Small Animal Dermatology

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Self-Assessment Color Review
Small Animal
Dermatology
Volume 2: Advanced Cases
Karen A Moriello
DVM, DACVD
Department of Medical Sciences
School of Veterinary Medicine
University of Wisconsin–Madison, Wisconsin, USA
Alison Diesel
DVM, DACVD
Department of Small Animal Clinical Sciences
College of Veterinary Medicine and Biomedical Sciences
Texas A&M University, Texas, USA
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K21949 Moriello vol2 final.indd 1 6/9/13 11:38 PM
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Preface
The first edition of this book covered a general review of basic small animal
dermatology. In this book, we have used the case-based and question format to
present a review of advanced small animal dermatology. Also different from the
first text is an expanded bibliography of references.
Karen A. Moriello
Alison Diesel
Acknowledgements
We would like to thank our colleagues for contributing cases in the following
specialties.
Dermatology Neurology/neurosurgery
Adam P Patterson DVM DACVD** Heidi Barnes Heller DVM DACVIM
William Oldenhoff DVM* (Neurology)*
Darcie Kunder VMD*
Radiation therapy
Internal medicine Michael A Deveau DVM, MS,
JD Foster VMD* DACVR (Radiation Oncology)**
Surgery Pathology
Jason A Bleedorn DVM DACVS* Aline Rodrigues Hoffmann DVM, MS,
PhD, DACVP***
* Department of Medical Sciences
School of Veterinary Medicine, University of Wisconsin–Madison, Wisconsin, USA
** Department of Small Animal Clinical Sciences

College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, Texas, USA
*** Department of Veterinary Pathobiology

College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, Texas, USA

Abbreviations
ACTH adrenocorticotropic hormone NSAID non-steroidal anti-
AD atopic dermatitis inflammatory drug
ANA antinuclear antibody PAS periodic acid–Schiff
ASIT allergen-specific PCD plasma cell pododermatitis
immunotherapy PCR polymerase chain reaction
CBC complete blood count PF pemphigus foliaceus
CDA color dilution alopecia PNU protein nitrogen unit
CLE cutaneous lupus PSOM primary secretory otitis media
erythematosus RAST radioallergosorbent test
CNS central nervous system RNA ribonucleic acid
CPV canine papillomavirus SCC squamous cell carcinoma
CsA cyclosporine A SIG Staphylococcus intermedius
CSF cerebrospinal fluid group
CT computed tomography SLE systemic lupus erythematosus
DIM Dermatophyte Identification T4 thyroxine
Medium TEN toxic epidermal necrolysis
DLE discoid lupus erythematosus TEWL transepidermal water loss
DLH domestic longhair (cat) Th T helper (cell)
DMSO dimethyl sulfoxide TNF tumor necrosis factor
DNA deoxyribonucleic acid TSH thyroid-stimulating hormone
DSH domestic shorthair (cat) VCAM vascular cell adhesion
DTM dermatophyte test medium molecule
EDS Ehlers–Danlos syndrome VCLE vesicular cutaneous lupus
ELISA enzyme-linked erythematosus
immunosorbent assay
EM erythema multiforme
FeLV feline leukemia virus
FIV feline immunodeficiency virus
FNA fine needle aspiration
GABA gamma-aminobutyric acid
Gy gray (radiation measurement)
HA hyaluronan
IDT intradermal skin test/testing
Ig immunoglobulin
IL interleukin
IVIG intravenous immunoglobulin
kDa kiloDalton (molecular weight
measurement)
MCT mast cell tumor
MIC minimum inhibitory
concentration
MRI magnetic resonance imaging
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Broad classification of cases
Allergic cases Metabolic cases
1, 11, 13, 15, 17, 27, 38, 44, 59, 61, 21, 57, 82, 90, 168
62, 67, 74, 81, 106, 116, 134, 174,
184, 187, 188, 198, 242 Miscellaneous cases
31, 55, 78, 84, 87, 105, 137, 147, 152,
Alopecic cases 161, 163, 165, 169, 177, 181, 183,
4, 26, 29, 76, 94, 109, 121, 182 200, 207, 213, 214, 224, 226, 229,
240, 241
Autoimmune cases
19, 28, 40, 45, 52, 60, 83, 138, 142, Neoplasia cases
149, 151, 171, 185, 196, 199, 205, 7, 51, 92, 111, 118, 119, 122, 126,
210, 215 128, 130, 178, 190, 201, 236, 246
Bacterial cases Nutrition cases

2, 10, 16, 34, 36, 37, 48, 50, 53, 66, 42, 223
93, 98, 129, 146, 153, 158, 204, 217,
219, 233, 239 Parasite cases
12, 18, 22, 64, 71, 72, 73, 80, 89, 96,
Congenital cases 101, 113, 136, 140, 141, 144, 159,
107, 135, 209, 221, 227, 230 173, 179, 194, 195, 202, 211, 220,
222
Diagnostic cases
14, 24, 25, 30, 68, 70, 77, 100, 104, Pigmentation cases
115, 127, 156, 189, 228, 231, 243, 3, 23, 85, 88, 139, 166
244
Structure and function cases
Ear cases 58, 95, 114, 170, 172, 193
9, 56, 97, 108, 132, 148, 150, 167,
203, 234, 238 Therapy cases
6, 8, 32, 43, 49, 63, 75, 86, 91, 99,
Endocrine cases 103, 117, 123, 125, 131, 154, 164,
39, 41, 79, 110, 112, 155, 157, 191, 206, 208, 216, 225
245
Viral cases
Fungal cases 35, 47, 69, 102, 141, 192
5, 33, 54, 120, 133, 145, 160, 162,
175, 176, 180, 210, 218
Keratinization cases
20, 46, 124, 143, 186, 197, 212, 235,
237

To my family – Mark, Ethan, and Doug
Thanks TEAM!
KAM
To Mike – for allowing me to be ‘boring’ and work too many late nights
and evenings. This could not have been completed without the support and
understanding of my wonderful family
– thanks Mom, Dad, and Erica for bearing with me through the holiday!
AD

Questions: 1, 2
1a 1b
1 The owners of a dog and cat presented them in the morning for the complaint
of acute onset of skin lesions overnight. The cat had lesions limited to the nose
(1a) and the dog had lesions limited to the ventrum (1b). Close examination of the
cat’s nose revealed swelling and erythema of the haired area of the nose, multifocal
areas of hair loss, and hemorrhagic crusts with small areas of focal erosion at the
junction of the nasal planum and haired skin. Examination of the dog revealed
a ventral distribution of lesions most noticeable in the thinly haired areas of the
inguinal region. Skin lesions consisted of multifocal crusted papules surrounded by
circular erythematous macules. The skin lesions were notably pruritic in the dog.
When asked about the previous evening’s activities, the owners reported that the
dog and cat had spent the evening in their garden and yard, as usual.
i. Focusing just on the presentation of the skin lesions, what are possible differential
diagnoses for the nasal lesions in the cat and the ventral skin lesions in the dog?
ii. Considering the clinical presentation of these patients, what is the most likely
cause of the skin lesions? How can this be definitively diagnosed?
iii. What treatment do you recommend?
2 Bacterial cultures of the skin are necessary for the appropriate treatment of many
skin infections.
i. What is the standard bacterium inoculum for testing antimicrobial susceptibility?
ii. Describe three techniques for determining the MIC of antibiotics. What is the
‘breakpoint MIC’?

Answers: 1, 2
1 i. Cat: pemphigus foliaceus, dermatophytosis, demodicosis, atopy, food allergy,
insect bite hypersensitivity. Dog: bacterial pyoderma, insect bite hypersensitivity,
chigger bites, flea bites, purpura, vasculitis, erythema multiforme, drug reaction.
ii. Insect bite hypersensitivity, most likely mosquito, gnat, or Culicoides spp. These
are most common in the evening. Definitive diagnosis requires keeping both pets
out of the garden in the evening hours and observing resolution of the skin lesions
followed by challenge exposure. This could be difficult as outdoor conditions vary.
Wind, temperature, and humidity are factors affecting the presence or absence of
insects.
iii. The lesions will resolve without treatment if repeated exposure is prevented.
Topical therapy is difficult in cats and the lesions are not serious enough to warrant
systemic glucocorticoid therapy unless they progress. The dog is pruritic; skin
cytology is recommended to ensure bacterial overgrowth is not a complicating
factor. Treatment is guided by cytologic findings, which in this case revealed no
microbial overgrowth. The dog was treated with a topical glucocorticoid spray
containing triamcinolone. Flea control products with permethrins designed to
repel mosquitoes can be used in dogs to prevent recurrence. Permethrins are toxic
to cats.
2 i. The standard inoculum is 105 colony forming units/ml of the bacterium.

ii. (1) Broth microdilution technique. Drug is added to medium in a 96-well
microtiter tray and serially diluted to the desired drug concentration to be tested.
The microorganism is then added and the tray incubated for 18–24 hours. The
lowest concentration preventing visible growth is the MIC. (2) Agar dilution test
(Kirby–Bauer, disk diffusion). Agar plates incorporating antimicrobial drugs at
pre-determined drug concentrations directly into the medium are inoculated with
a known concentration of the microbe directly onto the plate. Plates are incubated
and again the lowest drug concentration inhibiting growth is the MIC. (3) E-test.
The microorganism is inoculated over the entire surface of an agar plate and an
E-strip containing gradients of drug concentrations is added to the surface of the
plate and incubated. After incubation, the point on the E-strip that intersects the
line of bacterial inhibition is the MIC. The breakpoint MIC is the highest drug
concentration that can be achieved safely with clinically acceptable drug doses
and routes of administration. Organisms are considered ‘sensitive’ if the MIC is
well below the breakpoint, ‘intermediately susceptible’ if the MIC approaches the
breakpoint, and ‘resistant’ if the MIC surpasses the breakpoint.

Questions: 3, 4
3 A 5-year-old female spayed husky 3
dog presents for the lesions shown (3).
The lesions are confined to the non-
haired skin of the nasal planum and
lips; no other skin lesions are present
at examination. The owner reports
that the dog is otherwise healthy, with
the exception of its eyes ‘looking a bit
different’ and it has been ‘squinting’
recently.
i. What are your differential diagnoses
for this patient?
ii. What diagnostic testing is indicated?
iii. What is the most likely diagnosis for
this patient?
4 A 9-month-old male neutered cat is recovering from panleukopenia. The

veterinary nursing staff report that the cat is shedding excessively (4). According
to the staff, the cat is not pruritic. On examination, the cat is not ‘shedding hairs’,
but rather the hairs are easily broken at the level of the follicular ostium.
i. What are the two major differential diagnoses?
ii. What diagnostic tests should you perform?
iii. Assuming the diagnostic testing is negative, what is your diagnosis and
prognosis?
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Answers: 3, 4
3 i. Lupus, uveodermatologic syndrome, idiopathic vitiligo, cutaneous epitheli
otropic T-cell lymphoma, contact hypersensitivity, irritant reaction.
ii. Skin biopsy to differentiate among the differential diagnoses listed above. Given
the concurrent involvement of an organ system other than the skin, skin biopsy
is indicated sooner rather than later. A thorough ophthalmologic examination is
needed to look for evidence of uveitis.
iii. Uveodermatologic syndrome. This is an immune-mediated disease that presents
similarly to Vogt–Koyanagi–Harada syndrome in people. In dogs, the disease
produces vitiligo and alopecia of the skin and mucosa along with granulomatous
panuveitis. Histopathologic examination of skin biopsy specimens shows acanthosis
of the epidermis, often with parakeratosis. Melanin in the basal layer is decreased
or absent. Dermal inflammation is present as a perivascular to dense lichenoid
infiltrate with the latter occasionally obscuring the dermal–epidermal junction.
Ophthalmic changes can be severe and, if diagnosis is delayed, enucleation is often
needed. Treatment includes immunosuppression (corticosteroids, cyclosporine,
topical tacrolimus, azathioprine) and management of the uveitis. The condition
has been reported in various breeds of dogs; however, Akita dogs appear to be
most commonly affected. A recent study identified an increased frequency of a
certain DLA class II allele (DQA1*00201) in American Akita dogs, which may be
involved in the pathogenesis of uveodermatologic syndrome.
4 i. Dermatophytosis and anagen effluvium.

ii. Skin scraping and fecal flotation examination are needed to rule out feline
demodicosis. Demodex gatoi is usually pruritic; the cat could be pruritic, but it
was simply not observed. D. cati is often found in cats with systemic illnesses.
Given that the hair breakage started suddenly and presumably the dermatologic
examination was normal at the time of admission, dermatophytosis is unlikely, but
a Wood’s lamp examination and fungal culture are indicated.
iii. Anagen effluvium, which is very common in cats that have been severely ill
or under other stressful situations (change of environment, surrender to animal
shelter, poor plane of nutrition). In cats with severe upper respiratory infections,
particularly kittens, the effluvium can start within a week of the event. Anagen
effluvium will occur in young animals that have a large number of actively growing
hairs; when the animal experiences a sudden illness, this will interrupt normal
hair growth, making them fragile and easily broken. Hairs break when traction
is placed on them, giving the impression that hairs are being shed. In telogen
effluvium, anagen hairs rapidly progress to the telogen state as a bodily defense
mechanism to conserve metabolic resources. Hairs are all synchronized in telogen
and when new hair growth starts, hairs are shed in large numbers or patches.
10

Questions: 5, 6
5a
5b
5 A 6-month-old dog is presented for multifocal areas of hair loss on the legs (5a),
face, ears, and trunk. The lesions shown here are characteristic of others present
over the dog’s body. The dog lives outside in a dog pen; alopecia developed shortly
after it started to dig holes in the ground. The dog is not reported to be pruritic.
i. What are the differential diagnoses?
ii. Initial diagnostic tests do not reveal a diagnosis and the owner declines treatment
pending further results. A cytologic preparation from a pending diagnostic test is
shown (5b). What is the diagnosis, how is this treated, and how do you explain
the source of the infection?
6 Essential fatty acid (EFA) supplementation has long been a recommendation for
the management of various inflammatory disorders in dogs and cats.
i. What is the difference between omega-3 and omega-6 fatty acids?
ii. What organs may be affected by the anti-inflammatory effects of omega-3 fatty
acid supplementation?
iii. How have EFAs been utilized in the management of dermatologic conditions
in dogs and cats?
11

Answers: 5, 6
5 i. Demodicosis, dermatophytosis, and bacterial pyoderma with or without
secondary yeast overgrowth.
ii. Microsporum gypseum dermatophytosis. M. gypseum is a geophilic dermatophyte
and infections often are inflammatory; the more inflammatory the reaction to
a dermatophyte the faster the infection will self-cure. Ideal treatment includes
both a systemic antifungal (itraconazole or terbinafine) and a topical antifungal
rinse (lime sulfur, enilconazole). Dermatophytosis will self-cure, but the purpose
of treatment is to hasten recovery and minimize contagion to other animals and
people. The most likely source of infection is the dirt in the dog pen. Dogs that dig
and/or spend large amounts of time outdoors exposed to soil are the ones most
likely to contract this dermatophyte. There is no way of decontaminating the dog
pen. In fact, little is known about how to control the organism in the environment.
Decontamination attempts would only be reasonable if the dog continues to
contract infection from the dog pen.
6 i. Omega-3 fatty acids (e.g. docosahexaenoic acid [DHA] and eicosapentaenoic

acid [EPA]) are found in cold water fish (mackerel, cod), walnuts, and flaxseed.
Omega-6 fatty acids are found in seeds and nuts and their extracted/refined oils.
Gamma-linolenic acid (GLA) is an example of an omega-6 fatty acid; it is the
precursor to dihomo-γ-linolenic acid (DGLA) as well as arachidonic acid. Fatty
acids are a component of the phospholipid bilayer that comprises cell membranes;
dietary intake of the various fatty acids will alter the composition of the cell
membrane. Both omega-3 and omega-6 fatty acids compete for metabolic enzymes;
activation of cell membrane phospholipases initiates an inflammatory cascade.
Omega-6 fatty acids typically form pro-inflammatory mediators such as series 4
leukotrienes (e.g. B4) and series 2 prostaglandins (e.g. E2). Omega-3 fatty acids
tend to form less pro-inflammatory mediators; series 3 prostaglandins (e.g. E3)
and series 5 leukotrienes (e.g. B5) are formed instead.
ii. Include the skin, kidneys, gastrointestinal tract, neural tissues, cardiovascular
system, and bones.
iii. EFA administration has been evaluated in dogs and cats with various
inflammatory skin diseases including AD, cutaneous adverse reactions to food,
and various feline cutaneous reaction patterns (miliary dermatitis, eosinophilic
skin lesions). Various dosing regimens have been recommended, ranging from
35–90 mg/kg/day of combined DHA and EPA. Supplementation as part of or sole
therapy for symmetrical lupoid onychodystrophy has also been reported.
12

Questions: 7, 8
7a 7b
7 An 18-month-old female spayed Siamese cat was presented for evaluation of

multiple abnormal claw growths involving all four feet. Multiple digits on each
paw were affected as well as the metacarpal pads of both paws (7a, b).
i. What is this condition?
ii. What are the clinical features of this disease?
iii. Describe the etiology of the disease.
iv. What is the treatment of choice?
8
Time post administration
MPC
MSW
MIC
Serum or tissue drug concentration
8 Define mutant prevention concentration (MPC) (8) and mutant selection

window (MSW) and how these hypotheses relate to selection for resistant strains
of bacteria. What weaknesses of minimum inhibitory concentration (MIC) values
does the MPC hypothesis seek to correct?
13

Answers: 7, 8
7 i. Cutaneous horns.
ii. Cutaneous horn is a general term that describes a well circumscribed, conical or
cylindrical mass of keratin. Lesions may be single or multiple and are firm on palpation.
Trauma to the masses may result in localized hemorrhage. Lesions may vary from
several millimeters to >2 cm in height. Lesions have been described in association with
and in the absence of FeLV. Lesions are typically located in the center of digital, central,
or metacarpal pads in cases of viral-associated cutaneous horns. In the non-viral form,
masses may only form on digital pads just below the claw.
iii. Examination of the epithelium underlying the cutaneous horn is necessary to
determine the etiology of the condition. Lesions may arise from viral papillomas,
actinic keratosis, bowenoid in situ carcinoma, or invasive SCC. Virus isolation
may be necessary to confirm or refute the presence of FeLV.
iv. Surgical removal. This may be accomplished via cryotherapy, laser removal,
or classical surgical techniques. Owners must be alerted to the possibility of
lesion recurrence. Based on the underlying cause of cutaneous horn development,
prognosis is considered to be variable.
8 MPC can be defined as the MIC (minimal concentration of antibiotic that

inhibits the growth of 105 colony-forming units) of the most resistant bacterial
organism. For drugs such as fluoroquinolones, MPC can be defined as the antibiotic
concentration that would require a microorganism to possess two simultaneous
mutations at two different metabolic steps to grow in the presence of the antibiotic.
Mutant subpopulations are typically present at low frequencies (e.g. 10-6 to 10-8).
In some infections, there may be several-fold more bacteria than the numbers used
in standard MIC testing. As a consequence, it becomes likely that first-step mutants
are present, thus selecting for resistant bacteria. These first-step mutants carry a
single mutation conferring partial resistance to the antibiotic. The MPC hypothesis
states that with higher concentrations of antibiotics, one can inhibit both susceptible
and first-step resistant bacterial cells. MSW is the drug concentration range between
the MIC and the MPC and can be thought of as the range that selects for first-step
resistant organisms. One study found two distinct regions of growth inhibition when
studying fluoroquinolone resistance patterns in higher density (>109) concentrations
of bacteria. The first region of inhibition was approximated to the MIC. The second
region, which completely blocked all growth, was termed the MPC. Between the
MIC and the concentration of complete inhibition, viable bacteria could be isolated.
These bacteria were found to have mutations that conferred resistance to the
antibiotic being tested. Weaknesses of MPC include lack of standardization, lack of
data, and the fact that MPC calculations are labor intensive. MPC is helpful only for
bacteria that acquire resistance via mutations and not gene transfer.
14

