Pharmacokinetics of nebulized and subcutaneously implanted terbinafine in cottonmouths (Agkistrodon piscivorus )

PILOT STUDY OF INTRACOELOMIC TERBINAFINE IMPLANTS IN GREATER SIRENS (SIREN LACERTINA)

Chytridiomycosis caused by Batrachochytrium dendrobatidis (Bd) has been documented in greater sirens (Siren lacertina) in the wild and in the pet trade. This study evaluated the use of terbinafine-impregnated implants for chytridiomycosis prophylaxis in greater sirens exposed to Bd. Implants were placed intracoelomically in both control (blank implant, n = 4) and treatment (24.5 mg of terbinafine implant, n = 4) groups. Sirens were exposed to Bd zoospores via 24-h immersion bath at 1 and 2 mon postimplant placement. Blood was collected monthly for plasma terbinafine levels, and skin swabs were collected weekly for Bd quantitative PCR. Animals with terbinafine implants had detectable concentrations of plasma terbinafine ranging from 17 to 102 ng/ml. Only one terbinafine-implanted animal had a peak concentration above the published minimum inhibitory concentration for terbinafine against Bd zoospores (63 ng/ml); however, it is unknown how plasma terbinafine concentrations relate to concentrations in the skin. There was no difference between the two treatment groups in clinical signs or Bd clearance rate, and no adverse effects from implants were observed. These findings indicate using intracoelomic drug implants for drug delivery in amphibians is safe; however, terbinafine efficacy in preventing Bd chytridiomycosis in sirens remains unclear. Further investigation of the use of intracoelomic implants and identification of effective drugs and doses in other amphibian species against Bd and other infectious diseases is warranted, as this may provide a practical method for long-term drug delivery in wildlife.

CONTROLLED CLINICAL TRIAL USING TERBINAFINE NEBULIZATION TO TREAT WILD LAKE ERIE WATERSNAKES (NERODIA SIPEDON INSULARUM) WITH OPHIDIOMYCOSIS

Ophidiomycosis (snake fungal disease) is an important infectious disease caused by the fungus Ophidiomyces ophidiicola. To mitigate the disease's impact on individual snakes, a controlled clinical trial was conducted using terbinafine nebulization to treat snakes with ophidiomycosis. Fifty-three wild-caught Lake Erie watersnakes (Nerodia sipedon insularum) with apparent ophidiomycosis (skin lesions present, qPCR positive for O. ophidiicola) were divided into treatment and control groups: treatment snakes were nebulized with a 2 mg/ml terbinafine solution for 30 min daily for 30 d; control snakes received nebulization with 0.9% saline or no nebulization. Weekly physical exams were conducted to assign disease severity scores based on the number, type, location, and size of lesions, and qPCR was repeated after each 30-d course of treatment. Persistently qPCR-positive snakes received multiple nebulization courses. Terbinafine nebulization showed mixed results as a treatment for ophidiomycosis: 29.2% of animals treated with terbinafine showed molecular resolution of external disease, based on antemortem swabbing, following 3-6 mon of daily nebulization; this was significantly more than with saline nebulization (5%), but molecular resolution also occurred in 11.1% of snakes that received no treatment. Terbinafine nebulization did not significantly decrease clinical disease, as measured by disease severity scores. Evaluating molecular response to treatment using fungal quantities, terbinafine nebulization significantly reduced fungal quantity after three or more courses of treatment. These results indicate that, although terbinafine nebulization is a promising treatment for ophidiomycosis, snakes may require multiple nebulization courses and disease may not always resolve completely, despite treatment. This treatment may be most useful in snakes from managed populations that can be treated for several months, rather than wild snakes who are not releasable after multiple months in captivity.

A Critical Review on the Dosing and Safety of Antifungals Used in Exotic Avian and Reptile Species

Antifungals are used in exotic avian and reptile species for the treatment of fungal diseases. Dose extrapolations across species are common due to lack of species-specific pharmacological data. This may not be ideal because interspecies physiological differences may result in subtherapeutic dosing or toxicity. This critical review aims to collate existing pharmacological data to identify antifungals with the most evidence to support their safe and effective use. In the process, significant trends and gaps are also identified and discussed. An extensive search was conducted on PubMed and JSTOR, and relevant data were critically appraised. Itraconazole or voriconazole showed promising results in Japanese quails, racing pigeons and inland bearded dragons for the treatment of aspergillosis and CANV-related infections. Voriconazole neurotoxicity manifested as seizures in multiple penguins, but as lethargy or torticollis in cottonmouths. Itraconazole toxicity was predominantly hepatotoxicity, observed as liver abnormalities in inland bearded dragons and a Parson's chameleon. Differences in formulations of itraconazole affected various absorption parameters. Non-linearities in voriconazole due to saturable metabolism and autoinduction showed opposing effects on clearance, especially in multiple-dosing regimens. These differences in pharmacokinetic parameters across species resulted in varying elimination half-lives. Terbinafine has been used in dermatomycoses, especially in reptiles, due to its keratinophilic nature, and no significant adverse events were observed. The use of fluconazole has declined due to resistance or its narrow spectrum of activity.

