Medical management of hypovitaminosis D with cholecalciferol and elastic therapeutic taping in red-legged seriema (Cariama cristata) chicks.
Key words: hypovitaminosis D, cholecalciferol, elastic therapeutic taping, avian, red-legged seriema, Cariama cristata
Three hand-reared, 50-53-day-old, red-legged seriema (Cariama cristata) chicks were presented to the Saint Louis Zoo's veterinary hospital after keepers reported acute lameness and reluctance to ambulate. All 3 chicks were artificially incubated because the parents unexpectedly clutched during inclement weather. The chicks were housed indoors at the time of presentation and were fed a diet consisting of mice, crickets, dog food, mealworms, and Nebraska feline diet (Central Nebraska Packing Inc, North Platte, NE, USA). Chick 1, the oldest chick at presentation (53 days old), was hesitant to stand and ambulated by partially bearing weight on both wings. Chick 2 (50 days old) was lame on the right leg 3 days before presentation and was initially treated empirically with meloxicam (0.2 mg/kg PO for 3 days; Metacam, Boehringer Ingelheim Vetmedica, St Joseph, MO, USA) after physical examination revealed no concerning orthopedic or soft tissue abnormalities. (1,2) After 3 days, the lameness improved; however, repeat physical examination revealed a valgus limb deformity of the left leg. Chick 3 (52 days old) demonstrated no clinical signs. This chick was evaluated at the veterinary hospital based on lameness and angular limb deformities documented in the clutch mates.
For examination, each bird was induced with isoflurane in oxygen delivered by facemask, and an endotracheal tube was placed for anesthesia maintenance. A blood sample was collected for complete blood count (CBC), plasma biochemical analysis, and 25-hydroxycholecalciferol (Michigan State University Diagnostic Center for Population and Animal Health, Lansing, MI, USA) from the jugular or medial metatarsal vein. Results from initial blood tests showed all 3 seriema chicks were deficient in vitamin [D.sub.3], had mildly elevated creatine kinase levels, and were hyperglycemic; total calcium and ionized calcium concentrations were unremarkable (Table 1). (3,4) Physical examinations revealed all birds were in good body condition (weight range = 1.038-1.168 kg) with excellent plumage. Chick 1 had multiple orthopedic abnormalities, including deviation of the distal keel to the left, bilateral swelling of the tibiotarsaltarsometatarsal joints, and prominent lateral swellings of the proximal metaphyses of the tarsometatarsi. Chick 2 had a 15[degrees] tibiotarsaltarsometatarsal valgus abnormality and external rotation of the left leg. Palpation of the gastrocnemius muscle revealed tendon laxity immediately proximal to the tibiotarsal-tarsometatarsal joint. Physical examination of chick 3 was unremarkable, aside from subjectively increased swelling of the tibiotarsal-tarsometatarsal joints bilaterally.
[FIGURE 1 OMITTED]
Orthogonal-view, whole-body radiographs were performed at initial presentation for all 3 chicks, and all had decreased long bone opacity. Chick 1 demonstrated increased radiolucency of the long bones of the right and left leg with the proximal metaphyses of the tarsometatarsi most severely affected. The medial and lateral cortices were poorly delineated, and lateral deviation of the proximal tarsometatarsi was present bilaterally (Fig 1). Chick 2 demonstrated left proximal tarsometatarsal metaphysis swelling. A greenstick fracture was present on the medial cortex of the left tarsometatarsus at the junction of the diaphysis and proximal metaphysis (Fig 2). Chick 3 demonstrated relatively minor radiographic changes, including increased radiolucency of the proximal metaphyses bilaterally (Fig 3).
