Good evening, everybody, and welcome to tonight's webinar. My name is Bruce Stevenson, and I have the honour and privilege of chairing the webinar this evening. Before we jump in, a big thank you to our sponsors, Burgess.
Peter is on with us and we will be hearing from him later. But thank you to Burgess and to Peter for the sponsorship of this evening because it gives us the opportunity to listen to a fantastic speaker like John Chitty. For those of you that haven't been with us before, just a little bit of housekeeping.
If you have any questions, just move your mouse over the screen. You'll see a little control bar pop up. It's normally a black bar at the bottom of your screen.
There's a Q&A box. Click on that, pop in all the questions there, and then we will do our best to get to as many of those as we can at the end of the webinar. Please remember that we are recording the webinar, so, if there is something that you want to go back and watch, or a table or something like that, the recording will be up on the webinarvet website in the next day or two, and then you can go and fast forward and rewind to your heart's content.
So, don't forget about the recording. It is a great source to go back when you have questions, that the speaker has already answered. Our speaker tonight is Doctor John Chiddy.
He's an RCVS advanced practitioner in zoological medicine. John qualified from the Royal Veterinary College in 1990 and gained his RCVS certificate in zoological medicine in 2000. Until recently, John was employed in small animal exotic practise in Andover, in Hampshire, with a 100% avian exotic small mammal caseload, both referral and first opinion.
As well as consulting to various zoos and reintroduction projects. Now, John provides a consultancy and advisory service for zoos, local authorities, and vets. He's co-editor of 3 texts on avian medicine, 1 on rabbit surgery, and co-author of a textbook on tortoise medicine.
Author of various book chapters and papers on a range of species, president of the Association of Avian Veterinarians, 2015 to 2017, and on the editorial boards of the Journal of Exotic Pet Medicine, the Veterinary Record, and Veterinary Evidence. John was the president of the British Small Animal Veterinary Association 2017 to 2018, and I happen to know that one of John's most prestigious and close to his heart, claims to fame is the fact that he's a trustee and honorary secretary of VetLife. John, welcome back to the webinar, vet, and over to you.
Hi Bruce, thank you very much indeed for that and thanks again for joining us on a now dark evening, hopefully it's not been too long a day for you. Thanks too to Burgess for sponsoring this talk. I'm usually very rude and forget to thank them, so make sure I do that right at the beginning this time.
Many thanks to them yet again for sponsoring these talks, and they're absolutely fantastic and the support they give us all. So, late in the evening always seems that thing about, you know, what. You know, what do we, how do we feel about these, these tricky cases, and how, how do you view a difficult case when it comes in?
You know, is it an opportunity, is it a great learning curve? Is it really getting your intellectual, taste buds going, or is it one of those things of, oh no, it's 62:25, and I really do want to go home tonight. And it, it can be quite a mixed feeling when you see such a case, about how, how you go with that, and that's what we're gonna be looking at tonight, some of these cases that Maybe, you know, weren't your favourites of the time, but did hopefully get you thinking.
So what I'm presenting today is, it's not going to be an approach to rabbit medicine, . What hoping may give you some different treatment options, and variety of things you could do. Be a little bit as ever about what imaging can show because I always like imaging and and you know it's good to show that.
I am hoping to show you some of the lessons sort of learned along the way, about what these each one can actually teach you there. And there is as ever going to be a little element of what would you do in this case. Now I haven't done set poll questions, I'm not very good at those, .
And so it's not like Q&A and you're not going to be taking part in the quiz, so there's no need to feel that anything has got wrong or anything like that too, but we may have some little pauses every now and then, probably as I or not I remember, to give you time to think of some differentials and think what would you do next and that kind of stuff too, so it's one of those things where if there is any element of competition in quizzing, it's within yourself. And, you don't have to reveal how you did either or the scores, but perhaps we can explore, that in the chat afterwards in the Q&A because. There's at least one of these cases where we didn't really get to the bottom of it, and, an extra opinions would be really good to look back on and say, yeah, it could be that, it could have been this, that'd be really fantastic.
So let let's get started. I'm gonna start with er dysmia case. A 2 year old male neutered rabbit, .
Presented with tachypnea and dyspnea, . And he'd recently started to cough. And coughing is a little unusual in rabbits, happen occasionally, but very unusual, much more common in guinea pigs, but, rabbits is really quite strange.
It was a referral case and had been given an antibiotic and had no response whatsoever, very noisy lungs and auscultation, I think I've listened to any of these talks before we know that auscultation's really weird in rabbits because you very often get silence, and silence can be normal or silence can mean . Can mean consolidation, but actual increased respiratory sound is a little odd. Mucous membranes were fine, and wasn't open mouth breathing or anything like too, so nice, nice pink, membranes, everything looked good like too and good body condition which again has been going on for a little while, so that was a little surprising as well.
So I was gonna ask you, what are your differentials, I did say I forget, so time to think if you didn't notice that square outside too quickly, what your differentials here might be at this point, so . I did say I may forget which is the next slide and and forget to do that, so hope you've got some ideas. This is where my differentials at the time, so I think obviously infection, had had antibiotics, but it doesn't mean everything always responds.
Think about cardiac, the heart cough's really, really unusual in rabbits. Potentially extra extra respiratory pressure, could be especially pressure on airway. And that's sometimes where cardiac things can, cause respiratory things in rabbits just through space occupying, lesions, and of course, abdominal enlargements can press on the airways too, and press on the lungs, we're so small.
Inflammatory airway disease came to mind, also things like obstruction of foreign bodies down in the trachea do happen, and can be a problem, and also, even though young, sometimes think about neoplasia, and of course thymic tumours are, are not unusual in rabbits. So next test we want to do, so we've got a wide range of differentials, we're gonna have to start thinking about a very wide range of tests to do, so we might think about imaging. What imaging are we gonna do?
Well, generally we're gonna start with X-rays. We're looking at a broad picture, so X-rays were scheduled. Bloods, again, blood's not normally that useful for respiratory cases, but we did schedule them because we were dealing with something slightly unusual and just wanted a bit more background information on that too.
