the anorexic tortoise - BSAVA

How to approach
the anorexic
tortoise
John Chitty, who runs
the exotics service at
Anton Vets, helps us
tackle a challenging
topic
Anorexia is probably the most
common presenting sign for
tortoises seen in veterinary
practice. In some cases patients
are overtly unwell; in others the animal
still seems bright; and some will be in
between, appearing ‘just a little slow’
to their owners.
In an article such as this it is important
to define some of the terms used:
■■ Tortoise. For the purposes of this
article a tortoise is one of the Testudo
group of Mediterranean/Middle
Eastern tortoises – the Spur-thighed
group; Hermann’s: marginated; and
Horsfield’s tortoises: these are the
tortoises most commonly kept as pets
in the UK. With the exception of some
North African spur-thighed tortoises,
the majority will hibernate. All are
herbivorous and terrestrial.
■■ Anorexia. Literally means lack of, or
reduced appetite. However, reptiles do
not always eat every day, especially
when breeding or immediately before/
after hibernation. Therefore it is
important to determine whether the
anorexia is persistent and significant or
a single occurrence. It is necessary to
investigate further if:
– ■ There is concurrent weight loss.
– ■ There are any other signs of ill
health, including lethargy.
– ■ The tortoise has not eaten for over a
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week. If less than a week and the
tortoise appears well, advise
owners to keep the tortoise warm
(25–35°C in the day: 20–25°C at
night), bathe it daily in plain warm
water for 10–15 minutes and
monitor bodyweight daily.
Post-hibernation anorexia is not a
specific condition. Anorexia is common
during this period mainly because this is a
time of maximal metabolic stress in the
animal and because UK weather can be
particularly variable in Spring (for this
reason, it is also common to see anorexic
animals in Autumn too). In any event, the
diagnostic investigation of the anorexic
tortoise is largely the same whatever the
time of year.
With such a wide range of differentials
(Table 1) it is vital that a full assessment is
carried out in all cases. The old posthibernation
injection of B-vitamins really is
not enough!
Diagnosis Comments
“Depleti on” Most commonly seen post-hibernati on. It basically refers to the state
where energy stores are simply insuffi cient for the step up in metabolism
post-hibernati on and is probably the most common cause of anorexia
in this period. It is usually the cumulati ve result of years of sub-opti mal
husbandry.
Sub-opti mal
husbandry
Usually relati ng to temperature. Ideal keeping temperatures are described
earlier – basically UK weather is not suitable for these species without
additi onal support.
Hibernati on should be carried out in controlled units between 5 and 8°C.
Systemic disease Organ failure – many of these animals are extremely old.
Infecti on – bacterial/fungal/viral. Many are secondary to sub-opti mal
husbandry.
Gastrointesti nal
infecti ons
Respiratory
infecti ons
Reproducti ve
disease
Including stomati ti s, though this is normally secondary to one or more of
the above factors.
Similarly, gut parasiti sm is rarely a cause of anorexia in its own right but
will certainly be a contributory factor
Both of the upper (oft en associated with stomati ti s and with the same
underlying causes) and lower respiratory tract.
Assessment of lower respiratory disease is diffi cult. Auscultati on is of litt le
value and radiography is the method of choice.
Especially follicular stasis in females. Typically seen in lone females
that lack the pheromonal and physical sti muli of males to lay. It is also
husbandry-related in that the UK climate with frequent rises and falls in
temperature is ideal for sti mulati ng folliculogenesis but rarely has a long
hot spell to sti mulate entry to the egg-laying period.
Stress Especially if newly mixed; or if mixed with over-amorous males; or if mixed
with diff erent species.
Overgrown beak
Freezing during If hibernati on temperatures fall below zero during hibernati on there may
hibernati on
be damage due to ice crystal formati on in the lens of the eye and also in
olfactory and frontal lobes of the brain.