Based on clinical signs, radiographic findings, and interpretation of plasma vitamin D levels, treatment for hypovitaminosis D and orthopedic abnormalities associated with osteodystrophy were initiated immediately. All birds were administered cholecalciferol (vitamin [D.sub.3], 5000 IU IM, Taylor Pharmacy, Winter Park, FL, USA). (5) Oral vitamin [D.sub.3] (200 IU PO q24h for 88 days, D-Vi-Sol, Mead Johnson & Company LLC, Evansville, IN, USA) was initiated 5 days after cholecalciferol administration. An ultraviolet B (UV-B) light (ReptiSun 10.0 UV-B T5 High Output Linear Lamp, Zoo Med Laboratories, Inc, San Luis Obispo, CA, USA) was placed in the enclosure, which was partitioned to a smaller size once daily for 45 minutes to encourage the chicks to stand directly under the light. The light was positioned 95 cm from the ground, 49 cm from the birds' heads, and 57 cm from the birds' backs. A handheld UV-B meter (Solarmeter model SM 6.2, Solartech Inc, Harrison Township, MI, USA) indicated an intensity of 20 [micro]W/[cm.sup.2] at the ground and 50 [micro]W/[cm.sup.2] at the head of the birds.
[FIGURE 2 OMITTED]
Chick 1 was treated with parenteral fluids (Normosol-R 30 mL SQ; Hospira Inc, Lake Forest, IL, USA), meloxicam (0.25 mg/kg IM), and buprenorphine (0.025 mg/kg IM). (1-2,6,7) Elastic, therapeutic tape (Kinesology tape, McDavid Inc, Woodridge, IL, USA) was placed on the right leg in an attempt to correct the varus deformity and stabilize the tibiotarsal-tarsometatarsal joint. Elastic tape stripes, measuring 1 cm wide, were placed on the medial and lateral aspect of the leg extending from the mid tibiotarsus to the distal tarsometatarsi. The lateral, elastic tape stripes were placed under 15% tension, and the medial stripes were placed with 0% tension across the tibiotarsal-tarsalmetatarsal joint. A single elastic tape stripe was also placed in a circumferential pattern extending from the mid tibiotarsus to the distal tarsometarsi. (8) Two days after initial presentation, chick 1 was completely nonambulatory, and the previously placed medial and lateral elastic tape stripes were displaced cranial to the tibiotarsal-tarsometatarsal joint. The cranial displacement of the elastic tape was most noticeable when the leg was in a flexed position. The varus deformity of the left leg was more severe. The elastic tape was immediately removed from the patient and repeat anesthesia and radiographs were performed in a similar manner to the day of presentation. Orthogonal-view radiographs of both legs revealed significant changes to the right leg with continued, increased radiolucency of the right proximal tarsometatarsal metaphysis and greenstick fractures of the lateral and medial cortices of the metaphyses (Fig 4). Meloxicam (0.5 mg/kg IM) and buprenorphine (0.025 mg/kg IM) were administered. The medial and circumferential tape stripes were not replaced after day 1. Elastic tape was replaced on the lateral aspect of the tibiotarsustarsometatarsus with slight modifications. The tape was placed caudal to the lateral tibialtarsal condyles, and 1-cm stripes of white athletic tape were placed immediately proximal and distal to the tibiotarsal-tarsometatarsal joint, perpendicular to the therapeutic elastic tape, to prevent cranial displacement of the elastic tape stripes. A custom sling was constructed with an empty recycling bin (38 x 51 x 31 cm) and a nonslip rug pad. Briefly, the nonslip rug pad was placed over the top of the bin and attached with large binder clips. Two holes (6x6 cm) were cut in the rug pad and the bird was gently placed on the rug pad, resulting in a suspended patient with the legs in near full extension. Placing the patient in a sling allowed the bird to be positioned off the ground, which prevented continued pressure on the keel and allowed the tibiotarsus-tarsometatarsus to be straightened. When the legs were positioned in near-full extension, the elastic tape that was placed on the lateral aspect of the right leg only exerted force across the tibiotarsal-tarsometatarsal joint. The bird was placed in the sling for 20 minutes, twice daily, for 11 days until the patient was able to stand without assistance. During this period, the elastic tape was replaced every 2-3 days, and increasing lateral tension was placed across the tibiotarsal-tarsometatarsal joint until 40% tension was achieved. Elastic-tape bandaging on the lateral aspect of the right leg continued for 27 days total until the right leg varus was nearly resolved and the bird was ambulating and perching normally. At 24 days after initial presentation, a blood sample was collected from the medial metatarsal vein and submitted for 25-hydroxycholecalciferol levels. Results showed the level was increased to 27 nmol/L (Table 1).
