Assimilating my knowledge about Aspergillus

I’ve been wanting to write this post for awhile, because I view part of the purpose of this blog to share what I’m currently learning about. I have been working on a case that has been puzzling and frustrating me, and I think part of my frustration has to do with my inefficiency in looking up important information in a timely manner. In any case, I’m learning a lot from this situation, although some of it should not need to be re-learned in this way.

The patient I’m writing about is a 25-year old Timneh African Grey parrot. The owner acquired him from her father, and although the bird has been well-loved, it has not been particularly well cared for. I’m the first vet the bird has ever seen. She brought it to me because his nostrils keep getting clogged up (one was completely closed with dried debris). He’s been on an all-seed diet his whole life. That right there is a big problem.

I’ll cut to the chase, because there’s no sense in sharing my experiences step by step, when I can do a summarized version. The bird has localized nasal aspergillosis. No, I did not know that right off the bat. For almost two months, I’ve been seeing the bird every 2-3 weeks because I’ve been struggling with reaching a definitive diagnosis and finding effective treatment. It seems like anytime cost is a concern, I try so hard to avoid unnecessarily spending a client’s money, that I probably end up wasting more of their money in the long run. This because I’m trying to do things so piece-meal (one little thing at a time), that I waste valuable time in reaching a diagnosis and implementing effective treatment. This is just as frustrating for me as it is the owner (perhaps more so).

Here’s a general summary of how this case has played out:

  • Visit #1: Flushed the nares, performed a gram stain on the very gross, white goopy discharge (yes, that’s the technical term!) from the nares, had no idea what I was looking at (see below) but sent in a sample for aerobic culture and sensitivity, performed a Standard Avian Profile blood panel (through Antech Laboratories), and started on drops of gentamicin ophthalmic solution in the nostrils twice daily and crushed Baytril (enrofloxacin) tablets in the water because the owner was concerned she coudn’t get the meds in his mouth (mistake #1).
  • Visit #2: Zero improvement, repeated the sinus flush, tons more white goop, switched to baytril given directly by mouth. The culture had grown: Providencia rettgeri (never heard of it before), Serratia Marcescens, Klebsiella Oxytoca, and Enterococcus species. (Mistake #2 = not requesting a fungal culture.)  We had discussed doing an aspergillus titer on the first visit, but since the WBC was normal (total count 4100, heterophils 2700), I didn’t think asper was likely our culprit (mistake #3), so I elected to have us stay the course with oral meds (rather than in the water, where he likely wasn’t getting enough).
  • Visit #3: Slight improvement (nostrils not as clogged up). Flushed nares and was absolutely horrified at how much debris I dislodged. I mean, I couldn’t believe it. And afterwards, you could see clear through one nostril to the other–that is not normal, I repeat, not normal! I was thinking to myself, what on earth is going on here?! I am missing something really important and obvious! So I made another slide of the discharge using diff-quick. I also convinced the owner to spend the money on an asper titer (mistake #4). Here is what I saw on my slide and why I didn’t need to waste the owner’s money on an asper titer:

Branching aspergillus hyphae from African Grey's nasal discharge

The picture is one I took through the microscope at 40x, and at 100x, you can actually see the little conidiophores (sorry, I don’t have that picture). After having looked at that slide multiple times over the course of several days, I finally began to make sense of it. I built up my confidence in knowing what I was looking at. I can now say, yes, that’s asper.

However, when the aspergillus titer came back, it was totally normal. And now I know (though I should have already known) that when a bird has such a localized infection like my patient had, they usually don’t get the heterophilia/leukocytosis and can have normal titers. Now I also know how to better recognize asper on cytology.

Luckily, when I called the bird’s owner to inform her that I had confirmed asper, she reported that his nostrils were finally staying clear! We’ve been working on the diet, among other things, and I think we’re finally on the right track. Unlike systemic aspergillosis, which is much more serious and life-threatening, I don’t think (at this time anyway) that I will need to use systemic anti-fungals for this bird. I switched from using topical gentamicin to topical clotrimazole (an anti-fungal), and increased the baytril dose from 10 mg/kg to 15 mg/kg PO BID. I’m looking forward to our next recheck because I finally have a sense that we’re headed in the right direction.

If you want, you can read another blogger’s account of aspergillus in their African Grey Parrot, Coco. She had a more serious form of the disease and nearly died (but made a full recovery!).

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4 Comments

Filed under Today I Learned

4 responses to “Assimilating my knowledge about Aspergillus

  1. Vogue Vet

    Interesting case. I just went to a lecture on Aspergillosis a couple weeks ago at our state VMA conference. Luckily you learned from relatively minor mistakes and the bird seems to be doing okay!

  2. Don’t beat yourself up. It sometimes takes a while to come to a diagnosis, no matter how diligent you are. Do you use VIN? That might have expedited the diagnosis. There are some really excellent people on there, and I know they have helped me with tricky diagnosis before. Just having a fresh set of eyes on a case (posted on the message boards) can be enormously helpful. I post frequently on the ER boards.

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