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Journal of Feline Medicine and Surgery (2016) 18, 7–20

PREMIER review

diagnosis and management of

lungworm infections in cats
Cornerstones, dilemmas
and new avenues
Donato Traversa and Angela Di Cesare

Lungworms of cats Practical relevance: Respiratory

parasites infecting domestic cats
Traditionally, feline lungworms have been reported to be are attracting increased attention in
Aelurostrongylus abstrusus (Nematoda, Metastrongyloidea, feline clinical practice. In addition to
Angiostrongylidae) and Capillaria aerophila (syn Eucoleus aerophilus) the most commonly recognised ‘cat
(Nematoda, Trichocephalida, Trichuridae).1 of these, A abstrusus lungworm’ Aelurostrongylus abstrusus,
(ie, the ‘cat lungworm’) has long been regarded as the most significant Troglostrongylus brevior and Capillaria
respiratory parasite of domestic cats (Felis silvestris catus) in terms of aerophila are now considered important pathogens

adult stages of A abstrusus (length ~5–12 mm, width ~54–80 µm) reside
worldwide geographic distribution and clinical importance.1,2 The of the respiratory tract of cats.
Global importance: These parasites are being
in nodules within the bronchi- increasingly diagnosed in several regions of the

Clinical signs of lungworm oles, alveolar ducts and alve- world and a continuous update on epidemiological

Conversely, C aerophila has

oli of infected hosts. changes and advances in diagnosis and control

been little recognised as a sig-

infection can be identical to is of practical importance.

nificant pathogen until recent-

Aims: This article reviews current knowledge of
those caused by bronchial
ly.2 This nematode infects the
lungworms affecting cats, with a special focus on

lungs of domestic and wild

recent insights into diagnosis and management of
disease/asthma, leading to
carnivores and, sometimes,
the diseases they cause. The article also explores
potential misdiagnosis.
people.2 The adult stages
some potential new avenues for control of feline

(length ~20–30 mm) are slen-

parasitic respiratory diseases, and highlights some

der (width ~60–180 µm),

key areas requiring further research.

whitish and filamentous, and live beneath the epithelium of the tra-
chea and bronchi.3 This nematode has a direct life cycle (Figure 1).
After mating, the females release eggs that are coughed, ingested and
passed in the faeces of the infected animal. In the environment, they
reach infectivity in 1–2 months.4 Earthworms have been hypothesised
to act as facultative intermediate or paratenic hosts, but this biological
feature has not been conclusively established.3,4 Animals become
infected by ingesting lar-
vated eggs present in
the environment or,
potentially, infected
JFMS Premier Reviews are invited state-of-

earthworms.
it is now known
that A abstrusus and
C aerophila are not the
the-art review papers on key issues in feline
medicine and surgery. Written by expert
international authors, these reviews are made
freely available to maximise their impact.

Donato Traversa
DVM PhD Dipl EVPC*

Angela Di Cesare
DVM PhD

Faculty of Veterinary Medicine, Teaching Veterinary

Hospital, University of Teramo, Teramo, Italy
*Corresponding author: dtraversa@unite.it

doi: 10.1177/1098612X15623113
© The Author(s) 2016 JFMS CLINICAL PRACTICE 7
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R E V I E W / Advances in understanding of feline lungworm disease

Lungworm life cycles

C aerophila A abstrusus and T brevior

Recent
evidence
suggests that
T brevior might
also be directly
transmitted
from an
infected queen
to her litter.

Figure 1 The adult stages of Capillaria aerophila live under
the epithelium of the trachea and bronchi. After mating,
the females release eggs that are coughed, ingested and
passed in the faeces of the infected animal. In the
environment, they mature and become infective.
Earthworms have been hypothesised to act as facultative
intermediate or paratenic hosts. Animals become infected
by ingesting environmental larvated eggs or, potentially,
infected earthworms
Figure 2 The adult stages of these nematodes live in the
respiratory system of the definitive host: bronchioles, alveolar
ducts and alveoli (Aelurostrongylus abstrusus) or bronchi and
bronchioles (Troglostrongylus brevior). The females release
eggs that develop within the parenchyma and, after hatching,
first stage larvae (L1s) pass up the respiratory escalator,
are swallowed and excreted via the faeces, and reach the
environment. L1s continue their development in intermediate
hosts (slugs and snails), in which they reach the third larval
stage (L3), which is infective for cats. Cats become infected
by ingesting the mollusc or, more frequently, paratenic hosts
(rodents, frogs, lizards, snakes, birds). Thereafter, L3s migrate
to the lungs via the haemolymphatic vessels and evolve to
adulthood in the respiratory system

only lungworms to infect domestic cats. The snails), in which they reach the third, infec-
genus Troglostrongylus (Nematoda, Meta- tive, larval stage (L3) after a variable period of
strongyloidea, Crenosomatidae), which time dependent on the invertebrate species
includes four species of lungworms, mostly and environmental temperature.4,6–9 Animals
reported from wildlife (eg, leopard, African become infected by ingesting the intermediate
wildcat),5 has also now been identified in host containing L3s or, most often, paratenic
domestic cats. Troglostrongylus brevior, first hosts including rodents, frogs, lizards, snakes
described in Felis silvestris lybica, the African and birds (Figure 2).4,6,7 Recent evidence
wildcat, and in Felis chaus, the Jungle cat,6 has suggests that T brevior might also be directly
recently been reported.2,5 Adult worms of transmitted from an infected queen to her

