Unusual Clinicopathologic Findings of Chronic Colitis Associated With Anemia, Myopathy, and Steatitis in a Common Marmoset (Callithrix jacchus)
Abstract
The common marmoset (Callithrix jacchus) of this report was a privately owned, 2-year-old female housed with an age-matched male. The facility housed another breeding pair of common marmosets, a squirrel monkey, and a variety of birds and reptiles in separate rooms. At the time of acquisition, hypotrichosis of the tail of the female marmoset was present and the female was noted to routinely consume more food than the male. The initial diet consisted of cereal mixes supplemented with powdered calcium and animal protein (milk and egg yolk), commercial dry parrot food, mixed fruits (fresh and dry), and insects. Fifteen days after acquisition, the female was presented with a 2-day history of partial anorexia and a several-hour history of vomiting. Examination revealed a high body weight (375 g) despite suboptimal body condition, locally extensive hypotrichosis of the tail, and pregnancy. Supportive therapy consisted of metoclopramide (0.05 mg IM, Primperan®, Barcelona, Spain), vitamin E-selenium (7 mg/kg E - 0.07 mg/kg Se IM, Vitasel®, Laboratorios Ovejero, León, Spain). Hematologic findings were hemoconcentration (PCV 52%, albumin = 4.07 g/dl), eosinophilia (2059/µl, 29%), hyperfibrinogenemia (507 mg/dl), hypocalcemia (corrected calcium 7.23 mg/dl), low BUN (7 mg/dl) and hyperglycemia (308 mg/dl after an 8-hours fasting). ALT, AST, amylase, lipase, cholesterol, triglycerides, and total blood lipids were normal. Serum insulin was 0.6 µU/ml (tested 11 months later with serum stored at -80°C). Anorexia and vomiting resolved. Four days later, hyperglycemia (310 mg/dl after a 12-hours fasting) was still present. A presumptive diagnosis of acute pancreatitis and/or diabetes associated with pregnancy was made. Therapy affected both animals and consisted of dietary control of diabetes by reducing simple carbohydrates in diet (fruits and cereal mixes discontinued; Acacia arabic gum, cottage cheese, callitrichid maintenance pellets (Marmoset diet 52840000, Zeigler Bros., Inc., Garners, PA, USA) and increased numbers insects offered), ivermectin (200 µg/kg PO repeated in 15 days; Ivomec®, Merck Sharp & Dohme BV, Haarlem, The Netherlands) and 60 ppm zinc in the drinking water.
At the time of female’s first presentation, the male also shared a history of partial anorexia and intermittent vomiting for 12 days. The first morning urine of both animals was checked SID for glucose. Glucosuria was present intermittently in both marmosets; in the male, glucosuria always followed episodes of vomiting for 1–2 days. The male was presented for examination 7 days after the last episode of vomiting and glucosuria; examination revealed a high body weight (425 g). Hematologic findings were eosinophilia (984/µl, 8%), hypoalbuminemia (0.299 g/dl, albumin/globulin ratio 0.77), and apparent elevations of α1 globulins (0.86 g/dl, 12.53%; institution normal = <0.55 g/dl and/or 8%). The incidence and intensity of glucosuria progressively decreased in the female and finally disappeared within 20 days of diet change. Fetal resorption was suspected whenever she did not deliver at the expected time of parturition. Both animals remained apparently normal for the following months.
