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Diagnostic Approach to

Infectious Respiratory Disorders


Nicola Pusterla, DVM, DACVIM, Johanna L. Watson, DVM, PhD, DACVIM, and
W. David Wilson, BVMS, MS

Infectious respiratory tract diseases in horses have been identified as one of the most
common medical entities by veterinarians nationwide. Because of the contagious nature of
certain pathogens involved in these diseases, early diagnosis is important to allow proper
management and reduce the risk of exposure to other horses. The combination of general
clinical signs, such as fever, anorexia, and depression, with specific respiratory signs such
as tachypnea, nasal discharge, coughing, submandibular lymphadenopathy, and adventitial
lung sounds should alert the veterinarian to a respiratory tract infection. The individual,
herd, and farm histories are important in determining the contagious nature of the disease.
Once the patient’s problems have been assessed and the differential diagnosis considered,
a diagnostic workup is instituted. There are several diagnostic tools available to investigate
a respiratory tract infection to achieve an accurate diagnosis in a timely manner. Generally,
imaging techniques are performed at referral clinics, whereas samples of the respiratory
tract can easily be collected in the field. Samples such as nasopharyngeal swab, transtra-
cheal wash fluid, bronchoalveolar lavage fluid, or pleural fluid are routinely used for
cytology and culture to detect the inciting pathogen(s). Molecular biological methods
based on antigen (ELISA) or nucleic acid (PCR) detection have become more widespread
in recent years, increasing the sensitivity and speed for detection of specific respiratory
tract pathogens.
Clin Tech Equine Pract 5:174-186 © 2006 Elsevier Inc. All rights reserved.

KEYWORDS horse, infectious respiratory disease, history, physical examination, diagnostic


tools

I nfectious diseases involving the respiratory tract of horses


have been identified as one of the most common medical
entities encountered by ambulatory practitioners or equine
patient’s problems, establishment of a differential diagnosis,
and the constitution of an efficient and organized diagnostic
workup plan. This article will review the history, physical
internists. Often the course of the disease is determined by examination, and specific diagnostics associated with infec-
the nature and the epidemiology of the causative pathogen. tious respiratory tract diseases.
Coccidioidomycosis, for example, is a sporadic fungal disease
endemic in the southwestern States. The disease is character-
ized by a protracted course and affects single horses. On the History
other side, viral pathogens, such as equine influenza virus,
The approach to the patient with respiratory disease begins
have a worldwide distribution and spread rapidly through-
appropriately with a carefully and systematically taken his-
out a naïve horse population, resulting in great economical
losses. The major challenge encountered by the equine vet- tory. It is the responsibility of the veterinarian to ask specific
erinarian when confronted with a case of respiratory tract questions to retrieve the most pertinent information. To get
infection is to determine the contagious nature of the disease the most accurate information pertaining to the horse’s prob-
to prevent a possible outbreak. The clinician will rely mostly lem, questions should be directed to the person most closely
on the initial complete history and physical examination. involved with the care of the horse. As with illness involving
These two simple procedures allow for recognition of the any of the body systems, information regarding age, breed,
sex, origin, environment, herd or group history, vaccination
and deworming history, and previous medical history pro-
Department of Medicine and Epidemiology, School of Veterinary Medicine, vide important starting points. Information concerning on-
University of California, Davis, CA
Address reprint requests to N. Pusterla, Department of Medicine and Epide-
set, duration, and nature of the presenting signs should also
miology, School of Veterinary Medicine, University of California, One be obtained.
Shields Avenue, Davis, CA 95616. E-mail: npusterla@ucdavis.edu The age of the diseased animal exhibiting respiratory signs

174 1534-7516/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.ctep.2006.03.012
Infectious respiratory disorders 175

