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The Perfect storm

So, I wish I did not have to start this process again…but unfortunately, I do. Once again I have a senior horse with a variety of acute and chronic conditions that all hit at the same time. Right now I am trying to make her comfortable while also trying to figure out what is what and how to best respond.

Three months ago Tilly was tested for EPM due to muscle wasting and weight loss.The first time she was in the lower end of an active infection. We started a compounded medicine for 1 month and her numbers decreased. We decided to do another round as she responded well to the first round. However, the numbers remained the same. We also tested her for Lyme which showed a chronic and an active infection but the numbers were in the high normal range and the vet felt that it was not treatment worthy at the time.

Last month Tilly began “crab walking” out of the blue. Called the vet. They came out. Her ataxia was bilateral- both her left and right hind- whereas EPM tends to be unilateral. Further, her presentation was not suggestive of Lyme.

We started steroids (dexamethasone oral power) for 5 days with Banamine, tapering as we went, and she seemed to recover. The consensus was it was an acute attack that may have occurred given she is a senior with a history of being an Amish workhorse and perhaps, she pulled something in her neck.

Treatment was complete and another week went by and again, she showed some ataxia. This time less severe. The vet felt that since she responded well to the first round of steroids that it was not EPM-related as you would not see improvement. Further, if it were Lyme related the presentation would be more consistent. Again, a round of Dex and improved quickly. The next week we had her neck x-rayed and there were some arthritic changes. However, she was running around and moving well so the vet felt injections in her neck would not be necessary at that time.

Seventy two hours later, she had some trouble getting up but eventually succeeded. The next morning my sweet girl was spinning, crab walking, and falling over. It was absolutely terrible to see. I immediately gave her 10cc IV Banamine and she calmed down and stopped spinning. The vet came out and administered Dex IV and thought that due to her inflammatory bowel disease we should try Dex IM to ensure absorption. We also decided to pull blood to test for Cushings as she seemed to lose weight overnight and was not shedding out well. The next day she was lame on her right front. Panicked I called the vet fearing that if she did have Cushings, she was trying to founder due to the steroid use. Thankfully, the vet came out, did a nerve block on her right front (this helps to see if the horse has laminitis as they will improve once blocked) and checked for pulses (if a horse has laminitis typically they will have pulses in their hooves) and Tilly did not have any. So, the vet did not feel we were dealing with founder. However, the lameness presented a major challenge due to her still being ataxic on the hind end. The vet did cortisone injections into her neck hoping to help with inflammation due to arthritis. Tilly did great and suddenly, began freaking out. Spinning, knocking into the doors, etc. The vet explained that the injections likely added more pressure on her spinal cord causing her to react. Again, once the vet was able to safely administer Banamine and some Dorm, she calmed and laid down for the first time in over a week for a good 45 minutes. We decided to make sure she was able to get back up. Although she had some trouble, after a couple tries, she was able to do so. Her breathing was heavy, wheezy, almost like she was having a panic attack and hyperventilating. A few minutes later, her breathing returned to normal.

Tilly’s Cushing’s text level was about 100 pg/mL (it should be about 30 pg/mL during mid-November to mid-July) meaning, she does have Cushings. The vet decided to wean her off of the steroid as to not increase the risk of Laminitis even more but also to give neck injections time to work (5-7 days). We also immediately began Prescend (2 tabs) a day to treat her Cushings.

We are on day 5 since the 3rd ataxic episode and day 3 post neck injection and she is still lame on her right front along with ataxic on her hind end. However, she is still eating, engaging, and is bright and alert. She does not seemed distressed or in pain thankfully. Due to Tilly not showing much improvement (even though it can take 5-7 days to see improvements from the neck injections) I decided to start her on a non-compounded EPM medication, Protazil. According to the vet, Protazil should not cause any harm whether her symptoms are EMP related or not. I also began 10cc of Vitamin E oil. Tilly was previously on pelleted Vitamin E but due to her inflammatory bowel disorder, she may struggle to absorb the pelleted form of the supplement. Further, there are a number of studies showing the benefits of Vitamin E and the connection between Vitamin E and ataxia.

