Clinical Notes - Individual Specimen Report OREGON ZOO ELEPHAS Sex: Male ACC. #183009 Asian elephant Age: 31V 11M 290 Birth: 1.Apr.1983 Name: RAMA 31.Mar.2014 Problem: AN KYLOSIS - left elbow (Confirmed); lameness - left front limb (Confirmed); fracture left front digit 5 (Confirmed); fracture? right front digit 5 (Confirmed); fracture - left rear digit 1 (Confirmed); fracture - left rear digit 2 (Confirmed); HYPEREXTENSION - right carpus (Confirmed); degenerative arthritis - left carpus (Suspected); degenerative arthritis right carpus (Suspected); lameness - right front limb (Confirmed); fracture left front digit 2 (Confirmed); ulcer - right hip region (Confirmed); mycobacteriosis (Confirmed); TWO DRUG TB TREATMENT STARTED S: Delivered "Paramount for keepers to use as a potential vehicle for oral medication. The are composed of partially hydrogenated vegetable oil and lecithin. They are intended to be used to smooth/thin chocolate recipes and melt at approx. body temperature. Our intention with them is to use them as a vehicle for oral rifampin. The were melted and mixed with sugar (250 grams of mixed with 1/4 cup fine sugar). The liquid was poured into candy molds and the result were small rectangles approx mm. The idea is that the waxy material will keep most ofthe rifampin locked into its waxy matrix and will not be released until it is melted/digested in the stomach. The intention is to keep the material refrigerated or frozen until immediately prior to feeding to increase the chances that it will be swallowed prior to melting. Human taste tests showed that the material appears to make the rifampin essentially flavorless. P: Keepers are to work on rebuilding Rama?s trust in taking treats from them (he stopped after previous rifampin attempts) and then slowly integrate the Paramount rectangles into the mix to see if he will take them without any drugs in themtake them without drugs we will slowly introduce rifampin into the to see if we can get him taking oral medications to improve our TB treatment protocol. (MVF) 2.Apr.2014 S: Wrote prescription for levofloxacin as a trial dose to see if we can get adequate levels for TB treatment. Will give for two days and then the PK study will occur on the third day. Rx: LEVOFLOXACIN 58 gm rectally SID for 3 days. (MVF) 3.Apr.2014 O1NVSL reports that a mucus sample from this animal that was found on 1/29/14 was negative for growth. (MVF) 4.Apr.2014 Problem: PHARMACOKINETIC TRIAL S: Drew blood samples at timed intervals during the morning to check for plasma levels of levofloxacin; isoniazid and pyrazinamide. P: Will submit frozen plasma to lab for analysis. (MVF) 5.Apr.2014 S: Rechecked ulcerated tail tip. The end ofthis animal's tail (stump) had very heavily keratinized skin covering it. The keratinized skin became wet and macerated and sloughed with the help of minimal debridement leaving a granulating ulcer. A: It looks like the abnormal conformation ofthe tail amputation site allowed heavy keratin to develop which became saturated and macerated due to the chronically wet conditions. This may have led to ulceration and sloughing of the keratinaceous material. P: Keepers will allow the ulcer to dry and scab and will be mindful to manage the skin at the tip of the tail to not allow overgrowth of keratinized skin to occur again. 15.Apr.2014 0: UP Pharmacokinetics lab reported values from pyrazinamide (PZA) and levofloxacin pharmacokinetic testing that was collected last week PZA:Dosed at Dose the day before was at 9:30am Pre?dose (09:02): Trace 30 min (09:37): 11.28 mcg/mL 45 min (09:51): 19.11 mcg/mL 60 min (10:08): 20.75 mcg/mL 90 min (10:41): 16.55 mcg/ml LEV02Dosed at 09:07 AM. Dose the day before was at 09:30 Pre?dose (09:02): 0.29 mcg/mL 45 min (09:51): 8.11 mcg/dl 60 min (10:08): 8.32 mcg/mL 90 min (10:41): 5.53 mcg/dl 120 min (11:07): 4.97 mcg/mL 180 min (12:11): 3.86 mcg/mL A: Target minimum for pyrazinamide is 20-60 mcg/mL which was achieved. Target minimum for levofloxacin is 8-12 mcg/mL which was achieved. (MIM) 18.Apr.2014 O: UF Pharmacokinetics lab reported values from isoniazid (INH) pharmacokinetic testing that was collected last week at Dose the day before was at 9:30am Pre?dose (09:02): 0.00 15 min (09:22): 1.31 mcg/mL 30 min (09:37): 1.37 mcg/mL 45 min (09:51): 1.35 mcg/mL 60 min (10:08): 1.29 mcg/mL A: Target minimum for INH is 3-5 mcg/mL which was not achieved. Not sure why this dose of INH did not result in adequate levels. Possible interference of Levofloxacin or degradation of INH prior to administration. Possible random variation in PK results. P: Will repeat the study tomorrow without Levofloxacin to see if not having levo will affect the results. Will test INH 15 min for one hour and will test for PZA only at 60 min since that is when it peaked. (MVF) 19.Apr.2014 Problem: PHARMACOKINETIC TRIAL S: Performed a recheck pharmacokinetic study to follow-up on the study done on 4/4/14 which showed inadequate plasma levels. Rama was dosed rectally with 19 grams of INH and 153 grams of PZA in 800 ml water at 13:29 (previous dose was at 13:00 on 4/18). Blood (heparanized plasma) samples were taken prior to dosing for PZA and INH and then at 15, 30 and 45 minutes post closing for INH alone (actual sample times: Pre-dose 13:22; 15 min 13:44; 30 min 13:59,- 