Resolution of Xanthomatosis without Surgical Intervention - A Case Study

Introduction

In June of 2010, I rescued a very ill cockatiel which had multiple illnesses and conditions (including C. perfringens and Giardia) and took her immediately to my avian veterinarian. Among those illnesses were multiple discreet and diffuse xanthomas along her dorsal and ventral wing areas, wrapping under the wings to her axial areas (her sides). My avian veterinarian, Dr. Bob Dahlhausen, worked with me to diminish and eliminate these growths over the following year and a half. I named her Marcie.

Figure 1. Jun. 30, 2010 - Marcie’s xanthomas grew on her wings, sides, and up into her neck area.

1. Xanthomatosis

Xanthomas are benign growths consisting of fat cells and cholesterol. They are usually yellow but may also be brown, reddish, or cream. Under the microscope, the lesions show light cells with foamy protoplasm (foam cells) [1]. Xanthomas can be discrete (single growths) or diffuse (connected to other xanthomas) and are often associated with hypothyroidism, Clostridium perfringens, clinical or sub-clinical illness, and a poor immune system. These growths generally begin forming "on the distal end of one or both wings and progress down the wing toward the body" [2]. However, in this bird, they were located mainly on the patagia (wing webs), elbow joints, and bones and tissues of the wing. They also extended up toward the neck, and they progressed along the wing bones toward the wing tip. They are observed mostly in cockatiels, although other species may develop them as well. They are caused by high-fat diets, specifically all-seed diets including sunflower and safflower seeds; a sedentary, cage-bound, flightless lifestyle; and lack of quality veterinary care.

The following excerpt is from Dr. Ewing’s paper

"Predisposing Conditions to Consider for Xanthoma Formation" [3].

Hypercholesteremia/hyperlipidemia caused by:

• High-fat diet
• Disorders of lipid metabolism
• Metabolic conditions
• Drugs (corticosteroids, progesterone)
• Endocrine disorders such as diabetes mellitus, hypothyroidism, hyperadrenocorticism (Cushing’s disease)
• Idiopathic hyperlipidemia (too much fat in the blood and of unknown origin)
• Pancreatitis

"Other factors that may lead to xanthomatosis are:

• Prior tissue necrosis at the site.
• Prior hemorrhage due to trauma or feather cyst removal.
• Exposure to toxic fat-soluble substances (example: chlorinated hydrocarbons).
• Underlying cysts, lipomas or other tumors" [3]

(Additional information on xanthomatosis may be found in the Appendix)

2. Treatment

Marcie’s condition was critical. She had multiple illnesses which compromised her ability to heal. Dr. Dahlhausen administered a doxycycline injection and dispensed oral and topical medications for her diseases, directing me to massage the topical medications into the wounded areas. She was near death, so we had to work quickly to save her life.

Standard Treatment of Xanthomatosis

Xanthomatosis may be confirmed through histopathological examination [2]. There are three possible treatments that are routinely used:

• Excision of the masses, if they are not too large or involved. If the xanthomas are discrete masses rather than diffuse, it is possible that the surgeon may be able to excise only the masses, along with some of the immediate surrounding tissue, and that would be sufficient to eliminate them.
• Amputation of the wing tips containing the xanthomas.
• Full-wing amputation in severe, life threatening cases [2].

She would not have survived any of these procedures, and I would have rejected all three of these options even if she had been healthy. I determined instead to devise a method of eliminating these masses by non-surgical means. I observed over the first few weeks that as I worked to heal the wounds and remove necrotic tissue, using massage with the medicated cream, an astringent, and liquid aloe vera, the xanthomas began to shrink as well.

Figure 2. The left underwing xanthomas. Note the necrotic lesions under the wing and the xanthomatous tissue on her axial areas.

3. Development of the Treatment Method

Since the massage with the medications appeared to be shrinking the xanthomas as the other wounds were healing, it made sense that the friction and resultant heat caused by massaging the tissue would break down the fat and cholesterol and thus shrink the tissue. Since the body would then excrete the fat cells, I reasoned that the masses would reduce in size as a result.