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
Chick 2 was administered meloxicam (0.25 mg/ kg IM), and elastic, therapeutic tape was placed after initial evaluation revealed a 15[degrees] valgus deformity and external rotation of the tibiotarsal-tarsalmetatarsal joint. Two separate pieces of elastic tape were placed: one on the medial aspect of the leg, and one in a circumferential pattern extending from the mid tibiotarsus to the distal tarsometatarsus. The tape placed on the medial aspect of the leg was initially placed under 15% tension. Every 2-3 days, the tape was removed and replaced with slightly increased tension until 40% tension was placed across the joint. The circumferential tape stripe was maintained under mild (10%) to moderate (20%) tension for the duration of treatment. After 11 days of taping, no lameness was noted, and the previously noted valgus deformity and external rotation were resolved. At 24 days after initial presentation, a blood sample was collected from the medial metatarsal vein for measurement of 25-hydroxycholecalciferol levels. Results showed an increase to 22 nmol/L (Table 1).
Chick 3 exhibited no lameness or orthopedic concerns aside from mild deviation of the keel to the left. No therapeutic taping or analgesics were administered. Similar to chicks 1 and 2, this chick was treated for presumptive hypovitaminosis D and was administered injectable cholecalciferol (5000 IU IM) and oral cholecalciferol (200 IU q24h) and was placed under UV-B light twice daily for 20 minutes. No concerns were noted throughout the treatment period and 25-hydroxycholecalciferol quantification was not repeated.
Blood was collected from the parents of the seriema chicks to determine 25-hydroxycholecalciferol levels in adult birds housed indoors. At the time of sampling, both parents were 34 months old and had been housed indoors for 3 months before blood collection. The 25-hydroxycholecalciferol levels were reported as 22 and 28 nmol/L. The adult birds were not exposed to UV-B light while indoors and were maintained on a diet of adult mice, various insects, and meat without supplemental oral cholecalciferol. Repeat measurement of 25-hydroxycholecalciferol levels from chick 1 was determined at 4 months of age, 2 weeks after discontinuation of supplemental UV lighting. The 25-hydroxycholecalciferol level at this time was 32 nmol/L. At the time of sampling, oral cholecalciferol (200 IU) continued to be provided to the chicks but has since been discontinued. Physical examination at the time of blood collection was unremarkable, and the bird was perching and ambulating normally.
This case report describes the clinical presentation, diagnosis, and treatment of hypovitaminosis D in 3 red-legged seriema chicks and the corresponding secondary osteodystrophy and angular limb deformities of the proximal tarsometatarsi in 2 of the birds. Osteodystrophy can develop because of a deficiency in dietary calcium, vitamin [D.sub.3], or both or from an inadequate dietary ratio of calcium to phosphorus. (9) Birds, compared with mammals, are at increased risk to develop osteodystrophy because of their rapid rate of growth and the accompanying increased requirement for calcium deposition. (10,11) If the required deposition of calcium cannot be maintained during growth, normal mineralization fails and can result in bone deformities. Common clinical signs associated with metabolic bone disease in bird species are deformable beaks, sterna, and tibiotarsi; an inability to ambulate or fly; lower limb lameness and folding fractures of the tibiotarsi; and retained feather shafts. (9)
Hypovitaminosis D is a common cause of osteodystrophy in birds. (10,12) Hypovitaminosis D can be the result of an imbalanced or incomplete diet or insufficient exposure to UV-B light. (9) Vitamin [D.sub.3] (cholecalciferol) functions by stimulating absorption of calcium and phosphorus via the kidneys and intestine and stimulating bone mineralization. In cases of vitamin [D.sub.3] deficiency, plasma concentrations of calcium and phosphorus fall below the level required for the proper mineralization of bone. (13) Birds absorb cholecalciferol via dietary sources or synthesize cholecalciferol in unfeathered skin in an isomerization reaction catalyzed by UV light. Cholecalciferol is hydroxylated to 25-hydroxycholecalciferol in the liver; 25-hydroxycholecalciferol is then transformed by the kidneys to the hormonally active metabolite calcitriol, 1,25-dihydroxycholecalciferol (1,25-[(OH).sub.2][D.sub.3]). This reaction is activated by parathyroid hormone in response to low plasma concentrations of calcium. In turn, 1,25-[(OH).sub.2][D.sub.3] activates the renal enzyme 25-(OH)[D.sub.3]-24R-hydrolyase to produce 24,25-(OH)2[D.sub.3]. Both 1,25[(OH).sub.2][D.sub.3] and 24,25-[(OH).sub.2][D.sub.3] are necessary for normal chondrocytic differentiation at the level of the growth plate. (14) The seriema chicks were at increased risk for developing osteodystrophy secondary to hypovitaminosis D because of being housed indoors without exposure to sunlight, as well as potentially low dietary vitamin [D.sub.3] and calcium.
