Ringworm 101 for Shelters - PDF Document

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  1. 9/24/2012 Sandra Newbury, DVM Koret Shelter Medicine Program Center for Companion Animal Health U C Davis School of Veterinary Medicine U C Davis School of Veterinary Medicine www.sheltermedicine.com Adjunct Assistant Professor of Shelter Animal Medicine Department of Pathobiological Sciences University of Wisconsin‐School of Veterinary Medicine Ringworm 101 for Shelters 1

  2. 9/24/2012 Dedicated to volunteers everywhere  but especially to… • Sue Meyer who passed away this year. • Sue was among the first to volunteer when Karen  Moriello and I started the Dane County Humane  Society Dermatophyte Treatment Project in 2003. • Her ongoing leadership and mentoring for new  volunteers played an immeasurably important role in  keeping that program alive. • Animals everywhere can hope many others will  follow her incredible example. Fungus is a lot like us. thrives in soil? vigorous growth? The similarities between mammalian cells and fungal cells make it difficult to design drugs that will kill the fungus without killing us. 2

  3. 9/24/2012 Potential for human infection:  Zoonosis Mechanical Carriers vs.  True Infection i f ti h • True infection happens when micro-trauma allows fungal spores to invade the skin and hair to establish growth. T h i t • Mechanical carriers are animals who have lik d t spores, like dust, on their hair coat from the environment. th i h i t f th • No true carrier state 3

  4. 9/24/2012 Know your Dust Mop Screening Animals for Ringworm: Screening Animals for Ringworm: Recognition and Diagnostics Screening e ams Wood’s lamp e ams direct e ams Screening exams, Wood s lamp exams, direct exams of hair and cultures define cases, direct animal movement and guide treatment protocols. 4

  5. 9/24/2012 Screening Protocol Screening exam at admission includes a Wood’s Lamp exam GO HOME! Fluorescing Lesions? No lesions? Non- Fluorescing Lesions? Direct exam Neg. Pos. Wait for culture results Treat as true infection Culture Choose the Right Location • Non-Lesional first, Non Lesional first, please. • Clean up after yourself. • Admitting areas consistently have the consistently have the highest levels of environmental contamination. 5

  6. 9/24/2012 Screening Exam • Get into the habit of doing an exam the same way every time • Document lesions • Use a physical exam form • A careful physical at A intake also helps identify other problems. f l h i l Check for Lesions Look for inflammatory abnormalities of the skin. 6

  7. 9/24/2012 Classic Lesions Sites Not to Be Missed • Inside the ears N • Nose, eyes and whiskers • Tips of toes and bottoms of the feet d 7

  8. 9/24/2012 Ringworm Lesions? Systematic Wood’s Lamp  Screening  8

  9. 9/24/2012 W Wood’s Lamp 101 d’ L 101 Woods’ Lamp 101 • Invest in a good lamp. • Wood’s lamps have UV wavelength that will cause the most effective fluorescence. • Consider a magnifying glass. ? http://www.minresco.com/uvlamps/fraud.htm (see UVL- 21 compact lamp at bottom of page) 9

  10. 9/24/2012 Turn out the lights, warm up the  lamp, invite company • Give your eyes time to adjust to the dark. • Give the lamp time to warm up. • You will need at least three hands. Ringworm Glow: Basics • Apple-green • Occasionally blue-white • The whole hair shaft should glow • Especially the base F l th d • Fungal growth does not make the hairs stick together. t k th 10

  11. 9/24/2012 Why Cats Glow Fluorescence is a metabolite of the fungus that coats the Fluorescence is a metabolite of the fungus that coats the hair as it is produced. The fungus grows in the hair follicle and along the base of the hair. So, fluorescence will be seen most commonly close to the skin. Often the entire shaft of the hair will glow. What will glow? • M. canis is the only pathogen of veterinary importance that veterinary importance that fluoresces • Previously estimated that only 50% of M.canis strains glow • The truth is we don’t know how many strains glow and what many strains glow and what factors influence fluorescence. • In our experience, most infected cats do have fluorescing hairs. 11

