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This page describes the technique of blood collection and hematology with special attention to white blood cell counts in elephants (because of different monocytes, manual counting is required in elephants). Hematology Blood collection Hematology Blood chemistry Reference values blood Blood collection There are 3 anatomical sites on the elephants body where blood can be collected: One of the ear veins (or arteries for arterial blood sample) One of the branches of the saphenous veins (hindlegs) Cephalic vein (front legs) How to collect a blood sample: Most elephants can be trained for this procedure using positive reinforcement training. If not trained, standing sedation (or general anesthesia) in case of free ranging elephants) will be required. When alpha-2 agonists are used , vasoconstriction may hinder the access to the ear veins, especially in young calves. Combining alpha-2 agonists with butorphanol may help to increase the filling of these veins. When the environmental temperature is low, the ear veins may collapse. Flushing the inner side of the ear with large amounts of warm water (or packing the area with heated bean or rice bags) can increase the filling of these veins. The collection site should be clean and dry before blood is collected. Ear veins : press firmly on the site where you can see the shape of the vein. Press until you see the vein becoming larger in diameter. Use a small butterfly needle and collect the blood in a vacuum blood tube. If not available, you can use a small needle (23G) and a syringe and empty the syringe in the blood collection tube after removing the needle. To avoid damaging the blood cells (hemolysis), the tube should be filled slowly while flushing the blood carefully against the wall of the tube, that is slightly tilted. Saphenous and cephalic veins : these veins are larger in diameter than the ear veins, but covered by a thicker skin. A 19G or 21G needle (preferably connected to a vacuum tube) can be used and should be inserted perpendicular to the skin. Indication of the blood collection sites on the front leg (left photo, Vena cephalica) and the inner side of the hind leg (middle and right photo, Vena saphena). Blood collection from the inner side of the ear using a butterfly needle and vaccum tube. Blood cellection from the inner side of the hind leg of a well-trained adult Asian elephant bull using a vacuum bottle for collecting large amounts. Courtesy: Rotterdam Zoo Hematology This chapter includes a lab manual that was developed for a Healthcare and Welfare Workshop for elephant veterinarians given in Myanmar in 2018, organized by Elephant Care Asia (an initiative or elephant Care International - http://elephantcare.org/ . Get PDF of the manual PLEASE NOTE: white blood cell differentiation in elephants must always be done by MANUAL DIFFERENTIATION Erythrocytes: Erythrocytes in elephant whole blood EDTA samples can best be counted on an automated blood cell analyzer. Such an analyzer automatically measures the hematocrit . After centrifugation of the blood sample, a plasma evaluation should always be performed. The morphology of the erythocytes should be examined microscopically in a (preferably fresh) blood smear , stained with Wright-Giemsa. If no automated cell counter is available, manual erythrocyte count is a second option. Total white Blood count (WBC): Automated analyzers have limited value in elephant hematology. However, they can be used to measure the total amount of white blood cell. Automated cell counters come in several forms. Those used for other mammalians can only be used for total WBC in elephants. Manual WBC count can be done using a Hemocytometer Counting Chamber . Differential White Blood Cell (WBC) count: Automated analyzers cannot be used to differentiate the white blood cells of elephants. This should ALWAYS be done by manual counting the different cell types on blood smears , stained with Wright-Giemsa. See also the Manual Differential WBC Count . Platelets: Estimating the platelet count is best done by calculating the average of platelets counts in 10 fields x 15,000, which gives the Estimated platelet count/µL . See also: Manual platelet count (Cornell University) . Reference values: The table below shows the normal hematology values for Asian and African elephants (Wiedner, E. 2015). References Perryn K.L. et al. 2020. Biological variation of hematology and biochemistry parameters for Asian elephant (Elephas maximus), and applicability of population-derived reference intervals. Journal of Zoo and Wildlife Medicine 51(3): 643–651 Steyrer C, Miller M, Hewlett J, Buss P and Hooijberg EH (2021) Reference Intervals for Hematology and Clinical Chemistry for the African Elephant (Loxodonta africana). Front. Vet. Sci. 8:599387 Weisbrod T.C., Isaza R., Cray C., Adler L., and Stacy N.I. 2021. The importance of manual white blood cell differential counts and platelet estimates in elephant hematology: blood film review is essential. Veterinary Quarterly, 41:1, 30-35, DOI: 10.1080/01652176.2020.1867329. (Click here for the complete text). Wiedner E. 2015. Proboscidea. In: Fowler's Zoo and Wild animal Medicine 8. Species 360 - ZIMS 2023. Reference values To hematology gallery Back to Top To lab diagnosis Hematology Blood collection

An adult Asian elephant suffered form a severe infection of Salmonellosis (S. saintpaul). It went down and was unresponsive. Hematology and treatment results are discussed. To Salmonellosis Next case Next case Case Report Next case Salomonella saintpaul septicemia in an adult Asian elephant Next case Date: 2021 Location: Italy (zoo) Submitted by: Fieke Molenaar DVM and Pasqualino Silvestre DVM History Three months after the move to another zoo, a 37 year-old female Asian elephant (Elephas maximus) presented mild lethargy and a reduction of food and water intake. Mild colics were suspected and the elephant was treated with non-steroidal anti-inflammatories (NSAID, meloxicam i.m. ~ 0.2 mg/kg) and spasmolytics (metamizole and butylscopolamine bromide i.m., ~ 80 and 5mg/kg). As no improvement was noticed on Day 2, a standing sedation was carried out (detomidine i.m., ~ 0.018 mg/kg, and butorphanol (i.m., ~ 0.017 mg/kg). Rectal fluids (20 L of hand-warm tap water) and i.v. fluids (4 L of 0.9% saline solution) were administered, as well as i.m. injections with amoxicillin (~ 15 mg/kg), vitamin B-complex and vitamin E/selenium. Flunixin meglumine was given in the auricular vein. Sedation was reversed using atipamezole (i.m., ~ 0.05 mg/kg). Blood was collected during this procedure. Unfortunately, the elephant collapsed 9 hours later in lateral recumbency. The animal was unresponsive and could be approached while it kept its eyes wide open (see videos). The araol mucosa was very pale. After 25 minutes it managed to stand up without any assistance but remained lethargic. Respiration was shallow. During the night the elephant went down in lateral recumbency again. During the following 5 days, the elephant was sedated every day for treatment and blood collection. Next case Collapsed Asian elephant due to septicemia caused by Salmonella saintpaul . Note the pale oral mucosa. The state of paralysis very much looks like the paralysis seen in botulism ( see case report ). Laboratory results: Hematology: Leucopenia was evident on the first blood smear that was made, with a clear increase of bands and a reduction of matured heterophils. An interesting finding was the presence of immature granulocytes (myelocytes) that could not be identified exactly. The platelet count was low and schistocytes (fragments of erythrocytes) were observed in each view. The presence of schistocytes is suggestive for the presences of a coagulopathy. In conclusion: based on the hemogram, a diffuse intravascular coagulopathy (DIC) was suspected, most likely associated with septicemia caused by a bacterial infection or a toxicosis. Interestingly, EEHV 3/4 was detected by a combined PCR test for subtype 3 and 4 in a blood sample and in trunk swabs. The elephant had been tested PCR positive for EEHV4 previously. A trunk swab taken from the conspecific that shared the enclosure was PCR-negative. For photos of elephant heterophils, bands, platelets and schitsocytes: click here . Human myelocyte, containing both primary (azurophilic) and secondary/specific (pink or lilac) cytoplasmic granules. The proportion of secondary granules increases as the cell matures. The nucleus is round and lacks a nucleolus. Courtesy: ASH Image Bank Myelocyte of the Asian elephant in this case report. The quality of this photo is poor as it was taken with a cell-phone through the ocular lens of the microscope. Urinalysis: Daily urine samples were taken and analyzed using a dipstick and refractometer from Day 3 onwards. Initially a high specific gravity with a low pH was determined, suggestive for severe dehydration and metabolic acidosis. Fecal culture and treatment: A fecal sample collected on Day 3 was submitted for bacteriology. The treatment plan focused on the suspected septicemia. Treatment with NSAID was continued and the antimicrobial treatment was switched to enrofloxacin (per rectum, ~ 2.5 mg/kg) and metronidazole (per rectum, ~ 11 mg/kg). Administration of vitamin B-complex and E/selenium was repeated on day 4 and day 5. Preventive measures In an attempt to find the causative agent of the suspected septicemia, stored hay was inspected for mould and other conditions that favor (an)aerobic growth of toxin producing bacteria, more specifically Clostridium spp. All sand in the enclosure was replaced; drains and surfaces were disinfected with 5% sodium hypochlorite before new sand was brought in. Treatment (continuation) On Day 9 Salmonella saintpaul sensitive for enrofloxacin was isolated from the feces. Until Day 6, dehydration was getting worse, based on hematological findings (increased Ht) and urinalysis (increased specific gravity). On Day 7 no feces were produced (probably caused by the anorexia and repeated administration of detomidine) and diphteric necrotic tissue was observed