~294–430 µm in width, and inhabit the

T brevior vary from ~5–13 mm in length and litter.10
in the past few years, several studies have
bronchi and bronchioles of infected hosts. shed light on new epidemiological scenarios,
T brevior and A abstrusus have a similar bio- and provided a better understanding of prac-
logical cycle (Figure 2). Adult females lay eggs tical aspects of feline aelurostrongylosis (eg,
that develop within the lungs. First stage lar- diagnosis and therapy) and intriguing novel
vae (L1s) reach the pharynx via the respirato- data on ‘new’ and/or neglected lungworms
ry escalator, then are swallowed and pass into affecting domestic cats. The present article
the environment in cat faeces.2,4–7 L1s continue provides an update on current knowledge
their life cycle in intermediate hosts (slugs and and discusses priorities for the practitioner.

8 JFMS CLINICAL PRACTICE

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New paradigms for a changing
epidemiology
it is speculated that the geographic range of
lungworms infecting cats is possibly expand-
ing. Global warming, movements of animals
from endemic to free regions, changing vector
phenology, and modification in wildlife
habitat and populations may be involved.11
Alternatively, heightened awareness may
have led to an increase in documented clinical
diagnoses of previously unknown or under-
estimated nematodes.
A abstrusus
A abstrusus is distributed worldwide and may
infect all cats regardless of their habitat,
lifestyle, sex and breed. it is present in nearly
every European country, and has been
described in Australia and the Americas, as
well as in some reports from Asia and
Africa.2,11 owned animals and cats living
indoors or with few chances to access the
environment are at less risk of A abstrusus
infection. However, infection should not be
ruled out in household cats. Young animals,
with a less efficient immune system, and adult
and old cats, with better hunting ability and a
cumulative greater risk of exposure, may be
infected by A abstrusus.12–15
C aerophila
C aerophila has long been found in wildlife. in
Europe it has occasionally been reported in
companion animals, while for many years up
to 5% of feral cats in Australia have consistent-
ly been found to be infected with C aerophi-
la.2,16 over the past couple of decades there
has been an increase in the number of clinical
descriptions, and epidemiological studies
have documented the occurrence of C aerophi-
la in cats from different countries,3,17,18 and in
humans as well.19 in some European countries
it is likely that wildlife may influence the dis-
persion of lung capillariosis in cats, as sug-
gested by recent genetic studies that have
indicated that C aerophila populations co-
infect pets and wildlife in the same areas.20
T brevior
Nematodes of the genus Troglostrongylus have
historically been regarded as parasites of wild
felids2,5 but infections in domestic cats are
being increasingly reported, mostly in young
animals. The first report of troglostrongylosis
in a domestic host was from the last century
when a feral cat was found to harbour T brev-
ior.21 Since 2010, however, T brevior has been
described in domestic cats from several
European islands (ibiza, Sicily, Sardinia,
Crete),22–25 and in central and southern
Apennine regions of italy.10,26–28
R E V I E W / Advances in understanding of feline lungworm disease
Wild animals such as the European wildcat play
a role as spreaders of T brevior in areas where
wildcats and domestic cats coexist.
This increased detection rate in domestic
cats has raised questions regarding the origin
and actual distribution of T brevior in felid
populations.2 it is not known whether:
(i) T brevior infects F s catus more frequently
than previously thought and that historically
it has been mistaken for A abstrusus; (ii) recent
reports reflect increased infection in domestic
felids only in particular areas; and/or (iii)
some epidemiological drivers have nurtured a
spillover of lungworms from wildlife to
F s catus.2
Reduction of woodland habitat drives wild
animals into new hospitable environments,
such as suburbs and cities, in search of anthro-
pogenic food sources. These movements
increase the contact between wildlife and pets
and contribute to the spread of parasites har-
boured by wildlife. Wild animals such as the
European wildcat (Felis silvestris silvestris), in
which T brevior has been found, play a role as
spreaders of the parasite in those areas where
wildcats and domestic cats live in sympa-
try.5,29,30 indeed, T brevior has been mostly
described thus far in cats living in areas of
italy and Greece where wildcat populations
are present.2,5,30,31 Additionally, in domestic
cats, T brevior is often found in association
with A abstrusus.22,25–27
A recent retrospective study demonstrated
negligible occurrence of Troglostrongylus
species in domestic cats living in sub-
Apennine territories of central italy during
the years 2002–2013.31 The high presence of
T brevior in wildcats originating from the same
geographic areas,30 along with other find-
ings,29,32 ultimately confirm the role of the
European wildcat as a natural host of T brev-
ior. other data collected in 2014/2015 have
shown that the prevalence of monospecific
infections by T brevior or A abstrusus in domes-
tic cat populations living in regions of the
sub-Apennine territories of central italy is sim-
