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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

Preventive medicine in elephants include several vaccinations foot care, monitoring for EEHV and tuberculosis and fecal check for parasites Preventive Medicine EEHV Monitoring Fecal check Foot care Tuberculosis γ-interferon testing Tuberculosis DPP tesing Vaccination To page top

The "Infectious diseases"pages directs you to diseases caused by viruses, bacteria, protozoa and parasites. Infectious diseases Virus infections Rabies Foot and Mouth disease Encephalomyocarditis EEHV Pox virus Bacterial infections Tuberculosis Anthrax Salmonellosis Leptospirosis Pasteurellosis Parasite infections Ectoparasites Stomach bots Nematodes Cestodes Trematodes Blood parasites Cutaneous filariasis Zoonotic diseases To page top

A variety of clinical procedures are described here: anesthesia, standing sedation, necropsy, broncho-alveolar lage, trunk wash, body condition score, serum banking, monitoring estrous cycle, pedicure, plasma transfusion, tusk repair, injection technique. Blood collection Hand-rasing Fecal quality control Foot care - curative Foot Care - regular Necropsy procedure Plasma transfusion Surgery Trunk wash procedure Tusk repair procedure Clinical Procedures Anesthesia Banking serum Body condition score Broncho-alveolar & Gastric lavage Injection techniques Monitoring estrous cycle Procedures

The morphology of elephant blood cells is described and demonstrated by photos. To hematology Hematology gallery Compiled by: Willem Schaftenaar and Fieke Molenaar On this page we give examples of normal blood cells stained with Wright-Giemsa. An excellent description of normal and abnormal white blood cells in elephants was published by Stasi et al in 2017. Click here to read that article. Morphology of blood cells, stained with Wright-Giemsa Wright-Giemsa stained blood smear of a healthy adult Asian elephant displaying normal erythrocytes, 1 heterophil, 1 bi-lobed monocyte and several thrombocytes (Courtesy: Rotterdam Zoo). Wright-Giemsa stained blood smear of a healthy adult Asian elephant displaying normal erythrocytes, 1 bi-lobed monocyte, 1 lymphocyte and several thrombocytes (Courtesy: Rotterdam Zoo). The images below were published in the Proceedings of the Zoo and Wildlife Health Conference 2020, 23-31: Molenaar F.M. 2020. Developing haematology skills to enable decision making in suspected cases of Elephant Endotheliotropic Herpesvirus hemorrhagic disease. Heterophil (H), single lobed and bi-lobed monocytes (M), lymphocyte (L). The arrows pont at platelets (Courtesy: Fieke Molenaar). Immature heterophils: bands (Courtesy: Fieke Molenaar). Eosinophil (Courtesy: Fieke Molenaar). Lymphocyte (Courtesy: Fieke Molenaar). Immature lymphocyte (Courtesy: Fieke Molenaar). Monocyte (Courtesy: Fieke Molenaar). Monocytes (Courtesy: Fieke Molenaar). Immature monocytes (Courtesy: Fieke Molenaar). Lymphocyte and 2 monocytes (Courtesy: Fieke Molenaar). Platelets (arrows) (Courtesy: Fieke Molenaar). Erythrocytes: "codocytes" (target cells with a bulls-eye appearance) occur naturally in elephants (Courtesy: Fieke Molenaar). Fragmented erythrocytes Fragments of erythrocytes (schistocytes) as can be seen in elephants suffering of Disseminated Intravascular Coagulation (e.g. EEHV-HD) (Courtesy: Fieke Molenaar). To page top

Clostridiosis in elephants: The following manifestations of clostridiosis have been described in elephants: Tetanus (C. tetani) Enterotoxemia (C. perfringens) Enterocolitis (C. difficile) Malignant edema (C. septicum) Blackleg  (C. chauvoei, C. septicum) Botulism (C. botulinum) CLOSTRIDIOSIS General information Clostridiosis represents a group of diseases caused by members of the Clostridium species. They occur worldwide and can affect many mammalian species, including elephants. Clostridium spp. are gram-positive, rod-shaped, anaerobic bacilli. They form spores that may persist in the soil for months or years. Some of these organisms may be found in the normal flora of the digestive tract and become pathogenic only if accessible tissue is damaged as a result of deep penetrating trauma to the muscle bundles or a compromised gastrointestinal mucosa. Clostridial organisms produce exotoxins, with local and/or systemic effect; including hemolysis and local tissue necrosis. These toxins are produced when the organism grows in the host tissues with the exception of the toxin of Clostridium botulinum , which is formed outside the body and ingested orally by the host. Some Clostridial organisms can produce multiple toxins, each with a specific activity. Clostridiosis in elephants The following manifestations of clostridiosis have been described in elephants: Tetanus (C. tetani) Enterotoxemia (C. perfringens) Enterocolitis (C. difficile) Malignant edema (C. septicum) Clostridium novyi Blackleg (C. chauvoei, C. septicum) has