What Happened To Solo (Punctuation Mark Of Choice) - The Bullet List

This post took me far longer than it should have to put together, in part because it required reliving some horrible times.  You can read here for the original post when Solo was still in hospital in 2017.  As stated there, I never could have done this without generous assistance from my mom, as well as a donation from our amazing friend, Erica, I thank you both.  We also received a care grant from the vet school since our case qualified for "high educational potential."  I would not have done this for any other horse..but it is Solo.  And he said he wasn't ready to go.    

Today I sit & watch the horses relish grass.  Solo glances over towards my chair in the shade to check in & the ripple of gratitude between us is an almost tangible pulse of energy.  "This is what we held on for, buddy," I tell him as he blows a contented snort of agreement into the breeze.

Because his 2017 case was so rare, I'm going to try & run through the executive summary of the roller coaster from hell.  As both a horse owner & a scientist, I know the value of case history & felt the acute lack of it as we tried to figure this thing out.  There is virtually nothing in peer-reviewed literature outside of one paper on ~30 horses in Europe, because there have been so few cases where it was identified, diagnosed correctly, & treatment was attempted.  Symptoms were all over the map, & if I hadn't known Solo as well as I do, I'm not sure we'd have gotten as far as we did.

Without further ado, since there is enough material to base a Master's thesis on (& one is more than enough for me), here is the bare timeline.  If nothing else, I want the information to be out there for other owners & vets.  I saw Solo's file in the arms of a student...

Not a record I wanted to set

*Before proceeding, be aware there are unappetizing photos below.  Some things I did not take photos of because I never want to remember them.  But I wanted to document improvement as long as I felt we had some.  NCSU did an amazing job with pain management & my heat-intolerant horse did at least get to spend much of the summer in a climate-controlled barn, away from flies.*

Final NCSU Diagnosis:  Septic sialoadenitis with associated abscessation & draining wound.  Associated necrotic plaque within left gutteral pouch, mid-stylohyoid.  Cultured Fusobacterium, Prevotella, Klebsiella, and Enterobacter.

So It Begins

Thurs, June 15: While feeding dinner, I noticed Solo eating really really slowly, rather listlessly, & there was significant swelling developing rapidly around his throatlatch. I thought it was choke at first, but it didn’t fit; I made the first emergency call to Dr. Bob. Phone fiasco resulted in 4 tries, with me finally blurting, “PLEASE, WE NEED HELP!” (as Dr. Bob is awesome, he asked no further questions & said he was on his way).

It had been hot, I knew Solo was dehydrated, but I couldn't get anything in him. We had to tube him to deliver water, oil, & electrolytes, during which he got a bloody nose, resulting in my crossties resembling a crime scene.  No throat blockage, it looked like an allergic reaction, so he got dexamethasone, but it took about an hour (in the dark) of watching him sweat (xylazine...) & roll & generally scare the life out of me for things to begin to settle. 

The next day.  Horses have a lot of blood.  That fan never recovered.

Dr. Bob waited with me, bless him forever, leaving my farm close to midnight with instructions to give dex injections twice a day over the weekend to prevent re-occurance & call if anything changed.  We were both unsettled by the oddity of it all.

June 18:  Sunday evening feeding, Solo walked up next to me, looked sadly down at his food, then leaned into me, telling me it hurt again. Swelling reappeared, I spent most of night on phone with our clinic's other vet on call, Dr. Michelle & giving repeated shots of dex, as we thought the "reaction" had kicked back in.

He was dehydrated again after another hot day, so every hour I was holding tiny, wet, salty grain mixes under his nose, begging him to nibble on them (he gamely did). He finally took a big drink around 1 am, seeming better.  I allowed myself a few hours sleep before meeting the vet again the next day.

Emergency Hospital Admission

June 19: Dr. Michelle came out, didn't find anything apparent, we debate allergy testing pending blood panel results. Solo had been grazing & acting relatively normally, but later in the day, he stopped eating, swelling began to come back, & he wasn't drinking. By evening, the only thing clear is that we don’t understand what’s going on & he needs to go to NCSU emergency services.

He is admitted after ultrasound reveals abscess & needle aspiration brings out the stink of anaerobic bacteria.  Upper airway scope, including gutteral pouches, was clear.

Initial drainage

June 20: First abscess opened to drain through incision on back of his jaw.  Detailed oral exam revealed:

• A hole of necrotic tissue under tongue where one salivary gland (horses have six) drains in,
• Big ulcerations on both sides of his tongue & in mouth,
• Severe tissue necrosis around abscess. 