Questions: 9, 10
9a 9b
9 A 5-year-old male neutered DSH

cat presented for a 3-month history of
respiratory stertor. Physical examination
was unremarkable other than the previously mentioned stertorous breathing noted
at rest. Otic examination was within normal limits. Sedated oral examination
revealed the presence of a large, pink, soft tissue mass located dorsal to the soft
palate (9a). Retraction of the soft palate with a snook hook allowed exteriorization
of the mass using a stay suture (9b).
i. What is this mass?
ii. What additional diagnostics and treatment are recommended for this patient?
iii. What complications are associated with treatment? What is the prognosis?
10 A 4-year-old female spayed Labra 10

dor retriever dog is presented for
moderate pruritus. The owner describes
an increase in licking and scratching,
particularly along the ventral abdomen
and flanks. The owner seems to remem
ber a similar occurrence the previous
year around the same time. On physical
examination, you notice these lesions
on the ventral abdomen (10). No other
lesions are noted on the dog.
i. Describe the lesions seen on this patient.
ii. This is a common presentation of skin disease in dogs. What are three possible
causes of the lesions seen?
iii. Of the possible etiologies, which is most common in the dog?
iv. What organism is isolated most commonly?
15

Answers: 9, 10
9 i. A feline nasopharyngeal polyp, the most common nasopharyngeal disease of
younger cats and the most common non-neoplastic mass of the feline ear. Although the
etiology is unknown, it is hypothesized that the polyps are congenital defects arising
from remnants of branchial arches or are a response to irritation from chronic viral
infections. Histopathologically, these masses contain a core of loose fibrovascular
tissue covered by a stratified squamous to ciliated columnar epithelium with variable
inflammatory infiltrates. Viral PCR for feline herpesvirus 1 or feline calicivirus has
failed to substantiate the tissue persistence of these viruses in inflammatory polyps.
ii. Diagnostic imaging can be performed under heavy sedation or general anesthesia
to further localize the polyp and determine if involvement of the bulla exists.
Conventional skull radiographs of the bulla include right and left lateral oblique and
open mouth rostrocaudal views, but these often lack sensitivity and are compromised
by superimposition of the bones of the skull. Cross-sectional imaging using CT and
MRI are complementary imaging studies of the middle ear and auditory canal and
their contents; they are superior diagnostics for diseases of the ear. CT provides
excellent images of bony structures and is indicated where osseous changes are of
greatest diagnostic importance. MRI is superior in imaging soft tissue components
including fluid and soft tissue density within the middle ear. Removal of the polyp is
recommended by either simple traction/avulsion or ventral bulla osteotomy (VBO).
iii. Traction/avulsion of the polyp is considered if adequate grasp of the polypoid stalk is
possible; however, the recurrence rate approaches 33%. Polyps without evidence of bulla
involvement may be arising from the Eustachian tube, not the middle ear, allowing more
complete removal of affected tissue via traction/avulsion. When bulla involvement is
present, complete removal of affected tissue cannot be achieved without VBO. Surgical
excision through VBO is recommended for definitive treatment and allows for complete
removal of polyps and the epithelial lining of the bulla. Complications include Horner’s
syndrome, respiratory compromise, hemorrhage, seroma/hematoma formation, and
recurrence. Features of Horner’s syndrome include miosis, ptosis, enophthalmos, and
elevation of the third eyelid; this occurs in up to 80% of cats postoperatively, although is
often transient. Deafness is also reported in cats with nasopharyngeal polyps, although
VBO does not appear to contribute to or provide resolution of hearing impairment as
measured by air-conducted brainstem auditory evoked response.
10 i. Papules, pustules, and epidermal collarettes are noted along the ventral
abdomen. Small erythematous macules may also be seen.
ii. These lesions are compatible with folliculitis. Common causes include bacterial
pyoderma (superficial), demodicosis, and dermatophytosis.
iii. Bacterial pyoderma. Dermatophytosis, on the other hand, is the most common
cause of folliculitis in the cat.
iv. Staphylococcus pseudintermedius.
16

Questions: 11, 12
11a 11b
11 A 5-year-old female spayed Doberman

pinscher dog presented on emergency
because of an acute nodular eruption over
her head, face, and neck that had been persistent over 2 days (11a). Prior to lesion
development, the dog had been running in the woods without owner supervision.
On physical examination, there were numerous cutaneous, fairly firm nodular
lesions, some as large as 3 cm in diameter, located multifocally over the head,
face, and neck. Facial swelling was also noted, particularly along the muzzle and
periocular region. A serous exudate was present from the center of several nodules;
others were covered by a dried, adherent crust.
i. List the differential diagnoses.
ii. A biopsy from one of the nodular lesions is shown (11b, 40x). Histopathologic
findings showed several intracorneal and subcorneal vesicles and vesicopustules
containing low numbers of inflammatory cells, including neutrophils and
eosinophils. Spongiosis and exocytosis of neutrophils and eosinophils were noted
throughout the epithelium. There was intense edema in the subjacent dermis and
marked superficial hemorrhage. A perivascular to interstitial infiltration with
neutrophils and eosinophils was present. The histopathologic diagnosis was
‘severe neutrophilic and eosinophilic vesiculopustular dermatitis; severe diffuse
eosinophilic and neutrophilic dermatitis with marked vascular reactivity’. Based
on this description, how is the differential list changed?
iii. What is the pathogenesis of urticaria and angioedema?
iv. What are common triggers of urticaria and angioedema in the dog?
12 How much blood can an actively feeding female cat flea (Ctenocephalides felis)
consume?
17

Answers: 11, 12
11 i. Infections (bacterial: atypical Mycobacteria, Nocardia, Actinomyces, botryo
mycosis, L-form bacteria; fungal: blastomycosis, histoplasmosis, cryptococcosis,
coccidioidomycosis), inflammatory processes (urticaria and angioedema,
eosino philic furunculosis, eosinophilic cellulitis, cutaneous histiocytosis, sterile
pyogranuloma/granuloma syndrome), neoplasia (mast cell tumor, cutaneous
lymphoma).
ii. Urticarial allergic reaction, contact hypersensitivity reaction, eosinophilic
cellulitis. Culture is necessary to rule out bacterial infection (negative). Urticarial
allergic eruption, insect bite reaction, and contact hypersensitivity reaction were
considered most likely.
iii. Mast cell (or basophil) degranulation causes release of histamine, leukotrienes,
and prostaglandins. These chemokines cause increased vascular permeability
and smooth muscle contraction, causing an immediate (type I) hypersensitivity
reaction. Release of IL-4 from mast cells and/or basophils causes Th2 cell
differentiation and activation, leading to elevations in eotaxin and VCAM, thereby
increasing tissue eosinophils, basophils, and Th2 cells. This causes a later phase
inflammatory response. Type III hypersensitivity reactions may also be involved in
urticaria development along with non-immunologic triggers that may precipitate
or intensify the presence of lesions.
iv. Various drugs and chemicals, vaccines, food or food additives, stinging or biting
insects, plants, bacterins, physical forces (pressure, cold, heat, sunlight, exercise),
physiologic stress, genetic abnormalities. Infusion of human serum albumin has
been associated with both acute anaphylactoid reactions and delayed development
of urticaria and angioedema in dogs.
12 An average of 13.6 microliters of blood per day or approximately 15.15 times

their body weight. A heavy infestation of fleas could easily cause anemia in a
puppy or kitten. For example, a 0.5 kg kitten has approximately 30 ml of blood.
An infestation of 220 female fleas could potentially consume 10% (3.0 ml) of the
kitten’s blood per day.
18

Questions: 13, 14
13 A 2-year-old male castrated 13
Persian cat presented for intense
facial pruritus with exudation
(13). The cat had been obtained
from a rescue organization 1 year
previously. Dermatologic abnor
malities at the time had been mild,
limited to occasional serous ocular
and nasal exudation with staining
and debris on the face. Pruritus
at the time of adoption was
mild; however, it had progressed
continuously until the time of
presentation. The owner reported
minimal response to antibiotic therapy. The cat was considered to be otherwise
healthy, although it did have a history of intermittent sneezing and mucoid nasal
discharge. On dermatologic examination, there was moderate conjunctivitis and
periocular swelling with serous to slightly mucoid exudation adhered to the face,
neck, perioral, and periocular regions. Moderate erythema was present along the
medial aspects of the pinnae, periocular, and facial skin. Dark debris was present
within both external ear canals and facial folds. The facial folds were noted to be
more severely erythematous, moist, and abraded.
i. What is the list of differential diagnoses for this patient?
ii. What diagnostic tests do you recommend for this patient?
iii. A skin biopsy specimen was obtained from the affected skin on the muzzle.
Biopsy results showed severe acanthosis with spongiosis of the epidermis,
occasional to sparse individual keratinocyte degeneration (apoptosis), and a thick
serocellular crust. There were numerous mast cells, moderate neutrophils, and a
few eosinophils infiltrating the superficial dermis. Sebaceous hyperplasia was also
noted. Given the clinical appearance, breed, and diagnostic findings, what is the
most likely diagnosis for this patient?
iv. What is the underlying etiology of the condition?
v. What secondary complications are noted with the condition?
14 Specimens for bacterial culture and susceptibility or cytologic examination are

easily collected from pustules. How do you collect specimens for culture and/or
cytology from pyoderma lesions when pustules are not present?
19
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Answers: 13, 14
13 i. Dermatophytosis, demodicosis, Malassezia dermatitis, bacterial folliculitis,
cutaneous adverse reaction to food, environmental allergies, primary seborrhea,
facial dermatitis of Persian and Himalayan cats. Given the history of sneezing
and nasal discharge, upper respiratory infection (e.g. calicivirus, herpesvirus,
Mycoplasma) should also be considered.
ii. Deep and superficial skin scrapings (negative); impression cytology (several cocci
bacteria and yeast, occasional neutrophils, ceruminous debris); ear swab cytology
(excessive ceruminous debris, no organisms); fungal culture for dermatophytes
(negative); possible treatment trial for mites (Notoedres cati and Demodex gatoi),
possible hypoallergenic diet trial based on other test results. Additional diagnostics
could include intradermal or serum allergy testing, skin biopsy, Mycoplasma PCR,
viral isolation, and transtracheal wash.
iii. Facial dermatitis of Persian and Himalayan cats.
iv. This condition is suspected to have a hereditary or genetic basis. Facial dermatitis
is uncommon to rare in both Persian and Himalayan cats. It presents initially in older
kittens or young adult cats and tends to progress in severity over time. Adherent
debris, presumed to be sebaceous gland material, is a striking feature of the disease;
a defect in cornification is suspected. Lesions are typically confined to the muzzle,
periorbital region, and chin. In the initial stages of disease, pruritus may be absent to
mild. As the disease becomes chronic, intense pruritus is often reported.
v. Secondary infections with bacteria and/or Malassezia yeast are common and
may increase the severity of clinical signs. Submandibular lymphadenopathy has
been reported in affected cats.
14 Look for areas of crusts and gently lift the crust with a sterile instrument to collect
bacterial culture specimens and/or cytologic specimens (14). Crusted lesions with
erythema often have areas of moist exudation beneath crusts at the periphery. If no
such lesions can be found, bacterial cultures can be obtained from ‘dry’ lesions. If this
is necessary, moisten the tip of the sterile culturette within the transport medium and
then vigorously rub it over the site. Rotate the swab to ensure that any organisms
are inoculated onto the surface of the swab. Ideally, the microbiologist will rotate the
swab as it is being inoculated onto the surface of the culture plate; routinely doing this
will minimize false ‘no growth’ reports due to poor laboratory techniques. Cytology
specimens can be collected from these sites
14 using either clear acetate tape or impression
smears. The latter is often difficult to do if the
skin cannot be manipulated.
20

Questions: 15, 16
15 How is facial dermatitis of Persian and Himalayan cats (see case 13) treated?
16a
16b
16 A 1-year-old female spayed golden retriever dog presented without any previous
history of dermatologic abnormalities. The owners had taken the dog swimming
over the weekend and noted these lesions on the dog’s ventrum early Monday
morning (16a). The dog had been mildly pruritic over the weekend, with pruritus
concentrated along the ventrum where the lesions were present.
i. How would you describe the lesions seen?
ii. What are the differential diagnoses for the lesions?
iii. Cytology from a ruptured papule is shown (16b). What is the diagnosis?
iv. What is the recommendation for treatment?
21

Answers: 15, 16
15 Various treatment options have been evaluated, but no specific therapy has
been determined. Therapy is aimed at treating secondary infections (antibiotics
and/or antifungal medications) and minimizing the frequency of recurrence.
Various topical products/shampoos have been evaluated to minimize and remove
adherent debris (4% chlorhexidine, 2.5% benzoyl peroxide, 2% miconazole/2%
chlorhexidine, other antiseborrheics); however, in most cats that permitted the
washing, debris accumulated again within 1–3 days of therapy. Corticosteroid
administration (prednisolone; periodic injections of repositol methylprednisolone
acetate) partially controlled pruritus in some cats. Anecdotally, cyclosporine may
be beneficial in some cats. A recent case reported successful management of facial
dermatitis in a Persian cat with topical tacrolimus applied twice daily. Further
evaluation of this option in more cats is necessary to determine the overall efficacy
for management. In this case, cyclosporine (modified) showed fair treatment
efficacy. The cat initially required concurrent administration of prednisolone
(1 mg/kg q24h) to manage the intense pruritus; this was discontinued after 2
weeks. A protective Elizabethan collar was applied by the owner to help minimize
self-trauma.
16 i. Papules and small pustules are present along the intertriginous skin of the
ventral abdomen.
ii. These lesions are consistent with folliculitis. Common causes include bacterial
pyoderma (superficial), dermatophytosis, and demodicosis.
iii. Superficial bacterial pyoderma.
iv. Since this is the dog’s first episode of skin disease and the lesions are so diffuse,
treatment should focus on resolving the current infection. An empiric systemic
antibiotic may be prescribed; cephalexin would be a reasonable consideration
since this is a large-breed dog. If the owners are unable to medicate the dog
orally, cefovecin could be an alternative choice. This injection would need to be
repeated in 7–14 days. Bathing with an antiseptic shampoo (e.g. ethyl lactate,
chlorhexidine) would be a good adjunct therapy to help remove any adherent
debris, aid in antimicrobial control of the organisms, and get the owners involved
in disease monitoring. Bathing would be recommended 2–3 times weekly.
22

Questions: 17, 18
17a 17b
17 A 2-year-old male castrated DSH cat presented with a history of the lesions
shown (17a). The cat was noted to be excessively pruritic with self-induced alopecia
due to over grooming present along the ventral abdomen and medial aspects of
both hindlimbs. The lesions responded well to corticosteroid administration;
however, the owner was concerned about continued administration of these drugs
and the young age of the cat. The cat lived strictly indoors and received year-round
monthly topical flea prevention. Administration of several courses of antimicrobial
treatments (antibiotics, antifungals) at adequate doses and duration did not lead to
complete lesion resolution. Multiple strict hypoallergenic diet trials (commercial
hydrolyzed and novel protein diets) had been attempted, but did not result in any
decrease in pruritus. Biopsy of the lesions had been performed by the referring
veterinarian (17b).
i. What are the lesions shown?
ii. This lesion has been associated with underlying allergic disease in cats. What
other reaction patterns have been associated with feline AD?
iii. What are the options for long-term management of this cat?
18 An indoor/outdoor cat has a compound fracture of the femur of unknown

duration. The wound at the site of the fracture is putrid and exudative, and the
hair coat matted. Close examination of the wound reveals extensive myiasis.
i. What is the etiology and pathogenesis of myiasis?
ii. How will you manage the wound?
23

Answers: 17, 18
17 i. Eosinophilic plaques.
ii. Self-induced alopecia, head and neck pruritus, miliary dermatitis, eosinophilic
lesions (eosinophilic plaques, eosinophilic granulomas, and indolent ulcers).
iii. Medical management or pursuing allergy testing with the goal of starting ASIT.
Medical therapeutic options in cats are different to those in dogs. Topical bathing
and topical antipruritics are common recommendations for pruritic dogs, but many
cats do not tolerate bathing or topical products. Fatty acids and antihistamines
may be helpful as adjunct therapy. Oral liquid modified cyclosporine for cats is well
tolerated; adverse effects are similar to those seen in dogs, with gastrointestinal
upset reported most commonly. The other option is to pursue allergy testing and
ASIT administration. Serum allergy testing is often recommended initially in cats
with a presumed diagnosis of AD since IDT may not be widely available and tests
in cats can be more difficult to interpret. Cats often have less distinct wheals, which
are softer and less erythematous than those found in dogs or people. If serum in-
vitro test results are negative and AD is still suspected, IDT should be pursued.
Injection of fluorescein dye may improve visualization of reactions; however, the
usefulness of this is inconsistent. ASIT appears to be beneficial in approximately
50–75% of cats with a clinical diagnosis of AD.
18 i. Myiasis is infestation of tissues by fly larvae of the order Diptera. It is a

disease of neglect or inattention. Adult flies lay eggs in open wounds, on moist
skin, and on soiled hair coats (e.g. feces and/or urine), particularly in debilitated
and recumbent animals. Larvae (maggots) hatch and secrete proteolytic enzymes
that liquefy tissue and can create full-thickness damage within hours.
ii. Stabilize the patient, treat for shock and infection, identify the underlying
neglect cause, kill/remove larvae, clip and clean the wound. Nitenpyram is a water-
soluble neonicotinoid that is rapidly absorbed and rapidly excreted by the host;
it has low toxicity for mammals. Within 20 minutes of administration, it reaches
serum concentrations sufficient to act against insects. The most common use is
for flea control. Recently, dogs with spontaneously occurring screw worm myiasis
were treated with nitenpyram and within 1–2 hours of administration, 86% of
larvae were spontaneously expelled. Dogs received a second dose 6 hours later and
larval expulsion continued for 18 hours. Administration of nitenpyram as soon
as myiasis is detected allows for larval kill to start before mechanical removal can
be done humanely and safely. This can be administered rectally (off-label use) in
animals too debilitated to swallow. Concurrent systemic treatments that can be
used once the patient is stable include ivermectin, selamectin, and imidacloprid
and moxidectin.
24

Questions: 19, 20
19a 19b
19 This 6-year-old male castrated

Great Pyrenees dog was presented for
skin lesions of approximately 2 weeks’
duration (19a). The owner reported
marked pruritus at the lesion site and in the axillary area; scratching had led
to self-induced excoriations with serous exudate matting the hair. On physical
examination, the dog appeared otherwise healthy except for the dermatologic
abnormalities, but was notably pruritic during the examination when lesions were
manipulated. The ventrum (mostly abdomen and inguinal region) had diffuse
follicular and non-follicularly oriented pustules with erythematous margins.
Large epidermal collarettes with erythematous margins and erosions were present.
Some of the lesions appeared targetoid. The head was unaffected. The mucous
membranes and non-haired skin were unaffected.
i. What are your differential diagnoses for this patient?
ii. What would you recommend regarding diagnostic work-up?
iii. Cytology from an intact pustule is shown (19b). CBC showed moderate to
severe peripheral eosinophilia. Serum biochemistries did not reveal any significant
abnormalities. Based on these findings, what is your diagnosis?
20 An extreme example of a common 20

dermatologic lesion is shown (20).
i. What is this lesion called?
ii. What is the proposed pathogenesis?
iii. How can it be managed?
25

