Disease treatment in horses encompasses a range of medical interventions and management strategies aimed at addressing various health conditions affecting equine species. These treatments can include pharmacological approaches, such as the administration of antibiotics, anti-inflammatory drugs, and antiparasitic medications, as well as non-pharmacological methods like physical therapy, dietary adjustments, and surgical procedures. The selection of appropriate treatments depends on the specific disease, its severity, and the individual needs of the horse. This topic brings together peer-reviewed research studies and scholarly articles that explore the efficacy, safety, and advancements in therapeutic options for equine diseases, providing insights into best practices and emerging trends in equine veterinary medicine.
Venner M, Astheimer K, Lämmer M, Giguère S.Mass antimicrobial treatment of foals with small subclinical ultrasonographic pulmonary lesions is empirical practice on many farms with endemic disease caused by Rhodococcus equi. Objective: Mass antimicrobial treatment of foals with subclinical ultrasonographic pulmonary lesions is unnecessary. Methods: One hundred and eight foals on a farm endemic for infections caused by R. equi. Methods: Controlled, randomized, and double-blinded prospective study. Foals with ultrasonographic evidence of pulmonary abscesses 5.0-10 cm in diameter (n = 108) were randomly allocated in 5 treatment groups: (1)...
Aktan I, Dunkel B, Cunningham FM.Activated platelets can contribute to host defense through release of products with bactericidal actions such as antimicrobial peptides and reactive oxygen species (ROS), as well as by forming heterotypic aggregates with neutrophils and enhancing their antimicrobial properties. Whilst release of vasoactive mediators from equine platelets in response to stimuli including bacterial lipopolysaccharide (LPS) has been documented, neither ROS production, nor the effects of activated platelets on equine neutrophil ROS production, have been reported. This study first sought evidence that activated equ...
Schemann K, Gillespie JA, Toribio JA, Ward MP, Dhand NK.Rapid, evidence-based decision-making is critical during a disease outbreak response; however, compliance by stakeholders is necessary to ensure that such decisions are effective - especially if the response depends on voluntary action. This mixed method study evaluated technical policy decision-making processes during the 2007 outbreak of equine influenza in Australia by identifying and analysing the stakeholder network involved and the factors driving policy decision-making. The study started with a review of the outbreak literature and published policy documents. This identified six policy ...
Litterio ML, Arazi S, Hernández C, Lopardo H.Horse bite infections are very rarely reported in the medical literature. Here we present a case of a severe facial infection in a 2-year-old boy after a horse bite, from which Serratia rubidaea and Enterobacter cloacae were isolated. Some pieces of grass were found inside the wound and were removed before performing a surgical toilet. The presence of these two gram-negative bacteria associated with a horse bite infection, as well as other organisms such as anaerobes, Pseudomonas, gram-positive cocci, Actinobacillus spp., previously described in other works, should be taken into account when s...
Tavela Ade O, de Araújo JV, Braga FR, da Silveira WF, Dornelas e Silva VH, Carretta Júnior M, Borges LA, Araujo JM, Benjamin Ldos A, Carvalho GR....The predatory nematophagous fungi have been used as an alternative control of gastrointestinal nematodes of domestic animals in natural and laboratory conditions. However, it is unclear if the association of some of these species could bring some kind of advantage, from a biological standpoint. In this context, this study consisted of two tests in vitro: in assay A, the assessment of the viability of the association of pellets in sodium alginate matrix containing the fungus Duddingtonia flagrans (AC001) and Monacrosporium thaumasium (NF34) and its predatory activity on infective larvae (L3) of...
Mambelli LI, Winter GH, Kerkis A, Malschitzky E, Mattos RC, Kerkis I.Mesenchymal stem cells (MSCs), because of their immunomodulation and trophic activities, in addition to their capacity to regenerate damaged tissues, have potential for treatment of many diseases. The success of stem cell therapies depends, in part, on the method of cell delivery, which should provide wide cell distribution and homing in to injured sites. The objective of the present study was to developing a novel strategy for delivery of MSCs into the uterus of mares with endometrosis (degenerative alteration of uterine glands and surrounding stroma). Endometrosis was confirmed in all mares ...
