EQUINE VETERINARY EDUCATION Equine vet. Educ. (2018) 30 (4) 187-191 doi: 10.1111/eve.12696
Case Report
Polyarthritis secondary to septic thrombophlebitis in an Arabian mare
M. Lores*, J. Cantos, M. De Rijck and C. O’Shea Sharjah Equine Hospital, Sharjah, United Arab Emirates. *Corresponding author email:
marcolores@hotmail.com
Keywords: horse; thrombophlebitis; jugular; phlebotomy; arthritis; septic
Summary A 3-year-old Arabian mare presented with diarrhoea and depression. During hospitalisation, the mare developed septic thrombophlebitis associated with a jugular catheter. One week later, she developed secondary bilateral tarsocrural joint septic arthritis. Following surgical intervention and intensive medical therapy, the mare recovered successfully. The case highlights an unusual and previously unreported complication of septic thrombophlebitis.
Introduction
Septic thrombosis may progress to serious complications that can be life-threatening and lead to increased mortality rates or loss of use of the horse for its intended purpose (Dolente et al. 2005). Previously reported complications of septic thrombophlebitis in mature horses include bacteraemia, endotoxaemia, vegetative endocarditis, pulmonary thromboembolism and pleuropneumonia via the pulmonary circulation (Ryu et al. 2004; Dolente et al. 2005; Dias and de Lacerda Neto 2013). In the present case, haematogenous spread of septic thrombi from the jugular vein resulted in development of bilateral tarsocrural septic arthritis. The septic thrombosis was addressed successfully by
standing jugular phlebotomy and drainage of infected material within the vein. Additionally, the septic arthritis was treated successfully by systemic administration of antimicrobials and anti-inflammatory drugs, arthroscopic debridement, repeated joint lavage, multiple intra-articular administration of antimicrobials and several i.v. regional limb perfusions with antimicrobials.
History
A 3-year-old Arabian mare was admitted to Sharjah Equine Hospital for evaluation and treatment of diarrhoea and signs of abdominal discomfort of 2 days’ duration. The mare appeared dull and dehydrated and exhibited tachycardia of 80 beats/min. On abdominal auscultation, intestinal borborygmi were absent in all quadrants. A large, firm impaction was identified in the large colon on rectal palpation. Transabdominal ultrasonographic examination was unremarkable and complete blood count was within normal limits. Plasma fibrinogen was elevated (5.05 g/L; reference range [rr] 2.0–4.5 g/L) and serum biochemistry revealed a moderate elevation of creatinine (32 mg/L; rr: 8–22 mg/L), and a mild elevation of aspartate aminotransferase (625 U/L; rr: 100–600 U/L). Treatment of the large colon impaction included feed withholding, the administration of balanced i.v.
fluids and enteral rehydration therapy via nasogastric intubation. The impaction resolved in 2 days, so the mare was reintroduced to feed. On Day 3, all the laboratory parameters had normalised and the i.v. catheter was removed.
Thrombophlebitis – clinical findings and diagnosis
On Day 4, a swelling was noticed over the left jugular vein. Ultrasonographic examination of the area revealed perivascular oedema, thickening of the vein wall and an occlusive hyperechoic thrombus at the prior insertion site of the catheter. Treatment including application of warm compresses, hydrotherapy and topical application of dimethyl sulfoxide solution to the swollen vein was performed three times daily. Systemic antibiotic therapy using oral enrofloxacin (Uvetril1)was commenced and aspirin (Jusprin2) was given orally on alternate days (Dias and de Lacerda Neto 2013). However, over the following days the swelling increased markedly, the proximal two-thirds of the jugular vein palpated very firm and a purulent discharge drained out at the catheter’s insertion site. Streptococcus equi
ssp. zooepidemicus, sensitive to
enrofloxacin, ceftiofur and chloramphenicol, was isolated on bacterial culture of the discharge.
Septic arthritis – clinical findings and diagnosis
One week after the septic thrombophlebitis was observed, the mare developed acute bilateral hindlimb lameness with severe distension of both tarsocrural joints. Haematology revealed a moderate neutrophilic leucocytosis characterised by a regenerative left shift (17.4 9 109/L; rr: 6.0–12.5 9 109/L) and hyperfibrinogenaemia (10.17 g/L). Synovial fluid from both tarsocrural joints was obtained and fluid analysis concentration revealed increased total protein (40 g/L in both joints, normal <20 g/L) and increased white blood cell (WBC) count (left tarsocrural joint 85 9 109 cells/L and the right 67 9 109 cells/L; normal <0.2 9 109 cells/L); cytological examination revealed >80% neutrophils in both joints (normal <10%) (Morton 2005). No organisms were isolated from the synovial fluid using routine culture techniques. As the condition had worsened over 7 days of therapy,
systemic antibiotic and anti-inflammatory medications were adjusted. The antibiotic was changed to oral chloramphenicol (Viceton3) based on the sensitivity of bacteriological culture. Nonsteroidal anti-inflammatory therapy using phenylbutazone (Bute4) was started and aspirin administration was discontinued. In an attempt to eliminate the jugular vein infection rapidly and thereby eradicate the presumed source of the
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