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C h a p t e r 3 3
Pneumonia, Pleuropneumonia, Lung
Abscess, and Pleuritis
III RADIOGRAPHIC APPEARANCE OF
PNEUMONIA
Kangstrom and I published the radiographic appear-
ance of equine pneumonia.1,2 Although there are ten-
dencies, for example, caudoventral consolidation,
there are few if any reliable disease patterns and no
evidence to support the use of pattern recognition
(e.g., interstitial pattern, bronchial pattern).
III PNEUMONIA
Newborn Foals
Potential Causes of Abnormal Lung Density.
Newborn foals (also termed neonatal foals) may have
abnormally dense lungs for a variety of reasons, the
most common of which include (1) pneumonia, (2) an
insufficient volume of pulmonary surfactant, (3) pos-
tural atelectasis that may or may not be disease related,
and (4) the presence of residual lung water and atelec-
tasis, often observed in normal foals for a brief period
of time shortly after birth.
What Precisely Is a Septicemic Foal, and Are There
Any Reliable Radiographic Abnormalities? In my
experience, there are no consistently reliable, specific
signs of septicemia in newborn foals (see the potential
causes of abnormal lung density listed in the preced-
ing section); but not everyone agrees with this view-
point. Some contend that there are dependable signs
of neonatal lung disease that produce characteristic
lung patterns.3
Bacterial Pneumonia in Foals. Foals do not show
etiospecific pulmonary disease patterns (Figure 33-1).
Rhodococcus equi (Formerly
Corynebacterium equi )
Rhodococcus equi is the most serious form of pneumo-
nia, and it affects foals between the ages of 3 weeks
and 5 months. In addition to lung abscesses, the infec-
tion can cause (1) ulcerative enterocolitis, (2) colonic
or mesenteric lymphadenopathy, (3) immune-medi-
ated synovitis or uveitis, (4) septic arthritis, and (5)
osteomyelitis.4-6 Falcon and co-workers described the
clinical and radiographic features of Corynebacterium
pneumonia in foals, emphasizing the diagnostic value
of thoracic radiography in detecting pulmonary
abscessation.7 Ainsworth and co-workers showed that
foals that survive R. equi pneumonia and go on even-
tually to race do so as effectively as horses that did not
previously have pneumonia.8
Radiographically, R. equi pneumonia may appear in
at least three different ways:
1. Nonspecific lung consolidation over the heart base,
often extending as far caudally as the diaphragm
2. Nonspecific lung consolidation over the heart base
associated with numerous vague patchy masses
greater than 0.5 cm in diameter
3. Multiple, variably sized masses resembling pul-
monary metastasis
Interstitial Pneumonia in Foals
The term interstitial pneumonia may be used in at least
two distinct ways: (1) as a radiographic diagnosis and
(2) as a pathologic diagnosis. Used in radiology, it
refers to abnormal lung density perceived to be in the
interstitium, which is then attributed to one cause or
another, depending on the clinical context. In pathol-
ogy, interstitial pneumonia generally refers to a spe-
cific type of equine lung disease of unknown etiology
(Figure 33-2).
According to Buergelt, there are two types of
equine interstitial pneumonia: one that occurs in foals,
the other in adults.9 In foals the disease usually occurs
between 6 days and 6 months of age and causes severe
respiratory distress and elevated heart rate. No effec-
tive treatment is known, and the disease is often fatal.
Postmortem findings in the acute form of the
disease include (1) grossly moist, rubbery, diffusely
481
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482 SECTION V III The Thorax

A B

C D
Figure 33-1 • Acute bronchopneumonia in a pair of foals. Foal 1: Lateral (A) and ultra-close-up (B) views show a faint vertical
band of consolidation running along the caudal edge of the heart, consistent with pneumonic consolidation. Foal 2: Lateral (C)
and lateral close-up (D) views show a roughly circular area of consolidation just caudal to the heart base, which then drapes
down over the caudal margin of the heart nearly to the sternum. This is the most commonly identified site of pulmonary
consolidation in pneumonic foals and adult horses.

