Epizootic Catarrhal Enteritis

The"Green" Virus

It's known by a few different names. "Green Diarrhea." "Green Slime." "Green Poop." It even has an official title: Epizootic Catarrhal Enteritis of Ferrets, or E.C.E. No matter what you call it, it strikes fear into the hearts of ferret owners.

At the Ferret Association of Connecticut, Inc. Halfway House, they have had over 100 ferrets per year through their shelter since the home became infected and have therefore gained daily "in the trenches" experience caring for animals with E.C.E. that very few veterinarians in the country have. They have worked closely with the shelter vet, Dr. Wil Barriosnuevo of the East Hartford Animal Clinic, and have arrived at treatments that have worked for them. This of this article is to share their experience with others across the country who may only have heard of this illness or who may be currently battling it. These are their personal experiences and opinions and may not reflect the opinions of Dr. Barrios or other people or vets quoted.

We first saw this illness in our shelter in the last week of June, 1993. It was well over a month since we had attended any show, fun fest, or visited anywhere with our animals. It was, however, only a few days after one of our rescue volunteers came to clean while recovering from a very bad flu which she had picked up at her college. Dr. Williams', other vets, and our experience all indicate the virus, after exposure, manifests itself in 3 to 5 days. Also, it first hit three older ferrets who lived exclusively in our "rescue room." We have seen ourselves, and other owners have remarked upon, how any illness will travel from room to room or cage to cage when your animals are kept separate. This certainly happened here. First the rescue was hit, then our own animals.

The first few months were very hard. No one understood how the illness operated; what symptoms to watch for, or how to treat it. Two of those first sick ferrets had to be hospitalized for two days. Two of our own animals were also hospitalized, and both lost over half their body weight. In those first six months, we lost two ferrets. One animal had insulinoma; the glucose we and our vet used to pull him out of seizure was too strong, and sent his blood sugar "spiraling" from too low to way too high. We were unable to stabilize him. Although the virus precipitated the seizure, the insulinoma was the real culprit. Another animal suffered severe intestinal collapse. Again, while the E.C.E. triggered the problem, it was not the only cause. Through trial and error, we gradually learned more and more. Since that time, we have lost no more ferrets to this disease. We've had to fight to keep some going, but all the rest have struggled through.

Now we simply live with it on a daily basis, as a fact of our lives. I'm sure many of the people who were hit with it initially are doing the same thing. But now it seems to be spreading. Many people who only heard of it before are now being faced head-on with the problem and are understandably nervous. This article is meant to both dispel some of the myths and misconceptions as well as offer care suggestions should your ferret be diagnosed with this illness. Please consult with your vet for specific treatments and medicines.

WHERE DID IT COME FROM?

The disease was first publicly identified in the mid-Atlantic states (Virginia, Maryland) in Spring, 1993. At the time, the area was just recovering from a distemper outbreak that frightened many people and forced shows to become very strict with vaccine requirements and disinfecting show tables. These were precautions that should have been enforced all along, but had become lax. In retrospect, stiffer rules probably helped prevent the spread of this virus via the East coast show circuit. However, as people were unaware of its "contagiousness," local breeders and friends who swapped animals for stud service or visited may have unwittingly passed it on.

HOW IS IT SPREAD?

The primary mode of transmission seems to be ferret-to-ferret, but no method has yet to be formally documented. Direct contact with an infected animal is not the only means of infection. Our observations suggest the virus does not cling to fabric itself, as judges may brush or hold animals against their clothes and no illness has been reported to us from that exposure. However, we believe it may be found in fecal material, which would explain one transmission we experienced via cage carpeting and how some people may have brought it into their homes - on their shoes.

Cases have been documented of the illness affecting a home without any contact of the ferrets or owners with shows, infected animals or homes. Often someone in the home had recently recovered from the flu. Several people in the ferret community suspect this virus may have begun as a mutated human flu virus. The initial outbreak coincided with a particularly nasty flu season. Two years ago, Mary Van Dahm of F.A.I.R. ferret shelter in Illinois related how a similar type of virus had been reported there some years ago, also coinciding with a flu outbreak. Further evidence of this conclusion is that when Dr. Michael Fox and Dr. Susan Erdman of the Massachusetts Institute of Technology first began to study the illness, we understand the only infection they were able to isolate was an influenza strain. I am convinced this is how the FACT, Inc. shelter became exposed.