been reported once, but this report could not be tracked down (Prescott, C.W. 1971. Blackleg in an elephant. Vet Rec 88:1971) Botulism (C. botulinum ) Elephant care manual for mahouts and camp managers Preecha Phuangkum Richard C. Lair and Taweepoke Angkawanith Tetanus Tetanus is caused by a long-living anaerobic bacterium that is found in the soil and in moist areas. Tetanus is usually found in elephants that have suffered deep wounds, usually in the foot and particularly through the footpad being pierced by a metal object such as an old, rusty nail. After the bacteria have entered the elephant's body they thrive and, after an incubation period of 15-20 days, neurotoxins are produced that damage the nervous system and cause typical muscular spasms. Between about 1977 and 1992 Thailand experienced, on a massive scale, thieves cutting off elephants' tusks by stealth in order to sell them. One result was that many tuskers contracted tetanus and died. Path of infection: Infection proceeds from stepping on a piece of metal or other contaminated object that causes a deep wound. With elephants, however, the wound might not be obvious because elephants can and do use their trunks to gather dirt (which might be contaminated) to stuff in wounds, including cut tusks. When tetanus enters a tusk's pulp cavity, it spreads very quickly because it thrives in environments where there is no oxygen. All wounds must, of course, be carefully cleaned but be especially careful where the puncture is from nails or rusty old metal, especially in an area that has long housed many animals. After infection, the disease does not progress quickly and the elephant will appear normal for 15-20 days (sometimes even longer) before symptoms appear. Even if the elephant receives treatment, the survival rate is very low. Clinical signs: The elephant often has a temperature of over 37.8° C or 100° F, although this is not certain. The breath will be noticeably hot to feel. The eyes will be very red, and the soft tissue inside the mouth and the trunk will be a dark red. The elephant is listless and does not eat or drink water. The nervous system is affected, and the leg muscles harden in muscular contraction; the tail has a supple, snake-like feel. There are periodic spasms, particularly when the elephant is startled, as by a loud noise or bright light. In following days, it becomes difficult for the elephant to walk and stand because of the contraction of the leg muscles. The jaws lock tightly, making it difficult to chew food. Eating and drinking become very difficult and the elephant dies. Treatment: Consult a veterinarian immediately. Even though tetanus is not contagious to other elephants, separate the elephant from other animals as it will be more peaceful. Take the elephant to a shady shelter with a clean surface, such as a concrete floor (it should not be slippery) to prevent it from introducing earth or other unclean materials into the wound or the pulp cavity. The area should have good ventilation. In cases of an exposed pulp cavity, it is best to clean it with running tap water through a hose. Wash all wounds thoroughly with clean water then flush with an antiseptic solution such as Betadine or Povidine-iodine 1% in a 20:1 solution. Finally, apply an anti-insect powder that includes an antibiotic, such as Negasunt. Hand feed the elephant with small amounts of easy to eat foods with high nutritional value, such as ripe bananas, sticky rice, ripe papayas, etc. Clean the wound every day. Prevention: For elephants that have open wounds or exposed pulp cavities in tusks, prevent the elephant from contracting tetanus by daily cleaning of the wound and by keeping the elephant on a clean surface. Otherwise the elephant is likely to introduce dirt or other unclean material that could contain tetanus germs into the wound. No vaccine yet exists for elephants but if an elephant with a wound seems to have been exposed to tetanus, a veterinarian can inject an antitoxin to prevent infection from the bacteria. To page top Tetanus Tetanus is a potentially fatal disease characterized by muscular spasms caused by a neurotoxin produced by the bacterium Clostridium tetani (vetmed.ucdavis.edu, 2021). These organisms, and their spores, are found in the intestinal tract of several mammalian species and are abundant in the soil, where they can survive for many years. The spores can enter open wounds, particularly puncture wounds, where they proliferate under the right anaerobic conditions. When the spores die, they release the tetanospasmin neurotoxin that is responsible for clinical signs. The size of the wound does not correlate to risk of developing tetanus. Even superficial wounds have been associated with clinical cases. Clinical signs of tetanus in horses usually include history of a wound (typically within the preceding month) and stiffness, lameness, or