Because foreign bodies were a potential differential here, we did target some endoscopy, . And we did think about some trial therapy, but antibiotics had already been used, didn't have any any success, while we're booking everything in we did start some non-steroidal, but we didn't want to do anything else in the meantime because, Be because we we didn't want to throw any test results or anything too, so. Essentially what we answer those, what tests you do next is really all of the above sometime.
Because some of you aren't gonna need all those, they're all gonna provide different elements, so what do we find? Well, blood's, we actually found something really unusual, and we did get an inflammatory picture, and with heterophils raised and monocytes raised, we are looking at a very chronic inflammatory picture. And that's really unusual for rabbits because rabbits tend to lower their counts, and if they have infection, having severe inflammation, they'll tend to lower their counts and and just get lower and lower and lower.
So actually having high levels is really significant indeed. We took some radiographs, you can comment to yourselves please, that this is not the world's greatest positioned, radiograph when you're looking at the chest, . But nonetheless, we can see the chest on there, and I think we can see quite a a reasonable pattern on there as well.
We can see the abdomen abdomen really well, and that's showing we haven't got any compression of the chest, that's all looking OK, we haven't got any fluid lines either, and if we do a DV view, we we have a marked airway pattern in that chest, again slightly unusual. There's no consolidation there, it's just simply in the airways. So that was quite cool.
So what next? So we're talking about range tests we're gonna do next, which one would we probably go for straight away? And we thought that with the risk of being a foreign body, although there's quite a diffuse set of changes and the airways being affected, we'd go for endoscopy.
And endoscopy in rabbits lungs is really quite tricky. We were fortunate we had a 2 millimetre flexible endoscope, which meant we could go down into the bronchi, . It did mean we've got no ability to samplify it because it's too small to have a working channel or anything, but it's quite useful, and as they see we've got no sign of foreign bodies.
Here is the endoscopy. It's very red and inflamed, hence the fact that everything you touched bled, it's indistinct. We can see we've got some thickenings there.
I think first of all that's pus, but as you get close, you can see this like granulomatous tissue, within the airways, so that was quite weird as well, I say bleeding quite freely and very, very fragile, areas there too. So that was the endoscopy. Now, we've got quite diffuse changes.
We can't sample directly because the endoscope is too small to allow that, and the airways are too narrow to allow a bigger endoscope, with sampling, ability. So what we're gonna do is we want some more, idea of what's going on there. So this is where we, do a lung wash.
This had to wait a bit because the bleeding was gonna throw it, so we had to had to wait a few days before we could do this. And lung washing is really useful, we've got generalised lung changes in these guys, . And simple to do, you can do it by passing you use sterile urinary catheters straight into the trachea under direct visualisation, as you can see here, or the other thing to do is is place an ET tube and simply just thread the the the catheter down the ET tube.
Both ways work pretty well. Generally putting something like 2 to 5 mL of saline, per kilo of rabbit into, into the lungs, and sluice it about a bit and then withdraw a very small sample from that. And what we got from here we sent for culture, we sent dip for cytology as well, that's really useful.
And what we, we got from there was no bacterial fungal growth, which is interesting, even though I've been off antibiotics for a while, and we did have a mixed inflammatory response, and this is a bit from that sample there, and you can see we've got some monocytes, you see they're actually a bit active there. We've also got some, I've got a mast cell there too, so that was really quite exciting, so we're having a big inflammatory reaction too. And the other thing that came up though, we had respiratory epithelial hyperplasia, lots of of lining cells coming away as well, and that would probably fit with the picture we had of the granulomatous changes on those airways.
So what's our diagnosis? And my feeling at this point we really were dealing with primary inflammatory disease, so, slightly unusual, slightly odd. To treat primary inflammatories, we want to use anti-inflammatories, but here's the problem, now we had started some non-steroidals, they hadn't had a massive effect, so what do we want to do, we want to do something like steroids, and these are a problem in rabbits because they are very sensitive to their effects, they will get sort of liver changes where we're with them, they can get immunosuppression, where, where with steroids, so you can get quite a bit of a problem when they're not very tolerant of these at all.
So, big worry with that. So what can we do instead? .
Well, we started systemic antibiosis, the reason for that was because we were gonna use steroids, and we wanted some covering antibiotic because in case we took the immune system out too far in a damaged set of lungs. So we aerosolize the steroid. Now, fluticasone is available, used a lot in cat medicine, and is .
Is very useful in some of these airway diseases, which of course what's used for in in people and people it's used via puffers, now very difficult to use a direct puffer in an animal because you've got to time that inhalation with the puff. So the other way we tend to use animals is nebulization. Now the trouble with that is with steroids is that you're not really fixing the dose, so you're very, very uncertain about how much steroid you're giving.
It's also gonna go all over the animal, it's gonna groom and you get systemic effects. And the whole point about using it localised is you get fewer systemic effects from that. So we decided we'd go through a through a different route there too using a spacer.
We did also warn the owners about side effects and this is really important we're doing something like this too, the owners do have to understand what risk you're taking with the drug and what likely benefits are, and they were really fully on board, which is great. So we use a spacer, and a spacer is basically a tube and then using an Aeroat or something like that, this was an AeroCat. You know, you've basically put the, put the, tube over the animal's nose, you puff into that, and although you don't get a full dose, you do get quite good and precise, more precise dosing.
I mean I think everything was well tolerated, so as the animal's doing this, and they puff in there too. I'm not sure why they musicalised this, I didn't realise they did this, but they put music to it. So we did and then very useful, we used to the sounds a couple of times a day, and that went well.
And before we did this, we did some positive reinforcement training, so we didn't just walk up to the rabbit with a with a pufferful or whatever else, so we provided them with the Eat and we got them to train the rabbit, to accept it over its nose, all the time, because one of the big problems is, is. If you Frighten the rabbit too much, because one of the things rabbits do is go into apnea, and what we don't want when we're trying to aerosolize a drug is an apneic rabbit, so we had to get rabbit to be quite calm, which he actually was, he trusted them a great deal, and he was absolutely brilliant with it, and they gave him lots of treats and stuff, and once they got used to it, once it wasn't a hassle for catching, he was perfectly happy coming to them for the treat and for the E cat, then we could, then we could start the drug. We also got changes to the bedding and ventilation, so everything well ventilate as possible.
