Pet Ownership. Conflict of Interest Disclosure Infectious Disease Course C021

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Nicholas White
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Infectious Disease Course C021 I have NO relevant disclosure or

of Medicine Houston, Texas This talk is dedicated to Smog Rosen

http://www.americanpetproducts.org/press_industrytrends.

least one pet ~40% of all US households contain two or more pets

1 Forget Fido! Serious Threats from Exotic Pets Conflict of Interest Disclosure Infectious Disease Course C021 I have NO relevant disclosure or conflict of interest for this talk Ted Rosen, MD Baylor College of Medicine Houston, Texas This talk is dedicated to Smog Rosen The Best Pet Ever, Sorely Missed $63 Billion in Pet Ownership ~60-65% of all US households contain at least one pet ~40% of all US households contain two or more pets It is estimated that about 1-2 million American homes harbor at least one exotic J Am Vet Med Assoc 232:695,

2 Routine domestic pets....when in close proximity Can cause problems! (Tinea) New kitten...new problem Animal Dermatophyte Fur loss major sign 2

Animal Dermatophyte: Rx Miconazole spray Conofite cr/spray Dermazole shampoo Miconazole

Cellulitis from bite (Pasturella multocida) Cat scratch disease Bacillary angiomatosis

Dermatol 66(Suppl1):S121, 2011 Dermatol Online J 17(6):2, 2011 Nocardia Cheyletiella

or cat) Amphibian: salamander, frog Avian: cockatoo, macaw, parrot, ostrich Carnivore:

3 Animal Dermatophyte: Rx Miconazole spray Conofite cr/spray Dermazole shampoo Miconazole products Save patient $ by giving samples of any antifungal Resizole conditioner CATS! Cellulitis from bite (Pasturella multocida) Cat scratch disease Bacillary angiomatosis Catpox (orthomyxovirus = Cowpox) Sporotrichosis Int J Dermatol 51:434, 2012 An Bras Dermatol 66(Suppl1):S121, 2011 Dermatol Online J 17(6):2, 2011 Nocardia Cheyletiella infestation Cutaneous larval migrans Exotic Pets WHAT ABOUT EXOTIC PETS? What is an exotic pet? Strange or different in a striking or fascinating way (dictionary) Non-customary (Not dog or cat) Amphibian: salamander, frog Avian: cockatoo, macaw, parrot, ostrich Carnivore: mink, weasel, raccoon Feline: tiger, panther, bobcat, lynx Mammal: sugar glider, hedgehog; skunk Reptile: snake, iguana, lizard Petaurus breviceps USA Today Dec 6, 2002 US News and World Report June 23,

exotics into US yearly Tropical fish to kinkajous $10

quarantine, minimal screening ONLY 120 full-time

wildlife Discovery Channel News 11/27/2006 http://www.

jurisdictions Canadian Constitution (92-13) deems

property Various provincial Animal Welfare Acts

import and export of exotic animals Canadian Wildlife

animals Canadian Assoc Zoos and Aquariums (voluntary

4 China, too! Bejing News, 2014 Exotic Pets 650 MILLION imported exotics into US yearly Tropical fish to kinkajous $10 billion ILLEGAL importation business as well No quarantine, minimal screening ONLY 120 full-time inspectors employed by USA to inspect ALL arriving wildlife Discovery Channel News 11/27/ Exotic Pets: Canada Many agencies: conflicting and overlapping jurisdictions Canadian Constitution (92-13) deems animals as property; provinces have primary power over property Various provincial Animal Welfare Acts Canadian Food Inspection Agency: rules regarding the import and export of exotic animals Canadian Wildlife Service administers rules regarding endangered exotic animals Canadian Assoc Zoos and Aquariums (voluntary membership) Pet Industry Advisory Council; different set of rules Hedgehog 11 distinct species of nocturnal, quilled mammals African pygmy variety is common pet $ ,000 pets in USA 4

