This page directs you to the following reproduction-related topics in elephants: -estrous cycle -normal birth process -vaginal vestibulotomy -tumors and cysts in the reproductive organs -cesarian -dystocia -fetal retention -infertility (female) -infertility (male) To dashboard Reproduction Estrous cycle Endoscopy urogenital tract Pregnancy confirmation Normal birth process Dystocia Vaginal vestibulotomy Fetotomy Tumors and cysts I need your input to write these chapters: Cesarian Infertility (female) Infertility (male)

Broncho-alveolar lavage (BAL) describes: gastroscopy, bronchoscopy, esophagus, trachea, mouth-opener, mouth gag. Approach is done either via the trunk or via the via, always under standing sedation. The purpose of a BAL is to collect samples for culture/PCR (tuberculosis) or histology. To physical examination Sample collection Trunk wash Broncho-alveolar lavage Trunk wash procedure Trunk wash procedure Compiled by Willem Schaftenaar Background The trunk wash procedure was developed as a method for diagnosing tuberculosis or the detection of Elephant Endotheliotropic Herpes Virus. This procedure is an active manipulation at the elephant trunk, which can be performed in free and protected contact systems in non-immobilized elephants after they are conditioned for this procedure. The principle is that a sterile 0,9% saline solution (approx. 100 ml) is injected in each nostril of the trunk. The trunk has to be lifted actively by the elephant or passively by the keeper so that the solution is running up to the base of the trunk. The mixture of the solution and trunk mucus is collected in sterile plastic bags by active blowing of the elephant through its trunk (training required). The staff should protect themselves against spilling trunk content into their face. A full trunk wash procedure requires 3 different trunk washes performed within a period of 7 days. Each sample must be sealed and stored at 4°C. Depending on the quality of the samples, the diagnostic lab can decide to pool the samples for culture/PCR. Samples must be shipped to the TB-diagnostic lab immediately after the 3-rd sample has been taken. The maximum storage period at 4°C is 7 days. NB: follow the EU guideline for shipment of potentially hazardous biomaterials. For the (q)PCR detection of EEHV, the sample can be shipped directly or kept frozen at -20°C until shipment. Trunk wash in a non-contact situation requires a full anesthesia of the elephant and a portable fluid pump and sucking system, which allows the operation under sterile condition. The external pump and sucking system will be connected to a sterile PVC tube (1 cm diameter, with distance markers) with a length of approx. 2 meter. The amount of sterile solution and the collection bag are like described before. In non-contact situations, a bronchoalveolar lavage (BAL) under standing sedation is the preferred procedure. Training for a trunkwash procedure Broncho-alveolar lavage (BAL) and Gastroscopy Broncho-alveolar lavage Compiled by Willem Schaftenaar Procedure A bronchoalveolar lavage (BAL) may be indicated when a sample from the deeper regions of the lungs is required, such as for the diagnosis of tuberculosis (TB). Gastroscopy is a procedure that allows direct visualization of the esophagus and stomach. It enables the collection of biopsy specimens and stomach contents, and it can also be used to perform a lavage for TB diagnosis. Fluids obtained through BAL are additionally used for the isolation of mononuclear cells and for cytological evaluation (Engel, 2005). The procedure has been performed in free-ranging savanna African elephants under general anesthesia (Engel, 2005). The protocol described here outlines a workflow for the successful isolation and characterization of alveolar cells, predominantly alveolar macrophages, from BAL fluid. Differential cell counts and cellular characterization were carried out. This technique for isolating alveolar mononuclear cells provides a foundation for further investigation into the functions of respiratory immune cells. Under more controlled conditions, the procedure can also be performed under standing sedation . There are 2 ways to approach the alveoli: 1. Trunk approach An endoscope measuring 10–12 m in length is advanced through the trunk ( Hermes et al, 2017 ). The main advantage of this method is that the operator can remain outside the enclosure. However, the procedure requires an extra-long endoscope, which is not readily available. To facilitate passage of the endoscope alongside the cartilage plate in the trunk, bilateral block anesthesia of the nerve rami at the base of the trunk has been recommended (Hildebrandt et al.). Nonetheless, D. Schmidt has reported performing a similar procedure without block anesthesia (pers. comm., 2019). Once advanced, the endoscope allows visualization of the inner walls of the trachea and bronchi for bronchoalveolar lavage; biopsy samples can also be collected if required. In addition, the endoscope can be directed into the esophagus to perform gastroscopy or gastric lavage. 2. Oral Approach In this method, a 5 m long endoscope is introduced through the mouth. The primary disadvantage is that the operator must remain inside the elephant enclosure. A specialized mouth opener for elephants is required to provide access to the oral cavity. The endoscope may be guided manually into the trachea or introduced through a rigid plastic tube, which can be advanced relatively easily into either the trachea or the esophagus. Once within the trachea, the bronchial branches can be examined. Abnormalities may be assessed, and biopsy samples collected. Bronchoalveolar lavage samples are obtained by instilling 50–60 ml of 0.09% sterile saline into a bronchus, followed by aspiration of the fluid. For TB diagnosis, this procedure is repeated three times in each lung. Collection of stomach fluid and broncho-alveolar lavage in an adult African elephant by Dr. Imke Lueders ( https://www.geolifes.com/en/services/index.html) References: Engel S.C., Kerr T.J., van der Spuy G.D., Jooste T., Buss P.E., Johns J.L., Miller M.A., Kleynhans L.2025. Optimisation of bronchoalveolar lavage fluid preparation for mononuclear cell isolation and cytologic evaluation in free-ranging African elephants (Loxodonta africana ). Veterinary Immunology and Immunopathology, Volume 286 , August 2025, 110974. https://doi.org/10.1016/j.vetimm.2025.110974 Hermes R et al. 2018. Bronchoalveolar lavage for diagnosis of tuberculosis infection in elephants. Epidemiology and Infection https://doi.org/10.1017/S0950268818000122 To page top