Major Emerging Fungal Diseases of Reptiles and Amphibians

Emerging infectious diseases (EIDs) are caused by pathogens that have undergone recent changes in terms of geographic spread, increasing incidence, or expanding host range. In this narrative review, we describe three important fungal EIDs with keratin trophism that are relevant to reptile and amphibian conservation and veterinary practice. Nannizziopsis spp. have been mainly described in saurians; infection results in thickened, discolored skin crusting, with eventual progression to deep tissues. Previously only reported in captive populations, it was first described in wild animals in Australia in 2020. Ophidiomyces ophidiicola (formely O. ophiodiicola) is only known to infect snakes; clinical signs include ulcerating lesions in the cranial, ventral, and pericloacal regions. It has been associated with mortality events in wild populations in North America. Batrachochytrium spp. cause ulceration, hyperkeratosis, and erythema in amphibians. They are a major cause of catastrophic amphibian declines worldwide. In general, infection and clinical course are determined by host-related characteristics (e.g., nutritional, metabolic, and immune status), pathogens (e.g., virulence and environmental survival), and environment (e.g., temperature, hygrometry, and water quality). The animal trade is thought to be an important cause of worldwide spread, with global modifications in temperature, hygrometry, and water quality further affecting fungal pathogenicity and host immune response.

Single-dose pharmacokinetics of orally administered terbinafine in bearded dragons (Pogona vitticeps) and the antifungal susceptibility patterns of Nannizziopsis guarroi

OBJECTIVE

To identify the antifungal susceptibility of Nanniziopsis guarroi isolates and to evaluate the single-dose pharmacokinetics of orally administered terbinafine in bearded dragons.

ANIMALS

8 healthy adult bearded dragons.

PROCEDURES

4 isolates of N guarroi were tested for antifungal susceptibility. A compounded oral solution of terbinafine (25 mg/mL [20 mg/kg]) was given before blood (0.2 mL) was drawn from the ventral tail vein at 0, 4, 8, 12, 24, 48, 72, and 96 hours after administration. Plasma terbinafine concentrations were measured with high-performance liquid chromatography.

RESULTS

The antifungal minimum inhibitory concentrations against N guarroi isolates ranged from 4,000 to > 64,000 ng/mL for fluconazole, 125 to 2,000 ng/mL for itraconazole, 125 to 2,000 ng/mL for ketoconazole, 125 to 1,000 ng/mL for posaconazole, 60 to 250 ng/mL for voriconazole, and 15 to 30 ng/mL for terbinafine. The mean ± SD peak plasma terbinafine concentration in bearded dragons was 435 ± 338 ng/mL at 13 ± 4.66 hours after administration. Plasma concentrations remained > 30 ng/mL for > 24 hours in all bearded dragons and for > 48 hours in 6 of 8 bearded dragons. Mean ± SD terminal half-life following oral administration was 21.2 ± 12.40 hours.

CLINICAL RELEVANCE

Antifungal susceptibility data are available for use in clinical decision making. Results indicated that administration of terbinafine (20 mg/kg, PO, q 24 to 48 h) in bearded dragons may be appropriate for the treatment of dermatomycoses caused by N guarroi. Clinical studies are needed to determine the efficacy of such treatment.

TERBINAFINE PHARMACOKINETICS FOLLOWING SINGLE-DOSE ORAL ADMINISTRATION IN RED-EARED SLIDER TURTLES (TRACHEMYS SCRIPTA ELEGANS): A PILOT STUDY

In this pilot study, the pharmacokinetics of terbinafine were determined in six apparently healthy red-eared slider turtles (Trachemys scripta elegans) after a single PO administration. Terbinafine suspension (15 mg/kg, once) was administered via gavage tube to all turtles. Blood samples were collected immediately before (time 0) and at 1, 2, 4, 8, 24, and 48 h after drug administration. Plasma terbinafine concentrations were quantified by ultra-performance liquid chromatography-mass spectrometry, and noncompartmental pharmacokinetic analysis was performed. None of the animals showed any adverse responses following terbinafine administration. Mean area under the curve from time 0 to 24 h was 1,213 h × ng/ml (range 319-7,309), mean peak plasma concentration was 201.5 ng/ml (range 45.8-585.3), mean time to maximum plasma concentration was 1.26 h (range 1-4), mean residence time was 7.71 h (range 3.85-14.8), and mean terminal half-life was 5.35 h (range 2.67-9.83). The administration of terbinafine (15 mg/kg, PO) may be appropriate for treatment of select fungal organisms with low minimum inhibitory concentrations in red-eared slider turtles but may require q12h administration even for organisms with low minimum inhibitory concentrations. Multiple-dose studies as well as clinical studies are needed to determine ideal dosages and efficacy.

