Comments from Zoo veterinarian Dr. Ben Okimoto, DVM

September 25, 2000:  

Thank you for sharing our concerns. Yes, "Pandji" is gravely ill. It started on August 29th as we had completed a routine physical on him. About 40 minutes after the end of the procedure and as he appeared to be recovering normally, he started having repetitive seizures. I gave him medication to stop the seizures, but after he quieted down, he appeared to be going into shock so we immediately started shock treatment. I also heard a loud heart murmur which I had not heard from him before. His condition was stabilized and we had zoo staff monitoring and stimulating him all night.

The next day his condition had not really changed and I called in a colleague to assist with more intensive treatment. Besides the usual blood and urine samples, we obtained cerebral spinal fluid (normal), chest tap fluid (normal) and a EKG strip. We inserted an indwelling IV catheter in his jugular vein and so had him on an IV drip for about 3-4 days. We obtained more blood samples and adjusted his fluids and medication throughout, which included IV drugs and oxygen by nasal tube. As he was recovering, we observed abnormal pupil sizes, which indicates brain abnormalities. He slowly recovered over the next 5-7 days, where his pupils returned to normal, the heart murmur went away, he started to eat and drink again, and he became more active.

By the 13th and 14th of September, "Pandji" was acting quite normal, eating 8 lbs. of food a day, bm and urination normal, we let him out on exhibit and he was interacting with our female tiger. I had already been scheduled to leave for the annual zoo vet conference the night of the 14th, so I was much relieved when I left. Unfortunately, from that night, he has had problems keeping food down and is losing weight. He also lapses into periods of stupor and unresponsiveness.

At the zoo vet conference, I took advantage of the opportunity to consult with some of the best zoo vets in the country, if not the world (e.g.. head vet at San Diego Zoo). The consensus was that he has multiple problems, some possibly congenital (he did have a heart murmur as a young cub, and he was born with an undescended testicle). About 8 years ago, he developed lesions diagnosed as Idiopathic Eosinophilic Granuloma complex and has been on medication for that ever since.

We have been keeping him hydrated with SQ fluids and have been trying multiple types of food to offer to him. I'm sorry if this is rambling, but we are actually still working with him at present. We are reviewing a EKG printout that a colleague from the Kansas City Zoo sent me of a normal Siberian tiger to compare to "Pandji's" EKG.

I have been consulting with human doctors and we plan to do another workup on him tomorrow, getting X-rays, endoscopy of his esophagus and stomach, liver biopsy, and ultrasound of his heart. So I can assure you that there have been many zoo staff members, zoo volunteers, and outside consultants that have spent many days (and nights) at his side caring for him. What is really worrisome and confusing is that after seeming to be well on his way to recovery, "Pandji" has relapsed into periodic depression and has started to show abnormal signs which he did not have before. We will not know much more until we do more diagnostic work tomorrow. I will try to keep you posted on his condition but please recognize that we need to spend a lot of time studying and caring for him. Again, thank you for your concern.

September 29, 2000:  

Thank you for your continued concern for "Pandji". Unfortunately, the latest information is not good. On Sept. 26, with the help of my small animal vet colleague, a DVM/MD from Straub Hospital, and an MD Cardiologist from Straub Hospital, we conducted more tests on "Pandji". A complete heart exam with ultrasound and EKG showed that except for a slightly thickened pulmonary valve, his heart function appeared normal. X-rays of his chest and abdomen were normal except for possibly a small liver and possibly an abdominal mass that could be his retained testicle.

However, when my colleague, Dr. Kau, was conducting the endoscopy of "Pandji's" esophagus, we found what appeared to be a stricture, or abnormal narrowing of the esophagus. It was located in the middle of his chest, near the heart. The remaining opening was so small that even the endoscope could not pass through it, meaning it is smaller than 1/2 inch wide. It was also very tight and could not be forced open. There were no signs of previous trauma (ulcerations or abrasions or scarring) at that site. Dr. Kau was able to take about 5 biopsy samples from the stricture.