Answers: 19, 20
19 i. Superficial spreading pyoderma, superficial bacterial folliculitis, pustular drug
eruption, dermatophytosis, demodicosis, sterile eosinophilic pustulosis, subcorneal
pustular dermatosis, PF, CLE, neoplasia (cutaneous lymphoma, mast cell tumor).
ii. Deep skin scrapings to look for Demodex mites, cytology from the most active
lesions, fungal culture, and bacterial culture and susceptibility. Since autoimmune
diseases are on the list of differentials, infectious causes must be ruled out prior
to treating the patient with immunsuppressive drugs. Biopsy may be necessary
depending on the results of initial diagnostics (e.g. if parasitic, bacterial, or
fungal organisms are not identified). CBC and serum biochemistries should be
considered if warranted by the screening diagnostic tests. In general, CBC and
serum biochemistries are not high-yield tests for strictly dermatologic diseases.
iii. Cytology revealed large numbers of eosinophils, which is not a common finding
in bacterial pyoderma. A peripheral eosinophilia was noted. These preliminary
findings are consistent with a diagnosis of sterile eosinophilic pustulosis. They
should be confirmed with histopathologic analysis (biopsy will show superficial
and subcorneal pustules containing large numbers of eosinophils; deeper hair
follicles may also be affected) and negative bacterial and fungal cultures. This is a
rare immune-mediated skin disease in the dog.
20 i. A comedone.
ii. Comedones are common in dogs and cats, but little is known about their
pathogenesis. In people, comedones result from abnormalities in proliferation
and differentiation of ductal keratinocytes. Comedones result from retention of
hyperproliferating ductal keratinocytes; this has been confirmed by 3H-thymidine
labeling and an increase in Ki-67 labeling of ductal keratinocytes in comedone
lesions. In addition, there is an increase in the presence of keratins 5 and 16 (keratin
markers of hyperproliferation). Ductal hyperproliferation can result from abnormal
sebaceous lipid composition, androgens, local cytokine production, and bacteria.
iii. Close inspection of the lesions reveals that many comedones are open; topical
treatment could encourage evacuation of contents. Warm packing of the lesion
for 5–10 minutes followed by gentle washing in clockwise and counter-clockwise
directions will gradually evacuate lesions. Treatment of this area with topical
retinoids or benzoyl peroxide will also help. Manually evacuating lesions via
pressure (i.e. squeezing) should be strongly discouraged to prevent follicular
rupture, development of deep pyoderma, and foreign body reaction.
26

Questions: 21, 22
21 A 6-year-old spayed female 21
dog presented to the emergency
service for vomiting, lethargy,
and bloody diarrhea, as well
as ecchymoses and petechiae
on various skin surfaces.
Approxi mately 2 weeks’ prior,
the dog was diagnosed with
an open pyometra. At that
time, an ovariohysterectomy
and prophylactic gastropexy
were performed in the same
surgical procedure. The dog was
discharged and cephalexin (30 mg/kg q12h), meloxicam (0.1 mg/kg q24h), and
tramadol (3–4 mg/kg q8–12h) were prescribed. At the time of presentation to the
emergency service, CBC showed decreased platelet count and mild left shift, and
serum chemistries showed hypoalbuminemia (16 g/l [1.6 g/dl]; range 26–40 g/l
[2.6–4 g/dl). Clotting times were within reported normal ranges for the diagnostic
laboratory.
Skin lesions consisted of marked petechiae and ecchymoses on the ventral
abdomen and inguinal region, which extended to the medial thighs (21). Lesions
appeared targetoid and slightly raised in some locations. New pustular lesions
were present around the mammae and ventral thorax. There was severe chemosis
and conjunctival hemorrhage in both eyes and the muzzle was mildly edematous.
Petechiation and small ulcers were present on the oral mucous membranes.
ii. Skin biopsy report showed ‘patchy dermal hemorrhage with perivascular
neutrophilic dermatitis affecting superficial and periadnexal vessels. The main
change is edema, congestion, and areas of focal microhemorrhage. There is
no fibrinoid necrosis to suggest vasculitis. In the worst affected areas there are
large numbers of extravasated eosinophils and neutrophils in the perivascular
dermis. Inflammation affecting the periadnexal vessels contains a large number of
marginating leukocytes, chiefly neutrophils and eosinophils’. How do these biopsy
findings relate to the patient’s clinical presentation?
22 Approximately how many flea species have been identified? Summarize the
general information known about the life cycle of the flea.
27

Answers: 21, 22
21 i. EM, drug reaction (antibiotics, NSAIDs), vasculitis/vasculopathy, warfarin
poisoning.
ii. The extreme extravasation of leukocytes and edema noted in the biopsy samples
is suggestive of ‘leaky’ blood vessels supplying the skin. The vascular integrity in this
patient is compromised, leading to the petechiation and ecchymotic hemorrhages
seen clinically. Decreased vascular integrity has been shown to be a consistent
finding in human and animal patients with sepsis. The previous presentation for
open pyometra likely contributed to systemic infection or inflammation, possibly
related to endotoxemia. Similar skin lesions are seen in dogs that ingest garbage and
develop endotoxemia secondarily. The endotoxemia reportedly causes increased
chemotaxis of inflammatory cells, primarily eosinophils and neutrophils. The
release of inflammatory cytokines from the eosinophilic granules (e.g. bradykinin,
histamine, leukotrienes) induces increased vascular permeability (‘leaky vessels’)
manifesting with extravasation of leukocytes. In this case, the cutaneous lesions
are a reaction to a systemic process: development of sepsis and decreased vascular
integrity.
22 Approximately 2,500 species. Fleas complete a full life cycle from egg to adult
that includes several larval stages and a pupal stage. The time from egg to adult
varies among species. Once on a host, adult fleas feed and mate. A blood meal is
required to complete ovary development in female fleas. Eggs are laid in the hair or
surroundings of the host. Depending on conditions, eggs hatch into larvae in 1–10
days; temperature and humidity are key factors. Larvae lack legs but have biting
mouthparts. They pass through three instar stages of varying duration relative
to temperature and humidity. They are free moving and feed on organic debris,
including flea feces. Larvae are negatively phototactic (avoid light) and positively
geotrophic (prefer downward movement); they hide in carpets, couches, organic
material, or bedding. The last instar stage develops into a pupa, which develops
inside a cocoon. The cocoon is sticky and rapidly becomes covered with external
debris thereby protecting and camouflaging it. Pupae last for weeks, months, and
even up to a year until a host arrives. Once the flea emerges, it seeks a host for a
blood meal. Depending on the species, adult fleas live either in the host’s habitat
(‘nest’ fleas) or on the host (‘body’ fleas). Fleas are variably host specific; mammals
that range usually do not have fleas of their own as opposed to animals that have
dens or nests.
28

Questions: 23, 24
23a 23b
23 Two cats (23a) are presented for

routine vaccinations. The owner reports
that the cat with yellow eyes is clumsy,
has ‘twitchy eyes’, and bleeds easily if
injured. Physical examination of this
particular cat reveals photophobia,
nuclear cataracts, and prolonged nys 23c
tagmus on intentional rotation.
i. What is the name of the coat color in
these cats?
ii. A blood smear (23b) and a hair
trichogram (23c) from the cat with
yellow eyes are shown. What are the
findings?
iii. What is the diagnosis?
24 Infectious skin diseases can be diagnosed via cytologic techniques, histo

pathologic techniques, and microbial cultures. In addition, serologic tests can
be used to detect antigens from an agent or an antibody response. In the last
decade, molecular testing has become commercially available for the detection
and diagnosis of many infectious agents. Molecular assays rely on the detection of
RNA and DNA and consist of four nucleotides in varying sequences. Molecular
testing takes advantage of the fact that many portions of DNA and RNA are
conserved between organisms, whereas others are very specific to the organism
on a family, genus, species, or even strain level. The sequence specificity is used to
detect the organisms in clinical samples. Briefly describe the molecular detection of
pathogens without DNA or RNA amplification.
29

Answers: 23, 24
23 i. Color dilution of the hair coat, 23d
often described as ‘blue smoke’ color.
ii. Note the large intracytoplasmic vesicles
(see 23b) in the neutrophils. This cat was
also neutropenic. The hair trichogram
shows abnormally large melanin clumps
(23c) within the hair shaft compared with
normal hairs (23d).
iii. Chediak–Higashi syndrome. This
is a primary immunodeficiency of cats,
specifically Persian or Persian cat-crosses with blue and cream or blue smoke hair
color and yellow eyes. The disease is genetic and is inherited in an autosomal
recessive manner with complete penetrance. Cats are born with normal eyes, but
by 28 days of age, irreversible changes in the tapetum are found; the structure is
completely lost by 1 year of age. Cats can be described as ‘clumsy’ due to visual
impairment as cataract development is common. Prolonged nystagmus is common
after activity or intentional rotation during examination. Recurrent infections and
abnormal bleeding can occur in affected cats. In a blood smear, neutrophils have
large intracytoplasmic vesicles (lysosomes). Skin biopsy and hair trichogram show
enlarged and clumped melanin granules. Diagnosis is made by clinical signs (blue
smoke coat color, yellow eyes), finding of enlarged melanin granules in hair, and
enlarged vesicles in neutrophils. Other hereditary causes of hypopigmentation in
dogs and cats include albinism, piebaldsim, Waardenburg–Klein syndrome, and
canine cyclic hematopoiesis of collie dogs.
24 The simplest molecular test for detecting infectious agents is a ‘probe’. In this test, a
complementary nucleic acid sequence is tagged with a fluorescent molecule to improve
sensitivity. The probe is then added directly to the sample (fluid or tissue). Depending
on the agent, multiple probes can be used on the same specimen for the detection of
multiple infectious agents. This technique is rapid and easy to perform. Unfortunately,
the sensitivity of this technique is not high compared with the sensitivity of other
molecular tests. It can be improved with microbiologic culture, but this then requires
knowledge of the culture requirements of the microbe and delays the testing results.
This test is useful for slow growing organisms such as fungi or mycobacteria that are
growing in the presence of other more rapidly growing organisms. It is also useful for
rapid quantification of microbes in a sample. In-situ hybridization is a specialized type
of probe applied to tissue. It allows for the detection of organisms in inflammatory
lesions or in specific tissue in which the microbe might be part of a large number of
organisms, many of which are normal flora.
30

Questions: 25, 26
25 What is real-time quantitative PCR (qPCR)?
26
26 This 9-year-old cat (26) presented for the complaint of hair loss on the ears. The
owners have pictures of the cat as a young adult and the ears are fully haired. Other
than the noted alopecia on the ears, the dermatologic and medical examination
was normal.
i. What is the most likely diagnosis?
ii. What are the causes of focal non-inflammatory alopecia in cats?
31

Answers: 25, 26
25 A technique that allows for both detection of the pathogen and the quantification
of microbial load. The production of DNA during each amplification cycle is
monitored so that the original quantity can be extrapolated by identification of
the logarithmic amplification phase of each individual reaction. This technique
uses fluorescent dyes or probes that produce a signal after formation of the
product. During each cycle, a detector monitor records the amount of fluorescence
in the sample. This assay has all the advantages of traditional PCR, but offers
a more rapid result and can be used to quantitate the microbial DNA or RNA
load. Problems with this assay are related to quality control; the use of dyes or
fluorescent probes can lead to false-positive results. Quality control is dependent
on the use of a published protocol and minimum laboratory standards. Problems
occur when diagnostic laboratories use proprietary reactions not subject to
independent validation and peer review.
26 i. Pattern baldness. Cats have two common presentations of non-inflammatory

hair loss on the head: normal pre-auricular alopecia, which is most notable in
darkly haired cats, and acquired pinnal alopecia. Skin biopsy shows small, atrophic
hair follicles or total loss of hair. This is a heritable disease and is common in
some breeds of cats (e.g. Siamese). It is important when presented with a case of
pinnal alopecia to determine whether it is inflammatory or non-inflammatory. If
inflammatory, issues such as coat color and symmetry become important in the
diagnosis. Cats with light colored hair coats may have inflammatory pinnal hair
loss due to solar exposure. Actinic changes and squamous cell carcinoma should
be considered differential diagnoses. Actinic changes are most commonly bilateral,
but they can be unilateral if the cat has ‘sunburn’ on one side of its face. The other
major causes of inflammatory hair loss are dermatophytosis, PF, and insect bite
hypersensitivity. Fungal culture, impression smears (bacteria, yeast, acantholytic
keratinocytes [e.g. PF]), and skin biopsy may be needed. A cosmetic outcome
can be problematic with skin biopsy. Take a representative sample as close to the
base of the ear as possible. Full-thickness through and through samples are rarely
needed.
ii. Post-traumatic alopecia, post-injection alopecia (e.g. glucocorticoids), post-
spot-on flea control alopecia, pattern baldness, pre-auricular alopecia, traction
alopecia, alopecia areata, anagen or telogen defluxion.
32

Questions: 27, 28
27 There are two routes for immunotherapy administration: injection and sub
lingual. What are the advantages and disadvantages for each route?
28a 28b
28 A 1-year-old German short-haired pointer dog was presented for the complaint
of ‘excessive dandruff’ of several months’ duration. The dog was also reported to
be less active and reluctant to move at times; these clinical signs waxed and waned.
The owner reported that one other littermate had similar clinical signs. Clinical
examination revealed generalized exfoliative dermatitis over the entire body (28a,
b). Follicular casts and thick adherent scaling were noted. No primary lesions were
found. Skin scrapings were negative for Demodex mites, impression smears did
not reveal bacteria or Malassezia, a fungal culture was negative, and there was no
response to a trial of combined antimicrobial therapy for yeast and bacteria.
i. What are possible differential diagnoses?
ii. A skin biopsy was performed and the following findings were noted: orthokeratotic
hyperkeratosis with moderate to diffuse interface dermatitis, mild to moderate
apoptosis, and a lymphocytic interface mural folliculitis. A CBC revealed anemia
and thrombocytopenia, ANA was negative, and direct immunofluorescence testing
revealed IgG deposition at the epidermal basement membrane. What is the most
likely diagnosis? What is the treatment and prognosis?
33

Answers: 27, 28
27 ASIT can be administered via subcutaneous injections or via sublingual immuno
therapy (SLIT). The latter has been used in people for many years and is considered
safe and efficacious. Recently, SLIT has been evaluated in house dust allergic dogs
and found to be safe and effective; it is currently a treatment option for ASIT in
veterinary patients. The cost of allergen prescriptions can be comparable depending
on dispensing practices. The major advantage of SLIT is that it eliminates the
‘needle’ and offers a therapy option for patients whose owners do not want to
give injections. SLIT therapy needs to be administered twice daily every day. Care
must be taken to position the pump vial vertically for proper allergen delivery.
Side-effects are minimal; oral discomfort (face rubbing) and diarrhea have been
reported. Allergen administration via injection is less time-consuming after the
induction period. Local and major anaphylactic reactions have not been observed
with SLIT in dogs; this may be a benefit or be yet undetermined since this therapy
has only recently been introduced. Local allergic reaction post allergen injection is
common and consists of pruritus at the site of the injection. Urticaria, angioedema,
and generalized anaphylaxis are rare, but occur often enough to warrant client
education.
28 i. The young age of onset and the fact that one other littermate was affected
suggests a possible congenital or hereditary skin disease. The widespread
distribution of lesions, history of waxing and waning, and clinical signs of systemic
illness suggest the underlying etiology may be metabolic or immune mediated.
Generalized exfoliative dermatitis in a dog <1 year of age in which other littermates
may be affected is most compatible with ichthyosis or a primary disorder of
keratinization; however, clinical signs of systemic illness are not associated with
either disease. The young age of onset and the breed of dog make metabolic
diseases such as zinc deficiency, vitamin A responsive disease, or superficial
necrolytic dermatitis unlikely, as these scaling diseases are typically found in older
dogs. Breed-related CLE is one possible explanation as this would account for
other affected littermates and concurrent systemic signs of illness. Demodicosis is
a considered differential diagnosis until ruled out via deep skin scrapings.
ii. Exfoliative CLE of German short-haired pointer dogs. Treatment is palliative and
dogs show variable response to prednisolone, cyclosporine, hydroxychloroquine,
and adalimumab. Topical treatment with keratolytic/keratoplastic shampoos and
emollient therapy is helpful. Ultimately, the disease progresses and most dogs are
euthanized by 4 years of age.
34
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Questions: 29, 30
29
29 A young adult, female spayed boxer dog is presented for isolated hair loss
along the left lateral flank (29). Alopecia began about 2 months previously and
has progressively worsened. Pruritus or clinical signs associated with a systemic
disease are not reported by the owner. Results of skin scrapings and skin cytology
do not provide any definitive information.
i. List probable differential diagnoses based on the signalment, pattern of alopecia,
and test results.
ii. How will you obtain a diagnosis?
iii. What is the most likely diagnosis for this focal hyperpigmented patch of non-
pruritic alopecia on the flank?
iv. Is there an effective treatment for this condition?
30 Special stains are frequently used in histopathology to better identify a particular

disease or disease process. They may be used to identify infectious organisms or
highlight characteristics of various tissue types. The properties of each stain are
variable; picking the correct stain for aiding in a diagnosis requires knowledge
of the various stains available. What are the tissue-staining characteristics for the
following special stains?
i. Periodic acid–Schiff.
ii. Brown–Brenn or Gram’s.
iii. Gomori’s methenamine silver.
iv. Verhoeff–van Gieson.
v. Masson trichrome.
vi. Alcian blue.
vii. Toluidine blue.
viii. Fite’s.
ix. Sudan Black B.
x. Orcein–Giemsa.
35

Answers: 29, 30
29 i. Dermatophytosis, hypothyroidism, injection-site alopecia, canine recurrent
flank alopecia (CRFA), alopecia areata, possible cutaneous reaction to topically
administered steroids.
ii. Dermatophytosis can be excluded by fungal culture. Serum total thyroxine
(TT4) concentration along with the history and physical examination can assess
thyroid function. Illness (sick euthyroid syndrome) and drug administration (e.g.
sulfa antibiotics, steroids, NSAIDs, phenobarbital, clomipramine) can affect TT4
interpretation, leading to a misdiagnosis. Skin biopsy from an area of maximal
alopecia is needed to exclude other differentials.
iii. Given the signalment, distribution of alopecia, and lack of systemic signs,
CRFA is most likely. CRFA (also known as seasonal or cyclic flank alopecia) is
an uncommon form of recurring follicular dysplasia. Affected dog breeds include
boxers, English bulldogs, schnauzers, and Airedale terriers. Well-circumscribed,
usually hyperpigmented patches of ‘geographical’ or polycyclic-shaped alopecia
develop focally or bilaterally along the flanks. This cyclic behavior may occur
regularly or sporadically, or happen only once. Repeated episodes may eventually
result in permanent alopecia. Skin biopsy shows dysplastic, atrophic, dilated,
keratin-filled hair follicles with poorly formed secondary follicles extending into
the surrounding dermis, and increased melanin deposition in adnexa.
iv. In some instances, oral melatonin (3–12 mg/dog q8–24h) will result in new
hair growth within 2 months. Once new hair growth is observed, melatonin can
be discontinued. If therapy is effective, it can be given pre-emptively several weeks
before the next regularly recurring episode. Since this condition is considered a
cosmetic disorder that may resolve spontaneously, generally no treatment is required.
30 i. Glycogen, neutral mucopolysaccharides, fungi, basement membrane = red.

ii. Gram-positive bacteria = blue; gram-negative bacteria = red.
iii. Fungi, melanin = black.
iv. Mature collagen = red; immature collagen, keratin, muscle, nerves = yellow;
elastin, nuclei = black.
v. Mature collagen = blue/green; immature collagen, keratin, muscle, nerves = red.
vi. Acid mucopolysaccharides (e.g. mucin) = blue.
vii. Acid mucopolysaccharides, mast cell granules = purple.
viii. Acid-fast bacteria = red.
ix. Lipids = green-black.
x. Elastic tissue = black-brown; hemosiderin = green-black; melanin = gold-yellow;
smooth muscle = light blue; collagen = pink; mast cell granules = metachromatic/
purple; amyloid, cytoplasm of many cells = light or dark blue (dependent on cell
type); nuclei = dark blue.
36

