646584

research-article2016

JOR0010.1177/2055116916646584Journal of Feline Medicine and Surgery Open ReportsGambino et al

Case Report

Diagnosis of Aelurostrongylus
abstrusus verminous pneumonia
via sonography-guided fine-needle
pulmonary parenchymal aspiration
in a cat

Journal of Feline Medicine and Surgery

Open Reports
17
The Author(s) 2016
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DOI: 10.1177/2055116916646584
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Jennifer Gambino1, Elizabeth Hiebert2, Melanie Johnson3*

and Matthew Williams4

Abstract

Case summary A 9-year-old, male neutered, indooroutdoor domestic shorthair cat from the northern Alabama
countryside presented for a 3 week history of coughing, lethargy and an episode of self-resolving dyspnea that
occurred 1 week prior to presentation. Three-view thoracic radiographs revealed a moderate-to-severe, diffuse,
mixed bronchial to structured interstitial (miliary-to-nodular) pulmonary pattern in all lung lobes with peribronchial
cuffing and multifocal areas of mild patchy alveolar opacity. Ultrasound-guided evaluation and fine-needle aspiration
of the caudodorsal lung parenchyma was performed with sedation. Cytology revealed many widely scattered
Aelurostrongylus abstrusus larvae and ova. Upon the confirmed diagnosis of A abstrusus verminous pneumonia,
treatment with fenbendazole and selamectin resulted in complete resolution of clinical signs within 6 weeks of the
initial diagnosis.
Relevance and novel informationWe report herein the first documented case in the Americas of A abstrusus
verminous pneumonia diagnosed via cytologic evaluation of an in vivo, percutaneous ultrasound-guided fineneedle aspirate of affected lung. Additionally, to our knowledge, we offer the first account of the sonographic
(pulmonary) features of the disease.
Accepted: 28 March 2016

Case description
A 9-year-old, male neutered domestic shorthair cat with
outdoor access was evaluated for a 3 week history of lethargy and coughing. One week prior to presentation, the
owner reported that the cat had an episode of self-resolving dyspnea. A complete blood count (CBC [IDEXX
Procyte Dx Hematology Analyzer; IDEXX Laboratories])
performed by the referring veterinarian was normal.
Referral veterinarian imaging included thoracic radiographs, which demonstrated a severe, diffuse, mixed,
predominantly bronchial pulmonary pattern with structured interstitial (miliary-to-nodular) components.
Although the exact methodology was not provided, a
transtracheal wash with cytology had been performed
and was evaluated by the referring veterinarian, and
reportedly revealed mixed/suppurative inflammation.
Culture of the bronchial fluid was negative for growth.

1Department

of Clinical Sciences, Diagnostic Imaging, Mississippi

State University, College of Veterinary Medicine, Mississippi
State, MS 39762, USA
2Central Texas Veterinary Specialty Hospital, Austin, TX 78745,
USA
3Department of Pathobiology and Population Medicine,
Mississippi State University, College of Veterinary Medicine,
Mississippi State, MS, 39762, USA
4Department of Pathobiology and Population Medicine,
Mississippi State University, College of Veterinary Medicine,
Mississippi State, MS 39762, USA
Corresponding author:
Jennifer Gambino DVM, DACVR, Mississippi State University,
College of Veterinary Medicine, Animal Health Center, 240 Wise
Center Drive, Mississippi State, MS 39762, USA
Email: gambino@cvm.msstate.edu
*Current address: Winder, Georgia, 30680, USA

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Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

