Vet. Pathol.

22: 333-337 (1985)

Endocarditis in Six Horses

A. J. COOLEY,S. A. HINES,and F. S. PIPERS

C. D. BUERGELT,

Departments of Comparative and Experimental Pathology and Medical Sciences, College of Veterinary
Medicine, University of Florida, Gainesville, Fla.

Abstract. Six horses (five males) aged three months to fourteen years had endocarditis at necropsy. Two of the horses had
a clinical diagnosis of valvular endocarditis with negative blood cultures. Single or complex valvular involvement was present
in five horses. One horse had non-infectious thrombi associated only with the chordae tendineae. Mitral valves were affected
in four horses, and aortic semilunar valves were affected in two. Infarcts had occurred in the kidneys and the myocardium of
four horses. Bacteria were isolated postmortem from the valvular vegetations of two horses; Candida parapsilosis was isolated
and demonstrated morphologically in a third horse.

Although frequently encountered in other domestic
animal species and man, infective endocarditis appar-
ently is rare is horses. There are reports on isolated
cases of equine vegetative valvular endocarditis found
. ~ . ~ such as Strep-
unexpectedly at n e c r o ~ s y . ~Bacteria
tococcus sp and Actinobacillus equuli have been isolated
from these horses.’, lo. 1 2 , l 5 Strongylus vulgaris larvae
have been incriminated as a cause of aortic semilunar
valvuliti~.~.
l 2 The introduction of echocardiography
hematoxylin and eosin (HE), Brown and Brenn, and Good-
pasture’s, as well as Gomori’s methenamine silver stains.
Tissues from endocardial vegetations were removed asepti-
cally and submitted for microbiologicisolation. Microbiologic
examination included aerobic and anaerobic bacterial, as well
as fungal, cultures. Candida parapsilosis was isolated on
Sabouraud’sagar sheets incubated at 37°C. Yeast-like colonies
were confirmed by microscopy, and strain identification by
germ tube formation, and by biochemical assimilation and
fermentation reactions was done.

into veterinary cardiology has facilitated the diagnosis

of cardiac disorders-including those of the cardiac
valves. This technique has been considered useful for
the clinical diagnosis of infective endocarditis.2, l 3 This
paper will summarize the pathologic findings of endo-
carditis in six horses necropsied between 1980 and
1983.
Case Histories
Most horses in this series were male thoroughbreds between
three months and fourteen years of age (table I). Only two
horses had a clinical diagnosis of endocarditis as evidenced
by auscultation and echocardiography (horses 1 and 4). Blood
cultures were negative in both horses. Horse 1 developed no
fever, but arrhythmias and pulmonary edema were present.
Horse 4 had fever, tachycardia, heart murmurs, and a diffuse
interstitial pneumonia radiographically.The other four horses
died or were sacrificed because of other ailments.
Materials and Methods
A standard necropsy was done on all horses. Tissues were
fixed in neutral buffered 10% formalin and routinely proc-
essed for histology. Tissues were cut at 5 pm and stained with
333
Results
By gross examination, isolated vegetations were
found in four horses. Complex valvular involvement
was present in two horses with left and right heart valve
lesions. The mitral cusp or cusps were involved in four
horses, the aortic semilunar valves in two, tricuspid and
pulmonic valves in one each, and the chordae tendineae
in two horses. The polypoid vegetations ranged between
4 x 2 x 1.5 cm and 1.5 x 1 x 1 cm (figs. 1-3). The
atrial septum, as direct extension from the aortic semi-
lunar valve vegetations, had mural endocarditis in one
horse. Focal endocardial fibrosis was present in the left
atrium of another horse. Ventricles were unremarkable
except in horse 1 where the right ventricle was hyper-
trophic. Visible pale infarcts were present in one kidney
of two horses and both kidneys of a third horse. A
fourth horse had multiple, firm, white foci in the myo-
cardium of the left ventricle.
Microscopically, the affected valve leaflets had lost
their endothelial surface and were generally thickened
by granulation tissue characterized by fibroblasts, col-
334 Buergelt ef al.

