Cryotherapy for acute

ARTICLE post-treatment (median: 39.44). We also believe the transient ankle sprains: A randomised controlled study of two different icing nature of lameness induction was demonstrated by resolution protocols. Brit J Sport Med 2006;40:700–705. 11. Chughtai M, Sodhi N, Jawad M, et al. Cryotherapy treatment after of lameness immediately following screw removal. In horses unicompartmental and total knee arthroplasty: A review. J Arthroplasty with pain associated with inflammation, the analgesic effect of 2017;32.12:3822–3832. cryotherapy will likely differ and may be even greater. With a 12. Francisco AA, De Oliveira SMJV, Steen M, Nobre MRC, De Souza EV. Ice pack induced perineal analgesia after spontaneous vaginal birth: larger study population, different method of lameness induction Randomized controlled trial. Women Birth 2018;31.5:334–340. or longer duration of cryotherapy, the effects of cryotherapy may 13. Guillot X, Tordi N, Prati C, Verhoeven F, Pazart L, Wendling D. become more evident. Cryotherapy decreases synovial Doppler activity and pain in knee arthritis: A randomized-controlled trial. Joint Bone Spine 2017;84:477–483. In conclusion, there was a modest reduction in lameness 14. Van Eps AW, Leise BS, Watts M, Politt CC, Belknap JK. Digital resulting from 1 h of cryotherapy. Although the therapeutic hypothermia inhibits early lamellar inflammatory signalling in the effect diminished over the post-treatment hour, significant oligofructose laminitis model. Equine Vet J 2012;44:230–237. 15. Van Eps AW, Pollitt CC, Underwood C, Medina-Torres CE, Goodwin lameness improvement continued at least 10 min after cryo- WA, Belknap JK. Continuous digital hypothermia initiated after the therapy. Given that the reduction of lameness in horses in the onset of lameness prevents lamellar failure in the oligofructose laminitis cryotherapy group was only significantly greater than the con- model. Equine Vet J 2014;46:625–630. 16. Pollitt C, Van Eps AW. Prolonged, continuous distal limb cryotherapy trol group at 15 min after treatment in this study, additional in the horse. Equine Vet J 2004;36:216–220. research is required to determine the ideal method, duration, 17. Van Eps AW, Orsini J. A comparison of seven methods for continuous and temperature for provision of analgesia. Although action- therapeutic cooling of the equine digit. Equine Vet J 2016;48:120–124. 18. Guide to Veterinary Services for Horse Shows. 7th ed. Lexington, able clinical recommendations based on the evidence generated Kentucky: American Association of Equine Practitioners, 1999. by this study are limited, the study laid much of groundwork 19. Silva GB, De La Côrte FD, Brass KE, et al. Duration and effect of necessary for designing further research more comprehensively different local anesthetics on the palmar digital nerve block in horses. J Equine Vet Sci 2015;35:749–755. investigating the promising utility of cryotherapy in equine pain 20. Radtke A, Fortier LA, Regan S, Kraus S, Delco ML. Intra-articular management. CVJ anaesthesia of the equine stifle improves foot lameness. Equine Vet J 2019;52:314–319. References 21. Schumacher J, Steiger R, Schumacher J, et al. Effects of analgesia of the distal interphalangeal joint or palmar digital nerves on lameness caused . 1 USDA National economic cost of equine lameness, colic, and equine by solar pain in horses. Vet Surg 2000;29:54–58. protozoal myeloencephalitis in the United States. USDA APHIS VS, 22. da Silva Azevedo M, De La Côrt FD, Brass KE, et al. The use of xylazine National Health Monitoring System Information sheet, Fort Collins, or acepromazine does not interfere in the lameness evaluation by inertial Colorado, USA, #N348.1001. sensors. J Equine Vet Sci 2015;35:27–30. 2. Beisser A, McClure S, Rezabek G, Soring KH, Wang C. Frequency of 23. Ross MW. Movement. In: Diagnosis and Management of Lameness in and risk factors associated with catastrophic musculoskeletal injuries in the Horse. St. Louis, Missouri: Elsevier Saunders, 2011:1395. Quarter Horses at two Midwestern racetracks: 67 cases (2000–2011). 24. McCracken MJ, Kramer J, Keegan KG, et al. Comparison of an inter- J Am Vet Med Assoc 2014;245:1160–1168. tial sensor system of lameness quantification with subjective lameness 3. Peat FJ, Kawcak CE. Musculoskeletal pathology. Vet Clin North Am evaluation. Equine Vet J 2012;44.6:652–656. Equine Pract 2015;31:407–424. 25. Reed SK, Kramer J, Thombs L, Pitts JB, Wilson DA, Keegan KG. 4. Dyson S. Evaluation of poor performance in competition horses: Comparison of results for body-mounted inertial sensor assessment A musculoskeletal perspective. Part 1: Clinical assessment. Equine Vet with final lameness determination in 1,224 equids. J Am Vet Med Assoc J 2016;28.5:284–293. 2020;256.5:590–599. 5. Reformed Racing Medication Rules. The Jockey Club. August 12, 2012. Available from: http://jockeyclub.com/pdfs/reformed_rules.pdf Last accessed June 11, 2021. 6. FEI Equine Anti-Doping and Controlled Medication Regulations. 2nd ed. Lausanne, Switzerland, 2017. Available from: https://inside.fei. org/system/files/GA18_Annex_28.2_PART% 202_Mark-up%20Rules. pdf Last accessed June 11, 2021.

838 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Article

Indications and outcomes for puppies undergoing mechanical ventilation: 59 cases (2006 to 2020)

Elyzabeth Lemieux, Elizabeth Rozanski, Gareth Buckley, Nolan Chalifoux, Christopher Kennedy, Alex Lynch, Chrissie Rutter, Alyx Tracy, Deborah C. Silverstein

Abstract — The medical records of 59 puppies from 6 hospitals undergoing mechanical ventilation (MV) between 2006 and 2020 were reviewed to describe the signalment, underlying disease, duration of ventilation, and outcome. The most common underlying diseases were pneumonia (n = 18), non-cardiogenic pulmonary edema (n = 16), and trauma (n = 8). Twenty-six (44%) puppies were weaned from the ventilator. The overall survival rate was 39% (23/59) including 19 non-brachycephalic dogs and 4 brachycephalics. Median duration of mechanical ventilation was 27 hours (range: 4 to 144 hours). Brachycephalic dogs were less likely to survive than non- brachycephalic dogs (P = 0.032). English bulldogs were over-represented with pneumonia. No association between age and survival to discharge (P = 0.716) or outcome (P = 0.579) was detected. The survival rate, and underlying disease process and severity for mechanically ventilated puppies was similar to previous studies in adult dogs.

Résumé — Indications et issues chez les chiots sous ventilation mécanique : 59 cas (2006 à 2020). Les dossiers médicaux de 59 chiots de six hôpitaux soumis à une ventilation mécanique (VM) entre 2006 et 2020 ont été examinés pour décrire le signalement, la maladie sous-jacente, la durée de la ventilation et le résultat. Les maladies sous-jacentes les plus courantes étaient la pneumonie (n = 18), l’œdème pulmonaire non cardiogénique (n = 16) et les traumatismes (n = 8). Vingt-six (44 %) chiots ont été sevrés du ventilateur. Le taux de survie global était de 39 % (23/59) dont 19 chiens non brachycéphales et quatre brachycéphales. La durée médiane de la ventilation mécanique était de 27 heures (intervalle : 4 à 144 heures). Les chiens brachycéphales étaient moins susceptibles de survivre que les chiens non brachycéphales (P = 0,032). Les bouledogues anglais étaient surreprésentés avec la pneumonie. Aucune association entre l’âge et la survie à la sortie (P = 0,716) ou le résultat (P = 0,579) n’a été détectée. Le taux de survie, ainsi que le processus et la gravité de la maladie sous-jacente chez les chiots ventilés mécaniquement étaient similaires à ceux des études précédentes chez les chiens adultes. (Traduit par Dr Serge Messier) Can Vet J 2021;62:839–842

Introduction client to establish realistic expectations, including duration of echanical ventilation (MV) has been used with increas- MV and prognosis. Puppies are often very new to the household M ing frequency in veterinary medicine over the past and so the decision to make a considerable emotional and finan- 25 y (1–8). Provision of MV requires a knowledgeable and cial investment with an uncertain prognosis can be even more dedicated team with proper equipment and intensive nursing challenging. The success of ventilator support, defined either as care abilities. In addition to a significant financial commitment weaning from MV or discharge home, varies with the underly- by the client, the decision to pursue MV also has a considerable ing disease. Previously reported overall survival to discharge of emotional burden (9). It is important to properly inform the dogs undergoing MV ranged from 21 to 71% (2–8). Previous

Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts 01536, USA (Rozanski, Lemieux); University of Florida College of Veterinary Medicine — Small Animal Clinical Sciences, 2015 SW 16th Avenue, Gainesville, Florida 32608, USA (Buckley); University of Pennsylvania — Clinical Sciences and Advanced Medicine, 3900 Delancey Street, Ryan Veterinary Hospital, Philadelphia, Pennsylvania 19104, USA (Chalifoux, Silverstein); Canada West Veterinary Specialists Ringgold standard institution, Vancouver, British Columbia, Canada (Kennedy); North Carolina State University Ringgold standard institution — College of Veterinary Medicine, Raleigh, North Carolina, USA (Lynch, Tracy); College of Veterinary Medicine, Texas A&M University System Ringgold standard institution, College Station, Texas, USA (Rutter). Address all correspondence to Dr. Elizabeth Rozanski; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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studies have suggested that younger dogs are more likely to sur- Table 1. The most frequent underlying etiologies, successful weaning rate, and survival rate in puppies undergoing mechanical vive (2,3). One study with dogs ranging from 10 wk to 16 y of ventilation, in alphabetical order. age identified a 10% decrease in the odds of survival with every 1 y increase in age, although the number of puppies was not Survival to discharge, Successful weaning number of dogs reported (2). Puppies have never been studied specifically. The Underlying etiology from MV (number/%) (number/%) objectives of the present study, therefore, were to describe the Cardiogenic pulmonary 2/2 (100%) 2/2 (100%) indications for mechanical ventilation, duration of ventilation, edema due to patent and outcome in dogs less than 12 mo of age. ductus arteriosus Head trauma 1/3 (33%) 1/3 (33%)

ARTICLE Materials and methods Non-cardiogenic 7/16 (44%) 6/16 (38%) The medical records of 5 university teaching hospitals and 1 pri- pulmonary edema vate multispecialty referral hospital were reviewed to identify Other 4/8 (50%) 4/8 (50%) puppies (defined as dogs less than 12 mo of age), which underwent MV between August 2006 and February 2020. A standard- Pneumonia 6/18 (33%) 5/18 (28%) ized spreadsheet from a commercial software program (Microsoft Recovery after CPR 2/7 (29%) 1/7 (14%) Excel Version 16.36; Microsoft, Redmond, Washington, USA) Thoracic trauma 4/5 (80%) 4/5 (80%) was used to record signalment, body weight, indications for CPR — Cardiopulmonary resuscitation. MV, underlying disease, duration of MV, and outcome for each puppy. Brachycephalic breeds were noted as such (10). Outcome was classified as death during MV, euthanasia during MV, survival to extubation but death before discharge, or survival set hound, bichon frise, border terrier, Boston terrier, Brittany to discharge. When present in the medical record, the primary spaniel, Chihuahua, dachshund, Doberman pinscher, Gordon reason for euthanasia (prognosis or financial) was recorded. setter, Great Dane, Maltese, miniature poodle, shar pei, treeing Cases were excluded if the medical records were incomplete or if Walker coonhound, and Yorkshire terrier. The median body puppies were ventilated only long enough to contact the owners weight was 9.9 kg (range: 0.5 to 74.5 kg). Eighteen dogs were or to permit a visit after a clinical decline. categorized as brachycephalics.

Statistical analysis Indications for mechanical ventilation Statistical analyses were performed using a commercial software The most frequent underlying disease was pneumonia in package (SPSS Statistics 27.0; IBM, Armonk, New York, USA). 18/59 (31%) dogs, followed by non-cardiogenic pulmonary The distribution pattern of quantitative data was assessed by the edema (NCPE) in 16/59 (27%) dogs, and trauma in 8/59 (14%) Shapiro-Wilk test. Normally distributed data are reported as dogs (Table 1). Other conditions identified included recovery mean 6 standard deviation (SD) values, and nonparametric data from cardiopulmonary arrest (7/59), cardiogenic pulmonary are reported as medians and ranges. Quantitative variables were edema (2/59) and other diseases (8/59). compared between 2 groups (e.g., survivors versus non-survivors) Duration of MV ranged from 4 to 144 h (median 27 h). using Student’s t-test or Mann-Whitney U-test, depending on Twenty-six (44%) dogs were successfully weaned. Twenty-three data distribution patterns. Associations between categorical vari- of these 26 dogs (88%) survived to discharge with an overall ables were compared by Chi-square or Fisher’s exact tests. The discharge rate of 39% including 19/41 non-brachycephalics association between 2 quantitative variables was analyzed using dogs (46%) and 4/18 brachycephalic dogs (22%). Seven out Pearson’s or Spearman’s rank correlation tests, depending on of 10 dogs that were ventilated for more than 72 h survived to data distribution pattern. Post-hoc analyses between the differ- discharge. Of the 3 dogs that were weaned but not discharged, ent groups were carried out using Tukey’s multiple comparison 2 were euthanized due to progressive respiratory failure that test. P-values # 0.05 were considered significant in all cases. would have required re-initiation of MV, and 1 died from an unobserved cardiac arrest. Seven dogs died, 22 dogs were Results euthanized with prognosis as the main owner concern, and Population description 4 dogs were euthanized with cost of care as the limiting factor. Sixty-nine puppies were supported with mechanical ventila- The mortality rate was 72% during the first 24 h of ventilation during the study period. Ten dogs were excluded because tion, with 21 dogs out of 29 dying/being euthanized during of incomplete records, leaving 59 puppies for evaluation. The that specific period. mean age was 5.4 6 2.9 mo. The youngest puppy was 1 mo old There was no association between age and survival to dis- and the oldest 11 mo. charge (P = 0.716) or survival to weaning (P = 0.579), nor There were 26 intact females, 19 intact males, 9 spayed between weight and survival to discharge (P = 0.744) or survival females, and 5 neutered males. There were 11 English bulldogs, to weaning (P = 0.842). There was no correlation between age 7 mixed breed dogs, 5 Labrador retrievers, 4 German shepherds, and weight (r = 0.53), likely due to the wide variety of breeds 4 golden retrievers, 3 French bulldogs, 2 boxers, 2 English represented. Duration of mechanical ventilation was significantly springer spaniels, 2 mastiffs, 2 miniature pinschers, and 1 of associated with survival to discharge (P = 0.012) and outcome each of the following breeds: Akita, Australian shepherd, bas- (P = 0.005). Dogs that were ventilated longer than 72 h were

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more likely to survive (P = 0.027). Brachycephalic dogs were were very heterogeneous, which prevented clear-cut predication less likely to survive to discharge than non-brachycephalic dogs of the dogs with the highest chance of survival. The survival when all groups were combined (P = 0.032). rate for thoracic trauma, including pulmonary contusions and pneumothorax, was greater at 80% than other veterinary studies Sub-categories have reported, although there was a relatively small number of Pneumonia. Pneumonia was identified in 18 puppies; 28% dogs (2–4,12).

(5/18) of puppies with pneumonia survived. Brachycephalic In this study, brachycephalic dogs were less likely to survive ARTICLE breeds heavily contributed to the pneumonia group (10/18) with than non-brachycephalic dogs (P = 0.032). A previous retrospec- 6 puppies being English bulldogs. The median age for puppies tive study of brachycephalic dogs undergoing MV (6) did not with pneumonia was 5.5 mo (range: 2 to 11 mo). Puppies with identify this disadvantage and reported a discharge rate of 27%, pneumonia were ventilated for a median of 38.75 h (range: which was similar to the 22% (4/18) reported in this study. 4 to 131 h). Brachycephalic dogs, especially English bulldogs, were diagnosed Non-cardiogenic pulmonary edema. Non-cardiogenic pul- more frequently with pneumonia of all causes than any other monary edema was the second most frequent underlying disease, breed, which is consistent with findings of a previous study with 16 puppies being affected. The underlying cause was not on brachycephalic dogs requiring MV (6). This could be due always known but included history of drowning in 4 dogs, to the greater risk of aspiration pneumonia in brachycephalic choking in 3 dogs, seizures in 2 dogs, and following restraint dogs and the likely reduced ability to resolve pneumonia due to for a nail trim in 1 dog. The median age for puppies with non- hypoplastic trachea and upper airway obstruction. cardiogenic pulmonary edema was 3 mo (range: of 3 to 8 mo). Median duration of ventilation was significantly longer for Dogs were ventilated for a median of 38.5 h (range: 5 to 96 h). dogs that survived than for dogs that died or were euthanized. Survival to discharge in these dogs was 37.5% (6/16). It could be hypothesized that puppies that were cardiovascularly Trauma. Trauma, the third most frequent underlying cause, stable survived longer and, therefore, had a greater chance of was identified in 8 dogs; 5 with primarily thoracic trauma and recovering adequate pulmonary or ventilatory function and 3 with primarily head trauma. The median age in this category being weaned off the ventilator. This has also been reported in was 4 mo (range: 2 to 11 mo). Dogs were ventilated for a a retrospective study of cats undergoing MV (13) but to the median of 24 h (range: 12 to 144 h). Overall, patients with authors’ knowledge, this is the first time it has been reported trauma had a survival rate of 62.5% (5/8) with an 80% survival in dogs. Similar to previous studies, the mortality rate in this rate in thoracic trauma cases (4/5) and a 33% survival rate in study was highest within the first 24 h (6,7). This could be due head trauma cases (1/3). to a more severe disease process leading to an early patient death Miscellaneous. Dogs with underlying diseases included (cardiovascular instability, multiple organ dysfunction), or that 7 puppies which had had successful cardiopulmonary resuscita- failure to show improvement over 24 h was associated with a tion (CPR), 2 puppies with congestive heart failure from pat- higher risk of euthanasia. ent ductus arteriosus, 2 puppies with intoxications (unknown The are several limitations to this study. A small number of toxin), and 2 puppies with anaphylaxis. Dogs ventilated fol- puppies in each group could have led to both type-1 and type-2 lowing return of spontaneous circulation suffered from trauma errors. Additionally, data on ventilator settings was not included in 3 cases, anesthetic complications in 2, heatstroke in 1, and due to absence of standardization of recording protocols between intoxication in 1. Single cases each of coral snake envenomation, institutions and individual clinicians. Inherent to the retrospec- congenital lobar emphysema, and diaphragmatic agenesis, were tive nature of the study, there was no standardized approach to recorded. Two cases had unidentified pulmonary disease. initiation, maintenance, or monitoring of MV, with considerable variation in ventilator technique and weaning strategies. Discussion Clinicians at every institution treated each case individually This study describes the outcome in 59 puppies that were based on their clinical judgment which contributed to variabil- supported with mechanical ventilation and identified survival ity in case management including anesthesia and monitoring rates that were similar to those of adult dogs ventilated for techniques. Since the study period was over 10 y, it is possible various underlying disease. Puppies, as a unique group, had not that some management changes such as anesthetic agents and been previously evaluated. Due to the financial, technical, and ventilation techniques could have introduced variabilities; for emotional implications of MV, it is important that owners are example, high flow oxygen therapy has been recently introduced well-prepared for the potential benefits for a specific therapy. in dogs (14,15). The decision to institute mechanical ventilation Despite only an overall moderate survival to discharge, without is complex and could not be accurately reported in this study MV, it is unlikely any puppies would have survived. In addition, due to its retrospective nature. The number of puppies that were as puppies, there is tremendous potential for long-term benefit, critically ill but not ventilated during the study period due to with each surviving dog expected to survive at least 10 to 12 y. financial or other reasons was unknown. CVJ Other recent veterinary studies focusing on dogs mechanically ventilated for congestive heart failure, lower motor neuron References disease, pulmonary contusions, and cervical spinal disorders . 1 Vasillev E, McMichael M. An overview of positive pressure ventilation. J Vet Emerg Crit Care 2004;14:15–21. have reported survival rates of 62.5%, 21%, 30%, and 71%, 2. Hopper K, Haskins SC, Kass PH, Rezende ML, Aldrich J. Indications, respectively (4,5,8,11). Unfortunately, the underlying causes management, and outcome of long-term positive-pressure ventilation in

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dogs and cats: 148 cases (1990–2001). J Am Vet Med Assoc 2007;230: 9. Donaldson RE, Barfield D. Quality of life following mechanical ventila- 64–75. tion in dogs and cats. J Vet Emerg Crit Care 2020;30:718–721. 3. Bruchim Y, Aroch I, Sisso A, et al. A retrospective study of positive 10. Dupré G, Heidenreich D. Brachycephalic syndrome. Vet Clin North pressure ventilation in 58 dogs: Indications, prognostic factors and Am Small Anim Pract 2016;46:691–707. outcome. J Small Anim Pract 2014;55:314–319. 11. Beal MW, Paglia DT, Griffin GM, Hughes D, King LG. Ventilatory 4. Campbell VL, King LG. Pulmonary function, ventilator management, failure, ventilator management, and outcome in dogs with cervical and outcome of dogs with thoracic trauma and pulmonary contusions: spinal disorders: 14 cases (1991–1999). J Am Vet Med Assoc 2001;218: 10 cases (1994–1998). J Am Vet Med Assoc 2000;217:1505–1509. 1598–1602. 5. Edwards TH, Erickson Coleman A, Brainard BM, et al. Outcome of 12. Powell LL, Rozanski EA, Tidwell AS, Rush JE. A retrospective analysis positive-pressure ventilation in dogs and cats with congestive heart of pulmonary contusion secondary to motor vehicular accidents in failure: 16 cases (1992–2012). J Vet Emerg Crit Care 2014;24:586–593. 143 dogs: 1994–1997. J Vet Emerg Crit Care 1999;9:127–136. 6. Hoareau GL, Mellema MS, Silverstein DC. Indication, management, 13. Lee JA, Drobatz KJ, Koch MW, King LG. Indications for and outcome

ARTICLE and outcome of brachycephalic dogs requiring mechanical ventilation. of positive-pressure ventilation in cats: 53 cases (1993–2002). J Am Vet J Vet Emerg Crit Care 2011;21:226–235. Med Assoc 2005;226:924–931. 7. King LG, Hendricks JC. Use of positive-pressure ventilation in dogs and 14. Oura T, Rozanski EA, Buckley G, Bedenice D. Low tidal volume ven- cats: 41 cases (1990–1992). J Am Vet Med Assoc 1994;204:1045–1052. tilation in healthy dogs. J Vet Emerg Crit Care 2012;22:368–371. 8. Rutter CR, Rozanski EA, Sharp CR, Powell LL, Kent M. Outcome 15. Keir I, Daly J, Haggerty J, Guenther C. Retrospective evaluation of the

and medical management in dogs with lower motor neuron disease effect of high flow oxygen therapy delivered by nasal cannula on PaO2 undergoing mechanical ventilation: 14 cases (2003–2009). J Vet Emerg in dogs with moderate-to-severe hypoxemia. J Vet Emerg Crit Care Crit Care 2011;21:531–541. 2016;26:598–602.

842 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Article

Obstipation in pet pigs: 24 cases

Kallie J. Hobbs, SallyAnne L. DeNotta, Aitor Gallastegui, George L. Elane, Luis A. Rivero, Pamela Adkins, Diego E. Gomez

Abstract — Clinical features and patient outcomes for pet pigs with obstipation are poorly defined. This retrospective study reports the clinical findings from 24 pet (non-production) pigs with obstipation presented to 2 veterinary teaching hospitals. Clinical features of obstipated pet pigs included anorexia or hyporexia in 24 pigs (100%), pain on abdominal palpation in 22 (90%), lethargy in 21 (88%), tachypnea in 19 (79%), vomiting in 14 (58%), and tachycardia in 13 (54%). Frequently observed hematologic and biochemical abnormalities included leukopenia in 36% (8/22) of the pigs, lymphopenia in 75% (17/22), toxic changes in neutrophils in 63% (14/22), hypokalemia in 50% (9/18), and hypoglycemia in 28% (5/18). Diagnostic imaging via radiography and/or computed tomography frequently identified gastric distention and accumulation of ingesta and gas throughout the gastrointestinal tract. Medical treatments included fluid therapy, anti-emetics, oral administration of carbonated beverages, non-steroidal anti-inflammatory drugs, and systemic antimicrobials. Surgical intervention was performed in 7/29% of pigs. In this study, obstipation in pet pigs carried a fair to favorable prognosis for survival, with 70% of patients surviving to discharge.