during the administration of rectal fluids. In the mean time, hematology results started to show evidence of recovery from the septicemia: bands had dropped from 36% (Day 5) to 11%, while platelets increased from 320 (Day 2) to 437 x109/L. WBCs increased from 3.3 (Day3) to 10.5 x 106/L. Interestingly, the number of myelocytes increased to 35% on Day 7, but sharply dropped to 5% on Day 8 and they totally disappeared after that day. All hematological parameters were normal when checked again on Day 48 and 55. In order to stimulate the appetite and the intake of fibrous food, daily sedations were discontinued as from Day 8, and the focus of treatment moved to provide gastro-protection and stimulation of the duodenal motility by the administration of ranitidine (oral, ~ 0.25 mg/kg) twice daily. Water soaked bran and hay ad lib, bamboo browse and banana tree-trunks were offered as much as possible. Sugar-containing food items were restricted to treats for compliance to vocal commands by the keepers in order to get cooperation from the elephant for the necessary treatment procedures. The animal regained its strength and body condition over the 3 month-period following this clinical episode. The presence of EEHV3/4 in the blood and trunk swab can be explained by a virus reactivation due to the sudden deficiency of the immune system as a result of the septicemia and DIC. No clinical impact is to be expected from this finding, as the animal known to be a carrier of EEHV4. References Molenaar, F.M. and Silvestre S. 2021. Clinical approach to colic and collapse in an Asian elephant ( Elephas maximus ) with Salmonella saintpaul septicaemia and subsequent ileus. Vet Rec Case Rep. 2021;e214. https://doi.org/10.1002/vrc2.214 . To page top

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

Only a handful of fetotomies have been performed in elephants. The case described here is the only one in which the dam survived. Wound healing is similar to the vaginal vestibulotomy, however, wound infection may occur due to the heavy manipulations during the long procedure and the passage of sharp bony fragments of the fetus through the created opening. To Reproduction To dermatology Case report Fetotomy and wound treatment Date: 2008 Place: Rotterdam Zoo Data provided by: Willem Schaftenaar History A 37 years old matriarch Asian elephant failed to deliver her 5th calf. At 13 months from the failed parturition, a herd mate of this animal delivered a healthy full-term calf. The calf tried to nurse from the matriarch and this elephant actively encouraged the calf to do so. Within 6 hours of this behavior, the matriarch displayed intense labor. After 24 hr, the hind legs of the retained calf could be palpated transrectally in the vagina, and several sharp fetal bone fragments (dorsal spines, fractured ribs) were palpated as they almost penetrated the vaginal wall. At that time, the animal was completely exhausted and contractions had ceased. With a failed attempt to extract the fetal carcass through the intact birth canal using two Krey-Schöttler fetotomy hooks, a decision was made to perform a vagino-vestibulotomy. Onset of labor 6 hours after the birth of a calf in the herd Six hours after the birth of a calf in the herd, labour in the matriach started, 13 months after the first signs of labour had come to a stop. Treatment The animal was chained on one front leg and the opposite hind leg. 150 mg xylazine was slowly hand-injected intravenously. During the entitre procedure (11 hours) extra doses of 75 mg xylazine were given intravenously every 50-60 minutes. Four 4 local depositions of 20 ml Lidocain 2% (with adrenaline) were injected in the midline below the anus. Epidural anesthesia was not used, however new insides have proven that this is an important method to reduce movement of the tail and decreases pain perception in the perineal region. The animal remained standing throughout the entire procedure. A 15cm skin incision was made in the midline. A rubber (cattle) stomach tube with a 10x60mm window at the tip was inserted in the vestibulum vaginae and advanced till the tip reached the dorsal edge of the incision. The vestibulum vaginae was incised over the window of the tube. The legs of the calf could be visualized in the horizontal part of the vagina. At least 4 fractured ribs were found, probably fractured by the natural contractions of the uterus duting the past 24 hours. The fractured ends had penetrated the wall of the vestibulum on the left caudo-ventral side, but not completely perforated, resulting in several tears of the mucosa (20cm long). The roof of the vestibulum vaginae had some mucosa tears too, also not perforating the wall totally. The carcass was cut into more then 100 large pieces; many ribs were removed one by one to avoid damage to the wall of the vestibulum vaginae. A complete fetotomy was performed using a Thygesen fetotome (Utrecht model). Finger knifes, Krey Schüttler hooks, saw directors and calf delivery chaines were used to cut the carcass in smaller lieces and pull them out. Large pieces were pulled out with extra support by a calving-pully for cattle. A long blunt "eye-hook" (used to grab a dead cattle or horse fetus in the orbit) was modified at the spot making it a prolonged knife (like a "finger knife" for fetotomy). Muscles were split from their bone attachment using this knife and blunt fingers. Lumbs of the carcass that were too big to pass through the fetotomy opening, were removed via the normal birth canal. After 3 hours 40 ml Duphaspasmin (11.58 mg isoxsuprinelactate per ml, Fort Dodge NL8514) ws injected i.m. followed 30 minutes later by another 40 ml Duphaspasmin i.m. as well as 100 ml Amoxicilline 20% (200 mg amoxicilline trihydrate/ml, NL 2795) i.m. After 9 ¾ hours the entire carcass of the fetus was removed. 5 ml Oxytocin (oxytocine 10 IU/ml, NL3852) was given intravenously. The uterus was flushed with large amonts of luke-warm water using a plastic hoose pipe. The water was drained as much as possible. Ten liters of 0.09% NaCl was brought into the uterus using a cattle stomach tube and a funnel. Thirty minutes after the previous injection, another 5 ml Oxytocin (oxytocine 10 IU/ml) was given i.v. The uterus started to show moderate contraction on the ventral side. The rest of the uterus was still filled with air. A custom-made balloon (100 ml volume) catheter was advanced into the urinary bladder. The mucosa of the vestibulum vaginae was sutered with 2/0 PDS, continuous Cushing stitches. The overlying muscular tissue and connective tissue was sutured in 2 layers using) Vicryl, continuous stitches. Only the dorsal 5 cm of the skin was sutured intradermally using 1 Vicryl, single stitches. The mucosa of the vulva and the distal part of the vaginal vestibule had been severed by the passage of large lumps of the carcass with sharp bony edges. A 84 kg female calf carcass was removed in more than 100 pieces. The carpal joints were in flexed position and could not be bent unless the flexor tendons were cut thorught. This condition is known as arthrogryposis. Whether this had caused the initial dystocia remains inclear. Antibiotic treatment (150 ml amoxicilline 20%, i.m. SID) was given for 9 days. The balloon catheter came out one day after the fetotomy. During the following weeks the vulva and vaginal vestibule became heavily infected and large pieces of necrotic tissues were lost. After 5 days transrectal ultrasonographic examination demonstrated that there was still a lot of detritus in the uterus. Five ml. of oxytocine (10 IU/ml) was given i.m. Surprisingly the uterus was still responsive to oxytocine, as aftre a few hours a lot of fluid was discharged through the vulva. When this was repeated 2 days later, no reaction of the uterus was observed. Making an incision in the vaginal vestibule guided by a plastic tube (with a window cut out) advanced in the vaginal vestibule. The Thygesen fetotome is advanced into the horizontal birth canal. Most parts of the fetus were removed through the vulva, which allowed a relatively small incision of the vaginal vestibule Krey-Schüttler hook Thygesen Fetotome Giggli saw director Custom-made balloon catheter Finger knife Pieces of the carcass were put together to check whether bones were missing. One femoral condyl was missing. It was found the following day. Note the arthrogryposis in the right carpal joint. The left carpal joint is stretchted after cutting through the flexor tendons. Treatment results All sutures came off after 14 days, which facilitated the daily treatment of the distal part of the birth canal: flushing with 50-100 liters of 0.09% saline solution through the surgical wound. This treatment was continued for several weeks. Six weeks after the fetotomy, the elephant was sedated again with xylazine, and the necrotic area of the surgery wound was debrided. In the following weeks, the surgery wound and the wounds in the distal part of the birth canal started to heal nicely. Ten weeks after the fetotomy the surgery wound had reduced in size from 15cm to 10 cm. Flushing with saline water was discontinued. At 14 weeks the surgery wound was 5.7 cm long. At 5 months the skin and mucosa of the vaginal vestibule had fused completely, leaving a 4 cm opening. The elephant was sedated again with xylazine and the skin-mucosa fusion was surgically disconnected. Over a circular area of 4 cm around the opening, the skin was seprated from the vaginal vestibule. The vaginal vestibulum was closed in 2 layers using 2/0 Moncryl; first layer: Schmieden suture; second layer: Lambert suture. The skin was left open. All sutures came off after 5 days. It was decided to allow the wound to heal per secundam. The wound was flushed with saline solution on a daily base. Two months later, the wound diameter was 4 cm and the epithelization between skin and mucosa was complete again. One year after the fetotomy the opening was still 4 cm. Standing sedation was performed using xylazine. The tissues around the fistula were injected with a total amount of 17 ml Lidocain 2% (with adrenaline). A small strip of the epithelium layer that formed the edges of the fistula was cut off and the subcutis was incised, separating the vestibulo-vaginal wall from the skin over 2-3 cm. The vestibulo-vaginal wall was closed using Vicryl 1, continous Utrecht-uterus suture. Antiseptic, silver impregnated gauze was inserted in the subcutaneous space. The gauze was sutured to the ventral edge of the wound using Vicryl 1 to facilitate later removal. The skin was closed using a continuous intracutaneous suture (Vicryl 1). Three extra single matrass sutures (Vicryl 6) and 1 single suture were applied as an extra support for the intracutaneous sutures. The ventral part of the fistula was left open to allow later removal of the gauze. 