This page directs you to a variety of non-infectious disease conditions in elephants: -bone fractures -botulism -colic -dental problems -dermatology -esophagus obstruction/impaction -esophagus spasm -hiccup -intoxication -lameness/orthopedic problems -mesenteric hernia -ophthalmology -perineal hernia -reproduction problems -tetanus -umbilical hernia Non-infectious diseases Bone fractures 'Hiccup' Botulism Clostridiosis Colic (abdominal pain) Dentistry Intestinal impaction Intoxication Lameness/orthopedic problems Mesenteric hernia Dermatology Edema Esophagus obstruction Esophagus spasm Ophthalmology Perineal hernia Reproduction problems Tetanus Umbilical hernia Clostridiosis I need your input to write these chapters: Bloat Constipation Neonatal problems Urinary/kidney problems Clostridiosis Tetanus Enterotoxemia Clostridioides difficile Malignant edema Black leg Clostridium novyi Botulism

Clinical examination is the fundament of clinical interventions. It includes extended anamnesis, observation, clinical examination, palpation, collecting samples (blood, urine, feces, mucosal swabs, skin scrapings, wound materials, broncho-alveolar lavage), ultrasonographic examination (ultrasound), radiology (X-ray), and thermography. Physical examination This chapter serves as a checklist for conducting a complete clinical examination. Performing the full examination as outlined here will not always be necessary. However, it is generally better to collect more information than strictly required, rather than risk overlooking something potentially critical. An excellent and detailed description of the complete clinical examination is provided by E. Wiedner (2015). Elephants can live for 50–70 years, and most will experience health issues at some point in their lives. Determining the exact cause of a problem—the definitive diagnosis—can be challenging. Due to the elephant’s size, not all diagnostic tools and technologies used in domestic species are applicable. Despite these limitations, the overall approach to patient evaluation in elephants is the same as for other large mammals. When presented with a sick elephant, the typical sequence of evaluation begins with taking the history, followed by a physical examination. If these steps do not provide enough information for a diagnosis, laboratory tests are performed. A list of possible causes—the differential diagnosis—is then compiled. Using all available information, we arrive at a final diagnosis and develop an appropriate therapeutic plan. . 1. History It is important to collect as much information about the history of the animal as is available. The information consists of the elements that are directly related to the animal and its surrounding and elements related to the presence of a disease. (Some) symptoms may be absent at the time of clinical examination, but may have been observed by the caretaker. Describe each symptom as clearly as possible. Basic background information: Age; if no data about the age can be provided, the age can be estimated by checking the molars. Gender ID-number Body weight Reproduction history and current status Management related data (single kept, part of a herd, part of bachelor group, natural- or hand-raised, previous diseases history, free/protected contact) Disease monitoring history (TB, parasites , Salmonella , EE HV ) Characteristic normal behavior Physical signs: Symptoms observed (appetite, drinking, alert/inactive/slow/lethargic/apathy, weight loss). Has the elephant shown signs of pain (colic or lameness)? Describe the part of the body, expression of the pain, degree of pain, frequency, throwing sand to the painful body part. Defecation: frequency, amount per defecation, description of feces (soft, firm, watery, smelly, size of bolus, well/poor digested). See also: Fecal quality control . Urination: frequency, amount per urination, description of urine (color, clarity, smell). When did the elephant lose its most recent dental element? Respiration: increased/decreased rate, coughing, discharge from trunk (describe) Salivation: free dropping saliva from the mouth? Has there been discharge from the temporal gland recently? Describe if seen. Discharge from vulva or penis? Describe if seen. Has the elephant been regurgitating food or fluids? If so: describe. Has the elephant shown signs of bloat? Has the elephant shown signs of edema (ventral part of abdomen, head, neck, leg)? Have there been signs of ‘ hiccup ’ or other forms of rhythmic muscle spasms? Has there been a temporary or permanent swelling in the perineal area? When were the above-described symptoms seen for the first time? Continuous or sporadic? Has there been any other disease symptom not yet described here? Are other animals showing similar or different symptoms? If yes, describe. Since when? Have there been traumatic interactions with other elephants? Have there been traumatic interactions with humans? Additional questions for calves: Has there been discharge from the umbilicus (navel) How long before the calf was standing unsupported after it was born? How long before the calf was drinking after it was born? Was the calf rejected by the mother? Describe. Was the calf accepted in the herd? Describe. Additional questions for reproductive females: If the estrous cycle is monitored: describe its pattern (luteal phase, follicular phase, estrous periods, regularity, absence/flatliner, lactation-related anestrous period). When was the last mating? When was the last calving? Were there any problems in the calving process(es)? If yes: describe. Has the placenta come off completely? Milk production: any historical problems in the milk production? If yes: describe. Additional questions for reproductive males: Has the bull produced offspring before? When, how often? Musth periods: age of first musth, frequency of musth, musth behavior, draining temporal gland, swelling of bulbo-urethral gland. 2. Physical Examination Start by observing the elephant from a longer distance before making contact with the animal. Evaluate its behavior with its caretaker and herd mates (alert, depressed, lethargic, aggressive). Describe its posture and demeanors. Any abnormal posture may be an indication of lameness. Make an assessment of its body condition . Then move closer and make contact with the animal (voice, feeding). Only start making physical contact by touching and palpation when the animal trusts you. The more the animal trusts you, the more clinical data you may retrieve from your examination. Thoroughly observe the animal from a shorter distance. Count the respiratory rate at rest (normal value 4-12/minute). As thoracic movements may be hard to distinguish, it maybe necessary to feel the exhaled air streaming from the trunk nostrils. Count the pulse rate at rest (25–30 beats/minute, standing). This can be done on a large artery at the backside of an ear or by auscultation in an elephant less that 2500 kg BW. Pay attention to the regularity of the heart beat. Look for gross lesions or abnormalities (wounds, swellings, lameness, abnormal position of a body part, vulva/penis discharge, urine loss, edema, draining temporal gland(s), salivation, trembling, spasms, colic, bloat). Does the elephant stand quietly on 4 legs, or is it trying to avoid body support on one or more legs? Elephants never stay completely still. Take the body temperature (normal value 36–37°C /97–99°F) by measuring the thermometer in a freshly passed fecal bolus. The center of the bolus provides a more reliable value than rectal insertion would. Examination of the skin: Check for wounds, edema, scars, swellings and warm areas. Wart-like growths are often present in (older) elephants and usually have no clinical implications. The same applies to (large) papillomas in the vulva of old female elephants. However, vesicles or swellings on mucous membranes should always be investigated. Old Asian elephants may lo se pigmentation on the edges of the ears, the trunk and even the rest of the body. In neonates, the navel should be inspected. The mammary glands should be part of the skin examination. Salivary gland: this gland can be observed behind the ears, where it shows as a round, firm swelling ( see image below ). In elephants that receive a natural diet, the gland is usually much bigger than in captive elephants, due to insufficient provision of branches. Examination of the feet: If the animal is well enough trained, it should lift its legs to allow inspection of the nails and pad of each foot. Check the nail cuticles. Remember that elephants have sweat glands in their cuticles. Cuticles should not be too short as this may facilitate the invasion of micro-organisms. However, they should also not be too long. Elephants seem to care for their nails by rubbing them along hard objects or their own legs. Overgrown cuticles may result in accumulation of sweat: when trimmed these cuticles or when pressure is excerted on the cuticles, watery fluid may be discharged ( see video ). The nails should not be longer than the pad, as they do not bear weight when the elephant is standing still nor during walking (see video) . Long nails can easily develop a tear. The pad of the sole must be thick and have a distinct pattern of grooves. When wear is insufficient, the grooves may become too deep and form an easy entrance for dirt and microbes, which may result in a sole abscess. Too much wear results in a smooth surface and a thin pad, vulnerable for deeper sole lesions. Examination of the eyes: Elephants have no nasolacrimal duct, so tears run constantly through skin grooves down their face. The area around the eyes is often wet. The cornea should be clear. Congestion of the scleral blood vessels may be an indication for heart failure. The iris of an elephant varies in color from tan, yellow, brown or combinations. Blepharospasm is a strong indication for ocular disease. Cataract (white central spot) and keratitis (diffuse, superficial cloudiness of cornea) is frequently seen in elephants. Vision can be checked by passing the light bundle of a flashlight (cell phone) from the ear over the eye (blinking reflex). Ophthalmoscopy in elephants is quite a challenge, as the animal will usually not allow this kind of close examination that moreover uses a light source. The eyelashes should be long in order to protect dirt and objects from touching the eye ball. Oral examination: If the elephant is trained to open its mouth, an oral inspection should be done. The oral mucosa should be wet (shiny aspect) and pink. Lesions in the palate may have been caused by eating branches and are not necessarily associated with disease. They should be distinguished from ulcers and vesicles. Vesicles may be associated with avirus infection, one of these being EEHV. The mucosa of the soft palate may contain several small nodules, which are assumed to be lymphoid tissues (see photo). Tongue: the surface of the tongue should be light pink, smoth and wet. The molars can only be inspected if the elephant is trained to open its mouth. Lower molars are harder to visualize than upper molars, as the elephant tends to cover them with its tongue and cheeks. Check the status of the molars (number, size, position). See also the dentis try chapter. Tusk examination: Tusks in most African elephants are present in males and females. The tusks of female Asian elephants are very small or absent and are called tushes. The bull's tusks grow continuously during his entire life (approximately 10 mm per month) Tusks should be checked for the presence of cracks, fractures, excessive wear and color. A brown color can be an indication that the tusk is not vital anymore. The sulcus should be inspected if the behaviour of the elephant indicates irritation in that area. See also the dentistry chapter. Examination of the circulatory system: Edema : common areas for edema in elephants are the ventral part of abdomen, head, neck, leg. Congestion of the scleral blood vessels may be an indication of heart failure. Heart auscultation : pulse 25–30 beats/minute, standing (72–98 in lateral recumbency). The heart beat can best be heard on the left side when the elephant has brought its left front leg forward or has lifted that leg. The heart beat cannot be heard in most elephants over 2500 kg. An easier way to measure the pulse frequence is by palpation of one of the arteries on the backside of the ears. ECG : by using a so called DUO ECG + Digital Stethoscope it may be possible to make an ECG while visualizing the heart beat at the same time, however, this method still needs to be validated (see photo). Blood pressure can be measured on the tail; the compression pad should be placed at the level of the heart. To obtained the best results with minimal bias caused by stress, the elephant should be trained for this examination. There are very few references of this parameter; one study reported an average systolic pressure of 178 ± 3 mmHg and a dyastolic pressure of 118 ± 3 mmHg in the unsedated standing elephant, with a mean blood pressure of 146 ± 3 mmHg. The blood pressure increased over time to when the