22/10/2014. Duncan Graham BVSc BSc (hons). Massey grad Veterinarian with a particular interest in companion animal dermatology

Transcription

1 Duncan Graham BVSc BSc (hons). Massey grad 1984 Veterinarian with a particular interest in companion animal dermatology 1

2 Started Animal Dermatology NZ in 2001 Live in Nelson, NZ. Visit Palmerston North Wellington, ChCh, & Dunedin seeing referral dermatology cases Website: www animaldermatology.co.nz In language study, false friends are words in two languages that are similar in appearance and/or pronunciation but that have different meanings. An example is the English word embarrassed and the Spanish embarazada In Spanish if you say estoy embarazada 2

3 you are pregnant not embarrassed. In Barcelona I ordered a sock omelette when I wanted an zucchini omelette ( el calcitin means sock, el calabacin is zucchini). Similarly canine skin disease is filled with false friends, diseases that have similar symptoms or similar presentations but that are vastly different diseases, needing completely different treatments. 3

4 This presentation is going to focus on canine pyoderma Kinga Gortel in his article Recognizing Pyoderma more difficult than it may seem makes the point that despite it s prevalence and sometimes typical appearance Some cases of pyoderma present diagnostic challenges even to experienced clinicians. Initially I wanted to talk about a range of false friends in dermatology. But then I realized there were new 2014 guidelines for the treatment of superficial canine pyoderma = superficial bacterial folliculitis (SBF) and related topics that warranted discussion. 4

5 They are common, they are what we see every day in general practice. If we can learn to deal efficiently with them, other less common presentations will become easier to recognize and handle. So this is dermatology 101, back to the basics. 1. Guidelines for the diagnosis and antimicrobial therapy of canine superficial folliculitis. 2014, Vet Dermatol June Andrew Hillier, David Lloyd, Scott Weese, JM Blondeau, Dawn Boothe, Mark Papich et al. 2. Suggested guidelines for using systemic antimicrobials in bacterial skin infections, parts 1&2, Vet Rec Jan 19 & Feb 9, Beco, Gauguere, Mendez, Noli, Nuttall, Vroom. 5

6 3. Treatment of Superficial bacterial folliculitis, Current Vet therapy, 2014, Andrew Hillier 4. Recognizing Pyoderma More difficult than it may seem. Kinga Gortel (2013) Vet clinics Sm Animal 43: 1-18 Proceedings 39th WSAVA Congress Sept 2014: MULTIDRUG ANTIMICROBIAL RESISTANCE AND ITS AVOIDANCE IN DOGS & CATS D M Boothe Pyoderma of all types is common in dogs More common than in other domestic animals and humans. Why is this? We don t know. 6

7 The canine stratum corneum which gives the barrier protection is different 1. It is thinner and more compact 2. It has less intercellular lipids 3. It has a higher ph. In 2007 a Japanese study suggested that S. intermedius be reclassified into 3 distinct species, including S.intermedius, S. pseudintermedius and S. delphini 7

8 Other studies identified S. pseudintermedius as the most common causative organism in canine pyoderma. In 2009 it was proposed that all canine isolates be described as S. pseudintermedius 8

9 Can be superficial or deep We are going to concentrate on the superficial pyodermas Of the epidermis and of one its adnexae the follicle Our main every day diagnostic challenges involve the folliculo-centric diseases these diseases are characterized by the formation of pustules in the epidermis Pustules vary in depth from subcorneal (below the stratum corneum) to pan epidermal. However before we focus on the follicular diseases, let s look at a couple of epidermal pyodermas 9

10 Exfoliative superficial pyoderma aka superficial spreading pyoderma Often accompanies superficial bacterial folliculitis Exists in 2 overlapping types Has rapidly expanding, erythematous & pruritic epidermal collarettes Usually in the groin and axilla Often accompanies superficial bacterial folliculitis 10

11 Breed predilection: shetland sheepdogs, border collies, australian shepherd Distinctive clinical signs: collarettes with erythematous borders and alopoecia after a pustular stage. 11