Table 1: Common differential diagnoses for the anorexic tortoise

Figure 1: A male Hermann’s tortoise – note the
long keratinised end to the tail
Clinical assessment
A full history should be taken. This should
concentrate on:
■■ Signalment – unlike in dogs and cats
this is rarely known. Most owners can
say how long they have had the animal
but can rarely give more than an
indication of age. If owned for many
years it is worth asking if the tortoise
has grown in that time. If it has grown
significantly then likely it was young
when first owned. If not, then it was
probably mature when first owned. With
these species physical maturity would
probably suggest that the tortoise was
at least 20 years old when acquired.
The species of tortoise is also not
always known and it is worth being
familiar with the common species in
this group. Sex is often determined by
whether or not the tortoise has laid
eggs or not. This is not always reliable!
While Hermann’s and Horsfield’s are
relatively easy to sex (males have much
longer tails – Figure 1) the spur-thighed
group can be very hard to sex. Shell
shapes can be useful but are unreliable
in captive-bred animals as there are so
many diet-induced abnormalities.
Familiarity is the key!
■■ Husbandry. Full details are required:
– ■ Hibernation times and manner.
– ■ Temperature provision if any;
temperature measurements and
how these are are performed –
remember that a thermostat is a
control device not an accurate
measure of temperature.
– ■ If housed, vivarium or tray? Is the
tortoise kept outside?
– ■ Humidity (Mediterranean tortoises
generally require a dry environment).
– ■ Diet and feeding history.
– ■ Bathing?
– ■ Weight history. Many owners keep
accurate records of the animal’s
weight, especially before and after
hibernation. These data are very
valuable.
– ■ Contact with other animals,
especially other tortoise species.
■■ Medical history.
■■ Urination/defecation: absence of
these (especially if being bathed) is
significant.
■■ Reaction to food – is the tortoise
interested?
■■ Activity levels.
■■ Respiratory noise.
Before handling, the respiratory pattern
should be assessed. In most tortoises
breaths are infrequent and may be hard to
detect. However, if there is overt respiratory
effort, open-mouth breathing, or excessive
vocalisation on breathing then these may
be indicators of severe disease. Do not
confuse aggressive hissing with respiratory
noise, nor gular pumping (throat
movements) with respiratory movements.
A thorough clinical examination should
be performed. However, the presence of
the shell severely limits what can be
examined. All patients should be weighed
and this weight compared to any previously
recorded weights and, most importantly,
with the animal’s current body condition.
Body condition is assessed by the
amount of fat pad present in the prefemoral
fossa and between forelimbs and
neck. Sunken eyes may be a sign of
dehydration, but may also indicate a loss of
the fat pad behind the eyes.
The Jackson ratio (a graphical
comparison of weight:length allowing
assessment of ideal condition) may be of
some use for medium-sized spur-thighed
and Hermann’s tortoises, but generally is of
limited value compared to body condition
assessment – for example a tortoise
containing many eggs will have a good
Jackson “score” even though it may be
very thin.
The eyes should be assessed for
opacities and swelling of lids,
conjunctiva, etc.
The nares should be checked for
discharges, abscessation, etc.
The mouth should be carefully
assessed (Figure 2) for:
Figure 2: Oral examination – note normal
membrane colour and texture
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How to approach the anorexic tortoise
■■ Mucous membrane colour. Some
yellowing may be normal in the
post-hibernation period. Cyanosis
potentially indicates respiratory disease.
■■ Dry sticky membranes – may show
severe dehydration.
■■ Presence of purulent or diphtheritic
material.
■■ Foreign bodies within the choana
(passage in roof of mouth to nasal
chamber).
Limbs should be checked for swellings
and it is useful to see the tortoise walk,
though this is not always possible.
The cloaca should be examined as
much as possible, in particular for
discharges and ulceration.
The shell should be assessed for
damage or infection. In septicaemia
there may be a reddening of parts of the
shell. This will “blanch” when pressed with
a fingernail.
The skin may be checked for
ulceration, flakiness or other lesions.
Tenting of the skin is not a reliable indicator
of dehydration.