elephant was positioned in left lateral recumbency. (African elephants n=7, Asian elephants n=8) Examination of the respiratory system : Respiratory frequency: 10-12/minute (standing) and 4-5 (sleeping) Counting the respiratory rate is best done by feeling the expired air at the tip of the trunk. Check the type of respiration: abdominal, thoracic, panting, forcing Has the elephant been coughing? Auscultation: lung sounds are hard to distinguish by auscultation in elephants (only in very young calves). Check the smell of the exhaled air for abnormal odour that may be associated with pulmonary disease. Check the trunk openings for discharge. Examination of the vulva: The vulva in elephants in the reproductive age should not prolapse. If possible, the mucosa of the vaginal vestibule should be inspected and should be pink and moist. Sometimes hyperemic areas and/or vesicles can be observed higher up in the vaginal vestibule. This could be an indication of a reactivation process of EEHV, which has no clinical implication for the elephant, but this could be a source of virus shedding. In old, non-reproductive females the vulva can be prolapsed, exposing the clitoris. The mucosa in these animals is often pale. Swelling of the vulva can be caused by edema (check by"pitting edema assessment"), hyperplasia or tumors. To page top Salivary gland of an Asian elephant kept under semi free ranging conditions, provided with a 100% natural diet. The temperature measured by placing the thermometer in the middle of a fresh fecal ball, gives an accurate indication of the elephants body temperature (normal value 36–37°C /97–99°F) Thermometer Salivary gland Blinking reflex using a smartphone's flash light in an Asian elephant with chronic keratitis Auscultation of the heart beat and the ECG in an adult Asian elephant by using a combined electronic stethoscope. The left front leg is lifted. The sound cannot be heard, but visualized by the electronic device. Visualization of the heart beat and the ECG in the same animal by using a combined electronic stethoscope. The upper line represents the heart beat, while the right part of the lower line represents the ECG. This method still needs to be validated. Blood pressure can be measured on the tail. Make sure that the compression pad is located at the level of the elephant's heart. Training of the elephant for this procedure is required. Small nodular lumps in the oropharynx are assumed to be lymphoid tissue and can be found in healthy elephants. Whether they increase in size during certain infections is not yet known. The cuticles, the lengths and the shape of the nails in this adult Asian elephant look very nice. Pedicure was never done in this animal. Cuticles The cuticles of this elephant were overgrown and had blocked the draining of the sweat glands. Pressing on the tissue resulted in the release of a "stream" of accumulated clear sweat fluid (for a better view, enlarge the image). The sole pad of this elephant has the right thickness as can be appreciated from the presence of natural grooves. African elephant walking in Namibian desert. Slow motion. Note how the pad and the nails form one supporting surface. The nails are not used for support. (Footage of BBC documentary) Video locomotion 0.5x A swelling of the bulbo-urethral gland is sometimes seen in the perineal area during the musth period Full vulva relaxation in an old Asian elephant. Note the slightly pale mucosa. Firm mass in the vulva of a 19 yr-old nulliparous African elephant. The mass could be retracted into the vaginal vestibule. This animal was a flatliner. Poor digestion of long fibers in an old Asian elephant with molar teeth problems (rotated and insufficient dental wear. See also: Fecal quality control. 'Hiccup' in an adult Asian elephant bull 3. Laboratory tests Feces: Points of interest are: amount, frequency of defecation, size (small sizes are seen shortly before parturition), consistency, degree of digestion (long fibers are seen in elephants with molar problems), presence of sand (can be palpated or washed out in a bucket filled water), presence of blood, mucous or parasite. A fecal sample should be submitted for parasitology or bacteriology if an intestinal infection is suspected. These samples should be submitted fresh. In case of a suspicion of intoxication, a large fecal sample should be submitted to a relevant lab (always check the possibilities of the lab before you send the sample). Feces quality control Urine Blood Collection Blood (hematology/chemistry) Discharged fluids Wound swab Oral swab Vulva swab Eye swab Trunk wash sa mple Skin scraping Biopsy 4. Additional testing: Ultrasonography : ultrasonographic examination is possible in trained or sedated elephants to assess the reproductive organs and the kidneys, for pregnancy diagnosis and to evaluate abscesses and joints. Measuring the thickness of the foot pad will provide useful information about the degree of wear of the sole. Transcutaneous ultrasound examination can give some information about the liver, intestines, uterus and fetus. Transcutaneous ultrasound examination to assess the internal organs can only be performed in the small triangular window between the caudal side of the last ribs, the pelvic bones and the ventral midline. For good visualization, it can best be done while water (for example from a hose pipe) is running over the skin of the examination area; the ultrasound probe should be kept in the water stream. Drenching the skin with water before examination is also a good option; the probe should be well covered with ultrasound gel. Transrectal ultrasonography is used for examination of the reproductive organs, the fetus and the kidneys. The rectum needs to be cleaned out as much as possible by manual removal of the feces. Best results are obtained after flushing the rectum thoroughly with running water from a hose. Convex 1-5 MHz probes are best used for transrectal and transcutaneous examination of the abdomen. Linear 5-7.5 probes can be used for visualization of the ovaries during transrectal examination. A probe extender is helpful for reaching the ovaries. Special designed metal extenders have been developed. If these are not available, a home made extender can be tried. Ultrasonography is a useful tool to diagnose ocular diseases. The cornea, anterior eye chamber, lens, posterior eye chamber and retina can be visualized with linear or convex probes 5 and more mHz. The probe can be placed on the closed eye lid or on the cornea, in which case local anesthesia is required. The mammary gland can be examined transcutaneously using a convex 1-5 MHz probe. The thickness of the skin and more importantly that of the sole pad can be measured by ultrasound examination. Monitoring this thickness over time can help evaluate treatment started in case of abnormal padthickness. For pregnancy confirmation, click here. Thermography Thermography is an imaging technique using a specialized heat sensitive infrared camera, mapping body surface temperature changes which may indicate inflammatory, vascular or neurological disorders. It is a helpful tool to diagnose from a distance hot spots that are correlated with inflammation and abscesses in the elephant limb or any other place of the body. Click here for more technical details. To page top Hematology and urinalysis manual Transient hot spot (31.4°C) on the left thigh of an adult Asian elephant 1 day after vaccination with Modified Vaccinia Ankara-strain (MVA) Thermographic image of normal elephant feet Thermographic image of a swelling of the left front leg of an Asian elephant with severe chronic lameness. Note that the hot spot is on the proximal part of the abscess. Click here to download an overview on the use of infrared-thermography in Asian elephants by Kumar, 2024. 5. Radiography Most indications for radiographic examination are related to foot problems, anomalies in the carpal and tarsal joints and rarely more proximal joints. The reason is obvious: the elephant leg is too radiodense to allow sufficient penetration of the X-ray beam. A powerful portable X-ray machine (100 kV or more) is required to visualize the bony structures. Digital plates largely increase the quality of the image. It is important to work under safe conditions, which often requires training of the elephant to collaborate with the procedure. Fractures and joint anomalies of the carpal and tarsal areas and below can be visualized in most elephants. Radiographic images of the tusk can give an indication of the position of the tusk pulp cavity, which is important when potential exposure of the pulp tissue is suspected. The radiography procedure for the feet is described on the webpage about nail problems. Click he re for further reading. Some examples of radiographs are shown below. Radiograph showing pathological fractures consistent with secondary hyperparathyroidism (Courtesy: Charles Reid in: Fowler en Mikota, 2006). Fibula fracture and tibia dislocation in an adult Asian elephant (Courtesy: Taweepoke Angkawanish, Lampang elephant conservation center, Thailand) Radiograph of the remnant of a fractured tusk of an asian elephant. Note the pulp cavity that was not involved in this fracture. Radiograph of normal distal phalangeal joints of D3 of an Asian elephant (Courtesy: Rotterdam Zoo) Radiograph of the tarsal joint of a 21 yr-old Asian elephant with severe degenerative joint disease. Note the narrow joint spaces (Courtesy: Rotterdam Zoo). Radiograph of part of the tail of a 30 yr-old Asian elephant and an 18 yr-old Asian elephant. Note that the growth plates are not yet fully closed (Courtesy: Rotterdam Zoo) 6. Gastroscopy (needs your input) 7. Bronchoscopy and broncho-alveolar lavage 8. Differential Diagnosis (needs your input) 9. Final diagnosis (needs your input) 7. Therapeutic Plan (needs your input) References Wiedner, E. 2015. Proboscidea. In R. E. Miller & M. E. Fowler (Eds.), Fowler´s Zoo and Wild Animal Medicine (Vol. 8). St. Louis, Missouri: Elsevier Saunders. Avni-Magen, N., Zaken, S. Kaufman, E. and Kelmer, G. 2017. Use of Infrared Thermography in early diagnosis of Pathologies in Asian Elephants (Elephas maximus ). Israel Journal of Veterinary Medicine Vol. 72 (2) Honeywell V.L., Pettifer G.R., and Dyson D.H.,1992; Arterial blood pressure and blood gases in normal standing and laterally recumbent African (Loxodonta africana) and Asian (Elephas maximus) elephants. JZWM 23(2) 205-210 To page top

ElephantMedicine.info provides information about infectious and non-infectious diseases in elephants, case reports, clinical and laboratory procedures and management guidelines. -Elephant Medicine -Diseases -Treatment -Anesthesia -Dental problems -Tusk repair -Laboratory tests - Hematology -elephant disease treatment -dental problems -locomotion -diagnostic procedures -physical examination -laboratory procedures -reproduction and birth procedures -anesthesia procedure -lameness -pedicure Elephant Medicine Get started A website for veterinarians taking care of elephants Sharing your clinical experience in ELEPHANT MEDICINE with elephant clinicians worldwide This website provides information about elephant diseases, procedures and recommendations. It also includes a collection of clinical case reports, submitted by veterinarians from all over the world. You will find cases that have been successfully treated, but also cases that had a sad ending. Some basic disease information is provided as well as descriptions of clinical and laboratory procedures. The information on this website is subject to changes, as our knowledge about diseases in elephants will grow by sharing our experiences. Veterinarians involved in elephant medicine are encouraged to submit reports of their experiences. Together we can create a platform for the current and next generations of veterinarians. For the benefit of an amazing, but vulnerable species: the elephant. Disclaimer: The content of this website, such as graphics, images, text and all other materials, is provided for reference and educational purposes only. The content is not meant to be complete or exhaustive or to be applicable to any specific individual's medical condition. The information is based on scientific literature, open source information and anecdotal information provided by trusted sources. You assume full responsibility for using the information on this site, and you understand and agree that the authors are not responsible or liable for any claim, loss or damage resulting from its use by you or any user. Contact