We got bedding onto paper, because we weren't sure what was causing irritation and all his hay and stuff was fed and wetted after that, so we got no dust. And he responded really rapidly, very rare cough after afterwards, and he used to respond rapid rapidly, and they gradually weaned him, we, we got him off the antibiotics quite quickly, they gradually weaned him, . Off the steroid as he could do, and then long-term maintenance, was very much if he started coughing or breathing fast again, he'd have a few days of puffing, and then he he would not have that anymore, and we just played around with that, just tippy like an asthmatic person, so, yeah, just be aware that things can be a little unusual, but not all infections, and sometimes we have to do is be slightly novel with how we approach those, especially when dealing with drugs with potential side effects.
It'd be very sad talk, I think we didn't have any ear cases, . So we're gonna start with the with the diagnosis really, aren't we? So again, 2 year old male male male nuer again, .
Everything working fine, they had one of the rabbit in the household but had for 12 hours had a head tilt to the left hand side. On examination we had head tilt to the left, we had no other neuros signs, no nystagmus, nothing else on the examination apart from that rabbit was flattened, and really tilted quite severely to that side there too. Our main differentials at this point are the obvious two, which are.
I seem to give me time to think about that. But generally we're gonna think about Econiculi, and we're gonna think about ears, particularly ears, so what tests are we gonna do for that? So we're gonna want to look at, What sort of ear disease we have, now for ears, we can, we we're gonna want an image, we can use a combination of radiography and ultrasound, which can work OK, but it also doesn't give as much information as CT and in these cases CT is absolutely unparalleled in how good it is, especially as it's really difficult to position these guys when they've got head tilts and stuff, so CT does slightly overcome that.
And we're gonna and do some bloods and just rule out Echiniculi if nothing else by checking with serology. So this is what we did, we did do some bloods, we did see an inflammatory response, which is again interesting, polyclonal gammopathy, and again another little thing to be aware of when doing these, these the these these cases, we talked about earlier on about very rarely having a big inflammatory response in the haematology of rabbits. We'll very often see it though in the proteins, and so protein electrophoresis is a really useful thing to be doing in a lot of these cases, and again gives some idea about quality and amount of immune response there too, so say a polyclonal gammopathy is quite intriguing here, if you've really read the textbook on ecuiculi, it should be having more of a monoclonal response, but very often there's other stuff going on, so polyclonal is not unusual, but it just means just means you've got chronic inflammation there.
And on serology, Echiiculi was negative on both IgG and IgM. Now that's some practical purposes given that Echiiculi signs are caused by an immune response, if we have got negative, serology, and we've got clinical signs that's really effectively ruling out E. Caniculi as a cause of those signs, because there's no body responds to it.
So that's quite good, so now we really are left with the ears. So CT. And I think we can see that we do have a CT diagnosis here and two areas really to look at picture obviously we withstand it a bit here, we've got filling of the ear of the external ear here, slightly tilted view, filling of the external ear here there, we can also see we've got filling in the middle ear, which seems significant, and we've got some thinning of the bone in that middle ear as well.
Which again suggests some degree of chronicity to this, possibly some degree of active infection, which fits very well with the, inflammatory signs we're seeing. And the other thing we can notice, we can have a look in the inner ear, and this is why we're getting the head tilt, because the head tilt is really a sign of inner ear disease as much as middle ear, and we can see we've got changes there as well, so that's a, we do now have a really positive diagnosis of inner ear disease. What we can also do for that material then is we can sample it.
It's also quite a good thing to do in these cases. Again, very many of these cases can be simply build up a currument and pressure changes and things in there as much as we're gonna see, inflammation. So we can take a low power look there.
What we can see we've got a lot of material, we can see cells and high power, we can start seeing broken down, . Inflammatory cells, we can see microorganisms kicking about there, so our index suspicion for otitis are really quite high at this point. Contrast that with the right ear, which you'll sample at the same time, much lower cellularity on that slide too, and again, go at a higher power, and again you've got a few, you're always gonna get a few, bits of, some microorganisms living there, but you've got no cellular response or anything like that.
So again, good good contrast there. Culture from that left ear, slightly unusual to get pastorella in the ears, but most of them tend to be Staphylococcus, but pastorella can be a cause of otitis in rabbits, and again, typical pastorella, really very few sensitivity, resistances in there, it's very sensitive to most things, unfortunately our industry standard of TMPS it's sensitive to that, which is great. So therapy, well, we've got the nice thing about cytology is we got that out quite quickly so we can start things very fast with that.
Obviously we're not using good old panicure or whichever version of Fenenazole you wish to use. We could start trimethor and sulfonamide quite quickly, subcutaneously, move on to oral, and we could also start a non-steroidal because, you know, there is gonna be inflammation there, there is gonna be discomfort, and I think it's probably wise to do that at a start at a reasonable dose. In the acute case of head tilts, I like using midazolam.
I think generally what I've looked at, and this is probably anthromorphic, but at the same time I think sometimes it's fair to do that, is they do are panicking, they are really frightened. And a bit of midazolam just to calm them down, settle them down there seemed to work really well, and we use ranitidine as well, and this is because in in people, I'm sure anybody who's had middle ear disease will know really things like nausea and stuff are really quite nasty, and rabbits can experience nausea, they can't vomit, but they can experience nausea, so we used to use, these days we'll probably use Moropotent instead, and that may have an additional anti-in. Inflammatory effect but certainly will, will be a very good anti-nausea drug.
Once stabilised, we wash the ears with saline under anaesthesia, and this is a my standard approach to virtually all these cases just to wash them out, remove that material, just flush through there, and you can see with the syringe there you've got with white curumin coming out as well. And in this case, because we had the cytology, showing we had inflammation, and the CT indicating the same and the blood work, we placed an ear wick. Now these are I've really liked a lot because and but in true otitis cases and this is because we can actually put the antibiotic into the ear and into localised so we could stop systemic use and really just concentrate on treating locally with this.
