Severe Cartilage Degeneration in a Horse

A 12 year-old show jumper mare presented to PHD veterinary services for the history of recurring forelimb lameness. In the past 2 years, the mare had the left front coffin joint treated with corticosteroids and hyaluronic acid every 6 months. However, the most recent treatment with intra-articular corticosteroids did not result in resolution of the lameness. On presentation, the mare was a grade 3/5 lame in the left front. The lameness was most evident when trotting on firm ground and in a circle to the right. The mare was NOT positive to hoof tester exam and was mildly positive to lower limb flexion. The coffin joint was "blocked" with carbocain and the mare's lameness improved by >85%. Radiographic exam of the left front foot only revealed evidence of mild osteoarthritis of the coffin joint.  (Figure 1).

Figure 1

Due to the following factors: 1) a history of poor response to intra-articular therapy, 2) a positive response to blocking the coffin joint, and 3) minimal data via the radiographic exam, it was recommended that the distal forelimb of this mare be evaluated via magnetic resonance imaging (MRI).  The MRI exam requires general anesthesia and generally costs between $1800-$2000; however the information gathered from an MRI exam is far superior than any other type of diagnostic exam! As such, I strongly recommend considering an MRI exam in cases that the CAUSE for the lameness has not been determined and a reasonable attempt has been made to treat and/or diagnose the problem. Figures 2-4 includes several images from the MRI exam involving this show jumper mare. A small, blue circle is included in each image to high light the large articular cartilage and subchondral bone defect that was discovered through the MRI study. In each image, the lesion appears as a small black circle at the surface of the bone. In addition to this finding, the MRI study noted additional evidence of chronic degeneration of the coffin joint. The full extent of the degeneration and the cartilage damage was NOT evident in the radiographic exam!!

Figure 2

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Figure 4

Although the prognosis was poor for return to soundness, the mare was treated aggressively with various regenerative therapies and extended rest. Unfortunately, the mare remained significantly lame and it was determined that humane euthanasia was the best option due to the relentless foot pain. A post-mortom exam was performed and a very large area of abnormal cartilage loss (blue circle in Figure 5) was noted that corresponded to the MRI findings. This case represents yet another exam of the importance for getting an answer as to WHAT is causing the problem such that a prognosis can be provided followed by a proper course of action.

Figure 5

In the state of Florida, the most sensitive MRI for imaging in horses is ONLY available at the University of Florida's College of Veterinary Medicine. In addition, the board certified radiologists at the Veterinary College of Veterinary Medicine are especially well trained for the evaluation of MRI studies in horses! For more information about their services please go to:

http://largeanimal.vethospitals.ufl.edu/services/diagnostic-imaging/

Urinary Bladder tumor in a Horse

A 12 year old gelding presented to PHD veterinary services for the complaint of "dribbling" urine and intermittent bouts of urinating blood (hematuria). The horse had been treated with a combination of antibiotics and steroids which had resulted in resolution of blood in the urine however he continued to dribble urine. On presentation the physical exam was normal other than evidence of chronic urinary incontinence based on the accumulation of dried urine over the dorsum of both hind limb pasterns. A rectal exam was performed and a softball-size mass was palpated within the urinary bladder.

Figure1

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Cystoscopic exam noted several small soft tissue masses leading into the urinary bladder with evidence of active, mild hemorrhage (Figure 1). Once the urinary bladder was entered with the scope, a mass was noted lying underneath the urine that was present in the urinary bladder (Figure 2). The urine was evacuated through the scope revealing a large, soft tissue mass that was firmly attached to the ventral or bottom aspect of the urinary bladder (Figure 3 and 4).

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Urinary bladder neoplasia or cancer is rare in horses. The most common common type reported in horses is squamous cell carcinoma and it commonly associated with hematuria. Other types of cancer include transitional cell carcinoma, lymphosarcoma, leimyosarcoma and fibrous polyps. Management of urinary bladder neoplasia in horses involves surgical resection and possible intra-lesional chemotherapy; however the prognosis is poor for long term survival. This horse will be managed with systemic anti-inflammatory medications to reduce local inflammation within the urinary bladder and the proximal urethra.

