Challenging case series (Proceedings)

Case #1: Cali

Signalment: 4.5-year-old FS Labrador Retriever, weighing 59.8lbs

Presenting complaint: Pruritus (10/10 off meds) and recurrent skin and ear infections

History (day 1)

Cali was acquired by the owners at 8 weeks of age and has lived in Los Angeles her entire life. Her owner is a large animal veterinarian, and is very compliant. There are no other pets in the household, although she does frequent a barn where she does have some contact with horses.

The onset of dermatological disease was around 2 years of age in the summer, and the first sign of a skin problem was head shaking which was discovered to be secondary to otitis externa. Over the following months she became itchy on her body. The pruritus started in her axilla and sternum, but the owner thinks her itching is fairly generalized now. She does seem to particularly favor her front paws. She does still develop recurrent otitis externa-she gets an ear infection 2-3 times yearly which is easily controlled with appropriate ear drops.

The owner has tried multiple antihistamines, none of which she has responded to. She just finished a 60-day course of Atopica® 125mg BID with no response. She is somewhat responsive to Temaril P®. If she receives Temaril P®: 2 tablets in the am and 1 tablet in the pm QD she is a 4/10 itchy, and if she receives 1 tablet BID she is a 6/10 itchy. She previously did not respond at all to a 2-month food trial with an over the counter venison and potato diet.

Current medications: She is bathed weekly with a chlorhexidine-based shampoo followed by a pramoxine based crème rinse. She is on Sentinel® and Comfortis® monthly for parasite control. She is on phenylpropanolamine for urinary incontinence. She is currently on day 24 of a 30-day course of Simplicef™ 200mg QD that the owner thinks has significantly helped her recent bacterial folliculitis. She has had a chronic history of loose stool for the past 2 years which the owner thinks is unrelated to the skin problem, and this is controlled with metronidazole 500mg BID. She was started on immunotherapy 4 months previously, and the owner doesn't think she has responded at all to it yet. She was started on immunotherapy based on serology testing and the following is a summary of her results:

Physical Exam Findings

Otic examination revealed mild erythema of the vertical and horizontal canals AU with no exudate present and the tympanic membranes visualized and intact.

Dermatological examination revealed 1 healing epidermal collarette on the sternum and multiple excoriations on the ventral chest. The caudoventral abdomen displayed mild hyperpigmentation.

Differentials:

Diagnostics:

Plan:

Case #2: Maurie

Signalment: 11-year-old MC Beagle, weighing 42.2 lbs

Presenting compliant: Pruritus (10/10), odor, infections, hair loss

History (day 1)

Maurie was acquired by the owners as a puppy and has lived in Los Angeles his entire life. There used to be three other dogs in the household- all of which have passed away from old age in the past year and a half. Two of those three dogs had mild allergies.

Maurie has had a history of seasonal allergies since 5 years of age. He historically would develop moderate pruritus in the summer on the face and paws that would respond well to a glucocorticoid injection. In the past two years his clinical signs have become nonseasonal, progressive, and are minimally responsive to steroids. His pruritus is generalized and severe, to the point that he wakes the owner up in the middle of the night with his scratching. He has improved marginally with courses of cephalexin, ketoconazole and Temaril P® in the past, although these never obtain complete response and he immediately relapses off medications. Antihistamines have been ineffective in the past. The owner reports that he has started developing hair loss on the tail and dorsal cervical region in the past 6 months.

Current Medications: He is bathed every few weeks with Douxo® seborrhea shampoo and gets Frontline® monthly in the summer. He received one dose of Revolution® four months prior to presentation to treat sarcoptic mange, which did not help.

Physical Exam Findings

Otic examination revealed normal vertical and horizontal canals but the inner pinna were moderately lichenified and scaly.

Dermatological examination revealed droopy eyes with mild periocular hyperpigmentation. There was patchy alopecia on the dorsal head, dorsal cervical region, and dorsal lumbar region with moderate erythema, crust and scale. The entire ventrum displayed moderate-severe hyperpigmentation, lichenification, erythema and mild crust with the nipples all pendulous. The entire dorsal aspect of the tail from tail base to tip was completely alopecic. Maurie was significantly pruritic in the exam room, constantly scratching the chest with a hind paw.

Differentials:

Diagnostics:

Plan: