Hot Tamale required Mucho Dinero

This is going to be a rather technical and possibly tedious blog entry, but I think overall useful to include here.

Falconry can be seen as very glamorous, but it can also have its share of heartaches and disappointments. The incredible highs are all too often balanced with devastating lows. At the time I'm putting this finally in order and publishing it still remains to be seen if I have a falconry bird on my hands.  At least, I believe with the help of an excellent vet at the University of Minnesota Raptor Center (UMRC), we saved his life.

Shortly after trapping my little hawk for this season, who I named Tamale, and settling with what I could find as the trapping potentials were few and far between, I noticed something was just not right about him.  Sure, he was under weight at just 800 grams off the trap. As I have been working with him through this illness, and started back his training after, I have determined his approximate hunting weight is about 960 grams. We are usually shaving weight as we train, but I had to start our relationship by feeding him up.  Still, something just didn't seem right, and then there was some blood in his mutes.  I got him in to be seen by a veterinarian at UMRC where it was determined that he most likely had Aspergillosis.  This is a devastating fungal disease for birds, usually fatal. I lost my second hawk way back in 2004 to its ravages.  With this in mind, treatment was started with hopes he could be saved. 

11/2/2020 Initial visit medical notes

Interpretation: Tracheal culture on Sab-Dex plate: Results pending. Fecal: No parasites seen, clostridium overgrowth 2+. CBC: Mildly elevated total solids at 4.0 g/dL. Moderate-severe leukocytosis at 62,750 characterized by a heterophilia and monocytosis with normal morphology, low level leucocytozoon infection, 2+ anisocytosis. Rads: VD and lateral whole body radiographs available for review, adequate positioning and technique. On the VD radiograph there is severe increase in soft tissue opacity in the lung and air sac fields; the left side is almost completely filled with increased soft tissue opacity where there should be air opacity with very little to no air opacity visible; the right side has moderate patchy increase in soft tissue opacity in the right lung fields and extending to the area of the R caudal thoracic air sac. On the lateral radiograph there is diffuse increase in soft tissue opacity overlying the proventriculus and liver in the caudal thoracic air sac and increase soft tissue opacity dorsal to the heart base in the cranial thoracic air sac. No musculoskeletal abnormalities noted.

Describe: Severe lower respiratory tract disease, likely aspergillosis - increased respiratory rate and effort, inspiratory wheeze, radiographic abnormalities, leukocytosis characterized by a heterophilia and monocytosis. Other differentials include other fungal pneumonia vs. bacterial pneumonia vs. viral vs. neoplasia vs. other. Clostridium overgrowth, loose fecal output, one episode of frank blood in mutes - possible GI parasite infection, no eggs seen on todays fecal float, does have bacterial imbalance, will treat later with metronidazole if needed and deal with aspergillosis infection first, as this is not the birds most pressing medical problem. Thin body condition - improving.

Specify: Meloxicam 2 mg/kg PO BID for 14 days then as directed (7.5mg tablet, 1/4 tablet) - anti-inflammatory to decrease inflammation associated with aspergillosis infection. Voriconazole (50 mg tablet, 1/4 tablet) 14.5 mg/kg PO BID for at least 14 days (likely 21 days) then as directed - anti-fungal medication to treat suspected aspergillosis. Enrofloxacin (22.7mg tablets, 1/2 tablet) 13 mg/kg PO SID for 21 days - antibiotic to cover for possible secondary bacterial pneumonia given severity of respiratory disease