Questions: 31, 32
31
31 This lesion (31) is present bilaterally on the olecranon of a mastiff. On palpation,

the lesion is fluctuant. What is it, and how is it treated?
32
32 A 6-year-old German shepherd dog-cross presented for straining to defecate

and licking the perianal region. On physical examination, numerous fistulous
draining tracts were found in the perianal region (32). The dog was examined
under sedation and it was determined that the fistulae did not communicate with
the rectum and did not involve the anal glands. Oral anti-inflammatory drugs were
prescribed, but discontinued due to severe gastrointestinal upset.
i. What class of drug is tacrolimus?
ii. What is the mechanism of action for tacrolimus?
iii. What formulation is used most commonly in veterinary medicine?
37

Answers: 31, 32
31 A hygroma complicated by marked hyperkeratosis. A hygroma is a false bursa
that develops over bony prominences and pressure points, especially in large breeds
of dogs. The most common cause is repeated trauma from lying on hard surfaces.
This creates inflammation, which eventually results in development of a dense-
walled, fluid-filled cavity containing yellow to red fluid. Clinically it presents as a
soft, fluctuant, fluid-filled, painless swelling but in long-standing cases, ulceration,
infection, abscesses, granulomas, and fistulae may occur. In addition to the
hygroma, the skin becomes hyperkeratotic and proliferative. In general, hygromas
are better prevented rather than managed; however, not all dogs will be cooperative
and sleep on soft bedding. If the lesions are small, they can be managed via aseptic
needle aspiration, followed by corrective housing. Soft bedding or padding over
pressure points is imperative to prevent further trauma. Surgical drainage, flushing,
and placement of Penrose drains are indicated for chronic hygromas. Areas with
severe ulceration may require extensive drainage, extirpation, or skin grafting
procedures. Use of intralesional corticosteroids is not recommended. In this case,
the ‘feathering’ hyperkeratosis acted as a reservoir of microbial overgrowth,
preventing any type of surgical intervention. The lesion was managed with daily
bathing using an antibacterial–antifungal shampoo.
32 i. Calcineurin inhibitor.
ii. Tacrolimus (previously known as FK-506) binds to FK-506 binding protein in
the cytoplasm of T cells. The complex inhibits calcineurin from dephosphorylating
nuclear factor of activated T cells (NFAT), thus preventing it from being translocated
into the nucleus. The inhibition prevents transcription of various inflammatory
cytokines including IL-2, IL-3, IL-4, and TNF-α. Decreased inflammatory cytokine
synthesis results in decreased activation and proliferation of helper and cytotoxic
T cells.
iii. Although tacrolimus exists as an injectable and oral formulation, the latter of
which is noted to be approximately 10 to 100 times more potent than cyclosporine,
the topical formulation is used most commonly in veterinary medicine. Topical
tacrolimus is available as a 0.03% and 0.1% ointment. Most clinicians prefer
the 0.1% ointment unless the patient is not able to tolerate it due to discomfort.
The topical ointment does not have systemic side-effects, making it useful for the
treatment of localized disease. A common adverse effect reported by people is a mild
burning or tingling sensation. A study evaluating the use of topical tacrolimus for
treatment of perianal fistulae in dogs did not note post-application inflammation
as determined by the dog’s behavior (i.e. licking).
38

Questions: 33, 34
33a 33b
33 A 2-year-old indoor/outdoor cat is presented for evaluation of non-healing

wounds on the face, legs, and trunk (33a). The lesions had initially been treated
as cat bite abscesses with antibiotics at the correct dose and duration. Cytologic
findings of an impression smear are shown (33b).
i. What is the diagnosis in this case?
ii. What diagnostic tests can be used in cats and dogs?
34a 34b
34 Two dogs are presented for superficial bacterial pyoderma (34a, b). One had
an infection caused by a susceptible strain of Staphylococcus pseudintermedius,
while the other had an infection caused by methicillin-resistant Staphylococcus
pseudintermedius. Which one is which?
39
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Answers: 33, 34
33 i. Sporotrichosis. Sporotrix schenckii is a dimorphic fungus that exists in
mycelia form at 25–30°C and yeast form at body temperature (37°C). It has
worldwide distribution but is most common in tropical and subtropical climates.
Sporotrichosis is zoonotic; reports of transmission from cats to people have
increased. In 2004, an epidemic was reported in Rio de Janeiro over a 6-year
period in which 1,503 cats, 64 dogs, and 759 people had a diagnosis confirmed by
isolation of the organism via culture. Infection in people was associated with cats
with either clinical or non-clinical disease in 91% of cases. In 68% of human cases
in this series, exposure was via bites or scratches.
ii. Fungal culture, cytology, histopathology, PCR, and immunofluorescence. For
fungal culture, submit tissue wedges or exudate from deep inside the lesion.
Cytologic diagnosis in cats can be made by examining tissue aspirates or impression
smears. Seventy-nine percent sensitivity has been reported in a study comparing
cytology and culture. In contrast, the sensitivity in dogs is much lower (32%) with
these diagnostics; smaller numbers of organisms are present in the exudate of dogs.
Histologic specimens should be obtained from new nodular lesions. The sensitivity
of histologic examination when compared with culture is 62%. Two ELISA tests
for feline sporotrichosis have been developed; when compared with culture from
known cases they were reported to have a sensitivity and specificity of 90% and
96% (specific molecule test) and 96% and 98% (crude exoantigen), respectively.
34 Clinically, it is not possible to distinguish methicillin-susceptible from methicillin-

resistant staphylococcal skin infections. The only way to determine this is with
aerobic culture and susceptibility testing. It is important to remind the diagnostic
laboratory (especially if it is not a veterinary specific diagnostic laboratory) to
speciate the staphylococcal bacteria; both Staphylococcus aureus (primary
pathogen in people) and Staphylococcus pseudintermedius (primary pathogen in
dogs and cats) are coagulase-positive staphylococcal organisms. The implications
for zoonosis are necessary information with regard to client education and patient
handling. In general, Staphylococcus pseudintermedius does not readily colonize
or cause infections in people; however, infections have been reported in people due
to this organism, but it is not common. Colonization with this organism may be
more common in people within the veterinary profession.
40

Questions: 35, 36
35a
35b
35 A 9-month-old stray cat was presented for examination because of the

complaints of anorexia, fever, mild lethargy, and facial lesions (35a). Oral exam
ination revealed these lesions (35b). What are the differential diagnoses?
36 Prior to infection developing, bacteria must adhere to and colonize the skin.
If the environmental and source factors are right, then infection will subsequently
occur. This process has been evaluated in species including dogs, cats, and people.
i. What is known about the degree of bacterial adherence to the skin of dogs, cats,
and people?
ii. What is known about the mechanisms involved in the adherence and colonization
of the skin by bacteria in dogs?
41

Answers: 35, 36
35 Feline upper respiratory disease (most likely), in particular feline herpesvirus
(FHV) and feline calicivirus (FCV). Without any additional history, the differentials
for the facial lesions alone include, but are not limited to, trauma, neoplasia,
allergies, insect bite hypersensitivity, viral upper respiratory disease (herpes, calici)
and immune-mediated diseases.
Skin lesions associated with FHV and FCV are increasingly being diagnosed
because of immunohistochemistry (IHC) and PCR. Dermatologic lesions of acute FCV
infection include oral vesicles and ulcers, lip ulcers, ulcers of the nasal philtrum, and, on
rare occasions, ulcers on the body, although the latter are rare. Chronic FCV infection
has been implicated as one of the causes of progressive plasmacytic–lymphocytic
proliferative or ulcerative gingivitis and stomatitis. An uncommon but highly virulent
form of FCV (FCV-associated virulent systemic disease [VSD]) can result in death
within 1 week. These cats can show facial lesions and paw edema, pyrexia, ulceration,
icterus, and hemorrhage from the nose and in the feces. Many of the cats with FCV-
associated VSD have been vaccinated, suggesting the disease is caused by a strain not
associated with vaccination. In FHV, skin ulcers and nasal dermatitis and stomatitis
can occur and may have an eosinophilic infiltrate, making it a differential diagnosis for
any ulcerative eosinophilic disease (i.e. ‘eosinophilic granuloma complex’-like lesions).
In one study, PCR testing was determined to be useful as an initial screening test, but
due to false positives, IHC is needed to make a definitive diagnosis.
36 i. Feline corneocytes show reduced adherence of Staphylococcus species bacteria

compared with either dogs or people. In a study evaluating Staphylococcus species
from healthy individuals, feline keratinocytes were less likely to demonstrate
bacterial adherence on an in-vitro model. S. felis was most adherent, followed
by SIG, S. aureus, and S. hominis. Canine and human corneocytes demonstrated
similar adherence profiles to each other. This finding may explain why cats tend
to be ‘more resistant’ to development of bacterial pyoderma (or why their clinical
manifestations of disease are different) as well as interspecies transfer of organisms
compared with dogs and people, in which pyoderma is relatively common.
ii. In people, several bacterial surface proteins have been implicated in promoting
adhesion to corneocytes. Clumping factor B is one such molecule. Cytokeratin 10 is a
ligand implicated in bacterial binding. In dogs, Staphylococcus species bind to fibronectin,
fibrinogen, and cytokeratin, suggesting that SIG bacteria, like S. aureus, possess an array
of cell wall adhesins that allow them to recognize and bind various matrix proteins on
the cells. Cell wall virulence factors possessed by Staphylococcus species bacteria also
help mediate adhesion and colonization of skin. Two surface proteins (SpsD and SpsO)
have been identified in S. pseudintermedius, which mediate binding and adherence to
canine corneocytes. Others likely are present but await identification.
42

Questions: 37, 38
37 As discussed in case 36, prior to infection developing, bacteria must adhere to

and colonize the skin. How does underlying dermatologic disease factor into this
process?
38
38 A 3-year-old German shepherd dog presented for recurrent pyoderma and

chronic pruritus since 6 months of age (38). After a thorough work-up, the final
diagnosis was recurrent bacterial and yeast pyoderma due to house dust and
storage mite allergy. During discussion of immediate and long-term treatment
options, the owner asks ‘how do we get rid of the house dust mites?’.
i. What are the common house dust mites and storage mites?
ii. Where are these mites likely to be found in a home?
iii. What recommendations do you make to the client?
43

Answers: 37, 38
37 As with people, dogs with AD show a higher prevalence of S. pseudintermedius
colonization (which may be reported by the diagnostics laboratory as ‘SIG’
since molecular testing is necessary to specifically identify S. pseudintermedius)
of the skin compared with healthy counterparts. This degree of adhesion and
colonization contributes to the higher frequency of skin infections in these canine
patients. This is also true for people with AD. Similarly, it has been demonstrated
that dogs with AD have an increased expression of antimicrobial peptides in the
skin compared with non-atopic dogs; however, this expression is altered with
regard to which antimicrobial peptides. For example, beta-defensin expression is
different in dogs with AD compared with dogs lacking the disease. Although the
amount of antimicrobial peptides is increased overall, the altered expression may
also contribute to the development of secondary infections in atopic patients.
38 i. Dust mites: Dermatophagoides farinae and D. pteronyssinus are the most

common species. Storage, mold, or grain mites: include Acarus siro, Tryophagus
putrescentia, Glycyphagus domesticus, Blomia tropicalis, Lepidoglyphus destructor.
ii. House dust mites are found in pillows, mattresses, carpeting, upholstered
furniture, and the dog’s bed or bedding. Storage mites may be found outside food
storage areas or in the environment. The prevalence of mites is dependent on
environmental factors such as moisture and humidity. D. farinae is more tolerant
of dryer climates than D. pteronyssinus. These mites feed on human skin scales,
pollen, fungi, bacteria, and animal dander.
iii. House dust mites are found in all homes and are impossible to remove. An
extensive review of house dust mite control measures for asthma found that
intervention produced no significant difference in the number of patients that
improved clinically, their asthma symptom scores, or medication use. Routine
recommendations for control include: minimizing carpeting in the home;
frequent washing of bedding; dusting; and thoroughly vacuuming several times
a week. Electrostatic dusting cloths and filtered vacuums may be more effective
at minimizing disruption of dust and hence dust mites. Pyriproxifen has been
recommended as a method of controlling mites in the environment. Bathing to
remove mites on the body and maintain the epidermal barrier function is practical.
The allergic response is not just against live mites, but dead mite allergens as
well; therefore, immunotherapy is recommended along with reasonable cleaning
measures.
44
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Questions: 39, 40
39a 39b
39 A 12-year-old female spayed DSH cat presented for a recent history of several
cutaneous ulcers and erosions (39a). Minimal manipulation of the skin during
examination revealed easily torn, fragile, thin skin (39b). The owner reported no
other signs of systemic illness. The cat had a long history of non-seasonal moderate
pruritus that had been well managed with corticosteroid administration.
i. What are the most common clinical signs associated with feline hyperadreno
corticism?
ii. How does iatrogenic hyperadrenocorticism differ in dogs and cats?

Great Pyrenees dog presented for the
clinical lesions shown (40). No other
lesions are noted on dermatologic
examination. Previous CBC and serum
biochemistries performed by the dog’s
referring veterinarian did not reveal any
abnormalities.
i. What is the most likely diagnosis in
this patient?
ii. What are the options for treating this
condition?
45

Answers: 39, 40
39 i. Physical findings may include: abdominal enlargement, muscle atrophy,
thin skin, unkempt hair coat, hair loss (often bilaterally symmetrical), bruising,
hepatomegaly, plantigrade stance, hyperpigmentation, and seborrhea. Skin fragility
(skin that is easily torn with minimal handling or restraint) and curling of the ear
pinnae are cutaneous side-effects seen exclusively in cats with hypercortisolemia;
the latter is noted more frequently in iatrogenic hyperadrenocorticism compared
with spontaneous disease. Most cats with hyperadrenocorticism have concurrent
diabetes mellitus, typically insulin-resistant and difficult to regulate. Polyuria,
polydipsia, polyphagia, lethargy, and increased frequency of upper respiratory and
urinary tract infections may also be noted. Secondary bacterial pyoderma as well
as generalized demodicosis is common.
ii. Compared with dogs, cats are noted to be less prone to side-effects of
corticosteroid administration. Iatrogenic hyperadrenocorticism is much less
common in cats, possibly due to the relatively low expression of corticosteroid
receptors in cats compared with other species. Unlike dogs, cats may show signs of
skin fragility and curled pinnae, as mentioned above. Alkaline phosphatase may be
elevated; however, in cats this is a side-effect of poorly regulated concurrent diabetes
mellitus as opposed to elevated cortisol. While dogs with hyperadrenocorticism
show decreased urine specific gravity, cat urine typically remains concentrated
(>1.030) despite concurrent polyuria and polydipsia.
40 i. DLE, pemphigus erythematosus, CLE, or neoplasia. A skin biopsy is needed

to confirm the diagnosis.
ii. Numerous treatment options are available for DLE and pemphigus erythematosus
in dogs depending on disease severity. Since the condition is restricted to a single
body region, topical therapy may be considered to minimize systemic adverse effects.
Potent topical steroids (e.g. betamethasone valerate, betamethasone dipropionate)
may be used in severe cases in the initial stages to put the condition into remission.
Caution must be used with this treatment option because of the high possibility
for cutaneous atrophy. Alternatively, topical tacrolimus may be used to control the
disease. Cutaneous atrophy is not a side-effect with tacrolimus as opposed to topical
steroids. In more severe cases, systemic therapy may be indicated at least initially.
Options would include immunosuppressive doses of corticosteroids (prednisone or
prednisolone), cyclosporine, or combination therapy with tetracycline/doxycycline
and niacinamide. A recent study in a dog has reported efficacy in treating a
generalized variant of DLE with oral hydroxychloroquine. Additional research is
warranted to assess this option for other lupus variants in more patients.
46

Question: 41
41
41 A 5-year-old male beagle dog was presented for the complaint of ‘excessive
shedding’ of 4 months’ duration (41). The dog had a lifelong history of primary
seborrhea manifested by malodorous greasy skin with chronic recurrent infections/
overgrowth of bacteria and yeast. Examination revealed easily epilated hairs,
bilaterally symmetrical hair loss over the lumbosacral area, dry brittle hairs,
superficial pyoderma, and malodorous seborrhea. A review of the medical records
revealed that the dog had gained 6 kg since the last visit. Vital signs were within
normal limits for a dog. Based on the history and clinical signs, hypothyroidism
was suspected. A fasted serum chemistry panel revealed elevated cholesterol.
i. Hypercholesterolemia is a classic finding in dogs with hypothyroidism. In what
other diseases is hypercholesterolemia a common abnormal finding on serum
biochemistry panel?
ii. This dog has a lifelong history of recurrent bacterial and yeast pyoderma/
overgrowth and seborrhea. What is the likelihood that these problems are due to
the suspected hypothyroidism?
iii. What drugs might this dog have received that could interfere with thyroid
function testing?
iv. What are the most common thyroid function tests, and what are their limitations?
47

Answer: 41
41 i. Cholestasis, hyperadrenocorticism, diabetes mellitus, nephrotic syn
drome, post-prandial sampling, idiopathic hypercholesterolemia, familial hyper
cholesterolemia (schnauzers).
ii. If the dog truly has a lifelong problem with seborrhea that predisposes it to
secondary microbial overgrowth, it is unlikely that this is due to hypothyroidism.
Lifelong suggests the dog had the disease at a young age; dogs with hypothyroidism
presenting at a young age would have congenital hypothyroidism and show signs
of cretinism. The more likely scenario is that the dog has a primary disorder of
keratinization and has developed breed-associated thyroiditis that exacerbated the
pre-existing seborrhea and secondary microbial overgrowth.
iii. Glucocorticoids and sulfonamides. Glucocorticoids can decrease total T4, freeT4,
and TSH. They influence peripheral metabolism of thyroid hormones and inhibit
TSH secretion. The effect is dependent on dose and preparation. Sulfonamides can
decrease T4 and freeT4, and increase TSH. They block iodination of thyroglobulin
and can cause clinical hypothyroidism in a dose- and duration-dependent manner.
Other drugs that can cause low T4 include anticonvulsants, phenobarbital, NSAIDs,
furosemide, phenylbutazone, radiographic contrast agents, general anesthesia, and
previous levothyroxine therapy.
iv. Measurement of total T4 in combination with clinical signs and serum
chemistries can be used as a screening test. A normal total T4 makes the diagnosis of
hypothyroidism unlikely but not impossible. Sighthound dog breeds have normal
total T4 levels that are 50% lower than other breeds, therefore interpret with care.
Free T4 measured by equilibrium dialysis (FT4ED) is less likely to be affected by
most non-thyroidal illnesses and drugs and is not affected by autoantibodies. It
has an approximate diagnostic accuracy of 90%; low test results are compatible
with hypothyroidism, but also consider severe non-thyroidal illness, concurrent
glucocorticoid or phenobarbital administration, or hyperadrenocorticism. Endo
genous TSH is high in 60–80% of dogs with hypothyroidism and in 10–15% of
dogs with non-thyroidal illnesses. The ‘classic’ hypothyroid dog has a low total T4,
low FT4ED, and high TSH.
48