9 days after wound dressing: all sutures came off. The vaginal wound is retracting in the subcutaneous space (thus enlarging the wound surface). Diameter of skin wound: 6 cm. 15 months after fetotomy:wound almost closed, leaving a permanent opening of 3 mm, Wound healing Severely swollen vulva 3 days after the fetotomy. Two months after the fetotomy, the wound starts healing nicely. Necrotic tissue protruding through the vulva, 12 days after fetotomy. Five months after the fetotomy, epithelization of the edges of the skin and mucosa has interrupted wound healing Five months after the fetotomy, wound dressing is performed. The vaginal vestibule is closed. Photo taken before closing the skin. Five days after the surgical wound correction, all sutures came off. One year after the fetotomy, a second wound dressing is performed. One week later, the wound opened and the subcutaneous drain came off. Eighteen months after the fetotomy, the wound was closed, leaving only a 3 mm opening (black structure above the pink connective tissue area. Conclusion of the author: the skin should not be sutured after a vestibulotomy or a fetotomy in elephants, as it delays the healing process. Closing the vaginal vestibule is also questionable, as the mucosa around the surgical wound is heavily contaminated by the strong manipulations needed for the procedure, resulting in wound infection. Healing per secundam of the entire wound is recommended, no matter how hard it is for a vet to leave such a big wound open! To page top

Foot and sole or pad lesions are common in elephants and should be treated. Abnormal wear of the pad can be the result of joint disease. Sole lesions can result in fistulas. Pedicure must be part of the management. Foot and mouth disease and cowpox virus can cause complete slaughing of the pad. Back to index orthopedic problems Foot problems Foot problems in elephants under human care are frequently seen. Several anatomical structures can be involved in foot problems: the sole (pad or slipper), the nails, the joint ligaments, the tendons, the distal phalanges and the joints. Many of the problems are management-related. Abnormal wear, inappropriate substrate, stereotypic repetitive movements and lack of space to move around are some of the major causes of orthopedic problems in elephant feet. A separate chapter on regular foot care in elephants under human care can be found here . An elephant suffering of foot problems will often demonstrate one or more of the following symptoms: Swelling, pain Lameness, reluctance to move Black tracts on or beneath nails Discharge / bad odor Nail cracks Overgrowth / over-wear (nails and/or sole) Dry or overgrown cuticles Examination of the foot If the animal is well trained, it should lift its legs to allow inspection of the nails and pad of each foot. Alternatively the feet can be examined with the elephant in lateral recumbency. 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 microorganisms. 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 or when pressure is exerted on the cuticles, watery fluid may be discharged ( see video ). The nails and the sole are interconnected by a structure that is an equivalent of the white area in horses and cattle. It forms a delicate connection, where microbes can penetrate into deeper layers to cause an infection (pododermatitis) ultimately resulting in osteitis and arthritis of the interphalangeal joints. The nails should never be longer than the pad, as they should not bear weigth when the elephant is standing still nor during walking (see video) . Long nails can easily develop a tear, giving access to microbes. 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 stones, 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. 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) Sole lesions Sole lesions Normal sole of an Asian elephant kept in a zoo Normal sole of an Asian elephant semi-free ranging in the forest. Normal sole preparation of a free-ranging African elephant (Kruger National Park, South Africa) In order to maintain a healthy sole and nails, there should be a balance between wear and (re)growth of sole and nail tissues. The main factors that determine the wear are the type of substrate, activity of the elephant and the humidity. Best Practice Guidelines The EAZA Best Practice Guidelines for Elephants recommend: Indoor and outdoor substrates should: 1. Provide choice to the elephant, allowing elephants to explore and investigate a range of substrates within their enclosure. This can provide increased activity and the cognitive benefits of decision-making. 2. Provide a degree of flexibility and accommodate the vast body mass of an elephant. Flexible ‘soft substrate’ works to absorb impact, easing the pressure on the joints and feet. 3. Provide good drainage which is beneficial for respiratory, skin and foot health. Soft substrate (such as sand) can act as a “bio floor”, allowing drainage of urine and ensuring animals are not standing in their own quite aggressive urine or lying on wet/cold floors. 4. Provide opportunities for enrichment, such as digging/hiding food which can improve musculature. 5. Allow dust bathing which provides enrichment and is beneficial for skin health. Hard floors Should be used only in places where long standing of elephants is not expected to occur and the elephant’s time in these areas should be minimised where possible. Concrete or rubber floors should have a non-abrasive but not smooth finish. Solid floors should be cleaned regularly and disinfected where appropriate and should provide appropriate drainage to avoid pooling of urine where elephants stand. Sand floors If used, type of sand should be considered. It should not be dusty, should drain well and not be able to compact (in the enclosure or gut). Sand that includes fine sand, silt or clay grades is likely to result in a dusty enclosure and compact into a solid floor. Sand grains need to be of a single size to reduce compaction. A grain with a round, rather than angular, shape will reduce compaction and will not be over wearing on the feet. Sand depth should be of 0,8 m minimum depth, but 1,5 m is recommended. Daily maintenance of sand includes daily watering to prevent excessive dust. Sand must be regularly turned to prevent compaction and build-up of bacteria that can grow in anoxic conditions. Sand floors need to be easily accessed by specially designed heavy machinery (such as truck loaders), and purposely built concrete ramps are a must. Where sand is retro fitted into enclosures, drains should be protected with permeable membranes and sand depths maximised where possible. Door runners should be subject to increased maintenance procedures to mitigate sand ingress. Alteration of door runners can be considered in preference to removal of substrates. Benefits of sand include the ability to build up pillows or mounds which may be used by older animals to sleep against or aid older/arthritic elephants when getting up. Animals also can benefit from rolling/ playing in or on mounds and they can act as visual barrier. The drainage provided is beneficial to aid calves in standing up quickly post birth. Sand can be used in outdoor areas, in all weather, and can withstand extreme cold or wet weather (with appropriate drainage). Grass If possible (i.e. space available will not be significantly compromised with paddock rotation technique), allow grazing access for elephants, which prolongs foraging times. Under improper environmental conditions the following sole lesions can develop: Figure 1. Excessive wear: too much wear results in a smooth surface and a thin pad, vulnerable for deeper sole lesions.The sole of an adult elephant should be at least 20 mm thick. Figure 2. Insufficient wear: the grooves may become too deep and form pockets, which are an easy entrance site for stones, dirt and microbes and can lead to a sole abscess. Figure 3. Crack/tear Figure 4. Sole fistula/ulcer/abscess Figure 5. Sole detachment (partial or complete) Result from primary infection (cowpox and Foot-and-mouth disease) Secondary infection after trauma, moisture, weight overload, dirt: Figure 1. The sole of this zoo-kept African elephant is too thin and health a smooth surface, making it vulnerable to cracks, perforations and nail lesions. Note the small cracks in the nails. Figure 2. Overgrown pad and nails. See also: International Elephant Foundation. Figure 3. Crack in sole of African elephant kept on a concrete floor Figure 4. Fistula/ulcer/abscess in the sole of an Asian elephant spending most of the time on the streets in Laos. Figure 5. Partial sole detachment in an Asian elephant orphan at the Dak Lak Elephant Conservation Center (Vietnam), caused by keeping him on a wet floor (rainy season). Injuries to the sole of the foot are particularly difficult to manage because it is hard to keep them clean and prevent infection. Careful pedicure of the sole may reveal bruces in the soft horn tissue, that resulted from abnormal local pressure on the sole. (Courtesy: Susan Mikota). These bleedings are blood lines in the horn lamellae (not to be confused with sole bruses) that may be seen when abnormal forces have been excerted on the nail (e.g. too long nail) (Courtesy: Susan Mikota). Perforated, infected sole lesions due to trauma (Courtesy: Susan Mikota) Partial pad and nail loss in a 54-yrs-old female Asian elephant. Click here to read the case