3. Rabbits with large limb abscesses - Part 1

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Thur Jan 14, 2010, 6.40am Singapore time but it is dark in Siem Reap, Cambodia.
 
I took a short break to explore Angkor Wat in Siem Reap. It was a bright sunshine day and several thousand tourists were present to view history and the 12th century architecture of the temples. In the evening, before 5.30 pm, a big group had climbed up the steep steps of a temple to watch the pink golden sunset, taking great risk. I did not do it as there was no railing to guide climbers and the gradient was around 60 degrees. Life is filled with risks, so I did not want to take unnecessary risks in this situation. In veterinary practice, there are also risks of anaesthesia in operating on pets as the two cases of rabbit with large limb abscesses below illustrates.
CASE 1.
Male Rabbit, 6 years old. Molar spurs and a big limb abscess similar to Case 2.

A 6-year-old rabbit had not eating for 3-4 days and had salivation. The owner knew it was due to his sharp molar teeth. "3 vets advised euthanasia," she had found the 4th vet who solved her problem by filing the rabbit's molars under anaesthesia. This must be done every few weeks.

However this 4th vet worked certain days and was unavailable. I was available on Sunday and so she consulted me. Now, the 4th vet had her full confidence and if the rabbit passed away under anaesthesia, she would have no suspicion about his competence. I was a first-time vet. I advised her to consult the 4th vet on Monday even if she had to take leave to see him as I or no vet could guarantee no death during anaesthesia to file the molars. She accepted my advice.

This rabbit had a very big lump, similar in size to CASE 2. The 4th vet drained the abscess and gave her a white cream to rub onto it. So she did it and over time, it became bigger and bigger. "Can surgery be done?" I wondered. "Is it too late now as the lump is so big, around 2cm x 1.5cm", I explained to her that there would be a big hole.

Should surgery be done in the first instance when the abscess was small instead of lancing it and draining it?

This is hard to say as the standard practice for an abscess is to incise and drain the pus. This had been done at the first visit. However, Vet 4 had prescribed a cream to apply and the owner had been using this cream for a long time.

I don't give cream after drainage but each vet has his own preferences. The owner has to see the vet if the abscess recur instead of applying cream and seeing it swell to a bigger size over time. Seek a second opinion.

Now that this rabbit has become older and weaker due to loss of appetite attributed to molar spur formation, the anaesthetic risks have had doubled.

This growing abscess could have weakened the rabbit and made it high risk anaesthetic patient based on the application of a "white cream". This cream relieved itchiness in the rabbit and I presumed it must be a potent corticosteroid.

If the owner had consulted the vet again when the abscess recurred and the vet had drained the abscess, the rabbit might not be having such a large limb abscess now.

Of course, it would cost money to see the vet again.

It is very difficult to remove an abscess intact with its capsule and some rabbit abscess do recur. But many rabbit owners seem to give up consulting the vet.

Applying cream would not make any big abscesses disappear. In this case, the owner showed me a small plastic container with white cream given by Vet 4. There was no name of the cream and so I would presume that it was a corticosteroid as it would relieve the itchiness in the limb. However, it did not help the rabbit in the long term.

Other than the age of 6 years and a loss of appetite for a few days, the other factor to consider is the long-term use of corticosteroid. This may suppress the immune system and thereby weakening the rabbit. If I took on this new client and anaesthesized her rabbit for the treatment of molar spurs, the rabbit may just die on the operating table. A death on the operating table is unforgivable by many owners and their family members if you read the rabbit internet forum.

The only possible conclusion this owner and her family members would make would be that I killed the rabbit due to poor judgment or incompetence.

It would be very highly emotional and sometimes the owner would bad-mouth to all friends to avoid the practice.

No excuses or reasons would be acceptable to the owner and her family members when there is a death of a pet at the vet.

Therefore I advised and the owner accepted that her usual vet would handle her case on Monday.

It would appear that I was not confident enough to treat her rabbit. I did not have a good feeling in this case and it would be best to lose a client and have a live rabbit for the owner. Vets are not Gods.
CASE 2.
Male Rabbit, 10 years old. Big limb abscess similar to Case 1.

Two days after seeing Case 1, a 10-year-old thin rabbit came to challenge me as to how I should handle a similar case.

An almost identical case with the abscess equally as large but at the starting stage. No anti-inflammatory cream had been applied. I had seen this rabbit for nail clipping some 6 years ago and the young boy is now a grown up man. His silver-haired father said, "My son is upset that his rabbit has this large swelling in the right hind leg."

