Luc BECO, DMV, Dip.. ECVD

Transcription

1 Generalised pruritic dermatitis with papules and crusts Diagnostic procedure History First differential diagnosis Clinical examination Problem list Luc BECO, DMV, Dip.. ECVD Avenue Reine Astrid, Spa CC6/Bonten2008 Differential diagnosis Other tests or Treatments Diagnostic tools or Therapeutic trial Diagnosis not confirmed Final diagnosis Revised differential Treatment Main complain History: Peluche Intense pruritus «oozing sores» Last chance before euthanasia Golden Retriever, female, 1year 8 months Exclusively living outdoors: prairie shared with horses and sheep. At night in a kennel close to a chicken run. Concrete floor and plastic bed No traveling outside the country (Belgium) Exclusively commercial Hills Z/D Ultra diet since 3 weeks History: Peluche 1 other dog who died 6 months ago was in contact (at the beginning of the dermatitis) Water intake : water from river Appetite slightly reduced Vaccines and deworming: OK History One year ago: Pruritus and pyotraumatic dermatitis Isobetadine and antibiotics cured within one week Recently: recurrence of pyotraumatic dermatitis Isobetadine and antibiotics without any results Second vet consulted: Dexafort, Hibitane, Dogeczema, Advantix, Pyoderm, Atarax, Elisabethan collar poor efficacy Long Acting glucocorticoids Moderin no effect 1

2 Clinical examination Clinical aspect Good general condition Intense generalised pruritus Erythema, erythematous papules, crusts Forehead, neck, trunk Distal limbs are spared Clinical aspect Clinical aspect Clinical aspect Problem list Pruritus Papules crusts - (excoriations) 2

3 Differential diagnosis for pruritus 1. Sarcoptic mange 2. Dermatitis caused by Dermanyssus 3. Flea Allergy Dermatitis 4. «Food allergy» 5. Canine Atopic dermatitis (CAD) 6. Bacterial folliculitis / furonculosis 7. Differential diagnosis for papules and crusts Sarcoptic mange Bacterial folliculitis Primary Secondary (demodicosis ) Dermatitis due to insect bites F.A.D. Dermatitis caused by Dermanyssus Ancillary exams Otopodal reflex: Skin scrapes and hair plucks: Scotch test: Under the crust cytology: Identify this parasite 1. Demodex canis 2. Sarcoptes scabei 3. Otodectes cynotis Skin scraping 4. Dermanyssus gallinae 5. Ixodes ricinus Identify this parasite 1. Demodex canis 2. Sarcoptes 3. Otodectes cynotis Skin scraping 4. Dermanyssus gallinae 5. Ixodes ricinus Ancillary exams Otopodal reflex: positive Skin scrapes and hair plucks: Demodex and Sarcoptes = 0 Scotch test: negative Under the crust cytology: neutrophils + cocci 3

4 Differential diagnosis Sarcoptic mange Bacterial folliculitis Dermatitis induced by insect bites Pruritus and sarcoptic mange (SM) Which statement is incorrect? 1. SM is characterized by papules, crusts and intense pruritus 2. SM affects mainly ear pinnae, elbows, abdomen and digits 3. SM can be diagnosed by a specific serology test 4. SM can affect humans in contact 5. Sarcoptes are difficult to observe in skin scrapings Pruritus and sarcoptic mange (SM) Which statement is incorrect? 1. Glucocorticoids can reduce pruritus 2. Selamectin (Stronghold ) or Imidacloprid/Moxidectin (Advocate ) are effective treatments 3. Fipronil spray (Frontline ) can be an effective treatment 4. Treatment of every dog and cat in contact is mandatory Pruritus and Atopic Dermatitis With regards to the diagnosis of CAD, which statement is correct? 1. The diagnosis is based on history and clinical signs 2. The diagnosis is based on clinical signs and a positive intradermal test 3. The diagnosis is based on clinical signs and a positive IgE-specific serology 4. Pruritus is not an essential feature for CAD Pruritus and «food allergy» With regards to the diagnosis of food allergy, which is the wrong statement? 1. A 3 week food trial is enough 2. A food trial with hydrolyzed proteins is NOT 100% sensitive 3. Vitamine supplements and treats/snacks are forbidden during the trial 4. Beef, chicken and dairy products are the major allergens involved Pruritus and «food allergy» With regards to the diagnosis of food allergy, which is the wrong statement? 1. The diagnosis requests a 6 to 8 weeks food trial followed by a reintroduction of the previous diet 2. The clinical examination does not permit the differentiation between food allergy and CAD 3. A serology or an intradermal test with food extracts are not useful 4. A food trial using a Lamb & Rice food is useful for the diagnosis 4

5 Systemic antibiotics Treatment Cefalexine: : bid 3 weeks (Rilexine( Rilexine ) Ectoparasite treatments Ivermectin SQ 3 times with 15 days interval Continue to treat with Advantix spot on Shampoo Benzoyl peroxide: once a week (Paxcutol( Paxcutol ) Diminish pruritus for owner s compliance Hydroxyzine (Atarax ) Modify the sleeping area and search for dermanyssus in the chicken run Continue to feed with Hills Z/d ultra Follow up Numerous 1mm parasites are found in the chicken run Coq au vin or BBQ chicken to treat the chicken Chicken run is cleaned, desinfected and burned down Final diagnosis Dermatitis secondary to Dermanyssus Gallinae bites Questions? A Pekinese with a subcutaneous mass on the thigh Diagnostic procedure History First differential diagnosis Clinical examination Problem list Luc BECO, DMV, Dip.. ECVD Avenue Reine Astrid, Spa CC7/Blaise2008 Differential diagnosis Other tests or Treatments Diagnostic tools or Therapeutic trial Diagnosis not confirmed Final diagnosis Revised differential Treatment 5