Ten months later, the female was presented with a 10-day history of wasting, intermittent diarrhea, occasional vomiting, polyuria, polydipsia, and partial anorexia, and an episode of falling from a perch. Examination revealed marked dehydration, weight loss (245 g), pale mucous membranes, severe generalized muscle atrophy, hypothermia (34.36°C), bradypnea, abnormal vocalizations, a dry haircoat, and an excrement-tinged tail. Therapy consisted of SC fluids (15 ml lactated Ringer’s solution and 5 ml 5% glucosaline, followed by 20 ml saline), oral fluids ad libitum, vitamin E-selenium (10 mg/kg E - 0.1 mg/kg Se IM, Vitasel®, Laboratorios Ovejero, León, Spain), and enrofloxacin (5 mg/kg IM, Baytril® 2,5%, Bayer, Leverkusen, Germany). Polyuria and polydipsia were prominent clinical signs during hospitalization. Oral cytology was negative for fungus and bacteria. Direct fecals and culture of a rectal swab for enteropathogenic bacteria were negative. Hematology performed 12 hours before death revealed anemia (3.14 × 106 RBCs/µl, hemoglobin = 8.24 g/dl), leukopenia (1600/µl), thrombocytosis (1033 × 103/µl), hypoalbuminemia (2.51 g/dl; albumin/globulin ratio 0.63), elevated α1-globulins (0.89 g/dl, 13.74%), hyperphosphatemia (10 mg/dl) with a high calcium × phosphorus product (94), elevated ALT (64 U/L), hyperamylasemia (1917 U/L) with normal lipase, azotemia (BUN 43.45 mg/dl, creatinine 1.9 mg/dl), hypercholesterolemia (480 mg/dl), and normoglycemia (94 mg/dl). A few hours before death, urinalysis performed with dry reagent dipsticks (Urispec 9-Way, Port Washington, NY, USA) on reddish urine collected from the floor just after voiding revealed hematuria (250 RBCs/µl), proteinuria (30 mg/dl), and glucosuria (500 mg/dl). The animal was euthanatized when moribund after 26 hours of hospitalization. Insulin (0.3 µU/ml) and vitamin E 4.5 (µg/ml) levels were determined retrospectively (collected and stored at -80°C). Necropsy revealed depletion of adipose tissue with generalized muscle atrophy, catarrhal enterocolitis with mesenteric lymphadenopathy, whitish pinpointing of the renal cortex, and multiple reddish areas up to 1 mm in diameter in both adrenal glands.
Histopathologic examination revealed multiorgan involvement and the following major lesions:
1. Severe chronic colitis
2. Severe generalized degenerative myopathy
3. Moderate pyogranulomatous steatitis with ceroid pigment
4. Prominent systemic lipopigment deposition
5. Severe mesangioproliferative glomerulonephritis with prominent hyaline and cellular (giant cell) cast formation and phagocytosis of hyaline casts
6. Severe generalized islet hyperplasia with insulin overexpression demonstrated by immunohistochemistry
7. Severe hemosiderosis affecting mostly hepatocytes and the reticuloendothelial system
8. Extramedullary hematopoiesis and increased erythrophagocytosis in lymph nodes
9. Deep duodenal ulceration
10. Severe vaquolation and ballooning degeneration of the superficial layer of the esophageal epithelium
The male was presented 7 days after the demise of his mate with a history of intermittent diarrhea and occasional vomiting. Examination revealed weight loss (337 g) and mild to moderate generalized muscle atrophy. Hematologic findings included macrocytic anemia (3.72x106 RBCs/µl, hemoglobin = 9.61 g/dl, MCV = 77.9 fl), hypoproteinemia (5.1 g/dl), hypoalbuminemia (2.88 g/dl), and possible hypergammaglobulinemia (0.95 g/dl, 18.6%; institution normals = <0.7 g/dl and 13%). Serum vitamin E (0.5 µg/ml) was determined retrospectively. Therapy consisted of vitamin E-selenium (8 mg/kg E-0.06 mg/kg Se IM, q 1 week for 4 weeks; Toco-Selenio®, Calier, Barcelona, Spain). For the treatment of episodes of diarrhea, the animal was offered less food for 1–2 days, water was supplemented with water- and fat-soluble vitamins and minerals, the diet was changed for 7–14 days to a ration based on cottage cheese and boiled rice, and a treatment regimen was initiated that included sulfasalazine (14 mg PO BID for 14 days, Salazopyrina, Pharmacia and Upjohn S.A., Barcelona, Spain), lactobacilli and cod-liver oil. Three weeks later anemia persisted (3.48 × 106 RBCs/µl, hemoglobin = 9.84 g/dl, MCV = 80.5 fl); body weight (361 g) and total proteins (6.0 g/dl) were increased, and γ-globulins (1.07 g/dl, 17.83%) were elevated. The renal function biochemistry panel and glucose/protein urine strips were normal. Treatment with vitamin E and selenium was continued for 3 weeks. Five weeks later an increasing body weight (386 g) and a 2-weeks history of normal stools were found upon reevaluation of the animal. Anemia was less pronounced (4.54 x 106 RBCs/µl, hemoglobin 11 g/dl, MCV 79.4 fl), and total proteins were at 7.0 g/dl with albumin and γ-globulins at 3.57 g/dl and 0.91 g/dl (13%), respectively. At the time of writing of this abstract this marmoset is doing well.