colic. These signs generally progress quickly to an abnormal gait, trembling, and muscle spasm. An inability to open the mouth, known as “lockjaw”, may occur. Horses can exhibit profuse sweating, saliva accumulation in the mouth, and may aspirate feed material. Excitement, including loud sounds or bright light, often exacerbates clinical signs. Horses may become very sensitive to touch. Stiffness in the leg muscles may result in a characteristic “sawhorse” stance. Affected horses can progress to severe muscle rigidity, making it difficult to rise, urinate, or defecate. Respiratory failure can occur. Tetanus in elephants Only a few cases of clinical tetanus in elephants have been described in the literature (Goss 1947, Burke 1975, Fowler & Mikota 2006) or have been reported anecdotally for Asian elephants in Southeast Asia. Inspection of the pads and nails is imporatant for the detection of wounds. Sharp objects, like steel nails may have penetrated the pad. (Illegaly) cut off tusks may provide an opportunity for C. tetani to infect the tusk pulpa. After an incubation period of 7-20 days, the elephant will show symptoms similar to those seen in horses. Spasms are usually aggravated when the elephant is startled. Burke reports an 8-year-old female that was unable to open her mouth: "She was hypersensitive to noise and touch, becoming tense and raising her tail. Her body temperature was 37°C (98.6°F, normal range 36–37°C /97–99°F). An elevated body temperature can be expected when there are spasms. Although there were several cracks around the toenails, none of the wounds were thought to be anaerobic. 100,000 units of tetanus antitoxin (TAT) were administered and the next day she seemed somewhat relaxed. However, on the third day she was found in lateral recumbency and in tetanic spasms. A sedative (112 grams of chloral hydrate per rectum) was administered. Periodic sedation was necessary to keep her relaxed. She was raised to her feet with a sling and left in the sling overnight. On the fifth day she was unable to stand without the sling. Over the previous 5 days 360,000 units of TAT were administered subcutaneously. The elephant was kept in a sling and force-fed a slurry of bran mash through a stomach tube for 29 days, at which time she began to masticate and swallow feed"(Fowler & Mikota 2006). Treatment Tetanus antitoxin should be administered at a dose of 225 units/kg body weight, half intravenously, the other half intramuscularly. Anaphylactic shock is a hazard of this therapy because tetanus antitoxin is a horse serum product. Be prepared to administer epinephrine Broad-spectrum antibiotics should be administered to kill organisms that may not be reached with wound cleansing. The elephant should be placed in a non-stimulating environment and tranquilized as appropriate. Serum transfusion with serum from a vaccinated elephant should be considered (after cross-matching). Supportive care is crucial to success. Be prepared to sling the elephant. Water may be administered by rectal lavage. For food, the author uses a slurry of quick-cooking rolled oats. The quantity of the breakfast cereal selected is put into boiling hot water, allowed to cool, and then diluted to a consistency that may be pumped through a stomach pump. (Fowler & Mikota 2006). Vaccination In a preliminary study, measurable titers against tetanus were achieved in Asian elephants vaccinated with a 1 ml dose of monovalent equine tetanus toxoid followed by a booster at 4 weeks. The titers remained elevated for >1 year; however, the appropriate vaccination interval has not yet been determined. Annual vaccination is commonly practiced, although it is likely that the duration of immunity may be longer. In a study in which 9 Asian elephants were involved, Muir et al (2021) demonstrated that the antibody titers in these elephants remained at adequate levels with little fluctuations when 3-5 years intervals were applied. It is therefore recommended to adhere to the suggested vaccination regime for horses with booster vaccinations every 2-3 years. References tetanus Goss, L.J. 1942. Tetanus in an elephant. Elephas maximus. Zoologica NY 27:5–6. Burke, T.J. 1975. Probable tetanus in an Asian elephant. JZ&WM, vol 6 – 1 22-24 Fowler, M.E. and Mikota, S.K. 2006. Preventive health care and physical examination / Chemical Restraint and General Anesthesia in. In: Biology, Medicine, and Surgery of Elephants. 2006. Ed. Fowler & Mikota page 68-84, 147-148. Lindsay, W. A., Wiedner, E., Isaza, R., Townsend, H. G., Boleslawski, M., Lunn, D. P. 2010. Immune responses of Asian elephants (Elephas maximus) to commercial tetanus toxoid vaccine. Vet Immunol Immunopathol 133 (2-4), 287-289 Transmissible Diseases Handbook. 