Treating Ringworm in Shelter Settings The Fungus Among Us

Who we are Michael Keiley Director

Dr. Pamela Wilmot DVM Veterinarian

Noble Family Animal Care and Adoption Center MSPCA at Nevins Farm 400 Broadway Methuen, MA

A bit about our shelter • 19,000 sq. ft building built opened November 7th, 2004 • Open admission shelter taking in about 6,000 animals a year • About 2300 cats a year • Between 40-50% of cats are “stray” • 87.6% adoption rate for cats • 1 full time veterinarian, 1 full time tech and 1 part time tech

What we will be talking about today • The goals of this presentation • Not to try to convince everyone to treat • Challenge euthanasia protocols

• The concerns and risks of treating ringworm • The realities of treatment • Cases we have treated • How to treat ringworm • Other tips we have learned • Can you treat ringworm?

Concerns about ringworm What makes us fear ringworm? • Staff can catch it • There will be an outbreak throughout the shelter • The public will get it • You’ll have to shut down your shelter/intake • You have to treat your whole population preemptively

The reality of the risk…

Athlete’s face

The Realities of the risk • Ringworm comes in and out of your shelter without you ever knowing it • The most likely time for ringworm to spread is before you even know you have it • Not all staff or animals will catch it even with direct exposure

The realities of treatment • You DO NOT have to treat your whole population as a precaution • You DO NOT have to shut down your shelter/intake • It IS labor intensive • It IS unpleasant for the staff • You DO have to commit the space to quarantine the animals

Cases we have treated…”the big one” First big case – May 2008 45 exotic cats and two boring old DSH cats Devon Rex, Ragdoll, Siamese, Sphynx, Himalayan 30 adults and 17 kittens ranging from 2 weeks-4mos Ringworm, URI, Ear mites, conjunctivitis, giardia

Challenges with treatment Shelter was full Not equipped to quarantine 47 cats Animals had to be housed in groups for space Treating multiple medical issues on intake Animals were surrendered, but multiple owners involved which made an unclear surrender High profile case High interest in adoption

“The big one” continued All cats were started on Lime Sulfur dips immediately after cultures were taken 23 cats tested negative on the first culture 24 cats tested positive After initial clearing it took 10 months to clear the last cat Extremely laborious

“The big one” • The 24 positive cats started treatment 5/9/08 • 5 cleared on 7/10/08(3 cultures) • 1 cleared on 7/14/08(3 cultures) • 5 cleared on 8/7/08(3 cultures) • 3 cleared on 8/30/08 (4 cultures) • 3 cleared on 11/4/08(4 cultures) • 2 cleared on 3/9/09 (6 cultures)

Additional cases - Milly and Kittens Milly and kittens – December 2010 • Mother cat and 7 kittens (5-6 weeks old) • Lesions on feet and face (initially looked like hair loss from messy eating of canned food) • Treatment started 12/9/10 • Treatment ended 1/20/11 • Total treatment days: 42 days

Challenges with treatment Shelter was full Isolation spaces unavailable Makeshift isolation space had to be created Animals had to be housed in groups Kittens were nuts!!

Group of four, eight week old kittens • Started treatment on 9/30/11 • Treatment ended 12/1/11 • Total treatment days:62 days

Challenges for treatment • Quarantine space available, but could not separate • Initial diagnosis determined while in foster care • Foster home initially tried to treat but later needed to be absorbed into shelter • Maintaining socialization, enrichment in isolated space

Django • Single 8 week old kitten • Started treatment: 7/7/2011 • Treatment ended: 9/26/11 • Total treatment days:81 days

Challenges • Why wasn’t this one easy!!?? • Tested positive on 3 consecutive cultures

Other tips we have learned • Be sure everyone has bought in to the plan • Be fair – share treatments • Stay the course – do not stop treating until you get 2 negative cultures • Its ok to throw it away • Don’t forget the enrichment

Can you treat ringworm? • You never know until you try • Best if you are a shelter vs. a foster home • Best if you have a committed quarantine space

Ringworm Considerations • Mandatory factors when considering to treat: • • • • • • •

Need to work closely with a veterinarian Look at cost and capability of shelter Fungal culture in-house or lab Quarantine ability Personnel ability (and time for daily/ weekly care) Ability to care for a potentially long-term zoonotic animal. May get URI during the treatment period.

Ringworm Considerations • Can be treated successfully in the shelter with proper quarantining, disinfecting, and treatment procedures • Zoonotic. Animal must be isolated, and must wear protective clothing at all times. • Foster. Consider person’s immunity, family, lifestyle, living arrangement. Will need to consider the foster person’s house contaminated and remove them from the foster pool.

Ringworm – Microsporum Canis • • • • •

Occurs in all mammals Incubation period 1-3 weeks Fungus grows in the hair follicles and hair shafts Outside of shelter, can be self-limiting Susceptible in young, immunosuppressed, debilitated, or previously unexposed animals • Presentation of hair loss highly variable • Some environments can’t be decontaminated

Ringworm - Diagnosis • Work closely with a veterinarian for diagnosis and treatment • Woods lamp – let warm up for a few minutes. Bright green apple glow (not all cases) • Glows on entire hair shaft and base • Don’t confuse with yellow glow from surface debris

• If not sure, always quarantine and culture

Ringworm - Diagnosis • Direct exam (if experienced): spores on hair, mineral oil or KOH prep • Fungal culture: in-house or Lab - In-house 7-10 days in 80 degree temp. - Lab may wait up to 25-30 days to post final results

• Culture at 4 weeks and once/week until negative culture. • If multiple cats per cage, need 2 consecutive negative cultures from each cat.