mottled lungs; (2) microscopically necrotic alveolar
walls; (3) hyaline membranes; (4) alveolar hemor-
rhage; and (5) fibrinous thrombi in the alveolar capil-
laries. In effect, the foal suffocates to death.
Combined Immunodeficiency of Arabian Horses.
Heritable deficiency of T- and B-lymphocytes leaves
Arabian foals vulnerable to a variety of bacterial, viral,
and protozoal infections, especially rhodococcal pneu-
monia.10 The last of these usually appears as numer-
ous metastatic-like lung lesions.
Pneumocystis carinii Pneumonia. Ewing and co-
workers reported the clinicopathologic features of
Pneumocystis carinii in three Quarter Horse foals
between 2 and 3 months of age. Unfortunately there
was no characteristic radiographic appearance.11 In my
experience, the radiographic findings associated with
a pure Pneumocystis pneumonia are often quite subtle
and impossible to distinguish from postural atelecta-
sis. As far as I know, Pneumocystis pneumonia is the
only equine lung disease that begins in the alveoli and
thus is capable of producing a pure alveolar pattern on
a thoracic radiograph.
Adult Horses
Bacterial Pneumonia and Pleuropneumonia in
Adult Horses
Radiology. Bacterial pneumonia in adult horses is
characterized by a wide variety of nonspecific radio-
graphic appearances, with many featuring some
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CHAPTER 33 III Pneumonia, Pleuropneumonia, Lung Abscess, and Pleuritis 483

B
Figure 33-2 • Chronic interstitial pneumonia in a foal. Lateral (A), close-up lateral (B), and ventrodorsal (C) views show
severe widespread lung consolidation with secondary bronchial dilation.

degree of lung consolidation, usually situated in the
ventral half of the lung. Thus there is no single char-
acteristic lung pattern that signifies bacterial pneu-
monia in horses, with perhaps the exception of
rhodococcal abscesses (Figure 33-3).
Once the infection spreads to the lung surface and
into the pleural space, the disease is referred to as pleu-
ropneumonia. More often than not, pleuropneumonia is
associated with pleural fluid, sometimes in very large
quantities. It is quite important to emphasize at this
point that even very large volumes of pleural fluid do
not result in a discrete fluid line, contrary to some
reports.12 Seltzer and Byars estimate that the probabil-
ity of a full recovery in an active racehorse that devel-
ops pleuropneumonia is about 61 percent.13
A distinct fluid line or level will form only when free
air and fluid are in direct contact with each another
within a confined space, such as a traumatic bulla, a
lung abscess that communicates with a functional
bronchus, or a hydropneumothorax. Intrathoracic
fluid levels may also be seen in some diaphragmatic
hernias that result in gastrointestinal displacement.
Only rarely do gas-forming bacteria result in radio-
graphically visible intrathoracic fluid levels.
With severe pleuritis, pleural adhesions may
develop, which in turn may lead to pleural abscessa-
tion or, if they tear, pneumothorax. Radiographically,
it is difficult or impossible to distinguish pleural from
pulmonary abscesses unless they are situated on the
foremost portion of the diaphragm, where it may be
possible to make such distinctions.14
Sonology
Requisites of Pleuropneumonia. Sonographically pleu-
ropneumonia must, at the very least, feature pleuritis
and lung consolidation. Usually there is also pleural
fluid, although the amount is highly variable.
Peripheral atelectasis, often in company with consoli-
dation, is a common sonographic feature of medium
and large volumes of pleural fluid (Figure 33-4).
Consolidated Lung. Sonographically, peripheral consol-
idation can be difficult to distinguish from fluid. The
most reliable means of distinguishing between the two
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484 SECTION V III The Thorax
Figure 33-3 • Acute bronchopneumonia in an adult horse.