Résumé — Obstipation chez les porcs de compagnie : 24 cas. Les caractéristiques cliniques et l’issue des porcs de compagnie souffrant d’obstipation sont mal définis. Cette étude rétrospective rapporte les résultats cliniques de 24 porcs de compagnie (hors production) souffrant d’obstipation présentés à deux hôpitaux d’enseignement vétérinaire. Les caractéristiques cliniques des porcs de compagnie avec obstipation comprenaient l’anorexie ou l’hyporexie chez 24 porcs (100 %), des douleurs à la palpation abdominale chez 22 (90 %), une léthargie chez 21 (88 %), une tachypnée chez 19 (79 %), des vomissements chez 14 (58 %), et tachycardie dans 13 cas (54 %). Les anomalies hématologiques et biochimiques fréquemment observées comprenaient une leucopénie chez 36 % (8/22) des porcs, une lymphopénie chez 75 % (17/22), des modifications toxiques des neutrophiles chez 63 % (14/22), une hypokaliémie chez 50 % (9/18), et une hypoglycémie dans 28 % (5/18). L’imagerie diagnostique par radiographie et/ou tomodensitométrie a fréquemment identifié une distension gastrique et une accumulation d’ingesta et de gaz dans le tractus gastro-intestinal. Les traitements médicaux comprenaient la fluidothérapie, les antiémétiques, l’administration orale de boissons gazeuses, les anti-inflammatoires non stéroïdiens et les antimicrobiens systémiques. Une intervention chirurgicale a été réalisée chez sept (29 %) des porcs. Dans cette étude, l’obstipation chez les porcs de compagnie avait un pronostic de survie allant de passable à favorable, avec 70 % des patients survivant jusqu’à leur congé. (Traduit par Dr Serge Messier) Can Vet J 2021;62:843–848

Introduction pet pigs in the United States and Canada today (1), resulting ecent decades have seen an exponential growth in the num- in a marked increase in the number of pet pigs presenting to R ber of pet pigs in North America, from a small number of veterinary hospitals. Although porcine production medicine imported potbellied pet pigs in 1986 (1) to 35 000 registered topics are present in both veterinary education curriculae and and 200 000 unregistered purebred potbellied pigs in 2002 (2). the veterinary literature, the scant amount of scholarly informa- This number has continued to climb to an estimated 1 million tion regarding medical care of pet pigs is disproportionate to

University of Florida College of Veterinary Medicine, Gainesville, Florida, USA (Hobbs, DeNotta, Gallastegui, Elane); University of Missouri College of Veterinary Medicine, Columbia, Missouri, USA (Rivero, Adkins); Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada (Gomez). Address all correspondence to Dr. Diego Gomez; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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the number of pet pigs in the country today. Pigs as household for 22 pigs. Of these 22 pigs, 10 were castrated males, 9 were pets differ greatly from production pigs in their housing, diet, spayed females, and 3 were intact females. In addition to absent management, and owner expectations, and studies that shed fecal production, presenting complaints included lethargy in light on the diagnosis and treatment of commonly encountered 21 pigs (88%), anorexia or hyporexia in 24 (100%), and vom- diseases in pet pigs are of great value to veterinarians treating iting in 14 (58%). Median time since last defecation was 48 h these animals in their practices. (range: 24 to 336 h), with 11/24 pigs having not defecated for It is the authors’ observation that obstipation is a commonly $ 72 h. Two pigs had undergone surgical procedures and were encountered problem in pet pigs presenting to university discharged from the hospital in the days before re-presenting teaching hospitals. To our knowledge, no peer-reviewed litera- with obstipation. Nine pigs received medical treatment either

ARTICLE ture exists regarding the diagnosis, treatment, and prognosis from the owners or a referring veterinarian before admission. for this condition in pet pigs. In other species, obstipation These treatments included intravenous fluids (n = 1), enemas may occur as a primary intestinal condition, or secondary to (n = 5), non-steroidal anti-inflammatories (NSAIDs) (n = 5), non-intestinal systemic illness (3–6). The objective of this systemic antimicrobials (n = 3), and antiemetics (n = 2). retrospective study was to describe the clinical and diagnostic features of pet pigs diagnosed with obstipation at 2 university Physical findings teaching hospitals in North America. Medical and surgical treat- At the time of presentation, all 24 pigs were hyporectic or inap- ments, patient outcomes, and post-mortem findings were also petent. Thirteen pigs vomited during physical examination. examined. Median rectal temperature was 38°C (range: 36.5 to 40.3°C). Two pigs were febrile with rectal temperatures . 39.2°C. Materials and methods Median heart rate (HR) was 93 beats/min (bpm) (range: 52 to Medical records of pet pigs presented to the University of 140 bpm). Thirteen pigs were tachycardic with HR . 90 bpm. Florida and University of Missouri Veterinary Teaching Median respiratory rate (RR) was 30 respirations/min (rpm) Hospitals between 2007 and 2019 were reviewed. All ages and (range: 12 to 60 rpm). Nineteen pigs were tachypneic with breeds of pigs were considered. Pet pigs were defined as those RR . 20 rpm. Hydration status was available for 23 pigs; not used for commercial (breeding or meat production) pur- however, the parameters used by clinicians to determine the poses. Pigs presenting for elective procedures (e.g., ovariohys- hydration status of each pig were not available. Of those, terectomy, castration, routine foot and tusk maintenance) were 14 pigs (60%) were reported to be adequately hydrated, 4 (18%) excluded. Obstipation was defined as the absence of fecal output were mildly dehydrated, and 5 (22%) were moderately dehy- for more than 24 h either before or after admission, without the drated. No pigs were reported to be severely dehydrated. presence of a foreign body as the inciting cause. Abdominal palpation was performed in 21 pigs; 90% exhibited Records were systematically reviewed, and the following pain on palpation. Four pigs were noted to have mild to moder- information was recorded: age, breed, sex and sterilization status, ate abdominal distention. treatments administered before admission, presenting complaint, and time since last defecation. Recorded clinical data included Clinicopathological findings physical examination findings, additional clinical problems The CBC results were available for 22 cases and PBP results (e.g., anorexia, lethargy, vomiting), medical comorbidities, com- were available for 18 cases. Hematologic abnormalities plete blood (cell) count (CBC) results, and plasma biochemistry included leukopenia (, 11 000 cells/mL) in 9/41% of pigs profile (PBP) results. Laboratory reference ranges were sourced (median: 13 000 cells/mL; range: 4300 to 34 000 cells/mL), from existing veterinary literature (7,8). Diagnostic imaging neutrophilia (. 10 000 cells/mL) in 5 pigs (23%) (median: modality and findings were also recorded. Surgical intervention, 8100 cells/mL, range: 600 to 23 000 cells/mL), and lymphopenia when performed, was recorded along with intra-operative find- (, 5300 cells/mL) in 18 pigs (82%) (median: 3008 cells/mL, ings. All in-hospital medical treatments were recorded, as well range: 610 to 7670 cells/mL). Toxic changes were noted in as time to first feces production, duration of hospitalization, the descriptions of neutrophil morphology in 15 cases (68%). and survival to discharge. Post-mortem findings were recorded Hyperfibrinogenemia (. 4 g/L) was observed in 4 pigs (18%) for pigs that died or were euthanized. Population characteristics (median: 7 g/L, range: 1 to 10 g/L). Overall, 13 pigs (60%) had were described using range and median values. $ 1 leukogram abnormalities consistent with systemic inflammation, e.g., hyperfibrinogenemia, leukopenia, leukocytosis, Results neutropenia, and/or neutrophilia (Table 1). Study population Abnormalities noted on PBP included hypochloremia During the study period, 779 pigs were presented to the (, 106 mEq/L) in 18 pigs (100%) (median: 97 mEq/L; range: University of Florida (UF) and 639 pigs were presented to 86 to 108 mEq/L), hypokalemia (, 4 mEq/L) in 12 pigs (67%) the University of Missouri (MU) for evaluation. A total of (median: 4 mEq/L; range: 2.7 to 4.7 mEq/L), hypoglycemia 24 pigs (20 from UF and 4 from MU) met the inclusion cri- (, 65 mg/dL) in 7 pigs (39%) (median: 85 mEq/L; range: 38 to teria for pet pigs with obstipation. Of the 24 cases, 18 were 198 mEq/L), hyperglobulinemia (. 7.0 g/dL) in 6 pigs (33%) potbellied pigs and 6 mixed-breed miniature pigs. Median (median: 7.1 g/dL; range: 5 to 8.7 g/dL), and hypoalbuminemia age was 5 y (range: 0.6 to 17 y). There were 13 females and (, 3.0 g/dL) in 3 pigs (17%) (median: 3.6 g/dL; range: 2 to 11 males. Information regarding sterilization status was available 4.7 g/dL) (Table 1).

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Diagnostic imaging Table 1. Admission values (median and range) of selected laboratory variables of 24 obstipated pigs presented to 2 veterinary Abdominal radiographs were performed in 19 of the 24 pigs. In teaching hospitals. all cases, mild distension of the large colon and spiral colon with Reference intestinal content and feces (appearing as soft tissue opacities) Parameter interval Median Range was noted. Distension was subjectively assessed by comparing BUN (mg/dL) 4.2 to 15.1 11 6 to 43 the abnormal intestinal segments to the normally expected size. Creatinine (mg/dL) 1.0 to 2.3 1 0.9 to 3.4 Distention was designated as mild, moderate, or severe based Albumin (g/dL) 6.6 to 8.9 3.6 2.0 to 4.7 ARTICLE on volume of intestinal contents. In the small intestine, moder- ALP (U/L) 27 to 160 50 21 to 189 Glucose (mg/dL) 59.8 to 175.2 85 38 to 198 ate gas accumulation was also observed in all 19 cases. Within Na (mEq/L) 139 to 148.8 140 130 to 148 the ventral aspect of the stomach, soft tissue opacities and gas, K (mEq/L) 3.7 to 5.0 4 2.7 to 4.7 presumed to be feed material, was noted in 2 cases (Figure 1). Cl (mEq/L) 106 to 113 97 86 to 108 AST (U/L) 16.0 to 65.0 58 15 to 3175 Computed tomography (CT) of the abdomen was performed Creatine kinase (U/L) 212.5 to 2851.5 1929 161 to 4176 in 7 of the 24 pigs. In all cases, soft tissue attenuating material T. bilirubin (mg/dL) 0.2 to 0.45 0.3 0.1 to 14.2 and gas were noted within the stomach and the spiral colon, as GGT (U/L) 14.5 to 56.2 66 37 to 146 Fibrinogen (g/L) 1 to 4 7 1 to 10 well as gas accumulation within the large colon and the small PCV (%) 22 to 50 35.5 22 to 54 intestine. Moderate gastric distention due to accumulation of Leukocytes (cells/Ul) 11.0 to 22.0 13 4.3 to 34.0 feed material was observed in 6 pigs (Figure 2). Severe disten- Neutrophils seg (cells/mL) 4.0 to 9.5 8.1 0.6 to 23.0 Neutrophils band (cells/mL) 0.0 to 0.6 0.13 0.1 to 5.2 tion of the spiral colon (n = 1) and pneumohydroperitoneum Lymphocytes (cells/mL) 6.0 to 12.6 3 0.6 to 7.6 (n = 1) were also noted. Monocytes (cells/mL) 0.3 to 2.2 0.69 0.07 to 1.44

Five pigs underwent repeated imaging, with 4 receiving serial BUN — Blood urea nitrogen; ALP — Alkaline phosphatase; Na — Sodium; K — abdominal radiographs and 1 undergoing abdominal radio- Potassium; Cl — Chloride; AST — Aspartate aminotransferase; GGT — graphs followed by CT. In all cases, repeat imaging revealed Gamma-glutamyl transferase; PCV — Packed cell volume. a reduction in gastric and colonic distention with persistent radio-opaque material within the colon.

Comorbidities One or more comorbidities were identified in 18 of the 24 pigs. These included obesity (n = 10), radiographic or CT evidence of pneumonia (n = 4), enteritis (n = 4), retinal degeneration (n = 1), adhesions of the small intestine (n = 1), hepatic lipidosis (n = 1), and pyometra (n = 1).

Treatment Twenty-two pigs (92%) were treated with intravenous (IV) or rectal fluid therapy. Ten pigs received intravenous constant rate infusions (CRI) with commercial crystalloid fluids at rates ranging from 1 to 6 mL/kg body weight (BW) per hour (median: 3 mL/kg BW per hour). Twelve pigs were administered rectal fluids via a 14-gauge red rubber catheter, consisting of plain water (n = 8), proprietary isotonic fluids (n = 3), or balanced electrolyte isotonic fluids (n = 1) (Plasma-Lyte 148; Baxter Figure 1. Radiograph in lateral projection of cranial and caudal abdomen. A large amount of granular, heterogeneously Pharmaceuticals, Deerfield, Illinois, USA). Rectal fluid rates soft tissue opaque material is present in the stomach (S). The ranged from 4 to 10 mL/kg BW per hour (median: 7 mL/kg BW intestine contains a mixture of heterogenous soft tissue opaque per hour). Duration of fluid therapy ranged from 24 to 144 h material or gas. (median: 48 h). Twenty pigs were offered free choice access to water, balanced electrolyte solution, and/or cranberry juice. All pigs that received juice and/or electrolytes were also offered plain (Naxcel; Zoetis, Parsippany, New Jersey, USA), amoxicillin/ water. In addition, the 6 pigs with enlarged stomachs noted clavulanic acid (n = 2) (Clavamox; Zoetis), enrofloxacin (n = 2) on CT were offered non-caffeinated, sugar-free carbonated (Baytril; Bayer Corporation, Whippany, New Jersey, USA), beverages. Of the 17 pigs that survived to discharge, 13 (76%) and florfenicol (n = 1) (Nuflor; Schering-Plough Animal, received some form of fluid therapy. Kenilworth, New Jersey, USA). Median duration of anti- Sixteen pigs (67%) were administered antimicrobials at microbial therapy was 3 d (range: 1 to 7 d). Of the 17 pigs admission. All pigs treated with antimicrobials had inflamma- that survived to discharge, 15 pigs (88%) were treated with tory leukograms, fever, and/or a potentially infectious comor- antimicrobials. Twelve pigs (50%) were treated with non- bidity such as pneumonia or pyometra. Antimicrobial selec- steroidal anti-inflammatory drugs (NSAIDs) including flu- tion and dosing protocol were clinician-dependent and varied nixin meglumine (n = 9) (Banamine; Merck Pharmaceuticals, across cases. Antimicrobials included sodium ceftiofur (n = 11) Kenilworth, New Jersey, USA), 2.2 mg/kg BW, IM, q24h

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Figure 2. Computed tomographic sagittal multiplanar image in soft tissue algorithm of the abdomen. A large amount of mixed granular soft tissue and mineral attenuating material is present in the gravity-dependent portion of the stomach (S). Moderately gas-filled small intestine with a large amount of mixed granular soft tissue and mineral attenuating material in the colon is present.

and meloxicam (n = 3) (Lupin Pharmaceuticals, Baltimore, canned pumpkin, during hospitalization. In the 12 pigs that Maryland, USA), 0.4 mg/kg BW, PO, q24h. Median duration were treated medically and survived, a return of appetite was of treatment with NSAIDs was 3 d (range: 1 to 6 d). Of the noted within 24 h in 5 pigs, within 48 h in 3 pigs, and within 17 pigs that survived to discharge, 10 pigs (59%) were treated 72 h in 2 pigs. Two of the medically managed pigs remained with NSAIDs. Additional treatments administered included inappetent for . 72 h. All pigs passed feces before a return to the antiemetic maropitant (n = 3) (Cerenia; Zoetis), 1 mg/kg normal appetite. In the 5 pigs treated surgically that survived, a BW, SQ, q24h for 1 to 3 d and the proton pump inhibitor return of appetite was noted within 12 h after surgery in 2 pigs, omeprazole (n = 6) (Equate; Walmart Specialty Pharmacy, and 24 h after surgery in 3 pigs. Surviving pigs were gradually Orlando, Florida, USA), 1 mg/kg BW, PO, q24h for 2 to 6 d. reintroduced to small meals of fruit and commercial pig pellets Five pigs received $ 1 soapy water enemas during the initial with the long-term home recommendation to maintain a bal- 24 h of hospitalization. anced, high-fiber diet of fresh fruits, vegetables, and commercial pig pellets. Owners were advised against the feeding high-calorie Surgical intervention table scraps and/or canine and feline commercial diets. Seven pigs (29%) underwent exploratory laparotomy via ventral midline incision. Median interval from admission to surgery Interval to fecal production was 2.5 d (range: 12 h to 7 d). Of the 7 pigs that underwent In the 12 surviving pigs treated medically, first fecal passage surgery, 2 were euthanized intra-operatively for poor prognosis occurred at a median time of 60 h (range: 12 to 120 h) after associated with fecal contamination of the abdomen because of admission. In the 5 surviving pigs treated surgically, first fecal small intestine perforation and jejunal necrosis with suspected passage occurred at a median time of 48 h (range: 12 to 72 h) neoplastic nodules on the pylorus and spleen. Both intraopera- after surgery. One pig was discharged before first fecal passage tively euthanized pigs had marked intestinal adhesion forma- due to owner financial limitations but was reported to pass tion. Intraoperative findings for the 5 pigs that survived surgery feces at home 24 h after discharge. Three of the non-surviving included $ 1 or more of the following: gastric impaction pigs were each noted to pass scant feces at a single time point; (n = 2), cecal impaction (n = 2), spiral colon impaction (n = 2), however, none of these pigs resumed normal fecal production duodenal impaction (n = 1), and jejunal rupture (n = 1). Gastric during hospitalization. impactions and duodenal impaction were resolved with intraluminal injection of 0.9% saline and manual reduction. In 1 pig, Outcome severe cecal and spiral colon impactions could not be manually Of the 24 total pigs in this study, 17 (71%) were discharged reduced, necessitating typhlotomy and spiral colotomy. In the from the hospital, whereas 7 (29%) were euthanized due to fail- case of jejunal rupture, a side-to-side anastomosis was performed ure to respond to therapy, poor prognosis at surgery, or financial and the abdomen was thoroughly lavaged with 0.9% saline. constraints. The median time between admission and euthanasia in non-surviving pigs was 24 h (range: 0.5 to 6 d). The median Dietary management time of hospitalization for pigs that survived to discharge was At admission, all 24 pigs in this study were hyporectic or 4 d (range: 1 to 7 d). Surviving pigs managed medically (12 out inappetent. All pigs were offered food, initially fresh fruit and of 17) had a median hospitalization time of 4.5 d (range: 1 to

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7 d), whereas surviving pigs managed surgically (5 out of 7) Similar inflammatory responses can be observed in horses (12). had a median hospitalization time of 3 d (range: 2 to 6 d) Furthermore, in dogs and cats, gastrointestinal stasis has been (P . 0.05). Long-term followup was not available for pigs associated with bacteremia and sepsis (13). Translocation of discharged from the hospital. enteric bacteria and endotoxin across compromised intestinal walls could have contributed to the hematological and clinical Post-mortem examination findings abnormalities observed in our study. Thus, empirical treatment

Post-mortem examination was performed in 4 of the euthanized with fluids, systemic antimicrobials, and anti-inflammatory ARTICLE pigs. Moderate to severe impaction of the spiral colon and colon drugs was deemed necessary by some clinicians to mitigate pos- was identified in all pigs submitted for necropsy. Evidence of sible effects of bacteremia and toxemia in obstipated pet pigs. septicemia and necrotizing vasculitis of the colon secondary However, it is important to mention that the reference ranges to fecal impaction was noted in 1 pig. A pyloric mass and a used at both institutions are based on production pigs and duodenal mass were each identified in 1 pig. The duodenal vary significantly from those published for potbellied pigs (7). mass was also associated with numerous chronic fibrous adhe- Therefore, studies investigating hematologic alterations in sions between loops of small and large intestines. In both cases, obstipated pigs using specific reference ranges for potbellied the masses or adhesions, or both could have led to intestinal pigs are warranted. obstruction and contributed to decreased intestinal motility. In humans, especially in pediatric medicine, conflicting evidence for an association between a clinical and a radiographic Discussion diagnosis of constipation exist. Studies in children (14,15) This study describes the clinical and diagnostic features, treat- and adults (16–18) document low sensitivity and specificity of ments, and outcomes of pet pigs diagnosed with obstipation. In abdominal radiography for diagnosing functional obstipation this study, the most frequently observed clinical findings were because the fecal burden on radiographs is similar in patients inappetence or hyporexia, pain on abdominal palpation, leth- with and without obstipation (16–18). The use of advanced argy, tachypnea, vomiting, and tachycardia. Commonly observed imaging for diagnosis of idiopathic obstipation in humans, hematologic and biochemical abnormalities included leukope- therefore, is discouraged (16–18). Currently, guidelines for using nia, lymphopenia, toxic changes in neutrophils, hypokalemia, radiographs or CT for diagnosis of obstipation in pigs are lack- and hypoglycemia. Radiography and CT revealed abnormal ing. Emergency physicians suggest using radiographs for specific findings in all pigs that underwent diagnostic imaging. Imaging groups of children with abdominal pain, e.g., suspected foreign with radiographs and CT frequently revealed significant feed body ingestion or severe abdominal distention (19). The clini- distension within the large intestine and spiral colon, and gas cal signs displayed by pigs suffering from obstipation resemble distention in the small intestine. those identified in pigs with intestinal foreign bodies. Therefore, Causes of obstipation in humans include inadequate dietary radiographs and CT scans could be indicated in pigs to differ- fiber intake, insufficient fluid intake, reduced physical activity, entiate these diseases. Future studies are warranted to compare side effects of medications (calcium and iron supplements, opi- the sensitivity and specificity of radiographs and CT scans for oids, anticonvulsants, and antihistamines), hypothyroidism, and the diagnosis of gastrointestinal disease in pigs. colorectal cancer obstruction (9). Other causes include constipa- In dogs, severe obstipation is treated with intravenous fluid tion associated with abnormal bowel motility, anatomical rectal administration to correct water and electrolytes disorders, disorders, or neurological disorders (9). The retrospective nature and to hydrate and soften the fecal material (6). In addition, of this study prevented us from drawing conclusions regarding enemas and manual evacuation of feces is performed in some the causes of obstipation in pigs; however, a thorough review of cases (6). Administration of fluids, both intravenous and oral, is the pig’s diet, eating habits, water consumption, activity level, a mainstay of treating gastrointestinal impactions in other spe- and medications would be advisable to determine possible causes cies (3,20,21), with the goal of hydrating impacted ingesta and for obstipation, and to provide dietary, exercise, and medication encouraging intestinal motility. In horses, enteral fluid therapy recommendations. can provide better ingesta hydration compared with use of The American College of Gastroenterology (ACG) recom- intravenous fluids (22). However, options for oral fluid therapy mends clinicians perform systematic clinical workup, e.g., are limited in pigs due to difficulty placing and maintaining CBC, basic metabolic panel, thyroid tests, and colonoscopy indwelling nasogastric tubes. Intravenous fluid administra- in obstipated patients with “alarm” signs, which include fever, tion can also be challenging in pigs, due to limited accessible nausea, vomiting, weight loss, anorexia, blood in stool, and superficial veins and high rate of failure in the commonly used anemia (10,11). The pigs in our study frequently presented with ear vein catheters. Administration of fluid per rectum (procto- anorexia, fever, vomiting, and abdominal pain. These clinical clysis) has historically been used in humans (23,24), rats (25), signs directed additional diagnostic tests including CBC, PBP, elephants (26), and horses (27), and is currently used in limited and advanced imaging to determine severity of disease and conditions when administration of intravenous fluids is not need for specific treatments. Interestingly, the pigs reported feasible (24,28). Administration of fluids per rectum was often here often presented with 1 or more clinical signs of systemic done in our study population, appeared to be well-tolerated by inflammation, e.g., abnormal leukogram, toxic neutrophil mor- the pigs, and was an inexpensive and safe alternative to admin- phology, hyperfibrinogenemia, hyperglobulinemia, and/or fever istration of intravenous and oral fluids. The use of carbonated based on the reference intervals for CBCs at both institutions. beverages, though not previously described in pigs, was based

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on literature in equine and human patients with gastric impac- 7. Brockus CW, Mahaffey EA, Bush SE, KruppDespain W. Hematologic tions (29,30). In humans, the use of carbonated beverages has and serum biochemical reference intervals for Vietnamese potbellied pigs. Comp Clin Path 2005;13:162–165. been recommended as a first line of treatment in patients with 8. Constable PD, Hinchcliff KW, Done SH, Grünberg W, Radostits OM. phytobezoars (30). The dosage range used in the pigs in this Veterinary Medicine: A Textbook of the Diseases of Cattle, Horses, population was extrapolated from the literature on humans. Sheep, Pigs and Goats. St. Louis, Missouri: Elsevier, 2017. 9. Leung FW. Etiologic factors of chronic constipation: Review of the In this study, obstipation in pet pigs carried a fair to favor- scientific evidence. Dig Dis Sci 2007;52:313–316. able prognosis for survival, with 70% of patients surviving to 10. Cash BD, Chang L, Sabesin SM, Vitat P. Update on the management discharge. Case reports of human deaths due to bowel per- of adults with chronic idiopathic constipation. J Fam Pract 2007;56: S13–19, quiz S20. foration attributed to obstipation have been published (31); 11. American College of Gastroenterology Chronic Constipation Task Force.

ARTICLE however, there are no current data documenting mortality An evidence-based approach to the management of chronic constipation rates of humans with obstipation. Survival rates of horses with in North America. Am J Gastroenterol 2005;100:S1–4. 12. Auer JA. Equine Surgery. 5th ed. St. Louis, Missouri: Elsevier, 2018. gastrointestinal impactions vary depending on the site of the 13. Whitehead K, Cortes Y, Eirmann L. Gastrointestinal dysmotility disor- impaction. At 1-year followup, survival rates were 73% for small ders in critically ill dogs and cats. J Vet Emerg Crit Care (San Antonio) colon impaction (28), 91% for ileal impaction (29), and 65% 2016;26:234–253. 14. Reuchlin-Vroklage LM, Bierma-Zeinstra S, Benninga MA, Berger MY. for cecal impaction (30). Survival percentages for pigs treated Diagnostic value of abdominal radiography in constipated children: surgically (71%) or medically (70%) were similar; however, A systematic review. Arch Pediatr Adolesc Med 2005;159:671–678. median hospitalization time was shorter for pigs treated surgi- 15. Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr cally than those treated medically. Limitations of this study 2014;164:83–88 e2. include the retrospective nature, incomplete medical records, 16. Cowlam S, Vinayagam R, Khan U, et al. Blinded comparison of faecal lack of standardization for data collection, and the ambiguity of loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation. Clin Radiol 2008;63:1326–1331. presenting complaints resulting in the potential for missed cases. 17. Clark K, Lam L, Talley MJ, et al. A pragmatic comparative study of pal- The small sample size of various treatment groups also prevented liative care clinician’s reports of the degree of shadowing visible on plain assessment of the efficacy of various treatments. abdominal radiographs. Support Care Cancer 2018;26:3749–3754. 18. Ferguson D, Holmes RD, Scott R, et al. Colonic stool burden on com- In conclusion, obstipation appeared to be an infrequent puted tomography does not correlate with bowel habit: A cross-sectional condition in this sample population of pet pigs referred to study. Abdom Radiol (NY) 2021;46:506–516. tertiary hospitals. This condition can occur more frequently 19. Yilmaz G, Pekindl G, Akpinar S, et al. The radiologic evaluation of pediatric acute abdomen; Results of tertiary referral center. J Belg Soc in other geographic regions or clinical practices that admit a Radiol 2015;99:34–42. higher number of obstipated pigs that do not require refer- 20. Benjamin SE, Drobatz KJ. Retrospective evaluation of risk factors and ral to tertiary institutions. Clinicopathological abnormalities treatment outcome predictors in cats presenting to the emergency room for constipation. J Feline Med Surg 2020;22:153–160. typically include inappetence, fever, vomiting, abdominal 21. Plummer AE. Impactions of the small and large intestines. Vet Clin pain, and an abnormal leukogram. Imaging with radiographs North Am Equine Pract 2009;25:317–327. and CT frequently revealed significant feed distension within 22. Lester GD, Merritt AM, Kuck HV, Burrow JA. Systemic, renal, and colonic effects of intravenous and enteral rehydration in horses. J Vet the large intestine and spiral colon, and gas distention in the Intern Med 2013;27:554–566. small intestine. Based on current recommendations in human 23. Trout HH. Proctoclysis: Some clinical and experimental observations. and equine medicine (25,27) and the response to the treatment JAMA 1912;LVIII(18):1352–1354. 24. Grocott MP, McCorkell S, Cox ML, Resuscitation from hemorrhagic protocols used in this study, fluid therapy (intravenous, oral, or shock using rectally administered fluids in a wilderness environment. rectal), antimicrobials, and anti-inflammatory drugs appeared Wilderness Environ Med 2005;16:209–211. to be indicated for treatment of obstipated pigs. However, a 25. Girisgin AS, Acar F, Cander B, Gul M, Kocak S, Bodur S. Fluid replace- ment via the rectum for treatment of hypovolaemic shock in an animal larger sample population is required to determine the optimal model. Emerg Med J 2006;23:862–864. treatment for obstipated pigs. Obstipation in pet pigs appeared 26. Miller RE, Fowler ME. Fowler’s Zoo and Wild Animal Medicine. 8th ed. Vol. 8. St. Louis, Missouri: Elsevier/Saunders, 2015:773pp. to have a favorable prognosis for survival to discharge. CVJ 27. Khan A, Hallowell GD, Underwood C, Van Eps AW. Continuous fluid infusion per rectum compared with intravenous and nasogastric References fluid administration in horses. Equine Vet J 2019;51:767–773. . 1 Curnutte M. The big problem with mini pigs. National Geographic, 28. Lyons N, Nejak D, Lomotan N, et al. An alternative for rapid adminis- 2014. tration of medication and fluids in the emergency setting using a novel 2. Ostevik L, Elmas C, Rubio-Martinez LM. Castration of the Vietnamese device. Am J Emerg Med 2015;33:1113 e5–6. pot-bellied boar: 8 cases. Can Vet J 2012;53:943–948. 29. Rodriguez Hurtado I, Stewart A, Pellegrini-Masini A. Successful treat- 3. Dabareiner RM, White NA. Large colon impaction in horses: ment for a gastric persimmon bezoar in a pony using nasogastric lavage 147 cases (1985–1991). J Am Vet Med Assoc 1995;206:679–685. with a carbonated cola soft drink. Equine Vet Ed 2007;19:571–574. 4. Andrews CN, Storr M. The pathophysiology of chronic constipation. 30. Ladas SD, Kamberoglou D, Karamanolis G, Vlachoginnakos J, Can J Gastroenterol 2011;25:16B–21B. Zouboulis-Vafiadis I. Systematic review: Coca-Cola can effectively dis- 5. Obokhare I. Fecal impaction: A cause for concern? Clin Colon Rectal solve gastric phytobezoars as a first-line treatment. Aliment Pharmacol Surg 2012;25:53–58. Ther 2013;37:169–173. 6. Tzimtzimis E, Papazoglou L, Patsikas M, et al. Colonic impaction in 31. Goldlist B, Naglie G, Gordon M. Constipation can be deadly: How dogs: A retrospective study of 58 cases (1996 to 2014). J Small Anim to prevent this serious complication in the elderly. Can Fam Physician Pract 2019;60:444–449. 1992;38:2419–2421.

