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Emergent Diseases in Reptiles

Article in Seminars in Avian and Exotic Pet Medicine · July 2004

DOI: 10.1053/j.saep.2004.03.006

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Emergent Diseases in Reptiles
James F.X. Wellehan, DVM, MS, and
Cornelia I. Gunkel, DVM

is better able to select an appropriate temperature

This article reviews basic clinical techniques necessary
than the clinician. To thermoregulate properly,
for emergency treatment of reptile patients. Ap-
the patient needs to have a range of temperatures
proaches to common emergency presentations of rep-
tile patients, including trauma, burns, dystocia, renal
to choose from. This is most easily accomplished
failure, sepsis, dyspnea, gastrointestinal foreign bodies,
by use of a radiant heat source such as incandes-
cloacal prolapse, and toxicosis are covered. © 2004
cent heat lamps or ceramic heat bulbs or panels to
Elsevier Inc. All rights reserved. create an even gradient. Contact heat sources,
such as heat rocks, offer only two options for
Key words: Reptiles; emergency medicine; emergencies temperature, on and off the source, which is un-
acceptable for the critical patient.2 For animals
that are stressed by the presence of people, hiding

T
he reptile patient presents a novel chal- areas should be added. Appropriate hiding areas
lenge to the emergency clinician. Reptiles must be provided throughout the temperature
are good at masking illness, and clients gradient so that the animal chooses where to be
often fail to recognize disease in their pet and based on choice of temperature rather than
seek veterinary assistance only in advanced stages choosing the only hide area.
of disease. Many emergencies are secondary to In nonambulatory animals, the clinician must
inappropriate husbandry for a given species. It is choose the temperature for the animal, making it
important when taking a history to discuss hous- even more critical for the clinician to be familiar
ing and diet, and to determine how the owner is with the species. It has been shown that desert
measuring parameters such as temperature and iguanas (Dipsosaurus dorsalis) undergo respiratory
humidity. Reptiles may tolerate inappropriate recovery more rapidly and incur lower energetic
husbandry for very long periods of time before costs when they recover from exercise at 20°C
disease manifests, so just because an animal has instead of 40°C.3 In splenic macrophages of the
been kept under the same conditions for years wall lizard (Hemidactylus flaviviridis), phagocytosis
does not mean that the conditions are appropri- was found to be maximal at 25°C and was de-
ate. The diversity of species also presents a chal- creased at either higher (37°C) or lower (15°C)
lenge, and the clinician must be familiar with temperatures.4 It has been recommended by oth-
what is normal for each species to recognize the ers that chelonians not be warmed beyond ambi-
abnormal. It is important to maintain hospitalized ent indoor temperature until hemostasis is
reptiles under optimal environmental conditions, achieved, vital signs are stable, and antibiotics
including temperature, humidity, light, noise, ac- have been administered.5 The practice of not pro-
tivity, and exposure. An appropriate temperature viding supplemental heat until stabilization likely
gradient should be provided to allow the patient varies according to species, and the authors advise
to thermoregulate. This article will discuss basic this in species from temperate but not tropical
clinical techniques and common emergency pre- climates. The hydration status of the animal must
sentations in reptiles.

From the College of Veterinary Medicine, University of Flor-

ida, Gainesville, FL 32610.
Hospital Caging Address correspondence to Jim Wellehan, Zoological Medi-
cine Service, College of Veterinary Medicine, University of
As ectotherms, reptiles thermoregulate by moving Florida, Gainesville, FL 32610.
to warmer or cooler areas. Reptiles have been © 2004 Elsevier Inc. All rights reserved.
shown to select higher temperatures in response 1055-937X/04/1303-0007$30.00
to bacterial infection,1 and an ambulatory patient doi:10.1053/j.saep.2004.03.006

