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Sepsis and Disseminated Intravascular Coagulation in anEastern Spiny Softshell Turtle (Apalone spinifera spinifera) withAcute MycobacteriosisAuthor(s): Maureen Murray, D.V.M., Nicole T. Waliszewski, D.V.M., MichaelM. Garner, D.V.M., Dipl. A.C.V.P., and Florina S. Tseng, D.V.M.Source: Journal of Zoo and Wildlife Medicine, 40(3):572-575. 2009.Published By: American Association of Zoo VeterinariansDOI: http://dx.doi.org/10.1638/2008-0125.1URL: http://www.bioone.org/doi/full/10.1638/2008-0125.1

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SEPSIS AND DISSEMINATED INTRAVASCULAR COAGULATION

IN AN EASTERN SPINY SOFTSHELL TURTLE (APALONE

SPINIFERA SPINIFERA) WITH ACUTE MYCOBACTERIOSIS

Maureen Murray, D.V.M., Nicole T. Waliszewski, D.V.M., Michael M. Garner, D.V.M., Dipl.

A.C.V.P., and Florina S. Tseng, D.V.M.

Abstract: An adult, captive eastern spiny softshell turtle (Apalone spinifera spinifera) was examined for a 4-day

history of lethargy and plastron discoloration. The turtle was obtunded and had pale mucous membranes,

hemorrhagic nasal discharge, and petechiae on all limbs. The turtle was euthanized due to its grave condition.

Necropsy revealed hemorrhagic coelomic effusion, petechiae on the serosal surfaces of the intestinal tract, and

bilaterally hemorrhagic lungs. Histologic examination revealed numerous emboli of bacteria associated with

fibrinocellular thrombi throughout the blood vessels of multiple tissues. The bacteria in the thrombi were slender

bacilli that stained intensely acid fast. Culture of the coelomic fluid yielded Mycobacterium chelonae. Although

mycobacteriosis in reptiles is typically a chronic, granulomatous disease, this case demonstrates that

mycobacteriosis should be considered in reptiles presenting with acute, nongranulomatous disease. This case

also describes clinically apparent hemorrhage due to disseminated intravascular coagulation, which is rarely

described in chelonians.

Key words: disseminated intravascular coagulation, eastern spiny softshell turtle, Apalone spinifera spinifera,

mycobacteriosis, Mycobacterium chelonae, sepsis.

BRIEF COMMUNICATION

A 24-yr-old, 744 g (1.6 pound), male eastern

spiny softshell turtle (Apalone spinifera spinifera)

was presented to the Wildlife Clinic at Tufts

University Cummings School of Veterinary

Medicine for acute onset of lethargy and plastron

discoloration. The turtle had been at the same

institution for its entire life and was housed in an

approximately 1,060 L freshwater exhibit with

two Blanding’s turtles (Emydoidea blandingii), a

common musk turtle (Sternotherus odoratus),

and, for a short period, a spotted turtle (Clemmys

guttata), none of which showed signs of illness.

Husbandry parameters included ultraviolet

lighting, water temperature ranging from 23–

24uC (74–75uF), constant water filtration through

a sand filter, sand substrate, and weekly water

quality testing. Heat lamps, rocks, and logs for

basking surfaces were provided. Diet offered

daily for all turtles in the exhibit included a

rotation of smelt, chopped mice, earthworms,

crickets, mealworms, and dark leafy greens.

Four days before presentation, caretakers

noted that the turtle was not burrowing in the

sand in the exhibit as it normally did. After 2

days of decreased burrowing, the turtle was

removed from the exhibit, at which time caretak-

ers noted that the plastron appeared discolored.

The turtle’s mentation was normal. Two days

after being taken off exhibit and housed in a

holding area, the plastron discoloration seemed

worse and the turtle was dull. At this time, the

turtle was presented for examination.

Physical examination revealed that the turtle

was obtunded and had markedly pale mucous

membranes. Other findings included hemorrhagic

discharge from the nares and glottis, petechiae on

all limbs, a diffusely erythematous plastron, and

peripheral edema. Due to the grave condition of

the turtle, euthanasia was performed. Necropsy

revealed a large volume of hemorrhagic fluid in

the coelom. Petechiae were noted on the serosal

surfaces of the intestinal tract. Both lungs were

consolidated and hemorrhagic. Culture of the

coelomic fluid revealed a rapidly growing bacte-

rium identified at the National Jewish Medical

and Research Center (Denver, Colorado, USA)

as Mycobacterium chelonae.