45 min 14:14). A final sample was ta ken at 60 min post-dosing (time 14:29) for both PZA and INH. All samples were immediately centrifuged and the plasma was frozen in a conventional freezer. Once the study was completed the plasma was transferred to an ultralow freezer pending shipment to the Univ. of Florida. P: Results pending. (MVF) 28.Apr.2014 O: UF Pharmacokinetics lab reported values from isoniazid (INH) and pyrazinamided (PZA) pharmacokinetic testing that was collected last week This study was done because a prior study run with these drugs and levofloxacin showed lower than expected INH values. lNH:Dosed at Dose the day before was at Pre-dose Trace 15 min 1.75 mcg/mL 30 min 4.11 mcg/mL 45 min 3.09 mcg/mL 60 min 3.00 mcg/mL PZAzDosed at Dose the day before was at Pre-dose Trace 60 min 20.38 mcg/mL A: Target range for INH is 3-5 mcg/mL which was achieved. Target range for PZA is 20?60 mcg/ml A: Possible interference from levofloxacin on previous study. These doses appear to work well for the animal without thelevo. P: Will consult with pharmacologist prior to starting levofloxacin to make necessary dose adjustments. (MVF) 17.May.2014 S: from IDEXX for routine monitoring is WNL. (KF) 27.May.2014 5: Received preliminary report from NVSL that they are growing a small amount of material on one of three culture plates from Tusko from trunk wash samples collected 3/27/14 and submitted with samples from the rest ofthe herd at the same time. This growth was a single colony on one plate, and was replated to accelerate the growth after testing it with a gene probe, which identified it as being in the M. tuberculosis complex (but it is not yet speciated). They will notify us when speciation is possible, and I also requested genotyping and sensitivity testing ofthis organism. Packy and Rama both had no growth on all three of their trunk wash samples from 3/27/14. P: Pursuing additional testing. Will collect five trunk wash samples this next week (Tusko, Rama and Packy), and divide each into three portions: 1/3 frozen and banked, 1/3 submitted to NVSL for culture, and 1/3 submitted to National Jewish lab for culture. At NVSL, will also run a PCR on the trunk wash samples that is not validated for elephants but that they have been using for cattle. It has high sensitivity and specificity, but will pick up any DNA fragment, notjust living organisms. This test will be performed alongside the cultures on all trunk wash samples for all three bulls. (TS) 2.]un.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk P: Trunk wash collected for Mycobacterial culture. Presented for rectal medication administration this afternoon. (EWL) 3.Jun.2014 Problem: CULTURE (MYCOBACTERIAL) trunk Performed 2/5 trunk washes on Rama this morning. (KF) 5: Results received from Chembio for Rama. There is now a decrease in apparent circulating antibodies to M. tuberculosis antigens compared with the sample from October 2013. This is a good prognostic indicator and correlates with his successful treatment course thus far. Comments from Chembio: ?Attached please find MAPIA results obtained with sera form your elephants. For Rama, Packy and Tusko, we have included their earlier samples for comparison. As you can see, the antibody levels in Rama continue declining good news reflecting successful treatment so far. This does not seem to be the case for Packy though, as the last serum shows further increase ofthe antibody response, particularly to antigen, which is not a good sign. Tusko did not show any reactivity in MAPIA, in contrast to DPP As I recall, IVIAPIA was not clearly positive (borderline/suspect) last year. To confirm this result, we will try to re-run Tusko's samples when we do MAPIA next time." (TS) 4.]un.2014 5: Present for rectal medication administration this afternoon. (KA) Problem: CULTURE (MYCOBACTERIAL) trunk Senior keeper reports that Rama had a trunk full of water this am prior to trunk wash. He may have dropped it when keepers interrupted him. Prior to trunk wash, Rama was asked to blow multiple times out of his trunk to disperse any remaining water. 3/5 trunk wash sample was then collected. A fair amount of mucous was in the sample. (KF) 5.]un.2014 Problem: CULTURE (MYCOBACTERIAL) trunk Performed 4/5 trunk washes today. Samples will be split to be submitted to several labs for testing. (KF) 6.]un.2014 Problem: CULTURE (MYCOBACTERIAL) trunk 0: Received speciation ofthe mycobacterial organism recovered from 1 out of 3 trunk wash samples from Tusko on 3/27/14, by DNA probe M. tuberculosis. Due to the very small amount of material recovered from Tusko (they commented that this was on the very edge of detection by culture, in contrast to our previous positives), this requires further growth before being able to speciate by normal methodology--this will be finished in 10?14 days from now. We will formulate a plan for treatment of Tusko to begin ASAP. Rama continues to be treated with two drugs, without complications or compliance problemstherapy. His MAPIA results are encouraging. P: Performed 5 of trunk wash collections today. As mentioned previously, all 5 samples collected this week will be split into three portions--1/3 submitted to NVSL for MB culture and PCR, 1/3 submitted to National Jewish Health for AFS and MB culture, and 1/3 