  12. 9/24/2012 Tricky Things that also Glow • Doxycycline • Terramycin • Carpet fibers • Dust Direct Examinations of Direct Examinations of  Fluorescing Hair 12

  13. 9/24/2012 Direct exam of Wood’s  positive hair S Supplies: Wood’s lamp Mineral oil li (Chlorphenolac or KOH with caution) Microscope Microscope slide One cat or one dog At least FOUR hands Patience, practice and testing Third Hand Plucking hairs  Wood’s Lamp Fourth Hand Glowing hair Drop of mineral oil or  chlorphenolac 13

  14. 9/24/2012 Setting up the microscope LOOK • With the room lights low and the microscope OFF a d t e c oscope O • Look through the eyepiece • Find the glowing hair using woods lamp next to the stage • NEXT • NEXT • Turn on the microscope light to examine the hair ON OFF Direct Exam 14

  15. 9/24/2012 Direct exam Always back up your results  with a culture. As close as we get to a SNAP test for ringworm Using and Understanding  Fungal Cultures  15

  16. 9/24/2012 How to Culture • A toothbrush is an ideal means of collecting spores from the hair coat. • Brush the whole cat vigorously from nose to toes. • Remember to brush common areas of infection such as the face, inside the bell of the ears and tips of toes. • For lesional cats, brush the whole cat first, then the lesion. • Most cats love this! cost comes to $0.06 per toothbrush TB50 50 tuft polypropolene bristle Tooth brush $88.40 1,440 http://www.hotelsupplies‐online.com/fs_toothpaste.htm Dermatophyte Test Media • Fungal culture media. • Contains an indicator Contains an indicator that turns the media gel from orange to red as the pH of the media changes. • Incubate at slightly warmer than room warmer than room temperature. (78-80 F) www.remel.com and search under Catalog for DTM 16

  17. 9/24/2012 Inoculating Culture Media • Always set up cultures i l in a clean area. • Hold culture plates upside-down. • Gently stab the tips of the toothbrush into the media. • Cover the whole plate in a consistent pattern. DTM • Avoid using slants, if possible. • Purchased petri dish style plates are currently the best alternative to making your own plates. • Derm Duets from Bacti e uets o Labs as a substitute • Treat fungal cultures as a biohazard for disposal. act 17

  18. 9/24/2012 Culture Interpretation • Red only means Red only means “ “Look at me!” ” • All pathogens turn DTM red. • Not every organism that t th turns the media red is a pathogen. di d i Contaminant Growth • Pigmented colonies are th non-pathogenic contaminants. i • Contaminants are often common environmental organisms. organisms. • Ringworm is never normal flora. 18

  19. 9/24/2012 Early Growth Culture Interpretation • All suspect fungal colonies should be examined microscopically to identify the organism. g • Microsporum species are most common • M. canis *** • M. gypseum • Trichophyton species b may be pathogenic but are less common. th i b t 19

  20. 9/24/2012 Tape Preps • Supplies • Supplies • Clear tape works best • Stains – Lactophenol cotton blue or New Methylene blue – New Methylene blue • Microscope • Microscope slides Tape Preps 1. Drop of stain on microscope slide 2. Gently touch tape to colony (sticky side down) 3 Place tape sticky side 3. Place tape sticky side down over stain 4. Drop of stain on top 5. Cover-slip 20

  21. 9/24/2012 Microscopic Identification M. gypseum M. canis The P Scoring System • Pathogen Score strongly • Pathogen Score strongly influences treatment decisions • Helps define cases • Benefits from complete and consistent sampling method M t b d i • Must be used in conjunction with a thorough check for lesions j ti 21

  22. 9/24/2012 Assessment Based on Pathogen  Score Results P1 or P2 P1 or P2 1 -9 cfu P3 10 or more cfu Lesions? All P3 cats NO YES fomite carriers true true infection infection Screening the Environment  • Use all the same tools Use all the same tools • Substitute a Swiffer  for the toothbrush • Look for where hair Look for where hair  and dust would  collect 22