Early on, rumors abounded in the absence of any real information. A couple of ferret organizations used it as an opportunity to jab at others they had political differences with, complaining that it had been spread at each other's shows. There have been scattered reports of people claiming to have become infected at shows. Every event I have attended has required champion judges as well as specialty ring judges to disinfect tables and their hands between animals with Nolvasan® or a similar professional strength, bacterial cleanser, and I have heard of no instances of transmission from these specific events. Many shows also now standardly issue a health notice that warns attendees not to "pass around" ferrets and to wash hands thoroughly before and after handling another person's animal. I cannot speak for how some other events may operate, however, if these procedures are faithfully followed, there should be little risk of exposure. Unconfirmed rumors currently exist that say some pet shop kits may recently have become carriers, as well.

WHO GETS IT?

The illness strikes entirely at random. In the same home you may see one animal become very ill, one mildly so, and one never show a single symptom. We estimate about 70-80% of the animals we have taken in have become ill. Approximately 10% become seriously ill. 10-20% never have any signs. Elderly ferrets (6 years and older) and those under one year usually have only a minor case, if at all. Kits may show minor symptoms for a day or two, but barely skip a hop. The group we've experienced as most at risk for serious complications are those between 2 and 4 years old.

CAN YOU PROTECT AGAINST IT?

No animals we have cared for, once recovered, have become ill again. However, all ferrets within an infected household, whether they become ill or not, appear to become carriers. The household also appears to remain infected. When we became aware it was in our shelter, we voluntarily quarantined ourselves for 3 months, scrubbed, and disinfected. As soon as we began taking in animals again, we had "green poop" again. As mentioned above, households with no infectious contacts have had the illness enter their home. Short of both you and your pets living in a plastic bubble, it is unlikely you can completely guard against this virus.

WHAT ARE THE SYMPTOMS?

The dreaded "green diarrhea" is only the first and by far the lesser sign. Be aware that ferrets may get greenish diarrhea from any number of intestinal upsets. The specific diarrhea associated with E.C.E. is a foul-smelling, neon green. It normally only lasts 2-4 days. Weak or older animals may become badly dehydrated. An otherwise healthy ferret is not usually seriously affected within this initial period. To check for dehydration, pinch the skin over the animal's shoulder blades between thumb and forefinger. It should quickly smooth back. If it "sticks" together, you may have a problem. Be aware that older ferrets normally have thinner, dryer skin. Do this pinch test with an oldie and with a youngster and you can easily see the difference. Learn what's normal for your ferret now and you will know when something becomes abnormal. In some cases, vomiting may be the first symptom, lasting up to 24 hours followed by the "greenies."

The most serious symptom arrives several days after the diarrhea has passed. What is especially dangerous is a false sense of security - since the "green poop" is gone, people assume everything is fine and stop monitoring their animal. Then, within 7 to 12 days, they begin to notice severe weight loss. What has occurred is that the ferret has stopped eating. Ferrets have a very short, simple and acidic digestive system. The stomach acid attacks the digestive tract and begins to form ulcerations in the stomach, throat, or mouth. These are uncomfortable and make the animal eat less, which makes the ulcers worse, which makes them eat even less... This downward spiral of symptoms happens very fast. Within days the animal may be eating and drinking nothing at all.

CAN THIS KILL MY FERRET?

For an animal with hypoglycemia or insulinoma, the anorexia can be quickly fatal. Any ferret either untreated or misdiagnosed may die within days if severe anorexia sets in. We have seen only one casualty of the diarrhea itself: the ferret hemorrhaged internally and nothing could be done to save him. Our vet likened it to a canine parvo virus, and the suspicion remains that some other illness or disease was also at work in this animal. Dr. Williams estimates, while 95% of ferrets will contract the illness, only 5% will die of it. Our experience has been that properly and carefully treated, only 1-2% will be fatally affected. The difference between Dr. Williams' 5 in 100 chance of fatality and our 1 to 2 in 100 estimate is early detection and the care and attention that the individual owner is willing to do to pull their animals through.

HOW LONG DOES IT LAST?

As stated above, the diarrhea usually lasts for 2-4 days. There may be periodic recurrences on and off for a couple weeks, or you may suddenly see one or two episodes of greenish diarrhea months later. Whether this is an after effect of the illness or some unrelated stomach upset is unknown. The anorexia, if it does set in, is highly individual. It can last for a week up to almost two months. Animals may begin eating a little after a short period, but still require supplemental feedings for a couple months to bolster their weight and speed recovery.