Resting behavior and allonursing in elephants are described in this page. Resting in lateral recumbancy requires a trustful social environment. Comfortable resting is promoted by the provision of sand piles. A case of allonursing (drinking milk from a non-mother) describes this phenomenon in an African elephant that never produced offspring herself. Behavior & Training Resting behavior Behavior & Training Resting behavior Allonursing Case Report: Spontaneous Lactation and Allonursing in a Captive African Elephant (Loxodonta africana ) Date: December 2024 Place: Erfurt Zoo Data provided by: Tina Risch, DVM Introduction Allomothering, the care of an infant by an individual other than the biological mother, is a well-known behavior in social animals, including African elephants (Loxodonta africana). However, allonursing—the act of an allomother providing milk to a non-biological calf—is rare and typically observed in females with previous reproductive experience. This case report describes an unusual instance of allomothering and allonursing by a nulliparous (never pregnant) adult female African elephant in a zoo setting. Case Presentation As a neonate, a male captive African elephant calf (Banjoko) started looking for drinking opportunities from 3 adult females, including its mother. When he was 5 month-old, the 29-year-old female herd member, named Csami, admitted him unrestrictedly (figure 1). Csami, a wild-caught elephant, arrived at the zoo at the age of four and had never been pregnant. The calf's biological mother, Chupa, continued to actively nurse her offspring while at the same time Csami's involvement progressively intensified. Notably, Csami had previously shown nurturing behaviors towards Chupa's older calf, a 4-year-old female. However, Csami's maternal instincts towards the youngest calf manifested to the extent that she began producing a milk-like fluid. Figure 1. The 7-month-old African elephant calf, Banjoko, nursing from Csani, the allomother that never produced a calf herself (Erfurt Zoo, Germany, 2024) Clinical Observations and Milk Analysis A sample of the fluid secreted by Csami was collected and analyzed for fat, protein, lactose, and pH levels. These values were compared to a milk sample obtained from Chupa. The results are summarized in Table 1. The results indicate that Csami's milk-like fluid closely resembled Chupa's milk in composition, suggesting that the fluid could adequately support the calf's nutritional needs with regard to fat, protein and lactose. Table 1. Comparative analysis of milk composition from Chupa (dam) and Csami (allomother). Discussion The phenomenon of allomothering is widely observed in species that rely on cooperative group dynamics, such as lions, seals, and elephants. While allonursing is less frequent, it has been documented in elephants, typically involving females with prior lactation experience. This case represents a rare instance of spontaneous lactation and allonursing by an elephant with no prior reproductive history. The physiological mechanism behind Csami's lactation remains unclear but is must be linked to hormonal or social factors triggered by the presence of the calf. This behavior may enhance calf survival by providing supplemental nutrition and fostering stronger social bonds within the herd. To the best of our knowledge, this case is one of only two recorded instances of allonursing by a nulliparous elephant. The first case was reported from Gangala-na-Bodio Elephant station in Congo, documented by Harald H. Roth in 1961 (figure 2). Figure 2. A 32-month-old African elephant nursing from an allomother that never produced a calf herself (Der Zoologische Garten, 1961) Conclusion This report highlights the complex social structures and nurturing behaviors of African elephants. Csami's spontaneous lactation and allonursing underscore the adaptability and cooperative nature of elephants in captivity. Reference Roth HH. Short communication. Der Zoologischen Garten 26, 1.2, pg 123. 1961. Allonursing

Anchor 1 To necropsy procedure Necropsy reports EEHV-HD Mesenteric hernia Tuberculosis ...............................

This page describes the normal birth process in elephants, including progesterone and ultrasound monitoring, preparation, list of requirements for veterinary assistance, transrectal massage to induce the Ferguson reflex and post-partem care. To reproduction Normal birth process This chapter is based on the EAZA Guidelines for the reproduction-related management of female elephants . Taken care at the birth process means that the pregnancy has been confirmed. More detailed information is provided in the chapter: pregnancy confirmation. After a pregnancy period of 87- 95 weeks (610- 670 days, 20-22 months), parturition is sometimes announced by subtile changes in the behaviour of the elephant. Twentyfour hours observation including the use of a (time-lapse) video recorder starting in week 85 may add to information about relevant events prior to parturition: night pacing, kneeling down, climbing, short periods of separation from the group, beating the vulva with the tail, frequent production of small-sized feces and small quantities of urine, loss of mucous plug, playing with mucous plug, rupture of the allantois sac, labour waves. Preceding any recommendation in this chapter, the following remarks need to be made: It is a myth to think that a multiparous elephant does not need to be monitored and assisted during parturition according to this protocol. Too many calves have been born dead or very weak because of the fact that parturition had started unnoticed and stopped unnoticed. In our view, this protocol should be followed in ALL cases of elephant parturition as much as the elephant management allows. It is a also myth that oxytocin is a harmless drug to be used in elephant parturitions. In at least 3 cases the administration of oxytocin has been associated with the occurrence of an uterus rupture because of insufficient cervix dilatation. It should never be used without ultrasonographic examination of the cervix uteri. The visible presence of the allantois sac as a subcutaneous bulging mass under the tail is not a guarantee for a sufficiently dilated cervix. Many elephants, including very experienced multiparous elephants may just stop the parturition process, often unnoticed. Hypocalcemia is one of the main causes for this phenomenon to happen.This will compromise the health of the calf. Don’t relay only on what you see from the outside! For a proper judgment about the presence of labor activities or the progress of parturition, your professional judgment should be based on the results of progesterone tests and ultrasonographic examinations. If you do not believe in the above mentioned statements, you may find yourself confronted with a dead elephant calf or a dead elephant mother or both. So, discuss this item with your staff and make your decision before you start breeding your elephants. If the management of elephants in your zoo does not allow blood sampling or ultrasonographic examinations, you must be aware of the risks associated with a silently interrupted birth process, no matter the reproductive experience of the animal involved. Safety for the personnel should never be challenged by unacceptable risks. Predicting the time of parturition, measures and observations: Daily blood sampling from week 89: every other a day progesterone assay, until week 91 (637 days). From week 91 (637 days): daily assays and as soon as progesterone starts to decrease: sample twice daily. Daily monitoring of progesterone is only possible if you have a nearby facility that runs these assays on a daily basis. Find out from your nearby hospital in the early stage of pregnancy! Many veterinary labs do not have tests that are sensitive for levels of progesterone (P4) in elephants 1-3 days prior to delivery. Also check the availability during the weekend. NOTE: a decrease of progesterone to baseline level is not always occurring. A 23-yrs-old Asian elephant at the Rotterdam zoo (with a baseline progesterone level < 0.6 nmol/l) delivered a healthy calf while her progesterone remained above 0.65 nmol/l. Progesterone plasma concentration during pregnancy. After a gradual decrease in the last months of gestation, progesterone drops to baseline level a few days before parturition. Note that the absolute height of the progesterone concentration depends on the assay used! Different assays measure different metabolites = different levels! Signs of an approaching parturition may include: ·Loss of mucous plug (not seen in many facilities) ·Pre-and post-parturition ventral edema may be noticed. ·Group members may