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A fractured elephant tusk can cause traumatic lesions of the tusk sulcus when the fracture site is located proximal to the sulcus. To page top To tusk fracture Case report Tusk fracture and sulcus trauma (Asian elephant) Place: Planckendael Zoo Date: 2016 Data provided by: Francis Vercammen DVM History 6 yrs-old female Asian elephant with mucosal damage due to the sharp edges of the distal part of a fractured tush. Note the swollen sulcus mucosa. The pulp tissue was not exposed Treatment As the pulp tissue was not exposed, treatment was limited to grinding sharp edges away using a round-topped milling cutter on a hand-held drill (Dremel). The sulcus was flushed 3 times per day with a mild antiseptic solution (Iso-Betadine Gynecology) Treatment results The sulcus healed and the tusk continued to grow. Tusk fracture and sulcus trauma (Asian elephant) Date: 2020 History A 30 mo-old Asian elephant kept in a zoo fractured its right tusk. The pulp cavity was not exposed, but the sharp edges of the tusk remnant caused wounds on the sulcus mucosa. The sharp edges of the fractured tusk are often the cause trauma to the sulcus mucosa, resulting in a prulent infection. The sharp edges of the fractured tusk have caused a purulent infection of the sulcus. Treatment A conservative treatment was elected, consisting of flushing the wound several times per day with a saline solution and a 10% Betadine solution. Treatment result Within 3 months the tusk had grown out of the sulcus again and the wounds had healed completely. To page top

Salmonellosis is a zoonotic disease that affects many vertebrate species. It has been described for the first time as a pathogen in elephants in 1940 (Matzek 1940). The symptoms of salmonellosis can range from mild depression, colic, diarrhea, ventral edema, weight loss, cachexia to death. To infectious diseases Salmonellosis General information General information Salmonellosis is a zoonotic disease that affects many vertebrate species. It has been described for the first time as a pathogen in elephants in 1940 (Matzek 1940). The symptoms of salmonellosis can range from mild depression, colic, diarrhea, ventral edema, weight loss, cachexia to death. A fatal Salmonella hadar infection in an 18-year-old African elephant has been described, including necrosis and sloughing of the region above the toes (Scott 1984). Subclinical infections do also occur (Scharling 2021). One case of abortion in an African elephant has been described (Emanuelson 2000). Salmonellosis can manifest itself as an acute illness as well as a chronic disease. Different serotypes have been associated with intestinal disease and death (S. typhimurium , S. blockley ) (Matzke 1940, Windsor 1972 and 1976, Chooi 1988). S. saintpaul was associated with septicemia in an adult Asian elephant (Molenaar 2021). The source of the infection is not always found, but can be contaminated food, infected conspecifics, care takers and other species sharing the exhibit with the elephant. Diagnosis of salmonellosis Detection of Salmonella spp. in feces is by culture or PCR the most common way to demonstrate the presence in an elephant. However, shedding of the pathogen is intermittent, which means that multiple fecal samples taken in a period of at least 3 days are required. Salmonella spp. are more likely to be detected in elephants with abnormal feces. Selective media like selenite cystine broth and MacConkey agar are part of the routine culture method for Salmonella spp . (FAO 1992). To detect Salmonella in food samples in general, molecular testing in addition to conventional culture-based methods can be used. Multiplex quantitative PCR (qPCR) has proven to be a fast, easy to perform, and sensitive molecular technique for the detection of Salmonella species and various Salmonella serovars (Heymans 2018). Treatment of salmonellosis The decision to treat an elephant for salmonellosis depends on the clinical situation. Subclinical infections may be hard to clear. If attempted, treatment should be based on an antibiogram. In humans, common first-line oral antibiotics for susceptible Salmonella infections are fluoroquinolones (for adults) and azithromycin (for children). Ceftriaxone is an alternative first-line treatment agent (CDC 2018). In order to reduce the risk of antibiotic resistance to these antibiotics, their use in elephants should be considered only after the antibiogram has demonstrated that other antibiotics (e.g. sulfonamides) are not effective. Information on dosage and administration of antibiotics can be found on: https://www.elephantcare.org/formulary References: Chooi K.F., and Z. Z. Zahari. 1988. Salmonellosis in a Captive Asian Elephant. The Journal of Zoo Animal Medicine, Vol. 19, No. 1/2 (1988), pp. 48-50 Matzke, M. 1940. Salmonella typhimurium Infection in Elephants. Tierarztliche Rundschau 1940 Vol.46 pp.521-522 Emanuelson K.A., Kinzley C.E. 2000. Salmonellosis and subsequent abortion in two African Elephants ( Loxodonta africana ). IAAAM 2000. Heymans R, Vila A, van Heerwaarden C.A.M., Jansen C.C.C., Castelijn G.A.A.,van der Voort, Biesta-Peters E.G. (2018). Rapid detection and differentiation of Salmonella species, Salmonella Typhimurium and Salmonella Enteritidis by multiplex quantitative PCR. PLOS ONE 13(10) 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. Scharling F.S., Bertelsen M.F., Sós E., Bojesen A.M. 2021. Prevalence of Salmonella species, and Clostridium difficile in feces of healthy elephants (Loxodonta africana and Elephas maximus ). Journal of Zoo and Wildlife Medicine 51(4), 752-760. Scott W.A. 1984. Salmonellosis in an African elephant. Vet. Rec. October 13, 391. Windsor R.S. and Ashford W.A. 1972. Salmonella infection in the African elephant and the black rhinoceros. Tropical Animal Health and Production volume 4, pp 214–219. Windsor R.S. and W. A. Scott. 1976. Fascioliasis and Salmonellosis in African elephants in captivity. Br. vet., 132, 313 Websites: http://www.fao.org/3/T0610E/T0610E.pdf https://www.cdc.gov/salmonella/infantis-10-18/advice.html https://www.elephantcare.org/formulary Salmonellosis Case reports Abdominal pain and salmonellosis Salmonellosis in 7 yr-old Asian elephant Salmonella septicemia in adult Asian elephant

Bone fractures are not uncommon in elephants. Radiography is needed for a proper diagnosis. A case of mandibular fracture is described in this chapter. To non-infectious diseases Bone fractures Mandibular fracture Mandibular fracture Mandibular fracture Mandibular fracture Mandibular fracture Mandibular fracture Bone fractures Mandibular fracture

Nail issues in elephants are common and usually need treatment. Pedicure should be part of the management procedures. Untreated nail cracks can result in osteoarthritis of the phalangeal joints. Radiography procedures are described in this chapter. Back to index orthopedic problems Nail lesions The most common nail lesion is the crack , perpendicular to the ground. These cracks are often the result of overpressure on the nail tip, when the nail is longer than the sole. In that situation, each step the elephant makes results in heavy forces on the nail tip during the phase when the elephant unwinds its foot. As demonstrated clearly in the slow-motion video below, the tip of the elephant's nails hardly touches the ground. When the nail becomes too long like in the Asian elephant nail in this photo, the excessive pressure on the nail edge can cause a small crack that enlarges over time if not properly treated. Cracks in the nails of an African elephant When left untreated, these cracks will become larger and can affect deeper structures, resulting in an abscess , pododermatitis or even osteomyelitis of the phalangeal bones. If only the horn-producing tissue is involved, we usually call this a pododermatitis. When the infection is trapped in the underlying tissue, an abscess can easily develop. Onychia is an infection or trauma to the horn lamellae of the nail, which may result in complete loss of the nail. Pododermatitis in the nail of an African elephant. Note the excessive wear of the sole. Nail abscess with osteolysis in an Asian elephant. Nail abscess with complete loss of the 2 distal phalanges osteolysis in an Asian elephant. If phalanges are affected as the result of a deep nail abscess and pododermatitis, the recommended treatment of such an osteitis is the surgical removal of the affected bones. Click here to read more about this treatment. More examples of nail abscesses (photos: Susan Mikota). Treatment may take a long time, requiring multiple pedicure sessions, daily cleaning and foot soaks (click here for foot soak information) Traumatic onychia in an Asian elephant. Complete nail loss due to traumatic onychia in an Asian elephant. Diagnostic procedures nail lesions Use your eyes: check if there is any visible lameness. Describe the visible lesions. Use your hand: does the affected area feels warm? Is it painful when pressure is applied? Use your nose: if there is a wound, try to identify the smell of necrosis. Take a swab for bacterial culture. Additional diagnostic steps: If there is a deep lesion: radiographs should be taken to look at the integrety of the underlying bony structures (phalanges and phalangeal