2019. Infectious diseases Fact sheet TETANUS (Annex 4) Muir, Y.S.S., Bryant, B., Campbell-Ward, M., Higgins, D.P., 2021. Retrospective anti-tetanus antibody responses of zoo-based Asian elephants (Elephas maximus) and rhinoceros (Rhinocerotidae). Developmental & Comparative Immunology 114, 103841.. doi:10.1016/j.dci.2020.103841 https://ceh.vetmed.ucdavis.edu/health-topics/tetanus Tetanus Enterotoxemia (C. perfringens) Enterotoxemia is caused by the toxin of Clostridium perfringens . There are 4 subtypes of C. perfringens, all grwoing under anaerobic conditions that have been associated with elephants: type A, C, D and E. The diagnosis 'enterotoxemia' in based on culture and PCR of the toxin-associated genes in the histological lesions. Clinical manifestation in elephants Although there are few reports of enterotoxemia caused by C. perfringens in elephants , it might be an underreported disease in this species (see references below). Usually the disease has an acute course, with symptoms like diarrhea, colic, lethargy, anorexia and finally collaps in lateral recumbancy. If not treated agressively in time, the elephant usually dies. C. perfringens is an environmental bacterium which can be present in the elephant's gut without doing any harm. Under certain conditions (gastric pH decrease by nutritional overload of easily digestable carbohydrates or badly fermented silage products) it can overgrow the natural gut flora and produce large amounts of toxins that lead to the symtoms described above. Septicemia can lead to multiple abdominal organs involvement, as well as muscles. When young elephants are affected, the disease resembles Elephant Endotheliotropic Herpes Virus-Hemorrhagic Disease ( EEHV-HD ) as the symptoms in both diseases are associated with Disseminated Intravascular Coagulopathy (DIC). In some reports C.perfringens enterotoxemia and EEHV-HD were simultaneously diagnosed in diseased elephants (Boonsri et al. 2018, Costa et al, 2022). The prevalence of C. perfringens in European zoos was studied in 2020: in fecal samples of 86 healthy Asian elephants the presence of type A and type E was PCR-confirmed in 3 animals (2.2%). All fecal samples obtained from 50 African elephants were negative. In an overview of necropsy reports of 226 Asian elephants and 110 African elephants kept in the European Taxon Advisory Group between 1985 and 2018, 4 Asian elephants and 1 African elephant were reported to have died from an ulcerative enteritis caused by C. perfringens (Hes 2022). Few reports on enterotoxima in elephants are available in the literature. One author described the outbreak of C. perfringens in a group of African elephants kept in a European zoo (Göltenboth et al 1974): 2 days after feeding fresh grass, a young elephant developed diarrhea and was lying down more frequently. It was treated with a spasmolytic and vitamin C. The following morning it seemed much better and was returned to the group of 4 young elephants, where it deteriorated within 1 hour and died. At necropsy, severe blood staint edema and gas accumaltion was found in the subcutis of the neck, pharynx and larynx as well as a severe cathharal enteritis and gas accumulation in all internal organs, from which C. perfringens was cultured. A second case in a young elephant of the same herd occured 5 weeks later, again 2 days after feeding fresh grass. Symptoms were even more pronounced and C. perfringens was cultured form all organs (septicemia). The third elephant of the group fell ill a few days later. This animal did not develop diarrhea, but was lethargic and refused to eat and drink for 5 days. Despite of treatment with antibiotics and all kinds of supportive medications (including IV-administration of Clostridium antitoxin), it died after 10 days of illness. At necropsy more chronic lesions were found: enteritis, fatty liver degeneration, bronchopneumonia and myocardial degeneration. In this animal C. perfringens could not be detected. In one fatal case, acute myonecrosis was found in an 8 yr-old Asian elephant, resembling blackleg/ black quarter(C. chovoei) or malignant edema (C. septicum) (Rahman, 2009) . The elephant calf showed clinical signs of sudden illness characterised by loss of appetite with high fever (39°C) and reluctance to walk. The animal was treated with an intramuscular injection of enrofloxacin, 5 mg/kg body weight. The animal did not respond to treatment and its condition deteriorated rapidly. The animal stopped taking feed and water, became recumbent and finally died within 48 h of the onset of clinical signs. At necropsy, dark, discoloured, swollen muscles with rancid odour from the affected region and intramuscular aspirates were observed. C. perfringens was cultured from these lesions and the presence of alpha-toxin genes could be demonstrated by PCR. One case reports describes a fatal infection of Clostridium perfringens type C in an adult Asian zoo elephant (Costa et al. 2022). Evidence of involvement of EEHV4 was demonstrated by qPCR and the presence of intranuclear