Durward-Akhurst SA, Mair TS, Boston R, Dunkel B.Appropriate durations of perioperative antimicrobial therapy following exploratory coeliotomy in horses are controversial, and with the rising prevalence of multiresistant bacteria there is a strong incentive to use antimicrobials for the shortest time possible. Following exploratory coeliotomies, incisional infections are an important cause of morbidity in horses and could be influenced by the duration of systemic antimicrobial therapy. The aim of this study was to investigate whether 72 hours of perioperative antimicrobial therapy is as effective as 120 hours at preventing the development of...
Lerche P.Total intravenous anesthesia (TIVA) is the mainstay of short-term (up to 60 minutes) and field anesthesia in horses. This article discusses the pros and cons of TIVA, commonly used TIVA protocols, and their use, monitoring during, and recovery from, TIVA.
Valverde A.Balanced anesthetic techniques are commonly used in equine patients, and include the combination of a volatile anesthetic with at least one injectable anesthetic throughout the maintenance period. Injectable anesthetics used in balanced anesthesia include the α2-agonists, lidocaine, ketamine, and opioids, and those with muscle-relaxant properties such as benzodiazepines and guaifenesin. Administration of these injectable anesthetics is best using constant-rate infusions based on the pharmacokinetics of the drug, which allows steady-state concentrations and predictable pharmacodynamic actions....
Tappenbeck K, Hoppe S, Hopster K, Kietzmann M, Feige K, Huber K.Postoperative ileus (POI) is a severe complication following small intestinal surgery in horses. It was hypothesised that prokinetic effects of lidocaine, the most commonly chosen drug for treatment of POI, resulted from drug integration into smooth muscle (SM) cell membranes, thereby modulating cell membrane properties. This would probably depend on the structural and lipophilic characteristics of lidocaine. To assess the influence of molecular structure and lipophilicity on prokinetic effects in vitro, the current study compared the effects of lidocaine with four structure-related drugs, nam...
Pascucci I, Di Provvido A, Cammà C, Di Francesco G, Calistri P, Tittarelli M, Ferri N, Scacchia M, Caporale V.Dourine is trypanosomosis that affects equids, it's mainly sexually transmitted. The disease was first eradicated in Italy in the 1940s, but there was then a serious epidemic in the mid-70s. After sporadic reports at the end of the 1990s, in May 2011 it was reported once more. Clinical diagnosis of dourine can be complex, as clinical signs and gross lesions are not always present. Direct laboratory diagnosis is also problematic, given the low number of parasites normally present in infected tissues and the mild, short-lasting parasitaemia. This article describes the epidemiological, clinical a...
Canever RJ, Braga PR, Boeckh A, Grycajuck M, Bier D, Molento MB.The increase of anthelmintic resistance in the last years in the nematode population of veterinary importance has become a major concern. The objective of the present study was to evaluate the efficacy of the main anthelmintic drugs available in the market against small strongyles of horses in Brazil. A total of 498 horses from 11 horse farms, located in the states of Paraná, São Paulo, Rio de Janeiro and Minas Gerais, in Brazil, were treated with ivermectin, moxidectin, pyrantel and fenbendazole, orally at their recommended doses. The fecal egg count reduction test (FECRT) was used to deter...
Caston S, McClure S, Beug J, Kersh K, Reinertson E, Wang C.While surgical arthrodesis is the treatment of choice for osteoarthritis of the proximal interphalangeal joint, some clients are unable to pursue surgery due to costs. A more economical technique was sought using intra-articular ethyl alcohol injections to facilitate ankylosis. Objective: To describe the technique and outcome of intra-articular ethyl alcohol injections for facilitated ankylosis of proximal interphalangeal joints with osteoarthritis. Methods: As a retrospective case series, the medical records (2006-2012) of clinical cases diagnosed with proximal interphalangeal joint osteoarth...