Hedgehog African Pygmy Hedgehog Atelerix

to hold/pet May be vicious Quills for defense

Inflammatory dermatomycoses: tinea corporis,

Direct contact w/ hedgehog Mycoses 57:125,

158:59, 2006 South Med J 93:936, 2000 Clin Exp

5 Hedgehog African Pygmy Hedgehog Atelerix albiventris Four-toed hedgie Eats roaches Hard to hold/pet May be vicious Quills for defense Hedgehog Hedgehogs routinely carry T. mentagrophytes var. erinacei Fungi on quills and underbelly Inflammatory dermatomycoses: tinea corporis, tinea manum, tinea barbae, and tinea capitis Direct contact w/ hedgehog Mycoses 57:125, 2014 Int J Dermatol 51:283, 2012 Vet Rec 158:59, 2006 South Med J 93:936, 2000 Clin Exp Derm 17:156, 1992 African Pygmy Hedgehog African Pygmy Hedgehog 21 year-old Int J Dermatol 51:283,

6 Chinchilla 2 distinct species of South American herbivore Rodents Raised in farms $ ,000 pets in USA Chinchilla Chinchilla laniger Chinchilla brevicaudata Hide from noise and bright light Susceptible to heat stroke Chinchilla Chinchilla Many carry T. mentagrophytes and M. gypseum Associated with inflammatory tinea corporis and capitis Also harbor Aspergillus niger and Rhizopus sp. and therefore theoretical threat to diabetics, leukemia & transplant patients Nippon Ishinkin Gakkai Zasshi 41:269, 2000 Mycopathologia 137:107, 1997 Vet Rec 127:119, 1990 Mom s Back Mycoses 2013; 56 Suppl 1:33-7 Mycoses 2013; 56 Suppl 1:33-7 6

study: 2/3 in pet stores harboe J Mycol Med.

Mexican variety most common pet $15-50 700,000 in USA $37.

Iguana Iguana iguana Friendly and quiet Will attack its

100 pounds Iguana: Serratia cellulitis Iguana: Serratia

beta-hemolytic strep Associated with ESBL (Extended

7 Guinea pigs are fungal cesspools T. Mentagrophytes var, porcellae Inflammatory tinea French study: 2/3 in pet stores harboe J Mycol Med. 2016;26: Iguana 13 distinct species of large lizards Mexican variety most common pet $ ,000 in USA $37.99 Sale! Iguana Iguana iguana Friendly and quiet Will attack its own reflection Can grow up to six feet long & weigh up to 100 pounds Iguana: Serratia cellulitis Iguana: Serratia Cellulitis May be bullous, simulating that caused by beta-hemolytic strep Associated with ESBL (Extended spectrum b-lactamase) Usually resist cephalosporins Quinolones & TMP-SMX are drugs of choice J Am Acd Dermatol 62:1075, 2010 Clin Infect Dis 28(5):1181,

Iguana: Serratia Cellulitis Iguana More Iguana Problems!

discoloration Drug resistant bacteria may be harbored, including multiply-drug

Venom chemically similar to snake toxin Bite site: red, swollen (looks like

439:584, 2006 Green Iguana Bearded Dragon ICD-10 Bearded Dragon at County Fair

8 Iguana: Serratia Cellulitis Iguana More Iguana Problems! Breeders utilize broad spectrum antibiotics as prophylaxis against disease and discoloration Drug resistant bacteria may be harbored, including multiply-drug resistant organisms Recent unexpected discovery of venom in two groups of lizards Venom chemically similar to snake toxin Bite site: red, swollen (looks like infection) Accompanied by widespread purpura, hypotension, malaise Nature 439:584, 2006 Green Iguana Bearded Dragon ICD-10 Bearded Dragon at County Fair Bitten by other nonvenomous lizard, initial W59.01XA Toxic effect of venom of other lizard, unintentional, initial T63.121A 8

Kinkajou (aka Honey Bear) Potos flavus Raccoon relative Central & S.

crying woman $2000-3000 each Kinkajou ATTACKS!

8/2006 Got rid of animal (illegal in CA) W55.

