She Who Rules

Maeve was never your average lamb, and from the start Emily Jaramillo, V’26, was smitten.

“She has a really vibrant personality,” Jaramillo said. “She knows when you’re around, and she’ll be very loud and vocal to make sure that she gets attention. And if there’s no one paying attention to her, she will yell so loudly until someone comes and gives her attention. She’s so sweet.”

But Maeve was also in a great deal of pain when the student met her. The Dorper lamb, orphaned at just a few days old, was afflicted with congenital cutaneous angiomatosis, a rare progressive vascular disorder. It’s characterized by an abnormal proliferation of small blood vessels in and below the skin, as well as bleeding, inflammation, and infection. For an animal like Maeve, it can be a death sentence.

However, the nature of Maeve’s ailment wasn’t immediately known. From the time she was a few weeks old, an ever-growing team of Penn Vet veterinarians at both New Bolton Center and Ryan Hospital did battle with her many mysterious infections, trying to find the lasting answer. No one wanted to give up on a spirited little creature that worked her way into so many hearts.

Still, by the time Maeve was about six months old, her care options appeared to have gone dry. Her owners Sarah Salluzzo and Jonina Turzi brought her home on hospice care to their Lancaster Farm Sanctuary, a nonprofit animal rescue in Lancaster County. With heavy hearts, they posted to Maeve’s many social media followers locally and abroad: “Please join us in welcoming Maeve back home for what is likely going to be the last time.”

Around then, Jaramillo was in oncology rounds with Thomas Lee, assistant professor in radiation oncology, DVM, DACVR, assistant professor in radiation oncology. Lee lectured about radiation—how it can be used to control bleeding in non-cancerous diseases, as well as with cancer.

Something in Jaramillo’s brain clicked. She told Lee about Maeve. Could radiation possibly help her?

Lee told her he thought it could.

The next day, Jaramillo shared her conversation with Daniela Luethy, assistant professor of large animal medicine, DVM, DACVIM, assistant professor of large animal medicine, and one of Maeve’s doctors. She told Luethy about her conversation with Lee. Luethy quickly reached out to Lee and Christine Cain, DVM, DACVD, associate professor of dermatology, and another principal member of Maeve’s care team.

Shortly afterward, Salluzzo’s cell phone rang. It was Cain. Salluzzo couldn’t imagine why the doctor would be calling at that point.

“Dr. Cain said, ‘We was talking to our radiation oncologist at the Ryan small animal hospital. We have this idea.’”

And what an idea it was:

Lee was going to treat Maeve with radiation—an almost unheard of course of action for a very rare condition, and even more rare in ruminants. But Lee considered radiation therapy for Maeve despite the rarity of the condition. While no reports described its use in sheep, the veterinary literature included two canine cases of angiomatosis that responded to radiation, providing a rationale for its consideration.

“Maeve was out of options, and (her people) were almost out of hope,” Lee said. “They were already considering humane euthanasia.”

“I knew theoretically radiation could work,” he said. “I was open to giving it a try.”

It was a Hail Mary pass after months of committed effort and outside-of-the-box thinking by a lot of clinicians in a broad range of specialties. Maeve’s last best chance would call on all those reserves, creativity, open minds, and a lot of coordination.

It was no small feat the lamb had even gotten that far. Maeve was born defying the odds.

Last April, Salluzzo and Turzi were at a slaughter auction elsewhere in Pennsylvania, looking for animals to rescue when they heard an awful racket coming from a pick-up truck.

“We heard this lamb screaming, screaming, and screaming in the parking lot,” Salluzzo said.

That was Maeve. Born at the auction three days before, she was orphaned when her mother was sold. The animal lovers managed to convince the person who had her to give her to them.

A feisty little lamb and a lot of people fighting to save her

They called her Maeve, meaning “She who rules” in Old Irish. Far from docile, she started living up to her name right away. At first that odd, purple discoloration on her right hind leg that extended into her midsection didn’t keep her from being a perky baby. But other health problems soon flared.

Maeve was just a few weeks old when she had her first admission to New Bolton Center. She had a bad case of diarrhea which her owners couldn’t bring under control. It was cryptosporidiosis, a highly contagious gastrointestinal disease caused by parasites. While at New Bolton Center, her clinicians noted that her odd purple skin condition was advancing, Salluzzo said. The lamb had already started to show lameness in her right leg.