report. Foreign body pad perforation One case report describes the treatment of a pad abscess resulting from the penetration of a wire through the pad in a 19-yr-old female Asian elephant (Elephas maximus ) housed at the Paris Zoo (Ollivet-Courtois 2003). The cow presented with acute right forelimb lameness and swelling that persisted despite 4 days of anti-inflammatory therapy. Under anesthesia, a 10 x 0.5 x 0.5 cm wire was extracted from the sole of the right foot. There was a 2-cm-deep, 7-cm-diameter abscess pocket that was subsequently debrided. Regional digital i.v. perfusion was performed and repeated 15 days later, using cefoxitin and gentamicin on both occasions. Between treatments, the cow received trimethoprim–sulfamethoxazole and phenylbutazone orally. Within 2 days of administering anesthesia and the first perfusion treatment, the lameness improved dramatically. When phenylbutazone was discontinued 1 wk after the first treatment, the lameness had completely resolved. At the second treatment, there was no evidence of further soft tissue infection, and the abscess pocket had resolved. A 10 x 0.5 x 0.5 cm piece of curved wire was found penetrating the right front foot of a female Asian elephant. A rope tourniquet was placed above the right carpus, and venous access was obtained using a 21-gauge, 0.8 mm butterfly catheter in a palmar superficial vein of the right foot to perform regional interdigital perfusion. Complete sole detachment can be caused by: Foot-and-Mouth disease (FMD) Generalized Cowpox infection. Foot and Mouth disease Both elephant species are susceptible to FMD. However, severe disease has been reported (anecdotically) more in Asian elephants than in African elephants. A description of FMD in African elephants after experimental (!) infection is found here (Howell, 1973). In range countries it is important to avoid direct and indirect contact between cattle and elephants, especially during FMD-outbreaks in the cattle population. Vaccination of cattle is important to reduce the risk of FMD to elephants living in the same area as cattle. For vaccination data, see also: The use of Vaccination of FMD in zoo animals (Schaftenaar, 2002) Complete sole detachment in an African elephant after experimental infection with FMD-virus. Cowpox Both elephant species are susceptible to cowpox infections, though more severe clinical impact is seen in Asian elephants. Symptoms can range between external pox lesions on the skin to complete sole detachment, as well as internal pox lesions in various organs. Vaccination is practiced in European zoos (for vaccine information, click here ). NB: Cowpox disease is a zoonotic disease! To reduce the pressure on a thin or perforated sole, a rubber sole can be glued on the thin sole. This material can last for 2-6 weeks when properly glued to the sole. Avenir Light is a clean and stylish font favored by designers. It's easy on the eyes and a great go-to font for titles, paragraphs & more. A more frequently used tool to reduce the pressure on the sole, is a sandal or boot made locally, fitting the foot of the elephant. This shoe should be removed daily to inspect and treat the injury. Custom-made sandal, Fowler & Mikota 2006 Custom-made boots, Singapore zoo 2007 Another example of custom-made sandals to protect an injured sole (Myanmar. Courtesy Susan Mikota) These sandals were made by commercial companies Teva and Nike (Courtesy Susan Mikota) Edges of the sole bordering the sole defect were thinned (Dak Lak Elephant Conservation Center, Vietnam) Treatment of sole lesions Excessive wear: the thin and smooth horn layer has to regrow. This means that wear has to be reduced. This can be achieved by reducing the time spent by the animal on a hard floor, changing the floor surface and substituting it by softer materials; i.e. concrete floors can be covered by an epoxy layer or deep sand. A concrete sleeping area should be replaced by a sand floor (see EAZA Best Practice Guidelines for Elephants) . The thickness of the pad can be measured by ultrasound examination. Overgrown sole: horn can be trimmed away using a hoof knife. Usually the nails will also need trimming. The use of a drawknife is not recommended, as it easily removes too much from the sole. Make sure that the nails are always shorter than the sole! Crack/tear: as these are usually the result of a too thin sole, measures to increase the sole thickness should always be taken. If the crack hasn't perforated the sole completely, the edges of the crack can be cut away using a hoof knife with the aim to prevent accumulation of dirt and to reduce the pressure on the thinnest part of the crack. A sandal should be considered is there is a risk of sole perforation. Sole fistula/ulcer/abscess: if the sole is perforated, microbes will have entered the underlying tissue. Frequent pedicure will be required in order to drain the affected tissues. The edges of the fistula need to be made as thin as possible with a smooth transition to the thicker part of the sole. This will reduce the pressure on the infected area. The fistula/ulcer/abscess must be flushed daily with saline solution and a mild disinfectant. Soaking the foot in a foot bath should be considered (see images below). Several solutions have been used in elephants (see table below). Epsom salt is probably superior to the other solutions, while copper sulfate might be too caustic for this type of injury. As long as the effluent is sufficiently drained with the help of frequent trimming, the use of systematic antibiotics is not indicated. List of foot bath solutions as described in Fowler & Mikota 2006 Simple foot soaking bath by a well trained Asian elephant, Dak Lak Elephant Conservation Center (Vietnam) Custom-made foot soaking bath, Laos (courtesy Dionne Slagter) Partial sole detachment: this condition can be the result of long exposure of the sole to water and dirt. Standing on a hard floor will predispose for this lesion. P arts of the sole that are detached from the underlying tissue must be entirely trimmed away using a hoof knife. Leaving a sole flap - even a small one - will result in extension of the infected area. The edges of the sole bordering the defect, must be made thin and smooth in order to avoid pressure of the remaining sole on the fragile exposed tissues. Regular trimming of the edges of the sole around the defect and daily flushing and foot bath are required. In some cases the use of a sandal or boot may be needed. Foot bath Complete sole detachement: this condition is usually the result of trauma or a viral infection : Foot and Mouth Disease and Cowpox have been associated with complete sole detachment, always accompanied by other severe symptoms caused by these viruses. As there are no specific treatment options for these viral diseases, only symptomatic treatment can be given. Bandaging the affected legs has been practiced, but one should not be optimistic about the results. In some cases, humane euthanasia will be the only option to prevent the animal from suffering. Traumatic sole detachment can be expected if the elephant has been trapped in a snare. Cleaning, disinfection (mild solution soaking foot bath) and sometimes bandaging of the affected foot will be necessary until the wound has closed. In some cases, the regenerated tissue that covers the wound is strong enough to withstand the pressure of the body weight. If that is not the case, a prosthesis will be needed to provide sufficient protection. References: Cowpox infection in elephants. 1996. Proceedings of the annual conference of the European Association of Zoo and Wildlife Veterinarians. Fowler ME 2006. Foot disorders. In: Biology, Medicine, and Surgery of Elephants. Fowler & Mikota, 271-290. Howell P.G. , Young E , Hedger R.S . 1973. Foot-and-mouth disease in the African elephant (Loxodonta africana ). Onderstepoort J Vet Res. 1973 Jun;40(2):41-52. Johnson G., Smith J., Peddie J., Peddie L., DeMarco J., Wiedner E. 2018. Use of glue-on shoes to improve conformational abnormalities in two Asian elephants ( Elephas maximus ). J. Zoo&Wildl Med. 49(1): 183–188, 2018. Ollivet-Courtois, F., Lécu, A., Yates R.A., Spelman L.H. 2003. Treatment of a sole abscess in an Asian elephant (Elephas maximus ) using regional digital intravenous perfusion. Journal of Zoo and Wildlife Medicine 34(3): 292–295, 2003 Schaftenaar W. 2002. Use of vaccination against foot and mouth disease in zoo animals, endangered species and exceptionally valuable animals. Rev. sci. tech. Off. int. Epiz., 2002, 21 (3), 613-623. To page top

A 1 yr-old Asian elephant suffered of colics as a result of a (traumatic) hernia mesenterialis. A torsio of the small intestines was incarcerated in the hernia. Consequently the intestine ruptured. The calf died due to acute peritonitis. To non-infectious diseases Case report Hernia mesenterialis and intestinal rupture Date: 2002 Place: Rotterdam Zoo Data provided by: Willem Schaftenaar History Species: Asian elephant Accommodation: Zoo, free contact Age, gender: 1 year, male Five years before this episode, a 3 yrs-old calf at the same zoo had died of EEHV1a . The calf (300 kg estimated BW) was heavily hit on its abdomen by a herd mate. Two days later (Day 1) it became very lethargic and stopped drinking from its mother. Day 1 08:30: Very lethargic, not eating. Laying flat on the ground, while kicking with his hind legs ( colic ). Sometimes standing with the mouth widely opened. Conjunctivae: slightly congested. Tongue: normal color. No edema on head or shoulders. Defense musculaire: normal. Rectal temperature: 36.8°C A standing sedation using xylazine (0.1 mg/kg BW IM for the calf, 0.08mg/kg BW for the dam) was performed in both the affected calf and its mother. As soon as sedation started, the calf was brought to its mothers mammary glands and it started drinking from the mother. EDTA and full blood samples were taken and rectal fluids were given during the sedation. Rectal palpation: only one handfull of soft feces in distal part of the rectum. The rectal wall is very dry. Urine sample: all values (dipstick) within normal ranges. Blood sample collected. Hematology and blood chemistry results were all within normal ranges. EDTA whole blood sample submitted for PCR on EEHV. Results: PCR-positive EEHV1a. Rx: 6 ml Finadyne (flunixinemeglumine 50 mg/ml, NL1726) i.m. 15 ml Baytril 10% (enrofloxacin 100 mg/ml, NL3489) i.m. 3000 mg famciclovir mixed with 15 ml utrasound gel per rectum. Calf during standing sedation and suckling from its mother. Note the penis relaxation, typical for alpha-2-agonist sedation. 