This page describes eye problems in elephants and how to treat them. Blepharitis, conjunctivitis, cornea edema, keratitis, vitamin A deficiency, corneal ulcer, cataract, hypopion, uveitis, synechia, iris prolaps, and panopthalmitis. Ophthalmology Compiled by Dr. Khyne U Mar, DVM and Willem Schaftenaar, DVM Eye problems are common in elephants. They are often the result of trauma and present as superficial or deep cornea lesions and ulcers. Cataracts are also regularly seen in elephants. If the vision in one eye is reduced, the animal should be approached with care from that side. In a study in 1478 captive elephants (2956 eyes) in Thailand, 17.83% of the examined eyes from 369 elephants (24.97% of the total number of elephants) had anterior ocular abnormalities. The most common lesions in these examined eyes were frothy ocular discharge (5.85%), corneal edema (5.31%), and conjunctivitis (5.18%). In addition, epiphora, phthisis bulbi, other corneal abnormalities, anterior uveitis, and lens abnormalities were noted. Almost all lesions increased in frequency with age (Kraiwong, 2015). Regular ophthalmic examination in elephants should be included in their annual health check program. Early detection and treatment of any ocular abnormality may avoid the development of subsequent irreversible ocular pathology. Clinical examination overview and diagnostic techniques The clinical examination of the eye starts with the anamnesis (history) and observation of the animal. The eyelashes should be long in order to protect dirt and objects from touching the surface of the eye. They are located mostly superior to the eye and can be as long as 11 cm. The inferior eyelid has less and smaller (2 cm) lashes. A unique feature of the elephant eye is the lack of a lacrimal apparatus (lacrimal glands as well as nasolacrimal duct) and eye brows. Tear films simply flow towards the medial canthus and exit along a groove in the skin onto the face in Asian elephants (Wong et al. 2012). The area around the eyes is therefore often wet. A Schirmer tear test can be performed in elephants. In a research cohort of 80 healthy Asian elephants the mean value was 34.3+/- 1.7 mm/min with older elephants (>40 years) having higher values than younger ones (<20 years). The cornea should be clear, without any irregularities. The iris of an elephant varies in color from tan, yellow, brown or the combinations. Blepharospasm is a strong indication for ocular disease. Conjunctiva cultures can be taken, though the strong palpebrae can make sampling for culture a challenge. Ophthalmic anesthetics can be used safely in elephants and may facilitate clinical examination and allow ophthalmoscopic examination of the deeper ocular structures. The pupillary light response can be performed if the elephant trusts the clinician enough to approach the animal with a proper light source at the required short distance. This test should be performed in subdued light. The menace response can be performed if the animal allows the clinician at short distance by moving fingers towards the elephant's eye without causing air movement. The numerous hairs on the skin of the palpebrae are not true cilia or true eyelashes as they are not associated with the margins of the palpebrae (Wong et al 2012, J. Zoo and Wildlife Med., 43(4), pp 793-801). The lower eyelid is more developed and ascends to a greater degree than the upper lid descends (Suedmeyer, 2006). (Photo KUMar) The iris of an elephant can have several colors: tan, yellow, brown or a combination. (Photo: W.Schaftenaar) A white, circumferential ring, similar to the arcus senilis in man is noticed in 40+ yr Asian elephant (fat deposit or aging?). (Photo: KUMar) Fluorescein staining of the cornea may be difficult as the elephant will close its eye immediately when approached. A fluorescein strip can be placed in a 10 ml syringe with sterile water or saline; this solution can then be sprayed over the eye in a constant flow using a blunt small gauge needle. This should be sprayed on the eye from the medial or lateral side. It helps when at the same time a steady water stream is directed at the periocular skin, which may result in relaxation of the animal. After fluorescein has been sprayed on the cornea, the eye should be flushed with sterile saline to remove excessive fluorescin. If present, cornea defects will stain green under blacklight and even under regular light. Cataracts which appear as a white central spot and keratitis (diffuse, superficial cloudiness of cornea) are frequently seen in elephants. Vision can be checked by passing the light of a flashlight (or cell phone) from the ear over the eye to observe for a blinking reflex. Ophthalmoscopy in the untrained elephant can be quite a challenge, as the animal will usually not allow this kind of close examination that moreover uses a light source. However, the animal can be trained to allow ophthalmoscopy. The third eyelid or nictitating membrane is located at the ventro-medial aspect of the orbit. Inside the nictitating membrane, an oblong, flanged-shaped piece of hyaline cartilage supports the anterior palpebral aspect of the nictitating membrane. The harderian gland that is located here, plays a role in the lubrication of the cornea. Zeis's glands (modified sebaceous glands) are located in the margins of the lid. They produce an oily substance that helps lubricate the cornea. Blinking reflex The nictitating membrane in an Asian elephant (arrow).(Photo: KUMar) Blinking reflex using a smartphone's flash light in an Asian elephant with chronic keratitis. (Video: W.Schaftenaar) Ultrasonographic examination The clinical examination of the elephant's eye can benefit from transcutaneous ultrasonographic examination. The anterior eye chamber, the lens end the posterior eye chamber can be visualized using a 4-7 MHz convex probe (Bapodra et al. 2010). Following are descriptions of the anatomical components of the eye and the medical condition that may occur Eyelids Blepharitis is an inflammation of the eyelids than can be caused by trauma (rubbing), parasite infection or as part of a localized dermatitis. The accompanying symptoms are blepharospasm, epiphora (tearing that appears as wet skin area below the eye) and often photophobia. Sometimes lice (Haematomyzus elephantis ) or ticks (Amblyomma tholloni) can be found on the eyelids causing local skin lesions. Blepharitis in an Asian elephant. (Photo: KUMar) Small skin lesion caused by ticks (Amblyomma tholloni) (Photo: KUMar) Conjunctiva The conjunctiva is the tissue that lines the inside of the eyelids and covers the sclera (the white part of the eye ). It is composed of unkeratinized, stratified squamous epithelium with goblet cells , and stratified columnar epithelium . The conjunctiva is highly vascularized, with many microvessels . Conjunctivitis is an inflammation of the conjunctiva and is a common finding in elephants. In some cases small nodules and vesicles may be observed (lymphoid tissue on histology), possibly associated with chronic irritation. A conjunctivitis is often the result of trauma (hard object, dust, irritating liquid or smoke). Conjunctivitis is also seen in poxvirus infections. Conjunctivitis in an Asian elephant (From: Elephant care manual for mahouts and camp managers, FAO 2005 , Conjuctivitis and keratitis in an Asian elephant. Note the swollen mucosa. (Photo: KUMar) The conjunctival sac is a connection between the palpebral and bulbar conjunctiva. Under certain conditions (hypoproteinemia, trauma, insect bites or allergic reactions), a prolapse of this part of the cornea can develop, which protrudes like a mucosal sac between the eye and the lower eyelid. Prolapse of the conjuncitival sac in an Asian elephant. (Photo: KUMar) Cornea The cornea is transparent because it lacks cells and blood vessels and has no pigment. The cornea should always be wet thanks to a pre-corneal film tear. Oxygen and nutrients are available from the aqueous cornea tear film, the limbal capillary plexus and the palpebral conjunctival capillaries. Several disorders of the elephant cornea have been reported. Most of the corneal lesions seem to have a traumatic cause: trauma by rubbing, allergy by environmental irritants such as exposure to direct sunlight or continued exposure to dryness or small particles, e.g. dust, smoke, grass seed etc. that damage the corneal epithelium. Hypovitaminosis-A has also been suggested as a cause of cornea disorder as well as hypoproteinemia. Acanthamoebae Spp. has been identified in corneal swabs. It's presence has been associated with corneal ulcers (Dangolla, 2005). However, the protozoa was also found in swabs taken from healthy elephant eyes (Wijesekara, 2007). Corneal edema Corneal edema, also called corneal swelling, is a buildup of fluid in the cornea. It is caused by dysfunction of the endothelial membrane on the inner side of the cornea, that normally pumps fluid out of the cornea in order to keep it transparent and clear. This can happen after a blow to the eye or a puncture of the cornea (e.g. by small branches), or by contact with toxic substances. Cornea edema in an Asian elephant. (Photo: KUMar) Cornea edema in an Asian elephant. (Photo: KUMar) Cornea opacities - keratitis Opacities in the cornea are called keratitis and are very common in elephants. They present as whitish, "cloudy" areas usually in the central part of the cornea. It has been suggested that they are caused by trauma (thorns, heat, dust, and chemicals), direct sunlight or chronic dehydration. The cornea must be checked for foreign bodies. In severe keratitis, the entire cornea turns white. This reduces the vision of the animal to only being able to distinguish just between light and dark. This can be tested with the blinking reflex . In some cases, keratitis can be painful: the elephant shows blepharospasm and the third eyelid may be protruded (partly) over the eyeball. In that case involvement of the iris should be considered. It is recommended to perform cytology, aerobic bacterial culture, and sometimes fungal culture. When opacities are only found in the superficial epithelium, and dispersed over the entire cornea surface, it might be the result of hypovitaminosis-A (vitamin A is essential for the normal functioning of the corneal epithelium, including the production of the tear film). This condition is called "xerophthalmia". As fluid makes its way into the cornea it can accumulate and cause the formation of small bullae or "blisters." This is called bullous keratopathy. If the blisters break or rupture, a corneal ulcer will result. Mild, superficial opacity in the central area of the cornea in an Asian elephant (keratitis). (Photo: KUMar) To page top Diffuse, superficial opacities spread over the entire cornea of an Asian elephant, possibly caused by hypovitaminosis-A (xerophthalmia). (Photo: KUMar) Mild keratitis in an Asian elephant. (Photo: KUMar) Severe keratitis involving the entire cornea of an Asian elephant. (Photo: KUMar) Severe keratitis with protrusion of the third eyelid in an Asian elephant. This could be an expression of pain, in which case iris involvement should be considered. (Photo: KUMar) Corneal ulcer A cornea ulcer is an open sore on the cornea. The epithelial outer layer and the middle layer of the cornea (stroma) are disrupted. This condition is also called a melting corneal ulcer. Usually the primary cause is trauma of the cornea. This traumatic lesion can become infected by bacteria (Pseudomonas, Neisseria spp, fungi and other microbes. This condition is very painful a nd blepharospasm is often seen. The elephant may be rubbing the area around the affected eye against an object. There may be protrusion of the third eyelid. An ulcer is usually the result of trauma. Treatment of keratitis with NSAID's or glucocorticosteroids increases the risk of ulceration. As a reaction to the ulcer and to repair the lesion, blood vessels will grow into the stroma of the cornea, visible as small red lines, sometimes forming a network of small vessels. This process takes several weeks. When the cornea surface has been repaired, the remnants of these blood vessels will be visible as white connective tissue strands. The major risk in an ulcerated cornea is perforation of the entire cornea, which will result in loss of the ocular fluids and complete loss of the eye. When blood vessels fail to grow towards the ulcer, the ulcer remains in an unchanged form as an indolent corneal ulcer, needing a special treatment. Two manifestations of a severe keratitis and cornea ulcer with a prolapse of the iris in an Asian elephant. (Photo: KUMar) Hypopyon Hypopyon keratitis is an accumulation of pus (heterophils and fibrin) in the anterior eye chamber (between cornea and lens). It is accompanied by profuse discharge and signs of ocular pain. Ultrasonographic examination may be helpful for diagnosing pus in the anterior chamber. One case report describes the treatment of hypopyon in an Asian bull elephant. Hypopyon and uveitis have been described in a case of leptospirosis (Fowler. 