WHAT ARE THE OTHER EFFECTS OF THE ILLNESS?

The effects depend greatly on how long the symptoms last. Prolonged dehydration can impact the function of the internal organs. And, obviously, if an animal is not eating there will be losses to body weight and muscle tone. In isolated cases, there appears to be damage to the intestinal system, requiring long-term monitoring of food intake and watching out for ulcer formation.

HOW DO YOU TREAT IT?

As stated above, these are the methods we at FACT, Inc. have utilized to fight E.C.E. and are not meant to be either a substitute for qualified veterinary care or the only treatment methods. Please consult with your vet if your animal is seriously ill! Be aware that any virus can mutate and symptoms may change. Individual animals may also be affected differently, especially if there are underlying conditions. This information is offered as an aid in the hope it will be helpful; we cannot accept responsibility should it fail to save a particular animal.

DEFINITIONS & ITEM AVAILABILITY:

Pedialyte®: Electrolyte and mineral replacement fluid for infants with diarrhea. Available in drugstores. Other electrolyte formulas can also be obtained via your veterinarian or a major veterinary supply dealer.

Lactated Ringers: Subcutaneous injectable fluid solution with or without dextrose. For severe dehydration. Can be performed at vet or obtained there for those experienced with medical care.

NutriCal® or NutriStat®: High calorie, malt-flavored paste nutritional supplement available at vet or large pet supply store.

Ensure® or Sustacal®: High calorie, high protein liquid human nutritional supplement. Tastes great to most ferrets but contains no milk products. Available in drug or large grocery stores (similar generic products are also available).

Gruel: Our food recipe for the ill or aged. Grind animal's regular dry food, mix with water, and microwave until "pea soup" consistency. Add NutriCal® or Pedialyte® as needed and Ensure® for taste.

Syringe: With cc measurements, to force-feed or accurately dose medicine. Your vet should be able to spare a couple.

Amoxycillin or Cephlexen: Antibiotic medicine to kill bacteria. Prescription only. May suppress appetite. We follow treatment with acidophillus to help restore normal intestinal bacteria.

Prednisone: Steroid often used to boost appetite and energy level. Prescription only.

Azium: Injectable steroid diluted with distilled water and given orally. Often used as treatment for hypoglycemia and/or insulinoma. Quicker acting than Prednisone. Prescription only.

Flagyl® (chemical name: metronidazole): Prescription medication for severe diarrhea. Foully bitter.

Tagamet® (cimetidine): More palatable medication for diarrhea. Now available without prescription, but check with vet for correct dosage. Available as pill, injectable, or can be specially ordered in liquid form.

Pepto Bismol®: Human antacid/diarrheal medication. Find in any store.

Carafate®: Concentrated form of ingredients similar to Pepto Bismol. Prescription only.

Regelan®: For vomiting. Prescription medication available in pill or injectable form.

CliniCare®: Veterinary food formula gentle enough to be force fed directly into an animal's stomach. Available in powder form to mix with water. Highly palatable. Prescription only.

Slippery Elm Bark Powder: Native American herbal remedy for ulcers and sore throats. Mixed with water, becomes gelatinous. Inoffensive tasting. Available in health food stores.

TREATMENT

A day or two after we move a new ferret into the shelter, we begin to watch out for neon green diarrhea. As noted above, we may see it only briefly, or not at all. If we've seen nothing after a week, we usually assume the animal will not be affected. The only exception is for unneutered animals - we have seen cases where a nursing jill did not become ill until after spaying. We suspect that stress - surgery or simply the stress of a new environment - may play a part in the development of the illness, but cannot confirm this. If the diarrhea is severe and profuse, and/or the animal is older or already thin, we monitor their hydration level. We may begin by supplementing with Pedialyte®; if the skin appears particularly dry our vet may recommend a lactated ringer injection several times a day. (Note: We have found ferrets tolerate the subcutaneous fluid injection better if it is warm. If you can obtain a large syringe, remove the needle after filling from the ringer bag and warm the syringe and solution in the microwave.) The fluid is injected in the loose skin over the shoulders.

You may see the diarrhea change from neon to a darker green, then to a brown with what looks like small beige seeds in it. The "seeds" are undigested food that has passed through the malfunctioning intestinal system. It is a sign of improvement! You may see "seeds" on and off throughout the recovery period, but you probably won't see that nasty neon stuff again.

