Transcript Case of the Month

Crusting of muzzle and
perineum in a Cavalier
King Charles spaniel
Author: Ross Bond
Editor: David Lloyd
© European Society of Veterinary Dermatology
History - 1
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11 year-old entire male Cavalier King Charles
spaniel
Progressive skin disease of 3 weeks duration
Owner reported reluctance to walk and interdigital
dermatitis. Now “blisters” on perineum and scrotum
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History | Signs | Differentials | Tests | Therapy | Notes
History - 2
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Dog reportedly depressed
Skin lesions progressively more severe
Thirst and appetite considered normal
Moderate pedal and perineal pruritus
History | Signs | Differentials | Tests | Therapy | Notes
Clinical signs - 1
Peri-oral crusts and
fissures
History | Signs | Differentials | Tests | Therapy | Notes
Clinical signs - 2
Linear preputial
lesion; erythema,
erosion, crust
History | Signs | Differentials | Tests | Therapy | Notes
Clinical signs - 3
Interdigital erythema
and exudation
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
Case investigation
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Principle differential diagnoses
• Metabolic epidermal necrosis (superficial necrolytic
dermatitis, hepatocutaneous syndrome, necrolytic
migratory erythema)
• Pemphigus foliaceus
History | Signs | Differentials
Differentials | Tests | Therapy | Notes
Tests - 1
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Diagnostic tests
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Skin scrapings
Skin biopsy
Haematological and biochemical profiles
Urinalysis
History | Signs | Differentials | Tests | Therapy | Notes
Tests - 2
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No evidence of parasites and fungal elements on
microscopy
Elevated alkaline phosphatase, alanine
aminotransferase, glucose, cholesterol
Mild lymphopenia and eosinopenia
Urinalysis unremarkable
History | Signs | Differentials | Tests | Therapy | Notes
Tests - 3
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Skin biopsies showed
• compact diffuse parakeratosis and hydropic
degeneration of the upper epidermis
• Mild acanthosis and sparse mononuclear cell infiltrate
in the upper dermis
History | Signs | Differentials | Tests | Therapy | Notes
What is your
diagnosis?
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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
Diagnosis
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Metabolic epidermal necrosis
• Historical and clinical features suggestive, supported
by biopsy results
• Laboratory tests support a metabolic disorder
History | Signs | Differentials | Tests | Therapy | Notes
Further tests
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Post-prandial bile acids were elevated, consistent with
hepatobiliary dysfunction
Abdominal ultrasonography showed diffuse hepatic
disease
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
Prognosis
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Prognosis is poor
• Many cases are difficult to manage and require
euthanasia, either because of the severe skin
disease or due to hepatic disease or pancreatic
neoplasia
History | Signs | Differentials | Tests | Therapy | Notes
Therapy - 1
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Symptomatic therapy only
Systemic and / or topical antibacterial therapy
Nutritional supplementation with high protein diets
are helpful in some cases
History | Signs | Differentials | Tests | Therapy | Notes
Therapy - 2
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Glucocorticoids are generally contra-indicated due to
the metabolic disease
Specific therapy for hepatic or pancreatic disease is
ideal but seldom possible
History | Signs | Differentials | Tests | Therapy | Notes
Comment - 1
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Most dogs have associated hepatic disease
(vacuolar alteration or cirrhosis); a few have
pancreatic glucagonomas
Some dogs become diabetic
The cause of the hepatic and skin disease is
unknown
Skin lesions may reflect hypoaminoacidemia
(present in this case)
History | Signs | Differentials | Tests | Therapy | Notes
Comment - 2
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The periorificial lesions plus footpad hyperkeratosis
are the usual findings
Often confused with autoimmune diseases
Ultrasound may allow visualisation of pancreatic
neoplasia or metastases in rare cases, and
distinguish from liver disease
Bile acid assays useful for assessment of hepatic
function
History | Signs | Differentials | Tests | Therapy | Notes
Review
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History | Signs | Differentials | Tests | Therapy | Notes