EFFICACY OF SUBCUTANEOUS IMPLANTS TO PROVIDE CONTINUOUS PLASMA TERBINAFINE IN HELLBENDERS (CRYPTOBRANCHUS ALLEGANIENSI) FOR FUTURE PROPHYLACTIC USE AGAINST CHYTRIDIOMYCOSIS

Batrachochytrium dendrobatidis (Bd) is an important fungal pathogen present in wild hellbender (Cryptobranchus alleganiensis) populations that appears to cause disease during novel exposure and acute stress. Hellbender repatriation efforts are ongoing to combat declining populations, but mortality by chytridiomycosis (disease from Bd) after release has been reported. The goal was to determine whether a safe antifungal agent could be administered and provide prolonged plasma concentrations without repeated handling. A subcutaneous implant impregnated with 24.5 mg of terbinafine was tested in three juvenile eastern hellbenders (C. a. alleganiensis) raised in human care, and plasma terbinafine concentrations were recorded from weekly to biweekly for 141 days. Plasma concentrations were variable, with peak plasma concentrations of 1,610, 112, and 66 ng/ml between 28 and 56 days postimplant. Although all hellbenders achieved plasma concentrations above the published minimum inhibitory concentration for terbinafine against Bd zoospores (63 ng/ml) at several time points, only one individual remained above this threshold for more than two consecutive time intervals. Results show the potential for these implants as a prophylaxis for chytridiomycosis in captive-to-wild hellbender releases. However, further investigation will be needed to determine the plasma concentrations required to achieve prophylaxis in vivo and implant reliability.

POSTNATAL MORTALITY IN NEONATE RATTLESNAKES ASSOCIATED WITH OPHIDIOMYCES OPHIODIICOLA

Ophidiomycosis, historically referred to as snake fungal disease (SFD), caused by Ophidiomyces ophiodiicola, is a significant disease of snakes characterized by crusty scales, pustules, subcutaneous nodules, and death. Ophidiomycosis is a proposed threat to sustainability of free-ranging snake populations throughout the United States and Europe, but the clinical progression during periods of reproductive activity (gravid females, neonates) is unknown. In spring 2012, five apparently healthy gravid eastern massasauga (Sistrurus catenatus) rattlesnakes from Clinton County, Illinois, were brought into captivity to give birth and be returned into the population. While in captivity, one adult female and 21 neonates died. Five individuals were subsequently confirmed positive for O. ophiodiicola by using quantitative polymerase chain reaction (qPCR). In 2016, a gravid timber rattlesnake (Crotalus horridus) with ophidiomycosis from Jackson County, Illinois, gave birth in captivity to 13 neonates. Skin swabs were taken from all neonates immediately after birth and confirmed negative for O. ophiodiicola by using qPCR. The neonates remained housed with the positive female for 10 days before all animals were reswabbed and released back into the wild. One neonate was O. ophiodiicola positive at time of release. The initial negative result followed by a positive result several days postpartum suggests that the neonate was infected by the female after direct contact. Both case series represent natural infection of neonates after parturition and highlight the importance of this disease in a demographically important age class.

Pharmacokinetics of single dose oral Terbinafine in common shelducks (Tadorna tadorna)

Fungal disease is a major cause of morbidity and mortality in avian species; thus, antifungals are the treatment of choice. Despite widely used in clinical practice, terbinafine pharmacokinetic studies are scarce in literature and only cover some avian families, with marked differences between them. This study evaluates the pharmacokinetic behaviour of terbinafine after a single oral administration of 60 mg/kg in 7 healthy adult common shelducks (Tadorna tadorna) by measuring plasma concentrations through high-performance liquid chromatography (HPLC) at times 0, 30 min, 1, 2, 4, 6, 8, 10, 12, 24, 36 and 48 hr postadministration. Noncompartmental analyses of the data showed a C_max (geometric mean) of 5.43 µg/ml, t_max (median) 1.0 hr and AUC_0-∞ 29.70 mg h/L. Elimination half-life was 6.33 hr and MRT 6.61 hr. Plasma concentrations remained above previously described MIC for terbinafine in some fungal species for at least 6 to 8 hr. A single oral administration of 60 mg/kg terbinafine did not produce adverse effects and could be a good treatment choice for fungal diseases in anatids.