is important and may provide information as to the nature of and anorexia. Information regarding prior use and duration
the problem. Chronic bacterial pneumonia in foals aged 3 of medication by the owner or trainer should be requested as
weeks to 6 months may be associated with Rhodococcus equi. well. Predisposing factors for developing respiratory disease
Viral and bacterial upper respiratory tract infections are com- such as stressful events (racing, showing, transportation),
monly observed in young horses (weanlings, yearlings, 2- major alterations in husbandry practices, or new arrival of
and 3-year-old horses), that are concentrated for transporta- inadequately quarantined horses on the premise should also
tion, sales, training, or racing purposes. In contrast, sporadic be ascertained.
fungal and bacterial pneumonias are primarily diagnosed in
the more mature horse. The number of horses affected at the
farm is a direct reflection of the contagious or enzootic nature
Physical Examination
of the inciting pathogen. At this stage and before beginning a physical examination,
The origin and environment of the horse should be thor- the veterinarian should consider taking precautionary mea-
oughly evaluated. If the horse is stabled at a facility with a sures if a contagious respiratory disease is suspected based on
high population turnover, the risk for a viral respiratory out- the history. Wearing a disposable gown or coveralls and
break is increased. Sole horses without contact to others or gloves may prevent spread of the disease. Before examination
horses kept in a closed environment are less likely to be of the horse, it is helpful to simply step back and evaluate the
exposed to viral respiratory pathogens, although reactivation horse’s demeanor, mental status, manner of movement, and
and shedding of virus from a latent carrier is considered body condition. In particular, note posture (eg, extended
important in the epidemiology of equine herpesvirus 1 and 4. head and/or neck), respiratory rate, degree of intercostal
The endemic status of the farm or location of origin of the and/or abdominal movement, and presence of nostril flare
affected horse needs to be investigated in regard to infectious and/or stridor. These are the signs on which recognition of
pathogens such as Streptococcus equi subsp. equi, Rhodococcus respiratory distress is based. Observation of breathing fre-
equi, Corynebacterium pseudotuberculosis, or Coccidioides immi- quency and pattern of breathing will provide the first indica-
tis. Travel history to endemic regions should also be ascer- tion of the functional nature of the respiratory disease. This is
tained. If the environment can be directly evaluated, one especially important when evaluating foals or nervous horses
should assess ventilation, cleanliness, and type and quality of whose breathing rate rapidly increases with the stress of han-
hay and bedding material to determine the possible influence dling. The normal breathing rate of a quiet adult horse is 12
of dust in the development of respiratory signs. to 20 breaths per minute with a slightly noticeable abdominal
Information regarding the deworming and vaccination component during expiration. In foals, the normal breathing
schedules are pertinent to the history. Young horses are at rate may be up to 40 breaths per minute.
risk for developing verminous pneumonia secondary to The physical examination follows the distant observation
Parascaris equorum migrations if not properly dewormed. in an orderly and systematic manner. Proceeding from the
Horses pastured with donkeys are at risk of developing lung- head to the tail is suggested, since most horses are accus-
worm infection with Dictyocaulus arnfieldi. Type and fre- tomed to head handling. Mucus membranes (color and
quency of administration of vaccines should be evaluated for moistness) and capillary refill time should be noted and the
the patient. The current range of vaccines includes some very face and head examined for swelling or asymmetry. Note the
effective products and some less effective ones. Vaccines tend nature and odor of any ocular or nasal discharge or crusting
to be effective when they are specific for diseases that nor- and determine whether they are unilateral or bilateral. The
mally result in protective immunity in patients that survive patency of nasal air passages may be checked using a cooled
the disease and when the vaccines mimic the immunologic glass slide or a hand held at the external nares. Partial, uni-
effects of the infectious agent itself. The less efficacious vac- lateral decrease in nasal air flow can be detected by occluding
cines frequently fail to induce the type of immune responses one nostril opening and listening to the quality of the air
that result from natural infection. Vaccinations against upper movement of the contralateral side. The area over the para-
respiratory tract pathogens such as equine influenza virus, nasal sinuses should be evaluated for symmetry, swelling and
equine herpesvirus 1 and 4, or S. equi subsp. equi have been pain, and when indicated, the sinuses should be percussed.
shown to be protective by reducing the severity of clinical The pharyngeal area should be carefully palpated, and the
signs as well as pathogen shedding via nasal secretions. size of the submandibular lymph nodes should be noted. The
Prior medical problems are important to assess because guttural pouches may be palpated or visualized if distended
they may have a direct association with the present disease. because of tympanism. Masses in the retropharyngeal area
Viral respiratory infections often precede the development of are most often caused by enlarged or abscessed lymph nodes
bacterial pneumonia in young horses. Guttural pouch empy- as seen in cases of S. equi subsp. equi infection. Palpation of
ema, metastatic and retropharyngeal abscess-formation, or the larynx and extrathoracic trachea is routinely performed
purpura hemorrhagica are sequelae of S. equi subsp. equi and should not elicit paroxysmal coughing episodes in the
infection. Finally, questions are directed at defining the exact normal horse. Check for patency of the jugular veins or for
problem, at establishing the chronicity of the disorder, and evidence of perivascular injections which may contribute to
the rapidity of its development. Common presenting signs upper respiratory tract obstructions by their involvement of
associated with respiratory diseases include cough, nasal the recurrent laryngeal nerve or vagosympathetic trunk.
and/or ocular discharge, exercise intolerance, respiratory dis- Careful auscultation of the heart, thorax, and trachea follows.
tress, sneezing, abnormal respiratory noise, elevated breath- Concentrate on the heart rate and rhythm and on any mur-
ing rate, abnormal respiration pattern, and, particularly with mur noted. Radiation of heart sounds over a larger area than
infectious diseases, systemic signs such as depression, fever, normal may be associated with pleural effusion. Remember
176 N. Pusterla, J.L. Watson, and W.D. Wilson

sounds. The inspiratory phase of vesicular sounds is much


longer and louder than the expiratory phase. Bronchial
sounds are louder, more tubular in quality, and have a wider
range of frequencies than vesicular sounds. They are heard
over the larger airways and resemble the sound of air blowing
through a hollow pipe. Their expiratory phase is longer and
may be louder than their inspiratory phase. In regions where
both types of normal sounds are heard, the term bronchove-
sicular is commonly used. The relative loudness and distri-
bution of normal breath sounds needs to be considered dur-
ing auscultation of the chest. Increased ventilation results in
increased loudness of normal breath sounds since the inten-
sity of breath sounds produced is related to the velocity of gas
flow within the airways. Therefore, any horse with an in-
creased level of ventilation will have what appears to be ab-
normally loud breath sounds on auscultation even in the
absence of respiratory abnormalities. This situation is often
characterized as “harsh lung sounds” and can also be associ-
ated with lung disease. The appropriateness of the level of
ventilation needs to be considered, and factors such as pant-
ing, exercise, environmental temperature, fever, excitement,
and body condition need to be taken into consideration.
Adventitial lung sounds are abnormal sounds associated with
narrowing or closure of airways and are superimposed on the
normal breath sounds. Abnormalities that may be detected
include wheezes and crackles. Wheezes are musical, contin-
uous, and frequently high-pitched sounds caused by the pas-
Figure 1 Rebreathing examination using a bag. Care must be taken sage of air at high velocity through narrowed airways. Crack-
not to occlude the nares with the plastic bag. (Color version of figure les are short, explosive, nonmusical, discontinuous sounds
is available online.) caused by reopening of airways at the end of inspiration or by
air passage through fluid. Pleural friction rubs or pleural
crackles may be heard when pleural surfaces roughened by
that cardiac diseases may mimic signs of respiratory disease
fibrin deposits, inflammation, or neoplasia rub together.
in the presence of pulmonary edema and/or exercise intoler-
Note that pleural crackles will not be generated when pleural
ance.
surfaces are separated, eg, by pleural effusion. Pleural crack-
One of the most important diagnostic techniques available
to veterinary practitioners for the assessment of pulmonary les have been described as sounding like the creaking of old
disease is auscultation of the respiratory system using a leather. If pleural effusion is present, decreased sounds or the
stethoscope. The larynx, trachea, and both sides of the chest, absence of sounds is noted ventrally, whereas in case of a
at 8 to 10 sites over both large and small airways, should be pneumothorax, no sounds are detected dorsally. Severe con-
carefully ausculted in a quiet environment to assess the solidation, atelectasis, or abscessation of a portion of the
source, audibility, and nature of both normal and abnormal lung, neoplasia, or herniation of the abdominal contents into
sounds. Environmental noise and adipose coverage over the the pleural cavity may also result in silent areas on ausculta-
ribs may interfere with adequate examination in a quiet and tion. Normal tracheal sounds reflect air movement during
healthy horse. Therefore, assuming that the horse can toler- inspiration and expiration. Tracheal rattle is associated with
ate further stress on his respiratory system, a soft plastic bag excessive mucous accumulation, which often results from
can be applied to the horse’s nose to create a system in which inflammatory diseases of the lower airways.
the horse is forced to rebreathe its exhaled gases (Fig. 1). This The thorax of the horse may also be percussed. Percussion
increases the horse’s arterial carbon dioxide and minute ven- is achieved by methodically tapping the intercostal spaces of
tilation, and the resulting faster and deeper respiratory pat- the thoracic cavity using one’s finger, a neurological hammer,
tern makes it easier for the examiner to detect any anomalies. and a spoon, or a commercial plexor and pleximeter, and
This examination should be performed in a quiet environ- evaluating the nature of the sound produced. The most com-
ment and care must be taken not to induce respiratory dis- mon finding in equine respiratory cases is ventral dullness
tress in the horse. The goals of the rebreathing examination suggestive of pleural effusion, pleural thickening, lung con-
are to determine whether respiratory noises are heard over solidation, or pericardial effusion. The technique of percus-
the entire lung fields and trachea, and to detect abnormal or sion is not painful and resentment by the horse may be in-
adventitial lung sounds. Coughing, development of respira- dicative of a thoracic disorder. Horses with pleuritis and
tory distress, and prolonged recovery time after the bag is associated pleurodynia may stand with their elbows ab-
removed are signs of respiratory compromise. Normal breath ducted and have asymmetric thoracic cage abduction during
sounds include faint rustling sounds heard over areas of the inspiration. On finishing the examination of the thorax, the
chest away from large airways and are known as vesicular examiner should palpate the horse for evidence of sternal
Infectious respiratory disorders 177