On a positive note, since starting Prescend for her Cushings, I have noticed that she is drinking less water. Increased water intake is a symptom of unmanaged Cushings. I am hopeful that means the medication has started to work at regulating her hormones. We are now at a wait and see point. I continue to try to make her comfortable. Tons of bedding in her huge foaling stall, hay everywhere, fans on, doors open. She has been a trooper. My hope is that she recovers from this and enjoy whatever time she has left and fights this as she has so many other things- the reason she was given the name, Ottilie.

RESOURCES

https://www.horseillustrated.com/horse-health-equine-cushings-disease-24321

https://www.horseillustrated.com/horse-experts-horse-vet-advice-cushings-disease-diet

https://cvm.msu.edu/vdl/laboratory-sections/endocrinology/equine-endocrine-testing

https://www.horseillustrated.com/horse-experts-horse-vet-advice-cushings-horse-treats

https://resources.integricare.ca/blog/cushings-disease-in-horses

https://equine-vets.com/health/l/laminitis-is-one-of-the-most-common-causes-of-lameness-in-horses-and-ponies/

Testing for Equine Cushing’s Disease

Hannibal.

2 Replies

Today Chance got his teeth floated by his very first dentist from 2000! Due to his cribbing history his front teeth were significantly worn down. His molars were not in bad shape but were a bit jagged. The dentist noticed that Chance’s left side was more sensitive to the filing and put a jaw opening device in C’s mouth to keep it open (see below right photo). The molars all looked like they were holding strong and there was no smell that would be indicative of an infection or decay. The dentist indicated that Chance was missing three back molars and that he felt that he was about 24 years old.

The dentist asked me about the nutritional care Chance was receiving due to his age, and I gave him the run down- 2 quarts twice a day of hay stretcher, hay/alfalfa mix throughout the day, 4 quarts of Nutrina Smart Feed Senior twice a day, 2 cups of Rice Bran twice a day in feed, SmartPak Senior Flex and Immune Boost, DuraLactin once a day for arthritic pain and inflammation, Vitamin E once a day, and Transfer Factor for an immune system booster. He continued to explain that when he asks the owners of most of the older horses he goes to sees, they do not have them on the proper diet. I explained that we are still trying to get more weight on Chance but that he has put on a good amount of weight since last summer. He suggested that our next appointment be this December before Chance has the opportunity to go into the winter and lose any weight, which is common in older horses, especially cribbers and thoroughbreds, in the winter months.

Later that day, Chance seemed to have some difficulty eating his hay; wads of hay were scattered around his stall. This is something that I have seen intermittently, maybe once or twice, but not to this extreme. I decided to give him alfalfa cubes to substitute the hay until the next day when, hopefully, he would be able to eat more easily. Sure enough the next morning there were no wads of hay!

Our Regiment

Chance receives the following:

AM:

1. Protazil 50mls

2. Vitamin E 4 scoops (Watch for loose stools. This would indicate that his VitE should be cut down)

PM:

1. SmartPak: Immune Boost

2. SmartPak: Senior Flex

3. Equinyl 2 scoops first two weeks, 1 scoop after

OTHER:

If Chance’s symptoms are worse, he can receive Equinox and UlcerGuard.

How to we get there?

Other EPM Therapies

Inflammation

An active S. neurona infection in the central nervous system (CNS) will produce both temporary inflammation and permanent nerve damage. The inflammation can get worse when the protozoa start to die during treatment. This can happen as the treatment drug level builds in the CNS, and is known as a ‘treatment crisis’. Watch for symptoms to get worse 7 to 14 days after the start of treatment drugs.

Inflammation by itself can cause permanent nerve damage, so treating it is important. Veterinarians report that horses with higher neurologic deficiencies, and possibly higher levels of protozoa, tend to get treatment crises more often that horses with a Mayhew score of 1. Some veterinarians will place a horse on anti-inflammatory drugs immediately, to prevent additional damage to the CNS.

Banamine Many owners already have the non-steroidal anti-inflammatory drug (NSAID) Banamine at the barn. Even if your horse is a 1 on the Mayhew scale, you may wish to have Banamine on-hand to deal with any worsening of the symptoms. Banamine can cause gastro-intestinal side effects such as ulcers when given in high doses, or longer than five days. A January 2009 cost was $35 for 5 doses.

