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  Discussion on Procaine penicillin induced infection/inflammation
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New Member:
jessblue

Posted on Saturday, Mar 2, 2013 - 6:50 pm:

Hello, I am looking for any advice here as I am afraid things are going from bad to worse for my horse and I seem to be unable to get the right help for him. Breif history is TH x wb 8 yr old gelding developed FUO 4 weeks ago. No other symptoms except slightly swollen lymph nodes under jaw and raised heart rate/ Temp 104. Depression inappetance. Was treated with bute and equitrim abs. Over 4 days no improvement and vet suspected peritonitis or internal abcess. Horse showed mild colic signs on day 4 so I asked for referral to equine hospital. Once there he was given gent/pen treatment and many tests. Ultrasound on abdomen, thorax. Heart was checked lungs checked. Tried to do abdominal tap but no free fluid. Bloods showed inflammatory marker up and white cell changes consistent with infection. Nothing else remarkable in bloods. All tests were normal and he slowly started to improve. 3 days later he was no longer pyrexic without bute. He remained there a further week and just before discharge he showed signs or an inflammatory response to the penicillin injections. His rump was swollen and incredibly painful. He could not walk easily but once walking seemed easier. Very painful to palpate. Ultrasound showed fluidy odaemous swelling no obvious abcessed areas. He was discharged with bute only for management at home.

After a week he was no better, in fact slightly worse. My vet came out and rescanned. He could see some small pockets of fluid but said they could be pus or just blood. No way to know if it was abcessed. Put him on equitrim again. 2 days later it looked like it may be coming to a head. There was a small spot like area and a scab revealed a weeping perforation wound. Very small but slightly weepy. I hot packed to try to bring infection to the surface. The next day, it had all dried up!! No more spot no more weeping. Rump was still huge but slightly better, so continued with antibiotics for another week. He got better day by day. The swelling reduced each day and he became more and more comfortable. Started to lay down (he couldnt before) and roll in the paddock. I started very gently ridden exercise and all seemd ok. I noticed he was still grinding his teeth when ridden which he had been doing for some months. Gradual at first and getting worse over recent weeks. While at the clinic he was scoped and ulcers were found. He is at the end of treatment with gastrogard for ulcers. So on the last day of his antibiotics he suddenly could hardly walk. I couldnt get him out of his stable he was so sore. The swelling had DrOpped down to his stifle/flank and was incredibly painful to touch even the lightest touch made his leg shake!! I had stopped bute 2 days before so I started him back on bute and called the vet. Vet said he thought it was gravity pulling the infection downwards! He put him on doxycycline and I asked if I could have metacam for him instead of but as this would be better for his stomach. My vet doesnt want to open the area to drain becasue it is so close to his stifle. He siad it will be a real mess if he opens him up. However today his swelling is even bigger. It looks like a balloon hanging from his stifle, although he was happier to walk today. No fever at present and still eating. Very very sore to touch and I am hot packing/icing cold hosing the area.

I am incrediby worried about this. Its just not getting better and I cant leave him in pain like this much longer. I am really worried the infection may get into his stifle if not drained. Can anyone please advise of similar experiences or should I ask to be referred back to hospital for better investigation? I have spoken to hospital and they just say it may take weeks to right itself. Could the vet put a needle in to draw fluid off and then test for bacterias involved?? I feel I should be doing more for my boy.
Member:
vickiann

Posted on Saturday, Mar 2, 2013 - 10:06 pm:

Dr. O will need to answer this one!

Hope there is not cellulitis in that very painful swollen area, which would need very aggressive treatment with heavy-duty antibiotics, most likely IV.
Member:
frances

Posted on Sunday, Mar 3, 2013 - 4:51 am:

What an awful situation for you both. Sadly I have no advice to offer but I hope you hear from DrO soon, and send you best wishes for a good outcome in the shortest possible space of time.
Member:
rtrotter

Posted on Sunday, Mar 3, 2013 - 7:21 am:

Hi Jessica,

The vet that told you that this was gravity pulling the infection downward, IMO has nailed this, as I have seen this happen with my own horses. The exercise that this horse has been getting is probably the best thing you can do.

This will work its way down the leg and eventually out of the leg. The problem will be where it comes out. I think the hot packing and hosing may work but if it can be lanced and drained that would probably be better because if it does travel all the way down the leg to the foot, that can cause its own set of problems.

