Poisoning in horses refers to the ingestion, inhalation, or absorption of toxic substances that can adversely affect their health. These substances may include plants, chemicals, medications, or environmental toxins. Poisoning can lead to a range of clinical signs, from mild gastrointestinal upset to severe neurological or systemic effects, depending on the toxin involved. Common toxic substances for horses include certain plants like oleander and yew, heavy metals such as lead and arsenic, and specific pesticides or herbicides. This page compiles peer-reviewed research studies and scholarly articles that investigate the causes, effects, diagnosis, and management of poisoning in horses.
Ayala I, Rodríguez MJ, Martos N, Zilberschtein J, Ruíz I, Motas M.Fatal brodifacoum poisoning in a pony is described; this condition has not previously been reported in ponies. Discussion of what factors in the pony's history and treatment may have predisposed to the severity and ultimate death is provided. Cet article décrit un empoisonnement mortel au brodifacoum chez un poney, condition jamais rapportée auparavant. La discussion porte sur les liens entre les divers éléments de l’anamnèse et les traitements reçus par rapport à la sévérité de la condition et ultimement à la mort de l’animal. (Traduit par Docteur André Blouin)
Wilson SJ, Taylor J, Gibson J, McKenzie R.A dense population of Pimelea trichostachya plants (Family Thymelaeaceae) in pasture poisoned a horse herd in southern inland Queensland in October-November 2005. Plant density was 2 to 45 g wet weight/m(2) (mean 16 g/m(2)) from 5 to 69 plants/m(2) (mean 38 plants/m(2)) representing 3 to 20% (mean 9%) of the volume of pasture on offer. Ten of 35 mares, fillies and geldings were affected. Clinical signs were loss of body weight, profound lethargy, serous nasal discharge, severe watery diarrhoea and subcutaneous oedema of the intermandibular space, chest and ventral midline. Pathological finding...
Binev R, Valchev I, Nikolov J.Spontaneous intoxication in 34 horses after ingesting freshly harvested maize that was to be used for ensiling and heavily contaminated with young Datura stramonium plants, is described. The clinical status of all horses was monitored for 7 days, and included body (rectal) temperature, respiratory and heart rates, colour and moistness of visible mucosae, changes in pupil size, appetite, thirst, general behaviour, locomotion, sensory perceptions, urination and defaecation. The intoxication was accompanied by altered clinical status, namely mild hyperthermia, tachycardia, polypnoea, dyspnoea and...
Landolt GA.Acute poisoning and envenomation often represent a diagnostic and therapeutic challenge. Although identification ultimately may benefit the affected animal, treatment frequently must commence before an etiologic diagnosis is established. Therefore, the goals for the management of acutely intoxicated horses must be focused on emergency intervention and stabilization of the patient, prevention of further exposure, and aggressive decontamination. This article reviews the treatment steps that should be considered during the management of horses experiencing poisoning or envenomation.
Binev R, Valchev I, Nikolov J.Monitoring of changes in some blood laboratory parameters in 34 horses after ingesting freshly harvested maize that was to be used for ensiling, heavily contaminated with young Datura stramonium plants, is described. For a 7-day period the following parameters were monitored: haemoglobin content (HGB), red blood cell counts (RBC), white blood cell counts (WBC), haematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC), differential white cell counts (DWC), erythrocyte sedimentation rate (ESR), protein fractions, aspa...
Gerber R, Naudé TW, de Kock SS.Two out of a group of 23 mares exposed to tef hay contaminated with Datura ferox (and possibly D. stramonium) developed colic. The 1st animal was unresponsive to conservative treatment, underwent surgery for severe intestinal atony and had to be euthanased. The 2nd was less seriously affected, responded well to analgesics and made an uneventful recovery. This horse exhibited marked mydriasis on the first 2 days of being poisoned and showed protracted, milder mydriasis for a further 7 days. Scopolamine was chemically confirmed in urine from this horse for 3 days following the colic attack, whil...
Snowden NJ, Helyar CV, Platt SR, Penderis J.Moxidectin is a macrocyclic lactone related to ivermectin used in horses and dogs for endoparasite treatment and prophylaxis. The clinical and neurological presentation of moxidectin toxicity in two dogs following inadvertent poisoning with a moxidectin-containing equine de-worming medication is reported here. In both the dogs, the predominant clinical signs were generalised tremors and ataxia. Moxidectin exerts its neurotoxic effects in mammals by potentiating the effect of gamma-aminobutyric acid and, consistent with this, both the dogs demonstrated a poor response to treatment with diazepam...