inclusion bodies in the endothelial cells of the intestinal blood vessels. Treatment of C. perfringens enterotoxemia In most cases it will be hard to make the diagnose in the living elephant. When enterotoxemia is suspected, agressive antimicrobial therapy, preferably based on an antibiogram and supportive therapy is mandatory. Depending on their bioavailability, antibiotics should be given IV or IM. Oral administration might result in low absorption from the intestines due to the enteritis. IV and rectal administration of fluids and IM NSAIDs are highly recommended. Early treatment of enterotoxemia is essential for the survival of the elephant. The list of recommended drugs is shown below. The clinician should not hesitate to administer all these drugs and should even sedate the sick elephant if needed for its treatment. Circulatory support: Rectal fluids: Luke-warm water 10-20 ml/kg BW TID or QID, up to every 2 hours Crystalloids: I V as a bolus of 0.3-4 ml/kg BW Antibiotic treatment: Penicillins are the first choice antibiotics. Penicillin G can be given IV and will have a quick action. Amoxicilline is a good representative as well ( 11 mg/kg IM q 24 h). Pain management: Pain management (opioids, NSAIDs) is recommended if there are clear signs of pain or discomfort: Butorphanol: 0.008-0.014 mg/kg IM Q 4 hrs Flunixin: 0.25 to 0.5 mg/kg IM SID Omiprazole: 0.7 to 1.4 mg/kg PO SID Anti-inflammatory treatment: Gluco-corticosteroid drugs are indicated in case of suspicion of DIC. Dexamethasone: 0.05-0.1 mg/kg IV or IM SID for 1-3 days. Prevention Although there is no scientific data on the efficacy of preventive vaccination, several zoos do practice annual vaccination with a multivalent vaccine. Care should be taken not to use an oil-based adjuvant, as these may cause necrosis around the injection site . As a general precaution, major diet changes should always be introduced slowly. When large amounts of easily digestible carbohydrates (like fresh grass, large amount of vegetables and silage) become available as a major food component, the diet change should be made over period of 7-10 days in order to allow the intestinal flora to adapt to the new diet. References: Bacciarini, L.N., Pagan, O., Frey, J., Grone, A., 2001. Clostridium perfringens b2-toxin in an African elephant (Loxodonta africana) with ulcerative enteritis. Vet. Rec. 149, 618–620. Boonsri, K., Somgird, C., Noinafai, P.,Pringproa, K., Janyamethakul, T., Angkawanish, T., Brown, J.L., Tankaew, P., Srivorakul, S., and Thitaram, C. 2018. Elephant Endotheliotropic herpes Virus associated with Clostridium perfringens infection in two Asian elephants (Elephas maximus) calves. Journal of Zoo and Wildlife Medicine 49(1): 178–182, 2018. Costa T, Rocchigiani G, Zendri F, Drake G, Lopez J, Chantrey J and Ricci E. 2022. Elephant Endotheliotropic Herpesvirus 4 and Clostridium perfringens Type C fatal Co-infection in an adult Asian Elephant (Elephas maximus). Animals 2022, 12, 349. https://doi.org/10.3390/ani12030349. Das A, Mazumder Y, Dutta B.K., Shome B.R., Bujarbaruah K.M. and Sharma G.D. 2008. Clostridium perfringens type A beta2 toxin in elephant (Elephas maximus indicus ) and pygmy hog (Sus salvanius ) with haemorrhagic enteritis in Assam, India. Afr. J. of Microb. Res. Vol.(2) pp. 196-201 2008. Goltenboth, R. and Klos, H.-G. 1974. On several diseases and causes of death in elephants in the Berlin Zoo (Zu einigen erkrankungen und todesfallen bei elefanten des Zoologischen Gartens Berlin. XVI Verhandlungsbericht Internationalen Symposiums Erkrankungen Zoo und Wildtiere, Berlin, Akademie Verlag, pp. 175–179. Hes. A 2022.Thesis: 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. University of Veterinary Medicine BudapestBudapest, 2022. Rahman H., Chakraborty A., Rahman T., Sharma R., Shome B.R. and Shakuntala I. 2009. Clostridial myonecrosis clinically resembling black quarter in an Indian elephant ( Elephas maximus ) Rev. sci. tech. Off. int. Epiz., 2009, 28 (3), 1069-1075, 2009. To page top Enterotoxemia Clostridioides difficile (previous name: Clostridium difficile ) Another potential pathogenic Clostridioides sp . is C. difficile . Clostridia are commonly encountered in the intestinal tract without being associated with disease, as soil and feedstuffs seem to be natural habitats for these organisms. However at rare occasions C.difficile can cause a severe, fatal enterocolitis. As in entertoxemia, the disease can have a fast fatal outcome within 2-3 days. A more chronic course of enteritis was associated with the same strain of C.difficile that had killed 2 adult Asian elephants in the same herd a few days before. This elephant recovered over a period of 5 weeks of severe illness with diarrhea. It was speculated that the feeding of large quantities of broccoli, a rich source of sulforaphane, which has been shown to inhibit the growth of many intestinal