saved frozen. (TS) 11.Jun.2014 O: AFS results from National Jewish Health: All five trunk wash samples were negative for acid-fast bacilli. Will report further AFS results at 1, 3, 6, and 8 weeks (the latter only reported if positive). (TS) 16Jun.2014 O: NVSL Mycobacterium tuberculosis PCR was negative on five of five trunk wash samples obtained 6/2-6/6. These five samples were also set up for MB culture. (TS) 17Jun.2014 Keepers noted small abrasion on ventral surface of prepuce today during a routine bath. Abrasion is raw, yet has a healthy granulation bed. A: Minor abrasion. P: Instructed keepers to monitor and clean with chlorohexadine if the area appears soiled. Continue TB medications as planned. (KF) 30..lun.2014 S: This elephant was given all of his medications rectally by vet staff and elephant staff. (KA) 14Ju .2014 Rx: ISONIAZID 19 gm rectally SID for 365 days. Rx: PYRAZINAMIDE 153 gm rectally SID for 365 days. (TS) 28.Ju .2014 0: MB culture results from National Jewish Health: All five trunk wash samples are negative for Mycobacteria culture at 6 weeks. This is a final report, with additional reporting only if positive growth in the next two weeks. (TS 3.Aug.2014 O: NVSL reports that the trunk wash cultures collected on 3/18, 3/19 and 3/20/2014 were negative for mycobacterial growth on culture. (MVF) 8.Aug.2014 S: Reviewed pharmacology data and discussed chemotherapy plan with experienced pharmacologist with elephant experience. P: The current Rx plan is: 1. Continue with at current dose and schedule 2. Plan to establish levofloxacin dose and use it to replace pyrazinamide to give better protection against the development of bacterial resistance. Will also look into creating an INH or NH+Levo suppository to simplify treatment. (MVF) 17.Aug.2014 S: This elephant accepted some sample doses of levofloxacin orally mixed with food items. Will dispense a single 5 mg/kg dose to try orally tomorrow. Rx: LEVOFLOXACIN 19.2 gm PO for 1 day. (TS) 20.Aug.2014 Rx: LEVOFLOXACIN 19 gm PO SID for 7 days. (MVF) 23.Aug.2014 Problem: PHARMACOKINETIC TRIAL S: Performed pharmacokinetic trial for oral levofloxacin and rectal pyrazinamide and isoniazid. P: Submit serum next week. (MVF) 27.Aug.2014 Rx: LEVOFLOXACIN 19 gm PO SID for 7 days. (IVIVF) 29.Aug.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Performed first of a scheduled three daily trunk washes for culture for Mycobacterium spp. Standard technique using 60 ml sterile saline (30 ml per nostril); trunk up for thirty seconds; forcible exhalation into a gallon plastic bag. Samples transferred to plastic sample bottles and then frozen at pending shipment to NVSL for culture. P: Will alter sampling frequency for mycobacterial culture: positive animals on treatment will be cultured once a month and negative animals will be cultured 3 months. (MVF) 30.Aug.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Performed second of a schedule three daily trunk washes for mycobacterial culture. Samples frozen at pending shipment to NVSL for culture. P: Collect one more trunk wash tomorrow to complete the series. (MVF) 31.Aug.2014 Problem: CULTURE (MYCOBACTERIAL) trunk S: Performed third of a schedule three daily trunk washes for mycobacterial culture. Samples frozen at -80C pending shipment to NVSL for culture. P: Trunk wash complete. Cultures pending. (KF) 2.5ep.2014 S: Pharmacokinetic study showed adequate isoniazid and below adequate levofloxacin. Pyrazinamide levels are still pending. P: Will increase oral levofloxacin dose and re-test. (MVP) 3.Sep.2014 Rx: LEVOFLOXACIN 38 gm PO SID for 14 days. (MVP) 4.Sep.2014 0: Lab reported adequate levels of pyrazinamide reached on last PK study. Peak value was 31.88mcg/ml at 30min but values stayed above minimum levels throughout the entire sampling period. P: Need to schedule a levofloxacin PK study. (MVF) 6.Sep.2014 Problem: PHARMACOKINETIC TRIAL S: Performed routine PK study for levofloxacin. Samples were taken at intervals up to 6 hours post medication. P: Results pending. (MVF) 13.5ep.2014 S: Results of most recent PK studies show that both PZA and INH are above minimum levels. The levofloxacin is still below Optimum. The INH is higher than necessary so the dose was reduced to avoid toxicity issues. P: New doses to start tomorrow. Levofloxacin increased and isoniazid decreased. PZA dose left alone. Will need to run new PK studies to evaluate to confirm minimum levels have been met. (MVF) 14.5ep.2014 Rx: ISONIAZID 12 gm rectally SID until further notice. Rx: LEVOFLOXACIN 64 gm PO SID until further notice. (MVF) 16.Sep.2014 0: Lab work from last week (9/12) showed decreased alk. Phos. and monocytosis. Serum amyloid A was well within the normal range. A: Monocytosis is likely an indicator of chronic infection (M tb). Decreased alk phos is probably not clinically significant. P: Will monitor regularly. (MVF) 17.Sep.2014 CBC and chem panel submitted today show no significant deviations from expected values. (MW) 18.Sep.2014 S: We had a compounder make up a wax coated granular version of rifampin powder which is intended to mask the taste ofthe product. According to the compounder it will last 30 minutes in a wet food item before it starts to leach out. We received 4 doses. The product is ?diluted? by the wax so 100 grams ofgranules only contains 40 grams of drug. P: Keepers will see if he will take it. Rx: RIFAMPIN 40 gm PO SID for 4 doses. (IVIVF) 25.Sep.