Histologic examination revealed numerous

emboli of bacteria associated with fibrinocellular

thrombi throughout the blood vessels of the liver,

adrenal, lung, testicle, heart, brain, meninges, and

vomeronasal gland. Pulmonary blood vessels

sometimes had transmural circumferential fibri-

From the Wildlife Clinic, Tufts University Cummings

School of Veterinary Medicine, 200 Westboro Road,

North Grafton, Massachusetts 01536, USA (Murray,

Waliszewski, Tseng) and Northwest ZooPath, 654 West

Main, Monroe, Washington 98272, USA (Garner).

Present address (Waliszewski): Mukwonago Animal

Hospital, 1065 North Rochester Street, Mukwonago,

Wisconsin 53149, USA. Correspondence should be

directed to Dr. Murray (maureen.murray@tufts.edu).

Journal of Zoo and Wildlife Medicine 40(3): 572–575, 2009

Copyright 2009 by American Association of Zoo Veterinarians

572

noid degeneration associated with mild-to-mod-

erate hemorrhage and edema in the interstitium

and faveoli (Fig. 1A). The bacteria in the thrombi

were slender bacilli that were faintly basophilic in

hematoxylin and eosin stained sections and

stained intensely acid fast with Fite Farocco

acid-fast technique (Fig. 1B). Additional histo-

logic findings included acute heterophilic inflam-

mation with varying degrees of necrosis and

intralesional bacteria in the renal interstitium,

hepatic parenchyma, pulmonary interstitium,

myocardium, lamina propria of the intestine,

and red pulp of the spleen. Acute renal tubular

necrosis and luminal accumulation of yellow

pigmented material interpreted as bile also were

noted. Mild infiltrates of lymphocytes were

present in the lamina propria of the stomach

and intestine. The urinary bladder had mild

multifocal squamous metaplasia of the mucosal

epithelium. No abnormalities were noted in the

pancreas, facial skin, musculoskeletal system,

ears, eyes, and oral and nasal cavities. The shell

was not examined histologically.

The clinical, gross, and histologic findings in

this case indicate acute, overwhelming bacterial

septicemia and disseminated intravascular coag-

ulation (DIC) caused by mycobacteriosis. Myco-

bacterium chelonae is a member of the atypical,

rapidly growing group of mycobacteria. Infection

and mortality in chelonians from Mycobacterium

spp. have been reported, including M. chelonae,1

Mycobacterium marinum,2 Mycobacterium ter-

rae,3 Mycobacterium kansasii,4 Mycobacterium

haemophilum, Mycobacterium nonchromogenicum,

and other nontuberculous mycobacteria.5 Myco-

bacterial infections also have been documented in

other reptile taxa.5,6 The most frequent isolate in

reptiles is M. marinum.6

Many mycobacterial organisms are widely

distributed in the environment and generally

considered to be of low virulence.6,7 It has been

suggested that mycobacterial infections in reptiles

may be secondary to debilitation or impaired

immune function, which, in captive reptiles, can

result from improper husbandry.5,7,8 Mycobacte-

riosis in reptiles is typically a chronic disease

characterized by visceral or cutaneous granulo-

mas.6–8

In turtles with mycobacteriosis, commonly

reported postmortem findings are multiple gray-

white nodules in various visceral organs, includ-

ing lungs, liver, spleen, and kidney.2–4 In several

cases, cutaneous papules or nodules, carapacial

papules or nodules, or a combination were

present.1,3,4 In contrast to previous reports of

mycobacteriosis in chelonians, the turtle in this

report had no visceral, cutaneous, or grossly

visible carapacial granulomas. An acute, non-

granulomatous form of mycobacteriosis charac-

terized by inappetence, depression, and sudden

death has been described in reptiles.7,8 However,

this acute form is rarely reported,6–8 and minimal

information specifically characterizing this pre-

sentation is documented in the literature. One

author describes gross and microscopic findings

in acute pulmonary mycobacteriosis in reptiles.7

Another uncommon feature of the case report-

ed here is the presence of clinical DIC, evidenced

Figure 1. Photomicrographs of a portion of the lung from an eastern spiny softshell turtle with acute