react differently (vocalizations, restlessness) ·In most cases (75%) rupture of allantois sac and loss of allantois fluid (looks like urine) is seen within 2 hours prior to birth. ·The size of fecal balls may get smaller towards the end of pregnancy. ·Frequency of urination may increase around parturition, resulting in more “watery” consistency of the urine, resembling more like allantois fluid . ·Development of mammary gland and production of milk shortly before birth is often seen, however this may also occur in a much earlier stage of pregnancy . Milk accumulation can be visualized using transcutaneous ultrasonography several hours prior to parturition. ·Softening of the pelvic ligaments (due to estrogen surge) may result in slightly abnormal locomotion of the hind legs. Parturition/Preparations for calving: ·Training and/or desensitizing of the pregnant elephant for veterinary intervention, like blood sampling, injections, IV-infusions, milking and rectal manipulations ·If possible, store some colostrum (freezer) or store plasma obtained from the dam in weeks prior to parturition. ·Have artificial milk available (Salvana GmbH, Germany; hand raising has been done at Emmen Zoo and Berlin Zoo) ·Check restraint chains and fixation points for the legs and one extra fixation point between the hind legs for pulling devices. Soft ropes for pulling the calf away if needed should be available. The use of a calf harness has been described. ·Check the stable and place bars where a calf could possibly escape. Block all possible escaping routes for the calf (not for staff!!). ·Take out all obstacles. ·Be prepared for closing the elephant house for the public (sign post, etc.) ·Make sure there is a good stock of commercial cat litter or saw dust to be used on a concrete floor as soon as the calf is born. This will absorb much of the allantois fluids and prevent the animals from slipping on the wet floor. ·2 or 3 pairs of keeper-gloves (soccer) to get a better grip on the wet, slippery calf when needed ·Plastic hose pipe (with pump, if necessary) for rectal cleaning with lukewarm water ·3 birth-chains with proper handles (2 for the legs, 1 for trunk or tail); find a way to avoid back sliding when manual extraction (vaginal vestibulotomy) is required. ·Drugs to be kept in store: ·Ca-borogluconate for I.V. infusion ·Estradiol gel (EstroGel® 0.06%) ·Oxytocin ·Lidocain ·Xylazine, detomidine or medetomidine ·Butorphanol ·Azaperone ·Atipamezole ·Doxapram ·Oxygen ·(Betadine®-)iodine solution for navel disinfection (umbilical infection is a major cause of perinatal complications) ·Lubricant (many liters). J-lube®, a concentrated lubrication powder, has proven to be very useful. The normal calving process should take place within 2 hours after rupture of membranes (release of fetal fluids). If the plasma progesterone level decreases to below base line concentration, this is a signal that calving should take place within 48 hours. Prolonged intervals have been reported (as long as 14 days) still resulting in the birth of a living calf, but it is very likely that this is due to a disturbance of the normal birth process that should be corrected before the health of the calf is jeopardized. There is one report of a parturition taking place without a complete drop to base line level. The calving process is a natural process. Elephants should give birth in their own social environment, excluding any external disturbing factors (e.g. noisy building in the neighborhood, visits of unknown individuals, etc.). With a well trained animal, blood sampling and ultrasonographic examinations can be done while the animal is temporarily separated from the group. Immediately afterwards, the animal should return to its group. All efforts should be made to make sure that the calf is born in the group while the mother is NOT chained! This will stimulate the acceptance of the calf by the mother and group members and is an investment for future breeding successes for the entire elephant group. To determine the right moment when calving starts, 2 parameters are essential: - The progesterone blood level - The relaxation of the cervix, monitored by ultrasonographic examination. Progesterone: the sensitivity of the equipment and the time needed to run the assay are the bottleneck for using the progesterone concentration as a reliable tool. Today many human hospitals use advanced equipment with a very low detection level that can provide results in less than 2 hours. Make sure that you have made arrangements with a lab long before you expect the parturition. Ultrasonography: to use this technique as a reliable tool, it is indispensable for the veterinarian to gain experience long before the elephant birth is expected. This will enable the veterinarian to distinguish a normal cervix from the relaxed cervix (figure 4a + b) from the normal cervix. Preferably a 3.5 MHz probe should be used transrectally. Longitudinal, transrectal ultrasonographic image of the vagina and the closed cervix of a pregnant e lephant. The same image as with the vagina and cervix indicated with white lines. Transversal, transrectal ultrasonographic vagina and cervix of a pregnant elephant. Allantois sac with cloudy fetal fluid in the (partly) dilated cervix of an Asian elephant 12 hours prior to delivery (transverse section, white arrows: allantois sac, open arrow: pelvic bone) The same image with the vagina and the closed cervix indicated by white lines. Note the folds in the cervix uteri. Allantois sac with cloudy fetal fluid in the (partly) dilated cervix of an Asian elephant 12 hours prior to delivery (longitudinal section, white arrows: allantois sac, open arrow: pelvic bone) During the last 2 weeks of gestation, the mucous that is present in the vagina during gestation will be discharged gradually. This is a clear indication for a pending parturition. Recognizable onset of parturition occurs normally within 24-48 hours after progesterone has dropped to below base-line level. In these guidelines the absence of visible signs of parturition in the same time frame is considered an abnormal condition; this status requires veterinary intervention. At this point 2 situations may occur: the parturition process has started but has been interrupted without or with spontaneous rupturing of the allantois sac. Interpretation of findings and action to be taken 1. No rupture of allantois sac noticed If the calf is not born by natural way 24 hours after blood progesterone has dropped to baseline level, rectal palpation and ultrasonographic examination of the cervix is highly recommended. This will demonstrate the rate of relaxation of the cervix, the presence of the allantois sac or parts of the fetus in the cervix or vagina and should be repeated at least every 8 hours. A blood sample should be taken to measure the calcium level. If below 2.5 Mmol/l, calcium should be administered as an IV-infusion (NB: when given in an ear vein, it should be given strictly IV in order to avoid damage to the vein) or orally (suggestion: calcium syrup concentrate for human use, enveloped in the carton core of toilet paper, covered and sealed with fresh tamarind paste has worked well; most elephants will eat it, including the carton material). The effect of the calcium administration should be confirmed by rectal palpation (increase of contractibility of the uterus) and determination of the blood calcium level. Store an EDTA and heparine sample for herpes virus diagnostic purpose (both cells and plasma in freezer after separation). Transrectal ultrasonographic examination at 48 hours: A. No relaxation of the cervix at 48 hours: search for