Transcript Case of the Month - Ross Bond

Dorsal alopecia in
a male crossbred dog
Author: Ewan Ferguson
Editor: David Lloyd
© European Society of Veterinary Dermatology
History - 1
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Dorsal alopecia and mild pruritus of 9 months
duration in a male crossbred dog
Weight 25 kg
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History | Signs | Differentials | Tests | Therapy | Notes
History - 2
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Mild papular rash on dorsum and ventrum.
Comedones on dorsum and ventrum.
Ventral coat thin but skin “normal”
History | Signs | Differentials | Tests | Therapy | Notes
History - 3
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Coat has become longer and finer in texture in recent
months
Polyuria and polydipsia (3 litres per day) reported
Good appetite. Poor exercise tolerance
No previous history of dermatological disease
2 cats in the house, both healthy
Diagnosed by the referring veterinarian as flea allergy
dermatitis
History | Signs | Differentials | Tests | Therapy | Notes
History - 4
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Ectoparasite control
• Dog and both cats treated with fipronil (Frontline SpotOn, Merial) monthly
• Home environment treated annually with pyroxyfen
and permethrin spray (Indorex, Virbac)
• No improvement
History | Signs | Differentials | Tests | Therapy | Notes
History - 5
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Pruritus now reported to be controlled with 10 mg
prednisolone orally once daily, over the last 4 months
No hair re-growth seen
All therapy stopped 2 weeks before referral
appointment
History | Signs | Differentials | Tests | Therapy | Notes
Clinical signs - 1
The ventral abdominal skin
A few scattered
papules, epidermal
collarettes & crusts on
dorsum & ventrum
History | Signs | Differentials | Tests | Therapy | Notes
Clinical signs - 2
Alopecia & hyperpigmentation in dorsal lumbar region
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No visual evidence of
ectoparasitism
Pendulous abdomen
& ventral liver lobes
palpably enlarged
Testes normal on
palpation
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
Differential
diagnoses
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Principle differential diagnoses
• Allergy (fleas, atopy, ?food), Hormonal imbalance
including iatrogenic Cushings syndrome, ectoparasitic
infestation, dermatophytosis
• Secondary pyoderma, Malassezia dermatitis
History | Signs | Differentials
Differentials | Tests | Therapy | Notes
Tests - 1
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Skin scrapings, tape strips, hair plucks and coat
brushings - no evidence of ectoparasites or fungi
Fasted blood sample
• Biochemistry: Alkaline phosphatase - 1850 iu/l;
Alanine aminotransferase - 170 iu/l; Glucose - 8.4
mmol/l; Cholesterol - 9.1 mmol/l
• Haematology: Mild mature neutrophilia &
eosinopenia
• Urianalysis: Specific gravity - 1.005; No glycosuria
History | Signs | Differentials | Tests | Therapy | Notes
What now?
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What are the next steps you would take?
What are now your principle differential
diagnoses?
Are there any other samples you would collect?
List any tests you would perform to assist in
making a definitive diagnosis
History | Signs | Differentials | Tests | Therapy | Notes
Tests - 2
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Principal differential diagnosis
• Hormonal imbalance particularly natural and
iatrogenic Cushings syndrome
• Secondary folliculitis
Tests
• ACTH response test to provide evidence of
possible Cushings syndrome and to identify
iatrogenic disease
History | Signs | Differentials | Tests | Therapy | Notes
Results - 1
ACTH response test
500
400
Cortisol
300
nmol/l
200
100
0
Basal
60 min.
Time
What is the significance of this test?
History | Signs | Differentials | Tests | Therapy | Notes
Results - 2
Low dose dexamethasone suppression test
250
200
Cortisol 150
nmol/l
100
50
0
Basal
3 hours
8 hours
Time
History | Signs | Differentials | Tests | Therapy | Notes
Results - 3
High dose dexamethasone suppression test
300
250
Cortisol 200
nmol/l 150
100
50
0
Basal
3 hour
8 hour
Time
What do these tests tell us?
History | Signs | Differentials | Tests | Therapy | Notes
What is your
diagnosis?
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Do the investigations permit a definitive diagnosis?
List any additional investigations which you think may
need to be done
History | Signs | Differentials | Tests | Therapy | Notes
Tests - 3
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Radiography
• Mass suspected in the left adrenal region
Ultrasonography
• Hypoechoic foci in the liver suggestive of
metastases
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
Therapy | Notes
Diagnosis
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Hyperadrenocorticism resulting from adrenal
neoplasia
Likely metastasis
History | Signs | Differentials | Tests | Therapy | Notes
Prognosis
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Prognosis is guarded
• Surgery is not indicated in view of likely metastasis
• Medical management with trilstane (Vetoryl,
Arnolds) recommended
History | Signs | Differentials | Tests | Therapy | Notes
Notes
Conclusion
The owner requested
euthanasia. At post
mortem examination an
adrenal neoplasm and
multifocal metastases
were demonstrated.
The adrenal tumour can
be seen in the centre of
the photograph, the
kidney is on the left side
History | Signs | Differentials | Tests | Therapy | Notes
Notes
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History | Signs | Differentials | Tests | Therapy | Notes
Notes