diagnosis & treatment

Diagnosis & Treatment Diseases of the Cranial Coelom

J. Jill Heatley DVM MS DABVP DACZM

Reptile Diagnosis and Treatment

• Challenges at most steps in the process

• Treatment options remain anecdotal

• Further Investigation continues

• Antibiotics

• Analgesics

• pharmacokinetics

• Doses

• Options

• Thought process

Diagnosis

Exam

Sample

Evaluate

ARAV ExoticsCON JheatleyDVM August 2016

Overview

• Organ Based

• Trachea

• Lung

• Esophagus

• Stomach

• Thyroid

• Thymus

• Parathyroids

• Ultimobranchial

• Diseases

• Common

• Nontraumatic

• Diagnosis

• Techniques

• Treatment

• Techniques

• Options

• Efficacy

Start

Stop

August 2016 ARAV ExoticsCON JheatleyDVM

Goals

• Diagnostic

• Clinical signs

• reported in literature

• Expected

• Screening Diagnostics

• Useful

• Clinical Pathology

• Imaging

• Etiology Diagnostics

• For “Definitive” Diagnosis

• Culture

• PCR

• Serology

• Histopathology

Diagnostic Options

Literature Review

Abstracted

Recommendations

Use in NonTarget Species


Goals

• Treatment

• Options

• Best treatment options

• Literature review

• Anecdotal

• Dose modification

Literature Review

Recommendations

Off-Label Use


TracheaSo much more than just a path to the Lung / Air Sac

Diseases

Diagnosis

Treatment

ARAV ExoticsCON JheatleyDVM

Tracheal DiseaseTrauma

Obstruction

Tracheitis

Neoplasia

Tracheal Disease Diagnosis

• Pediatric human bacterial tracheitis clinical course

• prodromal upper respiratory illness

• Fever

• Inspiratory stridor

• Cough

• Acute obstructive airway disease

• May occur

• respiratory distress

• acute respiratory decompensation

• Require endotracheal intubation or tracheostomy, ICU.

• Complications

• Pneumonia, toxic shock syndrome, cardiopulmonary arrest, death


Necrotizing Tracheitis

• Sequella

• Bacterial - Mycoplasmosis

• Fungal

• Viral - Herpes Virus, Iridovirus, Nidovirus, Coronavirus, Adenovirus, Ferlavirus (OPMV)

• Proliferation of etiologic agents in tracheal mucosa


Tracheitis

• Proliferation in tracheal mucosa

• Necrotizing tracheitis sequella

• Mycoplasmosis

• Herpesvirus

• Tortoises, Green Sea Turtles (LETD)

• Iridovirus

• Nidovirus

• Coronavirus

• Adenovirus

• Ferlavirus(OPMV)

• Fungal Diseases

Viral, Bacterial


Tracheal Virus

• Adeno-like Virus in Esophageal and Tracheal Mucosa of a Jackson's Chameleon (Chamaeleo jacksoni)

• Jacobsen 1990

• A 6-month-old, 15-g, Jackson’s Chameleon

• 3 days anorexia, 1.5 days Opisthotonos, death More common than you thought


Tracheal Obstruction• Complete Tracheal Rings

• Chelonians, crocodilians

• Proximal tracheal some snakes

• Indian and Burmese pythons (Python molurus) and western rattlesnakes (Crotalus viridis)

• Monitor for obstruction when using smaller endotracheal tubes.

• Cuffed ET tubes contraindicated

• Reactive trachea, healing by adhesions or stenosis (as in Avian species) yet to be decribed

Not reported in Reptiles


Vitamin A deficiency• Degeneration/ Metaplasia of epithelium

• Including lung faveoli

• Rhinitis

• Lung, respiratory tract disease

• External Clinical signs

• Poor epithelial quality

• Skin

• Nails

• Conjunctivitis

Plasma [Vitamin A]; Liver vitamin A

San-Jose LM at al. Vitamin E, vitamin A, and carotenoids in male common lizard tissues. Herpetologica. 2012 Mar;68(1):88-99.