I worked the gentamicin sulfate antibiotic cream into the necrotic lesions on her body, her elbow joints, and under her wings, at least three times a day. At first the sessions were extremely short because of the pain and discomfort she was experiencing. Later, I could extend that time just a little; however, it was never more than a minute. Over time, the black, dried blood and the fresh, red blood oozing from these gaping wounds began to diminish, and the inflamed, raw and bleeding skin on both sides of the wing began to heal. There were xanthomatous masses interwoven within these lesions, so I gently massaged the xanthomas as well in order to decrease their mass. According to Dr. Dahlhausen, the lipid part of the growths would be reabsorbed into the body and eliminated, but the cholesterol would not. The yellow masses would shrink a little as the fat dissolved, but the cholesterol--filled cells would always be with her, enlarging and spreading. I resolved that they would, instead, be eliminated. It seemed reasonable to me that the cholesterol would respond to massage and that the pressure and manipulation would stimulate the cholesterol to break down, the blood to absorb it, and the body to eliminate as it was doing with the lipids.

4. Healing Progress, July through September

In the early weeks of this treatment, Marcie's raw, necrotic wounds began to heal, but the xanthomas were unyielding. She was at Dr. Dahlhausen’s office at least once a week, and at the visit two months later, he did notice a slight decrease in the size of the xanthomas under her wings. The ones on her elbow joints and around her neck and back remained the same.

Figure 3. Jul. 3, 2010 - Marcie's right wing and side. Note the xanthomatous growth on the patagium and above the elbow and the xanthomatous tissue on and below the neck. These areas would prove to be the most difficult to deal with. The xanthomas on her muscles and tendons were visible, and the xanthomatous tissue extended up the wing from the elbow to the manus, or hand, joint. The resulting feather dystrophy from all her illnesses was also severe.

Figure 4. Marcie's left underwing, showing the growth pattern of the xanthomas. They were attached to the muscles, tendons and bones. The xanthomas were inhibiting her wing movement, and if left to continue growing, they would have eventually prevented her from extending her wings at all.

Figure 5. Sep. 15, 2010 - Marcie's back, showing the xanthomas wrapping around the elbow joints.

Figure 6. Sep. 20, 2010 - The left underwing, showing gradual shrinking of the xanthomas due to the daily massage with the cream. The yellowed, xanthomatous tissue still filled the wing web and traveled down her side.

5. The Message Technique

By September, we were beginning to notice some improvement in the lesions under her wings and a reduction in the size of some of the xanthomas. I had developed a massage technique which was working. Directions are as follows:

• Work the gentamicin cream into the xanthomatous tissue. Manipulate the xanthoma between thumb and forefinger, gently squeezing the tissue and working it with the fingers. Alternate squeezing it with manipulating it back and forth and massaging the top and sides of the xanthoma. Apply a very small amount of liquid aloe vera between the sessions as needed; it is very soothing to the skin.
• After a few weeks, the tissue became soft and pliable as the fat dissolves and the cholesterol-based tissue begins to flake off. This oily tissue will break down as you work with it, feeling greasy to your fingertips. Blot away the excess sticky fluid with cotton balls dampened with Domeboro®. This may need to be done several times during the session.
• After each session, massage in more gentamicin sulfate cream. The next day, the surface of the xanthomas should once again be friable, hard and crusty, flaking off as you do the massage. The tissue lysis, or breakdown, may occur during each session or less often. You may perform this treatment two or three times a day. Keep them brief, only a minute at most at a time, depending on the bird’s ability to tolerate the sessions.

6. Healing Progress, October through December

Figure 7. Oct. 20, 2010 - Marcie’s right underwing; note the improvement in the xanthoma at the elbow joint. The one at the top of the wing web was thicker and took longer to work through.

When the body must deal with multiple illnesses, it is extremely stressed in its attempts to heal them all. We had to deal with Marcie’s life-threatening internal diseases and external wounds. Therefore, it took a long time for the xanthomatosis to respond to treatment. Under the best of circumstances, the body is challenged to heal all of these concurrent ailments, but when it is also immune-compromised and suffering from previous poor nutrition and husbandry, it takes even longer. In spite of that, Marcie’s healing progressed more quickly than we thought it would.

Figure 8. Nov. 16, 2010 - The left underwing. Note the reduced size of the xanthoma at the elbow joint.

Figure 9. Nov. 16, 2010 - The right underwing. The xanthomas which stretched across the bones and muscles were shrinking, and so the wing was now able to extend fully. The fat and cholesterol cells were beginning to collect to the right of the elbow joint.

Figure 10. Dec. 5, 2010 - Marcie's left wing; note the reduced size of the xanthomas on her elbow, up her ulna and on her side.