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Performed first ofthree scheduled routine trunk washes for mycobacterial culture. 60 ml of saline was instilled into the trunk (30 ml per nostril); the trunk was held up for 30 seconds; saline was collected into a zip-loc bag after forcable exhalation. The sample was frozen at -80C pending shipment to lab for culture. P: Perform two more cultures for this series. (IVIVF) 26.5ep.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Performed second of three scheduled routine trunk washes for mycobacterial culture. P: Perform one more culture for this series. (MVF) 27.Sep.2014 Problem: CULTURE (MYCOBACTERIAL) trunk S: Performed third of three scheduled trunk washes for Mycobacteria culture. P: Reculture in approx. one month. (MVF) 11.0Ct.2014 Keepers have been noted that Rama seems more stiff in the hind right limb over the past few days. He is having difficulty with the ?foot under? behavior, and is swinging the entire limb laterally when ambulating. The tarsus and stifle palapte normally with no noticeable increase in heat/swelling. Keepers started hydrotherapy today with warm water on the stifle and tarsus, which appeared to help him move more normally upon completion. A: Progressive OA P: Consider re-dosing pain management plan. (KF) 12.0ct.2014 S: Rama is again very stiff this morning. The keepers noted that he was having difficulty stepping down from the scale when weighing him in the hallway. A large sand bed was provided for him overnight, however there was no evidence that he laid down last night. 0: Rama continues to swing his right hind limb (and to some extent the left hind limb) laterally to avoid flexion of the stifle. Rama was reluctant to bend the stifle in order to place his foot up on the tub for hydrotherapy with warm water. After the warm water session (approximately 20 minutes) Rama flexed the stifle a small amount, but was still unwilling to place the cranial portion of the foot/nails on the tub stand. A: Progressive OA of stifles. P: After discussion with curator and vet staff, plan to change Rama?s medications and monitor for improvement. Plan to start Tramadol TID, and discontinue previcox. Plan to start ibprofen 48 hours post last previcox administration to allow for a NSAID wash out period. Asked keepers to administer legend injection a few days early during the wash out to provide additional analgesia. Keepers will continue with warm water hydrotherapy on both right and left stifles. Rx: TRAMADOL 1250 mg PO TID for 14 days. (TR-11) (KF) 15.0ct.2014 Rx: ACETAMINOPHEN 4.55 gm PO BID until further notice. (MVF) 18.0ct.2014 S: Rama's lameness has improved gradually over the past three days. He is now flexing his right stifle when he goes over door thresholds and other obstacles. Continues to do well otherwise too. Eating and tolerating his TB treatments without problems. P: Continue with meds as per Rxs. (MVF) 21.0ct.2014 Problem: CULTURE (IVIYCOBACTERIAL) trunk First of three schedule trunk washes collected today for mycobacterium screening. P: Send samples out for culture. (KF) 22.0ct.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Performed second ofthree scheduled trunk washes for Mycobacteria spp. culture. Used standard technique of instilling 30 ml sterile saline into each nostril, having animal hold trunk elevated for 30 seconds and then expelling the solution into a gallon Zip~loc bag. All samples transferred to sterile vials and frozen at -80C pending shipment to lab. P: One more culture tomorrow. (MVF) 23.0ct.2014 Problem: CULTURE (MYCOBACTERIAL) trunk S: Performed third of three scheduled routine trunk washes for tb culture. Used standard technique of instilling 30 ml saline per nostril, elevating trunk for 30 seconds then expelling into a gallon zip-loc. All samples frozen at pending shipment to lab for culture. P: Females will be cultured again in approx. 3 months. Males will be cultured again at the beginning of next month to get them back on their montth schedule. (MVF) 24.0ct.2014 CBC/chemistry panel submitted yesterday show no significant deviations from expected values. (MVF) 25.0ct.2014 S: Rama continues to incrementally improve. I did not see him move today - he was standing still eating when I observed him - but keepers report that he is improving and getting around better. He is flexing both stifles now although he still abducts the right rear limb as he brings it forward. He is flexing his right carpus fairly well {for him) as he crosses thresholds. Appetite and attitude are normal. A: Improving condition following unknown exacerbation of chronic degenerative joint disease. P: Will decrease tramadol from TID to BID. If he continues to improve we will scale back his ibuprofen dose and work toward maintaining him on a chronic low dose of ibuprofen and acetaminOphen along with the tramadol for chronic pain control given the severity of his orthopedic issues. (IVIVF) 26.0ct.2014 Rx: TRAMADOL 1250 mg PO BID until further notice. (TR-11) (MVF) 29.0ct.2014 Problem: PHARMACOKINETIC S: Performed routine pharmacokinetic trials for isoniazid, rifampin microspheres (see Rx below), pyrazinamide and levofloxacin. Rama was dosed with rifampin and levofloxacin orally at 6AM and isoniazid/pyrazinamide rectally at 8AM. Sampling started at and ended at 2PM. Plasma samples saved at -80C pending shipment to lab for analysis. Rx: RIFAMPIN microspheres 150 gm total (60 gm rifampin) PO for 1 dose. (MVF) 30.0ct.