Hypovitaminosis A

Chelonians


Tracheal Obstruction

Clinical Signs

• Ball Python Python regius

• Chondroma

• Respiratory noise, wheezing, episodic harsh breathing

• severely dyspneic, open mouth breathing.

• exaggerated / pronounced inspiratory effort

• Expiratory wheezing

• Head, neck flexed dorsal, 90˚ angle to body during inspiratory efforts

• Tracheitis/Pneumonia -Providencia rettgeri

• acute respiratory distress, severe dyspnea, open mouth breathing, moist rales, glottal bubbles, head and neck vertical position. Copious thick yellow tracheal discharge

• Green Sea turtles Chelonia mydas

• Phaeohyphomycosis

• alive but lethargic “stranded” , subsequently died.

• Honduran Milk Snake Lampropeltis hondurensis

• Salmonella arizonae

• Bicephalic

• No premortem clinical signs, Unexpected death

Tracheal Obstruction

Green turtle

Chelonia mydas

Stranded Indian River Lagoon, Florida, USA,

cranial trachea obstructed by locally extensive, ulcerated mass.

Scale bar ~ 0.4 cm.


Tracheal Malformation

• Honduran Milk Snake

• No antemortem clinical signs

• Atypically Wide, collapsed tracheal rings

• Necrotic epithelial debris/Inflammatory cells

• Luminal obstruction

• Salmonella arizonae

• Radiographs, Necropsy Diagnosis


Bronchial Collapse

• Hermann’s tortoise, Testudo hermanni boettgeri

• 45 YOA, therapy resistant respiratory distress several months

• Clinical Signs limited to:

• Marked inspiratory distress, wheezing sounds during inspiration.

• Inspiratory distress increased with neck extended.

• Respiratory distress persisted with neck extension and sedation.

Clinical Signs


Tracheobronchial collapse

Pulmonary-tracheobronchial prolapse

New Caledonian giant gecko, Leach’s gecko

(Rhacodactylus leachianus) 3y male

1-day hx lethargy, labored breathing, coelomic distention.

Intermittent dyspnea, pronounced expiratory stridor

Moderate coelomic tympany

DDX: infectious respiratory disease, obstructive condition leading to pneumocoelom, gas distended gastrointestinal tract, or lung hyperinflation.


CLINICAL DIAGNOSIS

2 kg , 1.7 m juvenile boa constrictor

Good BCS, anorexic for 3 weeks

Rescued from a rescue 3 weeks ago,

Companion snake dies two weeks ago with “neurologic signs”

Snake held head vertically, open mouth breathing

10% dehydration

Retained spectacles, cloudy anterior chambers OU

HISTOPATHOLOGY

Hepatitis

Nephritis

Glossitis

NL: lungs, trachea, glottis. Lung viral isolation negative

SNAKES HOLD UP THE PROBLEM….

Snake dyspnea


URTD

• Common causes of primary upper respiratory tract disease

• Trauma

• Mycoplasma agassizzi in North American tortoises,

• tracheal chondromas in ball pythons (Python regius)

• herpesviruses, iridoviruses in tortoises,

• Tortoises with mycoplasmosis, herpesvirus, iridovirus similar signs; dyspnea, serous to mucopurulent nasal discharge, rhinitis, conjunctivitis

• Stomatitis and glossitis

• present in herpesvirus infections, not mycoplasmosis

• Sudan plated lizard (Gerrrhosaurus major) with dyspnea

• Obstructive periglottal lesions with eosinophilic intranuclear inclusions

• Herpesvirus

Is it Upper or Lower Respiratory Tract Disease

Is It Both????


Lung Disease

Pneumonia

• SubOptimal Husbandry

• Bacterial

• Chlamydia spp. • puff adders - Bitis arietans

• Greek tortoises - Testudo graeca

• Mycoplasma • Crocodilians, Torts

• Burmese python Python molurus bivittatus

• proliferative tracheitis, pneumonia.

• Viral - paramyxoviridae, reoviridae

• Traumatic

• Turtle HBC, pulmonary hemorrhage sequela to shell

• Parasitic

• Pentastomids, Rhabdias, Roundworms, Intranuclear coccidia

• Fungal – candida spp RES


Pneumonia• High fever, shaking chills

• Cough with phlegm

• Shortness of breath

• Chest pain when breathing or coughing

• Pediatric - may lack signs of infection

• vomit, fever cough, restless, sick, tired, lack energy

• Geriatric, Immune Suppressed

• fewer and milder symptoms, hypothermic.