In order to obtain the fastest report, we sent the biopsy tissues by courier to IDEXX labs in California. The initial report that we received late yesterday indicates that the tissue at the site of the stricture may be precancerous ("focal squamous dysplasia, could be associated with an early or premalignant change to squamous cell carcinoma"). I have asked my regular zoo animal pathologist, Dr Bob Schmidt in Sacramento, to review the tissue slides for his concurrence. If Dr. Schmidt agrees with the diagnosis, then "Pandji's" future is very grim. I am also consulting with other colleagues for their opinion, but at this point, it appears that despite "Pandji's" impressive recovery earlier this month, we may not be able to do much more to cure him this time. Surgical removal of the stricture would be extremely difficult and dangerous, due to the location of the site.

"Pandji" has shown great strength and character throughout this whole ordeal and he has been a favorite personality to many of us. We are all concerned about his quality of life. There are many times when we human beings must act in the best interest of the animals under our care, and Veterinarians are responsible and sometimes obligated to make life and death decisions. I suspect that I will have to make that decision for "Pandji" in the very near future. Thank you for your support.

October 6, 2000:  

To all of you who have been concerned about the plight of our male tiger "Pandji", I finally have some good news. On October 4, Dr. Hartman, a Gastroenterologist from Straub Hospital, conducted an endoscopic exam of "Pandji" and found 3 sites with strictures of the esophagus. The remaining size of the openings were as small as 3 mm (or about 1/8 inch) in diameter. It's no wonder that he couldn't keep any food down. Dr. Hartman's instruments (which he uses on humans) were small enough to fit into the strictures and he could dilate them with balloon cuffs. He also took several more biopsy samples from each stricture site.

Dr. Hartman also found a hiatal hernia, which is an abnormal opening at the diaphragm. The histopathology results from the biopsy samples have not returned yet. Again, that will probably give us a better prognosis of recurrence and might indicate the cause of the strictures. From what could be seen with the endoscopes, we are thinking now that the strictures may have been caused by gastric reflux through the hiatal hernia. The strictures were chronic in appearance, meaning it took a while for them to form, so hopefully it will take a long time if they do recur. "Pandji's" stomach and upper intestinal tract appeared normal to Dr. Hartman.

"Pandji" has been on a liquid diet through this morning, but the plan is to slowly start adding more solids and increasing the volume of food offered to him. Although he did vomit a portion of the liquid diet shortly after he recovered from anesthesia, he has kept down all of the liquid diet that he has consumed. We have also let him out on exhibit for a few hours a day. He consumes most of his food at night. What was interesting was that the case at the Chaffee Zoo in Fresno, California, showed very similar anatomical changes with the strictures in the esophagus and the hiatal hernia. We will be following up with them to see if other zoos have seen a similar problem with tigers.

At this point, I am much more optimistic than I was just three days ago. We still need to wait for final reading of his biopsy tissues and "Pandji" still needs to be eating more solids, but there is now more reason to hope for recovery.

October 19, 2000:  

Well, it appears we have "Pandji's" condition stabilized, but he is still far from normal. The last biopsy tissues did not reveal any signs of cancer or overwhelming bacterial infection. It still appears that his esophogeal strictures are the result of gastric reflux related to hiatal hernia. Over the last 2 weeks since the first dilation, "Pandji" was not able to consume anything other than a liquid diet. He also started to regurgitate a little, so yesterday, Oct. 18th, Dr. Hartman again performed an endoscopic exam and found that 2 of the 3 original strictures had reformed. They were not as small as the original strictures, but one of them was very tight. He dilated all the strictures to 2 cm. diameter, about the maximum diameter that can be done in humans and in large domestic dogs. "Pandji" had lost another 2 Kg. in the two weeks since the first dilation. He is noticeably thinner in his hindlegs, but he is still at 87 Kg. Dr. Hartman took some more biopsy samples yesterday just to recheck some areas that looked suspicious. "Pandji" did not have much of an appetite after the procedure. We are hoping that with the larger dilation, he can consume more substantial food. So far today he has been able to eat food with more solids added in to his regular liquid diet. We are feeding him Hills brand A/D and C/D blended with liver chunks. He is on 3 to 4 different types of medication, including Propulsid, Prilosec, and Carafate, mixed in the food. He is resposive and his attitude appears normal. We have let him back out on exhibit with "Djelita".