mycobacteriosis and disseminated intravascular coagulation. A. Note fibrinocellular thrombus (t) in large

interstitial vein, leakage of erythrocytes through the wall (arrow), and associated hemorrhage and edema (clear

spaces) in the interstitium (i). Hematoxylin and eosin stain. Bar 5 100 mm. B. Note large numbers of acid-fast

bacilli within the venous thrombus. Fite’s acid-fast stain. Bar 5 100 mm. Inset: Higher magnification showing

bacillary appearance of the acid-fast bacteria, Fite’s acid-fast stain. Bar 5 10 mm.

MURRAY ET AL.—ACUTE MYCOBACTERIOSIS IN A SOFTSHELL TURTLE 573

by hemoptysis, coelomic hemorrhage, and pul-

monary hemorrhage along with widespread

petechiae and ecchymoses, these findings corrob-

orated by histologic evidence of disseminated

fibrinocellular thrombosis. Septicemia in reptiles

is frequently associated with the presence of

petechiae and ecchymoses, which are believed to

be secondary to vascular damage caused by

endotoxin release.9 These signs also can be

indicative of thrombocytopenia or coagulopa-

thies.9 Little is documented about coagulation

pathways or DIC in reptiles, and this syndrome is

reported to be rare.9 Different forms of DIC are

recognized based on whether the syndrome is

characterized by thromboembolism or overt

hemorrhage.9 All cases of DIC observed by one

author were characterized by signs of thrombo-

embolism, with none displaying hemorrhage.9

This case demonstrates that clinically apparent

hemorrhage due to DIC can occur in a turtle

secondary to sepsis.

Because of the grave condition of the turtle on

presentation, antemortem tests were not per-

formed. It is possible that acid-fast staining of a

peripheral blood smear or coelomic fluid may

have diagnostic value. Treatment of mycobacte-

riosis is not advisable in most cases. Because

mycobacteriosis is most commonly chronic and

systemic in nature, successful treatment in a

reptile has not been described.10 Moreover, due to

the zoonotic potential of Mycobacterium spp.,

treatment presents a risk to owners and caretak-

ers.10

Although the turtle in this report appeared

clinically normal before the onset of signs caused

by acute mycobacteriosis, the presence of mild,

chronic gastroenteritis, and squamous metaplasia

of the urinary bladder indicates that the health

status of this turtle was not optimal. Gastroen-

teritis in reptiles can be associated with bacterial,

fungal, or parasitic infections as well as inappro-

priate diet and stress.11 Squamous metaplasia of

epithelial-lined surfaces is often caused by hypo-

vitaminosis A,12 reflecting a potential underlying

nutritional deficiency in this turtle. All turtles in

the exhibit were offered a varied diet; however, in

multianimal exhibits it can be difficult to

accurately assess what each individual consumes.

It is possible that this turtle selectively ate dietary

items that did not provide adequate vitamin A.

Routes of entry for mycobacteria include cuta-

neous defects and epithelial linings of gastroin-

testinal, genitourinary, and pulmonary mucosa,

particularly if the epithelium is disrupted.7,8 Thus,

compromise of the mucosa of the gastrointestinal

tract, urinary bladder, or both may have resulted

in the septicemia seen in this turtle.

The most common source of exposure to

Mycobacterium spp. in reptiles is thought to be

contaminated water.7 Infected food items are also

a potential route of exposure.7,8 Mycobacteria are

able to survive in biofilms and are resistant to

many disinfectants.7,8 The source of M. chelonae

in this case is not known. Due to the saprophytic

nature of the organism, no cultures of the exhibit

were performed. It is possible that the bacteria

were present in the water in the exhibit and that

this turtle became susceptible to infection due to

underlying subclinical gastroenteritis and poten-

tial hypovitaminosis A. However, it is unknown

why acute, overwhelming sepsis, and DIC from

mycobacteriosis occurred in this case. The other

turtles in the exhibit as well as reptiles in other

areas of the facility remain clinically healthy more

than 1 yr after the death of the turtle in this report.