Client communication: Discussed exam findings and results as outlined above. Bird is more sick than he appears externally and has a pretty advanced case of respiratory disease, likely respiratory aspergillosis. Unsure if the bird will survive or not. Have had birds at this stage respond well to medications and recover, and have had some birds get worse with treatment and either die or elect euthanasia. Guarded prognosis. Will need to monitor closely and see how he responds to treatment. Offered hospitalization and told client that would be the ideal treatment if possible - hospitalize for intensive care and oxygen support - quoted ~$50 per day and 3-5 day hospital stay to start treatment. Since bird is still eating could try treatment at home as well with close monitoring. Client declines hospitalization and elects to treat at home. Recommend recheck exam in about 2 weeks if doing well at home to see how his bloodwork and x-rays are improving with treatment to help direct the duration of treatment. If discontinue the voriconazole too early risk the infection coming back. Monitor closely at home - if respiratory rate or effort worsens, bird stops eating, or other abnormalities noted contact TRC - might require hospitalization. Discussed that bird has a bacterial imbalance in GIT but will treat primary problem first and sometimes the GI signs will sort themselves out after the systemic disease is treated. Can address later if does not resolve and if bird responds to treatment

I know this image is hard to read if you have no skill at x-rays, and even if you do it can still be difficult. This is filmed with the bird anesthetized and laying on his back. Mostly, just note that in the middle and to the side on the left as we see it is a darker area. This is lung above and air sac below (birds have many air sacs throughout their body). Open air space on an x-ray is dark. Note on the right there is NO DARK SPACE. His entire left lung and air sac is opaque. He was a very sick boy! However, other than getting out of breath easy, he was not showing it. I elected to begin treatment at home, fully prepared that he could get worse and die. He began anti-fungal treatment, the most important drug, as well as an anti-inflammatory and antibiotic in case of opportunistic infections.  He did well for the two weeks. I even mixed up a 3% saline solution and gave him breathing treatments like I would do for my human patients. He did well and was seen in follow-up in two weeks.

11/16/2020 Follow-up:

 Interpretation: CBC- Improved. WBC count is now WNL with a normal differential and normal total solids. Within reference interval for the species. Radiographs- VD and lateral whole body radiographs available for review. Adequate positioning and technique. Bird has gained weight since first set of radiographs so intra-coelomic fat stores and increase overlying musculature make interpretation of the coelomic cavity and comparison to images obtained on 11/2/2020 a little more challenging. BCS 3.5/5 - improved from previous. Static increased bone opacity within the medullary cavity of the right humerus compared to the left - same as previous radiographs. Respiratory tract on the VD radiograph is still abnormal but has improved - increased soft tissue opacity in the right caudal lung fields has improved compared to previous, now minimal mild residual increase soft tissue opacity in that area on today's rads; the severe diffuse increase in soft tissue opacity in the left lung and air sac fields has improved but is still moderate-severely increased, there is more air space visible than previous both cranial and caudal but is still moderately increased soft tissue opacity on the entire left side of the coelomic cavity including all lungs and air sac fields. On the lateral radiograph there is significant increase in soft tissue within the coelomic cavity caudally compared to previous images - likely intracoelomic fat. The poor serosal detail and increased soft tissue opacity overlying the heart base and overlying the upper GIT and liver has improved - the heart base appears relatively normal now. Still some air sac lines visible overlying the proventriculus on the lateral radiograph. No other abnormalities noted.

Describe: Severe lower respiratory tract disease, likely aspergillosis - Improving with treatment. On 11/2/2020 resting respiratory rate was 60 b/min, today was 28 b/min; on 11/2/2020 auscultation was abnormal both awake and under anesthesia, today auscultated normally under anesthesia; CBC has returned to normal; radiographs have improved but are still abnormal and still have evidence of moderate persistence lower respiratory tract disease. Bird still has increased respiratory rate and effort and wheezes when stressed. Other differentials include other fungal pneumonia vs. bacterial pneumonia vs. viral vs. neoplasia vs. other. Clostridium overgrowth, loose fecal output, one episode of frank blood in mutes - Normal mutes in giant hood today, no additional blood in mutes reported. Did not repeat fecal cytology today. Thin body condition - resolved

Specify: Complete 21 day course of enrofloxacin as previously prescribed (21 days total). Decrease meloxicam to 2 mg/kg PO SID until gone (10 more days). Continue voriconazole (50mg tablets, 1/4 tablet, 12.5mg) 12.5 mg/kg PO BID until further notice. Recommend recheck radiographs in 3 weeks. Recommend continuing BID voriconazole until bird no longer has increased respiratory effort/wheezing with stress and/or until radiographs return to normal, or until radiographs do not show any signs of active respiratory disease. In general, the recommendation for treating respiratory infections is to continue antibiotics/antifungals until 2 weeks past normal radiographs and/or past resolution of clinical signs. Bird may have permanent respiratory abnormalities on radiographs if walls off an area and makes a chronic granuloma. 