joints). Thermography may help to identify if the affected area has a higher temperature than the surrounding tissues. Radiography of the elephant's foot Radiography foot A powerful portable X-ray machine (100 kV or more) is required to visualize the bony structures in the elephant foot. Digital plates largely increase the quality of the image. It is important to work under safe conditions. Under free contact management , the fore foot can be positioned on a stand for the oblique palmar-dorsal shooting direction. The angle required for visualization of the phalangeal joints is indicated in the images below. Oblique palmar-dorsal image of the hind foot under free contact management condition (Mumby et al 2015) Positioning for the oblique dorsal-plantar image of the hind foot, this foot can be can be positioned on a stand (Mumby et al 2015). A different approach is required when working under protected contact management . The elephant needs to be trained to position its legs on a horizontal bar of the training wall. It should also be accustomed to the proximity of the X-ray-machine, the plate and the protective clothing of the operators. Lateral shooting position of the right front foot of an Asian elephant under protected contact. The angle of the beam depends on which phalanges need to be visualized. To avoid superposition and depending on the selected phalanges, the beam should have a more or less oblique direction. (Courtesy Rotterdam Zoo). Oblique dorsal-plantar shooting position of the left rear foot (Courtesy Rotterdam Zoo). Click here to view the radiograph. Oblique palmar-dorsal shooting postion of the right front foot of an Asian elephant under protected contact. Note that the X-ray machine is positioned upside down (use a support block to protect the electric wires)! (Courtesy Rotterdam Zoo and Emmen Zoo). Click here to view the radiograph. Lateral shooting postion of the left hind foot of an Asian elephant under protected contact (Courtesy Rotterdam Zoo). Click here to view the radiograph. Some examples of radiographs of the distal part of the right front leg of a 24 yr-old female Asian elephant at Rotterdam Zoo (the Netherlands) are shown below. The elephant is under standing sedation for an unrelated reason. Lateral shooting position of the right front leg (distal part of the radius and ulna, Courtesy Rotterdam Zoo). Click here to view the radiograph. Anterior-posterior shooting position of the right radio-carpal and ulnar carpal joint AP front leg (Courtesy Rotterdam Zoo). Click here to view the radiograph. Posterior-anterior shooting position of the right radial-carpal and ulnar-carpal joint (Courtesy Rotterdam Zoo). Click here to view the radiograph. Lateral position of the right carpal joint (Courtesy Rotterdam Zoo). Click here to view the radiograph. Lateral shooting position of the right foot (Courtesy Rotterdam Zoo). Click here to view the radiograph. Lateral shooting position of the right tarsal joint (Courtesy Rotterdam Zoo). Click here to view the radiograph. Lateral shooting position of the right tarsal joint (Courtesy Rotterdam Zoo). Click here to view the radiograph. Posterior-anterior shooting position of the right tarsal joint (Courtesy Rotterdam Zoo). Stereo radiography A technique, which is called stereo radiography can help interpreting the X-rays. Two radiographs of the same areas are made each of them taken 10 cm more lateral from the other. Digital images were converted to bitmap (BMP) format to preserve image quality. The 3D stereoradiograph images can be constructed using special software (Bentley 2021). The images can be viewed with red-cyan 3D glasses. Illustration of how 3D stereoradiograph images are produced. (a) Original radiograph that provides the ‘‘left’’ image for the 3D Anaglyph software. (b) Paired radiograph used for ‘‘right’’ image. (c) Completed stereoradiograph that has been inverted with red-cyan settings applied. (Bentley 2021) Thermography of nail lesions Thermographic imaging can be used to measure the absolute temperature and the difference in temperature between the lesion and its surrounding tissues. Below a severe case of a nail abscess-related osteomyelitis and osteolysis of Ph4 in an old Asian elephant bulls is shown. The thermografic image shows a low temperature of the skin that covers the affected are. This is suggestive for a large necro-purulent process. The thermographic image shown here demonstrates the low temperature of the skin covering the abscess, associated with deep lesions of D4 of the left front leg of an Asian elephant bull, involving a lot of necrosis and complete loss of the distal phalanx of the toe. On radiology this bone is completely missing and the distal part of the toe shows an irregular surface: Osteomyelitis and purulent arthritis of the Ph3-4 joint of D4. Treatment nail lesions Treatment of nail lesions Pedicure is usually the treatment of choice in cases of nail lesions. There are a few principles to be respected in pedicure: Use proper equipment Always remove all abnormal horn tissue (undermined, infected) and loose nail flaps. Make the transition from healthy horn to the deepest point of the lesion as smooth as possible. Directly adjacent to the lesion, the horn must be flexible and as thin as a piece of paper. Permanently check this flexibility by gently pressing the area where just cut away the horn. The most important pieces of equipment needed for pedicure are 2 hoof knives (left and right handed), a scalpel and a sharpening stone for hoof knives, preferably with round edges (see photos above). Just with hoof knives alone, most of the clinical pedicure treatment can be done. A scalpel can be useful when very small pieces of horn are to be removed adjacent to a lesion. A horse hoof rasp is a useful tool to shorten the nail and remove excessive horn from the sole. Care should be taken NOT to make the nail edges round, what is often practiced (see below). A strong nail brush is needed for cleaning the nail prior to pedicure and a smaller brush can be used to remove dirt from areas that cannot be reached by a large brush. Small wood carving knives can be used when thin layers of nail horn are to be removed (similar to the use of a scalpel). Pedicure equipment White line Very often the tip of the nails are made round by rasping the corners. There is no justification for doing so rather than a cosmetic one. However, one should avoid to remove tissue from the nail wall/nale sole junction (comparible to the "white line " in the horse hoof) as this junction is a very important barrier against infiltration of dirt and pathogens. So the advice is: do not file the nail corners to leave the entire white line in tact. Situation before a pedicure session of a deep nail crack Situation after a pedicure session of a deep nail crack Pedicure around a (deep) crack serves 2 main purposes: Draining of infected area Removing pressure on the wound, which enables the regeneration of destroyed horn lamellae. In order to achieve both goals, the deepest point of the crack has to be freed from covering horn. One should start making the horn wall thinner at a distance of several centimeters from the lesion and continue the pedicure towards the deepest point in a gradual way. Each nail crack should be considered as being a wound, because the crack has usually damaged the horn lamellae. When the pedicure has reached the wound area, it is of utmost importance that the edges bordering the wound are made as thin and flexible as possible. Check this by pressing your finger on the horn adjacent to the wound. Large cracks usually need to be treated in several sessions. Bleeding may occur when the lamellae are cut, which is no direct reason to worry! Pain reactions of the elephant will tell the operator when the session should be stopped and continued a few days later Cuticle lesions The cuticles form a natural barrier against dirt and pathogens. When they overgrow the nails, this protective barrier is weakened and infiltration of microoganisms may result in lesions in the horn lamellae underneath the nail (onychia). Sweat glands are embedded in the cuticles. Overgrown cuticles may become hard and crack or form interdigital callus. When abnormal horn tissue blocks the sweat glands, fluid pockets may be formed. This can be a painful process and needs to be treated. Minor cuticle lesion in a African elephant, which may be connected to a deeper lesion underneath the nail. Explorative pedicure is probably needed to find the cause (Courtesy: Barcelona Zoo) Extensive overgrown cuticles with feathering and interdigital callus formation (Fowler & Mikota 2006) Interdigital callus formation in an Asian elephant (Courtesy: Susan Mikota) Sweat glands are present in large numbers in the cuticles. When the cuticles are overgrown, they may form pockets in which the sweat-fluid may accumulate ("blisters"or "blebs"). When cutting in such a fluid-filled pocket, the contents may squirt out (see video; courtesy: Susan Mikota). Careful (!) trimming of the cuticles is only indicated when they have overgrown the nail (Courtesy: Susan Mikota) Applying oil on the cuticles will make them softer and may resolve the problem of cuticle overgrowth in most situations. Example of a pedicure procedure of a nail abscess in conjunction with