Thanks again to all of you who have expressed concern for "Pandji" and support for our efforts. Please join me in expressing gratitude to Dr. Hartman and his staff at Straub Hospital for their overwhelming support and voluntary assistance in helping to save "Pandji".

We still hope for "Pandji's" complete recovery, knowing that his strictures reformed within 2 weeks, and aware that the similar case at Fresno zoo has required at least 4 repeated dilations.

November 28, 2000:  

Thank you Noreen, Sandi, Ted, Cynthya, and to all of you who have expressed continuing concern for "Pandji". By the end of this week, it will have been 3 months from the time that he first became ill. "Pandji's" condition is stable, for now. I mean that he is not showing signs of continued deterioration, but I would like to see more signs of continued improvement. For the last few days, he has been let out onto the exhibit with "Djelita" after he has consumed his morning medications. He also has a late afternoon feeding, so he may be pulled off exhibit earlier than usual. Most of the tiger feeding is done in their holding pens by our Night-keepers, after the zoo is closed.

Earlier this month, "Panji" started to show signs of strictures, so I again asked for Dr. Hartman's assistance. On November 14th, Dr. Hartman and his staff again performed endoscopy and dilation. Two strictures had reformed, one of them down to 3 - 5 mm. Dr. Hartman, Dr. Kau, and I discussed whether we should proceed with further dilation (beyond the balloon dilation that Dr. Hartman would be performing). I felt we needed to attempt more aggressive dilation and so requested that Dr. Kau attempt dilation with a rigid plastic tube. This technique is called "Bougienage". Using progressively wider tubes, he was able to dilate the esophagus up to 2.5 cm. (the softer balloon catheters can only inflate up to 2.0 cm.). However this technique causes more tearing of the walls of the esophagus.

"Panji" was still thin, but he had lost only a few Kg. in the month since the previous dilation. He was down to 84.4 Kg on 11/14. His appetite did not recover as quickly this time, I suspect due to the increased tearing of his esophagus. We started him back on the same medication as before, but added more antibiotics and appetite stimulants. I also started offering him IAMS/Eukanuba brand Maximum calorie diet and Beef liver diet. We noticed that he started to eat more solid food, first the canned diets, then small chunks of raw meat, and finally some of his regular horse meat commercial diet. At this point, he is consuming a fair amount of solid food, around 4 - 5 lbs. per day, plus 30 - 40 oz. of canned food. We noticed that he seems to be having more difficulty swallowing his regular commercial horse meat diet and are now offering him ground beef supplemented with vitamins.

The tiger at the Fresno Zoo has undergone 4 dilation procedures and is now on a different diet called "Breeders Choice". We have been in contact with the manufacturer and found out that it would be difficult to ship this product into Hawaii. I have asked our colleagues in Fresno to send me a few pounds of the stuff to offer to "Pandji". If the ground beef doesn't work out, we may still ship in the "Breeder's Choice" just for "Pandji".

FYI: "Djelita" started to show signs of illness several weeks ago. She was less responsive, didn't eat as much, and of course we were very concerned. We didn't think her problems could be related to "Pandji's" but it did seem to be too coincidental. On November 9th, we anesthetized her and did a full physical exam. She weighed 90 Kg. and we found signs of very bloody diarrhea. Besides the physical, we took Xrays, lots of lab samples, and did an endoscopic exam of her esophagus. Although the inside of her esophagus looked a little inflamed, biopsy samples proved to be all normal and there were no signs of any strictures or hernias. We started her on medication and awaited the lab results. So far, all the lab results have been normal or not significant, and there have been no more signs of diarrhea. "Djelita's" appetite and food consumption have returned to normal, and at this point I would propose that she had suffered some kind of bacterial or toxic enteritis, which has resolved itself, and is not related in any way to "Pandji's" illness.