Questions: 42, 43
42a
42b
42 Nutrition, trace minerals, and vitamins play various roles in different aspects of
skin health and disease. For each of the following vitamins, discuss their importance
with regard to skin structure and function, and the disease states associated with
vitamin abnormalities.
i. Vitamin A (42a)
ii. Vitamin B
iii. Vitamin C
iv. Vitamin D
v. Vitamin E (42b)
vi. Vitamin K
43 How was it discovered that a mutation in the ABCB1 (MDR1) gene leads to
increased toxicity to ivermectin?
49
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Answers: 42, 43
42 i. Vitamin A is involved in corni 42c
fication defects seen in cocker spaniel
dogs. Compared with primary seborr
hea, which presents at a young age,
vitamin A-responsive dermatosis mani
fests in adults. Clinical signs include
crusting, scaling, and alopecia. Follicular
plugging, follicular casts, and frond-
like keratinous debris are noted on the
ventral and lateral thorax and abdomen.
ii. In dogs and cats, vitamin B abnormalities are associated with neurologic and/or
gastrointestinal dysfunction. A spontaneously occurring cutaneous manifestation
of vitamin B deficiency has not yet been reported in small animals.
iii. Vitamin C is a cofactor in collagen synthesis. It is required by prolyl and
lysyl hydroxylases for post-translational hydroxylation of procollagen. Vitamin
C deficiency causes immature and insufficient collagen formation. Clinical signs
include poor wound healing and dermal and capillary fragility.
iv. With solar exposure, the epidermis transforms provitamin D3 into vitamin D3
via previtamin D3. It is translocated into the blood stream where it is hydroxylated
in the liver (to 25-hydroxyvitamin D3) and kidney (to 1,25-dihydroxyvitamin D3).
1,25-dihydroxyvitamin D3 is necessary in epidermal proliferation and differentiation.
v. Vitamin E is an antioxidant. Deficiency causes feline pansteatitis and is most
commonly reported in cats fed exclusively a tuna diet or those supplemented with
excess cod liver oil. Signs include widespread cellular damage and deposition of
ceroid pigment. Nodules, typically without fistulation and drainage, are found in
the subcutaneous and mesenteric abdominal fat.
vi. Vitamin K is a necessary cofactor for coagulation factors II, VII, IX, and X.
Deficiency results in hemorrhage and spontaneous bleeding. Petechiae and ecchymotic
hemorrhage may be easily visible on the skin and mucous membranes (42c).
43 In order to study the function of the MDR1 gene, mice were developed that
were homozygous for deletion mutations in the gene. The mice were viable and
appeared phenotypically normal. However, when the colony became infested with
mites, the mice were sprayed with a dilute ivermectin solution, which is normally
considered to be a safe procedure. To the researchers’ surprise, large numbers of
mice were found dead shortly afterwards. Subsequent analysis revealed that all the
dead mice were homozygous for the MDR1 deletion (mdr1a -/-). Toxicity analysis
demonstrated that the mdr1a-/- mice were 50–100-fold more susceptible to orally
administered ivermectin than mdr1a+/+ or mdr1a+/- mice.
50

Questions: 44, 45
44 A 3-year-old female spayed golden retriever dog presented for moderate non-
seasonal pruritus, mainly involving all four paws, face, ear pinnae, and ventrum,
that had progressed in severity since the age of 8 months. The owners reported
that clinical signs improved with the administration of anti-inflammatory doses
of corticosteroids, but pruritus recurred once treatment was discontinued. Mild
erythema of the affected body areas was the only abnormal finding on dermatologic
examination. Multiple skin scrapings (deep and superficial) were negative for
mites. Cytology did not show evidence of infection with either bacteria or yeast.
Previous treatments for microbial overgrowth had not provided relief of pruritus
according to the owner. There was no improvement following a miticidal treatment
trial (for scabies) with ivermectin. No benefits were noted with regard to skin
comfort following multiple strict hypoallergenic diet trials (hydrolyzed, multiple
commercial novel protein diets). Both allergen-specific IgE serum tests and IDT
were negative.
i. What is the definition of canine atopic-like dermatitis?
ii. What are the recommendations for medical management for this patient?
45
45 This cat was presented for the lesions shown (45). They had developed slowly
over several months. What are possible differential diagnoses?
51

Answers: 44, 45
44 i. An inflammatory and pruritic skin disease with clinical features identical
to those seen in canine AD in which an IgE response to environmental or other
allergens cannot be documented.
ii. Very similar to those for dogs with documented IgE involvement; however, since
the offending allergens are not able to be documented in these patients, ASIT is
not part of the disease management. As with canine AD, avoidance of flare factors
is a necessary part of long-term treatment. This includes an effective flea control
program and antimicrobial therapy if signs of infection (bacteria or yeast) are
present. Improving skin hygiene and coat care is also part of the management.
Frequent bathing with a non-irritating or soothing shampoo, plus dietary fatty
acid supplementation, is recommended. Topical glucocorticoids or tacrolimus may
be beneficial for localized pruritus; however, systemic medication is often necessary
for more widespread disease. Oral glucocorticoids, cyclosporine (modified), and
subcutaneous interferon can help control clinical signs. When glucocorticoids
are part of the management, steroid-sparing agents such as essential fatty acids
or antihistamines may also be incorporated. As evidence for the involvement of
epidermal barrier dysfunction in canine AD continues to accumulate, it is not
unreasonable to suspect barrier dysfunction in canine atopic-like dermatitis as
well. Improvements in barrier function may be more important for these patients
if a ‘leaky’ epidermis takes precedence over immunologic disturbances with regard
to disease pathogenesis.
45 The skin lesions shown are uncommon and not suggestive of a particular skin
disease. Although unlikely, dermatophytosis needs to be considered, as it can mimic
almost any known feline skin disease. Hair trichograms looking for demodicosis
are indicated; however, if these mites are found, there is a strong possibility that
demodicosis is secondary to an underlying disease. The marked symmetry of the
lesions strongly suggests that the dermatologic lesions are a cutaneous marker of
systemic illness or are immune mediated. Possible differential diagnoses include
early epitheliotropic T-cell lymphoma, pseudopelade, sebaceous adentitis, follicular
mucinosis, adverse drug reaction, SLE, and skin disease secondary to FIV. This is a
case of follicular mucinosis, a rare, presumably immune-mediated skin disease that
has been seen in association with cutaneous lymphoma in cats. Pseudopelade is a
rare immune-mediated disease characterized by generally symmetrical alopecia that
begins on the head and spreads to the legs, paws, and ventrum. Onychomadesis is
a common finding. The alopecia tends to be non-inflammatory.
52

Questions: 46, 47
46a 46b
46 Note the nasal lesions in this crossbred Labrador retriever dog (46a).
i. What differential diagnoses would you consider if the owner reported that the
onset of the lesions was rapid? What differential diagnoses would you consider if
the lesions were reported to be slow in onset?
ii. A photomicrograph of a skin biopsy from the margin of the dog’s nose is shown
(46b). What key epidermal abnormality is shown?
iii. A complete dermatologic examination was performed and lesions were found
to be limited to the planum nasale. The owner reports that the lesions began at
approximately 6 months of age and have slowly progressed over the last several
years. What is the most likely diagnosis?
47a 47b
47 A farm cat was presented for a lesion on its nose (47a). The lesion was reported
to have started slowly and is not painful. Examination under general anesthesia
revealed more extensive lesions (47b). A skin biopsy was obtained and the lesion
was identified as a ‘feline sarcoid’. What is known about this disease?
53

Answers: 46, 47
46 i. Rapid onset: pemphigus foliaceus/erythematosus, lupus erythematosus, drug
reaction, hepatocutaneous disorder. Slow onset and progression: zinc-responsive
skin disease, nasal hyperkeratosis, ichthyosis in healthy younger dogs. In either
situation it is important to examine the dog for lesions on other parts of the body,
in particular the foot pads.
ii. Parakeratotic hyperkeratosis. Diffuse parakeratotic hyperkeratosis is most commonly
seen in parasitic infestations, zinc-responsive skin diseases, lethal acrodermatitis,
Malassezia dermatitis, hepatocutaneous syndrome (necrolytic migratory erythema,
superficial necrolytic dermatitis), and breed-related nasal digital hyperkeratosis.
iii. Nasal parakeratosis of Labrador retriever dogs. This is a hereditary disease of
Labrador retriever and Labrador retriever-cross dogs. Typically, lesions begin to
develop between 6 months and 1 year of age and start as dry, rough, proliferative
adherent keratin on the planum nasale. The disease is believed to have an autosomal
recessive mode of inheritance. Histologically, parakeratotic hyperkeratosis is a
striking feature. Nasal digital hyperkeratosis occurs in middle-aged to older dogs,
whereas Labrador nasal parakeratosis occurs in young dogs. Zinc-responsive skin
diseases usually are not limited to the nose. Inherited zinc-responsive skin disease
(type I) occurs in northern breeds of dogs (e.g. Akitas, Malamutes, Huskies).
If zinc-responsive skin disease caused the lesions in this dog, it would be most
likely related to dietary deficiency (type II). Immune-mediated diseases would not
progress this slowly and would damage the nasal planum and/or adjacent nares.
47 Feline sarcoids are rare skin tumors of cats. They can occur on the philtrum,
nares, lip, digits, ears, and tail. They are more common in male cats from rural areas.
They have been reported in domestic cats, bobcats, Florida panthers, Asian lions,
snow leopards, and clouded leopards. They are usually solitary, slow growing, and
may be locally infiltrative. Typical histologic findings include non-encapsulated,
poorly demarcated dermal nodules that may invade the epidermis. The lesions need
to be differentiated from spindle cell tumors such as fibroscarcomas, histiocytic
sarcomas, and melanomas. The lesions are caused by a feline sarcoid-associated
papillomavirus (FeSarPV). This virus has been detected in lesions in cats from
both the USA and New Zealand. The virus is presumed to be of bovine origin
and recently FeSarPV has been detected within bovine skin. This suggests that
cattle may be the reservoir host of this virus and feline sarcoids are a ‘dead end’
infection by a bovine papillomavirus. Lesions often recur after surgical excision.
Cryotherapy, radiation, or amputation has been used for permanent resolution of
lesions.
54

Questions: 48, 49
48 A 13-year-old male castrated golden retriever 48a
dog presented for acute and rapidly progressive
skin lesions involving the right forelimb. The owner
had noted the dog limping on the limb 1 week
prior to presentation; no traumatic injury had been
observed. The dog was presented on emergency, was
febrile (40oC [104oF]), tachycardic, and painful on
palpation. The entire right forelimb was clipped
and the full extent of the lesions was noted (48a, b).
Multiple draining tracts were evident with purulent–
hemorrhagic exudate oozing from the tracts and
matting the surrounding hair. There were irregular
patches of black tissue, which were extremely painful,
surrounded by erythema and edema extending from
the ventral neck to the carpus. Cytology of the
exudate showed large numbers of bacterial organisms
(cocci with occasional rods) with large numbers of
neutrophils and occasional macrophages. 48b
i. Because of the clinical appearance, aggressive
surgical debridement was recommended along with
culture and biopsy of the affected tissue. On surgical
exploration, the subcutaneous tissue and deep fascia
could easily be separated by gentle manipulation
with one finger. What is the clinical suspicion given
the lesion and surgical appearance?
ii. What organisms have been associated with this
disease development in dogs?
49 Ketoconazole, itraconazole, fluconazole, and terbinafine are antifungal drugs

commonly used in veterinary dermatology. What is the spectrum of activity of each
drug with respect to fungal infections, and what are the common adverse effects
in dogs and cats?
55

Answers: 48, 49
48 i. The discoloration associated with the lesions on the limb is tissue necrosis.
This may have developed due to thrombus formation, chemical irritant (does
not fit with the dog’s history) or other reason for tissue devitalization (e.g. blunt
trauma, infection). Systemic signs combined with the lesions lend concern for toxic
shock syndrome or necrotizing fasciitis. Surgical findings are key; based on easily
separated tissue, the dog was diagnosed with necrotizing fasciitis. Also known as
‘flesh eating disease’, this rare condition is caused by rapidly spreading bacterial
infection leading to soft tissue damage. Most dogs have a history of even mild
trauma, but this may not be required for disease development. Infection spreads,
migrating through fascial planes, and involves deep tissues; ischemic necrosis from
vasoconstriction and/or thrombosis leads to clinical lesions.
ii. The most commonly implicated bacterial organism in dogs is group G Strepto
coccus species (e.g. Streptococcus canis); this is the organism most commonly
involved in canine toxic shock syndrome. Other reports have involved Escherichia
coli and Staphylococcus pseudintermedius. Methicillin-resistant Staphylococcus
aureus has been reported in association with necrotizing fasciitis in people due
to virulence factors associated with this organism. There is suspicion that S.
pseudintermedius may have similar virulence factors and should be considered a
potential causative agent in this disease in dogs.
49
• Ketoconazole. Candida, Malassezia, Blastomyces, Histoplamsa, Coccidioides,
Cryptococcus, less effective against Sporothrix and Aspergillus. Can be used
for dermatophyte infections but itraconazole, fluconazole and terbinafine are
preferred. Can cause anorexia, vomiting, diarrhea, abdominal pain, weight
loss, hepatotoxicity. Do not use in cats as it is not well tolerated.
• Itraconazole. Cryptococcus, Candida, Blastomyces, Histoplamsa,
Coccidioides, Malassezia, Aspergillus, Sporothrix, zygomycosis,
chromomycosis, fungal keratitis, onychomycosis, dermatophytosis. It can
cause vomiting, diarrhea, abdominal pain, inappetence, increased serum liver
enzymes, fever, hypertension, skin rash, and ulceration.
• Fluconazole. Cryptococcus, Candida, Blastomyces, Histoplamsa, Coccidioides,
Malassezia, variable efficacy against dermatophytes and Aspergillus. It
can cause vomiting, diarrhea, cutaneous eruptions, and hepatotoxicity
(elevated transaminases, cholestasis, hepatitis), although much less than with
ketoconazole or itraconazole.
• Terbinafine. Dermatophytes, some activity against Sporothrix. Low efficacy
against yeast. It can cause vomiting, diarrhea, abdominal pain, and rarely
hepatotoxicity.
56

Questions: 50, 51
50 What is the overall prognosis for the dog in case 48?
51
51 A 9-year-old DLH cat presented for a non-healing wound on the right

hindlimb (51). The lesion had been present for several months without significant
improvement noted by the owner. Systemic antibiotic administration had not
provided any visible benefit to the patient. The cat resisted close examination
of the lesion; however, it was noted to be a fairly well-circumscribed epidermal/
superficial dermal mass. The cat appeared somewhat painful on palpation. The
owners also reported that the cat would groom excessively at the hindlimb. No
other lesions were found on physical examination.
i. What are the differential diagnoses for the lesion seen on this cat?
ii. Biopsy of the mass revealed an unencapsulated mass involving primarily the
superficial dermis, which was contiguous with the epidermis in several areas.
Ulceration and erosion were present along the surface. The mass was composed
of multiple, discrete aggregates of epithelial cells of variable size and shape. The
cells were polygonal and occasionally had indistinct borders, with a high nuclear
to cytoplasmic ratio. They were arranged in large lobules extending to the deep
dermis; the lobules were composed of smaller variably sized nests and trabeculae
separated by a small amount of fibrovascular stroma. Cell polarity was haphazard,
particularly along the internal portion of the mass. The pathologist’s note indicated
that the appearance of the neoplastic cells resembled that of basal cells of the
epidermis. Based on this description, what is the histopathologic diagnosis?
iii. How are these tumors in dogs and cats classified histopathologically?
iv. What is the typical behavior of these tumors in cats?
57

Answers: 50, 51
50 In general, the prognosis for 50
necrotizing fasciitis in dogs is very
poor. Fatality is common, parti cu
larly if the condition is not identified
and addressed rapidly. Mul tiple
surgeries, long-term antibiotic
administration, and supportive care
are indicated to give the patient the
best chance. There is one report of
successful management with a single
surgical debridement; however, it is
not the normal progression. In this case, the dog’s right forelimb and surrounding
tissue was amputated and thoroughly debrided. Approximately 1 week after the
initial surgery, necrotic tissue was noted along the surgical site (50). A second
aggressive, revisional surgery was performed to remove more of the devitalized
tissue. The dog was provided with supportive care with appropriate antibiotic,
fluid, and nutritional support for 3 weeks while he recovered. He was eventually
discharged from the hospital, but was euthanized approximately 1 month following
the procedure because of continued complications.
51 i. Non-healing wound with excessive granulation tissue (e.g. trauma, foreign

body, infection); neoplasia; fungal granuloma; dermatophytic pseudomycetoma.
ii. Trichoblastoma (basal cell carcinoma).
iii. Into three different forms: solid, keratinizing, clear cell. Solid basal cell carcinoma
is the most common variant noted in cats, whereas keratinizing carcinomas are
most common in dogs. Clear cell basal cell carcinomas to date have only been
reported in cats, but this variant is considered to be rare.
iv. Trichoblastomas are uncommon in cats and rare in dogs. Lesions are typically
solitary, well-circumscribed plaques or nodules often with an ulcerated surface.
Multicentric trichoblastoma appears to be more common in cats than dogs.
Masses may have a blue or black pigmented appearance due to melanin pigment
within the lesion. In cats, lesions are frequently located on the nose, face, and ears;
truncal lesions are more common in dogs. In general, these tumors in cats have a
very low rate of recurrence and metastasis. Analysis of nuclear morphology may
be helpful in determining histologic subtype and predicting recurrence of tumor
growth in cats with trichoblastoma; quantitative analysis of area, perimeter, and
mean diameter of nuclei were found to be appropriate parameters in one study.
58

Questions: 52, 53
52a 52b
52c
52 A 12-year-old male castrated DSH

cat presented with the skin lesions
shown (52a, b). The lesions had been
progressing for approximately 2 months
and were not responsive to anti biotic
administration. The cat had a concurrent
history of hyperthyroidism, which was
well-managed with methimazole administration. No other signs of systemic illness
were noted by the owner.
ii. Cytology from under the crusts/pustules is shown at 40x magnification (52c).
What cytologic findings are noted?
iii. What is your most likely diagnosis for this patient?
iv. What treatment options are available for consideration?
53 A current topic in the veterinary literature is the increasing frequency of

methicillin-resistant staphylococcal infections in animals. This trend is also seen
in the human medical field. In dogs and cats, with regard to skin infections,
Staphylococcus pseudintermedius is the most common isolate. This is different
from people, in whom Staphylococcus aureus is most commonly isolated.
i. What does methicillin resistance mean?
ii. What implication does this have for public health?
59
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Answers: 52, 53
52 i. Dermatophytosis, superficial bacterial pyoderma, PF, drug-associated PF
or other drug reaction, subcorneal pustular dermatosis, eosinophilic pustulosis,
cutaneous neoplasia (lymphoma, thymoma-associated exfoliative dermatitis),
mosquito bite hypersensitivity.
ii. Large numbers of neutrophils (mostly intact and viable) with fewer eosinophils,
lymphocytes, and macrophages; large numbers of acantholytic keratinocytes,
often in groups or ‘rafts’.
iii. PF and drug-associated PF are the most likely differentials due to the large
number of acantholytic keratinocytes noted on cytology.
iv. The most commonly used and effective treatment options include glucocorticoid
medication (prednisone, triamcinolone, dexamethasone) with or without adjunct non-
steroidal medications. In some cats, a reasonably low dose of glucocorticoid alone
may be sufficient to control the clinical signs of PF. In others, however, the addition of
a non-steroidal medication (chlorambucil, cyclosporine) will allow for a more rapid
and effective glucocorticoid dose reduction. In this case, treatment was initiated with
prednisolone (4 mg/kg/daily for 10 days and tapered over several weeks). Methimazole
was discontinued because of the potential for drug-associated PF. Radioactive iodine
(I131) was administered to control the cat’s concurrent hyperthyroidism. Eventually, all
treatment for PF was able to be discontinued without evidence of relapse.
53 i. Methicillin resistance in Staphylococcus species is due to an altered penicillin

binding protein, PBP2a. This protein is unable to bind antibiotics with a beta lactam
ring. This includes all penicillins, cephalosporins, and carbapenems. Methicillin is a semi-
synthetic, penicillinase-resistant antibiotic. It is no longer produced; on susceptibility
profiles, oxacillin (a more stable antibiotic) is used instead. Resistance to oxacillin is
the same as methicillin resistance. Methicillin resistance is due to the presence of the
mecA gene; mecA encodes for the altered penicillin binding protein. The mecA gene
is carried on a staphylococcal chromosome cassette (SCCmec); this mobile genetic
element becomes integrated into the Staphylococcus species genome. The cassette varies
in size, but always contains the mecA gene. Also, it will frequently contain other genes
responsible for antimicrobial resistance, thereby further limiting treatment options.
ii. The mecA gene responsible for methicillin resistance in S. pseudintermedius
is the same gene that encodes for methicillin resistance in S. aureus. This has
implication with regard to public health in that even though S. pseudintermedius
does not readily colonize or infect people, the organism can potentially transfer
the chromosomal cassette to S. aureus in a susceptible human carrier; resistance,
therefore, can be transferred between species. The organism can persist in the
environment for a fairly long period of time, lending concern for infection and/or
colonization persistence or recurrence. This is true for both animals and people.
60