Kelmer G, Martin-Jimenez T, Saxton AM, Catasus C, Elliot SB, Lakritz J.There are no reported studies evaluating the use of erythromycin for regional limb perfusion (RLP) in horses. Our hypothesis was that using the cephalic and saphenous veins for RLP will enable delivery of therapeutic concentrations of erythromycin to the distal limb. Nineteen healthy horses participated in the study. The cephalic, saphenous or palmar digital (PD) vein was used to perfuse the limb with erythromycin. Synovial samples were collected from the metacarpo/metatarso-phalangeal (MCP/MTP) joint and blood samples were collected from the jugular vein. Maximum concentration (C(max)) of ery...
de Araújo Silva DO, Matis GK, Costa LF, Kitamura MA, de Carvalho Junior EV, de Moura Silva M, Barbosa BJ, Pereira CU, da Silva JC, Birbilis TA....To present the accumulated experience from treating chronic subdural hematomas (CSDH) in a local hospital of a third world country. Methods: One hundred and twenty-five consecutive patients with CSDH who were surgically treated in the Neurosurgical Department of the Hospital da Restauração, Recife-PE, Brazil, between January 2006 and May 2008, were retrospectively studied. Glasgow Outcome Scale (GOS) was employed to define outcome at 6 months as good (GOS 4 and 5) or poor (GOS ≤ 3). Age, admission Glasgow Coma Scale (GCS), location of hematomas (unilateral/bilateral), drainage system place...
UpRichard K, Elce YA, Piat P, Beauchamp G, Laverty S.To determine the short- and long-term outcome for sport horses after arthroscopic treatment of osteochondrosis of the lateral trochlear ridge of the femur. Methods: A retrospective study was performed using the medical records of horses intended for use as English sport horses. Outcome was obtained through telephone questionnaire. Results: Thirty-seven horses, mainly Warmbloods, underwent arthroscopic surgery for treatment of lateral femoral trochlear ridge osteochondrosis. Short-term outcome revealed that 27 of 37 horses had no complications. Seven horses had postoperative lameness and effusi...
Rubio-Martínez LM, Elmas CR, Black B, Monteith G.To describe the clinical use of regional limb perfusion with antimicrobials (A-RLP), complications, and outcome in a large series of patients. Methods: Retrospective case series. Methods: 174 horses. Methods: Medical records of horses treated with A-RLP between 1999 and 2009 were reviewed. Signalment, primary complaint, horse use, etiology, duration of clinical signs, previous treatment, structures involved, concurrent conditions, A-RLP characteristics, additional treatments, complications, and outcome were recorded. At long-term follow-up, 2 outcomes were investigated: survival rate and retur...
Stopyra A, Sobiech P, Waclawska-Matyjasik A.The acid-base equilibrium is closely linked to gas exchange in the lungs, and respiratory exchange ratios are used to evaluate respiratory effectiveness and tissue oxygen levels. Acid-base indicators are determined in both arterial and venous blood samples. This study compares the usefulness of acid-base indicators of venous and arterial blood in monitoring the condition of horses with recurrent airway obstruction. Prior to treatment involving bronchodilating glucocorticoids, expectorant and mucolytic drugs, more pronounced changes were observed in venous blood (pH 7.283, pCO2 61.92 mmHg, pO2 ...
Nolen-Walston RD.Large animal species in states of shock can require particularly high flow rates for volume resuscitation and the ability to deliver adequate volumes rapidly may be a rate-limiting step. The objective of this study was to determine the maximum flow rates of common combinations of IV catheter, extension set, and fluid administration sets. Methods: University veterinary teaching hospital. Methods: In vitro experimental study. Methods: Maximum flow rates were measured using combinations of 4 IV catheters (3 14-Ga and a single 10-Ga), 2 IV catheter extension sets (small bore and large bore), and 2...
Guasco PG, Kelly G, Schumacher J, Henry RW.To assess outcome after neurectomy of the deep branch of the lateral palmar nerve (DBLPaN) as a treatment for horses with persistent lameness associated with chronic proximal suspensory desmitis (PSD) of the thoracic limb. Methods: Case series. Methods: Adult, mixed-breed horses (n = 4), weighing 510-585 kg, used for amateur show-jumping. Methods: Records of 4 horses chronically lame because of PSD of one or both thoracic limbs that were treated by neurectomy of the DBLPaN were reviewed. The site of pain causing lameness was localized using regional anesthesia. The proximal aspect of the suspe...
Sharrow-Reabe KL, Townsend WM.To compare the corneal anesthetic effects and duration of action of 2 ophthalmic anesthetic agents in horses. Methods: Prospective, randomized masked crossover study. Methods: 8 clinically normal adult horses. Methods: Corneal sensitivity was determined by measuring each eye's corneal touch threshold (CTT) with a Cochet-Bonnet esthesiometer. Each eye's baseline CTT was recorded prior to anesthetic instillation at 0 minutes and every 10 minutes thereafter for 60 minutes. Each eye was randomly assigned to receive 2 of 4 treatments: 0.5% aqueous proparacaine ophthalmic solution (aqueous proparaca...