Limited palpation of the abdomen
may be performed by placing fingers in
the prefemoral fossae and gently
rocking the tortoise side-to-side.
Large masses or eggs may bump
against the fingers.
The heart may be auscultated using
a 8MHz Doppler device (as used for
measuring feline blood pressure) placed
on the skin between forelimb and neck.
Harsh murmurs may be an indication
of endocarditis.
Sample taking
Clinical findings will dictate which
samples are taken. However, a blood
sample is essential in nearly all cases in
order to assess underlying disease, fluid
and electrolyte balance, nutritional status
and immune status and inflammatory
status. Without sampling it is nearly
impossible to assess hydration and
feeding needs adequately.
Table 2 details the parameters
evaluated in blood analysis of these
patients. Some tests are performed patientside,
others by a diagnostic laboratory.
Most laboratories will be able to assess
these on approx 1 ml heparinised blood
(haematology is performed on blood taken
into heparin not EDTA) and two fresh blood
smears, however they should be consulted
prior to sampling to check their needs and
also which parameters they include in their
profiles. Blood samples may be taken from
jugular, subcarapacial (Figure 3) or tail
veins. It is always worth stating on
submission forms which sampling site has
been used, as there is a much higher
incidence of lymphodilution from the tail
vein. Where obvious lymphodilution
occurs, the sample should be discarded.
Interpretation of blood parameters
(Table 2) can be very difficult. Not only do
individual labs and machines vary in their
reference intervals, but there may be
differences between species and certainly
Figure 3: Sampling from subcarapacial vein – a
bent needle is inserted in the dorsal midline
approximately where skin joins shell
major differences in individual parameters
through the annual cycle. It is very
important to use laboratories with
experienced consultants to assist in such
interpretation – to this end a thorough
written history and as accurate a
signalment as possible should accompany
each case submission.
Parameter Notes
Haematology Full haematology – red and white cell parameters. Oft en the cell counts are
of lesser importance than cell morphology which is why an experienced
“exoti cs” haematologist should always be consulted.
Urea See Table 3.
Uric acid See Table 3. Also a useful assessment of renal disease. Levels >1000 µmol/l
indicati ve of renal disease: >2500 µmol/l grave prognosis.
Electrolytes Sodium, potassium, ionised calcium. Potassium levels >5 mmol/l are
signifi cant; >9 mmol/l grave prognosis. These should be measured
pati entside or a spun heparin gel tube should also be supplied. Otherwise
post-sampling changes may arti fi cially raise potassium levels.
Total calcium and Not as useful in assessment of renal disease as in iguanas, but of use in
phosphate assessing reproducti ve functi on in females (Box 1).
Glucose Measure pati entside – immediate assessment of nutriti onal status/depleti on.
Beta-
Ketosis.
Hydroxybutyrate
Liver enzymes AST, CK, GLDH and GGT may all be assessed. These allow some assessment
of hepatocellular damage and ti ssue damage. However, none is sensiti ve nor
specifi c and it is hard to assess liver disease in chelonians. Biliverdinuria is a
more specifi c indicator, though not sensiti ve.
Bile acids Can be hard to assess unless extremely high.
Proteins Albumin, globulins and rati o. Assessment of protein balance and
infl ammatory responses. Electrophoresis may be helpful in the latt er case.
Table 2: Parameters to be included in an anorexic tortoise blood panel

Parameter Comments
Skin tenting Hard to assess and a very insensitive measure.
Mucous membranes Dry sticky membranes more sensitive than skin tenting.
Haemoconcentration In theory, raised albumin and haematocrit should accompany
dehydration. However, most of these tortoises will have varying degrees
of hypoalbuminaemia and anaemia (due to underlying disease/debility/
anorexia) that such an interpretation is confounded.
Uric acid Will rise in dehydration. However, will also rise in renal disease.