calf movements and nail position of the fetus (palpation and ultrasound) and blood flow in fetal vessels (ultrasound). Transcutaneous ultrasonographic examination (both flanks have a small ”window” where visualization of fetal movements may be seen) may help to determine the status of the fetus. Apply estrogens rectally. Good results have been obtained by the rectal and transdermal (perineum) application of an estradiol containing estrogen gel (Estrogel 0,06%, total dose 700-800 mg estradiol). The effect on the cervix dilatation should be monitored closely by transrectal ultrasonography! At this time, at least 1 hour after the local application of estradiol, rectal massage should be applied to test and stimulate the contractibility of the uterus. Technique: remove feces from rectum, flush out the rectum, use abundant lubrification, keep both gloved hands (NB: the rectal mucosa is vulnerable due to estrogens) with the fists joined in a firm grip and press with the wrists or the dorsal sides of the hands against the pelvic ring to stimulate the pelvic receptors until strong labor waves appear or at least 10 minutes. When labor waves occur, continue this massage for 3 hours (if needed change operator). Check regularly by means of ultrasound the condition of the cervix. If there is still no cervix relaxation, continue monitoring the viability of the calf. If no fetal parts can be detected, consider the presence of pseudopregnancy (ovarian tumor, dysfunction of the pituitary gland, etc.). The application of estradiol gel (total dose: 400-500 mg 17-β-estradiol) as described above may be repeated 3-4 hours after the first treatment if the cervix dilatation is still incomplete. B. Partial or complete relaxation of the cervix at 48 hours or later as a result of the situation described under 1A: Apply rectal massage to test contractibility of the uterus. If limited or no reaction, the administration of oxytocin is contra-indicated. In this case, the administration of calcium is recommended (even when blood calcium level is within normal ranges). After 2 hours the use of estradiol as described under 1.A is recommended. Only if uterus contraction can be provoked by the rectal massage, the use of oxytocin may be considered using the following dosage: 25-50 IU oxytocin s.c. or i.m. (if needed use a blow dart). Oxytocin should be used with care, as it may dramatically exhaust the contractibility of the uterus muscles as well as the general condition of the female. There might also be the risk of reduced blood circulation in the umbilical chord, due to the spasms in the myometrium. Prostaglandine E (dinoproston) has been used on a few occasions for cervix dilatation (after the administration of estradiol) and to stimulate uterus contractions. As there is still limited knowledge of its efficacy after transrectal administration and the risk of stormy uterus contractions, it should only be used when any obstructions or abnormalities of the calf can be ruled out. Depending on the progress obtained, rectal massage and the administration of oxytocin are the 2 major treatments to follow from this point. In between these treatment events, the animal should be exercised to relieve the pain and stimulate position changes of the calf and preferably it should be kept in the group. Only when the animal cannot be separated whenever required, the cow should be kept separated from the group, but with as much physical contact as possible. Oxytocin should be given in intervals of at least 2 hours for a maximum of 12-24 hours under the guidance of ultrasound to evaluate tAhe progress. Continue this approach of treatment until parts of the calf have entered the pelvic cavity. If the efforts remain unrewarded and no access to fetal parts is possible, not much can be done. Continue monitoring the viability of the calf. If the calf has died, while the membranes are still intact, the risk of intoxication is limited, but immunosuppresion could be a complication for the cow. To date, no proper data are available. The dosage of oxytocin may only be increased to 100 I.U. after parts of the calf have entered the pelvic area and progress is clearly observed. At this time, a bulge containing parts of the body under the tail of the dam should be visible. Progress of parturition must be monitored strictly at this stage. If this increased dose of oxytocin does not result in parturition a vaginal vestibulotomy should be performed soon to get better access to the calf. See next chapter. Expulsion of the calf should follow soon after the bulge appears under the tail of the dam. The allantois sac usually ruptures during the (induced) passage through the pelvic canal. One complication described at this stage, is reduced passage space as a result of edema in the urogenital canal resulting in a “catching effect” of the head and/or shoulder of the calf inside the soft part of the distal (vertical part) genital tract. Suffocation of the calf is a realistic complication. This condition has been observed several times in primiparous elephants of more advanced age. Elephants in this category should be prepared by the local application of J-Lube in the distal part of the vaginal vestibulum and massage of oestrogel/creme in the skin between anus and vulva. If this condition occurs, quick intervention is required by applying firm manual pressure from the outside on the calf in the sliding direction of the calf. Be aware of the risk of kicking by the mother. 2. Ruptured allantois sac A significant event in the parturition process is the rupturing of the allantois sac, which – when intact - acts as a hydraulic dilatator for the cervix, a natural lubrication for the dam and a pressure protection for the calf. NB: The amniotic sac that covers the body directly, usually remains intact during the expulsion of the calf and ruptures during the final passage through the birth canal and is actively removed by the dam. NB: a chained dam, may not be in the position to remove these membranes, possibly resulting in suffocation of the calf. Differentiation between urine and fetal fluids is extremely difficult; smell, creatinin test strips and possibly protein concentration could be helpful. If no progress in parturition is observed, major complications should be considered, like a dead calf, malposition of the calf (which is often dead), oversized calf, malformation and twin pregnancy. Because of the urgency of this situation, the calf should be born within 2 hours after rupture of the allantois sac and loss of allantois fluid. If not so, veterinary intervention has to take place. Two situations may occur: No fetal parts positioned in the pelvic area: treatment should aim on the urgent relaxation of the cervix. Calcium status should be determined and treated accordingly (see above). The further approach is according to 1A, however the situation is more critical for both the dam and the calf. Fetal parts have entered the pelvic area: Calcium status should be determined and treated accordingly (see above). Ultrasound is essential to determine which fetal parts have entered the birth canal, determine the position of the calf (visualization of the nails, posterior or anterior position, number of nails, trunk) and viability. Malposition (e.g. only one leg in birth canal, no head while in anterior position) is an indication for vaginal vestibulotomy or fetotomy. If no abnormalities are found during ultrasound, 50-100 I.U. of oxytocin should be given i.v. or i.m. and rectal massage should be practiced. Birth should be completed within 1 hour. Other drugs used Uterine laxants have been used in elephants on rare