Document Type : Case Report
1 Veterinary Clinical Surgery Department. School of Veterinary Medicine and Animal Science, University of S&atilde;o Paulo, Brazil.
2 Veterinary Clinical Surgery Department. School of Veterinary Medicine and Animal Science, University of São Paulo, Brazil.
3 Autonomous veterinarian
4 Department of Internal Medicine. School of Veterinary Medicine and Animal Science, University of São Paulo, Brazil.
5 Department of Surgery and Diagnostic imaging. School of Veterinary Medicine and Animal Science, University of São Paulo, Brazil.
6 Department of Diagnostic imaging. School of Veterinary Medicine and Animal Science, University of São Paulo, Brazil.
7 Department of Animal Pathology. School of Veterinary Medicine and Animal Science, University of São Paulo, Brazil.
8 Department of Surgery. School of Veterinary Medicine and Animal Science, University of São Paulo, Brazil.
9 School of Veterinary Medicine and Animal Science, University of São Paulo, Brazil.
Article Title [Persian]
An equine, female, American Trotter, 115 days old, was referred to the veterinary hos- pital presenting incoordination since the day before, that started with the forelimbs and extended to the hindlimbs. The owner denies previous infection by Herpesvirus or Lepto- spirosis in the property. The filly was treated previously with three liters of Ringer-lac- tate solution, corticosteroids, flunixin me- glumine, trimethoprim-sulfamethoxazole, and 100mL of dimethyl sulfoxide (DMSO). Additional information regarding doses and treatment duration were not obtained. After therapy, the filly showed improvement on the incoordination of the forelimbs. Howev- er, still had trouble getting up and nursing.
Physical exam showed a heart rate of 60 beats per minute (bpm), respiratory rate of 30 breaths per minute (bpm), congested mu- cous membranes, capillary refill time of two seconds. There were no adventitious lung
sounds. At palpation, the cervical region had an increase in volume with fluctuant consis- tency on the atlantoaxial joint. The animal could not maintain itself stable when up, nor lifting its head. The hooves had elevat- ed temperature and distal a strong pulse was felt on the palmar and plantar arteries, being more intensive on the right forelimb.
In the simple radiographic examination of the vertebral column (Fig. 1), the initial sus- picion was a fracture of the odontoid process causing compression of the spine. After exam- ining the alterations in the radiographs associ- ated with clinical manifestations of the foal and the owner’s interests, euthanize was chosen.
In order to get a more precise diagnosis, by educational and scientific interests, a myelog- raphy and myelotomography post-mortem was made. The first showed dorsal displace- ment of the spine on the atlantoaxial joint and in the dorsoventral projection a thinning of
Figure 1. Cervical spine simple radiographic exam: Simple radiographic exam in laterolateral projection of the cranial cervical spine. The atlantoaxial relation is preserved, with an increase of volume in an area that has soft tissue radiopacity curved dorsal and ventrally (arrows), and a discrete diffuse heterogeneous radiopacity at the extension of the odontoid pro- cess ossification nucleus and of the axis cranial epiphysis extremity (*).
contrast columns and right lateral displace- ment, compatible with extradural compres- sion. Figure 2 shows which changes were de- tected in myelography, suggesting infection.
The skull and the spine were sent to pa- thology for a more definitive diagnosis. After cutting the atlantoaxial joint, a high amount of purulent fluid was drained and a nodular formation of approximately two centimeters in diameter was observed in the joint, reach- ing the vertebral canal, with irregular and yellow surfaces, friable to the cut. No mac- roscopic changes were observed on the spine and the encephalon.
Marked Wallerian degeneration was ob-
served at the histopathology exam, especial- ly on the ventral area, with moderate axonal swollen focuses. The neural bodies present- ed strongly eosinophilic, reduced in size, and with pyknotic nucleus (neuronal necro- sis). Both dorsal and ventral roots showed marked Wallerian degeneration. The brain showed moderate multifocal neuronal necro- sis, neurophagia focuses, and marked gliosis. Cytologic exam revealed a high amount of integrated and degenerated neutrophils asso- ciated to a high number of coccoid bacteria, and eventually, of intra and extracellular ba- cillus, suggesting a septic acute inflammato-
Figure 2. Cervical spine myelotomography: (A) Reformatting of the cervical spine in sagittal plane shows thinning and dorsal displacement of the ventral contrast column (white arrow) and presence of hypodense material in ventral vertebral canal in atlantoaxial transition (*). The dashed black line indicates the location of the transversal cut showed on the right. (B) Myelotomography in transversal plane, soft tissue window, shows a marked osteolysis on the right side of the axis’ cranial epiphysis (white arrow) and bone irregularity (black arrow). Hypodense homogeneous material in ventral vertebral canal on the right (*) compresses and displaces dorsolateral the spine to the left (extradural compression). A hypodense halo in soft tissues surrounds all the extension of this region (edema/inflammation) (white triangles).
