Traumatic reticuloperitonitis combined with embolic pneumonia and hepatitis as unusual symptoms of foreign body syndrome in a Holstein bull

Abstract Traumatic reticuloperitonitis combined with embolic pneumonia and hepatitis is unusual signs of foreign body syndrome in cattle. A 4‐year‐old Holstein bull presented decreased appetite, dry cough, progressive weight loss, sternal recumbence and reluctance to stand and move. Laboratory tests revealed leucocytosis (18.4 × 103/μl) accompanied by neutrophilia (10.48 × 103/μl), and monocytosis (1.28 × 103/μl), hyperglobulinaemia (6.3 g/dl), hypoalbuminaemia (1.5 g/dl), hyperfibrinogenaemia (10 g/L) and severe increase in gamma‐glutamyl transferase activity (1,216 U/L). Reticular ultrasonographical examination showed a large amount of hyperechoic and hypoechoic content between the reticular serosa and the hepatic visceral surface. The main gross findings included fibrin deposition and adhesions between the reticulum, liver and diaphragm surfaces; a 4.0 mm in diameter transmural reticular perforation; a 12.0‐cm diameter and scarce small randomly abscesses in the liver's parenchyma. The lungs presented multifocal areas of suppurative embolic foci (pulmonary abscesses), interstitial emphysema and multifocal fibrin deposition on the pleural surface. Ancillary diagnostic tests, such as ultrasonography and laboratory test, associated with clinical evaluation, may increase the accuracy of the correct diagnosis and avoid wasting time and money on untreatable cases.


| C A S E HIS TORY
A 4-year-old Holstein bull was referred for veterinary evaluation at the Large Animal Veterinary Teaching Hospital, University of Brasília, Distrito Federal, Midwestern Brazil. The owner reported that the bull had decreased appetite, dry cough and progressive weight loss for one week. Three days before it was presented at the clinic, the bull had been founded grunting in sternal recumbence with reluctance to stand and move. The bull did not receive any medications on the farm.
Clinical examination was performed (Dirksen, Gründer, & Stöber, 1993), and revealed apathy, a moderate body condition score (graded as 3/5), dehydration with enophthalmos, normal heart rate (72 beats/min), tachypnea (64 breaths/min) with mixed dyspnoea and crackles, sporadic dry cough, elbow abduction and ruminal and intestinal hypomotility. Rectal body temperature was 38°C. Reticular foreign bodies' clinical tests were conducted, such as pinching of the withers, upward pressure on the xiphoid area and reticular percussion. The bull elicited a positive response only in the withers pinch test. Ororuminal probe passing was unremarkable. The ruminal fluid analysis revealed increased pH (8.0), and rumen fluid was considered inactive (>6 min) based on the results of the methylene blue reduction test (Braun et al., 2018;Dirksen et al., 1993).
Ultrasonographical examination was performed on the reticulum and surrounding areas using a 3.5-MHz convex transducer from the 6th to 8th intercostal spaces. On the paramedian region to the left of the xiphoid process, the caudoventral reticular wall was found to has slightly irregular serosa and attachment of echogenic deposits.
Additionally, there was a moderate amount of free anechoic fluid in the abdominal cavity with a large amount of hypoechoic filaments adhering to the surfaces of adjacent organs (Figure 1a, white arrow). During biphasic contractions, the reticulum contracts by only 1-3 cm, suggesting adhesions (Braun, 2003). On the right paramedian region, hyperechoic and hypoechoic content between the reticular serosa and the hepatic visceral surface was noted, suggesting fibrinous adhesions between these organs (Figure 1b, black arrows).
Thoracic and reticular radiographs were taken, but the low potency of our equipment precluded useful radiographs imaging.
