TB or Not TB Kit Darling MS M

TB or Not TB? Kit Darling MS, M, MT(ASCP), CIC Sharman Hoppes DVM, ABVP-avian Texas A&M University College of Veterinary Medicine Beverlee Nix, DVM, MPH Texas Department of State Health Services

Mycobacteria in birds n Parrots are common pets with close bond to owner n n Share food, kiss, cuddle And although an uncommon disease, parrots are most common bird to develop M. tuberculosis

Mycobacterium tuberculosis in birds n n Rare disease in birds Considered zoonotic: n n Reports of human to bird transmission No reports of bird to human transmission Granulomatous disease of GI tract; shedding Difficult to diagnose Few reports of treatment Treatment: same antibiotics used in birds as in humans n In birds: n n Long term treatment with multiple drugs Could lead to increased antibiotic resistance

Mycobacteria in birds n n n Most common avian mycobacterium: n M. avium, M. genovense, M. intracellulare Soil, other birds Granulomatous intestinal disease n n n Fecal shedding Fecal / oral inhalation Long term exposure Chronic disease n n Weight loss Anorexia n Diagnosis is difficult n n PCR, serology Liver biopsy n n FNA-PCR Treatment only offered in specific cases.

Mycobacteria Treatment in birds? n Controversial n n n Committed client Understands zoonotic potential and need for long term treatment No immunocompromised people in house n Treatment: 6 months to a year n n Monitoring of organ function from long term antibiotic therapy and the disease Recheck every 3 to 4 months

Treatment is: n n n Expensive Long term 2 to 3 times a day Birds are difficult to medicate Most owners and veterinarians elect not to treat

Mycobacteria tuberculosis in an Amazon Parrot n An amazon parrot referred to TAMUrespiratory issues in September 2008 n n n Aspergillus Clinical signs included dyspnea and voice change CBC- leukocytosis, monocytosis

n Radiographsincreased opacities in in lungs/airsacs n n All consistent w/ Aspergillus Which is also not an easy disease to treat!

n Parrot hospitalized: Nov 18 –Dec 3 rd n n Owners could not medicate Bird responded to treatment n Slowly improving

n While hospitalizedsmall mass noted on chest and eyelid - biopsied n n Acid fast organisms FNA of both to VMD for Avian Mycobacteria DNA probe- negative

n n n Diagnostic lab felt sample not adequate. Recommend culturing organism for best results. Most likely organism: genavense, avium Attending clinician experienced with culturing mycobacterium (masters program)

n Resubmitted cultured sample n n Culture (took about 6 weeks) Jan 20 -Mycobacteriapositive, but negative for avium, genavense, intracellulare.

Is it TB or not? n Concern now: M. tuberculosis n Next step?

n n Bird presented next day Jan 21 st in severe respiratory distress. Euthanized and since potential for M. tuberculosis- the bird was placed in a biohazard bag and sent for cremation. n No necropsy performed.

n n n Jan 22 - infection control coordinator notified of potential M. tuberculosis infection Jan 23 - Zoonosis Control Veterinarian for State Health Department notified Contacted crematorium n A heat inactivated mycobacterium sample had been saved by the clinician n n Jan 26 - Sent to Nat Vet Services Lab Jan 30 - results 100% match to M. tuberculosis

Exposure investigation begins… n n n University laboratory that handled specimen contacted Tracheal aspirate from clinician sent to NVSL All staff and students involved in direct care of bird were contacted n n An e-mail was sent out to be sure no potential exposure was overlooked. 41 individuals had contact with the bird or its laboratory samples

n n n Feb 9 th- A TB skin test was administered 40 negative / 1 positive Positive ind. had Quanti. FERON testnegative n Apr-27 - 2 nd test n n All negative Owners of bird and r. DVM- tested negative

Lessons learned n n Although the blood work and Radiographs were consistent with Aspergillus, they were also consistent with Mycobacterial disease and Aspergillus are often diseases that occur in immunocompromised birds- so possibility of both diseases concurrently should be considered.

Lessons learned n Due to the growing number of pet birds and the intimate relationship of owners and birds and the growing number of immunocompromised people, Mycobacterial infection should be higher on our differential list. n n M. tuberculosis is increasing in humans therefore higher risk in pet birds! Do not assume!! Our assumption that the most likely organism was M. avium or M. genevense led to increased exposure of individuals.

Lessons learned n Have protocol for doing diagnostic tests for zoonotic disease even if the owner cannot afford the cost.

M. tuberculosis n n Most commonly transmitted from infected owners to birds People diagnosed with TB should be asked if they have pet birds and be made aware of the potential transmission of their disease to birds.

Interestingly… n n The current owners had not known the prior history or age of this bird Current owners had bird >5 years n With further investigation n Bird had been abandoned by previous owners in old apartment building Previous owners were thought to be drug dealers Very likely previous owner was source of infection

Any questions?

Acknowledgement n Texas Department of State Health Services Zoonosis Control n TB Section n Dr. Patricia Gray Debra Turner