Transcript Case of the Month - Ross Bond

Crusting and exudation
in a Welsh stallion pony
Author: Mark Craig
Editor: David Lloyd
© European Society of Veterinary Dermatology
History -1
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10-year-old Welsh pony stallion
Weight 300 kg
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History | Signs | Differentials | Tests | Therapy | Notes
History -2
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First signs developing over a 4-week period
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Papules on flank and neck, pruritus
Generalised crusting and exudation
Swelling of all four legs accompanied by stiffness and
lameness
Weight loss and lethargy
No treatment by the referring vet
History | Signs | Differentials | Tests | Therapy | Notes
Clinical signs - 1
The horse was thin and there was generalised
crusting with diffuse alopecia
No peripheral
lymphadenopathy
was detected
History | Signs | Differentials | Tests | Therapy | Notes
Clinical signs - 2
Close-up views of alopecic and crusted areas
Clipped area on the
withers
History | Signs | Differentials | Tests | Therapy | Notes
How would you
approach this case?
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What are the next steps you would take?
Make a list of your principle differential diagnoses
List any samples you would collect
List any tests you would perform to assist in making a
definitive diagnosis
History | Signs | Differentials | Tests | Therapy | Notes
Test - 1
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Principle differential diagnoses
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Bacterial folliculitis, dermatophilosis, dermatophytosis
Ectoparasitic infestation
Pemphigus complex, SLE, drug eruption
Allergy
History | Signs | Differentials | Tests | Therapy | Notes
Tests - 2
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Tests
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Blood tests: routine haematology and biochemical
screens; ANA test
Multiple punch and excision biopsy samples from
crusted and alopecic areas
Skin scrapings, crusts and hair pluckings for
microscopic examination, smears, bacterial and
fungal culture
History | Signs | Differentials | Tests | Therapy | Notes
Results
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Scrapings, crusts and hairs did not reveal
ectoparasites or fungal structures; Dermatophilus
was not demonstrated on microscopic
examination
Haematological and biochemical profiles were
within accepted limits. The ANA test was
negative
Histopathology revealed a superficial pustular
dermatitis. No micro-organisms were found in the
lesions
History | Signs | Differentials | Tests | Therapy | Notes
What now?
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What treatment, if any, should you now institute
whilst waiting for the fungal cultures?
What are now your principle differential
diagnoses?
Are there any other samples you would collect?
History | Signs | Differentials | Tests | Therapy | Notes
Initial therapy
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Ectoparasitism and neoplasia were deemed
unlikely
Autoimmune or immune-mediated disease
seemed likely and the horse was deteriorating
hence therapy was initiated
Prednisolone, 0.5 mg/kg daily; trimethoprim and
sulphadiazine (Uniprim), 0.5 sachet daily
History | Signs | Differentials | Tests | Therapy | Notes
What is your
diagnosis?
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What is your principle diagnosis?
Do the investigations permit a definitive diagnosis?
Are there any additional investigations which you
think may need to be done?
History | Signs | Differentials | Tests | Therapy | Notes
Further tests
Histopathology
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A superficial pustular
dermatitis was present
The pustules contained
many neutrophils &
acanthocytes but no
micro-organisms
History | Signs | Differentials | Tests | Therapy | Notes
Diagnosis
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Pemphigus foliaceus
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Lesion type and histopathology are consistent
No history of previous drug therapy
Fungal culture was negative
History | Signs | Differentials | Tests | Therapy | Notes
How would you deal
with this case?
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What is your prognosis?
How will you advise the owner?
What treatment would you consider?
History | Signs | Differentials | Tests | Therapy | Notes
Response to therapy - 1
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After 5 days the lesions were unchanged
The prednisolone dose was increased to 300 mg
per day and there was a moderate improvement
over a period of 10 days - decreased scaling and
some hair regrowth
Steroid therapy lapsed (owner’s choice) and the
horse’s condition remained stable over a twomonth period but then again worsened
History | Signs | Differentials | Tests | Therapy | Notes
Notes
Response to therapy - 2
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Prednisolone therapy at 300 mg twice daily (1
mg/kg b.i.d.) was resumed. Within 2 weeks all
lesions had disappeared and after 1 month the
horse was reported to be in good condition
Attempts will be made to lower the dose over the
coming months
History | Signs | Differentials | Tests | Therapy | Notes
Prognosis
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Prognosis is guarded
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The disease may require potent immunosuppressive
therapy with significant side effects
It may not respond adequately
History | Signs | Differentials | Tests | Therapy | Notes
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History | Signs | Differentials | Tests | Therapy | Notes