848 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Case Report Rapport de cas

Multiple myeloma and primary erythrocytosis in a dog

Marianna Ricci, Giulia De Feo, Martin Konar, George Lubas

Abstract — A 13-year-old spayed female mixed breed dog was referred for impaired ambulation, limb tremors, back pain, hypergammaglobulinemia on cellulose acetate electrophoresis, and mild proteinuria. Conventional radiology and magnetic resonance imaging (MRI) suggested multifocal neoplastic bone lesions. At the referral examination, lameness and bright red mucous membranes were observed. Severe erythrocytosis, a monoclonal peak in the b-2 globulin detected by capillary zone electrophoresis, severe proteinuria, bone marrow infiltration of plasma cells, and low serum erythropoietin concentrations were reported. The final diagnosis was multiple myeloma associated with severe primary erythrocytosis. This presentation in a dog is interesting because the combination of both disorders is rare in humans and has not been reported in dogs. Key clinical message: Although rare, multiple myeloma and primary erythrocytosis can occur together in dogs.

Résumé — Myélome multiple et érythrocytose primaire chez un chien. Une chienne de race mixte stérilisée âgée de 13 ans a été référée pour troubles de la marche, tremblements des membres, maux de dos, hypergammaglobulinémie à l’électrophorèse sur acétate de cellulose et protéinurie légère. La radiologie conventionnelle et l’imagerie par résonance magnétique (IRM) suggéraient des lésions osseuses néoplasiques multifocales. Lors de l’examen de référence, une boiterie et des muqueuses rouge vif ont été observées. Une érythrocytose sévère, un pic monoclonal de la globuline b-2 détecté par électrophorèse capillaire, une protéinurie sévère, une infiltration de la moëlle osseuse par des plasmocytes et de faibles concentrations sériques d’érythropoïétine ont été rapportés. Le diagnostic final était un myélome multiple associé à une érythrocytose primaire sévère. Cette présentation chez un chien est intéressante car l’association des deux conditions est rare chez l’homme et n’a pas été rapportée chez le chien. Message clinique clé : Bien que rares, le myélome multiple et l’érythrocytose primaire peuvent survenir simultanément chez le chien. (Traduit par Dr Serge Messier) Can Vet J 2021;62:849–853

ultiple myeloma is an uncommon lymphoproliferative as reported in 2 recent studies (3,4). The diagnostic approach M disease, accounting for , 1% of all cancers occurring in to multiple myeloma in dogs requires evidence of at least 2 of humans and dogs. It accounts for , 10% of all hematological the following 4 criteria: i) monoclonal/biclonal gammopathy malignancies in humans and , 8% in dogs (1,2). In dogs, the or paraproteinemia; ii) diagnostic imaging of osteolytic bone giant schnauzer breed (of 22 breeds investigated), neutered lesions; iii) . 10 to 20% plasma cells in the bone marrow; iv) females or intact males, heavier (median body weight 26.4 kg immunoglobulin light chain (Bence-Jones) proteinuria (5–9). versus 16.0 kg in controls), and older (median age 124 mo versus Multiple myeloma is associated with several disturbances 78 mo in controls) animals were significantly more affected, that are related to the effects of the circulating paraprotein and organ or bone marrow dysfunction due to neoplastic infiltration, and lead to a wide array of clinical manifestations, including Department of Veterinary Science, Veterinary Teaching moderate to severe cytopenias. Based on complete blood (cell) Hospital “Mario Modenato,” University of Pisa, Via Livornese, counts (CBC), non-regenerative anemia is the most common SP 22 km 2.6, 56122 San Piero a Grado, Pisa, Italy (Ricci, De Feo, finding and affects up to 68% of dogs. Approximately 25% of Lubas); Associated Veterinary Facility Konar & Tartarelli, 54100 patients are presented with leukopenia, and thrombocytopenia Massa, Italy (Konar). is observed in 17% of cases. Anemia is linked to various causes Address all correspondence to Professor George Lubas; e-mail: including chronic disease, hemorrhage due to coagulopathy, [email protected] myelophthisis, and red blood cell destruction (2,5,7–9). Use of this article is limited to a single copy for personal study. Erythrocytosis is defined as an increase in red blood (cell) Anyone interested in obtaining reprints should contact the count (RBC), hemoglobin concentration (Hgb), and hematocrit CVMA office ([email protected]) for additional (Hct) above established species and breed reference intervals. copies or permission to use this material elsewhere. This condition can be artifactually determined by a decrease

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Figure 1. Radiographical study of thoraco-lumbar-sacral left lateral view; white arrows indicate the suspected osteolytic bone RAPPORTCAS DE lesions.

in plasma fluid volume (relative erythrocytosis) rather than a real increase in RBC mass. In every other case, erythrocytosis is defined as “absolute” and can be primary or secondary. Primary erythrocytosis (PE) [also called “polycythemia vera,” (PV), as occurs in humans in whom an increase in erythrocytes, granulocytes and platelets is frequently documented], is a chronic myeloproliferative disorder with clonal expansion of erythroid cells, which requires little or no erythropoietin (EPO) for differentiation. Secondary erythrocytosis can result from an appropriate (mainly due to cardiac or respiratory disorders) or inappropriate (primarily due to several types of neoplasia) secre- Figure 2. Magnetic resonance images of the thoracolumbar tion of EPO, resulting in a high serum EPO concentration. It spine. STIR dorsal–the vertebral body L2 (long arrow) shows may also be related to an increase in erythrocyte production, diffusely increased signal intensity consistent with infiltration. L1 (short arrow) is partially infiltrated and the 13th rib on the likely linked to an increased activity in specific endocrine glands right side (arrowhead) is infiltrated and thickened. and endocrinopathy (i.e., hyperadrenocorticism, hyperthyroid- ism, and acromegaly) (6,10–12). hypergammaglobulinemia, compatible with a monoclonal peak, Case description 48.6%, RR: 6 to 12), a urinalysis (specific gravity, USG 1.010, A 13-year-old neutered female mixed breed dog was presented proteinuria 2.5 g/L, and urinary protein creatinine ratio, UPCR to the Veterinary Teaching Hospital (VTH) of the University of of 0.8; RR: 0.0 to 0.5), and a coagulation profile (slight increase Pisa with a long clinical history. Approximately 2 mo before the in partial thromboplastin time, PTT, 16.3 s, RR: 10.4 to 16.0 s). hospital referral, the owners presented the dog to the veterinar- An imaging assessment, which included a radiographical study ian because of impaired ambulation, hind-limb tremors, and of the thorax, abdomen, and pelvis, had suspected osteolytic back pain. At that time, the dog was treated with a combina- lesions involving some vertebrae of the thoracolumbar tract tion of robenacoxib, 1 mg/kg body weight (BW) and firocoxib, and one rib (Figure 1). 5 mg/kg BW, both PO, for 2 to 3 d. At this consultation, the A few days later, magnetic resonance imaging (MRI) was dog was slightly depressed and had mild weight loss (21 kg performed (Philips NT Intera, 1.0 T; Philips, Milan, Italy). compared to 22.5 kg before the illness) and a body condition The protocol included dorsal STIR, T2 sagittal and transverse, score (BCS) of 3/9. The CBC had mild erythrocytosis [Hct T1 transverse and 3D T1 dorsal (both pre- and post-contrast) 56%; reference range (RR): 40 to 55%] and mild leukopenia of the thoracic spine, and T2 sagittal and STIR dorsal (both late [white blood (cell) count, WBC 5.2 3 103/mL; RR: 6 to contrast phase) of the lumbar spine (Figure 2). The examination 16 3 103/mL]. The dog tested negative in rapid immunochro- revealed multiple hyperintense lesions of the vertebrae and ribs matographic assays for Leishmania infantum, Ehrlichia canis, in STIR and T2. The lesions were isointense on plain T1, with and Borrelia burgdorferi. mild to moderate contrast uptake. Specifically, the vertebral After 1 mo, the dog was referred again for general lameness, bodies of Th 3, 5, 6, 8, 11, 12, and L1 were partially affected, difficulties in hind-limb movements, progressive weight loss, and the body of L2 had diffusely increased signal intensity and was treated with occasional nonsteroidal anti-inflammatory consistent with infiltration. The right vertebral arch of Th 3, drugs (NSAIDs). Hematocrit was repeated with similar results both vertebral arches of L2 and the left vertebral arch of L3 (Hct 58%; RR: 38 to 55%). Clinicopathological tests deter- were involved. Several ribs had diffusely increased bone marrow mined an unremarkable serum biochemistry analysis, except for signal and at the 13th right rib there was also thickening of the a slight increase in total protein (84 g/L, RR: 54 to 76 g/L) and affected part. At L2, the lesion had also invaded the vertebral a decrease in albumin/globulin (A/G) ratio (0.4, RR: 0.8 to 1.3), canal ventrally and bilaterally to the spinal cord. The latter was a serum protein electrophoresis on cellulose acetate (marked mildly elevated and bilaterally flattened. The findings were

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Figure 3. Magnetic resonance images of the thoracolumbar -2 globulin globulin g spine. T2 sagittal–dorsally to the vertebral body L2 (asterisk) the a ventral CSF line is interrupted (arrowheads) and the spinal cord is slightly elevated. -1 globulin b -1 globulin a -2 globulin Albumin b

Figure 4. Serum protein on capillary zone electrophoresis; note the monoclonal peak in the b-2 globulin region, with reduced consistent with multifocal neoplastic bone marrow infiltration albumin. whose differential diagnoses were multiple myeloma, lymphoma, or other aggressive bone marrow neoplasia (Figures 3, 4). On suspicion of multiple myeloma (MM), the dog was Lastly, the serum erythropoietin concentration was referred to the VTH of Pisa. At clinical examination, a BCS low (0.38 mU/mL; RR: 0.41 to 0.65 mU/mL) by chemilumi- of 3/9 and generalized lameness were confirmed, and bright nescent immunometric assay (Private Veterinary Laboratory, red mucous membranes were observed, with no other signs San Marco, Padua, Italy). of disease. The CBC showed severe erythrocytosis (Hct 73%; The JAK2 mutation was investigated by the Cell Biology RR: 37.3 to 61.7%), moderate hypochromia, no sign of regener- Service (Saint-Louis Hospital, Paris, France) on a blood sample ation, leukogram values at the lower end of the reference range, with K3-EDTA anticoagulant. In nearly 95% of cases of PV in some activated lymphocytes, and normal platelet count. The humans there is an acquired mutation in exon 14 or 12 of the biochemistry panel revealed an increase in total proteins (97 g/L; tyrosine kinase JAK2 (V617F) and the same mutation has been RR: 58 to 78 g/L) with a low A/G ratio (0.47; RR: 0.8 to 1.3), reported in dogs (11,13). In our case, the test was negative for and slight increase in alkaline phosphatase (643 U/L; RR: 45 to the occurrence of this mutation. 250 U/L). Serum capillary zone electrophoresis (CZE) revealed The final diagnosis was multiple myeloma with a monoclonal a monoclonal peak located in the b-2 globulin region (41%; M-component associated with severe primary erythrocytosis. RR: 9.8 to 18.7%; 39.8 g/L; RR: 5.1 to 13.0 g/L) and low Due to the severe lameness and pain and because the owners did albumin (29.2%; RR: 44.5 to 62.2; 28.3 g/L; RR: 28 to 47 g/L) not wish to start antineoplastic treatment, a few days after the (Figure 4). Urinalysis showed isosthenuria (USG 1.010), marked consultation, the dog was euthanized by the local veterinarian, proteinuria (5 g/L), and UPCR of 2.5 (RR: 0.0 to 0.5). The with no opportunity for necropsy. coagulation profile highlighted a slightly prolonged PTT (18.1 s; RR: 10.7 to 17.5 s) and prothrombin time or PT (18.4 s; Discussion RR: 5.4 to 8.1 s). Indirect immunofluorescence tests (IFATs) The simultaneous occurrence of multiple myeloma and primary for L. infantum. and E. canis were both negative. An ultrasono- erythrocytosis in a dog is interesting because both disorders are graphic examination of the abdomen was unremarkable in terms very rare. The combination of multiple myeloma and erythrocy- of any pathological condition related to multiple myeloma or tosis is rarely reported in humans, with some case reports having erythrocytosis. combined multiple myeloma and polycythemia vera and some Bone marrow cytology (sample collected from the iliac having multiple myeloma and erythrocytosis of undetermined crest) revealed an adequate cellularity for megakaryocyte, ery- etiology (14–17). In recent years, a syndrome called TEMPI throid, and myeloid cell lines, with a slight increase in the (telangiectasias, elevated EPO and erythrocytosis, monoclonal myeloid:erythroid ratio (1.91; RR: 0.6 to 1.8), and normal gammopathy, perinephric fluid collection, and intrapulmonary morphological appearance. There was an infiltration of plasma shunting) has been identified in humans and includes 2 of the cells in some spicules, representing . 10% of the overall nucle- main signs presented by our patient, namely erythrocytosis and ated cells. Most plasma cells were clustered and characterized monoclonal gammopathy (18–20). The same 2 signs also occur by a round and eccentric nucleus with a coarsely clumped in another human syndrome called POEMS (polyneuropathy, chromatin surrounded by a blue cytoplasm with a perinuclear organomegaly, endocrinopathy, monoclonal protein, and skin halo or pale zone, sometimes with vacuoles. Plasma cells had changes) in which the endocrinopathy is related to erythrocyto- moderate anisocytosis, anisokaryosis, and some atypical forms sis (21). Neither of the syndromes would appear to match our (binucleated cells, slightly indented nuclei, rarely decondensed patient’s clinical signs. chromatin). Many flame cells (plasma cells with pinkish shade in Multiple myeloma in humans is a slow-growing malignancy, the outer rim of the cytoplasm) were observed (Figures 5A, B). which develops over many years and can lower the efficiency

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A B

RAPPORTCAS DE Figure 5. A — Cluster of various sized plasma cells with different maturation stages in the bone marrow (4003 magnification). B — Several plasma cells with moderate anisocytosis and anisokaryosis, characterized by a round and eccentric nucleus with a coarsely clumped chromatin surrounded by a blue cytoplasm with a perinuclear halo or pale zone, sometimes with vacuoles. A few flame cells (i.e., plasma cells with pinkish shade on the outer rim of the cytoplasm) were observed (arrows) (10003 magnification).

of the immune system, impeding its ability to destroy newly myeloma (23–25). The most striking clinical findings were formed malignant cells (1,22). Multiple myeloma may create lameness and difficulties in hind-limb movements related to a more sustainable environment for formation of secondary spinal cord compression at L2. blood malignancies because it is associated with dysregulation High RBC counts and a low serum EPO concentrations, of genes that control cell growth and survival, resulting in a without any sign of dehydration, supported a diagnosis of multistep process involving alterations in oncogenes and tumor primary erythrocytosis. The normal leukogram was in contrast suppressor genes (23). with the stress condition caused by the disease. Prolongation Polycythemia vera in humans is associated with overproduc- of PT and PTT could be secondary to the unbalanced tion of all 3 cell lines, but with a notable prominence of RBCs. anticoagulant:blood ratio and due to the interference of the Generally, as happens in dogs, the differential diagnosis between M-component. The typical erythroid hyperplasia in the bone primary or secondary polycythemia could be based on serum marrow and the JAK2 mutation were not detected. Moreover, at EPO serum concentration with the reference ranges, low/normal that time we were unable to conduct arterial blood gas analysis and high level, respectively. Moreover, in humans, a mutation that assesses tissue oxygenation as a partial pressure of oxygen

in exon 14 or 12 of the tyrosine kinase JAK2 (V617F) is now (PaO2) and hemoglobin oxygen saturation (SaO2). However, key for polycythemia vera diagnosis (10,11). there were no indications of a pulmonary or cardiac disorder As the canine JAK2 gene shares a strong homology with its on the chest X-ray (12). human counterpart, the presence of the JAK2 mutation in our The coincidence of primary erythrocytosis with multiple patient with an elevated hematocrit was investigated. Identical myeloma could be related to a paraneoplastic condition, since mutations of the JAK2 gene occur in humans and dogs, lead- the dog initially presented with signs of multiple myeloma, ing to a constitutively active JAK2 kinase, suggesting a com- and PE was documented only at a second presentation. Could mon mechanism for human and canine diseases (13). These some substances secreted by multiple myeloma induce primary mutations result in a loss of the auto-inhibitory pseudo-kinase erythrocytosis? This question remains unanswered with just a domain of JAK2, inducing its constitutive activation. This few theories that have been proposed in humans to explain the results in both hypersensitivity to EPO and EPO-independent coexistence of multiple myeloma and polycythemia vera. These erythroid colony formation. Investigation of these mutations include: i) a mutation at the tumor suppressor von Hippel gene; might be more helpful than bone marrow histopathology, which ii) the chance that a group of JAK family of tyrosine kinase, generally has hypercellular marrow with erythroid hyperplasia including the JAK2, may have a role in multiple myeloma and subtle megakaryocytic atypia (10,11). development; iii) the occurrence of TEMPI syndrome; and This case report is compatible with the concurrent condition iv) deposition of monoclonal light chains in the kidney tubules of multiple myeloma and primary erythrocytosis (or polycythe- leading to hypoxia, resulting in increased or impaired EPO mia vera). Supporting the diagnosis of multiple myeloma, the production (14,15,18,26–28). following signs were observed: monoclonal peak, localized in To the best of our knowledge, this is the first case report of the b-2 globulins using capillary zone electrophoresis (a more a dog with a simultaneous diagnosis of multiple myeloma and powerful technique to separate the proteins in comparison to primary erythrocytosis. The precise mechanism for the coexis- cellulose acetate that gave a hyper g-globulinemia); diagnostic tence of these extremely rare diseases remains unknown and it imaging evidence of osteolytic bone lesions, also confirmed may simply have been pure chance. with MRI; and . 10% of plasma cells in the bone marrow. The In our opinion, it is possible that primary erythrocytosis significant proteinuria due to tubular overload of proteins and developed after the appearance of the plasma cell tumor, pos- prolongation of both PTT and PT due to possible paraprotein sibly through multiple processes involving common genetic interference (M-component) are consequences of multiple mutations, changes in the bone marrow microenvironment,

852 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY host-specific factors, and other reasons that might be established 14. Hutchison EL, Taverna JA, Yu Q, Yeager AM. Polycythemia: An unusual presentation of multiple myeloma. Br Med J Case Rep 2016;2016: in the future. CVJ bcr2016216686. 15. Katerji R, Hudson CA. Concurrent polycythemia of undetermined References etiology and smouldering plasma cell myeloma. Case Rep Pathol . 1 Moreau P, San Miguel J, Sonneveld P, et al. Multiple myeloma. ESMO 2018;2018:8781721. Clinical Practice guidelines for diagnosis, treatment and follow-up. Ann 16. Lawrence JH, Rosenthal RL. Multiple myeloma associated with poly- Oncol 2017;28:iv52–iv61. cythemia; report of four cases. Am J Med Sci 1949;218:194–154. REPORT CASE 2. Vail DM. Myeloma-related disorders. In: Vail DM, Thamm DH, Liptak 17. Sang-Guk L, Gayoung L, Sun Young C, et al. JAK2 mutation-negative JM. eds. Withrow and MacEwen’s Small Animal Clinical Oncology. secondary erythrocytosis in smouldering plasma cell myeloma: A case 6th ed. St. Louis, Missouri: Elsevier Saunders, 2020:739–752. study and review of the literature. Acta Haematol 2011;126:169–171. 3. Campigli M, Zoia A, Lubas G, Caldin M. Canine multiple myeloma: 18. Rosado FG, Oliveira JL, Sohani AR, et al. Bone marrow findings of the A retrospective case-control epidemiological survey in Italy. Proc Eur newly described TEMPI syndrome: When erythrocytosis and plasma Soc Vet Oncol 2015:84. cell dyscrasia coexist. Mod Pathol 2015;28:367–372. 4. Campigli M. Multiple myeloma in dog and hemostatic profile as prog- 19. Sykes DR, O’Connell C, Schroyens WA. The TEMPI syndrome. Blood nostic factor: Comparative aspects with human (Italian). PhD thesis, 2020;135:1199–1203. University of Pisa, 2016:184. 20. Zhang X, Fang M. TEMPI syndrome: Erythrocytosis in plasma cell 5. Borgatti A. Plasma cell tumor. In: Weiss DJ, Wardrop KJ, eds. dyscrasia. Clin Lymph Myel Leuk 2018;18:724–730. Schalm’s Veterinary Hematology. 6th ed. Ames, Iowa: Wiley Blackwell, 21. Dispenzieri A. POEMS syndrome: 2017 update on diagnosis, risk 2010:511–519. stratification and management. Am J Hematol 2016;92:814–829. 6. Harvey JW. Evaluation of erythrocytes and disorders of bone marrow. 22. Mehta GR, Suhail F, Haddad RY, Zalzaleh H, Lerma EV. Multiple In: Harvey JW, Veterinary Hematology. A Diagnostic Guide and Color myeloma. Dis Month 2014;60:483–488. Atlas. St. Louis, Missouri: Elsevier Saunders, 2012:49–121; 260–327. 23. Maerki J, Katava G, Siegel D, Silberberg J, Bhattacharyya PK. Unusual 7. Matus RE, Leifer CE, MacEwen EG, Hurvitz AI. Prognostic factors case of simultaneous presentation of plasma cell myeloma, chronic for multiple myeloma in the dog. J Am Vet Med Assoc 1986;188: myelogenous leukemia, and a Jak2 positive myeloproliferative disorder. 1288–1292. Case Rep Hematol 2014;2014:738428. 8. Osborne CA, Perman V, Sautter JH, Stevens JB, Hanlon GF. Multiple 24. Margetic S, Celap I, Dikic L, Vukasovic I, Virovic-Jukic L. Interference myeloma in the dog. J Am Vet Med Assoc 1968;153:1300–1319. of M-protein on prothrombin time test — Case report. Bioch Med 9. Sternberg R, Wypij JM, Barger A. An overview of multiple myeloma in 2016;26:248–254. dogs and cats. Vet Med 2009;104:468–476. 25. Pandey S, Post SR, Alapat DV, Smock KJ, Post GR. Prolonged pro- 10. Cuthbert D, Stein BL. Polycythemia vera-associated complications: thrombin time correlates with serum monoclonal protein concentration Pathogenesis, clinical manifestations, and effects on outcomes. J Blood in patients with plasma cell dyscrasia. Intl J Lab Hematol 2013;35: Med 2019;10:359–371. 421–427. 11. Pillai AA, Babiker HM. Polycythemia. NCBI Bookshelf — Stat Pearls 26. Chang H, Shih LY. Concurrence of multiple myeloma and idiopathic (Internet). Treasure Island, Florida: Stat Pearls Publishing, 2020:1–8. erythrocytosis. Acta Clin Belg 2009;64:434–435. 12. Randolph JF, Peterson ME, Stokol T. Erythrocytosis and polycythemia. 27. Langabeer SE. The JAK2 V617F mutation in plasma cell neoplasms In: Weiss DJ, Wardrop KJ, eds. Schalm’s Veterinary Hematology. 6th ed. with co-exiting erythrocytosis. J Clin Diagn Res 2015;9:EL01. Ames, Iowa: Wiley Blackwell, 2010:162–166. 28. Ghermezi M, Spektor TM, Berenson JR. The role of JAK inhibitors in 13. Beurlet S, Krief P, Sansonetti A, et al. Identification of JAK2 mutations multiple myeloma. Clin Adv Hematol Oncol 2019;17:500–505. in canine primary polycythemia. Exp Hematol 2011;39:542–545.

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CVJ / VOL 62 / AUGUST 2021 853 FOR PERSONAL USE ONLY Case Report Rapport de cas

Subcutaneous and cardiopulmonary dirofilariasis in a dog

Leticia B. Oliveira, Brittany J. McHale, Guilherme G. Verocai, Daniel R. Rissi

Abstract — Canine subcutaneous dirofilariasis is rare and typically caused by Dirofilaria repens. An adult male, intact, mixed breed dog from South Carolina, USA, was examined because of physical trauma to the right maxilla. The dog died during hospitalization and was submitted for necropsy. Gross post-mortem changes included approximately 150 adult nematodes morphologically consistent with Dirofilaria spp. in the pulmonary artery, right atrium, and right ventricle. Histologically there was widespread proliferative pulmonary endarteritis with intraluminal nematodes morphologically consistent with Dirofilaria spp. Four similar nematodes were present in the subcutaneous tissue of the left medial thigh and tibial area. These nematodes were located within the fascia and skeletal muscles. They were surrounded by epithelioid macrophages and multinucleated giant cells, with some lymphocytes and plasma cells, and areas of mineralization (interpreted as mineralized cross sections of nematodes). Nematodes were morphologically identified as D. immitis. Subcutaneous dirofilariasis caused by D. immitis occurs when migrating nematode larvae develop into adults in the subcutaneous and skeletal muscle tissues. Key clinical message: Subcutaneous dirofilariasis in dogs is rare and most often associated with Dirofilaria repens. This case highlights the pathology findings of subcutaneous D. immitis in a dog.

