Transcript Case of the Month

Dorsal alopecia in
a male crossbred dog
Author: Ewan Ferguson
Editor: David Lloyd
© European Society of Veterinary Dermatology
History and presenting
clinical signs - 1
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Dorsal alopecia in a male crossbred dog
Weight 25 kg
Dorsal alopecia and mild pruritus of 9 months
duration
Mild papular rash on dorsum and ventrum.
Comedones on dorsum and ventrum. Ventral coat
thin but skin “normal”
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History | Signs | Approach | Tests | Treatment | Notes
History
History and presenting
clinical signs - 2
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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 | Approach | Tests | Treatment | Notes
Initial therapy - 1
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Ectoparasite control
• Dog and both cats sprayed fortnightly with
dichlorvos + fenitrothion
• Home environment treated every 2 to 3 months
with permethrin + methoprene spray
• No improvement
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History | Signs | Approach | Tests | Treatment | Notes
Initial therapy - 2
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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 | Approach | Tests | Treatment | Notes
Clinical findings
on referral - 1
The ventral abdominal skin
A few scattered
papules, epidermal
collarettes & crusts
on dorsum &
ventrum
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History | Signs
Signs | Approach | Tests | Treatment | Notes
Clinical findings
on referral - 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
Signs | Approach | Tests | Treatment | 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
a definitive
definitive
diagnosis
diagnosis
History | Signs | Approach | Tests | Treatment | Notes
Case
investigation
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Principle differential diagnoses
• Allergy (fleas, atopy, ?food), Hormonal imbalance
including iatrogenic Cushings syndrome,
ectoparasitic infestation, dermatophytosis
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• Secondary pyoderma, Malassezia dermatitis
Samples
• Coat brushings, deep and superficial skin scrapings,
tape strippings, and hair plucks - search for flea
dirt, ectoparasites, dermatophytes, yeasts
• Biochemistry and haematology panels, urinalysis
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History | Signs | Approach | Tests | Treatment | Notes
Preliminary results
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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
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History | Signs | Approach | Tests | Treatment | 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 | Approach | Tests | Treatment | Notes
Further tests
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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
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History | Signs | Approach | Tests | Treatment | 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?
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History | Signs | Approach | Tests | Treatment | Notes
Results - 2
Low dose dexamethasone suppression test
250
200
Cortisol 150
nmol/l
100
50
0
Basal
3 hours
8 hours
Time
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History | Signs | Approach | Tests | Treatment | 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?
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History | Signs | Approach | Tests | Treatment | Notes
Further tests
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Radiography
• Mass suspected in the left adrenal region
Ultrasonography
• Hypoechoic foci in the liver suggestive of
metastases
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History | Signs | Approach | Tests | Treatment | Notes
What is your
diagnosis?
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What is your principle diagnosis?
List any additional problems which you think may need
treatment
Are there any other possibilities which should be
considered at this stage?
History | Signs | Approach | Tests | Treatment | Notes
Diagnosis
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Hyperadrenocorticism resulting from adrenal
neoplasia
Likely metastasis
History | Signs | Approach | Tests | Treatment | 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 | Approach | Tests | Treatment
Treatment | Notes
Prognosis
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Prognosis is guarded
• Surgery is not indicated in view of likely metastasis
• Medical management with Lysodren
recommended but results not predictable
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History | Signs | Approach | Tests | Treatment
Treatment | 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 sde
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History | Signs | Approach | Tests | Treatment
Treatment | Notes
Review
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History | Signs | Approach | Tests | Treatment | Notes
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