12 Onset 16mo of age. Minor lesions on lips Ddx: exfoliative Superficial pyoderma/ Vesicular cutaneous lupus erythematosus Dx: biopsy is ideal. Previous biopsy: drug reaction but no drugs had been given Cytology: cocci, pmn No response to previous Clavulox or Baytril What can i do? Get second opinion on the biopsy. while waiting for 2 nd opinion trial Rilexine 22mg/kg bid for 3 weeks and assess response. After 3 weeks there was 30-40% improvement 12

13 LICHENOID INTERFACE LYMPHOCYTIC PLASMACYTIC DERMATITIS CHARACTERISTIC OF LUPOID REACTION AND TYPICAL OVERALL WITH VESICULAR CUTANEOUS LUPUS ERYTHEMATOSIS OF COLLIES 13

14 Normally difficult to treat, often needs high doses of pred and azathioprine Overseas topical tacrolimus has been used successfully in mild cases. We don t have tacrolimus Trialed a course of Dermol (clobetasol) a potent topical steroid. After 10 days Dermol 14

15 But need radically different treatments Both diseases have a predilection for border collies and shelties Both target the glabrous inguinal area Biopsy is the best diagnostic tool Exfoliative spreading pyoderma needs antibiotics good response confirms dx Vesicular Cutaneous Lupus Erythematosus needs immunosuppression. Case 2: 1 week ago 18 mnth old MN French Bulldog presented at your clinic after hours for acute onset of dermal lumps that were mildly to moderately pruritic. 15

16 They saw your colleague who made a tentative diagnosis of an urticarial reaction to an insect bite and treated it with a short acting steroid injection and an anti histamine. A common scenario- insect bite reactions were common when I was in general practice No breed predilection has been published, but short coated dogs appear to be at risk (Small Animal Dermatology 7 th ed) In short coated dogs urticaria may lead to raised tufts of hair. Urticaria is characterized by erythematous wheals, macules and plaques. Lesions are more easily seen on glabrous areas. 16

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18 The presentation is vastly different There are dorsally orientated coalescing, spreading areas of alopoecia with some associated mild crusting. these lesions involve the back & lateral thorax There is moderate pruritus He has a history of playing with hedgehogs. 18

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21 CD is common disease. Gross et al in Skin diseases of the dog & cat say that it presents as an expanding circular patch of alopecia with an erythematous active crusted border There may be an area of central clearing and healing Follicular papules or frank pustules may be seen. This completely describes what you see 21

22 Canine hair follicles are considered skin adnexa (appendages) Hair follicles Sebaceous glands Eccrine sweat glands Apocrine glands 22

23 The dermal hair papilla The hair matrix The hair itself The inner root sheath The outer root sheath There are 4 main folliculo-centric canine skin diseases that focus on the canine hair follicle without destroying it where the inflammation of the follicle is the main histo-pathological lesion but the follicle remains intact. 23

24 superficial bacterial folliculitis (SBF) canine dermatophytosis canine demodicosis pemphigus foliaceus. 24

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26 Probably not, but first, Is it a follicle based disease?? HOW DO YOU DECIDE? You are presented with a short coated dog with pruritic, focal, patchy hair loss Moth eaten coat How do you go forward in deciding between SBF, dermatophytosis or one of the other follicle based diseases? 26

27 THE first job is to establish that it is follicle based, and not just a non follicle papule presentation. Many of the superficial perivascular diseases have papules which may or may not be oriented around a follicle If the papules are non follicular then one of the hypersensitivities, including ectoparasites are likely. If the papule is follicular, then folliculitis is likely. 27

28 SBF is the second most common skin disease. Only flea allergy dermatitis is more common (Gross et al, 406). So play the odds, if it is follicular - suspect SBF If it non follicular suspect FAD Go on a pustule/ papule hunt and decide if it is folliculo centric or not. 28

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30 Once you find a pustule, does it have a hair coming out of the middle of it? If so, it is an example of folliculitis, either sterile or bacterial. CYTOLOGY OF COURSE This is a derm talk; I have to give cytology a plug I hope that some, even many of you went to Craig Griffin s seminar. 30