So we placed an ear wick and then after a week in place we we we took it out and rewashed it again. And ear wicks, in case you're not aware, are these, sponges, they become a dry sponge, and you basically put them in place and you expand them with an antimicrobial, and typically I would use TMPS, . Nice water soluble drug and no real low toxicity to it either.
He's like triotitis, I'm gonna leave him for no more than a week because rabbits do granulate like mad, and longer than that we did find they they they did cause a lot of reaction and it can be quite hard to find and remove. So this just goes in there because it's like a square dry sponge beginning to expand. And we can see as it fills up with the antibiotic, it becomes like it sort of fills the whole area with this soft sponge and was actually quite well tolerated and did provide a a really good intense antimicrobial treatment for the truly infected ear.
For the curriin filling ones, obviously it didn't do much help at all, so we didn't use them for those at all. Bear in mind, other causes of head tilt and ear damage do happen, this is a just a single case, very sad one, a rabbit got trapped in a folding, sofa bed, and what we can see is that, it, it, it came with a marked head tilt there, we can see this is blood through the middle ear and the external ear, and we can see we've actually got a fracture of the bulla, just about to see it on, on, on here as well, just through there, and, we actually had a, A contralateral fracture in the skull as well, and so this guy didn't make it, but you can see the type of injury you might have and the prognosis is pretty well said by that picture. Mention about Echiiculi, and I think it's worth just digressing quickly into that too.
Echio diagnosis here we're using serology, and it's really a difficult one to diagnose, so, It's very hard to do by signs because it's so nebulous, and typically we'll talk about a head tilt being one of the big signs of E. Coli. In reality it's not, it's not a predilection site for the the for the for the parasite or for the fungus.
You can do it by rule out, in fact one of the best ways to do is ruling out, other diseases that could be, differentials there too, but it can be concurrent, and the big thing not to do is to respond to therapy because many of the things will wax and wane. Especially ear disease, so you know you can be fooled by, apparent response to panicure, serology has said is very good, and it's very good particularly at ruling it out, it's not always good at ruling it in unless you've got both IgG and IgM raised and the right signs. You can use PCR but generally by the time you've got that immune response going, you've got the clinical signs, they've stopped excreting it, so very often you get negative PCR in urine.
And sadly you can't really do, you think CSF might be quite good, and it says CSF tap in this rabbit on the right, but it doesn't work very well. It does, it always seem to be negative in those cases, which is again surprising. This is actually what I found echiicli generally looked like, so this little rabbit wings you see this very fine tremor, it's gonna start at the beginning again, you see a little tremory head, and that was much more typical of Echiniuli cases I saw.
And when you go back to some older papers and find that the predilection site for echiniculima brain is actually the cerebrum. And of course if you think about it, we all think about focal disease with granulomas, actually you're gonna get millions of spores being placed and being being released and taken in, we're gonna get more diffuse disease from multiple, multiple tiny granulomas than actually this is the sort of picture that's much more realistic, and many of these would come up to IgG, IgM, so generalised neurosease, with central signs are really what you're looking for for your echiiculi. Peripheral signs very, very unusual to be kiuli, and head tilt again, pretty unusual to be that.
So cardiac cases, one I have presented before in a webinar, and it's one of my favourite cases, so that's why I do it because it just hopefully shows what's possible. So I have a 5 year old female neuter rabbit, very quiet, came with weight loss, and our initial workup revealed this, . Weight loss in rabbits is probably one of the most typical signs of heart disease, and the main reason I've always felt is that this is such a big space occupying lesion in the chest, very hard for him to eat past it, and of course very hard for him to breathe and eat eat at the same time, so he found it very difficult.
So, big globby heart, we can measure that in rabbits, . And do a vertebral heart score, scoring is very similar to dogs. The trouble with this rabbit, of course we couldn't do that very easily because we had this, these spinal lesions as well, and these are typical old .
Handling injuries from when very, very young indeed and it's amazing how many rabbits do have these, it made it very difficult. Different rabbit, which, again heart disease case, but you can see we measured that too and we can actually get them from typically from T1 or T2 rather, we can actually measure the, the VHS. So having enlarged heart, we then did ultranography, found we had dilative cardiomyopathy.
Bloods were pretty unremarkable, but we just investigated, you know, much as we would probably do with any other species. Popped on to rest initially, always a good thing to do with heart cases to restrict them, get my heart, get back settled again, not overwork it, added an ACE inhibitor, and everything seemed to be OK. We also gave Metaca and tramadol for the, spine and to keep things more comfortable.
And everything went fine. 6 months later we had did several checks, we had a recurrences signed, suddenly became much more lethargic and had some funny terms as well, as well as a dysrhythmia. And like everything else, we have a dysrhythmia, let's do an ECG, we said we had a skin lesion on the back there, which was totally unrelated.
Now, the trouble with rabbits is they've got a very, very rapid heart, very small ECG complexes, so you do need to have a really sensitive monitor, and, a digital ECG is definitely in order for these cases. And if you've got atraumatic clips, that really does help with rabbits because they don't like the full crocodile clips, they do get very upset by those. So atraumatic clips are really helpful.
And this is what we've got. So, brief pause, while people will consider this ECG I don't know if you want to get your rulers out, along the thing there, one grenaceous one millivolt and it is running at, I think. I wish I hadn't started that because I can't remember what the actual time spacing is too, but take it from me it's pretty rapid.
So, go through this, looking through it, we've got, heart rate of approximately 350 a minute. It's irregularly irregular, as you can see from the spacing of the S waves. The axis is pretty hard to measure as well, and the axis probably in rabbits, it is not really well calculated and probably not worth worrying too much about.
We've got no clear P waves in there, not associated with each complex. We might have a bit of an F wave going on there. So in most species that would give us a diagnosis of atrial fibrillation.