Tsujita H, Plummer CE.To describe and evaluate intrastromal and subconjunctival injection of voriconazole for the therapy of deep corneal stromal abscess (DSA) in horses. Methods: A retrospective clinical study describing the indications for intrastromal and subconjunctival voriconazole injection and the outcomes of this procedure in two eyes of two horses. Methods: The two horses in this study failed to respond to medical therapy. Treatment with intracorneal and subconjunctival administration of 1% voriconazole was performed in this study. Results: Treatment with intracorneal and subconjunctival administration of ...
Diouf ND, Etter E, Lo MM, Lo M, Akakpo AJ.Since first being detected in Nigeria in January 2007, African horse sickness virus serotype 2 (AHSV-2) has spread throughout the northern hemisphere, and was first reported in Senegal. A retrospective study was conducted from December 2009 to April 2010 using data collected in the field combined with information available at the Direction of Veterinary Services. The epidemic started in the Dakar region with two outbreaks in March and June 2007, respectively, and spread in several parts of the country between July and November 2007. During this period, 232 outbreaks and 1137 horse deaths were ...
Bischofberger AS, Dart CM, Perkins NR, Kelly A, Jeffcott L, Dart AJ.To compare the effects of manuka honey and manuka honey gel on second intention healing of noncontaminated distal limb wounds and those contaminated with feces. Methods: Experimental study. Methods: Standardbred horses (n = 10). Methods: Five full-thickness wounds (2 × 2 cm) were created on both metacarpi. Wounds on 1 forelimb were covered with horse feces for 24 hours. Wounds on the contralateral limb were left uncontaminated. Wounds were assigned to the following 5 different treatments: manuka honey, manuka honey gel or gel applied for 12 days, manuka honey gel applied throughout healing an...
Di Stefano DA, Andreasi Bassi M, Cinci L, Pieri L, Ammirabile G.While deproteinized bovine bone and bovine membranes have been well studied and can yield good results when used to treat bone defects and peri-implant dehiscences, enzymatically deantigenated equine bone and equine membranes have emerged as possible alternative biomaterials. The objective of this study was the clinical and histological assessment of such materials: equine bone granules, an equine collagen membrane and an equine pericardium membrane. Methods: Enzymatically deantigenated equine bone and an equine collagen membrane were used to restore a bone defect caused by the removal of a bo...
Lacourt M, MacDonald M, Rossier Y, Laverty S.To report the clinical findings, diagnosis, treatment and outcome of equine patients with articular synovial cysts. Methods: Retrospective case series. Methods: Horses (n = 16) with articular synovial cysts. Methods: Horses diagnosed with articular synovial cysts (1988-2009) at 2 veterinary teaching hospitals were studied. Signalment, history, clinical signs, diagnostic methods and treatment were retrieved and telephone follow-up was obtained. Results: Sixteen horses with articular synovial cysts were identified. Lameness was the reason for referral in most (n = 9) horses. Diagnosis was based ...
Jones SL, Langer DL, Sterner-Kock A, Snyder JR, Carlson GP.A 4-month-old male Trakehner foal with a history of hematuria, poor growth, and abnormal hair was found to have unilateral hydronephrosis and hydroureter, as determined by ultrasonography and surgical exploration. Nephrectomy and ureterectomy were performed as treatment. Gross examination of the ureter and kidney revealed renal pelvic and ureteral polyps causing obstruction and subsequent hydronephrosis. The histologic features were consistent with renal dysplasia. The polyps and renal dysplasia were likely to be congenital, but the etiopathogenesis is not known. The finding that urinary outfl...
Verhoef JNC, Allen AL, Harding JCS, Al-Dissi AN.Chronic liver disease is an important cause of illness in horses, and treatment is mainly supportive. Research into new treatment modalities for humans has shown promising data regarding metallothionein (MT), which has been shown to possess regenerative, antifibrotic, and anti-inflammatory properties. This study aimed to examine the relationship between hepatic MT expression and the histopathologic markers of hepatic inflammation, fibrosis and bile duct proliferation, as well as cellular regeneration in 77 selected cases of chronic liver disease in horses. We hypothesized that higher MT expres...