Maeve got to go home but not for very long. Her skin condition continued to worsen. Her right leg was bothering her more. “She wouldn’t even put weight on it. She was really, really uncomfortable,” Salluzzo recalled.

Maeve was re-admitted to New Bolton Center for tests. The results were not conclusive, even after consulting with multiple pathologists and dermatologists.

Maeve did have a nasty Pseudomonas infection in the area of the skin condition, along with inflammation around her blood vessels. Curing her wouldn’t be easy.

“Pseudomonas is a bacteria that likes to form biofilms,” said Joy Tomlinson, DVM, PhD, DACVIM (LAIM), assistant professor of large animal medicine, who treated Maeve early on. “Biofilms are where the bacteria encase themselves in this protective environment and it makes them much more resistant to antibiotics.”

 The only antibiotic predicted to work was an IV antibiotic that Maeve would need for several weeks, possibly longer.

Her owners were committed. Every morning, they administered the antibiotic, plus the required catheter flushes multiple times a day. It was a lot for a young animal to endure. But Maeve was a trouper.

“She was jaunty, and she was just so brave,” Salluzzo said. “I think the biggest thing was she really trusted us.”

Turzi held Maeve on her lap during the antibiotic treatments. “And through it all,” Salluzzo, “we fed her cookies.” Animal crackers—what else?—became her favorite.

During all this, Maeve went to New Bolton Center for periodic check-ups. The dermatology department at Ryan Hospital was called in. Cain became one of her main doctors. Her owners gave her frequent baths with bacteria-fighting shampoo. Maeve loved it; she pranced—as well as she could—straight into the house on her three good legs.

All the care seemed to be paying off.

“Over time, she improved overall in the appearance of her leg,” Luethy said. Eventually she was taken off the antibiotics. “Then the issue returned.”

Her doctors at New Bolton Center were going to give Maeve a repeat skin biopsy and CT scan. Salluzzo and Turzi decided to get a second opinion due to the complexity of Maeve’s case. With her affliction more developed than just a few months before, that second opinion, after repeating those tests, yielded the diagnosis of angiomatosis, but no hope. Salluzzo said they were told hospice care was really their only option.

“So, then we brought her home,” she said. “We were absolutely devastated.”

And Maeve’s condition worsened. The owners brought her back to New Bolton Center, not yet ready to give up.

Maeve’s New Bolton clinicians didn’t want to give up, either.

“At that point, we talked about things we could consider,” said Luethy, who by then was Maeve’s main veterinarian along with Cain. “But we didn’t think any of those options would be effective.”

Amputation even came up, but the angiomatosis was too widespread.

“In any species, this is a rare condition,” said Cain, who had begun to suspect Maeve had angiomatosis even before the actual diagnosis. “I’ve been a dermatologist for 15 years, and I’ve only seen probably three or four cases.” None were sheep.

She had managed one dog’s case, less severe than Maeve’s, with medical treatments, along with carbon dioxide laser therapy.

“But that was not a good option for Maeve because of how extensive her disease is,” Cain said. “It’s too deep within her skin for us to really be confident that it would be effective for her.”

She and Luethy decided to try beta blockers, a medication used to treat a similar condition in children and that was part of the therapy she used for the dog with angiomatosis. Again, Cain said, there was a dearth of information about using them with ruminants.

“We tried it with Maeve, but it just wasn’t clear if it was having any effectiveness for her,” Cain said.

They had even considered radiation but didn’t think it was a good option for Maeve until consulting with Lee.

It seemed Maeve’s clinicians were left little choice but to prescribe medication that would at least help alleviate her suffering.

“As kind of a last-ditch effort, we started her on a steroid medication just to help decrease the inflammation and swelling,” Cain said. “That’s not a great long-term option, but we thought it might at least buy her some comfort.”

Her owners took Maeve home. “We were kind of like, ‘We’re going to give her as much happiness as we can, but this is the end.’ I think everybody at that time felt that way,” Salluzzo said.

A bold plan, a glimmer of hope

Over the course of her care, however, Maeve had made two dedicated friends. She captured the hearts of two Penn Vet students, Jaramillo and Tiffany Chou, V’26.

