A Picture Worth a Thousand Tests This article originally appeared in Equus Magazine
I ran outside the heated tack room that doubled as lab and dark room.
"Jim, it’s going to be this morning. We’re at 275". I had just read the CHEMetrics FoalWatch test that I had run on
a tiny sample of now white milk from Jet, an 18 year old Quarter Horse mare. She was acting normally and eating a good
breakfast but we wanted to attend the delivery in this older mare having only her second foal. The FoalWatch had been
completely accurate in predicting foaling in the six mares we had used it on.
"I’m going to go get the thermos of coffee. Be right back." My husband and partner, Dr. Jim Latham, left for the house.
One hour later, Jet foaled without complication and we had a beautiful, vigorous bay filly on our hands. The baby, Lilly,
followed a normal pattern, scrambling to rise within an hour after accepting our introduction to handling and sounds, and she
nursed within two. Jet was an attentive, nurturing mom.
We were a bit surprised when the Gamma GT test was sluggish in turning positive when we checked Lilly’s plasma for immunoglobulin
transfer at 8 hours of age—it took 5 minutes instead of 2. We checked again that evening and the test looked good, so we didn’t
worry further. We continued to treat the umbilical stump with diluted chlorhexidine and monitored the filly’s development. She just felt great.
As three weeks of age approached, we expected the umbilicus to have shriveled, but instead it remained pencil thick. One morning,
there was a drop of pus at the end of the umbilical stump. Lilly’s temperature was normal and her lungs sounded fine, but I pulled a
blood sample from her jugular vein. An inflammatory panel, including CBC and fibrinogen, was normal.
Because we are both veterinarians and because I had waited ten years to breed my mare, hoping for the filly of my lifetime, we did not just accept the
apparently good test results. We got out the ultrasound and examined the caudal ventral abdomen of the filly and discovered a distention of the urachus,
the fetal urinary outflow tract that is destined to become a scar at the apex of the bladder.
We carefully measured all of the umbilical structures and then collected a culture of the tiny amount of discharge at the end of the umbilical stump.
Consultation with neonatal experts at UC Davis, CSU, TAMU, and Littleton Large Animal Clinic in Colorado gave us a conflict of opinion; surgery to remove
the umbilical structures to the apex of the bladder was advised by half the clinicians and discouraged by others. The culture came back a pure Strep zooepidemicus.
Dr. Johanna Reimer, VMD, DACVIM, of Rood and Riddle Equine Hospital in Lexington, KY, had reported at the 2002 ACVIM that
in their practice medical management of umbilical remnant infections was always preferred over surgery, with long term ultrasonographic monitoring of a favorable response.
Infections or abscesses of the umbilical arteries, vein, or urachus may occur without external signs of disease but these structures should always be evaluated ultrasonographically
in foals who have unexplained fevers, increased white blood cells or high levels of fibrinogen—an indication of inflammation—in the blood.
We began IV potassium penicillin four times daily in this 20 day old filly and continued that treatment for four days before switching to azithromycin, a once daily
oral antibiotic suspension used in children and adults for sensitive bacterial infections. We used the one gram packets, mixing it in water and honey and using
half the volume per day. After four more days, we dropped to every other, then every third day.
We performed follow-up ultrasound exams every seven days and were happy to measure the reducing size of the urachus. We followed the umbilical structures
weekly with the ultrasound until they were no longer visible and discontinued antibiotics. Lilly remained completely asymptomatic for the duration of what
could have been a life-threatening infection. We were convinced of the value of ultrasonic screening and monitoring of umbilical disease in foals.
The following spring, a client called to ask if we wanted to look at her new Clydesdale filly, 12 hours old. She had also used the Foalwatch test
and was able to observe the delivery of the foal. The big bay mare had significant bruising of the vaginal tissue and the umbilical cord had been
badly twisted. The delivered placenta was edematous and there were multiple hematomas (blood clots) and deep purple bruising visible in the last 10
inches of the umbilical cord where it had separated from the foal. We took a look at the large, active Clydesdale foal. The filly had a normal temp,
and appeared vigorous and healthy, but her umbilical area was markedly thickened. There was still a drop or two of blood, but no umbilical hernia. We
advised treatment of the umbilical stump with diluted chlorhexidine solution every six hours and careful monitoring of the filly’s temp and attitude.
One week later, the filly had a thick tan discharge from the umbilicus.
are you Mrs. Fields?
We cleaned the stump after collecting a culture. We advised the client that antibiotics should be given and an umbilical scan performed.
We started the filly on injectable gentamicin and trimethoprim sulfa oral antibiotics. An inflammatory panel in this case reflected systemic inflammation
with both an elevated white blood cell count and fibrinogen. The culture grew E. coli and Strep zooepidemicus. This filly was significantly infected.
Jim performed an ultrasound scan of the umbilical structures and the caudal abdomen. The skin of the umbilicus was still edematous and inflamed.
The abdominal ultrasound demonstrated enlargement of the right umbilical artery that provides blood from the placenta to the fetus in utero and becomes the fibrous
right round ligament of the bladder. The vessel wall was thickened and the lumen was enlarged.
Again, we followed the infected structures until they reduced in size and closed, at about one month of age.
The diagnosis and observation of clinical improvement by ultrasound gave us confidence that this filly was free of infection and would not need invasive surgery.
Umbilical infections in the first week of life can spread via the blood stream to joints or the lungs. Untreated umbilical infections can potentially lead to infections
of the bladder (cystitis) or rupture of umbilical abscesses with resulting peritonitis, infection of the lining of the abdomen peritoneum, or even death. Additionally,
surgery to remove infected umbilical structures in a neonatal foal may release infection into the abdomen and peritonitis, with resulting failure of the suture line, or adhesions.
Early ultrasonographic diagnosis of umbilical remnant infections can lead to early medical intervention and treatment and subsequent monitoring can ensure a successful outcome.
The careful daily observations of the owner of a neonatal foal can mean the difference between good health and a devastating illness.