a cuticle lesion in an African elephant (courtesy Barcelona Zoo) Nail abscess in an African elephant. Note the excessive wear of the sole and the large defect of the cuticle. Second step: follow-up the necrotic tissue and find the connection with the cuticle defect. Note that a large part of the nail was undermined, causing the cuticle defect. First step in pedicure: making the horn on each side of the lesion thinner and removing necrotic tissues. By frequently removing all necrotic tissues and keeping the edges of the wound thin, the horn lamellae can produce healthy horn again. SUCCESSFUL TREATMENT OF DIGITAL OSTEITIS BY INTRAVENOUS REGIONAL PERFUSION OF CEFTIOFUR IN AN AFRICAN ELEPHANT (Loxodonta africana ) (Dutton C.J., Delnatte P.G., Hollamby S.R., and Crawshaw G.J. Journal of Zoo and Wildlife Medicine 48(2): 554–558, 2017) A 41-yr-old African elephant (Loxodonta africana) presented with a swollen third digit of the left forelimb and a 2-cm hole in the pad. Corrective trimming, topical treatments, and an oral antibiotic resulted in apparent resolution; however, it reoccurred after 4 mo. Radiographs suggested bone lysis in the third phalanx, with the primary differential diagnosis being septic osteitis. Flushing with metronidazole solution and intravenous regional perfusion (IVRP) of the foot were commenced. A tourniquet was applied just above the carpus, an interdigital vein was identified by ultrasound, and into this vein 2 g (20 ml) of ceftiofur sodium solution, followed by 60 ml of heparinized saline, was administered. The foot was kept raised for 25 min and then the tourniquet was removed. IVRP was repeated every other day for 70 treatments over 6 mo. Healing occurred, which was confirmed radiographically. IVRP offers an excellent treatment modality in a well-trained elephant. SURGICAL REMOVAL OF INFECTED PHALANGES FROM AN ASIAN ELEPHANT (Elephas maximus ) Gage, L. Blasko D, Fowler M.E. and Pascoe J. Joint Conference AAZ/WDA/AAWV After unsuccessful antimicrobial treatment of an osteitis in a 40 yr-old Asian elephant, surgical removal of the affected phalanges resulted in the complete healing of the foot. Click here to read the report. Digital osteitis treatment Literature Bentley C.E., Cracknell J.N., Kitchener A.C., Pereira Y.M., Pizzi R. 2021. Improved diagnosis of foot osteoarthritis in elephants (Elephas maximus , Loxodonta africana ) using stereoradiography. Journal of Zoo and Wildlife Medicine 52(1): 67–74, 2021. Dutton C.J., Delnatte P.G., Hollamby S.R., and Crawshaw G.J. 2017. Successfull treatment of digital osteitis by intravenous regional prefusion of ceftiofur in an african elephant (Loxodonta africana) . Journal of Zoo and Wildlife Medicine 48(2): 554–558, 2017). Fowler M.E. and Mikota S.K. 2006. Biology, Medicine, and Surgery of Elephants. 271-290. Gage, L. Blasko D, Fowler M.E. and Pascoe J. 1995. Surgical removal of infected phalanges from an asian elephant (Elephas maximus ). Joint conference AAZV / WDA/ AAWV . Mumby, C., Bouts, T., Sambrook, L., Danika, S., Rees, E., Parry, A., Rendle, M., Masters, N. and Weller, R. (2013), Validation of a new radiographic protocol for Asian elephant feet and description of their radiographic anatomy. Veterinary Record, 173: 318-318. https://doi.org/10.1136/vr.101696 . Nigam, P., Sarma, K.K., Kumar S. and Pandey, R. (Eds.) 2025. Healthy Feet, Healthy Elephants: A Guide to Foot Care in Captive Asian Elephants . Project Elephant Division, MoEF&CC, GoI- Wildlife Institute of India. To page top

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A 14-month-old African elephant presented with colic caused by colon obstipation. Due to the severity of the symptoms, it was decided to perform abdominal surgery.  A second surgery was required after 3 months. To colic general information Case report Colic and abdominal surgery in 14-month-old African elephant Date: 2018 Place: South Africa Data provided by: History A 14-month-old African elephant presented with colic caused by colon obstipation. Due to the severity of the symptoms, it was decided to perform abdominal surgery. A second surgery was required after 3 months. Treatment The animal was anesthetized with etorphin, intubated in the trachea, maintained on isoflurane and positioned in dorsal recumbancy. A midline incision was elected to approach the intestines. An obstruction of the colon was found and surgically removed. The peritoneum and muscle layers in the ventral midline were closed in one layer with Number 1 Maxon loop sutures, used in horse colic surgery to close the abdomen. Each suture knot was thrown 5 times, instead of the normal 3 times. The subcutis was closed with 2/0 Vicryl (continuous sutures) and the skin with Number 1 Nylon (single sutures). Reaction of the wound occured both times and she developed an incisional infection . This infection was treated by keeping the wound clean and both times the wound finally healed well. Treatment results The elephant recovered completely without further complications. Paramedian incision Instead of a midline incision, aparamedian incision can be used, just several centimeters left or right of the ventral midline. The advantage of this approach is the possibility to suture more muscle tissue compared to the connective tissue of the linea alba. There may, however, be more bleeding during surgery and access may be more limited than when a midline incision is used. Diagram of the closure of a paramedian incision. A) Skin B) Abdominal tunic C) Aponeurosis of the external abdominal oblique muscles D Rectus abdominal muscle E) Aponeurosis of the transverse abdominal muscle F) Peritoneum To page top

EEHV hemorrhagic disease in elephants is often fatal as a result of DIC. Antibody assays and PCR monitoring may help to treat affected elephants in an early stage. This page describes the virus, the disease, its treatment, plasma transfusion, cross matching and standing sedation. To infectious diseases Elephant Endotheliotropic Herpes Virus-Hemorrhagic Disease (EEHV-HD) Compiled by Willem Schaftenaar History: EEHV-HD is caused by a delta-herpesvirus. The virus has evolved with the elephant species and is older than the currently living elephant species. Most (if not all) adult elephants are latently infected with EEHV. Young elephants between 1 and 9 years of age can be susceptable for an often fatal syndrom: EEHV-Hemorrhagic Disease. It is hypothesized that the long half-lifetime of maternal antibodies (EEHV maternal antibodies can circulate for up to 36 months in a calf) protects the calf against developing this syndrome. If this is true, it means that calves need to be exposed to EEHV during the phase in which antibodies are decreasing, but still protecting the calf. Fatal cases in Asian elephants have been reported over 20 times more than in African elephants. One of the hypotheses is that African elephant are shedding the virus much more frequent than Asian elephants, which offers a better opportunity for the calf to build up a solid immunity during the period that it is still protected by maternal antibodies. Asian elephants can carry EEHV1a, EEHV1b, EEHV4 and EEHV5, of which EEHV1a has caused the vast majority of the fatal cases. African elephants can carry EEHV2, EEHV3a, EEHV3b, EEHV6 and EEHV7. EEHV3 and EEHV6 have been associated with fatal cases, while the other African EEHV-subtypes are associated with lymphoid nodules in lungs and skin of African elephants. There is one report of a fatal case caused associated with EEHV3 in an Asian elphant. Like all herpesviruses, EEHV has a latent phase in a so far unknown tissue of the elephant body. For reasons that are not yet known, the virus can be reactivated, probably due to a (temporary) weakening of the elephant's immune system. The virus migrates to the mucous membranes of the mouth, trunk, eyes and the female genital tract. Shedding in semen or mucous membranes of the penis has not yet b een reported. Shedding has been observed in a zoo-kept herd of Asian elephants after the introduction of a bull and on a second occasion after the introduction of 2 females (Titus, 2022). In another zoo, 2 young Asian elephant calves died of EEHV1 within 2 weeks after the introduction of a breeding bull (Dublin zoo, 2024). Both calves appeared to have no antibodies against EEHV1a and EEHV1b. These findings suggest that the introduction of adult elephants in a herd can induce virus reactivation and consequently virus shedding. (Maternal) antibodies Humoral antibodies can be demonstrated by using recently developed antibody assays. A fluorescence based assay (Lips assay) has become available in the USA (Fuery, 2020) and an ELISA-based assay in the Netherlands (Hoornweg, 2021 ) . Serological studies using these assays demonstrated that maternal antibodies remain circulating for up to 36 months in elephant calves (Fuery, 2020). These maternal antibodies are transmitted in the uterus. The long period during which they are circulating at high levels in a young elephant, suggests that this species is able to absorb antibodies excreted by the dam in her milk. This is also suggested by Takehana et al 2024 , who described that the antibody level in a bottle-fed elephant calf decreased within 14 months as compared to 2 other calves in the same herd, in which antibodies remained