16:30: No change. Not eating, laying. Less signs of colics. Rx: 1500 mg famciclovir mixed with 10 ml ultrasound gel per rectum. 23:00: Animal is lethargic. Laying down most of the time. Rx: 1500 mg famciclovir mixed with 10 ml ultrasound gel per rectum. Day 2 Slightly alerter than before. Treatment was continued similar to day 1. Day 3 08:30 Alerter, but no attempts to nurse from its mother. Rx: 15 ml Baytril 10% (enrofloxacin 100 mg/ml, NL3489) i.m. 1500 mg famciclovir mixed with 10 ml ultrasound gel per rectum. 16:00 Agian very lethargic. Has not eaten or nursed at all. No feces nor urine produced. Standing sedation (calf and dam, see day 1). Again the calf was drinking well during the sedation. Also defecating and urinating. Firm feces. Rx: 1500 mg famciclovir per rectum dissolved in 20 ml water. 600 ml Amynin (per ml: 50 mg glucose anhydrate, electrolytes, aminoacids and B-vitamins, NL 4137) per rectum. Blood and urine samples collected. All values within normal ranges. EDTA: EEHV-PCR signal much lower than day 1. Day 4 08:00 Alerter, has not been laying excessively long during the night. Rx: 1500 mg famciclovir per rectum (dissolved in 20 ml water). During the morning the animal has been drinking spontaneously from his mother. Treatment similar today 2. Day 5 09:00 Leaning against the poles. Rx: 1500 mg famciclovir per rectum (dissolved in 20 ml water). Keepers think his behaviour is about the same. Is drinking water from the hosepipe. Some normal feces manually removed from the rectum. 16:00 Still leaning against the poles but sometimes giving a more alert impression by moving his tail. Rx: 1500 mg famciclovir per rectum (dissolved in 20 ml water). Standing sedation (xylazin 0.1 mg/kg IM). Drinking from his mother. Day 5 08:00: Very lethargic; did not drink during the night. Tympanic, bilateral; intestinal obstruction suspected. Some dry feces were collected from the rectum. Rx: 1500 mg famciclovir per rectum (dissolved in 20 ml water). 6 ml Finadyne (flunixinemeglumine 50 mg/ml, NL1726) i.m. 15 ml Baytril 10% (enrofloxacin 100 mg/ml, NL3489) i.m. During the day the condition of the animal deteriorated. 14:00: sedated with xylazine (0.1 mg kg IM). Blood sample collected - heparin and EDTA and fluride. Rectal palpation: balloon-like intestines. The calf suddenly regurgitated and threw up stomach content. Rectal fluids were given. At 15:00 the animal died. Necropsy Necropsy hernia mesenterialis 1) Cause of death: * Rupture of the ileum resulting in peracute peritonitis. * Mesenteric hernia. * Intestinal mesentery, small intestine (jejunum), ileum: Venous infarction, acute, marked, with venous and lymphatic thrombosis, fibrinoid arterial necrosis, and interstitial haemorrhage and necrosis. * Intestinal mesentery, small intestine, hepatic capsule, pancreas: Peritonitis, fibrino-purulent, diffuse, peracute, moderate, associated with bacterial infection. 2) Significant diagnoses: * Liver: pericholangitis, eosinophilic, diffuse, chronic, severe, with bile duct hyperplasia and portal fibrosis. * Liver: hepatitis, granulomatous, eosinophilic, multifocal, chronic, moderate. 3) Incidental diagnoses: * Heart: haemorrhage, subendocardial, epicardial, multifocal, acute, mild. * Lung: pulmonary oedema, diffuse, acute, mild. * Adrenal cortex: adrenocortical necrosis, multifocal, acute. Cyanosis of the tongue and epicardial hemorrhages that are seen in EEHV-HD were also present in this case. They are the result of circulatory shock and are not pathognomitic for EEHV-HD. The intestinal contents was found freely in the abdomen. The hernia and the torio of the mesenterium is well demonstrated on the last photo. Conclusion Initially, when the PCR-result was positive for EEHV, EEHV was considered the cause of the disease and anti-EEHV treatment was started. Based on previous findings, the mother of the calf was assumed to be a carrier of EEHV1. However, the normal hemogram was not in line with what was seen in other EEHV-HD cases. At necropsy, multiple hemorrhages were seen in almost all organs, which is also seen in EEHV-HD. However, the predominant pathological conditions (hernia mesenterials, volvulus, torsio and rupture of the ileum were the cause of death. The presence of EEHV1a can only be explained as a virus reactivation due to a heavy stress respons of the calf in relation to the intestinal problems. Peritonitis in elephants has only been mentioned in a paper describing the presence of unrelated dermoid cysts in an Asian elephant (Wayn, 1991). References Wayne I., Anderson & Danny W. Scott. 1991. Epidermoid Cysts in the Skin of an Asian Elephant (Elephas maximus). Vererinary Dermarology. Vol. 2, No. 3/4, pp. 171-172. To page top

Molar teeth in elephants: development, age estimation, malformation, malpositioning, molar extraction and shortening of molar teeth are presented in this chapter. Back to dentistry A very informative article about the development of molar teeth and several disorders in molars and tusks has been written by D.A. Fagan, J.E.Oosterhuis, and A. Roocroft (Colyer Institute). Click here to read the entire manuscript. Molar development Written by Willem Schaftenaar Dental formula in elephants The molars in elephants differ from other mammalians. In each side of the mandible and the maxilla a single molar tooth develops at a time. This molar consists of lamellae that are compressed together to form one dental element, which slowly progresses in forward direction, pushed as it is by a new molar that is developing caudal to the functional molar. During their entire life span, an elephant develops only 6 molars on each side of the mandible and upper jaw. The lamellae are fused together with cement and at the grinding side covert with enamel. The different length of the lamellae give the molars its irregular shape at the grinding surface, which is extra supported by the difference in hardness between enamel and dentine. During the development of molar teeth, two processes are very important: Dentinogenesis: the formation of dentin. Amelogenesis: the formation of enamel. Any disturbance in these processes may result in malformation or poor quality of that molar, which is manifested as dental dysplasia. Such an abnormal molar may be weak and prone to deformity, malposition and malocclusion. This can lead to food impaction and consequently infection of the peridontal structures. The condition of the molar teeth is important for the physical condition of the elephant. The body mass of both breeding and non-breeding female zoo elephants shows a cyclic undulation with peaks separated by many years, and correlated with the total surface of the functional the molar teeth (Schiffmann 2018). Molars are important for the estimation of the age of an elephant. The numbers of the lamellae are quite specific for the sequential number of the molar. These numbers differ slightly between Asian and African elephants. So, by counting the lamellae of the presented molar, the sequential number of that particular molar tooth can be estimated. The lamellae of molars that have not yet erupted are loose. The same applies for molars in the embryonic stage. A drawing of the distinctive Occlusal Wear Patterns characteristic of Asian and African elephant molar dentition. It is this unique diamond shaped patten which provides the origin of the African elephant's scientific name Loxodonta - from the Greek word loxos - meaning oblique. (Modified from KINGDON 1971 & STERNDALE 1929) Age estimation This table shows when a new molar erupts and at which age this particular molar is replaced by a new one. When the number of lamellae has informed us about the sequential number of the molar tooth, we can simply look at this table to estimate the age of the elephant. The final molar tooth that appears is the 6th one, that erupts at the age of 40 years. When this molar is gone (usually between 60 and 80 years), no new molar develops and the elephant will have no proper molars to mastigate its food. This radiograph shows the tusks and the molar teeth in the skull of a young elephant. Each tusk has a large, distinct pulpa chamber (Courtesy: Basel Zoo). This radiograph shows you the mandibles. As indicated on the picture, each side contains a very small erupted molar on the left side, followed by another (erupted) molar in the middle and finally a large molar on the right side. (Courtesy: Basel Zoo). The erupted molar in the middle consists of 6 lamellae. This means that it is the second molar tooth that has developed in this elephant. There is still a small remnant of the first molar. The 3rd molar is at the point of eruption. The dentition of the jaw on the X-ray corresponds with the dentition of the jaw preparation. Both elephants was approximately 2,5 years old. Molar tooth disorders Molar tooth disorders are quite common in elephants, especially in the older ones. The progressive changes of the molars make them prone to malpositioning. Pathological changes during the development of the molar before it erupts, can result in a deformed or rotated tooth. Like in all animals with teeth, the quality of the food correlates with the quality of the teeth. If the speed of the abrasive wear is faster than the mineralization, the pulp of the molar tooth can become exposed. Insufficient abrasive wear (for example if the diet contains insufficient branches) will result in the opposite: long molar teeth, which often often are rotated. A loose piece of an old molar in this 40 yrs-old Asian elephant caused pain, which became manifest by the animal's reluctance to eat hard food items. Video: Willem Schaftenaar Sometimes, especially when there is a certain