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338 Equine Compendium April 2002

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Equine West Nile Virus:


Diagnosis and Treatment
Corrina S. Snook, VMD species has been significant, and birds which confirmed cases of equine
New Bolton Center act as sentinels for virus activity. The WNV encephalomyelitis occurred in
School of Veterinary Medicine virus, which is an arbovirus (specifi- 2001 include Alabama, Connecticut,
University of Pennsylvania cally a flavivirus) of the Japanese Delaware, Florida, Georgia, Illinois,
encephalitic complex, was first iso- Indiana, Kentucky, Louisiana, Mary-
ABSTRACT: West Nile virus was first lated in Uganda in 1937.1 Its appear- land, Massachusetts, Mississippi,
identified in the United States in 1999 ance in the United States marked the New Jersey, New York, North Car-
when it triggered an epizootic of first time the virus had been seen in olina, Pennsylvania, Rhode Island,
encephalitis and meningitis, causing the western hemisphere.2 Although Tennessee, and Virginia.3 Four hun-
death in humans and horses. Since WNV can infect many animal dred sixty-seven cases have been
1999, both the number of affected species, including ruminants, camels, reported in Florida alone.a Although
horses and the geographic range have dogs, nonhuman primates, rodents, final figures for cases occurring in
increased dramatically. West Nile virus
bats, pigs, rabbits, and amphibia,1 2001 are not yet available, new cases
infection in horses may be subclinical, or
signs may range from mild peripheral
clinical disease is most
neurologic disease to encephalitis. Most important in birds,
KEY POINTS

affected horses recover. Supportive care horses, and humans. West Nile virus is currently considered endemic
is the only treatment currently available Birds can develop a in the United States.
for horses, although new modalities are viremic state capable of The virus will likely continue to spread through-
being explored in humans that may be infecting mosquitoes, out the country in ensuing vector seasons.
adapted to horses in the future. Ante- thereby propagating
mortem diagnostic techniques that moni- the virus.1
tor the serologic status of suspected were still being reported in Florida in
cases are improving. An equine vaccine Spread of the Virus in the December.
is available under conditional licensure
United States The virus isolated in the 1999 epi-
and may prove beneficial in decreasing
the incidence of disease. Studies on the
In 2001, WNV encephalomyelitis zootic in the United States had a high
efficacy of this vaccine are still in the was reported in more than 700 degree of genomic sequence similarity
early stages. horses in 19 states.a This represents a to an isolate that circulated in Israel
significant increase from the 1999 between 1997 and 2000.4 To date,
epizootic in which 25 horses were the virus has been found in numerous

W
est Nile virus (WNV) affected in only New York state and mosquito species in the United
infection, initially an epi- the 2000 outbreak in which 60 horses States5 and worldwide. Since hiber-
zootic occurring in New in seven states were affected. States in nating Culex mosquito species were
York City in 1999, has become aPersonal communication: Crom RL, found to contain the virus in New
endemic in the United States. The York, there is strong evidence to sup-
DVM Veterinary Services, Emergency
virus causes encephalitis, meningitis, Programs Animal and Plant Health port the overwintering of the virus as
and death in both humans and Inspection Service, USDA, Riverdale, the means of maintaining an endemic
horses. The death rate in avian MD, February 2002. mosquito population. 6 The exact

SERIES Debra Deem Morris, DVM, MS


EDITOR North Jersey Animal Hospital, PA, Wayne, New Jersey
Compendium April 2002 West Nile Virus 339