• Older adults who have pneumonia sometimes have sudden changes in mental awareness.

Human Symptoms


Pneumonia

• Early stage clinical signs difficult to detect.

• Nonspecific - lethargy, anorexia weight loss

• Lizards

• Sneezing, serous - mucoid DC, severe cases of pneumonia, increased respiratory effort

• Snake

• Serous - purulent nasal DC, wheezing, respiratory secretions in oral cavity, stomatitis.

• Increased respiratory efforts, dyspnea

• Open mouth breathing cranial aspect of body extended to facilitate air movement through “filled” trachea

• Chelonia

• Stomatitis, necrotizing lesions, abscesses

upper & lower respiratory tract disease.

• Open mouth breathing - severe, chronic , obstructive processes hypertrophy of upper respiratory tract epithelium.

• Aquatic species

• buoyancy problems, inability to dive,

• unilateral or bilateral gas pockets in the lungs

• consolidation of lung parenchyma.

• Differing percussion of carapace

Clinical Signs

Upper Respiratory Disease

Lower Respiratory Disease

HEAT SEEKING BEHAVIOR

Inspiratory/Expiratory

Lung Sounds

Respiratory RATE


Trachea & LungsRespiratory Rate

at least 1 minute

preferably unrestrained/ observational

Repeat at POTZ if necessary

Noise or difficulty

Inspiratory or Expiratory

Percuss

Auscult…?

Obtain Temperature

Heart Rate

REPORT IN CASE REPORTS

Physical Exam


Respiratory Diagnostics• Respiratory sample

• Tracheal

• Percutaneous

• Surgical

• Image

• Noninvasive – RAD, CT, MRI

• Invasive – Endoscopy, Surgery

• Blood

• Hematology – CBC, Chem, Blood Gases

• Acute Phase Proteins

• Serology – Antibody Response

• Capnography


Respiratory Diagnostics

• Adequate Uncontaminated Sample

• Cytology

• Histopathology

• PCR

• Culture

• Above all do no harm

• Avoid iatrogenic patient damage

• Respiratory Arrest or Death

GOALS


Respiratory Diagnostics

• IMAGING

• Glottal Swab

• Tracheal Swab

• Tracheal Lung Lavage

• BAL, TTW

• Percutaneous Lung Aspirate

• Fine-needle aspiration

• Craniodorsal aspect prefemoral fossa in chelonians via long needle

• Risk greater, use with caution

• Vessel Confluence

• Endoscopy

• ventrolateral celiotomy and pneumotomy (40% - 50% SVL) endoscope directly into the lungs.

• Chelonian lungs

• Prefemoral via septum horizontale

• Temporary carapacial osteotomy

• Flexible bronchoscopy techniques - Large species

OPTIONS

August 2016


Radiography Lung / Trachea

• Lack of radiographic contrast of soft tissues of the coelomic cavity is common in reptiles and prevents individual recognition of several coelomic organs.

• Plain radiographs

• Trachea can be evaluated in snakes and lizards.

• In snakes limited diagnostic tool for lung evaluation ---------CONSIDER CT, MRI

• Evaluation of lung fields using horizontal beam radiographs may reveal fluid in the lungs

• Lungs pattern classification scheme not applicable to reptiles

• Radiographic signs of pulmonary disease become apparent only at a late stage

• “If pneumonia is suspected, clinician should rely on the clinical examination of the patient and combine results of different diagnostic tests, such as bronchoalveolar lavage, haematologicalscreening, bronchoscopy and radiography to obtain the diagnosis”


Computed tomography for the diagnosis andtreatment monitoring of bacterial pneumoniain Indian pythons (Python molurus) Pees et al.