IV antibiotics, daily lavages of damaged tissue, packing of wounds with antibiotic-infused gauze, & butorphenol (horse morphine) all begin.

The most difficult part of treating this is now revealed:  this area is full of vital blood vessels (carotid, jugular), nerves that supply the face & tongue, & a myriad of other structures that you can't risk nicking via cutting.  Imagine an abscess wrapped around someone's brain stem & you have an approximation of the area we were dealing with.

Gross but pain-free

June 24 (five days in hospital): Secondary abscess under tongue discovered & opened to drain through chin.

• Has direct connection to necrotic hole under tongue, smells like a rotting corpse. 
• Low gut motility problems developed due to opiod painkillers, hydration a struggle. 
• Appetite is good, but eating is difficult & inefficient due to mass internal mouth carnage.

Translation:  he needed to poop more to avoid impaction, but had to eat more to make poop.  Bacterial culture/sensitivity results indicate Fusobacteria species (ubiquitous in mammalian mouths, guts, soil, the world, not a problem except when they get into places they are not supposed to be, common in human sore throats & tonsil infections) responding to the antibiotic metronidazole.

I thought we'd hit the lowest point.  We hadn't.

It Gets Much Worse

June 28 (nine days): At 1 am, our resident, Dr. Fowler calls to request permission for tracheostomy; Solo is in respiratory distress due to severe pharyngeal compression found on scope. This was a very bad call & a very bad night.  I thought we'd hit the lowest point.  We hadn't.

Prior to this, Solo's ability to eat was improving, he could go out for walks & be in the round pen. Skull radiographs on June 29.

Still the sexiest patient there

July 1 weekend: Solo spiked a high fever on Saturday morning & additional abscess pockets are found & opened (all draining from primary incision on jaw). Second round of bacteria cultures ordered.  This was even more disheartening as there had not been any systemic problems until the fever, it was all localized to his poor necrotic head.

July 3 (two weeks):  Following his afternoon treatment, I noticed Solo staring at his belly, which I'd never seen him do, & I alerted his team of potential colic.

• Hadn't been drinking or pooping well
• Immediately tubed, given water & Epsom salts
• Back in stall, I then saw the ominous flank twitching & fur standing on end that is Solo's sign of a systemic allergic reaction (which I've only seen once before)
• Sedated & walked in case it’s a pain response.

I then noticed his tongue is swollen & blueish, hanging out of his mouth while he stands head down.  I poked it & it was hard like a bar of soap.  It's late evening by now, we're all exhausted, I didn't know what to think, so I asked Dr. Fowler if sedation ever causes that.  He took one look & immediately called Dr. Prange, one of our lead surgeons, back in (who fortunately lives ten minutes away).

Bizarre mas on hyoid bone

Scope reveals

• Total airway collapse due to swelling; if he had not already had the trach tube in, he would have suffocated.
• Also found a mass in his left guttural pouch.  No idea where it came from or what it is, but it wasn't there in the beginning.

Dr. Prange & I had a very, very sombre conversation.  I thought we'd hit the lowest point.  We were pretty close.

Fighter

July 4:  Incredibly, unbelievably, Solo recovered after overnight solumedrol for the reaction & was chowing down on his alfalfa when I arrived.

• Most recent culture indicated Pseudomonas (nasty, resistant anaerobe, common to infections in long-term human hospital patients). 
• It was luckily responding to gentamicin in sensitivity tests. 
• Solo's eating was improving, his fever finally began to subside.

The Tunnel & The Light

July 6:  Another blow; Solo was trending dull again, not wanting to chew.  We were at a loss, knew something was missing, but had another terrible conversation.  There were few, if any, options left.  This was indeed the lowest point.  And then...

As I helped support Solo's head in the treatment stocks (staff shortages & waves of emergency cases had everyone stretched thin), Dr. Prange discovered a big abscess, possibly the original, encapsulated in very thick tissue on the inside of the mandible. Opened with a burst of foul necrotic tissue, gaseous buildup, & pus, this pocket connected to the primary drain tract.  We hoped it was our missing piece & as the weekend rolled around, we finally started to see real improvement. A foley catheter was also run up Solo's nose to drain saliva pooling from the gutteral pouch (a clever invention which worked brilliantly).

You can see the nostril button anchoring the drain - & no more IV!