ilar.33 These recent studies suggest that in the
past few years some epidemiological and bio-
logical drivers might have nurtured bridging
infections by T brevior between wildlife and F s
catus, and that the nematode is now expanding
its host range to include domestic hosts.
This assumption is corroborated by recent
findings pertaining to the closely related
metastrongyloid Angiostrongylus vasorum,
which affects canids in Europe. The high
occurrence of this mollusc-borne nematode in
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R E V I E W / Advances in understanding of feline lungworm disease
foxes living in italy, denmark
and the UK and the dense fox
population in these same areas
have been incriminated in the
transmission of this parasite
to the domestic dog.11,34–37
Studies have demonstrated
the existence of shared popu-
lations of A vasorum among
dogs, foxes and wolves in Figure 3 The Mediterranean
endemic regions.37–39 land snail Helix aspersa
may be contributing to
the expansion of feline
Possible influence of global warming metastrongyloids
Another possible driver influencing current
changes in feline lungworm epidemiology
is global warming. Temperature, moisture
and water availability affect the development
and survival of molluscs. The development
of nematode larvae in snails and slugs is
also known to be influenced by temperature
changes. For instance, the higher the
average temperature, the higher the rate of
Clinical presentation
A abstrusus infection
Adult parasites, production of eggs and larval migration elicit a
mild to heavy granulomatous or mixed inflammatory response in
A abstrusus-infected cats.45,46 Clinical signs depend on factors
such as the worm burden and health status, age and immune
response of the animal.47,48 Cats may be subclinically infected or
show mild to severe disease, including, occasionally, fatal
pneumonia. When signs are mild (eg, in adult cats and/or in the
presence of low worm burdens), aelurostrongylosis may be self-
limiting with respiratory signs spontaneously resolving within
weeks.11,47 The most frequent signs are mild to intense cough-
ing, wheezing, sneezing, nasal discharge, dyspnoea and
tachypnoea.13,49 Generalised signs such as lethargy and weight
loss have also been described.50,51 Severe signs such as open-
mouth abdominal breathing (Figure 4), tachycardia and even
death may occur in young, debilitated and/or immunosup-
pressed cats.52 Aelurostrongylosis has furthermore been impli-
cated in cases of anaesthetic-associated deaths, likely due to
the decreased surface area for gas exchange and a combination
of impaired lung perfusion and ventilation, hypoxia and systemic
hypotension, culminating in cardiovascular collapse.53
T brevior infection
Kittens and young cats seem to be more susceptible than adult
animals to T brevior infection. This may be due to a vertical route
of transmission, which does not occur in adult animals,
or to the body size of adult parasites and their localisation in the
bronchi and bronchioles. Respiratory signs include a severe
cough, dyspnoea and nasal discharge. Infection may lead to
fatal respiratory failure in kittens despite appropriate
anthelmintic treatment.5,10,23,26
Importantly, a case of irreversible (despite anthelmintic treat-
ment) pulmonary hypertension in a kitten with troglostrongylosis
has recently been described.54 No other reports of pulmonary
hypertension in lungworm-infected cats have been document-
10 JFMS CLINICAL PRACTICE
larval development of A abstrusus in Helix
aspersa (Figure 3), the Mediterranean edible
snail.40 H aspersa, one of the most widely
distributed land snails in the world,41 has
been deliberately or accidentally imported
into different regions and is widely regarded
as a pest outside its native Mediterranean
range.42 This mollusc is one of the most impor-
tant intermediate hosts of A abstrusus and
T brevior, and it is plausible that it has
contributed (and is contributing) to the expan-
sion of feline metastrongyloids in European
countries.43
Changes in geographic distribution influ-
enced by global warming have been
predicted for A vasorum via a climatic-based
model.44 No similar information is available
for A abstrusus or T brevior; however, with
similar biological cycles, the same factors
involved in the expansion of canine angio-
strongylosis would likely also affect feline
lungworms. Further studies in this field are
warranted.
ed, with the exception of an A abstrusus-infected cat from the
Netherlands; in this case, the hypertension was reversible and
resolved after repeated parasiticide treatment.55 Self-limiting or
subclinical infections occur in older cats.5 The severity of clinical
signs in infected cats probably depends on the extent of pul-
monary oedema, congestion, haemorrhage, hepatisation and
lobular phlogosis of the infected lungs.28
C aerophila infection
Cats with a C aerophila parasitosis may either have a subclinical
infection or may display respiratory distress. Adult parasites
induce lesions in the trachea and lung parenchyma, leading to
increased bronchovesicular breath sounds, sneezing, wheezing
and a dry cough that can become productive when bacterial
complications intervene.56
Figure 4 Open-mouth breathing in a cat infected with Aelurostrongylus
abstrusus
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R E V I E W / Advances in understanding of feline lungworm disease