Lung CTImprovement of Disease


Tracheal Imaging


Lateral radiograph, cranial 16 cm of ball python intraluminal, irregularly marginated, soft tissue opacities (arrows) silhouetting with the ventral wall of the trachea. TRACHEAL CHONDROMA

Herman’s TortoiseCervical Region Caudal to Tracheal Bifurcation

NORMAL CT


R bronchus black arrowL bronchus white arrow hypodense (-980 HU) structures

Herman’s TortoiseCervical Region Caudal to Tracheal Bifurcation

Bronchial Collapse

BLACK ARROW

R bronchus hypodense (-980 HU) figure-8 due to central collapse

WHITE ARROW

L brochus nearly completely collapsed barely visible


Tracheal Imaging

FAIL


Rat Snake

RATSNAKE HBC, Found in parking lot

Multiple episodes open mouth breathing Possible free gas cranial to the heart. Rupture of respiratory tract suspected.

4: Possible hemorrhage cranial to the heart.


COACHWHIP HBC

traumatized "flattened" region is skeletally unremarkable. Irregular skin margins are present along the left body wall throughout this region. On several images, barium paste marks the grossly traumatized region. Fragmented gas is present within the GI tract.

Conclusions: Trauma in the mid body, just caudal to the lungs. Spinal displacement is not appreciated.

Lung

• Tracheal (lung) lavage preferred to glottal swab

• Cytology, microbiology, PCR

• Sedation or light anesthesia

• Lidocaine glottis

• sterile catheter into the lung

• Sterile endotracheal tube placement

• From snout to cranial third of the coelom

• insert through glottis, avoid oral mucosa

• Aspiration of exudate

• 0.5 ml of 0.9% sterile saline per 100 g of body weight instilled

• 1-10 mg/kg

• Rotate patient, gentle reaspiration reattempted.

• For unilateral lung disease, direct catheter into affected lung with curved stylet, confirm placement radiographically

Diagnostics


Tracheal Wash• Bronchofaveolar Lavage

• American Alligator , Healthy

• Small amounts of mucous

• Low numbers in 90% of samples

• ciliated columnar epithelium

• Cuboidal epithelium

• Keratinized squamous cells

• No

• Bacteria, parasites, seasonal change

• NORMAL SNAKE, TORTOISE, TURTLE

• Unreported


Trachea / Lung

• Snakes , Lizards

• fine-diameter (1 to 2.7 mm), rigid endoscope examine the trachea enter the lung(s) examination / diagnostic

• Preoxygenation recommended, tracheal occlusion tolerated

• Direct visual guidance of scope necessary to avoid tracheal damage

• Snakes

• Ventrolateral celiotomy / pneumotomy

• 40% - 50% SVL ; Pulmonoscopy

• Chelonian

• Sharp bronchial bend before entering the lungs, makes endotracheal approach to chelonian lung impossible (rigid endoscope)

• Caudal prefemoral, soft-tissue approach

• through septum horizontale

• thin, horizontal membrane separates lungs from viscera

• Transcarapace temporary carapacial osteotomy

• direct examination and collection of tissue biopsies

• Large reptiles

• Typical flexible bronchoscopy techniques

Endoscopy


Lung Endoscopy

• Left lateral recumbency

• Entry site

• 90 (95) ventral scales caudal to head,

• 9 scales lateral right side

• Vertical 8-10 mm interscalar skin incision

• Blunt subcutis dissection, identify ribs, intercostal space

• Hemostats penetrate intercostal muscles, separate 2 adjacent ribs

• Inflation of lungs for ID, Penetrate with hemostats

• 3-4 mm pneumotomy

• Skin closure only

• BIOPSY SPECIMEN HANDLING:

• gently shake from forceps into tube with saline then decanted and replaced with fixative.