occasions. There are some anecdotal reports about the use of denaverinehydrochloride (Sensiblex®, Veyx) at a dose of 0,04 – 0,05 mg/kg BW (i.m.). Isoxsuprinelactate (Duphaspasmin. Fort Dodge Animal Health, 6290AA Vaals, The Netherlands) was used in a fetotomy case at 0,15 mg/kg BM (i.m.). Carbetocine (Depotocin®, Veyx), a long acting oxytocine has been used in 3 occasions dosage (0,09 µg/kg BW) i.m. Presentation of the calf A study in 46 elephants demonstrated that the overall ratio between anterior and posterior presentation was 12:34. In dystochia cases the situation was quite different: 6:3. In normal birth procedures the ratio was 6: 29. Anterior presentation has a higher risk of dystochia than posterior presentation of the calf. (Ilic D. et al. 2021. The incidence of anterior and posterior presentation at birth in Asian (Elephas maximus ) and African elephants (Loxodonta africana ): A Review Study. Indian Journal of Animal Research.DOI: 10.18805/IJAR.B-1319) It has been observed that the calf may rotate during the final phase of the expulsion, similar to what happens in horses and cattle (see video). This may be important in case of a dystocia, if the calf has remained in complete 'horizontal position' and a vaginal vestibulotomy is indicated. Note that the calf has rotated during the final phase of the expulsion. Transrectal massage: Transrectal massage is a very effective method to stimulate uterine contractions if the uterus is prepared for it . Certain conditions (especially hypocalcemia) may impair the contractions. This should be solved first. Stimulation of the pelvic wall by rectal massage is known as the Ferguson reflex . Transrectal massage of the pelvic wall is best performed by firmly pressing the closed fost against the roof and sides of the pelvic cavity and on the dorsal side of the vagina making the movements as shown in this video. Post-partum care Disinfection of the navel with Betadine® iodine is strongly recommended (if the mother allows its application). The afterbirth usually comes off within 12 hours. There are a few reports on retained (parts of) placenta for several weeks, without major complications for the dam. Hygienic measures should be applied to reduce the infectious burden for the calf. Be aware of the fact that a second calf can still be present in the dam. There are reports that second calves were born between several hours up to 3 months (the prevalence of twins in elephants is 1:3000). The calf should drink (colostrum) as soon as possible, at least within 24 hours. If not, or when the calf makes a weak impression, the banked serum (or freshly taken serum) should be given to it orally. Try to find out the reason why the calf is not drinking successfully: e.g. too small, weak, painful mammary glands, malbehaviour of the dam. If for any reason the mother is rejecting the calf, lactating herd member can take care of the calf. There is evidence that the mother takes over from this surrogate mother during the first 72 hours. If no lactating elephant is present in the herd, training for bottle feeding should start after 12 hours and continued for 72 hours. If the mother still rejects her calf, the best option for the calf is to move it to another herd with a lactating elephant. If introduction to this herd fails too, bottle feeding is the last option. To date very few bottle-raised elephants have reached the age of puberty. To page top

This page directs you to the following case reports about botulism, Dieffenbachia and paraquat intoxication in elephants. To non-infectious diseases Intoxication Botulism Dieffenbachia intoxication Paraquat intoxication Kodo millet intoxication Reference values toxicology

This page describes an intoxicationnwith the plant Dieffenbachia, causing obvious pain reactions in the oral cavity of an adult Asian elephant in a zoo. The symptomes disppeared after several hours. Continue To intoxication Case report Dieffenbachia intoxication Place: Date: 2019, July Data provided by: History A 12 years old Asian elephant in a zoo showed sudden symptoms: standing still with its mouth widely open, tongue pressed cranially, frequent urinating small amounts of urine. The other elephants at the zoo remained normal. Differential diagnose: tongue in contact with setae (hairs )of the caterpillar of the oak processionary (Thaumetopoea processionea ); oak leaves had been fed during the preceeding week; insect sting in the oral cavity, eaten from an unknown irritating substance; urethra obstruction by urinary stones. Treatment No treatment was given, as the cause of the intoxication was found soon: one of the ornamental plants outside the enclosure showed clear signs of having been chewed on: Dieffenbachia sp. Treatment results The symptoms disappeared within several hours after onset. Dieffenbachia species To page top

Miscellaneous

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. 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. Symptoms and diagnosis: 10-14 days before the elephant shows external symptoms 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). 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. Elevated levels of these two interleukins are commonly associated with cytokine storms, suggesting that this phenomenon may also occur in EEHV-HD. 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: hemorrhages in most of the organs, joints and muscles, ranging from petechiae to large hematomas. There may also be a hydro-or hemopericardium. Hemorrhages in the heart, intestines, brain and liver of a yound elephant that died of EEHV1a-HD. Photos by Arun Zacharia 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. 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 succombed to EEHV-HD and in blood in 2 survivors. The survivors were treated with dexamethasone, resulting in a decrease of IL6 and IL10 (Hoornweg et al., study submitted for publication). 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 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 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: 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. Howard L.L. & Schaftenaar W. 2017. Elephant Endotheliotropic Herpes Virus. In: Fowler’s Zoo and Wild Animal Medicine Current Therapy, Volume 9. 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. 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 susequently 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

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

A ±4.5-yrs-old male African elephant calf had been rescued from the wild after being injured in a bush fire. While in the rescue facility, it developed episodes of “choke”, caused by impaction of the esophagus with ingested foodstuff. This resulted in regurgitation, and the inability to eat and drink without the food or liquid dribbling out of the animal’s mouth. Multiple treatment interventions under general anesthesia are described. Case report Esophagus impaction in a 4.5-yrs-old African elephant Date: 2019-2021 Place: Botswana Data provided by: Rob Jackson DVM History “Choke” symptoms can be associated with: Congenital abnormalities of the upper digestive system; symptoms usually show up when the animal is weaned and starts eating solid food. Megaesophagus, which can be congenital or acquired; Foreign bodies that get stuck in the upper digestive system; Impaction or blockage of the stomach/duodenum; Abnormal function of the cardiac sphincter which is the valve allowing food to flow into the stomach. Blockage of the upper digestive system can cause damage to the esophagus resulting in strictures and narrowing, which makes the problem worse