160 Seminars in Avian and Exotic Pet Medicine, Vol 13, No 3 ( July), 2004: pp 160-174
Emergent Diseases in Reptiles 161

also be taken into account. The critical thermal the carapace. This is also a good site for venous
maximum was shown to be decreased in dehy- access for injection. The anastomosis of the inter-
drated ornate box turtles.6 costal arteries and the external jugular veins is
Other factors, such as space and humidity, accessible for blood collection by directing a nee-
need to be appropriate for the species. It is essen- dle under the carapace mid-sagitally above the
tial for caging to be easily disinfected, and this head,12 although lymph contamination is also
influences substrate and cage furniture choice. common at this site. Intraosseous catheter place-
ment in the cancellous bone of the bridge be-
Venipuncture tween the carapace and plastron is a good site for
fluid administration,9 although technically diffi-
It is important to determine the maximum cult and not present in all species. Prior identifi-
amount of blood that may be sampled safely. Ten cation of this site in a cadaver of the same species
percent of the blood volume may be safely with- is strongly recommended.
drawn from a healthy animal, and the blood vol- In iguanas and other lizards, the ventral coccy-
ume of reptiles is approximately 5% to 8% of geal vein is the site of choice for sample collec-
body weight,7 so 0.5% to 0.8% of body weight may tion7,9 and catheter placement.13 This may be ac-
be collected. Arterial blood pressures have been cessed either by advancing the needle from a
shown to fall precipitously in green iguanas ventral midline approach or laterally from a level
(Iguana iguana) after loss of 35 ⫾ 19% of blood just below the vertebral body. Blood flow may be
volume.8 Blood smears are best made fresh, since improved if the animal is held vertically so that
anticoagulants, especially EDTA, may alter cell the tail is dependent. The jugular vein has also
morphology and staining.9 Clotting times in rep- been used for catheter placement in green igua-
tiles are significantly longer than in mammals.10 nas (M. Johnston, personal communication). Spi-
As serum chemistry changes occur rapidly on rep- nal needles normograded into the medial aspect
tile cells,11 it is the preference of the authors to of the tibial plateau as intraosseous catheters are
spin and separate heparinized samples immedi- also useful for fluid administration14 (Fig 1). Fem-
ately after blood collection for plasma chemistry oral and humeral intraosseous catheter place-
rather than serum chemistry. ment is also possible.9 The cephalic vein is also a
In turtles and tortoises, the jugular is often a possible site for venous access, although cutdown
preferred site for sample collection and catheter and dissection to the vein is typically required for
placement, as lymph contamination is less com- catheter placement.9 The ventral abdominal vein
mon at this site.7 The jugular is also the only site is accessible,7,9 and lies just beneath the skin on
where the vein is palpable. In debilitated turtles ventral midline.
and tortoises, the head can often be coaxed out
In snakes, the ventral coccygeal vein is useful
with steady, gentle traction on the rhinotheca
for venous access.7 Cardiocentesis is also a com-
(upper beak) with a blunt tipped probe. Pressure
mon site for blood collection, although it is rec-
may then be applied at the base of the neck to
ommended only in snakes weighing greater than
raise the vein, located laterally.9 However, this
100 to 300 g, depending on the reference.7,9 The
may not be feasible in large resistant unsedated
beating of the heart may be externally visualized
chelonans, and caution must be used to avoid
trauma to the patient. In common snapping tur- in the ventral surface approximately one quarter
tles (Chelydra serpentina), the ventral coccygeal of the body length from the head, just cranial to
vein is very accessible for sample collection and the movement of the expansion of the lung(s).
catheter placement, and less risky to personnel. The heart generally tends to be more caudal in
The brachial vein is accessible from the caudoven- terrestrial snakes and more cranial in arboreal
tral surface of the elbow. The tortoise is placed in snakes. Although the jugular vein is the best site
dorsal recumbency, the arm is extended, and the for catheter placement, access usually requires
skin fold on the caudoventral aspect is used as a cutdown and dissection to the vein.7,9 The right
marker to advance the needle in a proximal di- jugular vein is larger and therefore preferred.14
rection. The dorsal coccygeal vein is also a good The palatine vein is also a possible site for sample
site for venous access in many species, although collection.7,9
there is a higher incidence of lymph contamina- In crocodilians, the ventral coccygeal vein is
tion in samples from this site.7 In many tortoise useful for blood collection9 and catheter place-
species, a venous sinus lies above the tail, beneath ment.13 The supravertebral vessel located just cau-
162 Wellehan and Gunkel

Maintenance fluid requirements in reptiles

range from 15 to 25 mL/kg/d,14 which are lower
than those reported for mammals (40 to 60 mL/
kg/d), due to the lower metabolic rates and re-
quirements of reptiles. The definitive rate should
be based on the habitat to which the reptile is
adapted and the effect of the altered health status
of the animal on electrolytes and fluid require-
ments. Small-volume infusion pumps are essential
for accurate fluid infusion in small anesthetized
patients to prevent overloading.17
An interpretation of the acid-base balance of the
animal as well as determining PCV, TP and uric acid
is helpful for choosing the appropriate fluid solu-
tion and route of administration. The choice of
fluids is dependent on the reason for fluid loss.
Acute fluid therapy replaces absolute or rela-
tive plasma volume deficits within a period of
minutes to a few hours. Hypovolemia, shock, and
hypotension are indications for acute fluid re-
placement therapy using solutions such as Lac-
tated Ringer’s, Normosol-R or Plasmalyte 148. In
addition, 0.9% NaCl with added KCl to achieve a
K⫹ concentration of 4 to 10 mEq/L can also be
used as an alternative; however, the latter is an
acidifying solution in contrast to the alkalinizing
properties of the former standard fluid replace-
ment solutions that contain one or several bicar-
bonate precursors such as acetate, gluconate or
bicarbonate. Originally it was believed that lac-
tated Ringer’s solution was contraindicated in
reptiles due to the perception that adding lactate
could lead to increased production of lactic acid
in stress situations.16 This concept is erroneous, as
bicarbonate precursors including lactate in fluid
solutions cause an alkaline milieu, due to the use
of hydrogen ions and the regeneration of bicar-
bonate, which counteracts the lactic acidosis of
Figure 1. Radiograph of tibial intraosseous catheter placement the animal.18 Isotonic dextrose solution (5%) or
in a green iguana (Iguana iguana). combinations are indicated, when hypoglycemia
is present.17
In situations of moderate to severe blood loss
dal to the occiput is a useful sample collection site (more than 10% of blood volume) volume should
in larger crocodilians.9 be replaced with colloid fluids like Hetastarch,
Dextran 70, or Oxyglobin (Fig 2). They provide
Fluid Therapy more efficient volume restoration than crystalloid
solutions, through volume expansion due to the
Assessment of hydration in reptiles may be accom- oncotic properties of the large size molecules
plished by skin turgor, mucous membranes, oral present in colloids. Volume expansion is also ac-
secretions, dryness/sinking of eyes, and packed companied with less alteration of the packed cell
cell volume.15 Slightly over 50% of body fluid is volume and total solids when compared with crys-
maintained in the intracellular compartment in talloids. With an approximate total plasma vol-
reptiles and the circulating fluid volume percent- ume of 40 mL/kg in reptiles,19 the authors set the
age is lower than in mammals.16 maximum colloid volume at 20 mL/kg. Colloid
Emergent Diseases in Reptiles 163