Close-up lateral view of the caudoventral lung field shows a
faint triangular density superimposed on the caudoventral
aspect of the heart caused by localized lung consolidation.
The adjacent large white area is one of the upper forelimbs.
Figure 33-4 • Close-up thoracic sonogram of a horse with
pleuropneumonia shows a small wedge of mildly echogenic
pleural fluid overlying a partially consolidated, partially
atelectatic lung lobe.
is nonuniform interior structure: air pockets, fluid
pockets, and fluid- and air-filled bronchi. Consolidated
lung usually has some or all of these features (Figure
33-5), but pleural fluid does not (Figure 33-6). Small
amounts of fluid may become trapped between the
Figure 33-5 • Close-up thoracic sonogram of a horse with
pleuropneumonia shows a roughly circular area of consoli-
dation (electronic cursors) featuring a poorly marginated
exterior and a nonuniform interior.
visceral and parietal pleural surfaces, loosely resem-
bling protective bubble wrap. The underlying lung
may be partially consolidated or atelectatic, merging
almost imperceptibly with the loculated fluid (Figure
33-7).
Atelectatic Lung. The fully atelectatic lung, surrounded
by fluid, is distinguishable from consolidation by the
following characteristics: (1) leaflike shape, (2) discrete
margin, (3) relatively bright exterior, and (4) uniform
interior echo texture.
Interstitial Pneumonia in Adult Horses. A disease of
2-year-olds and beyond, the adult form of interstitial
pneumonia (as opposed to that seen in foals) causes
alveolar fibrosis, leading to a distinctive radiographic
appearance consisting of multiple diffusely distrib-
uted, fluffy lung densities, which may be diagnosti-
cally mistaken for pulmonary metastasis or mycotic
pneumonia, especially in high-contrast films in which
the ribs accentuate the abnormally dense lung (Figure
33-8).
Septicemia and Toxemia (Toxic Shock, Toxic Shock
Syndrome). Toxic shock has been reported as a con-
sequence of Staphylococcus aureus pneumonia in a
horse, resulting in vasculitis and intractable fever.15
Anaerobic bacterial pneumonia (Bacteroides) can also
lead to septicemia, as described by Carlsen and
O’Brien.16 Radiographically, there does not appear to
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CHAPTER 33 III Pneumonia, Pleuropneumonia, Lung Abscess, and Pleuritis
Figure 33-6 • Close-up thoracic sonogram of a horse with
pleuropneumonia shows a thick band of uniformly echoic
pleural fluid underlain by the tip of a consolidated lung lobe.
Figure 33-7 • Close-up thoracic sonogram of a horse with
pleuropneumonia shows a loculated fluid pocket blending
almost imperceptibly with underlying lung consolidation and
atelectasis.
be any consistent appearance associated with these
diseases.
Fungal Pneumonia (Mycotic Pneumonia). In the
United States, fungal pneumonia is most common in
the southern region of the country, but in no instance
is it the prevalent form of pneumonia in horses.
485
Figure 33-8 • Chronic interstitial pneumonia in an adult
horse. Close-up view of the dorsocaudal lung field shows
an increase in overall lung density accentuated by rib super-
imposition, making it falsely appear as if there are multiple
lung masses and nodules.
Histoplasma and Coccidiodes are the most commonly
encountered pathogenic fungi in horses, and
Aspergillus, Cryptococcus, Pthium, and Candida are the
usual opportunists.17
Although not widely appreciated, disseminated
fungal pneumonia has a rather characteristic appear-
ance comprising large numbers of nodules or small
masses.18 Although pulmonary metastasis may also
appear this way, it rarely does so in the horse. Bacterial
pneumonia, depending on its form and causative
organism, usually results in defined consolidations
(typically over the caudal heart base or, alternatively,
nonstructured opacification).