or even necrosis and rupture of the oesophagus. Regurgitation can result in food and liquid entering the trachea and the lungs. This causes a foreign body pneumonia, which in chronic cases can result in the eventual death of the animal. A ±4.5-yrs-old male African elephant calf had been rescued from the wild after being injured in a bush fire. While in the rescue facility, it developed episodes of “choke”, caused by impaction of the esophagus with ingested foodstuff. This resulted in regurgitation, and the inability to eat and drink without the food or liquid dribbling out of the animal’s mouth. “Choke” symptoms can be associated with: Congenital abnormalities of the upper digestive system; symptoms usually show up when the animal is weaned and starts eating solid food. Megaesophagus, which can be congenital or acquired; Foreign bodies that get stuck in the upper digestive system; Impaction or blockage of the stomach/duodenum; Abnormal function of the cardiac sphincter which is the valve allowing food to flow into the stomach. Blockage of the upper digestive system can cause damage to the oesophagus resulting in strictures and narrowing, which makes the problem worse or even necrosis and rupture of the oesophagus. Regurgitation can result in food and liquid entering the trachea and the lungs. This causes a foreign body pneumonia, which in chronic cases can result in the eventual death of the animal. Treatment At first consultation, the elephant was not eating and was salivating. Under standing sedation, a stomach tube was advanced into the esophagus which immediately created passage. Painkillers, antibiotics, and Buscopan were given The cause of the blockage could not be determined. Ten weeks later, the animal showed similar symptoms, however, they were more severe and they had possibly been going for longer than the previous episode. Awaiting the arrival of the vet, the animal was given Buscopan, antibiotics and anti-inflammatories. As there was no improvement, the elephant was sedated again. This time, 4 sedations during 2 days were required before the blockage of the esophagus could be cleared. High volumes of fluids were given intravenously, tubes of different diameters were introduced (one for flushing with water and one for drainage), and foodstuff was removed mechanically. The impaction could be visualised with a three-meter endoscope as twigs and leaves jammed proximal to the cardiac sphincter. The esophagus appeared enlarged and flaccid. The wall of the stomach looked normal at endoscopic inspection. The animal was treated with a long course of antibiotics, liquid food slowly changing to solids over two months and he recovered well. Four months later the animal once again showed signs of discomfort, inappetence, regurgitation and salivation. Finally he vomited chewed bark and milk. He did not respond to the treatment with antibiotics, NSAIDs and Buscopan. He was sedated again for three hours, initially standing and then recumbent. The esophagus was blocked and passage of a tube failed. However, large volumes of chewed bark could be removed manually from the oro- and nasopharynx. The pharynx and esophagus were completely blocked with chewed bark. A large-bore tube was introduced into the proximal esephagus and a small-bore tube within it attached to a hose pipe was used to flush the esophagus and pharynx. At the same time high volumes of intravenous fluids and rectal fluids were administered. After this procedure, antibiotics and NSAIDs, steroids were given for several days. Sildanefil rectally was used to try and relax the cardiac sphincter. The following day the elephant was anesthetized and went into lateral recumbency. Medetomidine/butorphanol was used for induction of anaesthesia, which was maintained with intravenous ketamine. A cuffed endotracheal tube was inserted into the trachea. The two tubes as described above were introduced into the esophagus. Large volumes of finely chewed bark were flushed from the esephagus, through the mouth and trunk. A handful of 12 mm gravel was also recovered. Eventually the esophagus and the stomach were cleared from these materials. No abnormalities gross lesions were seen with the endoscope. The esophagus was suspected to be flaccid and dilated, with possible damage at the level of the cardiac sphincter, possibly caused by impaction with gravel. During anaesthesia high volumes of intravenous and rectal fluids were given. Grey, hard stools were being passed irregularly. A secondary impaction as a result of pain and dehydration was suspected. No discomfort was observed. Fluid, intravenous and rectal continued during several days after anaesthesia. Finadyne was given at lower dose to treat the impaction. Oral fluids were being swallowed and volumes were slowly increased. The administration of antibiotics was continued as complications in the form of a regurgitation pneumonia were anticipated. The prognosis for full recovery was guarded as recurrence was anticipated. In the following 2 months, the elephant went through several similar episodes, which luckily resolved on their own. Repeated bouts of pneumonia were expected, which need to be treated aggressively each time they occur. This follows a classic congenital abnormality/megaesephagus pattern but in this case the damage resulting in the impaction may be the result of injuries from the original fire, possibly by inhalation. However, it cannot be ruled out that this animal is just a naughty, hand-reared baby elephant eating strange objects. Treatment results Two months after the last treatment the elephant calf is recovering well, tired but improving. Showing some discomfort in one leg. Suspect an infection or damaged areas of skin with secondary infection. He showed ventral oedema which improved with a course of antibiotics. It appears that areas of skin are sloughing off. Antibiotic treatment has been instituted. The skin problems are suspected to be part of a systemic infection originating from a regurgitation pneumonia. Another theory to explain the skin necrosis is the involvement of an autoimmune circulatory component as there had been peripheral lesions on the ears at the start of treatment, which later also showed oedema. To page top

Edema in elephants is not uncommon. The 2 most frequently seen forms are edema in the neck, head and upper parts of the front legs (EEHV-HD) and ventral edema (general edema). Figure 1. (a) A focal moderate ventral edema. Note the smooth skin structure with reduced wrinkles in the edematous region. (0.1 African elephant, 33yrs.) (b) Focal moderate ventral edema in lateral view. (0.1 African elephant, 22yrs., 2.5 months before giving birth) (c) A moderate ventral edema extending to the external genital region. (0.1 African elephant, 46yrs., advanced pregnancy >18 months). Figure 2. Ventral edema in a 7 yr-old Asian elephant bull suffering of Salmonellosis (Photo: Willem Schaftenaar). Click here to read this case report. Figure 3. A 45 yr-old female African elephant with ventral edema showing signs of irritation (left) and sloughing of skin (right, arrow). Differential diagnosis of ventral edema In the young elephant a swelling around the umbilicus can be an indication of an umbilical hernia , sometimes accompanied by local edema. A blunt trauma of the abdominal wall can result in an abdominal hernia. Intestines can be visualized using ultrasound examination. Figure 4. Asian elephant (>35yrs) with traumatic ventral hernia. Movement of the intestines and fecal balls in the subcutaneous space could be visualized during transcutaneous ultrasound examination. Photo: Willem Schaftenaar Pathogenesis In