Résumé — Dirofilariose sous-cutanée et cardio-pulmonaire chez un chien. La dirofilariose sous-cutanée canine est rare et généralement causée par Dirofilaria repens. Un chien de race mixte, mâle adulte intact, originaire de la Caroline du Sud, aux États-Unis, a été examiné en raison d’un traumatisme physique au maxillaire droit. Le chien est décédé pendant l’hospitalisation et a été soumis à une nécropsie. Les changements post-mortem macroscopiques incluaient environ 150 nématodes adultes morphologiquement compatibles avec Dirofilaria spp. dans l’artère pulmonaire, l’oreillette droite et le ventricule droit. Sur le plan histologique, il y avait une endartérite pulmonaire proliférative généralisée avec des nématodes intraluminaux morphologiquement compatibles avec Dirofilaria spp. Quatre nématodes similaires étaient présents dans le tissu sous-cutané de la cuisse médiale gauche et de la région tibiale. Ces nématodes étaient situés dans le fascia et les muscles squelettiques. Ils étaient entourés de macrophages épithélioïdes et de cellules géantes multinucléées, avec quelques lymphocytes et plasmocytes, et des zones de minéralisation (interprétées comme des coupes transversales minéralisées de nématodes). Les nématodes ont été identifiés morphologiquement comme D. immitis. La dirofilariose sous-cutanée causée par D. immitis survient lorsque les larves de nématodes en migration se développent en adultes dans les tissus musculaires sous-cutanés et squelettiques. Message clinique clé : La dirofilariose sous-cutanée chez les chiens est rare et le plus souvent associée à Dirofilaria repens. Le cas présent souligne les trouvailles pathologiques associées à la présence sous-cutanée de D. immitis chez un chien. (Traduit par Dr Serge Messier) Can Vet J 2021;62:854–856

Minas Gerais Federal University Veterinary School, Minas Gerais, Belo Horizonte, Brazil (Oliveira); Infectious Disease Laboratory, Small Animal Medicine and Surgery (McHale), Athens Veterinary Diagnostic Laboratory, Department of Pathology (Rissi), University of Georgia College of Veterinary Medicine, Athens, Georgia, USA; Department of Veterinary Pathobiology, Texas A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, Texas, USA (Verocai). Address all correspondence to Dr. Daniel R. Rissi; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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irofilaria immitis and D. repens are filarial nematodes D (family Onchocercidae) that infect dogs, cats, and wild carnivores (1–5). Dirofilaria immitis has a worldwide distribution and it is highly prevalent in the southern USA (1–3). In contrast, the distribution of D. repens is primarily restricted to

Europe, Africa, and Asia. Dirofilaria repens has been recently REPORT CASE confirmed in the southern USA (6). Dirofilaria immitis is the causative agent of heartworm disease, a potentially fatal disease and one of the most serious parasitic infection of dogs (1–3). Infection with Dirofilaria spp. is also associated with subcutaneous dirofilariasis in dogs and cats (7). Dirofilaria immitis is transmitted to the definitive host by an infected female mosquito (Aedes spp., Culex spp., and Anopheles spp.), which releases infective third-stage larvae (L3) from its mouthparts during a blood meal. Subsequently, L3 will enter the Figure 1. Inner aspect of the left thigh of a dog that died after puncture wound and, once in the subcutaneous tissues, will molt physical trauma to the right maxilla. Three adult nematodes are to fourth-stage larvae (L4), then migrate to the heart and pul- embedded in the skeletal muscle fascia (arrow). monary arteries (4,8). During migration, immature adults (L5) dwell within subcutaneous tissues and skeletal muscle of affected dogs (8). Dirofilaria immitis will reach their destination 79 to 120 d after infection. In the heart and pulmonary arteries, plasma cells, and a few eosinophils evident. Nematodes had nematodes become sexually mature and release a new generation a thin eosinophilic cuticle, lateral cords with internal lateral of microfilariae into the bloodstream as early as 6 mo after infec- cuticular ridges, and coelomyrian-polymyarian musculature. In tion. Mosquitoes will become infected after taking a blood meal addition, there was thickening of alveolar septa by macrophages from a microfilaremic host (4). Adult nematodes are typically and neutrophils and eosinophilic proteinaceous edema fluid in the heart and pulmonary arteries, but can be occasionally within alveolar spaces. Subcutaneous nematodes were located detected in other locations, such as the eye, brain, and rarely, within the fascia and skeletal muscle from the left thigh and subcutaneous tissues (1,2,5). Canine subcutaneous dirofilariasis tibial area. Nematodes were surrounded by layers of epithelioid caused by D. immitis is rare (5). This report describes a case of macrophages and multinucleated giant cells with some lym- subcutaneous and cardiopulmonary dirofilariasis (heartworm phocytes and plasma cells (Figure 2B). Small, well-demarcated disease) in a dog associated with D. immitis infection. areas of mineralization (interpreted as mineralized cross sections of nematodes) were seen throughout. Cardiac and subcutane- Case description ous nematodes were collected and submitted for morphologic An adult male mixed-breed dog from South Carolina, USA, examination, and were identified as mature adult specimens died after acute physical trauma of unknown origin to the right of D. immitis based on the pattern of cuticular striations in maxilla. The dog had no history of travel. No other historical male and female specimens and on the length of spicules of information was available. Clinically, there was avulsion of males (1:2 ratio) (9). the gingival mucosa and left pelvic limb lameness. The dog Pathological changes and parasitology results in this case are died during hospitalization and was submitted for necropsy. consistent with concomitant subcutaneous and cardiopulmonary Gross anatomic changes were characterized by the presence of D. immitis infection (1–5,9). Subcutaneous dirofilariasis in approximately 150, white, 2 mm 3 300 mm adult nematodes dogs is most often associated with D. repens (10–13). Although that occluded the pulmonary artery, right atrium, and right endemic in the Old World (6), D. repens has not been reliably ventricle. Four similar nematodes were discovered in the subcu- identified in the New World until recently (7). Nevertheless, taneous tissue of the left medial thigh and tibial area (Figure 1). subcutaneous dirofilariasis in dogs in the Americas is rare and The lungs were edematous, and the right kidney had 2 irregular, mainly associated with D. immitis (5). Recently in Europe, depressed, and pale-yellow areas in the cortex (diagnosed as subcutaneous D. repens infection has been spreading from chronic infarcts). No other gross changes were observed. endemic areas in the south to areas in the north and the east of Routine tissue samples were collected, immersed in 10% the continent. This has been associated with increasing incidence buffered formalin, processed for histology, and stained with of subcutaneous infection in dogs and subcutaneous and ocular hematoxylin and eosin. Histologically, widespread prolifera- disease in humans (6). tive endarteritis with intraluminal nematodes was observed Clinical signs of cutaneous and subcutaneous dirofilariasis in throughout the lungs (Figure 2A). Affected arteries exhibited dogs include pruritus, alopecia, erythema, and papular or nodu- tortuous architecture characterized by a thickened tunica intima, lar dermatitis, and/or panniculitis (5,10). However, most natural with subendothelial proliferation of spindle cells that formed and experimental cases are subclinical (6,10,12). Histologically, papillary projections into the vascular lumen. These areas were lesions are characterized by single or multiple areas of dermal covered by reactive endothelium and had scattered lymphocytes, and/or subcutaneous granulomatous or pyogranulomatous

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Figure 2. A — Histological appearance of the pulmonary artery. There is proliferative endarteritis (asterisk) and an intraluminal nematode with a thin eosinophilic cuticle (arrowhead) and coelomyrian-polymyarian musculature (arrow). Hematoxylin and eosin (H&E); bar = 1 mm. B — Photomicrograph of cross sections of nematodes pictured in Figure 1. Four cross sections of nematodes (arrows) are scattered throughout the muscular fascia and skeletal muscle of the left thigh. H&E; bar = 1 mm. Inset: Closer view of a mineralized nematode surrounded by epithelioid macrophages. H&E; bar = 300 mm.

inflammation with occasional eosinophils, lymphocytes, and disturbances caused by the presence of cardiac nematodes, as no plasma cells associated with intralesional adult nematodes or evidence of microfilaremia was detected based on histological microfilariae (5,10,11,13). The pathogenesis of subcutaneous examination of multiple organs (1). CVJ dirofilariasis is poorly understood and it is unknown whether the lesions are caused by direct mechanical action by the nematodes References or secondary to the secretion of pro-inflammatory cytokines . 1 Anvari D, Narouei E, Daryani A, et al. The global status of Dirofilaria immitis in dogs: A systematic review and meta-analysis based on pub- and subsequent inflammation (10). Similar to this case, affected lished articles. Res Vet Sci 2020;131:104–116. tissues can often have a mild or no inflammatory reaction to 2. Bowman DD, Atkins CE. Heartworm biology, treatment, and control. the parasites (12). Vet Clin North Am Small Anim Pract 2009;39:1127–1158. 3. Dantas-Torres F, Otranto D. Dirofilariosis in the Americas: A more A key histologic feature to distinguish among species of virulent Dirofilaria immitis? Parasit Vectors 2013;6:288. Dirofilaria includes the lack of longitudinal cuticular striations 4. McCall JW, Genchi C, Kramer LH, Guerrero J, Venco L. Heartworm in D. immitis, which are present in D. repens (11,14). Based on disease in animals and humans. Adv Parasitol 2008;66:193–285. 5. Scott DW. Nodular skin disease associated with Dirofilaria immitis these characteristics, the nematodes observed in tissue sections infection in the dog. Cornell Vet 1979;69:233–240. in this case were morphologically consistent with D. immitis. 6. Genchi C, Kramer L. Subcutaneous dirofilariosis (Dirofilaria repens): This was confirmed by parasitological identification. The pres- An infection spreading throughout the old world. Parasit Vectors 2017; 10:517. ence of subcutaneous granulomatous inflammation with areas 7. Hays KM, Rodriguez JY, Little SE, et al. Heartworm prevalence in dogs of mineralization in the current case were indicative of a chronic versus cats: Multiple diagnostic modalities provide new insights. Vet infection. It remains unknown whether the reported left pelvic Parasitol: X 2020;4:100027. 8. Kotani T, Powers KG. Developmental stages of Dirofilaria immitis in limb lameness in the current case was associated with the pres- the dog. Am J Vet Res 1982;43:2199–2206. ence of the nematodes or was associated with the traumatic 9. Furtado AP, Melo FT, Giese EG, dos Santos JN. Morphological rede- event that caused damage to the maxilla. The absence of joint scription of Dirofilaria immitis. J Parasitol 2010;96:499–504. 10. Albanese F, Abramo F, Braglia C, et al. Nodular lesions due to infes- and bone lesions may suggest the former. tation by Dirofilaria repens in dogs from Italy. Vet Dermatol 2013; Although typically non-pathogenic, Acanthocheilonema recon- 24:255–e256. ditum is another filarial nematode that affects dogs and wild 11. Bredal WP, Gjerde B, Eberhard ML, Aleksandersen M, Wilhelmsen DK, Mansfield LS. Adult Dirofilaria repens in a subcutaneous granuloma on canids in North America and should be considered as a differ- the chest of a dog. J Small Anim Pract 1998;39:595–597. ential diagnosis for subcutaneous nematodiasis (15). Similar to 12. Genchi M, Pengo G, Genchi C. Efficacy of moxidectin microsphere the current case, adult A. reconditum reside in the subcutaneous sustained release formulation for the prevention of subcutaneous filarial (Dirofilaria repens) infection in dogs. Vet Parasitol 2010;170:167–169. tissues of affected individuals but are rarely observed during 13. Tarello W. Clinical aspects of dermatitis associated with Dirofilaria necropsy because of their minute size (1 to 3 cm long) and low repens in pets: A review of 100 canine and 31 feline cases (1990–2010) prevalence of infection (15). and a report of a new clinic case imported from Italy to Dubai. J Parasitol Res 2011;2011:578385. In addition to D. immitis in the subcutaneous tissues, the 14. Gardiner CH, Poynton SL, eds. An Atlas of Metazoan Parasites in dog of the current report had a high infestation in the heart Animal Tissues. Washington, DC: American Registry of Pathology, and pulmonary arteries which likely contributed to the rapid 1999:38. 15. Patton S, Faulkner CT. Prevalence of Dirofilaria immitis and clinical decline and death following hospitalization. The renal Dipetalonema reconditum infection in dogs: 805 cases (1980–1989). infarcts in the current case were likely secondary to circulatory J Am Vet Med Assoc 1992;200:1533–1534.

856 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Case Report Rapport de cas

Intramuscular Grade 1 fibrosarcoma: Magnetic resonance imaging findings in 2 dogs

Karine P. Gendron, Elizabeth W. Howerth, Koichi Nagata, Michael Perlini, Nicole Northrup

Abstract — Two adult neutered male dogs were presented for evaluation of firm, painless masses arising within muscle: an 8-year-old German wirehaired pointer dog with an accessory tricipital growth, and a 3-year-old German shepherd dog with a gracilis muscle growth. Magnetic resonance imaging (MRI) characteristics suggested malignant behavior, with a central fluid-like portion with a hyperenhancing lining, a nidus of disorganized tissue, and an extensive reactive zone, whereas histopathology was consistent with low-grade fibrosarcoma. This report describes histologically low-grade, yet biologically high-grade intramuscular fibrosarcoma, in which MRI provided detailed information on tumor behavior and assisted with biopsy and surgical planning.

Résumé — Fibrosarcome intramusculaire de Grade 1 chez deux chiens : Imagerie par résonance magnétique. Ce rapport de cas décrit des fibrosarcomes intramusculaires de bas grade histologique mais au comportement biologique de haut grade ainsi que leur imagerie par résonance magnétique (IRM) chez deux chiens mâles castrés évalués pour des masses musculaires fermes et indolores : un Braque Allemand de 8 ans avec une masse originant de la branche accessoire du muscle triceps, et un Berger Allemand de 3 ans avec une masse au muscle gracile. L’IRM a révélé une zone centrale liquide bordée d’une mince couche au rehaussement marqué, adjacent à un foyer de tissu désorganisé, entourés par une zone réactive étendue. L’histopathologie des lésions révèle un fibrosarcome et malgré la présence d’anomalies histologiques de bas grade, l’infiltration des muscles adjacents est documentée par microscopie et les caractéristiques d’imagerie sont celles associées chez l’humain avec un comportement malin. (Traduit par les auteurs) Can Vet J 2021;62:857–860

Case descriptions Bayer HealthCare, Whippany, New Jersey, USA) as contrast Dog 1 medium [0.1 mmol/kg body weight (BW), IV]. The following sequences were acquired: sagittal plane T2-weighted (T2w) and n 8.5-year-old neutered male German wirehaired pointer PD DIXON in 3-mm slices and T1-weighted (T1w) DIXON dog was presented for a non-painful mass caudal to the A pre- and post-contrast in 0.8-mm slices, and transverse plane right humerus. No lameness was detected; however, the owner T2w in 4-mm slices, T2* and DWI in 5-mm slices. reported that the dog stumbled a few times the previous week. The accessory head of the right triceps was enlarged by a Magnetic resonance (MR) images were acquired in a 3T unit lesion consisting of a medium-sized (L 4.3 cm 3 W 2.7 cm 3 (Skyra 3T; Siemens Healthcare, Erlangen, Germany) using an H 3.5 cm) amorphous mass adjacent to a 3.8-cm long crescen- 18-channel body coil and gadopentate dimeglumine (Magnevist; tic core of fluid intensity (Figure 1). Tissular components were moderately heterogeneous and hyperintense to muscle in T2w and proton density (PD) sequences and minimally hyperin- Department of Veterinary Biosciences and Diagnostic Imaging tense to muscle in T1w sequences. Wispy T2w-hyperintensity (Gendron, Perlini), Department of Pathology (Howerth), extended to the extremities of the muscle and into the adjacent Department of Small Animal Medicine and Surgery (Nagata, portions of the lateral, medial and long heads of the triceps Northrup), College of Veterinary Medicine, University of (Figure 1C, D), consistent with local invasion. Strong contrast Georgia, Athens, Georgia 30602, USA. enhancement along the T2w- and PD-hypointense cavity mar- Address all correspondence to Dr. Karine P. Gendron; e-mail: gins decreased to streaky enhancement peripherally. Humeral [email protected] surfaces and cortex were normal; however, the marrow had a Use of this article is limited to a single copy for personal study. pronounced T1w hypointense non-enhancing arborescent pat- Anyone interested in obtaining reprints should contact the tern, consistent with hemopoietic elements (1). A computed CVMA office ([email protected]) for additional tomographic study (Siemens Somatom Sensation, Munich, copies or permission to use this material elsewhere. Germany) of the thorax, abdomen, and forelimbs was performed

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Figure 1. Magnetic resonance image of Dog 1, Grade 1 fibrosarcoma in the accessory head of the triceps muscle. Extensive peritumoral hyperintensity and enhancement are present in A — Sagittal plane T2w and B — T1w post-contrast. Images C and D are T2w transverse images along the reference lines in A. Tumor infiltration of the adjacent tricipital heads: arrows point to T2w hyperintensity effacing fascial planes and extending into muscles. Lat — lateral; Long — long; M — medial head. E — In delayed phase CT at the same level as C there is poor definition of the tricipital heads and difficulty in estimating peritumoral edema and tumor infiltration.

including non-enhanced, vascular and delayed phases, using Trilogy linear accelerator (Varian Medical Systems, Palo Alto, iohexol as contrast agent (Omnipaque 350; GE Healthcare, California, USA), with a total dose of 57 Gray in 19 daily Princeton, New Jersey, USA, at 600 mgI/kg BW, IV at 5 mL/s). (Monday to Friday) fractions. Twenty-six months after surgery Helical acquisition parameters consisted of spiral pitch 0.8, the dog is alive, with a moderate, weight-bearing mechanical 120 kV and 250 mAs, 0.625 mm slices reconstructed to 2 mm lameness, but otherwise well. in bone and soft tissue algorithms. The thorax and abdomen were negative for metastasis or concurrent disease. The right Dog 2 tricipital lesion was diffusely similarly hypoattenuating prior A 3-year-old neutered male German shepherd dog was presented to contrast, without arterial enhancement. Two minutes after for hind-limb lameness of 4 mo duration, characterized by a injection, the cavity borders enhanced moderately, with less reluctance to rise and ambulate. A stiff gait with bilateral hind- radial extension than on MRI. Fascial planes between muscles limb lameness was noted. On palpation, the inner thigh, specifi- were diffusely effaced (Figure 1E). cally the gracilis muscle region, was asymmetrically enlarged, Cytologic examination of the bone marrow was consistent which was worse on the right. No abnormality was detected on with mild myeloid hyperplasia. Preliminary histopathologic referral pelvic radiographs. assessment by incisional biopsy was consistent with fibrosar- Magnetic resonance imaging of the pelvic and thigh region coma. Six days after the biopsy, the dog underwent surgical was obtained in a similar fashion as in Dog 1. Sequences removal of the accessory head of the triceps muscle. The muscle obtained included sagittal plane PD DIXON in 3-mm slices and was pale tan to white and firm, and fascial planes between the T1w DIXON pre- and post-contrast in 0.8-mm slices, dorsal accessory head and the lateral head were unclear, forcing par- T2w DIXON in 3-mm slices, and transverse PD DIXON in tial myectomy of the lateral head. An approximately 7 cm 3 3-mm slices. The right gracilis muscle was moderately enlarged 4.5 cm 3 3 cm section of muscle was submitted for histo- with a lesion originating 1.5 cm distal to the pelvic symphysis pathologic examination. It contained an unencapsulated, poorly (Figure 2). The epicenter of the lesion consisted of a large area demarcated, infiltrative, mild to moderately cellular neoplasm (L 4.2 cm 3 W 2.3 cm 3 H 2.4 cm) of fluid intensity, adja- composed of spindle cells producing moderate to abundant col- cent to which muscle was distorted with a swirling T2w- and lagen arranged in intersecting and anastomosing bundles and PD-hyperintense pattern, T1w isointense and strongly enhanc- streams. Neoplastic cells had scant to moderate eosinophilic ing. T2w and PD hyperintensities consistent with peritumoral cytoplasm and ovoid to elongate nuclei with stippled chroma- edema tracked the entire length of the gracilis muscle from tin and variably distinct nucleoli. The mitotic count was 5 per its symphysial origin to tibial insertion and into the proximal 2.4 mm2 (equivalent to 10 FN22/403 field). Binucleate and aspect of the contralateral gracilis muscle. Irregular hyperen- multinucleate cells were occasional. Foci of necrosis (, 10%) hancing digitations reached the subcutaneous tissues of the were scattered within the neoplasm. Neoplastic cells multifocally caudal aspect of the thigh. No bone involvement was detected. extended to all surgical margins, including into the lateral head Surgical wedge biopsies were obtained. A firm, discolored mass of the triceps. Identifiable myofibers had a spectrum of changes was identified. Fragments of the muscle mass were submitted including necrosis, contraction bands, pyknosis, and karyolysis. for histopathology and contained an unencapsulated, expansile, Fibrosarcoma, Grade 1, based on the criteria of Dennis et al (2), partially circumscribed, mildly cellular neoplasm composed of was diagnosed. spindle cells producing abundant collagen and forming streams One month after surgery, the dog underwent definitive and bundles (Figure 3). Tumor cells had scant eosinophilic intensity-modulated radiation therapy delivered by a Varian cytoplasm and small oval to elongate central nuclei with coarsely

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Figure 2. Magnetic resonance images of the pelvic region of Dog 2. A — Dorsal plane T2w DIXON FS. B — Transverse PD DIXON FS at the level of the reference line. C — Sagittal T1w VIBE DIXON FS after contrast. A Grade 1 fibrosarcoma is present in the right gracilis muscle, with peritumoral hyperintensities reaching far along fascial planes from insertion (not pictured), into the adjacent right adductor and semimembranosus muscles, and proximally to the symphysis and into the left gracilis muscle. Despite a histologic diagnosis of a Grade 1 fibrosarcoma, several features of high-grade sarcoma are present: peritumoral enhancement, poor margin definition, heterogeneity, and peritumoral high signal intensity on T2w images.

Figure 3. Histologic findings of intramuscular fibrosarcoma in each dog. Hematoxylin and eosin stain. A — Dog 1. Area where fibrosarcoma (F) infiltrates into adjacent myofibers (M). Note the poorly defined, infiltrative margin (arrows). Associated myofibers are separated and of variable diameter with degenerative and regenerative changes. B — Dog 2. In this area the mass is fairly circumscribed, although unencapsulated (arrows). There is coagulative necrosis of the adjacent myofibers.

stippled chromatin and 1 to 2 small nucleoli. Anisocytosis and tion with or without radiation therapy (5–10). Histopathologic anisokaryosis were minimal and the mitotic count was 3 per grade in the 2 cases of intramuscular fibrosarcoma presented 2.4 mm2 (equivalent to 10 FN22/403 field). Fibrosarcoma, here was based on criteria used for cutaneous and subcutaneous Grade 1 was diagnosed (2). Further diagnostic options including soft tissue tumors in dogs as no grading scheme exists for these biopsy of the left gracilis muscle were declined by the owner and tumors within muscle (2). The current WHO classification, no follow-up was available. which does not apply to dogs, recognizes 4 malignant types of fibroblastic/myofibroblastic tumors (11). This list includes Discussion adult fibrosarcoma, a slowly growing tumor originating from the Fibrosarcomas involving the deep soft tissues are rare in humans intramuscular and intermuscular fibrous tissue, fascial envelopes, and in recent veterinary textbooks are only discussed together aponeuroses or tendons, which when large, grows in a diffusely with other soft tissue sarcomas (3–7). In dogs, fibrosarcomas invasive manner (3,4,12). For the 2 cases herein, there are imag- most commonly arise in the skin, subcutaneous tissue, and ing and histologic similarities with adult fibrosarcoma. oral cavity, and comprise between 3.1 to 3.4% of canine can- Despite receiving a low histologic grade, MRI features of cers (7,8). Fibrosarcomas are locally infiltrative and prone to both dogs’ lesions are listed in humans as being more common recurrence (6–9), and standard of care therapy is surgical resec- with high-grade tumors, such as poor margin definition on