a b

Common
radiographic
findings are an
alveolar pattern
followed by
Figure 5 (a) Right lateral and (b) ventrodorsal thoracic
radiographs of a 2-year-old cat with Aelurostrongylus
bronchial and
abstrusus infection. A complex pulmonary pattern is visible
throughout the lung fields, characterised by bronchial interstitial
and alveolar changes and a mild reticular interstitial pattern.
(c) Right lateral and (d) ventrodorsal thoracic radiographs of
a 3-month-old kitten infected by Troglostrongylus brevior. An
patterns,
d
interstitial pattern (c,d) is present throughout the lungs fields
and there is enlargement of the caudal lobar pulmonary artery bronchial wall
(d). Courtesy of Dr Paolo Emidio Crisi, Teaching Veterinary Hospital,
University of Teramo, Italy thickening and
c increased
interstitial
opacity.

Diagnostic features T brevior are an alveolar pattern followed by

Respiratory parasitoses of cats are often chal-

bronchial and interstitial patterns, bronchial

lenging to diagnose clinically because other

wall thickening and increased interstitial opac-

conditions present with similar signs.

ity (Figure 5), depending on the worm burden

Differential diagnoses include bacterial infec-

and the chronicity of infection.

tions, other parasitic infections such as pul-

Assays for the serological diagnosis of feline

monary toxoplasmosis, respiratory mycoses,

lungworms are still awaited. A recently devel-

feline bronchial disease/asthma, airway

oped immunofluoresence antibody test (iFAT)

foreign bodies and pulmonary tumours.11,16

able to detect antibodies against A abstrusus in

Signs caused by A abstrusus can be identical to

sera from both experimentally and naturally

those associated with feline bronchial disease/

infected cats showed promising sensitivity
Figure 6 Dehydrated larva

asthma.16 Furthermore, treatment for bronchial

of Troglostrongylus brevior and specificity.59 However, currently, defini-

disease/asthma with corticosteroids and

observed on flotation with tive ante-mortem diagnosis of respiratory
zinc sulphate solution

bronchodilators may produce a clinical

parasitosis can be achieved only with

recovery in cats with respiratory para-

copromicroscopic or airway wash exam-

sitoses; thus veterinarians have no

inations that reveal L1s of A abstrusus

reason to suspect a misdiagnosis.3,16

and T brevior, and eggs of C aerophila.

There is no evidence at the moment, but

direct faecal smears and classical

it is likely that similar confusion might

sedimentation and flotation methods

arise in cats infected with T brevior.

are unreliable for diagnosing meta-
strongyloid infections, because of the
Features of radiographic examinations unpredictable presence of L1s, inade-
are not pathognomonic for aeluro- quate sample size, low sensitivity and
strongylosis.57,58 The most common find- larval osmotic damage (Figure 6) due
ings in cats infected by A abstrusus and to the high specific gravity concentrated

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R E V I E W / Advances in understanding of feline lungworm disease

~300 µm have been reported in

solutions.11,49,60 The gold stan-
dard faecal test to diagnose feline
aelurostrongylosis and troglo-
strongylosis is the Baermann
migration method. However, it
requires 12–48 h before larvae
can be found and specific skills
in discriminating between
L1s.2,11,61 in addition, repeated
examinations are necessary to
avoid false negative samples due
to prepatent infections or inter-
mittent eliminating and non-
eliminating shedding cycles.11,43
An accurate morphological
and morphometric appraisal of L1s is neces-
sary to achieve a species-specific diagnosis
but microscopic differentiation between
A abstrusus and T brevior (Figure 7) is often
difficult due to overlapping morphological
features and individual variations in some
b The head of A abstrusus L1s is
Figure 7 First stage larvae
of (a) Aelurostrongylus
abstrusus and
(b) Troglostrongylus brevior
ever, A abstrusus L1s as short as
cases confirmed with histo-
logical64 and genetic charac-
a terisation.22 Thus, L1s of the two
species should also be differentiat-
ed based on head and tail features.
rounded and has a terminal oral
opening, while the tail is kinked
(S-shaped) with distinct knob-like
or small finger-like projections
at the tip of cuticular spines
(Figure 8).5,7,43 L1s of T brevior have
a pointed anterior extremity and a
subterminal (dorsal) oral opening, while the
tail gradually tapers towards the extremity, and
possesses a deep dorsal incisure and a shallow-
er ventral incisure near the tip (Figure 8).5
L1s of A abstrusus (and presumably of
T brevior, although no evidence is published)

and T brevior L1s are ~360–415 μm and

characteristics.2,5,6,62 The lengths of A abstrusus can be detected in other samples such as

~300–357 µm, respectively.2,4,5,23,43,60,63 How -

transtracheal aspirates, tracheal swabs, bron-
choalveolar lavage fluid and pleural effusions.

a b

Given potential
overlap in
A abstrusus
and T brevior
L1 length, the
two species
c d
should be
differentiated
based on
head and tail
features.

Figure 8 (a,b) First stage larva of Aelurostrongylus abstrusus: (a) magnification of the anterior
end, showing a rounded extremity and a terminal oral opening; (b) magnification of the tail,
which is kinked, with distinct knob-like or small finger-like projections at the tip of cuticular
spines. Note the dorsal incisure (bold arrow) and the anal opening (light arrow). (c,d) First
stage larva of Troglostrongylus brevior: (c) magnification of the anterior end, showing a pointed
head and a subterminal oral opening; (d) magnification of the tail, showing the presence of a
deeper dorsal incisure (bold arrow) and a shallower ventral incisure. Note the anal opening
(light arrow). Scale bar = 20 µm

