Guttural Pouch Empyema Research Articles

Concurrent Streptococcus equi subsp. equi infection, purpura haemorrhagica and immune‐mediated myositis in a Quarter Horse filly

SummaryThis report describes a 2‐year‐old Quarter Horse filly that was diagnosed with concurrent Streptococcus equi subsp. equi infection, purpura haemorrhagica, and immune‐mediated myositis. The filly was presented for evaluation of fever of unknown origin, rapid weight loss and inappetence after exposure to strangles that was initially unknown. Over the course of hospitalisation the filly developed mandibular lymphadenopathy, guttural pouch empyema, and mucosal petechiation and ecchymoses. The presence of Streptococcus equi subsp. equi was confirmed via PCR and culture of a lymph node aspirate and biopsies of the skin confirmed leukocytoclastic vasculitis, consistent with purpura haemorrhagica. Genetic testing confirmed that the filly had one copy of the MYH1 mutation (N/My). Following therapy with systemic corticosteroids, plasma transfusion and antimicrobial therapy the filly improved and was discharged. Communication with the owner 11 months later confirmed that filly appeared healthy but remained poorly muscled. This report is the first to the authors' knowledge describing concurrent Streptococcus equi subsp. equi infection, purpura haemorrhagica, and immune‐mediated myositis.

A case-control study of atypical guttural pouch empyema in Arabian foals.

Upper respiratory disease was reported over many seasons in Arabian foals on a single stud farm in the Middle East. Affected foals were noted to have mucopurulent nasal discharge, cough, fever and tachypnea. All affected foals had been empirically treated with a macrolide and rifampicin, by the referring veterinarian without improvement. On endoscopic examination, all affected foals had significant guttural pouch empyema (GPE). (1) To document a previously unreported presentation of guttural pouch empyema (GPE) in a family of juvenile Arabian foals; (2) To document the cytological and microbial composition of the empyema; (3) To identify clinical signs significantly correlated with the presence of GPE, as predictors for the need for guttural pouch (GP) endoscopy; (4) To demonstrate successful resolution of the identified syndrome with mechanical GP lavage and evidence based antimicrobial use, improving antibiotic stewardship and the one-health approach to respiratory disease in this demographic of foals. Evaluation and scoring of clinical signs, upper airway endoscopy and thoracic ultrasound were performed in 14 affected foals and 10 age-matched controls, followed by comparative tracheal and guttural pouch sputum culture and cytological evaluation. Therapeutic GP lavage was performed and response to therapy monitored. GPE, cranioventrally distributed ultrasonographic lesions and opportunistic pathogen infection suggested a primary lesion of GPE with aspiration of GP discharge into the lungs. GP lavage resolved the empyema and associated clinical signs in all cases. Cytological examination of tracheal and guttural pouch aspirates revealed a neutrophilic exudate with lipid-laden phagocytes, suggestive of engulfed milk. Bacteriology revealed a high prevalence of Streptococcus equi ssp. zooepidemicus admixed with other opportunistic pathogens. Streptococcus equi ssp. equi was not isolated in any case.

Diagnosis and treatment of the otitis externa and media

Diagnosis and treatment of the otitis externa and media

Creation of salpingopharyngeal fistulae for the management of guttural pouch tympany and persistent guttural pouch empyema

SummaryCase 1, Guttural pouch tympanyAn 8‐month‐old Arabian filly presented with a history of longstanding bilateral fluctuant parotid region swelling and acute onset dyspnoea, tachypnoea, inspiratory stridor and right mucopurulent nasal discharge. Endoscopy and drainage (mucopus from the right, air from the left) of the GPs resulted in temporary reduction in the bilateral parotid region swelling. Marked dyspnoea recurred 48 h later, with accompanying external GP distention. A diagnosis of bilateral (R > L) GP tympany with secondary guttural pouch empyema of the right GP was therefore made. An indwelling Foley catheter was positioned in the right GP, but the filly dislodged the catheter daily and after 5 days, surgery was performed.Case 2, Persistent guttural pouch empyemaAn 18‐year‐old pony gelding had chondroids found in the right GP 6 months previously and was diagnosed with a ‘strangles’ (Streptococcus equi var. equi) infection. Over subsequent months, multiple medical and surgical treatments were attempted but empyema kept recurring. After 6 months, it became difficult to introduce an endoscope into the right pouch, due to stenosis of the auditory tube. A laser salpingopharyngostomy procedure was recommended.Both horses underwent endoscopically guided salpingopharyngeal fistulation in the midline dorsal nasopharyngeal recess using a diode laser under standing sedation after topical application of local anaesthetic. A fistula approximately 1.5 × 2 cm was created (Figure 1) and then the median septum between the left and right pouches was resected caudally with the laser creating a large fenestration between the two pouches. No complications of surgery occurred.In Case 1, external GP distension resolved immediately following surgery. Re‐examination at 6 weeks post‐operatively showed continued patency of the fistula and resolution of secondary empyema. The foal remained asymptomatic thereafter until it was lost to follow‐up.Case 2 had resolution of nasal discharge. A final follow‐up endoscopy 3 months post‐operatively revealed both pouches to be clear, and the salpingopharyngeal fistula to still be patent. Telephone follow‐up 6 months post‐surgery revealed that the pony had no recurrence of clinical signs.