general The body always tries to maintain the balance between intravascular and interstitial fluid, driven by four different pressures acting in the capillary bed (Fig. 5). In addition, the capacity of the lymphatic system is critical for the physiologic reabsorption of interstitial fluid and its return transport into the blood circulation (Fig. 5). Beside an increased permeability of the capillary wall, any alteration in each of these five factors can cause edema. In particular an increase in the capillary hydrostatic pressure and a decrease in the plasma oncotic pressure (= osmotic pressure induced by the plasma proteins) lead to an increased shift of fluid towards the interstitial space. If this fluid load exceeds the lymphatic capacity, fluid will accumulate and edema will develop. The aforementioned parameters do vary across different body regions, leading to a locally varying susceptibility to edema development. Therefore, edema can occur both multifocal (e.g. EEHV-HD) or focal (e.g. ventral edema) with respect to the predisposition of certain body regions and the underlying cause. The latter can be systemic or focal. The localization of edema is also determined by gravity forces and species-specific anatomical characteristics. Extracellular fluid will have the tendency to migrate downwards due to gravity. Extracellular spaces that are surrounded by tightly fitting, non-elastic tissue, are not prone to show edema, even if they are at the lowest point of the body: in humans edema can easily develop in the feet, while in elephants edema has never been reported in the distal parts of the limbs. Figure 5. Four critical parameters are determining fluid shift in the capillary bed through the semipermeable capillary wall. An increase in capillary hydrostatic pressure and interstitial oncotic pressure leads to an increased fluid shift towards the interstitial space, as well as a decrease in plasma oncotic pressure and interstitial hydrostatic pressure. The lymphatic vessels are running in parallel to the blood vessels and are collecting the interstitial fluid according to their transport capacity. In elephants According to Mikota (2006), no single underlying etiology for ventral edema in elephants has been identified so far. More likely, it presents a non-specific response to a variety of physiological stressors (Mikota 2006). In our opinion these stressors or pathological alterations can be categorized based on the general pathogenesis of an edema (Fig. 5). With this approach, each condition reported to be associated with edema in elephants so far, can be ascertained to one of the four defined etiologic categories (Fig. 6). Fowler & Mikota (2006) consider the ventral distribution of an edema in elephants caused by the gravitation of fluids into this area. But if gravitation alone would present the critical parameter for the characteristic ventral occurrence of an edema in the elephant, one would expect the swelling to occur primarily in the distal limb regions. The very thigh skin surrounding the legs with minimal elasticity may prevent this pattern. Apart from this, we assume the anatomy and physiology of the lymphatic system to explain the specific distribution pattern of ventral edema in elephants (Fig. 7). Unfortunately, anatomical knowledge on the lymphatic system in elephants is limited to one incomplete description in a fetal Asian elephant (Mariappa 1986). In this individual, a peculiarity was reported with the Cisterna chyli located in the thoracic cavity (Mariappa 1986). In humans, the horse, dogs & cats the Cisterna chyli is located in the abdominal cavity (Berens von Rautenfeld 2000, Herpertz 2013, Salomon et al. 2008). We do rather question the validity of the report for the fetal Asian elephant, than expect a significant peculiarity in the anatomy of the lymphatic system in the elephant. Figure 6. Four defined etiologic categories for edema in elephants, each with examples reported in the existing literature. Note that underlying alterations may vary extremely but result in the same clinical sign of accumulated interstitial fluid. Therefore, due to the lack of solid evidence, our line of arguments is largely based on the anatomy of the lymphatic system in horses and extrapolated to the elephant (Berens von Rautenfeld 2000, Salomon et al. 2008; Fig. 7). Assuming that the lymphatic watersheds in the elephant are running similar to the situation in the horse, it becomes obvious that the characteristic location of a ventral edema presents the region between the major transversal and horizontal watershed (Fig. 7). In this proximal part of the lymphatic territory VII, the lymphatic vessels drain towards the deep abdominal lymphatic centers and have no connection to a relevant superficial lymphocentrum. Therefore, it seems reasonable that increased abdominal pressure (e.g. during late pregnancy) may reduce the drainage of this territory. At the same time, interstitial hydrostatic pressure in the subcutaneous tissue of this body region may be low compared to the limb or the thoracic wall where bony and muscular structures are supporting the lymphatic capacity. These factors together with gravitation can serve as an explanation for the specific distribution of ventral edema in elephants. In contrast, the limbs may rarely be affected by edema, because the relatively rigid skin in combination with the underlying musculoskeletal apparatus will result in kind of a physiologic compression bandage as reported for the horse (Aurenz 2020). Figure 7. Hypothesized lymphatic territories in the elephant. The seven distinct lymphatic territories with their specific drainage areas were extrapolated from the situation in the horse (Berens von Rautenfeld et al. 2000) and numbered accordingly. The blue lines indicate the lymphatic watersheds. Note the proximal part of area VII is lacking a connection to a relevant superficial lymphocentrum. Treatment of ventral edema Given the wide diversity of underlying causes (Fig. 6) no general treatment protocol can be defined. In the literature, hot and cold pressure bandages (du Toit 2001) and increasing protein in the diet (Fowler & Mikota 2006) have been recommended. The administration of Furosemide (1mg/kg i.m.) has been unsuccessful (Martelli 2006). Considering the different etiological pathways leading to an edema, we strongly encourage the treatment of the underlying cause. To do so, an underlying cause needs to be determined or at least a classification according to Figure 6 should be strived for. The latter seems realistic by a thorough anamnesis and clinical examination. For example in cases of heart failure, positive inotropic agents may reduce the capillary hydrostatic pressure and simultaneously support the lymphatic capacity, as shown in humans (Scallan et al. 2016). In less severe cases of assumed cardiorespiratory insufficiency, which has been observed to repeatedly cause ventral edema in geriatric Asian females during hot summer days, herbal medicine can present a helpful approach (Crataegus Dilution vet.