Questions: 54, 55
54a 54b
54 This is a DTM fungal culture plate inoculated 7 days ago (54a). Note the white
glistening growth on the plate and how the microbial growth seems to have an
irregular, if not serpiginous, growth pattern. An acetate tape preparation of the
white growth was made and no evidence of bacteria, yeast, or fungi was found.
Instead, this organism was found on the tape (54b). Close examination of other
fungal culture plates in the same container revealed similar growth and tracks.
i. What is this organism?
ii. What is its source?
iii. How do you prevent other cultures from being contaminated?
55
55 A 5-year-old German shepherd dog presents with presumed perianal fistulae

(55). The owner reports the dog has difficulty defecating and is bleeding around
the anus.
i. Name two other possible differential diagnoses.
ii. List other clinical signs dogs with perianal fistula may display.
iii. How is this treated?
61
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Answers: 54, 55
54 i. A storage mite, which infests fungal culture medium. The two most common
species are Tyroglyphus and Tarsonemus.
ii. Storage mites are usually brought into the laboratory on fresh materials and
deposited onto the medium during inoculation of plates. The first indication of
contamination may be moth-eaten fungal cultures or ‘wandering trails of colonies’
on the fungal culture medium. These mites not only eat the cultures, they will also
carry fungal spores and bacteria from one culture to another.
iii. In clinical practice, prevention of infestation of in-house fungal cultures starts
with sample acquisition. Inoculate samples quickly and discard any remaining
specimens, store inoculated plates individually in self-sealing bags. If an infestation
does occur, mites are very susceptible to environmental flea control products.
55 i. Anal gland abscess/rupture and perianal neoplasia. The former might be a

confounding consequential factor with perianal fistulae.
ii. Hematochezia, dyschezia, obstipation, diarrhea, ribbon-like stool, increased
frequency of defecation, perianal licking, self-mutilation, scooting, offensive odor,
and/or weight loss.
iii. Perianal fistula is a relapsing and remitting disease; the disease is managed,
but not necessarily cured. The first goal is to alleviate large bowel clinical signs
(e.g. hematochezia, tenesmus, dyschezia). Reduction in the diameter, depth, extent,
and recurrence of tracts/fistulae is the second goal. Medical management offers
the best chance for resolution and consists of combined immunosuppressive/
immunomodulatory (e.g. glucocorticoids, calcineurin inhibitors, azathioprine),
dietary (e.g. elimination diet, stool softeners), and hygiene (e.g. clipping, cleaning,
antibiotics) therapy.
This disease is best managed medically; the most effective treatment has been
cyclosporine. The ‘modified’ formulation of cyclosporine should be used as it is
more bioavailable than earlier formulations. Although the use of an antimicrobial
agent to reduce the cost of medical care with cyclosporine should be questioned,
ketoconazole (8 mg/kg PO q24h) co-administered with CsA allows for an
approximate 50% reduction in the dose. Ketoconazole is a P-450 enzyme inhibitor
and reduces the metabolism of CsA. A tapering course of anti-inflammatory to
immunosuppressive dosages of systemic glucocorticoids may be helpful. Once
clinical signs have improved, especially pain, medical therapy can be transitioned
from systemic to topical treatments. Tacrolimus (0.1%) ointment is applied twice
daily and then slowly tapered to the most infrequent effective dose possible to
maintain clinical resolution.
62

Questions: 56, 57
56 A 4-year-old female spayed 56
Labrador retriever dog presented
for unilateral otitis externa of
approximately 7 days’ duration.
The dog was being treated for con
current immune-mediated thrombo
cytopenia of unknown underlying
cause. The dog had a history of
intermittent otitis externa, often with
secondary Malassezia overgrowth,
primarily in the warmer months
when she spent a lot of time in the
water. The owner had been cleaning the ear every other day with an acidifying
cleaner; however, the ear appeared to be worsening. On otoscopic examination, the
external ear canal was markedly erythematous and several ulcerations were present
along the vertical and horizontal canal walls. A moderate amount of purulent debris
was present in the canal and the tympanic membrane appeared to be intact.
i. Cytology of the exudate is shown (56). What are the differential diagnoses for
this patient?
ii. Culture and susceptibility isolated solely Aspergillus niger from the ear. What is
the pathogenesis of this condition with regard to this specific patient?
57 The Chinese shar pei dog is 57

phenotypically identified as having
‘excessive folds and wrinkles’.
i. What metabolic disease is this breed
predisposed to as a result of the genetic
mutation that causes the excessive
wrinkling (57)?
ii. What disease in people is clinically
similar?
iii. How is this disease treated?
63

Answers: 56, 57
56 i. Cytology shows neutrophilic exudate with ceruminous debris. Septate hyphae
are also present. Otomycosis would be the top differential. Secondary bacterial
otitis externa cannot be ruled out despite the lack of bacterial organisms detected
on cytology.
ii. Aspergillus spp. are found in the environment in soil and organic debris. They
produce small (2–3 µm) airborne conidia, which land on animate and inanimate
objects. In most cases, these organisms represent transient inhabitants of the skin
and hair in healthy individuals; however, Aspergillus can produce opportunistic
infection in compromised individuals through mucosal or cutaneous surfaces.
Nasal aspergillosis is the most common presentation in dogs. Cutaneous lesions are
noted with disseminated disease and are rarely seen in healthy animals. This may
be accompanied by musculoskeletal changes, neurologic signs, respiratory disease,
or gastrointestinal illness. German shepherd dogs, particularly young to middle-
aged females, are overrepresented, suggesting a possible inherited immunologic
defect. In a recent literature review, cases of otomycosis due to Aspergillus spp.
were evaluated. Compromised aural health is suspected to be involved in disease
pathogenesis. With regard to this dog, both the history of previous episodes of
otitis externa as well as the noted immunocompromised state may have led to the
development of otomycosis.
57 i. Familial shar pei fever (FSF). It is estimated that 23% of shar pei dogs are
affected by this autoinflammatory disease. FSF is characterized by chronic recurrent
episodes of high fever and inflammation of the joints (especially tibiotarsal joints).
Episodes can occur every few weeks or months. Secondary complications of the
disease are reactive amyloidosis and kidney or liver failure due to amyloid deposits
in these organs. Recently, the genome of Chinese shar pei dogs was compared with
that of other dogs; a unique 16.1 Kb duplication was identified on the gene that
codes for production of an important rate-limiting enzyme (HAS2) in hyaluronan
synthesis. This is believed to be the causative mutation for both excessive
hyaluronanosis and FSF.
ii. Familial Mediterranean fever. The finding that HAS2 is associated with FSF as
well as with sterile fever and inflammation is of interest, as this canine disease may
offer clues to the etiology of the disease in people and/or be an animal model of
the disease.
iii. With colchicine, which is used to prevent excessively high levels of uric acid in
the blood associated with episodes of gout. Potential adverse effects include bone
marrow suppression. Colchicine binds selectively and reversibly to microtubules,
causing metaphase arrest and preventing many cell functions including
degranulation, chemotaxis, and mitosis.
64

Questions: 58, 59
58
6
5
) 4
3
2
58 A diagrammatic representation of the skin is shown (58).

i. Identify layers 1, 2, 3, 4, 5, and 6.
ii. How does layer 5 form? What are the components of this layer?
iii. What is transepidermal water loss (TEWL)? How is it measured?
59 A 2-year-old female spayed Egyptian 59

Mau cat presented for severe pruritus
involving the head, neck, and ear pinnae.
According to the owner, who adopted
the cat from a rescue organization 6
months prior to presentation, pruritus
ranged from moderate to severe and
frequently progressed to self-induced
excoriation over the cervical region.
Scarring was present over the dorsal
cervical region due to repeated, severe
self-trauma (59). No response to aggres
sive parasite control (including an ivermectin treatment trial, lime sulfur dips, and
monthly application of adulticide flea prevention) or antimicrobial therapy for
bacteria or yeast was reported.
ii. What reaction patterns have been associated with cutaneous reactions to food
in the cat?
iii. What does a ‘novel protein hypoallergenic diet’ consist of?
65

Answers: 58, 59
58 i. 1 = basal cell layer; 2 = spinous cell layer; 3 = granular layer; 4 = corneal layer;
5 = epidermal lipid layer; 6 = cornified cells undergoing desquamation.
ii. The epidermal lipid layer (5) is formed from lamellar granules fusing with the
cell membrane at the junction of the granular layer (3) and the corneal layer (4).
When lamellar granules fuse with cell membranes and expel their contents into the
intercellular space, the contents are modified by enzymes. Glycolipids are converted
to ceramides by glucosidases and phospholipids to fatty acids by phospholipases.
This results in the formation of the ‘barrier lipids’, which are comprised of
ceramides, cholesterol, and free fatty acids. Ceramides are the dominant lipid and
are generated from a sphingoid base and a fatty acid. The sphingoid base includes,
but is not limited to, sphingosine, dihydrosphingosine, and phytosphingosine.
iii. TEWL refers to the amount of water vapor lost through the stratum corneum
each day. In healthy people this is estimated to be 0.5 liters/day; in people with
psoriasis, loss can be as high as 6 liters/day. TEWL is measured with a probe
applied to the skin using either a closed or an open chamber. Closed chambered
probes are not affected by ambient or body-induced airflows. Open chamber
probes can be affected by ambient and body-induced airflows, probe size, and the
angle of measurement. Air currents, room temperature, and ambient humidity can
also affect test results.
59 i. Allergy (cutaneous adverse reaction to food, environmental allergies),

dermatophytosis, injection site reaction, vasculitis, reaction to topical flea control
or other topical medication.
ii. Miliary dermatitis, eosinophilic skin lesions (granuloma, plaque, indolent ulcer),
erosions/ulcerations of the head and neck (cervical–facial pruritic dermatitis),
and self-induced symmetrical alopecia. Compared with other feline allergic skin
diseases, cats with food allergy more frequently present with lesions affecting the
head, neck, and pinnae.
iii. A protein is considered ‘novel’ if the animal has not been exposed to the protein
even in small quantities. A ‘novel protein hypoallergenic diet’ may be a home-
prepared diet or a limited ingredient commercial diet. Many dermatologists regard
the home-prepared novel protein diet to be the ‘gold standard’ for evaluating food
allergy in the dog and cat, as the ingredients and additives are completely controlled.
Limited ingredient diets need to be carefully evaluated when used in an elimination
diet trial to ensure that other potential allergens (animal by-products, additional
protein and/or carbohydrate sources) are not included on the ingredients list. (Note:
Manufacturing control can be variable; a recent study detected common food
allergens in diets often used for elimination diet trials [non-prescription, over-the-
counter] even when the ingredients were not listed on the package.)
66

Questions: 60, 61
60
60 A 3-year-old dog presented for a second opinion on the management of these

nasal lesions (60).
i. What are the possible differential diagnoses?
ii. The pathologist noted the following key findings: ‘lichenoid interface dermatitis
with basal cell degeneration and apoptosis, no signs of inflammatory cells in the
cutaneous or follicular epidermal layers, and pigmentary incontinence’. What is
the most compatible diagnosis?
iii. What are the treatment options for this disease?
61 What common pitfalls are associated with diagnosing food allergy in dogs or
cats?
67

Answers: 60, 61
60 i. Lupus erythematosus, mucocutaneous pyoderma, dermatophytosis,
pemphigus, Malassezia overgrowth, vitiligo, trauma, cutaneous lymphoma,
uveodermatologic syndrome.
ii. Lupus erythematosus.
iii. In severe cases, remission needs to be induced with aggressive prednisone/
prednisolone therapy (2–4 mg/kg PO divided q12h). Once remission is achieved,
long-term care requires a second immunosuppressive agent as the steroid dose
is gradually decreased (over months). One option is cyclosporine (5 mg/kg PO
q24h); once in remission it may be possible to reduce the dose. Intermittent waxing
and waning of lesions can occur. Potent topical steroids or tacrolimus can be
used as adjunct therapy. In mild cases, oral combinations can be used as initial
therapy in place of steroids, and adjunct topical steroids or tacrolimus used at
the beginning of therapy or for relapses. Topical treatment of the nose is difficult
and complications include mechanical removal, difficulty finding a potent topical
steroid in a penetrating base, continued client compliance, thinning of the nasal
planum, secondary nasal cartilage erosion, arteriole hemorrhage, and elevations in
liver enzymes, as topical steroids are absorbed systemically. Owners should wear
gloves when applying topical therapies to the nose.
61 Include, but are not limited to: not feeding the diet long enough to fully
evaluate a response; failure to select a ‘novel’ protein based on the animal’s
previous dietary history (including consideration of potentially cross-reactive food
allergens [e.g. cross-reaction of other feathered poultry such as goose, turkey, or
duck with chicken; cross-reaction of bison with beef]); reaction of the animal to
the hydrolyzed diet when allergy to parent protein is present; failing to control
secondary pruritic skin disease (e.g. external parasites, secondary bacterial
pyoderma, or Malassezia overgrowth); failure of the diet trial to be completely
strict. Exclusion of flavored medications (particularly parasite prevention, certain
antibiotics, NSAIDs), animal-based chew toys (rawhide, pigs’ ears, ‘bully bones’),
normal treats, table scraps, food used to hide medication, and gelatin-containing
products or medications (certain marshmallows, medication capsules) is necessary.
68

Questions: 62, 63
62
62 A three-year-old male neutered Great Dane dog (68 kg [150 lb]) presented
because of lack of response to immunotherapy. The dog had been diagnosed with
AD two years ago via IDT and has been receiving ASIT for months. Other than
immunotherapy, the dog is not currently receiving any other medication, but
review of the medical records reveals numerous courses of antibiotics including
cefpodoxime (200 mg/day) and enrofloxacin (2.5 mg/kg). Representative clinical
signs of the dermatologic examination are shown (62). Other than the skin, physical
examination is normal. Dermatologic examination reveals extensive superficial
pyoderma on the ventral abdomen, diffuse lichenification, and thickening of the
skin on the ventrum, in flexor areas, medial aspects of the legs, ventral neck, and
ears. There is a diffuse papular eruption on the dog’s ventrum. The dog’s coat is
‘greasy’ and malodorous. The dog’s vaccinations are current and the owners have
administered inconsistent flea and tick control. Skin scrapings for demodicosis
were negative. Skin cytology revealed large numbers of Malassezia organisms,
cocci, and neutrophils. A bacterial culture isolated an oxacillin-resistant SIG
susceptible only to chloramphenicol.
i. The owners believe that the immunotherapy has failed. What is your response?
ii. What is your treatment plan for this dog at this time?
iii. The dog returns for a recheck visit 6 weeks later. What will be your plan if the
dog is severely pruritic, moderately pruritic, or not pruritic at all?
63 What are probiotics? What skin diseases may benefit from their use?
69
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Answers: 62, 63
62 i. It is impossible to assess accurately the dog’s response to immunotherapy;
inconsistent flea prevention (possible flare factor) and secondary microbial infec
tions may be masking true efficacy of ASIT.
ii. Restart flea control and aggressively treat the microbial overgrowth before
pursuing further diagnostics. The dog should be bathed at least 2–3 times a week
in medicated shampoo; a combination antibacterial/antifungal shampoo should
be used. If the dog cannot be bathed frequently, a thorough sprayed application
of 2% chlorhexidine solution can substitute for one bath. Systemic ketoconazole
(5 mg/kg q24h) in addition to topical antifungal shampoo therapy is beneficial.
Oral antibiotic treatment for bacterial pyoderma is difficult, as the only drug
available for use is chloramphenicol. Although effective, the drug requires three
times daily administration and can cause nausea and vomiting. Owners need to
wear gloves when administering the drug and when cleaning up any vomitus;
aplastic anemia is a risk in people.
iii. If the dog is severely pruritic at recheck and microbial overgrowth has resolved,
response to a treatment trial for scabies should be discussed with the clients. If
the dog is non-pruritic, one assumption is that the intense pruritus was due to the
combined bacterial/yeast infection. Given the strength of IDT and clinical history,
continued ASIT would be advisable. If the dog is improved but still pruritic, a food
trial would be indicated. If that fails to resolve the problem, before repeating IDT,
owner compliance with therapy should be assessed, again.
63 A ‘probiotic’ is defined as ‘live microorganisms which, when administered in

adequate amounts, confer a health benefit to the host’. The most commonly used
probiotics are strains of lactic acid fermenting bacteria such as Lactobacillus,
Bifidobacterium, and Streptococcus (S. thermophilus). Their mechanism of action
is not well understood, but three major modes of action have been suggested:
probiotics might be able to modulate the host’s defenses including the innate as
well as the acquired immune system; probiotics may have a direct effect on other
microorganisms (commensal and/or pathogenic ones); probiotic effects may be
based on actions affecting microbial products such as toxins. Probiotic use has
been studied in a wide range of diseases, but small pilot studies have suggested that
their administration may protect against allergies.
70

Questions: 64, 65
64a 64b
64 A 7-year-old dog is presented for the problem of crusting and scaling of

2 months’ duration (64a). Past pertinent history includes a diagnosis of cutaneous
lymphoma in the last year; the dog was in remission at the time of presentation.
The owners report that the dog is not pruritic. Skin scrapings were negative for
Demodex mites, but large numbers of oval eggs were found on skin scraping (64b).
i. What are these organisms?
ii. What is the diagnosis, and how does it relate to the dog’s past pertinent history?
iii. How would you treat this dog?
65 A 7-year-old male castrated DSH cat is 65

presented for the lesions shown (65). Only a
single limb is affected on examination. Both the
dorsal and ventral surfaces of the distal limb
have multiple cutaneous nodules and draining
tracts. The cat is noted to be indoor/outdoor and
will frequently stay out overnight. No known
trauma predisposed the lesion development;
however, the owner is not sure what happens
with the cat on nights he stays away from home.
The cat is otherwise healthy, is not currently
being administered any medications other than
monthly topical parasite preventive, and is up to
date on vaccinations.
i. Given the nodular clinical appearance of the
lesions, what are your differential diagnoses?
ii. What diagnostic tests are recommended?
71