high for more than 2 years. However, this hypothesis still needs to be proven. EEHV-subspecies and subtype-specificity has been demonstrated for these assays (Hoornweg, 2023 ) . Another finding was that antibodies against EEHV4 were not protective against fatal EEHV1a infections, while antibodies against EEHV1a seem to protect against illness caused by EEHV4 and EEHV5. Hoornweg et al. studied 23 fetal EEHV-HD cases in European zoos and found that all fatalities had low antibody levels against gH/gL of the EEHV (sub)species they succumbed to (Hoornweg, 2024) . During the first 12 months of life, maternal antibodies seem to remain stable at a high level, which seems to protect the calf from developing Hemorrhagic Disease when infected by EEHV. This may explain why clinical EEHV-cases have never been reported below the age of 1 year. This has lead to the hypothesis that young elephants need to be exposed to EEHV while they are still (partly) protected by maternal antibodies. Shedding of EEHV by herd mates is therefore essential for the calf to build up natural immunity. In an elephant that is permanently infected with EEHV, shedding takes place after reactivation of EEHV. In 2 elephant orphanages in Sri Lanka (31 and 93 elephants), all calves had high levels of EEHV-gB antibodies. These 2 institutions never lost a calf to EEHV-HD. This leads to the conclusion that the larger herd sized in these 2 orphanages (compared to zoos increases the likelihood of cantact between EEHV-shedders. Herpes viruses in general can become reactivated during a stressful situation, when the immune system of the host seems to become weaker, possibly under the influence of endogenous glucocorticosteroids. Specific stress inducers that result in EEHV-reactivation are not yet known for elephants. It is tempting to hypothesize that social stress could be one of those factors, as elephants are highly social animals. Zoos generally try to avoid stress situations for their animals, including elephants, especially when there is a young calf in the herd. In the light of the recent findings, the absence of stress might as well work against the development of acquired immunity against EEHV in young calves. The same hypothesis could be valid for elephants in wild situations: if social stress factors are absent in some of the wild situations (less contact with other herds due to habitat fragmentation, less contact with bulls in musth), reactivation frequency of EEHV may be reduced in (sub)adults, preventing calves younger than 12 months from building up immunity during the crucial time frame when they are still protected by maternal antibodies. Clinical signs and diagnosis: 10-14 days before the elephant shows clinical signs of EEHV-HD, the presence of the virus can be demonstrated in the blood by qPCR (EDTA blood sample). It is important to monitor the presence of EEHV in calves between 1 and 9 years of age on a weekly base. As soon as the presence of EEHV has been confirmed, the number of monocytes and platelets are indicative for the further development of the virus in the days to come. When monocytes and platelets are stable and the viral load remains below 5.000 Viral Genome Equivalents (VGE's)/ml, close observation is required. As soon as the viral load in the blood increases or monocytes or platelets drop, immediate treatment is required. If the initial viremia has passed unnoticed, the young elephant may display one or more of the following unspecific symptoms: lethargy, reduced appetite, lameness, abnormal sleeping pattern, soft feces. In more advanced cases petechiae are seen on the tongue, edema on the head and front legs and finally cyanosis (purple tongue). Sometimes the severe symptoms are the first ones to be discovered. Photo: courtesy of Florence Ollivet-Courtois The most relevant tools needed for the diagnosis of EEHV-HD are: qPCR and total WBC, platelet count and blood smear (manual count of monocyte and heterophyls). The monocyte/heterophil (M/H) ratio is an important prognostic indicator for EEHV-HD. A ratio below 1 is reason for great concern and immediate treatment should be started. Blood smears are essential for manual differentiation of the white blood cells and recognition of the morphology. Note that the presence band-heterophils in young elephants is a bad sign! Lactate is an important serum parameter to monitor in a EEHV-HD case. Normal values are between 0--0.11 mmol/L (0-1 mg/dL). Values >0.44 mmol/L (4 mg/dL) are indicative for perfusion problems due to DIC (see below). EEHV-HD patients often have lactate value > 0.22 mmol/L (2 mg/dL) (Wiedner, pers. comm. 2022). Reports from Thailand suggest that a (primary?) infection with EEHV4 is generally associated with intestinal problems (Kittisirikul, 2025). At rectal examination, edema of the rectal mucosa can be diagnosed. This finding is supported by histopathological findings in fatal EEHV-HD cases ( Sripiboon, 2013) . Disseminated Intravascular Coagulopathy (DIC) One of the main reasons an EEHV infection can lead to severe illness or death is the development of DIC in young calves that are not adequately protected by (maternal) antibodies. DIC results from a severe, dysregulated immune response triggered when endothelial cells are damaged by the virus (endothelial glycocalyx degradation). Two independent studies have clearly demonstrated the occurrence of DIC in fatal cases of EEHV-HD (Guntawang, 2021; Perrin, 2021). In the treatment protocol for EEHV-HD, addressing DIC is a top priority. Cytokine Storm? In recent years, researchers have questioned whether a cytokine storm—described in human hemorrhagic fevers such as Ebola and Dengue—also plays a role in the development of EEHV-related DIC in elephants. A recent study reported a significant increase in interleukin-6 (IL-6) and interleukin-10 (IL-10) levels in the tissues and blood of six elephants suffering from clinical EEHV1a-HD (Hoornweg, 2025). Moreover, 2 elephants with clinical EEHV1a-HD that were treated with glucocorticosteroids, had lower serum levels of IL6 and IL10 than those that were not treated and even lower than the assumed reference level. Both elephants survived the clinical EEHV-HD infection. Elevated levels of these two interleukins are commonly associated with cytokine storms, suggesting that this phenomenon may also occur in EEHV-HD. These findings support the theory that the administration of glucocorticosteroids are indicated in the early phase of the hemorrhagic disease. Photo: courtesy African Lion Safari Park Photo: courtesy Amersfoort Zoo Pathological findings at necropsy The most prominent signs of EEHV-HD at necropsy are those that resulted from DIC: cyanosis of the tongue, subcutaneous edema, hemorrhages in most of the organs, joints and muscles, ranging from petechiae to large hematomas. There may also be a hydro-or hemopericardium. Especially in the case of EEHV4, the cecum and colon can be congested, hemorrrhagic and containing abnormal watery dark-brown content. Hemorrhages in the heart, intestines, brain and liver of a yound elephant that died of EEHV1a-HD. Photos by Arun Zacharia Coinfection of EEHV-HD and Clostridium perfringens α, βand ε. One report describes a coinfection of EEHV4 and Clostridium perfringens in a 7-month-old Asian elephant bull calf (Boonsri et al., 2018). The animal died within 2 days after the onset of the first clinical signs. At necropsy, basophilic intranuclear inclusion bodies were identified in the endothelial cells of blood vessels in the heart, lungs, liver, and spleen. This finding is indicative of a primary EEHV4 infection, despite the calf being suckled by its mother. Under normal circumstances, maternally derived antibodies would be expected to confer partial protection; however, this protection may have been insufficient, possibly due to a lack of prior immunity in the dam. Alternatively, the concurrent C. perfringens infection may have predisposed the calf to viral disease by compromising mucosal barriers or inducing systemic stress, thereby reducing the effectiveness of existing maternal antibodies against the virulence of the virus. The same authors also describe a coinfection involving EEHV1a and C. perfringens in a 3-month-old, female, wild-born Asian elephant that died within 6 hours after the onset of clinical signs. Although samples from the heart, lungs, liver, and spleen tested positive for EEHV by polymerase chain reaction, no intranuclear inclusion bodies were observed upon histopathological examination. This discrepancy suggests that, in this case, maternally derived antibodies may have partially inhibited viral replication within endothelial cells, thereby preventing the formation of characteristic inclusion bodies. Nevertheless, the rapid clinical deterioration indicates that other pathogenic mechanisms, potentially including the effects of C. perfringens toxins, may have played a decisive role in the fatal outcome. Taken together, these cases highlight the potential for synergistic interactions between EEHV and C. perfringens infections. Such interactions may exacerbate disease severity through combined effects on vascular integrity, immune function, and systemic homeostasis. Click here for the EAZA elephant TAG EEHV treatment protocol Treatment of EEHV-HD Early treatment of EEHV-HD is