Setbacks & Progress

Packed & healing

July 14 (four weeks):

• Mild colic behaviour, needed another tubing, 
• On 15^th, low albumin levels pointed to right dorsal colitis. 
• No displacement of colon, began sucralfate & misoprostol, no more hay. 
• Improvement of abscess issues continues with daily lavages.
• Eating well, begins going to paddocks.
• Injectable anitbiotics discontinued & amikacin gel on packing started. 
• Vetericyn gel added in gauze July 16.

July 24 (six weeks): After noting some dullness the previous weekend, ultrasound revealed a final (we hoped & thankfully it was) abscess Monday morning, which opened into pharynx (which was a whole lot better than if it had erupted into gutteral pouch).

• Nasal catheter was removed, no more buildup was occurring in the pouch. 
• Instead of gauze packing, pair of foley catheters placed in drain tracts to hold them open. 
• Third culture of new abscess material was ordered.

The Home Stretch

Catheters taped on

July 28: Scope revealed drain tracts healing, less unhealthy tissue (yay!). Solo was on pasture full time for most of the week & enjoying profusely, flirting with the mares, getting fat on clover.  Bacterial culture did show an extremely resistant aerobic Klebsiella, but in the absence of any clinical issues, we did not attempt treating (it would have involved even more expensive medications with questionable success).  I learned how to place catheters & flush myself for home care.

July 29 (seven weeks):  Discharge! With a big bag for daily catheter care, metronidazole, misoprostol, & follow up in a week.

We still had a ways to go.  But he was home.  And he was happy.

And he was alive.

A most wonderful sight

Progress And Setbacks

Because you can't have one without the other, at least when it comes to horses.

As I mentioned in my last post, Echo recently got a pretty big chiro adjustment.  Twice in a week, actually, because it didn't hold the first time.  I did notice some initial improvement, but there are some lingering issues that I sure wish would just quit.

He's still a little bit puffy around that side of his SI & when I was riding him last week, I could definitely feel that he wasn't quite comfortable back there.  The feeling would come & go at the trot, but was most noticeable when he swapped behind twice on his right lead canter, which he's never done before.  Nothing like a new thing to make it harder to wait & easier to worry.

See, not a waste

I talked to Dr. Bob & gave Baby Monster the rest of the week off, in combination with some bute for the inflammation & Dr. Bob's Magical Steroid Creme that he concocts.  We're supposed to give it one more week & if it doesn't improve, we'll reconvene. 

Yeah, yeah, mantra.  I still hate waiting.

I don't think it's anything huge, the adjustments were pretty dramatic.  It does bother me a bit that he still feels uncomfortable with certain things.  But I also know that the unevenness was going on for a while, so those are big muscles that have to be retrained & retoned to do their job in a different way.  I'm pretty squarely on the worry seesaw, so am trying to be patient & not imagine too many nightmarish scenarios.

Trying.

In positive news, y'all, this horse looks really good.  Finally!  He's 99% shed out & his summer coat shines like a new penny.  I can no longer count his ribs from any angle & am at long last able to reduce his rice bran helpings.  And...there are muscles!  And a neck!!!  The vienna reins are such a wonderful tool for this, if you aren't familiar with them, you can read our primer on them here.

Getting even sexier

Under saddle, he's now working easily for 40 minute stretches, sometimes a little longer, without brain dissolution.  Yay for aging (I don't get to say that very often)!  Our skillset now includes:

• Working on a steady contact & able to bend (mostly) through our body both ways at walk & trot,
• Up & down transitions W/T/halt are prompt & balanced, no bracing in bridle, back stays up,
• Confirmed lateral aids for basic leg yield at the walk, they exist at trot, I think they'd be better if rider was a little more organized about them,
• Turn on forehand (one step at a time) with minimal fussing (this was very irritating for him for whatever reason),
• Picking up both canter leads correctly without a ground pole (I think, haven't had too many tests yet),
• W/T/C in a steady rhythm with reasonable balance, while remaining light in the bridle,
• Jumping small x-rails & logs with no rushing,
• And we are dang ground pole champions -- with sproing!

Showing that ground pole who's boss

This may not seem like a lot for 15 months, but I'm pretty happy with it because (a) we had a lot of other body challenges to deal with & (b) this has been what HE was ready for.  I want to do a separate post on that topic, but it really is different for different horses.  I also work my horses in my top field -- there are slopes, uneven footing, clumps of grass -- but I welcome these challenges because it helps me a build a stronger, more balanced partner in the long run.  If he can maintain himself on a bumpy, downhill slope, he will find a flat, boring arena so easy, he won't even have to think about it.