6 History : Noisette Pekinese, female, 9 year old Indoor and outdoor (country side) Food: homemade and commercial No animals in contact Mammary tumors Since 1 week: vomiting Since 3 days: anorexia Dermatology history One month ago: Subcutaneous mass with a rapid growth on the right thigh History: previous treatment No specific treatment except anti-emetic drugs Clinical aspect Good general condition Subcutaneous non painful, firm mass, adherent to the skin Involves the entire thigh No specific skin lesion Ecchymosis on the abdominal wall Clinical aspect Clinical aspect 6

7 Clinical aspect Problems list Subcutaneous mass, non painful, firm, rapidly growing Ecchymosis Vomiting and anorexia Differential diagnosis Differential diagnosis Subcutaneous mass, non painful, firm, rapidly growing At this stage, select the good answer? 1. Tumors: Soft tissue sarcoma (Hemangiopericytoma, Schwannoma), Mast cell tumor, Lipoma, Muscle sarcoma 2. Abcess 3. Cyst 4. Hematoma 5. All of those hypothesis Subcutaneous mass What is the most important ancillary exam to perform? 1. Complete blood count 2. Abdominal ultrasound 3. Thoracic radiographs 4. Fine needle aspiration for cytological examination 5. Biopsy Subcutaneous mass What can you identify in this cytology? 1. Epithelial cells 2. Mast cells 3. Histiocytes 4. Melanocytes 5. Fibrocytes Ancillary exams Ultrasound of the mass: heterogenicity with important vascularization Fine needle aspiration: Round cells, discohesive with round nucleus Binucleated cells Cytoplasm +with metachromatic granules Low nucleus/cytoplasmic ratio Nuclear pleiomorphism Blood: Anemia: 4,68 106/mm³ (5-8,5 106/mm³) Cl: 94mEq/l ( ) 7

8 Final diagnosis Mast cell tumor: cytology Mast cell tumour D. Kunkel Discohesive round cells Mast cell tumor: cytology Mast cell tumor: cytology High grade Multinucleated cells Mast cell tumor Select the wrong answer? 1. Cytology does not permit the grading of the tumor 2. Skin biopsy allows a severity grading of the mast cell tumor 3. Mast cell tumor metastases first to the regional lymph nodes followed by the lungs 4. The proliferation factor Ki 67 is a useful pronostic tool Select the wrong answer? Mast cell tumor 1. A wide surgical margin is needed (minimum 3cm) 2. Chemotherapy in not useful in a grade 1 mast cell tumor 3. Vinblastin and glucocorticoids chemotherapy is useful in a grade 2 or if Ki 67 is >10% 4. FNA of the regional lymph node is necessary 5. A mast cell tumor biopsy is recommended 10 days before the complete surgical resection to permit grading of the tumor 8

9 Treatment plan Staging: abdominal utrasound: refused by the owner Treatment Amputation + Chemotherapy: Prednisolone, Vinblastine, COP, Lomustin Cimetidine Radiotherapy Euthanasia Follow up: The owner has chosen euthanasia Mast cell tumor Mast cell tumor Mast cell tumor Mast cell tumor: grand immitator Perineal, preputial, scrotum, digital = More agressive Grade 1 9

10 Mast cell tumor: wide margins Mast cell tumors Mast cell tumors Mast cell tumors: wide margins Surgery: 3cm margins Mast cell tumors: wide margins(2) Diagnosis (1) Clinical: different aspects! Grade 1: 1 tumor, 0 lymph node Grade 2: 1 tumor + lymph node involved Grade 3: some tumors, large, infiltrative ± lymph nodes ± general signs Grade 4: tumor + metastasis Cytology (no possible grading ) Skin biopsy (histological grading) Prognosis: histological grading + Ki67 + extension work up 10

11 Q u e s t i o n s? Dermatosis, moderately pruriginous with papules, scales and crusts in a 6 months old Maltese Luc BECO, DMV, Dip.. ECVD Avenue Reine Astrid, Spa CC8/Magermans2008 Diagnostic procedure History Differential diagnosis Other tests or Treatments First differential diagnosis Diagnostic tools or Therapeutic trial Final diagnosis Clinical examination Problem list Diagnosis not confirmed Revised differential Treatment History: Lady Maltese, female, 6 month old Bought in a shop at 3 months Living indoor and outdoors Premium pet food and hypoallergenic diet since 2 months No animals in contact Fleas: no preventitive treatment The dog is not active, refuses to spring in the boot of the car Dermatology history Directly after bying (at 3 months): Fleas+++ (treated with Bolfo spray: permethrin) At 4 months: Papules, crusts and lesional pruritus (initial site: neck) At 5 months: Papules, scales, crusts generalised History: previous treatments 3 months: fleas Bolfo shampoo 4 months: papules, crusts, lesional pruritus 20mg/kg q12h Ceporex + Moderin tablets 1mg/kg q24h 5 months: papules, scales, crusts: generalised Synulox 12,5 mg/kg q12h orally (10 days) 5 months and 1 week: Ectodex lotion1x/sem + Paxcutol shampoo 1x/sem between the application of the lotion 5 months and 3 weeks: pruritus +++ Moderin injection (long acting glucocorticoid) 11