Ball Pythons (Python regius)

Tracheal Wash Sample Options

• Wet mount

• Microscopic exam protozoa, parasitic ova

• Lugol’s iodine

• 1 - 2 drop ethanol / ml of sample

• Microbiologic swab soaked w sample transport media (culturette)

• Bacterial & fungal culture media

• Fresh, air-dried smear

• cytologic and microbiologic staining

• PCR, Viral culture

• Lung Biopsy – Histopath, PCR, Cytologic Imprint, Culture


Culture interpretation challenging

• Most bacteria isolated from reptiles with pneumonia are aerobic Gram-negative rods

• Chlamydia, Mycoplasma, Fungi

• Glottal Culture

• 3 boa constrictors (Constrictor constrictor), 3 Indian pythons (Python molurus), 2 reticulated pythons (Python reticulatus)

• Pneumonia Snakes - criteria - oral/ nasal bubbling respiration, open mouth breathing, rhinitis, nasal discharge, and rales on lung auscultation

• No anaerobes cultured

• Quantity of bacteria greater from diseased snakes than those apparently healthy

• Glottal culture results matched those obtained from necropsy of snakes suffering pneumonia


Snake Glottal Culture results

Bacteria Pneumonia Healthy

Aeromonashydrophila

1 2

E. Coli 0 1

Klebsiella spp. 0 1

Pasteurella spp. 1 0

Proteus spp. 1 1

Pseudomonas spp. 1 6

Salmonella spp. 3 1


Reptile Respiratory Culture

• The tracheal lavage more sensitive than pharyngeal swabs.

• Most common bacteria:

• Pseudomonas aeruginosa, Klebsiella pneumoniae, Stenotrophomonas maltophila.

Most common fungi - Aspergillus sp. , yeast In boids

75% Pythons bacteriologic results considered pathologic.

48% Tortoises mycologic results were considered pathologic.

Aerobic cultivation on standard media: Columbia-Agar with sheep blood, brilliant-green-, Sabouraud-Agar recommended as an initial diagnostic measure in reptiles with respiratory signs

Additional pathogens (viral ,Mycoplasma) should also be checked


Trachea & LungsTreatment

Trachea Treatment

• Pediatric Tracheitis Serious Consequences

• Close observation and monitoring

• Early admin of broad spectrum antibiotics

• Pain management

• Aggressive airway clearance

• Fluid therapy

• Nutritional support

• Contact precautions

• Drugs

• Expectorants, proteolytics, mucolytics, bronchodilators

• ANECDOTAL, Modification for pediatric dosing

• Trachea blood supply limited, consider Nebulization

• Surgical

• Lung cannulation, tracheal resection…ball pythons

HUMAN

REPTILE

OPTIONS

Pneumonia Treatment

• Parenteral, Nebulization, POTZ, Supportive Care

• Appropriate antibiotic therapy

• Mycoplasma spp. lack call wall

• Fluoroquinolones, Azithromycin, Clarithromycin

• Tissue necrosis: Iatrogenic radial nerve paralysis in chelonians: repeated injections into the antebrachium. eradication Mycoplasma unknown, lifelong carriers.

• Fungal pneumonias

• Itraconazole, intrapulmonary application of amphotericin B

• herpesvirus infection

• Acyclovir, famcyclovir

• Appropriate antiparasitic therapy for Rhabdias spp. and fluke spp.

• Ivermectin is toxic in chelonians


Pneumonia Treatment

• Surgical treatment of pentastomids

• Medical treatment of pentastomids

• Egyptian toads – Fenbendazole formulary dose – sepsis, death

• intrapulmonary application of amphotericin B

• Endoscopy sample trancarapacial


Texas Tortoise 17


Clinical Signs

• Atlas

• Adult male Russian Tortoise

• Referral for increased respiratory rate

• Overweight

• Radiographs

• Endoscopy

• Liver Biopsy

Non Specific


APLung field size ?


Endoscopic ViewAtlas’ Liver


Esophagus

• Esophageal Disease Rare?

• Sea Turtles

• Ulcerative & Fibrinous esophagitis

• Traumatic esophageal perforation common lesion

• FOREIGN BODY

• long line tuna fishery

• Esophageal impaction with balls of crude oil in 2 turtles (2.15%)