Guttural pouch empyema in a Mangalarga Marchador filly: Case report

Guttural pouch empyema is usually a consequence of upper respiratory tract infections, especially those caused by Streptococcus equi. In adult horses, empyema is a common disease, whereas considered rare in foals. The aim of this work was to report a case of unilateral guttural pouch empyema in a filly, with a focus on diagnostic and treatment approaches. A 1-month-old filly, 68 kg, Mangalarga Marchador, was admitted because of respiratory distress and enlargement caudally in the head. Clinical examination revealed dyspnea, dysphagia, lymphadenopathy, unilateral enlargement in the retropharyngeal area, and mucopurulent nasal discharge. Further, endoscopic examination confirmed the presence of purulent material inside the left guttural pouch and a diagnosis of empyema was arrived at. Drainage was performed surgically, a catheter was inserted for guttural pouch lavage. The animal received bromexin, dexamethasone, flunixin meglumine, ceftiofur, probiotics, vitamin complexes, and ringer lactate solution. Hematological evaluation performed every 24-72h, showed a decrease in total leukocytes, fibrinogen, platelets, total plasma protein, hematocrit, hemoglobin, and erythrocytes. Eleven days after drainage, the filly’s clinical condition was stable and the wound has healing. The animal was discharged following a good prognosis. Differential diagnoses can include other respiratory diseases, such as guttural pouch timpanism, strangles, and Rhodococcus, which are excluded due to the clinical signs and complementary examinations. In the present case early diagnosis, based on physical examination, hematological parameters, and radiography, combined with adequate treatment methods, including surgical procedures, lavages, antibiotics, and anti-non-steroidal inflammatory therapy, contributed to resolving the guttural pouch empyema in the filly.

Spontaneous bilateral superficial digital flexor tendon rupture in a horse with guttural pouch empyema and suspected purpura hemorrhagica

SummaryCase historyAn 11‐year‐old Quarter Horse gelding was evaluated for urticaria, generalised discomfort, distal limb oedema, spontaneous dropped fetlocks, and progressive hindlimb lameness. Prior infection status with Streptococcus equi subspecies equi was unknown.Clinical findingsThe horse had bilateral hindlimb oedema, generalised wheals, progressive hindlimb lameness, and dropped fetlocks of the right and left hindlimbs. The horse was intermittently pyrexic and was ultimately subjected to euthanasia due to deteriorating clinical status.DiagnosisSuspected purpura hemorrhagica associated with leukocytoclastic vasculitis of the superficial digital flexor tendons and spontaneous tendon rupture.Treatment and outcomeThe horse was treated with a combination of antibiotic therapy (enrofloxacin and penicillin), nonsteroidal anti‐inflammatory drugs (phenylbutazone) and corticosteroids (dexamethasone), with no improvement in clinical status. The horse was subjected to euthanasia due to poor prognosis and unfavourable response to therapy. Post‐mortem examination revealed unilateral guttural pouch empyema, multifocal cutaneous infarction and bilateral rupture of the superficial digital flexor tendons. Streptococcus equi subspecies equi was isolated in pure culture from the guttural pouch. Microscopically, leukocytoclastic vasculitis typical of purpura hemorrhagica was documented in the skin. Unexpectedly, similar vasculitis was also observed in the superficial digital flexor tendons.Clinical relevanceThis report documents the first equine case of suspected purpura hemorrhagica associated with leukocytoclastic vasculitis of the superficial digital flexor tendons and spontaneous tendon rupture. Spontaneous tendon rupture should be considered a potential sequela to infection with Streptococcus equi subspecies equi in horses due to immune‐mediated vasculitis.

