526
Case Report
Bacterial pneumonia and pleuropneumonia in sport horses:
17 cases (2001–2003)
F. FERRUCCI*, E. ZUCCA, C. CROCI, V. DI FABIO, P. A. MARTINO†
Department of Veterinary Clinical Sciences, Unit of Equine Internal Medicine; and †Department of Veterinary
Pathology, Hygiene and Public Health, Unit of Microbiology, University of Milan, Italy.
Keywords: horse; pneumonia; pleuropneumonia; aerobic bacteria; rate of recovery
Summary
Seventeen racehorses were referred with a history of
poor performance, recurrent fever, coughing and/or
nasal discharge. All patients underwent a thorough
diagnostic procedure, including physical examination,
complete blood count, plasma fibrinogen estimation,
arterial blood gas analysis, thoracic radiology and
ultrasonography, endoscopy, tracheal aspiration with
cytological and cultural evaluation, including sensitivity
test. According to these procedures, bacterial
pneumonia was diagnosed in 14 horses and bacterial
pleuropneumonia in 3 horses. Streptococcus spp. were
isolated in 11 cases (61.2%), Rhodococcus equi in 3 cases
(16.6%), Klebsiella pneumoniae in 3 cases (16.6%) and
Pseudomonas aeruginosa in one case (5.6%).
Introduction
High performance horses are particularly predisposed to
develop bacterial infections of the lower airways. Risk factors
implicated in the pathogenesis of pneumonia and
pleuropneumonia include: strenuous exercise, which impairs
alveolar macrophage and peripheral lymphocyte function and
promotes deep inhalation of microscopic particles, such as
dust, pollen, bacteria, fungal spores etc. (Moore 1996; Raidal
et al. 1997); transport over long distances, which prevents
frequent lowering of the horses’ head and drainage of
respiratory secretions, facilitating colonisation of the
respiratory tree by oropharyngeal microbial flora (Austin et al.
1995; Racklyeft et al. 2000); and frequent contacts between
animals of different origins, as occurs in training centres or
during the competitions, promote exposure to several
respiratory viruses (influenza, herpesvirus, adenovirus etc.)
which damage the mechanism of mucociliary clearance,
*Author to whom correspondence should be addressed. Present
address: Università degli Studi di Milano, Ospedale Veterinario per
Grandi Animali, via dell’Università, 6 26900 Lodi, Italy.
EQUINE VETERINARY EDUCATION / AE / october 2008
AND E. FERRO
bronchial submucosal lymphoid tissue and alveolar
macrophage function (Anderson et al. 1985; Chaffin and
Carter 1993), promoting secondary bacterial colonisation of
the lower airways. Additionally, the presence of blood in the
airways, due to previous episodes of pulmonary haemorrhage
(EIPH), which occur frequently in racehorses, promotes the
onset of airway inflammation (MacKane and Slocombe 1999)
and represents an ideal pabulum for bacterial growth. Several
aerobic bacterial species responsible for respiratory infection
were identified in horses: among these, β-haemolytic
Streptococci, Pasteurellaceae, Klebsiella pneumoniae,
Rhodococcus equi and Enterobacteriaceae should be
mentioned (Sweeney et al. 1991; Chaffin and Carter 1993;
Lakritz et al. 1993; Lavoie et al. 1994; Raidal 1995; Raclyeft
and Love 2000; Vengust et al. 2002; Waldridge et al. 2008).
Early identification of a pneumonic process and of the
causative agent, and prompt institution of a specific
antimicrobial therapy, are fundamental for the prognosis. In
fact, secondary invasion of the lung tissue by anaerobic
bacteria (Bacteroides spp., Clostridium spp.) and/or extension
of the pneumonic process to the visceral pleura and pleural
space, may notably worsen the clinical conditions of the
patient and surgical drainage and/or resection of necrotic
tissue may be necessary, reducing the chances for an adequate
functional recovery (Mair 1991; Sweeney et al. 1991; Chaffin
et al. 1994a; Raidal 1995; Sprayberry and Byars 1999). In
uncomplicated pneumonia cases, the prognosis for a return to
racing appears more favourable (Seltzer and Byars 1996).