Radiography is a common method used for diagnosing cases of juvenile osteodystrophy in avian species. (10,15) As affected juvenile birds grow, their weakened bones are deformed and bent by the increasing weight of the growing bird's body mass. Without external manipulation or surgical correction, these bone deformities are permanent. (10) In birds with shorter legs, the tibiotarsal bone is most commonly affected because this bone bears the most weight in standing and walking. (10) The proximal tarsometatarsi were most affected in the seriema chicks, suggesting that this bone may be susceptible to osteodystrophy in long-legged avian species. Antemortem diagnosis of osteodystrophy involves analyzing the plasma concentration of 25-hydroxycholecalciferol, the major circulating metabolite of cholecalciferol. (16,17) Plasma analysis of 25-hydroxycholecalciferol is a useful, highly accurate diagnostic tool in cases of suspected metabolic bone disease. At initial presentation, the seriema chicks had plasma concentrations of 25-hydroxycholecalciferol ranging from 3-7 nmol/L, consistent with their clinical signs of osteodystrophy. After 24 days of receiving supplemental vitamin [D.sub.3] and UV-B light, their 25-hydroxycholecalciferol concentrations were in the range of 22-27 nmol/L, consistent with their improving ambulation.
Treatment for hypovitaminosis D in avian species includes supplemental cholecalciferol and the addition of UVB light. (9) Dietary vitamin [D.sub.3] is considered a more significant source for avian species than cholecalciferol synthesized in the skin. (18) One study reports that clinical response in vitamin D-deficient chicks is more rapid with supplemental calcitriol, (19) whereas another found dietary cholecalciferol to be equally effective to fluorescent lighting or dietary calcitriol alone in reducing the severity of hypovitaminosis D in chicks. (20) Broiler chicks have a cholecalciferol requirement of 10 [micro]g/kg diet (12.5 nmol/L 25-hydroxycholecalciferol) with a theoretical maximal response in bone calcium content seen at 20 [micro]g/kg diet (25 nmol/L 25-hydroxycholecalciferol). (17) The seriemas were fed a combination of pinkie mice, fuzzy mice, crickets, and meat, and total dietary 25-hydroxycholecalciferol was not calculated. Additionally, they were housed indoors without exposure to UV-B until a UV-B light was placed in the enclosure to supplement the cholecalciferol being supplied by the diet after the birds became clinical. In the future, chicks born indoors without sunlight exposure will be supplemented with UV-B light and started on oral vitamin [D.sub.3] between days 7 and 10 of life to prevent osteodystrophy from hypovitaminosis D.