Fístula salpingofaríngea por videocirurgia para tratamento de empiema crônico de bolsa gutural bilateral em equino – relato de caso

The aim of this paper is to report the Salpingopharyngeus fistula technique by means of videosurgery through a natural orifice (NOTES) in order to treat bilateral empyema. A mare was seen at the Large Animal Sector of UFPR, with a history of bilateral purulent nasal discharge associated with dysphagia lasting for ninety days. The animal was submitted to endoscopy, showing a moderate amount of purulent secretion in both guttural pouches. With no improvement on the clinical treatment, we opted for surgical treatment by endoscopy through Salpingopharyngeus fistula made with the aid of a device containing an electrical scalpel developed to perform this technique. It consisted of making an incision in the pharyngeal recess in order to access the guttural pouches and subsequently drain the purulent content. The patient was discharged at the same day and returned to work 30 days after the procedure. Surgical treatment for cases of guttural pouch empyema is indicated when the clinical resolution has not been effective, and the minimally invasive technique is indicated due to the reduction of risks and the easiness of postoperative management. Until this moment, there are no reports of the salpingopharyngeal fistula technique through video surgery for the treatment of guttural pouch empyema, which has proved to be efficient for the treatment of the disease.

Non-surgical Treatment of Guttural Pouch Empyema with Presence of Chondroids in a Filly

Background: Guttural pouch empyema in horses is a disease described by the accumulation of purulent/mucopurulent exudate, which with chronification of the disease can become chondroids, affecting horses of any age and not presenting breed predisposition. The main cause of empyema is upper respiratory infection, associated or not with failure in the defense mechanisms, as well as drainage to the guttural pouch of retropharyngeal lymph node abscesses; the main pathogen related to this condition is Streptococcus equi. This paper aims to describes a case of a filly that presented a mucopurulent nasal discharge, five months of evolution, and irresponsive to antibiotic therapy.Case: A 2.5-year-old quarter filly was referred to the veterinary hospital presenting a five months evolution mucopurulent nasal discharge, irresponsive to gentamicin and ceftiofur, and later doxycycline, acetylcysteine and clenbuterol that were instituted on the farm. Throw the endoscopic examination of the upper respiratory tract, was observed the presence of mucopurulent content and chondroids inside the right guttural pouch. This material was collected and sent for culture and antibiogram tests. Streptococcus equi was isolated, and was only sensitive to ceftiofur. The treatment included the guttural pouches flushes with warm saline solution (0.9%) associated with Lauryl Dietylene Glycol Ether Sulfate Sodium (28%) and acetylcysteine (10%). In addition to topical treatment, 5 mg/kg of ceftiofur was administered intramuscularly daily for 7 days. After 10 flushes of the guttural pouch, was observed a total absence of chondroid and mucopurulent contents.Discussion: The treatment of the guttural pouch empyema can be performed either by conservative methods or by the surgical drainage. Among the benefits of the conservative treatment are the absence of the risks related to the surgical procedure and the possibility of doing the treatment without a surgical facility. On the other hand, it usually presents a longer time to the remission of the clinical signs compared with the surgical drainage, since the mucopurulent content and the chondroids have to be disassembled and dissolved before being able to be drained from the guttural pouch. Even though, the conservative treatment is effective to a large number of cases, and with the utilization of agents to dissolve the chondroids can be performed with success in cases with a large number and size of chondroids. The surgical treatment is considered the gold standard in chronic cases, due to the difficult of removal of the chondroids with the conservative methods. The main complications related with the method are the iatrogenic lesions to noble structures present inside the guttural pouches, as cranial nerves and arteries. The decision of the treatment, surgical or conservative, must consider the risks to the patient, the facilities, and the costs of the procedure. The present study demonstrates that agents as lauryl-diethylene-glycol-ether sodium sulfate (28%) and acetyl cysteine can be effective as diluents for thick secretions and organic contents, and for that reason, increase the success of the conservative treatment of guttural pouch empyema. Consequently, improving the outcome and the rate of remission in cases of guttural pouch empyema that have a large number of chondroids, and are located remotely from referring veterinary hospitals or that cannot afford the surgical procedure.

Diagnostic evaluation for sinus pathology

Paranasal sinusitis is the most common cause of a unilateral nasal discharge. External clinical signs such as nasal discharge and lymphadenopathy are common to both primary sinusitis and many causes of secondary sinusitis creating a diagnostic challenge. The complex anatomy coupled with relative inaccessibility precludes direct examination so a clinician must rely on carefully performed diagnostic tests. Upper respiratory endoscopy should be used to eliminate other causes of unilateral nasal discharge such as guttural pouch empyema. Detailed oral examination should be used to eliminate occlusal dental problems and radiography used to determine precise sinus involvement and apical dental pathology. Should these tests yield equivocal results, advanced head imaging such as computed tomography (CT) may provide a definitive diagnosis and further anatomical information. Direct sinus endoscopy through trephination can be both diagnostic for inspissated material, and therapeutic by allowing lavage to be performed.