2
When clinical signs did not resolve the cat was referred
for further diagnostics.
At presentation the cat was bright, alert and responsive, with a body condition score of 3/5.1 Bilaterally
harsh lung sounds were auscultated. Repeated CBC
(Cell-Dyn 3700; Abbott Laboratories) and serum biochemistries (Vet Axcel Clinical Chemistry System; Alfa
Wassermann Diagnostic Technologies) revealed a moderate leukopenia (3.7 K/l; reference interval [RI] 5.5
20.0 K/l) and persistent moderate neutropenia
(1702/l; RI 250012,500/l) with a left shift (bands
222/l, RI 0300/l), mild lymphopenia (1369/l; RI
15007000/l) and mild hyperglycemia (178 mg/dl; RI
70160 mg/dl). Repeat, three-view thoracic radiographs revealed a moderately progressed severe,
diffuse, mixed bronchial-to-structured interstitial (miliary-to-nodular) pulmonary pattern in all lung lobes
but most severe in the caudodorsal lung fields.
Peribronchial cuffing was evident, with multifocal
areas of poorly defined alveolar disease (especially in
the perihilar and caudal dorsal lung fields) (Figure 1).

Journal of Feline Medicine and Surgery Open Reports

Differential diagnoses for a middle-aged-to-elderly cat
with dyspnea and the combined radiographic abnormalities included feline asthma, allergic pneumonitis
(secondary to inhaling irritants such as mold, smoke
or household chemicals), feline heartworm eosinophilic pneumonitis or other verminous pneumonia
(Aelurostrongylus species, Eucoleus species, Filaroides
species and Dirofilaria immitis), and neoplasia (such as
bronchogenic adenocarcinoma).
Thoracic and abdominal sonography were performed
with a BioSoundEsoate MyLab50 ultrasound machine
and microconvex ultrasound probe with available frequencies from 5 to 8 mHz. Abdominal sonography was
normal. Thoracic sonography revealed many B-lines
(comet tail artifact, a subtype of reverberation artifact)
with intermittent, well-defined, small (23 mm), hypoechoic nodules, intermittent irregular pleural margins
and multifocal, intermittent, variously sized (24 mm)
shred signs (Figure 2).24 The cat was sedated (dexmedetomidine 4.7 g/kg IM). Following aseptic preparation of the clipped skin, percutaneous ultrasound-guided

Figure 1 Three-view thoracic radiographs of a 9-year-old male neutered cat taken 3 weeks following the onset of lethargy,
coughing and an episode of dyspnea. (a) Ventrodorsal, (b) left lateral and (c) right lateral radiographic projections. Note the
severe diffuse, mixed bronchial-to-structured interstitial (miliary-to-nodular) pattern with peribronchial cuffing in all lung lobes.
Note also the mild alveolar opacity present throughout the caudodorsal lung fields. The pulmonary pattern causes border
effacement of the caudal pulmonary lobar vasculature, great vessels and, to a lesser degree, the caudal border of the cardiac
silhouette, especially on the lateral projections. Note the normal extrapulmonary and extrathoracic structures

Gambino et al

Figure 2 Transabdominal thoracic sonography of the same cat shown in Figure 1, performed immediately following thoracic
radiographic evaluation. Images depict the diaphragmatic hepatic view of the caudal lung fields. (a) The right caudal lung
field. The liver and gall bladder (GB) are to the right of the diaphragm (arrows). Note the multiple (>3), hyperechoic B-lines
(comet tail artifacts) emanating to the left of the image into the distal field from the pleuropulmonarydiaphragmatic junction.
These are indicative of consolidated lung fields and mixed interstitial pulmonary pathology within the right caudal lung field. (b)
Similar images as (a) of the right caudal lung field. The gall bladder is not within the image field of view. Note a larger nodule
(arrowhead) and shred sign (denoted by the white V). In all sonographic images, the margins of the pleura are irregular.
In real time, multifocal, intermittent shred signs were noted. A shred sign is consistent with alveolar parenchymal disease in
contact with aerated sections of lung producing irregular sonographic borders. (c) The left caudal lung field. Note that findings
within the left caudal lung lobe were similar to that of the right. Falciform fat (labeled falc fat) and the liver are to the right of the
pleuropulmonarydiaphragmatic interface (arrows)