microorganisms might have triggered a subsequent overgrowth by C. difficile (Bojesen et al. 2006). The diagnose of C.difficile associated disease is based on aerobic and anaerobic culture and PCR, including the demonstration of toxins. Special culture media have been developed to grow C. difficile . Treatment Metronidazole and vancomycin are used to address clinical disease caused by C.difficile . The sensitivity to these drugs was studied in 6 isolates of C.difficili obtained from feces of clinically healthy Asian elephants (Sthitmatee et al. 2013). There was no evidence of resistance of these isolates to metronidazole and vancomycin. However, sensitivity may vary per country, depending on the antimicrobial policy followed. References Bojesen A.M., Olsen K.E.P. and Bertelsen M.F. 2006. Fatal enterocolitis in Asian elephants (Elephas maximus) caused by Clostridium difficile . Veterinary Microbiology 116 (329–335), 2006. Sthitmatee N., Warinrak T. and Wongkalasin W. 2013. Susceptibility of Clostridium difficile Isolated from Healthy Captive Asian Elephants to Metronidazole and Vancomycin. Thai J Vet Med. 43(2): 313-316. To page top Clostridium difficile Malignant edema Malignant edema (Clostridium septicum ) There is one report on malignant edema in an adult Asian elephant that lived in a European zoo (Goltenboth et al, 1974). The elephant died within 48 hours after the onset of the symptoms, that consisted of lethargy and general malaise. Severe edema was found in the entire intestinal tract. Clostridium novyi Report by Dr. Arun Zachariah et al. (Kerala Forests and Wildlife Department, Kerala, India) 19th International Elephant Conservation and Research Symposium, 2023 Chiangmai - International Elephant Foundation Since 2014, unusual mortality was observed in Asian elephants in Kerala state of South India.26 per acute mortalities were observed in a wild elephant population within a span of two years. Whereas two captive elephants were found dead with similar lesions but sporadic in nature. These animal deaths were per acute with quick autolytic changes and discharge of serosanguineous fluids from external orifices mainly anus. Possibility for Anthrax was ruled. Detailed autopsies were conducted in all the animals. Gross pathological lesions were identified as, petechial to echymotic hemorrhages in major organs, liver was friable with accumulation of gas in the parenchyma, blackening of the sub-cutaneous muscles and accumulation of serosanguineous fluid in the abdominal and pericardial cavity. Gram-positive spore bearing bacteria were seen in blood smear examination. Histologically, there was coagulative necrosis surrounded by inflammatory cells and large numbers of gram-positive rods were observed. High throughput sequencing of conserved 16S ribosomal gene revealed abundance of C.novyi in various tissue samples. Further, liver samples tested by PCR were positive for C. novyi type B flagellin and alpha toxin genes, but negative for other pathologic clostridia. Clostridium novyi type B causes infectious necrotic hepatitis in sheep and less frequently in other species. However reports of C.novyi infections in wild animals were scanty except for few species like Bighorn sheep and farmed Reindeer but not in outbreak proportions. This is the first report of C. novyi infection and mortality in Asian elephants in a large scale. Clostridium novyi Black leg Black leg (Clostridium chauvoei, C. septicum ) There is one report of black leg in a 50 yr-old Asian elephant kept in Australia (Prescott, 1971). The animal was on a diet of fresh grass (grazing), eucalyptus and lucerne hay. Two days before it died, the elephant had been off food and fell against a round timber pallisade, hurting its right shoulder. The following day it was depressed and fell down again and was unable to stand up. It died 52 hours after the first signs of illness. At necropsy the right foreleg was swollen from carpus to shoulder. On incision of the swollen muscles, sero-sanguineous fluid and gas bubbled from the emphysematous tissues. Clostridium septicum was cultured from this fluid. The wall of the stomach and large parts of the intestines was thickened, edematous and inflamed, while the spleen was very distended. References 1. Goltenboth, R. and Klos, H.-G. 1974. On several diseases and causes of death in elephants in the Berlin Zoo (Zu einigen erkrankungen und todesfallen bei elefanten des Zoologischen Gartens Berlin. XVI Verhandlungsbericht Internationalen Symposiums Erkrankungen Zoo und Wildtiere, Berlin, Akademie Verlag, pp. 175–179. 