Equine guttural pouch empyema, why does it become chronic?

Equine guttural pouch empyema, why does it become chronic?

Guttural pouch empyema caused by Corynebacterium pseudotuberculosis in a pregnant mare

SummaryDuring medical management of mild colic in a 12‐year‐old Quarter Horse, mid‐gestation mare, unilateral purulent nasal discharge from the right nostril was noted. Endoscopic examination revealed guttural pouch empyema. Culture was positive for Corynebacterium pseudotuberculosis and negative for Streptococcus equi ssp. equi. A synergistic haemolysis inhibition titre of 1024 was consistent with C. pseudotuberculosis infection. Treatment included serial lavages and local infusion of antibiotics into the guttural pouches along with a 6‐week course of oral trimethoprim–sulfamethoxazole and rifampicin. Overall, no additional sites of infection were identified and the mare responded well to treatment, delivering a healthy, full‐term foal. This case emphasises that C. pseudotuberculosis, although uncommon, should be considered as a differential for guttural pouch empyema.

Strangles and its complications

SummaryStrangles, caused by the Gram‐positive bacteriaStreptococcus equisubspeciesequi(S. equi), is a highly contagious upper respiratory infection in horses. The infection is transmitted by inhalation or direct contact with mucopurulent discharge from an infected animal, resulting in fever, depression, and submandibular and retropharyngeal lymph node enlargement that can lead to respiratory distress. Complications include secondary cellulitis at external abscessation sites, guttural pouch empyema and its persistence into the carrier state, purpura haemorrhagica, metastatic abscessation, emergency tracheostomies and rarely secondaryS. equipneumonia or myositis. Control of outbreaks requires strict isolation protocols and hygiene measures. Detection methods of the index case and carrier state are constantly being refined to assist in the identification and prevention of disease perpetuation.

Correlation between endoscopic findings and real-time PCR analysis for Streptococcus equi subsp. equi DNA of guttural pouches in recovered strangles cases

Horses that lack obvious clinical signs of respiratory disease can be silent carries of Streptococcus equi subsp. equi (S. equi) in their guttural pouches. Guttural pouch lavage and repeated nasopharyngeal lavages(1) analyzed by real-time PCR(2) are sensitive methods for analysis for S.equi and are considered to be a standard to identify carrier stage. The carrier screening, identifying and treatment of carriers, in the end of a disease outbreak by sampling guttural pouches is expensive and time consuming. According guidelines carriers that have endoscopic findings of guttural pouch empyema, chondroids or discharging lymph nodules are sampled and treated. The sensitivity of using macroscopic appearance of guttural pouches as an indication of persistent S. equi colonization is poorly studied. The aim of this study was to investigate if there is a correlation between endoscopic findings in guttural pouches and positive qPCR analysis for S.equi. In total 179 endoscopic findings from upper airways from 91 individual horses after a strangles outbreak were compared with positive qPCR results from nasopharyngeal lavage and guttural pouch lavage samples. Nasopharyngeal lavage was performed with 120 ml saline and guttural pouch lavage with 40 ml saline for each pouch and analyzed separately. The nasopharyngeal lavage was performed with 120 ml saline prior endoscopy and endoscopic guttural pouch lavages using 40 ml saline for each pouch and analyzed separately. The endoscopic findings of guttural pouches, including empyema, chondroids or discharging retropharyngeal lymph nodules were recorded and compared to the qPCR analysis for S. equi. Therewas no statistical correlation between endoscopy findings and qPCR results. However, if the first guttural pouch lavage was positive by qPCR for S. equi, it was statistically more likely that the contralateral guttural pouch also was positive, indicating a risk for contamination of the second sample. Horses that lack obvious clinical abnormalities on upper airway endoscopy including the guttural pouches can be silent carriers of S. equi. In conclusion, negative endoscopic findings of the guttural pouches of recovered strangles cases cannot rule out silent carrier status. This study was approved by the Swedish Ethical Committee on Animal Experiments and each horse owner had given their informed consent to participate in the study. Financial support was achieved from The Swedish-Norwegian Foundation for Equine Research and Swedish Research Council Formas.

Predictor variables for and complications associated with Streptococcus equi subsp equi infection in horses.