Urea These species use the urinary bladder as a water store. Accessing this
allows smaller molecules, including urea, to enter the bloodstream – i.e.
urea is a measure of degree of access to stores. The higher the level of
urea, the greater the dehydration. It is unaffected by renal disease (except
in severe disease) so is an extremely important indicator of hydration.
Table 3: Assessment of dehydration in the tortoise
BOX 1: Markers of reproductive function in female tortoises
The following parameters may all rise in the reproductively active female:
■■ Protein – total/albumin/globulin
■■ Total calcium
■■ Phosphate – Calcium:phosphate ratio usually remains in normal range
■■ AST/ALKP/CK
■■ Cholesterol/triglyceride
NB: This “pattern” is not a marker for reproductive disease or follicular stasis unless such
levels remain high and the tortoise is not recovering. Rather, it indicates a need to assess the
reproductive system via radiography/ultrasonography.
Follicular stasis is diagnosed by a persistent:
■■ Reproductive blood picture
■■ Ovarian follicles – these show no evidence of atresia nor progression to egg
Test Comments Indication
Faecal analysis May be hard to obtain! Worth
bathing daily to twice daily to
stimulate defecation. Fresh (

Apart from the very mildest cases, it is
highly unlikely this can be provided at
home, so almost all cases will require
hospitalisation. As husbandry problems
started at home, out-patient therapy is
unlikely to be successful.
Hospitalisation is usually 5–14 days for
the average case. Therefore a practice
treating these species will need specific
facilities. This may vary from a heat lamp in
a kennel for the occasional case, to vivaria
or tortoise trays where there is a greater
caseload (Figure 5).
Again, important biological parameters,
especially temperature should be
measured and maintained at correct levels
in hospital (Figure 6). Half measures will
not suffice and result in more unsuccessful
cases and frustrated owners.
It is vital that owner education is a part
of the treatment plan. This is especially
important for older tortoises as owners do
not see why there is a problem now with
their husbandry when there had been no
issues over the previous thirty-odd years!
However, reluctance to change husbandry
will simply result in relapsing cases. A
frequent finding with inadequate home
temperatures is that the tortoise will do well
for 48 hours following discharge and then
stop eating: some research suggests
reptiles can maintain internal temperatures
for up to 2 days!
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How to approach the anorexic tortoise
A B Figure 7: Daily bathing is vital. It also helps
Figure 5: Hospitalisation units. Vivaria are a typical means of housing all reptiles. They have,
erroneously, gained a reputation as a cause of respiratory disease in tortoises due to high humidity.
However, this can be controlled as well as temperature. Trays are excellent means of hospitalising
tortoises but rely on a high background room temperature as it is this that sets crucial minimum
temperatures. The author’s unit uses combined ultra-violet and heat sources as basking points
Figure 6: Digital maximum–minimum
thermometers are easily available and these
units with two probes are inexpensive. This
photo shows minimum values that should be
achieved in the hospitalised setting. If using
vivaria, they should be insulated to achieve
these temperatures. If using trays, room
temperature needs controlling to these levels
While hospitalised, all cases will require
basic supportive care.
Rehydration
All tortoises should be bathed daily in plain
warm water or in a glucose/electrolyte mix
(e.g. Reptoboost (Vetark, Winchester UK)).
For mildly dehydrated animals this may be
sufficient to restore fluid balance. Bathing
will also help to stimulate urination/
defecation (Figure 7).
stimulate defecation/urination (see tortoise on
left). Biosecurity is vital – all equipment should
be labelled (in this case bath numbers match
tray numbers) so no fomite transfer occurs
between in-patients
For more severe cases, fluids may be
given:
■■ Oral fluids – Hypotonic fluids (including
plain water!) may be given by gavage
tube. Around 20ml/kg in single or
divided doses (Figure 8).
■■ Intra- or epi-coelomic (Figure 9) – Up to
30 ml/kg once daily of isotonic fluid.
