VWH – 15th July

Tuesday 15th July

After we finished lecturing in Helsinki it was back to the port and onto another overnight ferry to Stockholm. We were crammed into windowless cabins (four of us per cabin) in the bottom of the boat next to the engine rooms and it was a relief to reach Stockholm. The approach to Stockholm by water is beautiful with hundreds of small islands each with the Swedes' summer houses and yachts moored outside. The Swedish police were on fearsome top form and breathalysed every driver coming off the ferry with a 'welcome to Sweden' message for each of us! A long ride to the lecture venue in the middle of Sweden with 35 Swedish equine vets in attendance to hear the full 5 hour programme of talks. There was a lot of discussion about back problems and how best to treat these, in addition to practical questions abut how to manage outbreaks of infectious diseases like flu and strangles. The local organiser did an amazing job and there was a supper for the speakers and delegates at the end of the evening's lectures. Tomorrow we are back on the bikes and off to Norway for an evening of lectures at Sandefjord.

VWH 2014 Tour

Andy Crawford, one of the surgeons from The Arundel Equine Hospital is currently making his way around North Europe with Vets With Horsepower.

Vets with Horsepower is a charity, orginally set up by Professor Derek Knottenbelt from Liverpool University, in which a group of equine specialists partake in long distance tours on motorbikes giving talks to other vets and members of the public on veterinary topics. The fees raised by these talks are all donated to two charities:-

'Gambia Horse and Donkey Trust' www.gambiahorseanddonkey.org.uk

'The Smile Train' www.smiletrain.org.uk

Andy's first blog....

I left Arundel on Friday afternoon on the bike and before I had got to Horsham I had to stop to put on wet weather gear! Great, only 2700 miles to go! I met up with Professors Roger Smith and Josh Slater at Folkestone and we rode the three bikes in the rain to Antwerp on Friday night. The next day took us 400 miles through industrial Holland beyond Eindhoven where we finally got into green countryside with small farms and yards with lots of very smart Warmbloods and a big selection of other breeds including ponies and a few heavy horses. It was a relief to see a gentle landscape with trees, grass paddocks and horses after so many miles of industry. The rest of the day was a high speed blast up the German autobahns past the industrial centers of Essen and Dortmund, across the Rhine and the Ruhr and then a turn northwards through more horse country to Munster and then onto Bremen and finally Hamburg.

We had a 30 hour ferry journey to Helsinki which gave us time to work on our talks for the lecture tour this week and, of course, experience our first Scandinavian sauna. We discovered two things: first the Finns are passionate about saunas, and everyone goes for at least one sauna a day, second, the Finns do everything naked - not for the fainthearted! (and certainly not for us).

We arrived in Helsinki the next morning and met up with the main bike group to give our first lectures of the Scandinavian leg. The lectures covered flu vaccination, tendon injuries, back problems, sedation and I spoke on advanced diagnostic imaging in the horse including scintigraphy, MRI, and CT. We had 55 delegates which was great and an unexpectedly large turnout because this is normally a holiday in Finland. We are back on the ferry this evening for a night crossing to Stockholm and tomorrow morning's lectures. Not sure whether we will be brave enough to try the sauna again......


Chronic obstructive pulmonary disease (COPD) also known as recurrent airway obstruction (RAO) or “broken wind” is a chronic condition of horses involving an allergic bronchitis characterised by wheezing, laboured breathing, coughing (usually associated with exercise or eating) and nasal discharge (especially when the head is lowered or after exercise).

The condition was known as ‘heaves’ because horses with COPD have very inflamed narrow airways and as such breathing both in and out is difficult and requires recruitment of other chest and abdominal muscles to aid with respiration, these muscles become enlarged and hence the horse develops “heave” lines.

COPD is an allergic reaction to certain otherwise innocuous substances - allergens. These allergens are typically dust, mould and fungal spores (e.g. Aspergillus). It is therefore most common in horses fed hay and bedded on straw. It is similar to asthma and farmer’s lung in humans.

Allergens enter the horse’s lungs and the horse’s hypersensitive immune system over-reacts to the “normal” pollens. The lungs become inflamed and swollen, causing the airways to become narrowed and mucus production to increase, which then leads to the signs we see in our horses.

Diagnosis is usually based on the results of a clinical exam and auscultation of the horse’s lungs. However sometimes further diagnostics are required, in which instance an endoscopic exam of your horses trachea and bronchioles can be performed and samples can be taken.