Figure 2 Endoscopic picture of the right guttural pouch demonstrating mucopurulent secretions on the floor of the
medial compartment of a horse with S. equi subsp. equi infection. (Color version of figure is available online.)

edema, a common finding in the presence of pleural effusion Endoscopy not only allows visualization of the pouches, but
in the horse. also sampling of secretions and flushing of purulent material
Next, the legs and feet should be palpated for any abnor- for cytology and culture. Endoscopy is a useful means of
malities, paying attention to the digital pulses and tempera- obtaining tracheobronchial aspirates using guarded swabs or
ture of the extremities. The examination should conclude catheters as well. Advantages and inconveniences associated
with auscultation of the abdomen and by measurement of the with this collection technique in comparison with transtra-
rectal temperature. cheal aspiration will be discussed later. When scoping a horse
with a contagious respiratory tract disease, one must be
aware of the risk of instrument contamination. Therefore,
Imaging the Respiratory Tract proper handling and disinfection of the endoscope must be
Endoscopy considered. Glutaraldehyde (Cidex, ASP, Irvine, CA) is an
Fiberoptic endoscopy provides an invaluable means of as- appropriate disinfectant.
sessing the upper respiratory and proximal lower respiratory
tract of the horse. Although most horses tolerate the proce- Radiography
dure well, care must always be taken to restrain the horse Radiography can be helpful in the diagnosis of equine respi-
adequately. The use of a nose twitch and/or chemical seda- ratory infectious diseases of the paranasal sinuses, guttural
tion can be used to restrain refractory patients. Indications pouches, retropharyngeal area, or lungs. The size of the horse
for endoscopic examination in the context of infectious dis- and the inherent low output of portable machines limit the
eases include abnormal nasal discharge, poor performance, usefulness of this technique to the upper respiratory tract in
and cough. The upper respiratory tract can be examined with a field setting, however. Proper restraint of the horse for
a 1-m long endoscope, but a 2- to 3-m endoscope is needed positioning of the cassette can be achieved with xylazine (0.5
for bronchoscopy. An endoscope with an external diameter mg/kg IV) or detomidine (0.01 mg/kg IV) sedation.
no larger than 11 mm is required to evaluate the guttural Evaluation of the upper airways can be performed in the
pouches. The guttural pouches represent a common site for field by taking lateral, oblique, and dorsoventral views. The
infection. It is usually easier to enter the pouch situated on lateral view of the paranasal sinuses is useful in demonstrat-
the same side as the nostril used to gain access to the pharynx. ing the presence of fluid or soft tissue densities. A distinct
The use of a blunt stylet, passed through the biopsy channel horizontal fluid-to-air interface can be seen in sinusitis or
of the endoscope, facilitates the access into the pouch. Ret- masses with concomitant fluid exudates. Oblique radio-
ropharyngeal lymph nodes may be seen protruding through graphs are helpful to determine the extent of filling, lateral-
the wall of the pouches if they are increased in size. Empyema ization of the lesion, and tooth root involvement. Dorsoven-
or chondroids, often associated with S. equi subsp. equi infec- tral views also aid in localization of the abnormality and
tion, may be seen on the floor of the pouches (Figs. 2 and 3). demonstrate extension of masses into the nasal cavity, and
178 N. Pusterla, J.L. Watson, and W.D. Wilson

Figure 3 Endoscopic picture of the right guttural pouch demonstrating chondroids on the floor of the medial compart-
ment of a horse with S. equi subsp. equi infection. (Color version of figure is available online.)