2006. Infectious diseases. In: Fowler and Mikota, 2006, 403). Hypopyon Iris and uvea The iris is a diaphragm that regulates the influx of light. It is a very vulnerable structure that consists of two layers: the outer (anterior) pigmented fibrovascular layer (known as stroma, which lacks an epithelial layer) and the inner (posterior) surface covered by a heavily pigmented epithelial layer that is two cells thick (the iris pigment epithelium). This anterior surface projects as the dilator muscles. The high pigment content of the iris blocks light from passing through to the retina, restricting it to the pupil. The outer edge of the iris, known as the root, is attached to the sclera and the anterior ciliary body . The iris and ciliary body together are known as the anterior uvea . Uveitis Any lesions in the anterior part of the eye can result in damage to the iris. Parts of the affected iris may come into contact with the inner layer of the cornea (anterior synechia) or the lens (posterior synechia). If there is also a corneal ulcer, the iris may prolapse through the ulcer (iris prolapse). Iris lesions are considered to be very painful in all animal species. These conditions need immediate veterinary attention. Lesions of the iris and uvea are called uveitis . If only the anterior part is involved, we call it iritis . In reality it will be hard to distinguish these conditions in elephant ophthalmology, unless proper ophthalmoscopy can be performed under sedation or general anesthesia. Lens The lens is a transparent biconvex structure in the eyes that, along with the cornea , helps to refract light to be focused on the retina . Any lesions of the lens will result in white discoloration and loss of transparency (cataract). This is seen as a white area in the central pupillary space. Young cataracts will appear as cloudy structures. A mature cataract appears as a completely white pupil. A complete, mature cataract will reduce the vision of the elephant which may finally result in complete blindness of the affected eye. When an elephant is approached on the side of the blind eye, the clinician should be aware of the compensating behavior of the elephant, when it tries to keep its functional eye on the investigator. Cataracts are quite common in Asian elephants in range countries. One paper notes that 6-8% of the elephants kept in Sri Lanka suffer from this condition (Kuruwita, 1991). Several causes of cataracts are known in other animal species: trauma, overexposure to sun light, deficiency of vitamin A, C, E or riboflavin, diabetes and dehydration. Often the cause of a cataract in elephants cannot be determined. Early stage of a cataract in an Asian elephant. (Photo: KUMar) Advanced stage of a cataract in an Asian elephant. (Photo: KUMar) Advanced stage of a cataract in an Asian elephant. (Photo: KUMar) Panopthalmitis and phthisis bulbi Panophthalmitis is inflammation of all layers of the eye including the intraocular structures. It has been documented in nine eyes postmortem during a field study of eye lesions in African elephants ( McCullagh, 1969). Phthisis bulbi is a shrunken, non-functional eye. It may result from severe eye disease, inflammation or injury. Phthisis bulbi after chronically infected cornea ulcer. (Photo: KUMar) Subdermal injection of Plancentrex (0.1 mg/ml) in an Asian elephant with uveitis. (Photo: KUMar) Summary of the most frequently used drugs in ophthalmology Standard frequency of treatment applications: 3-5 per day Antibiotic treatment should be based on sensitivity test Flushing with 0.9% NaCl solution is recommended before every topical drug application The elephant's eye can be flushed using a long, small diameter tube place on a syringe. (Photo: KUMar) Treatment options in elephant ophthalmology Blepharitis: Treatments of blepharitis in elephants have not been described in the literature. A similar approach as in other mammals is recommended: elimination of the cause (parasites, dermatitis) and flushing the eye (see photo below) with saline solution, 3-5 times a day. Conjunctivitis, prolapse of the conjunctival sac : elimination of the cause and flushing the eye with saline solution, 3-5 times a day and antibiotic ointment, 3-5 times a day. Corneal edema: flushing with a hypertonic saline solution, 3-5 times a day. Keratitis in early stage: flushing with saline solution, 3-5 times a day, antibiotic ointment, 3-5 times a day. If there is no ulceration, topical application of 0.1% dexamethasone eye drops may be used; be aware that corticosteroids will stop the regeneration of the epithelial cells. Chronic keratitis: treatment will have no effect. Xerophthalmia: oral vitamin A supplementation. Corneal ulcer: flushing with saline solution, and topical application of antibiotic eye ointment 3-5 times a day. Topical application of Diclofenac sodium 1% eye solution may help reducing the pain. Promising results of the use of autologous serum have been reported (Janyamethakul, 2015), applied twice daily. Preparation of autologous serum: Five 10 ml. syringes were used to collect a total of 50 ml. Then, the blood was allowed to clot for 2 hours at room temperature before being centrifuged at 3,000 rpm for 15 minutes. The separated serum was collected (about 20-25 ml.) into a sterile container to which 1 mg. of gentamicin was added. The autologous serum was then aliquoted into sterile tubes, each containing 3 ml. Additionally, the serum was stored at 4°C and used within 7 days. Topical treatment with acetylcysteine (0.02%) was used in case of a corneal abscess along with gentamycin and atropine (Pipitwanichtham, 2023). Other treatments attempts that have been tried: Indolent (non-healing) corneal ulc ers are hard to treat. Debridement of necrotic corneal stro ma should be considered. This can be done by using a cotton tip, or in more severe cases the abnormal cornea tissue can be scraped using a corneal spatula. Theoretically, after the debridement, the cornea should be protected by a contact lens as used in horses. This has been repo rted once in a 44 yrs-old Asian elephant, in which case the lens was lost soon after application. In elephants flushing the eye and applying antibiotic eye ointment and autologous serum is probably the only possible post-debridement treatment. Stem cell application: pr omising results were seen at the Elephant Conservation Center Lampang (Thailand). Although never reported in elephants, the application of a few droplets of cyano-acrylate might be an alternative for a contact lens in elephants. Hypopyon: pain relief (NSAID), systemic antibiotics (DDX: leptospirosis!). Uveitis and Synechia: Atropine sulfate eye ointment (1%), 4-6 times a day, is a commonly used mydriatic drug in horses. It may stabilize the blood-aqueous barrier, reducing vascular protein leakage, minimizing pain from ciliary muscle spasm, and reducing the chance of synechia formation by causing pupillary dilatation. Pupil dilation is an indicator for the drug to be effective on the ciliary muscles. In horses even topical atropine has been shown to prolong intestinal transit time, reduce and abolish intestinal sounds, and diminish the normal myoelectric patterns in the small intestine and large colon of horses. Whether this also applies to elephants is unknown. Subdermal injection of placental extract (Placentrex®) is a common treatment for uveitis, hypopyon and corneal opacities in elephants in Asia (Suedmeyer, 2006). See also photo below. Iris prolapse: systemic NSAID, flushing with saline solution, 3-5 times a day. As the cornea is perforated by the prolapsed iris, the elephant should be treated systemically with antibiotics. Cataract: only 2 cases of (mature) cataract removal by phaecoemulsification have been reported (cataract surgery-UK and cataract surgery-USA). However, artificial lenses to replace the removed lens contents are not available. The significant lens instability (first noted following the initial stages of surgery in the USA-case, i.e., during creation of the anterior capsulorhexis) prevented implantation of an intraocular lens implant. See for more detailed information the references below (Cerrata, 2019 and Manchip 2020). Panophthalmitis: Enucleation is the only treatment indicated for this condition. However, there are no published data on the treatment of panophthalmitis. Placentrex Flushing References and further reading: Bapodra P, Bouts T, Mahoney P, Turner S, Silva-Fletcher A, and Waters M. 2010. Ultrasonographic examination of the Asian elephant (Elephas maximus) eye. Journal of Zoo and Wildlife Medicine , Vol. 41, No. 3, 409–417. Cerreta, A.J., McMullen Jr R.J., Scott, H.E., Ringenberg, J.R., Hempstead, J.E., DeVoe, R.S., Loomis, M.R., and Minter, L.J.. 2020. Bilateral Phacoemulsification in an African Elephant (Loxodonta africana). Hindawi Case Reports in Veterinary Medicine Volume 2019, Article ID 2506263, https://doi.org/10.1155/2019/2506263 or click here to download the manuscript. Dangolla A, JS Edirisinghe and ID Silva (2005). Association of Acanthamoeba with a corneal ulcer in a captive elephant (Elephas maximum maximus). Proceedings of 57th Annual Convention and Scientific Sessions of the Sri Lanka Veterinary Association. 33pp Fowler M. 2006. Infectious diseases. In: Biology, Medicine and Surgery of Elephants, Ed. Fowler and Mikota, 148. Janyamethakul T, Moleechat P, Gohain R, Somgird C, Pongsopavijit P, and Wititkornkul B. 2015. Efficacy of Autologous Serum as An Adjunct Treatment for A Melting Corneal Ulcer in A Captive Asian Elephant. Thai Journal of Veterinary Medicine: Vol. 45: 2, Article 18. Kraiwong, N., P. Sanyathitiseree, K. Boonprasert, P. Diskul, P. Charoenphan, W. Pintawong and A. Thayananuphat (2016). "Anterior ocular abnormalities of captive Asian elephants (Elephas maximus indicus) in Thailand." Vet Ophthalmol 19(4): 269-274. Kuruwita VY and Abeysinghe AB. 1991. Surgical correction of blindness due to mature cataract in a domesticated Asian elephant. International Seminar on Veterinary Medicine in Wild & Captive Animals, Bangalore, India, November 8 to 10, 1991; 23 Manchip, K.E.L., Sayers, G., Lewis, J.C.M., and Carter, J.W. 2019. Unilateral phacoemulsification in a captive African elephant (Loxodonta africana). Open Veterinary Journal, (2019), Vol. 9(4): 294–300. ISSN: 2218-6050 (Online) DOI: http://dx.doi.org/10.4314/ovj.v9i4.3 . or click here to download the manuscript. McCullagh, K.G. and Gresham, G.A. 1969. Eye lesions in the African elephant (Loxodonta africana). Res Vet Sci 10(6): 587–589. Pipitwanichtham S, Dittawong P, Meetipkit P, Sitdhibutr R, Pattanapon N, Kasornsri M, Phetudomsinsuk K, Thongtip N, Sripiboon S. Case report: Corneal stromal abscess in a captive Asian elephant: diagnosis and treatment regimes. Veterinary Integrative Sciences 2023; 21(3): 693 - 703 DOI; 10.12982/VIS.2023.050 . Suedmeyer Wm. K. 2006. Special senses. In: Biology, Medicine and Surgery of Elephants, Ed. Fowler and Mikota, 399-403. Use of a contact lens for horses in an Asian elephant (PDF) Wijesekara PNK, Bandara KAPA, Dangolla A, Silva ID and Edirisinghe JS. 2007. Incidence of Acanthamoebae Spp . in the eyes of a group of captive elephants in Sri Lanka. Conference: International Elephant Conservation & Research Symposium Florida USA At: Orlando, Florida USA, November 2007. Wong MA, Isaza R, Cuthbert JK, Brooks DE and Samuelson DA. 2012. Periocular anterior adnexal anatomy and clinical adnexal examinaton of the adult Asian elephant (Elephas maximus) . Journal of Zoo and Wildlife Medicine , Vol. 43, No. 4, pp. 793-80. To page top

This chapter describes cases reports submitted by veterinarians worldwide. Case reports Dentistry Back to Top Tusk fracture in 36 months old African elephant Tusk fracture repair in 9 yr-old Asian elephant Tusk fracture repair in 4 yr-old African elephant Tusk (crack) fissure repair in 22 yr-old Asian elephant Tusk sulcus infection in adult Asian elephant T usk sulcus trauma after tusk fracture (2x) Tush loss in female Asian elephant Mandibular fracture Weight loss due to abnormal molar change Supernumerary tusk in an African elephant Impacted Molar Dentition in a 27 yr-old Asian elephant Dermatology Skin wounds in adult Asian elephant Wound treatment after fetotomy Wound treatment after vaginal vestibulotomy Temporal gland impaction: non-surgical treatment Temporal gland impaction: surgical treatment Back to Top Reproduction Vaginal vestibulotomy (1996) Vaginal vestibulotomy (2014) Fetotomy Back to Top Ophthalmology Bilateral corneal opacity Back to Top Orthopedic problems Partial pad and nail loss in a 54 yrs-old female Asian elephant Back to Top Infectious diseases Salmonellosis in a group of African elephants Salmonellosis in 7 yr-old Asian elephant Colic and Salmonellosis in an adult Asian elephant Salmonella septicemia in an adult Asian elephant Elephant Endotheliotropic Herpes Virus-Hemorrhagic Disease (EEHV-HD) Fasciolasis in a group of African elephants Rabies in an Asian elephant Back to Top Non-infectious diseases Clostridium botulinum in a herd of elephants Back to Top Clostridium perfringens enterotoxemia in a 6 weeks-old African elephant Intoxication Dieffenbacchia intoxication Paraquat intoxication Back to Top Gastro-intestinal problems Esophagus spasm in an adult Asian elephant Esophagus impaction in a 4.5-yrs-old African elephant Hernia mesenterialis and intestinal rupture in an Asian elephant calf (1 year old) Intestinal impaction caused by Saccharum bengalense in a captive juvenile Asian Elephant: Implications for captive management. Back to Top Miscellaneous Hiccup Asian elephant with suspected hypocalcemia Hiccup Asian elephant with polycystic nephritis Perineal hernia Colic and abdominal surgery Allonursing in an African elephant Back to Top