Again, thank you for all your concern. I will keep you posted.

January 11, 2001:

"Pandji's" condition remains stable, and the cause of his problem continues unchanged. Last month, his keepers noticed that he was starting to regurgitate again, so I asked Dr. Hartman for his assistance. On January 4th we found that "Pandji's" overall body condition had improved and that he had gained 15 pounds since the last procedure on November 14th. Although he doesn't look it, he is actually heavier than "Djelita".

Unfortunately we also found that one of the strictures had reformed at the same site, and it was quite small again. However, one of Dr. Hartman's technicians had modified one of the balloon catheters and this time they were able to expand the stricture up to 3.5 cm. This is the widest dilation that we have been able to accomplish thus far. Dr. Hartman also made small nicks into the band of tissue that was forming the stricture to try to prevent it from reforming as quickly. "Pandji's" mouth granulomas seemed larger and more inflamed this time, so Dr. Kau injected the involved sites with long acting steroids.

"Pandji" seems to be recovering fine. We are trying to get him to consume larger chunks of meat to force expansion of the stricture site, again trying to delay the reformation of the stricture. "Pandji" is not fully complying with our instructions and at times is quite finicky about the flavoring of his diet. He really likes beef liver and will consume larger chucks of liver than meat chunks. So the keepers have tried marinating the meat chunks with blended liver and that seems to improve his consumption. We are still offering him lots of canned food and hamburger gruel. His medications continue to be Omeprazol and Prednisolone daily.

Coincidentally, the zoo vet from the Fresno Zoo, where they have a similar medical case in a tiger, will be here at the end of the month as part of a accreditation inspection team. We have been in consultation already with "Pandji's" condition, so we will have lots to compare and commiserate about.

Again thank you to all who have expressed concern for "Pandji". He is being let out daily, so you should be able to see him on exhibit.

February 14, 2001:  

"Pandji" started to show the same signs of going off feed and regurgitation during the later part of January, so I again asked Dr. Hartman for assistance. On February 2nd, Dr. Hartman and his staff again performed dilation of "Panjdi's" strictures. We did find some improvement in his overall conditon. He had gained about 16 lbs. since the last procedure on January the 4th, increasing from 91.4 kg. to 98.6 kg (217 lb.). He is getting closer to his normal weight of around 110 kg.

Dr. Hartman also found that although two of the three strictures had recurred, they were not as narrow as they were previously. The middle stricture was again the smallest one and his hiatal hernia was unchanged. Dr. Hartman again dilated the strictures with balloon catheters (which you should be able to see on the video). This time he followed the dilation with electrosurgery using a "needle knife". We use a smaller version made for use on animals. The electrosurgical unit powers an electrode with a wire tip. The current can be adjusted so that a spark emitting from the electrode tip will cut and/or coagulate tissue. The "needle knife" that Dr. Hartman used could be slid through the flexible endoscope and positioned with the tip of the endoscope. So after dilating the strictures he incised the inner lining of the esophagus to produce longitudinal slits where the strictures were recurring (this is also on the video). Hopefully these incisions will prevent or prolong the time interval between strictures recurring.

"Pandji's" mouth lesions seemed to be inflammed, so Dr. Kau injected the granulomas again with steroid.

"Pandji" is recovering better than before and his appetite seems to be improved. Last week, he ate 100% of his night feeding (the major meal offered to him) for 4 nights in a row. That was the best he has eaten in several months and amounts to 5 lbs. of hamburger and about a dozen small cans of commercial diet. My plan now is to continue to reduce the number of canned commercial diet and increase the amount of hambuger (with supplemental vitamins and minerals).