So we do what we do most things, we already had an ACE inhibitor, we added in Pimmbendan to make sure we had, hopefully improved output, and then a beta blocker two of atenolol just to try and address that fibrillation. We calculated doses or estimated them from, dog doses and then rechecked a week later. What we can see is we're getting much closer to, normal rhythm.
So we've got P waves visible now. We've got, most complexes do have a P wave. You can see it's slower, it's about 240 a minute now, which is much more normal for a rabbit, and it's irregular-ish, and we've got P waves, so that's really showing we're getting somewhere.
What we do with that, so rabbit lived another 2.5 years, which is great, mostly in normal sinus rhythm, we did a few more ECGs. Throughout most of that time, was in really bright, really good condition, fantastic owners who were able to do all these these give all these tablets and treatments and things, and they really had no further episodes until a final collapse and when they decided, OK, fine, we had a good run, and that's been been time to stop.
So really nice what you can do sometimes, and, you know, you can approach it just like you would a dog or even a cat with these problems too, and you can give a reasonable quality of life. And the other problem was too we did have with the Pimmbendan is that the producers switched from the non-tasting tablets to liver flavour and certainly I can tell you rabbits don't like liver flavour tablets. What we do have now is you can get liquid form from one of the compounders and that's really useful in these guys.
So we're gonna do a few fractures now. I dreaded fracture cases. I was never an orthopaedic surgeon, I never felt very comfortable with it.
So, these are always I would class as tricky cases, but also because we know rabbits are not nice animals to deal with fractures for, they've got dreadful bones, so very thin cortices, very brittle bones, so their fractures tend to be very complicated and can be quite hard to deal with, so. They also have a weird calcium metabolism, and if they stop using a limb, they will tend to take the calcium out of it, which again another good reason for non-healing, they will also often circulate bacteria in the blood, so these are great places to start getting abscesses and infections too, and overall they just respond really badly to fractures, so these were the cases I dreaded. So we're gonna start with this one, it's very typical .
Place to break a leg, the lower third of the tibia is typical fracture, very typical for RV fracture too, you can see it's quite complicated, it's spiralling, we can see few little cracks and things in there too, and these are not nice fractures. Now you've got no option here of using external captation of things because you've got to try and immobilise high up the joint as well, and you're not gonna get a bandage or any casting stay on above the stifle, so that's something's not gonna work. Similarly, there's also very little tissue around that bone, so things like resting them isn't gonna work either because it's gonna be just inherently unstable, so it really doesn't work, so you are left with a choice of either amputation, if, if people aren't fancying going for the fracture, or it's too complex, or too much collateral damage, or it's open, or an internal repair.
The internal repair, you're really looking at obviously maintaining bone length, you're looking at maintaining bone rotation and things, so typically we would use . an intraillary pin, if we could place it normal grade, we would, so down from a stifle and, and, and, and into the, in the bone without opening a fracture site, something we'd place it retrograde through there, and what we then do is tie that into the external fixator. What we're using here is a fessor device, and this is developed for finger, fractures, In the French army and it's really light, these are aluminium frames, and if you're like me and not overly fond of orthopaedics, these are just fantastic because you've got guide holes for your pins and I absolutely loved it for that if nothing else, and then at the end of it you can put your pins through there, so you've got 3 pins into the bone, and we've got the the end pin through a stifle.
And we've got a device that looks something like that, very, very light, very well tolerated. In this case, we're using little, screws that come with it to secure the, pins, and but we can also do is we can use, ESF putty to do the same thing as well, a little bit more robust at times for for for for dealing with rabbits, but either way it worked absolutely perfectly. And then we'd manages obviously with analgesia, we would rest, we did like moving a little bit because it kept the bone moving, and we also found that things like calcium and management was really important in these cases, so we would supplement with a calcium and activated vitamin D supplement, just so we were, they had a lot of calcium in them and they weren't.
Attempted to start removing the calcium from the bone and getting non-union. And what we generally do with these is we would remove the external fixator after about 2 to 3 weeks, we re x-ray, make sure we've got some healing going on there, remove that too, and then the intramedullary pin would come out probably a couple of weeks after that, so we're looking to have them healed in around about 1 month. And that generally worked pretty well.
Part of that tree was rest, and this is the other fracture we saw an awful lot of, and that was a femoral fracture, and generally in giant rabbits, and we get it usually been dropped and we used to get these these mid-shaft femoral fractures, again pretty complicated in cases, and, very difficult to deal with. Now Again, you can repair these with difficulty sometimes, nasty ones to open up and go to open because there's so much muscle around there, and a lot of bleeding and stuff. This is a bit of a cheat slide, this is actually a guinea pig femoral fracture, it's very unusual, but we, we did see one and this is it, in this case you can see the ends are nowhere near each other, so we did have to do, you can see almost few too, we did have to put a pin through there, but even this is not the world's greatest pinning by any stretch.
But even a simple pinning like that because there's so much muscle around it was really, great at, just, just healed together because you put the ends together. In many cases, amputation is advised on these cases, it's difficult to repair, the bones aren't great, and, it, it's tricky, but there's often other issues going on as well, and actually we found that just plain rest worked really well, and especially when we go back to these slides here, in both cases, this is a nice simple one, this is a much more complicated case, but you can see the ends are very close to each other, there's a lot of overlap here too, there's not much distance between them, and nature is very good at putting bits of bone back together again. And especially in a case like this is one of the giant rabbits with a femoral fracture, when you X-ray the rest of it thinking, well, can I amputate, can I do whatever else there, is you find there are many issues going on there, you don't want to destabilise the whole, the whole movement, the whole body with that.
And this is what you get after a few weeks, they're generally tolerated it very well, pain relief, close confinement, really seem to get very well, and this was the x-ray, we were really thinking, oh gosh, is it just not uniting, and we CT'd and we started seeing, you could see a beginning of calcified union and certainly a lot of fibrous union occurring between these ends, and this rabbit did really well, and once they've joined together, the bone remodels, although it's never perfectly long, it's never perfectly healing, they get about really, really well, they cope with that extremely well. So just an option there if you can do that. If you are amputating, techniques very much the same as with dogs and cats, don't forget to assess contralaterals and in in giant rabbits assess that spine as well.