Table I. Histories, pathological and microbiological findings in horses with infective endocarditis
Horse Site of endocardia1 Other major le-
Age Breed Sex Clinical diagnosis Culture Infarcts
number involvement sions
1 1 1 years TB M Valvular endocarditis; Aortic valve; right Candida parap Kidney Right ventricular
aortic insufficiency. atrium. silosis hypertrophy;
adrenal corti-
cal adenoma;
verminous
endarteritis.
2 14 yearsMixed MC Eosinophilia and fever Chordae tendineae Not done None Visceral mast cell
of unknown origin. of left ventricle. tumor.
3 1 year TB M Toxic enteritis. Mitral and tricuspid Escherichia None Ulcerative colitis.
valves, chordae coli
tendinae of right
ventricle.
4 3 StB F Valvular endocarditis. Aortic, pulmonic, No growth Kidney Chronic passive
months and mitral valves. congestion of
lung.
5 6 TB M Enterocolitis. Mitral valve. Pseudomonas Kidneys Fibrinonecrotic
months aeruginosa entercolitis.
6 2 years TB M Ventricular Mitral valve. Not done Myocar- Forelimb frac-
fibrillation. dium ture; myocar-
~ -
dial fibrosis.
TB = thoroughbred; StB = standardbred; M = male; MC = castrated male; F = female.

lagen, angioblasts, and newly formed small blood ves-
sels. The vegetations were composed of large masses of
fibrin and scattered groups of degenerating and viable
neutrophils and lymphocytes (fig. 4). Frequently, the
necrotic debris on the luminal surface of the vegetation
was mineralized as evidenced by dense, basophilic,
refractile material. In horse 6, long papillary projections
were scattered along the valvular surface (fig. 5). Fibrin
deposits were evident at the edge where the endothe-
lium had erupted (fig. 6). The projections had a core of
proliferating granulation tissue with a few inflammatory
cells, and were covered by multiple layers of large,
irregular, palisading, individualized, endothelial-like
cells. They probably represented an attempt at endo-
thelialization.
The thrombi associated with the chordae tendineae
were composed of granulation tissue and amorphous,
eosinophilic, fibrillar material similar to fibrin. Occa-
sional foci of entrapped neutrophils and platelets were
seen. No agents could be demonstrated with special
stains in these thrombi.
Small clusters of gram-negative bacterial rods were
embedded deep in the valvular lesions between inflam-
matory cells in horses 3 and 4 as demonstrated by
bacterial stains. Massive numbers of fungal pseudohy-
phae were present thrughout most areas of the vegeta-
tions in horse l (fig. 7). A silver stain revealed the
pseudohyphae to be long and broad, septate, and
branching; they had occasional spores (fig. 8). A few
fragmented pseudohyphae were present within the
atrial septa1 myocardium where most of the myocytes
were replaced by granulation tissue that contained mod-
erate numbers of neutrophils, macrophages, and he-
mosiderin. No infectious agents were demonstrated in
the valvular vegetations of horses 5 and 6.
Mild to moderate congestion and edema were ob-
served in the lung of horses 1,2, 3 , and 4.Hemisiderin-
laden macrophages were present in horses 3 and 4.
Renal infarctions were verified histologically in horses
1, 4, and 5 . Myocardial infarction and fibrosis were
present in horse 6.
In the six horses described, isolation of a n infectious
agent from the valvular lesions was successful in three;
in one horse, isolation was negative; in the other two
horses, no isolation was attempted. Gram-negative bac-
teria were cultured from two horses, and a yeast in pure
culture on Sabouraud's agar was isolated from a third
horse. Microbiologically, the yeast which was demon-
strated morphologically in the vegetation of horse 1 was
identified as Candida parapsilosis because of its aerobic
growth at 37"C, the morphologic features of the colo-
nies, the negative germ tube test, and its biochemical
behavior during carbohydrate assimilation and sugar
fermentation tests. Horse 4 had negative microbiologic
findings, but Gram-negative rods that were deeply
embedded in the vegetations were found microscopi-
 Equine Infective Endocarditis 335