The present paper reports 17 cases of pneumonia and
pleuropneumonia in racing horses, 11 of which, after prolonged
antimicrobial therapy, returned to racing satisfactorily.
Materials and methods
Horses
The patients were 7 mares, 2 geldings and 8 stallions, age
2–7 years (mean 3.5 ± 1.4 years), 2 Thoroughbred and
15 Standardbred racehorses. All animals were referred with a
EQUINE VETERINARY EDUCATION / AE / october 2008
history of poor performance, recurrent fever, coughing and/or
nasal discharge. For each patient the investigations listed
below were performed.
Physical examination
After taking the history, a thorough physical examination of
respiratory and cardiovascular systems was performed.
Laboratory evaluation
A venous blood sample was collected from the left jugular
vein into vials containing sodium citrate for plasma fibrinogen
concentration and EDTA for complete blood count. Plasma
fibrinogen concentration was determined with an Iris
photometer1. Complete blood count was performed with an
automated Technicon H12. For blood gas analysis 1.5 ml of
arterial blood were anaerobically collected from the right
carotid artery with a heparinised syringe and immediately
processed with an IL 1630 analyser3. For each sampling, the
rectal temperature of the patient was determined to
automatically adjust blood gas parameters. Arterial blood
oxygen and carbon dioxide partial pressures (pO2 and pCO2)
were determined. In a few horses (Cases 1, 2 and 8 in which
R. equi was cultured) serology for equine viral arteritis (EVA)
and equine herpesvirus-1 (EHV-1) as well as serum protein
electrophoresis were performed.
Thoracic ultrasonography and radiography
To visualise the pleural and pulmonary surfaces, all intercostal
spaces (from 4th to 17th) of both sides were scanned in a
dorsoventral direction with a 5.0 MHz sector transducer
(Technos MPX)4. In 14 horses, radiographs of the ventrocaudal
and dorsocaudal lung fields were obtained.
Endoscopy and tracheal aspirate
Endoscopy of upper and lower airways was performed with a
fibreoptic endoscope (Olympus CF30L)5, previously cleaned
and disinfected with a glutaraldehyde solution (Olympus ETD3,
automatic washer)5. The nasal cavities, pharynx, guttural
pouches, larynx, trachea, carena and main bronchi were
sequentially visualised and scored. Particularly, pharyngeal
lymphoid hyperplasia was graded 0 to IV according to Baker
(1987), tracheal mucopus was graded 0 to V according to
Gerber et al. (2004) and the lower airways were subjectively
scored 0 to IV by the authors (0: normally sharp carena; I: little
mucosal swelling of the carena and main bronchi; II: moderate
mucosal swelling; III: marked mucosal swelling; IV: severe
mucosal swelling). Tracheal aspirate was performed during
endoscopic examination, by flushing into the intrathoracic
portion of the tracheal lumen 60 ml of sterile saline at 37°C,
through a sterile indwelling catheter previously introduced into
the biopsy channel of the endoscope. Tracheal wash fluid (TW)
was aspirated with a sterile 60 ml syringe and transferred into
sterile tubes for submission to the laboratory. To perform
527
cytological evaluation, a few drops of TW were centrifuged at
22.68 g for 5 min (Rotofix 32)6. The slides were air-dried,
stained with May Gruenwald-Giemsa and with Gram stain and
observed at 400x and 1000x for differential count. In Cases 2
and 14, the presence of a large amount of pleural fluid
necessitated the daily aspiration of fluid, by means of a human
thorachocentesis device with atraumatic trochar7. For each
sample of TW, and pleural fluid obtained by ultrasound guided
thoracocentesis in Cases 2, 12 and 14, 100 µl were inoculated
onto blood agar plates (with 5% sheep blood)8 under
microaerophilic atmosphere and 100 µl under an anaerobic
atmosphere (GasPak Plus)9, both for 48 h at 37°C. After the
incubation time, the colonies were identified using
macroscopic and microscopic characteristics: haemolysis, size,
pigmentation, positivity or negativity to the Gram stain, and
CFU count. For the identification, selective media (MacConkey
agar, mannitol salt agar, cetrimide agar) and miniaturised
biochemical system (API System)10 were also used.