III PULMONARY
COCCIDIOIDOMYCOSIS
Coccidioidomycosis is a fungal disease of mammals,
including people, and is found in Utah, Nevada,
California, Arizona, New Mexico, and Texas. Infection
is usually by inhalation; chronic weight loss is the most
common clinical sign.
Radiographic Findings
According to Ziemer and co-workers, the most
common radiographic expression of pulmonary coc-
cidioidomycosis in horses appears to be a nonspecific
increase in interstitial lung density, with or without
associated pleural fluid.19 Discrete lung masses, as
described by Kramme and Ziemer, are less common.
Spread of the infection to regional lymph nodes, and
eventually the skeleton (distal scapula), has also been
described.20
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486 SECTION V III The Thorax
III PULMONARY ASPERGILLOSIS
(INVASIVE PULMONARY
ASPERGILLOSIS)
Pulmonary aspergillosis (also termed invasive pul-
monary aspergillosis) is uncommon in horses, with most
infections involving the guttural pouch or uterus.
Immunocompromised horses are more likely to be
infected than healthy animals. Concurrent pulmonary
and enteric aspergillosis has been reported, suggesting
a causal relationship.21-23
Pulmonary Blastomycosis
Toribio and co-workers reported a case of thoracic and
abdominal blastomycosis in a 5-year-old Quarter Horse
mare. A lateral thoracic radiograph showed a large,
well-marginated object in the caudodorsal part of the
lung, initially believed to be an abscess. Thoracic
sonography revealed pleural fluid and surface fibrin,
and sonographic assessment showed an abdominal
abscess situated between the spleen and left kidney.24
Mycetoma and Other Cavitating
Lung Lesions
Fungal infection of the lung may eventually lead to
cavitation, although this is by no means a certain
outcome. Alternatively, opportunistic fungi such as
Aspergillus spp. may colonize a preexisting lung lesion
and in so doing cause secondary cavitation.25
III VIRAL PNEUMONIA
Equine Viral Arteritis
Equine viral arteritis causes a generalized influenza-
like illness in adult horses, abortion in mares, and
interstitial pneumonia in foals. After the acute phase
of the infection, recovery is usually complete. Foals,
mares, and geldings can infect other animals for about
2 weeks after infection; however, stallions may shed
the virus in their semen for much longer periods.26
Granulomatous Pneumonia
Pearson and co-workers described the radiographic
appearance of cryptococcal pneumonia in a 3-year-old
Quarter Horses mare, hospitalized because of chronic
cough and nasal discharge.27 Radiographically, the
lung contained a combination of discrete masses and
nondescript consolidation. Fluid levels were men-
tioned but were not visible in any of the published
images.
III INHALATION PNEUMONIA
Acute Versus Chronic Forms
The inhalation of liquid or particulate matter into the
tracheobronchial tree is termed aspiration pneumonia.
There are two forms: acute and chronic. The acute form
results from the inhalation of foreign material over
a short span, causing an acute onset of clinical signs.
The aspirate may be in either solid or liquid form.
Aspiration of solid particulate matter causes varying
degrees of bronchiole obstruction. Aspiration of highly
acidic digestive fluids can cause severe illness, includ-
ing dyspnea, cyanosis, and occasionally shock.
The chronic form of inhalation pneumonia results
from repeated aspiration and frequently leads to gran-
ulomatous pneumonia. This form of the disease is
most common in horses with chronic choke or dys-
phasia. Inhalation of oil-based medicaments may
result in lipoid pneumonia.
Radiographic Findings
There are no defining radiographic findings in inhala-
tion pneumonia. The nature and volume of the aspi-
rate and the position of the animal at the time of
occurrence dictate specific disease patterns. The initial
radiographic appearance is often quite labile, depend-
ing on the type of treatment (if any), the presence of
related infection, and the duration of the illness.