• Viral Lesions

• Ranavirus

• Adenovirus

Diseases

Diagnosis

Treatment


Panther Chameleon• No gross lesions observed

• Oral cavity thick yellow mucoid discharge

• Sepsis

• Microscopic Lesions

• Esophagus

• Lymphoplasmacytic heterophilis esophagitis with ulceration

3 yoa Male

Anorexia, Open mouth breathing, Frothing at the mouth

Profuse Ptyalism

Increased upper respiratory noise


Human esophagitis

• Symptoms

• Odynophagia

• Retrosternal pain upon swallowing

• Dysphagia, Nausea, Substernal burning pain

• ANOREXIA

• Diagnosis

• Endoscopic Visualization

• Brush samples - cytology +/- Culture

• More sensitive than biopsy

• Blind brush sample sensitivity good 75-84%

• Treatment

• ID, etiologic treatment

• Analgesia, Liquid topical anti-ulcer medication

• Sulcralfate, calcium alginate

Rare, Immunocompromise

Herpes simplex, Cytomegalovirus, Candidiasis, Idiopathic


StomachDiseases

Diagnosis

Treatment


Stomach Diseases

• Trauma

• Foreign Body Ingestion, Caustic Insult

• Neoplasia

• Gastric Neuroendocrine Carcinoma

• Endoparasitism

• Cryptosporidiosis, Physaloptera

• Gastritis - Bacterial/ Fungal/ Toxic/Viral

• Poor husbandry commensal overgrowth

• Ulcers (gastric)

• Nutritional/Renal

• Gout, Mineralization


Gastritis

• Inflammatory Response Lining of Stomach

• Acute - “severe thermal burns, major surgery, anti-inflammatory agents, corticosteroid administration, toxins, and infectious diseases”

• Chronic “Chronic poor husbandry, neoplasia, bacterial infections”

• Diptheritic necrotizing gastritis Rosy Boa (Lichanaura trivergata) – Salmonella arizonae -32-33

• Atrophic gastritis – RES, Herman’s tortoises (Testudo hermanii)

• Helicobacter associated gastritis (5/28 histopath )–

• Cuoro spp. Asian box turtles

• Californian Desert Tortoise (Gopherus agasizzi) -


Stomach Clinical Signs

• Anorexia, Nausea, Vomiting

• Frank or digested blood

• Vomitus, Feces

• Midbody Swelling

• Ill-thrift

• Pain or tenderness upper abdomen

• Pain upon eating

• Bruxism

• HUMAN COMMON CAUSES: H. pylori, NSAIDS, Vitamin B Deficiency


Gastric Disease Clinical Signs• 5 y Male Diamond python Morelia spilota spilota

• Regurgitation, anorexia, discrete coelomic distention, Firm, immobile mass, 2/ 3 SVL

• Adenocarcinoma

• Adult Male Madagascar tree boa Sanzinia madagascarensis

• 3 m regurgitation, weight loss. marked cachexia, lethargy, weakness

• Cryptosporidium

• 8 y Female Green Iguana Iguana iguana

• Reduced condition, pain upon abdominal palpation, vomiting 2 days

• Radiolucent foreign body

• 2 Reticulated pythons Python reticulatus 7 & 20 y

• Dullness, anorexia,lethargy; Dysecdysis, firm papillomas mucosal masses

• Ascardia galli ulcerative gastritis


Gastric Disease Clinical Signs

• Gastric neuroendocrine carcinoma of bearded dragons

• Anorexia

• Vomiting

• Hyperglycemia

• Anemia

• Gastric Ulcers in green iguanas, Iguana iguana; 3

• Nonspecific clinical signs: apathy, anemia, anorexia, vomiting


Stomach

Diagnosis

Sample Decision


Image

Radiographs +/- Contrast

CT, MRI, Endoscopy Ultrasound (GAS )

Noninvasive Sample

Blood, Plasma, Serum Fecal, Cloacal Lavage

Occult Blood – remains unvalidated for reptiles

Invasive Sample

Gastric Wash

Endoscopy, Surgery

Stomach Diagnostics

•CBC Chem

•GI Assay

Blood

•Cytologic•Histologic

GI

•PCR•Culture

Etiologic

Sample options

• CBC, Chem – nonspecific Pb, Zn metallic FB Vitamin Levels

• GI Specific Assays – not validated for reptiles

• Gastrin Immunoassay - serum gastrin concentration

• Diagnostic test of choice for diagnosis of gastrinoma

• Feces– Float, Direct, Sedimentation, Cytology, PCR , Acid Fast, Culture

• Gastric Wash - above + pH evaluation

• Biopsy – Histopathology, Special stains

• Gastric neuroendocrine carcinoma

• Deep tissue section biopsy, (surgical approach) may be necessary



Gastric Lavage• Catheter advanced to the midcoelom

• as far as possible into esophagus large snakes

• Lavage tubes measure snout to midcoelom

• inadequate insertion - regurgitation

• excessive insertion gastric penetration

• gavage sample (centrifuged, if necessary)

• wet-preparation direct microscopy, microbiology, cytology

• Flotation, culture/ PCR Acid fast staining

• Occult blood in herbivores?