Once we have identified an animal as having the diarrhea, they go "on watch" for eating disorders. The easiest way to monitor their food intake is to separate them into a clean carrier, cage, or small room. Put only a small amount of food in their bowl; if it appears they are eating very little, you can count out exactly how many pieces of food you place in the bowl and check their intake that way. A ferret that does not eat 15-25 pieces of food overnight is not eating anywhere near enough! Note the level of water in their bowl or bottle, as well.

Keep an eye on their temperature. Your vet can show you how to take it and rectal thermometers can be found in drugstores. A ferret's normal temperature should be between 100-102 degrees. Over 103 or under 98 is cause for serious alarm and may require immediate veterinary attention.

The faster you catch any budding problems, the less likely they are to snowball into serious conditions. At FACT, an animal not eating is immediately fed. You may try tempting them by dipping their dry kibbles in water to enhance the scent, or using NutriCal or a treat, but these are only stopgap measures. (You may find a previously irresistible treat is now refused.) They must have the fiber and protein found in their regular food, and this is where the gruel formula detailed above is invaluable. While we usually add Ensure for taste, a ferret cannot eat only Ensure. It has far too much sugar (dangerous to those with insulinoma) and may increase the diarrhea. Since most ferrets love it, a little will encourage them to eat the gruel mix. You may need to use some imagination to get them to try it initially. Try feeding them off a spoon, or dip your finger in it. (It should be room temperature or warmer - if it feels too hot on your finger, it's too hot for them.) Many ferrets hate the liquid on their whiskers or chin, but once they become accustomed to the sensation and realize the gruel tastes good, they will begin to eat. The faster you catch the anorexia, the easier it will be to encourage eating. If necessary, you must force feed them.

Many people are squeamish about making their pet eat. However, the ulcerations that can rapidly form in their mouth, throat, and stomach and the resulting refusal to eat is extremely serious. You can either make them eat or watch them die of starvation. Be aware that only a very few ferrets must be force fed for any extended period. Most will begin licking within a day or two. However, we have handled animals that had to be force fed for almost two months. It's not a lot of fun. However, the good news is that in each case, one day they just decided to start eating and have since fully recovered. Being ferrets, and contrary by nature, of course now all three of these guys LOVE gruel!

Obviously, you must be careful when forcing any liquid into an animal's mouth. Never force liquid or food into an animal who is unconscious! To carefully control the amount inserted, we use a small syringe. The gruel should be liquid enough to easily be pulled into it and pushed out a drop or two at a time. Again, most ferrets will begin licking at fluid dripped between their lips. However, those demon few may GRIT THEIR TEETH. Insert the syringe nozzle in the side of their mouth and squeeze out a couple drops. WAIT AND WATCH FOR THEM TO SWALLOW. When they have, insert a little more. You may very well have to scruff them to keep their head still. If they are really obstinate, they may dribble, shake their head, or outright spit it on you. Using an old towel as an apron is a smart move! For anyone especially nervous, you might ask your vet to show you how to feed the first time.

Initially, they should eat about 1 ounce of food. This is equivalent to about two tablespoons. A full meal is 1 1/2 to 2 ounces; we feed so many old-timers gruel daily that we purchase small 2 oz. plastic sauce cups from our local "warehouse" store (i.e. Sam's or Price Club). They are the perfect size for one meal. While reusable, they're inexpensive enough to toss and it saves a lot of time washing dishes! You might beg or buy a dozen from any Chinese restaurant.

Remember that a ferret normally eats every few hours. If you can maintain a similar schedule for the worst part of their illness, great, but don't feel bad if you must work or sleep uninterrupted. They can go up to eight to ten hours between feedings. You may not see them drinking much water when eating gruel - keep in mind it is made with water so a lot of their fluid intake will be coming from that. We rarely see our elderly ferrets  eat gruel drinking water. (But continue to leave their usual food and water available.) If the diarrhea continues, it would help to feed them extra water or electrolyte replacement fluid through the syringe once or twice a day. (Avoid Gatorade, which contains excessive salt.)