essential for the survival of the elephant. The list of recommended drugs is shown below. The clinician should not hesitate to administer all these drugs and should even sedate the sick elephant if needed for its treatment. Repetitive sedations have been given to sick calves without negative effects. If butorphanol is used to obtain sedation, it should not be antagonized as it will help to relieve the pain in the patient. Circulatory support: Rectal fluids: Luke-warm water 10-20 ml/kg BW TID or QID, up to every 2 hours NB: As repeated rectal fluid administrations may be needed, the anus of the elephant may become sensitive to these procedures. Rx: mix 15 ml lidocaine 2% with some lubricant and carefully apply on the anus. Wait for 10 minutes before placing the tube in the rectum for the administration of fluids. Repeated rectal exploration may be cause painful irritation of the anal sphincter and perianal skin. Adding lidocain to the lubricant may facilitate the exploration. Crystalloids: IV as a bolus of 0.3-4 ml/kg BW When blood or plasma is available, the administration of those products has preference over crystolloids. Whole blood transfusion: Indicated in case of anemia or severely delayed coagulation. The advantage of whole blood administration lays in the rapid availability: no waiting time for preparing plasma. A practical strategy is to collect sufficient blood from a donor elephant to make it available for whole blood (1-2 L) and save the rest to prepare it for plasma transfusions. Dosage whole blood transfusion: 1-2 L. Cross matching needs to be done prior to the transfusion. Plasma transfusion: IV bolus of 0.5-2 ml/kg BW (after minor cross matching of donor and recipient blood) For plasma transfusion in elephants see: Emergency care for elephants clinically ill from Elephant Endotheliotropic Herpes Virus–hemorrhagic disease (EEHV-HD, EAZA Elephant TAG, compiled by Fieke Molenaar (ZSL-Whipsnade zoo), Mads Bertelsen and Kathryn Perrin (Copenhagen zoo), Imke Lueders (GEOLifes), Lauren Howard (Houston zoo), Willem Schaftenaar (vet adv. EAZA Elephant TAG, 9 February 2021) Plasma is currently considered one of the best supportive therapies to provide, as platelets, clotting factors and potentially protective antibodies can thus be provided. Note that the freezing process activates platelets, which may render them useless at the time of transfusion. Therefore - where possible - freshly collected plasma is preferred. The following should be considered for plasma transfusions: If frozen plasma is available, this can be given in an early stage of the disease to save time (despite the activated and spent platelets). Blood collection from an adult elephant (plasma donor) should be initiated to provide fresh plasma as soon as possible. Cross-matching the donor animals with the recipients, especially if one donor will be used on multiple occasions. For more information about plasma transfusion: click here Anti-inflammatory treatment : Gluco-corticosteroid drugs are indicated in case of suspicion of DIC. Recent research could demonstrate an increase of interleukin 6 (IL6) and interleukin 10 (IL10) in tissues of elephants that succumbed to EEHV-HD and below-normal levels in blood of 2 survivors that were treated with glucocorticosteroids (Hoornweg, 2025). Dexamethasone: Used in 2 EEHV1a-HD survivor cases: Case 1: started with 0.2 mg/kg (200 mg) IV and continued daily for 12 days (final dose 0.007 mg/kg = 7 mg). Case 2: 2 mg/kg iv SID for 5 days, followed by 1 mg/kg iv SID for 2 days Triamcinolon : 0.067 mg/kg IV SID for 1-3 days (used in 1 EEHV1a-HD survivor case). Methylprednisolone sodium succinate: 0.5 mg/kg IV or IM; much higher doses are used for treatment of shock in horses: 10 - 20 mg/kg IV. Please note that in human medicine DIC (e.g. in Covid-19 cases) is treated with Dexamethasone 0.1mg/kg SID for 7-10 days ( https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-dexamethasone#:~:text=Recommendation%201%3AWHO%20strongly,medication%20for%20another%20condition .) Antiviral treatment: Several antiviral drugs are routinely used, although none of these have proven to be effective; preliminary studies are suggesting that the TK-gene of EEHV does not make the virus sensitive for the group of “ciclovirs” that is currently used. Famciclovir has been used most frequently, followed by ganciclovir. In the absence of the former antivirals, aciclovir has been given in several cases. Famciclovir: 15 mg/kg orally or rectally, TID Aciclovir: 15 mg/kg BID orally, rectally or IV (Ganciclovir: 5 mg/kg BW BID 5 mg/kg IV, BID, each dose given slowly diluted in 1 liter of NaCl. NB Ganciclovir is not preferred, as it is considered a potential human carcinogen, teratogen, and mutagen) Antibiotic treatment: A broad-spectrum antibiotic is recommended as the integrity of the intestinal wall may be disrupted and gut bacteria may leak into the abdominal cavity. Pain management: Pain management (opioids, NSAIDs) is generally recommended if there are clear signs of pain or discomfort. Butorphanol (first choice): 0.008-0.014 mg/kg IM Q 4 hrs Flunixin: 0.25 to 0.5 mg/kg IM SID Omeprazole: 0.7 to 1.4 mg/kg PO SID Warning: I personally think that NSAIDs may not be recommended, as they can cause hemorrhages. Immunostimulating drugs: Immunostimulants have been used in one case of EEHV1a-HD: Interferon alpha 2a or 2b (25 mIU/2.5 ml Intron A, Merck or 4.5 mIU/0.5 ml Roferon A, Roche) were administered at 27–33 mIU intramuscularly once a day on days 1–12 then every 48 hours to day 20, administered by dart on days with no treatment session, incomplete delivery on days 8 and 14. Bacterial plasmid DNA in a liposome carrier (Zelnate DNA immunostimulant, Bayer HealthCare LLC) was given to the same elephant (2 ml intramuscularly on days 0, 4, 7 and 12). It should be noted that the same elephant was also given anti-inflammatory treatment (dexamethasone). WS personal note: It should also be noted that interferon levels are expected to be elevated in case of a cytokine storm. As there is no scientific proof of the benefits of interferon treatment in EEHV-HD, care must be taken to use any interferon-containing drug formulation! Adjunctive drugs: Oxygen should always be standby and administered as soon as signs of hypoxemia are seen. Furosemide (1 mg/kg IM ) has been given occasionally. Vitamin C, routine used in Asia (dos age depends on product; use equine dose). Vitamin E (dosage depends on product; use equine dose). Monitoring the course of the disease: The serum lactate level gives an indication of the organ perfusion. In EEHV-HD patients, the lactate level is often higher than 2 mmol/L (normal value: 0-1 mmol/L). Rehydration by the fluid administrations will help to decrease an elevated lactate. Platelet counts during the treatment course are helpfull in evaluating the success of the treatment. The administration of whole blood and plasma will compensate partly the loss of platelets and also provide antibodies if the donor is an adult elephant. It is advisable to make sure that the donor does have antibodies. Blood pressure : in severe EEHV-case, the blood pressure may decrease or decrease. Fluid administration may help to stabilize the blood pressure. When the patient has a vascular shock, the blood pressure may be low. A fast administered bolus of rectal fluids (0.5-5 ml/kg BW) within 15-30 minutes may help to increase the blood pressure. To standing sedation Treatment of EEHV-HD Cross-matching procedure Based on design elaborated by Houston Zoo, Inc. Step one: Prepare a 3-5% red cell suspension. 1. Collect blood from both donor and recipient in EDTA. 2. Centrifuge the tube and separate the plasma from the red cells. Save both. 3. Place 1 drop of recipient red cells into a small (2-5 ml) clean test tube. 4. Add approx. 1-2 ml of normal saline to the tube with the red cells (or 1 drop RBC to 40 drops saline) 5. Centrifuge at 2500 RPM for 20 seconds. 6. Remove the supernatant, leaving the red cell button on the bottom. 7. Repeat steps 4-6 three times (for a total of 4 washes). 8. Add 1 drop of newly washed recipient red cells to a new test tube. 9. Add approximately 20-40 drops of saline and mix to suspend the red cells. This should be an approximate 3-5% cell suspension to work with. Step two: Minor cross-match (for plasma transfusion). 1. Add 1 drop of the recipient’s 3-5% red cell suspension to a labeled test tube. Add 1 drop of the recipient’s 3-5% red cell suspension to another labeled test tube to be used as a control. 2. Add 2 drops of donor plasma or serum to the test tube. 3. Add 2 drops of saline to the control tube. 4. Incubate these tubes at 37oC for 15 minutes. 5. Centrifuge the tubes for 20 seconds at 2500 RPM. 6. Observe the supernatant for signs of haemolysis. If present in the cross-match tube and not the control tube, the match is not compatible. If present in both, start again with a new cell suspension. 7. If no haemolysis, then gently rock the test tube back and forth to re-suspend the cell button. Observe the cell button while rocking the tube and grade for the presence of agglutination. Grade on a 0-4 scale where 0 is no agglutination and 4 is heavy clumping. Record your results. Step three: Major cross-match (for whole blood transfusion). 