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Performed routine trunk wash for TB monitoring using standard technique (30 ml sterile saline per nostril). This set of cultures is coming close on the heels of the last set of cultures in order to get the animals caught up and back on schedule with trunk washes that will occur near the beginning of each month. P: Sample frozen at pending shipment. Collect two more samples to complete this series. (MVF) 31.0ct.2014 Problem: CULTURE - trunk S: Collected second ofthree scheduled trunk washes for routine TB surveillance. Rama is BAR and his mobility is essentially normal. P: Will reduce ibuprofen dose to 2 mg/kg to try to minimize potential for GI upset (which has occurred with him previously). Continue with acetaminophen and other pain meds as per previous Rxs. One more trunk wash culture tomorrow to complete series for TB surveillance. Rx: IBUPROFEN 8.0 gm PO BID until further notice. (MVF) 1.Nov.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Collected final trunk wash ofthe series of three for TB monitoring. P: Cultures pending. Culture again in approx. 30 days. (MVF) 11.N0v.2014 0: Lab reports PZA levels were within therapeutic range (ie, >20 mcg/mL) at 1.5 and 2 hrs. Levo levels were just below therapeutic range [8 mcg/m L) and peaked at 7.1. P: Latest round of PK data showed good levels with INH, PZA, and RIF. Once RIF order is here we will convert him to RIF and INH. repeat INH PK once we do so since it will not be mixed with PZA anymore and this may affect absorption. (MVF) 26.Nov.2014 S: The new microencapsulated version of Rifampin just came in so we will be changing Rama's medication from oral levofloxacin and rectal PZA and INH to oral rifampin and rectal LEVO and INH. The levo was not getting good levels orally but previously we did confirm good levels with it given rectally. P: Will start tomorrow on rectal LEVO and INH and oral RIF (to start as soon as he starts taking oral meds again). (MVF) 27.N0v.2014 Problem: THREE DRUG TB PROTOCOL STARTED Rx: RIFAMPIN 60 gm PO SID until further notice. Rx: LEVOFLOXACIN 64 gm rectally SID until further notice. (IVIVF) 29.N0v.2014 S: Rama is in musth presently now (as are the other two bulls) and his appetite is down. Yesterday he took very little oral rifampin but today the keepers were able to get approx. 90% into him. P: Will continue to try to get oral rifampin into him. (MVF) 2.Dec.2014 Problem: CULTURE (MYCOBACTERIAL) trunk S: Performed first of three scheduled trunk washes for routine TB surveillance. 30ml sterile saline was instilled into each nostril and he was asked to hold the trunk elevated for 30 seconds prior to having him forcibly exhale into a collection bag. The sample was frozen at -80C prior to submission to lab for culture. Continued musth behavior. P: Collect two more trunk washes for TB culture to complete this series. (IVIVF) 3.Dec.2014 Problem: CULTURE (MYCOBACTERIAL) trunk S: Collected second of three routine trunk wash specimens for routine TB surveillance. P: Sample frozen pending submission to lab. (MVF) 4.Dec.2014 Problem: CULTURE (MYCOBACTERIAL) - trunk S: Collected third of three routine trunk wash specimens for routine TB surveillance. P: Sample frozen pending submission to lab. (MVF) 6.Dec.2014 S: Requested keepers submit a free catch urine sample to use as a comparison to another patient (0801) - another bull that is also currently in musth. (MVF) 13.Dec.2014 Problem: PHARMACOKINETIC TRIAL S: Performed routine confirmatory pharmacokinetic trial for isoniazid, rifampin and levofloxacin. A small amount of the rectal dose (INH and LEVO) leaked out immediately after dosing but I decided to go ahead with the trial nonetheless. A: PK trial on RIF, LEVO and INH. INH and LEVO values may be low due to drug spillage. P: Send in samples at the start of next week. (MVF) 20.Dec.2014 S: Lab reported lower than target range values on plasma levels of both rectally administered drugs (isoniazid and levofloxacin) but good levels of rifampin {orally administered). Because there was leakage ofthe rectally administered meds right after they were given last time, we repeated the PK study today at the same doses to measure plasma levels ofjust those two medications. P: PK results pending. (MVF) 23.Dec.2014 O: NVSL reports that trunk washes taken on 10/21,10/22 and 10/23/14 were all negative for Mycobacteria spp. on culture. None ofthe elephants cultured positive on this round. (MVF) 26.Dec.2014 S: Results of INH pharmacokinetic trial that was done on 12/20 showed that peaked within the desired range (3.03 mcg/mL 15 min).This was the only INH value that was within range. P: Will increase INH dose (12 grams to 14 grams) to increase levels. Target level is 3.5 mcg/mL. Used and solved for to get new dose. (MVF) 27.Dec.2014 Rx: 14 gm rectally SID until further notice. (MVF) 30.Dec.2014 Problem: THREE DRUG TB PROTOCOL STARTED 31.Dec.2014 Rx: LEVOFLOXACIN 200 gm rectally SID until further notice. (MVF) 