means of harboring the virus, or serum. In equine patients, sero- that are not drinking or eating. The
whether by transovarial vertical trans- conversion from negative to positive use of corticosteroids in affected
mission to offspring or by mosquitoes or a fourfold or greater rise in paired horses is controversial based on find-
taking a blood meal just prior to sera taken 10 to 14 days apart indi- ings in humans. Some cases of
hibernation, is not well known. 6 cates recent WNV infection. Neu- human Streptococcus pneumoniae and
Migratory patterns of birds have tralizing antibody may persist for Haemophilus influenzae bacterial
likely helped to establish the virus in many months in horses and for up to meningitis have benefited from the
other areas of the United States. 2 years in humans.9 The IgM-capture use of corticosteroid therapy in con-
ELISA is a valuable tool for detecting junction with appropriate antimicro-
Diagnosis recent infections. The technique is bials.10 One report of viral encephali-
WNV infection in horses may be species specific but will often cross- tis in humans indicated a favorable
subclinical or may produce diseases react with other closely related fla- response to treatment with corticos-
ranging from mild peripheral neuri- viviruses. IgM antibodies develop teroids when the CSF contained
tis to encephalitis. Clinical signs early after infection with the virus more than 15% of CD4+ CD26+
reported include hindlimb and fore- and do not persist until the next vec- memory helper T cells, supporting
limb ataxia, recumbency, difficulty tor season (antibodies last less than 3 the involvement of autoimmune
rising, hyperesthesia, altered menta- months).9 Hemagglutination inhibi- mechanisms. 11 Other reports state
tion, hyperresponsiveness to sound, tion and complement fixation tests that the use of corticosteroids may be
muscle fasciculations over the muz- are also available.9 Virus isolation in contraindicated in patients with viral
zle and triceps region, drooping serum or CSF is not routinely per- central nervous system infections.12
lower lip, stupor, falling to the formed in horses because their New therapeutic modalities being
knees, blindness, and seizures. 7 viremic stage is short and low levels explored in humans with WNV
Some human patients have low of virus are present.9 WNV infection encephalitis include intravenous
serum sodium levels that are should be suspected in unvaccinated immunoglobulin containing high
thought to result from the syndrome horses with positive antibody titers. titers for WNV antibody and rib-
of inappropriate antidiuretic hor- Postmortem diagnosis by virus isola- avirin. Ribavirin, a guanosine ana-
mone secretion. 5 To the authors tion on chilled fresh samples of logue, has in vitro antiviral activity
knowledge, this has not been brainstem, cerebellum, cerebrum, against a broad spectrum of RNA
reported in horses. Fever has been and spinal cord is possible; histologic and DNA viruses. High doses of rib-
reported in less than 25% of affected examination of fixed tissues should avirin have been shown to inhibit
horses. This is in direct contrast to also be performed. Because of the WNV cytopathogenicity and viral
human infection in which fever is zoonotic potential, practitioners who replication in human neural cells in
found in a high percentage of cases. perform field necropsies should fol- vitro.13 One report has shown rib-
In humans, a cerebrospinal fluid low the guidelines established by the avirin therapy to be a factor associ-
(CSF) tap is often performed for USDA to avoid exposure to the virus ated with death in Israeli patients
diagnostic purposes and to rule out through contact with potentially with WNV encephalitis. 14 Con-
bacterial meningitis/encephalitis. infected tissues.9 trolled studies demonstrating in vivo
Reports of human CSF findings are efficacy have not been performed.
consistent with viral infection, Treatment Specific antiviral or immunoglobulin
including pleocytosis (often neu- There is no established protocol for therapies for equine WNV enceph-
trophilic) with increased total pro- treating WNV encephalitis or menin- alitis are not likely to be available
tein count.8 There are few reports of gitis in humans or horses. Supportive soon. The single most important
CSF findings in affected horses. In a care, which may include fluid therapy treatment of equine patients is to
study of CSF from four horses with and ventilatory support, is the gener- prevent severely ataxic animals from
WNV infection in 2001, CSF was ally accepted means of treatment in injuring themselves. Sling support
reported to be normal in three humans. Equine patients have been may be beneficial in horses that have
horses but was xanthochromic with treated with intravenous dimethyl difficulty rising. With supportive
an increased total protein in one.7 sulfoxide (for purported antiinflam- care, the prognosis for clinically
Antemortem diagnosis of WNV matory effects on the central nervous affected horses has been fairly good,
infection is based on serologic evalu- system) and NSAIDs (e.g., phenylbu- with a total death rate of 39%
ation. The serum plaque reduction tazone, flunixin meglumine). Intra- reported for 1999 through 2000.7 An
neutralizing antibody test measures venous fluid and nutritional support accurate death rate for the year 2001
virus-neutralizing antibody in CSF are necessary in somnolent animals is not yet available. Most reports
340 Equine Compendium April 2002