7. Healing Progress, December 2010 through March 2011

By December, we noticed a change in the nature of the xanthomas. The lipids, for the most part, had been absorbed and eliminated, and all that remained were the cholesterol layers which by now had converted to friable, brittle, crusty deposits. The skin covering the xanthomas had shrunk so much that the globs of yellow-orange, dimpled xanthomatous matter were embedded in the tissues. One xanthoma was suspended from the underside of the right wing. Since the epidermis is only three cell layers thick and the skin was extremely fragile, I had to be very careful not to irritate it and cause it to bleed.

The skin tissue on her back and around the xanthomas was peeling off, layer by layer, exposing the tender new skin tissue underneath. Her body was shedding the dead skin and replacing it with new. This highly vascular, delicate, and fragile tissue would bleed as the layers peeled away. At the lower section of the xanthomas, on the elbow joints, new feathers were attempting to emerge through the xanthomas. They irritated her, and she would pick at the xanthomas to relieve the discomfort; sometimes this resulted in a slight amount of bleeding.

After each treatment, I would dab the areas with the Domeboro® solution on a cotton ball and apply more cream. This would reduce the inflammation and soften her skin. She felt better after these treatments, and her energy level would improve. By this time, her general health was improving, and I was able to do this three times a day.

Figure 11. Dec. 5, 2010 - Note the feathers trying to break through the xanthomas on her elbow joints.

Figure 12. Dec. 20, 2010 - The right wing, showing continued irritation and xanthomatous tissue in the wing web and from the elbow joint to the body.

Figure 13. Dec. 26, 2010 - Marcie’s left underwing is showing great improvement; the xanthomas are shrinking and the tissue is healing.

Figure 14. Jan. 30, 2011 - Marcie’s right underwing still shows a yellowed, webbed, intricately involved xanthoma where the wing meets the body. This would prove to be the most difficult one to eliminate, but the one at her elbow is nearly gone. The veins are visible above the ulna bone.

Figure 15. Jan. 30, 2011 - The xanthoma on her left elbow joint has shrunk a little, but is somewhat peduncular from the elbow. The wing is extending more easily.

Figure 16. January, 2011 - The left wing elbow joint. The xanthoma had covered the entire joint, but now all that is left of it is the lower, yellowish, dimpled part, where the feather is coming through. The pink area above it is bone and skin tissue. Those feathers eventually fell out as the xanthoma reduced in size.

By January of 2011, the xanthomas were showing definite improvement. They had been steadily shrinking due to the daily massage. As a result of the vascular nature of the tissue, the manipulation caused some redness and irritation. Since the cream played such a key role in the healing process of the tissue, it was essential to work it in again at the end of the session so that the tissue would stay clean and free of any bacteria. The cream also served to break down the xanthomatous tissue in preparation for the next day’s work. I would apply liquid aloe vera as needed between treatments.

Figure 17. Mar. 14, 2011 - Marcie’s right underwing showing dark feathers emerging from the xanthoma on the elbow joint. This xanthoma is quite complex, wrapping around the bone and interconnecting muscle and tendons. The arrow points to a knot-like protrusion of the xanthomatous matter that is visible above the black feathers, in the lower right area of the wing web, near her body. It had begun to connect to the body when I took her in.

This knot-like protrusion in the above picture had me puzzled. Instead of the large, spread-out xanthoma she had earlier, this looked very condensed, as though it had bundled up in that one place and moved closer to the body. (See arrow in Fig. 17). I didn’t understand where this was going until much later in her recovery.

Figure 18. Mar. 14, 2011 - The left underwing skin displayed rapid regeneration as the xanthoma yielded to healthy tissue on the patagium and over the bones. All that remained of this xanthoma is the slightly raised area by the elbow. It has been nine months since I took Marcie in and began working with her. I was pleased with her progress.

8. Healing Progress, April through May

In late April, Marcie began showing signs of soreness and irritation under her right wing again. The right axial area of the body had become involved as well, but the right underwing itself was taking the brunt of the tissue damage. A clear, yellowish, heavy fluid was seeping through the skin. I reasoned that this heavy, sticky fluid was probably cholesterol, and it was undergoing lysis—breaking down and converting to a liquid. Only a few places remained which harbored a bit of xanthomatous tissue: under the right wing and on the skin around her neck. The right underwing xanthomatous growths might have been the source of the liquid, but the fluid was leaching out from the inside of the body! The skin under that exudate on the wing was inordinately slow to heal. I resolved to find the source of this fluid.