31 Cytology isn t always necessary (CVT XV, 437) but it is reassuring to find cocci, especially in their tidy grouping of two or four, plus or minus neutrophils and macrophages. And you need to ruleout malassezia Finding a hair oriented pustule with associated neutrophils and cocci is diagnostic. BUT pustules can be very transient, and the hair may be shed, leaving only a much less diagnostic crusted papule, with or without a hair. 31

32 Crusted papules are much less exciting because they can be associated as I mentioned previously with the peri vascular diseases (think hypersensitivity) As the 2014 Guidelines say follicular involvement may be difficult to appreciate macroscopically A recent poster demonstrated that in 28 cases of superficial pyoderma cello tape preps weren t as good as direct smears at finding neutrophils. 32

33 Don t be discouraged if you don t find PMNs on your cello tape. Both methods were equally good at finding bacteria and Malassezia. If you find only eosinophils and no bacteria, you will start to wonder about sterile eosinophilic pustulosis, a rare disease or if you have sampled papules, you will want to ruleout Sarcoptes, fleas and other ectoparasitic diseases that cause an exodus of eosinophils. 33

34 If, especially under crusts, you find acantholytic cells then pemphigus becomes your top differential. 34

35 Deep skin scraping or hair pluck. A hair pluck is not considered to be as sensitive as a deep scrape but usually it is easier and quicker So I start with that, and if it s negative, and my index of suspicion is high, I will then scrape. 35

36 Culture is never wrong, but takes 3 weeks. Wood s light Trichogram: hairs are swollen with hyphae 36

37 WHY SBF first? It is more common The evaluation is quicker Treat with 14 days bid with first generation cephalosporin at 22mg/kg twice daily with food. 37

38 one first generation cephalosporin has recently been licenced in NZ for once daily treatment at 30mg/kg The lesions of bacterial folliculitis will start to respond in three to five days, while the pruritus usually begins to subside in two to three days Should you treat simultaneously with corticosteroids? Perhaps a short course? Both diseases- SBF and fungal- are moderately pruritic, but so are the hypersensitivities. Treating with antibiotics and corticosteroids is a very common clinical practice nearly ubiquitous. 38

39 concurrent glucocorticoid use during therapy of SBF is strongly discouraged because it may improve the clinical appearance of the lesions and result in premature discontinuation of AMD (antimicrobial drug) administration whilst also reducing the patient s innate and adaptive immune response to infection. You are using antibiotic treatment as part of the diagnostic approach. You want to confirm that the lesions have a bacterial etiology Furthermore you want establish how much of the pruritus is due to bacteria. If you use concurrent antibiotics and corticosteroid, you cannot confirm either of these points. 39

40 Because things are seldom clear cut at the coal face, and you have to make some clinical decisions Even though you might not have found an intact pustule Even though the presentation is a mixed bag of flea bite induced papules and bacterial induced folliculitis. Gross et al say most bacterial folliculitis is seen secondary to co-existent disease or other predisposing factors. 40

41 Triggering diseases or syndromes in the dog include atopic dermatitis, flea allergy dermatitis, food allergy, primary seborrhea, hypothyroidism, demodicosis, naturally occurring and iatrogenic hyperglucocorticoidism & colour dilution alopoecia. ( Gross et al 406) 41

42 Because you can have two diseases together, both presenting with papules and pustules, both follicular and non follicular in orientation. if you use concurrent corticosteroids and antibiotics, you won t realize that there is more than one disease until later down the track you have been falsely reassured by the excellent response. you will most definitely want to re-evaluate your working diagnosis. Perhaps it isn t SBF. You will want to recheck for Demodex. You might want to send off a fungal culture. You will want to recheck your cytology. In some cases, and increasingly, especially if you have confirmed bacteria on cytology, you will want to do culture and sensitivity. 42