Kite GC, Stoneham CA, Veitch NC, Stein BK, Whitwell KE.Liquid chromatography-mass spectrometry (LC-MS) analysis of methanol extracts of Oenanthe crocata roots revealed that oenanthotoxin co-eluted with another major polyalkyne, 2,3-dihydro-oenanthotoxin, using the existing high performance liquid chromatography (HPLC) method (isocratic elution from C18 with aqueous methanol) for investigating Oenanthe poisoning. Positive ES or APCI gave [(M+H)-H(2)O](+) and its methanol adduct as major ion species for oenanthotoxin, whereas 2,3-dihydro-oenanthotoxin formed [M+H](+) and its methanol adduct. The two polyalkynes could be chromatographically resolved ...
Naudé TW, Gerber R, Smith RJ, Botha CJ.Datura poisoning of horses is extensively reviewed. An outbreak of intractable impaction colic affecting 18 of 83 horses was stopped by withdrawing dried tef hay contaminated with young Datura plants. The dried, botanically identified Datura stramonium and D. ferox contained respectively 0.15% mass/mass (m/m) hyoscyamine as well as 0.16% m/m hyoscine (scopolamine) and only hyoscine at a concentration of 0.11% m/m. Immature, unidentifiable plants resembling D. stramonium, contained 0.14% m/m and 0.12% m/m of the 2 respective tropane alkaloids. The outbreak was characterised by protracted and re...
Tiwary AK, Puschner B, Kinde H, Tor ER.A 2-year-old bay Thoroughbred colt was found dead overnight in its stall without a known history of any illness, existing disease, or toxicant exposure. No information on the clinical signs before this animal's death was reported. A full necropsy was performed the next morning and revealed a mild to moderate degree of endocardial hemorrhages in both ventricles. Microscopic examination of the heart showed an acute mild multifocal necrosis of papillary muscles and ventricles. The stomach content contained approximately 2% Taxus alkaloids as determined by gas chromatography/mass spectrometry. In ...
Cope RB, Camp C, Lohr CV.Despite the well-founded reputation of plants of the genus Taxus as being amongst the most toxic plants for domestic livestock in the US, there are surprisingly few published case reports of yew poisoning in horses. This report documents 2 acute fatalities in horses in the central Willamette Valley, OR associated with the consumption of Taxus sp. The predominant features of the intoxication were peracute death, with no signs of struggling or convulsions, in otherwise fit and well managed adult horses. The most significant gross necropsy findings were limited to pulmonary congestion and hemorrh...
Westermann CM, Boerma S, van Nieuwstadt RA.Since the only registrated anti-ectoparasiticum for horses (foxim) is no longer available in The Netherlands, some cases of amitraz intoxication of the horse have occurred. In this article the literature concerning amitraz intoxications and experiments will be discussed and some cases will be described.
Woods LW, Filigenzi MS, Booth MC, Rodger LD, Arnold JS, Puschner B.Three horses died as a result of eating grass hay containing summer pheasant's eye (Adonis aestivalis L.), a plant containing cardenolides similar to oleander and foxglove. A 9-year-old thoroughbred gelding, a 20-year-old appaloosa gelding, and a 5-year-old quarter horse gelding initially presented with signs of colic 24-48 hours after first exposure to the hay. Gastrointestinal gaseous distension was the primary finding on clinical examination of all three horses. Two horses became moribund and were euthanatized 1 day after first showing clinical signs, and the third horse was euthanatized af...
Carmalt J, Rosel K, Burns T, Janzen E.Thirty-four mixed breed horses from two separate farms showed signs of abdominal discomfort, pyrexia and dehydration after being exposed to a new batch of 14% complete horse feed. A new batch of cattle feed from the same manufacturer resulted in dairy cows showing depression, a drop in milk production and diarrhoea. Examination of both diets revealed the presence of white kidney beans (Phaseolus vulgaris). Inclusion of raw beans of this genus in animal feeds is to be avoided.