Carries a UNIQUE bacteria in its oral flora: Kingella potus Gram-negative rod, related to Neisseria spp by 16S

TMP-SMX Intermediate to Amoxicillin-Clavulanate Sensitive to Ceftriaxone & Ciprofloxacin J Clin Microbiol

9 Kinkajou (aka Honey Bear) Potos flavus Raccoon relative Central & S. America 14 subspecies Lifespan 25years; some have lived 40yrs Shrill calls sound like a woman: folk name The crying woman $ each Kinkajou ATTACKS! Paris Hilton was attacked by her pet, Baby Luv Ended up in the emergency room with deep bite wounds (arm) in 8/2006 Got rid of animal (illegal in CA) W55.81A: Bitten by other mammals, accidental, initial encounter Kinkajou: DANGER! Carries a UNIQUE bacteria in its oral flora: Kingella potus Gram-negative rod, related to Neisseria spp by 16S rrna gene typing DEEP destructive cellulitis/tenosynovitis from penetrating bites Resistant: Doxy, TCN, clinda, TMP-SMX Intermediate to Amoxicillin-Clavulanate Sensitive to Ceftriaxone & Ciprofloxacin J Clin Microbiol 43:3526, 2005 Emerg Infect Dis 2011;17: Flying Squirrel 35 distinct species of gliding animals Southern flying squirrel and sugar glider are pets $ pets in USA Petaurus breviceps Flying Squirrels Gluaucomys volans Northern and Southern types Southern small and aggressive Leaps of 150ft Domesticated as newborns only 9

Flying Squirrels Associated with human typhus due to Rickettsia prowazekii Flying squirrels are the ONLY zoonotic source of typhus

inhalation of aerosolized ectoparasite feces Flying Squirrels Fever, blanchable erythematous macular eruption, headache, myalgia,

Vector Borne Zoonotic Dis 14:240, 2014 (Cluster) Clin Infect Dis 51:712, 2010 Emerg Infect Dis 15:1005, 2009 (Cluster) JAMA 245:2318,

Camp counselors, Park rangers, Woodsmen Tarantula Nearly worldwide Tiny to foot-long Cheap!

10 Flying Squirrels Associated with human typhus due to Rickettsia prowazekii Flying squirrels are the ONLY zoonotic source of typhus Lancet Infect Dis 8:417, 2008 Ectoparasites (lice/ticks) found on flying squirrel harbor the causative organism Humans infected by inhalation of aerosolized ectoparasite feces Flying Squirrels Fever, blanchable erythematous macular eruption, headache, myalgia, nausea & vomting, and photophobia suggest typhus Thus: fever, rash and systemic toxicity in owner of a flying squirrel: think typhus! Vector Borne Zoonotic Dis 14:240, 2014 (Cluster) Clin Infect Dis 51:712, 2010 Emerg Infect Dis 15:1005, 2009 (Cluster) JAMA 245:2318, 1980 This has actually happened. Who is at risk? Camp counselors, Park rangers, Woodsmen Tarantula Nearly worldwide Tiny to foot-long Cheap! Flea markets $10-20 altho in pet stores more costly Various species pets: Brachypelma smithi = Mexican Redknee Grammostola rosea = Chilean Rosehair Aphonoplema seemani = Costa Rican Zebrahair Avicularia urticans = Pinktoe tarantula Zebrahair 10

Tarantula: Risks They bite: painful venom, tho not typically causing systemic rxn; activates

flick those hairs at their owner if threatened: go into eye and cause uveitis, cornea clouding Am J

2000 Acta Ophthalmol Scand 79:531,2001 Eye 17:433, 2003 Nature 444:208, 2006 Corneal opacities

Bite: T63.321A Toxic effect of venom of tarantula, accidental, initial encounter Ocular: H20.