Mycobacteriosis should always be considered

as a differential diagnosis in any granulomatous

disease in reptiles and may be more common in

captive reptiles than previously thought.5 One

retrospective study found that more than 25% of

90 captive reptiles with granulomatous lesions

had mycobacterial infections.5 Based on the

findings in the case reported here, mycobacteri-

osis also should be considered in cases of acute

sepsis, with or without the presence of granulo-

mas. Because the signs and histopathologic

findings in acute mycobacteriosis can be similar

to acute sepsis caused by other organisms, cases

of acute mycobacteriosis can be overlooked

unless acid-fast staining and organism isolation

and identification are performed.7 Diagnosis and

reporting of additional cases of acute mycobac-

teriosis are needed to determine whether this

condition is underdiagnosed in captive reptiles.

LITERATURE CITED

1. Greer, L. L., J. D. Strandberg, and B. R.

Whitaker. 2003. Mycobacterium chelonae osteoarthritis

in a Kemp’s ridley sea turtle (Lepidochelys kempii). J.

Wildl. Dis. 39: 736–741.

2. Hsieh, C. Y., T. C. Chang, Y. L. Shen, C. D.

Chang, C. Tu, M. C. Tung, L. C. Chen, and S. S. Tsai.

2006. Pathological and PCR detection of mycobacteri-

osis in pond-cultured Chinese soft shell turtles, Trionyx

sinensis. Aquaculture 261: 10–16.

3. Noyes, H., E. Bronson, S. L. Deem, C. Sanchez,

and S. Murray. 2007. Systemic Mycobacterium terrae

infection in an eastern box turtle, Terrapene carolina

carolina. J. Herpetol. Med. Surg. 17: 100–103.

4. Oros J., B. Acosta, J. M. Gaskin, S. Deniz, and H.

E. Jensen. 2003. Mycobacterium kansasii infection in a

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Chinese soft shell turtle (Pelodiscus sinensis). Vet. Rec.

152: 474–476.

5. Soldati G., Z. H. Lu, L. Vaughan, A. Polk-

inghorne, D. R. Zimmermann, J. B. Huder, and A.

Pospischil. 2004. Detection of mycobacteria and

chlamydiae in granulomatous inflammation of reptiles:

a retrospective study. Vet. Pathol. 41: 388–397.

6. Jacobson, E. R. 2007. Bacterial diseases of

reptiles. In: Jacobson, E. R. (ed.). Infectious Diseases

and Pathology of Reptiles: Color Atlas and Text. CRC

Press, Boca Raton, Florida. Pp. 461–526.

7. Brownstein, D. G. 1984. Mycobacteriosis. In:

Hoff, G. L., F. L. Frye, and E. R. Jacobson (eds.).

Diseases of Amphibians and Reptiles. Plenum Press,

New York, New York. Pp. 1–23.

8. Frye, F. L. 1991. Infectious diseases: fungal,

actinomycete, bacterial, rickettsial and viral diseases.

In: Frye, F. L. (ed.). Biomedical and Surgical Aspects of

Captive Reptile Husbandry, 2nd ed. Krieger Publishing

Co., Malabar, Florida. Pp. 101–160.

9. Frye, F. L. 1991. Common pathologic lesions and

disease process. In: Frye, F. L. (ed.). Biomedical and

Surgical Aspects of Captive Reptile Husbandry, 2nd ed.

Krieger Publishing Co., Malabar, Florida. Pp. 529–619.

10. Pare, J. A., L. Sigler, K. L. Rosenthal, and D. R.

Mader. 2006. Microbiology: fungal and bacterial

diseases of reptiles. In: Mader, D. R. (ed.). Reptile

Medicine and Surgery, 2nd ed. Saunders Elsevier, St.

Louis, Missouri. Pp. 217–238.

11. Diaz-Figueroa, O., and M. A. Mitchell. 2006.

Gastrointestinal anatomy and physiology. In: Mader,

D. R. (ed.). Reptile Medicine and Surgery, 2nd ed.

Saunders Elsevier, St. Louis, Missouri. Pp. 145–162.

12. Boyer, T. H. 2006. Hypovitaminosis A and

hypervitaminosis A. In: Mader, D. R. (ed.). Reptile

Medicine and Surgery, 2nd ed. Saunders Elsevier, St.

Louis, Missouri. Pp. 831–835.

Received for publication 28 July 2008

MURRAY ET AL.—ACUTE MYCOBACTERIOSIS IN A SOFTSHELL TURTLE 575