2. Prescott C.W> 1971. Black leg in an elephant. Veterinary Record 83, pp 598-599. To page top To page top Botulism Botulism is caused by the toxin of Clostridium botulinum (FAO). Clostridial organisms are strict anaerobes, meaning they do not grow in the presence of oxygen or in healthy, well-oxygenated tissues. Clostridium botulinum produces seven different neurotoxins, each of which is distinct and different enough from the others that antibodies against one type do not protect an animal against botulism from another type. Botulinum toxin is one of the most potent biotoxins known. Sometimes the onset of Clostridial disease is so rapid that no clinical signs are ever manifested; animals are simply found dead. The toxin is formed by the organisms outside the elephant under certain circumstances, characterized by an anaerobic environment (pH ± 4) and an environmental temperature between 10 and 50°C (FAO). Examples of these sources are poor-quality silage or poor-quality drinking water (anaerobic conditions in a pond without streaming water). Botulism in elephants Botulism was first reported in Asian elephants in a German zoo (Elze 1962). One adult elephant became paralyzed and died within one day. A cause of this sudden death could not be determined. Four days later an adult herd mate started to show the first signs of paralysis. Initially the animal remained standing with the neck stretched in forward direction, mouth opened, salivating and teeth grinding. The elephant only ate some fruits and was extremely weak in all its legs and the trunk. Pulse frequency was 68/minute. The animal went down sleeping several times, but with great strength it managed to get up by itself. On the second day a Botulism-antitoxin serum (Sachsisches Serumwerken A.G. Dresden, DDR) is administered (3x50 ml s.c.). On the next the animal is given 37 x 50 ml of this antitoxin serum, partly s.c., partly intramuscular in 50-100 ml portions in a time span of 2.5 hours. The total dose given was 20-40 times the dose given to humans. No adverse reactions were observed. During the first 8 hours after the administration of the antitoxin, the elephant went down and was almost unresponsive, until it managed to stand up again with the help of human manpower. In the following hours it started eating some fruits and hay. In the following week the animal recovered completely. The diagnosis ‘Botulism’ was made based on the symptoms and the positive reaction on the administration of the Botulism antitoxine. Other drugs that were given throughout the disease episode were caffeine, metamizole, calciumgluconate, Methiovert® (?), Algopyrin®, papaverine and streptomysine-penicilline. A second case of botulism in elephants was reported by Gart et.al (1977). Unfortunately, no details of that report could be retrieved. In 2017 a severe outbreak was reported in a captive bachelor herd of 6 Asian elephant bulls in Spain, which resulted in the death of 5 of the elephants. For the case report “Botulism in elephants”, click here . Botulism has been reported in horses that were exposed to botulism toxin in the feed, usually involving type B and C toxin. Toxin might be present as a contaminant in feed, or if there are droppings or carcasses of small rodents in the feed bunk or water tub. One problem occurs when rodents or other animals die in a field of forage, and a carcass is incorporated into a bale during baling. Contaminated hay cubes have been responsible for at least one large outbreak of botulism in horses. Even if a carcass has undergone dessication (it’s dried out) or is unrecognizable in a flake of hay, enough spores can remain to kill a horse. Toxico-infectious botulism is the second most common form of botulism in horses, and this arises when the bacterium itself is ingested from soil and colonizes the gastrointestinal tract. As it grows inside the body, it produces the toxin, and signs of disease become apparent as toxin is absorbed into the bloodstream from the intestinal tract. Clostridium botulinum type B has been associated with this form of botulism. Symptoms of botulism in elephants The typical symptoms include flaccid muscle paralysis. The major clinical signs consisted of gradually increasing general weakness, shivering, muscle fasciculations (involuntary contractions) or trembling and shaking, particularly in the shoulder and flank muscles, mild to heavy salivation, inability to swallow and stand and properly use the trunk and dilated pupils that respond poorly on light. Death can occur within a few days as a result of respiratory distress. Click here to see for a full description of the histological lesions in the case report described here . Treatment, diagnosis and prevention Treatment of botulism is very challenging: when treatment is started in the early phase of the disease, the administration of specific antitoxins might be helpful, as suggested in the 1962 case. In horses respiratory support is important, however challenging in elephants. Soft bedding should be provided. Eye protection with an eye ointment is important when the elephant has gone into lateral recumbency. During the phase of complete paralysis, the administration of oxygen through the trunk will probably support the oxygen exchange in the elephant’s lungs. A definitive diagnosis of botulism can only be made by performing a mouse bioassay test. Prevention: there is no commercially available vaccine against botulism, except for type B (AAEP) References Andrés Gamazo PJ, Pavón E, Stumpel J, Bouts T, Schaftenaar W, Kik M, de los Ángeles Jiménez Martínez M. 2023. Botulism outbreak in Asian elephants: histopathological findings at necropsy. Poster at ESVP-ECVP Congress, August 2023, Lisbon. Elze, K. 1962. Botulism in an elephant (Über Eine Unter dem klinischen bild des botulismus verlaufend Erkrankung beim elephanten). 