The glottis in most reptiles is easily visualized

for intubation. Crocodilians have a well-devel-
oped basihyal valve that must be pushed down to
gain access to the glottis.20 Gentle intubation is
necessary to prevent damage and swelling. In rep-
tiles that are too small for standard endotracheal
tubes, intravenous catheters may be used as endo-
tracheal tubes (Fig 3), but careful monitoring for
obstruction is necessary when using smaller tubes.
Chelonians and crocodilians have complete tra-
cheal rings,20 like birds, which makes the use of
cuffed tubes usually contraindicated. Addition-
ally, some snakes, such as Indian and Burmese
pythons (Python molurus) and western rattlesnakes
(Crotalus viridis) have complete tracheal rings in
Figure 2. Oxyglobin administration via a coccygeal vein
catheter in a bearded dragon (Pogona vitticeps). the proximal trachea,21 and use of cuffed tubes is
again usually contraindicated.
Inhalant anesthesia is most commonly used for
fluids should only be administered by intravascu- maintenance and occasionally induction in rep-
lar or intraosseous routes. tiles.17 Despite the fact that reptiles may wake up
Of the different routes of administration (en- faster after use of inhalant anesthesia as a sole anes-
teric, intracoelomic, subcutaneous, intravenous thetic, it is important to remember that the inhalant
and intraosseous), in the critical patient, intrave- agents are all cardiovascular and respiratory depres-
nous or intraosseous fluid administration is pre- sants and don’t provide good analgesia. A balanced
ferred. Disadvantages of the intraosseous route anesthetic regime is often beneficial.
are the rate limitation as well as the painful stim- In general, premedication reduces stress and
ulus or impracticality in larger reptiles especially makes intubation easier for handler and animal.
when maintained over a longer period of time. Midazolam (0.3 ⫺2 mg/kg) can be given intra-
The main disadvantage of the intravenous route is muscularly and is the safest drug from a cardio-
the difficulty of access in the hypovolemic patient. vascular standpoint for a decent sedation. Ket-
amine can be added if the animal is healthy and
fights the physical restraint, but respiratory de-
Anesthesia and Analgesia pression has been reported and care should be
taken in renally compromised animals due to re-
A combination of analgesia and appropriate physi- nal excretion of Ketamine.16 Intravenous propo-
cal restraint is often all that is needed for most fol is commonly used for induction, with a dose
diagnostic procedures, especially when the animal is range of 2 to 10 mg/kg dependent on disease
a critically ill patient. Lizards and crocodilians can status and temperament of the animal.22,23 Apnea
be calmed down with slight pressure on the eyes, is common with the use of propofol and should
which causes a vagal reflex. For all procedures be anticipated.
which include any surgical incision or other painful
stimulus, an analgesic should be administered and
sufficient time should be given for the onset of the
drug, which may be delayed in reptiles.
If general anesthesia is required, the choice of
premedication, induction and maintenance is de-
pendent on the disease status of the animal, espe-
cially from the cardiovascular and respiratory as-
pects. In an animal with respiratory distress or
other acutely life-threatening concerns, a mask
induction is contraindicated and rapid intubation
is necessary. Many reptiles can be gently intubated
with physical restraint and a bite-block like a
tongue depressor, but extra caution needs to be Figure 3. A 20-gauge catheter used as an endotracheal tube
taken in venomous animals. in a garter snake (Thamnophis sirtalis).
164 Wellehan and Gunkel

iguanas,25 suggesting that it is a poor analgesic.