In the female, chronic colitis (CC) was severe and associated with other life-threatening conditions: anemia, degenerative myopathy (DM), and glomerulonephritis (GN). Chronic colitis is a major disease of callitrichids, especially the cotton-top tamarin (Saguinus oedipus).2,4,8 This is the first case of CC out of 32 admissions (corresponding to 26 different animals) diagnosed in callitrichids at the primary authors facility. The etiology of CC is unknown, but likely multifactorial; possible causes include antigenic compounds in diet and infectious agents (e.g., Campylobacter and a novel Helicobacter species isolated from affected cotton-top tamarins), and the disease incidence and severity may be modulated by dietary factors (e.g., fiber contents and antioxidant levels), environmental stressors and/or species susceptibility.8,15 These marmosets had access to a great variety of protein sources in the diet; culture for enteropathogenic bacteria in the female did not grow Campylobacter and Warthin-Starry stain of the intestine did not reveal spiral bacteria. A rare complication of CC in humans is GN,5 that may be due to the abnormal secretion of IgA by the chronically inflamed intestinal mucosa with subsequent immune complex formation and deposition in the glomerular mesangium. Immune complexes from dietary antigens (e.g., gliadin) may be implicated in CC and GN of callitrichids.16 Although immune complex GN is common in captive callitrichids, there appears to be no published reports of its association with CC. Vomiting, polyuria, and polydipsia, accompanied by biochemical evidence of renal failure, were attributed mostly to chronic renal insufficiency (CRI). Although the female marmoset had hypercholesterolemia, hypoalbuminemia, and proteinuria were moderate and mild, respectively, despite severe CC and hyaline cast formation in the kidneys, and this may explain the lack of ascites and/or edema. The association of CC with anemia, DM, and/or steatitis has been previously reported in common marmosets and moustached tamarins (Saguinus labiatus) with evidence of vitamin E deficiency in some animals.2,4 Anemia may be due to chronic disease, vitamin E deficiency, CC, and/or CRI.
Different types of anemia (e.g., autoimmune hemolytic, anemia due to erythropoietin deficiency) are possible complications of CC in humans.7,18 Although no Heinz bodies were seen in both marmosets and initially there was no response of anemia to vitamin E and selenium in the male marmoset, anemia in the female was accompanied by DM and steatitis, findings strongly suggestive of vitamin E deficiency and common in New World primates at the primary authors facility.2,4,9 Furthermore, systemic lipopigment deposition and increased erythrophagocytosis supported the existence of a suboptimal vitamin E status. Serum vitamin E levels in the female were considered suboptimal to low normal as most primates range 5–20 µg/ml;9 however, the male was in the deficiency range, and this further supports vitamin E deficiency. Oxidative stress may play an important role in the pathogenesis of CC;1,19 furthermore, in a rat model of CC, antioxidant enzymes and vitamin E levels were decreased.19 In humans with inflammatory bowel disease, vitamin E levels may be either decreased or normal.6,9 Despite severe DM, only moderate elevations of ALT were detected and CPK, LDH, and GOT were normal a few hours before death.
Another unusual association of CC in the female was histopathologic islet hyperplasia and a previous history of hyperglycemia, glucosuria, and vomiting associated with pregnancy. At the primary authors facility, islet hyperplasia, obesity, and/or diabetes are common in callitrichids affected with a variety of disorders such as lipomatosis, fatal fatty liver-kidney syndrome, pancreatic necrosis, pancreatic steatonecrosis, acute pancreatitis, systemic iron overload, hyperlipidemia, hypertriglyceridemia, hypercholesterolemia, and/or dyslipoproteinemia (Juan-Sallés, manuscript in preparation). The excessive body weight of the female at first presentation, when she was in early stages of pregnancy, associated with persistent hyperglycemia and the response of glucosuria to diet change suggest a diagnosis of gestational diabetes. Gestational diabetes has been previously reported in a white-faced saki (Pithecia pithecia)12 and is a known complication in pregnant women. Islet hyperplasia has been noted in tamarins (Saguinus fuscicollis and S. oedipus) with heavy weight, obesity, pancreatitis, and/or pancreatic steatonecrosis.3 Islet hyperplasia is associated with insulin resistance, type 2 diabetes, and obesity.3,11,17 However, insulin levels at both presentations in the female seemed not to be high. Although insulin levels have not been reported in callitrichids, two normoglycemic, physically-obese marmosets were at 8 and 11.2 µU/ml at the primary authors facility. Normoglycemia was accompanied a few hours later by marked glucosuria in the female shortly after death; normoglycemia is a common finding in obese mice with islet hyperplasia and diabetes as disease progresses.11,17 It is likely that the disorder of the endocrine pancreas seen in this marmoset contributed to the appearance of some clinical findings such as polyuria and polydipsia; these and other signs of overt diabetes (e.g., uriposia, polyphagia) have been observed in other callitrichids at the primary authors facility. Hemosiderosis, a common finding in captive callitrichds,14 can be attributed to wasting, chronic inflammation, and/or increased erythroid turnover; however, apparent insulin resistance may be also involved.13
Acknowledgments
This report is part of a prospective study on wasting syndromes and antioxidant deficiencies of New World primates that is supported by Laboratorio de Diagnóstico General, Universitat Autònoma de Barcelona, and Clínica Exòtics (Barcelona, Spain).