Antimicrobial susceptibility tests were performed according to
the standardised agar diffusion tests (Kirby-Bauer test) (Poli
et al. 2005) with antimicrobials used in equine medicine.
Results
At the time of referral, rectal temperature ranged from
37.5–40.3°C (mean: 38.3 ± 0.8°C), heart rate from
32–48 beats/min (mean: 38 ± 5.4 beats/min) and respiratory
rate from 12–24 breaths/min (mean: 18.8 ± 5.6 breaths/min).
Coughing was present in 16 horses (94.1%) and a bilateral
mucopurulent nasal discharge was observed in 12 horses
(70.5%). Eleven horses (64.7%) had enlarged intermandibular
lymph nodes. Red blood cell counts ranged from 5.91–
11.01 x 1012/l (mean: 7.64 ± 1.20 x 1012/l); 11 horses (64.7%)
had leucocytosis, ranging from 11.37–26.20 x 109/l (mean:
15.01 ± 4.59 x 109/l) and relative neutrophilia was observed in
12 horses (mean: 77.65 ± 6.16%). Plasma fibrinogen
concentration was elevated (>2.50 g/l) in all patients, and
ranged from 3.05–8.08 g/l (mean: 5.068 ± 1.618 g/l). Blood
gas analysis showed the presence of hypoxaemia (paO2
<90 mmHg) in 7 horses (41.1%), with paO2 ranging from
77–89 mmHg (mean: 84.3 ± 4.6 mmHg), while all animals
were normocapnic (paCO2 mean: 42.6 ± 1.8 mmHg). In Cases
1, 2, and 8 the antibody titres for EHV-1 were 1:48, 1:16 and
1:64 respectively. In the same horses, no antibody titre was
detected for EVA. Serum protein electrophoresis showed a
mild to strong elevation in the gamma-globulin fraction in all
cases (20.8, 51.4 and 26.5 g/l, respectively)
In all patients, ultrasonography of the chest showed
heterogeneous variably extended portions of consolidated
hypoechoic lung parenchyma (Fig 1) in which disseminated
hyperechoic areas and fluid bronchograms were often
observed. These findings were consistent with pneumonic
lesions, mucopurulent and/or gaseous collections, and
presence of fluid into the bronchial lumen. In some cases,
hepatisation of the lung parenchyma was observed. Single or
multiple pneumonic lesions were localised in the right side of
the chest in 6 horses (35.3%) and in both sides in the other
528
11 horses (64.7%). In the majority of cases, the lesions
involved the medio-ventral portion of the lung. In 3 horses
(Cases 2, 12 and 14) ultrasonography showed the presence of
anechoic fluid and hyperechoic fibrin in the pleural space,
bilaterally (Fig 2). In 2 patients (Cases 2 and 14) the collection
was large and the fluid line reached approximately the level of
the supraglenoid tubercle of the scapula. Thoracic radiography
revealed, in the areas of pulmonary parenchyma
corresponding to the lesions shown by ultrasonography, an
increase in radio-opacity, with irregular and ill-defined margins
(Fig 3) and presence, in some cases, of air bronchograms. The
remaining portion of lung parenchyma often showed an
increase in bronchial and interstitial pattern. In pleural effusion
cases, the presence of fluid resulted in an intense, diffuse
opacity - that prevented the visualisation of lung parenchyma
details - which extended dorsally to the upper limit of the
Fig 1: Ultrasonographic image from a case of pneumonia. There
is consolidation of the lung parenchyma, which appears
hypoechoic. There is some air entrapped within the lesion
which appears hyperechoic.