• Lugol’s iodine allows visualization of encysted Entamoeba spp, kills live protozoa

Imaging Esophagus Stomach

• Lack of radiographic contrast of soft tissues of the coelomic cavity is common in reptiles and prevents individual recognition of several coelomic organs.

• Esophagus (only in lizards) and gastrointestinal tract (if the intestines are ingesta- or gas-filled) can be evaluated in snakes and lizards

• Contrast Radiography, CT MRI helpful


Soft-shelled turtleHook in esophagus


Gastritis

• Red Eared Sliders (n=22)

• Radiographic Evidence

• annular-shaped radiolucency visible left half of the plastron

• Accumulation of gas in the stomach -typical finding for gastritis.

• Inappropriate Diet/ Husbandry


Lateral view which shows gastritis. Globular gas-filled stomach marked

Contrast Radiographic Imaging Bearded Dragon DV Radiograph

15 min

gavage 15 ml/kg 35% w/v barium suspension - thoracic esophagus.

WHITE ARROWS

esophageal folds

BLACK ARROWS

Gas filled colon

R of coelomic cavity

Contrast ImagingAnesthesia not required

Time consuming (POTZ)

Economical

Radiologist not required

GI Transit time

Mucosal defects

Gastrointestinal anatomy

Obstruction (+/-)

Gastric culture, pH

Fluconazole-Resistant Candida Species in Tortoises

• Antifungal susceptibility of Candida spp. from tortoises (Chelonoidis spp.).

• Oral cavity & cloaca of 77 animals (60 tortoises) collected.

• 2% Sabouraud dextrose agar + chloramphenicol, ID via morph and biochem.

• 66 isolates from tortoises

• 27 C. tropicalis, 27 C. famata, 7 C. albicans, 4 C. guilliermondii 1 C. intermedia,

• MIC amphotericin B, itraconazole, fluconazole from 0.03125 to 0.5, 0.03125 to >16 and 0.125 to >64, respectively.

• 19 azole-resistant strains (14 C. tropicalis and 5 C. albicans) found.

• Testudines carry azole-resistant Candida spp.

• Fungal colonization of feeding tubes (UF, Jacobsen) - chlorhexidine/nystatin



Surgical treatment may be required for alleviation of

gastrointestinal bloat and mass removal

Stomach, Esophagus Treatment Options

• Optimize Husbandry

• Treat/ Remove Etiologic Agent

• Antibiotic/ Antifungal/ Antiparasitic

• Analgesia

• Antinausea agents? -unvalidated for reptiles

• Acid Control

• H2 blockers –cimetidine, famotidine - unvalidated for reptiles, Stomach pH

• Antacid (Calcium supplement, TUMS)

• Physical Barrier

• Sucralfate, Sodium alginate ---pH appropriate

• Dysbiosis? Probiotics/ Transfaunation

• CULTURE LACKING


Gastritis Diet

• Broccolli - Suphoraphene kills H. pylori

• Brassica oleracea - May limit iodine upate and induce goiter

• Garlic – Antimicrobial/ Antifungal agent –Antitoxin agent

• Rats, goats, parrots, chicken, dogs and cats toxic

• Probiotic – Lactobacillus / Bifidobacteria

• Vitamin A – healthy epithelium - sweet potato / yam, carrots, leafy greens, asparagus, apricots


Thyroid• Ecdysis, Endocrine Function, Hematopoesis, Tail

Regeneration

• Experimentally

• Thyroidectomy: increased shedding frequency, testicular regression

• Thyroid dysfunction causes: improper light cycle, hibernation, thermal gradient