There's a lot of rumour about whether you can do forelegs or hind legs, the answer is you can do either, both are fine as long as you've done the evaluation and the other legs are up to tolerating that too. Generally, I would amputate through bone, so I'd go just approximal to the elbow, proximal to the stifle, and then suture muscle over the end of the bone so I haven't got sharp edges on the skin, so a lot of subcuticular stitches, sutures, and a lot of local anaesthetic used in that too, but in this case in particular here it's a fibro sarcoma, at the top of the humerus there too, this is the one we did actually strip out the whole, scapula, and, remove everything which sometimes you have to do. So basically there are options, and even when things don't seem to seem bad, if it's a good padded region, if the ends are close to each other and it's stable enough, you can sometimes rest them through it.
Next we're gonna talk about is an unusual subcutaneous mass, this is a 3 year old male, neuter again, soft mass on the right-hand side, very well in itself, no problems moving, even though it's quite a big mass, and lived outside in a hutch and run. On examination we can see it's a very big mass here. Over its right side, very fluctuent, but in a good body condition, so brief pause again while you think of some differentials.
Just a brief pause, and this is what I was thinking of, abscess obviously, you know, it's a rabbit, some fluidy sort of flexulent mass that, you're really thinking abscess almost every time, maybe a cyst, maybe a developmental cyst, quite a relatively young rabbit, could be hematoma or trauma, blocked lymphatic drainage, a little unusual in localised fish like that too, possible, and even again though young, you do think about neoplasia, sometimes unusual signs. To investigate, well, typical for us, you know, imaging, and we might think about X-ray, but with soft mass, not always great. CT was, was declined in this case on cost grains, but we've got fluidy mass, ultrasound, fantastic, we can, we can ultrasound masses too.
And of course we can put a needle in there too, we can draw some stuff out and we can do cytology, find an aspirate, that kind of stuff. So let's see what X-ray, we did do an X-ray, we can see the limit of a mass there you can see if it doesn't help there too as a side issue, we have got something happening in that spine which become a degenerative lesion, which was interesting given that rabbit had no trouble moving, so just be aware that sometimes you will find sort of comorbidities going on. Ultrasound was really interesting, lots of fluid, not much happened there too, and these structures within it, there were quite a few, and they would, if you wobbled the the the the the structure, they would move around as well.
So we withdrew some and we've got this very clear fluid coming out there, when you look, we have these white lumps, and hopefully we're getting to what the diagnosis is quite quickly because when we put them onto a slide, we don't need much microscopy to see that these are parasites, these are tapeworms, this is a tapeworm cyst with tinea serialis. Not a common diagnosis. In 30 odd years I saw two cases, and that will happen from time to time, quite unusual.
The nice thing is that treatment is really, really simple. So Praza Quanto, 10 mg per gig, already twice a day, already on two occasions, 14 days apart, they just disappear, they go. Important is control, because the infection's picked up from dogs or foxes and the the the eggs are coming out with faeces and rabbits obviously ingested those, in this case, all the dogs in the household have been wormed up to date, including tapewormer.
But there were foxes about. The rabbits were outside. There might have been the run moved on to an area we had some fox faeces contaminating it too.
It might even be the hay brought into, into there had also been contaminated as well. So it's always a possibility with that too. So foxproofing really important, especially keeping rabbits in the garden.
And while sticking to the skin and some masses, this was a really unusual case. So nine year old male, lots of small lumps on the legs, some scurf, well in itself and not reported pruritic, which is really important. Pruritic don't always show, but rabbit wasn't scratching and very, very good owner who, who would have noticed if there'd been any excessive greening or anything like that happening.
On examination, we had lots of small subcutaneous nodules, a few millimetres in diameter. There's no hair loss particularly, but while we pull that and look at things. There was some erythema, there were some areas of scurf and scabbing.
And he was slightly thin as well. Some pictures, we can see, we've moved from here, we see erythema there too, and we can see these little masses through here. So pause while we think of some differentials.
Don't you love skin, it always looks the same, until it doesn't one day. And this is scabbard area too, so scabbard and scarf on a different part there too. It does look pruritic, but nothing reported.
And again, the other thing too, rabbits, is when you're feeling around, you tickle them a bit and they often scratch, in this case, no reaction at all. So these are my differentials, the first one being what the hell is going on? You know, as well as skin case thinking I do not, I've never seen anything like this before.
Think about pyoderma, I've seen a few cases of pyoderma, which in some cases like is primary or. The primary causes disappeared, did think neoplasia because older rabbit, and also sebaceous adenitis, we see a couple of cases sebaceous adenitis a year, they would show with scurf atypically, not usually in nodules, but I think well, could be the first one. So what are you gonna do in these cases, what, what's the obvious test?
The nice thing about skin is you can get to easily seen do lots of different tests, well, this is my, one of my bits of advice is, if you're seeing a what the hell is that lesion on the skin, I would always biopsy it, and biopsy for histology and for culture if at all possible. Worse than bloods, just because the, we're looking at generalised changes, we could be looking at a reflecting internal disease, and also things like scrapes and acetates are always useful. Now bloods were unremarkable, scrapes and acetate showed nothing as well.
Culture, nothing grew, and the biopsy was fascinating. We got p granulomata, and the other thing which again I had to look up, I've cut this out of the internet too, so it's this lendori Huy material, and these are these really odd precipitates of form and tissue around either microorganisms or foreign bodies. No sign of foreign bodies in this case, but coccal bacteria, and so presumption was it was probably a Staph aureus, it hadn't grown.
And staph is a good, good thing, I think, oh, it's very common in rabbit skin. So why not? So, antibiotics in order, put on TMPS and things got worse, so we changed onto Marbifloxin, we had a marginal improvement.