Outbreak of Paranannizziopsis australasiensis Infection in Captive African Bush Vipers (Atheris squamigera)

We report the epidemiological, clinical and pathological features of an outbreak of Paranannizziopsis australasiensis (order Onygenales) in captive African bush vipers (Atheris squamigera) (ABVs) that died suddenly. The snakes had multifocal, raised, white-grey to dark brown discoloured cutaneous patches. Microscopically, all had integumentary lesions characterized by multifocal to coalescent necroheterophilic epidermitis with superficial and intraepidermal fungal elements and bacteria. Concurrent epidermal hyperplasia, hyperkeratosis and intracellular and intercellular oedema, often leading to vesiculation, and fasciitis/superficial myositis, were consistent findings in all snakes, while ulceration (9/11) and dysecdysis (5/11) varied. A panfungal polymerase chain reaction targeting the internal transcribed spacer-2 region, and gene sequencing, confirmed P. australasiensis infection in three cases. This is the first report of P. australasiensis in the USA and the first record of paranannizziopsis infection in African bush vipers. P. australasiensis should be considered in the differential diagnosis of dermatomycosis in snakes and represents a potential threat to reptile conservation programmes.

Selected Emerging Infectious Diseases of Squamata: An Update

This article details emerging infectious diseases that have devastating impacts on captive and wild squamates. Treatment advances have been attempted for Cryptosporidium infections in squamates. Gram-positive bacteria, Devriesea agamarum and Austwickia chelonae, are contributing to severe disease in captive and now in wild reptiles, some critically endangered. Nannizziposis, Paranannizziopsis, and Ophidiomyces continue to cause fatal disease as primary pathogens in wild and captive populations of squamates and sphenodontids. Nidovirus, bornavirus, paramyxovirus, sunshine virus, and arenavirus have emerged to be significant causes of neurorespiratory disease in snakes. Controlled studies evaluating environmental stability, disinfection, transmission control, and treatment are lacking.

Emydomyces testavorans, a New Genus and Species of Onygenalean Fungus Isolated from Shell Lesions of Freshwater Aquatic Turtles

The fungal order Onygenales includes many pathogens of humans and animals, and recent studies have shown some onygenalean fungi to be significant emerging pathogens of reptiles. Although many of these fungi have similar morphological features in histologic tissue sections, recent molecular analyses have revealed a genetically complex and diverse group of reptile pathogens comprising several genera, most notably Nannizziopsis, Ophidiomyces, and Paranannizziopsis Infections by members of these genera have been previously reported in a variety of reptile species, including crocodilians, lizards, snakes, and tuataras, with negative impacts on conservation efforts for some reptiles. Despite the well-documented pathogenicity of these fungi in all other extant reptile lineages, infection has not yet been reported in aquatic turtles. In this study, we report the isolation of an onygenalean fungus associated with shell lesions in freshwater aquatic turtles. The morphologic and genetic characteristics of multiple isolates (n = 21) are described and illustrated. Based on these features and results of a multigene phylogenetic analysis, a new genus and species, Emydomyces testavorans, are proposed for these fungi isolated from turtle shell lesions.

Biomimicry of volatile-based microbial control for managing emerging fungal pathogens

Volatile organic compounds (VOCs) are known to be produced by a wide range of micro-organisms and for a number of purposes. Volatile-based microbial inhibition in environments such as soil is well-founded, with numerous antimicrobial VOCs having been identified. Inhibitory VOCs are of interest as microbial control agents, as low concentrations of gaseous VOCs can elicit significant antimicrobial effects. Volatile organic compounds are organic chemicals typically characterized as having low molecular weight, low solubility in water, and high vapour pressure. Consequently, VOCs readily evaporate to the gaseous phase at standard temperature and pressure. This contact-independent antagonism presents unique advantages over traditional, contact-dependent microbial control methods, including increased surface exposure and reduced environmental persistence. This approach has been the focus of our recent research, with positive results suggesting it may be particularly promising for the management of emerging fungal pathogens, such as the causative agents of white-nose syndrome of bats and snake fungal disease, which are difficult or impossible to treat using traditional approaches. Here, we review the history of volatile-based microbial control, discuss recent progress in formulations that mimic naturally antagonistic VOCs, outline the development of a novel treatment device, and highlight areas where further work is needed to successfully deploy VOCs against existing and emerging fungal pathogens.