4th Verhandlungsbericht Internationalen Symposiums Erkrankungen Zoo und Wildtiere, Berlin, Akademie Verlag, pp. 259–271. Fowler M.E. 2006. Infectious diseases. In: Biology, Medicine and Surgery of Elephants, Ed. Fowler and Mikota, Chapter 11, Infectious diseases Garlt, C., Kiupel, H. and Ehrentraut, W. 1977. Botulism in elephants (Ein beitrag zum Botulismus bei elefanten). 21st Verhandlungsbericht Internationalen Symposiums ErkrankungenZoo und Wildtiere, Berlin, Akademie Verlag, pp. 207–211. Websites: FAO: https://www.fao.org/3/t0756e/T0756E03.htm American Association of Equine Practicioners (AAEP): https://aaep.org/guidelines/vaccination-guidelines/risk-based-vaccination-guidelines/botulism Botulism

Perineal hernia in elephants are rare, but have been described. One surgical treatment has been described. To non-infectious diseases Perineal hernia Compiled by Willem Schaftenaar, 2020 Definition : A perineal hernia is a disruption of the pelvic diaphragm musculature that allows contents of the pelvic canal and/or abdominal cavity to herniate into the perineal subcutaneous tissues. In elephants this condition presents as a large bulging mass below the tail. Diagnose : 1. Pressure on the bulging area sometimes results in urination. This is suggestive for the presence of the urinary bladder in the perineal subcutaneous space. 2. Rectal palpation: if the urinary bladder is present in the perineal subcutaneous space, the bladder may empty when pression is used by the hand through the rectal wall. 3. Transrectal and transcutaneous ultrasonographic examination: visualization of the urinary bladder, cervix uteri or parts of the uterus in the subcutaneous space definitely confirms a hernia perinealis. History The cause of this condition in elephants is unknown. Complications: insufficient emptying of the urinary bladder may predispose for urine retention. There are no reports of urinary infection in elephants due to this condition. The first report on a perineal hernia dates from 1967 (Stehlik, 1967): a 20 yr-old female Asian elephant showed an over time increasing swelling in the perineal area, which aggravated each time the elephant had to stand on its hind legs for performance. Kuntze described a second case in 1989 and the author hypothesized that the hernia in this 6-yr-old circus Asian elephant might have been caused by the act that forced the elephant to stand on its hind legs, while supporting its front legs on another elephant ( Kuntze 1989). During this act, a 30 cm diameter ball-shaped swelling was noticed in the perineal area. As soon as the elphant stood on 4 legs, the swelling disappeared. Four years after the elephant had stopped this circus act, the swelling had disappeared. Hernia perinealis in an adult Asian elephant in a North American zoo. Treatment In the 4 cases that I am aware of, clinical signs were limited and did not cause discomfort to the elephant. These elephants were not treated for this condition. There is only one report about surgical repair of the perineal hernia, as the perineal subcutaneous mass became larger over a period of 10 years (Myanmar, 2016). Treatment results In one case in a 4 years old female Asian elephant, only the urinary bladder was involved. This case was not treated and the condition resolved within the next 3 years (Bernhardine, 1988, Rotterdam Zoo). The surgical repair in the Myanmar case was reported as a succesful intervention. Click here for the report. References Kuntze A. 1989. Arbeitsbedingter Krankheitsbilder: Hernia perinealis, bursitis praepatellaris und Tyloma Olecrani bei Zirkuselephantinnen (Elephas maximus ). 1989. 31st International Symposium on Diseases of Zoo and Wild animals, Dortmund (Germany) 1989, 185-187. Oo Z.M., et al. 2016 Surgical treatment of a cervico-vaginal prolapse in an Asian elephant in Myanmar. Gajah 44, 36-39 Stehlik M. 1967. Über zwei Fällen von Fussleiden, einen Fall von Volvulus und einen Fall von Hernia Perinealis bei indischen Elephanten. Nineth International Symposium on Diseases of Zoo and Wild animals, Prague 243-247. To page top

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

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

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