CASE REPORT Dentistry

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Prevalence, symptoms, treatment and vaccination against anthrax (Bacillus anthracis) in elephants are described. To infectious diseases Anthrax This figure gives a nice overview of the epidemiological cycles of Bacillus anthracis (https://anipedia.org/resources/anthrax/1203 ). Anthrax infection in humans Human anthrax infections are often contracted during work activities in oneofthe following fields: Tanneries Wool sorters Bone processors Slaughterhouses Laboratory workers When humans become infected, the disease is usually presented as skin wounds that heal very slowly. The bacteria can penetrate the skin if they come in contact with a fresh skin wound. These photos demonstrate the type of wound that results from such an infection. The person with the wound on the left image worked on a cattle carcass that died from anthrax. While handling this carcass, he injured himself by a sharp bone fragment that was infected with the anthrax bacteria ( https://www.microbiologybook.org/ghaffar/anthrax-pennsylvania.htm ). The person on the right image is probably a tannery worker, who infected himself by rubbing his knuckles on the skin of an animal that died of anthrax ( http://www.fao.org/ag/againfo/programmes/en/empres/news_070212.html ) If untreated or if the infected wound is big, the bacteria can spread in a large area around the wound, as is shown here. This severe wound needs immediate treatment with the right antibiotic. Anthrax spores can also be inhaled. In the lungs the anthrax bacteria can cause a very severe inflammation. On the left image you can see an X-ray of healthy lungs, with a clear heart shadow. On the right X-ray you can distinguish a big mass in the thorax that does not allow the x-rays to get through. If this disease is left untreated until obvious symptoms occur, it is usually fatal. This patient had a business where he made drums using cattle and goat skins imported from Africa. He died 1 day after this X-ray was made. (https://www.microbiologybook.org/ghaffar/anthrax-pennsylvania.htm ) Anthrax infection in animals Typically, the incubation period is 3–7 days (range 1−14 days). The clinical course ranges from peracute to chronic. The peracute form (common in cattle and sheep) is characterized by sudden onset and a rapidly fatal course. Staggering, dyspnea, trembling, collapse, a few convulsive movements, and death may occur in cattle, sheep, or goats with only a brief evidence of illness. Often, the course of disease is so rapid that illness is not observed and animals are found dead. A very characteristic feature of acute anthrax is free non-coagulating blood running from body openings, due to the disturbed coagulation. The disease in horses may be acute. Signs may include fever, chills, severe colic, anorexia, depression, weakness, bloody diarrhea, and swellings of the neck, sternum, lower abdomen, and external genitalia. Death usually occurs within 2–3 days of onset. Anthrax bacteria disturb the natural blood coagulation. This results in bleedings in the skin and all internal organs. Non-coagulated blood is collected in the lymph nodes, while free-running blood appears from all openings. These symptoms usually lead to a sudden death. Anthrax can affect multiple species, like cattle and wild ruminants (greater kudu), zebras as well as predators (lion). Note the running blood from nostrils or eyes in all these animals and the small bleedings in the skin of the kudu. (https://anipedia.org/resources/1203) Multiple outbreaks of anthrax in wild hippopothamus has been reported in several southern African countries ( https://www.sciencealert.com/anthrax-outbreak-suspected-to-have-killed-more-than-100-hippos-in-namibia ) Animal to animal transmission There are several ways of transmission of B. anthracis between animals. Animals grazing in areas where anthrax victims have been buried, can be infected when the carcass remnants are digged up either by the feeding animal or through human activities (road or building constructions). Flies that have fed on an anthrax-carcass can easily spread the bacteria through their droppings that remain on leaves. Predators (big cats) that feed on infected carcasses can become infected and die of anthrax. Flies that feed on an infected carcass may spread B.anthacis through their droppings as illustrated on these images (https://anipedia.org ). Anthrax in elephants Anthrax in elephants is usually a gastro-intestinal infection. The animal ingests the spores while feeding food or water contaminated with spores. After an incubation period of a few days, the animal dies of septicemia. Multiple cases have been reported from several range countries in Asia (Kumaraguru A. et al. 2015). In some areas Asian elephants play a role in the transmission of anthrax between wildlife and farm animals (Walsh M.G. et al. 2019). Like in other mammals, symptoms consist of rapid detoriation after infection. Usually the elephant is found dead before symptoms were observed. Running blood from the trunk, mouth, eyes, rectum or vagina should alarm the finder of the carcass for this being an anthrax case. Anti-PA antibodies were detected in elephants, which suggests that they can mount adaptive immune responses against anthrax. In addition, these results suggest that elephants can be infected with anthrax and survive infection under some circumstances (Cizauskas et al. 2014). A fatal case of anthrax in a 15-yrs-old African elephant was reported from a wildlife park in Nigeria (Okewole, 1993). Frequent urination, restlessness and weakeness of the hind quarters were observed prior to death. A co-infection with Cowdria ruminatium was diagnosed at post mortem examination (coccoid intracytoplasmatic bodies in the endothelia of the brain). A wild Asian elephant that died of anthrax in the forest of Myanmar. Note the amount of free running blood around the head. Photo courtesy: Myanmar Forest Police A wild Asian elephant that died of anthrax in the forest in India (Kumaraguru A. 2015) Treatment Early detection of the disease is essential, though difficult. Multiple classes of antibiotics can be used if treatment is started in time: oxytetracycline, penicillins, aminoglycosides, fluoroquinolones, macrolides, and sulfonamides. Dosages can be obtained from the website of Elephant Care International: https://www.elephantcare.org/formulary Diagnosis (post-mortem) Post mortem findings in elephants are: Bleedings In and under the skin Around muscles In organs Free blood in the intestines Free blood in the lungs Free blood in the abdomen Edematous swelling of the skin Swollen spleen with bleedings Liver and lymph nodes are swollen and contain a lot of blood Disposal of an anthrax carcass If a dead elephant is suspected of anthrax, a full necropsy is not recommended. A blood smear from a small incision made in an ear should first be made and examined microscopically for the presence of Gram-positive stained rods, lying in chains, sometimes accompanied by spores. The carcass should be disposed off as soon as possible in a proper way. The disposal must be done following the next steps: To minimize the spread of blood, you should try to plug the openings (trunk, ears, mouth, anus, vulva) with non-absorbent material. You can also wrap the head of the elephant in plastic and tape it with duct tape or tie it with a rope to the skin of the neck. Don’t move the animal around Incinerate the carcass if possible If incineration is not possible, burry the carcass as deep as possible. Use heavy excavating equipment (backhoe loader) to dig a deep, large hole, at least 2 meters deep Disinfect all materials that have been in contact: 10% formalin or 5% lime solution (sodium hydroxide) Necropsies of any animal should always be performed with great care. If there are signs of anthrax, a peripheral blood smear should always be examined first. If accidently the diagnose was missed, any signs of internal bleedings should alarm the prosector. B. anthacis can be cultured quite easily. Every necropsy should be performed with adequate body protection: proper eye protection, a respiration mask, long gloves, rubber boots and protective clothing. Vaccination Elephants can be vaccinated against anthrax with commercially available vaccines. This is highly recommended in areas where anthrax is seen in farm animals or if there is a history of anthrax in elephants in that area. References/further reading Berry HH. 1993. Surveillance and control of anthrax and rabies in wild herbivores and carnivores in Namibia. Rev Sci Tech 12(1):137–146.Cizauskas CA, Bellan SE, Turner WC, Vance RE, Getz WM. 2014. Frequent and seasonally variable sublethal anthrax infections are accompanied by short-lived immunity in an endemic system. J Anim Ecol 83(5):1078–1090 Hanna P., 1998. Anthrax pathogenesis and host response. Curr Top Microbiol Immunol 225:13–35 Turnbull PC, Bell RH, Saigawa K, Munyenyembe FE, Mulenga CK, Makala LH. 1991. Anthrax in wildlife in the Luangwa Valley, Zambia. Vet Rec 128(17):399–403. Kumaraguru A., Kumaraguru Arumugam , N.S. Manoharan , Ramakrishnan Balasundaram . 2015. Prevalence and disease management with reference to anthrax in the Asian elephant (Elephas maximus) in the Sathyamangalam Wildlife Santuary, Tamil Nadu, India & Indash; A case study. Scientific Transactions in Environment and Technovation, 5(1): 48-51. Okewole P.A., Oyetunde I.L., Irikanulo E.A., Chima J.C., Nwankpa N., Laleye Y., Bot C. 1993. Anthrax and cowdriosis in an African elephant (Loxodonta africana). Walsh, M.G., Mor, S.M., Hossain, S., 2019. The elephant–livestock interface modulates anthrax suitability in India. Proceedings of the Royal Society B: Biological Sciences 286 EAZWV Transmissible Disease Fact Sheet ANTHRAX American Association of Zoo Veterinarians Infectious Disease Manual ANTHRAX Recommended websites: Merck Veterinary Manual. 2021. https://www.merckvetmanual.com/generalized-conditions/anthrax/overview-of-anthrax OIE (Organization for Animal Health: https://anipedia.org/resources/anthrax/1203 FAO: http://www.fao.org/home/search/en/?q=anthrax Microbiology and Immunology On-line: https://www.microbiologybook.org/ghaffar/anthrax-pennsylvania.htm To page top General information Merck Veterinary Manual (2021) : Anthrax is a zoonotic disease caused by the sporeforming bacterium Bacillus anthracis . Anthrax is most common in wild and domestic herbivores (eg, cattle, sheep, goats, camels, antelopes) but can also be seen in people exposed to tissue from infected animals, to contaminated animal products, or directly to B anthracis spores under certain conditions. Depending on the route of infection, host factors, and potentially strain-specific factors, anthrax can have several different clinical presentations. In herbivores, anthrax commonly presents as an acute septicemia with a high fatality rate, often accompanied by hemorrhagic lymphadenitis. In dogs, people, horses, and pigs, it is usually less acute although still potentially fatal. Toxins are the source of most of the disease symptoms associated with anthrax. Edema toxin complex (EdTx) causes the fluid and edema seen in cutaneous anthrax infections, and lethal toxin complex (LeTx) causes shock and death from systemic anthrax (Hanna, 1998). B anthracis spores can remain viable in soil for many years. During this time, they are a potential source of infection for grazing livestock but generally do not represent a direct risk of infection for people. Grazing animals may become infected when they ingest sufficient quantities of these spores from the soil. In addition to direct transmission, biting flies may mechanically transmit B anthracis spores from one animal to another. The latter follows when there have been rains encouraging a high fly hatch and reporting has been delayed on the index ranch, such that there are 4–6 moribund or dead cattle for the flies to feed on. Feed contaminated with bone or other meal from infected animals can serve as a source of infection for livestock, as can hay muddy with contaminated soil. Raw or poorly cooked contaminated meat is a source of infection for zoo carnivores and omnivores; anthrax resulting from contaminated meat consumption has been reported in pigs, dogs, cats, mink, wild carnivores, and people. Human cases may follow contact with contaminated carcasses or animal products (raw meat, skins of animals that died of anthrax). Flies that have fed on a carcass from an anthrax victim can spread the disease over longer distances. Diagnosis Anthrax can be diagnosed in fresh blood smears taken from the ear. Microscopically, B. anthracis can be recognized as long chains of Gram-positive bacteria. If the smear has been exposed to air, the bacteria may have formed spores that can be easily detected. B. anthracis differs in shape from other Bacillus species, that may contaminate the sample in case the animal has been dead for a longer period. Whereas the bacteria chains of B. anthracis seem to be sharply cut off with a knife, the chains of B. cereus have round edges.