In addition to supplemental cholecalciferol and UV-B light, elastic, therapeutic taping was used to correct the angular limb deformities that occurred secondary to osteodystrophy. Historically, treatment options for pathologic bone deformities have included external coaptation, such as bandaging and splints or external fixators. (21-23) Coaptation is the preferred method in soft, brittle bones, such as those affected by metabolic bone disease, although recovery is usually prolonged, and fracture fragments are usually poorly aligned compared with those repaired with internal fixation. (21) Hobbling the legs of juvenile bustards (Chlamydotis macqueenii) has proved to be a successful, nonsurgical method to correct tibiotarsal external rotation. (24) To correct the angular limb deformities affecting the chicks in this study, elastic, therapeutic taping was used as a nonsurgical, noninvasive method. Boon and colleagues (8) used elastic taping to successfully correct unilateral angular limb deformities in 2 American flamingo (Phoenicopterus ruber) chicks. Unlike traditional white athletic tape, elastic therapeutic tape has the ability to stretch to 20%-40% of its original length and creates corrective tension where applied. (25,26) The proposed effects of taping include increased proprioception via cutaneous afferent stimulation, realigned fascial tissue function via normalized muscle tension, improved blood and lymph circulation via eliminated edema or bleeding beneath the skin, corrected muscle function via strengthened muscles, and decreased pain via neurologic suppression. Elastic therapy tape was designed to provide support and stability to muscles and joints without limiting range of motion. The enhanced proprioceptive sense achieved by taping is proposed to provide dynamic stability for joints via muscular reflexes and arthrokinetics while also correcting abnormal angulation and supporting weakened muscles. (27-29) Although there is a lack of sufficient evidence to support these claims, elastic therapy taping is used routinely in human physical therapy and has proven successful in avian medicine. (8,25) The angular limb deformities that occurred in 2 seriema chicks in this report, one varus and one valgus, were improved by the use of elastic therapy tape in addition to the cholecalciferol supplementation.
The seriema chicks improved clinically with a combination of injectable cholecalciferol, oral vitamin [D.sub.3] supplementation, and frequent elastic therapy taping. One chick required a moderate level of nursing care and construction of a custom-made sling. The chicks presented initially with hypovitaminosis D and varying degrees of orthopedic deformities. With clinical presentations ranging from mild to severe, all 3 chicks progressed to normal ambulation and activity with treatment. These cases demonstrate that osteodystrophy and angular limb deformities can be successfully treated in long-legged, juvenile birds with supplemental cholecalciferol in combination with elastic therapy taping.
Caitlin A. Kozel, MS, Matthew E. Kinney, DVM, Dipl ACZM, Christopher S. Hanley, DVM, Dipl ACZM, and Luis R. Padilla, DVM, Dipl ACZM
From Kansas State University, College of Veterinary Medicine, 1800 Denison Ave, Manhattan, KS 66506, USA (Kozel); and the Saint Louis Zoo, One Government Drive, St. Louis, MO 63110, USA (Kinney, Hanley, Padilla).
Acknowledgments: We thank Michael Macek, Anne Tieber, Sydney Oliveira, and KC McIndoe of the Saint Louis Zoo's bird department for their creativity and hard work. We also acknowledge support from the Association of Avian Veterinarians.
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Table 1. Select results of a complete blood cell count, plasma biochemical analysis, and 25[OH] [D.sub.3] (25-hydroxycholecalciferol) levels for 3 red-legged seriema chicks. Parameter Chick 1 Chick 2 Chick 3 White blood cells, x 26.3 21.7 20.1 [10.sup.3] cells/[micro]L Calcium, ionized, mmol/L 1.36 (5.4) 1.20 (4.8) 1.21 (4.8) (mg/dL) Calcium, total, mmol/L 2.4 (9.6) 2.25 (9.0) 2.25 (9.0) (mg/dL) Creatine phosphokinase, 4084 2773 2699 IU/L Glucose, mg/dL 458 318 359 Phosphorus, mg/dL 4.3 4.3 5.0 25-[OH][D.sub.3] nmol/L, 3 7 6 initial presentation 24 d after presentation 27 22 -- Parameter Reference mean Reference median White blood cells, x 11.5 (3) 10.9 (3) [10.sup.3] cells/[micro]L Calcium, ionized, mmol/L 1.12 (4) (4.5) 1.13 (4) (4.5) (mg/dL) Calcium, total, mmol/L 2.6 (10.4 (3)) 2.58 (10.3 (3)) (mg/dL) Creatine phosphokinase, 515 (3) 458 (3) IU/L Glucose, mg/dL 308 (3) 301 (3) Phosphorus, mg/dL 4.0 (3) 3.8 (3) 25-[OH][D.sub.3] nmol/L, 19 (4) 19 (4) initial presentation 24 d after presentation 19 (4) 19 (4)
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|Title Annotation:||Clinical Report|
|Author:||Kozel, Caitlin A.; Kinney, Matthew E.; Hanley, Christopher S.; Padilla, Luis R.|
|Publication:||Journal of Avian Medicine and Surgery|
|Article Type:||Clinical report|
|Date:||Mar 1, 2016|
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