Forrester MB, Stanley SK.A portion of calls handled by poison centers involve poisonings of animals; however, information on such calls is limited. This study used data from poison centers in Texas collected during 1998-2002 to document the epidemiology of animal poisoning calls. There were a total of 24,467 animal poisoning calls, representing 2.0% of all calls. Dogs were affected in 87% of the calls and cats in 11%. The exposures were unintentional in 99% of the cases, occurred via ingestion in 95% and involved dermal exposure in 5% of the cases. Exposures occurred at the owner's own residence 91% of the time and we...
Pfister JA, Stegelmeier BL, Gardner DR, James LF.Spotted locoweed (Astragalus lentiginosus var. diphysus) is a toxic, perennial plant that may, if sufficient precipitation occurs, dominate the herbaceous vegetation of pinyon-juniper woodlands on the Colorado Plateau. Six cow/calf pairs and four horses grazed a 20-ha pasture with dense patches of locoweed in eastern Arizona during spring 1998. Locoweed density was 0.7 plants/m2 in the pasture. Locoweed averaged 30.4% NDF and 18.4% CP. Concentrations of the locoweed toxin, swainsonine, fluctuated from 1.25 to 2 mg/g in locoweed. Horses ate more (P < 0.01) bites of locoweed than did cows (15...
Botha CJ, Naudé TW.Well-known plant poisonings such as 'dunsiekte' (seneciosis) and 'jaagsiekte' (crotalariosis) of horses in southern Africa are briefly reviewed. Relatively unfamiliar mycotoxicoses such as stachybotryotoxicosis and perennial rye grass staggers and potentially occurring exotic intoxications such as equine nigropallidal encephalomalacia and ergot alkaloid poisoning are also discussed. This article is aimed at informing the southern African equine practitioner about probable poisonings that might occur locally in horses.
Copetti MV, Santurio JM, Boeck AA, Silva RB, Bergermaier LA, Lubeck I, Leal AB, Leal AT, Alves SH, Ferreiro L.This article reports an outbreak of intoxication of female horses with Claviceps purpurea in southern Brazil. The outbreak affected twelve pregnant mares which were fed with black oat (Avena strigosa) during the pre-delivery period. Underdevelopment of the mammary gland in the pre-delivery period resulting in post-delivery agalactia was the most pronounced finding. These mares delivered weak and unviable foals, which showed no suckling reflex and died within a few hours of birth. Laboratory analysis of oat samples fed to the animals resulted in the identification of Claviceps purpurea scleroti...
Kronfeld DS.The current estimate of LD50, 21.5 mg/kg BW, for lasalocid in horses is based on an analysis of 8 data from 4 horses that died at dose levels of 15, 21, 22 and 26 mg/kg. This analysis neglected 14 data from another 6 horses that survived at dose levels of 5, 10,14, 18, 19, 25, 29 and 50 mg/kg, and so was biased by selection of data. An examination of all the data indicates they are insufficient to determine the LD50. In contrast, the whole data set suggests a lowest toxic dose of 15 mg/kg, although this estimate was based on only 1 affected animal in 8 tests from 5 to 15 mg/kg in an unbalanced...
Khan SA, Kuster DA, Hansen SR.Moxidectin is a macrolide endectocide available as a 2% equine oral gel in the US. This report presents clinical signs of moxidectin toxicosis and its treatment in equines as reported to the ASPCA Animal Poison Control Center (APCC) from January 1998 to December 2000. Nine cases of moxidectin overdose in equines occurred: 5 had signs of toxicosis such as coma, dyspnea, depression, ataxia, tremors, seizures, or weakness. The approximate dose of moxidectin at which these signs were observed ranged from 1.0 to 5.1 mg/kg. The 4 equines that ingested moxidectin between 0.9 mg/kg to 1.7 mg/kg did no...
Palacios H, Hibarren I, Olalla MJ, Cala V.The diagnosis of lead poisoning in horses living on farmland in the vicinity of a battery recycling plant was based on clinical signs as well as on laboratory findings. Chemical analysis of six surface soils (0-15 cm) and herbage samples taken at different distances to the recycling plant showed very high total lead levels in the closest sites to the facility and a clear decrease with distance. Total lead levels in soil samples ranged from 127 to 5657 mg kg(-1), with more than 70% of lead extractable by EDTA in the most polluted soils. Lead levels in the aerial part of herbage samples were in ...
