Foal Pneumonia: Beyond the Basics

Foal Pneumonia: Beyond the Basics

Photo: Anne M. Eberhardt/The Horse

Two important bacteria cause lung infections in foals; here's how the body and your veterinarian battle these sometimes-deadly pathogens.

Like pirates guarding treasure, breeders go to great lengths to ensure their mares deliver healthy foals. So it can be disheartening when these youngsters suddenly develop a fever, runny nose, and cough in their first few months. One of the reasons foals might show these pneumonialike signs is the way their fledgling immune systems work.

"A foal's immune system is different than an adult's, which partly explains why they are more prone to certain serious respiratory tract infections that don't generally affect adult horses," says Noah Cohen, VMD, MPH, PhD, Dipl. ACVIM, professor of equine medicine at Texas A&M University.

The immune system has two major "branches": one that fights microorganisms living inside foal's bodies but outside individual cells, and a second that fights microorganisms living inside specific cells. Ironically, the cells that some bacteria and viruses invade belong to the immune system itself.

While your foal's immune system is adept at protecting itself against many disease-causing organisms, two bacteria continue to present problems: Rhodococcus equi and Streptococcus zooepidemicus. In this article we'll describe why these pathogens are dangerous and ways owners can protect their four-legged treasures that would make any pirate proud. First, let's look at how a foal's immune system works and what makes him susceptible to pneumonia.

How Foals Fight Infection

All cells have microscopic molecules on their surfaces that essentially serve as flags of identity to the cells around them. In the case of viruses and bacteria, their flags are akin to the classic skull and crossbone flags on pirate ships. These symbols of danger are what signal the foal's immune system that an enemy is on board and needs to be dealt with swiftly.

Ideally, when a pathogen enters a horse's body, certain immune system cells quickly recognize the invader and surround and eliminate it. This works well for staving off bacteria and microorganisms that circulate in the bloodstream and live outside the horse's cells.

"Although there is some conflicting evidence, it appears that innate immune responses of neonates may be less effective than older foals and horses," says Cohen. "This contributes to increased susceptibility to both intracellular and extracellular bacterial infections. For intracellular bacteria such as R. equi, adaptive immune responses involving T helper lymphocytes are critical."

Helper T-cells (specific white blood cell types that help produce antibodies against antigens) play an important role in clearing intracellular bacteria. These cells produce a specific inflammatory mediator called interferon-gamma (INF-γ) that is important for eliminating such bacteria. At the 9th International Conference on Equine Infectious Diseases, held in Oct. 2012, David Horohov, PhD, a professor and the William Robert Mills Chair in Equine Immunology in the Department of Veterinary Science at the University of Kentucky's Gluck Equine Research Center, reported that foals 3 to 42 days old are far more susceptible to R. equi infections than older foals due to an apparent lack of INF-γ. Production of this mediator increases rapidly with age, which partly explains why older foals and adult horses can fight off R. equi infections better than younger foals.

If the foal doesn't have an adequate arsenal of IFN-γ, R. equi and even S. zooepidemicus can quickly commandeer certain types of cells in his body. Once the bacteria are inside those cells they reproduce rapidly, creating hundreds of new infection-causing bacteria that invade other nearby cells to continue the cycle.

Pirates of Respiration

R. equi and S. zooepidemicus are important causes of foal pneumonia. The signs of disease and treatment options have been well-described previously and are listed in the chart below. One of the more important issues researchers have discussed recently involves the benefits and drawbacks of early diagnosis via ultrasonography to initiate early mass treatment of foals.

"Ultrasound is widely used to examine foals' lungs for signs of pneumonia, particularly R. equi," Cohen relays. "The theory is that even though the foals appear outwardly healthy, an ultrasound exam can identify small areas of diseased lung that aren't yet causing outward signs of pneumonia. Such foals with subclinical signs of infection can therefore be treated before they become ill."

Considering the mortality rate of R. equi can reach 40%, very early detection and treatment is clearly desirable. Other benefits to ultrasound screening are that it is quick, results are available immediately, and it appears to be a better screening test for R. equi than a variety of blood tests.