I wish you luck and good health for both you and your horse.

take care
Rachelle
Moderator:
DrO

Posted on Sunday, Mar 3, 2013 - 10:53 am:

Hello Jessica,
As your vet indicates and rtrotter has seconded, the most likely explanation is an abscess that is trying to achieve ventral (from the pull of gravity) drainage. Such an abscess could be infectious or sterile. In the case of an unopened abscess drainage as quick as possible is the best treatment. Antibiotics and good wound care followed by adjustment based on culture and sensitivity the best course after opening.

I would be careful of exercise on an unopened abscess of the leg: it may lead to spreading of the infection between the muscle's fascial planes to other places that will not drain from where it is currently trying to break out and another place for ventral drainage will have to form.
DrO
New Member:
jessblue

Posted on Monday, Mar 4, 2013 - 3:52 pm:

Thank you so much for your replies. To update, my horse has responded well to the doxy and the bute. Now to be clear friday was his worst day having stopped bute but still on noradine. Started doxy friday evening and saturday saw him much more comfortable to walk out but swelling bigger. Really fluidy hanging from his stifle. Sunday, swelling was much improved, still tender to touch slightly less heat. Today, much less swelling ,much less heat. So my vet came to check him and was really pleased, however, i have seen this much improvement before, last week when the main swelling was higher in his rump. Exactly the same pattern. Antibiotics started, swelling got larger, 2 days in swelling suddenly responds and goes down. So I am sceptical. My vet didnt see him at his best, only when at his worst, when I call him out. So I am worried, still. There is a little swelling into his gaskin now, not too tender to touch but its sort of DrOpped down a little more. I wonder is it still roaming?? He is walking ok, still a little shuffly on the sloped concrete yard. It looks like his front feet are sore sometimes but maybe coming from that hind leg? Obviously he is not right, becasue he is grinding his teeth A LOT. He is getting gastrogard for ulcers but having a lot of drugs go through his system at the same time. I have no idea what is causing the grinding but i know he is not entirely happy. It may be there is still a lot of pain in that stifle area. I am thinking maybe the doxy is responsible for the swelling being better as it has powerful antiinflammatory effects. Are we just masking the infection?? At the moment there is nothing to "lance" no obvious place you would put a knife in, just a little gneral swelling. I dont have good feelings about this, he is a stoic horse and im not sure how much discomfort he is still in. Vet has given me succeed digestive supplement as he thinks he may have hindgut ulcers too. He believes a lot of horses have them if they have gastric ulcers. Ill try anything to get my lovely happy little horse back. Actually the teeth grinding is the thing that worries me the most as this has been an ongoing thing getting worse as he became unwell and then developed this inflammation. Is there something we are all missing behind this? Really sad situation as I really dont know what to do to help him. My vet is lovely but I think he is a little confused too.
Member:
jessblue

Posted on Monday, Mar 4, 2013 - 3:57 pm:

Oh just one more thing, exercise or no exercise?? My vet has said to increase the walking now to 15/20 mins twice a day to get him stepping out and draining the area?? I can imagine its not good to be too immobile but just wondered what your thoughts were Dr O. Is this amount of exercise reasonable do you think considering we may have an unopened abscess?
Moderator:
DrO

Posted on Tuesday, Mar 5, 2013 - 7:45 am:

Hello Jessica,
Without examining the horse Jessica I cannot answer your question. If there is active infection trapped in the tissues rest is generally recommended and for good reason as outlined above. If there is trauma and inflammation in the long muscles of the thigh exercise is recommended to prevent scar tissue formation resulting in gait abnormalities for more on this see HorseAdvice.com » Diseases of Horses » Lameness » Muscle & Tendon Diseases » Fibrotic or Ossifying Myopathy & Myositis.
DrO
Member:
jessblue

Posted on Tuesday, Mar 5, 2013 - 9:16 am:

Thank you Dr O. This seems to be where I hit a wall! My vet and those at the royal veterinary college who have examined him seem to be unable to tell if it is indeed trapped infection or just inflammation. Even after 2 ultrasound scans the result was inconclusive. Yes there were pockets of fluid but they were unable to tell if they were pus or just odeama or blood from haematoma. This is my concern as you will probably understand. Both conditions may require different approach where exercise is concerned. Today the swelling has DrOpped into his gaskin. The stifle looks quite normal but there is a lump now the size of a large egg in his gaskin. Its not too painful to palpate and theres not too much heat as yet. However this may be being kept under control by the doxy and metacam. I wonder what will happen when we stop the antibiotics. The real problem is determining if it is indeed an infection or just inflammation. He didnt receive the injections into his flank or thigh, only the rump where the initial reaction presented. If NOT infection why would the stifle/flank and now gaskin become effected? On the other hand I am not entirely convinced its infection because, he does not have fever and it flared up in his stifle when I had stopped the bute and was still on the noradine. Therefore maybe he missed the antiinflammatory rather than the antibiotic?? Just trying to make sense of the situation myself so I can drive his treatment in the right direction. I think it is fair to say my vet is unsure himself, so I feel I have to try and do something to help. I am considering asking my vet if he would be happy to put a needle into the swelling in his gaskin and see if he could aspirate some fluid or pus. Do you think this would be a sensible suggestion? I just dont want to wait until this inflammation/infection DrOps down into his hack. I feel this will not have a great outcome. I am worried about him becoming lame or his gait being affected by the stiffness and him developing compensatory issues. He seems sound in walk, but he does struggle to turn tightly on hard surface currently. Its as if his fronts hurt. I dont know if this is because he is trying to get the weight off the hind leg. Ahhh, it seems everything is going wrong right now. Thank you for your support.
Moderator:
DrO

Posted on Tuesday, Mar 5, 2013 - 6:56 pm:

Hmmm...a tap of the fluid pocket and a visual exam of the fluid would answer this question of puss, hemorrhage, or a serum pocket. Note that serum looks entirely different than the other two on ultrasound so the three should not be left together on the rule out list after ultrasound. A microscopic exam of the puss will help answer the infection question and a culture and sensitivity would help with specific antimicrobial therapy.

On the other hand if your horse is responding well to the doxy, I am uncertain how much more diagnostically is indicated. It will depend on your goals and resources.
DrO
Member:
jessblue

Posted on Wednesday, Mar 6, 2013 - 8:53 am:

Ok, well thats very helpful. I will speak to my vet with regard to getting a tap of the area. It may give us more direction, maybe not but not a lot to lose I feel. Ultrasounds were performed and no mention of serum. I assume the question was whether it was a pocket of pus or blood. The two scans could not determine if there was abscess or not. I doubt further ultrasounds will tell us much more, so I feel a tap would be more informative. He does seem to be responding well to the doxy and metacam currently. Dr O, does the doxy have an antiinflammatory effect itself. I have been told by some that it does and this was concerning me in case it was merely the antiinflammatory effect of the doxy combined with metacam that was making everything calm down. I dont suppose it much matters but would like to get the facts right. Many thanks
Moderator:
DrO

Posted on Saturday, Mar 9, 2013 - 10:00 am:

The tetracycline family of drugs are known to have a antiinflammatory effect via anticollagenolytic, antimatrix-degrading metalloproteinase, and cytokine down-regulating properties. However these effects, while significant, probably would not disguise a uncontrolled active infection like a glucocorticoid (steroid) might (my opinion). In other words if you are seeing a good response to therapeutic doses it is most likely due to the antimicrobial effects.
DrO
Member:
jessblue

Posted on Sunday, Mar 10, 2013 - 7:56 am:

Thank you so much Dr O. That information helps me to try and piece together what is going on here. My horse responded very well to doxy and metacam. Selling reduced by day 2, gone altogether by day 5. No heat, no pain. Stopped doxy friday morning and metacam friday evening. It is now sunday lunchtime and I can see a small swelling again in his flank. Not too painful yet to plapate, but a little heat. Reduced slightly and became softer on walk exercise for 30 mins. So I guess were not out of the woods yet. Again I now suspect that this may not necessarily be a septic infection rather sterile of just acute inflammatory response to some procaine penicillin that was maybe in an area it shouldnt have been. I suspect he may have been responding as much to the antiinflammatory and analgesic properties in the doxy combined with metacam more so than the antimicrobial aspect. But, of course no way of knowing for sure. My vet is of the thinking that doxy is only an antimicrobial so tends to think he responded to this. But I am not sure. I guess another round of doxy will be on the cards whatever and back to antiinflammatories. This is so disappointing, not sure we are going to get on top of it!

Thank you very much for your continued support at this worrying time.
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