MicroLactin This supplement is gaining recognition as an overall, mild anti-inflammatory. This non-prescription supplement is a derivative of cows milk, and is known as Duralactin, or the ingredient ComfortX in Equinyl. MicroLactin does not have side effects, so it can be used over the entire course of treatment. It is possible to supplement with Banamine during a treatment crisis. March 2009 price was $50 per month.

Dexamethazone (Dex) This steroid suppresses the immune system, so it should not be used as an anti-inflammatory for EPM horses except in an extreme neurological case. Used longer than 5 days, it can cause Laminitis.

DMSO Dimethyl sulfoxide given intravenously, can be useful when the horse has extreme neurological symptoms. The veterinarian should administer this drug, it should only be used for short time periods, and it can interact with other drugs.

Immune System

In many regions of the U.S. more than 50% of the horses have been exposed to EPM. Researchers do not know why less than 2% of them get an active infection in the CNS. Studies on blood of EPM horses indicate a change in the immune system response and cells. Relapse rates for EPM are high, often with the same symptoms. Some researchers believe that the relapses are latent infections which were never completely killed, and the immune system does not recognize. Immune system stimulants have been suggested to help the horse fight the infection.

Levasimole This drug has been used as part of a wormer, and anti-inflammatory. It is known to increase immune response. It has not been clinically tested specifically for use with EPM, but is being used for it.

Transfer Factor This supplement has been around since the 1940’s for human use. The older studies on humans suggest it increases the cell-mediated immune response. It has not been clinically tested in horses. The supplement is suggested to increase the cell-mediated immune response (see research below). It WILL NOT kill the protozoa; it is only an immune booster. It is made from cow colostrum, eggs, and mushrooms. At least two companies produce this for equine use, and while the main ingredients are the same, there are differences. 4 Life Research and Nutrition Horizons USA offer this at March 2009 prices of $150 to $200 per month.

Vitamin E

Vitamin E has been shown to relieve inflammation, promote regeneration of nerve cells, and is an anti-oxidant protecting the CNS. This vitamin is suggested by many veterinarians for supplementation during and after drug treatment for EPM. It crosses the blood-brain barrier to work in the CNS. A deficiency in Vitamin E is thought to impair the blood-brain barrier. It is suggested at therapeutic rates from 5,000 to 10,000 total IU per day. Add the total Vitamin E content of all supplements and feed to reach the target rate. Research has shown that natural source vitamin E (D-alpha tocopherol) is absorbed by the body better than manufactured E (DL-alpha-tocopherol).

Recent Research

A 2006 study published in Veterinary Parasitology indicated: “Our results demonstrated that naturally infected horses had significantly (P < 0.05) higher percentages of CD4 T-lymphocytes and neutrophils (PMN) in separated peripheral blood leukocytes than clinically normal horses. The product MicroLactin has been shown to limit neutrophil activity thereby reducing the inflammation process in the CNS. The study goes on to say, “Leukocytes from naturally infected EPM horses had significantly lower proliferation responses, as measured by thymidine incorporation, to a non-antigen specific mitogen than did clinically normal horses (P < 0.05). Cell-mediated immunity is lowered in EPM positive horses.

An ongoing study by Dr. Bello, Journal of Equine Veterinary Science, vol. 28, issue 8 (2008), uses Marquis, MicroLactin, and transfer factor in a protocol. The initial study involved 28 horses, and 8 more have been studied. This study was presented at the AVMA conference in 2007, and was published in 2008. The full text article is available below with permission from Dr. Bello.

Continuing research by others indicates controlling inflammation is a large part of the treatment process, and immune system stimulation is critical to avoiding relapses.

January 2012

References:

Veterinary Parasitology 138 (2006) 200–210

J Appl Res Vet Med 2003;1:272-8.

J Eq Vet Sc, vol. 28, issue 8 (2008) 479-482
An Intensive Approach in the Treatment of Clinical Equine Protozoal Myeloencephalitis

Am J Vet Research, June 2008 Vitamin E

J Eq Vet Sc, vol. 25, issue 9 (2005) 380-382

TheHorse.com articles # 12025, 4829

The Chances We Take

some things are worth fighting for