Ringworm - Diagnosis • For localized lesion, use sterile hemostat to pluck hairs and press into medium • For generalized, use “toothbrush” method – use individually packaged toothbrush or packaged dry surgical scrub brush • Brush cat all over 30-50 strokes (head, back, legs, tail), combing lesions last.

Ringworm - Diagnosis • Gently press into medium in several locations • Do not press so hard into medium as to crack the gel => • The growth in the cracks makes transfer to a slide difficult. • 7-10 days at 78-80 degrees 2-3 weeks at room temperature • Red color change with white cottony flat growth. • Spore ID: magic tape, clear double sided. Press onto fungus, then onto drop of stain Lactophenol blue or Dipquick (stain #3) purple stain on slide.

Spore Identification Microsporum Canis • Scan slide at 10X. Use 40X for closer evaluation

• Cigar shaped colonies with more than 6 cells

• Spines along wall

Spore Identification – Contaminants • Aspergillus Starburst on a stick appearance

• Penicillium Brush like appearance

Spore Identification – Contaminants • Alternaria (Environmental contaminant)

• Fungal hyphae (spores not present yet)

Ringworm - treatment • Always must wear protective gloves and clothing!! • Change clothes • Throw away items in cage or soak in bleach, minimum contact time 10 minutes

• Clean and remove hair from environment daily • Cats may get URI during the treatment period

Ringworm - Cleaning • When animal is present, bleach 1:32 dilution. Contact time 15 minutes. • When cage empty, bleach 1:10 dilution. Contact time 10 minutes. • Trifectant, Nolvasan, Virkon-S have not been shown to be effective for ringworm • Dishes & other washable items can be run through the dishwasher provided water temp reaches at least 110 F.

Ringworm – Treatment Localized • For solitary lesion not on face, if oral is not tolerated, or oral treatment not ideal (FELV/FIV, other immunosuppressed animal, geriatric animals) • Options: Spot-on lime sulfur dip. Topical wipes: Chloraseb (miconazole), Mal-a-ket (ketoconazole), Malaseb (miconazole) • OTC Topical antifungal ointment (2% ideal)

Ringworm – Treatment Generalized • Multiple lesions, and /or on the face making local treatment difficult • Oral itraconazole • Lime sulfur dip twice weekly – treats spores on hair. Follow diluting instructions on bottle. Use e-collar for 1-2 hours to prevent licking/ ingestion of dip from fur.

Ringworm – Treatment Generalized • Itraconazole 10mg/kg PO SID for 30 + days until a negative culture Order 100mg/ml or 50mg/ml from a reputable compounding pharmacy. Wedgewood Pharmacy/ NJ: Itraconazole 100mg/ml $38 for 15 mls. Good for 60 days from date of compounding • Sporonox 10mg/ml: $250 for 150 ml bottle • Side effects: not eating, vomiting, lethargy, hepatotoxic – jaundice. Discontinue immediately. Can try again after a few days if eating & active at 5mg/kg PO BID. If still not tolerated, don’t use oral.

Ringworm – Treatment Generalized • Fluconazole – works well

• Griseofulvin, Ketoconazole – No, too frequent side effects

• Chlorhexidine, iodine, Program (leufenuron) are not effective for ringworm

Ringworm – solitary lesion

Materials • Woods lamp Portable jor-vet Woods light j-132 $60-70 Plug in 115V model UVL-21 $135 -Mineralogical Research Co. http://www.minresco.com/uvlamps/comppn.htm • Culture plates Vetlab Supply Inc. www.vetlab.com/Dermatoplate.htm About $33 for 10. **Has microscopic interpretation chart available Hardy Diagnositics www.bactilab.com Derm-Duet II biplate About $25.50 for 10. • Stain, microscope. • Lab - Idexx cost fungal culture $60 each

Helpful Resources • Muller and Kirk’s Small Animal Dermatology, 7th ed. (Saunders) Descriptions and photos for fungal identification • Great series of articles on pathogenesis, testing, and treatment: Symposium on Feline Dermatophytosis Vet Med. October 2003; 98(10): 844. Karen A. Moriello.

Ringworm Look Alike • Not ringworm. This dog had hypothyroidism. Skin biopsy helped with diagnosis. • Skin lesions cleared up with treatment

• Not ringworm. Fur loss on back. Possibly due to another rabbit, fur shedding, or overgrooming

Ringworm Look Alike • This dog had demodex mites. Lesions cleared up with treatment.

• Not ringworm. Eosinophilic Granuloma Complex. Biopsy helped with diagnosis.

Ringworm – your shelter • Any suspicious hair loss – must quarantine

• Have plenty of disposable exam gloves available in all sizes. Some types extend up arm.

Ringworm – troubleshooting • Network with other shelters to troubleshoot issues • Maybe another facility has quarantine capability (Need to discuss with Dept of Ag before transporting)

Ringworm – your shelter • If you can’t treat for ringworm, try to get a positive diagnosis • Other types of hair loss in kittens might include fleas, a/d or food stuck to fur then rubbed off, unsanitary conditions, kittens nursing on each other, wounds, matts