Acute flare ups can present dramatically, your horse maybe distressed with markedly elevated respiratory rate and effort, flared nostrils and sweating. If a horse is severely dyspnoeic (really struggling to breathe), the most important measure to take is to REMOVE IT FROM THE STABLE OR BARN into FRESH AIR. Keep the horse (and yourself) CALM and CALL YOUR VET IMMEDIATELY.

Treatment is all about management and minimising exposure to the allergens. When removed from the allergens the symptoms will usually subside, although they will recur if the horse is exposed to the allergens again, even short periods of re-exposure can induce acute episodes.

If it is not practical to stop stabling all together then the following changes will be of benefit:

• Minimise dust and maximise air quality in the stable.
• Soak hay or feed a low dust alternative such as haylage or bagged grass. If you are going to feed hay it should be soaked hay, you only need to soak the hay for an hour to remove the majority of pollens and allergens 60 minutes. Soaking hay for longer will reduce the carbohydrate load of the forage, good for horses and ponies that suffer from laminitis or are looking to lose weight but not necessary in managing COPD.
• Feeding from the ground allows any mucous to drain out of the lungs. Horses are designed to graze for approximately 20 hours a day, during which time the horse has its head down to the ground where mucus within the horses trachea and bronchioles can be expelled, because of this design the horse is very poor at clearing mucus from its lungs without the aid of gravity, by feeding on the floor you encourage the horse natural mucus clearing function.
• Bed on a dust free bedding. Those horses that must be stabled should be bedded on rubber matting and paper, or low-dust wood shavings. Straw contains dust, moulds and fungal spores and so is least advisable. In severe cases horse may be intolerant of any bedding in which case the mats can be washed daily. The matting has a fairly high initial cost but there is a considerable saving in bedding (and veterinary costs if your horse has RAO).
• Make sure the stable is well ventilated.
• Don't muck out or brush up while your horse is in the stable to minimise the dust in the air.

All the stables in the vicinity need to be similarly maintained or the environment will remain high risk for the horse and aim to stable your horse away from the muck heap.

Despite management changes, medication is often required, these break down into 3 broad categories:

• Bronchodilators, theses dilate (open) the bronchioles and smaller airways allowing the horse to breath more freely.
• Corticosteroids: these reduce the inflammation in the airways and damped down the immune hypersensitivity reaction.
• Anti Histamines: these damped down the immune hypersensitivity reaction that leads to the inflammation in the lungs.
• Mucolytics: these make the horse’s mucus less viscose and so easier to clear form the airways.

Care should be taken with all these drugs in competition horses, as many of them are forbidden substances under racing and FEI rules.

If the condition occurs in the summer when the horse is at pasture then it is known as summer pasture associated obstructive pulmonary disease (SPAOPD) In this case, the allergens are derived from the pasture. This is more common is summer, and management is reversed: horses should be stabled in well ventilated areas. Some horses can suffer from RAO and SPARAO which can be very difficult to manage.

RAO often limits the horses' ability to work, and it may find strenuous activity difficult. However, with prompt diagnosis and treatment the condition can be managed successfully.


Ragwort (also known as Senecio Jacobaea) toxicity is one of the most common causes of poisoning to horses in the UK. A recent survey by the British Horse Society showed that 20% of respondents knew of a horse that had been affected. Toxicity is caused by substances in the plant called Pyrrolizidine alkaloids. The effect is cumulative and symptoms may not be seen for up to a year after exposure. The poison effects 3 main body systems - the liver, the central nervous system (brain, spine and its associated nerves) and the skin. Symptoms include weight loss, loss of appetite, depression, diarrhoea, jaundice (yellowing of the whites if the eyes and gums) and constipation. Neurological problems can be seen as wobbling and dizziness, pressing the head against the wall and the appearance of walking aimlessly. Toxic compounds can also enter the skin causing it to become particularly sensitive to sunlight resulting in crusting on white areas that looks like sun burn. This process is called Photosensitisation.

If you’re concerned your horse may have been affected please contact your vet. Blood tests can be used to confirm liver damage but cannot test specifically for the poisoning. A sample of tissue taken directly from the liver may be able to confirm the damage is caused by Ragwort. Horses diagnosed with poisoning rarely recover. Treatment is mostly supportive with nutrition to maintain condition and medications to control the symptoms.