deviation or thickening of the nasal septum. Although gut- ema or hematoma. The presence of chondroids can also be
tural pouches are soft-tissue structures, air surrounding this detected (Fig. 4). Radiologic evaluation of the equine thorax
area provides radiographic contrast; therefore, radiographic permits detection of diffuse parenchymal diseases such as
evaluation of the area is useful. The medial and lateral com- interstitial pneumonia, pulmonary edema, and chronic air-
partments of the guttural pouches are seen readily. Fluid way disorders, as well as mediastinal or deep parenchymal
lines seen within the pouches can be consistent with empy- abscesses. The indications for thoracic radiographic exami-
nation include a history compatible with intrathoracic dis-
ease, abnormal auscultatory findings, and other physical ex-
amination findings consistent with respiratory disease, such
as increased respiratory rate or effort and cough. The tech-
nique for thoracic radiography of the horse has been well
described elsewhere.1,2 Three to four overlapping lateral
views of the thorax are necessary to evaluate thoracic struc-
tures of the horse, and machines with high output are re-
quired. However, compared with human or small animal
medicine, in which correlations between the pulmonary dis-
orders and the radiographic findings are well-established, the
radiographic changes in equine respiratory disorders tend to
be rather nonspecific. Further, many pulmonary diseases
such as inflammatory airway disease, exercise-induced pul-
monary hemorrhage, lungworm infection, and recurrent air-
way obstruction may be associated with normal radiographs.
Four types of radiographic patterns have been described: an
alveolar, an interstitial, a bronchial, and a vascular pattern. In
the alveolar pattern, opaque areas coalesce and completely
obliterate the vessels and bronchi. Air bronchograms may be
notable. This pattern occurs with pulmonary edema, hemor-
rhage, lung consolidation, or neoplastic infiltration. Intersti-
tial patterns are found most commonly and are associated
Figure 4 Lateral radiographs of the pharynx demonstrating chon- with a variety of conditions. This pattern causes a blurring of
droids and fluid within the guttural pouch of a horse with guttural the edges of the pulmonary vessels, a diffuse increase in lung
pouch empyema secondary to S. equi subsp. equi infection. opacity, and variable reticular, linear, or nodular opacities. A
Infectious respiratory disorders 179

Figure 5 Ultrasonographic image of a horse with normal lungs, Figure 6 Ultrasonographic image of a horse with comet tail artifacts
showing a hyperechoic line representing the aerated visceral pleural created by irregularities on the pleural surface.
surface of the lung and the characteristic equidistant reverberation
echoes.
line and reverberation artifacts or concentric equidistant ech-
oes as the horse breathes (Fig. 5). Normal pleural fluid can be
detected in small amounts in the ventral thorax of racehorses
reticular pattern occurs with viral, bacterial, fungal or para- as anechoic (black) area separating the parietal pleura from
sitic pneumonia, pulmonary edema, interstitial pneumonia, the lung tissue.5 If some irregularities are present at the pleu-
and pulmonary fibrosis. An irregular linear pattern occurs ral surface, comet tail artifacts may be seen (Fig. 6). Comet
with resolving bronchopneumonia, and a nodular pattern tail artifacts may represent early pneumonia or scarring from
occurs with abscesses, granulomata, or neoplasm. Bronchial previous lower respiratory tract infection. Any area of
patterns alone are not found commonly but usually occur in nonaerated or consolidated lung, if peripheral, is easily visu-
association with interstitial patterns. Paired linear opacities alized with ultrasonography and appears as different shades
or numerous small circular opacities represent thickening of of gray. Pulmonary abscesses (Fig. 7) appear in ultrasonog-
the large- and medium-sized airways or of the septa around raphy as encapsulated cavitated areas filled with fluid or
the lobules. This pattern occurs in cases of equine bronchitis echogenic (white) material, whereas areas of pulmonary con-
and bronchiolitis. Variations in the size, shape, and number solidation (Fig. 8) appear as dense patterns of homogeneous
of the pulmonary vessels cause a vascular pattern and may be internal echoes with a gray tone. If pleural effusion is present,
visible in horses following exercise or in horses with left-to- it appears black on the screen because it allows free passage of
right cardiac shunt. the ultrasound waves. Fibrin in the pleural fluid appears as
bright strands floating in the fluid or adhered to the pleural
Thoracic Ultrasonography surfaces (Fig. 9). Extremely bright small particles floating in
Thoracic ultrasonography is useful for diagnostic, therapeu- the pleural effusion are thought to be trapped gas bubbles
tic, and prognostic evaluation of peripheral parenchymal and and indicate anaerobic infection. One may visualize masses
pleural disorders. As a tool for investigating respiratory dis- located in the cranial mediastinum at the third intercostal
eases, diagnostic ultrasonography may be more readily avail- space in the absence of pleural fluid. Diagnostically, certain
able than radiography to the equine practitioner. Ultrasonog-
raphy is considered to be superior to thoracic radiography for
detecting pleural effusion, pulmonary consolidation, pulmo-
nary or mediastinal abscesses, tumors, or granulomata and
should always be performed when clinical examination or
thoracic percussion reveals pain and areas of dullness within
the thorax.3,4 Patient preparation is important so that the
ultrasonographic examination is rewarding and nonfrustrat-
ing to the veterinarian. Ideally, the horse’s hair should be
clipped, because the air trapped between individual hair
shafts blocks the ultrasound beams. If this is not possible, the
hair should be thoroughly saturated with alcohol. The skin
must be clean, wet, and covered with a coupling gel. A 2.5- to
3.5-MHz sector probe is most suitable for the examination of
the lungs and cranial mediastinum especially in fat horses,
whereas superficial structures may be best visualized with a
5- to 7.5-MHz linear or microconvex probe. When imaging
the normal lung surface, the air filling the lungs reflects the Figure 7 Ultrasonographic image of a horse with a pulmonary ab-
ultrasound beams and therefore produces a moving bright scess appearing as a well circumscribed area of consolidation.
180 N. Pusterla, J.L. Watson, and W.D. Wilson

Figure 8 Ultrasonographic image of a horse with consolidated lung


tip representing nonaerated lung tissue due to cellular infiltrates.

limitations are inherent in ultrasonography. One must re-


member that deep lesions covered with aerated lung are not
detected with ultrasonography.