• Hypothyroidism

• Tortoises: Galapagos, Aldabra, Sulcata

• Goiter, Clinical disease

• Hyperthyroidism

• Green Iguana (Iguana iguana) thyroid follicular adenoma• weight loss, polyphagia, hyperactivity, aggression, tachycardia,

palpable ventral cervical mass, loss of dorsal cervical spines

• Corn snake (Pantherophis guttatus) hyperecdysis

• African Helmetted Turtle (Pelmedusa subrufa) Reduced appetite, continual shedding

Diseases

Diagnosis

Treatment


Hypothyroidism

• Top differential for thyroid enlargement in Tortoise

• Goiter

• Obesity/ Dietary Imbalance

• iodine-deficient soils (occur worldwide)

• Dietary goitrogens

• bok choy, broccoli, cabbage,

• cauliflower, kale, mustard seed, rapeseed,

• soy bean sprouts, and turnips.

• Feed these food items intermittently, or only small % of herbivorous reptile diet.


Thyroid Diagnosis

• Thyroid function

• Total T4 Thyroid Releasing Hormone

• Total T3 Thyroid Stimulating Hormone

• Free T3

• Free T4

• Imaging – CT, MRI, U/S

Total T4 values in reptilian species

Species Total T4 (nmol/L) Reference

Green iguana (Iguana iguana) 3.81 ± 0.84

Corn snakes (Elaphe guttata) 0.45–6.06

Milk snakes (Lampropeltis triangulum) 0.27–2.94

Ball python (Python regius) 0.93–4.79

Red-tailed boa (Boa constrictor) 0.24–3.98

Desert tortoise (Gopherus agassizii) 0.35–4

Eastern snake-necked turtle (Chelodina longicollis) 0.69 ± 0.11

Sulcata Tortoise


Tortoises

• Desert Tortoises

• Gopherus aggasizii

• Seasonality

• Males differ from Females

• T3 difficult to detect

• Sulcata Tortoises

• Reference Interval


Thyroid Treatment

• Hypothyroidism

• Levothyroxine supplementation

• Hyperthyroidism

• Thyroidectomy

• Methimazole

• Dietary management

• Avoid goitrogens

• Iodine supplementation

Ultimobranchial GlandsDiseases

Diagnosis

Treatment


Primary Disease of the ultimobranchialglands remains unreported.

• Cellular calcium homeostasis• Smooth muscle contraction

• Heart rate• Vasodilation• Blood pressure

• Pain, Heat• Ossification• Innate Immune response – antibacterial,

antifungal

Ultimobranchial bodies

Ultimobranchial bodies Diagnostics• [Calitonin]

• Evaluate as for Metabolic Bone Disease

• [Blood Pressure]

• Heart Rate

• Glucocorticoids

• Intestinal calcium absorption, PTH Renal calcium absorption

Bone calcium resorption

Thymus

• True thymic disease rare

• R/O seasonal change

• R/O generalized lymphatic proliferation

• Infectious, inflammatory

• Thoracic CT

• Human autoimmune component

• Red cell aplasia, hypogammaglobulinemia

• CBC, reticulocyte count, serum protein EPH

• Thymoma Thymic carcinoma

• Lymphoma, Teratoma, Seminoma, Primary lung carcinoma

• Biopsy recommended prior to complete resection

• Equivocal results still possible

Diseases

Diagnosis

Treatment


Parathyroid• Metabolic Diseases of the Bone

• Nutritional, Renal Secondary Hyperparathyroidism

• Remain commonly diagnosed in reptile practice

• Clinical findings: Fasciculation etc.

• Radiography

• Ionized calcium

• Renal assessment

• Primary parathyroid gland disease extremely rare in humans undescribed in reptiles

• Primary hyperparathyroidism (PHP)

• Lack of PTH assay

• Few normative ionized calcium values for reptiles

• Human diagnosis

• routine screening of blood calcium

• elderly patients with confusion and dehydration

• Confirmation for radioimmunoassay

Diseases

Diagnosis

Treatment


Much thanks for your attention

Questions?


diagnosis & treatment

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