Case Report Successful Treatment of Invasive Pulmonary Aspergillosis in a Neonatal Foal H. Hilton, L. Galuppo, S.M. Puchalski, L. Johnson, K. Robinson, F.C. Mohr, O. Maher, and N. Pusterla A 55 kg, 14-day-old, Thoroughbred colt foal was ex- amined because of acute respiratory distress of 4 hours duration. The colt had been born at 320 days ges- tation and parturition was normal. Serum IgG 48 hours after birth was 4800 mg/dL. a The colt was hospitalized for treatment of diarrhea 7 days after birth; acidemia (pH 7.247; reference range 7.32–7.44), hyponatremia (108 mEq/L; reference range 132–146 mEq/L), hypo- chloremia (89 mEq/L; reference range 99–109 mEq/L), and leukocytosis (22,500 cells/mL; reference range 5,300– 14,000 cells/mL) due to neutrophilia (18,913 neutrophils/ mL; reference range 3,400–11,900 neutrophils/mL) were documented. Thoracic radiography performed during hospitalization identified a thin-walled gas-filled struc- ture within the right caudo-dorsal lung field and increased soft-tissue opacity consistent with regional pulmonary consolidation (Fig 1). The radiographic diag- nosis was congenital pulmonary bulla. The foal responded to IV administration of fluids and antibiotic therapy but a CBC identified continued leukocytosis on days 2 and 4 of hospitalization (19,690 and 23,650 cells/ mL, respectively). The foal was discharged from the hos- pital with a recommendation for administration of ceftiofur sodium (10 mg/kg SQ q12h for 14 days) and amikacin (21 mg/kg IM q24h for 7 days). The foal presented for examination 24 hours after dis- charge with signs of respiratory distress including marked abdominal effort and nostril flare. Heart rate was 120 bpm, respiratory rate 60 bpm, and rectal tem- perature 100.11F. Mucous membranes were pale and cyanotic. Thoracic auscultation identified reduced bronchovesicular sounds bilaterally. Thoracic ultrasono- graphy and radiography identified free gas and pulmonary collapse within the right and left pleural cav- ities consistent with bilateral pneumothorax. The previously identified pulmonary bulla in the right ca- udo-dorsal lung field appeared attached to the dorsal parietal pleura (Fig 2). Bilateral thoracocentesis and as- piration of pleural gas relieved respiratory distress. Thoracic radiographs performed after thoracocentesis revealed bilateral inflation of the lungs with minimal re- sidual free air within the thoracic cavity. A CBC identified anemia (28.3%; reference range 30–46%), leukocytosis (34,640 cells/mL) because of neutrophilia (32,562 cells/mL) and hyperfibrinogenemia (600 mg/dL; reference range 100–400 mg/dL). Serum biochemistry identified hyperglycemia (304 mg/dL; refer- ence range 122–205 mg/dL), venous blood gas analysis indicated acidemia (pH 7.219) with both respiratory and metabolic components (PvCO 2 70.5 mmHg; reference range 40–50 mmHg, lactate 2.1 mmol/L; reference range 0–2 mmol/L). A diagnosis of bilateral pneumothorax sec- ondary to rupture of the pulmonary bulla was suspected based on the clinical presentation, diagnostic imaging findings, and previous identification of the pulmonary bulla. Within 1 hour of the initial stabilization, the foal was again noted to be in respiratory distress. A 2nd thor- acocentesis was performed and an indwelling thoracic catheter was placed. Conservative management was con- sidered unlikely to be successful given the rapid reaccumulation of air. Surgical management was recom- mended to assess the viability of the remaining lung and to remove or repair the pulmonary defect. The foal re- ceived ampicillin (21 mg/kg IV q8h), amikacin (25 mg/kg IV q24h), and flunixin meglumine (1.1 mg/kg IV q 12h). The colt was administered diazepam (0.05 mg/kg IV) and anesthesia was induced with ketamine hydrochloride (2 mg/kg IV). After oro-tracheal intubation, an esopha- geal dilation balloon, with a maximal inflated diameter of 25 mm, was passed into the right mainstem bronchus under endoscopic guidance. The balloon was inflated to occlude flow of anesthetic gases to the right lung. The foal was placed in left lateral recumbency and the right thorax was aseptically prepared and draped for ex- ploratory thoracoscopy. After skin desensitization with 3 mL, 2% lidocaine, a 12 mm skin incision was made at the 10th intercostal space, approximately 3–5 cm ventral to the dorsal costal arch. A Veress needle was introduced through the intercostal muscles and into the pleural cav- ity to induce a pneumothorax. Once collapse of the right lung was confirmed by free manipulation of the Veress needle, a grid approach was continued through the inter- costal muscle layers extending through the pleura into the pleural cavity. A 301, 50-cm laparoscope was intro- duced through the pleura and the right hemithorax was explored. A laparoscopic cannula was not used due to limitations of space between the 10th and 11th ribs. An open cavity was visualized at the caudo-dorsal and lat- eral aspect of the lung lobe, which was adhered to the dorso-lateral pleura from the 12th to the 14th ribs. A separate laparoscopic portal was localized with a 3.5-in., 18-G spinal needle and a 2nd 12 mm incision was made after infiltration of 2 mL, 2% lidocaine at the level of the From the William R. Pritchard Veterinary Medical Teaching Hos- pital (Hilton, Maher, Robinson), the Department of Surgical and Radiological Sciences (Galuppo, Puchalski), the Department of Pa- thology, Microbiology and Immunology (Mohr), and the Department of Medicine and Epidemiology (Johnson, Pusterla), School of Veter- inary Medicine, University of California, Davis, CA. Corresponding author: Dr Hugo Hilton, William R. Pritchard Vet- erinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, One Shields Avenue, Davis, CA 95616; e-mail: hghilton@ucdavis.edu. Submitted October 5, 2008; Revised October 17, 2008; Accepted December 11, 2008. Copyright r 2009 by the American College of Veterinary Internal Medicine 10.1111/j.1939-1676.2009.0272.x J Vet Intern Med 2009;23:375–378