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Table 1 Differential features of metastrongyloid larvae and trichurid eggs that can be found in feline
faecal samples
Nematode Length (μm) Width (μm) Head Tail Plugs Shell References
First stage larvae
Aelurostrongylus 360–415* 18–19 Rounded, terminal oral Kinked (S-shaped) – – 2,5
abstrusus opening Knob-like or small finger-
like projections at tip of
cuticular spines
Troglostrongylus 300–357 16–19 Pointed, subterminal Gradually tapered – – 5,6,23
brevior (dorsal) oral opening to the extremity
Deep dorsal incisure
and shallower ventral
incisure#
Troglostrongylus 269–300 14–19 Pointed, subterminal Gradually tapered – – 5,23
subcrenatus† (dorsal) oral opening to the extremity
Deep dorsal incisure and
shallower ventral incisure
Oslerus 335–412∞ 18–20 Oral opening central Deep incisure in the – – 5,63
rostratus‡ to the head and ventral side with a
surrounded by a cuticular spine#
cuticular ring with dorsal
and ventral prominences
Eggs
Capillaria 60–65 25–40 – – Asymmetrical Striated outer shell 65
aerophila No rings with a network of
anastomosing
ridges and bridges
Trichuris 63–85 34–39 – – Symmetrical – 4
campanula§
Trichuris 54 40 – – Symmetrical – 4
serrata§
Aonchotheca 57–66 21–28 – – Thickened Rough surface 4
putorii¶ ridges
Pearsonema 51–65 24–32 – – Asymmetrical Pitted surface with 4
feliscati¶ No rings bleb-like striations
Capillaria 51–68 30–35 – – Asymmetrical Highly striated shell 4
hepatica¶ No rings Porous surface
*A minimum length of ~300 μm has been reported in cases confirmed by histological64 and genetic characterisation22
†To date, recorded in only two domestic cats, in Malawi66 and in Sicily23
‡To date, described in domestic cats in limited areas: Sri Lanka, Majorca, Hawaii,67–69 Sicily,70 Sardinia71 and northern Spain63
§To date, recorded extremely rarely in certain regions;4 taxonomical identity has been questioned4

∞Larvae found in bronchi or trachea measured 300–320 μm in length:6 growth during larval passage in faeces has been hypothesised as a cause
¶Parasite with a non-respiratory localisation

of the size variation5,72

#Slight individual variation in shape of the caudal end has been reported5

However, sampling from the respira- lariids. There is a paucity of data on

tory tract requires sedation or anaes- feline Trichuris species, as they have
thesia and these procedures may fail to been recorded extremely rarely and
detect larvae due to absence of signifi- only in limited geographical areas.4,11
cant pulmonary tissue involvement, Their eggs reportedly have symmet-
limited numbers of L1s, prepatent rical and ringed plugs and differ
infection or poor sample recovery.11 in size compared with those of
Lung capillariosis is diagnosed by C aerophila. Faecal examination may
identification of typical eggs on con- be complicated by the fact that cats
ventional copromicroscopy. Eggs of may shed trichurid eggs laid by other
C aerophila (Figure 9) have a net-like capillariids or by parasites of ingest-

µm, are barrel shaped, and have

outer shell, measure ~60–65 x ~25–40
asymmetrical bipolar plugs with no
thickening at the base.65 These ova
should be differentiated from those
of feline whipworms or other capil-
Figure 9 Egg of Capillaria aerophila, showing
the typical barrel shape, asymmetry of polar plugs
and absence of ring thickening at the base of the
plug. Scale bar = 10 µm
ed prey.11
differential characteristics of the
most important metastrongyloid L1s
and trichurid eggs that can be found
in cat faecal samples are described in
Table 1.

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R E V I E W / Advances in understanding of feline lungworm disease

New diagnostic methods

innovative assays have been validated for the
genetic identification of A abstrusus, T brevior
and C aerophila in different biological samples.
A duplex PCR based on markers within the
ribosomal (rdNA) internal transcribed spacer
2 region (iTS2) was developed to discriminate
overcoming the constraints of classical methods.
between faecal L1s of A abstrusus and T brevior
in a single cat with a mixed infection.73 The two
metastrongyloids may also be identified by
species-specific nested PCRs based on differen-
tial markers within the iTS2 region; high
sensitivity and specificity was verified on large
subsets of samples.26,27 Very recently, a triplex
semi-nested PCR has been validated for the
simultaneous discrimination of A abstrusus,
T brevior and Angiostrongylus chabaudi;74 the last
is a very rare cardiopulmonary nematode of
wild felids that has been recorded in a mixed
infection with lungworms in a domestic cat.75
Recently developed molecular assays have
proved powerful for the diagnosis of feline
aelurostrongylosis and troglostrongylosis,
All of these recently developed molecular
assays have proved powerful for the
diagnosis of feline aelurostrongylosis and
troglostrongylosis, overcoming the con-
straints of classical diagnosis. The PCR assay
specific for A abstrusus was validated on a
panel of faecal (ie, faeces, flotation
supernatant, Baermann sediment) and pha-
ryngeal swab samples from infected cats. it
showed a specificity of 100% and a sensitivity
of ~97%, and was able to reveal infected cats