However, butorphanol has also been shown to be
a relatively poor analgesic in mammalian species
when compared with other opioids and NSAIDs.
Morphine and meperidine were studied in Nile
crocodiles (Crocodylus niloticus).26 Morphine was
found to reduce thermal withdrawal response at
0.05mg/kg, with a maximal response at 0.3mg/
kg. At 0.1mg/kg, effects were found to last ap-
proximately 2 hours. Meperidine was found to
reduce thermal withdrawal response at 2mg/kg.
This suggests that crocodiles are relatively sensi-
tive to mu-agonists. Lacking further data, the au-
Figure 4. Mandibular nerve block in a green iguana (Iguana thors use opioids in conjunction with NSAIDs and
iguana). local anesthetics for painful procedures. Bu-
prenorphine (0.03 mg /kg) has a very long onset,
but is the longest acting opioid with relatively few
side effects.
Analgesia is frequently an underutilized part of Careful anesthetic monitoring is even more
critical care management in reptiles. The phar- important in the critical patient. It is difficult to
macokinetics, safety, and efficacy of analgesic monitor heart rate with a stethoscope in most
drugs in reptiles are still poorly studied, and the reptiles. A Doppler ultrasound probe can be
presence and severity of pain in is underrecog- placed over the heart in lizards and snakes, which
nized in these species.24 Best studied is the highly gives an audible signal for heart rate. In cheloni-
developed skin sensitivity, which is sufficient rea- ans, probe placement over the carotid may be
son to provide analgesia every time an incision has useful. This can also be done in depressed or
to be made.16 The most commonly used analge- compromised conscious animals to monitor vital
sics in reptiles are the nonsteroidal antiinflamma- parameters. ECG clips can also be attached on
tories, local anesthetics and opioids. All analgesic needles between the scales and give a visual ob-
drugs need some further research to evaluate an- servation of rate and rhythm.
tinociception as well as pharmacokinetics/phar- Blood pressure is seldom monitored in rep-
macodynamics, but from personal opinion and tiles, due to difficulties with access and lack of
observation, the following agents seem to provide normal values. In some lizards and crocodilians
good analgesia and reduce the amount of anes- an arterial catheter can be placed,13 but some
thetics needed. experience is necessary for placement. Animals in
The nonsteroidal antiinflammatory drugs respiratory distress need detailed monitoring of
meloxicam (0.1-0.3mg/kg), carprofen (2-4 mg/ respiratory values like respiratory rate, end-tidal
kg), or ketoprofen (1-3mg/kg) show good effect, CO2, and blood gases. Mucous membrane color
especially for long term and postoperative analge- and capillary refill time should be monitored for
sia, but careful observation of the renal status perfusion, requiring familiarity with normal mem-
needs to be undertaken and fluid therapy is often brane color for a given species.
beneficial to prevent potential complications. For Recovery from anesthesia needs special care
any extremity procedures a local blockade pro- and monitoring in a critically ill reptile. Initiation
vides the best analgesia. Infiltration with 2% lido- of spontaneous breathing often takes a long time
caine or 1% procaine has been used with success and continued ventilation is needed. The endo-
for minor procedures,20 and the authors also fre- tracheal tube should not be removed until the
quently use 2% mepivacaine with apparent effi- control of the glottis musculature has returned.
cacy (Fig 4). Total amounts of local anesthetic
should be calculated to avoid systemic toxicity,
and until further data are available, mammalian
toxicity levels can be used. Trauma
As opioids have effects on mentation and be-
havior, it is difficult to assess analgesia in a reptile Etiology
that has received opioids. Butorphanol was found Trauma is a common presentation in reptiles. In
not to show any MAC sparing effect in green the authors’ experience, bite wounds from live
Emergent Diseases in Reptiles 165

prey, cagemates, or other pets, and being

dropped or stepped on are the most common
histories in captive reptiles. Vehicular trauma and
dog attacks are most common in wild reptiles.
Bite wounds from live rodents are a very common
cause of trauma in pet snakes, and feeding
prekilled whole prey should be encouraged. Live
crickets left unattended as prey with a debilitated
lizard are also a common cause of bite wounds,
and feeding of live crickets should be supervised.
Wild aquatic turtles that are hit by cars are fre-
quently gravid females looking for nesting sites;
damage to eggs and resultant dystocia/ yolk peri- Figure 5. Shell fracture repair in a Blanding’s turtle
tonitis may occur. (Emydoidea blandingii) using surgical wire.

Diagnosis
port the use of glucocorticoids for head trauma.
Diagnosis of trauma is typically evident from phys-
Wounds should be lavaged copiously with sterile
ical examination. During physical examination,
fluids. In chelonians with shell fractures, it is im-
careful neurologic and ophthalmic examination
portant to determine that one is not flushing
should be emphasized, and wounds should be
lavage fluids directly into the lungs. Foreign ma-
thoroughly examined for myiasis. Radiographic
terial should be removed. Fresh clean skin lacer-
evaluation of bone density is important for ruling
ations may be closed using an everting suture
out pathologic fractures, which are frequently
pattern with nonabsorbable monofilament su-
seen with osteomyelitis and nutritional or renal
ture. Drains are not very efficacious in reptiles.14
secondary hyperparathyroidism. In chelonians,
As virtually all traumatic wounds are contami-
pulmonary hemorrhage is a common sequela to
nated, antibiotic therapy should be initiated. As
shell fracture, since the lungs of turtles are lo-
discussed above, it has been recommended by
cated dorsally in the coelomic cavity. Each bron-
others that chelonians not be warmed beyond
chus gives rise to between three and eleven
ambient indoor temperature until hemostasis is
groups of chambers,27 in which blood may pool.
achieved, vital signs are stable, and antibiotics
Radiographic evaluation of lung fields using an-
have been administered.5 Shell repair in turtles
terioposterior and lateral horizontal beam radio-
may be accomplished by wiring fragments to-
graphs is helpful in identifying fluid in the lungs,
gether (Fig 5). Wires may be placed through
although more advanced imaging techniques
holes drilled in the shell or looped around surgi-
such as CT or MRI are more sensitive. Plasma
cal screws. It is easier to monitor healing in shells
chemistry and hematology are useful for identify-
repaired in this manner than shells repaired with
ing electrolyte imbalances and sepsis.
fiberglass/epoxy patches or dental acrylic. Espe-
cially in aquatic turtles, the incidence of infection
Therapy seems to be lower in wire shell repairs.5 Gaps left
Bleeding may be controlled with pressure, elec- by missing fragments may initially be covered with
trocautery, or ligation of vessels.14 Fluid therapy wet-to dry bandages and managed as open
should be commenced as appropriate. Oxygen wounds; eventually, granulation tissue will form.
therapy may be useful in patients with respiratory The use of vacuum-assisted closure also appears to
compromise. Glucocorticoids may be given to pa- be highly efficacious in chelonians with shell de-
tients with spinal trauma that is known to be less fects.
than 6 hours old. However, this should be done
with caution, as very low concentrations (10⫺13 M,
roughly equivalent to .00005mg/kg in an animal) Burns
of hydrocortisone sodium succinate have been
shown to significantly impair phagocytosis and Etiology
nitric oxide production in cultured wall lizard Burns in reptiles are typically due to inappropri-
splenic macrophages.28 Further study of the use ate or malfunctioning heat sources. Heat rocks
of glucocorticoids in reptilian spinal trauma is frequently short and overheat. If the ambient tem-
needed. There is no convincing evidence to sup- perature is too cool, the reptile will be forced
166 Wellehan and Gunkel