12 Clinical signs Clinical aspect Good general health Erythema, papules, pustules, scales, comedones, follicular casts, crusts and ulcerations Generalised Moderate pruritus Clinical aspect: forehead Clinical aspect: erythema, pustules Clinical aspect: scales, alopecia... Clinical aspect: crusts, ulcerations... 12

13 Differential diagnosis Squamous, erythematous dermatosis with comedones, follicular casts and crusts Bacterial folliculitis / furonculosis Demodicosis Dermatophytosis (Granulomatous Sebaceous Adenitis) ((Primary keratoseborrheic syndrome)) Bacterial folliculitis (BF) What is the wrong answer? 1. B.F. is a frequent cause of consultation 2. The major lesions are: papules, follicular pustules, epidermal collarettes or alopecia 3. BF affects mainly the head 4. The major bacterial agent is Staphylococcus intermedius Bacterial folliculitis With regards to treatment: what is wrong? 1. Amoxicillin is most often ineffective 2. Antibiotherapy with quinolones for 8 days is most often ineffective 3. Increasing the dosage of a quinolone is often needed to eliminate Staphylococcus intermedius 4. Shampoos are useful in combination with antibiotics What is this lesion? 1. Comedone 2. Follicle 3. Papule 4. Pustule 5. Vesicle 6. Macule 7. Purule 8. Plaque Lesion Skin scrape What can you observe in this slide? 1. A sarcoptes egg 2. A flea egg 3. A demodex egg 4. A lice egg 5. A yeast called malassezia 6. An amphora Bacterial folliculitis With regards to antibiotic treatment: what is the wrong statement? 1. Antibiotic treatment should be continued until a couple of days after clinical cure (+/- min 3 weeks) 2. TMP / Sulfonamides are contra-indicated in Doberman pinschers 3. TMP/ Sulfonamides can produce dry eyes (KCS), reduce the level of total T4 in serum and cause bone marrow suppression 4. TMP / Sulfonamides are toxic for the kidneys 13

14 Demodicosis Which is the wrong statement? 1. Demodex mites are usually easy to find in skin scrapes 2. Periophtalmic alopecia occurs always with demodicosis 3. Demodicosis creates alopecia, comedones. A concomitant pyoderma is frequently observed 4. Demodicosis is sometimes associated with pruritus Demodicosis Which is the wrong statement? 1. Localized demodicosis can cure by itself 2. Selamectin is not an effective treatment 3. SQ Ivermectin (1/15 days) can cure demodicosis 4. A primary cause should always be searched with adult onset demodicosis (tumors, hypothyroidism, hyperadrenocorticism ) Demodicosis: treatment Which is the wrong statement? Atipamezole (Antisedan ) is an antidote for the side effects of amitraz Amitraz should not be used by a diabetic owner Amitraz at the dosage of 10ml/l of water is effective to treat canine demodicosis Amitraz can induce tachycardia and vomiting Dermatophytosis Which is the wrong statement? 1. Dermatophytosis with Trichophyton and kerions are sometimes very pruritic 2. Cats can be healthy carriers 3. In cats Microsporum canis is cultured in the majority of the cases 4. Microsporum canis produces a violet fluorescence with wood lamp examination Hair plucks Ancillary exam > 50 demodex (adults, larvae, eggs) No dermatophytes Skin scrapes > 50 demodex (adults, larvae, eggs) Wood lamp examination: negative Cytology of an intact pustule Neutrophils, macrophages, phagocytized cocci Fungal culture: Negative (performed because children are in close contact!) Final diagnosis Generalized juvenile demodicosis + Bacterial folliculitis and furonculosis 14

15 Oral antibiotics Treatment plan Cephalexin 15mg q12h (Rilexine ), (min 1month) Shampoo Benzoyl peroxyde (Paxcutol ) once weekly Antiparasitic treatment Moxidectin: dosage slowly increased to 400µg/kg q24h orally (Oral Cydectin for sheep) Treatment Moxidectin or ivermectin should be used with caution Why? Those molecules produce gastric ulcers Because a defect of the mdr1 gene allows blood brain barrier passage The therapeutic dosages are toxic for the kidneys They present a special risk only in collies and similar breeds: Old English sheepdog and mongrels Follow up: Day 21: marked improvement of the lesions and pruritus. Crusts, pustules and ulcerations disappeared Skin scrapes and hair plucks: a decrease of the numbers of adults, larvae and eggs of demodex Day 42: Follicular casts are the only lesions observed Skin scrapes and hair plucks: a decrease of the numbers of adults and larvae. No more demodex eggs Monthly control. Day 120: Perfect skin: Adult demodex are rare Day 180: 2 nd month with negative skin scrapes Adult onset demodicosis Which is the wrong statement? Underlying hypothyroidism should be looked for Concomitant neoplasia should be search for An excess of glucocorticoids (secreted or administered) can be an underlying cause An underlying cause is always found Curative treatment is possible Dog Demodex mites: different types Demodex canis ( µm) Demodex short-bodied (D.Cornei) Stratum corneum (90-148µm) Demodex Injaï Pilosebaceous unit ( µm) Cat Demodex cati ( µm) Demodex gatoi Stratum corneum (110µm) Prostigmate mite Striated abdomen Demodex Demodex sp ( µm) (Chesney, 1988) Veterinary Dermatology