Tr e a t m e n t
A abstrusus
Treatment of A abstrusus infection with off-label
parasiticides has been described in research
papers and textbooks. For example, the use of
ivermectin for treating aelurostrongylosis is
reported in single animals and limited case series,
but this macrolactone has inconsistent activi-
ty.16,48,77–79 Two doses are described for off-label
ivermectin,16 but care is required in kittens.80 Two
doses of off-label abamectin, 300 µg/kg subcuta-
neously (SC), 2 weeks apart, have also been used
for treating A abstrusus.79
Several studies have evaluated the efficacy and
safety of feline parasiticides against A abstrusus.
An oral paste containing 18.75% fenbendazole
(Panacur; MSD Animal Health) is licensed in some
countries (eg, UK) for the treatment of A abstrusus at
a dosage of 50 mg/kg PO for 3 consecutive days, and
this treatment regimen has an efficacy of 99.29%.81,82
Two spot-on parasiticides, one containing imidaclo-
prid 10% and moxidectin 1% (Advocate; Bayer
Animal Health), and the other containing emodepside
2.1% and praziquantel 8.6% (Profender; Bayer
Animal Health), were compared with the formulation
containing oral fenbendazole in treating feline
aelurostrongylosis.81,82 The emodepside 2.1%/prazi-
quantel 8.6% spot-on and the fenbendazole paste
showed similar therapeutic performances (99.38% vs
99.29%), while the imidacloprid 10%/moxidectin 1%
spot-on was 100% effective in stopping larval shed-
ding and in curing clinical signs.81,82 This formulation
(Advocate; Bayer Animal Health) is licensed in some
markets (eg, Australia) for the treatment of cat
aelurostrongylosis. Additionally, the adulticidal effica-
cy of emodepside has been demonstrated in two ran-
domised, placebo-controlled experimental trials to be
up to 99.2%. These studies showed that two spot-on
administrations of emodepside 2 weeks apart are
safe and efficacious against cat aelurostrongylosis.83
Another macrocyclic lactone, selamectin
(Stronghold; Zoetis), used topically at 18 mg/kg,
reduced clinical signs after a single spot-on admin-
istration, while a second dose after 1 month
ensured improvement in respiratory function and
radiographic bronchial lesions.84 Selamectin at a
topical dose of 6 mg/kg was effective in eliminating
larvae from the faeces of a cat after 30 days;50 the
same drug was effective in producing a clinical
recovery and stopping larval shedding in 9/10 cats
infected with A abstrusus.85 Milbemycin oxime
4 mg/kg (plus praziquantel 10 mg/kg) (Milbemax;
Novartis Animal Health) PO at 2 week intervals was
also effective in stopping L1 elimination and result-
ed in resolution of clinical signs over a period of
6 weeks in a cat with clinical aelurostrongylosis.55
A novel topical formulation containing fipronil
8.3% w/v, (S)-methoprene 10% w/v, eprinomectin
0.4% w/v and praziquantel 8.3% w/v (Broadline;
Merial) was evaluated for efficacy against larval
and adult A abstrusus in experimentally infected
cats.86 This formulation is licensed in some coun-
tries for the treatment of A abstrusus. Using treat-
ment time points based on the life cycle of A
abstrusus in the cat (ie, from inoculated L3s to
adult stages), the study demonstrated that epri-
nomectin has high efficacy against all A abstrusus
stages; for example, 99.6% efficacy against adult
stages in the feline definitive host.86 In cats natu-
rally infected with A abstrusus, this formulation
showed 90.5% efficacy based on larval counts.87
Continued on page 15