Tuberculosis is an infectious zoonotic disease with a ubiquitous distribution, caused by Mycobacterium species. The most relevant species that affect mammals belong to the group of Mycobacterium tuberculosis-complex (MTBC). The disease is relevant for elephants under human care, as transmission from man to elephant and vice versa is possible. Being a chronic disease with a long incubation time, the initial stages of the disease are often missed. To infectious diseases By Willem Schaftenaar DVM Tuberculosis in zoos Based on positive cultures of trunk washing samples or necropsy results the median point prevalence within the Asian elephant in the USA zoo population between 1997 and 2011 increased was 5.1%, with a range from 0.3% to 6.7%. Similarly, the average annual incidence was 2.4 cases per year, with a range from 0 to 7. Since 1960, a total of 45 cases of MTBC (45 M. tuberculosis) were tabulated in Asian elephants in comparison to only 5 cases in African elephants (4 M. tuberculosis and 1 M. bovis), suggesting a difference in species susceptibility (Feldman et al, 2013). The results of a survey on necropsy reports of 301 Asian elephants and 196 African elephants kept in European zoos in the period from 1980 to 2024 is shown in table 1(Hess, 2021, updated by Willem Schaftenaar, 2024). Table 1. MTBC cases confirmed at necropsy in elephants kept in European zoos from 1980-2024. One case of M. caprae has been reported in a Bornean elephant housed in a zoo in Japan. Another M.caprae case in a European zoo is included in table 1. Tuberculosis in range-countries In countries where contact between man and elephant is close, tuberculosis forms a health risk for both humans and elephants. In a study in Malaysia under 60 elephants in 6 different facilities, the overall seroprevalence of TB amongst the elephants was 23.3% and the risk of seroconversion was significantly higher among elephants with assigned mahouts. The percentage of positive responders among wildlife staff was 24.8% and the risk of infection was observed to be significantly associated with being a zoo employee or elephant handler. These findings revealed a potential risk of TB infection in captive elephants and handlers in Malaysia (Yakubu, 2016). Tuberculosis in free ranging elephants Paudel et al (2020) gave an overview of tuberculosis in free ranging elephants. The first report of TB in wild Asian elephants was from Sri Lanka in 2014. A 35-year-old female elephant was found in a moribund condition in the corridor between Udawalawe and Lunugamwehera National Parks. Three wild male Asian elephants that died between 2007 and 2013 in a wildlife sanctuary in southern India were confirmed to be TB positive. One wild Asian elephant that died of suspected TB lesions in the forest of Rajiv Gandhi National Park, Karnataka, India in 2016, was confirmed as TB positive. The first case of TB infection in wild African elephants was reported in Kenya in. This elephant was an orphaned calf rescued from a national park in Kenya and raised with other rescued orphans and then was eventually released back into the wild. Serology, using STAT-PAK on banked serum samples collected from free-ranging African elephants between 2004 and 2018 in Kruger National Park (KNP) in South Africa showed that 9.3% of 161 elephants tested were MTBC positive (Kerr et al, 2019). MTBC was isolated for the first time from a wild African elephant from KNP in South Africa in 2016 (Miller et al, 2019). Zoonotic aspects Transmission of tuberculosis to elephant caretakers, mahouts or zoo visitors should always be considered as a threat to human health. Once an elephant is suspected of tuberculosis, caretakers should seek medical assistance and be checked for this disease on a regular basis. Transmission to other mammalian species The pathogen can be transmitted to humans and other mammalian species by direct contact, contaminated food and materials. Zoo animals treated by the same animal caretakers can transmit MTBC from a shedding elephant to other species (and vice versa). In a Swedish zoo 4 different M. tuberculosis strains were found in different elephants and other zoo animals in the same period (see diagram below): strain A was present in an Asian elephant, a gibbon and a group of South American tapirs. Strain B was found in 4 Asian elephants, while strain C was detected in a giraffe and one of the elephants that also harbored strain B. Strain D was found in an Asian elephant that also carried strain B (Sternberg et al, 2005). In an Australian zoo, a diseased chimpanzee was diagnosed with tuberculosis caused by a MTBC-strain that was indistinguishable from a strain found in an Asian elephant at the same zoo. Investigations included staff and animal screening. Four staff had tuberculin skin test conversions associated with spending at least 10 hours within the elephant enclosure; none had disease (Stephans et al, 2013). TB-suspected elephants should not be in contact with animals that are considered TB-free. Separate cleaning materials and equipment must be used for TB-suspected elephants. Symptoms Tuberculosis is a slow developing disease. Most elephants with TB are older than 5 years. One of the first signs of clinical disease is persistent weight loss. Often this is the only symptom seen. If no explanation can be found for this chronic weight loss, one should consider TB as its possible cause. Although the lungs are usually the first organs that are affected, respiratory signs are usually not observed. Other organs can also become affected, like kidneys, urinary bladder, GI-tract, uterus, liver pancreas and mesenteries. Metastatic MTBC-granulomas are often found in lymph nodes that drain the affected organ system. The lesions caused by MTBC consist of granulomas. If the immune system of the elephant is functioning well, such granulomatous inflammation can be contained, and a buffer zone of defensive cells can produce a capsula around this process. In old granulomas, the original inflammation tissue can become calcified. Even in such a calcified granuloma, vital Mycobacteria can still be present. The presence of such ‘inactive’ granulomas may go completely unnoticed without causing any visible discomfort. Only immunological diagnostic assays will detect such a silent carrier. Unfortunately, many elephants that become infected with MTBC will develop multiple granulomas often with metastasis to regional lymph nodes. Once a granuloma breaks through into the air-containing space of the lung alveoli or bronchi, the elephant can spread the disease to other elephants, humans or other mammals by direct and indirect contact. Sputum that has entered the lower airways can be brought up into the higher airways and, when swallowed, reach the stomach and intestines. MTBC has been detected in fecal samples. If the infection route is orally, granulomas can develop in the GI tract. MTBC-granulomas in the kidneys, urinary tract, uterus or other organs are the result of bacteremia. Figure 1. Granulomas caused by M.tuberculosi s in an adult African elephant bull. Courtesy: Christian Wenker Figurs 2. Sputum collected from the same elephant bull tested positive for M. tuberculosis in PCR and culture. Courtesy: Christian Wenker Transmission When the granulomas affect the excretion system of the organs, the pathogens can contaminate the environment (sputum, urine, feces, fetal fluids) and transmit the disease to other animals. Transmission by breeding has never been documented in elephants. The trunk is considered a major transmission organ of Mycobacterium spp. originating from the lungs. Nevertheless, it is very difficult to find TB-organisms in trunk washes (see trunk wash procedure ). There are several anecdotal reports that a sputum sample found on the floor was confirmed TB-positive while numerous trunk wash samples from the same elephant had been tested negative. Diagnosis Test samples Any granulomatous lesion that is found at necropsy should be suspected of MTBC. Trunk wash samples are frequently used to monitor elephants for MTBC. The elephant needs to be trained for this procedure. For the description of the procedure, click here . Fluids recovered from the trunkwash must be submitted for PCR and culture. The sensitivity of this procedure is extremely low (1-2%) (Sternberg et al. 2005, Vogelnest et al. 2015), which makes the trunkwash a questionable diagnostic tool. Samples obtained by Broncho Alveolar Lavage (BAL) are considered more sensitive than trunk wash samples. However, one should realize that the probability to target an infected bronchus by the BAL-method depends on the number and severity of the lesions. An elephant suspected of carrying MTBC based on immunological tests, can harbor just one or a few encapsulated granulomas in the lung; BAL-samples taken from the area of such granulomas will yield no MTBC. Click here to read more about BAL. A disadvantage of the procedure is that it requires standing sedation or general anesthesia. Excretions like sputum (see figure 2) urine, feces and fetal fluids in MTBC-suspected elephants (chronic weight loss) should be submitted for culture and PCR. Direct tests The golden standard method to diagnose MTBC is culturing of the pathogen. This requires a lab that is certified to culture this microbe. The culturing procedure can take as long as 6 -10 weeks. The cultured isolates must be spoligotyped and preferably submitted for multilocus, variable-number of tandem repeat analysis (MLVA) and whole-genome sequencing, as described previously (Ruetten et al, 2020, Ghielmetti, 2017). PCR is next in reliability and usually carried out in conjunction with culture. Results can be obtained within one day. Positive results should still be cultured. Acid-fast stain (Zhiel-Neelson) on tissue or swab samples can demonstrate the presence of acid-fast bacteria. Confirmation needs to come from culture. Indirect tests (immunological tests) 1. Tests based on cellular immunity . The WHO recommends the following immunological tests as the first choice (for humans): Interferon Gamma Release Assay (IGRA): PBMCs are stimulated with antigens of MTBC. After incubation the amount of elephant interferon is measured in the supernatant (Angkawanish et al, 2013). This assay is currently being practiced at the Utrecht University for monitoring TB in the European elephant population (click here for more information) . Another IGRA has been developed in Japan (Paudel et al, 2016). Skin test: in individuals that have been in contact or still carry MTBC intra-cutaneous injection of MTBC- derived antigens can cause a local reaction of the skin (swelling, redness, warm) after 72 hours. Due to the unique properties of the very thick elephant’s skin, this test is not recommended for elephants (Mikota et.al. 2001). 