®, DHU-Arzneimittel GmbH & Co. KG, Karlsruhe, Germany; three times a day, 6.0-8.0ml orally) (personal observation in four cases). In addition to the treatment of the underlying cause, or in cases where only a symptomatic treatment is realizable, the following methods may facilitate the reabsorption of an edema. Moderate walking will centrally activate the lymphatic flow and subsequently increase the lymphatic capacity. Hence locomotion is considered a critical part of edema therapy in horses (Aurenz 2020). A sufficient amount of satisfying recumbent rest will also support the reabsorption of interstitial fluid by reducing the negative impact of gravitation. Moderate pressure washing may have a positive effect similar to manual lymph drainage in horses (Aurenz 2020). Under the assumption of a similar anatomy of the lymphatic system, adhering to the protocols established in equine lymph drainage seems a reasonable approach (Berens von Rautenfeld 2000). Given that the selectively applied pressure for manual lymph drainage could be applied by a water jet, even treating from a safe distance might become an option. Further research is needed to base such an approach on scientific findings and formulate a detailed practical guidance. Additional note With respect to our very limited knowledge on the anatomy of the lymphatic system in elephants and the corresponding physiological pathways, a major part of this compilation is very hypothetical. Although we based these hypotheses on evidence from other mammalian species, they remain to a certain amount speculative and should be interpreted with caution. References Aurenz S (2020). Manuelle Lymphdrainage beim Pferd. Hands on 2:25-31. Berens von Rautenfeld D, Rötting A, Rothe K, Lüdemann W, Boos A, Schubert T, Hertsch B (2000). Manuelle Lymphdrainage beim Pferd zur Behandlung der Beckengliedmaße - Teil 1: Anatomische Grundlagen und Behandlungsstrategien. Pferdeheilkunde 16:30-36. Caple IW, Jainudeen MR, Buick TD, Song CY (1978). Someclinico-pathologicfindings in elephants (Elephas maximus) infectedwithFasciolajacksoni. Journal of Wildlife Diseases 14:110-115. Chandrasekharan K (2002). Specific diseases of Asian elephants. J Indian Vet Assoc Kerala 7:31-34. du Toit J (2001) Veterinary care of African elephants. South Africa, South African Veterinary Foundation and Novartis. Emanuelson K, Agnew DW (2002). Wasting syndrome in a bull African elephant (Loxodonta africana). IAAAM Joint Conf, New Orleans, Louisiana. Emanuelson K, Kinzley C (2000). Salmonellosis and subsequent abortion in two African elephants. IAAAM Joint Conference New Orleans, Louisiana. Fowler ME, Mikota SK (2006). Biology, Medicine, and Surgery of Elephants. Iowa, USA, Blackwell Publishing. Fuery A, Pursell T, Tan J, Peng R, Burbelo PD, Hayward GS, Ling PD (2020). Lethal hemorrhagic disease and clinical illness associated with the elephant EEHV1 virus are caused by primary infection: Implications for the detection of diagnostic proteins. Journal of Virology 94:1-14. Heard DJ, Kollias GV, Merritt AM, Jacobson ER (1988). Idiopathic chronic diarrhea and malabsorption in a juvenile African elephant (Loxodonta africana). The Journal of Zoo Animal Medicine 19:132-136. Herpertz U (2013). Ödeme und Lymphdrainage. Stuttgart, Schattauer Verlag. Howard L, Schaftenaar W (2019). Elephant endotheliotropic herpesvirus. Fowler´s zoo and wild animal medicine: current therapy. E. Miller, N. Lamberski and P. Calle. St. Louis, Elsevier:672-679. Jensen J (1986). Paralumbar kidney biopsy in a juvenile African elephant. Proc Amer Assoc Zoo Vet, Chicago, Illinois. Lueders I, Young D, Maree L, van der Horst G, Luther I, Botha S, Tindall B, Fosgate G, Ganswindt A, Bertschinger H (2017). Effects of GnRH vaccination in wild and captive African elephant bulls (Loxodonta africana) on reproductive organs and semen quality. PLoS ONE 12:e0178270. Mariappa D (1986). Anatomy and histology of the Indian elephant. Michigan, USA, Indira Publishing House, Michigan, USA. Martelli P (2006). Veterinary problems of geographical concern - Section III Indochina and Bangladesh. Biology, Medicine, and Surgery of Elephants. M. E. Fowler and S. K. Mikota. Ames, Iowa 50014, USA, Blackwell Publishing: p. 452. Mikota SK (2006). Chapter 18 - Integument System. Biology, Medicine, and Surgery of Elephants. M. E. Fowler and S. K. Mikota. Ames, Iowa 50014, USA, Blackwell Publishing: pp. 253-261. Morris P, Held J, Jensen J (1987). Clinical pathologic features of chronic renal failure in an African elephant (Loxodonta africana). 1st Intl Conf Zool Avian Med, Turtle Bay, Hawaii. Murray S, Bush M, Tell L (1996). Medical management of postpartum problems in an Asian elephant (Elephas maximus) cow and calf. J Zoo Wildl Med 27:255-258. 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 11(1):14173 Pinto M, Jainudeen MR, Panabokke R (1973). Tuberculosis in a domesticated Asiatic elephant (Elephas maximus). VetRec 93:662-664. Salomon F-V, Geyer H, Gille U (2008). Anatomie für die Tiermedizin. Stuttgart, Enke Verlag. Scallan J, Zawieja S, Castorena-Gonzalez J, Davis M (2016). Lymphaticpumping: mechanics, mechanisms and malfunction. J Physiol 594.20:5749-5768. Seneviratna P, Wettimuny S, Seneviratna D (1966). Fatal tuberculosis pneumonia in an elephant. Vet Med Small Anim Clin 60:129-132. Windsor RS, Scott WA (1976). Fascioliasis and salmonellosis in African elephants in captivity. British Veterinary Journal 132:313-317. Edema by Christian & Linda Schiffmann Definition A local or general swelling due to excessive accumulation of fluid in the interstitial space of tissues. This condition can be caused by various underlying alterations. Depending on the composition of the fluid (in particular the protein content), an edema can be further categorized. Relevance of edema in elephants In elephants the occurrence of the so-called ventral edema is a well-known and quite common clinical symptom (Mikota 1994) (Fig. 1 and 2). Ventral edema is defined as edematous swelling in the ventral abdominal wall and tissues surrounding the external genitalia (Mikota 2006). Although the clinical impact of ventral edema is often not visible, the underlying mechanism indicates a disturbance of the internal fluid balance. In addition, edema in the submandibular region and multifocal has been described in cases of hemorrhagic disease due to herpes virus infection (EEHV-HD) (Fuery et al. 2020, Howard & Schaftenaar 2019). Clinical signs The characteristic swelling in edema may develop immediately or over the course of several days, depending on the underlying cause. Edemas caused by a local inflammatory response may be warm and painful upon palpation. The swelling in case of ventral edema without any underlying inflammatory process may feel slightly cooler compared to other body regions. Palpation is not painful and moderate pressure with the thumb may result in a dent. Such dent may also be produced if the edema is the result of an inflammatory process, in which case the pressure will provoke a pain reaction. Compared to non-edematous areas, the skin will look smoother with reduced wrinkles (Fig. 1a). If ventral edema extends from the umbilical to the genital area (Fig. 1c), the skin may become irritated through the repeated contact with the medial hind legs while walking. In severe cases, this irritation may lead to pressure necrosis and sloughing (Mikota 2006). In cases without such complications, edema may resolve without treatment within months (Mikota 1994), although this will heavily depend on the underlying cause, which should be treated accordingly. Prevention Depending on the underlying cause, the occurrence of ventral edema in elephants can be prevented. A continuous health monitoring program with focus on individuals at peculiar risk such as geriatric elephants, pregnant females or individuals suffering from cardio-respiratory or renal insufficiency will enable early supportive and/or curative treatment. Is ventral edema bad? Although ventral edema as such may not necessarily present a serious condition in an elephant, it is often associated with serious health issues and bears the risk for complications. Therefore this symptom should be investigated thoroughly and its development monitored closely.