14 JFMS CLINICAL PRACTICE

7_20_Lungworms_Traversa.qxp_FAB 07/12/2015 10:20 Page 15
that were copromicroscopically negative.76
Similarly, a species-specific PCR proved
effective in identifying T brevior in faeces and
pharyngeal swabs, even in cats co-infected
with A abstrusus or C aerophila.27,28 These find-
ings have demonstrated that a pharyngeal
swab is the most suitable sample for the
molecular diagnosis of A abstrusus and T brev-
ior with respect to both experimental sensitiv-
ity and practicality (avoiding the difficulties
of adequate faecal collection in the field, long
parasite prepatent and migration periods,
laboriousness of dNA extraction from faeces,
and presence of PCR inhibitors in faecal sam-
ples).26,76 The assays have proved successful
in field studies investigating the occurrence of
A abstrusus and T brevior in cat populations13,31
and the efficacy of parasiticides in clinical
settings.27,54
A similar diagnostic assay specific for a
Continued from page 14
T brevior
Information on control options for troglostrongylo-
sis in domestic cats is incomplete. The adminis-
tration of imidacloprid 10%/moxidectin 1%
(Advocate) in a cat appeared unsuccessful,23 but
this may have been due to the severe clinical signs
and extensive lung lesions already present at the
point of referral. A kitten infected with T brevior
returned negative scores upon both copromicro-
scopic and biomolecular examinations for 3
months after a single administration of Advocate
and showed a corresponding improvement in
severe cardiorespiratory signs.54 A single adminis-
tration of milbemycin oxime 2 mg/kg (Milbemax)
was efficacious in stopping larval shedding in
one cat with a subclinical mixed infection of
A abstrusus and T brevior, but the same drug was
effective only against A abstrusus in another cat
from the same litter, which died due to infection
with T brevior despite the treatment.26 The topical
formulation containing emodepside 2.1%/prazi-
quantel 8.6% (Profender) recently showed promise
in the treatment of two kittens with mixed lung-
worm infections (T brevior and either A abstrusus
or C aerophila).27 Respiratory signs resolved after
one or two administrations of the spot-on solution,
and larval (T brevior and A abstrusus) and egg
(C aerophila) shedding was also eliminated 2–4
weeks after treatment.27
The spot-on containing eprinomectin
(Broadline) proved 100% efficacious in stopping
larval shedding in a few cats with natural T brevior
infection.87 It recently showed 100% efficacy
against developing larvae and adults of T brevior
under experimental conditions.88
R E V I E W / Advances in understanding of feline lungworm disease
partial region of the mitochondrial (mtdNA)
gene encoding for the cytochrome oxidase
subunit 1 (CoX-1) of C aerophila has been val-
idated.17 This method displayed a specificity
of 100% and sensitivity of 97–100% using fae-
cal samples from cats (and dogs) positive or
negative for C aerophila and other endopara-
sites, including A abstrusus.17 A similar genetic
approach has proved invaluable in assessing
the distribution of C aerophila haplotypes in
different host species and geographic regions,
enabling a better understanding of the
current epidemiology of lung capillariosis in
Europe.20
Any respiratory sign in an at-risk cat
(eg, free-roaming or kitten) should ring an
alarm bell for clinicians working in lungworm-
endemic areas or with travelling pets.
C aerophila
Available data on the treatment
of C aerophila infection in cats
include reports on the efficacy of
repeated administrations of a
variety of dosages of injectable or oral levamisole
and off-label abamectin.4,11,16,18,89 Importantly, the
spot-on formulation containing moxidectin 1%
(Advocate), which was efficacious against
aelurostrongylosis,82 demonstrated ~99.8% effica-
cy in stopping egg shedding and eliminating clini-
cal signs in cats with lung capillariosis.90 The safe-
ty and efficacy of the topical combination contain-
ing eprinomectin (Broadline) was evaluated
against helminths, including Capillaria species, in
domestic cats. An efficacy of 99.6% in reducing
counts of Capillaria eggs was reported after treat-
ment.91 Although no morphological identification
of the eggs was performed, it was assumed that
the vast majority were C aerophila.91 A very recent
study has demonstrated that a single treatment
with Broadline in naturally infected cats is able to
reduce the C aerophila parasite burden and to
lower or eliminate faecal egg shedding.92
In general, easy-to-apply topical
parasiticides are a suitable choice
for treating cat lungworms, because
of safety and ease of administration,
especially when multiple
dosing is required.
JFMS CLINICAL PRACTICE 15
7_20_Lungworms_Traversa.qxp_FAB 07/12/2015 10:20 Page 16
R E V I E W / Advances in understanding of feline lungworm disease
Current and future priorities
Lungworms are gaining more attention in
veterinary medicine. More frequent identifica-
tion of feline lungworm disease could be due
to increased prevalence of infections, expand-
ing geographic range, increased awareness,
or a combination of these factors. However,
it is likely that in certain areas (eg, Europe)
lungworms will be increasingly recognised as
having a clinical role in respiratory disease of
cats.
Practitioner vigilance
From a practical perspective, lungworms
infecting cats can be problematic to identify
and diagnose, even in the presence of clinical
signs. indeed, any respiratory sign in an at-
risk cat (eg, free-roaming animals, kittens)
should always ring an alarm bell for clinicians
working in endemic areas or with travelling
pets. Any suspected case should undergo
appropriate diagnostic work-up and, especial-
ly in endemic areas, even apparently healthy
cats should be screened regularly for lung-
worms. A routine check for metastrongyloid
infection is of importance also for any cat in an
endemic region that requires general anaes-
thesia, given the potential fatal risks associat-
ed with lungworm infections.53
Practitioners should be highly conscious
of the importance of lungworms, especially
A abstrusus, and must be vigilant for these
infections, both in cats living in endemic areas
and cats living in territories considered free of
infection. These nematodes may be easily
introduced into free regions, and thus they
should not be overlooked in the presence of
compatible clinical signs or ruled out in
apparently healthy cats. Veterinarians should
start routinely applying the Baermann migra-
tion technique (currently infrequently utilised
in practice) and perform a careful appraisal of
trichurid eggs in cat faeces.11 Whipworm and
capillariid infections in cats are often confused
by practitioners, and that it is likely that most
capillariid infections are misdiagnosed as
‘whipworm’ infections.2,65
Current armoury
The above advice assumes particular impor-
tance in the light of the fact that, in most cases,
lungworm treatment protocols are straight-
forward and effective, especially against
A abstrusus and C aerophila. To summarise the
treatment data discussed on pages 14 and 15:
< Spot-on moxidectin/imidacloprid was
effective in stopping larval and egg
shedding, respectively, by A abstrusus and
C aerophila, and in curing clinical signs in
naturally infected cats.82,90
< Spot-on emodepside,81,83 selamectin85 and
16 JFMS CLINICAL PRACTICE
eprinomectin86,87 similarly showed
high efficacy in the treatment of
aelurostrongylosis in natural and/or