Check their mouth for ulcerations. They will appear as a darker red spot, usually on the roof of the mouth or back in the throat. Your vet will be able to see farther back than you can. Ulcerations may occur deep in the throat or in the stomach, too. If you see ulcers or vomiting or signs of nausea lead you to suspect ulcers, further steps must be taken. (Pawing at the mouth is an indication of nausea.) A ferret REALLY DETERMINED not to eat should always be suspected of ulcers. When food passes the ulcerous sore, it actually hurts them to eat. A prescription for Carafate may be necessary. Extended vomiting is unusual, but can be treated with Regelan®, a musosal protectant your veterinarian can prescribe.

Some vets like to prescribe antibiotics for everything in sight. Before I ran a shelter, I seemed to never leave the vet - for any ailment - without a bottle of the "pink stuff" (amoxycillin). Be a little cautious before just accepting this as a cure-all. Many human doctors used to overprescribe antibiotics as well; overused, they can cause problems as bacteria are survivalists and can mutate into more resistant strains. Antibiotics will not cure a virus (if they did, we'd already have a cure for the common cold!) and can suppress the appetite. We do use antibiotics, but only if the ulcerations refuse to heal. The standard 14 day treatment seems to have little effect on stubborn cases. Dr. Barrios has, if necessary, had us keep them on the medication for up to a month, which finally cured the ulcers. After antibiotic treatment is concluded, we normally put the animal on acidophillus (the enzyme found in yogurt culture) to restore the healthy bacteria that normally exists in the intestinal system and helps digest food. (There is no point giving an animal acidophillus while they remain on antibiotics - you are killing the same bacteria you're trying to replace!)

A herbal remedy we've used with great success is slippery elm bark powder. A little mixed with hot water quickly forms a gelatinous goo which is very soothing to those painful ulcers. Slippery elm has been used in herbal medicine for humans for hundreds of years and all sources list it as safe. It does contain some nutrients and is so mild that even the most nauseous ferret can hold it down. Once they can take that simple mixture, you might ask your vet to prescribe a package of CliniCare®, and mix the slippery elm with that. We have fed this for a day or two to very weak animals recovering from surgery or animals seriously ill with E.C.E., and it has literally been a lifesaver.

Hopefully, your ferret simply will begin eating gruel on its own within a couple days. If he/she begins eating some of their regular food as well, celebrate! We normally continue to mix gruel for them in the morning and evening as a supplement until their body weight has been regained. If the diarrhea continues to be a problem, you should consult with your vet on anti-diarrhea medications. A little Pepto Bismol® might be the first step he/she suggests, or he may prescribe the stronger Tagamet®. It's readily available in pill form, but have the vet request the liquid version from their pharmacist. It's a lot easier to administer. Flagyl® (used to control severe diarreha) is completely nasty. Any ferret given Flagyl® will gag and paw at their mouth frantically. The report from someone who had to take Flagyl® themselves for a bad case of "Montezuma's revenge" was that years afterwards, she still couldn't forget the horrible taste! So try following it up with a tasty treat.

A tip passed along by Fara Shimbo of F.U.R.O. is to clip the hair between the legs and under the tail of an animal with severe diarrhea. Besides avoiding matting, cold wet fur from frequent washing will encourage more diarrhea. If a rash should occur, ask your vet for a soothing cream.

Your vet may also prescribe a steroid (Prednisone or Azium) to increase appetite and help stabilize the blood sugar, particularly for a ferret that is hypoglycemic or has been diagnosed with insulinoma. While an in-depth discussion of insulinoma is a subject for a whole other article, be aware that many ferrets over 4 years old show the staggering, staring into space, drooling, or "fainting fit" which are signs of hypoglycemia. The anorexia associated with E.C.E. is especially dangerous for them. Again, we stress avoiding giving them too much sugar. While Ensure® has a great deal of sugar, it also contains protein and carbohydrates and we only use a small amount mixed into their gruel. (NOTE: Once a can of Ensure is opened, it should be used within 24 hrs. To avoid waste, you can freeze it into an ice cube tray and defrost a cube a day.) NutriCal® also has a lot of sugar in the form of molasses. While a more complex sugar, it is still sugar. You may find that the weakened intestinal system which this illness can cause may make your ferret be unable to tolerate high levels of fat in a food. NutriCal also has a lot of fat. A good food option is 2nd stage infant chicken. It is high in protein, is easily digestible, and has no added sugar. Learn to read labels and you may find other foods that can be given to ill ferrets either as a treat, an enticement to eat, or a change from gruel. We'd love to hear your discoveries.

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