2. Tests based on humoral immunity DPP = Dual Path Platform Assay VetTB Assay for elephants: antibodies against several MTBC-antigens can be demonstrated in a quick test, which is based on ELISA-technology. Multi Antigene Print Immuno Assay (MAPIA). This test is offered by Chembio (USA) as a confirmation test of the DPP VetTB Assay for elephants. Each antigen that is present in the DPP is individually tested in the MAPIA. ELISA- some local labs had developed their own in-house ELISA. Currently they are not being used. Note: A study in Japan concluded that the discrepancies between serological and IGRA highlight that the two methods may detect different stages of elephant TB. Therefore, employing both tests may enable them to complement each other in correctly identifying elephants that have been exposed to MTBC (Songthammanuphap et al, 2020). Cross reactions Immunological tests have the disadvantage that they do not detect the pathogen itself, but only the immunological reaction of the host to MTBC. Unfortunately, several non-tuberculous Mycobacterium spp (such as M. kansasii, M. fortuitum) have some antigens in common with MTBC. Therefore, one should always take additional circumstances into account when an immunological test turns out positive for MTBC. Chronic weight loss, a history of MTBC in the herd, a caretaker suffering from tuberculosis are factors that can help form a stronger diagnosis than just the outcome of an immunological test. Non-tuberculous Mycobacterium spp. Several non-tuberculous Mycobacteria (NTM) have been identified, e.g. M. intracellulare, M. hominnisuis, M. fortuitum, M.avium, M. flehi, M kansasii. In one study, isolates of M. avium, M. peregrinum, and M. novocastrense, three NTM species, were detected in samples from the lung or mouth (Hermes et al, 2018). One NTM, Mycobacterium szulgai, was associated with mortality in two captive African elephants (Loxodonta africana) (Lacasse et al, 2007). Treatment Treatment of MTBC has been an option when MTBC is confirmed by culture. One should realize, however, that the complete elimination of the pathogen by treatment is not guaranteed. Like in humans, MTBC can remain present in encapsulated foci and relapses after several years have occurred. Treating tuberculosis is expensive, laborious, and needs to be sustained for a long period. As some of the drugs are (nephro)toxic, negative side effects of the drugs need to be monitored closely. The elephant protocol is based on treatment regimens that are used to treat TB in humans. The basic protocol calls for 3-4 drugs for 2 months followed by 2 drugs for 10 months. Isoniazid, rifampin, ethambutol, and pyrazinamide are the first line drugs that are typically used. Administration is oral or rectal although rectal Rx has some limitations. If at all possible, serum drug levels should be monitored. Treatment details can be found in chapter 9 and 10 of the Guidelines for the control of tuberculosis in elephants 2010 . Surveillance Monitoring elephants that have been in contact with other animals suffering of MTBC (including humans) by regular TB-testing is the most effective way to detect an infection. Elephants with a TB-history (treated or in contact with MTBC-positive animals) should not be moved to a TB-free facility. Annual TB-screening of caretakers should be part of the elephant management in zoos. Moving elephants Elephants that will be moved from one zoo to another should be checked before the transfer. Click here for TB-recommendation for European zoos and click here for TB-recommendation for USA zoos. The release of orphaned elephants after rehabilitation in a management system under human care, carries a risk of transmission of tuberculosis to free ranging elephants. The disease may have been present unnoticed during the rehab period. Testing for MTBC prior to release should be a requirement without which no release should take place. Prevention A vaccine against tuberculosis in elephants is not available. The value of BCG-vaccination, used to vaccinate humans in endemic areas, has not been tested in elephants. Even in humans, it only prevents the childhood meningitis form of TB and does not protect against pulmonary TB. Government regulations Though M. bovis is just one of the MTB-complex group, for economic reasons related to the cattle industry, most governments only have strong regulations for cases of tuberculosis caused by M. bovis. In those countries, tuberculosis caused by M. bovis in elephants is notifiable. Because of the zoonotic aspects of the disease it is, however, strongly recommended to contact government officials in any case of confirmed tuberculosis. References Hess A. 2021. Lesions found in the post-mortem reports of the Asian (Elephas maximus) and African (Loxodonta africana) elephants of the European Association of Zoos and Aquaria. Thesis at the Department of Exotic Animal and Wildlife Medicine University of Veterinary Medicine Budapest, Hungary. Updated by Schaftenaar W. 2024. Unpublished data EAZA elephant TAG studbook. Paudel S, Sreevatsan S. 2020. Tuberculosis in elephants: Origins and evidence of interspecies transmission. Science direct: Tuberculosis 123 (2020) 101962. Ruetten M, Steinmetz HW, Thiersch M, Kik M, Vaughan L, Altamura S, Muckenthaler MU and Gassmann M. 2020. Iron regulation in elderly Asian elephants (Elephas maximus) chronically infected with Mycobacterium tuberculosis. Front. Vet. Sci. 7:596379. doi: 10.3389/fvets.2020.596379 Songthammanuphap S, Puthong S, Pongma C, BuakeawA, Prammananan T, Warit S, Tipkantha W, Kaewkhunjob E, Yindeeyoungyeon W, and Palaga T. 2020. Detection of Mycobacterium tuberculosis complex infection in Asian elephants (Elephas maximus) using an interferon gamma release assay in a captive elephant herd. Scientific Reports (2020) 10:14551; https://doi.org/10.1038/s41598-020-71099-3 Kerr TJ, de Waal CR, Buss PE, Hofmeyer J, Lyashchenko KP, Miller M.A. 2019. Seroprevalence of Mycobacterium tuberculosis Complex in Free-ranging African Elephants (Loxodonta africana) in Kruger National Park, South Africa. J Wildl Dis (2019) 55 (4): 923–927. Miller MA, Buss P, Roos EO, Hausler G, Dippenaar A, Mitchell E, van Schalkwyk L, Robbe-Austerman S, Waters WR, Sikar-Gang A, Lyashchenko KP, Parsons SDC, Warren R and van Helden P. (2019). Fatal Tuberculosis in a Free-Ranging African Elephant and One Health Implications of Human Pathogens in Wildlife. Front. Vet. Sci. 6:18. doi: 10.3389/fvets.2019.00018 R. Hermes R, Saragusty J, Holtze S, Nieter J, Sachse K, Voracek T, Bouts T, Göritz F, and Hildebrandt TB. 2018. Bronchoalveolar lavage for diagnosis of tuberculosis infection in elephants. Epidemiology and Infection 146, 481–488. https://doi.org/10.1017/S0950268818000122 Ghielmetti G, Coscolla M, Ruetten M, Friedel U, Loiseau C, Feldmann J. 2017. Tuberculosis in Swiss captive Asian elephants: microevolution of Mycobacterium tuberculosis characterized by multilocus variable-number tandem-repeat analysis and whole-genome sequencing. Sci Rep. (2017) 7:14647. doi: 10.1038/s41598-017-15278-9 Paudel S, Villanueva M.A, Mikota S.K, Nakajima C, Gairhe K.P, Subedi S, Rayamajhi N, Sashika M, Shimozuru M, Matsuba T, ySuzuki Y and Tsubota T. 2016. Development and evaluation of an interferon-γ release assay in Asian elephants (Elephas maximus). J. Vet. Med. Sci. 78(7): 1117–1121, 2016 Yakubua Y, Onga B.L., Zakaria Z, Hassan L, Mutalib A.R., Ngeowc Y.F., Verasahib K, Razak M.F.A.A. 2016. Evidence and potential risk factors of tuberculosis among captive Asian elephants and wildlife staff in Peninsular Malaysia. Preventive Veterinary Medicine Volume 125, 1 March 2016, Pages 147-153. Vogelnest L, Hulst F, Thompson P, Lyashchenko K.P., Vinette Herrin K.A. 2015. Diagnosis and management of tuberculosis (Mycobacterium tuberculosis) in an Asian elephant (Elephas maximus) with a newborn calf. Journal of Zoo and Wildlife Medicine 46(1): 77–85, 2015. Angkawanish T, Morar D, van Kooten P, Bontekoning I, Schreuder J, Maas M, Wajjwalku W, Sirimalaisuwan A, Michel A, Tijhaar E and Rutten V. 2013. The Elephant Interferon Gamma Assay: A Contribution to Diagnosis of Tuberculosis in Elephants. Transboundary and Emerging Diseases. 60 (Suppl. 1) (2013) 53–59. Feldman M, Isaza R, Prins C, Hernandez J. 2013.Point prevalence and incidence of Mycobacterium tuberculosis complex in captive elephants in the United States of America. Vet Q 2013; 33:25–9. Stephans N, Vogelnest L, Lowbridge C, Christensen A, Marks G.B., Sintchenko V, McAnulty J. 2013. Transmission of Mycobacterium tuberculosis from an Asian elephant (Elephas maximus) to a chimpanzee (Pan troglodytes) and humans in an Australian zoo. Epidemiol. Infect. (2013), 141, 1488–1497. © Cambridge University Press 2013 Lacasse C, Terio K, Kinsel M.J, Farina L.L, Travis D.A. D.A, Rena Greenwald, Konstantin P. Lyashchenko, Miller M, Gamble K.C. 2007. Two cases of atypical mycobacteriosis caused by Mycobacterium szulgai associated with mortality in captive African elephants (Loxodonta africana). J. of Zoo and Wildlife Medicine, 38(1 ) :101-107 (2007). Sternberg Lewerin S, Olsson S-L, Eld K, Röken B, Ghebremichael S, Koivula T, Källenius G, Bölske G. 2005. Outbreak of Mycobacterium tuberculosis infection among captive Asian elephants in a Swedish zoo. Veterinary Record (2005) 156, 171-175. Mikota SK, Peddie L, Peddie J, Isaza R, Dunker F, West G, Lindsay L, Larsen RS. 2001. Epidemiology and diagnosis of M. tb in captive Asian elephants. J. Zoo Wildl. Med. 32: 1-16 To page top Tuberculosis Tuberculosis is an infectious zoonotic disease with a ubiquitous distribution, caused by Mycobacterium species. The most relevant species that affect mammals belong to the group of Mycobacterium tuberculosis-complex (MTBC), including M. tuberculosis, M. bovis, M. pinnipedi, M. africanum, M. microti, M. canetii, M.caprae and Bacillus Calmette-Guérin (vaccine). The disease is relevant for elephants under human care, as transmission from man to elephant and vice versa is possible. TB is a chronic disease with a long incubation period, and the initial stages of the disease are often missed. To infectious diseases

Dystocia is quite common in older elephants and can be associated with old age at first calving, uterine inertia, fetal overweight, intra-uterine death, malposition, malformation, psychological and physical factors or tumors. Retention of the fetus has been described. Dystocia Text by Willem Schaftenaar Obstructed labor, also known as labor dystocia, can be defined as the condition in which the fetus is unable to pass through the birth canal because the passage is physically blocked. As per definition, the birth process has already started, indicated by the drop of blood progesterone to base-line level. This hormonal change should be followed by labor activities within about 3 days. The longer this period takes, the higher the chances are that a dystocia will develop. Monitoring the birth process using transrectal ultrasonographic examination is of great importance, especially in older elephants. Click here to read more about the normal birth process. In elephants, the main causes for dystocia are: Insufficient dilatation of the vaginal vestibulum due to lack of elasticity of the skin that covers the vaginal vestibulum; Malposition Intra-uterine fetal death Relatively too large fetus Uterine inertia (physical and psychological) Too small pelvis of the dam Intra-uterine death Retained fetus T umors/cysts 1. Insufficient dilatation of the vaginal vestibulum due to lack of elasticity of the skin that covers the vaginal vestibulum. This is probably the major cause of dystocia and stillbirth in older elephants getting their first calf. Whether this is caused by insufficient production of estrogens, is unknown. Once the major part of the calf's body has entered the vertical part of the birth canal, the contractions of the uterus have very little (if any) influence on the propulsion of the calf. Gravity force has taken over the forces produced by uterine contractions. In this position, the umbilical cord may have ruptured already or might be compressed, as the calf is literally squeezed into a narrow space. The author has assisted in at least 5 dystocia cases caused by this phenomenon. Too narrow birth canal in an aged nulliparous elephant resulted in the suffocation of the calf in the vertical part of the vaginal vestibulum. Courtesy: Dak Lak Elephant Conservation Center. 2. Malposition is another important cause of dystocia similar to other mammalian species. The malposition may be caused after the calf died in the uterus. This happened in a 29 yr-old Asian elephant when the umbilical cord was twisted twice around the first presenting leg of her calf. As a result, the calf got stuck in a horizontal position, unable to make the necessary longitudinal twist-movement when entering the vaginal vestibulum. Click here to read this case report. 3. Intra-uterine fetal death can be the result of a fatal infection, e.g. cowpox, salmonellosis or any other form of septicemia. Usually there has been a known episode of illness of the dam during her pregnancy. 