fine-needle aspiration of the sonographically affected

lung parenchyma was performed. A 5 ml syringe with
1 ml room air within the syringe chamber was attached
to a 22 G 1.5 inch fine needle (without stylet).
Approximately one-half the length of the needle was
gently inserted through the skin at the right proximal
third of the eighth intercostal space and was directed
with ultrasound guidance into the affected pulmonary
parenchyma/nodules. Negative pressure (14 ml) was
applied, while 35 to and from movements were performed within the lesions. The collected material was
sprayed onto glass slides for evaluation by an on-site,
board-certified veterinary clinical pathologist. All

samples were grossly and subjectively productive. When

necessary, color flow Doppler evaluation was intermittently used to evaluate adjacent vascular supply and to
avoid the vascular structures. The procedure was
repeated twice more at the eighth and seventh intercostal spaces, respectively, for a total of three passes so that
adequate material could be obtained.5 Based on followup sonographic evaluation, no evidence of pleural gas or
fluid was noted.4,6 In addition, periprocedural sonographic monitoring within the first 10 mins of the procedure revealed no progression of the parenchymal
disease. Thus, the procedure was deemed sonographically negative for associated parenchymal hemorrhage

Figure 3 Cytologic sample obtained via pulmonary

ultrasound-guided fine-needle aspirate containing
Aelurostrongylus abstrusus larva. Just to the right of the
center of the image is a large, curved, basophilic larva with
a kinked tail (far right) and non-rhabditiform esophagus (left)
extending approximately half of the length of the parasite,
consistent with a stage 1 A abstrusus larva. The background
consists of blood and proteinaceous debris interspersed
with occasional non-degenerate neutrophils and alveolar
macrophages. Modified Wrights stain

Figure 4 Cytologic sample obtained by way of ultrasoundguided pulmonary fine-needle aspiration showing A abstrusus
ova. At the center of the image is a large, oval egg containing
numerous basophilic-staining blastomeres surrounded
by abundant non-degenerate neutrophils and alveolar
macrophages (characterized by their abundant, vacuolated
cytoplasm) on a background of blood and proteinaceous
debris. Modified Wrights stain

and pneumothorax. During the recovery period (approximately 30 mins), the cat was monitored closely for clinical signs of respiratory distress and pallor.
Cytologic evaluation revealed high cellularity aspirate samples consisting of innumerable macrophages
and non-degenerate neutrophils admixed with fewer
eosinophils. Numerous multinucleated giant cells were
observed, along with several clusters of respiratory
endothelial cells. Widely scattered larvae, measuring

Journal of Feline Medicine and Surgery Open Reports

approximately 350 m, were observed throughout the
smears and, occasionally, were seen in concentric coils.
Some of these larvae possessed distinctly notched tails
(Figure 3). Also present were multiple oval structures
measuring approximately 80 m 70 m, with a
frothy interior, containing numerous round basophilic
structures consistent with blastomeres (Figure 4).
Long, beaded, filamentous, extracellular rods were
noted on one slide. These findings were consistent
with pyogranulomatous-to-eosinophilic inflammation
with intralesional A abstrusus larvae and ova, with possible additional concurrent nocardiosis. Additional
acid-fast staining was performed to confirm the presence of Nocardia species; in the interim, a Baermann
test was performed and confirmed the presence of
A abstrusus.
The cat was hospitalized for treatment and observation. Intravenous trimethoprim sulfa for presumed
nocardiosis (16.7 mg/kg diluted in 2 ml D5W IV q12h for
7 days) was instituted pending acid-fast staining of cytologic samples. In addition, the cat was placed on oral
prednisolone to decrease inflammation associated with
parasite death (0.5 mg/kg PO q24h for 10 days).
Fenbendazole was instituted to eliminate the A abstrusus
(50 mg/kg PO q24h for 14 days), in addition to monthly
topical selamectin.
A repeat CBC 5 days following initial diagnosis demonstrated resolved neutropenia (2829/l; RI 1500
7000/l), improving leukopenia (4.1 K/l; RI 5.520.0
K/l) and moderate lymphopenia (861/l; RI 1500
7000/l). Acid-fast staining of the filamentous organisms identified during cytology was negative for Nocardia
species and was obtained on the seventh day of hospitalization. No episodes of respiratory distress or coughing were noted during the hospitalization period. The
cats attitude and appetite improved. A repeated
Baermann test 2 weeks following initial hospitalization
was negative for A abstrusus larvae. The patient was discharged on day 16 of hospitalization, with clinically normal behavior, a normal resting respiration rate (2342
breaths per min)7 and normal lung auscultation bilaterally. Six weeks following initial diagnosis, recheck thoracic radiographs demonstrated almost complete
resolution of the previously described pulmonary pattern. A residual, but much improved, mild-to-moderate,
mixed bronchial and unstructured interstitial pulmonary pattern persisted within the right caudal dorsal and
accessory lung lobes (Figure 5). The cat was bright, alert
and responsive, with no abnormal lung sounds heard
upon auscultation. All coughing and lethargy had
resolved.