indicate that surviving horses return ditional vaccine was released in early Inspection Service: West Nile virus in
to complete function within a few fall 2001, over one million doses have equids in the northeastern United
States in 2000. Available at: www.aphis.
weeks to months after the onset of been distributed throughout the usda.gov/vs/ceah/wnvreport.pdf;
disease. Horses with rapid progres- United States. To date, adverse effects updated August 2001.
sion of clinical signs to recumbency of the vaccine are few and are com- 5. Craven RB, Roehrig JT: West Nile
have shown an unfavorable outcome. monly seen with other killed virus virus. JAMA 286(6):651653, 2001.
vaccines. Challenge studies are 6. Nasci RS, Savage HM, White DJ, et al:
Prevention and Control required for full licensure but have West Nile virus in overwintering Culex
Prevention and control measures not yet been performed. Fort Dodge mosquitos, New York City, 2000.
recommended by the USDA for has submitted an application to the Emerg Infect Dis 7(4):13, 2001.
WNV include reduction of mosquito USDA to perform challenge studies 7. Snook CS, Hyman SS, Del Piero F, et
breeding sites on farms, thereby designed to demonstrate the efficacy al: West Nile virus encephalomyelitis
decreasing the exposure of horses to and potency of the vaccine. Unpub- in eight horses. JAVMA 218(10):
15761579, 2001.
adult mosquitoes, and vaccination.15 lished data demonstrate an increase
Steps to reduce mosquito breeding in neutralizing antibody in horses 8. Weiss D, Carr D, Kellachan J, et al:
Clinical findings of West Nile infec-
sites include eliminating standing vaccinated intramuscularly with the tion in hospitalized patients, New York
pools of water, maintaining cleanli- WNV vaccine twice, 3 to 6 weeks and New Jersey, 2000. Emerg Infect
ness of watering troughs, and apply- apart.b Each state has restrictions on Dis 7(4):654658, 2001.
ing larvicidals to any pools of water the distribution and sale of the vac- 9. Ostlund EN, Andresen JE, Andresen
that are difficult or impossible to cine, and individual state veterinari- M: West Nile encephalitis. Vet Clin
remove. Screened housing, use of ans should be contacted prior to vac- North Am Equine Pract 16:427442,
mosquito repellents, and reducing cine procurement and use. This is 2000.
the horses access to the outdoors may especially important in states in 10. Zia W, Romergryko GG: Central
help prevent exposure to adult mos- which the virus has not yet been nervous system infections: A critical
care approach. Curr Neurol Neurosci
quitoes.15 The mosquito vector and known to circulate and the serologic
Rep 1:577586, 2001.
the times at which animals are most status of horses has not been assessed.
at risk of virus exposure have not It is likely that WNV will persist in 11. Matsui M: Infection in the central
nervous system and corticosteroid ther-
been definitively determined in the western hemisphere and continue apy. Clin Neurol 39(1):2628, 1999.
horses. In 2000, the Culex pipiens and to spread throughout the United
12. Nishikawa M, Ichiyama T, Hayashi T,
Culex restuans mosquito species were States. Diagnosis of the disease has et al: Intravenous immunoglobulin
most frequently identified as WNV greatly improved since the virus was therapy in acute disseminated
positive.16 The 2001 USDA report first seen in this country, and vaccina- encephalomyelitis. Pediatr Neurol
suggested that horses infected with tion may prove helpful in preventing 21(2):583586, 1999.
WNV are more likely to be turned the disease in horses. 13. Jordan I, Briese T, Fischer N, et al:
out at night or used as pleasure Ribavirin inhibits West Nile virus
mounts.4 The presence of blackbird References replication and cytopathic effect in
1. Peiris JS, Amerasinghe FP: West Nile neural cells. J Infect Dis 182:1214
roosts and waterfowl aggregations 1217, 2000.
fever, in Beran GW, Steele JH (eds):
within a half mile of the affected Handbook of Zoonoses. Section B: Viral, 14. Chowers MY, Lang R, Nassar F, et al:
horses premises was of marginal sig- ed 2. Boca Raton, FL, CRC Press, Clinical characteristics of the West
nificance.4 The incidence of WNV in 1994, pp 139148. Nile fever outbreak, Israel, 2000.
birds and humans may prove as sen- 2. Centers for Disease Control and Pre- Emerg Infect Dis 7(4):675678, 2001.
tinels for equine cases. WNV has vention: Update: West Nile-like viral
15. USDA Animal and Plant Health
been found in birds at least 3 months encephalitisNew York, 1999.
Inspection Service: Prevention and
MMWR Morb Mortal Wkly Rep
prior to infections in humans.17 Dur- 48:944946, 1999.
control of West Nile infection in
ing the 1999 and 2000 U.S. out- equine and other livestock or poultry.
3. USDA Animal and Plant Health In- Available at: www.aphis.usda.gov/oa/
breaks, WNV infections in humans spection Service: Update on the current wnv/prv.html; updated 2001.
and horses peaked in August and status of West Nile virus. Available at:
www.aphis.usda.gov/oa/wnv/wnvstats. 16. Peterson LR, Roehrig JT: West Nile
September, respectively.16
html; updated November 20, 2001. virus: A reemerging global pathogen.
On August 1, 2001 the USDA Emerg Infect Dis 7(4):611614, 2001.
issued a conditional license to Fort 4. USDA Animal and Plant Health
17. Eidson ME, Kramer L, Stone W, et al:
Dodge Animal Health, Fort Dodge, bPersonal communication: Carlson M, Dead bird surveillance as an early
Iowa, for production of a WNV vac- Fort Dodge Industries, Fort Dodge, IA, warning system for West Nile virus.
cine for use in horses. Since the con- January 2002. Emerg Infect Dis 7(4):631635, 2001.