Fig 2: Ultrasonographic image from a case of pleuropneumonia.
The pleural space is filled with anechoic fluid; the
pericardiodiaphragmatic ligament is visible within the fluid
(arrow).
EQUINE VETERINARY EDUCATION / AE / october 2008
collection. Endoscopy allowed the identification of pharyngeal
lymphoid hyperplasia in all patients, ranging from grade II to
grade IV, which involved in some cases the guttural pouch
mucosa. Within the tracheal lumen a variable degree of
mucopus was always present: grade II in 2 horses, grade III in
14 horses and grade IV in one horse. Tracheobronchial mucosa
was hyperaemic and there was oedema of the carina and
main bronchi, ranging in grade from II to IV. Tracheal aspirate
cytology showed neutrophilia with degenerated neutrophils
(kariolysis and kariorexis), often (11 horses, 64.7%) with active
phagocytosis of cocci and/or rods (Fig 4). Coccobacilli
phagocytised by alveolar macrophages were identified in
Cases 1, 2 and 8. Neutrophilia ranged from 68–100% of the
differential count with a mean value of 91 ± 8%. Cultural and
sensitivity test results are shown in Table 1.
According to the above mentioned procedures, a
diagnosis of bacterial pneumonia in 14 cases and of bacterial
pleuropneumonia in 3 cases, was made.
Fig 3: Radiographic image of the dorsocaudal lung field from a
case of pneumonia. There is an area of intense opacity with ill-
defined margins along the diaphragm (arrows).
Fig 4: Cytological evaluation of tracheal wash. Degenerate
neutrophils with bacterial phagocytosis (1000x).
EQUINE VETERINARY EDUCATION / AE / october 2008 529

TABLE 1: Bacteria isolated from TW and administered antibiotics according to sensitivity test results

Age Bacteria Antibiotic Dosage4

Case 1 3 years Rhodococcus equi Erythromicin3 25 mg/kg bwt per os t.i.d.

Case 22 2 years Rhodococcus equi Oxytetracicline 15 mg/kg bwt i.v. s.i.d.
Ampicillin1
Case 3 5 years β-haemolytic Streptococcus Ceftiofur 2.2 mg/kg bwt b.i.d.
Case 4 3 years Streptococcus equi Ampicillin 20 mg/kg bwt i.v. t.i.d.
Case 5 3 years β-haemolytic Streptococcus Erythromicin3 25 mg/kg bwt per os t.i.d.
Case 6 4 years β-haemolytic Streptococcus Ceftiofur 2.2 mg/kg bwt b.i.d.
Enrofloxacin1
Case 7 5 years Klebsiella pneumoniae Enrofloxacin 2.5 mg/kg bwt per os b.i.d.
Case 8 4 years Rhodococcus equi Amikacin 20 mg/kg bwt i.v. b.i.d.
Sulphametazine1
Case 9 3 years β-haemolytic Streptococcus Enrofloxacin 2.5 mg/kg bwt per os b.i.d.
Case 10 3 years β-haemolytic Streptococcus Ampicillin 20 mg/kg bwt i.v. t.i.d.
Case 11 2 years β-haemolytic Streptococcus Ampicillin 20 mg/kg bwt i.v. t.i.d.
Case 122* 7 years β-haemolytic Streptococcus Oxytetracicline 15 mg/kg bwt i.v. s.i.d.
Case 13 6 years β-haemolytic Streptococcus + Enrofloxacin 2.5 mg/kg bwt per os b.i.d.
Klebsiella pneumoniae Ceftiofur1
Case 142* 2 years Klebsiella pneumoniae Enrofloxacin 2.5 mg/kg bwt per os b.i.d.
Case 15 3 years β-haemolytic Streptococcus Enrofloxacin 2.5 mg/kg bwt per os b.i.d.
Case 16 3 years Streptococcus pneumoniae Erythromicin3 25 mg/kg bwt per os t.i.d.