43 The 2014 Guidelines say that Bacterial culture of SBF is never contraindicated. However, it is expensive so it is good to have some guidelines about when to do it. There are no published reports demonstrating that current use of AMDs has a significant effect on isolation of causative bacteria from dogs with persistent SBF It is acceptable to collect samples for bacterial C & S testing from SBF lesions regardless of the current use of topical or systemic AMDs 43

44 the 2014 guidelines go on to say there are primarily five situations which may indicate the likelihood of AMD resistance and mandate bacterial culture of apparent SBF, as follows: (i) less than 50% reduction in extent of lesions within 2 weeks of appropriate systemic antimicrobial therapy. Think back to our VCLE border collie. (ii) emergence of new lesions(papules, pustules, collarettes) 2 weeks or more after beginning appropriate AMD therapy; 44

45 (iii) presence of residual SBF lesions after 6 weeks of appropriate systemic antimicrobial therapy together with the presence of cocci on cytology. while a typical course of therapy may be days, several studies indicate that therapy for up to 6 weeks may be necessary to resolve the infection in some cases (iv) intracellular rod-shaped bacteria are detected on cytology; (v) there is a prior history of multidrug-resistant infection in the dog or in a pet from the same household as the affected dog. Drug resistant bacteria Clinical success 45

46 From the Melbourne Vet Specialist Centre June 2014 newsletter: with permission How common is MRSP? MRSP bacterial infections (primarily pyodermas) continue to be diagnosed at the Animal Skin Ear and Allergy service at MVSC, averaging at about 1-2 new cases per week. There is no doubt this organism is now present and entrenched in Melbourne and while it seems very likely that there is some geographical variation at this stage, it is safe to assume that this problem is only going to become more prevalent with time. Melbourne dermatologists currently have a study underway looking at where the strains they are seeing have originated from (Asia and the US seem more likely but they will not know until the results are back later in the year). 46

47 There are several key points that are important to know about MRSP: unlike human MR S. aureus, it is neither more infectious nor more virulent than regular methicillin susceptible S. pseudintermedius (MSSP). MRSP infection can be quite mild in some cases it is not more contagious between dogs than MSSP; studies suggest asymptomatic colonisation of incontact dogs and cats is common in households with an MRSP positive pet MRSP is not more contagious to humans than MSSP. S. pseudintermedius infections of humans are rare however transient asymptomatic colonisation of humans is not uncommon; in summary, MRSP behaves as MSSP except for the fact it is not responsive to most antibiotics. 47

48 MRSP pyoderma is suggested where there are lesions consistent with pyoderma, where cocci are seen on cytology, and when there is a history of failure to respond to a course (of appropriate dose and duration) of an appropriate antibiotic Culture write on the request form to the lab that you are suspicious of MRSP It is especially important to write on the request form to the lab that you are suspicious of MRSP so they can pick it out of the culture. Remember that labs use oxacillin sensitivity to stand in for methicillin sensitivity 48

49 Swabs are usually taken (wearing gloves to avoid possible contamination) from intact pustules if present (break with a sterile needle) or underneath crusts (rub the dry swab on the skin until lightly abraded). Try to avoid sampling from areas where gross contamination is likely (near the anus, the underside of the paws, lip folds etc.) though this is not always possible. 49

50 The best way diagnose a MRSP deep pyoderma, if FNA from an intact bulla is not possible, is with a sterile tissue biopsy. In this case a punch biopsy is taken from intact but affected skin, the top 25% cut off in a sterile manner and the remaining 75% put in a sterile saline soaked swab in a yellow top container. This is sent off for tissue culture. Swabs from draining sinuses should not be performed as there is a high probability of growing irrelevant contaminants. We need more information, especially from the diagnostic labs. Last survey done in 2008 showed regional differences Especially with ampicillin & cephalothin resistance in E.coli. A 2012 study showed increasing resistance in E. coli associated with urinary tract infection We have only anecdotal evidence about MRSP. 50