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nonenhanced images, heterogeneity, and extensive peritumoral fibrosarcoma; however, MRI provided subtle detail of locore- edema (13,14). Peritumoral enhancement, the strongest inde- gional invasive behavior, supporting its value in the presurgical pendent indicator of high-grade, was also present (13). These planning of soft tissue sarcoma in dogs. CVJ findings suggest there may be a mismatch between histologic and biologic behaviors of intramuscular fibrosarcoma in dogs as References previously reported for tumors in the oral cavity (6–9). Further . 1 Romano L, Pinto A. Errors in Radiology. Milan, Italy: Springer, 2012. 2. Dennis MM, McSporran KD, Bacon NJ, Schulman FY, Foster RA, correlation between imaging, pathology, and clinical behavior in Powers BE. Prognostic factors for cutaneous and subcutaneous soft such cases would be required to test the tenet that in the man- tissue sarcomas in dogs. Vet Pathol 2011;48:73–84. agement of soft tissue sarcoma, histologic type is less important 3. Bahrami A, Folpe AL. Adult-type fibrosarcoma: A reevaluation of 163 putative cases diagnosed at a single institution over a 48-year than histologic grade (2,7,13,15). period. Am J Surg Path 2010;34:1504–1513. The reactive zone around a tumor, also referred to as peri- 4. Folpe AL. Fibrosarcoma: A review and update. Histopathology RAPPORTCAS DE tumoral edema, consists of reactive mesenchymal cells, neo- 2014;64:12–25. 5. Kudnig ST, Séguin B, eds. Veterinary Surgical Oncology. Chichester, vascularization, inflammation, and possibly satellite tumor UK: Wiley-Blackwell, 2012. cells (12,16). Areas of peritumoral T2w-hyperintensities are 6. Klopfleisch R. Veterinary Oncology — A Short Textbook. Cham, generally considered to be an integral part of the lesion, and Switzerland: Springer, 2016. 7. Vail D, Thamm D, Liptak J. Withrow and MacEwen’s Small Animal in humans are removed together with the tumor (17,18). Clinical Oncology. 6th ed. St. Louis, Missouri: Elsevier, 2020. Granulation tissue secondary to surgical interventions would 8. Gustafson DL, Duval DL, Regan DP, Thamm DH. Canine sarcomas as display T2w-hyperintensity and enhancement similar to tumor a surrogate for the human disease. Pharmacol Ther 2018;188:80–96. 9. Ciekot PA, Powers BE, Withrow SJ, Straw RC, Ogilvie GK, LaRue SM. tissue, and for this reason it is strongly recommended that imag- Histologically low-grade, yet biologically high-grade, fibrosarcomas of ing for tumor extent be completed prior to biopsy (12). the mandible and maxilla in dogs: 25 cases (1982–1991). J Am Vet Med The changes observed in the 2 cases described here differ Assoc 1994;204:610–615. 10. Kung MBJ, Poirier VJ, Dennis MM, Vail DM, Straw RC. Hypo from low-field MRI characteristics of injection site sarcoma in fractionated radiation therapy for the treatment of microscopic canine cats, in which tumor tissue is T2w and T1w hyperintense, and soft tissue sarcoma. Vet Comp Oncol 2016;14:e135–e145. moderate to marked heterogeneous contrast enhancement and 11. Fletcher CDM, Bridge JA, Hogendoorn P, Mertens F, eds. WHO classification of tumours of soft tissue and bone (IARC WHO classification mineralization of larger masses are reported (19). Magnetic reso- of tumours). 4th ed. Vol 5. World Health Organization, 2013. nance imaging changes also differed from those seen in abscesses 12. Vanhoenacker FP, Parizel PM, Gielen JL. Imaging of Soft Tissue Tumors. in that secondary signs such as lymphadenopathy or draining 4th ed. Cham, Switzerland: Springer, 2017. 13. Zhao F, Ahlawat S, Farahani SJ, et al. Can MR imaging be used to pre- tract were absent, the lining of the cavities appeared thinner dict tumor grade in soft-tissue sarcoma? Radiology 2014;272:192–201. and more distinct compared to mature abscess capsules, and 14. Xiang P, Zhang X, Liu D, Wang C, Ding L, Zhang Z. Distinguishing T2w-hyperintensities peripheral to the epicenter of the lesion soft tissue sarcomas of different histologic grades based on quantitative MR assessment of intratumoral heterogeneity. Eur J Radiol 2019; were not regional but rather compartmentalized. 118:194–199. In veterinary medicine, surgical and radiation therapy plan- 15. Hohenhaus AE, Kelsey JL, Haddad J, et al. Canine cutaneous and ning for soft tissue tumors are commonly performed using subcutaneous soft tissue sarcoma: An evidence-based review of case management. J Am Anim Hosp Assoc 2016;52:77–79. computed tomography (CT) out of convenience, whereas in 16. White LM, Wunder JS, Bell RS, et al. Histologic assessment of peri- humans, MRI is regarded as the modality of choice by virtue tumoral edema in soft tissue sarcoma. Int J Radiat Oncol Biol Phys of its ability to distinguish whether a mass is confined to a 2005;61:1439–1445. 17. Kaya M, Wada T, Nagoya S, et al. MRI and histological evaluation of single muscle compartment or invades surrounding struc- the infiltrative growth pattern of myxofibrosarcoma. Skeletal Radiol tures (12,13,20,21). In both cases presented here, MRI revealed 2008;37:1085–1090. local invasion. In Dog 1, encroachment of the fascial planes by 18. McDonald DJ. Limb-salvage surgery for treatment of sarcomas of the extremities. AJR Am J Roentgenol 1994;163:509–513. the tumor was not detected as clearly with CT as with MRI. 19. Rousset N, Holmes MA, Caine A, Dobson J, Herrtage ME. Clinical In accordance with the literature on humans, transverse planes and low-field MRI characteristics of injection site sarcoma in 19 cats. were determined to be more useful for the evaluation of the Vet Radiol Ultrasound 2013;54:623–629. 20. Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: A sys- fascial margins, and in hindsight this plane was underused in tematic imaging approach. Radiology 2009;253:297–316. both cases (12,20). Magnetic resonance imaging characteristics 21. Bahig H, Roberge D, Bosch W, et al. Agreement among RTOG Sarcoma of soft tissue sarcoma are often nonspecific of a tumor type (12). Radiation Oncologists in contouring suspicious peritumoral edema for preoperative radiation therapy of soft tissue sarcoma of the extremity. Based on this information, the similar MRI features of the cases Int J Radiat Oncol Biol Phys 2013;86:298–303. presented in this report likely are not pathognomonic of Grade 1

860 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Case Report Rapport de cas

Medial malleolus fragmentation following talocalcaneal arthrodesis by a dorsomedial approach in a horse

Pablo Espinosa-Mur, Mathieu Spriet, Marcos Perez Nogues, Thomas Cullen, Larry D. Galuppo

Abstract — A 16-year-old, Quarter Horse mare was presented for a 3/5 right hind lameness associated with osteoarthritis of the talocalcaneal joint (TCLJ). Positron emission tomography (PET) and computed tomography (CT) demonstrated marked increased uptake of 18F-sodium fluoride and bone remodeling at the medial facet of the TCLJ, respectively. Under general anesthesia 2 cortical screws (4.5 and 5.5 mm) were placed in neutral fashion via an arthrotomy from dorsomedial to plantaromedial through the medial facet of the TCLJ followed by copious lavage of the tarsocrural joint. Eight weeks after surgery, observable effusion of the tarsocrural joint was present and lameness had worsened. Radiographic examination revealed a fragmented medial malleolus of the tibia, likely secondary to repetitive trauma of the screw heads during tarsal flexion. Repeated CT showed partial fusion of the TCLJ. Both screws were removed and the tarsocrural joint was thoroughly lavaged arthroscopically. At a 20-month recheck the lameness had not improved, and ultrasound examination revealed severe thickening of the TCLJ capsule. Recheck examination 48 mo after surgery showed complete fusion of the TCLJ and resolution of the lameness. Key clinical message: Diagnosis of osteoarthritis of the TCLJ is challenging. Management by arthrodesis using a dorsomedial approach can result in fragmentation of the medial malleolus, with secondary synovitis and capsulitis of the tarsocrural joint.

Résumé — Fragmentation de la malléole médiale suite à une arthrodèse talo-calcanéenne par voie dorso- médiale chez un cheval. Une jument Quarter Horse âgée de 16 ans a été présentée pour une boiterie postérieure droite de 3/5 associée à une arthrose de l’articulation talo-calcanéenne (TCLJ). La tomographie par émission de positrons (TEP) et la tomodensitométrie (CT) ont démontré une augmentation marquée de l’absorption du fluorure de sodium-18F et un remodelage osseux significatif au niveau de la facette médiale du TCLJ, respectivement. Sous anesthésie générale, deux vis corticales (4,5 et 5,5 mm) ont été placées de façon neutre via une arthrotomie dorso- médiale à plantaro-médiale à travers la face médiale du TCLJ suivie d’un lavage abondant de l’articulation tarso- crurale. Huit semaines après la chirurgie, un épanchement significatif de l’articulation tarso-crurale était présent et la boiterie s’était aggravée. L’examen radiographique a révélé une malléole médiale du tibia fragmentée, probablement secondaire à un traumatisme répétitif des têtes de vis lors de la flexion du tarse. La tomodensitométrie répétée a montré une fusion partielle du TCLJ. Les deux vis ont été retirées et l’articulation tarso-crurale a été soigneusement lavée par arthroscopie. Lors d’un nouveau contrôle après 20 mois, la boiterie ne s’était pas améliorée, et l’échographie a révélé un épaississement sévère de la capsule TCLJ. Un nouvel examen 48 mois après la chirurgie a montré une fusion complète du TCLJ et une résolution de la boiterie. Message clinique clé : Le diagnostic de l’arthrose du TCLJ est difficile. La prise en charge par arthrodèse par voie dorso-médiale peut entraîner une fragmentation de la malléole médiale, avec synovite secondaire et capsulite de l’articulation tarso-crurale. (Traduit par Dr Serge Messier) Can Vet J 2021;62:861–866

Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada (Espinosa Mur), Department of Surgical and Radiological Sciences (Spriet, Galuppo); Veterinary Medical Teaching Hospital (Perez Nogues, Cullen), School of Veterinary Medicine, University of California, Davis, California, USA. Address all correspondence to Dr. Pablo Espinosa Mur; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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he talocalcaneal joint (TCLJ) is composed of 4 articular T facets (1,2). The medial and lateral facets of the talus located proximally are the largest and both articulate with the calcaneus (1,2). The strong interosseous ligament occupies a central tarsal sinus holding both bones together (1,2). Motion of the TCLJ is limited and the forces applied between both bones by adjacent tendons and ligaments are complex (1). Contraction of the gastrocnemius muscle allows tarsal extension by pulling proximally on the tuber calcani (1,3). A B Only 3 reports regarding TCLJ osteoarthritis management in Figure 1. Lateral to medial radiographs of the right tarsus taken horses are available in the literature (2–4) and surgical arthrod- 6 mo before presentation (A) and at the time of presentation (B). RAPPORTCAS DE esis has only been reported in 8 cases (6 by plantarolateral Between A and B there is progression of the arthritic changes approach, 1 by dorsomedial approach and 1 by combination of specially at the most distal portion of the talocalcaneal joint immediately proximal to its articulation with the tarsal plantarolateral and dorsomedial approaches) (2,4). The reported bones 1 and 2. outcome in these cases has been generally good (8/8 had improved lameness score) (2,4). The aim of this report is to describe lameness evaluation and advanced diagnostic imaging findings in a horse affected by osteoarthritis (OA) of the TCLJ and to report a major post operative complication not previously described after arthrodesis by a dorsomedial approach. A Case description A 16-year-old Quarter Horse mare used for trail riding was admitted for evaluation of right hind lameness of 4 mo duration. Prior to referral, the tarsometatarsal (TMT) and distal intertarsal (DIT) joints were radiographed, showing bilateral moderate osteoarthritis of the TMT and DIT joints. These joints were B previously medicated (14 and 6 mo before admission) with Figure 2. Multiplanar reformat computed tomography (CT) intra-articular corticosteroids by the referring veterinarian. Due (top row, A) and fused positron emission tomography (PET)/CT to the lack of a satisfactory response with the injections, the case (bottom row, B) images (sagittal, transverse, and dorsal from left to right) of the right tarsus are shown. Lateral is to the left. There was referred for surgical arthrodesis of the TMT joint. is partial fusion of the tarsometatarsal and distal intertarsal joints without 18F-NaF uptake. Marked 18F-NaF uptake, is however, Clinical findings present at the medial aspect of the talocalcaneal joint. At presentation, mild to moderate osseous proliferation at the medial aspect of the TMT and DIT joints was palpable bilaterally. Palpation of the tarsocrural joint (TCJ) indicated that it tomography (CT) scan was performed under general anesthesia was normal. Lameness examination revealed a 3/5 right hind to further characterize the tarsal joints changes for surgical plan- lameness (5). Proximal limb flexion of the right hind exacerbated ning. The PET images were acquired with a compact scanner the lameness. No change in lameness was noted after an abaxial (PiPET; Brain Biosciences, Rockville, Maryland, USA) 90 min sesamoidean nerve block and subsequent low 6 point nerve after intravenous injection of 20 mCi of 18F-sodium fluoride block of the right hind limb with lidocaine hydrochloride 2% (18F-NaF). Computed tomography was performed immediately (APP, Zurich, Illinois, USA) (2 mL per side). A high 4-point after the PET scan under the same anesthetic episode using a nerve block was performed (4 mL of lidocaine 2% per site) and 16-slice GE Lightspeed scanner (GE Healthcare, Princeton, resulted in a 50% reduction in lameness. Finally, a tibial nerve New Jersey, USA). The PET images were co-registered with the block (15 mL lidocaine 2%) completely abolished the right hind CT images using 3D visualization and analysis software (Amira, lameness 10 min after the injection. Intra-articular anesthesia FEI; ThermoFisher Scientific, Waltham, Massachusetts, USA) of the TMT and DIT with lidocaine 2% was later attempted and fused using a DICOM viewer (Horos; Nimble, Annapolis, but the osseous proliferation and resulting reduced joint space Maryland, USA). made intra-articular administration impossible. Focal 18F-NaF uptake was seen at the dorsolateral aspect of the TMT joint and at the proximomedial aspect of the third Diagnostic imaging metatarsal bone consistent with the sites of osseous remodeling Repeat tarsal radiographs (Figure 1) confirmed the presence observed with CT. The PET/CT demonstrated fusion of the of moderate OA at the level of the TMT and DIT joints. plantar and medial aspect of the DIT joint without concurrent Ultrasound examination of the proximal plantar metatarsal increased 18F-NaF uptake. Marked 18F-NaF uptake was present region revealed mild thickening of the suspensory ligament at at the medial aspect of the TCLJ (Figure 2) with osseous remod- its origin. A positron emission tomography (PET)/computed eling visible at the distal aspect of this joint. On CT, marked

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A B A C Figure 3. A — Ultrasound image of the medial side of the B D talocalcaneal joint. Irregular joint margins (yellow arrow) and effusion (arrowheads) are visible. The deep fibers of the medial collateral ligament are visible (red arrows). B — 3D-volume rendering CT image after needle placement confirming proper intra-articular positioning.

Figure 5. A — Opened tarsocrural joint of cadaveric specimen after placement of two 4.5-mm cortical screws and maximal flexion of the tarsus. Proximal is to the top and medial is to the right. There is clear impingement of the screw head of the proximal screw in the medial malleolus (red arrowheads). B — Three-dimensional CT reconstruction of the CT performed immediately before screw removal. The distal screw head appears to protrude more dorsally compared to the proximal one. C — Intra-operative arthroscopic from second surgery showing both screw heads. Proximal is the right. In this image, the distal screw head also appears to slightly protrude more compared to the proximal one. D — Intra-operative arthroscopic image of the Figure 4. Multiplanar reformat computed tomography (CT) on medial malleolus. Impression marks from the distal screw head transverse (left image) and dorsal plane (right image) illustrating are obvious (red arrowheads). the angulation required to reach the medial facet of the talocalcaneal joint using the plantarolateral approach.

Prior to surgery, 6 cadaveric limbs were used to test the opti- osseous remodeling of the distal aspect of the TCLJ was visible mal point for drilling and angle for screw placement targeting without notable increase in 18F-NaF uptake visible on PET scan. the medial facet of the TCLJ from a dorsomedial approach These findings suggested that active osteoarthritis of the TCLJ with the starting point dorsal to the distal tubercle of the talus. was likely the main cause of the lameness as the DIT changes After screw placement, maximal flexion of the tarsus revealed appeared inactive and the TMT abnormalities were mild. impingement between the screw heads and the medial malleo- Ultrasound revealed effusion of the medial aspect of the lus (Figure 5) in the first 3 specimens. In the remaining limbs, TCLJ (Figure 3). An ultrasound-guided injection of 80 mg a more aggressive countersink was performed before screw of methylprednisolone (Zoetis, Kalamazoo, Michigan, USA) insertion and the impingement with the medial malleolus was into the TCLJ was performed in a sterile fashion using a linear avoided. The horse was premedicated with procaine penicil- 5–10 MHz transducer (LOGIQ e Ultrasound; GE Healthcare) lin G (VetOne, Boise, Idaho, USA), 22 000 IU/kg body weight and a 21-gauge 1.5 inch needle. The position of the needle was (BW), IM, gentamicin (Phoenix TM, St. Joseph, Missouri, confirmed with CT (Figure 3). The horse had an uneventful USA), 6.6 mg/kg BW, IV, and phenylbutazone (Phoenix TM), assisted recovery from general anesthesia. 4.4 mg/kg BW, IV. After sedation with xylazine hydrochloride (Sigma Aldrich, St. Louis, Missouri, USA), 1.1 mg/kg BW, Surgery IV, anesthesia was induced using a combination of midazolam Two weeks after injection, notable, gradual improvement of (Cerilliant, Round Rock, Texas, USA), 0.2 mg/kg BW, IV, and lameness was reported by the owner. Eight weeks later, the ketamine (Cerilliant), 2.2 mg/kg BW, IV, and maintained on lameness had worsened and was similar to the degree of lame- isofluorane (Zoetis) with a closed circuit system. The horse was ness at initial presentation. Surgical arthrodesis of the medial positioned in dorsal recumbency with the affected hind limb facet of the TCLJ was then elected. A dorsomedial approach was extended. A 4-cm incision was made axial to the saphenous chosen over a plantarolateral approach in order to better target vein. The proximal part of the cunean tendon was transected to the distal portion of the TCLJ medial facet that was severely facilitate access to the distal talus. The joint capsule of the TCJ affected in this case. A plantarolateral approach would imply was incised. Lateral radiographs were taken to ensure proper that the medial facet is entered at a very acute angle as illustrated positioning of a 3.2-mm drill bit in the dorsal aspect of the talus in Figure 4. For the most proximal portion of the medial facet, and proper angulation in a distoproximal direction (Figure 6). the plantarolateral approach would have risked penetration of Plantaroproximal-plantarodistal oblique (calcaneal skyline) the tarsal sheath and disruption of the plantar concave cortex views were taken to ensure correct lateral to medial angulation of the sustentaculum tali. of the drill bit with respect to the medial facet of the TCLJ

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A B

A B C C D Figure 7. Dorsolateral-plantaromedial oblique (A), latero- medial (B), and dorsomedial-plantarolateral oblique (C) projections taken at the 8-week postoperative recheck examination. There is moderate to severe soft tissue swelling on

RAPPORTCAS DE the dorsomedial aspect of the tarsus and bony debris originating from fragmentation of the medial malleolus. Both screws appeared to be in the same position when compared to the intra-operative radiographs.

Figure 6. Latero-medial (A) and calcaneal skyline (B) intra- operative radiographs showing drill bits orientation targeting when compared to the examination performed before surgery. the medial facet of the talocalcaneal joint. Subcutaneous needles were placed in the plantar aspect of the tarsus in order Radiographs showed fragmentation of the medial malleolus to facilitate orientation. Lateral to medial (C) and calcaneal and incomplete fusion of the TCLJ. A CT was performed to skyline (D) intra-operative views after screw placement. Intra- assess the degree of fusion of the TCLJ. Computed tomography operative dorso-plantar view after screw placement (E). showed several small osseous fragments adjacent to the medial malleolus. There was progressive sclerosis and osteophytosis along the length of the talocalcaneal joint and along the medial (Figure 6). The 3.2-mm drill bit was left in place and a second aspect of the calcaneus; however, fusion of the joint remained 3.2-mm drill bit was placed more proximally using the first drill incomplete. Considering the fragmentation of the medial mal- bit and the same radiographic projections (lateral to medial and leolus associated with impingement of the screw heads as noted calcaneal skyline) to assist with targeting of the medial facet of during the pre-operative cadaveric trial, removal of both screws the TCLJ. After satisfactory positioning of the bits was achieved, under arthroscopic guidance under the same anesthetic episode the second more proximal 3.2-mm drill bit was replaced with as the CT was performed. Arthroscopic exploration revealed a 4.0-mm drill bit. Both drill bits were advanced into the cal- severe synovitis and multiple adhesions dorsally. Mild cartilage caneus without penetrating the far cortex of the sustantaculum fibrillation was present at the distal portion of the medial troch- tali. Both holes were deeply countersunk, measured, and tapped. lear ridge; no wear lines were visualized. The proximal screw For the distal hole, a 46-mm 4.5-mm cortical screw was placed head appeared well-buried and the distal screw head seemed to in neutral fashion. Proximally a 50-mm 5.5-mm cortical screw protrude very slightly from the hole (Figure 5C). A defect on the was placed, also in neutral fashion. Intra-operative radiographs medial malleolus from the screw head was evident (Figure 5D). confirmed correct angulation and slight divergence of the screws During flexion of the tarsus under arthroscopic guidance, the (Figure 6). The TCJ was then needle lavaged. defect aligned with the distal screw head. Instrumental portal The TCJ capsule and subcutaneous space were closed and location was guided by inserting a percutaneous needle into the the limb was bandaged in a sterile fashion. Assisted recovery dorsomedial pouch of the TCJ. A motorized synovial resector from general anesthesia using head and tail ropes was unevent- (Karl Storz, Goleta, California, USA) connected to a suction ful. Phenylbutazone was administered (1.1 mg/kg BW, PO) pump was used to debride proliferative synovium. Osseous twice daily for 3 d and once daily for another 7 d. After surgery, debris was removed from the space between the distal tubercle the horse was kept under strict stall rest for 2 wk, followed by of the talus and the medial malleolus using a Ferris Smith 5 min hand walks for 6 wk. rongeur (Sontec Instruments, Centennial, Colorado, USA). Larger bony fragments were also removed with the rongeurs. Outcome The medial malleolus was curetted until subchondral bone was Eight weeks after surgery, the owner reported that the mare exposed. A third incision was made dorsomedially by the screw appeared more painful when standing. A postoperative heads. A notable amount of metallic debris resulted from the recheck examination revealed moderate to severe TCJ effusion. impact of the screwdriver with the screwheads. After removal Radiographs showed a fragmented medial malleolus of the right of both screws the joint was copiously lavaged. The horse was tibia (Figure 7). Minimal fusion of the TCLJ was noted to have discharged 2 d later with recommendations for 2 wk of strict occurred with the joint margins stillvisible, although slightly less stall rest followed by short periods of hand walking. Three doses well-defined. Rehabilitation maneuvers (passive flexion exercises of autologous conditioned serum (IRAP; Orthokine, Dechra twice daily) were recommended and a 3-week course of firocoxib Veterinary Products, Leawood, Kansas, USA) were injected (Merial, Duluth, Georgia, USA), 0.1 mg/kg BW, PO, q24h, was into the TCJ at 2-week intervals starting at the time of suture started. Ten weeks after surgery, the effusion and pain were still removal. Eight weeks later, the horse was admitted for recheck apparent. The degree of lameness seen at the trot had worsened evaluation. The lameness grade was static (3/5), the TCJ was still

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fusion of the DIT. These changes, however, were not associated with uptake on the PET scan, suggesting the lesions were not active and likely not clinically relevant at this stage. The PET demonstrated that the most active lesions in the tarsus were in the talocalcaneal joint. Nuclear scintigraphy has been previously

used to identify osteoarthritis of the TCLJ (2,4). It is likely REPORT CASE that in the current case, scintigraphy would also have shown increased radiopharmaceutical uptake in the TCLJ region, but A B PET was chosen over scintigraphy for its 3-dimensional properties that allow for direct pairing with the excellent anatomi- Figure 8. Radiographs taken 48 months after surgery. A — Lateral to medial projection and calcaneal skyline (B) views cal resolution provided by the CT. Due to the cross-sectional of the right tarsus showing complete fusion of the TCLJ and nature, the higher spatial resolution and the higher affinity progressive loss of visualization of the distal intertarsal joint of the 18F-NaF for areas of bone remodeling, PET compares space with bridging new bone. favorably to scintigraphy as was recently demonstrated in the racehorse fetlock (9). Positron emission tomography is not only more sensitive than scintigraphy, but it also greatly improves the localization of active osseous lesions. Whereas scintigraphy effusive, and tarsal flexion elucidated an obvious pain response. would indicate uptake in the region of the talus and calca- Radiographs taken at this time showed almost complete fusion neus, PET can specify which part of which articular surface is of the medial facet of the TCLJ. The horse had been turned involved, which is important for surgical planning. out in a small paddock when at home. Twenty months after the In retrospect, arthritic changes of the TCLJ were present on initial surgery the horse was still lame at the trot (3/5) and it the radiographs of the case reported here. The advanced arthritic was retired from any future athletic activity. Ultrasonographic changes and remodeling at the TMT and DIT joints present at examination showed severe capsulitis and synovitis of the TCJ. that time had likely distracted examiners attention away from the Radiographic examination showed progression of the arthritic TCLJ. This report shows that careful assessment of the TCLJ should changes at the level of the DIT joint and improved but still always be performed when lameness is localized to the tarsal region. incomplete fusion of the TCLJ. Intra-articular block of the Intra-operative imaging was essential to better target the TCJ with 15 mL lidocaine hydrochloride 2% (VetOne, Boise, medial facet. More specifically, a vertical calcaneal skyline view Idaho, USA) induced a marked improvement of the lameness helped to precisely target the affected medial facet. To our (approximatively 75% reduction of lameness). knowledge, this intra-operative view for this procedure has not A recheck examination 48 mo after the initial surgery showed been reported. In the current case, slight divergence between the absence of lameness and negative flexion test. Radiographs 2 drill bits was achieved in the lateral to medial plane by leaving revealed complete fusion of the TCLJ visible on both lateral to 1 drill bit in place, placing subcutaneous needles on the plantar medial and the calcaneal skyline view (Figure 8). Progressive loss aspect of the tarsus, and by using the vertical calcaneal skyline of visualization of the distal intertarsal joint space with bridging view. A repeat PET scan before the second surgery in order to new bone was also visible. The intracapsular soft tissue swelling assess the changes in bone activity subsequent to the initial had improved and the horse was used for pleasure riding. examination could have yielded valuable information; however, as surgical removal of the screws was planned under the same Discussion anesthetic episode, PET was not possible due to radiation safety This is the first report of severe TCLJ osteoarthritis treated with concerns. Therefore, only a CT scan was performed. Ultrasound surgical arthrodesis that included the use of PET/CT to assess of the TCLJ, although primarily used for needle guidance, was complex tarsal lesions in horses. A rare complication not previ- able to identify changes including joint effusion and irregular ously described is also reported. joint margins with periarticular osteophytosis. Advanced imaging was indicated in this case for further Pauwels et al (2) reported the use of 3 screws inserted at the characterization of the tarsal lesions and to better determine distal tubercle of the talus in a pony. The aim of the surgical appropriate surgical options. Computed tomography is com- arthrodesis was to provide stability to the medial facet of the monly used for this purpose as it provides cross-sectional data TCLJ. In the current report, the cortical screws were placed in and allows for excellent assessment of osseous structures. The neutral over lag fashion to avoid modifying the biomechanical addition of 18F-NaF PET imaging provided functional informa- relationship of the talus and the calcaneus to one another (4). tion, which is complementary to the structural information from A dorsomedial approach was chosen in this case. However, the CT. 18F-NaF incorporates at sites of exposed hydroxyapatite relatively successful outcomes were reported by Smith et al (4) matrix, thus highlighting active bone turnover (6). In humans, using the plantarolateral approach. Future studies evaluating the 18F-NaF PET has been used to detect, and precisely localize effect of screw angulation are necessary to better determine the sites of active bone modelling in patients with foot pain of optimal screw position. undetermined origin (7,8). This case is an excellent illustration The cadaveric specimens used for preparation showed the of the use of 2 synergistic imaging modalities. The most severe potential complication of impingement of the screw heads with changes observed on CT related to the disease and subsequent the medial malleolus and the dorsomedial approach. Awareness

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of this complication meant that both screw holes were deeply References countersunk during surgery. Computed tomographic examina- . 1 Barone R. Arthrologie et Myologie. Anatomie comparée des mammifères tion showed that the distal screw head was protruding slightly domestiques. vol. 7. Paris, France: Vigot, 1983:291–321. more than the proximal one. We suspect that this complication 2. Pauwels FE, Adams SB, Blevins WB. Arthrodesis of the talocalcaneal joint for the treatment of two horses with talocalcaneal osteoarthritis. could have been avoided with even more aggressive coun- Vet Comp Orthop Traumatol 2005;18:7–12. tersinking, using another approach (plantaromedial or plan- 3. White NA, Turner TA. Hock lameness associated with degeneration of tarolateral), applying headless compression screws (10), or by the talocalcaneal articulation: Report of two cases in horses. Vet Med Small Anim Clin 1980;75:678–681. using arthroscopy during the initial surgery in order to directly 4. Smith RK, Dyson SJ, Schramme MC, et al. Osteoarthritis of the talo- assess the depth of the screw head within the countersunk hole. calcaneal joint in 18 horses. Equine Vet J 2005;37:166–171. Alternatively, a more medial location of the screws may have 5. American Association of Equine Practitioners. Definition and classification of lameness. Guide for Veterinary service and judging of minimized the risk of screw impingement. The fragmentation

RAPPORTCAS DE equestrian events. Lexington, Kentucky: American Association of Equine of the medial malleolus seen on this case lead to severe synovitis Practitioners, 1991. and capsulitis of the TCJ and secondary chronic pain and lame- 6. Even-Sapir E, Mishani E, Flusser G, Metser U. 18F-Fluoride positron ness at this location. emission tomography and positron emission tomography/computed tomography. Semin Nucl Med 2007;37:462–469. The current article reports a major postoperative complica- 7. Rauscher I, Beer AJ, Schaeffeler C, et al. Evaluation of 18F-fluoride tion after surgical arthrodesis of the TCLJ that equine orthope- PET/MR and PET/CT in patients with foot pain of unclear cause. dic surgeons should be aware of. This report also highlights the J Nucl Med 2015;56:430–435. 8. Fischer DR, Maquieira GJ, Espinosa N, et al. Therapeutic impact of complexity of tarsal osteoarthritis in horses and demonstrate [(18)F]fluoride positron-emission tomography/computed tomography the value of 18F-NaF PET for specific assessment of activity and on patients with unclear foot pain. Skeletal Radiol 2010;39:987–997. localization of osseous lesions. 9. Spriet M, Espinosa-Mur P, Cissell DD, et al. (18) F-sodium fluoride positron emission tomography of the racing Thoroughbred fetlock: Validation and comparison with other imaging modalities in nine Acknowledgments horses. Equine Vet J 2019;51:375–383. We thank the referring veterinarian and owner Dr. Jill Higgins 10. Hirsch JE, Galuppo LD, Graham LE, Simpson EL, Ferraro GL. Clinical evaluation of a titanium, headless variable-pitched tapered cannulated without whom this case report would not have been possible. compression screw for repair of frontal plane slab fractures of the third CVJ carpal bone in thoroughbred racehorses. Vet Surg 2007;36:178–184.