Control of ragwort is crucial in avoiding illness. The first step is the identification of plants. For the first year of life the plant is a small dark green rosette. In subsequent years it becomes the characteristic bright yellow flowers between June and October. Ragwort cannot be entirely eliminated from the UK as it forms an important part of the ecosystem. However, the Weeds Act 1959 made ragwort control a legal obligation for owners and occupiers of grazing land. Those who keep their horses in livery and are unsure of their responsibility in ragwort control should check their contract.

Cutting of ragwort plants is only suitable in emergency short term control to prevent seeding. Cutting the stem stimulates growth and will cause the plant to re flower later in the season. If removing plants by hand, they should be pulled up or levered out by the roots. Ensure the entire root is removed as any left behind will re-grow. Ragwort is best pulled early in the summer before flower heads mature and when the ground is wet. As well as removing adult plants it is important to identify first year rosettes to prevent them seeding the next year. Ragwort is toxic to all species including humans so gloves and long sleeves should be worn. Any skin exposed to the plant should be thoroughly washed in warm soapy water. Once pulled the plants are still toxic and may still seed, in fact wilted plants are more palatable to horses. It is essential all plants are collected and placed in sealed boxes or bags. Disposal can be by incineration, rotting or removal by a waste-management company. The plants should never be composted, placed on the muck heap or transported without being properly sealed in bags.

It is possible to use herbicides as part of a ragwort control strategy although it must be considered that one application does not guarantee total removal. Most products require application in the spring to the growing rosettes and a calm dry day. When choosing a product thought must be given to the environmental implications and proximity to water sources which may become polluted. If spraying you will need a suitably trained person and the means to correctly dispose of unused chemicals. Horses must be moved off the pasture for application and for a period of time afterwards. The manufacturers of pesticides will make recommendations on when it is safe to use the pasture but it is the keeper's responsibility to ensure all dead ragwort is fully wilted before exposing to horses. For a list of approved pesticides please see pesticides.gov.uk.

Ragwort thrives in areas of poorly kept grassland so plant numbers can be reduced by improving pasture management. This includes not over-gazing, adequate manure removal and removing uneaten stale hay. Poaching the ground should be avoided wherever possible as bare patches are ideal for ragwort growth. Co-gazing with sheep can be beneficial as they are far less susceptible to ragwort poisoning than horses and will eat the young first year rosette plants.

For any advice on ragwort control or if you think your horse may be affected by poisoning contact The Arundel Equine Hospital on 01903883050.

Written by Rebecca Dobinson, BVSc, MRCVS

Cushings & EMS

Cushings (Pars Pituitary Intermedius Disorder ((PPID)) and Equine Metabolic Syndrome (EMS) are the two most common metabolic/hormone disorders of the horse and pony. In general, Cushings affects older horses, whereas EMS first develops in young and middle-aged animals. Although they are two separate conditions, they can overlap. All breeds are susceptible but ponies are most at risk.


This is due to a dysfunction in a small area of the horse’s brain and it disrupts the normal balance of hormones, mainly affecting ACTH and cortisol (stress hormones). The most common sign are your horse developing a long, thick, curly coat or not losing his/her winter coat. Other early signs of Cushings are vague but include; reduced performance, lethargy and regional fat deposits (bulging supraorbital fat pads, shoulder fat pads, “cresty neck” and fat accumulation around their tail base). The more advanced signs of the disease include; muscle wasting, a pendulous abdomen, sway back, increased sweating (linked to not shedding their coat), blindness, recurrent infections (including parasites, skin infections and synovitis), reduced fertility in mares and increase drinking and urination.

The most import aspect of this disease is laminitis; this can feature early on in the disease process and is usually the condition, which leads to diagnosis of Cushing’s. Laminitis is an inflammation and breakdown of the lamellae. The lamellae suspends and supports the pedal bone within the hoof capsule. When these lamellae are disrupted, the pedal bone sinks and rotates which then causes lameness. Cushings causes a break down in the lamellae proteins and reduces lamellae blood flow. This is why horses with Cushings are predisposed to laminitis.