Case 17* 3 years Pseudomonas aeruginosa Gentamicin 6.6 mg/kg bwt i.v. s.i.d.

Legends: 1antibiotic replaced due to occurrence of antibiotic-resistance; 2pleuropneumonia; 3estolate salt; 4Prescott 1997; *Metronidazole
administered (15 mg/kg bwt per os q.i.d.).

Antimicrobial therapy, lasting an average of 45 days
(30–60 days), was established according to sensitivity test
results (Table 1) and was suspended only after 2 successive
negative tracheal washes. In Cases 12, 14 and 17, breath and
tracheal exudate malodour suggested the possible presence of
anaerobic bacteria and metronidazole, at a dosage of
15 mg/kg bwt per os q.i.d., was administered in association
with the antimicrobial selected for bacteria isolated in
microaerophilia. Antimicrobial treatment was adjuvated by
inhalatory administration of bronchodilators (Ipratropium
bromide, 3 µg/kg bwt b.i.d. or t.i.d. with an aero mask),
immunomodulators (α-interferon, 50 iu per os s.i.d.) and, to
control hyperthermia and inflammation, flunixin meglumine
(1.1. mg/kg bwt i.v. s.i.d. or b.i.d.). In Cases 2 and 14, the
presence of a large amount of pleural fluid necessitated the
daily aspiration of 4–8 l of fluid until remission (Fig 5). A total
of 81 l were aspirated from Case 2 and 25 l from Case 14. In
Case 12, the small amount of fluid identified with
ultrasonography, spontaneously regressed after
pharmacological treatment. During the course of treatment
serial tracheal washes were performed at weekly intervals in
order to rule out the occurrence of antibiotic-resistance. In 4
cases (Cases 2, 6, 8 and 13) it was necessary to change the
antibiotic (Table 1). After the end of antimicrobial treatment,
a period of rest of 60 days was recommended for all patients.
After discharge, follow-up information was collected for
all horses, by phone enquiry or, for Standardbred horses, by
consulting the internet site www.anagt.it. Eleven horses
(64.7%) returned to racing satisfactorily, whereas the other
6 horses (35.3%) were retired from competition (Cases 1, 2, 5,
12, 14 and 17).

Discussion

The procedures described in the present paper are useful and

Fig 5: Pleuropneumonia. Aspiration of pleural fluid with a
thoracocentesis device.
comprehensive for diagnosis of bacterial pneumonia and
pleuropneumonia in sport horses, even at an early stage.
Particularly, they helped to identify pulmonary lesions even in
those patients that did not present with any specific clinical
sign, such as fever and nasal discharge, at the time of the
examination, possibly because of previous administration of
NSAIDs and antibiotics by the trainer or attending
veterinarian. Amongst laboratory parameters, plasma
fibrinogen concentration was particularly reliable as an
indicator of sepsis, being elevated in all cases, while
leucocytosis was only present in 64.7% of cases, as previously
reported in Standardbred racehorses affected with IAD
530
(Di Fabio et al. 2002). In all patients, the association of
different diagnostic imaging procedures (ultrasonography,
radiography, endoscopy) allowed precise identification of the
localisation and extension of pneumonic lesions, and the
presence of fluid in pleural spaces (Chaffin et al. 1994b). The
procedures were also helpful for monitoring patients during
treatment, allowing evaluation of the regression of
pulmonary lesions and the decrease in the pleural fluid. Daily
thoracocentesis with an atraumatic trochar was preferred to
an indwelling thoracic catheter for several reasons: this
system allows slow drainage of pleural effusion to prevent
possible collapse ex vacuo due to excessively rapid emptying
of the thoracic cavity; it prevents contamination of the
thoracic cavity due to the indwelling catheter and the
possible occurrence of pneumothorax. The procedure was
easy to perform and well tolerated by the patients.
The bacterial species isolated and their prevalence
substantially agree with that reported for aerobic bacteria in
horses (Sweeney et al. 1991; Chaffin and Carter 1993; Lakritz
et al. 1993; Lavoie et al. 1994; Raidal 1995; Carr et al. 1997;
Racklyeft and Love 2000; Vengust et al. 2002; Waldridge et al.