Literature Cited
1. Babbs CF. Oxygen radicals in ulcerative colitis. Free Radic Biol Med. 1992;13:169–181.
2. Baskin GB, Wolf RH, Worth CL, Soike K, Gibson SV, Bieri JG. Anemia, steatitis and muscle necrosis in marmosets (Saguinus labiatus). Lab Anim Sci. 1983;33:74–80.
3. Brack M, Gatesman TJ, Olfenbüttel T. Heavy weight, obesity and pancreatic lesions in callitrichids. Erkr Zootiere. 1987;29:217–224.
4. Chalmers DT, Murgatroyd LB, Wadsworth PF. A survey of the pathology of marmosets (Callithrix jacchus) derived from a marmoset breeding unit. Lab Anim. 1983;17:270–279.
5. Dhiman RK, Poddar U, Sharma BC, Arora P, Saraswat VA, Pandey R, Naik SR. Membranous glomerulonephritis in association with ulcerative colitis. Indian J Gastroenterol. 1998;17:62.
6. Hoffenberg EJ, Deutsch J, Sokol RJ. Circulating antioxidant concentrations in children with inflammatory bowel disease. Am J Clin Nutr. 1997;65:1482–1488.
7. Horina JH, Petritsch W, Schmid CR, Reicht G, Wenzl H, Silly H, Krejs GJ. Treatment of anemia in inflammatory bowel disease with recombinant human erythropoietin: results in three patients. Gastroenterology. 1993;104:1828–1831.
8. Johnson LD, Ausman LM, Sehgal PK, King NW Jr. A prospective study of the epidemiology of colitis and colon cancer in cotton-top tamarins (Saguinus oedipus). Gastroenterology. 1996;110:102–115.
9. Juan-Sallés C, Prats N, Ruiz JM, Valls X, Giné J, Garner MM, et al. Antioxidant status in a squirrel monkey (Saimiri sciureus) with chronic pancreatitis and degenerative myopathy. J Comp Pathol. 2000;123(2–3):202–206.
10. Krasinski SD, Russell RM, Furie BC, Kruger SF, Jacques PF, Furie B. The prevalence of vitamin K deficiency in chronic gastrointestinal disorders. Am J Clin Nutr. 1985;41:639–643.
11. Leiter EH, Coleman DL, Eisenstein AB, Strack I. A new mutation (db3J) at the diabetes locus in strain 129/J mice. I. Physiological and histological characterization. Diabetologia. 1980;19:58–65.
12. Lloyd ML, Susa JB, Pelto JA, Savage A. Gestational diabetes mellitus in a white-faced saki (Pithecia pithecia). J Zoo Wildl Med.1995;26:76–81.
13. Mendler MH, Turlin B, Moirand R, Jouanolle AM, Sapey T, Guyader D, et al. Insulin resistance-associated hepatic iron overload. Gastroenterology. 1999;117:1155–1163.
14. Miller GF, Barnard DE, Woodward RA, Flynn BM, Bulte JWM. Hepatic hemosiderosis in common marmosets, Callithrix jacchus: effect of diet on incidence and severity. Lab Anim Sci. 1997;47:138–142.
15. Saunders KE, Shen Z, Dewhirst FE, Paster BJ, Dangler CA, Fox JG. Novel intestinal Helicobacter species isolated from cotton-top tamarins (Saguinus oedipus). J Clin Microbiol. 1999;37:146–151.
16. Schroeder C, Brack M, Brandes F, Bruno SF. Immune complex glomerulopathy in marmosets at the German Primate Center. Proc Am Assoc Zoo Vet. 1997:339–342.
17. Tomita T, Doull V, Pollock HG, Krizsan D. Pancreatic islets of obese hyperglycemic mice (ob/ob). Pancreas. 1992;7:367–375.
18. Vilaseca J, Tor J, Puig Costa M, Ribera A, Martín C, Guardia J. Colitis ulcerativa crónica y anemia hemolítica autoinmune. Med Clin (Barc.). 75:126–128.
19. Yoshikawa T, Takahashi S, Kondo M. Possible role of free radicals in the chronic inflammation of the gut. EXS. 1992;62:353–358.