A culture of the material collected from the atlantoaxial region was made and no bac- terial growth was observed. Therefore, it was not possible to conclude with agent was the one responsible for the osteomyelitis occur- rence. The liquor was also evaluated, and no significant alterations were found.
Supporting the two foals’ reports that showed vertebral osteomyelitis and septic ar- thritis caused by R. equi infection (Guiguère & Lavoi,1994), the equine from this report probably had a hematogenous microorgan- ism spread, since the patient history did not show any information regarding trauma or medications administered by contaminated needles or tools that might have caused a lo- cal infection. However, the filly did not show signs of pulmonary or gastrointestinal disor- ders related to a possible R. equi or another pathogen infection.
Although the hematogenous spread through suppurative lesions originated by lungs seems common, most agents are successfully elim- inated from the blood by the endoplasmatic reticulum system, constituted by reticular and endothelial cells which have a phagocyto- sis function, performing the defense against pathogens (Prescott,1994; Cabtree & Jor- gense, 2012).
The low potential to eliminate the microor- ganisms by alveolar macrophages, when com- pared to macrophages of other parts of the or- ganism, suggests that R. equi causes vertebral infection through alveolar macrophage migra- tion. In this context, some studies report that the disease may occur spontaneously when there is no pulmonary injury or another kind of infection (Prescott, 1994), as happened to the filly in this report.
For diagnosis purposes, radiographic eval-
uation is very important in the vertebral os- teomyelitis cases, but the classic radiographic lesions of osteolysis and bone proliferation may not be evident two to eight weeks after clinical signs appears, and bone lysis is not ra- diographic recognized until 30-50% of bone mineralization is lost. In a study made, four to six foals presenting vertebral osteomyelitis did not showed radiographic changes, despite the extensive osteolysis observed at macro- scopic and histologic post-mortem evaluation (Stewart et al., 2007).
In conjunction with this information, in a published article regarding a 3-month-old colt that showed acute neurologic signs and was diagnosed with osteomyelitis of the occipital bone, the cervical radiographs and the ones made on the cranium basis were inconclu- sive with no evidence of osteolysis or chang- es in the soft tissue radiopacity (Morresey et al., 2007). Along with the study mentioned, this report was also not able to detect typical changes that mark the vertebral osteomyeli- tis after the acute onset of clinical signs, only being able to find heterogeneous and diffuse radiopacity at the axis odontoid process and a likely loss of bone continuity, which led to a mistaken fracture suspicion.
Another study about the computerized to- mography use in cases of cervical osteomy- elitis reports a 3-month-old foal with head tilt history after R. equi treatment that was sent to a CT exam that revealed a left parietal bone and occipital bone osteolysis, resulting in a caudal displacement of the latter. As a con- sequence of the infection that reached bone structures, a soft tissue mass was formed as- sociated to the osteolytic lesions, compressing the cerebellum and rostrally displacing the occipital lobe of the brain. The mass expand- ed medially, taking up part of the magnum foramen without invading the atlantooccipital
joint apparently (Janiceck et al., 2006).
The filly in this report also showed a mass but it was a nodular formation and it was also caused by an infection and it was responsible for compressing the spine. Besides this, the vertebral osteomyelitis diagnosis was effi- ciently made by computerized myelotomog- raphy that was able to identify osteolysis at the axis cranial epiphysis and an increase in the volume of the soft tissue between C1 and C2 corresponding to the nodular formation that was later detected on necropsy.
The bacterial culture of the atlantoaxial joint matter was negative, although the cyto- logical evaluation detected coccoid and ba- cillus bacteria. Though the fact that R. equi is very resilient to temperature changes, de- pending on how the samples are stored, the culture sensibility for this microorganism may reduce. This can explain the negative culture result in some situations (Huber et a.l, 2018). Therefore, not identifying bacte- ria in the filly’s joint of this report does not rule out a R. equi infection possibility.
In conclusion, the cervical vertebrae os- teomyelitis is a grave affection that requires agility and precision in its diagnosis, so an ad- equate treatment can be started soon enough. In this report, the myelotomography showed more detailed images, contributing to a more effective and precise diagnosis. It is possible then, to highlight the highly importance of different images to assist the diagnosis and avoid mistakes when making diagnostic sup- positions.
The author declared no conflict of interest