16 Demodicosis: clinical aspect Demodicosis Juvenile localized form «Pedal demodicosis» Otitis with demodex Generalized form Juvenile Adult onset Demodicosis and pyoderma Demodex L. Beco L. Beco Skin scrapes: egg and adult Cytology: smear from a pustule Demodex Demodicosis Scotch test L. Beco Localized form T. Olivry Demodicosis: clinical aspect Demodicosis Pedal form A severe localized form progresses rapidly with deep pyoderma complication T. Olivry Pedal form L. Beco 16

17 Demodicosis Demodicosis: clinical aspect Generalized form Generalized juvenile form T. Olivry Demodicosis Demodicosis: clinical aspect Generalized juvenile form Demodicosis: clinical aspect Demodicosis Demodicosis + bacterial folliculitis / furonculosis 17

18 Demodicosis: clinical aspect Demodicosis: clinical aspect Generalized adult onset Demodicosis Recommendations for treatment Good evidence Topical Amitraz: once per week to 15d 0,025-0,05% Oral Ivermectin: µg/kg q24h Milbemycine oxime: 2mg/kg q24h PO Oral Moxidectin: 400µg/kg q24h Fair evidence Higher dosage or more often Amitraz dips Doramectine: 400µg/kg/week SQ Histopathology S Shaw Recommendations for treatment Insufficient or contrary evidence Amitraz collar (Preventic ) Delthamethrine Phoxime Vitamin E Homeopathy Phytotherapy Recommandations for treatment Fair evidence against treatment with Ivermectin 1x/week SQ or poor on Lufenuron Good evidence against the use of Levamisole If the first treatment is not efficacious : try another molecule (124 dogs: 2nd molecule is efficacious in 76/124 (61%)) If recurrence : treat again with the same or another molecule (70% remission rate) Follow up for 12 months before claiming that the dog is cured 18

19 Q u e s t i o n s? Scaling and crusting dermatosis with a non inflammatory alopecia in a labrador cross Luc BECO, DMV, Dip.. ECVD Avenue Reine Astrid, Spa CC5/Dussart2008 History: Rupel Labrador cross, male, 9 year Living outdoor and indoors Exclusively commercial premium diet No animals in contact Monthly flea prevention with Frontline spot on The dog is not active, refuses to spring in the boot of the car Dermatology history For 1 year (when 8 years old): Scales Poor quality hair coat Dry, dull and brittle Same color as before The dermatosis started on the back and lumbosacral area History: previous treatment Shampoos: Sebomild, Paxcutol Antimycotics: Nizoral 10mg/kg q24h (4 weeks) Antibiotics: Keforal 20mg/kg q12h (2weeks), Minocin Essential fatty acids: Viacutan 3 pump spray per day Antihistamine: Tinset 30mg/kg q12h (4 weeks) mild improvement with topical and systemic treatment Clinical signs Lethargic dog, non responsive to stimuli Dull appearence Heart rate 60/min, regularly irregular, without murmur Poor quality hair coat, hairs easy to pluck Thick hyperpigmented skin Psoriasiform scales, epidermal collarettes, crusts and target lesions Non inflammatory alopecia: bridge of the nose and tail 19

20 Clinical aspect Problem list Non inflammatory and non scaring alopecia associated with a hyperpigmentation of the bridge of the nose and the tail Scaling and moderately crusting generalized dermatitis Poor quality hair coat Differential diagnosis Differential diagnosis Non inflammatory and non scaring alopecia associated with a hyperpigmentation of the bridge of the nose and the tail 1. Endocrine skin disease : 1. Hypothyroidism 2. Sex hormone responsive dermatosis 3. Hyperadrenocorticism 2. Follicular dystrophy or dysplasia 3. Dermatophytosis 4. Demodicosis 5. Alopecia areata Differential diagnosis Scaling and moderately crusting generalized dermatitis 1. Primary or secondary keratoseborrheic syndrome 2. Dermatophytosis 3. Malassezia dermatitis 4. Bacterial folliculitis 5. Cheleytiellosis Differential diagnosis Poor quality hair coat Endocrine skin disease Poor quality nutrition Internal disease (neoplasia ) Ancillary exams Skin scrapes: Parasites (negative( negative) Scotch test: Cheleytiella (negative) Trichogram: 100% telogene, negative for dermatophyt yte Wood lamp examination: negative Blood: Moderate normocytic, normochrome anemia RBC: 4,67 106/mm³ (5-8,5 106/mm³) Hypercholesterolemia: : 8,93g/l (1-3g/l) Thyroxine: total T4: <4,67 ng/ml ( ng/ml) ctsh: : 0,41ng/ml (<0,3 ng/ml) 20

21 Final diagnosis Hypothyroidism Clinical aspect What is your first diagnosis? 1. Obesity 2. Pyometra 3. Hypothyroidism 4. Hyperadrenocorticism 5. Sex hormone responsive 6. Bacterial folliculitis Clinical aspect What is the lesion? 1. Papules 2. Pustules 3. Vesicules 4. Crustules 5. Calcinosis cutis 6. Eosinophilic plaque Hypothyroidism Which CBC and serum biochemistry modification is not a feature of hypothyroidism? 1. Normocytic, normochrome, regenerative anemia 2. Hypercholesterolemia 3. Hypertriglyceridemia 4. Increase of the fructosamine level Hypothyroidism Which is the wrong statement? 1. Equilibrium dialysis dosage of freet4 is less influenced by concurrent drug administration or concomitant disease 2. A low total T4 level is enough to diagnose canine hypothyroidism 3. RIA dosage of the free T4 is not more interesting than total T4 measurement 4. A low total T4 associated with an elevated ctsh support the diagnosis 5. 25% of hypothyroid dogs have a normal ctsh Hypothyroidism Which statement is incorrect? 1. Total T4 is low in Whippets, Salukis, Greyhounds 2. Diabetis mellitus, epilepsy and liver disorders produce low Tt4 levels 3. Phenobarbital reduces Tt4 4. KBr reduces Tt4 5. Sulfonamides reduces Tt4 6. Immune suppressive dosage of glucocorticoids reduces Tt4 21

22 Hypothyroidism About treatment: which statement is incorrect? 1. A blood control 4 to 6 hours after oral administration of thyroxin is recommended after 4 to 6 weeks of administration 2. Thyroxin should be given with food 3. The treatment of an alopecic dog with thyroxin is without any danger and can be proposed as a diagnostic tool 4. Sucralfate (Ulcogant ) interferes with the thyroxin absorption Hypothyroidism About treatment: which statement is incorrect? 1. An initial dosage of thyroxin (T4) of 10 to 22µg/kg bid is recommended 2. A 50% reduction of the dosage of thyroxine is needed if cardiac disease or diabetis mellitus is associated 3. The association T3 / tt4 produces a more rapid improvement than single thyroxine supplementation 4. Oral administration of thyroxin modifies the serum level of tt4 for at least one month Oral antibiotics Treatment plan Cephalexin 15mg/kg q12h (Rilexine ) Shampoo Salicylic acid - Sulfur (Sebomild ) Levothyroxin: Elthyrone 20µg/kg q12h per os Follow up: Day 40: more active dog, loss of 4 kg, heart rate 90/min Hair regrowth on the bridge of the nose Less scales Blood control post thyroxin administration Hematology: RBC 5, /mm³ Cholesterol: 1,42 g/l Total T4: 17,6ng/ml Day 70: normal hair regrowth, good quality hair coat Levothyroxin 20µg/kg q24h Clinical aspect after treatment Hypothyroidism Primary hypothyroidism Lymphocytic thyroiditis Idiopathic atrophy Secondary hypothyroidism Suppression of pituitaty thyreotrope cells Spontaneous hyperadrenocorticism Euthyroïd sick syndrom Iatrogenic Drugs: glucocorticoids, phenobarbital, sulfonamides 22

23 Hypothyroidism: clinical signs Metabolic signs 84% Lethargy 76% Dermatological signs Alopecia 56% Poor quality hair coat 30% Hyperpigmentation 20% Reproductive disorders Neuromuscular abnormalities Blood modifications Hypercholesterolemia 78% Hypothyroidism Hypothyroidism Treatment (3) Why should we use very high doses of thyroxin in dogs compared to humans? Different half lives: Human 7days / Dog 18 hours Intestinal absorption: Human 50-80% / Dog 10-50% Q u e s t i o n s? Alopecic, erythematous and moderately pruritic dermatosis in a 4 year old Basset Hound Luc BECO, DMV, Dip. ECVD Avenue Reine Astrid, Spa CC4/Thibaux

24 History: Abigaël Dermatology history Basset Hound, female, 4 years Indoor and outdoors (park and forest) Commercial and home made diet 3 cats in contact: without any lesion Flea prevention: Frontline once/month: only during summer Frequent ceruminous otitis externa 1 month ago Alopecia without pruritus (first lesions appeared around the eyes and the lips) Progressed rapidly to involve the back, the head, front part of the neck and perineal area + Pruritus History of the treatment At first clinical signs Stronghold 2 times with 1 month interval Clinical signs Large alopecic areas «geographic maps» moderately squamous : back Erythema and partial alopecia: axilla,, front neck Erythema: ear pinnae and between the mammary chains Erythema with a brown exsudate: interdigital Bilateral erythemato-ceruminous otitis externa Clinical aspect Clinical aspect : back 24

25 Clinical aspect : back Clinical aspect Clinical aspect Clinical aspect Problem list Alopecia with a geographic map shape, moderately squamous Erythema and partial alopecia /interdigital brown deposits Pruritus Differential diagnosis Differential diagnosis Map shape alopecia moderately squamous Bacterial folliculitis Demodicosis Dermatophytosis Malassezia dermatitis (Epitheliotropic cutaneous lymphoma (M.F.)) (Granulomatous sebaceous adenitis) (Erythema multiforme) 25

26 Differential diagnosis Erythema and partial alopecia /interdigital brown deposits / erythemato-ceruminous otitis externa Malassezia dermatitis and otitis Atopic dermatitis Adverse food reaction... Pruritus Differential diagnosis Malassezia dermatitis and otitis Atopic dermatitis Adverse food reaction Bacterial folliculitis... Ancillary exams: demodicosis Demodicosis: which statement is incorrect? 1. In the majority of the cases skin scrapes and epilation lead to the diagnosis 2. Without the observation of demodex (adult, larva, egg) in the skin scrape I can treat one month to confirm my clinical impression 3. Skin biopsy is sometimes a useful tool to diagnose pedal demodicosis 4. The periphery of the alopecia is NOT a preferred site for skin scraping Ancillary exams Which statement is correct for bacterial folliculitis 1. Skin scapes are useful for the diagnosis 2. The cytology of a pustule is the most important ancillary exam 3. Bacterial culture and sensitivity testing are always needed to treat adequately 4. Skin biopsies are important for the diagnosis Identification What can you observe in this slide? 1. Cryptococcus 2. Malassezia yeast 3. Microsporum spores 4. Chirodiscoïdes eggs 5. Pseudomonas aeruginosa Ancillary exams: Malassezia dermatitis Which statement is incorrect? 1. Smear or stained Scotch tape cytology are ideal to diagnose malassezia dermatitis 2. Culture is not useful 3. Wood lamp exam is negative 4. Skin biopsy is useful for diagnosis 5. Malassezia yeasts are not contagious for humans 26