This rabbit is ancient and towards the end of his life span! "He had not been eating for 2 days," the mum said. Well, when the parents said 2 days of anorexia, it could be more than 2 days of inappetance or loss of appetite. So, here I have. A more high risk anaesthetic case. I gave him less than 30% chances of survival under anaesthesia and prolonged surgery. There was no point incising the abscess and draining out as much of the pus as possible. This rabbit would not have a second chance at surgery as he is so old. I decide to try and get the capsule of the abscesses shelled out but this is easier said than done. On closer inspection, he had 2 abscesses. The medial one appeared encapsulated. The lateral one was soft and both were connected to give the impression they were one large swelling.

So, one cut to drain both would not be satisfactory. The abscess would recur.
"Telephone your son to let him know this is high risk and he may not see his rabbit alive today if anaesthesia is done." The father phoned but there was no response. "Go ahead. Do your best." he said. He knew the odds. He was the father who took time off to get the rabbit's nails clipped some 6 years ago and there was no medical problems till now.

To shorten the story, here is what I did.

1. Dextrose saline 20 ml with baytril antibiotics. It was not possible to give an IV drip in small rabbits.

2. Ear vein. 0.1 ml Domitor. Isoflurane gas mask to maintain when the rabbit needed anaesthesia e.g. squealing or moving a bit.

3. Incision as long as possible to get all pus out. I could not see the capsule in the medial side but much of the debris and capsule were scrapped off. The lateral side had soft cheesy pus. "Why is the pus so thick," Alice, a 4th year Murdoch vet student asked me. Dog abscesses are usually watery and she was asking a pertinent question. I wanted my vet assistant to answer but they might not know and so I saved them the embarrassment. Fortunately I had an answer. "Rabbits do not have an enzyme to liquefy the pus, unlike dogs," I hope this answer would satisfy her. Having vet interns can be quite problematic or challenging if one has no answers? So some vets don't want interns.

4. Surgery. 2 incisions at the side. Large enough to view and scrap off infected capsule if possible. Normal saline flushed out all debris. 5/0 nylon sutures, simple interrupted.

5. Trimethoprim and meloxicalm oral for 14 days. Rabbit goes home after 2 days. Stitch removal in Day 14.

Will abscess recur? Follow up by the owner is essential. The rabbit was caged since the past year as the owner shifted to a much smaller apartment. He was permitted out but would not dare to come out as his cage was in the balcony. "He may be afraid of being preyed upon by birds or the smell of breeze," I explain as this rabbit was active and was roaming the room in the old residence for the past 9 years. "Why not permit him in the living area?" How he got this big abscess, I don't know. I hope he recover fully and will not need any surgery. He may live past 10 years as he is well cared for. This is a very long-lived rabbit in Singapore. If he was not caged, he might not have this abscess. But who knows?
4 days after the surgery, I phoned the owners as we had a relationship of trust. "I leave it to my husband and son to nurse the rabbit," the wife answered the phone as the husband was driving. The husband phoned me later and said: "No biting of stitches. The rabbit is eating normal and receiving his medication. Does he need stitch removal?"

"Yes," I said. "The rabbit was stitched up with 5/0 nylon sutures which would not dissolved. Bring the rabbit in 14 days after his surgery for stitch removal."

This old rabbit hides behind the sofa set when released in the living room or will just stay inside the cage when placed in the balcony. Before the shifting to a new apartment one year ago, this rabbit was sociable and running around inside the apartment. What causes this change in behaviour is hard to say.









Large abscesses in a 10-year-old rabbit
Large limb abscesses on the dorsal surface in rabbits are rare compared to facial abscesses and bumble foot. Therefore, having two cases in a short time appeared to me to be too much of a coincidence. I am not superstitious but was this situation a test by Divine Powers. Like scientists experimenting on animals, Divine Powers experiment on human beings? Sounds like a Science Fantasy?

SOME RABBIT REFERENCES
http://www.bio.miami.edu/hare/ileus.html - Ileus in Rabbits
http://www.bio.miami.edu/hare/dental.html - Dental Problems in Rabbits
http://www.bio.miami.edu/hare/urinary.html - Urinary Problems in Rabbits
http://www.bio.miami.edu/hare/sneezing.html - Respiratory Problems in Rabbits
http://www.bio.miami.edu/hare/tilt.html - Head Tilt in Rabbits