| Summary: | Abstract Background Upper respiratory disease was reported over many seasons in Arabian foals on a single stud farm in the Middle East. Affected foals were noted to have mucopurulent nasal discharge, cough, fever and tachypnea. All affected foals had been empirically treated with a macrolide and rifampicin, by the referring veterinarian without improvement. On endoscopic examination, all affected foals had significant guttural pouch empyema (GPE). Objectives (1) To document a previously unreported presentation of guttural pouch empyema (GPE) in a family of juvenile Arabian foals; (2) To document the cytological and microbial composition of the empyema; (3) To identify clinical signs significantly correlated with the presence of GPE, as predictors for the need for guttural pouch (GP) endoscopy; (4) To demonstrate successful resolution of the identified syndrome with mechanical GP lavage and evidence based antimicrobial use, improving antibiotic stewardship and the one‐health approach to respiratory disease in this demographic of foals. Methods Evaluation and scoring of clinical signs, upper airway endoscopy and thoracic ultrasound were performed in 14 affected foals and 10 age‐matched controls, followed by comparative tracheal and guttural pouch sputum culture and cytological evaluation. Therapeutic GP lavage was performed and response to therapy monitored. Results GPE, cranioventrally distributed ultrasonographic lesions and opportunistic pathogen infection suggested a primary lesion of GPE with aspiration of GP discharge into the lungs. GP lavage resolved the empyema and associated clinical signs in all cases. Conclusions Cytological examination of tracheal and guttural pouch aspirates revealed a neutrophilic exudate with lipid‐laden phagocytes, suggestive of engulfed milk. Bacteriology revealed a high prevalence of Streptococcus equi ssp. zooepidemicus admixed with other opportunistic pathogens. Streptococcus equi ssp. equi was not isolated in any case.
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