Fig. 1: Horse 4; small vegetation associated with cusp of pulmonic semilunar valve (arrow). PA = pulmonic artery; RV =
right ventricle. Bar = 1 cm.
Fig. 2: Horse 4; septa1 mitral valve leaflet (arrow) and two cusps of aortic semilunar valve (double arrows) reveal cauliflower-
like vegetations of various sizes. Left atrial endocardium reveals “jet lesions.” A = aorta; MV = mitral valve; LV = left
ventricle.
Fig. 3: Horse 1 ; gross appearance of Cundidu purupsilosis vegetation in cusps of aortic semilunar valve (arrow). A = aorta;
LV = left ventricle. Bar = 1 cm.
Fig. 4: Microscopic composition of active, infective endocarditis. Wall of inflammatory cells and granulation tissue, rich
in blood vessels, organizing thrombotic, necrotic material. Foci of mineralization (arrow). Fi = fibrin; G = granulation tissue;
I = inflammatory cells. HE.

cally. Blood cultures taken from four horses were neg- horses from Florida breeding farms. In people as well
ative for infectious agents on repeated occasions. as in dogs, males are affected more frequently with
infective endocarditis than female^.^
Four of our horses were young, with a mean age of
Discussion eleven months. Dealing with young horses and cardiac
In our small series, five of the six horses were males; lesions, one has to consider cardiac malformations in
four of these male horses were intact thoroughbred the clinical and pathologic differential diagnoses. In the
336 Buergelt et al.

Fig. 5: Horse 6; mitral leaflets with villous projections on surface. HE.

Fig. 6: Horse 6; fibrin deposits at edge of leaflet endothelium. Fi = fibrin; MV = mitral valve matrix; En = endothelium.
HE.
Fig. 7: Mycotic vegetation; horse I . Remnants of pseudohyphae are visible within necrotic, inflammatory exudate. HE.
Fig. 8: Morphologic appearance of C. purupsilosis in vegetation of horse 1. Giant pseudohyphae. Gomori’s methenamine.
 Equine Infective Endocarditis 337