During May, Marcie’s right underwing tissue was still discharging the sticky, yellow, viscous substance. Dr. Dahlhausen had originally projected that this condition would have run its course in a few weeks. He agreed that it was most probably the cholesterol breaking down, and that the massaging had broken down the molecules of cholesterol so that the body could reabsorb and eliminate them. Since he had not seen this happen before, we could only deal with what we thought was happening now.

This brought forth several questions:

• Wouldn’t she be eliminating the cholesterol through the intestinal system as she had the lipids? How had the body disposed of the cholesterol in the larger xanthomas?
• Was her body excreting the cholesterol through the intestinal system as well as through the skin?
• Why was the cholesterol being excreted through the wing web and other places in the area?

I concluded that the cholesterol was breaking down within the dermal layers and oozing out through the patagium; there was no other explanation for this phenomenon. Dr. Dahlhausen ran cytology tests from several locations on the right underwing tissue. There were no fungal cells, so it could only be coming from the xanthomatous tissue lysis.

9. Ginseng

Dr. Dahlhausen suggested I try giving her ginseng orally since it could break down and eliminate any cholesterol inside the body. Sometime later, he explained that cholesterol also builds up around the heart:

"Since it is only the right wing, it points to problems in the aortic arch and cardiac outflow from the heart. The great vessels of the heart are the site that is often thickened with cholesterol deposits which impede blood flow. I am thinking that this is part of Marcie's problem." (Dr. Bob Dahlhausen)

If indeed the ginseng were to work, it could take a long time, since the natural remedies do not show results quickly, but in the long run they are often very effective when other medications fail.

I began to put just a few drops of the dark liquid in with her Emeraid twice a day.

At first, my goal was to stop the leaking of the cholesterol; but, the more I thought about it, I realized that this leaching was necessary. The body was rejecting it for a reason, so it was important that the seepage continue as long as there were still cholesterol remaining inside her aortic arch and within her dermal tissue. If her body did not expel the cholesterol, it would continue to build up around her heart and on her skin, and more xanthomas could develop. It needed to release the cholesterol until no more remained in her blood. Hopefully, the ginseng would stimulate the body to accomplish this. After two weeks, the affected tissue began to display gradual—but unmistakable—improvement. We’ll never be certain if it were the ginseng taking effect, if the tissues would have healed to this extent on their own, or if were a combination of the two. Even if the ginseng were only of minimal effectiveness, it had still given her more consistent new-tissue growth than we’d observed before. The ginseng might have been the missing piece in this puzzle—the essential component that her body had required to resolve the issue.

Once she had been receiving the ginseng for several weeks and the leakage had ceased, I searched her neck and back and found that xanthomatous matter had been completely eliminated. I believe now that my theory was correct: The ginseng had succeeded in pulling all the cholesterol out of the aortic arch and what still remained in the dermal tissue. The cholesterol that did not respond to massage was excreted through the skin. The ginseng, massage, medications, and good nutrition enabled her body to rid itself of the cholesterol accumulations.

10. The following are the medications and products used:

Be sure hands are very clean before working with the bird and applying any creams or other products.

• Gentamicin sulfate antibiotic cream: Perrigo, 0.1 %, available with a prescription from the pharmacy. Apply and massage in with little finger.
• Aloe vera for Sensitive Skin®: Mix with distilled water until you have a thin gel. I recommend using only this product. Apply with little finger or roll on with a cotton-tipped swab.
• Domeboro® astringent powder: Available over-the-counter at the drugstore. It comes in packets. Mix 1 packet with 2 ½ cups water. Apply with small cotton ball. Freeze in small containers, keeping out just what you need for a few days.
• Ginseng: Nature’s Answer: Non-Alcoholic, American Ginseng is the product I have used. It has a terrible taste, so I suspended it in the Emeraid complement. It could be put in another liquid to make it more palatable. The product may be purchased at any on-line pharmacy that carries it.

Figure 19. December, 2011 - The xanthomas on Marcie’s elbow joints have been resolved, and the covert feathers grew in over the joints.

Figure 20. December, 2011 - The fat and cholesterol in the xanthomas were eliminated from the patagia and bones.

Figure 21. The right wing has healed from the xanthomas, but it never grew feathers as the left wing did. It had been too damaged.

Conclusion

I am unsure about whether I would have achieved the same results had I used a different cream. The antibiotic cream was necessary because of the extensive dermatological infections and open wounds. It took a full year and a half to resolve the xanthomas completely and for new tissues and feathers to regrow, but the time investment allowed her to heal without surgery. Time, commitment, and patience.

