October 2012 ● Volume 10

Case File: Fever of Unknown Origin

CONTACT INFO

Signalment and History Colorado State University

Veterinary Teaching Hospital
“Cody,” 4-year-old American Paint Horse, gelding 300 West Drake Road
One day following vaccination for EVA, Cody became ill and Fort Collins, CO 80523-1620
Phone: (970) 297-5000
developed a fever of 104.8˚.
Fax: (970) 297-4100
Cody’s boarding facility had a strangles outbreak three weeks prior, Web: csuvth.colostate.edu
and he had been vaccinated with an intranasal strangles vaccine.
At Colorado State University,
Cody was treated with trimethoprim sulfa for four days with no equine veterinary care is delivered
resolution of fever, followed by Baytril and ceftiofur for three days with through the collaboration of three
resolution of fever that returned when antibiotics were discontinued. nationally recognized equine
service centers:
Further treatment included ceftiofur, gentamicin, and phenylbutazone
with continued worsening of clinical signs and subsequent referral to
the CSU VTH Equine Hospital. Colorado State University
Veterinary Teaching Hospital
Physical Exam Equine Service
Colorado State University
Upon arrival, Cody was obtunded with a mild amount of abdominal Equine Reproduction
discomfort. Laboratory
Temperature=100.4˚; Heart Rate=52; Respiration Rate=32; normal Colorado State University
hydration status; pink mucous membranes; CRT<2 sec Orthopaedic Research Center
Rectal palpation revealed a large round mass (estimated 20–25 cm) at
the root of the mesentery. Equine treatment capabilities at
CSU are at the forefront of equine
Findings veterinary medicine through the
shared expertise of these
CBC was characteristic of a chronic inflammatory response organizations.
(leukocytosis, 21.6; neutrophilia, 16.6; anemia, 28;
hyperfibrinogenemia, 1200).
Questions regarding this case file
Serum biochemistry panel revealed hyperproteinemia (9.3), may be directed to:
hypoalbuminemia (2.1), and hyperglobulinemia (7.2).
Dr. Diana Hassel, DVM, PhD,
An abdominal ultrasound was performed, and 2–3 cm of free fluid was DACVS, DACVECC
identified in the ventral abdomen with distended loops of small
intestine. Transrectal ultrasound of the mass revealed a fluid-filled Email: dhassel@colostate.edu
cavity with echogenic content and a thick capsule, characteristic of an
abdominal abscess.
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 An abdominocentesis was performed and fluid analysis revealed a suppurative exudate (161,590
WBCs with 86 percent neutrophils; TP 5.3 g/dl; 50,000 RBCs).
A Streptococcus equi ELISA was performed and revealed a very strong positive titer of 1:12,800.

Proposed Treatment
Due to the very large size of the abscess and
concurrent peritonitis and small intestinal
ileus with colic signs, exploratory celiotomy
was recommended to lavage the abdomen
and drain the abscess, as well as gain
valuable information on prognosis.

Treatment
Ventral midline celiotomy was performed
which revealed gross peritoneal
inflammation (Fig. 1). The abdominal
abscess was located at the root of the
mesentery and the bowel was protected
from adhering to the abscess by the Fig. 1: Abdominal exploration showing diffuse peritonitis
sheets of adhered mesentery. After pre- with hyperemic surfaces on the bowel and mesentery.
placement of a purse-string suture, a 30
french chest trochar drain was driven through the thick wall of the abscess and the content of the
cavity was aspirated followed by lavage with dilute betadine solution in saline via a closed system to
avoid peritoneal contamination (Fig. 2). Ten million IU of potassium penicillin was left in the abscess
cavity prior to pulling the drain, and the purse string suture was tightened to seal the abscess from the
abdominal cavity (Fig. 3). Culture of the abscess confirmed the presence of S. equi.
Post-operative care included abdominal
lavage with 10 L warmed Normasol-R
every 12 hours for three days (Fig. 4),
potassium penicillin (33,000 IU/kg IV
q6h), GastroGard (4 mg/kg p.o. q24h),
flunixin meglumine (0.5 mg/kg IV q8h),
and ICU monitoring.
Cody was able to go home after six days
in the hospital and remained on oral
doxycycline (10 mg/kg p.o.) for 30 days.
He continues to do well three years after
dismissal and is in full work with no further
signs of colic.

Discussion Points
Intra-abdominal abscesses are often seen
in association with pathogens such as Fig. 2: Aspiration of exudate from the deep abdominal
Streptococcus spp., Corynebacterium, abscess using a 30 French chest trocar catheter and 60 ml
and Rhodococcus equi. These abscesses catheter-tipped syringe.
may also occur secondary to GI
perforation from foreign body ingestion or
other means.

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 Fig. 3: Purse-string suture in the wall of the deep Fig. 4: Abdominal lavage with 10 L
abdominal abscess to seal it from the peritoneal cavity after Norm-R was performed post-
drainage. operatively.

Mesenteric abscessation from infectious diseases, such as S. equi, can often be successfully treated
with long-term antimicrobial therapy, however, those complicated by peritonitis, colic, or other
systemic signs may benefit most from surgical exploration and drainage. This also allows for
identifying the presence of adhesions and the assessment of long-term prognosis.
The size of the abdominal abscess may also dictate the best course of therapy. Large abdominal
abscesses, such as seen in this case, may be most effectively treated by surgical drainage, as
penetration of antimicrobial agents may be insufficient to allow complete resolution, even with
prolonged treatment.

Take Home Message

Intra-abdominal abscessation should be included among differential diagnoses in any case of fever of
unknown origin with a supporting leukogram demonstrating presence of chronic inflammation. Although
long-term medical treatment is effective in some cases, surgical exploration is a viable option for those
horses with large abdominal abscesses or concurrent signs of peritonitis or colic.
Questions regarding this case file may be directed to: Dr. Diana Hassel.

csuvth.colostate.edu
 VTH Equine News & Calendar

Call for Clinical Study Participants

For validation purposes of our newly purchased EEG equipment, we are looking to enroll horses with a
presumed diagnosis of Seizures/Epilepsy in a study that includes a routine work-up with a neurological
examination, a CT-exam of the head, CSF analysis, and routine blood work. Prior to the CT exam, but
while under general anesthesia, EEG-data will be collected (free of charge). A $700 refund will be
deducted from the total hospital invoice for each patient enrolled in this study.
For more information, please call or email:
Dr. Lutz Goehring
(970) 297-4246
lutz.goehring@colostate.edu

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