Client communication: Relayed information outlined above. Emailed client a copy of the record and radiographs (client is a respiratory therapist). Discussed that the bird may have chronic physical limitations due to scaring of the respiratory tract due to the severity of the respiratory illness. Given species and hunting style less of a concern than it would be for a bird like a peregrine or gyrfalcon. Will need to monitor progress and see how he responds to gradually introducing physical activity when the respiratory disease is resolved.   

As you may notice, there is some darkening of the left lung (on the right as we look at it), which is improvement, but still opaque, so not out of the woods yet. The medication for the inflammation was completed. He would continue to receive an antibiotic, and of most importance, the antifungal treatment was ongoing.

12/8/2020 Three Weeks and Two Days:

Interpretation: Rads- VD and lateral whole body radiographs, adequate positioning and technique. Significant improvement in respiratory tract compared to 11/2, and continued improvement when compared to 11/17 rads. On the VD radiograph the right lung and air sac fields have returned to normal (On 11/17 there was still mild diffuse increase in soft tissue opacity in the right lung fields on the VD radiograph). There is a soft tissue opaque mass effect present at the cardio-hepatic waist on the left side - appears to be consolidation and granuloma formation from the previous large, severe increased soft tissue opacity in this area. Significant improvement from 11/17 radiographs on the left side on the VD view - significant decrease in soft tissue opacity in the left lung fields, consolidation of the soft tissue mass effect in the region of the cardiohepatic waist, and decrease in soft tissue opacity in the right abdominal air sacs. The lateral view is now WNL - the mild air sac lines that were present on 11/17 have resolved and there is normal serosal detail overlying the heart base, lung fields are WNL on lateral rad today.

Describe: Severe lower respiratory tract disease, likely aspergillosis - significant improvement with treatment. Bird has a normal RR/RE at rest, and auscultates normally under general anesthesia; still has mild respiratory wheeze when exerts himself; radiographs have significantly improved compared to previous.

Specify: Decrease voriconazole to 12.5 mg PO SID (by mouth once daily) for 3-4 more weeks. At the end of this week, start gradually introducing exercise and monitor the birds response. As his cardiovascular and respiratory capacity gradually improves with exercise (meaning he is less winded with the same amount of exercise he did a few days prior), then gradually increase the intensity of exercise over a period of 3-4 weeks. Send DFK an update on clinical status at about 2.5-3 weeks; depending how bird is doing clinically with exercise and how quickly his respiratory endurance has improved will help direct how long to continue the once daily voriconazole to ensure that fungal pneumonia/aspergillosis airsaculitis is fully resolved prior to Next diagnostics discontinuing. : As long as bird continues to do well clinically, no recheck.

His final x-ray shows a good dark outline of both lungs. His doctor did indicate he has an area of most likely what is called granuloma, or essentially scarring in his lung. She outlined it below, which is good as I would not have noticed the difference. Because his species are ambush hunters, usually attacking from a sitting perch, and not so much on the wing like a falcon would hunt, this possibly permanent lung damage may not impact his ability to find food.  

It remains to be seen if he will hunt for me under falconry conditions. My little Tamale cost me Mucho Dinero. Hopefully his care will pan out for us both.

Above is one of his training sessions just prior to us reaching a good hunt weight. There is still some hesitation, but you can see he can fly just fine. He gets pretty excited when he sees the lure, just didn't fly in right away. Since this video was shot we've made progress.