Case Report
An atypical case of recurrent cellulitis/lymphangitis in a Dutch
Warmblood horse treated by surgical intervention
A. M. Oomen*, M. Moleman, A. J. M. van den Belt †and H. Brommer
Department of Equine Sciences and †Companion Animals, Division of Diagnostic Imaging, Faculty of
Veterinary Medicine, Utrecht University, Yalelaan, Utrecht, The Netherlands.
*Corresponding author email: A.M.Oomen@uu.nl
Keywords: horse; lymphangitis; lymphoedema; surgery; lymphangiectasia
Summary
The case reported here describes an atypical presentation
of cellulitis/lymphangitis in an 8-year-old Dutch Warmblood
mare. The horse was presented with a history of recurrent
episodes of cellulitis/lymphangitis and the presence of
fluctuating cyst-like lesions on the left hindlimb. These lesions
appeared to be interconnected lymphangiectasias. Surgical
debridement followed by primary wound closure and local
drainage was performed under general anaesthesia. Twelve
months post surgery, no recurrence of cellulitis/lymphangitis
had occurred and the mare had returned to her former use as
a dressage horse.
Introduction
In horses, septic inflammation of subcutaneous tissue
and vascular structures leading to insufficient lymphatic
drainage and development of chronic lymphoedema is a
frustrating condition. A painful and generalised limb swelling
due to accumulation of fluid with high protein concentration
and subsequent formation of interstitial oedema are the
clinical symptoms in the acute phase. After recurrent
episodes and as a more long-term effect, fibrotic changes in
the affected limbs with persistent limb swelling and limb
deformation (elephantiasis) can develop that may lead to loss
of functionality of the affected limb with a negative effect on
athletic performance (Adam and Southwood 2007; Fjordbakk
et al . 2008).
The syndrome in horses is generally caused by pastern
dermatitis or other small skin lesions that become infected
secondarily by Staphylococcus spp. and/or Streptococcus
spp. (Risberg et al . 2005; Adam and Southwood 2007;
Fjordbakk et al . 2008). Whether a primary cellulitis develops
with secondary inflammatory response in the lymphatic
and/or vascular vessels or the reverse occurs, is often
difficult to determine, as the inflammatory response mostly
takes place concurrently in both types of tissues (Risberg
et al . 2005; Adam and Southwood 2007; Fjordbakk
et al . 2008). Treatment consists of broad spectrum
antimicrobials, nonsteroidal anti-inflammatory agents, and
ultrasound-guided surgical drainage of fluid accumulations
(Fjordbakk et al . 2008).
A primary nonseptic disease of the skin and its lymphatic
system in the distal limb has been described in draught
horses (de Cock et al . 2003, 2006; Ferraro 2003; van
Brantegem et al . 2007). In Shires and Clydesdales, it has
been reported that elastin degradation of the lymphatic
wall seems to play a central role. A failure of elastic fibres
to support the skin and its lymphatics appropriately is
proposed as a possible contributing factor for chronic
progressive lymphoedema of the limb in these breeds of
horses (de Cock et al . 2003, 2006; Ferraro 2003; van
Brantegem et al . 2007).
Other diseases related to the lymphatic system are
lymphangioma/lymphangiosarcoma and development
of lymphangiectasia. Cutaneous lymphangioma has been
described as a solitary mass on the limb, thigh or inguinal
region of horses without the typical signs of progressive
lymphoedema (Turk et al . 1979; Gehlen and Wohlsein
2000; Junginger et al . 2010). Lymphangiectasias in horses
have been described in the intestinal wall of foals and horses
with clinical signs of colic and diarrhoea (Milne et al . 1994;
Campbell-Beggs et al . 1995). To the authors’ knowledge, the
occurrence of lymphangiectasias in the limbs of horses, either
as a primary developmental disorder or as a secondary
feature to progressive lymphoedema due to recurrent attacks
of cellulitis/lymphangitis has not been reported before. This
report describes the presentation and surgical treatment
of an atypical case of recurrent, chronic cellulitis/lymphangitis
in the hindlimb of a Dutch Warmblood horse, in which
lymphangiectasias had developed during the course of the
disease.
Case details
History
An 8-year-old Dutch Warmblood mare used for dressage
(545 kg bwt) was admitted to the Veterinary Teaching
Hospital of Utrecht University, The Netherlands. The horse had
a history of pastern dermatitis and recurrent (at least 4)
episodes of the classical form of septic cellulitis/lymphangitis
with lymphoedema of the left hindlimb over a period of
4 months. The horse had repeatedly been treated with
trimethoprim-sulphdiazine (Sulfatrim 1, 30 mg/kg bwt per os
b.i.d. for 3–10 days), dexamethasone (Dexadresson 2,
0.055 mg/kg bwt i.v., single dose) and meloxicam (Metacam 3,
0.6 mg/kg bwt per os s.i.d. for 3–10 days). Each medical therapy
episode resulted in a partial resorption of the oedema and
reduction of limb swelling, but after the fourth treatment,
several ‘cyst-like’ swellings became apparent that did not
disappear with treatment. Six days before admittance, a new
episode of cellulitis/lymphangitis had started with a lameness of
Grade 1 /5(AAEP scale). The referring veterinarian had started
treatment immediately again with trimethoprim-sulfadiazine,
as described above, dexamethasone and meloxicam. On
admission the horse was still on trimethoprim-sulphadiazine and
meloxicam.
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EQUINE VETERINARY EDUCATION / AE / JANUARY 2013