Mosing M, Kuemmerle JM, Dadak A, Moens YP.A case of a pony with severe cyanide intoxication as a result of cherry ingestion is presented. General anaesthesia was performed for colic surgery. Severe metabolic lactate acidosis in combination with a high arterial oxygen partial pressure and clinically good peripheral perfusion parameters were the remarkable signs during anaesthesia. Severe hypothermia was obvious during recovery. Ten hours post-surgery the pony was euthanized as a result of neurological signs. The diagnosis of cyanide intoxication was made post-mortem. Conclusions: Cherry ingestion can lead to lethal cyanide intoxication...
Pessoa CR, Pessoa AF, Maia LA, Medeiros RM, Colegate SM, Barros SS, Soares MP, Borges AS, Riet-Correa F.The effects and susceptibility of donkeys to Crotalaria juncea and Crotalaria retusa poisoning were determined at high and low doses. Seeds of C. juncea containing 0.074% of dehydropyrrolizidine alkaloids (DHPAs) (isohemijunceines 0.05%, trichodesmine 0.016%, and junceine 0.008%) were administered to three donkeys at 0.3, 0.6 and 1 g/kg body weight (g/kg) daily for 365 days. No clinical signs were observed and, on liver and lung biopsies, the only lesion was a mild liver megalocytosis in the donkeys ingesting 0.6 and 1 g/kg/day. Two other donkeys that received daily doses of 3 and 5 g seed/...
Delfiol DJ, Oliveira-Filho JP, Casalecchi FL, Kievitsbosch T, Hussni CA, Riet-Correa F, Araujo JP, Borges AS.In Brazil, coffee (Coffea arabica) husks are reused in several ways due to their abundance, including as stall bedding. However, field veterinarians have reported that horses become intoxicated after ingesting the coffee husks that are used as bedding. The objective of this study was to evaluate whether coffee husk consumption causes intoxication in horses. Six horses fed coast cross hay ad libitum were given access to coffee husks and excitability, restlessness, involuntary muscle tremors, chewing movements and constant tremors of the lips and tongue, excessive sweating and increased respirat...
Nicholson SS.Grasses that are essential components of livestock grazing programs sometimes are the source of tremorgenic toxicants to the animals consuming them. Morbidity can be high but mortality need not be if management closely observes the cattle daily and removes them at first sign of trouble. Specific treatment generally is not available nor needed. Survivors recover completely within a few days or weeks, except in chronic phalaris poisoning, where sheep and cattle may die after prolonged illness--or at least not make an economical recovery. Certain poisonous plants are responsible for tremorgenic s...
Arnbjerg J.Peroral application of iron salts in various types of anemia was previously considered atoxic. The increased use of iron has, however, led to an increasing number of poisoning in children, taking iron tablets for candy. There have only been reported a few number of spontaneous intoxications in animals, but experimentally it has been possible to produce fatal intoxications in various kinds of animal species. The clinical findings are quite similar in the various animals, starting with vomiting, bloody diarrhoea and metabolic acidosis. If the intoxication is severe, shock and coma may develop, a...
Nicpon J, Czerw P, Harps O, Deegen E.24 cases of salinomycin poisoning in horses occurring recently in Silesia are discussed. All of these horses, used for riding-purposes, were fed with concentrate containing 61 mg/kg salinomycin as faulty prepared by the manufacturer. Each horse received approximately two to three kilograms of this forage. All horses developed severe clinical signs of intoxication. Despite therapy eight horses died within three to six days. Ten others became recumbent and had to be euthanased. Only six horses survived. Clinical and laboratory examinations were performed and are discussed. Laboratory examination...
Schediwy M, Mevissen M, Demuth D, Kupper J, Naegeli H.This retrospective study evaluated the frequency, etiology, therapy and prognosis of animal poisoning registered from 2003 to 2012. The relevant cases reported to the Swiss Toxicological Information Center (STIC) were compared with those from previously examined periods. Human medicines not approved for animals and pesticides represented the most common causes of poisoning in dogs. Novel cases occurred as a consequence of the exposure of dogs to ricinus fertilizers, grape residues from wineries, pepper lachrymatory spray and dry bouillon. Cats are still freequently poisoned by pyrethroid drugs...