■■ Intra-osseous – Needles may be
placed into the femur or humerus, or
Figure 8: Gavage tubing a tortoise. The neck is
held straight and the tube gently inserted down
the oesophagus

Figure 9: Epi-coelomic fluid injection into the
prefemoral fossa
the bridge of the shell between the
plastron and carapace. Isotonic fluids
are given at approx 30 ml/kg/day and a
syringe driver or Springfusor pump is
required for administration.
Fluid choice for systemic therapy
depends on electrolyte assessment.
Critical nutrition
It is important to stimulate eating as
quickly as possible. To this end, the
tortoise’s favourite foods should be
ascertained and offered.
Where there is no particular favourite,
this author offers a standard salad mix
(lettuce/cucumber/tomato) with
strawberries and dandelions whenever
available. This is not a balanced diet and
vitamin supplementation is not offered as
many tortoises do not like these. Once the
tortoise is eating well, the diet can be
amended to a more healthy one.
Those cases that are suspected of
being blind and/or cold-damaged should
be hand-fed especially if they actively
appear interested in food.
Otherwise critical nutrition is provided
by gavage tube. Initially, simple
carbohydrate mixes (e.g. Critical Care
Formula (Vetark, Winchester, UK) or Liquid
Lifeade (Norbrook, Carlisle, UK))
progressing to higher fibre formulas in
herbivores (e.g. Oxbow Fine Grind (Oxbow,
Nebraska, USA), Emeraid Herbivore
(Lafeber, USA)). Formulas for carnivores
should be avoided.
Animals that are difficult to tube, will
require long-term tubing or have sufficiently
good husbandry to be treated at home can
be fed by means of an oesophagostomy
tube. This should be fitted under sedation
or local anaesthesia (depending on level of
debility) in much the same way as in a cat.
Antibiotic therapy
Broad-spectrum “cover” is required in all
tortoises with extremely low white cell
counts or those showing an active
inflammatory response. Where there are
identifiable lesions (e.g. stomatitis,
pneumonia), drug choice should be
based on culture and sensitivity of
collected samples.
Where there are no obvious lesions,
fluoroquinolones or ceftazidime may be
used empirically. Care should be taken not
to select very irritant drugs for long-term
intramuscular administration. If long-term
use is needed, then either a less irritant
drug should be used or the medication
switched to oral dosing as soon as the
clinician is sure gut absorption is optimal.
Monitoring
Where the tortoise is clearly improving
clinically (appears stronger, eating,
urinating/defecating, etc.) and continues to
do well at home, there is rarely a need to
do more than physical checks.
However, for animals that either showed
severe abnormalities on initial blood
sampling or that are showing little or no
response to therapy, repeat blood sampling
at 7–10-day intervals is a very good means
of assessing progress and prognosis.
Prevention
It is clear that the key to avoiding anorexia
is maintenance of good husbandry.
Traditional means of keeping tortoises in
the UK, combined with the older methods
of hibernation (such as a box of hay in
garage/shed/loft), are simply not adequate
and as animals get older they will succumb.
For lone females, access to healthy
males of the same species in May and
June each year may assist in avoiding
follicular stasis.
Good advice on husbandry is now
available from many sources, including
the British Chelonia Group and The
Tortoise Trust.
It is also worthwhile carrying out
regular health checks to assess weight and
condition pre- and post-hibernation. This
can be combined with endoparasite
control and ultrasound scanning of females
to monitor ovarian activity.
In the author’s practice most checks are
done at twice yearly “parties” for “healthy”
tortoises. This enables not only the clinical
check, but also allows interested owners to
meet and exchange tips and techniques. It
is also a very good way for the lone females
with follicular stasis to meet males – speed
dating for tortoises!
Conclusion
Modern tortoise keeping recognises that
tortoises are reptiles and that their keeping
requires levels of biological support as
does keeping snakes and lizards.
The difficulty for the practitioner is that
many Mediterranean tortoises have coped
with the British climate for many years,
giving the illusion that these animals do not
need such support. To overcome this, vets
seeing these animals must communicate
well to educate the “traditional” keeper and
demonstrate such standards in their
hospitalisation and treatment. ■
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