  23. 9/24/2012 Create an Isolation Facility Mandatory Dress Code • Prevention of Prevention of zoonotic infection should be the top priority. 23

  24. 9/24/2012 Treatments and Cleaning T in order of infectious potential • Infectious potential may change weekly • Define clean and dirty zones • Treat and clean t d l Treatment Basics Topical  treatment Oral / systemic  treatment 24

  25. 9/24/2012 Topical Anti‐fungal Treatment Lime Sulfur Published clinical research with shelter animals (in  conjunction with oral itraconazole) has:  conjunction with oral itracona ole) has: • Demonstrated rapid times to cure (+/‐14 days) for  true infections (P3) • Demonstrated excellent control of environmental  contamination even after the first treatment D t t d th t d • Demonstrated that adverse reactions are very  rare (did not occur). • No other product has yet been shown to have  equivalent efficacy. ti 25

  26. 9/24/2012 Other Promising Topicals? • Accelerated Hydrogen Peroxide • BUT… How to Make a Dip Sink • Cheap • Cheap • Portable • No need to call a plumber. 26

  27. 9/24/2012 Garden Sprayers • Half gallon sprayer is preferred. • Easily lifted when full • Easily lifted when full. • Solution stays warm. • Short stubby spray nozzle helps with control. • Clean thoroughly after each use. • Fill with hot water and allow to discharge completely to prevent clogging of nozzle and valve. Dilution and Mixing • 8 oz LymeDyp in 1 ll gallon water • Higher concentration dilution on label • Mix by putting 8 oz. LymeDyp in the sprayer then fill to 1 sprayer then fill to 1 gallon • Mix fresh solution each time, discard excess t 27

  28. 9/24/2012 The Dyp Show • Use gentle but firm • Use gentle but firm handling. • Keep the spray close to the skin. • Allow most cats to find a secure place find a secure place to hold on. The Dyp Show • Soak the entire cat to the skin. • Treatment must reach the base of the hairs to be effective. • Pre-wetting is unnecessary and causes dilution. 28

  29. 9/24/2012 The Dyp Show • A small sponge or raglet may be used for the face and ears. • The face and ears The face and ears are the most difficult places to clear of infection. The Dyp Show • No need for party hats • Minimal side effects • No significant adverse reactions 29

  30. 9/24/2012 S Systemic (oral) Anti‐fungals i ( l) A i f l Remember this? Published clinical research with shelter animals oral  itraconazole in conjunction with lime sulfur has:  itracona ole in conjunction with lime sulfur has: • Demonstrated rapid times to cure (+/‐14 days) for  true infections (P3) • Demonstrated excellent control of environmental  contamination even after the first treatment D t t d th t d • Demonstrated that adverse reactions are very  rare (did not occur). • No other product has yet been shown to have  equivalent efficacy. ti 30

  31. 9/24/2012 Itraconazole 101 • 100 mg caps designed for humans can be split into doses for cats with a steady hand and some gel caps g p • Liquid is available for dosing kittens but more costly Published Protocol • LS (8 oz. / gallon) LS (8 oz. / gallon)  twice weekly until  cure is confirmed • Oral itraconazole • Oral itraconazole daily for 21 days • WITH THIS PROTOCOL: • Cure is defined as two  consecutive negative  cultures taken at one  week intervals 31

  32. 9/24/2012 Other Hopefuls • Fluconazole • Terbinafine • BUT…. BUT…. Thanks to you for your caring… Ken:  Our first  customer …and to the ASPCA for making my position possible 32

  33. 9/24/2012 A FEW COMING ATTRACTIONS FROM ASPCAPRO www.aspcapro.org/webinars • Does Spay/Neuter Have a “People Problem”? (9/26) • Ringworm Outbreak Management  (10/02) • Starting a TNR Program in Your Community (10/17) • Beating Ringworm: Yes, You Can! (10/23) 33