27 Cutaneous epitheliotropic lymphoma Which statement is incorrect? 1. Erythema and scales can be the unique clinical sign 2. Cutaneous nodules can be the unique clinical signs 3. Is sometimes only observed on the mucosae: oral, anal, lips 4. Induces always a lymph node hyperplasia 5. Is diagnosed by skin biopsies Granulomatous sebaceous adenitis (S.A.) Which statement is incorrect? 1. S.A. shows follicular casts and/or alopecia 2. Skin biopsies are needed to diagnose S.A. 3. Affects mainly Poodles, Akita Inu and Samoyedes 4. May induce a skin depigmentation Ancillary exams Skin scrapes and hair plucks No demodex mites No dermatophytes Wood lamp examination: negative Fungal culture: négative Scotch test: Neck: Malassezia +++ Elbow folds, perianal: Malassezia ++ Head: Malassezia + Ear cytology: Malassezia+++ Diagnosis Malassezia dermatitis and otitis Treatment plan Topical antifungal: shampoo Miconazole - Chlorhexidine (Malaseb ) twice a week Systemic antifungal Ketoconazole: 10mg/kg q24h per os (Nizoral ) Ear canals: cleaning Epiotic twice a week Ear canals: treatment Surolan bid for 15 days Follow up: Day 21 Less greasy skin, reduced pruritus but the circular alopecic lesions and the erythema remain Scotch test: major reduction of the yeast count Skin biopsies: Granulomatous sebaceous adenitis 27

28 Final diagnosis Malassezia dermatitis and otitis + Granulomatous sebaceous adenitis Treatment Ear canals: cleaning Epiotic twice a week Topical antifungal: shampoo Miconazole - Chlorhexidine (Malaseb) twice a week Vitamine A: UI per os Cyclosporine A Neoral 5mg/kg per os Follow up Day 42 Treatment: day 42 Improvement: hair regrowth, no more scales, evident reduction of erythema A fold erythema and a ceruminous otitis externa remain : malassezia yeast weekly Malaseb shampoo, Neoral sid, Vitamine A Day 63 The skin looks perfect but a mild erythema remains between the digits weekly Malaseb, Neoral every 2-3 days, Vitamine A Treatment: day 63 Treatment: day 63 28

29 Malassezia Malassezia Cytology Electron microscopy R. Bond >9 species: Lipid Asymptomatic carrier: Since the age of 3 days Lipid-dependents: : 8 Lipid-independent independent: : 1 (M. Pachydermatis) days (Wagner,, 2000) Perianal area 52%, lip fold: 75%, Interdigital: 60%, External ear canal: 33% (Bond, 1995) Human: Pityriasis Versicolor (M. Furfur), seborrheic dermatosis or malassezia folliculitis... Dog: Dermatitis, otitis and paronychia Malassezia dermatitis Malassezia dermatitis Granulomatous sebaceous adenitis Granulomatous sebaceous adenitis Clinical presentations Short haired: Vizsla, Dachshunds Annular lesions: small scales, follicular casts and alopecia. Coalescent, polycyclic lesions Back part of the body and head Long haired: Poodles, Samoyede Hyperkeratosis followed by alopecia. Sticky broken hairs within follicular casts Long haired: Akita: Secondary pyoderma is frequent Papules, pustules, scales and follicular casts Follicular casts 29

30 Granulomatous sebaceous adenitis Granulomatous sebaceous adenitis Treatment: Granulomatous sebaceous adenitis Keratolytic shampoos Rinces: 50-75% Propylene glycol - water Essential fatty acids? Synthetic retinoids or vitamine A Vizla, poodle: Isotretinoïn 1-2mg/kg q24h (Roacutane) Akita: Acitretin 1-2mg/kg q24h (Neotigason) Cyclosporine A: 5 mg/kg/24h Tetracyclin/Nicotinamid Q u e s t i o n s? Generalized scaling dermatosis with skin ulcers and chronic purulent otitis externa Luc BECO, DMV, Dip.. ECVD Avenue Reine Astrid, Spa History: Pipo Mongrel, male, 10 year old Indoor and outdoors (garden with grass) South of France 3 years ago Commercial canned food: Delhaize No animal in contact Water intake and appetite are normal Not vaccinated and not dewormed CC6/Lambion

31 Dermatology history 1 year ago: elbow callus / otitis Progressively pinnae For 3 months: aggravation Putrid purulent otitis externa ulcerations: periphery of the ear Ear pinnae,, digits, elbow ulcerations He bites his digits History: previous treatments Otitis treatment Cleaning: Epiotic twice a week Treatment: Oridermyl sid Ulceration treatment Oridermyl sid Clinical signs Clinical aspect Very thin dog Enlarged lymph nodes Sub-maxillar, inguinal, prescapular Generalized psoriasiform scaling Face and pressure points ++ Scales and ulcerations Ear pinnae periphery, hock, elbows, digits Onychogryphosis Food pads dried and fissured Clinical aspect Clinical aspect Elbow Hock 31