onto the heat rock and will burn itself. Inappro-

priate access to heat lamps may result in similar
burns. Many burns may extend through the full
thickness of the body wall.

Diagnosis
By the time a case is presented, diagnosis of ther-
mal burns is typically evident from physical exam-
ination and history. Reptiles may have erythema-
tous skin and blistering; it is important to distin-
guish burns from sepsis. Plasma chemistry and
hematology are useful for identifying electrolyte
imbalances and sepsis.

Therapy
Fluid support and electrolyte homeostasis is im-
portant in burn patients.14 Systemic antibiotic
therapy should be initiated, and topical silver sul-
fadiazine cream is useful as an adjunct. Based on
studies in mammals, pentoxifylline may be indi-
cated.29 Wet to dry bandages or semipermeable
bandaging are useful in covering wounds while
granulation occurs. The line of demarcation of
devitalized tissue may take weeks to form; once
this is clear, then surgical debridement should be Figure 6. Radiograph of dystocia in a Texas tortoise
pursued. (Gopherus berlandieri). Note the presence of the fractured egg.

Dystocia when gravid,32 and it is reasonable to expect that

this is the case in other reptiles. Gravid females
Etiology may be functionally hypocalcemic despite high
Reptiles without egg deposition sites of appropri- total plasma calcium, and resultant atony of the
ate temperature, humidity, depth, consistency, reproductive tract may result. Evaluation of ion-
and shelter will frequently retain eggs. Poor phys- ized calcium33 is needed in these patients.
ical condition may also result in egg retention. Of
more urgent concern is physical obstruction of Therapy
oviposition, which may be due to abnormal or Reptiles with dystocia should first be stabilized.
broken eggs, cystoliths, and reproductive tract Fluid therapy should be commenced as appropri-
malformation or scarring. ate. Oxygen therapy may be useful in patients with
respiratory compromise. Once patients are stabi-
Diagnosis lized, they should be reevaluated. When no phys-
Physical examination will usually reveal palpable ical obstruction is present and patients are pro-
eggs in the coelomic cavity. Eggs in turtles and vided with a suitable location for egg deposition,
tortoises may be palpated in the prefemoral fossa. the situation will often resolve. Chelonians re-
Radiographs are useful for diagnosis of abnormal- spond well to injection of oxytocin at 1 to 10
ities such as broken or abnormal eggs (Fig 6) or mg/kg.14 Chelonians and snakes tolerate ex-
cystoliths. Preovulatory follicles will not show shell tended dystocia better than lizards; dystocia in
deposition and appear as soft-tissue density. Ultra- lizards may lead to death within days,34 and dys-
sound is useful in diagnosis of these patients.30,31 tocia has often been prolonged by the time of
Bone density should be evaluated as an indication presentation. If patients have a physical obstruc-
of calcium stores. Evaluation of plasma chemistry tion, surgical removal is necessary and should be
and hematology is useful for identifying underly- initiated once the patient is stabilized. Occasion-
ing abnormalities. Female green iguanas have sig- ally, very caudal malformed eggs may be deflated
nificantly higher plasma calcium and phosphorus by ovocentesis per cloaca and removed. Details of
Emergent Diseases in Reptiles 167

and protein resorption may occur in the distal

gastrointestinal tract.36 Many species also have na-
sal salt glands that are involved in osmoregula-
tion.36 Causes of renal disease in reptiles include
dehydration, improper diet, infectious nephritis,
trauma, fibrosis, dystrophic calcification, amyloid-
osis, neoplasia, toxins, and inclusion body dis-
ease.37 Green iguanas seem particularly predis-
posed toward renal disease.

Diagnosis
On initial physical examination, reptiles with re-
nal failure are typically depressed. In green igua-
Figure 7. Celiotomy in a Texas tortoise (Gopherus berlandieri).
nas and other large species with intrapelvic kid-
Note the large venous sinuses.
neys, enlarged and irregular kidneys may be pal-
pated digitally via the vent. Iguana kidneys should
not protrude from the pelvis on radiographs;
surgery are given elsewhere.35 Important points
grossly enlarged iguana kidneys can be seen as
are avoidance of the abdominal vein lying be-
rounded soft-tissue opacities in the caudal coe-
neath the skin on the ventral midline in lizards
lom40 (Fig 8). Ultrasonography can be useful in
and avoidance of the two large venous sinuses that
the evaluation of reptilian renal disease.40 Hema-
lie beneath the plastron in chelonians (Fig 7).