degree of molar mal-positioning, the peridontal area can become infected. This is a painful condition which may lead to reduced appatite or selective food consumption, avoiding hard items. An example of mal-formation and rotation of the molar tooth in an Asian elephant. Click here to read a case report about this condition. Courtesy: Christian Schiffmann Excessive abrasive wear of the molar teeth in this elephant had opened the pulp cavity of the anterior lamella of this lower molar tooth af an African elephant. Courtesy Peter Kertesz. Insufficient abrasive wear or disturbed pre-eruption molar development has resulted in excessively long molar teeth in this 60 yrs-old female Asian elephant. As a result the animal could not masticate her food properly, which was expressed by the poorly digested, long fibers present in the feces. The photo in the middle was taken a few years after the first one. Molar extraction and shortening The extraction of a molar tooth in an elephant is quite challenging. The indication for an extraction is usually mal-positioning and abnormal abrasive wear of the tooth, which has a negative impact on the elephant's well being. Click here to watch the video about the extraction of the mal-positioned molar tooth in a female Asian elephant. This photo shows the extracted molar tooth. The cut in this tooth was made to get sufficient grip on the tooth for the extraction. Note the abnormal abrasive wear on the anterior side of the molar I n another adult Asian elephant the lower molar had been worn down insufficiently and this obstructed t he normal chewing action. By using a special pneumatic oscillating saw and chisel the length of the molar was reduced sufficiently to restore the normal chewing activities. The photos show stills from a video ( https://www.youtube.com/watch?v=lUHzCxL8FhI); note the special designed gingiva protector, a high potent vacuum cleaner and the oscillating saw in use. The short video fragment shows the end result of the shortened molar tooth. References Biology, Medicine, and Surgery of Elephants. Fowler & Mikota, 271-290. Fagan DA, Oosterhuis JE, and Roocroft A. Captivity Disorders in Elephants: Impacted Molars and Broken Tusks. Colyer Institute, San Diego (Ca) USA. Kertesz P. 1993. A colour atlas of Veterinary dentistry and oral surgery. Wolfe Publishing. ISBN 0 7234 1542 0. Schiffmann C, Hatt J-M, Hoby S, Codron D, Clauss M. 2018. Elephant body mass cyclicity suggests effect of molar progression on chewing efficienc y . Mammalian Biology, Volume 96, May 2019, Pages 81-8. https://www.youtube.com/watch?v=lUHzCxL8FhI Lucha the elephant visits the dentist (youtube.com) To page top Molar issues Molar development Age estimation Molar tooth disorders Molar tooth extraction Molar development Age estimation Molar disorders Molar extraction

Abdominal surgery for male castration, laparoscopic ligation of the ovarian pedicles, umbilical hernia and abdominal surgery to treat repeated colics are described here. To procedures Surgery Surgery in elephants usually follows the rules that are applicable to surgery in horses. Standing sedation with or without local anesthesia is required for minor procedures, while general anesthesia (in lateral or dorsal recumbancy) is required for large procedures (such as abdominal surgery) and if standing sedation poses a risk for the surgeons. See for anesthetic procedures the anesthesia page . Abdominal surgery in elephants Access to the elephant's abdomen is restricted to a relatively small area between the last ribs on the cranio-dorsal side, the hind leg on the caudal side fusing together in the ventral midline. Indications for abdominal surgery described in the literature are limited: cesarean sections have all resulted in the death of the dam. However, a dorso-lateral approach has been used for castration of male African and Asian elephants (Fowler 1973, Byron 1985, Fourner 1994). Fourteen male African elephants (12–35 years old) were anesthetized with etorphine and supported in a sling in a modified standing position, and positive pressure ventilated with oxygen (Rubio-Martinez 2014). Anesthesia was maintained with IV etorphine. Vasectomy was performed under field conditions by bilateral, open‐approach, flank laparoscopy with the abdomen insufflated with filtered ambient air. A 4‐cm segment of each ductus deferens was excised. Behavior and incision healing were recorded for 8 months postoperatively. Successful bilateral vasectomy (surgical time, 57–125 minutes) was confirmed by histologic examination of excised tissue. Recovery was uneventful without signs of abnormal behavior. Large intestine lacerations (3 elephants; 1 full and 2 partial thickness) were sutured extracorporeally. One elephant that was found dead at 6 weeks, had no prior abnormal signs. Skin incisions healed without complication. Laparoscopic ligation of the ovarian pedicles has been performed in free ranging African elephants (Stetter 2004). A specially designed 90 cm long operating laparoscope was used to reach for the ovaries. An umbilical hernia was diagnosed in a 2-wk-old Asian elephant (Elephas maximus) by physical and ultrasonographic examinations (Abou-Madi 2004). Umbilical herniorrhaphy was elected because the defect was large (approximately 7 cm long and 10 cm deep) and could potentially lead to incarceration of an intestinal loop. General anesthesia was induced with a combination of ketamine, xylazine, and diazepam and maintained with isoflurane in oxygen. The hernial sac was explored and contained fibrous tissue, fat, and an intestinal loop but no adhesions. The hernial sac was resected and the body wall closed using the technique of simple apposition. Following a superficial wound infection, the surgical site healed with no further complications. There is one anecdotal report on successfull abdominal surgery in a 14-month-old African elephant suffering of repeated colics ( click here for the case report). References Abou-Madi, N., Kollias G.V., Hackett R.P., Ducharme N.G., Gleed R.D., and Moakler J.P. 2004. Umbilical herniorrhaphy in a juvenile Asian elephant (Elephas maximus ). J. Zoo & Wildl. Med35(2): 221–225, 2004. Byron H.T., Olsen J., Schmidt M., Copeland J.F. and Byron L. 1987. Abdominal surgery in three adult male Asian elephants. J. Am. Vet. Ass. 187, 11. Foerner J.J., Houck R.I., Copeland J.F., Schmidt M.J., Byron H.T. and Olsen J.H. 1994.Surgical castration of the elephant (Elephas maximus and Loxodonta africana ). J. Zoo & Wildl. Med. 25 (3), pp 355-359. (Click here for summary) Fowler M .E., Hart R. 1973. Castration of an Asian elephant, using etorphine anesthesia. J. Am. Vet Ass 163, 6. Rubio- Martinez L.M. Hendrickson D.A., Stetter M., Zuba J.R. and Marais H.J. 2014. Laparoscopic Vasectomy in African Elephants (Loxodonta africana ). Veterinary Surgery 43 (2014) 507–514. Stetter M.D. 2004. Laparoscopic surgery in elephants. Int. Elephants Res. Symp. Fort worth, Texas. December 2-5, 2004 Non-abdominal surgery in elephants Surgical procedures not associated with open access to the abdomen are more common. Despite the enormous healing capacity of the elephant skin, wound healing often takes place per secundam, because it is hard to protect the sutured wound against negative mechanical and biological influences. However, even large wounds (like in vaginal vestibulotomy ) will heal completely per secundam, leaving at most a 2 mm fistula ( click here for wound healing in vaginal vestibulotomy). Trunk injuries are hard to repair because of the extreme mobility of this organ. Many attempts to suture large perfortaing trunk wounds have have failed or at best resulted in partial adhesion of the sutured sites. Repair of a perineal hernia has been described ( click here to read this case report).

Cowpox infections in elephants have been seen in several north/mid European countries, often with a fatal outcome. Lesions and preventive vaccination are described in this chapter. To infectious diseases Cowpox General information Cowpox virus infections (see EAZWV fact sheet info) have been reported as a cause of a severe, sometimes fatal disease in Asian elephants in European zoos. African elephants can be affected as well, but usually the lesions in this species are restricted to the skin and they tend to heal quickly. The causative virus is an orthopox virus, affecting rodents (endemic hosts), elephants, (wild felids), tapirs, okapis, antelopes, rhinoceros, primates (including humans). It causes local or generalized vesicular lesions of the skin and mucous membranes and can develop into a systemic disease, affecting the lungs and GI-tract. Intra-uterine infection in an Asian elephant has been reported. Pox infection in elephants is a zoonotic disease and has been reported in human caretakers after contact with affected elephants. Although the direct source of pox virus infections in elephants has never been found, it is generally accepted that infection takes place by consumption of roughage that has been contaminated with urine from affected rodents. Pox lesions in elephants occur on the skin (predominantly the trunk and the legs) and mucous membranes (tongue oral cavity). Lesions on the foot soles can result in complete sole detachments. One still birth case has been reported in an Asian elephant in a European zoo, that had been vaccinated twice with Modified Vaccina Ankara strain on days 293 and 322 of its pregnancy. A full-grown calf (117 kg) was born a-term with generalized pox lesions on the skin, air ways and gastro-intestinal track as well as the spleen and liver. The dam nor any of the other (vaccinated) elpehants in the same herd were affected. Treatment Treatment of a pox virus infection is symptomatic. Antibiotic treatment should be considered as a prevention of a secondary bacterial infection. Prevention Vaccination is strongly recommended for elephants living in European zoos. First injection injections (s.c. or i.m.) of 4 ml MVA at the age of 12-16 weeks. Second injection injections (s.c. or i.m.) of 4 ml MVA 4 weeks after the first injection. The producer of the vaccine advices and offers titer measurement before the vaccination and 3-4 weeks after second vaccination). In young and untrained elephants this may be not possible, and vaccination should be practiced without titer control. Booster vaccinations: generally once every 2-3 years, depending on the titer. Vaccination during pregnancy: following this vaccination advice, elephants should be immune before they become pregnant. There are no sound studies about the possible side effects of vaccination on the fetus. New non-vaccinated imports or elephants with unknown vaccination status should not be bred before they are properly vaccinated. Contact with rodents worldwide should be avoided. Literature Pilaski J, Schaller K, Matern B, Klöppel G, Mayer H. 1982. Outbreaks of pox among among elephants and rhinoceroses. Verh ber Erkrg Zootiere. 