31 Retained animal quills or spines Gerbil 100 distinct species of African and Asian herbivore

11 Tarantula: Risks They bite: painful venom, tho not typically causing systemic rxn; activates capsaicin receptor They have urticating, barbed hairs which can cause contact urticaria They may flick those hairs at their owner if threatened: go into eye and cause uveitis, cornea clouding Am J Trop Med Hyg 22:130, 1973 Am J Ophthalmol 96:118, 1983 J Am Optom Assoc 68:188, 1997 Cornea 19:393, 2000 Acta Ophthalmol Scand 79:531,2001 Eye 17:433, 2003 Nature 444:208, 2006 Corneal opacities Tarantula Photophobia Erythema Tearing Deep aching pain Reduced acuity Uveitis ICD-10 Conundrum Bite: T63.321A Toxic effect of venom of tarantula, accidental, initial encounter Ocular: H or H or H and.z18.31 Retained animal quills or spines Gerbil 100 distinct species of African and Asian herbivore rodents Mongolian gerbil is common pet Cheap! $ > 1,000,000 in USA Gerbil Meriones unguiculatus Can gnaw through anything except glass (aquarium) Very tame Epilepsy, diabetes and lead poisoning 11

Gerbil Almost never carry pathogenic fungi (dermatophytes) Have been associated with the transmission of avian mites

gerbil owner 59 yo female Acquires gerbil from local pet store (replaces dead husband) Begins to itch in four days

0 = dermatitis due to bird mite Many in gerbil cage Proc Natl Acad Sci U S A. 2015;112:3020-5 Parasit Vectors.

Ear swabs, total body combing, skin scraping of 600 dogs in animal clinics 15.4% were infested; 4.

12 Gerbil Almost never carry pathogenic fungi (dermatophytes) Have been associated with the transmission of avian mites to their human owners (mites were presumably acquired in pet store from birds) Arch Dermatol 137:167,2001 Itchy new gerbil owner 59 yo female Acquires gerbil from local pet store (replaces dead husband) Begins to itch in four days Excoriated papules Voila! Two stage transmission One on patient. ICD 10: B88.0 = dermatitis due to bird mite Many in gerbil cage Proc Natl Acad Sci U S A. 2015;112: Parasit Vectors. 2015;8:256. doi: /s z. Ear swabs, total body combing, skin scraping of 600 dogs in animal clinics 15.4% were infested; 4.3% with multiple species Ixodes ricinus, Rhipicephalus sanguineus, Demodex canis, Sarcoptes scabiei, Otodectes cynotis, Ctenocephalides canis, Ctenocephalides felis, Pulex irritans, and Trichodectes canis Ticks, mites and fleas! Parasitol Res. 2017;116:

13 What About Viral Diseases? No viral diseases: hedgehog, chinchilla, sugar glider BUT, some small mammals can carry zoonotic viral diseases that are devastating to man Gerbil, hamster, mouse, guinea pig, vole: Lymphocytic Choriomeningitis Virus Vector Borne Zoonotic Dis. 2014; 14: Marmoset 18 species of South American monkey Genus = Callithrix Primitive compared to most primates Live 7-20 years Pygmy marmoset is common pet Callithrix pygmaea Expensive $ Carriers of LCMV! Emerg Infect Dis 7:1062, 2001 Emerg Infect Dis 8:639, 2002 Lymphocytic Choriomeningitis Virus Systemic viremia and illness Altered mental status, seizures Fever and leukocytosis Abdominal pain and diarrhea Thrombocytopenia, DIC Hepatorenal dysfunction (late) Death (Fatality rate in transplants = 90%) MMWR 61:622, 2012 Lymphocytic Choriomeningitis Virus Systemic viremia and illness Altered mental status, seizures Fever and leukocytosis Abdominal pain and diarrhea Thrombocytopenia, DIC (skin signs) Hepatorenal dysfunction (late) Death (Fatality rate in transplants = 90%) MMWR 61:622, 2012 Lymphocytic Choriomeningitis Virus Fatalities in organ transplant RECIPIENTS who got organs contaminated with LCMV Organ DONORS had pets infected with LCMV (carriers) Donors ASx; BUT The organ recipients are immunosuppressed, don t handle virus well! Emerg Infect Dis 20:1443, 2014 Vet Microbiol 140:213, 2010 N Engl J Med 358:991, 2008 N Engl J Med 354:2235, 2006 MMWR 54:747, 2005 Lymphocytic Choriomeningitis Virus LCMV induced illness: shortly after transplant Deaths occur 9-76 days post-op Clinical clues: Peri-incisional eczematous eruption*along with petechiae, purpura or ecchymoses ( platelets) and alopecia 13