To evaluate predictor variables for and complications associated with Streptococcus equi subsp equi infection (strangles) in horses. Retrospective case-control study. 108 horses with strangles (cases) and 215 horses without strangles (controls). Medical records from January 2005 through July 2012 were reviewed. Cases were defined as horses with clinical signs of strangles (pyrexia, retropharyngeal lymphadenopathy, and mucopurulent nasal discharge) that were associated with a confirmed strangles outbreak or had positive results for S equi on PCR assay or bacteriologic culture. Controls were defined as horses with pyrexia that did not meet the other criteria for cases. Data compared between cases and controls included signalment, clinical signs, diagnostic test results, and disease complications and outcome. Logistic regression was used to identify variables associated with strangles and its complications. Clinical signs of strangles were not evident in 12 of 25 cases classified as S equi carriers (infected > 40 days). Predictor variables associated with strangles included mucopurulent nasal discharge and external abscesses in the pharyngeal region. Strangles was more likely to be diagnosed in the spring than in the summer. Cases with anemia were more likely to develop purpura hemorrhagica than were cases without anemia. No risk factors were identified for the development of guttural pouch empyema or metastatic abscesses. Results indicated that not all horses infected with S equi develop clinical signs of strangles. We recommend that guttural pouch endoscopy and lavage with PCR assay of lavage fluid samples be performed to identify S equi carrier horses.

The equine guttural pouch: Clinically relevant anatomy and basic treatment options for trauma

The equine guttural pouch: Clinically relevant anatomy and basic treatment options for trauma

Primary bilateral guttural pouch empyema in a two-month-old foal

The present report describes a 2-month-old foal which signs of respiratory infectious disease, bilateral retropharyngeal swelling and nasal mucopurulent discharge, suggesting guttural pouch empyema. The owners reported that the foal lived in a herd that experienced an outbreak of strangles. Foals younger than 3 months are usually protected against infectious diseases, however in this case, the foal was exposed to an environment heavily populated by Streptococcus equi equi during the outbreak of strangles. Although uncommon in such young animals, the foal was infected and developed a primary bilateral guttural pouch empyema, without signs of lymph nodes alteration

Guttural pouch empyema secondary to a periocular foreign body

SummaryThis report describes a 3‐year‐old gelding presenting with signs of injury to its left eye following an accident in which the horse crashed into a hedge. The first treatment attempted to treat infections in the eye and respiratory tract due to secretions identified in the trachea. The horse did not improve and further clinical and radiographic evaluations detected a guttural pouch empyema. Surgical drainage was performed and antimicrobial treatment continued. However, the horse presented with severe epistaxis and euthanasia was elected due to suspected arterial rupture. At necropsy, a round and stiff branch plant was found creating a fistula from the left orbit to the left guttural pouch. Another branch was found inside the pouch, confirming the origin of the persistent infection and severity of the tissue lesion.

Different strains of Streptococcus equi subsp. equi isolated from a guttural pouch empyema

Different strains of Streptococcus equi subsp. equi isolated from a guttural pouch empyema

Critical surgical affections at pharyngeal region in horses

The present study was performed for diagnosis and surgical management of critical surgical affections at the pharyngeal region in horses. It was carried out on a total number of 10 horses. Radiographical and histopathological examinations were performed to confirm the diagnosis in addition to endoscopic examination for subepiglottic cyst. Surgical and endoscopic interventions were performed. A subepiglottic cyst was diagnosed in a mare as a voluminous mass rostral to the epiglottis through endoscopic examination. A thyroglossal duct cyst was found in a filly foal as a large banana like, cystic fluctuant mass at the left retropharyngeal region. A melanotic melanoma was detected in a mare as a distinct midline cranial ventral cervical mass. Guttural pouch empyema was recorded in 7 horses. It could be concluded that surgical and endoscopic treatments were curative for management of such affections without recurrence. Also, thyroglossal duct cyst should be included as a differential diagnosis when encountering a foal with a fluid filled mass at the lateral retropharyngeal region.

Diagnostic Exercise: Equine Rhabdomyolysis

A 1.5-year-old Quarter Horse gelding with a history of chronic nasal discharge and leukocytosis presented with signs of increased lethargy and muscular pain. The horse quickly became recumbent and unable to rise and was euthanized due to a poor prognosis. At necropsy, severe bilateral guttural pouch empyema was observed, as well as numerous well-demarcated areas of pallor within the skeletal muscles of all major muscle groups. Polymerase chain reaction testing of the guttural pouch exudate confirmed an infection with Streptococcus equi subsp. equi, and an S. equi–associated immune-mediated rhabdomyolysis was initially considered to be the most likely diagnosis. This report briefly discusses the various etiologies that should be considered in cases of equine myopathy, and it demonstrates the complexity of these poorly understood muscular disorders.