51 I have had one case associated with prior AMD treatment And one unconfirmed case in a dog that moved from Melbourne Allan Bell has had 2 cases in Auckland. I would like to see Allan Bell s suggestion of swabbing dogs before importation put into place. Before we do that we need to have an idea of prevalence. What we do know is that overseas methicillin resistant S.pseudintermedius is a big problem We ve already seen the Melbourne information Dawn Boothe from Auburn, Alabama in her September 2014 presentation at the WSAVA conference said In our hospital, approximately 25 to 30% of Staphylococcus pseudintermedius express methicillin resistance. 51

52 The guidelines separate treatments of canine superficial bacterial folliculitis into Topical Systemic In the past topical treatments were considered adjunctive treatments Now that methicillin resistant bacteria & MDR bacteria have become a problem, topical treatment is routinely recommended. 52

53 As the 2014 guidelines say topical therapy of SBF is probably underused because of the perception that clients will find it more difficult to apply and that compliance may be poor. Personally I don t think this is a perception, it is a reality. BUT I WILL DO BETTER. I WILL TRY HARDER! We don t have Resi chlor or Resi ketochlor, 2 excellent Virbac leave on chlorhexidine products. Perhaps you could ask your Virbac rep to pass on that it would be useful if we had them. We don t have the MalAcetic Products We don t have Duoxo products HOWEVER MUSTN T GRUMBLE 53

54 3 4%Chlorhexidine shampoo has good robust studies showing that it clears pyoderma. Pyohex and Pyoderm-S are both 3% chlorhexidine. Pyoderm-S has spherulites Need to shampoo twice weekly to get the most benefit. Dermatology clinics use chlorhexidine solution- Andrew Hillier recommends 1-2% once daily Microshield 5% chlorhexidine can be diluted 1 to 4 to give a 1% solution. Wipe on once daily 54

55 Household bleach: sodium hypochlorite is a very effective antibacterial agent Increasingly used overseas as a treatment for MDR bacteria, especially pseudintermedius One recipe is ½ c of household bleach to ¼ full bathtub of water There are obvious problems with this: 1. Bleach damage 2. Inaccurate dilution Active ingredient in bleach More stable, nontoxic, ph neutral, does not bleach Can be used once daily for superficial and deep bacterial skin infections as an adjunct to shampooing. 55

56 Neutral Anolyte Antiseptic Sanitiser. Available from Envirolyte Strong, fast-acting disinfectant kills all known bacteria & viruses on contact NZFSA approved for food contact. Available in spray bottles: $16 for 500 ml Available from Scomac, a Christchurch distributing company. It handles a range of wound and skin products that use hypochlorous acid as their antimicrobial agent. Licenced for companion animal use. (03) (022) admin@scomac.co.nz 56

57 These will be available from Nov 6th (ETA for our first shipment). Initially we will offer $ GST delivered and $ GST delivered. We will offer a 20% discount on the first order from any clinic. There are samples available for any vets interested in the product. Just have them contact me directly. When trialling Vetericyn we suggest taking a before and after photo. Treat the wound or skin condition from start to finish with Vetericyn (don t wash it with saline or other product Vetericyn does everything) then send the owner home with a bottle to apply 2 to 3 times daily. 57

58 Not strictly a pyoderma because no neutrophils No typical lesions of pyoderma but dogs improve when treated with antibiotics Described by Pin, 2008 Characterized by marked pruritus, greasy seborrhoea and an offensive odour. Acutely there is erythema, which is converted to lichenification, hyperpigmentation & alopoecia No papules, pustules, epidermal collarettes or crusts. No folliculitis No PMN on cyto, only cocci Confirmed on biopsy 58

59 Typically BOGS is associated with an underlying hypersensitivity However I find that a proportion of these cases have their pruritus and clinical lesions completely disappear with the appropriate course of antibiotics. No clinical signs of pyoderma: no papules, pustules, crusts or epidermal collarettes Only pruritus and erythema Biopsy compatible with hypersensitivity No wonder these cases are almost always treated with antibiotics and corticosteroids However cytology and response to treatment are the only way to diagnose BOGS (Pin, 2008) 59