Diagnosis is usually made on history and clinical exam; however, to be sure a blood test is usually conducted. The blood test measures the hormone ACTH as horses and ponies with Cushings have significantly higher levels of ACTH. It is not 100% diagnostic and may miss early cases but will confirm most and gives you the ability to measure the success of treatment. The hormone ACTH usually peaks in the autumn naturally and so this is the best time of year to test horses suspected of having Cushings. When determining baseline ACTH concentrations it is important to consider that stress may increase ACTH levels so the horse must first recover any bouts of stress or laminitis. Other tests are available if the result of this test does not match with the clinical picture of the horse.

Cushings is a condition mainly of older horses and so management is vital, including; feeding high-quality foods, regular dental care, deworming, and farrier care. Management and treatment depends on severity of condition, if the horse has a hairy coat then you can manage them simply with regular clipping. However, if the horse or pony is suffering from laminitis then management and pharmacological intervention will be required.

Pergolide ‘Pracend’ is the first-line treatment of horses and ponies with Cushings, it is a lifelong treatment that needs to be coupled with management changes. Once a treatment has been started, if there are no signs of improvement after 4 to 6 weeks, the dose should be increased gradually every 3 to 4 weeks. Treatment should be monitored by assessing both improvement of clinical signs and repeat blood tests to check for normalisation of ACTH concentrations. Most horses show improvement within 6 to 8 weeks of treatment. Within a month you can expect to see an improved attitude and reduced lethargy, however improvements in coat, muscle mass and laminitis may take up to a year. This is a lifelong management that needs to include laminitis management as well.


This occurs because fat tissue is active and produces its own hormones. These hormones reduce your horse’s response to insulin, making your horse insulin resistant (IR) this leads to a high concentration of both insulin and glucose in your horse’s blood stream (it also increases the level of cortisol, like in Cushings). This condition in very basic terms can be considered “Horse Diabetes” with a bit of Cushings. These horses are usually obese or “good doers” however, some horses can be lean but still have EMS.

EMS is characterised by obesity or regional adiposity, insulin resistance (IR), and subclinical or clinical laminitis. Laminitis is the most important component of EMS; this condition is most difficult to manage. IR predisposes a horse to laminitis by; altering blood flow and reducing nutrient delivery to the hoof tissues and generating inflammatory or oxidative damage. EMS horses therefore cannot tolerate normal laminitis triggers such as; grass rich in sugars and starches, grazing on abundant and rapidly growing grass, grazing after a frost or in periods of cold night and warm days (this changes the sugars within the grass and they become more readily available).

Diagnosis is made on clinical examination and history but there are blood tests that can confirm the diagnosis and again it is good to have a base line from which to judge the success of treatment. To diagnose EMS in horses, insulin and glucose concentrations can be measured in a blood test. Horses are starved for 6 hours over night and a blood test taken in the morning. Stress raises insulin concentrations in horses so it is important not to take a blood sample whilst the horse is suffering from laminitis. Another test available is an Oral Glucose Test, the horse is starved overnight for 6 hours then a blood sample is taken in the morning before giving a high glucose feed (1g/kg) in a very small feed. After this, blood samples are collected 2 and 4 hours later.

Management of IR/EMS involves mainly weight loss and laminitis management. This can be achieved by reducing sugar and starch intake, soaking hay, removing fat supplements, restricting turnout and regular daily light exercise. Exercise when the horse is sound is essential as it can decreases IR. Leaner horses with EMS are challenging to manage from a dietary standpoint because more calories must be provided without exacerbating IR. Most horses or ponies with EMS can be effectively managed by controlling the diet and reducing body fat, however, it takes time for these management changes to take effect, so drugs such as Metformin can aid the process and accelerate the improvement if the patient suffers from recurrent laminitis.

For both these conditions, the horse needs to be treated as an individual so close work with your vet and farrier is essential in successful management. If you have any concerns, your horse or pony may be suffering from Cushings or EMS then contact your vet for a consultation.

Navicular Bursar

Once a diagnosis of a problem with the navicular bone, the deep digital flexor tendon or one of the other soft tissue structures associated with the navicular bone is made, one of the treatment options is to inject the navicular bursar with cortisone as an anti-inflammatory. The navicular bursar is the fluid filled pouch between the navicular bone and the deep digital flexor tendon.

The procedure involves injecting with a long needle between the heel bulbs, through the deep digital flexor tendon and into the navicular bursar. This is best carried out under x-ray guidance. First of all a radiograph is taken of the foot with a marker that shows up on the image, to identify the exact location of the navicular bone within the hoof, a mark is made on the hoof wall with a marker pen to be used as an aiming marker for the needle advancement. Often a nerve block will be placed at the palmar digital site to totally desensitise the heel region of the foot, sometimes just the location of the injection site is desensitised with local anaesthetic.

Once the injection site is desensitised the heel region is meticulous cleaned and then aseptically prepped. A 10cm spinal needle with a stylet is placed through the skin between the heel bulbs and advanced towards the navicular bone, roughly parallel with the ground, using the marker on the hoof wall as a guide to the angle of approach. As the needle is advanced it is possible to gently feel it contact the back of the navicular bone. At this point a second radiograph is taken to make sure the needle placement is correct. If the needle is in the right place behind the navicular bone and through the deep digital flexor tendon, then the stylet is removed from the needle and the cortisone is injected into the bursar. Mixed in with the cortisone is a radiopaque substance which shows up on x-rays, a third x-ray is taken to demonstrate filling of the drug within the pouch at the back of the navicular bone and therefore the drug within the navicular bursar, after the needle has been removed.

Following injection the heel region is bandaged to keep it clean for 24 hours. The patient is kept box rested also for the first day after the injection, then hand walked for a further 2 days, followed by an ascending exercise program dependent on what the actual diagnosis was.

It is important that this procedure is carried out as aseptically as possible as to avoid the introduction of infection into the navicular bursar. It is also important to be as accurate as possible with the needle placement, if we know from the series of images obtained that the needle was correctly positioned and that the cortisone was injected into the navicular bursar, then we know if the horse does not become sound it was not due to inaccurate drug placement and that a different treatment option is required.

Navicular bursar medication is only one treatment option available to us for the treatment of navicular disease syndrome. This technique should be used in conjunction with other medications such as Tildren (Equidronate), aspirin, isoxoprine, etc. Probably the most important aspect of treatment is the farriery and obtaining a correct and appropriate foot balance.

Dr. E.A.Lyall, BVetMed, CertEM (StudMed), MRCVS

New Born Foal Facts!

  • Suck Reflex should be present within 5-10 minutes of birth
  • Trying to stand within 30 minutes
  • Standing within approximately 60 minutes
  • Suckling within 2-3 hours (If not by 4 hours -call the vet!)
  • The best time for colostrum absorption is the first 12 hours
  • Should suck 5-7 times an hour
  • Will consume 10-15% of their bodyweight in milk in the first 24 hours.
  • This increases to 20-25% by a few days of age.
  • Meconium should be passed within the first 6 hours of life.
  • First urination is 6 hours for colts and 10-12 hours for fillies.
  • The umbilical stump should shrivel up within 24 hours.
  • Vet check at 12-18 hours of age

Foaling The Mare

Foaling the Mare
Most mares foal without complication, however it is important that they are monitored regularly as the foaling becomes imminent.  Mares prefer to foal when all is quiet, as such it is important that the checks do not disturb them.  The stable can be fitted with a low wattage light bulb that can be left on.  Small cameras are available so that foaling mares can be observed from a distance and sweat alarms can be used to indicate an imminent labour.  There are alarms that can be stitched into the vulva which call your mobile phone when the water bag is pushed through the vulva at the onset of labour.  In high-risk mares with complications, the milk secretions can be monitored to more accurately identify when labour is likely to begin. 

The mare herself will start to show signs impending foaling.  These may occur several weeks before foaling or may start much closer.  The signs include development of the udder, swelling in front of the udder, slackening of the pelvic ligaments resulting in hollowing and softening of the quarters, lengthening and relaxation of the vulva, changes in temperament and the production of wax on the teats.  The “waxing-up” of the mare is one of the last signs to occur. 

During the last month of pregnancy the udder produces the first milk, colostrum, this is rich in antibodies that protect the foal from infection.  Prior to foaling some mares drip or run milk and as a result lose the valuable colostrum, once lost it is not replaced.  If this occurs 200ml volumes can be milked from the mare and frozen, this stored colostrum can be thawed in warm water (not microwaved) and bottle-fed to the foal in the first 6 hours after foaling.

While a mare is foaling it is better to minimise interference and to only respond when there is a problem.  There are three stages of labour.  The first stage is when the foal is getting into the correct position to be born, this may take several hours.  During this time the mare may become restless, sweat, look at her flanks and get up and down.  The second stage of labour begins with the passing and breaking of the white water bag, it ends with the complete birth of the foal.  Ideally mares should foal lying down.  The second stage of labour involves the forceful uterine and abdominal contractions required to give birth to the foal, typically the mare will be lying on her side. The average length of the second stage is 17 minutes, if after this length of time when forceful expulsive efforts have been made and the foal has not been produced veterinary assistance should be sought. The third stage of labour involves the passing of the placenta.  Once the mare stands after foaling the placenta should be knotted at the level of the hocks to prevent the mare from standing on it.  The placenta is usually passed within one hour, if it is not passed within three hours veterinary assistance will be required.  The placenta should be kept for your vet to examine.

Most mares will foal without any complications.  The normal presentation is that of a diving posture where the two front feet and the head come together, so the first part of the foal to be seen will be a hoof, usually followed by a second hoof a little further back.  The soles of these hooves should be facing the ground, if they are facing upwards the foal is either rotated or it is breach and coming back feet first which is very unusual.  A rotated foal will end up in the correct orientation as the mare gets up and down, so let her do this.  The leg with the foot which is a little further back will have a flexed elbow, the elbow may catch on the brim of the pelvis, if the mare appears to be making little progress getting the foal out, then between the mare’s contractions grip the pastern on the shorter leg and pull the limb to the same length as the more forward hoof, this will extend the elbow and prevent it catching on the pelvis.  Once this is corrected often the foal will come away easily.

As well as two front legs there should be a nose, this should be at about the level of the foal’s mid canon on the forelimbs.  Once the nose is out of the vulva it is worth just clearing the membranes from the nostrils.  If little progress is being made by the mare a little traction can be put on the foal to help it out, the direction of pull should be down towards the mares hocks due to the shape of the birth canal and the posture of the foal.  Grasp the pastern regions and pull gently, particularly between the mare’s contractions to prevent the foal slipping back into the uterus, let the contractions push the foal out, just help her.  Once the foal gets it’s chest and then pelvis through the mare’s vulva it will come away very easily.  Ideally the foals back legs should be left in the birth canal and the mare allowed to lye quietly to regain her strength, in this position the foal will still remain attached to the placenta via the umbilical cord, during the time it lies here blood from the placenta will be retained by the foal.  The placenta should break at the natural weak point next to the foal’s abdomen when the mare stands up.  As the foal is lying there make sure the nostrils are clean, sit it on it’s chest with it’s front legs wide apart in front of it and rub it’s chest with straw to stimulate breathing.

If at any stage in the birth process there are concerns about the foals presentation or it’s viability then seek veterinary assistance immediately.

Respiratory Conditions

Diseases and Disorder of Youngstock – Respiratory Conditions
(By Ed Lyall, BVetMed, CertEM (StudMed), MRCVS)

Young horses are like children where they have quite naïve immune systems meaning they can pick up viral and bacterial infections much easier that an adult horse. Many of these manifest themselves when the antibodies, derived from the mothers colostrum, start to disappear from the foal’s blood stream. The most common infections are respiratory infections; it is not unusual to see paddocks full of weanlings with crusty snotty noses on stud farms, they are usually caused by viruses.

There is little treatment for respiratory viruses in horses other than supportive care, ideally the youngsters affected should have their temperature monitored and non-steroidal anti-inflammatory drugs such as bute can be given to bring the temperature down to normal.

Any foal with a snotty nose and a high temperature should be monitored for the development of swollen painful glands under the jaw and around the base of the ear. If such swellings are present, tests should be performed to rule out strangles, the bacterial respiratory infection caused by Streptococcus equi. Young horses often have slightly enlarged glands where their immune system is learning to deal with all the pathogens that the horse is being exposed to on a daily basis. The difference is that strangles causes abscesses with the glands that are very painful to palpate. Any horse, and its contact companions, that are suspiciously looking as though it has strangles should be isolated until the results of the appropriate tests are through.

Rhodococcus equi is a bacterial disease that causes abscessation in the lungs of young foals. It is derived from inhaled environmental bugs and can affect multiple foals on the same property, typically from two months of age. Foals will be found to be dull and lethargic with reasonably high temperatures, severe cases will be breathing difficulty; blood samples will show elevation of white cell counts and more importantly elevation of fibrinogen levels.

The diagnosis is confirmed by ultrasound scanning the chest to find evidence of the abscesses. Treatment is with appropriate long term antibiotics.