horse, nearly one-third of these malformations are ven- mon sources of infective endocarditis. Immunologic
tricular septal defects.’ I reactions may predispose valves to infection.”,’*
The distribution of the endocardial lesions varied in
our horses although there was a tendency toward left Acknowledgements
heart endocardial involvement. In a larger series of The authors thank Ms. M. R. Connelly for isolating and
equine heart examinations, it was shown that the left identifying Cundida purupsilosis. We extend our thanks to
side of the heart had a higher incidence of valvular the clinical faculty of the VMTH for providing the clinical
data.
lesions than the The aortic valve was affected
most frequently, followed by the mitral valve. Tricuspid
References
and pulmonic valves may be affected to a lesser de-
1 ANDRIOLE, V.T.; KRAVETZ, H.M.; ROBERTS, W.C.; UTZ,
gree.2.l 5 J.P.: Cundidu endocarditis. Clinical and pathologic stud-
Thrombotic involvement of chordae tendineae can ies. Am J Med 32:251-285, 1962
occur from extension of valvular vegetations as might 2 BONAGURA, J.D.; PIPERS, F.S.: Echocardiographic features
have been the case in horse 3 . Horse 2 only had the of aortic valve endocarditis in a dog, a cow, and a horse.
chordae tendineae involved, and no microorganisms J Am Vet Med Assoc 182:595-599, 1983
3 CALVERT, C.A.: Valvular bacterial endocarditis in the dog.
could be demonstrated within the thrombus. As such,
J Am Vet Med Assoc 180: 1080- 1084, I982
this should be considered as a non-infectious form of 4 CRANLEY, J.J.; MCCULLAGH, K.G.: Ischaemic myocardial
endocarditis. fibrosis and aortic strongylosis in the horse. Equine Vet J
Stenosis due to large, polypoid growths that ob- 13:35-42, 1981
structed the valvular orifice or valvular insufficiency 5 DEEGEN, E.; LIESKE,R.; SCHOON,H.: Klinische und kar-
that resulted from smaller vegetations are common diologische untersuchungsbefunde bei 3 deckhengsten mit
aortenklappen insuffizienz. Tieraerztl Prax 8:2 1 1-222,
functional valvular impairments. Atrioventricular valve 1980
incompetence, particularly of the mitral valve, may be 6 ELSE,R.W.; HOLMES, J.R.: Cardiac pathology in the horse.
associated with regurgitation of blood, and morpholog- 1. Gross pathology. Equine Vet J 4: 1-8, 1972
ically may lead to friction fibrosis in the atrial endocar- 7 ELSE,R.W.; HOLMES, J.R.: Cardiac pathology in the horse.
dium, the so-called “jet lesions.” Focal atrial thickening 2. Microscopic pathology. Equine Vet J 4:57-62, 1972
due to fibrosis was evident in horse 4; three other horses 8 GOMES, J.A.C.; CALDERON, J.; LAJAM,F.; SAKURAI, H.;
FRIEDMAN, H.S.: Echocardiographic detection of fungal
with mitral involvement did not reveal such secondary vegetations in Cundidu purupsilosis endocarditis. Am J
manifestations in the left atrium. Med 61:273-276, 1976
The incidence of human Candida spp endocarditis 9 INNES. J.R.M.: Subacute bacterial endocarditis with pul-
has been increasing in the past two decade^.'.','^ It is monary embolism in a horse associated with Shigellu
frequently encountered in drug addicts and patients equirailis. Br Vet J 106:245-246, 1950
10 JUBB,K.V.F.; KENNEDY, P.C.: Pathology of Domestic
which received multiple intravenous antibiotics or im-
Animals, vol. 1, pp. 1 1 1-1 14, 2nd ed. Academic Press,
munosuppressive therapy. Morphologically, bulky veg- New York, 1970
etations characterize the lesions on endocardial surfaces 1 1 LOMBARD, C.W.; SCARRATT, W.K.; BUERGELT, C.D.: Ven-
in human hearts. Echocardiography is considered a tricular septal defects in the horse. J Am Vet Med Assoc
sensitive technique to detect the fungal vegetations in 183:562-565, 1983
12 MANSMANN, R.A.; MCALLISTER, E.S.; PRATT,P.W.:
the absence of positive blood cultures and systemic
Equine Medicine and Surgery, p. 684, 3rd ed. American
embolization.’ Horse 1 had an abscess present near the Veterinary Publications, Santa Barbara, 1982
left jugular vein that ultimately eroded into the vein. 13 PIPERS,F.S.; HAMLIN, R.L.: Echocardiographic detection
Acute pulmonary edema and diastolic murmurs devel- of cardiovascular lesions in the horse. J Equine Med Surg
oped two months later. Echocardiography detected aor- 3~68-77, 1979
tic semilunar valve irregularities. The perijugular vein 14 RUBINSTEIN, E.; NORIEGA,E.R.; SIMBERKOFF, M.S.;
HOLZMAN, R.; RAHAL, J.J.: Fungal endocarditis: Analysis
abscess might have served as the source of infection in of 24 cases and review of the literature. Am J Med 54: 33 1-
this horse. 344, 1975
The mode of infection for the other five horses could 15 WAGENAAR, G.; KRONEMAN, J.; BREUKINK, H.: Endocar-
not be determined. Primary distant infections are com- ditis in the horse. Blue Book Vet Prof 12:38-45, 1967

Request reprints from C. D. Buergelt, Box 5-103, JHMHC, University of Florida, Gainesville, FL 32610 (USA).