experimental conditions.
< Clinical reports in single animals have
documented promising activity of
moxidectin54 and emodepside27 in curing
T brevior infection.
< Spot-on eprinomectin proved to be
efficacious in stopping larval shedding in
cats with natural T brevior infection,87 as well
as against both developing larvae and adults
of T brevior under experimental conditions.88
< Faecal egg shedding of C aerophila can be
reduced or eliminated following a single
Veterinarians treatment with eprinomectin.91,92 Also,
should start cats treated with eprinomectin harboured
significantly fewer C aerophila lungworms
routinely compared with untreated cats.92
< oral milbemycin oxime has been effective
applying the in treating single cases of A abstrusus or
Baermann T brevior infection.26
< Topical emodepside was effective in treating
migration a case of lung capillariosis,27 suggesting that
a formal evaluation of this formulation for
technique
treating C aerophila is worthwhile.
and perform Further field studies involving larger num-
bers of cases are necessary to evaluate the
a careful efficacy of milbemycin oxyme against
appraisal of A abstrusus, T brevior and C aerophila; of
selamectin against T brevior and C aerophila;
trichurid eggs and of moxidectin and emodepside against
T brevior. Such studies should take into
in cat faeces. account the observation that anthelmintic
efficacy in treating T brevior seems greatly
dependent on the age of the cat, parasite
burden, timing and number of administra-
tions, presence and severity of lung damage,
and/or host immunity.23,26,27,54
New avenues for control
The potential efficacy of parasiticides in the
prevention of metastrongyloid infections
opens new avenues for the control of cat lung-
worms. As a key example, spot-on moxidectin
has proved effective in preventing (and treat-
ing) infection caused by the closely related
parasite A vasorum.93 it has also been shown
that dogs in areas endemic for A vasorum treat-
ed every 3 months with milbemycin oxime are
half as likely to be infected as those that are
not treated,94 and that monthly treatments
with this molecule have the potential to pre-
vent the establishment of A vasorum in dogs.95
Given that these anthelmintics and others
(eg, emodepside, selamectin) have shown effi-
cacy in treating lungworms, further studies
are warranted to investigate this management
option. However, identifying a risk season
for seasonal chemoprevention of lungworms
is difficult. Recommendations for chemo-
prevention would have to consider each local
7_20_Lungworms_Traversa.qxp_FAB 07/12/2015 10:20 Page 17
epidemiological situation and take into
account the fact that paratenic hosts of
A abstrusus and T brevior may be present
throughout the year.
The activity of eprinomectin in the chemo-
prevention of aelurostrongylosis when
administered against prepatent developmen-
tal stages in experimental conditions is truly
promising from a clinical perspective.
Administration of this parasiticide86 is able
to limit the progressive pulmonary changes
usually occurring during the course of
infection.45,96 Field studies are, however,
required to support this efficacy, and to evalu-
ate the activity of other anthelmintics in the
prevention of cat lungworm infections.
Moxidectin needs to be considered for its
important pharmacokinetic properties. This
drug remains at detectable levels for
weeks after treatment,97 and it has been
demonstrated that consistent administrations
of topical spot-on formulations containing
moxidectin induce elevated and sustained
steady-state plasma concentrations.98
Thus, repeated administration of moxidectin
has the potential to protect animals prospec-
tively against parasites. For instance, the
steady-state in cats is reached after three to
five treatments, and this protected against
infection by hookworms and Dirofilaria immi-
tis.99,100 Studies evaluating the efficacy of
moxidectin steady-state in protecting from
subsequent infection by lungworms would be
very interesting in terms of offering further
approaches in the management of these
infections.
‘Novel’ lungworms
From an epidemiological perspective, if the
current trends in the apparent expansion of
feline lungworms continue, we will face an
increasing number of clinical cases in a variety
of geographic areas. Additionally, other little-
known lungworms could gain more impor-
tance. For instance, the metastrongyloid
Troglostrongylus subcrenatus has so far only
been recorded in two cats, one in Malawi,66
the other in Sicily.23 Oslerus rostratus has previ-
ously only been described in cats in limited
areas including Sri Lanka, Majorca and
Hawaii; however, more recently, there have
been reports in two single cats from Sicily and
Sardinia.5,67–71 Further diagnostic and clinical
problems will arise if more cats infected by
these two lungworms are identified in wider
geographic regions, because their L1s are
similar to those of other metastrongyloids and
there are no known therapeutic options.2 This
is especially relevant given that these ‘novel’
lungworms may be described in mixed infec-
tions, making a definitive diagnosis at the
species level truly complicated.
R E V I E W / Advances in understanding of feline lungworm disease
KEY points
< Feline respiratory parasites –
Aelurostrongylus abstrusus,
Troglostrongylus brevior and Capillaria
aerophila – are gaining increased
attention in feline practice due to their
worldwide distribution and clinical
importance.
< Recently, new insights into clinical and
laboratory diagnosis, and management
and treatment of these nematodes have
been gained.
< Continuous attention to respiratory
If the apparent parasitoses affecting cats is crucial
expansion to further elucidate their geographic
distribution, to assess new diagnostic
of feline methods and to improve treatment and
prevention approaches.
lungworms
< Feline practitioners are encouraged
continues, to include feline lungworms in the
we will face differential diagnosis of feline
respiratory diseases and to apply
an increasing appropriate diagnostic, therapeutic
and preventive measures.
number of
clinical cases
in a variety of
geographic
areas. Summary
Continuous awareness of lungworms affect-
ing cats is crucial to further elucidate their
geographic distribution and document possi-
ble expansion, to refine diagnostic techniques
and to improve the current methods available
for treatment and prevention of respiratory
parasitoses.
Acknowledgements
The authors thank all of the following friends
and colleagues for their valuable participation
in studies on feline respiratory nematodes:
Fabrizia Veronesi, Andrea Boari, Antonio
Frangipane di Regalbono, Anastasia diakou,
Paolo Emidio Crisi, Emanuela di Giulio,
Silvana Meloni, Raffaella iorio, Barbara
Paoletti, Roberto Bartolini, Giulia Morganti
and Giuseppe Castagna. The authors are
grateful to Matilde Vicovaro for the drawings
in Figures 1 and 2.
Funding
The authors received no financial support for
the research, authorship and/or publication of this
article.
JFMS CLINICAL PRACTICE 17
7_20_Lungworms_Traversa.qxp_FAB 07/12/2015 10:20 Page 18
R E V I E W / Advances in understanding of feline lungworm disease
Conflict of interest
AdC holds a post-doc fellowship on parasites other than feline 19
lungworms and she has participated in the present review in the
framework of her freedom of scientific research.
20
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