Erratum CVJ 2019:60:1060

Error in the Abstract:

Original: …however, dogs premedicated with methadone and alfaxalone appeared significantly less sedated than dogs premedicated with midazolam at 15, 20, and 25 minutes post-injection (P = 0.04). Dogs receiving methadone and alfaxalone were almost 5 times more likely to show excitement than those receiving midazolam (P = 0.03). We concluded that adding midazolam to an intramuscular combination of methadone and alfaxalone cannot be recommended in healthy dogs.

Correction: …“however, dogs premedicated with midazolam, methadone, and alfaxalone appeared significantly less sedated than dogs premedicated without midazolam at 15, 20, and 25 minutes post-injection (P = 0.04). Dogs receiving midazolam, methadone, and alfaxalone were almost 5 times more likely to show excitement than those not receiving midazolam (P = 0.03). We concluded that adding midazolam to an intramuscular combination of methadone and alfaxalone cannot be recommended in healthy dogs.”

866 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY Case Report Rapport de cas

Fungal osteitis of the axial aspect of the mid body of the medial proximal sesamoid bone in a horse

Alejandro Merchán, Jana K. Voss, Marie-Soleil Dubois

Abstract — The satisfactory outcome of fungal osteitis in an 8-year-old American Quarter Horse is described. The horse was admitted with a grade 4 out of 5 lameness and exhibited metacarpophalangeal synovial effusion, indicative of a mild suppurative inflammation. Results of initial radiographic and ultrasonographic examination were unremarkable. Intra-articular anesthesia of the metacarpophalangeal joint allowed localization of the insult. It was not until day 6 of hospitalization when lytic changes on the axial aspect were observed on radiographic examination. Arthroscopic examination permitted identification and debridement of the affected bone. Fungal culture of the bone yielded Pleosporales spp. The horse was sound at the time of discharge after 12 days of hospitalization. No complications occurred in the post-operative period and the horse resumed his initial level of activity and competition in barrel racing. Key clinical message: To our knowledge, this is the first description of successful outcome of a fungal osteitis of the sesamoid bones following arthroscopic debridement. We hypothesize that the satisfactory outcome is associated with early recognition of the condition and aggressive debridement of the lesion arthroscopically.

Résumé — Ostéite fongique de la face axiale du milieu du corps de l’os sésamoïde proximal médial chez un cheval. L’évolution satisfaisante de l’ostéite fongique chez un Quarter Horse américain de 8 ans est décrite. Le cheval a été admis avec une boiterie de grade 4 sur 5 et présentait un épanchement synovial métacarpo-phalangien, indicatif d’une légère inflammation suppurée. Les résultats de l’examen radiographique et échographique initial étaient sans particularité. L’anesthésie intra-articulaire de l’articulation métacarpo-phalangienne a permis de localiser le site affecté. Ce n’est qu’au jour 6 de l’hospitalisation que des modifications lytiques de la face axiale ont été observées à l’examen radiographique. L’examen arthroscopique a permis l’identification et le débridement de l’os affecté. La culture fongique de l’os a donné des Pleosporales spp. Le cheval était sain au moment de sa sortie après 12 jours d’hospitalisation. Aucune complication n’est survenue dans la période post-opératoire et le cheval a repris son niveau initial d’activité et de compétition en course de barils. Message clinique clé : A notre connaissance, il s’agit de la première description de l’issue positive d’une ostéite fongique des os sésamoïdes après débridement arthroscopique. Nous émettons l’hypothèse que le résultat satisfaisant est associé à une reconnaissance précoce de l’affection et à un débridement agressif de la lésion sous arthroscopie. (Traduit par Dr Serge Messier) Can Vet J 2021;62:867–871

acterial osteitis of the proximal sesamoid bones has been fungal septic arthritis and osteitis (6–10). In humans, especially B well-described, and various mechanisms have been pro- in the presence of immunodeficiency, treatment of fungal osteitis posed to explain its pathophysiology (1–6). However, fungal and fungal septic arthritis is challenging mainly because these involvement is not common, and information provided in the entities are rare and the available treatments are limited (11). veterinary literature is sparse, with only a few case reports of One report of this condition in the veterinary literature by

Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario N1G 2W1. Address all correspondence to Dr. Marie-Soleil Dubois; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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Sherman et al (8) involved a 12-year-old Standardbred horse A B with fungal osteitis of the axial border of the proximal sesamoid bone that was treated with amikacin by regional limb perfusions and intra-articular joint lavage and with systemic itraconazole. No surgical treatment was attempted and the horse was retired due to progression of osteoarthrosis and presence of a mild lameness (8). The present case report describes the clinical presentation, diagnostic procedures, medical and surgical treatments of fungal osteitis of the proximal sesamoid bone in an 8-year-old American Quarter Horse used for barrel racing. The outcome was satisfactory following arthroscopic identification of the RAPPORTCAS DE defect and debridement. Case description An 8-year-old American Quarter Horse gelding used for barrel Figure 1. Dorsal palmar view of the left metacarpophalangeal racing was referred to Ontario Veterinary College following a joint 4 d before admission (A) with no significant findings and left forelimb lameness of 1-week duration, which was thought to 6 d after admission (B), at which time a radiolucent area was have been initiated by an unobserved traumatic event. The horse observed on the axial aspect of the mid body of the medial proximal sesamoid bone (arrow). Lateral is to the left and medial was found at his return from pasture with minor lacerations to the right. on the head, as well as swelling of the left fore distal limb. The following day, lameness was noted as well as a mild fever. A complete radiographic series of the left fore distal limb centered over the fetlock area performed by the attending veterinarian showed twice a day and bandage management during the first 5 d of no abnormalities of the bones (Figure 1A). An initial tentative hospitalization. Although the soft tissue swelling decreased sub- diagnosis of cellulitis was made, and the horse was started on stantially during the initial 5 d, the joint effusion and lameness gentamicin, ceftiofur, and flunixin meglumine. Regional limb remained unchanged. Recheck synovial samples were obtained, perfusion with ceftiofur was performed twice before presenta- with results similar to those at admission. Intra-articular anes- tion. The horse’s clinical signs initially improved; however, the thesia of the left metacarpophalangeal joint with 20 mL of 2% day of presentation to Ontario Veterinary College — Health lidocaine (Lidocaine; Teligent, Mississauga, Ontario) resulted Sciences Centre (OVC — HSC) the horse had increased swell- in an improvement of 90% in the lameness. ing and lameness. Due to recurrence of the clinical signs, the Radiographs of the left metacarpophalangeal joint were horse was referred for further assessment. repeated on Day 6 of hospitalization. The medial proximal On admission, the horse showed marked lameness of the left sesamoid bone showed a radiolucent area consistent with lytic front limb, grade 4 out of 5 [American Association of Equine changes on the axial aspect of the mid body (Figure 1B). Upon Practitioners (AAEP) grading scale], edema over the fetlock ultrasonographic evaluation of the palmar aspect of the fetlock, region and synovial effusion of the left metacarpophalangeal an irregular surface of the axial contour of the mid body of the joint. The remainder of the physical examination was unre- medial sesamoid bone was observed. The horse had clinical evi- markable. An ultrasound of the left flexor tendons, suspen- dence of metacarpophalangeal joint involvement; however, due sory ligament, and metacarpophalangeal joint was performed. to the location of the lesions on diagnostic imaging, involvement Abnormalities were limited to effusion within the metacarpo- of the digital flexor tendon sheath could not be excluded, as phalangeal joint and thickening of the subcutaneous tissues. mild effusion of the digital flexor tendon sheath was recognized. Arthrocentesis of the metacarpophalangeal joint was performed Therefore, an intrathecal synovial sample was obtained from in the dorsal pouch, where swelling was minimal, and indicated the left distal digital flexor tendon sheath. The total nucleated a very mild suppurative inflammation and mild hemorrhage cell count was 2500 cells/mL with a total protein of , 20 g/L, (total cell count 6200 cells/mL with 78% lytic neutrophils, which was within normal limits. 15% small lymphocytes, and 7% macrophages, and a total Based on the radiographic, ultrasonographic, and intra- protein of 48 g/L); amikacin was administered intra-articularly articular/intrathecal synovial fluid analyses, it was decided after the sample was collected. No growth was observed on to perform an elective arthroscopic exploration of the left bacterial culture. Medical therapy consisted of sodium penicil- metacarpophalangeal joint on Day 7 of hospitalization. lin (Penicillin G Sodium; Fresenius Kabi Canada, Toronto, Pre-operative, venous blood gas and electrolyte analy- Ontario), 22 000 IU/kg body weight (BW), IV, q6h, and gen- sis were within normal limits. The horse was sedated with tamicin (Gentocin; Merck Animal Health, Kirkland, Quebec), xylazine (Xylamax; Vétoquinol Canada, Lavaltrie, Quebec), 6.6 mg/kg BW, IV, q24h, as well as the anti-inflammatory 1 mg/kg BW, IV, induced with ketamine (Narketan; Vétoquinol drug phenylbutazone (Rafters-McCarthy & Sons, Calgary, Canada), 2 mg/kg BW, IV, and diazepam (Diazepam; Sandoz, Alberta), and the gastro-protectant sucralfate (Sucralfate; Aptalis, Boucherville, Quebec), 0.05 mg/kg BW, IV, placed in dorsal Mont-St-Hilaire, Quebec), 20 mg/kg BW, PO, q8h, on Day 1. recumbency, and maintained with isoflurane (Fresenius Kabi In addition to medical therapy, the horse received hydrotherapy Canada, Toronto, Ontario) in 100% oxygen. The left front limb

868 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 2. Arthroscopic view of the left metacarpophalangeal Figure 3. Arthroscopic view of the left metacarpophalangeal joint showing the lesion on the axial aspect of the mid body of joint showing the lesion after debridement on the axial aspect of the medial proximal sesamoid bone characterized by an area of the mid body of the medial proximal sesamoid bone. Proximal is abnormal articular cartilage (green arrows). Proximal is at the at the bottom. bottom. was clipped from the coronary band to distal to the carpus and that could lead to tearing of the intersesamoidean ligament, aseptically prepared and draped. Upon exploration of the palmar extension of an infection of the metacarpo/tarsophalangeal joint aspect of the joint, an area of abnormal, discolored, irregular or digital flexor tendon sheath, and septic or aseptic thrombosis cartilage, approximately 8 mm in diameter, was identified on the of the microvasculature of the proximal sesamoid bone (2,5,6). axial aspect of the mid body of the medial proximal sesamoid In cases of proximal sesamoid bone osteitis, trauma can cause bone (Figure 2). A needle could easily be inserted in the defect, micro damage to the vasculature of the intersesamoidean liga- indicating abnormal softness of the subchondral bone. The ment, potentially leading to thrombi formation and avascular abnormal cartilage was debrided, revealing an area of necrotic necrosis of the adjacent bone (12). Trauma to the intersesamoi- subchondral bone 6 mm in depth. All necrotic bone and dean ligament is a less likely etiology in our case, due to normal loose cartilage were debrided down to healthy subchondral bone ultrasonographic appearance of the structure and direct visual- (Figure 3). No anomalies were identified in the lateral sesamoid ization of the intact ligament upon arthroscopic evaluation. It bone. Samples of the necrotic bone were submitted for bacterial remains unclear how the fungal osteitis developed. However, and fungal culture. The joint was thoroughly flushed, and the fungal infections can have a wide presentation from indolent to skin incisions were closed. A sterile dressing was applied. a rapid destruction. Normally, immunocompetent and immu- No bacteria were isolated from the bony samples; however, nocompromised individuals would have fungal involvement 30 d after submission the laboratory reported growth of a of the bone and joint associated with a hematogenous spread, filamentous fungus resembling Pleosporales spp. In the post- an inoculation by a foreign body, or by a nearby fungal infec- operative period, the effusion of the metacarpophalangeal tion (11). Considering this horse had no history of any type of joint was reduced significantly, and the lameness was markedly injection in the area and no signs of penetrating wound, direct improved. Re-evaluation of the synovial fluid on Day 3 after inoculation seems improbable. It is likely that the previously surgery revealed a return to normal of the total nucleated cell reported traumatic event initiated a process that ultimately count, 1000 cells/mL. Only a small sample could be obtained, resulted in the development of septic fungal osteitis. Therefore, so there was insufficient fluid for a total solid measurement. The it can be suspected that the fungus reached the osseous lesion horse was transitioned to oral trimethoprim-sulfamethoxazole via locoregional inoculation. (Apotex, Weston, Ontario), 30 mg/kg BW, PO, q12h, and This case was originally diagnosed as cellulitis due to the discharged from the clinic on Day 12 of hospitalization. The initial severe swelling of the area and the associated lameness. attending veterinarian repeated the radiographs 4 wk after However, as the swelling subsided, substantial lameness and discharge and the lesion remained unchanged. At the time of joint effusion remained. Arthrocentesis of the metacarpopha- writing (16 mo after discharge) the horse was sound and had langeal joint was performed to assess the joint status and there returned to the same level of performance as before the illness. was a slight increase in synovial total nucleated cell count and total protein, compatible with a traumatic or inflammatory Discussion process but not pathognomonic of a septic process. Cytological Septic osteitis of the proximal sesamoid bones has been well- results associated with sepsis have varied widely in the litera- described (1–4). Mechanisms that have been proposed to explain ture, ranging from 19 300 to 48 000 cells/mL (8,12). Bracken the pathophysiology of this condition, include trauma, injuries et al (13) investigated systemic inflammatory markers, total associated with lateral condylar fractures, biomechanical stresses synovial fluid leukocyte count, and neutrophil percentage in

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joints infected with bacteria or fungus. The results did not dis- available; therefore, antifungal therapy was not instituted. This criminate whether an infection could be of bacterial or fungal decision was based on the clinical progression of the horse and origin (13). In general, in cases presented in various reviews, after close follow-up with the referring veterinarian and owner; synovial fluid analysis values were within a normal reference considering the horse had no residual lameness or joint effusion range or significantly increased (2,8,12). Low values within it was deemed unnecessary to proceed with further treatments. the abnormal reference range could be associated with an early We acknowledge the lack of information on the outcomes stage of the disease. associated with unnecessarily broad empiric antimicrobial treat- Intra-articular anesthesia of the left metacarpophalangeal ment, as described in human medicine (20). As hypothesized in joint was conducted to further assess the lameness, which was Cohen et al (21) and other reviews (22), the aggressive systemic, markedly improved by the procedure. A radiographic survey of intra-articular and regional limb perfusion with antibiotic in the fetlock joint was then repeated at Day 6 of hospitalization, combination with local immune suppression could have had RAPPORTCAS DE identifying the lytic lesion of the axial aspect of the medial a role in creating an environment for the fungus, in our case proximal sesamoid bone. These findings were in accordance Pleosporales spp., to develop. with previous reports (2,3,6,8,14). Similar to 4 of the cases Mycology culture performed on the necrotic bone from the described by Dabareiner et al (2), radiographic examination lesion revealed a filamentous fungus resembling Pleosporales spp.; was not diagnostic early in the disease process. Radiography we have not found any case in the literature with this fungal continues to be the main diagnostic imaging tool for osteomy- growth. Of the 100 000 fungal species described, 150 have elitis (15). However, radiographic changes of osteomyelitis lag been reported to be pathologic in humans and animals (11). behind appearance of clinical signs. In acute cases, conventional In equine patients, the most common agents isolated in fun- radiographs may only show soft tissue swelling, but fail to gal infectious arthritis have been Candida, Aspergillus, and reveal early osseous lesions. A 30 to 50% loss in bone density Scedosporium (6,8,21). Garcia-Hermoso et al (23) conducted a is required before lucencies are visible on radiographs (16,17). study on coelomycetes identifying 66.1% of the strains belong- Sequential radiographic series are necessary for early recognition ing to the order Pleosporales. In humans, infections by these of an osteomyelitis process. Approximately 21 d post-infection fungi are rare and poorly characterized, due to the difficulty are necessary to obtain an 80 to 90% of diagnostic accuracy of in identifying these fungi using only phenotypic tools (24). radiographs (18,19). Computed tomography could provide an Superficial or subcutaneous infection is the most common clini- earlier identification of the bone insult, as described by Lean cal finding following a traumatic inoculation of contaminated et al (15). plant material or soil particles during agricultural work in tropi- The combination of the response to the intra-articular anes- cal and subtropical areas (24). Galipothu et al (25) described thesia and the radiographic findings prompted an exploratory a cutaneous fungal infection in a renal transplant patient arthroscopy of the palmar pouch of the left metacarpophalangeal due to a rare fungus that belonged to the order Pleosporales. joint. This exploration was beneficial to further characterize the Physiopathology of those infections in horses has not been lesion and to proceed to treatment. No other anomalies were described. seen in the joint, including the intersesamoidean ligament, The excellent clinical outcome of the single case described which was intact. This contrasts with the cases described by here does not correspond with results in horses with septic Dabareiner et al (2), in which arthroscopic exploration showed fungal processes described elsewhere (2,6,8,12). We believe that deleterious progress in the disease process such as intersesamoi- early recognition of the condition and thorough arthroscopic dean ligament discoloration, fraying and detachment from the debridement were decisive in the short- and long-term prog- corresponding proximal sesamoid bone, as well as osteochondral nosis and future athletic performance of this horse. However, fragmentation and osteomalacia involving the axial border of the the rapid response without the aid of antifungal therapy could proximal sesamoid bone. In addition, contrary to those cases, indicate that there was no primary fungal infection, and that the metacarpophalangeal joint in the case we describe did not contamination of the sample could have occurred, or that this communicate with the distal digital tendon sheath after debride- specific fungus was not particularly pathogenic and therefore ment of the lesion on the axial aspect of the medial proximal easier to eliminate. Overall, relying on the literature, a bacterial sesamoid bone. Unfortunately, the exact time of the surgical or fungal osteitis should be considered first on the list of dif- intervention after appearance of the clinical signs was not ferential diagnoses when diagnostic imaging modalities reveal specified; therefore, we cannot establish an exact comparison. osteolysis of the axial border of the proximal sesamoid bones. We hypothesize that surgical intervention early in the disease We conclude that early surgical intervention might result in a process prevents further progression of the condition, resulting good outcome. CVJ in a successful patient outcome. The horse was prescribed broad-spectrum antibiotics as a References septic process was suspected. A septic process can be present . 1 Chan CCH, Munroe GA. Septic tenosynovitis and focal osteomyelitis of the lateral proximal sesamoid bone in a thoroughbred gelding. Vet even in the face of negative bacterial culture results. In a retro- Rec 1997;141:147–150. spective study including 192 horses affected by septic arthritis 2. Dabareiner RM, Watkins JP, Carter GK, Honnas CM, Eastman T. and tenosynovitis, bacterial cultures were negative in 25.9% of Osteitis of the axial border of the proximal sesamoid bones in horses: Eight cases (1993–1999). J Am Vet Med Assoc 2001;219:82–86. the individuals (19). In the present case, the prescribed antibi- 3. Collins JN, Galuppo LD, Thomas HL, Wisner ER, Hornof WJ. otic therapy was completed before the mycology results became Use of computed tomography angiography to evaluate the vascular

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anatomy of the distal portion of the forelimb of horses. Am J Vet Res 14. Sedrish S, Burba D, Williams J. Radiographic diagnosis axial sesamoid 2004;65:1409–1420. osteomyelitis in a horse. Vet Radiol Ultrasound 1996;37:417–418. 4. Brommer H, Voermans M, Veraa S, et al. Axial osteitis of the proximal 15. Lean NE, Perkins NR, Ahern BJ. Comparison of conventional radiogra- sesamoid bones and desmitis of the intersesamoidean ligament in the phy and computed tomography as aids in the diagnosis of osteomyelitis hindlimb of Friesian horses: Review of 12 cases (2002–2012) and post- in 11 foals. Aust Vet J 2018;96:257–261. mortem analysis of the bone-ligament interface. BMC Vet Res 2014; 16. Harris WH, Boston MD, Heanley R. Skeletal renewal and metabolic 10:1–11. bone disease. Brit J Surg 1971;58:82. 5. Cornelissen BPM, Rijkenhuizen ABM, Buma P, Barneveld A. A study 17. Butler JA, Colles CM, Dyson SJ, Kold SE, Poulos PW. Clinical REPORT CASE on the pathogenesis of equine sesamoiditis: The effects of experimental Radiology of the Horse. 4th ed. Hoboken, New Jersey: Wiley-Blackwell, occlusion of the sesamoidean artery. J Vet Med Ser A Physiol Pathol 2018:808 pp. Clin Med 2002;49:244–250. 18. Paradis MR. Septic arthritis in the foal: What is the best imaging modal- 6. Swerczek TW, Donahue JM, Hunt RJ. Scedosporium prolificans infection ity? Equine Vet Educ 2010;22:334–335. associated with arthritis and osteomyelitis in a horse. J Am Vet Med 19. Schneider RK, Bramlage LR, Moore RM, Mecklenburg LM, Kohn Assoc 2001;218:1800–1802. CW, Gabel AA. A retrospective study of 192 horses affected with septic 7. Bertone AL, Cohen JM. Infectious arthritis and fungal infectious arthri- arthritis/tenosynovitis. Equine Vet J 1992;24:436–442. tis. In: Diagnosis and Management of Lameness in the Horse. 2d ed. 20. Rhee C, Kadri SS, Dekker JP, et al. Prevalence of antibiotic-resistant Elsevier, 2010:677–687. pathogens in culture-proven sepsis and outcomes associated with inad- 8. Sherman KM, Myhre GD, Heymann EI. Fungal osteomyelitis of the equate and broad-spectrum empiric antibiotic use. JAMA Netw open axial border of the proximal sesamoid bones in a horse. J Am Vet Med 2020;3:e202899. Assoc 2006;229:1607–1611. 21. Cohen JM, Ross MW, Busschers E. Diagnosis and management of 9. Madison JB, Reid BV, Raskin RE. Amphotericin B treatment of Candida Candida utilis infectious arthritis in a Standardbred filly. Equine Vet arthritis in two horses. J Am Vet Med Assoc 1995;206:338–341. Educ 2008;20:348–352. 10. Reilly LK, Palmer JE. Systemic candidiasis in four foals. J Am Vet Med 22. Kohli R, Hadley S. Fungal arthritis and osteomyelitis. Infect Dis Clin Assoc 1994;205:464–466. North Am 2005;19:831–851. 11. Bariteau JT, Waryasz GR, McDonnell M, Fischer SA, Hayda CRA, 23. Garcia-Hermoso D, Valenzuela-Lopez N, Rivero-Menendez O, et al. Born CT. Fungal osteomyelitis and septic arthritis. J Am Acad Orthop Fungal Biol 2019;123:341–349. 2014;22:390–401. 24. Stchigel AM, Sutton DA. Coelomycete fungi in the clinical lab. Curr 12. Wisner ER, O’Brien TR, Pool RR, et al. Osteomyelitis of the axial Fungal Infect Rep 2013;7:171–191. border of the proximal sesamoid bones in seven horses. Equine Vet J 25. Galipothu S, Kalawat U, Ram R, et al. Cutaneous fungal infection in 1991;23:383–389. a renal transplantation patient due to a rare fungus belonging to the 13. Bracken CD, Berbari EF, Hanssen AD, Mabry TM, Osmon DR, Sierra order Pleosporales. Indian J Med Microbiol 2015;33:165–167. RJ. Systemic inflammatory markers and aspiration cell count may not differentiate bacterial from fungal prosthetic infections. Clin Orthop Relat Res 2014;472:3291–3294.

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Surgical treatment of a double aortic arch in a dog

Maya Sekhar, Katherine Meyers, Susan W. Volk, David E. Holt

Abstract — An 8-month-old spayed female Labrador retriever dog was evaluated for regurgitation 6 months after surgery for a suspected vascular ring anomaly. The dog had a history of regurgitation and slow development as a puppy. An initial left-sided exploratory thoracotomy was unsuccessful in identifying and treating a vascular ring anomaly. The dog was subsequently presented to the PennVet Emergency Service for regurgitation. Thoracic radiography showed cranial thoracic esophageal dilation and an esophageal foreign body that was then removed endoscopically. Subsequent computed tomographic (CT) angiography revealed a double aortic arch. A left 4th intercostal space thoracotomy was performed. The smaller left aortic arch and a left ligamentum arteriosum were ligated and transected. The dog recovered uneventfully and was healthy at the 1-month follow-up visit. This is the 5th reported successful surgical correction of a double aortic arch in a dog. Computed tomographic angiography was essential in diagnosis and surgical planning. Key clinical message: Although uncommon, double aortic arches can occur and present a diagnostic and surgical challenge when a persistent right aortic arch is suspected. Computed tomographic angiography provides an accurate preoperative diagnosis and allows for surgical planning.