Discussion
We report herein the first documented case of A abstrusus
infection diagnosed by ultrasound-guided lung aspirate

Gambino et al

Figure 5 Two-view thoracic radiographs taken 6 weeks following the diagnosis and medical management of Aelurostrongylus
abstrusus. Note the degree of improvement of the previously described mixed pulmonary pattern compared with Figure 1.
A mild, diffuse mixed bronchial and unstructured interstitial pattern persists within the right caudodorsal and accessory lung
fields. Consideration was given to resolving verminous pneumonia with excellent clinical response to medical management
with mild residual pulmonary parenchymal pathology and/or fibrosis. No clinical signs were apparent at the time of imaging

in the Americas, with subsequent successful medical

management and outcome. Previously, the diagnosis of
A abstrusus via fine-needle biopsy is described in two
cats.8,9 In people, a broad spectrum of parasitic infections
can have thoracic manifestations, but sonography and
sonographic diagnosis are seldom used for screening.10
We describe herein the radiographic features, and, for
the first time in the veterinary literature, to our knowledge, the associated sonographic pulmonary parenchymal features of A abstrusus. Image-guided percutaneous
fine needle aspiration is less invasive than fine-needle
biopsy or excisional biopsy, and may be associated with
lower morbidity and mortality, as in the case of imageguided percutaneous biopsy in people and percutaneous fine-needle aspiration biopsy in dogs and cats.11,12
Indications for image-guided interventions include the
establishment of the benign or malignant nature of a
lesion, obtaining material for microbiologic analysis in
patients with known or suspected infections, staging
malignancy in cases of known or suspected malignancy,
and establishing the nature and extent of diffuse parenchymal disease.11
A abstrusus is a sporadically identified metastrongyloid nematode of cats responsible for cardiorespiratory

disease in Europe and the Americas.13 The parasite is

transmitted indirectly in a life cycle that incorporates
mollusks and snails as intermediate hosts, and rodents,
frogs, lizards, snakes, and birds as paratenic hosts.14,15
Cats are infected when they consume an intermediate
or paratenic host containing larvae; these larvae then
migrate to the lungs, mature to their adult forms, and
produce larvae that migrate to the pharynx and are
passed into the feces, thus completing the cycle.13 The
hatching of eggs and migration of larvae are responsible for most clinical signs.13 Clinical signs associated
with A abstrusus are uncommon but are primarily associated with parenchymal pulmonary infiltration and
the subsequent inflammatory response.13 Respiratory
signs can include coughing, sneezing, progressive
dyspnea and death.13,15 The Baermann fecal test is considered to be the gold-standard diagnostic technique
in living patients to achieve a diagnosis, followed by
other copromicroscopic techniques and bronchoalveolar lavage cytology.13,16,17 A abstrusus can be easily
detected at necropsy via histology of affected lung
lobes.18
Rarely, A abstrusus has been detected by other diagnostics. There is one documented case of A abstrusus