Now again with skin, it's just like in everything else that wouldn't, give up on antibiotics and had at least 2 weeks of it, so we were probably about 6 weeks down the line here and had only marginal improvement, which wasn't very helpful. So, what are we gonna do with this? Well, our hope was.
We should be able to have a better response than that too, and we're kind of missing why we're getting this too. We've always been looking at infections, well, what's going on, what's happened? I made a little bit of a worry about we have insect bites, what, what have we missed?
I also felt, well, hang on, is it worth resampling because if we've cleared the bacteria out of the way, maybe we're gonna get to a primary lesion behind that, and after this period of time, maybe that's what we're gonna be dealing with now is primary disease. So we went to resample, we went to rebiopsy, do the same again. So what do we have this time?
Well, we had nothing on culture. Once more. Once more we had pyo granuloma to them, and again with splendoria hooky material, still no sign of a foreign body in there too, but this time pathologists felt we might be dealing with streptococci rather than staphylococci.
So we then thought, well this is weird, similar pattern, it's obviously consistent, whatever's happening, we're not getting to it, what next? So we did, something called fish, which is one of these in situ hybridization tests looking for what DNA of bacteria we could find in there, and this was felt it could be Rhodococcus, but most likely streptomyces, and this is really unusual. It's soil-borne, it's not really a pathogen, but it can opportunistically cause things too.
So we moved on to an injectable penicillin, and there we did get some response. Unfortunately, after improvement we then had a head tilt presentation, and when we did the CT we can see that we've got exploded bulla here, we've got osteolysis, we've got Basically breakdown here, and in this case, this is one of those cases where we can't flush it out there, but if we do flush, we're gonna flush material from middle ear into the surrounding tissues. The fact the bone is obviously osteomyanalytic, shows we've got active infection going on, we've got to do something about it.
And these are the cases where we're probably gonna look to do actual marsupialization. We almost, we're gonna do bullet removal basically, and we're gonna have to do major surgery on this case, and it was felt really with everything going on there this was time to stop and we stopped. So why do we, we put to sleep?
The main reason is because we never found out why we had all these problems, and streptomy is not pathogenic. It's soil-borne, it's really common, and disease from there, and people get these things called actinomytotoma from it, which is what this looked like, these little subcutaneous or little little bacterial slash fungal abscesses, and they get this when they're really immunocompromised. So we think this is probably what's happening with rabbits, something was immunocompromising it.
Was this also in the ears, was it, was this streptomyces moved into the ears, again we never find that too, possibly the ears could have been the cause of immunosuppression, but unusual for a rabbit who's quite well in himself, to have that degree of immunosuppression from ears and things. So we really felt something else was happening, something else was going on, and really low immunity for everything too, and when we have a situation where we needed extensive surgery for the ears with ongoing, skin condition linked into some immunosuppressive cause. Sometimes you have to say, right, it's time to stop, we haven't got an exact diagnosis, we haven't got we haven't got we haven't got to the root of everything, but we've got enough suspicion there's something bad happening inside that it's time to stop there too, which is always a little bit unsatisfying, we can't say exactly why, but you just know there's something there.
And overall in veterinary medicine, prognosis is really key and probably more important than diagnosis most of the time. So again, we did a posh test, we did one was expensive, which actually the clinic could bear the cost of, which is great because it's really interesting. Did it actually help?
And actually in this case, yes, it did, it's very useful here too because it started telling us there was a big, big issue going on there. If we hadn't done that, we'd have mystery piogranulomata. Here we say yeah we know what's causing them, and we now know there's something big and immunosuppressive behind it that's causing a major problem as well as that, and we just haven't got to grips with that one too.
I'm gonna finish just with a weird lesion just because I love imaging so much too, and this is a rabbit who had . Weakness really, just generally weak, so we, we did a CT, we did the things we probably should never do is a body scan, see what we could pick up, really looking essentially we're probably looking for more signs of, orthopaedic problems of osteoarthritis, things like that to do more than anything else there, and we found this, . And we can see these, calcified lesions through here, and, again, Along through here as well, and We do 3D reconstruction, we can see it's beautifully as tubed through here.
So what is this? Again, brief pause for reflection. We'll go back.
And what we're dealing with, these are blood vessels, so this is the aorta, these are the great vessel emerging from the heart, the aorta nice long through here too, and this is calcified, probably, can be linked into, Cholesterol deposition in the blood vessels becoming calcified, so arteriosclerosis type of lesions, but overall not a great sign, and, not something we really do very much with, we did try amending, the diet wasn't particularly high in calcium, so we couldn't really take that much calcium from there too we tried giving some general supportive treatment, but obviously things are pretty well advanced by the time we get to that stage, but interestingly, Asian and just sometimes you do pick up weird things when you do look at a more generalised picture. So in summary, obviously difficult cases happen, we don't all follow all the rules, and actually one of the big things about dealing with rabbits and exotics and things in general is sometimes you actually have to write the rules, to, to, to, to, to, to get somewhere. And if in doubt, discuss it.
Have a chat to people, amazing what people have picked up, amazing what parallels you've got with other species, so discuss, always discuss as well with the owners, of course, and there's no harm in saying this is really weird, this is, unusual, we haven't seen this before, this is how we think we're going to investigate too, it's what we're looking for, this is why we're looking for it. It may come up with a negative result, but this is why we're trying to do it, that's really important people understand that you're managing their, their, their, their expectations as well. And you're going to basically .
Assess your ability to investigate too, and your ability to be allowed to investigate as well, but, overall, if you're in doubt, you can always treat as if they're a dog or a cat, how do you follow it through, how do you investigate, how do you treat, what trials do you do, what sort of similar lesions have you seen in those, that's quite good. And the big deal of all, when you see something unusual, and you do get something described from there, is do publish these, because the more it's published, the more body of information the rest of us have to be able to investigate these and we don't always see everything for the first time. Thank you.
John, as always, that was fascinating. I do like your imaging toys though. Those are really neat, especially that last case.
So thank you for sharing those with us. Peter, would you share your screen and come in here before we hopefully have a little bit of time for questions? Thanks John F, that was again another fascinating er presentation, and thank you for sharing your immense experience.