Answers: 64, 65
64 i. Sarcoptes scabiei mite eggs.
ii. Sarcoptes infestation or scabies is highly contagious and a known zoonosis.
There are two atypical presentations in dogs. The first is scabies incognito. Dogs
are intensely pruritic, there may be a mild eosinophilia, but classic lesions are
absent. The second presentation is ‘crusted scabies’, or what was once called
‘Norwegian’ scabies, because it was first recognized in Norway in 1848 in a
group of people with leprosy. In crusted scabies, immunosuppression from drugs
(corticosteroids, anti-neoplastic drugs) allows for rapid proliferation of mites with
little host immune response. Classically, these dogs have little to no pruritus and a
thick gray scaly material that contains large numbers of mites.
iii. All in-contact dogs require treatment. The dog will require bathing to remove
the thick crusts containing mites and debris. Preventive parasite control is
important adjunct therapy in patients being treated for chronic medical diseases
(e.g. neoplasia). Effective systemic therapies for scabies include: selamectin (6–12
mg/kg every 2 weeks for 4 treatments); ivermectin (0.2–0.4 mg/kg PO every 7
days for 4–6 weeks); doramectin (0.2–0.6 mg/kg SC every 7 days for 4–6 weeks);
milbemycin (0.5–2.0 mg/kg PO q24h for 30 days). Effective topical therapies
include amitraz (every 2 weeks for 6 weeks), fipronil spray (3–6 ml applied as a
sponge-on weekly for 4–6 weeks), and lime sulfur (every 5 days for 6 weeks).
65 i. Include infectious (bacterial deep pyoderma including atypical bacteria such

as Nocardia, Actinomyces, Mycobacterium spp.; deep fungal infection, including
blastomycosis, cryptococcosis, histoplasmosis, sporotrichosis, opportunistic fungal
infection), inflammatory (sterile pyogranuloma/granuloma syndrome, histiocytic
disease), or neoplasia (squamous cell carcinoma, soft tissue sarcoma). Foreign body
reaction or trauma with secondary infection should also be considered for this patient.
ii. Cytology of the exudates and culture and susceptibility looking for bacterial
and fungal infections. Because of the inherent danger of culturing deep fungal
organisms and zoonotic transmission, unstained cytologic preparations should be
included with the culture specimen. The laboratory can stain these and possibly
identify an infectious agent. Biopsy of the nodules is recommended to confirm the
diagnosis. Radiographs and/or advanced imaging of the limb may be indicated if
other diagnostics fail to identify an underlying cause for the lesions. A fistulogram
to identify draining tracts can be helpful when foreign body reaction is present.
In this case, skin biopsy revealed branching pigmented fungi on special stains;
a diagnosis of phaeohyphomycosis was made. This organism was most likely
inoculated via a puncture wound. Definitive diagnosis requires submission of a
wedge of tissue to a diagnostic laboratory familiar with advanced fungal culture
techniques. Surgical excision is often the treatment of choice.
72
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Questions: 66, 67
66
66 A 6-year-old, indoor/outdoor FeLV/FIV-negative intact male cat developed soft

tissue abscessation as shown (66). Despite repeated lancing, draining, and flushing
procedures with concomitant courses of cefovecin injections and oral amoxicillin
over the past 2 months, the lesions fail to heal. Other than these draining nodular
skin lesions, which appear to be limited to the inguinal fat pad, the cat is apparently
in good health.
i. Name the ‘dermatologic problem’ along with differential diagnoses that should
be excluded.
ii. What diagnostic tests are indicated?
iii. Pending a diagnosis, what treatment might be considered?
67 i. What is a hydrolyzed hypoallergenic diet?

ii. What evidence is available to support or refute the use of hydrolyzed diets in
suspected allergic patients?
73

Answers: 66, 67
66 i. ‘Non-healing panniculitis’ restricted to the inguinal fat pad. Differential
diagnoses include: inflammatory/infectious (deep methicillin-resistant staphylococcal
pyoderma, nocardiosis, actinomycosis, L-form bacteriosis, rapidly-growing myco
bacteriosis [RGM], subcutaneous mycoses), inflammatory/non-infectious (foreign
body, sterile panniculitis), and possibly neoplasia.
ii. Diagnostic imaging to determine the extent of the lesions and whether or not a foreign
body is present. Surgical exploration of inguinal skin with aseptic procurement of deep
subcutaneous wedges for culture and biopsy is required. Punch biopsy specimens of
nodules will not get deep tissue and may not provide the laboratory with enough
tissue for culture since organisms may be present in small quantities (especially rapidly-
growing Mycobacteria spp.). As some organisms in the differential list are better seen
cytologically, fine-needle aspirates of intact deep nodules and/or direct impressions of
cut sections of deep tissue can be made and submitted.
iii. Doxycycline could be administered for presumptive RGM. Selection of this antibiotic
would also target L-form bacteria as its mechanism of action is independent of the
presence of a bacterial cell wall. This cat had RGM, as evidenced by few aggregates of
acid-fast bacilli within nodular pyogranulomatous inflammation of the panniculus.
67 i. A parent protein (typically chicken or soy) is broken into smaller amino

acid fragments, which are then incorporated into the diet. Hydrolyzed diets are
formulated through enzymatic degradation and ultrafiltration to remove large
molecules and higher molecular weight peptides.
ii. In people, food allergy is a type 1 hypersensitivity reaction caused by binding
of epitopes or proteins to IgE molecules. These large molecules (>10 kDa) cross-
link IgE molecules on the surface of mast cells, leading to degranulation. Of food
allergens identified in the dog, allergenic proteins all had a molecular weight of
>20 kDa. Depending on the degree of hydrolysis, the molecule size of hydrolyzed
dietary amino acids ranges from <3 kDa (extensively hydrolyzed) to 10 kDa (partially
hydrolyzed). In an infant cow’s milk allergy study, it was noted that the smaller
molecule size was not able to cause IgE cross-linking, thereby preventing an allergic
reaction from occurring. The pathogenesis of food allergy in veterinary species is
not fully elucidated; however, cutaneous type 1 reactions have been noted both
immediately and later with food exposure in dogs and cats. Both immunologic and
non-immunologic cutaneous adverse reactions to food exist. A systematic review
uncovered evidence that suggests reduced immunologic and clinical allergenicity
of hydrolyzed diets in dogs with food allergy. Some dogs, however, experienced
recurrence of allergic symptoms when fed hydrolyzed diets; this was true in dogs
with food allergy of undetermined origin and in dogs with confirmed food allergy to
the parent protein used in the hydrolyzed diet. Whether this is true in cats with food
allergy is not known.
74

Questions: 68, 69
68 The diagnosis of AD is based 68
on the exclusion of all other causes
of pruritic skin disease. It relies
on the patient’s signalment, past
pertinent history, and clinical signs.
It is widely accepted that there is no
test available that will diagnose the
disease; ‘allergy tests’ are used once
the clinical diagnosis has been made
to support the clinician’s diagnosis,
to document IgE involvement (i.e.
rule out atopic-like dermatitis),
and to help guide immunotherapy
formulation if this is to be used as
part of the disease management.
i. What are the two categories of ‘allergy tests’ available?
ii. What is the principle behind the use of these tests in allergic disease?
iii. What is shown (68)?

keeshond dog was presented for
multiple deeply pigmented plaque-
like lesions on the ventral abdomen
(69). The owner reported that
the plaques had been present for
several years, appeared to wax
and wane (exfoliate and regress),
but always recurred at the same
site. There was no evidence that
the lesions were bothersome to the
dog, but the owner was concerned
about possible neoplasia.
i. What is the most likely diagnosis?
ii. What is the presumed underlying
etiology?
iii. With regard to prognosis, what do you tell the owner?
75

Answers: 68, 69
68 i. Allergen-specific IgE serology, intradermal allergy tests.
ii. Allergen-specific IgE serology tests detect circulating IgE antibody in serum
directed against a panel of environmental allergens. Most are ELISA-based tests
(others use radioallergosorbent tests); patient serum is added to allergen extracts
(in liquid or solid phase) and reaction is determined by antigen–antibody binding.
This is detected either by colorimetric, fluorometric, or radiometric analysis.
Intradermal testing also demonstrates IgE-mediated allergen hypersensitivity by
intradermal injections of various environmental allergens. Allergens bind to IgE
molecules on sensitized mast cells, causing degranulation; this leads to localized
extravasation of edema fluid, erythema, and formation of a wheal. ‘Positive results’
with either test are interpreted with regard to ‘importance’ based on the patient’s
history and seasonality.
iii. Allercept® E-screen, second generation, available only in European countries
(not USA). This rapid screening immunoassay allergy test incorporates the same
principles of complete serum-based allergen panels (ELISA-based technology utilizing
highly specific IgE detection reagent). Mixtures of allergens from environmental
groups (trees, grasses/weeds, indoor allergens) are ‘spotted’ onto the test cassette
to identify positive reactions to the patient’s serum by color indicator. This test has
been evaluated in dogs and cats for its ability to ‘predict’ results of a complete serum
allergen panel; the test demonstrated good predictability in both species.
69 i. Canine pigmented viral plaques.

ii. The plaques are caused by a papillomavirus that is distinctly different from
the virus that causes oral papillomatosis in the dog (canine oral papillomavirus;
COPV). At least three strains (COPV3, COPV4, COPV5) have been isolated from
pigmented viral plaque lesions in dogs.
iii. There appears to be a genetic predisposition of certain breeds (pug, miniature
schnauzer) to develop pigmented viral plaques, although the lesions have been
reported in several other breeds. SCC at the site of these lesions has been reported
due to transformation of pigmented viral plaques; however, pigmented viral
plaques and SCC have been reported on the same animal, making it difficult to
be certain about transformation of lesions. The metastatic potential of the lesions
in dogs is unknown. In pug dogs, malignant transformation of pigmented viral
plaques has not been reported, which differs from other breeds. Recommendations
are for owners to monitor lesions. Often, the pigmented plaques will enlarge to
a certain point and from there become stable with respect to size. Lesions rarely
cause clinical problems for the dog and are mostly cosmetic abnormalities;
however, because of the potential for malignant transformation, any change in
the lesion should be reported and investigated. Skin biopsy/surgical removal of the
lesion would be indicated.
76

Questions: 70, 71
70 i. Are there any drawbacks to the different kinds of ‘allergy tests’?
ii. In relation to allergy testing, what significance does ‘high-affinity Fc-epsilon
receptor’ have?
71
71 A 4-month-old male intact pit bull dog presents for progressive hair loss,
pruritus, and a generalized ‘rash’ on the body. The owner had initially found him as
a stray on the side of the road. Shortly after he was adopted, the puppy developed
juvenile cellulitis (‘puppy strangles’), which was treated with antibiotics and
corticosteroid administration. He was still being treated for the juvenile cellulitis
at the time of presentation for these problems. His peripheral lymph nodes are still
somewhat enlarged on palpation; however, he seems otherwise to be an active and
happy puppy. On physical examination you note complete alopecia with areas of
‘peach fuzz’, widespread erythema, and a severe papular–pustular eruption over
the entire body (71). All four paws and the face do not have this eruption, but they
are erythematous and partially alopecic. You perform multiple deep skin scrapings
and note numerous Demodex canis mites. Most of the mites are alive and all life
stages are present.
i. What are possible reasons for the development of generalized demodicosis?
ii. What are some potential complications of treatment in this patient?
77

Answers: 70, 71
70 i. Serum-based allergy tests have variability between laboratory reagents,
protocol, and interpretation methods. Allergenic extracts are one source of
variability, which can make test interpretation different between laboratories and
between allergen batches. The ability to bind IgE exclusively (as opposed to cross-
reacting with IgG) depends on the reagent used; some laboratories use less specific
binding reagents, leading to more false-positive reactions. Standardization of
protocols and reporting of results vary among laboratories. Sensitivity (44–100%)
and specificity (0–100%) is variable for serum-based allergy tests. Allergen extracts
also affect intradermal allergy testing. Individual interpretation of reactions is
another variable. Variability between individuals is noted with regard to allergens
used in testing as well as dilutions. Drug interactions have more influence with
intradermal testing than with serum allergy testing. Antihistamines, tricyclic
antidepressants, and glucocorticoids require adequate withdrawal to prevent
false-negative reactions. Sedation protocols can influence test results; opioids
(particularly oxymorphone), ketamine/diazepam, acepromazine, and propofol can
all adversely affect results.
ii. It refers to the technique in serum allergy testing in which the assay detects
allergen-specific IgE. Reagents bind strongly to the Fc-epsilon receptor, which
resides on the alpha chain of IgE molecules. Binding affinity is very high for this
receptor; tests that utilize this receptor technology have more specific binding with
less cross-reaction and binding of IgG.
71 i. The treatment for juvenile cellulitis may have influenced the development of
generalized demodicosis in this patient. As the treatment involves high doses of
corticosteroids (high anti-inflammatory to low immunosuppressive doses; 1–2 mg/
kg/day) this may have suppressed the puppy’s developing immune system, making
it more likely for demodicosis to develop. Also, this is a pit bull dog. This breed
has been shown to have a higher risk of demodicosis as well as a short hair coat,
which may also be a risk factor for this parasitic skin disease.
ii. Since the dog’s lymph nodes are persistently enlarged, treatment for juvenile
cellulitis is still indicated. Discontinuing treatment prematurely can lead to disease
relapse. However, the concurrent corticosteroid administration may make it more
difficult to resolve generalized demodicosis. Until the dose can be tapered and
discontinued, it is unlikely the demodicosis can be completely cured. Typically,
treatment for juvenile cellulitis is discontinued after a few weeks to months.
Additionally, dosing for whatever treatment option is elected for generalized
demodicosis (e.g. ivermectin, milbemycin oxime, amitraz, moxidectin) will need to
be continuously evaluated as the puppy continues to grow and gain weight.
78

Questions: 72, 73
72a
72b
72 A 12-year-old female spayed ragdoll cat presented for generalized excessive

scaling and mild pruritus (72a). The cat was also reported to be more lethargic
than usual.
i. What are the differential diagnoses for this patient?
ii. This parasite (72b) was identified on skin scraping. What is the definitive
diagnosis?
iii. What is the recommended treatment(s) for this condition?
73 With regard to the puppy described in case 71:

i. What is the treatment goal for resolving juvenile-onset generalized demodicosis?
ii. With regard to long-term prognosis, how likely are you to ‘cure’ this patient?
79
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Answers: 72, 73
72 i. Demodicosis, cheyletiellosis, dermatophytosis, bacterial pyoderma, metabolic
disease (kidney insufficiency, liver disease), endocrine disease (diabetes mellitus,
hyperthyroidism), neoplasia (either primary cutaneous neoplasia [e.g. cutaneous
lymphoma] or paraneoplastic syndrome), inability to groom appropriately (obesity,
musculoskeletal pain/arthritis).
ii. Demodex gatoi infestation.
iii. Based on an evidence-based review of demodicosis treatment protocols, there
is evidence to support application of lime sulfur 2% as a topical dip once weekly.
As this mite can be rather difficult to find on skin scraping, a lime sulfur trial is
recommended to rule out this parasite when suspected. To date, lime sulfur has
been the most efficacious treatment for feline D. gatoi infestation. There is evidence
to support the recommendation of amitraz rinses (0.0125–0.025% weekly). Cats
may be more sensitive to side-effects of this treatment option compared with dogs;
if considered, it is generally recommended to use a lower concentration. There
are anecdotal reports of efficacy of a combination spot-on product containing
imidacloprid 10% plus moxidectin 2.5% for treatment of D. gatoi infestation;
well-designed clinical trials to evaluate this treatment option need to be performed.
All in-contact animals (cats) need to be treated as this is considered to be a
contagious parasite.
73 i. To achieve 2–3 consecutive negative skin scrapings performed 2–4 weeks

apart. A negative skin scrape implies no mites of any life stage identified, alive or
dead. Skin scrapings should be performed from the same body region each time to
assess treatment efficacy. Treatment for demodicosis should be continued until this
end point is reached; premature discontinuation will cause a relapse. On average,
this takes several months (7 months on average and sometimes longer); however,
the prognosis for resolution is good.
ii. In general, the prognosis is good. Approximately 80% of cases will be cured
once the end point of treatment is reached (2–3 consecutive negative skin
scrapes, remaining negative on skin scrapes for a full year following treatment
discontinuation). The other 20% will have chronic demodicosis; however, these
dogs can have a good quality of life and be lesion-free with administration of
maintenance miticide therapy. Owners should be educated that although this is
an immunologic problem (cell-mediated immunodeficiency in identifying the
mites as ‘foreign’), it is not a general immunodeficiency; dogs with juvenile-onset
demodicosis are no more likely than the average to develop other illness in the
future.
80

Questions: 74, 75
74a 74b
74 What is the clinical diagnosis of 74c

each of the images shown (74a–c)? All
the cats are otherwise healthy. (a) Firm,
painless mass on the chin of a cat. (b)
Firm raised symmetrical, hairless, non-
pruritic lesions on the caudal thigh of a
cat. (c) Lip lesion on a cat.
75 Radiation therapy can be a beneficial treatment option for several cutaneous

abnormalities. Although it is used most commonly for neoplastic conditions
(e.g. mast cell tumor, soft tissue sarcomas), other more ‘benign’ conditions (e.g.
refractory acral lick lesions or eosinophilic granulomas) may also show beneficial
responses to radiation therapy.
i. What types of radiation delivery techniques exist in veterinary medicine?
ii. What types of radiation delivery systems exist in veterinary medicine? What are
the pros and cons of the options available?
81
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Answers: 74, 75
74 These three clinical presentations are part of the ‘eosinophilic’ reaction pattern
of cats. 74a and 74b are ‘eosinophilic granuloma’ lesions. Their biopsy specimens
have acellular foci of eosinophilic granulation around collagen fibers. True collagen
fiber degeneration or ‘collagenolysis’, as evidenced by Masson’s trichrome stain, is
not a consistent feature of feline eosinophilic granuloma. 74c is a feline indolent
ulcer. These lesions may be unilateral or bilateral. Unilateral lesions have been
observed to develop at the site of injuries (cacti thorn, tick bite) or infection (M.
canis infected hair).
75 i. (1) Brachytherapy: a radioactive material is implanted within the treatment

area of interest and radiation emanates from inside the patient outwards. (2)
Plesiotherapy (contact radiotherapy): utilizes radioactive materials similar to the
ones used in brachytherapy, but instead of implanting them within the treatment
area, the material is placed on top of the area using a special applicator. (3)
Teletherapy (most common delivery technique in veterinary medicine): utilizes
either man-made radiation in the form of x-rays or naturally produced gamma
rays from decaying radioactive materials.
ii. Linear accelerators and cobalt units. Linear accelerators are machines that
accelerate charged particles (typically electrons) using electromagnetic fields.
Different x-ray photons and electron beam energies are produced, allowing for
the treatment of deep and superficial tumors. Because of their increased flexibility
in design and dose delivery, linear accelerators have become the most common
delivery system in treatment centers. Unlike linear accelerators, cobalt units are
mechanically simple. The radioactive cobalt-60 source emits high-energy radiation
in the form of gamma rays as part of the natural decay process. While linear
accelerators allow the option to choose which energy photons (for deep-seated
tumors) or electrons (for superficial tumors) to use, cobalt units are limited to
photons of one energy only and have no electron capability. Since the source is
constantly decaying, care is necessary on a daily basis to ensure the safety of the
patients and staff who interact with it. With a half-life of about 5.25 years, to
maintain adequate output and minimize prolonged treatment times, the source is
typically replaced every 5–10 years.
82

Questions: 76, 77
76 A 2-year-old Boston terrier dog presented for 76
non-inflammatory hair loss along the ventral trunk
and caudomedial thighs (76). Alopecia had been
slow to develop, but was progressively worsening.
Skin scrapings and fungal culture were both
negative.
i. What is the most likely cause for the alopecia?
Describe four syndromes of this condition.
ii. What is tardive alopecia?
iii. If you were to biopsy the skin of this dog, what
findings would be compatible with your working
diagnosis?
iv. Is there an effective treatment for this condition?
77
77 i. What is dermatophyte test medium (DTM) (77)?

ii. What is the principle of its use, and what is the most common error made when
using DTM?
83

Answers: 76, 77
76 i. Pattern alopecia has four recognizable clinical syndromes. The first is pinnal
alopecia, most often seen in dachshund dogs. The second syndrome occurs in
young American water spaniels and Portuguese water dogs and is characterized as
hypotrichosis of the ventral neck, caudomedial thighs, and tail. Syndrome three is
typified by greyhound dogs with caudal thigh alopecia. This syndrome is different
from bald thigh syndrome (i.e. alopecia of the lateral thigh). The fourth syndrome
(this case) is the most common syndrome seen in Boston terriers, dachshunds,
Chihuahuas, Manchester terriers, whippets, and greyhound dogs. Beginning at
about 6 months of age, these dogs lose hair along the post-auricular area, ventral
neck, ventral trunk, and caudomedial thighs.
ii. Localized, regionalized, or generalized hair loss as an animal matures. These
animals are born with a normal coat, but alopecia becomes evident as the animal
ages. It is assumed that tardive alopecia is an inherited disorder.
iii. Pattern alopecia of dogs is characterized histopathologically by miniaturized hair
follicles and hair shafts with normal adnexal structures. The follicles are thin and
short, the hair bulbs are smaller than usual, and the hair shafts are fine and thin.
iv. No. In some instances, melatonin orally (3–9 mg/dog q8h) or by subcutaneous
implant (usually requires several [8, 12, or 18 mg, based on patient’s body weight])
will result in hair growth. If melatonin is effective, new hair growth should be
expected within 2 months. Since this condition, with its many clinical forms, is
often considered a cosmetic disorder, no treatment is required.
77 i. DTM was first described in 1969 and was developed to aid medics in
Vietnam in the identification of griseofulvin-sensitive dermatophytes in soldiers
with Trichophyton spp. infections. The base is a Sabouraud’s dextrose agar with
cyclohexamide and antibiotics (gentamicin and chlortetracycline) added to inhibit
growth of saprophytic fungi and bacteria. A pH indicator (phenol red) is added to
the medium; as dermatophytes grow they produce alkaline metabolites and turn
the DTM from yellow (pH 5.5) to red.
ii. Potential dermatophytes will grow faster and create a color change sooner than
other saprophytic fungi. The most common problem is the high number of false-
positive results when identification of a dermatophyte is made using the red color
change as the sole diagnostic criterion. Although all dermatophytes induce a color
change, many non-dermatophyte species will induce an almost equally intense
color changes. The most common non-pathogenic organisms that can mimic
dermatophytes include Alternaria spp., Aspergillus spp., Chrysosporium spp.,
Penicillium spp., and Scopulariopsis spp. Many of these saprophytes have similar
colony morphology to that of dermatophytes, making microscopic identification
mandatory.
84