However, veterinarians have expressed concerns about routine ultrasound screening of apparently healthy foals. For instance, not all foals with ultrasound evidence of pneumonia will ultimately develop clinical signs of the disease. So although early diagnosis and mass treatment might seem great, it's not all sunny skies.

"It is currently not known exactly how many foals with evidence of abscesses on the ultrasound examination do eventually develop pneumonia," notes Cohen. He estimates the proportion is around 15-30%.

Therefore, treating all foals with ultrasound evidence of pneumonia means veterinarians are treating many foals that might not need it. Treatment can be expensive because it's long-term (until clinical signs cease, which can take six to eight months), and foals can be at an increased risk for developing adverse reactions to the drugs.

"Another important concern associated with 'mass treating' is the potential for development of antibiotic resistance by bacteria," Cohen says. "Resistance to macrolides and rifampin (antibiotics commonly used to treat doal pneumonia) appears to be emerging."

In 2010, Steeve Giguère, DVM, PhD, Dipl. ACVIM, professor of veterinary medicine and the Marguerite Thomas Hodgson chair in equine studies at the University of Georgia's Department of Large Animal Medicine, and colleagues used ultrasound to screen 138 foals for R. equi. Forty-five apparently healthy foals with evidence of subclinical disease on the ultrasound were treated. Researchers collected tracheal wash samples from 28 of the treated foals, and 41% of the samples contained R. equi strains resistant to macrolides and ¬rifampin.

"These results support the theory that mass-treating foals based on ultrasound screening may be contributing to resistance, and because we don't currently have other effective treatment options against R. equi, this is concerning," Cohen says.

Despite ultrasonography's drawbacks, Cohen still advocates some screening. "We don't yet have effective vaccines for R. equi, and the insidious progression of the disease means that foals may not show outward signs until the infection has progressed to advanced stages," he says. "Screening will allow us to identify cases earlier in order to achieve better outcomes. We just need to modify our screening program to find something that has the sensitivity of ultrasound without the large number of false-positive results. Ultrasonography can also be used to help diagnose S. zooepidemicus, but it doesn't tend to be used as a screening tool like in R. equi."

Don't Walk the Plank

When it comes to foals and pneumonia, don't live dangerously. Basic preventive measures, such as ensuring mares are healthy, dewormed, and vaccinated pre-partum, and efforts to isolate mares and foals into groups based on age to minimize risk of infection can help minimize foal pneumonia's impact. But these methods aren't 100% foolproof, so researchers are continually trying to develop vaccines.

Other Important Causes of Pneumonia

Verminous pneumonia This form of pneumonia is caused by lungworms or roundworm larvae that migrate through the lungs. They not only cause inflammation and damage to the lungs but also predispose foals to secondary bacterial infections (due to damage to the lung's normal defense mechanisms). Veterinarians treat affected foals with anthelmintics and, if necessary, antibiotics.

Pneumonia of "unknown cause" Other viral and bacterial causes of pneumonia include Escherichia coli, Klebsiella spp, Actinobacillus equuli, equine herpesviruses-1 and -4, equine influenza, and equine arteritis virus. Veterinarians typically treat bacterial causes of pneumonia with antibiotics, whereas they usually advocate symptomatic treatment for viral infections.

Fungal pneumonia This is a rare cause of pneumonia following infection with Aspergilla spp (a common mold in the environment). Affected foals and horses are unresponsive to antibiotics and, by the time a diagnosis is made, prognosis is poor.

Rib fractures An estimated 3-5% of foals have rib fractures that can cause respiratory distress due to pain/discomfort (depending on the number of ribs fractured).

Idiopathic or transient tachypnea Due to immature thermoregulatory systems, affected foals are unable to control their body temperatures in warm environments. As such, these foals exhibit increased respiratory rates and their rectal temperatures are higher than normal. Move these foals to cooler environments or cool them with water, clipping, etc.

Stacey Oke, DVM, MSc

"Making a vaccine for intracellular bacteria such as R. equi and S. zooepidemicus is a mission for many veterinary researchers," says Nicola Pusterla, DVM, PhD, Dipl. ACVIM, an associate professor in the Department of Medicine and Epidemiology at the University of California, Davis. "A candidate vaccine for R. equi is being tested in Germany with promising preliminary results."