2.Jan.2015 Problem: PHARMACOKINETIC TRIAL S: Performed one hour pharmacokinetic trial to test new doses of isoniazid and levofloxacin. P: The levofloxacin supply is low and the pharmaceutical company has not gotten back to us about when to expect more in (due to holidays). Because ofthis Rama will not receive levofloxacin after today and will continue on just rifampin and isoniazid until the new supply of levofloxacin comes in. (IVIVF) 3.Jan.2015 S: Discontinued Rx for levofloxacin. The supplier is unable to get any right now and our supplies are out. (MVP) 5Jan.2015 Problem: T8 TRUNK WASH, 3 SAMPLE SERIES STARTED S: Performed first ofthree regularly scheduled trunk washes for mycobacterial culture. Standard protocol of instilling 30 ml sterile saline into each nostril; trunk elevated 30 seconds; forceful discharge into plastic bag; sample frozen at -80C pending shipment to NVSL for culture. P: Two more cultures to complete this series. (MVF) 7Jan.2015 S: Performed second of three schedule trunk washes for TB surveillance. Examined nail and sole lesion with keepers. There are two lesions on the left front foot: one is a 3cm diameter ulcer in the dorsal surface of the caudal aspect of the #5 nail near the cuticle. The other is a swollen area with a 6cm diameter ulcerjust caudal to the #5 nail. Both lesions are trimmed nicely and have beveled edges with no undermining into sole or adjacent tissues. The sole in this area is approx. 5-8mm thick. Rama tends to walk on the lateral aspects of his feet - especially the left front. When he stand still he tends to stand on the medial aspects of the feet and often will sway and rotate on the medial sides. These lesions appear to be a result of excessive wear on the lateral aspects. A: Ulcers are probably the result of his abnormal conformation secondary to an old injury to the left elbow and resulting DJD in the front limbs. P: Will monitor and advise keepers on the nail lesion. The idea will be to simply keep the lesions open and dry and not allow water or debris to become entrapped. The two lesions will probably unite into one lesion eventually but will keep separate for now to avoid them causing a larger area of unstable nail. One more trunk wash for mycobacterial culture to complete this series. 8.Jan.2015 S: Performed third of three trunk washes for mycobacterial culture for routine TB surveillance. P: Samples frozen pending submission. (MVF) 14.Jan.2015 Problem: PHARMACOKINETICTRIAL S: Performed PK trial for isoniazid. INH was given alone (no LEVO or PZA) for this trial to see how well it is absorbed on its own. Samples taken over 30 minutes. (MVF) 17Jan.2015 S: Spoke with curator. He reports that Rama continues to be very painful on the left front foot where the ulcer is developing. The ulcer is warm to the touch, but not open. Curator asked if i could prescribe a topical pain medication. I informed him that with the sore being closed, something like lidocaine jelly would not penetrate the skin, and we should focus more on systemic analgesia. Also recommended cool water hydrotherapy to help bring heat/swelling down. P: Plan to increase tramadol back up to three times daily and monitor for response. Rx: TRAMADOL 1250 mg PO TID for 14 days. (TR-11) (KF) 18Jan.2015 S: Spoke with keepers today. Rama is set up to receive TID tramadol with the last dose given by later keeper. No marked improvement from yesterday, but remaining stable. (KF) 19.]an.2015 S: Blood was drawn from each individual in the elephant herd to assess blood selenium levels since historically grass hay from this geographical region has been depleted in this mineral. O: 432ng/mL A: Normal selenium level. P: Majority ofthe herd maintaining normal Se levels (between 300?400ng/ml) with pellet supplementation. (KF) 28Jan.2015 S: Keepers report Rama is improved on the tramadol. He is moving his rear limbs better and shows normal (for him) flexion and extension in the hocks which had been stiff previously. P: Will continue with Tramadol TID UFN. 30Jan.2015 Problem: PHARMACOKINETIC TRIAL S: Performed routine pharmacokinetic trial for oral rifampoin microspheres and oral isoniazid. 31.Jan.2015 Rx: TRAMADOL 1250 mg PO TID until further notice. (TR-11) 3.Feb.2015 Problem: TB TRUNK WASH, 3 SAMPLE SERIES STARTED S: First ofthree scheduled trunk washes collected for mycobacterial culture. Standard collection technique used: instilled 30 ml sterile saline into each nostril; trunk held up for 30 seconds; saline exhaled into gallon plastic zip-Ioc. Sample transferred to plastic specimen container and frozen at pending shipment to NVSL. P: Two more cultures needed. (MVP) 4.Feb.2015 S: Performed second of three routine trunk washes for TB surveillance. P: One more sample to complete this series. Today's sample frozen at pending shipment to NVSL. (MVF) 5.Feb.2015 S: Performed third of three scheduled routine trunk washes for Mycobacteria. Samples were frozen and overnight shipped to the NVSL for culture today. P: Results pending. (MVF) 14.Feb.2015 8: Adjusted dosages of isoniazid and rifampin foilovving recent PK and drug potency testing. Rifampin increased from 60g to 70g and isoniazid increased from 14g to 18g and will be scripted for P0 administration. P: See below. Rx: RIFAMPIN 70 gm PO SID until further notice. Rx: ISONIAZID 