Renal Failure
Etiology
Reptilian renal physiology differs from mamma-
lian physiology in several clinically important
ways. The major route of nitrogen excretion in
most reptiles is as uric acid.36 Uric acid has a very
low aqueous solubility, and therefore does not
contribute to urine osmolality.36 This obviates the
need for urine concentration for efficient elimi-
nation of nitrogenous waste. The trade-off is that
large amounts of protein are needed to maintain
the uric acid in colloidal suspension.36 Protein-
uria is therefore normal in reptiles. The reptile
kidney does not have a loop of Henle,37 and
therefore cannot concentrate urine. The blood
supply to the reptile kidney has multiple arteries
as well as venous blood supply returning from the
hind end via the renal portal system.36 The arte-
rial blood flow perfuses glomeruli and tubules in
a manner similar to the blood supply of the mam-
malian nephron. The renal portal blood supply
perfuses only the tubules and not the glomeruli.38
Because the kidney cannot produce concentrated
urine, one method of conserving water is by de-
creasing glomerular filtration rate (GFR). The
GFR of reptiles is quite labile.39 Arterial blood
flow to the nephron can be markedly reduced,
and the tubules will continue to have blood flow
from the renal portal system. The ureters empty Figure 8. Radiographic appearance of renomegaly and ascites
directly into the cloaca. Concentration of urine in a green iguana (Iguana iguana).
168 Wellehan and Gunkel

tology may be of use in diagnosing infectious Bacteria may often be seen on the blood smear.
causes of renal disease. Urinalysis is not typically Blood cultures are useful for identification of bac-
useful in evaluation of renal function; since not all teria and sensitivity profiles, but therapy should
species have a bladder, and in those that do, the be initiated while cultures are pending. Radio-
ureters empty at the opening into the cloaca, graphs may be useful in identifying osteomyelitis,
urine samples are typically contaminated with fe- which may be multifocal. Chemistry panels will
cal material. However, the presence of tubular often reveal low glucose and elevated anion gap,
casts is of clinical concern.41 Creatinine and blood AST, and CK. Patients with osteomyelitis may have
urea nitrogen are poor diagnostic tests for renal elevated calcium and phosphorus.
failure in iguanas.42 Uric acid is of greater clinical
use; however, uric acid elevations are seen only Therapy
when greater than 70% of the kidney is nonfunc-
It has been recommended by one author that
tional.41 At the lower body temperatures found in
septic chelonians not be warmed beyond ambient
reptiles, urates are less soluble. Another biochem-
indoor temperature, until antibiotics and fluid
ical indicator of renal disease is the calcium: phos-
therapy have had time to start to work.5 This is
phorus ratio. A ratio of less than 1 is suggestive of
also probably advisable in squamates from more
renal disease.41 The most definitive method of
temperate habitats. However, this may be stressful
diagnosis is renal biopsy. In green iguanas, a min-
for species from tropical climates. Appropriate
imally invasive approach for renal biopsy has been
intravenous or intraosseous fluid and antibiotic
described.43
therapy should be commenced. Ceftazidime, a
third-generation cephalosporin, is commonly
Therapy used as a first choice in septic reptiles because of
Treatment of renal disease is generally based enhanced antipseudomonal activity, minimal
around hydration and restoration of electrolytes. nephrotoxic effects, and ability to deliver a large
In cases of infectious nephritis, appropriate anti- dose in a small volume.48 Pharmacokinetic studies
microbial therapy should be provided. in several species of snakes maintained at 30°C
suggested that a dosage of 20 mg/kg intramuscu-
larly every 72 hours should be efficacious.49 In
Sepsis juvenile loggerhead sea turtles (Caretta caretta)
kept at 24°C, pharmacokinetic studies suggested
Etiology
that a dosage of 22 mg/kg intravenously or intra-
Sepsis in reptiles is a common sequela to poor muscularly every 72 hours was appropriate.50
husbandry and stress. Aerobic bacteria commonly
isolated from blood cultures of septic reptiles in-
clude Salmonella spp., Pseudomonas spp., Citrobacter Dyspnea
spp., Aeromonas spp., and Micrococcus spp.44,45 In a
study of anaerobic blood cultures from apparently Etiology
healthy lizards, Clostridium spp. were isolated from Dyspnea in reptiles may be due to primary respi-
51 of 58 (88%).46 This raises the possibility that ratory disease or extrapulmonary interference
many reptiles may have subclinical bacteremia. with pulmonary function. Common causes of pri-
Septic snakes may present with proliferative ver- mary upper respiratory tract disease include
tebral osteoarthritis. One retrospective study trauma, Mycoplasma agassizzi in North American
found that blood cultures of eight of these snakes tortoises,51,52 tracheal chondromas in ball pythons
revealed Salmonella spp, Citrobacter spp, and Strep- (Python regius)53-55 herpesviruses in tortoises,56
tococcus spp.47 and iridoviruses in tortoises.57 Tortoises with my-
coplasmosis, herpesvirus, or iridovirus will present
Diagnosis with similar signs; dyspnea, serous to mucopuru-
Signs of septicemia in reptiles include depression, lent nasal discharge, rhinitis, and conjunctivitis.58
anorexia, weakness, erythema, and petechiation.5 Stomatitis and glossitis are signs present in her-
Septic reptiles will often be hypotensive due to pesvirus infections but not mycoplasmal disease.58
septic shock. Evaluation of a blood smear is help- Obstructive periglottal lesions with eosinophilic
ful in diagnosis of sepsis. Septic reptiles will have intranuclear inclusions has been seen in a Sudan
toxic heterophils, which show cytoplasmic baso- plated lizard (Gerrrhosaurus major) with dyspnea; a
philia, abnormal granulation, and vacuolation.42 herpesvirus was identified.59 Some species of liz-
Emergent Diseases in Reptiles 169