Résumé — Traitement chirurgical d’un double arc aortique chez un chien. Une chienne Labrador retriever femelle stérilisée âgée de 8 mois a été évaluée pour régurgitation 6 mois après une chirurgie pour une anomalie suspectée de l’anneau vasculaire. Le chien avait des antécédents de régurgitation et de développement lent en tant que chiot. Une première thoracotomie exploratrice gauche n’a pas permis d’identifier et de traiter une anomalie de l’anneau vasculaire. Le chien a ensuite été présenté au service d’urgence PennVet pour régurgitation. La radiographie thoracique a montré une dilatation de l’œsophage thoracique crânien et un corps étranger œsophagien qui a ensuite été retiré par endoscopie. L’angiographie tomodensitométrique (TDM) subséquente a révélé un double arc aortique. Une thoracotomie du 4e espace intercostal gauche a été réalisée. Le plus petit arc aortique gauche et un ligament artériel gauche ont été ligaturés et sectionnés. Le chien s’est rétabli sans incident et était en bonne santé lors de la visite de suivi à 1 mois. Il s’agit de la cinquième correction chirurgicale réussie d’un double arc aortique chez un chien. L’angiographie tomodensitométrique était essentielle dans le diagnostic et la planification chirurgicale. Message clinique clé : Bien que rares, des arcs aortiques doubles peuvent survenir et présenter un défi diagnostique et chirurgical lorsqu’un arc aortique droit persistant est suspecté. L’angiographie tomodensitométrique fournit un diagnostic préopératoire précis et permet une planification chirurgicale. (Traduit par Dr Serge Messier) Can Vet J 2021;62:872–876

University of Pennsylvania School of Veterinary Medicine, 3800 Spruce Street, Philadelphia, Pennsylvania 19104, USA. Address all correspondence to Dr. David Holt; e-mail: [email protected] Dr. Holt’s current address is c/o Matthew J. Ryan Veterinary Hospital, 3900 Delancey Street, Philadelphia, Pennsylvania 19104-6010, USA. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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ascular ring anomalies are a group of congenital cardio- V vascular malformations affecting the aortic arch and its branches (1). The vascular ring encircles or compresses the esophagus and causes clinical signs of regurgitation, generally at weaning. The diagnosis is suspected based on the history and radiographic dilation of the esophagus cranial to the heart REPORT CASE base (1). Persistence of the right aortic arch with an associated left ligamentum arteriosum is the most common vascular ring anomaly, accounting for 56% of cases (2,3). An accurate anatomical diagnosis of less common (4) vascular ring anomalies, including a left aortic arch with a right ligamentum arteriosum or ductus arteriosus (5), a retroesophageal subclavian artery (1), and double aortic arches (6) is vital to planning both the required surgical approach and procedure. Double aortic arches are uncommon based on the infrequent reports in the veterinary literature. The purpose of this report is to describe the success- Figure 1. Three-dimensional contrast computed tomography ful clinical investigation and treatment of double aortic arches reconstruction showing the right (RAA) and left (LAA) aortic arches, the right (*) and left (**) carotid arteries, and the right (#) in a dog that had previously had an unsuccessful exploratory and left (##) subclavian arteries. thoracotomy for a suspected vascular ring anomaly. Case description An 8-month-old, 22 kg, spayed female Labrador retriever dog ence range (RR): 41.0 to 58.0%] and hypoglycemia (glucose was referred to the PennVet Emergency Service for a 6-day 51 mg/dL; RR: 65.0 to 112 mg/dL). The dog was blood history of vomiting or regurgitation and decreased appetite. typed as DEA 1.1 negative. The dog was anesthetized but the The dog had a left-sided thoracotomy at 8 wk of age for a planned computed tomographic (CT) scan was unsuccessful suspected persistent right aortic arch (PRAA) after clinical signs due to a CT generator malfunction. The dog recovered and of regurgitation prompted a barium study showing dilation of was discharged. the cranial thoracic esophagus. A left aortic arch was visualized The dog was readmitted 2 wk later for CT angiography intraoperatively; no vascular ring anomaly was identified, and and surgery. The dog weighed 22 kg and no abnormalities the surgery was concluded. The dog recovered uneventfully after were detected on physical examination. The dog was premedi- surgery and was started on a gruel diet in a Bailey chair. The cated with butorphanol (Zoetis, Kalamazoo, Michigan, USA), dog had only 1 or 2 isolated instances of regurgitation in the 0.2 mg/kg body weight (BW), IM. Anesthesia was induced with following months. The dog had an episode of regurgitation and propofol (Fresenius Kali, Lake Zurich, Illinois, USA) 2.5 mg/kg suspected aspiration pneumonia 1 wk before presentation to the BW, IV and maintained with sevoflurane (Piramal Critical Care, University of Pennsylvania. Persistent vomiting or regurgitation Bethlehem, Pennsylvania, USA) in oxygen during the CT scan. 5 d later prompted referral. A sterile iodinated contrast agent (2.2 mg/kg BW) was injected On presentation the dog was bright, alert, and had normal vital intravenously to provide radiographic contrast. Computed parameters. The dog weighed 21.2 kg. The dog was hypersalivating tomographic angiography confirmed the presence of the double and the abdomen was tense on palpation. No other abnormali- aortic arch creating a vascular ring and allowed further character- ties were noted on physical examination. A focal gastrointestinal ization of the vascular anomalies. The common carotid arteries ultrasound showed a possible mild reactive mesenteric lymph- were the first branches arising from the aortic root, with the adenopathy with no foreign material or evidence of mechanical right slightly dorsal to the left. There was no brachiocephalic obstruction in the gastrointestinal tract. An abbreviated serum trunk present. The aorta then bifurcated into 2 aortic arches, chemistry panel was unremarkable. Thoracic radiographs were with the right subclavian artery arising from the right aortic taken and revealed a cranial thoracic esophageal dilation containing arch and the left subclavian and left aortic arch arising together foreign material. There was a slight leftward and dorsal deviation in from the aortic root then immediately separating (Figure 1). the trachea immediately cranial to the heart base. The dog was not The right aortic arch was much larger (50%) than the left coughing and there was no radiographic evidence of pneumonia and ran dorsally along midline to the right of the esophagus or other pulmonary disease. Esophagoscopy was performed under and trachea. The smaller left arch extended to the left of midline general anesthesia and cloth, food, and grass were removed from and wrapped dorsally around the left side of the esophagus and the esophagus. The dog recovered uneventfully. The radiographic trachea. The 2 aortic arches rejoined slightly left of midline and findings were suggestive of a vascular ring anomaly. Due to the dorsal to the trachea and esophagus creating a complete vascular findings of the previous thoracotomy, differentials including an ring around the esophagus and trachea (Figures 1, 2A–D). The atypical vascular ring anomaly and a congenital esophageal stricture descending aorta then continued caudally on the left side. A or stenosis were considered. dilation consistent with a ductus diverticulum was present on A complete blood (cell) count and serum chemistry were the ventral wall of the left aorta. The trachea was displaced to performed revealing a mild anemia [hematocrit 39.9%; refer- the left and was slightly narrowed at the level of the vascular

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A B RAPPORTCAS DE

C D

Figure 2A–D. Sequential transverse contrast CT images showing right (red arrow) and left (yellow arrow) aortic arches encircling the trachea and esophagus. T — Trachea; E — Esophagus.

ring. The cranial thoracic esophagus was positioned to the left mediastinum, and left cranial lung lobe at the site of prior tho- of the trachea, was enlarged, and contained a large volume of gas racotomy which were dissected. Self-retaining retractors were and hypoattenuating material. The esophagus was compressed used to maintain exposure of the surgical site. The mediastinum at the level of the vascular ring and was gas-filled caudal to it. was further dissected and the left ligamentum arteriosum was A band of soft tissue extending from the left thoracic wall to palpable overlying the esophagus. The ligamentum was isolated, the mediastinum, consistent with adhesions due to the previous ligated on either side with 3/0 polydioxanone suture (PDS), and thoracotomy, displaced the left cranial lung lobe caudally. This transected. The left aortic arch was identified, dissected, clamped lung lobe was scalloped on the dorsal margins. with ductus clamps and transected (Figure 3). Several attempts The dog was prepared for aseptic surgery. Additional propofol, were made to oversew the ends with 4/0 prolene using a 4.5 mg/kg BW, IV was administered and the dog was transitioned C1 needle, but the aortic tissue was too friable. Each side of the to inhalant isoflurane in oxygen to maintain anesthesia. Constant left arch was double ligated with encircling ligatures of O silk. rate infusions of lidocaine (APP Pharmaceuticals, Schaumburg. During thoracotomy closure, air leakage from an adhesion Illinois, USA), 50 mg/kg BW per minute and fentanyl (Hospira, site in the left cranial lung lobe was appreciated. A lobectomy Lake Forest, Illinois, USA), 50 mg/kg BW per minute were initi- was performed using a surgical stapler and a 30-mm cartridge. ated. A morphine (West-Ward Pharmaceutical, Eatontown, New A chest tube was placed, and the thoracotomy closed routinely. Jersey, USA), 0.1 mg/kg BW intercostal block was conducted The dog made an uneventful recovery from surgery. The chest and peri- and intraoperative doses of cefazolin, 22 mg/kg BW, tube was removed 24 h after surgery and the dog was discharged IV were administered every 90 min. The dog was maintained on 3 d later. The dog was re-evaluated 1 mo after surgery and was mechanical ventilation throughout the thoracotomy. eating in a normal position with no regurgitation. Four years A left 4th intercostal space thoracotomy was performed. after surgery, the dog is a normal size and weight (34 kg) and There were significant adhesions between the thoracic wall, is eating normally.

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dogs (6,13–19). The right arch dominant, as seen in this case, is the most common, although most diagnoses in veterinary medicine have been made at post-mortem (6). In this case the tentative diagnosis of a vascular ring anomaly was made when the dog was several months old and it was referred to a specialist

for surgery. Advanced imaging was not performed, however, and REPORT CASE the complex nature of vascular ring anomaly was not recognized before the initial surgery. This case is the 5th reported successful surgical correction of a double aortic arch in a dog that has survived to be discharged from the hospital (6,13,17,18). This is the 2nd reported case in which advanced imaging was performed before surgery to correct a double aortic arch. Both animals had an excellent outcome despite the historically poor prognosis for a surgical treatment of double aortic arches (13). We attributed this to CT imaging Figure 3. The left aortic arch dissected from the mediastinum. of the vascular anatomy before surgery that facilitated precise surgical planning. In this case, CT angiography was useful in assessing the diameters of both aortic arches and the decision to Discussion ligate and divide the smaller left arch. Ligation of the dominant This case highlights the importance of advanced imaging in aortic arch can lead to hypertension and increased cardiac after- planning surgery to treat a vascular ring anomaly. Computed load (12). In cases in which both arches are of similar size, each tomography angiography was vital in confirming the suspicion arch is separately isolated and temporarily occluded, as systemic of a double aortic arch and determining the dominant aortic blood pressure is measured to determine if 1 arch can be safely arch. Typically, history, clinical signs, and cranial thoracic ligated and divided (16). Although surgery to correct vascular esophageal dilation seen on plain thoracic radiographs and rings can correct esophageal constriction, esophageal dilation during a barium esophagram raise suspicion for a vascular ring and motility have variable degrees of resolution after surgery anomaly. Leftward deviation of the trachea at the cranial aspect and long-term medical management may be necessary (23). The of the cardiac silhouette on dorsoventral or ventrodorsal tho- degree of preoperative esophageal dilation may not necessarily racic radiographs indicates the likely presence of a right aortic correspond to the dog’s ability to swallow postoperatively. The arch (3). These diagnostics can provide adequate evidence for dog in this report was able to eat in a normal position without surgical exploration. However, the surgeon is at a disadvantage regurgitation soon after surgery and was clinically normal 4 y if the dog has a different type of vascular ring anomaly that later. CVJ requires more exploratory dissection. Both angiography and CT angiography have been used to preoperatively determine References the nature of canine vascular ring anomalies (7,8). . 1 Buchanan JW. Symposium: Thoracic surgery in the dog and cat III: In the embryo, paired dorsal, and ventral aortas are joined by Patent ductus arteriosus and persistent right aortic arch surgery in dogs. 6 pairs of arches that surround the embryonic foregut (9–11). J Small Anim Pract 1968;9:409–428. 2. Morgan KRS, Bray JP. Current diagnostic tests, surgical treatments, and The arches involute or develop to produce the aorta and its prognostic indicators for vascular ring anomalies in dogs. J Am Vet Med major initial branches. Vascular rings occur because of abnormal Assoc 2019;254:728–733. embryonal development of the aortic arches which can entrap 3. Buchanan JW. Tracheal signs and associated vascular anomalies in dogs with persistent right aortic arch. J Vet Intern Med 2004;18:510–514. the esophagus, resulting in clinical signs of regurgitation at 4. Hurley K, Miller MW, Willard MD, Boothe HW. Left aortic arch and weaning (9–11). In dogs, most vascular ring anomalies involve right ligamentum arteriosum causing esophageal obstruction in a dog. a persistence of the right 4th aortic arch as the ascending aorta J Am Vet Med Assoc 1993;203:410–412. 5. Holt DE, Heldmann E, Michel K, Buchanan JW. Esophageal obstruc- and the left 6th arch as the ligamentum arteriosum (9–11). tion caused by a left aortic arch and an anomalous right patent ductus However, as this case demonstrates, other types of vascular rings arteriosus in two German shepherd litter mates. Vet Surg 2000;29: occur in dogs. This dog had an initial exploratory thoracotomy 264–270. 6. Vianna L, Krahwinkel DJ. Double aortic arch in a dog. J Am Vet Med for a suspected vascular ring anomaly that was ended when a Assoc 2004;225:1222–1224. left aortic arch was visualized. 7. House AK, Summerfield NJ, German AJ, Noble PJM, Ibarrola P, Understanding the anatomy of the vascular ring is vital in Brockman DJ. Unusual vascular ring anomaly associated with a persistent right aortic arch in two dogs. J Small Anim Pract 2005;46:585–590. planning and performing surgery to correct the anomalies. 8. Joly H, D’Anjou MA, Huneault L. Imaging diagnosis-CT angiography Double aortic arches are uncommon but occur when the left of a rare vascular ring anomaly in a dog. Vet Radiol Ultrasound 2008; and right 4th aortic arches persist concurrently. This is classified 49:42–46. 9. Morgan KRS, Bray JP. Current diagnostic tests, surgical treatments, and as a Type 4 vascular ring anomaly (11). Double aortic arches prognostic indicators for vascular ring anomalies in dogs. J Am Vet Med have been described in humans (12), dogs (6,13–19), a mon- Assoc 2019;254:728–733. key (20), a cat (21), and a lion (22). Double aortic arches can 10. VanGundy T. Vascular ring anomalies. Compend Contin Educ Pract Vet 1989;11:36–48. be further classified as right arch dominant, left arch dominant 11. Helphrey ML. Vascular ring anomalies in the dog. Vet Clin North Am and symmetrical arches (12). All 3 types have been reported in Small Anim Pract 1979;9:207–218.

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12. Backer CL, Mavroudis C, Rigsby CK, Holinger LD. Trends in vascular health assessment four years after treatment: A case report. Vet Med ring surgery. J Thorac Cardiovasc Surg 2005;129:1339–1347. (Praha) 2017;62:279–284. 13. Follette CM, Terreros A, Padgett SL. Successful surgical therapy of a 19. Aultman SH, Chambers JN, Vestre WA. Double aortic arch and persis- double aortic arch in a 10-month-old mixed breed dog. Case Rep Vet tent right aortic arch in two littermates: Surgical treatment. J Am Vet Med 2019. Available from: https://doi.org/10.1155/2019/6519041 Last Med Assoc 1980:16:533–536. accessed June 10, 2021. 20. Still HF, Jr, Bond MG, Bullock BC. Double aortic arch in a talapoin 14. Martin DG, Ferguson EW, Gunnels RD, Robinowitz M, Toft JD, 2nd. monkey (Miopithecus talapoin). Vet Pathol 1979;16:266–267. Double aortic arch in a dog. J Am Vet Med Assoc 1983;183:697–699. 21. Yarim M, Gültiken ME, Oztürk S, Sahal M, Bumin A. Double aortic 15. Ricardo C, Augusto A, Canavese S, et al. Double aortic arch in a arch in a Siamese cat. Vet Pathol 1999;36:340–341. dog (Canis familiaris): A case report. Anat Histol Embryol 2001;30: 22. Goldin JP, Lambrechts NE. Double aortic arch and persistent left vena 379–381. cava in a white lion cub (Panthera leo). J Zoo Wildl Med 1999;30: 16. Du Plessis CJ, Keller N, Joubert KE. Symmetrical double aortic arch 145–150. in a beagle puppy. J Small Anim Pract 2006;47:31–34. 23. Muldoon MA, Birchard SJ, Ellison GW. Long-term results of surgical 17. Moonan N, Mootoo NFA, Mahler SP. Double aortic arch with a hypo- correction of persistent right aortic arch in dogs: 25 cases (1980–1995).

RAPPORTCAS DE plastic left arch and patent ductus arteriosus in a dog. J Vet Cardiol J Am Vet Med Assoc 1997;210:1761–1763. 2007;9:59–61. 18. Skrzypczak P, Piątek A, Bieżyński A, Kiet-bowicz Z. Double symmetrical aortic arch in a Czechoslovakian wolfdog — Surgical treatment and

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Hematuria in a 3-month-old filly with an internal umbilical abscess and internal iliac artery aneurysm

Luiza Zakia, Sarah Shaw, Natacha Bonomelli, Siobhan O’Sullivan, Alex zur Linden, Marie Dubois, John Baird, Bruce Guest

Abstract — A 3-month-old foal with a history of acute hematuria was evaluated. Hydronephrosis and hydroureter were visualized upon renal ultrasonography of the left kidney. Cystoscopy identified a blood clot occluding the left ureter. Computed tomography (CT) revealed a large retroperitoneal abscess at the level of the aortic bifurcation and a left internal iliac aneurysm. Due to the severity of the lesions and the poor prognosis, the filly was euthanized and the clinical findings were confirmed by post-mortem examination. This report emphasizes the value of obtaining a precise diagnosis via CT in order to avoid unviable treatment approaches when confronted with this unusual secondary complication of omphaloarteritis. Key clinical message: Umbilical complications are routinely diagnosed in equine neonatal medicine, and commonly lead to septicemia, physitis, and septic arthritis; severe internal umbilical abscessation, and subsequent vascular and urinary disorders are uncommon sequelae.

Résumé — Hématurie chez une pouliche de 3 mois avec abcès ombilical interne et anévrisme de l’artère iliaque interne. Un poulain de 3 mois ayant des antécédents d’hématurie aiguë a été évalué. L’hydronéphrose et l’hydro-uretère ont été visualisés par échographie rénale du rein gauche. La cystoscopie a identifié un caillot sanguin obstruant l’uretère gauche. La tomodensitométrie (TDM) a révélé un gros abcès rétropéritonéal au niveau de la bifurcation aortique et un anévrisme iliaque interne gauche. En raison de la gravité des lésions et du mauvais pronostic, la pouliche a été euthanasiée et les résultats cliniques ont été confirmés par un examen post-mortem. Ce rapport souligne l’intérêt d’obtenir un diagnostic précis par TDM afin d’éviter des approches thérapeutiques non-viables face à cette complication secondaire inhabituelle de l’omphalo-artérite. Message clinique clé : Les complications ombilicales sont couramment diagnostiquées en néonatalogie équine et conduisent généralement à une septicémie, une épiphysite et une arthrite septique; un abcès ombilical interne sévère et des troubles vasculaires et urinaires subséquents sont des séquelles peu fréquentes. (Traduit par Dr Serge Messier) Can Vet J 2021;62:877–881

Introduction of hospitalized foals with umbilical infection was 84.8% (2). In another study, 89% of the foals that underwent umbilical resec- he umbilical cord is composed of 2 arteries, 1 vein, the tion were discharged from the hospital; septic arthritis and/or urachus, and the amniotic sheath. Infection of the umbili- T physitis were significantly associated with non-survival (2). Oreff cal remnants is frequently seen in foals (1). Treatment can be et al (3) suggested that umbilical remnant infection carries a medical (antimicrobials) or surgical (resection). In a retrospec- good prognosis; however, lower long-term survival is associated tive study that evaluated 1065 neonatal foals, the survival rate with septic joints, multiple pathologies, younger age at presentation, longer periods between presentation and surgery, and Department of Clinical Studies, Ontario Veterinary College, post-operative complications. University of Guelph, Guelph, Ontario N1G 2W1. Hematuria has been reported as an uncommon complication Address all correspondence to Dr. Luiza Zakia; e-mail: of umbilical abscessation (4). Pigmenturia is grossly character- [email protected] ized by red, pink, or brown urine. Hematuria can be differenti- Use of this article is limited to a single copy for personal study. ated from myoglobinuria and hemoglobinuria if centrifugation Anyone interested in obtaining reprints should contact the results in a clear supernatant or if there are blood clots present CVMA office ([email protected]) for additional in the urine (5). Hematuria in the horse is well-reported and copies or permission to use this material elsewhere. has been recently reviewed (6). Reported causes of hematuria in

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horses include urethral rent, cystolith, exercise-induced hematuria, habronemiasis of the urethral process, urethrolithiasis, nephrolithiasis, renal or cystic neoplasia, hemorrhagic or pol- ypoid cystitis, idiopathic renal hematuria, cantharidin toxicosis, non-steroidal induced ulcerative cystitis, cystic hematoma, renal medullary necrosis, renal vascular anomalies, hemolytic uremic-like syndrome, verminous nephritis, pyelonephritis, lep- tospirosis, and osteochondroma of the os pubis. Hematuria has been rarely reported as a sequela of umbilical pathology (4,7,8), aneurysms (4,9,10), or in association with arterial malforma- tion (11) in foals. More common complications associated with RAPPORTCAS DE umbilical remnant infection are hernias, patent urachus, sepsis, liver abscesses, meningitis, peritonitis, intra-abdominal adhesions, and septic arthritis (1). Case description A 3-month-old, 188-kg Thoroughbred filly was brought to the Figure 1. Ultrasonographic image of the left kidney of a 3-month-old Thoroughbred filly examined at the farm for Ontario Veterinary College Health Science Centre to evaluate acute onset of hematuria. The left kidney has pelvic dilation her acute hematuria of several hours duration. The foal’s delivery (white arrow) consistent with hydronephrosis. An amorphic was attended and unassisted. Immunoglobulin G, which was and undetermined structure that appears to be abutting the left kidney is also identified (white asterisk). measured 24 h after birth, was . 8 g/L. The filly had contracted tendons and received intravenous oxytetracycline (2 g in 1 L 0.9% NaCl) on the 1st, 2nd, and 5th days of life. At 2 wk of age, the foal was dull and febrile. At that time, a working diagnosis of external umbilical abscessation was made via pal- RI: 2.8 to 7.7 3 109/L) without neutrophil toxicity. Red blood pation and ultrasonography of the umbilical region. Treatment cell count (9.0 3 1012/L, RI: 6.9 to 10.7 3 1012/L), hemoglo- with chloramphenicol (Tutrina Pharmacy, Ancaster, Ontario), bin (115 g/L, RI: 112 to 169 g/L), and hematocrit (0.33 L/L, 50 mg/kg body weight (BW), PO, q8h, was administered for RI: 0.28 to 0.44 L/L) were within normal ranges. Abnormalities 7 d, during which the foal was normothermic and became bright identified on the serum biochemistry profile included hypoalbu- in demeanor. On the 7th day of treatment, the filly became minemia (26 g/L, RI: 30 to 37 g/L), hyperglycemia (9 mmol/L, febrile and antimicrobial therapy was changed to clarithromycin RI: 3.7 to 6.7 mmol/L), and marginally increased creati- (Sandoz, Princeton, New Jersey, USA), 7.5 mg/kg BW, PO, nine (134 mmol/L, RI: 80 to 130 mmol/L). For urinalysis, urine q12h, and rifampin (Tutrina Pharmacy), 5 mg/kg BW, PO, specific gravity was 1.022, whereas the leukocyte count (80 to q12h, for an additional 2 wk. The filly remained bright, was 90; 4003 magnification) and red blood cell count (. 100; afebrile, had no umbilical abnormalities detectable on palpation, 4003 magnification) were both elevated. Cytologic analysis and appeared healthy until the morning of presentation to the of the urine identified marked suppurative inflammation with hospital, when she was seen in the stall with hemorrhagic vulvar hemorrhage. For centrifugation, the urine fluid fraction was discharge and with large blood clots observed in the bedding. clear with a packed cell volume of 2%. Upon veterinary examination at the farm, active vulvar hemor- Abdominal ultrasonographic examination confirmed marked rhage was not evident; the filly had clinical signs consistent with hydronephrosis of the left kidney (dimensions: 4 cm 3 14 cm), mild dehydration (i.e., prolonged capillary refill time and skin marked dilation of the left ureter (1.3 cm diameter), and an tent). Hydronephrosis of the left kidney (Figure 1) was identi- amorphic structure associated with the kidney. The right kidney fied ultrasonographically. No other diagnostic tests were per- appeared normal. No other clinically important abnormalities formed and the filly was promptly referred without treatment. were visualized ultrasonographically in the remainder of the Upon admission, the filly was bright, alert, and respon- abdomen and thorax. After cleaning the perineal region with sive, febrile (38.8°C), moderately tachycardic [72 beats/min soap and water, a sterilized endoscope was placed in the bladder. (bpm)], and tachypneic (40 breaths/min). The buccal mucous A small pool of blood-tinged urine containing a red gelatinous membranes were pink and dry. Peripheral extremities were structure with the appearance of a blood clot was present within normothermic and peripheral pulses were strong. No external the bladder. The left and dorsal aspects of the bladder wall were abnormalities were identified from palpation of the umbilical markedly and torturously distorted, impinging on the lumen. region. The filly was reactive when touched in the inguinal area, The left ureteral orifice was located dorsally and was obstructed which was attributed to her young age and to her being unac- by a gelatinous clot (Figure 2). Grossly normal appearing urine customed to extensive palpation. Urination without signs of was observed originating from the right ureteral orifice, but no dysuria was observed. The urine was dark red-brown and turbid urine emanated from the left orifice over approximately 10 min throughout the entire stream. A complete blood cell count iden- of observation. A bacteriological culture of urine collected tified leukocytosis [21.9 3 109/L, reference interval (RI): 5.1 to during the cystoscopy subsequently identified the presence of 11.0 3 109/L] characterized by neutrophilia (17.74 3 109/L, Streptococcus thoraltensis (11; sensitive to amikacin, ceftiofur,

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Figure 2. Cystoscopy images of a 3-month-old Thoroughbred filly presenting with acute hematuria lasting several hours. A — Cranio- ventral aspect of the bladder, with a normal-appearing urine pool (white arrow). B — Mid-dorsal aspect of the bladder: left and dorsal aspects are markedly and torturously distorted, extending into the lumen. The left ureter orifice is obstructed by a gelatinous clot (black arrow). The right ureteral orifice appears normal (black asterisk).