18 gm PO SID until further notice. (MVF) 17.Feb.2015 O: NVSL reports that the trunk wash cultures collected on 12/2, 12/3 and 12/4/2014 were negative for growth. (IVIVF) 19.Feb.2015 Problem: PHARMACOKINETIC TRIAL S: Performed PK Study On for INH. This one was done at the 14g dose. We recently bumped the dose to 18g which will start at the start of next week. Data from the last PK study suggested that the peak INH value may have been reached before the first sample was taken so this study started sampling earlier than the last one. If we get good values (>3mcg/dL) then we should continue on at 14g/dose rather than going ahead with the increase. (IVIVF) 28.Feb.2015 0: Results from the PK study done with at 14g orally are above 3mc/dL at the 30 minute mark, and then drop below 3 for the subsequent sampling times. Since we reached therapeutic levels at the 14g dose, plan to switch back to this close, rather than staying at the previously prescribed high dose of 18g. (KF) 2.Mar.2015 S: Observed Rama in yard today--it appears that his forelimb use is more impaired than I have previously seen. He is showing decreased carpal mobility in both forelimbs, and the keepers report that he intermittently drags his front feet when walking. Overall, he is walking more slowly and is more reluctant to walk. (TS) 3.Mar.2015 Problem: T8 TRUNK WASH, 3 SAMPLE SERIES STARTED 0: First of three scheduled trunk washes collected today by KH. P: Send frozen sample to NVSL for mycobacteria culture. (KF) 4.Mar.2015 0: Second of three scheduled trunk washes collected today by KH. P: Send frozen sample to NVSL for mycobacteria culture. (KF) 5.lV ar.2015 0: Third of three scheduled trunk washes collected today by KH. P: Send frozen sample to NVSL for mycobacteria culture. (KF) 8.Mar.2015 Rx: ISONIAZID 14 gm PO SID until further notice. (KF) 9.Mar.2015 O: Keepers noticed that Rama has a swelling just cranial to his prepuce. It feels fluid filled on palpation and more firm deeper. He does not appear to be bothered by it. A: Edema - unknown cause P: Keepers monitoring, FNA if swelling continues. (KF) 11.Mar.2015 S: Recheck of ventral focal swelling?there is no further enlargement of this swelling, which is approximately 9 5 cm and ovoid. This swelling is less fluctuant and more solid than noted previously, and remains insensitive to touch. No evidence of any other swelling or evidence ofdependent edema. Rama?s mobility continues to be an increasing concern, with continuing reluctance to move, evidence that he is not laying down, dragging of his front feet (incomplete carpal flexion) when walking. He is still interacting voluntarily with keepers and cooperating with training, although at a slower pace. Keepers are continuing to spend a lot oftime doing warm water hydrotherapy and measured physical therapy to encourage movement and general range of motion, but unsure how effective this is. (TS) 14.Mar.2015 Keepers noticed small abrasion on Rama?s left hip today. Appears superficial and clean. A: Superficial abrasion P: Keepers cleaning with nolvasan and applying TAB. (KF) 17.Mar.2015 5: Visual exam: Rama?s mobility is very poor and seems to have degenerated quite a bit over the past several weeks. His gait is slow and he drags both front feet through the sand. He is flexing his carpi though and is not swinging either front limb laterally as he walks. His rear legs are tucked beneath him in an apparent attempt to take weight off of his front limbs. He shows mild scoliosis with the spine curved to the left. Movement of both rear limbs is very stiff and passive range of motion exercises show significantly decreased ranges of motion on all limbs. There are two recently ruptured superficial abscesses on the palmar surface ofthe right carpal area. He is very thin at the moment and his weight is belowed his target range. Finally, he has a small decubital ulcer on the left hip. Keepers have not seen him sway in several months nor has he been observed laying down in at least that long. A: DJD of all four limbs most likely the ultimate result of an ankylosed left elbow that was the result of an injury suffered in the mid-19805. Overall he appears to be very uncomfortable. Keepers are doing single sessions of warm water hydrotherapy on him and taking him through passive range of motion exercises which seems to help if only temporarily. P: Will discuss with curatorial staff. It is doubtful that there is anything we can do to significantly improve his level of comfort. Consider changing to Adequan from Legend and/or adding amantadine to the he is already on. That said, it is unlikely to make enough of an improvement in his level of comfort to significantly improve his overall quality of life which seems inadequate presently. (MVF) 20.Mar.2015 S: Continued very poor mobility. Rama is not lying down at night, he is keeping his rear feet as far cranial as possible, seems especially stiff in his rear limbs and swings his pelvis in order to advance his rear limbs rather than to extend his hips. His left carpus is still showing a vargus deformity and the right carpus still hyperextends when loaded. These have not changed recently. He tends to stand with his front feet crossed with the left foot caudal to the right with most of his weight on the right. He is very slow walking and seems unwilling to walk any more than he absolutely has to. We had quality of life assessment discussions with keeper and management staff and there was consensus that Rama?s quality of life is questionable. A: Due to the left elbow injury Rama suffered nearly 25 years ago, he has developed DJD in his other limbs as he has had to compensate for the lameness (left elbow ankylosis). Progression of the DJD has led to severe mobility issues. P: Will alter his Rx plan: Increase ibuprofen to approx. 