ards, notably the green iguana, have salt glands in hypoproteinemia, liver failure, renal failure, car-
their nares; salty discharge is normal and should diac disease, septicemia, neoplasia, and iatrogenic
not be confused with respiratory disease. fluid overload.69
Reptilian lungs do not have alveoli; terminal
air spaces are described as faveola or edicula, Diagnosis
depending on whether the spaces are deeper than Radiographic evaluation of lung fields using hor-
they are wide or wider than they are deep, respec- izontal beam radiographs is helpful in identifying
tively.27 The edicular lungs of turtles are located fluid in the lungs. Radiographs are also useful for
dorsally in the coelomic cavity. Each bronchus identification of extrapulmonary causes of dys-
gives rise to between three and eleven groups of pnea. Aortic mineralization may commonly be
chambers,27 in which fluid may pool. The lungs of seen on radiographs in lizards and may indicate a
lizards differ between species. The edicular lungs cardiovascular component to ascites. Endoscopic
of chameleons are notable in that they have hol- evaluation of chelonian lungs may be done via
low tentacular diverticula that have been com- either a trans-carapace approach70 or by ap-
pared with avian air sacs.27 Snake lungs are asym- proaching caudally via the prefemoral fossa.
metric. In most snakes, the left lung is vestigial. In There is a sharp bend in the bronchi before en-
pythons and boas, the left lung is reduced in tering the lungs, making endotracheal approach
size.27 The caudal aspect of snake lungs and some to chelonian lung impossible with a rigid endo-
lizard lungs is avascular and not involved in gas scope. Sample collection by tracheal/pulmonary
exchange. The lungs of crocodilians are mul- wash followed by cytological evaluation, culture,
tichambered, with perforated septa separating the and sensitivity is indicated in cases of pneumonia.
tubular chambers.27 Testing for mycoplasmal and viral pathogens of
Lower respiratory tract disease may be bacte- reptiles is done at the University of Florida; the
rial, viral, traumatic, parasitic, or fungal. Most laboratory of Dr. Elliott Jacobson should be con-
bacteria isolated from reptiles with pneumonia tacted for specifics of sample submission for vi-
are aerobic Gram-negative rods.58,60,61 Patients ruses and the laboratory of Dr. Mary Brown
with bacterial pneumonia should be screened for should be contacted for specifics of sample sub-
underlying predisposing conditions such as im- mission for mycoplasma. Fecal examination is use-
proper husbandry, infection with more fastidious ful for identifying parasitic pneumonias. Evalua-
bacteria such as Mycoplasma spp and Chlamydia/ tion of serum chemistry and hematology is useful
Chlamydophila spp, fungal disease, or viral disease. for identifying underlying abnormalities.
Chlamydial pneumonia has been reported in puff
adders (Bitis arietans),62 and Chlamydophila (Chla- Therapy
mydia) psittaci has been reported in Greek tor- Appropriate antibiotic therapy is indicated in
toises (Testudo graeca) with pneumonia.63 Myco- cases of bacterial pneumonia. Since Mycoplasma
plasmal respiratory disease has been demon- spp. do not have a call wall, the use of cell wall
strated in crocodilians64 as well as North inhibitors such as penicillins and cephalosporins
American Tortoises, and a Mycoplasma spp. has is not appropriate in suspected mycoplasmal in-
been found in a Burmese python (Python molurus fections. Enrofloxacin doses appear to vary signif-
bivittatus) with proliferative tracheitis and pneu- icantly between species. Pharmacokinetic studies
monia.65 Viral causes of lower respiratory disease suggest optimal doses ranging from 5 mg/kg in-
include paramyxoviruses66 and reoviruses.67 Para- tramuscularly every 24 to 48 hours in gopher tor-
sites associated with lower respiratory tract disease toises (Gopherus polyphemus)71 to 10 mg/kg every
in reptiles include pentastomids, Rhabdias spp. 12 hours in Indian star tortoises (Geochelone el-
roundworms, flukes,68 and an intranuclear coc- egans).72 One possible complication of intramus-
cidia in tortoises.58 Pentastomids are potentially cular enrofloxacin injection is tissue necrosis;
zoonotic.68 care should be taken when injecting enrofloxacin
Extrapulmonary causes of dyspnea include gas- to avoid nerves. Iatrogenic radial nerve paralysis
trointestinal bloat, dystocia, abscesses, tumors, in chelonians is not uncommon with repeated
and ascites (Fig 8). Causes of gastrointestinal injections into the antebrachium. While treat-
bloat include inappropriate diet and husbandry, ment of mycoplasmosis may result in cessation of
renomegaly, obstruction, intestinal displacement clinical signs, eradication of the organism has not
and torsion, volvulus, intestinal intussusception, been shown and treated animals should be con-
abscesses, and neoplasia. Causes of ascites include sidered potential carriers. For fungal pneumo-
170 Wellehan and Gunkel