1. Add 1 drop of the donor’s 3-5% red cell suspension to a labeled test tube. Add 1 drop of the donor’s 3-5% red cell suspension to another labeled test tube to be used as a control. 2. Add 2 drops of recipient’s plasma or serum to the test tube. 3. Add 2 drops of saline to the control tube. 4. Incubate these tubes at 35-37oC for 15 minutes. 5. Centrifuge the tubes for 20 seconds at 2500 RPM. 6. Observe the supernatant for signs of haemolysis. If present in the cross-match tube and not the control tube, the match is not compatible. If present in both, start again with a new cell suspension. 7. If no haemolysis, then gently rock the test tube back and forth to re-suspend the cell button. Observe the cell button while rocking the tube and grade for the presence of agglutination. Grade on a 0-4 scale where 0 is no agglutination and 4 is heavy clumping. Record your results. Anchor 1 References: Boonsri K, Somgird C, Noinafai P, Pringproa K, Janyamethakul T, Angkawanish T, Brown JL, Tankaew P, Srivorakul S, and Thitaram C. 2018. Elephant Endotheliotropic Herpervirsus associated with Clostridium perfringens infection in two Asiane elephants ( Elephas maximus ) calves. Journal of Zoo and Wildlife Medicine 49(1): 178–182, 2018 Fuery, A, Pursell,T., Tan, J, Peng, R, Burbelo, P.D., Hayward, G.S., Ling, P.D.2020. Lethal Hemorrhagic Disease and Clinical Illness Associatedcwith Elephant Endotheliotropic Herpesvirus 1 Are Caused by Primary Infection: Implications for the Detection of Diagnostic Proteins. J. Vir. Volume 94 Issue 3. Guntawang T, Sittisak T, Kochagul V. ,Srivorakul S., Photichai K., Boonsri K., Janyamethakul T., Boonprasert K., Langkaphin W.5, Chatchote Thitaram C. and Pringproa K. 2021. Pathogenesis of hemorrhagic disease caused by elephant endotheliotropic herpesvirus (EEHV) in Asian elephants (Elephas maximus ). Scientific Reports (2021). 11:12998. https://doi.org/10.1038/s41598-021-92393-8 Hoornweg TE, Schaftenaar W, Maurer G, van der Doel PB, Molenaar F, Chamour-Galante A, Vercammen F, Rutten V and de Haan CAM. 2021. Elephant Endotheliotropic Herpes Virus is omnipresent in elephants in European zoos and an Asian elephant range country. Viruses 2021, 13, 283. https://doi.org/10.3390/v13020283. Hoornweg TE, Perere VP, Karunarathne NS, Schaftenaar W, Mahakapuge AN, Kalupahana AN, Rutten VPMG, de Haan CAM. 2022 . Young elephants in a large herd maintain high levels of elephant endotheliotropic herpesvirus-specific antibodies and do not succumb to fatal haemorrhagic disease. Transboundery and Emerging Diseases 69-5 . https://doi.org/10.1111/tbed.14644. Hoornweg TE, Schaftenaar W, Rutten VPMG, de Haan CAM. 2024. Low gH/gL (Sub)Species-Specific Antibody Levels Indicate Elephants at Risk of Fatal Elephant Endotheliotropic Herpesvirus Hemorrhagic Disease. Viruses. 2024; 16(2):268. https://doi.org/10.3390/v16020268. Hoornweg TE, Schaftenaar W, IJzer J, Mulder MMP, Lugtenburg M, van Beest A, de Haan CAM and Rutten VPMG (2025) Elevated IL-6, IL-10, and IFN-g levels in fatal elephant endotheliotropic herpesvirus – hemorrhagic disease cases suggest an excessive proinflammatory cytokine response contributes to pathogenesis. Front. Immunol. 16:1645752. doi: 10.3389/fimmu.2025.1645752 Howard L.L. & Schaftenaar W. 2017. Elephant Endotheliotropic Herpes Virus. In: Fowler’s Zoo and Wild Animal Medicine Current Therapy, Volume 9. Kittisirikul N, Angkawanish T, Langkaphin W, Chaopong O, Thaitam B and Sripiboon S. 2025 Challenging management of clinical EEHV4 infection in an adult Asian elephant. 21st International Elephant Conservation and Research Symposium. Fort Worth IEF, December 5-8. Luz S & Howard L.L. 2017. Elephant Endotheliotropic Herpesvirus (EEHV) in Asia. Recommendations from the 1st Asian EEHV Strategy Meeting (On behalf of the Asian EEHV Working Group), second edition. Perrin KL, Kristensen AT, Bertelsen MF, Denk D. 2021. Retrospective review of 27 European cases of fatal elephant endotheliotropic herpesvirus‑haemorrhagic disease reveals evidence of disseminated intravascular coagulation. Scientific Reports (2021) 11:14173, https://doi.org/10.1038/s41598-021-93478-0. Sripiboon S, Tankaew P, Lungka G and Thitaram C. 2013. The occurrence of Elephant Endotheliotropic Herpes Virus in captive Asian elephants (Elephas maximus ): first case of EEHV4 in Asia. Journal of Zoo and Wildlife Medicine 44(1): 100–104, 2013. Takehana K, Hoornweg TE, Schaftenaar W), Rutten VPMG, de Haan CAM, Matsuno K. 2024. Elephant endotheliotropic herpesvirus gB-specific antibody levels in sera of Asian elephants (Elephas maximus) in Japanese zoos. J Vet Med Sci 86(12): 1279–1283, 2024 doi: 10.1292/jvms.23-0503. Titus SE, Patterson S, Prince-Wright J, Dastjerdi A, Molenaar FM. 2022. Effects of between and within Herd Moves on Elephant Endotheliotropic Herpesvirus (EEHV) Recrudescence and Shedding in Captive Asian Elephants (Elephas maximus ). Viruses, 14(2) 2022. doi:10.3390/v14020229. Wissink N. et al. 2018. Using in-house hematology to direct decisionmaking in the successful treatment and monitoring of a clinical and subsequently subclinical case of Elephant Endotheliotropic Her Vitus 1B. J. of Zoo and Wildlife Med., 50(2): 498-502 For more information see: http://eehvinfo.org/ To page top

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

Tusk extraction By Willem Schaftenaar and Yves Debosschere Introduction The primary indication for tusk extraction is the cessation of tusk growth. In all other cases, determining the exact point at which treatment should shift from conservative management of pulpitis to extraction can be challenging. Consequently, there is not always complete agreement regarding the optimal treatment strategy. In an attempt to provide some help in decision making, a group of interested zoo vets and dentists (Elephant Dental Vets, 2025) produced a guideline for this purpose. In general, oblique tusk fractures that extend deeply into the gingival sulcus are more likely to require extraction than fractures in which the exposed pulp can be adequately protected through partial pulpectomy and placement of a suitable dental filling. When the fracture site remains accessible and a reliable seal of the pulp cavity can be achieved, preservation of the tusk is the preferred option. In cases where the prognosis is uncertain, a conservative approach may initially be adopted. This involves managing pulpitis and maintaining pulp vitality through repeated irrigation of the exposed pulp with lactated Ringer’s solution, while monitoring for continued tusk growth. Ongoing growth may gradually bring the fracture site into a position where definitive restorative treatment becomes feasible. However, when tusk growth has ceased, or when continued growth fails to expose the fracture sufficiently for successful restorative treatment, conservative management is unlikely to provide a long-term solution. In such cases, tusk extraction becomes the treatment of choice and represents the only definitive method of resolving the condition. It is highly recommended to make an X-ray before starting the treatment, as it will help to evaluate the condition of the tusk and the sulcus. Positioning of the X-ray machine and the plate to catch the alveolus. Procedure In most cases, tusk extraction is performed under general anesthesia, particularly in adult elephants. More recently, successful tusk extractions have also been performed under standing sedation in younger animals. The first reported cases involved the extraction of two tusks from an eight-year-old Bornean elephant (Roopan, 2025), followed in 2026 by the extraction of two tusks from a 3.5-year-old Asian elephant (Roopan, 2026, pers. comm.). In addition to sedation, regional anesthesia was achieved through an attempted nerve block in the infraorbital foramen combined with perialveolar infiltration of 20 mL of 2% lidocaine hydrochloride (Roopan, 2025). When general anesthesia is selected, sufficient expertise is required to position the elephant in lateral recumbency with the affected tusk facing upward. If the animal inadvertently falls onto the opposite side during induction, it can be rolled over its back into the desired position. If bilateral tusk extraction is indicated, the procedures should be performed during separate anesthetic events. Repositioning an elephant onto the opposite side after it has remained in prolonged lateral recumbency is contraindicated due to the increased anesthetic and physiological risks associated with such manipulation (lung hypostasis). Although only limited descriptions of tusk extraction techniques are available in the literature, all methods share a common prerequisite: complete disruption of the periodontal attachment between the tusk and the alveolar sulcus. The choice between standing sedation and general anesthesia, as well as between segmental and in toto extraction, should be based on the age of the elephant, tusk anatomy, available equipment, operator experience, and the anticipated difficulty of the procedure. In most contemporary cases, complete in toto extraction is considered the preferred approach whenever technically feasible. Tusk extraction performed under general anesthesia Block anesthesia in the foramen infraorbitalis (Courtecy: N. Roopan) Periodontal separation Before beginning the procedure, the total length of the sulcus