On a probability basis, pulmonary consolidation
resulting from inhalation will initially develop in the
dependent portion of the lung. For example, if an anes-
thetized horse is lying on its right side when it inhales
esophageal contents past its endotracheal tube, con-
solidation of collapse is most likely to first appear in
the right middle or caudal regions of the lung. Horses
that inhale low-viscosity liquids while standing may
or may not show caudodorsal lung lesions; but if they
do, follow-up radiographs will often reveal ventral
consolidation, presumably gravitationally induced.
Typically radiographs made within a few hours
after inhalation show nothing. Twenty-four-hour
progress films often show peribronchial cuffing but
rarely any overt lung consolidation. Later films (24 to
72 hours) may show consolidation or collapse, strong
presumptive evidence of a secondary pneumonia and
bronchial obstruction. Generally the more opaque the
lung becomes, the more serious the disease, especially
when combined with abnormal blood gases.
Abscessation, if it develops, may take weeks to become
apparent radiographically.
I have performed bronchography in horses with
inhalation pneumonia in an effort to establish the
extent of bronchial obstruction (nuclear ventilation
assessment is preferable, but was not available at the
time). In addition to blockages, I found that many of
the conducting bronchi were dilated, presumably an
attempt to improve ventilation.28
III LUNG ABSCESS
Most but not all lung abscesses are the results of pneu-
monia. In a retrospective study, Lavoie and co-workers
reported lung abscesses in 40 foals and adult horses
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CHAPTER 33 III Pneumonia, Pleuropneumonia, Lung Abscess, and Pleuritis 487

(mostly Standardbreds), unassociated with pleuropneu-

monia.29 Most of the affected animals were 6 months
old or younger, typically presenting with fever, ele-
vated heart and respiratory rates, and neutrophilia.
The most common bacteria obtained by transtracheal
aspiration were Streptococcus zooepidemicus and R. equi.
Most animals—foals and adults alike—had multiple
lung abscesses visible on thoracic radiographs.
Spurlock and co-workers described pneumothorax
in a 3-year-old Thoroughbred with pneumonia, which,
based on radiographic appearances, was most likely
due to a ruptured lung abscess.30 In addition to a pneu-
mothorax, a ruptured lung abscess may also cause
pleuritis and or pyothorax.
Ainsworth and co-workers determined that, based
on their experience treating 45 Thoroughbred and A
Standardbred racehorses with primary lung abscesses,
long-term performance prospects were unlikely to be
seriously affected.31 Of imaging interest is the fact
that two thirds of the abscesses were situated in the
caudodorsal lung field, raising question as to a pos-
sible relationship to exercise-induced pulmonary
hemorrhage.
Radiographically, the visibility of lung abscesses
depends mostly on their size: the larger they are, the
more likely they are to be detected, all other factors,
such as location, being equal. Small abscesses (i.e., 2 to
3 cm in diameter) situated in or around the hilus are
difficult to distinguish from normal vascular cross-
sections, which are large and numerous in this region
of the lung.
The relatively sharp borders of a lung abscess can B
generally be used to distinguish it from a localized area
of consolidation (Figure 33-9). Clusters of large
abscesses, for example, those caused by Rhodococcus,
can mimic a huge solitary lung abscess or a primary
lung tumor (Figure 33-10).

III PNEUMOCONIOSIS (INDUSTRIAL

LUNG DISEASE)
Schwartz and co-workers described a series of
California horses suffering chronic silicosis inhalation
causing pulmonary fibrosis.32 Pack animals chronically
exposed to coal dust inevitably develop anthracosis,
which may then lead to emphysema. C
Figure 33-9 • Close-up (A) and ultra-close-up (B) views of
the hilar region of the lung show multiple rhodococcal
abscesses featuring a great deal of marginal variability,
most of which is attributable to superimposition by adjacent
III IMMUNOPNEUMONIA blood vessels and other abscesses. Another close-up (C)
(HYPERSENSITIVITY PNEUMONIA) from the top center of the dorsocaudal lung field shows
more abscesses, most of which are superimposed on one
another, exaggerating their size, sometimes by as much as
Winder and co-workers described the clinicopatho- 200 or 300 percent.
logic findings in two horses with immunopneumo-
nia.33 Diagnostic criteria included (1) a history of
dyspnea, cough, and fever when exposed to organic
dusts; (2) the presence of antigen-specific antibodies in
the blood; and (3) radiographic evidence of diffuse
lung disease.