60 Guidelines with reference to BOGS say, because of the increasing prevalence of multi drug resistant bacteria, that The routine use of antimicrobial drugs is not recommended and Recommends shampooing and topical treatments BOGS cases are ideal candidates for chlorhexidine wipes or Vetericyn Traditionally the systemic antimicrobial treatment options for superficial bacterial folliculitis are divided into three categories or tiers. The first tier contains those antibiotics that should be considered as the primary choice for empirical treatment of known or suspected SBF. The second tier is to use either when there is known resistance based on culture results or when first tier systemic antibiotics and topical therapy are not appropriate. The third tier contains the drugs that should be reserved for the treatment of serious MRSA infections in humans. 60

61 The first tier antibiotics that the guidelines agree on are the first generation cephalosporins, amoxicillin-clavulanate, clindamycin or lincomycin, and potentiated sulphonamides. The guide lines say that members of the working group were unable to reach consensus on how the third generation cephalosporins, specifically cefpodoxime and cefovecin, known to us as Simplicef and Convenia, should be distributed within the tiers. The guidelines acknowledge that a recent systematic review has shown fair to good evidence for the moderate to high efficacy of cefovecin (Convenia) in the treatment of SBF. The same systematic review reported that there was insufficient evidence for/against recommending the use of cefpodoxime (Simplicef). 61

62 The guidelines say that simple consideration of clinical efficacy would support the inclusion of all these drugs as first tier AMDs. However, there is concern among some members of this panel about the potential selective effects of third generation cephalosporins (cefpodoxime and cefovecin) on the gram Gram-negative microbiota, due to their broader spectrum of activity compared with first generation cephalosporins. Both Simplicef and Convenia have approval for use against E. coli As the guidelines say this raises concerns about possible selection of highly resistant extended-spectrum beta lactamase (ESBL)-producing E.coli. 62

63 Bacteria that produce enzymes called extended-spectrum beta-lactamases (ESBLs) are resistant to many penicillin and cephalosporin antibiotics and often to other types of antibiotic. The 2 main bacteria that produce ESBLs are E. coli and Klebsiella species. Because of these considerations some dermatologists and microbiologists support using tier one antibiotics for staph treatments and Reserving tier 2 antibiotics for use after a culture. In other words they should not be used empirically. This would apply to the fluorquinolones and 3 rd generation cephalosporins 63

64 compliance: is the client able to administer drugs once daily, twice daily or not at all. I recently used Convenia in a little horror of a dog that is impossible to medicate orally. The severity and extent of the lesions will influence your choice. Is this a first presentation or a recurrence of a previous infection? If SBF is recurrent, how long was the initial course of treatment? Was it at the correct dose rate? I think weighing the animal and calculating the dose is critical 64

65 The skin is the largest organ of the body, and its blood supply is comparatively poor. Antibiotics should, therefore, be used at the upper end of their dose range in pyoderma. Animals should always be weighed to allow accurate dosing. Round up not down. The guidelines feel that when recurrence of SBF occurs, careful consideration of culture and susceptibility testing is encouraged because previous exposure to AMDs is a risk factor for resistance. They recommend that if a culture is not performed, the same AMD should be used that successfully resolved the previous infection. 65

66 The guidelines say that typically lesions rapidly improve in the first one to two weeks, but resolution of all lesions and prevention of rapid recurrence of disease requires 3-6 weeks of treatment. The ideal scenario is that you dispense two weeks of antibiotics, and see the animal back after 10 days to evaluate the response. The guidelines stress the importance of you making the decision of when to stop rather than the client. A very common problem is that the dog improves enough that the owner considers him cured, and cancels the revisit appointment. For this reason, it is important that at the initial consultation you emphasize the problem of stopping too early and the importance of the revisit appointment. 66