Superficial Flexor Tendonitis in a Horse

A 12 year old mare presented for sudden onset forelimb lameness and swelling of the tendons in the right front limb. On palpation, the swollen tendons were significantly sensitive to palpation yet it was not possible to determine if it was the superficial flexor tendon (SDF) or the deep digital flexor (DDF) tendon. The mare was a grade 3/5 lame in the right front when trotted in a straight line on firm ground. Ultrasound exam of the soft tissue structures revealed a core-like lesion within the outside corner of the SDF tendon. In Figures 1-3, the core-like lesion appears as a black area (red circle) within the body of the SDF tendon (blue circle).  In Figure 2, the image to the right is a cross-sectional view of the tendon and the lesion is a small black circle within the body of the SDF tendon. In the image to the left in Figure 2, the tendon is in a longitudinal view and the lesion appears as a black streak through the body of the SDF tendon.This view is important because it highlights the over-all length of the lesion which in this case was 4-5cm long. The cross-sectional area measured in Figure 3 determined that the core-like lesion was approximately 20% of the entire cross-sectional area of the SDF tendon.

Figure 1

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The mare was treated with ultrasound guided injection of Platelet rich plasma (PRP), stall rest, daily ice therapy and we will follow-up with 3 doses of extra-corporeal shock wave treatment. We anticipate a full return to work after the appropriate period of rehabilitation.

On-Line Pharmacy for PHD Veterinary Services!!

 

The above medications are just a few of the hundreds that my clients will be able to purchase via my on-line pharmacy!! The pharmacy will be open for business within the next 2 weeks and can be accessed at the following address:

PHD Veterinary Services On-Line Pharmacy

Once open for business, my clients will be able to register their pet's information and order the medications desired. I will receive an instant email to confirm authorization for the sale of the medications and the client will enter their credit card information. This pharmacy will contain hundreds of medications and nutraceuticals for cats, dogs, and horses! Once ordered the products will ship direct to my clients for quick delivery.

I anticipate that PHD Veterinary Service's on-line pharmacy will offer my clients an efficient and affordable method to purchase prescribed medications for their cats, dogs, and horses. There will be monthly sales on some of the more popular products so please visit my blog site to find out when the pharmacy is open for business!! Please visit the on-line pharmacy today and register your cats, dogs, and horses! 

Sarcoid Tumor in a Horse

A middle-aged gelding presented to PHD Veterinary services for the removal of a large tumor from the base of the right ear (Figures 1 and 2). Two years prior, a smaller tumor was surgically removed from the same ear. The histological report was consistent with a sarcoid tumor. At the time of the original surgery, several sarcoids were removed from different areas including the pectoral region and groin area. The recurring sarcoids were treated with intra-lesional chemotherapy, cryotherapy, topical medications and systemic herbal remedies. At presentation, a large, lobulated tumor was "hanging" from the base of the right ear. There was mild hemorrhage and evidence of moderate necrosis of the tumor. The gelding was resistant to manipulation of the tumor however gentle palpation of the ear noted that the tumor was NOT attached to the cartilage portion of the ear but only the skin and immediate subcutaneous tissues.

Figure 1

Figure 2

The gelding was rendered unconscious via injectable anesthetics and the tumor was removed through a large incision (Figure 3 and 4). Moderate hemorrhage was encountered confirming that the tumor was highly vascular. The incision was partially closed with sutures and the horse was recovered from anesthesia. Examination of the tumor after removal noted it consisted of 3 individual masses and weighed more than one pound (Figure 5).

Figure 3

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Figure 5

This case represents an extreme example of recurrent sarcoids in a horse. Per the owner, the previous management of the sarcoids were initially effective however in time the tumors returned. The removal or de-bulking of the ear-based tumor will most likely not be sufficient in keeping the sarcoid tumor from removal. Aggressive therapy involving intra-lesional chemotherapy agents and cryotherapy will be employed to keep these tumors from continuing the develop!!

