Lingering Cellulitis/Lymphangitis

[Ginnyjunior]

This is my first go around with any type of leg infection/cellulitis so most likely any advice or opinions will be new to me. I’ll give a little background on the horse and what has gone on up to this point.

Warmblood mare, 20 years old, retired jumper, no known health issues, no special needs, lives at home with me on my farm.

June 29th in the morning I found her reluctant to put any weight on her right hind. I called a vet out, not my usual vet because he passed away. This vet was young and acted unsure, the mare had swelling from her hoof, up the entire leg and into her abdomen area. There were no cuts or signs of any injury. No fever. His guess was that she pulled her groin muscle overnight in the stall. I didn’t agree 100% but kept my mouth shut because I’m not a vet. He came up with a plan and started her on SMZ and gave her a shot of Excede and Banamine and told me to epsom salt poultice and wrap. Also told me to sweat with Furazone. I did this 4 days with no change. I also cold hosed. In these few days her leg became SOAKED with draining lymph fluid and I knew I had a bigger issue that a pulled muscle. I called a more experienced vet in my area and continued treatment with him. We did everything from DMSO iv to penicillin, Baytril, banamine, naquazone w/Dex, pentoxifylline and cold hosing, wrapping etc. And just about everything in between. Now, July 20th I have still a warm swollen leg from the hock to hoof. All of the skin has sloughed off except for in a few areas. I am still cold hosing and wrapping daily. Also started using Game Ready cold compression. She is eating, great attitude, making plenty of manure, out in turnout about 6 hours a day in a grass 1 acre field (walking does not reduce the size of the leg) and overall she is her normal self except for this giant elephant leg.

Is this possibly her “new normal”? I have scheduled the vet to come back next week. I feel we are way past the acute phase and this is no longer an emergency or he would have come back this week. He did mention to me that because the first vet dropped the ball at the onset of this it’s going to take that much longer to heal and get back to normal.

Anyone deal with something similar and have any insight? Thank you.

[Simkie]

Have you cultured? I would culture and probably biopsy at this point. Figure out what infective agents you’re actually dealing with, and what they’re sensitive to, and find out what is happening in the skin on the cellular level.

I had a mare that presented with “cellulitis” and we treated as such but when the skin started sloughing, and the culture came back positive for strep, we realized what we actually had was purpura hemorrhagica. It was really ugly, and did not end well

[NaturallyHappy]

I agree w Simkie, and think I’d ask the vet back ASAP.

[Ginnyjunior]

It sloughed off after and during the lymph leakage. Almost like she blistered. She’s a flaxen, roan chestnut but oddly never had sensitive skin. I will ask the vet about culturing. Thank you.

[MsM]

Older horse in the stable where I board had struggles with something similar. It took quite some time, cultures and several different antibiotics before he made progress. His did improve with motion. There was a lot of serum leakage, he had many “sores” that eventually healed. At the worst of it, the vet did open one of the lower areas to allow some fluid to exit. His pastern area remained enlarged, but he was sound and unbothered. He has had one relapse which, happily, resolved fairly quickly with treatment.

Today the swelling may increase with inactivity but has stayed in the lower part of his leg,

[Simkie]

@Ginnyjunior

It sloughed off after and during the lymph leakage. Almost like she blistered.

Yes, lymph leakage also happens with purpura. I’d really prioritize that culture and biopsy. Best of luck, it’s certainly a long haul.

[hunterjumper98]

That’s a long time for it to not be responding to a multimodal treatment plan with multiple antibiotics. I would 100% ask your vet about culturing the serum leaking from the affected leg to see what you’re dealing with. Most cellulitis is caused by staph, but you may be dealing with a resistant strain of bacteria or even purpura hemorrhagica.

Is the leg still warm/hot to the touch or painful?

Once you’ve cultured it, determined what bacteria you’re dealing with, and have narrowed down what spectrum of antibiotics you need to treat with, I would ask your vet about possibly doing a regional limb perfusion on this horse. A regional limb perfusion delivers high concentrations of an antimicrobial to that specific area of the body to optimize killing the bacteria with minimal systemic effects. Long-term antimicrobial use in horses can lead to colitis, so the less systemic antibiotics we can use, the better.

Just another idea to throw out there for your vet would be trying a diuretic like Furosemide (Lasix) to try and bring down the swelling in the limb. They may also need to debride the leg some to get rid of any necrotic tissue, but it’s hard to say without knowing what the leg actually looks like.

I’m not sure how and what you’re wrapping with, but I would apply a healthy amount of Furazone mixed with DMSO to the leg, cover it with a layer of saran wrap, and wrap it with a standing wrap. Make sure the wrap covers all affected parts of the leg. I saw that she’s turned out, but I would also try to hand walk her as much as possible to keep the joints mobile and encourage some circulation in that leg. The more movement, the better. For more chronic cases of cellulitis and lymphangitis, it’s sometimes more helpful to alternate warm and cold hosing rather than just cold hosing it alone.