6mg/kg increase gabapentin by 2x, discontinue Tramadol and replace it with methadone. Will start on contiuous SandClear (metamucil) since keepers believe he is straining to defecate. Will stop tramadol as of today and make other drug changes starting tomorrow (Saturday). Will not start Methadone until Monday (3/23) to give wash?out time for Tramadol and to assess his mentation and ambulation on the higher gabapentin close before we start the methadone to avoid severe ataxia or sedation. Rx: OMEPRAZOLE 4.56 gm PO SID for 7 days. Rx: IBUPROFEN 22.4 gm PO BID for 7 days. Rx: GABAPENTIN 3200 mg PO BID for 7 days. (MVF) 21.Mar.2015 S: Rama is BAR and is not showing obvious signs of ataxia or lethargy from the increased gabapentin dose that started today. He is moving better which is mostly manifested as in increase in his rate of moving rather than an overt improvement in his lameness (he is still very lame). Examined three ruptured abscesses on the palmar side ofthe Rt front limb. There are two SQ abscesses that ruptured a week ago and a newer one on the palmarolateral aspect ofthe carpus which appears to have just ruptured today. The opening into the abscess was enlarged with a very sharp hoof knife and the cavity was flushed with a hose. He did not react to enlarging the orifice. A: Unsure of cause of abscesses on the right carpus. Modest improvement with increased ibuprofen and gabapentin. P: Recheck tomorrow. If he is still not showing overt signs of gabapentin will start on oral methadone on Monday Hydrotherapy on the abscesses SID. (MVF) 23.Mar.2015 Rx: METHADONE 200 mg PO BID until further notice. (145842) (MVF) 24.Mar.2015 S: Rama seems to be doing reasonably well on his new analgesic protocol. He is alert and eating and appears more willing to move about on his own. He has brief episodes where he seems to stare off into the distance but responds normally when he is called to. No ataxia or increased dragging of his feet has been seen. A: Apparently a good response to current drug regimen. The ibuprofen dose we are using is high for Rama (although it is the published dose for Asian elephants) and I would expect it to cause gastritis if used long-term without gastroprotectants. P: Continue on current plan. Will bring down one day's worth of methadone each afternoon. (MVF) 27.Mar.2015 S: Rama currently seems to be doing well on his current medication plan. He is eating well, is BAR and normally interactive with keepers. He is still very slow moving and has very significant orthopedic issues. This drug plan has improved his lameness somewhat, but it is still profound. A: Following discussions with keepers, zoo and Metro managers the decision was made to electiver euthanize Rama because we are unable to control his orthopedic pain enough to give him the quality of life that we feel is adequate. P: His TB positive status complicates post~mortem exam related issues. Work is being done now to arrange necropsy and diagnostics. His euthanasia is scheduled for Monday (3/30) with Nx to follow at an off site location immediately thereafter. Will continue with current Rx analgesic plan until then. We will switch from methadone to butorphanol starting with tomorrow?s AM dose. Butorphanol dose based on equine dose of0.015mg/kg parenteral dose. Equine research has shown a 6x reduction in bioavailability when given orally so will increase dose to compensate for that. See Rx starting tomorrow morning. (MVF) 28.Mar.2015 S: Transitioned Rama from methadone to butorphanol today. Rama remains BAR and eating well. There are no overt signs of sedation although he is less bright today compared to yesterday. He moves with severe lameness due to his chronic left elbow problem {ankylosis) but is Spontaneously moving about his large exhibit with no prompting from keepers. A: Apparently doing OK with new opiate component of analgesic plan. P: Things may change over time as more stable drug levels are achieved so will need to monitor for signs of sedation and ataxia. If subtle signs of ataxia or sedation are seen, reduce butorphanol dose to 150mg BID. If moderate or sever signs are seen then we should skip a dose and restart at a lower dose the next day. Rx: BUTORPHANOLTARTRATE 210 mg PO BID for 2 days. (arr?21) (MVF) 30.Mar.2015 Problem: Necropsy Examination S: Euthanized by inducing anesthesia with relatively high doses of etorphine and xylazine. Additional xylazine and euthanasia solution were given after he was deeply anesthetized to complete the euthanasia. See anesthesia notes for more details. Overall the procedure went well. Rama became anesthetized in several minutes and died approx. 27 minutes after the initial injection was given. See anesthesia record for more details. See separate gross necropsy report for necropsy details. (IVIVF)