Special Imaging Modalities


Special imaging modalities are now being made available for
equine practitioners at selected referral centers. Of these ap-
plications, the most widely available is nuclear scintigraphy,
which has been extensively used in lameness diagnosis and is Figure 10 Material used for the collection of nasopharyngeal sam-
ples. From the left to the right are a sterile transport device for
also being applied to the diagnosis of respiratory disorders.6
bacterial culture, viral transport medium in an eppendorf tube, and
Contrary to other imaging modalities, nuclear scintigraphy
two different nasopharyngeal swabs. (Color version of figure is
allows assessment of pulmonary ventilation and perfusion in available online.)
the horse. Two other modern imaging tools, computer to-
mography and magnetic resonance imaging, should become
more available to equine practitioners in future years.7 genic bacteria.8 Nasopharyngeal swabs are primarily used for
the detection of viral pathogens (equine influenza virus,
Sampling the Respiratory Tract equine herpes virus 1 and 4, equine viral arteritis, equine
rhinovirus, equine adenovirus) or for the retrieval of specific
Sampling the Upper Airways bacterial pathogens such as S. equi subsp. equi. Ideally a
The upper airways can be sampled using swabs, aspirates, or 40-cm swab (Fox Converting Swabs, Green Bay, WI) or a
lavages with or without endoscopic guidance. One must re- uterine culture swab (Animal Reproduction Systems, Chino,
member that the upper airways are colonized by nonpatho- CA) is used to collect nasopharyngeal secretions (Fig. 10).
The swab is advanced into the ventral meatus of the right or
left nostril to the pharynx and allowed to soak for 20 seconds
(Figs. 11 and 12). Swabs for viral detection (culture, molec-
ular detection, immunoassay) should be placed immediately
in a virus transport medium and maintained on ice. Virus
transport medium can be purchased from veterinary state
laboratories. If culture medium is not available, the material
should be rapidly frozen. Swabs collected for culture or mo-
lecular detection of S. equi subsp. equi are best placed in a
culture collection and transport device (TransPorter, MWI
Veterinary Supply Co, Meridian, ID). Independent of the
requested diagnostic test, the sample should be shipped re-
frigerated (cold packs) to the appropriate laboratory in a
styrofoam container. It is always advised to inquire about
availability of tests and notify the laboratory in advance about
a shipped sample. Information on where to send a sample for
a specific respiratory pathogen will be discussed in later arti-
Figure 9 Ultrasonographic image of a horse with pleural effusion and cles.
fibrin deposition on the pleural surface. Swabs and aspirates of guttural pouch material are per-
Infectious respiratory disorders 181

Co, Meridian, ID) is inserted between the tracheal rings and


directed into the tracheal lumen. A 22-inch, 5-French
polypropylene catheter (Sovereign, MWI Veterinary Supply
Co, Meridian, ID) is passed into the tracheal lumen through
the catheter, and 10 to 30 mL of sterile isotonic saline (not
containing bacteriostatic agents) is instilled and subsequently
retrieved by applying suction with the syringe. As an alterna-
tive, a transtracheal wash kit including a catheter-over-nee-
dle, a flushing catheter, and a stylet is offered by Mila Inter-
national (Erlanger, KY). In the event that a sample is not
retrieved, the infusion of saline can be repeated several more
times. Finally, the large-bore catheter should remain in place
during retraction of the polypropylene catheter, to minimize
contamination of the peritracheal tissue. Percutaneous TW
has the disadvantage that a surgical skin preparation is re-
quired and that it is associated in rare instances with a risk of
cellulitis at the insertion site of the catheter. For this reason,
it is advisable to administer an antimicrobial after performing
this technique in suspected cases of pneumonia, while await-
ing the bacterial culture results. An increasingly popular and
well-tolerated alternative for collection of TWs is via a fiber-
optic endoscope. However, samples collected using un-
guarded polyethylene catheters passed through the biopsy
channel of the endoscope are contaminated with nasopha-
ryngeal bacteria and are unsuitable for microbial cultivation.
The principal use of samples collected using this technique is
for cytologic examination. Recently, guarded systems have
Figure 11 Swab placed outside the ventral meatus before sample
been evaluated for collection of uncontaminated samples
collection. (Color version of figure is available online.) from the lower airways via endoscopy (Endoscopic microbi-

formed under endoscopic guidance using protected culture


swabs (Animal Reproduction Systems, Chino, CA) or poly-
ethylene catheters (Polyethylene Tubing, Becton Dickinson
and Company, Sparks, MD) via the biopsy channel of the
endoscope. Culture of guttural pouch lavages taken by en-
doscopy is a more sensitive method to identify chronic car-
riers of S. equi subsp. equi than culture of pharyngeal swabs.9
After each sample collection, the endoscope and its biopsy
channel must be disinfected. A technique for obtaining per-
cutaneous aspirates of the guttural pouches through Viborg’s
triangle has also been described.8

Tracheal Wash
Tracheal washes (TW) allow for the collection of secretions
from the distal trachea that are representative of both the
peripheral and central airways. Samples obtained by TW are
suitable for cytologic and Gram stain evaluation and bacteri-
ologic or fungal cultivation. Tracheal exudates are obtained
either via percutaneous tracheal wash or via endoscopy. It is
preferable to sedate the horse prior to sample collection with
a combination of alpha-2-agonists such as xylazine (0.5
mg/kg IV) or detomidine (0.01 mg/kg IV) and butorphanol
(0.01 mg/kg IV).
To perform a percutaneous TW, the skin should be
clipped and aseptically prepared on an area over the trachea
in the middle to upper third of the neck. A small stab incision
with a number 15 blade is performed over an area previously Figure 12 Proper placement of the 16-inch nasopharyngeal swab
anesthetized with 2% lidocaine. A 12-gauge, 2-inch large- during collection of nasopharyngeal secretions. (Color version of
bore intravenous catheter (Medicut, MWI Veterinary Supply figure is available online.)
182 N. Pusterla, J.L. Watson, and W.D. Wilson