Frazier K, Hullinger G, Hines M, Liggett A, Sangster L.A 10-y retrospective study of aldicarb intoxication in domestic animals from 1988 to 1998 is provided from animals submitted to the University of Georgia Veterinary Diagnostic and Investigational Laboratory. Within the period examined, 162 separate cases were confirmed and 18 additional cases were suspected based on bioassay but could not be confirmed. Some cases involving as many as 15 affected animals. Dogs were most often involved, but cats, horses, cattle and goats were also poisoned. Most intoxications appeared intentional or malicious. "Baits" including frankfurters, ham or ground beef w...
Locke KB, McEwan DR, Hamdorf IJ.Horses and cattle fed swainsona (Swainsona canescens var horniana) over a period of 8 to 10 weeks lost condition and became incoordinated and hypersensitive. Histological examination of tissues from affected animals revealed the characteristic changes of widespread cellular vacuolation and axonal spheroids in the CNS. Cattle withdrawn from the toxic plant after being fed for varying periods up to 8 weeks returned to normal. Serum alpha-mannosidase activity declined significantly in cattle during the test period, whereas in horses that activity rose. Serum alkaline phosphatase levels increased ...
Botha CJ, Lewis A, du Plessis EC, Clift SJ, Williams MC.Twenty-eight horses in southern Mozambique died after exhibiting severe respiratory distress. At necropsy, the overinflated lungs did not collapse, had prominent rib impressions, and were fibrotic and emphysematous. Microscopically, prominent proliferation of nonciliated epithelial (Clara) cells in the terminal bronchioles and pulmonary fibrosis were observed, indicative of chronic pneumotoxicity. Transmission electron microscopy demonstrated hyperplasia, desquamation, and apical bulging of Clara cells into the bronchiolar lumen. The outbreak was attributed to ingestion of Crotalaria dura J.M....
Pfister JA, Stegelmeier BL, Cheney CD, Ralphs MH, Gardner DR.Locoweed (Oxytropis sericea) is a serious poisoning problem for horses grazing on infested rangelands in the western United States. Our objectives were to determine 1) whether lithium chloride or apomorphine would condition aversions to palatable foods, and at what doses, and 2) whether horses could be averted to fresh locoweed in a pen and grazing situation. Apomorphine was not an acceptable aversive agent because at the dose required to condition an aversion (> or = 0.17 mg/kg BW), apomorphine induced unacceptable behavioral effects. Lithium chloride given via stomach tube at 190 mg/kg BW...
Duncan ID, Brook D.Four two-year-old Thoroughbreds suffered an acute gastrointestinal illness shortly after dosing with mineral oil which was thought to have been contaminated with an organophosphate compound. Three weeks later all four were noted to be dyspnoeic and endoscopic examination showed that they had developed bilateral laryngeal paralysis. Two of the horses died during severe bouts of dyspnoea six and eight months later and the third was killed shortly thereafter. Examination of the left and right recurrent laryngeal nerves from these horses showed a severe loss of myelinated fibres distally, especial...
Gerber R, Naudé TW, de Kock SS.Two out of a group of 23 mares exposed to tef hay contaminated with Datura ferox (and possibly D. stramonium) developed colic. The 1st animal was unresponsive to conservative treatment, underwent surgery for severe intestinal atony and had to be euthanased. The 2nd was less seriously affected, responded well to analgesics and made an uneventful recovery. This horse exhibited marked mydriasis on the first 2 days of being poisoned and showed protracted, milder mydriasis for a further 7 days. Scopolamine was chemically confirmed in urine from this horse for 3 days following the colic attack, whil...
Ossedryver SM, Baldwin GI, Stone BM, McKenzie RA, van Eps AW, Murray S, Fletcher MT.Three ponies continuously grazed a pasture containing an estimated 24% Indigofera spicata (wet weight basis) for 4-6 weeks in April and May 2004. They developed ataxia, paresis, depression, muscle fasciculations, dysphagia, ptyalism and halitosis. Two also developed corneal opacity. One pony recovered with supportive treatment, but the other two were euthanased and necropsied. Neuropathology was not present in either case, but both livers had periacinar and periportal lymphocytic infiltrations and hydropic degeneration of mid-zonal hepatocytes, with mild to moderate periacinar necrosis also ev...