Horses that have had chronic cellulitis may always have enlargement of that limb, but it shouldn’t continue to leak serum or have the skin sloughing off. Both of those signs tell you that there’s an active inflammatory process going on in that leg.

[Ginnyjunior]

She’s been on a diuretic. I’m familiar with perfusion, I have a gelding who needed it 2 years ago. There is no necrotic tissue, it’s all new pink healthy looking skin at this point. I’m not going to sweat with Furazone because she’s a flaxen chestnut and this new skin will surely blister. Vet is coming back to re-evaluate and come up with a treatment plan.

[Ginnyjunior]

It’s no longer leaking lymph fluid?? Maybe I forgot to say that. That process stopped about 2 weeks ago.

[Foxglove]

Any information I have is probably outdated. We had a 20+ year old jumping horse that would get “elephant leg” any time he was taken somewhere in the trailer. Vet’s best guess (this is 15 years ago) was that he had a blockage in his lymphatic system that was aggravated by the bouncing around in the trailer. We hosed, wrapped, and turned him out. Eventually, the leg would go down, although never “normal” --at least not huge. Until he was hauled again.

We placed him (he was an extremely well-trained dressage horse,and had a considerable show record) --we placed him with a young woman who only showed at her own stable (no trailering). I last saw him there at almost 30 --he’d escaped his rider and was racing around the show grounds having the time of his life as everyone tried to catch him.

He lived another 5 years --I was told he continued to have flare ups of “elephant leg” but was never lame. His death was peaceful, just didn’t wake up one morning.

Ironically the trainer I bought him from as a 10 year old, used to see me at horse shows now and then --he always remembered me and ask how the horse was doing for my daughter (great as always) but struggling with his “elephant leg” --which he didn’t have when I bought him. The trainer would say (every time) “He is an amazing horse --he’ll outlive me!” --and he did! The trainer died quite young of an obscure cancer . . .still remember him when I am at the various venues telling me “That horse will outlive me!”

He was never lame on it.

[Ginnyjunior]

That’s interesting, thank you for sharing! Sometimes these things are anybody’s best guess. She’s not suffering in any way but I do want to make sure that she lives her best, pain free life. She’s a special horse to me. Even though she’s retired, she gets the same care that all of my horses do. I bought her as a 5yr old and she won a ton and was the horse that brought me to the next level. I’ve been lucky to always have great mares that have never acted like one

[starhorse]

This was my horse. We tested for Cushing’s and she ended up having it. We have gotten her levels to normal(ish) with Prascend and she hasn’t had an issue since in her “fat leg”.

[victoriakent]

I have a mare with “pink” legs sometimes and a few things that helped me with her bout of cellulitis:

Deff culture. Once you are sure the infection itself is cleared I really like the silver honey to help protect the new/pink skin both for hair regrowth and for its anti-bacterial properties.

Silver sox for a while, fly boots thereafter to help protect the sensitive leg.

Big Dee’s has a cool cold-hosing tube that you can place on their leg while cold hosing if your horse is good at standing in a wash stall.

The leg will more than likely be more prone to future rounds of this, particuarly in the mud seasons - generic diaper cream on Amazon is way cheaper than in store, repels water, and protects white body parts from UV exposure. When I dont feel like dealing with the diaper cream I mix up a spray bottle of baby oil and water, shake well, and spray down her clean legs to repel moisture.

Really take extra care that the horse is getting good omegas and healthy fats to help keep their skin as healthy as possible while they are healing. Not saying they weren’t getting enough before, but a little extra ground flax certainly won’t hurt boost things.

[HorseLover65]

My very first horse (14 year old OTTB) ended up with lymphangitis about a week after I bought him. It arose from a puncture wound in the coronet band. He was very sick - fever, swelling up the right hind from the coronet band into the middle of his abdomen. His leg oozed. His hoof softened and the vet feared he was going to lose it. Multiple antibiotics (gentamicin was one) and months of cold hosing and hand walking. Swelling started to subside and I started riding, mostly at the walk. The exercise helped the most with the swelling. We eventually got back to jumping at our barn shows. He had two or three recurrences. It is manageable and exercise seemed to be the key for us. But the multiple rounds of antibiotics had an impact. He was pts 3 years later after developing pneumonia… even i.v. antibiotics couldn’t touch it. Wishing you much luck!

[DMK]

While newb vet may have been unsure of the dx at least he went with a pretty solid first line treatment plan for cellulitis. I typically start with just smzs and banamine and evaluate for 24 hours then hit the broad spectrum stuff if there isn’t rapid improvement.