ology aspiration catheter, Mila International, Erlanger, KY). macrophages can also be seen. As with bacterial infections,
Before each sample collection, the endoscope and its biopsy the presence of phagocytized fungal hyphae in neutrophils or
channel must be disinfected with glutaraldehyde (Cidex, macrophages may add more evidence of a true fungal infec-
ASP, Irvine, CA). The authors prefer to obtain tracheobron- tion as opposed to environmental contaminants. Primary vi-
chial aspirates percutaneously. Caution should be taken ral infections are rarely sampled, as most animals will have a
when febrile horses with an underlying respiratory disease secondary bacterial invader by the time of the examination.
are sedated with alpha-2-agonists. Idiopathic tachypnea and In some cases, there may be an increase in lymphocytes as
respiratory distress has been observed in such situations. Pre- well as some epithelial cell injury. Nonseptic inflammation is
medication with nonsteroidal antiinflammatory drugs such evidenced by the presence of nondegenerative inflammatory
as flunixin meglumine (0.5-1 mg/kg IV) 30 minutes before cells without evidence of an etiologic agent.
the procedure and alcohol baths have in our experience In equine practice, TW is often performed in the field,
helped reducing the risk of tachypnea and respiratory dis- which implies a delay until the sample is processed. The
tress. Further, to avoid such complications, affected horses cytology does not significantly change if the sample has been
can safely be sedated with a combination of valium (0.05 stored for 24 hours at 4°C in a capped syringe. If delays
mg/kg IV) and butorphanol (0.01 mg/kg IV). longer than 24 hours are anticipated, or access to a cool
The rationale for using TW is based on the assumption that environment is not possible, direct smears may be prepared,
the bacterial population derived from the upper airway of air-dried, and sent to the laboratory. In horses with pneumo-
normal horses is negligible beyond the proximal trachea. nia, the number of aerobic bacteria in the sample does not
Therefore, organisms cultivated from a TW represent bacte- alter over 24 hours; however, anaerobic bacteria do not sur-
ria found in the distal trachea and lower airways. The TW of vive storage and a delay in processing should be avoided
approximately 8% of normal pastured and stabled horses when these bacteria are suspected.
cultured pathogenic bacteria such as Klebsiella pneumoniae,
␤-hemolytic Streptococcus spp., Pasteurella spp., and Pseudo-
monas aeruginosa.10 In the same study, transient bacterial Bronchoalveolar Lavage
flora of questionable pathogenicity such as Enterobacter ag- In recent years, bronchoalveolar lavage (BAL) using either an
glomerans, Bacillus spp., Acinetobacter calcoaceticus, ␣-hemo- endoscope or specialized tubing (Equine BAL catheter,
lytic Streptococcus spp., Staphylococcus epidermidis and Bivona Medical Technologies, Gary, IN) has gained some
Pseudomonas stuterzi was cultured from the TW of 24% popularity for most cases in which a diffuse inflammatory
healthy stabled racehorses and 64% healthy pastured horses. disorder is suspected. In contrast to the TW, the BAL re-
In contrast, anaerobes, which are normal inhabitant of the trieves fluid and cells lining the distal airways and alveoli.
oropharyngeal flora, are rarely isolated from aspirates of Because the unprotected tube lumen is likely to be contami-
healthy horses, emphasizing their importance in disease pro- nated with bacteria found in the upper airways, BAL is used
cesses when isolated from respiratory cases. Fungal hyphae primarily for cytologic examination of nonseptic conditions,
may be found free or engulfed within mononuclear cells in such as exercise-induced pulmonary hemorrhage (EIPH), in-
normal horses. However, the presence of pathogenic fungal flammatory airway disease (IAD) in young horses, and heaves
organisms, such as C. immitis, in combination with abnormal syndrome in mature horses. BAL is sometimes used to re-
clinical and cytological findings strongly suggests its impli- cover bacteria, fungi, and interstitial pathogens such as Pneu-
cation in the disease process. Therefore, when examining a mocystis carinii.11,12 Contamination issues can be avoided by
horse with suspected lower airway infection, one must eval- quantitative culture techniques. Potential lower respiratory
uate culture results in light of the cytologic findings and tract pathogens present in concentrations greater than 105
clinical examination. Moderate to heavy growth of the organ- colony-forming units per ml of sample are considered etio-
ism on culture, identification of organisms within phagocytic logically significant, whereas microorganisms present at
cells, and the presence of degenerative neutrophils represent lower concentrations are not considered significant.13
strong evidence for a bacterial infection of the lower airways. The endoscope or tube is introduced through the nares of
The main emphasis of cytologic examination of tracheal a horse that has been mildly sedated (xylazine 0.5 mg/kg IV
wash specimens is to determine the disease mechanism (sep- and butorphanol 0.01 mg/kg IV) and is advanced down to
tic or nonseptic inflammation) and to provide an early guide the lower airways after airway desensitization by a local an-
to the type of organism before obtaining the results of bacte- esthetic (0.5% lidocaine, 50-100 mL) until it is wedged
riologic culture and antimicrobial sensitivity. A good sample against bronchi of the same dimension. Prewarmed sterile
generally will appear cloudy with large amounts of mucus saline (200-300 mL without bacteriostatic agents) is infused
and debris. Mostly clear fluid or retrieval of a small volume rapidly into the lungs and subsequently aspirated. The BAL
likely represents an inadequate sample and should lead the fluid should be kept refrigerated until submitted for cytologic
examiner to repeat the wash. In most instances of acute in- evaluation to a laboratory. If rapid processing is not possible
flammation, neutrophils predominate. In bacterial pneumo- air-dried smears from the sample pellet should be prepared
nia, there will often be numerous neutrophils, with many after centrifugation (1500⫻ g for 10 minute) of 5 to 10 mL of
showing signs of degeneration. In some cases, there will be BAL in either a serum or EDTA tube. It is imperative to
intra- and extracellular bacterial organisms. Credence is most rapidly air dry the smears to preserve quality, using a fan if
often given to the presence of intracellular bacteria. Prior necessary. The air-dried smears can be stained with Diff-
antimicrobial therapy might influence the number of bacteria Quick, Wright-Giemsa stain, May Gruenwald, or Gram stain
seen. Fungal infections most often result in a neutrophilic for cellular and noncellular constituent interpretation. The
infiltration; however, increased numbers of eosinophils and cellular profile and morphology may serve as a guide to the
Infectious respiratory disorders 183

Figure 13 Thoracocentesis collection equipment showing a 3-inch blunt teat cannula, a 14-gauge, 3.75-inch Teflon
catheter, a fluid extension set, a three-way stopcock, and a 60-mL syringe. (Color version of figure is available online.)