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488 SECTION V III The Thorax
Figure 33-10 • Lateral thoracic radiograph shows multiple
large lung abscesses clustered around the heart base of a
foal resembling a single lung mass, for example, a juvenile
lung tumor.
III PARASITIC PNEUMONIA
Lungworm (Dicyocaulus arnfieldi) has been reported in
horses kept with donkeys.34 The larval stages of some
intestinal parasites may migrate to the lung, causing
pneumonitis, with or without associated hypersensi-
tivity. A full appreciation of the potential threat posed
by primary and secondary lung parasites to horses
requires some understanding of the associated envi-
ronmental and host factors coming into play in any
type of equine respiratory disease, as aptly provided
by Clarke in his excellent review of the subject.35
III ADULT RESPIRATORY DISTRESS
SYNDROME
In my experience adult respiratory distress syndrome
(ARDS) is most likely to develop in horses exposed to
large volumes of smoke, in barn fires, for example.
Myocardial depressant factor resulting from related
burns may cause pulmonary edema, which is hard to
distinguish from the atelectasis caused by ARDS.
Horses suffering from serious smoke inhalation may
subsequently develop bacterial pneumonia.
III PULMONARY THROMBOSIS
Not a great deal is known about pulmonary thrombo-
sis in the horse, as evidenced by few publications on
the subject. One of the best of these, in terms of high-
quality radiographs and substantiating subgross and
histologic-bacteriologic evidence, is a case report by
Kerr and co-workers, which regrettably was published
under the unrevealing title of “Radiographic
Diagnosis” and, as such, escaped the attention of many
potential readers.36
The animal in question, a 21-year-old Arabian/
Quarter Horse mare, showed extensive consolidation
in one half of the lung but not the other, as revealed by
alternate-side radiographs. Postmortem examination
revealed a diffusely pneumonic left lung, featuring a
large thrombus lodged in the base of the left pul-
monary artery that extended into two of its secondary
branches. The diseased lung was surrounded by an
estimated 1 to 2 L of serosanguineous pleural fluid.
The right lung was partially consolidated ventrally.
Escherichia coli was cultured from both the thrombus
and the consolidated portion of the left lung, lending
credence to the authors’ theory that the thrombus was
caused by endothelial inflammation secondary to the
pneumonia.
III PULMONARY INFARCTION
Carr and co-workers described the radiographic and
sonographic appearance of acute hemorrhagic pul-
monary infarction in 21 horses with necrotic pneu-
monia.37 Typical presentations included (1) a
serosanguineous nasal discharge, (2) increased respi-
ratory rate, (3) increased heart rate, and (4) fever. Many
of the horses had a cough and were not eating.
Radiographic Findings
Most of the horses had ventral consolidation and
pleural fluid. More than half of the animals had mul-
tiple discrete lung masses located in various parts of
the lung. The lung abnormalities did not resemble
those typically found with exercise-induced pul-
monary hemorrhage.
Sonographic Findings
Discrete areas of consolidation, although not unique in
any way, corresponded to pulmonary infarcts identi-
fied at postmortem examination. Less discrete areas of
consolidation correlated with pneumonia. Pleural
fluid and fibrin tags were also found.
III PNEUMONIA AND
PNEUMOMEDIASTINUM
As mentioned in an earlier chapter, the most common
cause of pneumomediastinum in horses is transtra-
cheal irrigation-aspiration.38 Accordingly, the first
question that should be asked once a pneumomedi-
astinum is identified, especially in a pneumonic foal or
horse, is whether or not there has been a recent
tracheal wash.
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