That said, yeah, I battle a bad case for weeks with my old hunter. Ultimately it all but disappeared except for a puffy ankle and of course that leg always stocked up faster and more than the other leg, and it was always prone to repeat episodes.

Decades before that I had a mare that had a reaction to something, maybe in shavings? that I constantly battled cellulitis and she had the same post event issues. But that was the 80s so we were limited to naquasone boluses and massive doses of penicillin. Fun times.

I used to see a reliable old children’s hunter at the shows who just had leftover elephant leg from his own battle with it. Looked awful but didn’t affect him in any way I could see.

Bad episodes do leave residual evidence, it’s like wind puffs, once the balloon is inflated, it’s never the same. But very rarely have I seen prolonged or permanent elephant leg…

[Ginnyjunior]

Actually no, the newbie vet left me in the lurch and as I stated, I called in a second opinion. It was the second vet who started her on the more aggressive treatment plan.

[DMK]

@Ginnyjunior

He came up with a plan and started her on SMZ and gave her a shot of Excede and Banamine and told me to epsom salt poultice and wrap. Also told me to sweat with Furazone.

This is what I’m referring to, it’s really the standard when you are dealing with cellulitis: nsaid+broad spectrum abx, cold hose and sweat. SMZs and excede are pretty much the go to abx for cellulitis. Unfortunately, as you have found out, when they don’t work, not much else does either (except time). As for the skin sloughing off, that too is one of the unavoidable effects of really bad cellulitis cases, modern medicine be damned.

I suspect if you follow up with other vets, you may find that while the first vet didn’t give you a clear dx there wasn’t much else that most vets would have done. Some may have swapped out excede for baytril, others may have just tried SMZs first. All would have been standard for treatment. Most would not have thrown a steroid in the mix in the early stages because a steroid would mask any underlying more serious infection. And in all fairness, in the early stages it could have been a groin pull, ESPECIALLY since she didn’t have the trademark high temp/loss of appetite that almost always accompanies cellulitis. That’s a very atypical presentation. So yeah, you didn’t get the dx you wanted, but your horse got the trx she needed.

Which is all to say, having been around the block a few times with cellulitis, while I know you are frustrated, I think you are being unfair to the vet. Your frustration is better pointed towards the disease, which is VERY frustrating at times.

[theresak]

@DMK

SMZs and excede are pretty much the go to abx for cellulitis.

My vet is now doing Equisul for cellulitis. We originally started with Kpen and Gent for 5 days and then switching to SMZs 2x daily but when my horse became allergic to penicillin, we switched to Equisul (it had just come on the market). I once treated cellulitis with almost 2 months of antibiotics due to the severity.

@dr5627

Not to hijack but does anyone have suggestions for a horse with recurring infections?

I have a chestnut with 4 white legs that got cellulitis in all 4 legs at different times. I worked with my vet to figure out a better preventative plan and he went on a probiotic that was not heat treated, extra vitamin E, and copper and zinc. He wore nothing on his legs except during riding. I didn’t clip his legs ever. And if he got a wound on low enough on his legs that would come into contact with grass, bedding, etc. we would do 10 days of Equisul as a preventative.

[DMK]

SMZs, uniprim, tucoprim and equisol are all in the same family, they are all sulfa drugs aka sulfadiazine/trimethoprim or sulfamethaxole/trimethoprim (SMZs). They may come in different formulations and may have varying dosage requirements, but they are all targeting the same class of bacteria.

SMZs are 2x day plus grinding (back in the 80 they melted in 1 minute). Tucoprim/uniprim were easier in that they are 1x day and powder, but there were some palatability issues. Equisul (liquid) just looks like a much more palatable version of uniprim (especially since their advertising material targets uniprim).

PenK and gentomicin, that put me in the way back machine!!

[theresak]

@DMK

Equisul (liquid) just looks like a much more palatable version of uniprim (especially since their advertising material targets uniprim).

I was doing the PenK and gent not that many years ago, probably about 10? My vet, who is all up on the new things, just said that with my large horse and massive infection, he wanted to hit it with the big guns and cover all the bases right away. It worked the first time, so we used it for a few more occurrences until one day there were hives. I am allergic to penicillin so I’d have to find/pay someone to administer it. And we pushed the gent a little fast one time and made my horse a little woozy once - I think it can occasionally lower BP. My horse had all sorts of weird medical things…

I think there was something with the Equisul having better absorption than SMZs or working better in his experience.

I had my mom buy saran wrap from Costco once for sweating the leg and she got a 2 pack of the food service rolls of plastic wrap. I (hopefully) will never run out of it now. I have a whole kit ready to treat cellulitis and sweat a leg from hoof to elbow or stifle from a Friday evening through Monday morning until the vets office opens to get more abx. Because there were at least 2 occasions for a Friday 6 pm or Saturday evening vet call to get antibiotics.