nature of airway injury, inflammation, and the pulmonary tached to a fluid extension set, a three-way stopcock, and a
immunologic response to infections or foreign antigens. In syringe (Fig. 13) to stop the influx of air. It is important to tap
young horses (⬍6 years of age) normal cell differentiation both sides of the chest and submit the aspirates for cytologic
includes 65% macrophages, 30% lymphocytes, 3% neutro- and microbiologic examination. Samples of pleural fluid
phils, 0.5% mast cells, and 0% eosinophils. In mature horses should be collected in both an EDTA (lavender top) and a
(⬎6 years of age), the neutrophil population may average up sterile serum (red top) tube for cytologic analysis and bacte-
to 15% in healthy horses, with a corresponding decrease in rial culture, respectively. Rare complications associated with
the percentage of macrophages and lymphocyte popula- thoracocentesis include pneumothorax, cardiac puncture,
tions.14 Increase in mast cells or neutrophils has been de- intercostal artery or vein laceration, and patient collapse as a
scribed as evidence of IAD and heaves. result of rapid removal of large amounts of fluid.
The fluid obtained can be assessed for its color, odor, and
Thoracocentesis consistency. Normal pleural fluid is reported to be odorless,
Pleural fluid can generally be collected quickly and easily, slightly yellow-tinged, and transparent. Increasing cloudi-
with minimal equipment, and is generally a safe procedure. ness occurs with exudation of plasma and cells, reflecting the
Culture and cytology of the pleural fluid is beneficial for underlying inflammatory process. Hemorrhagic or serosan-
diagnostic, prognostic, and therapeutic purposes. Pleural guinous effusions can occur with trauma, as modified tran-
fluid abnormalities have been associated with many disor- sudates with heart failure, or as effusions associated with a
ders including pulmonary abscesses, pneumonia, chronic variety of neoplasms or parenchymal necrosis. A putrid-
obstructive lung disease, pulmonary granulomata, equine in- smelling fluid is often associated with anaerobic infection.
fectious anemia, systemic mycosis, traumatic penetration of The routine analysis of pleural fluid includes determination
the thorax, and primary and secondary thoracic neo- of protein content, total nucleated cell count, red cell count,
plasms.15-17 Ideally, the site chosen for the thoracocentesis is and cytologic evaluation. Further, to differentiate a septic
identified through a prior ultrasonographic examination. from a nonseptic effusion, glucose concentration, pH, lactate
Otherwise, the thoracocentesis should be performed in the and lactate dehydrogenase activity have also been used suc-
sixth or seventh intercostal space 10 cm dorsal to the olecra- cessfully. Normal pleural aspirates are classified as transudate
non and above the lateral thoracic vein. The site chosen is and contain less than 10,000 nucleated cells per ␮l and less
aseptically prepared and a local anesthetic is infiltrated into than 2.5 g/dL of protein.18 Nondegenerate neutrophils are
the skin, subcutaneous tissues, and intercostal muscles. A the primary cells seen, mononuclear cells (macrophages,
small stab incision of the skin is made next to the anterior lymphocytes) are the second most common. With inflamma-
surface of the rib to help avoid the vessels on the ribs caudal tory conditions, the relative percentage of neutrophils in-
border. Collection is performed using either a 3-inch blunt creases, and in cases where there are degenerate neutrophils,
teat cannula or a 14-gauge, 3.75-inch Teflon catheter at- a search for etiologic agents is indicated and both aerobic and
184 N. Pusterla, J.L. Watson, and W.D. Wilson

Figure 14 Equipment for the cutting needle lung biopsy showing the automated Biopty biopsy devise (Biopty gun and
14-gauge, 16-cm Bard Biopty-Cut needle) and a 14-gauge, 15-cm Tru-Cut biopsy needle. (Color version of figure is
available online.)

anaerobic cultures should be performed. The aerobic bacteria dial joint.23 However, in cases with diffuse pulmonary
most frequently isolated in infectious pleural effusions are changes, the authors prefer using more caudal intercostal
beta-Streptococcus spp., Pasteurella spp., Escherichia coli, and spaces (intercostal spaces 10-13) to avoid puncture of great
Enterobacter spp., whereas anaerobic species most frequently pulmonary vessels. The site should be clipped, aseptically
isolated are Bacteroides spp. and Clostridium spp.10 prepared, and the skin and subcutaneous tissues infiltrated
with lidocaine. Similar to the thoracocentesis, the insertion
Percutaneous Lung Biopsy site of the biopsy needle should be just cranial to the caudal
Percutaneous lung biopsy in the horse is indicated when a rib of the chosen intercostal space to avoid the blood vessels
histologic diagnosis is required for management or therapy of lying caudal to each rib. Ultrasonographic evaluation of the
a patient with diffuse lung disease of undetermined etiology chest before biopsy is advantageous since it allows visualiza-
and after other less invasive diagnostic methods failed to tion of landmarks, assessment of existence of consolidation
provide a definitive diagnosis. Percutaneous lung biopsy has in the superficial parenchymal tissue, and measurement of
been successfully used in cases where a pulmonary miliary the depth to pulmonary tissue. Further, accurate needle
pattern was identified on chest radiographs or in suspected placement under ultrasound guidance is possible in cases of
cases of neoplasia or granuloma.19-21 Pulmonary samples may focal lung consolidation. The procedure is not recommended
be submitted for histopathology, and bacterial or fungal cul- for patients presented with severe tachypnea, in respiratory
ture and sensitivity, depending on the suspected disease pro- distress, exhibiting uncontrollable coughing, or those with
cess. bleeding disorders. Complications observed with lung bi-
The technique has been described in the standing unse- opsy in horses include epistaxis, pulmonary hemorrhage,
dated horse; however, the authors prefer performing the bi- tachypnea, respiratory distress, and less commonly, pneu-
opsy in the stocks, if they are available, and like to chemically mothorax, collapse, and death.19,24
restrain (xylazine 0.05 mg/kg IV and butorphanol 0.1 mg/kg
IV) the horse during the procedure. Instruments used are
either a 14-gauge, 15-cm biopsy needle (Tru-Cut, St. Louis, Special Laboratory Diagnostics
MO) or an automated biopsy devise (Biopty, Bard Radiology for Respiratory Tract Infections
Division, Covington, GA; Fig. 14). Automated biopsy devices
have the advantage of easier use than manual biopsy instru- Hematology
ments and provide specimens that are highly accurate for Routine hematologic analysis should always be performed in
histologic diagnoses.22 The described site for lung biopsy is horses with respiratory signs to distinguish between an infec-
the seventh or eighth left or right intercostal space approxi- tious and a noninfectious process. It must be emphasized that
mately 8 cm above a horizontal line through the humerora- the timing of blood sampling and carefully standardized lab-
Infectious respiratory disorders 185