4. A relatively too large fetus can result in stagnation of the parturition. In several zoos the birth weight of the calves is too high. The body weight of a newborn calf should not exceed 120 kg. Lack of movement and/or an unbalanced diet are the main reasons for overweight of the new born. 5. Uterine inertia can play an important role in stagnation of the birth process. Exhaustion of the uterine muscle is a form of physiological uterine inertia. It can be induced by repeated administration of (high) doses of oxytocin, which has been reported anecdotally several times. Like in horses, elephants may react on environmental disturbances during the birth process by ceasing labor activities. Hypocalcemia can result in a decrease of the uterine muscle contractions. The author has noticed at multiple occasions, that intravenous infusion of 1-2 liter calcium-magnesium borogluconate increased the strength of the contractions. This was confirmed by transrectal ultrasound examination: the position of the uterus in the abdomen was higher than before the infusion. Monitoring blood calcium levels, and more specifically the ionized calcium concentration, should be part of the monitoring of the birth process. The ionized calcium levels should be around 1.25–1.30 mmol/L (van der Kolk, 2008). Finally, excessive body weight and/or lack of exercise of the dam can possibly play a negative role on the uterine fitness. 6. If the p elvis of the dam too small , the fetus may get stuck even before entering the birth canal. The author assisted a unsuccessful fetotomy in an Asian elephant with a relatively small pelvic diameter. The procedure failed, as the fetus's body could not be reached through the episiotomy -opening. 7. Intra-uterine death of the fetus can result in abnormal position of the fetus. Like in other mammalian species, the fetus should actively collaborate with the labor activities of the dam. If a leg or the head is not stretched at the right time, this may cause complete obstruction of the passage. The author has witnessed that rotation along the longitudinal axis of a dead calf (after creating access through episiotomy) resulted in the easy passage of the calf. Figure 1 shows that the calf rotated along its longitudinal axis on its way through the birth canal. Figure 1. Natural rotation along the longitudinal axis facilitated the birth of this healthy Asian elephant calf. 8. Retained fetus Retention of a dead fetus is not uncommon in elephants. It has been reported in African and Asian elephants kept in captivity. No study has been done on the mechanisms that lead to fetal retention. When the blood progesterone level drops to its baseline at the end of pregnancy, parturition should follow within a few days. The length of the period between baseline progesterone values and the actual birth of the calf is not known. However, following the expected physiological pattern of the birth process in other mammalians, birth should take place in about three days, though there are exceptions of calves being born alive after as long as 14 days. If the period of low progesterone levels exceeds 2 weeks, we can call it a prolonged pregnancy or fetal retention. The chances for the calf to survive a prolonged pregnancy are assumed to be low. To date, reported cases of prolonged pregnancies range from 3 to 60 months. Fetal membranes may or may not remain intact. In contrast to other mammalian species, the fetus is not always affected by microbial contamination. Sterile mummification can result in the conservation of the dead fetal carcass, due to the specific anatomy of the birth canal: the total length of the vaginal vestibulum ranges from 1-1,4 m, including a long vertical part and long horizontal part. In one case (Thitaram, 2006) the hind legs were macerated, while the anterior part of the calf (in anterior presentation!) was well conserved. Labour activities occurring around the expected calving date may have been missed. In 1 case (zoo-born 37 yr-old Asian elephant, 6th calf), vague signs of a birth process, including colic-like symptoms were observed 1 day after progesterone blood levels returned to its baseline level (Schaftenaar, 2013). From that moment the birth canal was ultrasonographically monitored. No changes were noted until 13 days later, when ultrasound examination confirmed partial relaxation of the cervix (13.7 mm, figure 2). In the following days the cervix closed again and remained closed until the final birth process started 13 months later. The mummified calf was removed by total fetotomy . The cause of the stagnation of the birth process could be explained by the congenital arthrogryposis of the calf's legs. This dam survived in good health for another 15 years, when it was euthanized because of chronic degenerative joint disease. At necropsy, the wall of the uterus appeared very thick and there was a known fistula (1 mm diameter) in the skin covering the vaginal vestibulum. No other remnants of the fetotomy were observed. Figure 2. Transrectal ultrasonographic examination of the Asian elephant shows the partial relaxation of the cervix uteri, with a 13.7 mm diameter of the cervix canal. Interestingly, the mother of the previous elephant also suffered a fetal retention of her 5th calf at the age of 38 years. This fetus probably died around 18 months of gestation due to severe illness of the dam. A pyometra was suspected based on the white-yellowish vaginal discharge, which at times contained pieces of (assumed) macerated tissue. The dam was humanely euthanized. Post-mortem examination showed massive adhesions between the uterus and the abdominal wall and the spleen, which probably prevented the uterus from contracting and expelling the dead foetus. After its death the fetus remained in the uterus for another 33 months (Pers. comm. Carsten Gröhndal, 2005). Repeated fetal retentions occurred in a herd of African elephants kept in one zoo. Over a period of 11 years, one female retained four female fetuses, sired by the same bull, while another female from the same herd, but sired by a different bull, retained one female fetus. The retention period ranged from 6-19 months. The calf on this photo was 6 months overdue. (Courtesy Colchester Zoo) One episiotomy or vaginal vestibulotomy after fetal retention in a 32 yr-old nulliparous Asian elephant in Thailand has been published (Thitaram, 2006). Four months before the expected birth, loss of vaginal fluid with necrotic pieces of amnion tissue was noticed. Twelve months later, the animal showed clear signs of signs of labor. As the fetus got stuck in the birth canal, a successful episiotomy was performed. Two cases of fetal retention that were successfully handled by episiotomy with manual traction in Nepal were mentioned in a short communication in the journal Gajah. No further details were provided (Mandal, 2013). 9. Tumors/cysts Tumors in the reproductive organs of female elephants are not uncommon. Leiomyomas are the most frequently found tumors. As they are associated with the uterine muscles, large leiomyomas can reduce the power of the uterine contractions. Due to the space they may occupy in the uterus, these tumors usually reduce the chances for a pregnancy and may result in early stage abortion rather than palying a role in retention of the fetus. In nulliparous cows >30 years of age, vaginal cysts can become so extensive that they fill the entire vaginal lumen, which may block the passage of the fetus. A 26 kg lipoma, situated on the peritoneal side of the uterus in a 22 yr-old Asian elephant in a European zoo had restricted the intra-uterine movement of the hind legs of the fetus, which resulted in ankylosis of those legs. As a consequence, the fetus could not be delivered and remained stuck inside the uterus. During the birth process the uterus ruptured and the dam was humanely euthanized (Figure 3 and 4; the lipoma was located outside within the red circle; photos taken by the author). Figure 3 Figure 4 No doubt that there are more conditions that are resulting in dystocia. Much is still unknown and many cases have not been reported. More information has been provided by Hermes et al. (Hermes, 2008). Dealing with dystocia Much depend on the degree of training of the elephant. If the animal is not trained for any medical intervention (e.g. blood collection, rectal examination), any diagnostic procedure or curative treatment must be done under standing sedation . Elephants that are trained for rectal examination should be monitored by ultrasound examination on a daily base once the progesterone level has dropped to baseline value. Ultrasound examination is the most important diagnostic tool to get data of the phase of the birth process. Click here to read more about the parturition process and the options for treatment of dystocia. References Hermes R, Saragusty J, Schaftenaar W, Göritz F, Schmitt DL, Hildebrandt TB. 2008. Obstetrics in elephants. Theriogenology 70 (2008) 131–144. van der Kolk JH, van Leeuwen JPTM, van den Belt AJM, van Schaik RHN, Schaftenaar W. Subclinical hypocalcaemia in captive Asian elephants (Elephas maximus ). Vet Rec 2008;162(15):475–9. Madal RK, and Khadka KK. 2013. Health Status of Captive Asian Elephants in Chitwan National Park, Nepal. 2013. Rabindra Kumar Mandal et al. Gajah 39, page 38. Schaftenaar W. 2013. Delayed postpartum fetotomy in an Asian elephant (Elephas maximus ). Journal of Zoo and Wildlife Medicine 44(1): 130–135, 2013. Thitaram C, Pongsopawijit P, Thongtip N, Angkavanich T, Chansittivej S, Wongkalasin W, Somgird C, Suwankong N, Prachsilpchai W, Suchit K, Clausen B, Boonthong P, Nimtrakul K, Niponkit C, Siritepsongklod S, Roongsri R, Mahasavankul S. 2006. Dystocia following prolonged retention of a dead fetus in an Asian elephant (Elephas maximus ) Theriogenology 66 (2006) 1284–1291. To page top

Body condition assesement is a method to make an realistic estimate of the physical condition of an elephant. Two different scalings are used, one ranging from 1-10 and one from 1-5. To clinical examination Body condition assessment Monitoring the physical state of an elephant presents a critical aspect in preventive elephant healthcare. It not only allows to quantify the body condition at a certain moment, but also helps to evaluate the effect of changes in management and nutrition when determined before and after implementation of the modification. Several systems to assess the body condition of elephants have been developed. It is important to evaluate the condition of the elephant at your first visit. The scoring system used in this document is based on the extent of visibility of depressions around bone structures when an elephant is viewed laterally. Depressions around bones become prominent as an animal loses its subcutaneous fat deposits and muscles in the region concerned, thereby making bones appear more prominent. This system use scores of 1-10, where 1 represents an extremely poor (cachectic) and 10 extremely fat (obese) bodycondition. An assessment that uses a 5-points scoring system can be found here . The table below shows the characteristics for each score in this 1-10 system and the selection path to be followed to determine the score that matches with the elephant. Examples of body condition scores (1-10) in Asian elephants are shown in the photos below. The most important reference poinst are the forehead, backbone (vertebral column), scapula, ribs and pelvic bone (ilium). Instead of using photos, the body condition can also be compared with drawings. For this purpose, Schiffmann et al. drew detailed pictures from both African and Asian elephants (2): Example drawings used for body condition scoring of Asian elephants (drawings by Jeanne Peter) Example drawings used for body condition scoring of African elephants (drawings by Jeanne Peter) References: 1. Morfeld K.A., Meehan C.L., Hogan J.N., Brown J.L. (2016) Assessment of body condition in African (Loxodonta africana) and Asian (Elephas maximus) elephants in North American zoos and management practices associated with high body condition scores. PLoS ONE 11:0155146. 2. Schiffmann C., Clauss M., Fernando P., Pastorini J., Wendler P., Ertl N., Hoby S.J-MHatt. (2018) Body condition scores of European zoo elephants (Elephas maximusand Loxodonta africana): Status quo and influencing factors. Journal of Zoo and Aquarium Research 6(3) 2018 To page top