Figure 6

 Fast forward 6 weeks and the surgical wound is in the process of healing nicely (Figure 6), however there are several small sarcoids along the tip of the ear and also within the surgical site that are inflamed and beginning to grow. Follow-up treatment included the injection of cisplatin directly into the small sarcoids. Unlike the initial procedure which was done under anesthesia, the cisplatin injection was performed with sedation and a local "block" of the ear. Two weeks after the cisplatin injection, the small sarcoids along the tip of the ear are shrinking however the sarcoids within the surgical site remain inflamed  (Figure 7).

Figure 7

 Hence, the small sarcoids were treated with cryotherapy and the picture in Figure 8 was approximately 2 weeks post cryotherapy. The initial surgical site is a scar and all of the small sarcoids are regressing nicely. This horse will be monitored very carefully to make sure that any new sarcoid growth is treated aggressively!! This case represents an excellent example of the need for early, aggressive and multi-drug treatment of sarcoids in horses.

Figure 8

Atrial Fibrillation in a Horse

 An 18 year-old gelding presented for a pre-lease exam. The horse was sound and displayed no clinical abnormalities. However, when the heart was auscultated the heart rhythm was abnormal. Normally, a horse's heart sounds like two distinct sounds, otherwise known as the "lub-dub". These two sounds correspond to the opening and closing of specific heart valves during contraction and filling of the heart's chambers . There are actually 4 heart sounds but typically we only describe the "lub-dub". In a normal horse, the number of lub-dubs that are counted in a minutes range between 28-40 lub-dubs or beats per minute and they should be equally spaced in time. The electrocardiogram (EKG) in Figure 1 is that of a normal horse. The red arrows correspond to the contraction of the ventricles and the green arrows correspond to the contraction of the atrial. Normally, the atria contract first followed by the contraction of the ventricle. The blue arrow corresponds to the time between ventricle contractions which should equal the heart rate or number of lub-dubs auscultated in a period of time. Notice that the blue arrows are equal in length between heart beats AND that there is one green arrow for every red arrow!!

Figure 1

The lub-dubs for this particular horse were irregular and there was no predictability of their irregularity hence the heart rhythm was described as "irregularly, irregular". This type of heart arrhythmia is consistent with a condition known as atrial fibrillation. In Figures 2 and 3 notice that the blue arrows which correspond to the time between heart beats vary significantly. Equally important, there appears to be many more green arrows (Figure 3) than red arrows. This would suggest that the atria is contracting more often than the ventricles, hence the term atrial fibrillation!!

Figure 2

Figure 3

 Atrial fibrillation in horses is not uncommon and young horses with this condition are often asymptomatic. Thoroughbreds are diagnosed most often and when it is diagnosed in younger horses, the cause for the arrhythmia is often not determined. However, in older horses underlying heart disease is often associated with atrial fibrillation.  The most common clinical complaint would be exercise intolerance and decline in performance. In addition, an elevated resting heart rate may be indicative of early congestive heart failure as well as persistently distended jugular veins (Figure 4). Diagnosis of atrial fibrillation requires an EKG and a cardiac ultrasound is recommended to determine if there is underlying heart disease. Often a 24 hr halter monitor (Figure 5) may be used to better describe the horse's 24 hr cardiac cycle. There are several methods available to try and "convert" a horse with atrial fibrillation. However, it is important to first determine that cardiac disease nor electrolyte disturbances are the root of the problem. The methods include various medications and electrical cardi-conversion.  Prognosis for horses with atrial fibrillation depends on whether the horse has underlying cardiac disease. In the case of cardiac disease, the prognosis is poor; however, in young horses with idiopathic atrial fibrillation, the prognosis can be good for full return to work as a sport horse!! This case re-inforces the need for a solid physical exam on a regular basis to make sure this type of disease does not go undetected!!
  

Figure 4

 

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Superficial Flexor Tendonitis in a Horse

A middle-aged gelding presented to PHD veterinary services for tendonitis of the superficial flexor tendon (SDF). The tendonitis was a result of an tendon-sheath penetrating injury and was associated with a severe tendon sheath infection. The tendon sheath infection was treated aggressively and effectively by an equine surgeon. An ultrasound exam was performed along the plantar aspect of the hind fetlock and a large, core-like lesion was identified (Figure 1, black area within red circle). The lesion consisted of disrupted tendon fiber and edema. Several options were considered to help the "healing process" involving the SDF tendonitis. These included extra corporeal shock wave treatment, platelet rich plasma (PRP) injection, stem cell injection, and/or concentrated bone marrow injection. The decision was made to treat the lesion by injecting a mixture of concentrated bone marrow mixed with PRP product. The bone marrow was collected from the horse's sternum and concentrated on site (Figure2). In addtion, a blood sample was collected from the horse and PRP was harvested on site. The PRP was mixed with the concentrated bone marrow and then injected into the lesion via ultra-sound guided technique.

Figure 1

Figure 2

In addition to the PRP+bone marrow injection, the horse was fitted with a corrective shoe that provided significant heel extension (Figure 3 and 4). This type of shoe is also known as a "fish tail" show and will reduce the "load" across the fetlock joint by supporting the lower limb. Horses recovering from tendon sheath infections and SDF tendonitis tend to avoid fully loading the back of the foot which may result in lower limb contracture. The fish tail shoe allows the horse to fully load the foot in a more comfortable fashion. The horse was walked daily and otherwise kept in stall confinement. In addition, the leg was treated daily with cold compresses.

Figure 3

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Approximately 30 days after the PRP+bone marrow injection, the horse's limb was re-ultrasounded. There has been significant "filling in" of the lesion (Figure 5). Although the area that was the lesion (red circle) remains identifiable, there has been a significant improvement in tendon fiber alignment and the edema (black) has nearly completely resolved! Although this represents a tremendous amount of improvement in just 30 days, there remains a significant period of rehabilitation before the ultimate out come of this case can be reported.  This case provides an example of a regenerative therapy that combines PRP and progenitor stem cells (bone marrow) for the treatment of tendonitis! The advantages of this approach versus stem cell treatment include reduced cost, on site harvesting and same-day treatment.

Figure 5

Ethmoid Hematoma versus Paranasal Sinus Cyst in a Horse

Two horses presented to PHD Veterinary services for the same complaint of "no air moving through one of the horse's nasal passages!" Both horses had a history of mild to moderate nasal discharge that had increased slowly over the past 6 months. On presentation, a simple evaluation of air passing through the nasal cavities revealed that there was NO air moving through the affected side on each horse however, endoscopic exam revealed a unique problem in each horse.

Figure 1

 In Figure 1, a smooth, white soft tissue mass was identified within 2 inches of the opening of the nasal cavity. This soft tissue mass was completely obstructing the nasal passage. In addition, when the scope was passed through the unaffected side, the soft tissue mass was noted to be extending into the naso-pharynx suggesting that the soft tissue mass extended through out the entire nasal passage (Figure 2). In Figure 2, the white wall of tissue noted along the right side of the image is the soft tissue mass as it extends into the naso-pharynx.The soft tissue mass is most likely consistent with a paranasal sinus cyst however surgical removal will be required to confirm the diagnosis. These types of cysts develop in young horses and grow slowly over months and years until a clinical problem develops. Surgical removal provides complete resolution of these types of cysts!!

Figure 2

Figure 3

In the second horse, a large golden-colored soft tissue mass was identified in the region of the nasal passage closest to the naso-pharynx. There was more discharge associated with this soft tissue mass and small areas of hemorrhage were noted. The soft tissue mass was completely obstructing the nasal passage and was originating from the ethmoid turbinate region which most likely classified it as a ethmoid hematoma!! These types of tumors typically present with a complaint of a unilateral bloody nasal discharge for months before they completely obstruct the nasal passage. However, they can be fast growing tumors and require an aggressive approach to eradicate. Treatment may involve either surgical removal or repeated injections of formalin. It has been my experience, having injected several horses for YEARS, that the tumors tend to return with this approach! Hence, I recommend surgical removal when first diagnosed, especially if the tumor is invading the sinus cavity or the naso-pharynx.