oratory techniques are essential if interpretation of leukocyte the detection of specific antibodies to pathogens in the pa-
patterns, in relation to viral infections, is to be useful as a tient’s serum. These tests can be used to diagnose active pro-
diagnostic aid. It is also necessary to be aware of the various gressive disease, ascertain recovery, detect carrier states, and
physiological (age, breed, diurnal variation, exercise) and distinguish among vaccination, exposure, and disease. The
pathological (stress) states which can influence the total and assays depend on the quantity of antibody present and the
differential leukocyte count in the horse. Ideally, horses with affinity of the antibody for the antigen. Once binding occurs,
acute disease processes should be sampled during the first 24 antigen–antibody complexes are detected via chromagenic,
hours of the febrile phase and because the leukocyte response fluorogenic or radioisotopic markers (ELISA, radioimmuno-
is transient, sequential sampling of individual horses is nec- assay, immunofluorescence), functional biologic effect (virus
essary to detect all changes. The most consistent findings in neutralization, complement fixation), or alterations in phys-
horses with viral infectious disease of the respiratory tract are ical properties (agglutination, precipitation). Tests may de-
initial lymphopenia, mild normocytic, normochromic ane- tect how much antibody binds to a fixed amount of antigen,
mia, and occasional mild thrombocytopenia. A decrease in or the serum may be serially diluted and a titer expressed to
neutrophils and monocytes also occurs, but the absolute val- signify how much the antibody can be diluted before anti-
ues of both cell types remain within normal limits. The blood gen–antibody complexes fail detection. To retrospectively di-
work rapidly normalizes within a few days and often a tran- agnose viral respiratory diseases (equine influenza, equine
sient mild monocytosis and relative lymphocytosis can be viral arteritis, equine herpesvirus 1 and 4, equine rhinovi-
observed following the acute onset. It is not uncommon for rus), paired serum samples from affected horses are assessed:
horses with viral respiratory tract infection to develop a mild an acute sample collected during the febrile phase of the
increase in fibrinogen postexposure as a reflection of inflam- disease and a convalescent sample collected 14 to 21 days
mation. Patients with chronic infectious disease processes of later. As a general rule, a fourfold increase in titer is consid-
the respiratory tract may present with leukocytosis, mature ered a positive test result and evidence for recent exposure.
neutrophilia, anemia, hyperfibrinogenemia, and often hyper- Chronic infectious respiratory diseases are diagnosed either
proteinemia due to hyperglobulinemia. The leukocytosis and on the presence of antibodies or on the antibody titer. How-
neutrophilia are a reflection of bone marrow response to ever, serologic results need to be interpreted carefully and
tissue demand, and if the inflammatory process is severe, a several factors need to be considered: (1) a positive test result
left shift (band neutrophils ⬎ 100/␮L) can be observed. With means exposure and not necessarily active infection, (2) a
inflammation, total leukocyte counts seldom exceed 30,000/ negative test result does not rule out the disease as shown
␮L. Anemia of inflammatory disease (anemia of chronic dis- with equine herpesvirus-4 in young horses after primary ex-
ease) may be the most common anemia of the horse and is posure, (3) the age of the horse needs to be considered since
generally of mild to moderate severity. The pathology of the the presence of maternal antibodies may interfere with an
anemia has been attributed to a defective iron metabolism adequate immune response in foals, and (4) the sensitivity
(block of iron release from reticuloendothelial storage), a (number of true positive samples which are classified as pos-
deficient response of the bone marrow to circulating eryth- itive by the test) and specificity (number of true negative
ropoietin, and a decreased life span of red blood cells. Plasma samples that are classified as negative by the test) of the test
fibrinogen concentrations are an important addition to the need to be understood. Serological tests for specific viral,
leukogram in detecting inflammation in horses. Plasma con- bacterial, and fungal pathogens will be discussed in later
centrations might be increased (⬎400 mg/dL) with inflam- articles.
matory conditions and can be detected as early as 48 hours
after the onset of inflammation. Peak concentrations usually
are reached within 5 to 7 days and might exceed 1000 mg/dL. Molecular Diagnostics
It is not uncommon in the horse to have increased plasma Molecular diagnostic methods have become increasingly ap-
fibrinogen levels as the sole indicator of inflammation. This is plicable to the diagnosis of infectious diseases, especially for
illustrated in 13 horses with Coccidioidomycosis, showing pathogens that are either difficult or slow to cultivate. To
that 62% and 30% of horses had leukocytosis and a mild left become widely used, the methods need to be easy, safe, cost-
shifts, respectively, but 100% of horses had increased plasma efficient, sensitive, reproducible, and eventually automated
fibrinogen concentrations.25 Hyperglobulinemia usually oc- to facilitate the evaluation of large number of samples. An-
curs in response to chronic antigen stimulation and is often other advantage of molecular techniques is the speed of sam-
present with chronic infection and abscessation. Another in- ple analysis. A fast and reliable diagnosis of a contagious viral
dicator of inflammation, which is often underutilized, is a or bacterial disease is essential in the management of the case
marked increase in thrombocyte counts (⬎400,000/␮L). and prevention of a disease outbreak. Antigen (generally pro-
The strong association of thrombocytosis with infectious/in- teins) or nucleic acid (DNA or RNA) can be detected in sam-
flammatory disorders, should lead clinicians to suspect bac- ples, such as nasal secretions or peripheral whole blood, to
terial infections, such as pleuropneumonia, septic arthritis, provide evidence of infection with specific organisms.
and peritonitis.26 Thrombocytosis has also been used as a Antigen-capture ELISA, such as the Directigen Flu A test
provisional indicator of R. equi pneumonia in foals in con- (BD, Diagnostic Systems, Sparks, MD) for the detection of
junction with additional diagnostic and clinical parameters.27 equine influenza virus from nasopharyngeal swabs, allows
the direct detection of antigen prior or during clinical signs
Immunodiagnostic Testing and is based on the use of specific antibodies. The main
Immunodiagnostic tools are valuable aids in the diagnosis component of the antigen-capture ELISA is a specific mono-
and management of infectious diseases. Serologic tests allow clonal or polyclonal antibody against the nucleoprotein of
186 N. Pusterla, J.L. Watson, and W.D. Wilson

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4. Reimer JM: Diagnostic ultrasonography of the equine thorax. Comp
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