Cockatoo 21 distinct species Australia, Philippines,

illness (seen as self-mutilation) Limited vocabulary

carry Cryptococcus neoformans and have been source of human

D) J Am Vet Med Assoc 187:1218, 1985 Ann Int Med 132:205,

!! J Intern Med 257:385, 2005 Cockatoo may either become ill

Cockatoo Owner (HIV+) Cockatoo Owner (HIV+) ICD 10 to the

14 Cockatoo 21 distinct species Australia, Philippines, Indonesia Long-lived (30-80 yrs) Inattention leads to mental illness (seen as self-mutilation) Limited vocabulary Expensive; > $1000 Cockatoo Cockatoo (and related macaw) carry Cryptococcus neoformans and have been source of human infection in HIV+ and transplant patients (Serotypes A and D) J Am Vet Med Assoc 187:1218, 1985 Ann Int Med 132:205, 2000 Rarely, normal hosts as well!!! J Intern Med 257:385, 2005 Cockatoo may either become ill from or often carry pathogenic aspergillus spp. Cockatoo Owner (HIV+) Cockatoo Owner (HIV+) ICD 10 to the rescue! B45.2 Cutaneous Cryptococcois B45.7 Disseminated Cryptococcosis Skin/node cultures + Cryptococcus neoformans 14

Cryptococcal Disease Infliximab Associated Otherwise

pneumonia Had pet cockatiel Avian excrement cultures

neoformans Respir Care 49:606, 2004 Advise patients

the cockatoo-macaw family Mankind craves pets.

5 mean per snake-owning household J Am Vet Med Assoc

legal and illegal trade ½ of states require no license to

15 Cryptococcal Disease Infliximab Associated Otherwise healthy RA arthritis patient Develops fatal Cryptococcal pneumonia Had pet cockatiel Avian excrement cultures positive for C. neoformans Respir Care 49:606, 2004 Advise patients receiving infliximab to avoid pet birds, especially of the cockatoo-macaw family Mankind craves pets...but any animal can bite! ~586,000 pet snakes in USA; 1.5 mean per snake-owning household J Am Vet Med Assoc 232:696, 2008 Snakes Vary from harmless to lethal Active legal and illegal trade ½ of states require no license to import; even deadly foreign snakes No Federal mandate to inspect imported snakes Variable price $35 to $2000+ Major problem is bite 15

16 Common Exotics Aug, 2013 Snake Bite ICD-10: W59.13XA Crushed by nonvenomous snake, initial encounter 16

Snake Bites None of the usual derm maneuvers is helpful Tourniquet, above and below Incision and

Zoo is most reliable source; Hospital ER short supply (if any) With non-us species, Zoo ONLY place

001 Toxic effect of unspecified snake venom, accidental (unintentional), initial visit The Elephant Who

0% Captive elephants have TB Bi-directional transmission documented Outbreak of TB in Portland, Oregon

17 Snake Bites None of the usual derm maneuvers is helpful Tourniquet, above and below Incision and suction drainage Snake Bite Kit Administration of anti-venin key! Zoo is most reliable source; Hospital ER short supply (if any) With non-us species, Zoo ONLY place where anti-venin might be ICD 10: T Toxic effect of unspecified snake venom, accidental (unintentional), initial visit The Elephant Who Painted MMWR 2016;64: Rama: Portland Zoo Elephants and TB % Captive elephants have TB Bi-directional transmission documented Outbreak of TB in Portland, Oregon zoo Among CLOSE contacts (19), six found to be seroconverted (31.6%) Among causal contacts (96), one with active TB Genotyping confirmed same strain Moral: Stay clear of coughing elephants ANY pet can attack. Gekko bite! MMWR 2016;64:

18 Since pets are dangerous. References Rosen T, Jablon J: Infectious threats from exotic pets. Dermatological implications. Dermatol Clin 21: , 2003 THE REFERENCE Get Them First! 18

Burr Ridge Community Consolidated School District #180 6:100. Instruction

Burr Ridge Community Consolidated School District #180 6:100 Instruction Using Animals in the Educational Program 1 Animals may be brought into school facilities for educational purposes according to procedures