nias, itraconazole has been used. Pharmacokinet-

ics in fence lizards (Sceloporus sp.) suggest that
treatment with 23.5mg/kg every 24 hours for 3
days resulted in plasma levels for 6 days.73 In-
trapulmonary application of amphotericin B has
been used to successfully treat fungal pneumo-
nia.70 In herpesvirus infections, acyclovir has been
used empirically at 80 mg/kg daily.74 Appropriate
antiparasitic therapy may be used for Rhabdias
and flukes. Ivermectin is toxic in chelonians. Sur-
gical treatment of pentastomids is required. Sur-
gical treatment may be required for many causes
of gastrointestinal bloat and mass removal. Ascites
has been empirically treated with furosemide Figure 9. Colonic prolapse in a veiled chameleon (Chamaeleo
at 5mg/kg orally, intramuscularly, or intrave- calyptratus).
nously.75 The authors are not aware of experi-
mental evidence for the efficacy of furosemide in
(Chrysemys picta) weighing as little as 70g, and a
reptiles. While reptiles do not have a loop of
22-gauge needle pass in an African spur-thighed
Henle, it is possible that furosemide acts at the
analogous intermediate segment of the nephron tortoise uneventfully. Animals were closely moni-
or at another site. tored with serial radiographs, which showed nor-
mal progression of the objects through the GI
tract.
Gastrointestinal Foreign Bodies Nonobstructed/nonperforated reptiles are
best treated with optimal environmental condi-
Etiology tions and fluid therapy. Psyllium may be useful.
Foreign bodies are more common in pet reptiles Obstructed reptiles with compromised gastroin-
given free reign of the house. Ingestion of bed- testinal tract need to go to surgery. Enterotomy is
ding material, especially corn cob, gravel, and descibed elsewhere.76 Important points are avoid-
shavings, may cause gastrointestinal obstruction. ance of the abdominal vein lying beneath the skin
Among tortoises, African spur-thighed tortoises on the ventral midline in lizards and avoidance of
(Geochelone sulcata) seem particularly disposed to- the two large venous sinuses that lie beneath the
ward ingestion of foreign objects. Obstructed an- plastron in chelonians (Fig 7).
imals may present with depression, anorexia,
and/or vomiting. Cloacal Prolapse
Diagnosis Etiology
Radiographs are useful for diagnosis of gastroin- Prolapse of the cloaca may be of reproductive,
testinal foreign bodies. Evidence of obstruction is urinary, or gastrointestinal origin. In females, ovi-
typically seen as gas-distended gastrointestinal duct and shell gland prolapse typically occur sec-
tract just proximal to the obstruction. Upper GI ondary to dystocia.77 Paraphimosis typically oc-
contrast studies and ultrasound may be useful in curs when there is trauma to the everted penis. It
equivocal cases. CBC and analysis of abdomino- is most often seen in aquatic turtles secondary to
centesis are useful for indication of compromised bite wounds when multiple turtles are housed
or perforated bowel. Plasma chemistry is useful together. The most common cause of urinary
for indication of electrolyte imbalances. Ob- bladder prolapse is cystoliths.77 Colonic prolapse
structed reptiles are usually depressed and an- may be secondary to constipation, bacterial enter-
orexic. Vomiting is a poor prognostic indicator in itis, and parasitic enteritis77 (Fig 9).
tortoises.14
Diagnosis
Therapy Identification of the prolapsed material is helpful
It is important not to get overaggressive in non- for identification of the underlying cause of the
obstructed foreign body cases. The authors have prolapse. Hematology and fecal examination are
seen fishhooks pass in western painted turtles useful for diagnosis of an infectious component.
Emergent Diseases in Reptiles 171

Treatment sue or serum samples may be submitted to a tox-

If the tissue is vital, reduction and placement of icology laboratory. Radiography may be useful in
transverse cloacal sutures is indicated.77 Colopexy identifying metallic densities in cases of heavy
may also be performed. If tissue is not vital, resec- metal toxicosis.
tion and anastomosis is indicated.77
Therapy
Basic treatment of toxicosis consists of fluids and
Toxicoses cooling.78 In cases of oral toxicosis, activated char-
coal may be administered. For organophosphate
Etiology toxicity, atropine administered at 0.1 to 0.2
Toxicoses in reptiles are typically iatrogenic. Di- mg/kg has been used.75 The use of 2-PAM is not
chlorvos, an organophosphate found in no-pest reported in reptiles. Diazepam at a rate of 0.5
strips, is commonly used by hobbyists to treat mg/kg has been used to control convulsions.78
snake mites. Dichlorvos intoxication may result in Calcium EDTA at 10 to 40 mg/kg intramuscularly
rhythmic contractions and loss of righting re- q12 hour has been used for treatment of lead
flex.78 toxicity.85
Ivermectin is toxic in chelonians. Tortoises ad-
ministered ivermectin will show flaccid paralysis
and a fatty change in the liver.79 Toxicosis with References
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