April 4, 2001:  

Thank you for your comments and concern. Pandji continues to do okay. We are at about 2 months since the last procedure, which is the longest we have gone between dilations. Within the last week he has shown some signs of mouth irritation and some regurgitation, which may be early signs of recurrrence, however he seems to be fine otherwise. Currently he is fed 4 lb. of hamburger, 3 pieces of liver, and 2 small cans of cat food every night. He also gets 2 cans of cat food every morning.

July 17, 2001:  

Hi Lisa, thank you for your continued interest in "Pandji". I'd say he is pretty much back to "normal". Since my last posting re: his condition on April 4, '01, he has shown fewer episodes of regurgitation, continues to eat well, and have normal bowel movements (an unpleasant subject matter but very important medically). He is fed essentially the same diet as he was in April. At this point I see no need to have to examine him again until his next scheduled physical, which will be around October. In the meantime, "Pandji" is out on exhibit daily if you would like to come down to visit him. Aloha

February 15, 2002:  

Pandji was due for his annual exam this month, so we immobilized and examined him on Wed. Feb. 13th.. Unfortunately Dr. Bill Hartman, who assisted in treating Pandji last year, has relocated to Hilo, but we were lucky to still have the staff from the Gastroenterology department of Straub Hospital come down to help us. Dr. Jerome Walsh, Judy and several other Doctors and nurses assisted in examining Pandji's esophagus. They were able to accomplish this due to Pentax Company providing the use of one of their best endoscopes and video monitor. What Dr. Walsh found was that a partial stricture had recurred at the same site in Pandji's esophagus. Dr. Walsh was able to break the stricture down using the same balloon device used last year. Pandji had been showing periodic partial regurgitation lately. Although we didn't like to see any recurrence of the stricture, it was not unexpected. And if that was the extent of recurrence after one year, then I am encouraged that we should be able to maintain him in good health otherwise for the forseeable future. Pandji's workup on Wed. was filmed and broadcast on KITV news by Gary Sprinkle. Thank you to all who have been concerned about Pandji's health.

June 11, 2005:

The Passing Of Pandji
By Dr. Ben Okimoto, DVM

On March 5, 2005, Pandji, our 14-year-old male Sumatran tiger, was euthanized. Over the last few years, Pandjis major medical problems had stabilized to where it was sufficient to treat his esophageal strictures only once a year during his annual exam.  Although Pandji was diagnosed with and treated for a urinary bladder infection in July of 2004, lab tests done on March 2^nd of 2005 indicated that his kidneys were failing, and even though we were treating him, his health continued to deteriorate. 

The frequency and quantity of his feedings had been increased because of the recurring esophageal strictures and his chronic mouth lesions. He also showed a tendency of decreased acceptance of his diet with any changes in the formulation. By February of 2005, Pandji was being offered 4.5 lbs. of meat mix plus 3 small cans of specialized animal food (1 lb.) plus 1.5 to 3 cups of water mixed in, twice a day. This totaled 11 lb. of food a day (he had access to water free choice all day and night). In past years (eg. year 2000) Pandji was consuming around 8 lb. of food a day, which was comparable to the daily consumption by our male lion, even though he outweighed Pandji by about 100 lbs.  

During the later part of February, Pandjis food consumption slowly decreased to where he would not eat even when offered only canned food mixed with raw liver.  He became very lethargic, so we conducted a medical work up on March 2^nd and found him to be thin, dehydrated, and incontinent. Lab tests run during that exam found that he was in kidney failure. Urine culture later confirmed that there was a Strep bacteria infection of his bladder. I consulted with Dr. Kau on further treatment and Pandji was given lots of fluids (total of 4.5 liters IV and 9 liters SQ) as part of the treatment for kidney failure. The next day Pandji was still very weak and slow to respond, although he did eat about 6 lbs. of strained food in the morning and about half that amount in the evening. On March 4^th his condition had deteriorated further. The morning of March 5^th showed no changes so he was euthanized. 