The Calm Following the Storm

Each year a multitude of foals are diagnosed, treated, and eventually recover from respiratory tract infections. But what are the consequences of foal pneumonia later in life? Researchers have published two separate studies in the past two years attempting to answer this question.

In the first study, researchers looked retrospectively at 1,200 Thoroughbred foals destined for the racetrack and determined that 4.7% experienced pneumonia in the first six months of life. Of those foals, 64% raced at least once, which was statistically comparable to the 67% of foals that did not have pneumonia and eventually raced. The investigators also noted no difference in number of career starts, wins, places, and total earnings between the foals that did and did not have pneumonia.

In the second study, researchers from Australia found that 125/491 Thoroughbred foals (25%) diagnosed with R. equi went on to have significantly fewer starts and shorter careers than foals not diagnosed with R. equi. "These results suggest that clinical R. equi pneumonia as a foal negatively impacts the career longevity and ultimate capacity to perform as an elite Thoroughbred," the authors -concluded.

Interestingly, the authors of the latter study did concede that the reasons for retirement were not noted and that the residual effects of R. equi pneumonia appeared to have "no impact on the ability for the horse to race, even as a 2-year-old."

Scientists stress the need for future studies to determine the true impact of both main types of foal pneumonia on future athletic performance.

Take-Home Message

Although there are a number of potential causes of pneumonia in foals, infections with the intracellular bacteria R. equi and S. zooepidemicus are the most common and important causes, as far as morbidity and expense of treatment. Until a vaccine is commercially available, the best way to minimize the chances of infection is prevention.


Review of Two Common Causes of Pneumonia in Foals

Intracellular Pathogen Streptococcus zooepidemicus* Rhodococcus equi
Description of disease each causes Bacterial pneumonia that often occurs secondary to an earlier viral infection Pyogranulomatous bronchopneumonia with abscesses scattered extensively through the lung
Age on onset Foals >1 month old Foals 1-6 months old
Signs of disease Fever; depression; nasal discharge; cough; increased respiratory rate; increased breathing effort Sporadic, intermittent cough; fever; lethargy; decreased appetite; ill thrift; respiratory distress
Source of bacteria Normally S. zooepidemicus,/i> is found in the upper respiratory tract. Following viral infection or stress (e.g., transport, weaning), S. zooepidemicus invades the lower airways. R. equi is found in the soil on farms around the world, but growth is optimized in warm and dry environments.
Treatment S. zooepidemicus is usually sensitive to beta-lactam antibiotics, rifampin, chloramphenicol, and erythromycin. Resistance to trimethoprim-sulfa has been reported. Foals are treated for a minimum of 10-14 days until all signs of pneumonia have resolves. Veterinarians prescribe a combination of rifampin and a macrolide antibiotic (e.g., erythromycin, clarithromycin, azithromycin). Foals are often treated for 30 days, but a course of treatment can last up to six to eight months (until all signs of pneumonia have completely resolved.)
Prognosis Prognosis is good for complete recovery if treated promptly and fully (until complete resolution of clinical signs). Approximately 70-80% of foals recover fully, but mortality rates can reach as high as 40%.
Possible sequelae (secondary conditions) Not reported Ulcerative colitis (diarrhea) and typhitis (cecum inflammation); septic arthritis; osteomyelitis (bone infection); and/or liver and kidney abscesses
Prevention Reduce or eliminate environmental stressors and viral or parasitic infections; ensure mares are fully vaccinated prepartum. Administer chemoprophylaxis (antibiotics in the first two weeks of life) and immunoprophylaxis/hyperimmune plasma (administered at birth and again at 21 days of age); use environmental management techniques to limit air and soil burdens of R. equi; practice responsible herd management (e.g., limit stocking densities and group foals together by age).


About the Author

Stacey Oke, DVM, MSc

Stacey Oke, MSc, DVM, is a practicing veterinarian and freelance medical writer and editor. She is interested in both large and small animals, as well as complementary and alternative medicine. Since 2005, she's worked as a research consultant for nutritional supplement companies, assisted physicians and veterinarians in publishing research articles and textbooks, and written for a number of educational magazines and websites.

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