The author is indebted to Dr. Bob Dahlhausen for his expertise, guidance, and support in curing Marcie of her illnesses. For the complete article on Marcie’s rescue and rehabilitation, go to www.beautyofbirds.com and enter "The Miracle that is Marcie".

Appendix

Excerpts from Xanthoma: The OTHER Fatty Skin Mass by Dr. Patty Ewing, Reprinted with permission. The link to the complete article may be found in the References below.

"Xanthomas present as firm, dimpled masses on the skin. Untreated, these lipid and cholesterol dermal plaque deposits continue to grow and damage the dermal tissue until they affect the capillaries and the rest of the circulatory system. As they enlarge, they spread quickly throughout the entire wing area and onto the rest of the body. Also, the bird’s movements become more and more impaired until it becomes moribund. Once the xanthoma becomes ulcerated, infection sets in, the capillaries become destroyed, and the bird experiences sudden bleeding episodes. These lead to massive hemorrhaging and eventual death".

Xanthomas can increase in size over time and be locally invasive. "They are relatively common skin masses in cockatiels and female budgerigars. The most common cutaneous sites observed in birds are wings, dorsal cervical region, sternum, back, ventral abdomen and uropygial area. Although they are most frequently observed in the skin, they have also been reported in the conjunctiva, internal structures of the eye, oral cavity, internal organs, tendons/periarticular regions, and remote sites such as bone marrow".

"These lipid and cholesterol masses are the result of a high-fat, high calorie, all seed diet which is high in sunflower and safflower seeds and peanuts. The formation of xanthomas often indicates an underlying metabolic disease in which the body is unable to eliminate excess lipids from the body. These are usually non-malignant masses; however, if left untreated, they could develop into cancerous growths".

"As the masses grow, they become thicker and surround the wing. The joints become involved and the wing may droop and flight may be impaired. The bird may traumatize the mass, causing bleeding. It will also hemorrhage on its own from circulatory involvement. The masses tend to occur over protruding parts of the body, such as abdominal hernias, tumors, or obese fat pads. Although in most cases the masses develop mainly on the wings, birds may present with smaller masses on the neck, upper back, sides, and elbow joints and up to the wing bones".

Figure 1. Photograph of a subcutaneous xanthoma excised from the left tibiotarsal region of an 11 year old male Monk parakeet (Quaker parrot). In this cross section of an oval, smoothly contoured mass, note the bright yellow color and small foci of red-tan mottling representing areas of hemorrhage and necrosis (black arrows). (Photo courtesy of Dr. Pam Mouser, Angell Pathology).

Figure 2. Photomicrograph of a histologic section of an oral cavity xanthoma that was surgically excised from a cat. Note sheets of foamy (lipid-laden) macrophages (thin black arrows) and fewer lipid-laden multinucleated giant cells (thick black arrows). H&E stain. (Photo courtesy of Dr. Pam Mouser, Angell Pathology).

"Definitive diagnosis of xanthomatosis requires histopathology. Fine-needle aspiration for cytological evaluation is a useful, non-invasive method of obtaining a presumptive diagnosis of xanthomatosis. An example of cytological features typical of a xanthoma is shown in Fig. 3."

Figure 3. Photomicrograph of a fine-needle aspirate from a subcutaneous mass on the wing of female green-winged macaw. Note lipogranulomatous inflammation consisting of lipid-laden macrophages (thin black arrows), multinucleated giant cell (thick black arrow), and a heterophil (red arrow). Angular plates representing cholesterol crystals (green arrows) and clear vacuoles representing free lipid are present in the background.

Most smaller xanthomas, on the skin or oral cavity, which are "ulcerated, infected or large enough to interfere with function, is surgical excision. Incomplete excision can lead to recurrence or poor wound healing". The size and location of the tissue involvement may make surgical excision. In some cases, the extent of tissue involvement and/or the location of the mass may prohibit surgical excision. "Cautery to control hemorrhage and use of an Elizabethan collar to prevent self-mutilation in birds may be helpful. Smaller, solitary, quiescent xanthomas that are not bothering the bird are frequently not excised and just monitored periodically for increase in size. Prior to surgery, and especially when multiple xanthomas are present, evaluation for underling dietary, metabolic, toxic and endocrinology disorders is warranted". Some smaller xanthomas may reduce in size with changes in diet, exercise, and predisposing conditions [3].