24: 257-265. Pilaski J, Rosen-Wölff R. 1987. Poxvirus infection in zoo-kept mammals. In: Darai G (ed) Virus diseases in laboratory and captive animals. Martinus Nijhoff Publishing, Boston. pp: 83-100. Pilaski J, Kulka D, Neuschulz N. 1992. Outbreak of pox disease in African elephants (Loxodonta africana) at the Thuringer Zoopark Erfurt. Verh ber Erkrg Zootiere. 34: 111-118. Wisser J, Pilaski J, Strauss G, Meyer H, Burck G, Truyen U, Rudolph M, Frölich K. 2001. Cowpox virus infection causing stillbirth in an Asian elephant (Elephas maximus). Vet Rec. 149: 244-246. Kurth A, Wibbelt G, Gerber HP, Petschaelis A, Pauli G, Nitsche A. 2008. Rat-to-elephant-to-human transmission of cowpox virus. Emerg Infect Dis. 14: 670-671. Photo gallery cowpox in elephants Typical cowpox lesions on the trunk (left) and tongue of an Asian elephant Typical cowpox lesions on the legs and the distal part of a leg after detachment of the sole. Detached sole horn of a front and a hind leg of an Asian elephant affected by cowpox virus. Pox lesion on the face of a caretaker of an elephant suffering of a cowpox infection Cowpox lesions in an old Asian elephant. In this case the lesions were restricted to the oral cavity. The elephant recovered completely. Cowpox lesions on the inner side of the trunk in a fullgrown, stillbirth Asian elephant calf (Vet Rec. 2001:149: 244-246). Ulcerated cowpox lesions in the somach of a fullgrown, stillbirth Asian elephant calf (Vet Rec. 2001:149: 244-246). To page top

This chapter describes (standing) sedation, general anesthesia, intubation and epidural anesthesia using xylazin, ketamine, azaperone, detomidine, medetomidine, etorphin, carfentanil, gas anesthesia and lidocain. To procedures This page describes the following procedures Standing sedation General anesthesia Epidural anesthesia Anesthesia Standing sedation Sedation: In case the elephant does not cooperate voluntarily with the manipulations needed for the diagnosis or treatment the animal should be sedated (including herd mates if needed to reduce stress in the herd) Standing sedation can be performed using xylazine or (preferred) detomidine in combination with butorphanol. Medetomidine works as good as detomidine, but is more expensive. Young elephants need the higher dose range compared to older elephants. Elephants that are excited can be premedicated with azaperone (Asian elephant 0.024-0.038 IM, African elephant 0.056-0.107 IM, IV). Detomidine 0.01-0.022 mg/kg IM (can be reversed by atipamezole at 3-5 times the dose of detomidine). Young calves may need a higher dose of detomidine (0.02-0.04 mg/kg). AND Butorphanol 0.015-0.025 mg/kg given at same time as detomidine. Butorphanol can be reversed with naltrexone at 2.5-5 times the dose of butorphanol in emergency situations, but reversal is not essential and should preferably not be carried out if the calf is considered to be in pain. Alternative option for sedation (if the above mentioned drugs are not available): Xylazine : 0.04-0.08 mg/kg IM for adult Asian elephants and 0.08-0.1 mg/kg for African elephants. Juvenile Asian elephants: 0.09–0.15 xylazine mg/kg IM (Jansson 2021) If insufficient sedation is obtained by xylazine alone, an additional (low) dose of ketamine (0.03 – 0.06 mg/kg) can be given IM or IV. Xylazine can be reversed with yohimbine (0.073-0.098 mg/kg slowly IV) or atipamezole (0.1 x xylazine dose IM or 30/70 IV/IM) Another alternative option for sedation of Asian elephants: Dexmedetomidine : 2 μg/kg BM IM will provide sufficient standing sedation for approximately 70 minutes. (Buranaprim, 2022). Dexmedetomidine can be antagonized by atipamezole (10 times the dexmedetomidine dosage). If a young calf needs to be sedated, it may be necessary to sedate the dam or other adult herd mates so they are not stressed during manipulations on a calf. This can be done by the administration of: Butorphanol 0.006 mg/kg IM and detomidine 0.0026 mg/kg IM (In adult female Asian elephants, 20mg butorphanol and 10mg detomidine have been effective) Sedation can be reversed as described above but is not necessary Alternatively, xylazine (0.04–0.08 mg/kg) or other sedative agents (e.g. Azaperone at 0.024–0.038 mg/kg) can be used if detomidine is unavailable. Laubscher LL et a. 2021 described a fixed drug combination of butorphanol, azaperone and medetomidine (BAM) for African elephants. The dose is given per cm shoulder height. The composition of this anesthetic mixture is: 30 mg/ml butorphanol, 12 mg/ml azaperone, and 12 mg/ml medetomidine. The use of this combination can be recommended in captive, trained African elephants at a dose of 0.006 6 ± 0.001 ml/cm shoulder height. Oral or rectal administration of detomidine in the form of a gel (Domosedan gel, 20-50 mcg/kg) to obtain mild sedation has been described (2020, Molter). The gel must be rubbed into the oral mucosa or rectal wall. Initial, mild sedation is seen after 15-20 minutes. The maximal effect is at 30-45 minutes. A full standard sedation is characterized by the following signs: Salivation Relaxation of the trunk; the tip of the trunk will touch the ground. Relaxation of the penis and (less obvious) relaxation of the vulva. Snooring sounds. It is important to cover the eyes with gauze pads (taped to the skin with Leucoplast or ducttape) and put cotton plugs in the ears. This will deepen the sedation and reduce the risk of sudden wakening. One should always be prepared that the elephant may wake up. Safety procedures need to be discussed in advance with everyone involved in the procedure. Summary agonist - antagonists Xylazine can be reversed by atipamezole : 0.1 x xylazine dose or yohimbine : 0,05-0,13 mg/kg IV Detomidine is reversed by: atipamezole: 3-5 times the detomidine dose IM or slow IV (30/70 IV/IM) Butorphanol is reversed by naltrexone: 2.5-5 x butorphenol dose IV. Skip naltrexone if pain relieve is desirable. The naltrexone dosage provided by Laubscher LL et a. 2020 is much lower: 1 mg naltrexone per mg butorphanol. References: Buranapim, N., Kulnanan, P., Chingpathomkul, K., Angkawanish, T., Chansitthiwet, S., Langkaphin, W., Sombutputorn, P., Monchaivanakit, N., Kasemjai, K., Namwongprom, K., Boonprasert, K., Bansiddhi, P., Thitaram, N., Sharp, P., Pacharinsak, C., Thitaram, C., 2022. Dexmedetomidine Effectively Sedates Asian Elephants (Elephas maximus ). Animals 12, 2787.. doi:10.3390/ani12202787 Fowler M.E. and Mikota S.K. 2006. Chemical restraint and general anesthesia. In: Biology, medicine and surgery of elephants. Blackwell Publishing. Jansson T., Vijitha P.B., Edner A., and Fahlman A. 2021. Standing sedation with xylazine and reversal with yohimbine in juvenile Asian elephants ( Elephas maximus ). Journal of Zoo and Wildlife Medicine, 52(2) : 437-444. Liesel L. Laubscher , Silke Pfitzer , Peter S. Rogers , Lisa L. Wolfe , Michael W. Miller , Aleksandr Semjonov , Jacobus P. Raath. 2021. Evaluating the use of a butorphanol-azaperone-medetomidine fixed-dose combination for standing sedation in African elephants (Loxodonta africana). J. of Zoo and Wildlife Medicine, 52(1) :287-294 (2021). Molter C. 2020. Diagnosis and treatment of EEHV-hemorrhagic disease. Proceedings of the annual AAZV- symposium 2020. Neiffer D.L. , Miller M.A., Weber M., Stetter M., Fontenot D.K., Robbins P.K., and Pye G.W. 2005. Standing sedation in African elephants (Loxodonta africana) using detomidine–butorphanol combinations. Journal of Zoo and Wildlife Medicine 36(2): 250–256, 2005. E. Wiedner. 2015. Proboscidea. In: Fowler's Zoo and Wild animal Medicine 8. Standing sedatin General Anesthesia General remarks: General anesthesia is required in those cases where standing sedation alone or in combination with local anesthesia does not suffice for the intervention that needs to be done. We can devide the indications in: Capture immobilization Immobilization for painful procedures Capture immobilization is mostly done in range countries. However, the escape of a captive elephant may also require capture immobilization. Elephants from this category have not been prepared for the immobilization. This means that they have been able to take food an water shortly prior to the immobilization. It aslo nmeasn that the circumstances have not (or insufficiently) been prepared for the procedure as compared to an immobilization under full captive conditions. Preparation : If possible, prepare a safe area for the people and elephant involved. Avoid an area with water and select a place that is reachable for heavy equipment. Provide shadow whenever possible. Make sure you can ccol the elephant with cold water when necessary. Heavy equipment to position the elephant in lateral recumbancy may be needed, as sternal recumbancy is highly associated with anesthetic death. If an elephant has gone down in sternal position and cannot be rolled over in lateral recumbancy, the anesthesia must be reversed immediately. Whenever possible, provide a soft bedding, preferably a deep sand layer covered by a deep layer of straw or matrasses. Straps or belts are required in case the elephant needs to be rolled over. It is important to thraw them under the elephant before the animal will go down. It helps if the elephant lays on sand and straw to get straps or a belt under the elephant's body with the help of a hooked steel wire. To protect the tusks against