Belknap JK, Nickels FA.Third-degree perineal lacerations or rectovestibular fistulae in 17 mares were repaired surgically by a one-stage method. Primary healing occurred in 14 mares; there were one complete dehiscence and two partial dehiscences with fistula formation. Twelve of 13 mares that were bred became pregnant; nine carried foals to term and two are still pregnant. Two mares have each produced one unthrifty foal. One mare repeatedly aborts in the first trimester. Four mares have produced several healthy foals with no further problems. One mare suffered further perineal trauma while foaling.
Bailey E.Segregation distortion was found for a haplotype of the equine lymphocyte antigen (ELA) system in an extended family of American Standardbred horses. In one sire family, consisting of a stallion and his 17 sons and grandsons, the gene for ELA-A10 (A10) was transmitted to 57.7% of 638 offspring scored (P = 0.001). Significant segregation distortion was not seen for mares or for unrelated stallions, regardless of the ELA markers they possessed. Since the effect was seen for this one sire family and not seen for other stallions with A10, it is unlikely that the gene for A10 is the cause of this p...
Marr KA, Lees P, Cunningham FM.Activation of circulating neutrophils has been observed following challenge of horses with chronic obstructive pulmonary disease (COPD) and may facilitate the accumulation of these cells in the airways. In this study, no significant difference was observed between adherence to protein coated plastic of blood neutrophils from asymptomatic COPD-susceptible and normal horses stimulated by the mediators PAF, human recombinant (hr)IL-8 and hrC5a. Twenty-four hours after the start of a 7 h antigen challenge, adherence of unstimulated neutrophils from COPD-susceptible horses increased from 2.5 (0.5-4...
Khan A, Mushtaq MH, Ahmad MUD, Nazir J, Farooqi SH, Khan A.A widespread epidemic of equine influenza (EI) occurred in nonvaccinated equine population across multiple districts in Khyber Pakhtunkhwa Province of Pakistan during 2015-2016. An epidemiological surveillance study was conducted from Oct 2015 to April 2016 to investigate the outbreak. EI virus strains were isolated in embryonated eggs from suspected equines swab samples and were subjected to genome sequencing using M13 tagged segment specific primers. Phylogenetic analyses of the nucleotide sequences were concluded using Geneious. Haemagglutinin (HA), Neuraminidase (NA), Matrix (M) and nucleo...
Higgins JC, Leith GS, Pappagianis D, Pusterla N.Pulmonary coccidioidomycosis in horses can often lead to severe systemic disease and its treatment has previously been expensive and has carried a poor prognosis. This paper describes the successful treatment of two horses with pulmonary coccidioidomycosis with a fluconazole product produced by a compounding pharmacy.
Mughannam AJ, Buyukmihci NC, Kass PH.The objective was to determine whether topically administered 1% atropine would alter intraocular pressure. The animals studied were four healthy adult horses. Intraocular pressure and pupil diameter were measured prior to and during a 2-day period of treatment with 1% atropine sulfate. No significant changes in intraocular pressure occurred as a result of the treatment with atropine. Pupil diameter increased significantly after atropine was applied. Available information on the outflow of aqueous humor from the horse eye suggests that atropine might reduce intraocular pressure in the horse by...
Klei TR, Torbert BJ, Chapman MR, Ochoa R.Nonimmune pony foals 9 to 12 mo of age were vaccinated with third-stage Strongylus vulgaris larvae (L3) irradiated with 70, 100, or 130 Kr of gamma radiation. Ponies receiving per os inoculations of L3 irradiated with 70 or 100 Kr were protected from the clinical disease and lesions associated with challenge infections of 4,300 L3, when compared to nonvaccinated controls. Similarly, the numbers of worms from the challenging population recovered from successfully vaccinated animals were significantly lower than from nonvaccinated controls. The degree of resistance that develops in individuals c...
Dohrmann J, Hildebrand F, Straub J, Wadephul R, Pusterla N, Freise F, Venner M.The goal of the current report was to describe the clinical signs, therapy and outcome of foals with suspected equine proliferative enteropathy (EPE) due to an infection with Lawsonia intracellularis. Forty foals, born on the same breeding farm, were diagnosed with suspected clinical EPE between September 2019 and January 2020. Data of these cases were analyzed retrospectively regarding the course of the disease, treatment, outcome and long-term prognosis. All horses, including randomly selected control horses, were reassessed about nine months after the suspicion of EPE. The horses affected w...