Although radiography is considered to be an efficient technique for identifying the location and position of metal foreign bodies in cattle or buffaloes (Abu-Seida & Al-Abbadi, 2016;Khalphallah et al., 2017), ultrasonography is considered to be the method of choice for detecting fibrinous deposits and abscesses that usually are not detected by radiographical examination (Abdelaal et al., 2009;Braun, 2003). In this report, ultrasonographical examination showed shortened biphasic reticular contractions and inflammatory material deposits between the reticular, ruminal and hepatic visceral surface. Herein, we are additionally reporting the relevance of ultrasonographic evaluation on reticulohepatitis sequelae, such as abdominal effusion and adhesions between the reticulum and liver. Alternatively, an ultrasonographical examination can provide information about the extent of the lesions and select the best suitable site for abdominocentesis (Abu-Seida & Al-Abbadi, 2016;Braun, 2003;Ellah, El-Hawari, Misk, Youssef, & Semieka, 2018;Khalphallah et al., 2017). Although thoracic ultrasonography has not been performed, it would add essential data reiterating the bull's euthanasia choice. Pulmonary abscesses are usually imaged at 3rd and 4th intercostal spaces as circumscribed masses with echogenic capsule and hypoechoic contents, but only pulmonary abscesses near the pleura can be imaged by ultrasound (Abu-Seida & Al-Abbadi, 2016).
Severe neutrophilic leucocytosis, hyperfibrinogenaemia and hyperglobulinaemia are consistent with bacterial infection. No immature leucocyte was found in smears, thus increased neutrophils counts might be attributed to movement of these cells from marginal pool to the circulating pool (Wood & Quiroz-Rocha, 2010). Hypoalbuminaemia occurred because albumin is a negative acute-phase protein, and it might be worsened by malnutrition and improper digestion due to pain and adhesions (Braun et al., 2018;Ellah et al., 2018). The highly elevated GGT activity (1,216 U/L) in this case was a remarkable biochemical finding; previously reported values vary from 16-256 U/L (Doré et al., 2007) and 7-73 U/L (Braun et al., 2007) to ≤154 UI/L (Braun et al., 2018) in cattle affected by liver abscesses, traumatic reticuloperitonitis or pericarditis, respectively. Serum GGT activity is a specific indicator of liver disorders because this enzyme is released by biliary ducts cells and, in lesser amounts, by hepatocytes (Kaneko et al., 2008); however, increases in GGT activity in cases of traumatic reticuloperitonitis (Braun et al., 2018) and pericarditis in cattle (Braun et al., 2007) or buffaloes (Ellah et al., 2018) are associated with liver congestion and not primary liver disease (Braun et al., 2007). In our case, multiple liver abscessation may had compressed, and partially obstructed adjacent bile ducts and canaliculi, resulting in markedly increased GGT activities.
Liver abscess in extension with the traumatic reticuloperitonitis observed in the Holstein bull, possibly led to bacterial spread and embolic septic dissemination to the liver and lungs. Traumatic reticuloperitonitis with abscessation of the reticulum wall are associated with bacteraemia and infection dissemination to the liver, lungs and other organs (Watts & Tulley, 2013) as a result of embolus formation into hepatic veins, leading to an acute fatal outcome (Cullen & Stalker, 2016). Despite we did not find a metallic body embedded in the liver or in the perforation, nails, screws and wires were detected in the reticular lumen. Possibly, reticular contractions pushed the metallic foreign bodies through the mucosa reaching the liver, allowing abscessation, adhesions and fibrosis. Reticular foreign bodies trapped in the reticular mucosa could also penetrate a mucosal fold or pierce the reticular wall (Dirksen, 2005;Farrow, 1999).
Random abscesses in the liver and pulmonary parenchyma supports the hypothesis of bacterial spreading from the primary septic focus. Direct or embolic infection dissemination is a common sequel in cattle with traumatic reticuloperitonitis (Cullen & Stalker, 2016;Roth & King, 1991) and may lead to other complications such as fibrinous inflammation and fibrous adhesions to adjacent viscera (Roth & King, 1991), septic arthritis and endocarditis (Watts & Tulley, 2013). In our case, septic emboli from the liver abscesses reached the lungs, resulting in multifocal embolic pneumonia and pleuritis (Braun, 2008;Gerspach et al., 2011).
Definitive diagnosis of traumatic reticulohepatitis and parareticular abscessation causing embolic pneumonia and pleuritis was established on the basis of clinical, laboratory, ultrasonographical and pathological findings. Foreign body syndrome may cause a wide variety of clinical signs and represents a challenge for practitioners, especially when multiple organs are involved, increasing the difficulty in early prediction of potential sequel, based only on clinical presentation. Ancillary diagnostic tests, such as ultrasonography and laboratory test, associated with clinical evaluation may increase the accuracy for correct diagnosis, and avoid wasting time and money on untreatable cases.