should be determined. This can be achieved using a sufficiently long probe inserted into the pulp canal until the osseous boundary is encountered. It should be remembered that the base of the sulcus is formed by the extremely thin bony wall separating the tusk cavity from the adjacent sinus. If the pulp cavity is blocked by a plug of tertiary dentine, a hole should be drilled in this plug by using a steel drill. Drilling a hole in the dentine plug Measuring the alveolar length Next, the soft tissue connection between the sulcus and the tusk (coronary band or gingiva) must be severed. This can be accomplished by using a scalpel. Incision of the coronary band or gingiva Separation of the periodontal tissues requires the use of custom-made tusk periotomes. These instruments consist of long, narrow steel blades, several millimeters thick, that must be sufficiently flexible to follow the natural curvature of the tusk while remaining strong enough to withstand repeated hammering with a dead-blow hammer. The tip of each blade should be sharpened to facilitate transection of the periodontal ligament. Observations from (at least one) clinical case indicate that the firm periodontal ligament does not extend all the way to the apex of the tusk. The apical portion, representing approximately 40–50% of the total sulcus length, is very thin and exhibits minimal attachment to the sulcus wall. Consequently, periotome length only needs to correspond to approximately 50–60% of the measured sulcus depth. Because of the curvature of the tusk, periotomes tend to deviate from the intended path. It is therefore advisable to leave one periotome in place after it has been advanced to the desired depth. This periotome then serves as a guide for subsequent blades. By progressively inserting multiple periotomes and leaving several in position, the periodontal attachment can be disrupted circumferentially around the entire tusk. Advancement of the periotomes is accomplished through controlled hammering with a dead-blow hammer. The separation of the tusk from the sulcus wall is a time-consuming activity, which can take several hours in an adult elephant. A periotome is inserted into to space between tusk and alveolus The periotome is advanced using a dead-blow hammer The periotome is advanced over a distance of 30 cm. Extraction techniques Once the periodontal attachment has been disrupted as completely as possible, two extraction techniques may be employed. 1. Segmental extraction Historically, tusks were removed by dividing them into longitudinal segments using a reciprocating saw (Welsch, 1989). This technique has several disadvantages. There is an increased risk of damaging the sulcus wall, as it can be difficult to accurately determine the depth of saw penetration into the dentine. After the tusk has been divided into multiple longitudinal sections, each segment can be removed individually. Although less commonly used today, this method remains a valuable alternative when complete extraction of the tusk cannot be achieved using the in toto extraction technique described below. Extracted segments of the necrotic tusk of a 25 yr-old adult Asian elephant bull 2. In toto extraction Currently, complete removal of the tusk as a single unit is generally preferred. After disruption of the periodontal attachment, extraction is achieved through repeated application of traction and rotational forces. Successful application of these forces requires a secure grip on the tusk. 2a. Extraction of a protruding tusk When a sufficient portion of the tusk extends beyond the sulcus, a transverse hole can be drilled through the protruding tip of the tusk using a steel drill bit. A solid steel pin (10 mm diameter) is then inserted through the hole. To generate rotational force, a hollow steel pipe can be placed over one end of the protruding pin, creating a lever arm. A sustained rotational force should be applied in one direction and maintained for at least one minute. This prolonged loading stretches the remaining intact periodontal fibers, promoting their rupture. In addition, fluid is expressed from the damaged connective tissue structures, further weakening the attachment between the tusk and its socket. The procedure is then repeated in the opposite direction by transferring the pipe to the other end of the steel pin. Alternating rotational forces, combined with traction, progressively loosen the tusk until extraction becomes possible. Traction can be increased by connecting the steel pin to a belt tensioner photo equipped with a ratchet mechanism (video extraction Taru). In one reported case involving an eighteen-year-old Asian elephant, additional rotational force was generated using a hydraulic spreader (see photo) positioned beneath the end of the steel pipe. Such equipment is commonly used by fire and rescue services, although a conventional automotive jack may provide a similar mechanical advantage. The sequence of rotation and traction must typically be repeated many times before complete release of the tusk is achieved. Solid steel pin inserted in the tusk to allow pulling and rotating On each side of the tusk, a steel pipe is placed over the steel pin. A hydraulic spreader is used to increase the rotational power. Tusk extraction Asian elephant Play Video Watch Now Facebook Twitter Pinterest Tumblr Copy Link Link Copied Close Final extraction of the tusk. Note the straps and the belt tensioner with ratchet. By increased pulling force and manual rotation force the last pieces of the fibrous connection between tusk and alveolus ruptured, allowing the tusk to be extracted. An extracted tusk that protruded 7 cm outside the sulcus. Note the slight narrowing at 22 cm (44% of total alveolar length). The peridontal ligament was severed only in the distal 27 cm (56% of the total alveolar length) of the tusk. This image shows the projection of the tusk on the skull. Note that the tusk reaches byond the orbita. 2b. Extraction of a non-protruding tusk If insufficient tusk projects beyond the sulcus to permit direct application of traction and torsion, a custom-made internal tusk extractor may be used (photo Oosterhuis and Fagan). This device consists of a hollow steel shaft with a T-handle. An expandable internal mechanism is inserted into the lumen of the tusk and subsequently expanded until it securely engages the internal dentinal walls. Once adequate purchase has been obtained, extraction proceeds according to the same principles described for protruding tusks, utilizing alternating rotational and traction forces. In toto extraction of a tusk that did not protrude ouside the sulcus using a custom-made extraction device. Post-extraction management Following removal of the tusk, the entire sulcus should be carefully explored manually to identify any damage to the bony walls or remnants of dentine inside the sulcus. Any remaining pulp tissue should be removed as completely as possible. However, accessibility and available anesthetic time frequently limit the extent of debridement. The confined dimensions of the sulcus provide little room for arm movement, and the dense, soft consistency of the pulp often creates a vacuum-like effect around the operator's arm. Introducing a flexible plastic tube alongside the arm may facilitate air displacement and improve access. If the procedure has already been prolonged and continuation of anesthesia is considered undesirable, residual pulp tissue may be left in situ. Such tissue is no longer viable following extraction and will undergo necrosis. It is recommended to gently debride the alveolus following extraction using stiff brushes or custom-made curettes (Woody, 2022). Control postoperative bleeding by tightly packing the alveolus with shaved ice. To page top Potential complications Retained dentine deposits and ankylosis Occasionally, hard dentinal masses may be encountered within the sulcus. These structures are the result of chronic pulpitis and are comparable to tertiary dentine pearls observed in other species. Such deposits may be extremely hard and difficult to remove as they may be strongly attached to the alveolus (ankylosis). Long periotomes and long-jawed extraction forceps should be used to remove them as completely as possible. Persistent retention of these mineralized structures can significantly interfere with normal healing of the extraction site. Parts of the periodontal ligament may have formed ankylosis between tusk and alveolar. Removing these parts may require the removal of some alveolar bone (Woody, 2022). Extracted tusk from a 5 yr-old Asian elephant bull. Note the formation of tertiary dentine ("pearls") at the apex. Damage to the alveolar wall Trauma to the thin osseous wall of the alveolus, particularly in the region adjacent to the sinus cavity, may occur during periotome insertion or sawing procedures. Careful instrumentation and thorough post-extraction inspection are therefore essential. Loose pieces of necrotic bone can sometimes be found in the sulcus during the weeks after the extraction. If large enough, they may obstruct the passage through the sulcus opening. They should be removed, if needed under standing sedation. Incomplete periodontal disruption: f ailure to completely disrupt the periodontal attachment may result in excessive