I've also spent a LOT of time on basic details, having learned from Solo & Encore that any training holes will always catch up later.  Things like maintaining balance in the down transition to walk without me holding him together, like freeing up & gaining control of each individual leg so I can move it where I want, like making sure a half halt gets a clear & instant response in every gait.

Plus lots of this for strength & well-roundedness

Spending time on these not-very-exciting details now means that I don't have to backtrack later.  It means that if I need to leg yield out in canter to get a better line to a jump or rebalance a gallop on course or teach walk-canter-walk transitions, the building blocks are already there to make my life safer & easier.

Now I just need his bum (well, the top of it) to chill & be happy so we can get back to it!

Just Wait

I am trying to adopt these two simple words as my Equine Mantra. 

Sigh, the gaping chasm between "simple" & "easy."

As you spend time trying to get horses to do things or, you know, keep them alive & healthy, you soon realize that patience is indispensable at every step of the process.  It's a near-guarantee that if you attempt to rush something, be it healing or trailer loading or a jump, the horse deities shall be vexed & it will now take you twice five times as long.  Doubly so with young horses.  

I excel at vexation

I am not always great at patience.

To summon it, I need reminders that are easy to remember.  Bonus if they are something I can chant softly (or loudly, as the case demands) to myself, which forces me to inhale AND exhale.

Echo, still a 3-yr-old when he came to me, is both the youngest horse I've owned & the first I've gotten less than 30 days off the track.  As a result, we are both learning a lot.  And in the process of all these "firsts", which of course come with their share of stress, I am seeing over & over & over that if I can just take a breath & wait, if I allow time its own pace, progress will, well, progress.  

Example 1:

Echo has been painstakingly slow to shed.  Dull, ugly, fuzzy winter hairs clung stubbornly to his withers, back, & sides.  Solo has already completed his transition to his slick, shiny(er) summer coat.  I glared at Echo's offending fur as I scraped & scraped with the shedding blade & the grooming block & the Tiger Tongue & the curry comb.

Maybe his thyroid is all messed up!  My brain effortlessly channels my old friend Anxiety Girl at the least opportunity.  Maybe he has freakishly early Cushings!  Maybe he has some weird glandular tumour!  Maybe I need to get him tested for All The Terrible Things?!!  

Just. Wait.

A few weeks later, with the help of my trusty Slick N' Easy, he is finally blowing out the last of those dull hairs.  The sleek, bay shine underneath is a brand new first for us, thanks to 15 months of Triple Crown & rice bran.

Freshly rained on, with a few, uh, nibbles from Solo

Example 2:

Two weeks ago, Echo got his second chiropractic adjustment.  His sacrum was all kinds of cattywompus, the reason he'd been tracking short on his left hind for several months.  Dr. Bob did lots of stretches of his haunches, hips, & back, but it was still a big adjustment, with lots of mashing.  Some soreness afterwards was to be expected; not a big deal, I had to be out of town for work anyway.

After a week, he was still really tight in that whole quadrant & moving stiffly in the hip.  I had been massaging & stretching, but... There were some improvements, but some things seemed almost worse.  I should probably just wait, but just in case, I'll call Dr. Bob & ask.  Guess what he said?

Just. Wait.

Today, another week later, he is more fluid in that hip & stepping under himself better with that left leg.  He's more willing to bend left through his body & stretch the tight right side.  Both trot diagonals now feel pretty similar.  I bet he'll feel even better a month from now & that's just exciting.

More of this, please! Except without my leaning.

I could list at least 87 more examples.  Hooves could probably be a treatise in themselves.  But you get the idea.  Sometimes, many times, things just take time.  Not the time that we WANT; in my experience, part of my brain nearly always expects things in an unreasonably short time.  Often, digging out just a little more patience can carry us through to the other side.

I'm not going to say, "Don't worry!"  That would be laughable -- if you have a horse in your life, worry is practically a job in & of itself!  It would be nice if they didn't feed our neuroses by fulfilling them quite so often. I can dream. And of course, waiting is not always applicable, use of judgement is required.

Truth for all vet things

But I can honestly say it is helping me to worry a little tiny bit miniscule amount (hey, baby steps) less in many equine situations by giving myself this simple, even if not easy, assignment:  before unleashing apocalyptic reactions...

Just. Wait. 

You just might be pleasantly surprised.

It's all good (for now, heh).  Just slightly blurry.