32 Problem list Generalized psoriasiform scaling Ear pinnae and pressure point ulcerations Enlarged lymph nodes Bilateral purulent otitis Differential diagnosis Differential diagnosis Generalized psoriasiform scaling Cheleytiellosis Keratoseborrheic disorders Dermatophytosis Leishmaniosis Hepatocutaneous syndrome / NME Zinc responsive dermatosis Cutaneous epitheliotrophic lymphoma (M.F.)... Differential diagnosis Ear pinnae and pressure point ulcerations Vasculitis /Vasculopathy Dermatomyositis Leishmaniosis Hepatocutaneous syndrome / NME Differential diagnosis Enlarged lymph nodes Infection Tumor Leishmaniosis Demodicosis... Identification Identify this parasite? 1. Ctenocephalides felis felis 2. Sarcoptes 3. Cheleytiella 4. Demodex canis 5. Dermanyssus gallinae 6. Leishmania Identification What can you observe in this slide? 1. Histiocytes 2. Macrophages + Leishmania 3. Neutrophils + Staphylococci 4. Eosinophils 5. Malassezia 32

33 Identification What can you observe in this slide? 1. Macrophages + Leishmania 2. Neutrophils + Staphylococci 3. Eosinophils 4. Malassezia 5. Cryptococcus Ancillary exams Skin scrapes / hair plucks:demodex, Dermatophytes = 0 Wood lamp examination: negative Cytology of an ulcer: neutrophils, histiocytes + cocci Ear cytology: neutrophils + cocci and rods FNA of a lymph node: weak leukocyte population, histiocytes +++ Bone marrow biopsy: normal population of histiocytes Ear canal bacterial culture: Proteus, Streptococci group G, Enterococcus,, Staphylococcus intermedius Ancillary exams CBC Hyperproteinemia, hypergammaglobulinemia Leishmaniosis serology: negative Skin biopsies Severe inflammatory reaction with an annexial orientation. Disappearence of the sebaceous glands Histiocytic, neutrophilic, lymphocytic inflammation with sometimes granulomatous infiltrations Severe diffuse dermatitis. Granulomatous, neutrophilic, lymphoplasmocytic chronic perifolliculitis and folliculitis with an active pyoderma Diagnosis Bacterial folliculitis/furonculosis + Granulomatous sebaceous adenitis? and / or Leishmaniosis? Systemic antibiotics Treatment plan Marbofloxacin 3mg/kg q12h (Marbocyl( Marbocyl ) Ear cleaning (under anesthesia in the clinic and at owner s home) Epiotic twice a week Ear treatment Topical enrofloxacin 5% (Baytril( Baytril ) Follow up Day 15: Cured ulcers on the limbs Cured otitis Scaling remains Bone marrow biopsy and FNA lymph nodes: no leishmania Marbocyl, Shampoos with salicylic acid and sulfur, Propylene glycol Immunohistochemistry on skin tissue: Leishmaniosis + Blood serology: leishmaniosis +: 1/

34 Final diagnosis Canine leishmaniosis + Secondary pyoderma Follow up Day 40 : start of the specific treatment Ulcerations remain on the ear pinnae s periphery New ulcers on the digits and the elbows Onychogryphosis Depigmentation of the left nare Scaling remains Treatment Follow up Ear cleaning Epiotic twice weekly Specific treatment Allopurinol 15mg/kg q12h (Zyloric( Zyloric ) Antimonium 100mg/kg q24h SQ (Glucanthime( Glucanthime ) (1 month) Day 65 Lymph nodes diminishes in size Scaling remains intense Ulcerations heales Glucanthime + Zyloric Follow up Leishmaniosis Day 80 Normal lymph nodes Sticky scales only left on the ear pinnae Glucanthime (until results of serology) Zyloric Serology and protein electrophoresis controlled once monthly Insect as vector: Phlebotome Promastigote form: flagellated Host: within the macrophages and dendritic cells / amastigote + kinetoplaste Unbalance TH1/TH2 TH1: IL2, TNFα, IFNγ: protection TH2: IL4, IL5, IL6, IL10: illness 34

35 Leishmaniosis General signs Lymphadenpathy,, pale mucosae, weight loss,, spleen and liver enlargement, fever, glomerulonephritis, ophthalmic lesions (uveitis,, KCS, keratitis), epistaxis, arthropathy, polymyositis, onychogryphosis Cutaneous signs: Exfoliative dermatosis, ulcerations, periophthalmic alopecia, paronychia, sterile pustular dermatosis, nose depigmentation, nose and food pads hyperkeratosis,, nodules Leishmaniosis: diagnosis Parasite identification Bone marrow biopsy and FNA of lymph nodes Cutaneous smears for cytology Histopathology: : 3 different presentations Granulomatous perifolliculitis Superficial and deep perivascular dermatitis Interstitial dermatitis Immunohistochemistry Isolation and culture Leishmaniosis: diagnosis (2) Leishmaniosis Serology Immunofluorescence: Se 95%, Sp 100% ELISA: GP63: false negative retested after weeks Protein electrophoresis Hyperglobulinemia (β et γ globulins) Molecular biology Polymerase Chain Reaction (PCR): sensible and specific (Fisa; Vet. Parasitology, 2001) Leishmaniosis Leishmaniosis 35