fractures, a car tyre can be placed under the head just before the elephant goes down. Trained elephant can be anesthetized when brought lateral recumbency. If the elephant is trained to ly down in sternal position, general anesthesia can be induced but this is very risky! Once the drugs have reached their effect, the elephant MUST be rolled over into lateral recumbency, which requires heavy equipment. Especially in trained elephants, ropes can be used to guide the elephant into lateral recumbency. Trained captive African elephant brought under general anesthesia while guided by ropes. Courtesy: Osterhaus and Fagan. For correct positioning of the elephant during general anesthesia, the use of a crane is highly recommended. First, a standing sedation is induced. After a net has been brought into position, this can be connected to the crane. This will support the elephant when the general anesthesia is induced by IV or IM injection of the narcotic drug (etorphine or ketamine). By lifting the elephant it can be positioned in the correct lateral recumbancy. Protecting cushions, matrasses and soft bedding materials should be placed underneath the head and the body. See the images of the use of a net below (Courtesy basel Zoo): Elephants should be fastened for 24-48 hours prior to anesthesia. Water should be withheld for 24 hours before the procedure. Capture immobilization is mostly done in range countries. The escape of a captive elephant may also require capture immobilization. Elephants from this category have not been prepared for the immobilization. This means that they have been able to take food an water shortly prior to the immobilization. It also means that the circumstances have not or insufficiently been prepared for the procedure as compared to an immobilization under full captive conditions. Preparation: if possible, prepare a safe area for the people and elephant involved. Avoid an area with water and select an area that is reachable for equipment. Provide shadow whenever possible. Make sure you cool the elephant with cold water when necessary. Heavy equipment to position the elephant in lateral recumbancy may be needed, as sternal recumbancy is highly associated with anesthetic death. If an elephant has gone down in sternal position and cannot be rolled over in lateral recumbancy, the anesthesia must be reversed immediately. Whenever possible, provide a soft bedding, preferably sand covered by a deep layer of straw or matrasses. If straps are required in case the elephant needs to be rolled over, it is important to thraw them under the elephant just before the animal will go down. It helps if the elephants lays on sand and straw to get straps or a belt under the elephant's body with the help of a hooked steel wire. The use of a suitable net is highly recommended as slings may slide away from the desired place of the elephant's body. Oxygen supplementation Oxygen must always be provided, even if the anesthetized elephant is not intubated. Arterial blood pressure will drop if no oxygen is provided (Heard 1986). An oxygen flow of 10-15 L/min for a juvenile up to 39-40 L/min for an adult elephant is required for maintaining arterial blood pressure at an acceptable level. Oxygen supply during general anesthesia of a 5 yr-old Asian elephant under field conditions. Due to lack of proper equipment, intubation was not possible. Oxygen was provided at a flow rate of 10 L/min via a small tube inserted in the trunk. Drugs used for general anesthesia: Captive elephants that are excited can be premedicated with azaperone (Asian elephant 0.024-0.038 IM, African elephant 0.056-0.107 IM, IV). Fast acting immobilizing drugs that are used for capture immobilization: Etorphine : 0.002-0.004 mg/kg IM (Asian elephant) and 0.0015-0.003 mg/kg IM (African elephant) OR Carfentanil : 0.002-0.004 mg/kg (Asian elephant) and 0.0013-0.0024 mg/kg IM (African elephant) These drugs can be antagonized with naltrexone 0.004 mg/kg IM (or 50/50 IV/IM) If carfentanil and etorphine are not available, xylazine (0.1 mg/kg) and ketamine (0.3-0.7 mg/kg) can be given together. The disadvantage is the large volume required for an adult elephant. For capture immobilization this combination is therefore not recommended. At the end of the procedure xylazine can be reversed with atipamezole (0.1 x dose of xylazine IM or slowly IV) or yohimbine (0.05-0.13 mg/kg IV). Under controlled conditions (if a crane is available) a standing sedation can be induced first, allowing to put a net or slings in place. When well secured, ketamine can be given i.m. (0.3-0.7 mg/kg). or i.v. using a long infusion tube for safety reasons. Once in lateral recumbancy, the elephant can be intubated and anesthesia can be maintained on isoflurane or halothane (1.5-3%). Inhalation anesthesia and intubation: Intubation in elephants is straightforward. A 30-50 mm diameter cuffed endotracheal tube can be inserted into the trachea. A rope around the lower jaw can be used to open the mouth. A gloved hand can reach the epiglottis and advance a lung tube (e.g. stocha tube for horses) into the trachea, while pushing the soft palate upward. Once in place, the endotracheal tube can be advanced into the trachea guided by the smaller tube. A special portable pressure ventilater has been developed and described by William et al. Jeff Zuba made some modifications to this design, which is now commercially available (http://www.incaseofanesthesia.com/Home_Page.html ). Schematic overview of a portable pressure ventilation device for elephants. "Zuba" ventilator used in an adult African elephant under field conditions Captive African elephant intubated for gas anesthesia using a "Zuba" ventilator. "Zuba" ventilator Under less favorable circumstances when a pressure ventilator is not available, intubation can be done in the trunk using 2 cuffed horse endotracheal tubes and 2 separate (portable) anesthetic machines (Tamas 1983). The advantages of this method are the easy intubation and the ample space in the oral cavity in the absence of the large tube. However the disadvantages are substantial: Two tubes increase the airway resistence Risk of regurgitation and aspiration of stomach contents An elephant can breath through its mouth, which will bypass the inhalation of the anethetic gas General anesthesia in a captive Asian elephant using bilateral trunk intubation (Rotterdam Zoo, 1989) Monitoring: Pulse oximetry is a reliable tool for monitoring heart frequency and venous oxygen saturation. A capnagraph is recommended to monitor the respiration. If not available, one individual should be assigned just to monitor respiratory rate and depth. ECG and arterial blood gases are recommended. As hypotension is quite common in anesthetized elephants, blood pressure measurement is also recommended. Hypotension has been treated successfully with ephedrine and dobutamine. Recovery support: Weak or debilitated animals may need help to get back on their feet during recovery. A deep sand layer is essential for the elephant to getting grip on the ground. A crane may be needed to lift the animal from the ground, using straps or belts applied around the body. References. Fowler M.E. and Mikota S.K. 2006. Chemical restraint and general anesthesia. In: Biology, medicine and surgery of elephants. Blackwell Publishing. Heard D.J., Jacobson E.R., and Brock K.A. 1986. Effects on oxygen supplementation on blood gas values in chemically restraint juvenile African elephants. J Am Vet Med Ass 189 (9)1071-1074. Tamas PM. and Geiser D.R. 1983. Etorphine analgesia supplemented by halothane anesthesia in an adult African elephant. JAVMA 183, 11 (1312-1314) . Wiedner E.. 2015. Proboscidea. In: Fowler's Zoo and Wild animal Medicine 8. Zuba J.R., Osterhaus J.E. 2012. Anesthetic complications and clinical intervention in opiod anesthetized captive elephants. In: Proceedings of the AAZV Conference, Oakland (1-6). Zuba J.R. http://www.incaseofanesthesia.com/Home_Page.html General anesthesia Always bring the elephant into LATERAL RECUMBANCY for general anesthesia Epidural anesthesia Epidural anesthesia in elephants is recommended when a vaginal vestibulotomy is performed in order to reduce tail movements of the elephant and provide additional analgesia in the perineal region. Procedure: Restrain the elephant as appropriate in a chute and sedated if necessary. Disinfect the injection site. Move the tail up and down to determine the position of the most mobile intercoccygeal space. Inject local anaesthetic (2% Lidocaine) into the skin over the injection site. Palpate the intercoccygeal space wearing a sterile glove and insert the needle (14 gauge, 3 inch) at approximately a 60 - 70 degree angle cranially. The epidural space is about 6.5 cm below the skin surface. Inject Lidocaine : 30 ml was sufficient to produce tail relaxation in a 3,000 kg elephant, and the elephant remained standing. Epidural anesthesia

This case report describes a colic episode in an adult Asian elephant. Salmonella sp. was identified in a fecal sample taken during this period of colic. - colic -Salmonella To salmonellosis CAse report Next case Colic and Salmonellosis in an adult Asian elephant History This adult multiparous female had been on GnRH-vaccine for over 4 years. Because of chronic joint disease, the elephant had been on phenylbutazone for over 1 year in combination with omeprazol. Sudden onset of apathy, anorexia and hardly drinking water. Normal feces. Occasionally the elephant goes into a sitting position or lateral recumbancy, showing moderate straining activities. After this labor-like behaviour, herd mates investigate the perineal area of the elephant with their trunk. Differential diagnose: Labour, colics (intestinal, uterine or urinary) Treatment The administration of phenylbutazone was discontinued No specific treatment was given on the first day. Treatment results During the night the elephant became more active and the symptoms decreased. The next morning, the animal behaved normal. Diagnostic notes Salmonella sp. was cultured from the feces on the day it showed the above mentioned symptoms To page top