6
obtained by lung impression of an affected kitten during
necropsy; a female larva was found in the bloodstream
of another stray cat during a blood parasite survey.19,20
Radiographic findings in the cat of this report were classic, prompting sonographic pulmonary evaluation and
the interventional procedure. At our institution, thoracic
sonography combined with fine-needle aspiration is
often performed to obtain samples for cytology and culture, especially when radiographs support the presence
of severe pulmonary disease such as severe bronchial,
interstitial or alveolar opacities. We consider sonographic-guided fine-needle pulmonary aspiration to be
a viable, quick, relatively safe and easily performed test
when severe disease is radiographically present. In addition, it is our experience that mild-to-moderate radiographic findings of pulmonary disease can have easily
identifiable sonographic lesions that may be amenable to
sonographic aspiration, especially when evaluation is
performed by trained ultrasound personnel. Pulmonary
fine-needle aspiration may be especially useful in unstable patients for which conventional testing may delay
diagnosis and treatment. The Baermann technique takes
considerable time to complete (at least 6 h) and is unable
to diagnose parasitic infections during the prepatent
period, while bronchoalveolar lavage requires general
anesthesia and has a mortality rate of up to 6% in cats
with respiratory compromise.13,21 An additional weakness of both transtracheal washes and the Baermann
technique is the tendency of A abstrusus to shed variable
numbers of ova and larvae during its life cycle, which
can result in false negatives when using either or both of
these diagnostic tests.13
There is limited literature available regarding the
safety of pulmonary aspiration in cats with verminous
pneumonia, and a prospective clinical study would be
ideal for complete assessment of this procedures clinical
performance, diagnostic efficacy and safety in patients
afflicted with this disease. Multiple studies assessing risk
associated with fine-needle aspiration in canine and
feline patients with fungal and neoplastic disease
revealed minimal risk of clinical signs secondary to aspiration and a high diagnostic yield when the aspirate was
sonographically guided.12,22 Three veterinary studies of
pulmonary aspiration assisted with an imaging modality
had only one animal with clinical pneumothorax out of
97 cases (an incidence of 1.03%).12,22,23 Another study
evaluating pulmonary aspiration without imaging guidance had a higher rate of clinical pneumothorax (6.2%).24
Complications associated with pulmonary fine-needle
aspiration biopsy with a 20 G Wescott-type needle include
a risk as high as 17% for pneumothorax and a mortality
rate of 2.1% secondary to pneumothorax.12 Greater risk
was associated with larger needle gauge, and although
more tissue may be obtained with a larger needle, blood
contamination can hamper the diagnostic quality of the

Journal of Feline Medicine and Surgery Open Reports

sample.12 In people there is a 1.6% incidence of dyspnea
due to tension pneumothorax secondary to endoscopic
sonographically guided fine-needle aspiration of large
pulmonary mass lesions.6 Complications were not noted
in the cat of this report but can include pneumothorax,
pulmonary parenchymal hemorrhage, pulmonary parenchymal lacerations and inadvertent cardiac puncture.
The cat of the current report was sedated, further reducing the risk of associated complications. Motion from
breathing, in our opinion, did not hamper the ability to
effectively perform the aspirate.

Conclusions
We describe our positive experience with, and the clinical utility of, percutaneous ultrasound-guided fine-needle aspiration of the pulmonary parenchyma of a cat
with A abstrusus, which resulted in a rapid definitive
diagnosis. The safety of pulmonary aspirates in cats with
pulmonary parasitism is not well assessed in the veterinary literature; owners should be counseled regarding
potential complications.
Conflict of interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/
or publication of this article.

Funding The authors received no financial support for the

research, authorship, and/or publication of this article.

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