2008). In particular, the 3 cases in which R. equi was cultured
(Cases 1, 2 and 8) could have been immunodeficient.
Although the immune status of these patients was not
thoroughly evaluated, serum protein electrophoresis showed a
mild to strong elevation in the γ-globulin fraction (20.8, 51.4
and 26.5 g/l, respectively), which suggests normal B cell
function, and the leucogram, showed low monocyte count
(0.08, 0.05 and 0.07 x 109/l, respectively), suggestive of
possible dysfunction in phagocytic activity. These results agree
with those reported by Vengust et al. (2002) and Waldridge
et al. (2008), although in their cases there was a mild
leucopenia and also a decrease in lymphocyte count, which
we did not observe in our horses, who had leucocytosis (11.3,
26.2 and 12.6 x 109/l, respectively) and normal to elevated
lymphocyte count (5.4, 5.3 and 3.8 x 109/l, respectively). We
hypothesise that this difference could be related to the
different age and activity of the patients, which, in our
population, were young racehorses under intensive training.
Age and training activity could partially explain the relatively
high rate of R. equi isolation in such a population. In fact,
young high performance horses are more likely to have
impaired phagocyte function (Moore 1996; Raidal et al. 1997),
and the frequent contacts with animals of different origins
during transport or at the racetrack, may have promoted a
higher likelihood of exposure to R. equi.
In suspected cases, the lack of anaerobic isolates could be
related to objective difficulties in keeping strict anaerobic
conditions during sample collection and storage before
submission to the laboratory, although preventive
administration of metronidazole apparently contributed to the
remission of pneumonic processes. The occurrence of
antibiotic resistance in 4 cases may support the practice of
monitoring the patients during treatment by repeated tracheal
washes (at weekly intervals) and to promptly change the
antibiotic drug in order to prevent relapses. It was considered
that the small increase in costs due to repeated sampling and
EQUINE VETERINARY EDUCATION / AE / october 2008
microbial culture was balanced by the possible reduction in
costs of prolonged ineffective antimicrobial treatment with
expensive drugs such as ceftiofur or amikacin.
Amongst the 6 horses that did not return to racing,
Cases 2 and 14 had severe pleural effusion, in which the
clinical remission of pleuropneumonia was not associated with
sufficient recovery of lung function. In the other 4 cases (1, 5,
12 and 17), whose owners were unwilling to allow
hospitalisation during treatment, the unsatisfactory functional
recovery could be related to short duration of antibiotic
treatment or insufficient monitoring during the course of the
disease. Additionally, Cases 1 and 2 had R. equi infection,
which could be related to immune system dysfunction.
The high rate of horses returning to racing activity (64.7%)
suggests that prolonged antibiotic treatment, associated with
intensive monitoring of the patient, may have enhanced the
complete functional recovery in those cases that were not
complicated (i.e. pleural effusion and/or R. equi infection).
Therefore, the presence of such complications, may have had
to be considered as negative prognostic factors.
Acknowledgements
The authors wish to acknowledge Prof. Mauro Di Giancamillo
and Mr Gilberto Panigada, Section of Radiology, Department
of Veterinary Clinical Sciences, University of Milan, for
performing thoracic radiography in this group of patients.
Manufacturers’ addresses
1Sclavo Diagnostics International, Sovicille, Italy.
2Bayer, Leverkusen, Germany.
3Instrumentation Laboratory UK Ltd, Warrington, Cheshire, UK.
4Esaote Biomedica, Genova, Italy.
5Olympus, Tokyo, Japan.
6Hettich Cyto System, Bäch, Switzerland.
7GTA Medical Product, Quistello, Italy.
8Oxoid, Milan, Italy.
9Becton Dickinson, Franklin Lakes, New Jersey, USA.
10bioMérieux, Marcy l'Etoile, France.
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