Chou was in her large animal medicine rotation with Luethy when she got involved in Maeve’s care.

“She has a very spunky personality,” said Chou.

Chou had to give the lamb frequent antiseptic baths for her secondary infections. Because of Maeve’s pain, these had to be done very gently. Jaramillo volunteered to help. That’s how she met Maeve.

“I do have a very special place in my heart for all the small ruminants, both sheep and goats,” said Jaramillo. “I really did bond with Maeve.”

The two friends would even brainstorm possible treatments for the lamb. Jaramillo tried to keep track of Maeve’s case after she was no longer in her care.

Then one day last fall, Jaramillo was in a lecture, learning about radiation. And that was about to change everything.

Lee, Luethy, and Cain had a meeting. Maeve’s owners got on board. Then there were the logistics—lots of them.

“It required a lot of moving parts,” Cain said. “There was a whole Maeve team involved—everyone from anesthesia to radiation oncology.” The radiation would be done at Ryan which usually doesn’t treat ruminants. ICU had to be looped in in case Maeve had difficulty with anesthesia. “Everyone was involved.” The plan was to give Maeve four radiation treatments, beginning early November and ending the day before Thanksgiving. No one knew if they would succeed.

“I think we may be able to see some improvement within a couple weeks,” said Lee shortly before the first treatment. “If it works, it will keep getting better.”

Lee had a plan.

He prescribed her a lower radiation dose than for cancer but higher than for other noncancerous conditions. The dosage he prescribed was intended to collapse abnormal vascularization without significant side effects.

To up Maeve’s odds even more, Lee created a resin bolus using a 3D printer that would fit over Maeve’s angiomatosis area. The purpose of the bolus was to allow the radiation to concentrate on the diseased area and lower the dose to deeper, normal tissue. Plus, Lee said a 3D-printed bolus could improve accuracy compared to a conventional bolus.

On treatment days, Team Maeve was out in force. In addition to Lee and his radiation team, there were Maeve’s New Bolton Center clinicians, residents who had assisted in her care, dermatologist Cain, anesthesiology, and a host of nurses. Even Jaramillo and Chou pitched in.

The patient’s owners printed “She Who Rules” T-shirts with Maeve’s likeness for her many fans. They gave them to her Penn Vet team, and the shirts became Team Maeve’s radiation day battle gear.

And, of course, there were always plenty of the ultimate weapon: animal crackers. Maeve got to recognize the box.

Her owners had worried the treatments would be stressful, but Maeve thrived on the attention.

“She walks in and out of that hospital like she owns the place,” Turzi said.

Concerns about Maeve and anesthesia proved needless.

“She’s an anesthesia champion!” Cain said.

Maeve was also quite the attraction as she walked through Ryan’s pup-and-cat-filled waiting room. Heads turned. There were gasps.

“Is that some kind of dog?” one incredulous man uttered.

The treatment takes effect

Shortly after the second treatment, Maeve showed improvement. She was walking better. The skin on her right leg looked less angry. It was way too soon to tell, cautioned the doctors.

But week after week, the improvement continued.

At her final treatment, a photo was taken of a contented Maeve, wearing a crown, surrounded by her pleased-looking caregivers.

By the New Year, Maeve was gamboling through the sanctuary’s fields. On their Instagram page, there’s a video of Maeve bursting out of the barn, and this message:

“Since Maeve’s life-saving radiation treatments, she had clearly been feeling better. But today, we can hardly believe our eyes. She is running and jumping and playing like we have not seen since she was a tiny baby. It’s incredible!!!!”

Lee, pleased with his patient’s progress, offered a caution: it’s still unknown how long Maeve’s improvements will last. If the angiomatosis remains under control for at least six months to a year but then flares up, more radiation may be considered, he said.

But with four months since her last treatment, Maeve was moving friskily toward her first birthday, and there seemed to be room for positive feelings.

“This experience was really special because there was such an extra effort,” Salluzzo said. “We can never say enough how grateful we are to those students and to the doctors who went above and beyond for Maeve.

“It was beautiful seeing all these people understand that Maeve deserves just as much as anybody’s dog or cat,” she said. “Those people sincerely cared about her. Even after reaching the conclusion of ‘Nothing else can be done,’ they kept trying.”