extraction forces, prolonged procedural times, or fracture of the tusk during removal. Fragment of necrotic bone tissue from the alveolus, recovered 6 months after tusk extraction Aftercare The extraction cavity should be flushed twice daily with lukewarm water. High-pressure irrigation must be avoided, as the purpose of flushing is solely to remove necrotic tissue and inflammatory exudate. This regimen should continue until the sulcus has completely closed and no further fluid drainage is observed. Regular clinical monitoring is recommended throughout the healing period to assess tissue contraction, drainage, and the development of any complications. Required equipment Anesthesia and monitoring General anesthesia equipment Monitoring equipment Local anesthetic agents Radiography equipment Irrigation and debridement Flushing pump Chlorhexidine solution Irrigation tubing Periodontal separation Multiple tusk periotomes (minimum of four) of various periotome lengths and thicknesses photos Dead-blow hammer Tusk cutting and drilling Reciprocating saw Steel drill and drill bits Extraction equipment Custom-made internal tusk extractor Solid steel pin Hollow steel pipe Straps Ropes Belt tensioner with ratchet Hydraulic spreader or automotive jack Surgical instruments Long-jawed extraction forceps Long probe for sulcus measurement Additional instruments for pulp debridement and exploration of the extraction cavity. The use of finger knives and a fetotome should be considered for removal of the pulp. Assortment of perotomes and dead-blow hammer Assortment of plyers with long jaws Custom-made internal tusk extractor Hydraulic spreader References Roopan N, Buranapim N, Sripiboon S, Balakrishnan Y, Sipangkui S, and Tum TC. 2025. Extraction of Nonvital Tusks in a Standing Sedated Bornean Elephant Using a Simple Noncollapsing Rotational Extraction Technique: A Case Report. Journal of Veterinary Dentistry 43 (3) 1-8. https://doi.org/10.1177/08987564251339734 . Welsch B, Jacobson ER, Kollias GV, Kramer L, Gardner H, Page CD. 1989. Tusk Extraction in the African Elephant (Loxodonta africana). Journal of Zoo and Wildlife Medicine,1989. Vol. 20, No. 4, pp. 446-453. Woody AD, Fagan DA, and Oosterhuis JE. 2022. Large mammal dental surgery. In: Surgery of Exotic Animals, First Edition. Edited by R. Avery Bennett and Geoffrey W. Pye. © 2022 John Wiley & Sons, Inc. Published 2022 by John Wiley & Sons, Inc. Pag. 370-375. To page top

Reproductive tumors and cysts are frequently seen in aging nulliparous elephants. Diagnosis is based on ultrasound examination. The anomalies may finally result in infertility. If leiomyomas need treatment (because of blood loss), Gonadotrophin Releasing Hormone (GnRH) vaccins can be used to down-regulate the estrous cycle, which will result in reduction of the size of the leiomyomas. To reproduction Reproductive Tumors and cysts Prevalence of tumors and cysts Abegglen et al. (2022) published an overview of reproductive tumors in elephants: "Asian elephants in particular are often diagnosed with benign uterine tumors called leiomyomas or fibroids (the term typically used to describe these lesions in humans). While malignant tumors overall are rare in elephants, when they do occur, the reproductive tract is disproportionately affected. Benign and malignant reproductive tract tumors are known to affect reproduction and pregnancy in other animals, and even tumors outside of the reproductive tract can have significant negative impacts on reproductive success." In a literature study of the same authors the following reproductive anomalies were found in (aged) Asian elephants : Uterine leiomyoma Uterine adenocarcinoma Anaplastic carcinoma (uterus) Carcinoma in situ in endometrial polyp Peripheral neuroectodermal tumor (uterus) Angiosarcoma (uterus) Anaplastic sarcoma (pelvic mass of presumed uterine origin) Ovarian carcinoma Ovarian cysts Hyperplastic endometrial disease Vestibular cysts Vaginal leiomyoma Hyperplastic, polyploidy or papillomatous mucosal lesions of vagina/vulva Vagina polyps Vulvar polyps Uterine polyps Uterus undifferentiated malignant neoplasm The vast majority of reproductive pathologies in Asian elephants consists of uterine leiomyomas, followed by hyperplastic endometrial disease and cyst s. Reproductive tumors and cystic changed found in African elephants are: Endometrial cysts Ovarian carcinoma Bilateral multilocular serous ovarian cystadenoma Hyperplastic endometrial disease Vestibular cysts Vestibular polyps Vagina polyps Polyps and Hyperplastic endometrial disease are the most frequently encountered reproductive anomalies. Symptoms and diagnosis Most elephants suffering from the above mentioned disorders are aged and nulliparous . There are no hard data about the impact of these abnormalities on the reproduction. No doubt that large areas of affected uterine surface may reduce implantation options for the embryo. The same applies to hyperplastic endometrial disease. Large polyps in the distal reproductive tract can impede copulation by blocking the passage of the penis. Symptoms are rarely observed. Occasionally blood loss can be observed in severe cases of leiomyomas. Diagnosis The only way to diagnoses these reproductive disorders is by transrectal ultrasound examination. Location and severity of the abnormalities can be evaluated when they can be reached during this examination. Figure 1: Transrectal examination in a 12 yr-old Asian elephant showing the early stage of an embryo in the left uterine horn and a large leiomyoma in the right uterine horn, clearly compressing the endometrium. The embryo developed normally and the elephant produced several calves after this diagnose was made. Figure 2: Leiomyoma (55 cm diameter) in an Asian elephant that produced 6 calves. (Courtecy: Planckendael Zoo) Figure 3: Transrectal examination in an adult African elephant showing a cyst in the cervix uteri. Figure 4: Transrectal sonogram (4-2MHZ) of the uterus (UT) with a cystic (CY) degenerated endometrium. The rectal wall (RW) appears as a moderate echoic strip on the top of the sonogram (Fowler & Mikota 2006) Treatment of severe cases of leiomyomas Female elephants suffering of chronic pathological conditions in the reproductive tract (leiomyomas) may benefit from a permanent shut-down of the estrous cycle by the administration of gonadotrophin releasing hormones (GnRH) vaccins. The following schedule should be used: A minimum of 450 μg of a GnRH vaccine (i.e. 3ml of Improvac©, Zoetis Animal Health)* deep intramuscularly once per month for 3 months. Thereafter booster vaccinations are given every 6 months (please note that some individuals may not respond and thus, require higher doses of up to 1000 μg protein conjugate or more frequent injection, in this case, please contact the v et advisors). Other available commercial products/brand names are Improvest©, Equity© and Bopriva©, depending on country. References Abegglen, L.M.; Harrison, T.M.; Moresco, A.; Fowles, J.S.; Troan, B.V.; Kiso,W.K.; Schmitt,D.; Boddy, A.M.; Schiffman, J.D. 2022. Of Elephants and Other Mammals: A Comparative Review of Reproductive Tumors and Potential Impact on Conservation. Animals 2022, 12, 2005. https:// doi.org/10.3390/ani121520052022 Reproductive Tumors and Potential Impact on Conservation Boedeker et al. 2012. Effects of a gonadotropin-releasing hormone vaccine on ovarian cyclicity and uterine morphology of an Asian elephant (Elephas maximus). Journal of Zoo and Wildlife Medicine 43(3): 603–614, 2012. Landolfi JA, Gaffney PM, McManamon R, et al. Reproductive tract neoplasia in adult female Asian elephants (Elephas maximus). Veterinary Pathology. 2021;58(6):1131-1141. https://doi : 10.1177/03009858211031843 Lueders et al. 2019. Use of gonadotrophin releasing hormone (GnRH) vaccines for behavioural and reproductive control in managed Asian elephant Elephas maximus and African elephant Loxodonta africana populations. Int. Zoo Yb. (2019) 53: 138–150. Thitaram et al. 2018. Monitoring and controlling ovarian activity in elephants. Theriogenology 109, 42-47.

This case report describes an open fracture of the mandible in a young Asian elephant, that resulted in a severe infection. The elephant was humanely euthanized. To bone fractures Case report Mandibular fracture Date: 2020 Place: 13th Asian Society of Conservation Medicine Virtual Conference History •Coconut-sized abscess on left mandible •Asymmetric buccal margins •Tongue ulceration •Periodontitis •Endodontitis •Foul-smelling caseous material •Malocclusion Diagnostic results •Radiography 70kVp, 10mAs •Lateral and intraoral bisecting angle •Soft tissue swelling •Callus formation Conclusion: Left sided comminuted fracture at the body of the mandible. Unilateral mandibular fracture on left side → Malocclusion → Failure of 𝑀3 extrusion on right side → Impeded eruption of caudal molar on right side → Abnormal eruption of 𝑀5 on right side → Excessive molar abrasion on the left side → Compromised mechanical digestion of food → Anorexia → Malnutrition Treatment The animal was not a release candidate, and keeping the animal in captivity for a prolonged period nor permanently was not an option. Therefore, the authorities opted for euthanasia. Read the poster To page top

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