I don’t have a T&P dx, or active points, as I am in NJ and the patient is in Western PA – I will see her in about 4 weeks – I do have a pretty thorough history and Western workup. Although this patient doesn’t strike me as an overly “hot” horse when I’ve met her, I’m debating among Huo Xiang Zheng Qi San vs Si Miao San (SMS) vs San Ren Tang (SRT), or maybe even HXZQS initially, followed by SMS. Thoughts?
I do have pics of the sputum and nasal discharge, plus a video of the cough, but can't seem to get them to upload. Open to suggestions.
CLINICAL SUMMARY
Glory, a 22-year-old Arab-Morgan mare, used primary for competitive gaming (a sort of “agility” for horses involving short sprinting runs and quick turns) and pleasure riding
Primary concern:
-persistent cough (about 4 months), for which steroid nebulization worsened clinical signs
-intermittent purulent to mucoid nasal discharge, white with yellow tinge
-better in cooler weather, worse in hot/humid weather
-cough initially improved w Trimethoprim-Sulfamethoxazole, then signs returned when d/c
-no improvement w 4 weeks of doxycycline following TTW results (below)
-currently nebulizing BID w albuterol; recently added ciclesonide nebulization which has help slightly, but still coughing during exercise and rest (just less so)
History:
-2y progressive history of tiring easily and breathing heavier than expected during exercise
-ongoing, intermittent “fecal water syndrome”, characterized by the passage of liquid feces alongside or separately from normal solid manure. Decently managed in past w minimal diet changes, and increased fiber intake, but has been increasing the last 2-3 years. Feces are particularly stinky when loose. Unresponsive to multiple pre and probiotics (both prescription and OTC).
-historical dx of asthma
-historical dx of PPID (Pituitary Pars Intermedia Dysfunction-equine Cushings); on Pergolide mesylate (Prascend®), a dopamine agonist, and highly responsive to low dosing (eg, I had NO idea she was “Cushingoid” – you wouldn’t know it to look at her).
-historical intermittent tying up (negative 5 panel and muscle biopsy testing, so dx open)
Went to The OSU Equine Internal Medicine service for respiratory evaluation. Presenting as:
-BAR w normal vital parameters (temperature, heart rate, respiratory rate)
-no crackles, arrhythmias, or murmurs were noted on cardiothoracic auscultation
-mild, intermittent wheezing noted in the craniodorsal aspect of the lungs on R side
-minimal mucoid nasal discharge and symmetric airflow through both nares
-remainder of PE was WNL
The following diagnostics were performed:
-CBC and chemistry: WNL, except SAA = 693 mg/L, consistent w systemic inflammation or infection (Serum Amyloid A is a major acute phase protein that acts as a sensitive and rapid indicator of inflammation and infection. It's produced by the liver in response to inflammation and its levels increase dramatically during infection or injury). Interestingly, the SAA recheck (1 week later, no treatment) had fallen to 8.
-thoracic radiographs: mild bronchial pattern, mild changes in the caudoventral lung
-transtracheal wash + culture: Interpretation=moderate septic neutrophilic inflammation with increased mucus. Details include notes of frequent, thick strands of eosinophilic material (mucus) and overall low cellularity including 98% degenerate neutrophils, 1% lymphocytes, and 1% large mononuclear cells; no neoplastic cells are identified; rare intracellular and extracellular rod shaped bacteria present, consistent with a lower respiratory infection (pneumonia); no growth on culture after 7 days