IIeal Hypertrophy in a Horse

A 10 year old Paso fino mare presented for recurrent colic for several months duration. The mare had a long history of being a "hard keeper" but in the past 3-4 months had begun to colic after each feeding. The mare was fed a diet of senior feed plus free-choice coastal bermuda grass hay. The mare was referred to PHD Veterinary services for a gastroscopy (stomach scope). The mare presented with a body condition score of 3 out of 9. The client reported that the mare had a good appetite yet shortly after eating, the mare would develop signs consistent with abdominal discomfort! The gastroscopy was normal therefore we opted to ultrasound the mare's abdomen.  In Figure 1 there is a cross-sectional image of a loop of intestine (black circle) that is grossly abnormal. The lumen (center) is completely filled in with soft tissue(grey area). The filled in center in Figure 1 corresponds to thickening of the small intestine which likely results in delayed passage of ingesta. Interestingly, there was only 1 very distinct area of the small intestine that scanned abnormally thick. However, there were several loops of small intestine that were dilated and had diminished peristalsis (Large black circles in Figure 2).

Figure 1

Figure 2

The ultrasound findings were consistent with a focal area of thickened small intestine and a large area of dilated small intestine. The dilated small intestine were likely "up stream" from the thickened small intestine and were as a result of partial obstruction of the thickened small intestine. Based on these findings, the mare was referred for abdominal exploratory surgery. During the abdominal exploration, a very thick region of the small intestine was identified. This region corresponded to the ileum which is the very final section of the small intestine. Approximately 12 inches of ileum were grossly thickened resulting in minimal lumen formation for passage of ingesta (Figure 3). Normally, the ileum is a wide-open tube as depicted in Figure 4!! Unfortunately, due to the severity of the condition, poor prognosis, and financial limitations, the mare was euthanized on the surgical table. Ileal hypertrophy has been reported in horses consuming coastal bermuda grass hay and it is theorized that some horses develop an "allergic" response to coastal hay resulting inflammation of the ileum and ultimately gross thickening. More commonly, colic symptoms associated with coastal hay is due to poor quality hay rather than ileal hypertrophy. However, any horse with chronic colic symptoms that is consuming coastal bermuda grass hay should be evaluated for this condition. 

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Extensor Process Fracture in a Horse

A teen-age gelding presnted for the complaint of forelimb lameness. The gelding had been purchased approximately 6 months prior and the prepurchase exam performed did NOT include a radiographic exam. The gelding was mildly lame in a straight line however the lameness was significantly worse when lunged in a small circle. Through a series of nerve blocks it was determined that the lameness was originating from the foot and a radiographic study was performed. The radiographic images in Figure 1-3 are lateral views of the foot in question. Two abnormalities are noted by the yellow and blue arrows in Figure 2. The blue arrow corresponds to a chip fracture of the extensor process of the coffin bone and the yellow lines correspond to extensive mineralization of the cartilage of the foot (side bone).

Figure 1

Figure 2

 In Figure 3, the extensor process chip fracture is magnified. It is likely that this chip fracture was present at the time of purchase and would have been discovered had the client opted for a radiographic exam of the forelimb feet.  In my opinion, this radiographic finding would have been reason enough the FAIL the horse at the time of prepurchase exam.  In addition to the extensor chip fracture, moderate "side bone" development is evident in the lateral view and the dorsal-palmar view (Figure 4). Typically, side-bone does not present a clinical problem however does consist of an abnormal finding and in this horse the side bone is more pronounced along the inside versus the outside of the foot. The asymmetry of the side-bone may be more clinically relevant that bilateral side-bone that is symmetrical.

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Figure 4

The horse was treated with intra-articular corticosteroid and is approximately 75% improved with respect to lameness. The long term prognosis for this horse is guarded due to fracture of the extensor process of the coffin bone. This case represents yet another example of the need for at least foot radiographs at the time of prepurchase exam.