Studzińska MB, Sallé G, Roczeń-Karczmarz M, Szczepaniak K, Demkowska-Kutrzepa M, Tomczuk K.Parascaris spp. are major gastro-intestinal nematodes that infect foals and can lead to respiratory symptoms, poor growth, and in some cases obstruction of the small intestine and death. Ivermectin resistance has been reported for Parascaris spp. in many countries. In Poland, the knowledge of the level of resistance against ivermectin in Parascaris spp. is limited. The aim of this study was to examine the efficacy of ivermectin against Parascaris spp. in foals from south-eastern Poland. Foals (n = 225 = reared in 7 stud farms) were treated orally with ivermectin paste. Faecal samples w...
Lomas HR, Robinson PA.Equine insect bite hypersensitivity (IBH), commonly known as sweet itch or summer eczema, is a frustrating recurrent skin disease in the equine industry involving an immune reaction to the bites of spp. midges. To investigate the impact of IBH in the field, an exploratory pilot study was conducted with equine stakeholders in one region of central England. Nine semi-structured, face-to-face interviews were conducted with horse owners and an equine veterinarian. The aim was to gain an understanding of experiences with IBH, and to gauge opinions on the value of the various management strategies ...
Wehrman RF, Gemensky-Metzler AJ, Zibura AE, Nyhart AB, Chandler HL.OBJECTIVE To determine the safety of topical administration of 1% atropine ophthalmic solution in healthy horses by objectively measuring gastrointestinal transit time. DESIGN Randomized, masked, controlled crossover study. ANIMALS 6 adult geldings. PROCEDURES Horses were randomly assigned (3/group) to first receive topical treatment of the left eye with 1% atropine or artificial tears solution; the right eye was left untreated. After 24 hours of treatment every 6 hours, 200 nontoxic beads were administered to each horse via nasogastric intubation and treatment frequency was decreased to every...
Fielding CL, Dechant JE.Colic is a common reason for elimination from equine endurance competitions and has recently been identified as the leading cause of mortality in this group of horses. Hydration and electrolyte derangements are often severe, but are probably related to endurance exercise and not necessarily the episode of colic. Better understanding of the causes of colic and the expected outcome is needed to guide treatment decisions in endurance horses. Objective: To describe the history, case details, clinical examination, laboratory, treatment and outcomes for horses presenting to equine referral centres f...
Gaughan EM.Early recognition and treatment of congenital and acquired flexural deformities of the carpi and fetlocks of foals can lead to conformation correction and an athletic future. Treatment is often based on rigid external coaptation assisted by systemic medical treatment. Foals that readily respond to treatment and correct conformation faults can have normal adult athletic expectations.
Aanes WA.The great variety of pathologic conditions associated with the peripartum period in the mare emphasizes the need for close observation and evaluation of the mare's condition during this period. The temperament and strength of the mare and violence of parturition undoubtedly produce extreme intraabdominal pressures that result in (or enhance preexisting) pathologic changes. Although the exact etiology of many of these disease processes is unknown, careful observation with properly timed medical and/or surgical intervention could reduce the losses associated with the peripartum period.
Herd RP.The serious and widespread problem of drug resistance has forced a re-thinking of basic philosophy regarding control of equine parasites. It has illustrated the dangers of total reliance on chemical control and stimulated the use of alternate strategies. Two new approaches are described. Prophylactic treatments in the spring and summer provide effective strongyle and colic control with less selection pressure for drug resistance. A nonchemical approach of pasture cleaning twice a week offers the same advantages with the added bonus of a 50 per cent increase in grazing area.
de Cock HE, Affolter VK, Wisner ER, Larson RF, Ferraro GL.Early diagnosis of chronic progressive lymphoedema (CPL) may result in more effective interventions and provide a basis for further investigation of whether early diagnosis could be used as a means of eliminating potential genetic influences by cessation of breeding from affected individuals. Objective: Lymphoscintigraphy may be useful in draught horses to differentiate early lesions of CPL from other conditions in the pastern region. Methods: Forelimbs of 2 normal and 5 CPL-affected draught horses were evaluated with lymphoscintigraphy. Results: Lymphoscintigraphy showed clearly the presence ...