Agrawal K, Ebel JG, Altier C, Bischoff K.The leaves of Acer rubrum (red maple), especially when wilted in the fall, cause severe oxidative damage to equine erythrocytes, leading to potentially fatal methemoglobinemia and hemolytic anemia. Gallic acid and tannins from A. rubrum leaves have been implicated as the toxic compounds responsible for red maple toxicosis, but the mechanism of action and toxic principle(s) have not been elucidated to date. In order to investigate further how red maple toxicosis occurs, aqueous solutions of gallic acid, tannic acid, and ground dried A. rubrum leaves were incubated with contents of equine ileum,...
Petzinger E.Pyrrolizidine alkaloids belong to a class of phytotoxins which are present in more than 6000 plant species. The disease seneciosis in farm animals represents the severe poisoning by pyrrolizidine alkaloids from plants of the genus Senecio. This form of poisoning has been known since the end of the 19th century in Germany, the USA, Canada and New Zealand, and is mainly caused by Senecio jacobaea and related Senecio spp. in farm animals, including poultry. Animal poisoning by pyrrolizidine alkaloids is of worldwide importance. In Germany poisoning of horses and cattle by Senecio jacobaea, which ...
Pfister JA, Stegelmeier BL, Gardner DR, James LF.Spotted locoweed (Astragalus lentiginosus var. diphysus) is a toxic, perennial plant that may, if sufficient precipitation occurs, dominate the herbaceous vegetation of pinyon-juniper woodlands on the Colorado Plateau. Six cow/calf pairs and four horses grazed a 20-ha pasture with dense patches of locoweed in eastern Arizona during spring 1998. Locoweed density was 0.7 plants/m2 in the pasture. Locoweed averaged 30.4% NDF and 18.4% CP. Concentrations of the locoweed toxin, swainsonine, fluctuated from 1.25 to 2 mg/g in locoweed. Horses ate more (P < 0.01) bites of locoweed than did cows (15...
Mount ME, Feldman BF.Strychnine toxicosis is characterized by inducible tetanic seizures and metaldehyde poisoning by fine fasciculations progressing to generalized tremors and seizures. Intoxication with 1080 causes seizures, random running movements, vomiting, defecation, urination, acidosis and hyperglycemia. Intoxication with rodenticides causing coagulopathy is characterized by hemorrhage into body cavities but not necessarily external hemorrhage. Anticholinesterase insecticides cause salivation, urination and defecation, while chlorinated hydrocarbon insecticides cause CNS disturbances. Ethylene glycol intox...
Nobre D, Dagli ML, Haraguchi M.Twenty horses died 30 d after being fed a diet containing 40% of tritured Crotalaria juncea seeds. Before death, they had staggering, dyspnea and fever. At necropsy the most evident lesions were areas of lung parenchyma consolidation and enlarged and congested livers. Histopathological examination revealed diffuse fibrosing alveolitis with hyaline membranes, suggesting a blood-borne insult, and passive congestion in the liver with compression of the hepatocyte trabecules. To confirm the diagnosis, guinea pigs were given 60% of a commercial diet + 40% tritured C juncea seeds. After 4 mo of feed...
Kronfeld DS.The current estimate of LD50, 21.5 mg/kg BW, for lasalocid in horses is based on an analysis of 8 data from 4 horses that died at dose levels of 15, 21, 22 and 26 mg/kg. This analysis neglected 14 data from another 6 horses that survived at dose levels of 5, 10,14, 18, 19, 25, 29 and 50 mg/kg, and so was biased by selection of data. An examination of all the data indicates they are insufficient to determine the LD50. In contrast, the whole data set suggests a lowest toxic dose of 15 mg/kg, although this estimate was based on only 1 affected animal in 8 tests from 5 to 15 mg/kg in an unbalanced...
Geor RJ, Becker RL, Kanara EW, Hovda LR, Sweeney WH, Winter TF, Rorick JK, Ruth GR, Hope E, Murphy MJ.Fever, limb edema, and laminitis were observed in horses 18 to 36 hours after they consumed hoary alyssum (Berteroa incana) under field and experimental conditions. Clinical signs were not observed in all horses that had ingested the plant. Diagnosis in the field cases was limited to observation of clinical signs and evidence of plant ingestion in hay or on pasture. In most cases, clinical remission was observed 2 to 4 days after empirical treatment, removal of the plant source, or both.
