Case of the Month - Ross Bond

Scaling and crusting and otitisin a springer spaniel

Author: Ewan Ferguson

Editor: David Lloyd

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Click to reveal the text on this screen

Click the forward arrow to jump to the next screen

History - 1

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\history.jpg$

•Entire 8-year-old male Welsh springer spaniel

•Weight 36 kg

•Non-seasonal dermatosis of 2 years duration

•Moderate erythema and severe lichenification ofpinnae, periaural skin, ventral neck, tail andabdomen. Moderate hyperpigmentation present

History

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

History - 2

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\history.jpg$

•Generalised “seborrhoea”, strong odour and dullbrittle coat. Purulent discharge from ears. Affectedareas severely pruritic

•Thirst and appetite unchanged. Alert but less activethan littermate

•Minimal response to appropriate doses of systemicantibiotics and glucocorticoids

History

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Clinical signs - 1

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\vetExamDogNarrow.jpg$

Signs

How would youdescribe the lesions?

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Clinical signs - 2

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\vetExamDogNarrow.jpg$

Signs

Alopecia,lichenification,erythema and crustingaffecting the groin andthe medial aspects ofboth thighs

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

How would youapproach this case?

•How would you describe the skin lesions?

•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 makinga definitive diagnosis

Signs

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\vetExamDogNarrow.jpg$

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Case investigation

•Next steps

•A thorough physical examination is mandatory

•Comparison with littermate would be valuable

•Principle differential diagnoses

•Primary problems: hypothyroidism, demodicosis,ectoparasitism, food intolerance, atopy

•Secondary problems: Malassezia dermatitis,pyoderma bacterial otitis

Differentials

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\vetExamDogNarrow.jpg$

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Tests - 1

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\culture.jpg$

Tests

•Samples

•Deep and superficial skin scrapings, tape strippingsand impression smears for cytology, biochemistryand haematology panels, swabs from ears forbacteriology

•Tests

•Thyroid tests (total T4 and TSH), elimination diet

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Tests - 2

•Comparison with littermate

•Obese, less active

•Skin scrapings

•No ectoparasites or fungal elements

•Tape strippings

•Many Malassezia yeasts in all samples

•Aural swabs

•Smears show yeasts and Gram-negative rods

•Pseudomonas spp. on culture, resistant to allcommonly used antibiotics except polymyxin B

Tests

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\culture.jpg$

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Clinical appearance -comparison with littermate

Tests

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\culture.jpg$

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Tests - 3

•Blood tests

•Mild normochromic, normocytic anaemia

•Fasted serum cholesterol = 8.2 mmol/l

•Elimination diet

•No change in clinical signs

•Thyroid evaluation

•Total T4 = 10.4 nmol/l (range 13-52 nmol/l)

•TSH = 3.9 mol/l (normal <0.41 mol/l )

Tests

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\culture.jpg$

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

What is yourdiagnosis?

•What is your principle diagnosis?

•List any additional problems which you think mayneed treatment

•Are there any other possibilities which should beconsidered at this stage?

Tests

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\culture.jpg$

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Diagnosis

•Hypothyroidism with secondary Malassezia dermatitisand otitis with Pseudomonas sp. infection

•It would probably be difficult to accurately assess anyconcurrent disease until these problems have beencontrolled

Tests

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\culture.jpg$

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

How would you dealwith this case?

Tests

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\culture.jpg$

List the steps you would now take to treat:

•The hypothyroidism

•The Malassezia dermatitis

•The (Pseudomonas) otitis

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Therapy - 1

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\pred.jpg$

Therapy

•Hypothyroidism

•Oral levothyroxine given at 10-20 µg/kg bid

•Monitor 4 hour post-pill serum total T4concentrations after 12 weeks

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Therapy - 2

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\pred.jpg$

Therapy

•Malassezia dermatitis

•Whole body baths with a 2% w/v miconazole and2% w/v chlorhexidine shampoo (Malaseb, LeoAnimal Health), 2-3 times weekly

$F:\-- Derm cases ESVD\images\new interface\titlebackground2.jpg$

$F:\-- Derm cases ESVD\images\new interface\buttonbackground3.jpg$

Therapy - 3

$F:\-- Derm cases ESVD\images\section images\edited on dk blue\pred.jpg$

•Pseudomonas otitis

•Flush both ear canals with saline until clean andinspect tympanic membranes (under generalanaesthetic)

•Bulla radiographs if otitis media suspected

•In this case, both tympanic membranes were intact.Both ears were to be cleaned twice daily withEpiOtic (Virbac), followed by Otomax (Schering-Plough) twice daily one hour after cleaning.

Therapy