A complete post mortem exam was done that day and multiple medical abnormalities were found. Ironically, although he had lost a lot of body weight, there was an excessive amount of fat in the coronary groove around his heart and it appeared to me that his heart was thin and soft. He also had a fair amount of fat stored inside his abdomen. We did find the esophageal strictures and oral (hard palate) granulomas as expected, but there were also surface ulcerations on this tongue and esophagus. The most dramatic changes were seen in his urinary system where there was extensive inflammation of his bladder wall, and both kidneys showed distention of the inner walls causing compression of the outer functional tissue (a condition called hydronephrosis).  Multiple (32) samples of tissues and organs were collected and sent to our consultant zoo animal pathologist in California for detailed histopathology review. 

The pathologists final report was received recently and it was an extensive four-page account listing 14 abnormal tissues or organs.  These included 3 sections of esophagus, both kidneys, urinary bladder, hard palate, salivary gland, tongue, heart, adrenal gland, liver, testicle, small intestine, and cecum. There were chronic lesions in his heart that suggested previous damage. The pathologist confirmed that Pandji was in kidney failure at the time of his death. The kidney failure was due to hydronephrosis, which probably resulted from the urinary bladder bacterial infection. 

Kidney failure results in uremia, a toxic condition that can lead to depression, nausea, vomiting, headache, vertigo, dimness of vision, lack of appetite, and oral surface ulcerations (as was found on his tongue and esophagus, which undoubtedly exacerbated his inappitence), coma or convulsions.   

Referring to Pandjis Illness at the Honolulu Zoos website will link you to photos and commentary regarding the early stages of his treatment. In September 2000, I wrote, Pandji has shown great strength and character throughout this whole ordeal and he has been a favorite personality to many of us.  We are all concerned about his quality of life. There are many times when we human beings must act in the best interest of the animals under our care, and Veterinarians are responsible and sometime obligated to make life and death decisions. I suspect that I will have to make that decision for Pandji in the very near future. As it turned out, I would not have to make that decision until 4 years later. 

The most significant reason for why Pandjis life was extended by 4 years (almost a third of his lifetime) was due to the voluntary assistance of nonzoo staff, including Dr. Phil Kau (Veterinarian), Dr. Jim Scoggin (Veterinarian/human Orthopedic Surgeon), Dr. Repique (Cardiologist), Dr. Walsh (Gastroenterologist), and Dr. Bill Hartman (Gastroenterologist). Dr. Kau selflessly and tirelessly assisted the zoo medical team in treating Pandji (Dr. Kau has done this continuously for many zoo animals for the past 17 years). However it was Dr. Hartman who was able to provide surgical treatment that was not available through veterinary means, and so it was Dr. Hartman who really saved Pandjis life. Only through the assistance of Dr. Hartman and his associates from Straub Hospital (Dr. Walsh, Judy, Wayne, and their fellow nurses and technicians) who gave their time and offered their expertise and use of state of the art equipment, were we able to really help Pandji and for that we will be forever grateful. 

Pandji will never be forgotten and he will always be missed. Rarely have I met animals that can serve as role models for humans, yet Pandjis strength of character, dignity, and perseverance while coping with multiple medical challenges served to inspire many people, zoo and nonzoo staff alike. Although the taxpayers of the City and County of Honolulu are the true owners of the zoo animals, it is the zookeepers who develop the closest emotional and spiritual bond with the animals that they care for. And with Pandji, perhaps those who were born in the Year of the Tiger developed an even greater affinity in bonding.  The effect that Pandji had on humans was clearly evident during the last couple days of his illness, as Judy and other nurses from Straub Hospital visited him, and his primary keepers, zoo staff and volunteers held a vigil for him until his last moments. In essence, people came to say goodbye and to pay their respects, a true and final tribute to Pandjis character, and it showed how much respect and love he generated among humans. I believe that animals have souls, and I believe that Pandji is in a better place, and that he is at peace.