36 Leishmaniosis: treatments Pentavalent antimonium (Glucantime ) interference with the glycolysis and oxydation of the essentiaol fatty acids in the amastigote form Allopurinol (Zyloric ) incorporation of the molecule within the leishmania s RNA Azols: ketoconazole, itraconazole, fluconazole Polyene: amphotericine B action on ergosterol Quinolones: Marbofloxacin Aminosidine: side effects on the kidneys and the ears Leishmaniosis: prevention Deltamethrin collar (Scalibor ) Reduce the phlebotomes bites = 80% To put in place 2 weeks before the travel Spot on Permethrine-Imidaclopride (Advantix ) Injection with non infected phlebotomes (Nature, 2000) Vaccinations? (Gradoni; Vet Vet. Parasitology,, 2001) Goal = induction of a long lasting TH1 response by increased synthesis of IL12 Q u e s t i o n s? Facial and nasal ulcerative dermatosis in a cat Luc BECO, DMV, Dip.. ECVD Avenue Reine Astrid, Spa CC3/Willems2008 History: Pitou DSH cat, male, castrated, 9 years old Living indoor and outdoors Fed with home made and commercial cat food 2 nd cat in contact without any skin lesion Flea prevention with Frontline spot on Chronic plasmocytic stomatitis treated with Moderin Past history: upper airway infections + chlamydiosis For 4 years: Dermatology history Plasmocytic ulcerative stomatitis For 3 months: Sore on the lateral aspect of the bridge of the nose crusts ulcers Lesional moderate pruritus 36

37 History: previous treatment Clinical aspect Alternating Moderin IM and orally every month Terramycin cream on the lesions Cephalexin (Ceporex)) 10mg/kg q12h Lesions remain stable for 3 weeks Clinical aspect Probleme list Cutaneous ulcerative and crusting lesions Erythematous and ulcerative stomatitis Stomatitis and plasmocytic Differential diagnosis Differential diagnosis Cutaneous ulcerative and crusting lesions Viral dermatitis : herpes, pox Mosquito bites hypersensitivity Dermatophytosis Neoplasia Cryptococcosis, Sprorotrichosis Auroimmune skin diseases: PF, DLE, MMP Bacterial folliculitis and furonculosis Demodicosis. Differential diagnosis Ulcerative and erythematous stomatitis Plasmocytic stomatitis Periodontal affections Viruses: herpes, calici, FIV, FeLV, Panleucopenia Uremia Autoimmune skin diseases: MMP, SLE, PV 37

38 Feline herpes virus and the skin How to diagnose feline herpes virus in the skin? What is the wrong answer? Histopathological examination of skin biopsies Detection of the virus in RBC Immunohistochemistry of skin tissue Brush sample for PCR Ancillary exams Skin scrapes: no demodex mites Trichogram: no dermatophyte... Wood lamp examination: negative Cytology: eosino++, non degenerated neutrophils, lymphocytes Fungal culture: neg / bacterial: Staph + Pasteurella Blood: eosinophilia, urea-creatinin creatinin-ph: : normal, FeLV-FIV: FIV: negative Serum freezed for cryptococcus serology if needed! Skin biopsies + Immunostainings: FeHV1 (PCR) Treatment plan 1 st step during anesthesia for taking biopsies Teeth extractions 2 nd step pending the laboratory results Mupirocine bid (Bactroban( Bactroban ) Enrofloxacin 5mg/kg q24h (Baytril( Baytril ) Lufenuron 100mg/kg (Program ) No more glucocorticoids Enrofloxacin and cats Which statement is correct? Enrofloxacin should not be administered to growing cats Enrofloxacin is not effective against Staphylococcus intermedius Enrofloxacin as the other quinolones is a time dependent antibiotic Increase of the dosage in cat may induce retinal lesions (blindness) Lufenuron (Program ) Which statement is correct? lufenuron Kills adult fleas Inhibits chitine synthesis Is a growth hormon analog of the flea Is effective against ticks Is repulsive against fleas Final diagnosis Ulcerative facial and nasal dermatitis associated with Feline Herpes Virus 1(FHV-1) Plasmocytic stomatitis and pharyngitis (FHV-1 or parodontal disease) 38

39 Follow up: Day 15: mild improvement of the cutaneous lesions Enrofloxacin 5mg/kg q24h per os (Baytril) Topical Acyclovir cream q8h (Zovirax( labialis) Pyrantel-Praziquantel Praziquantel (Drontal cat) Day 30: lesions regressed Day 50: lesions cured No recurrence within 6 weeks Recurrence of the oral lesions Clinical aspect: day 15 15d Baytril + Mupirocin Clinical aspect : day 30 Clinical aspect: day days topical Acyclovir 35 days topical Acyclovir Ulcerative facial and nasal dermatitis associated with feline herpes virus 1 (FHV1) Clinical signs: Ulcers and crusts on the bridge of the nose and the face Histopath: Differential diagnosis with mosquito bites HS and eosinophilic granulomas viral inclusions, immunohistochemistry,, PCR for FHV-1 Treatment: Lysine (action on the biodisponibility of arginin for FHV-1) Ulcerative facial and nasal dermatitis associated with feline herpes virus 1 (FHV1) Treatment: Oral Lysin (takes the place of arginin during the FHV-1 replication) ) (AJVR, 2000) Oral alpha interferon +/- Enrofloxacin or Amoxycillin-Clavulanic acid Oral acyclovir: resistance offhv-1 1 > Human Herpes Simplex (synergy( with α interferon) But : bone marrow and kidney toxicity Topical Acyclovir: : no good literature description Idoxuridine inhibits the replication in vitro Interferon Omega 39

40 Q u e s t i o n s? 40