I had no idea what the content was gonna be tonight, cos, we don't kind of content control what John says, so. I just wanted to share some of the work that we're doing to help owners make the right choices when it comes to looking after their rabbits. I'm gonna be fairly brief hopefully you should be familiar with or hopefully familiar with the the Excel feeding plan you can just see on the bottom of the slide here, around feeding her nuggets, .
Nurture snacks, some fresh greens and fresh water. And that's what we've been doing for, for a, a long time, you know, trying to get people to look after their, their pets, their rabbits in the right way. And what we continue to do is continue to innovate around that and, and look to, to build that and, and actually, as I say, help owners make the right choices.
Clearly the main part of the diet should be feeding hay, 85 to 90% feeding hay, . One of the things we did probably getting on for a decade ago now, it doesn't seem that long is actually to call our hairy feeding hay. And that that helped owners make er the right choice and understand that hay, is for feeding, we had some misconceptions back in the day that this was for, For, for bedding, I remember one focus group where the owner said that they'd stopped giving their rabbit hair, because it was eating it.
They thought it was just for sleeping in. These are two new products we launched the back end of last year, Long stem Feeding hair, which is one of our most popular products, but there's now a variant with an addition of Marigold. And I remember a webinar that we did with Gwen Bradbury, .
Couple of years ago now, while Timothy Hay's great and you know it's really palatable, offers, all the benefits that we'd expect in terms of providing the fibre and, and the dental benefits, it is kind of, we are at risk of creating a monoculture for the rabbits, and therefore what we're trying to do is also give a a meadow hay offer which is different mixed species of grasses. And this is one of the other new products we launched at the back end of last year, . Which kind of mimicking some of the things that the animals would find, the rabbits would find in the hedgerows, so that's got dandelion and nettle in it alongside chamomile and mallow flower, and just by offering that range of these feeding haze labelled as feeding haze, what we can help do is is make that an attractive proposition for the owners, and they understand the importance of that in their diets.
We've also launched, the mini bales, . Launch the two new variants coming out now, one is a a twin pack mini bale with Marigold, and we're working with an influencer on, on that, and then we have a chamomile variant as well, . Just share the, the video.
Working with the influencers does actually allow us to to reach a new audience. Now, I'm a little bit old for for TikTok and also for Instagram. But what these people can do is.
Give us a a a great new audience. And these these mini bales are a great way to actually, the owners think they're given a treat, but it, it's 99% hay. So again that that's a really good way to kind of get air into the into the animals in a in a fun way.
When we're looking at treats, we see lots of treats that are marketed for all small animals they tend to be quite low in fibre and then we also see things like yoghurt er drops and lots of things with with with sugars in and things like that. What we're trying to do through Excel is actually have appropriate treats so the range here you can see are all grass based and again they are palatable the animals really really go for them. But what it does do, it allows us to still get a appropriate levels of fibre without upsetting them.
The the things that we put into these products are what the animals would eat and, and have they've kind of evolved to to eat. And again, the attractive packaging, the wide availability of them, it, it is something that we, can get owners to start making the right moves. The one on the left there, the Vegeg Patch Bites, is literally just being launched, and that'll be, available on our website in the next couple of days.
So that's new news. And then, clearly, After all the work that's been done around selective feeding, we're still looking to to move people away from muesli. There's still a double figure on percentage of owners who are feeding muesli and when we've looked into this actually there are two things, it tends to be the owners who have, bought their animals for, for their children and they're attracted to the product because it's seen as being more fun and more interesting, product.
What we do have, at, at Burgess, it's not Excel, but we do have an entry level range, . Which follows what we're trying to do with Excel but is a little bit more accessible a little bit more affordable and attractive to the the owners who probably, as I say maybe have the animals for their kids. We have the nuggets which are single component nuggets, and we have the guinea pig and rabbit variants, we also have a hamster gerbil mouse variant.
We have bedding here and feeding hay, two different types of hay, two different types of quality of hay, and that helps the owners understand that there is a difference between bedding and, and feeding hay. And also at the bottom there you can see that we've got the treats, again these are kind of grass-based treats, high fibre treats, and that's a, that's a different range that we have to attract and, and, and get owners who are maybe just starting with their animals, not as well educated and getting them to, to move on to. Onto looking after their animals in the, in the right way.
And that really is my very brief bit. I know you'll have some questions. We have 3 QR codes here.
There are 3 different things that we're trying to, we're trying to share our knowledge and build our understanding on the left. It's where you can sign up to our vet portal and then you can download, digital versions of the posters that we have, and the care guides. Clearly, this year would this time of year would normally be at the SAVA, but unfortunately that's no longer.
So in the absence of the SAVA, please, download the, the posters and care guides there. We are launching a small animal census, that's a QR code in the middle and that's helping us to understand what owners are doing so please download that census census, photocopy that QR code or or whatever and share it with your clients, and we will be sending this out in, in emails and newsletters and things like that, but that understanding really helps us know what we need to do. And finally just the one on the right is for Rabbit Awareness Week which will be in late June.
And if you scan that then you can sign up for, for reminders there. That's it for me, hopefully there's still time for some questions and, thank you and good night. Peter, thank you so much.
If you wouldn't mind leaving that slide up so that people can scan those codes, please, I'd appreciate that. Thank you for your time tonight and a huge big thank you to Burgess for their generous sponsorship of this evening. Unfortunately, folks, we have run out of time, so we're not gonna get to any of the questions, but we will ask, John if he can reply to them on email and, Dawn will get those through to John.
I'm sure that he would be very kind in answering those questions for you. John, thank you very much and thank you, John, for your time as always and for sharing your vast knowledge. It is always a pleasure to listen to you, so thank you for that.
To all of you that attended tonight, thank you for your time. We really appreciate your attendance and, remember, the recording will be up on the webinar vet website in the next day or so. So if there is something you want to go back and have a look at, please do.
And, to my controller, Dawn, in the background, as always, for making things run smoothly. Thank you very much. And from myself, Bruce Stevenson, it's good night.