67 I know you are already short of time, so how do you get that message across? I am no better at it than you are, and I have more time. I have prepared a client hand out that addresses some of these issues. I am happy to send it to anyone that would like to use it. Clavulanate-amoxicillin: 12.5 to 25 mg/kg every 12 hours orally (Lloyd and others 1997). Cefalexin: 22 to 30 mg/kg every 12 hours, or 30 to 40 mg/kg every 24 hours orally (Toma and others 2008). Cefadroxil: 22 to 30 mg/kg every 12 hours orally (Angarano and MacDonald 1989, Frank and Kunkle 1993), or 30 to 40 mg/kg every 24 hours orally (Noli and Scarampella 1999). Lincomycin: 22 mg/kg every 12 hours orally (Harvey and others 1993). Clindamycin: 11 mg/kg every 12 to 24 hours orally (Harvey and others 1993, Saridomichelakis and others 2011). Cefovecin: 8 mg/kg every 14 days subcutaneously (Stegemann and others 2007, Six and others 2008). Cefpodoxime: 5 to 10 mg/kg every 24 hours orally (Brown and others 2007, Papich and others 2010, Kumar and others 2011). 67

68 Enrofloxacin: 5 to 20 mg/kg every 24 hours orally (DeManuelle and others 1998, Frazier and others 2000, Bidgood and Papich 2005, Boothe and others 2006). Marbofloxacin: 2.5 to 5 mg/kg every 24 hours orally (Schneider and others 1996, Carlotti and others 1999, Frazier and others2000, Paradis and others 2001, Horspool and others 2004, Boothe and others 2006). Difloxacin: 5 mg/kg every 24 hours orally (Boothe and others 2006). Orbifloxacin: 2.5 to 7.5 mg/kg every 24 hours orally (Boothe and others 2006, Scott and others 2006). Pradofloxacin: 3 mg/kg every 24 hours orally (Mueller and Stephan 2007, Restrepo and others 2010). Azithromycin: 10 mg/kg every 24 hours orally (Girard and others 1987, Shepard and Falkner 1990). Chloramphenicol: 50 mg/kg every eight hours orally. Rifampin: 5 to 10 mg/kg every 12 to 24 hours orally. Tobramycin: 9 to 14 mg/kg every 24 hours subcutaneously. Netilmicin: 9 to 14 mg/kg every 24 hours subcutaneously. Amikacin: 15 to 30 mg/kg every 24 hours subcutaneously. Gentamicin: 9 to 14 mg/kg every 24 hours subcutaneously. 68

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70 She uses them in her discussions of Superficial Bacterial Folliculitis To emphasize the importance of the examining the whole dog, not the hole of the dog. She agrees that this presentation could be urticarial But turn the dog over, and what do you find? 70

71 FLY BITE DERMATITIS CANINE LEPROID GRANULOMA 2 HOUNDS PRESENTED WITH LESIONS ON DORSAL EAR FOLDS AND DRAINING GRANULOMAS ON EXTREMITIES 71

72 GRANULOMATOUS AND PYOGRANULOMATOUS DERMATITIS AND CELLULITIS ZN AND FITES POSITIVE SMALL BEADED ORGANISMS definitely an infection here. The orgs are not typical Mycobacteria not long rods or filaments, but something is staining up in many of these macrophages. Now it is a matter of growing it. B. Smits et al: Case clusters of leproid granulomas in foxhounds in New Zealand and Australia. Vet Dermatol 23: /22/2014 MYCOBACTERIA UPDATE

73 10/22/2014 MYCOBACTERIA UPDATE /22/2014 MYCOBACTERIA UPDATE

74 single or multiple nodules easy to diagnose on cytology or histology (most of the time) pyogranulomatous inflammation with variable AFBs can t culture the organism in vitro; still trying!! 16S rrna and ITS PCR available; can have CLGS specific PCR lesions tend to be on head and ears short coated breeds especially Boxers predisposed lesions typically regress spontaneously ( self cure ) in 1-3 mnths aetiology unknown. biting insects? mechanical vector organisms may have a requirement for low temperature for growth organism present throughout the world If REFRACTORY, respond to rifampicin/clarithromycin systemically Topical formulations can be effective also 74

75 The support from Royal Canin has been awesome They made no demands about what I was to speak on. 75

76 Another spring has disappeared while I ve been in the books BUT I VE LEARNED A LOT SO IT WAS WORTH IT! THANKS everyone Give yourselves a clap Any questions? 76