chloramphenicol, enrofloxacin, gentamicin, kanamycin, peni- The left kidney was mildly enlarged with an undulant cortical cillin, rifampin, tetracycline, and trimethoprim/sulfa; resistant margin (Figure 3). The left renal pelvis and proximal left ureter to erythromycin), Staphylococcus haemolyticus (11; sensitive were markedly distended. The proximal left ureter was distended to amikacin, ampicillin, ceftiofur, chloramphenicol, erythro- to approximately 3 cm. Multiple punctate gas bubbles were mycin, kanamycin, penicillin, tetracycline, and trimethoprim/ present throughout the renal pelvis and proximal ureter in the sulfa; intermediate to rifampin; resistant to gentamicin), and non-gravity dependent portion. The left kidney had markedly Arcanobacterium hippocoleae (1 colony, no sensitivity performed). reduced cortical and medullary contrast uptake, with no filling The source of hematuria was localized to the left ureter or of the renal pelvis or ureter. The right renal pelvis was minimally left kidney. Differential diagnosis included pyelonephritis, idio- distended and the right ureter was filled with contrast medium, pathic renal hematuria, renal vascular anomalies, renal medullary which extended to the level of the trigone. In the retroperitoneal necrosis, nephrolithiasis, and renal neoplasia (6). Due to the space at the level of the aortic bifurcation, a large soft tissue severity of the findings, therapy with antimicrobials alone was mass containing multiple punctate gas bubbles throughout, considered unlikely to be successful. In order to better determine was observed. The mass was approximately 14 cm in length, the viability of surgical intervention, computed tomography 9.5 cm in width, and 11 cm in height, and had a moderate (CT) was planned to assess the severity and likely etiology of the heterogeneous contrast enhancement. The mass surrounded the nephropathy as well as provide a more accurate prognosis to the left internal iliac artery that was markedly dilated with a blunted owner before committing to the expense of surgery. caudal margin. The mass was  3.5 cm in width and  7.1 cm Although apparently comfortable during the initial diagnostic in length and was caudal to the aortic bifurcation. The left ureter procedures, the filly presented signs of discomfort, characterized could be traced into the mass, but no further. A tubular-shaped by tachycardia (88 bpm), flank watching, and rolling through- caudal extension of the mass extended along the left side of the out the first night of hospitalization; she became progressively urethra into the pelvic canal. The mass compressed the urinary pyrexic (39.5°C). bladder ventrally in the region of the apex. In summary, there The following day, the foal was placed under general anesthe- was a large retroperitoneal abscess at the level of the aortic sia and an abdominal CT was performed. A CT scanner with bifurcation, marked left hydronephrosis and hydroureter, and a 16-slice detector (BrightSpeed CT scanner; GE Healthcare, left pyelonephritis/pyonephrosis. There was a left internal iliac Milwaukee, Wisconsin, USA) was used and the raw data aneurysm and a suspected thrombus of the remnant of the left (0.625 mm slice thickness) were acquired with a standardized umbilical artery. Due to the extensive lesions and poor progno- protocol in helical mode, 1 s rotation time, 1.375:1 pitch, sis, the filly was euthanized. 120 kilovoltage peak (kVP), and 220 milliampere-second A gross post-mortem examination revealed a 14 3 12 3 (mAs). Contrast medium (50 mL) (iohexol 350 mg/mL; 10 cm mass of firm fibrous connective tissue adherent to the Bracco Imaging Canada, Montreal, Quebec), was administered dorsal cranial aspect of the urinary bladder, which extended to intravenously. the retroperitoneal region of the caudal aorta and left internal

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detected in the left kidney and the aneurysm. The endoscope was sterile prior to the collection of the urine sample; however, contamination with commensal bacteria is possible during the passage through the vestibule and urethra. Therefore, this result should be interpreted with caution. In addition, the swabs collected during necropsy were collected after opening the structure with a sterile blade, but possible contamination of the surface could have occurred. Clarithromycin was administered on the farm during the onset of omphalitis and fever when the filly was younger. The S. thoraltensis isolated from the urine obtained during the RAPPORTCAS DE cystoscopy was resistant to erythromycin (the macrolide class drug used by our laboratory). Interestingly, both S. thoraltensis and S. haemolyticus were susceptible to chloramphenicol and rifampin, also used on the farm for treatment of the initial condition. Streptococcus resistance to macrolides has been increasing in human isolates (13), as well as Rhodoccocus equi resistance in foal isolates (14). Additionally, all pneumococci that were Figure 3. Multiplanar reconstruction CT images at 5 mm thickness in dorsal plane (A and B) and transverse plane resistant in vitro to erythromycin, were also resistant to clar- (C and D), all following administration of iodinated contrast ithromycin (15). It is uncertain whether the resistance was a medium. A — The white arrows point to small gas bubbles in the consequence of antimicrobial administration or of persistent left kidney, which has a dilated renal pelvis and reduced cortical contrast medium uptake in comparison to the right kidney. The infection with bacteria initially resistant to this class of drugs. white X denotes the retroperitoneal mass with multiple gas At the time of presentation to the hospital, the foal in this bubbles. B — The asterisk (*) denotes the left internal iliac artery report did not have any signs of complications usually associated aneurysm. C — The white arrows are marking small gas bubbles in the left ureter (left) and left renal pelvis (right). D — The left with umbilical infection (1). No abnormalities on the external internal iliac aneurysm is denoted by the asterisk (*) and the remnant of the umbilicus were identified via palpation and no retroperitoneal mass by the white X. ultrasonographic abnormalities were visualized on the stump, similar to the case described by Johnston et al (8). During hospitalization, the foal was reactive to touch in the inguinal iliac artery and incorporated both umbilical arteries proximally area and intermittently showed signs of discomfort. A more and the left ureter distally. When sectioned, the mass was multi- detailed ultrasonographic examination of this region may have cavitated and contained pockets of clotted blood. The mass revealed evidence of abscessation and the aneurysm. However, caused unilateral (left) ureteral obstruction with renal pelvic it is unlikely that additional diagnostic information could have dilation and hemonephrosis. Abutting with the mass, the left been obtained in this case as the gas-filled colon limited the internal iliac artery was expanded by a 5 3 3 3 4 cm blind- ability to conduct a thorough ultrasonographic examination of ended dilated aneurysm filled with a loosely adherent thrombus. the abdomen. Histology confirmed bilateral neutrophilic umbilical arteritis Aortic aneurysm has been described in human infants as a surrounded by a mass of thick mature fibrous tissue containing consequence of umbilical artery catheterization with secondary pockets of necrotic debris, indicative of severe chronic abscessa- infection (16). More recently, it has been described as a compli- tion in the region of the internal umbilicus. There was unilateral cation of umbilical infection in 2 foals (4,17). The aneurysm is (left) nephropathy consisting of neutrophilic tubulointerstitial created secondary to ascending hematogenous infection, causing nephritis with corticomedullary interstitial fibrosis, and mod- intimal damage and generating a thrombus (17). The origin of erate fibroplasia of the dilated left ureter. Bacterial culture of the hematuria was identified as coming from the left ureter. swabs obtained during necropsy from the left kidney and the However, the source of the blood in the left ureter could not be aneurysm both yielded Escherichia coli (11) and Acinetobacter identified from CT evaluation. The main differential diagno- johnsonii (11). The swabs were not obtained aseptically and ses were disruption of the aorta and/or internal iliac artery or sensitivity testing was not performed. vasculitis of small vessels around the ureter secondary to severe local inflammation. Discussion The case described in this report is similar to previously In a study that evaluated 40 foals admitted to a tertiary hos- described cases (4,8,10,17). However, the onset of clinical signs pital, the most common bacteria isolated from umbilical in this case was acute, possibly explaining why anemia was not swabs was S. equi subsp. zooepidemicus (32.5%), followed identified as it was in 2 other reports (4,10). Similar to previ- by E. coli (27.5%) and S. aureus (17.5%) (12). In this case, ously described cases, the foal presented with fever, tachycardia, the bacteria isolated from the urine collected during cys- and tachypnea, most likely as a result of the infection, inflam- toscopy were S. thoraltensis (11), S. haemolyticus (11), and mation, pain, and dehydration. It is noteworthy that, despite A. hippocoleae (1 colony), whereas E. coli and A. johnsonii were the size and apparent chronicity of the lesion, this filly was in

880 CVJ / VOL 62 / AUGUST 2021 FOR PERSONAL USE ONLY good body condition (3/5), had a normal hair coat, and abnor- References malities were not palpable in the umbilical region. The foal in . 1 Elce YA. Infections in the equine abdomen and pelvis: Perirectal this report developed signs of colic and progressive fever during abscesses, umbilical infections, and peritonitis. Vet Clin North Am — the first day of hospitalization. These signs had not been seen Equine Pract 2006;22:419–436. 2. Codina LR, Werre SR, Brown JA. Short-term outcome and risk fac- before hospitalization. It is suspected that the abscess was walled tors for post-operative complications following umbilical resection in off and clinically silent until the day of admission and that the 82 foals (2004–2016). Equine Vet J 2019;51:323–328. REPORT CASE secondary ureteral obstruction was the main cause of the clinical 3. Oreff GL, Tatz AJ, Dahan R, Segev G, Berlin D, Kelmer G. Surgical management and long-term outcome of umbilical infection in discomfort observed during hospitalization. 65 foals (2010–2015). Vet Surg 2017;46:962–970. Computed tomography and angiography are commonly used 4. Nogradi N, Magdesian K, Whitcomb M, Church M, Spriet M. in human and small animal medicine to evaluate and character- Imagin diagnosis — Aortic aneurysm and ureteral obstruction secondary to umbilical artery abscessation in a 5-week-old foal. Vet Radiol ize vascular abnormalities in the abdomen before surgical inter- Ultrasound 2013;54:384–389. vention. Although there is 1 similar case describing CT evalu- 5. Barrell E, Burton A. Alterations in the urinary function. In: Smith B, ation in a 5-week-old foal (4) in which omphaloarteritis was Van Metre D, Pusterla N, eds. Large Animal Internal Medicine. 6th ed. St. Louis, Missouri: Elsevier, 2019:166–173. identifiable via ultrasonography, it is uncertain that the arterial 6. Schumacher J, Schumacher J. Bloody urine — The list of differential lesions could have been identified from ultrasonographic exami- diagnoses lengthens, but diagnostics remain the same. Equine Vet Educ nation of the 3-month-old filly presented in this case. The infor- 2019;31:255–259. 7. Arnold CE, Chaffin MK, Rush BR. Hematuria associated with cystic mation provided by the CT in the case described in this report hematomas in three neonatal foals. J Am Vet Med Assoc. 2005;227: enabled the accurate diagnosis of the foal’s abnormalities. The 778–780. arterial lesions, in addition to presenting daunting surgical com- 8. Johnston J, Neely S, Latterman S. Hematuria caused by abdominal abscessation in a foal. J Am Vet Med Assoc 1987;191:971–972. plications, suggested sequelae secondary to omphaloarteritis and 9. Latimer FG, Magnus R, Duncan RB. Arterioureteral fistula in a colt. the likely presence of additional surgical complications beyond Equine Vet Educ 1991;23:483–484. those anticipated from a primary pyelonephritis. Nephrectomy 10. Larsdotter S, Ley C, Pringle J. Renal pseudoaneurysm as a cause of hematuria in a colt. Can Vet J 2009;50:759–762. is a well-described procedure in horses (18) and was the initial 11. Schott HC, Barbee DD, Hines MT, et al. Renal arteriovenous mal surgical intervention suggested for this filly. However, with the formation in a quarter horse foal. J Vet Intern Med 1996;10:204–206. information obtained from the CT images, including the pres- 12. Rampacci E, Passamonti F, Bottinelli M, et al. Umbilical infections in foals: Microbiological investigation and management. Vet Rec 2017; ence of the aneurysm and secondary complications of abscessa- 180:543. tion, removal of the kidney was not considered a viable option 13. Schroeder MR, Stephens DS. Macrolide resistance in Streptococcus as it would likely have incited a massive hemorrhage. A decision pneumoniae. Front Cell Infect Microbiol 2016;6:1–9. 14. Huber L, Giguère S, Slovis NM, et al. Emergence of resistance to mac- to euthanize the filly was made based on the poor to grave prog- rolides and rifampin in clinical isolates of Rhodococcus equi from foals in nosis for survival. Novel approaches such as nephrectomy via central Kentucky, 1995 to 2017. Antimicrob Agents Chemother 2019; ventral median and minimally invasive ureteral osteoplasty, have 63:1–6. 15. Ednie LM, Visalli MA, Jacobs MR, Appelbaum PC. Comparative been described (19,20), and could have been considered for this activities of clarithromycin, erythromycin, and azithromycin against case if the abscess was not proximate to the aortic bifurcation penicillin-susceptible and penicillin-resistant pneumococci. Antimicrob and if there was no aneurysm within the internal iliac artery. Agents Chemother. 1996;40:1950–1952. 16. Mendeloff J, Stallion A, Hutton M, Goldstone J. Aortic aneurysm In conclusion, this case report highlights the value of CT in resulting from umbilical artery catheterization: Case report, literature diagnosing intra-abdominal abnormalities in foals, particularly review, and management algorithm. J Vasc Surg 2001:419–424. when surgical intervention is contemplated. Although this case 17. Archer R, Gordon SJG, Carslake H, Collett MG. Distal aortic aneurysm presumed to be secondary to an infected umbilical distal aortic shares similarities with cases of umbilical abscessation with renal aneurysm presumed to be secondary to an infected umbilical artery in and vascular complications previously reported in the literature, a foal. N Z Vet J 2012;60:65–68. it uniquely describes omphaloarteritis and internal iliac aneu- 18. Woodie J. Nephrectomy. In: Auer J, Stick J, Kummerle J, Prange T, eds. Equine Surgery. 5th ed. St. Louis, Missouri: Elsevier, 2019:1123–1125. rism in the absence of anemia and ultrasonographic evidence 19. Arnold CE, Taylor T, Chaffin MK, Schoot II HC, Caron JP. of umbilical artery abnormalities. It serves as a reminder that Nephrectomy via ventral median celiotomy in equids. Vet Surg 2013; sequelae of omphaloarteritis should remain on the list of dif- 42:275–279. 20. Jones A, Ragle C. A minimally invasive surgical technique for ureteral ferential diagnoses when managing cases where the primary ostioplasty in two fillies with ureteral ectopia. J Am Vet Med Assoc complaint is hematuria. CVJ 2018;253:1467–1472.

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The origins and lineage of One Health, Part I

Justin Ancheta, Raad Fadaak, R. Michele Anholt, Danielle Julien, Herman W. Barkema, Myles Leslie

oonotic diseases have become a major worldwide chal- Félix Vicq D’Azyr, the chair of comparative medicine at Z lenge; with COVID-19 being the latest and most dra- Lyon, expanded on Bourgelat’s work with his research, including matic example of an animal-derived virus affecting humans. dissecting animals to learn more about human anatomy (3,4). With COVID-19 and previous zoonotic disease epidemics, Anatomical similarities between humans and animals were the concept of One Health has gained prominence (1). Based the impetus to use animals to study human diseases. In 1790, upon several hundred years of thinking and social develop- Vicq D’Azyr also recommended that educational institutions ment, One Health has developed a holistic, systems approach work towards collaboration between human and animal health to address complex problems at the intersection of humans, in the curriculum(4). His goal to merge medicine, pharmacy, animals, and the environment. This paper summarizes evolv- veterinary, and surgery schools into a single institution (4) was ing and competing ideas underlying contemporary One Health interrupted by the French Revolution, an early example of social concepts and practices. developments affecting One Health ideas. In the 17th and 18th centuries, important figures in veteri- Edward Jenner introduced animal models for disease when nary medicine aligned aspects of human and animal medicine, he vaccinated dogs against rabies. His success demonstrated the thereby initiating comparative medicine (2). In 1761, Claude importance of comparative medicine and its value in evaluat- Bourgelat founded the first veterinary college in Lyon, France. ing medical interventions (3). Jenner later became famous for This college, focused entirely on horses, made veterinary medi- protecting humans against smallpox using cowpox inocula- cine a distinct discipline. Paradoxically, separation of veterinary tions, highlighting the equivalence between humans and ani- medicine from human medicine benefitted One Health, as mals regarding immunity and leading to the first vaccination it initiated an advantageous and reciprocal flow of ideas and campaign in France (3). Jenner’s use of comparative medicine perspectives between human and animal medicine. As vet- linked human and animal medicine to address a human health erinary researchers moved away from framing disease in exclu- issue at the population level; an early precursor of two of sively human terms, a new view of health emerged, leading to One Health’s constituent components being integrated as early investigations of herd animal health, with findings informing as the 18th century. human health. In addition, Bourgelat introduced comparative Collaborations between scientists in human and animal pathology (3). health continued into the 19th century (2). At that time, germ theory regarded disease as a product of germs and was heavily influenced by outbreaks in livestock, e.g., the 1867 cattle plague in Britain and early work on vaccines (2). Robert Koch One Health at UCalgary, University of Calgary, 3280 Hospital was an early germ theorist, a physician and microbiologist who Drive NW, Calgary, Alberta T2N 4Z6 (Ancheta, Fadaak, discovered Mycobacterium tuberculosis, Vibrio cholerae, and Anholt, Julien, Barkema, Leslie); School of Public Policy, Bacillus anthracis (3), contributing to his theory of contagium University of Calgary (Fadaak, Leslie); Department of vivum, the transfer of disease through a living organism (3). Production Animal Health, Faculty of Veterinary Medicine Using germ theory, Koch first combined human, animal, and (Barkema); Department of Community Health Science, environmental components of One Health, noting that livestock Cummings School of Medicine (Barkema, Leslie); Antimicrobial disease outbreaks could be related to environmental conditions. Resistance — One Health Consortium, University of Calgary, However, those treating patients based on Koch’s discoveries 3330 Hospital Drive NW, T2N 4N1 (Julien, Barkema, Leslie). usually regarded disease as the environment influencing human One Health is a regular feature in the CVJ. Articles are health, or as a direct invasion of human bodies (2). submitted by One Health researchers and practitioners from In the 19th century, there was public concern regarding epi- across Canada and the world. If you have a topic you would demics and increasing demand to investigate them. Research on like included or would like to contribute to this column, epidemics shifted from examining causes of individual cases to please contact us, Michele Anholt and Herman Barkema, at examining disease as a product of factors within a population [email protected]. and the broader environment. John Snow, a London physician, Use of this article is limited to a single copy for personal study. combined environmental and population health perspectives to Anyone interested in obtaining reprints should contact the examine disease outbreaks. He is widely regarded as the father CVMA office ([email protected]) for additional of epidemiology for his use of interviews, case-finding, and copies or permission to use this material elsewhere. statistical mapping to understand disease transmission in an

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1854 cholera outbreak (5). Early application of epidemiological lic health issues (10). Under Salmon’s direction, the Bureau, (i.e., “population”) methods to understand disease were a key created a foundation for VPH (10). In addition to bringing a contributor to One Health (6). public health population focus, VPH as imagined by Salmon, Veterinary Public Health (VPH) was established in the offered a unique view of health that differed from reduction- 19th century to address zoonotic diseases (2). Veterinary Public ism. Establishing a Division of Pathology within the Bureau, Health used epidemiological approaches and methods to address Salmon’s aim was to use pathology to support epidemiol- population-level health issues. Rudolph Virchow integrated germ ogy. Rather than using pathology for highlighting individual theory and the interface of human-animal populations to inves- abnormalities, he envisioned it holistically supporting systemic tigate zoonotic disease transmission in the meat industry (2). He investigations. Although the Bureau controlled livestock out- established new links in disease transmission between humans breaks, it lacked funding and training to discover the under- UNE SANTÉ and animals and the understanding that health of animals, espe- lying epidemiology of disease outbreaks and was not able to cially those consumed by humans, affected human health (2). garner support for One Health. However, this was not Salmon’s Although veterinary medicine had previously contributed to last attempt. public health with Edward Jenner’s use of cowpox to protect In 1890, Salmon founded a meat inspection service based against smallpox (3), VPH truly integrated public health and on similar principles, but the service unfortunately floun- veterinary medicine. dered as Salmon lacked support of health systems and authori- Demand for expansion of public health began in 1878 with ties (9). Salmon’s vision of a national meat inspection service a yellow fever epidemic in the southern US (7). Consequently, was “de-prioritized” by other nationwide public health initia- the National Board of Health (NBH) was created on March 3rd, tives, e.g., school vaccination laws (9,11). His 1890 Meat 1879 (7), the first attempt at nationalizing public health in the Inspection Act was contested by states arguing their rights US. The NBH president, James L. Cabell, was a physician with were being infringed upon and that national level action was a strong interest in environmental sanitation who subsequently unconstitutional (6,9). Although passed into law, the Act only achieved prominence in public health (8). Under his influence, allowed inspection if it was requested by the buyer, seller, or the NBH attributed yellow fever to an interaction of popula- exporter (12). A more effective public health intervention and tion and environmental elements. The NBH sought to promote efforts at combining One Health’s elements was not introduced population-level sanitation at a national level, advocating for a until 1906 when social developments favored national meat national quarantine to control the rapid spread of yellow fever, inspection (12). The impetus was public outrage at unsanitary especially in seaport towns (7). This attempt to combine popula- conditions in Chicago abattoirs, as described in a novel by the tion and environmental elements of One Health was contested popular writer Upton Sinclair (12). Billings’ and Salmon’s efforts by southern state representatives, who successfully argued that to combine human-animal, environmental, and population level nationalization would be ineffective and unconstitutional (7). elements were not entirely successful, but influenced veterinary The NBH, which lacked funding or quarantine powers and medicine to view disease as a multi-factorial phenomenon. could only allocate resources to state and municipal boards, was Veterinarians in the VPH tradition, influenced by Billings and forced to abandon its original goals of promoting sanitation by Salmon, encouraged researchers to understand disease within improving air and water quality, sewage, and drainage (7). The animal herds as well as within ecosystems, and to adopt research NBH, constantly in conflict with state and local health systems, methodology that emphasized statistics alongside an improved ultimately failed. Social developments thus prevented not just a understanding of diagnostic testing accuracy measures; disease national epidemic response, but also segregated key elements of approaches similar to current One Health principles (13). From what would eventually constitute One Health. the early 1940s to the late 1950s, disease became defined as an The introduction and expansion of VPH modified the role interaction among humans, the environment, and disease man- of veterinarians to include public health. Towards the late agement (13). This mid-century approach integrated the 3 key 19th century, there were advocates for the expansion of vet- elements in current One Health, albeit with different terms erinarians into public health, including Frank S. Billings. He and emphasis. What would become One Health’s examination applied the emerging science of bacteriology to identify the of interacting human-animal-environment systems was then causes of milk-borne illness with epidemiological approaches expressed as the study of the importance of the environment, to determine that milk from diseased cows was dangerous (9). including animals, on human health. Epidemiology (i.e., the Billings’ research combined key elements of One Health. With population element of contemporary One Health), increased his approach, health research expanded beyond the individual in importance, but was thought of and described as disease level to include potential environmental sources of disease at management. Our examination of the evolution of One Health the population level. Consequently, Billings’ work was the as it is understood today, and of the actors and social develop- impetus to integrate human and animal medicine with ecology; ments that led to its core concepts being combined or divided, combining environmental and population level components of will continue in our next column. One Health, and setting the stage for Dr. Daniel Salmon. Dr. Salmon oversaw multiple public health initiatives in References the US, including the Bureau of Animal Industry, a national . 1 Bidaisee S, Macpherson CN. Zoonoses and One Health: A review of the literature. J Parasitol Res 2014;874345. veterinary service organization launched in 1884 that focused 2. Bresalier M, Cassidy A, Woods A. One Health in history. In: Zinsstag on controlling livestock disease outbreaks and associated pub- J, Schelling E, Waltner-Toews D, Whittaker M, Tanner M, eds. One

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Health the Theory and Practice of Integrated Health Approaches. 9. Steele JH. Veterinary public health: Past success, new opportunities. Oxfordshire, UK: CAB International, 2015:22–38. Prev Vet Med 2008;86:3:224–243. 3. Jensen-Jarolim E. Definition of comparative medicine: History and new 10. Saunders LZ. A history of the pathological division of the bureau of identity. In: Jensen-Jarolim E, ed. Comparative Medicine: Anatomy and animal industry, United States department of agriculture, between Physiology. Vienna, Austria: Springer Vienna, 2014:1–18. 1891–1921. Vet Pathol 1989;26:6:531–550. 4. Parent A. Felix Vicq d’Azyr: Anatomy, medicine and revolution. Can J 11. Nathan RP. Federalism and health policy. Health Aff 2005;24:6: Neurol Sci 2007;34:1:30–37. 1458–1466.

5. Johnson S. The Ghost Map. New York, New York: Riverhead Books, 12. Institute of Medicine (US) Food and Nutrition Board. Introduction and HEALTHONE 2006. historical review of meat inspection. In: Cattle inspection: Committee 6. Waltner-Toews D. Zoonoses, One Health and complexity: Wicked on Evaluation of USDA Streamlined Inspection System for Cattle problems and constructive conflict. Philos Trans R Soc Lond B Biol (SIS-C). Washington, DC: National Academies Press (US), 1990:8–15. Sci 2017;372:1725. 13. Schwabe CW. History of the scientific relationships of veterinary public 7. Warner M. Local control versus national interest: The debate over health. Rev Sci Tech 1992;10:933–949. southern public health, 1878–1884. J South Hist 1984;50:3:407–448. 8. Michael JM. The National Board of Health: 1879–1883. Public Health Rep 2011;126:1:123–129.

Answers to Quiz Corner Les réponses du test éclair

1. D) Renal epithelial casts are present with acute tubular necrosis. C) Les petits ruminants souffrant de paratuberculose n’ont pas D) Les cylindres épithéliaux rénaux sont présents lors de nécrose de façon caractéristique de diarrhée comme on observe chez tubulaire aiguë. les bovins. Les signes cliniques les plus communs sont l’abattement, le dépérissement chronique et des concentrations 2. C) Gout is caused by diets high in protein. basses de protéines sériques. C) La goutte est causée par des diètes riches en protéines. 5. D) Melanoma lesions typically occur in gray adult horses and are 3. D) In an effort to prevent large, pulsatile release of massive nonpainful, spherical, smooth, alopecic, raised, or ulcerative amounts of insulin which can aggravate the disease, the masses and may be amelanotic or black to brown in color. feeding of small, frequent meals is preferred. The rest of The most common sites are the underside of the root of the the steps are appropriate measures to institute to prevent tail and the perianal/perineal region. neuroglycopenic episodes. D) Les lésions de mélanome se produisent de façon caractéris- D) Dans un effort pour prévenir de grandes libérations pulsatives tique chez les chevaux adultes gris et sont des masses non de quantités massives d’insuline qui peuvent aggraver la douloureuses, sphériques, lisses, alopéciques, élevées ou maladie, l’alimentation en petits repas fréquents est pré- ulcératives, qui peuvent être amélanotiques ou de couleur férable. Les autres options sont des mesures appropriées à noire à brune. Les sites les plus communs sont le dessous de instaurer pour prévenir des épisodes de neuroglycopénie. la base de la queue et la région périanale/périnéale. 4. C) Small ruminants affected by Johne’s disease do not typically have diarrhea as is seen in cattle. More common clinical signs are depression, chronic wasting, and low serum protein concentrations.

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