Questions: 78, 79
78a
78 A 4-year-old mixed-breed dog is presented for this lesion on its face (78a).
The lesion is painful, malodorous, and developed rapidly over 2 weeks. The lesion
is firm, movable in the dermis, and does not appear to be attached to underlying
tissue. This is the only abnormality found on examination.
i. What are possible differential diagnoses for this mass? What diagnostic tests are
indicated?
ii. The biopsy report shows the following: ulceration, perivascular inflammation,
severe diffuse infiltrate of eosinophils with large numbers oriented around
individual collagen fibers, prominent flame follicles and macrophages and giant
cells. There was no growth on bacterial culture and FNA was inflammatory with
large numbers of eosinophils and fewer mast cells. What is the diagnosis?
79 A 1-year-old male neutered 79

Labrador retriever dog is shown
(79). The owners adopted the
dog from a rescue organization
and are presenting the dog for a
physical examination. The dog
was surrendered by the previous
owners because they were unable to
train the dog to urinate or defecate
outside. Physical examination
revealed an inactive dog, mental
dullness, large broad head, short
neck, short limbs, and abnormal
dentition. What is the most likely diagnosis?
85
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Answers: 78, 79
78 i. Tumor, infection, granuloma. 78b
Mast cell tumor would be a major
differential diagnosis. FNA, multiple
impression smears (send several to
reference laboratory unstained), deep
wedge biopsy, and culture of the lesions.
Regarding skin biopsy, in order to
obtain a diagnostic specimen, a wedge
of tissue should be collected with every
effort made to get a deep specimen.
Many microbial organisms causing
granulomatous lesions create significant inflammation and are only isolated from
deep within the lesion. The laboratory should be made aware that potentially
zoonotic organisms (e.g. deep fungal mycoses) are a considered differential. Biopsy
is the most useful diagnostic test once mast cell tumor is ruled out.
ii. Canine eosinophilic granuloma, an uncommon skin lesion in dogs compared
with cats. Typically, lesions are found on the skin, oral cavity, or external ear. The
etiology is unknown; hypersensitivity reaction (e.g. arthropod bites) is suspected
based on observations that lesions are solitary, do not recur after treatment, and
are often found in areas where insect bites tend to occur. Siberian huskies and
Cavalier King Charles spaniels are predisposed. Lesions can be successfully treated
via excision, but they are usually glucocorticoid responsive. The lesion responded
completely to three subcutaneous injections of methylprednisolone without
reported recurrence (78b).
79 Congenital hypothyroidism or cretinism. This occurs when there is absent or

ineffective TSH, dyshormonogenesis of thyroid hormone, or defects in thyroid
gland development. If pituitary function is normal, the failure of thyroid hormone
production results in a goiter. In most cases of canine congenital hypothyroidism,
goiters are absent. Congenital hypothyroidism has been reported in several
breeds of dogs. In toy fox terriers and rat terriers, a nonsense mutation in the
thyroperoxidase gene causing hypothyroidism with goiter has been reported. A
lack of production of TSH is the suspected cause of juvenile hypothyroidism in
giant schnauzer, boxer, and Scottish deerhound breed dogs.
86

Questions: 80, 81
80a 80b
80 This 12-year-old indoor only female spayed DSH cat presented for self-
induced alopecia of the ventral abdomen. The cat had a previous diagnosis of
allergic skin disease and this was managed with intermittent long-acting injectable
corticosteroids for several years. Recently, however, the cat had been losing more
hair (80a). The owner also noted that the cat had been gaining weight and had
been urinating more frequently; the owner reported that the litter box is ‘wetter
than normal’. Although there is little in the history and clinical signs suggestive of
dermatophytosis, the owner insisted on a fungal culture being performed prior to
allowing any further diagnostics because of the cat having ringworm as a kitten. A
skin scraping was performed from the cat’s abdomen (80b).
ii. What is the difference between this skin disease in cats versus dogs?
iii. How is the condition managed?
81 When it comes to evaluating the outcome of clinical trials, it can be difficult

to determine objectively how much a certain therapeutic intervention is or is not
helping with regard to disease control. This can be particularly difficult in diseases
with a highly variable clinical appearance and severity, such as AD. Because of this,
various scales have been developed to help standardize measurements to allow for
comparisons between various clinical trial outcomes.
i. What is CADESI?
ii. What is a Visual Analog Scale?
87

Answers: 80, 81
80 i. Demodex cati.
ii. Two Demodex spp. mites are found in cats: D. cati and D. gatoi. D. gatoi is
considered to be contagious and typically is noted with moderate to severe pruritus.
With D. cati infestation, identification of this mite should strongly raise concerns
about underlying systemic illness. It is often reported in association with FeLV and
FIV, diabetes mellitus, hyperadrenocorticism, and neoplasia. To date, there is no
evidence that cats have a disease process similar to canine juvenile-onset demodicosis.
iii. When D. cati mites are identified and an obvious underlying cause (e.g. excessive
use of glucocorticoids, neoplasia) is not identified, thorough medical evaluation
is indicated. Diagnostics may include CBC, serum biochemistries, urinalysis,
retroviral testing, and possibly thoracic radiographs, abdominal ultrasound, or
CT. Identification of the concurrent systemic illness and initiation of treatment
are a necessary part of the management. If the underlying disease is managed, the
demodicosis may resolve on its own. There is no FDA (USA) approved treatment for
feline demodicosis. There are no evidence-based studies on the efficacy of compounds
for the treatment of feline demodicosis because of the lack of randomized controlled
studies. Therefore, at best the treatment recommendations are based on clinical
observations. Treatments include lime sulfur, ivermectin, milbemycin, amitraz,
fipronil, and, most recently, topical moxidectin/imidacloprid.
81 i. Canine Atopic Dermatitis Extent and Severity Index, a measurement system

that evaluates clinical lesion appearance and severity in atopic dogs based on body
site affected. It was designed along the same lines as the SCORAD (SCORing Atopic
Dermatitis) measurement system, which is used to assess the clinical severity of AD
in people. Both systems attempt to ‘quantify’ the disease as objectively as possible.
ii. A measurement tool often used with owners for determining severity of pruritus in
patients with AD. Various forms of the analog scale exist; however, among the different
forms, certain features hold constant. The scales are typically in the form of either a
vertical or horizontal line with text descriptions of activities indicating pruritus (81).
The scale may or may not include graduated lines or number rankings between the
text descriptions to further subdivide the scale line. Owners are asked to mark on the
scale where they feel their pet currently ranks in relation to the descriptive activities.
81
No scratching, Half of waking Scratching, biting,

biting, chewing, hours spent chewing, rubbing
rubbing. scratching, biting, constantly. Dog
Dog is very chewing, rubbing. only stops to eat
comfortable. Dog is often or drink, often
uncomfortable. wakes to scratch.
Dog is extremely
uncomfortable.
88

Questions: 82, 83
82 A 4-year-old female spayed Cavalier King Charles spaniel dog is presented with
a 24-hour history of acute right head tilt and right facial drooping. On physical
examination the dog is normal and is bright and interactive. Her neurologic
examination is also normal except for a persistent right head tilt, horizontal
nystagmus with fast phase towards the left, absent right palpebral reflex, and absent
nasal reflex. The nystagmus does not change direction or speed with rotation of the
head, but the dog does develop a positional ventrolateral strabismus with extreme
dorsoflexion of the head and neck. Based on the examination, what cranial nerves
are affected?
83
83 A 2-year-old female spayed Labrador retriever dog was presented with a

3-month history of skin lesions. The lesions began as a solitary mass between
the shoulders and gradually enlarged to involve the right shoulder, forelimb, and
right carpus (83). The lesion was linear and well circumscribed at the time of
presentation. The dog was not lame, but the lesions were somewhat pruritic. Skin
scrapings and fungal culture were negative, bacterial culture and susceptibility
showed no growth, and there was no response to trial antibiotic therapy using
cephalexin and fluoroquinolone antibiotics. Impression smears at the time of
referral revealed shed keratinocytes, eosinophils, and neutrophils with variable
numbers of acantholytic keratinocytes.
ii. Skin biopsy findings revealed subcorneal and intraepidermal eosinophilic and
neutrophilic acantholytic pustular dermatitis. What is the diagnosis?
89
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Answers: 82, 83
82 The facial nerve (CN7) originates in the rostral medulla, courses out of the
brainstem through the internal acoustic meatus, across the petrosal portion of
the temporal bone in the facial canal and exits the skull through the stylomastoid
foramen. Damage anywhere along the course of the nerve can result in inability
to move the lips, eyelids, or nares. To test the facial nerve you need a sensation
(transmitted by the trigeminal nerve [CN5]) and a response (performed by the
motor nerve [CN7]). Note: If either CN5 or CN7 is malfunctioning, these reflexes
will be absent. To isolate the trigeminal nerve from the facial nerve, perform a
corneal reflex. If the corneal reflex is normal and the palpebral reflex is abnormal,
CN7 must be the cause of palpebral reflex failure.
Head tilt, nystagmus, and positional strabismus are indications of vestibular
system dysfunction. The vestibulocochlear nerve (CN8) is a sensory nerve; it begins
at the receptors in the petrous temporal bone (inner ear) then courses through the
internal acoustic meatus, next to the fibers of CN7, to the rostral medulla. Head
tilt is the classic symptom of vestibular dysfunction, typically towards the side of
the lesion. Abnormal nystagmus occurs when the animal is at rest, and is described
by the direction (horizontal, vertical, rotary) and fast phase. The direction of
nystagmus is not used to localize to a specific side or anatomic location; it must
be interpreted as supportive evidence of vestibular disease. Positional strabismus
occurs because of a disruption of coordination between the vestibular system
and the nerves that innervate the periocular muscles (CNs 3, 4, 6). Positional
strabismus is best visualized with extreme dorsoflexion of the neck. This does not
indicate dysfunction in CNs 3, 4, or 6 because the animal has normal eye posture
without dorsoflexion. This dog has evidence of right CN7 and 8 dysfunction.
83 i. Nevoid malformation, linear trauma, idiopathic linear pustular acantholytic

dermatosis, pemphigus, infectious agent (e.g. sporotrichosis), dermatophytosis,
vasculitis, lymphangitis.
ii. Idiopathic linear pustular acantholytic dermatosis. This is a rare disease with
unique clinical features including marked linear development of lesions and skin
biopsies compatible with pemphigus. To date it has been reported in young dogs
and presents as a unilateral lesion. Lesions have been reported to affect the limbs
and face. The relationship to pemphigus is unknown in spite of the similarities in
lesions associated with the two disease conditions. Dogs may respond completely
to glucocorticoid therapy and the occurrence may be a one-time event; other
dogs may be refractory to treatment and/or experience multiple relapses and
spontaneous remissions.
90

Questions: 84, 85
84 This lesion (84a), 84a
located on the proximal
dorsal one-third of the tail,
is seen in a 5-year-old dog.
The owner reports that the
mass ‘falls off from time
to time’. What is the most
likely diagnosis?
85 A referring veterinarian presented 85

her dog, a 4-year-old male castrated
Labrador retriever, with a 2-month
history of depigmentation along the
upper lip and philtrum. The lesions
were multifocal and bordered the
haired and non-haired skin; four
totally depigmented circular areas were
present along the upper muzzle along
the border of the lip. As can be seen
(85), the lesions were subtle. There
was no evidence that the lesions were causing discomfort; no rubbing, scratching,
or rolling was reported. The owner reported having changed food dishes (from
plastic to ceramic) at or around the first time lesions were noted; however, new
lesions continued to develop.
i. What diagnostics do you recommend for this patient?
ii. What differential diagnoses are you considering?
iii. A biopsy was performed, which showed round cells infiltrating the superficial
dermis, epidermis, and multiple hair follicles. Occasionally, small aggregates
of round cells were present, forming microabscesses within the epidermis.
Immunohistochemistry was strongly positive for CD3. Antigen receptor
rearrangement PCR assay revealed a clonal population of T cells. Based on these
findings, what is your diagnosis?
iv. Is this a common appearance of the disease?
91
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Answers: 84, 85
84b 84c
84 The lesion is located in the area of the

oval tail gland. This is a concentrated
area of sebaceous glands. The history
and clinical signs are most compatible
with a cutaneous horn or focal area of
hyperkeratosis that sloughs off from the
tail. This site can be affected by primary
disorders of keratinization, focal areas
of alopecia (84b), or areas of focal infection. Cats have similar collections of
sebaceous glands on their tail, but they are present along the entire surface. One
manifestation of a primary disorder of keratinization in cats is ‘stud tail’ (84c).
Although the name implies this is a disease of intact male cats, lesions can be seen
in intact and neutered cats of either sex.
85 i. Skin scraping or hair trichograms to look for Demodex canis mites,

based on the appearance and location of the lesions. Also cytology to look for
overgrowth of bacteria and yeast. A fungal culture is indicated if the dog spends
time outside (digging in dirt) or if the history suggests contact with a cat at risk for
dermatophytosis. If these tests fail to yield diagnostic information, a skin biopsy
is indicated.
ii. Include demodicosis, dermatophytosis, bacterial overgrowth, Malassezia
overgrowth, possible contact hypersensitivity (although the asymmetrical pattern
is a bit unusual for this condition), vitiligo, cutaneous lymphoma, healing wound,
foreign body reaction.
iii. Cutaneous epitheliotropic T-cell lymphoma.
iv. This is not a typical appearance to the disease. By the time the patient is
presented for examination it is common for the disease to be extensive. This is a
very early presentation of cutaneous lymphoma. Many owners would not notice
these lesions until they are much more obvious.
92

Questions: 86, 87
86 With regard to radiation therapy: 86
i. What is the difference between a
definitive and a palliative treatment
protocol?
ii. What is tomotherapy (86)?
87 A 5-year-old female spayed indoor 87

cat was presented for the problem of
chronic grooming of the perianal area.
Examination revealed erythema of the
anal area and hair loss on the base of
the tail. The anal glands were empty on
manual expression. The cat was treated
with a 21-day course of amoxicillin (10
mg/kg PO q12h) for a presumed anal
gland infection. The owners reported
continued grooming post treatment;
the anal glands were infused with
antibiotic steroid cream, which
provided temporary relief. Clinical signs, however, returned within 2 weeks. Chronic
anal gland inflammation was diagnosed and the anal glands were ‘flushed’ with an
unknown compound. Within 48 hours the cat developed exudation and marked pain
and was presented for evaluation. At the time of examination the cat had developed
bilateral draining tracts and fecal incontinence (87).
i. The cat is suspected of having an anal gland abscess. What is the most important
rule out?
ii. What is the most likely cause of the cat’s pruritus?
93

Answers: 86, 87
86 i. Definitive protocols are designed specifically to give the patient the highest
probability of a cure or durable control over local/locoregional disease. They are
formulated to deliver a larger total dose using many smaller doses (fractions) of
radiation over longer periods of total treatment time (weeks). Definitive protocols
exchange the acute loss of quality of life (acute toxicities such as desquamation) and a
small risk of lifelong morbidities (late toxicities such as skin fibrosis) for the potential
of a cure or increase in overall survival. Palliative protocols are designed to give the
patient the highest quality of life by addressing a specific clinical sign. They typically
are formulated to deliver a smaller total dose using few larger doses of radiation over
a variable amount of total treatment time. Palliative treatments exchange treatment-
induced morbidity, overall survival, and a larger risk of lifelong morbidities associated
with treatment for an immediate improvement in quality of life.
ii. Helical tomotherapy represents hybridization between a linear accelerator
and helical CT scanner. Helical tomotherapy encompasses most of the parts of
a conventional linear accelerator, but mounts them on a slip ring style gantry.
This allows for complex dose distributions that maximize dose to the tumor while
minimizing dose to normal structures. Onboard detectors within the system provide
CT images of the patient, which provide information for reproducible, fraction-
to-fraction repositioning, minimizing the risk of tumor miss or unrecognized
high-dose gradients in normal structures. These detectors also provide dose
verification and reconstruction, which can help detect and correct variations from
the planned dose. For complex target shapes, multiple simultaneous treatment of
targets, or advanced stages (size), helical tomotherapy will outperform most linear
accelerators available in veterinary medicine.
87 i. Anal gland carcinoma.

ii. Anal gland abscesses and impactions are uncommon in cats. Cats rarely ‘scoot’
like dogs, but instead will lick and/or traumatize the hairs on the base of their
tail. Anal gland inflammation is also uncommon in cats. The lack of response to
standard therapy for anal gland infection but response to a locally applied steroid
suggests an underlying pruritic cause in this case. The most common allergic skin
diseases of cats are flea allergy, AD, and food allergy. In this case, the cat was
diagnosed with AD and was well managed with ASIT. The cat underwent surgical
removal of the remnant anal gland and necrotic tissue. The area was cleaned
regularly and monitored for fecal and urine scalding. Neurologic examination
revealed that there was still some sphincter tone and over a 1-year period the cat
regained enough sphincter tone to resolve the incontinence.
94
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Questions: 88, 89
88a 88b
88 A dog presented for nasal depigmentation. Skin lesions are limited to the
nose and muzzle (88a). Hair trichograms were negative for Demodex mites. Skin
cytology revealed these organisms (88b).
i. What are these organisms?
ii. The dog was treated with an appropriate systemic antimicrobial based on the
cytologic findings and the nose’s pigment returned. What is a possible explanation?
iii. What are other common causes of nasal depigmentation in dogs?
89
89 This organism (89) was removed from a subcutaneous swelling on the side of
the face of a cat.
i. What is the organism?
ii. What is its life cycle, and how did this cat acquire this organism?
iii. When are cats most likely to acquire this infection? This disease has been
associated with neurologic signs. How does this occur? What historical finding
may be helpful in increasing the index of suspicion of this disease in cats with
neurologic signs?
95

Answers: 88, 89
88 i. Malassezia spp. 88c
ii. There are several possible explan
ations. First, the dog’s muzzle is in
flamed, and changes in pigmentation
(increase or decrease) can occur as a
result of inflammation. Second, it is
possible that the Malassezia overgrowth
affected normal pigmentation. In
people, Malassezia furfur causes a
skin disease called pityriasis versicolor.
M. furfur has been found to produce
a by-product that blocks tyrosine
in melanin production and leads to
hypopigmentation in people with this
disease. The condition is temporary. This dog’s nose regained normal pigment after
resolution of the yeast overgrowth.
iii. Trauma, ‘snow nose’, or seasonal depigmentation (88c), early onset of cutaneous
lupus, early onset of cutaneous lymphoma, ketoconazole administration.
89 i. A fly larva of Cuterebra spp. (bot flies).

ii. These are obligate parasites of rodents and rabbits. A single female can lay up to
thousands of eggs, usually in groups of 10–15 per site. Eggs hatch within a week;
this is triggered by a rise in temperature, such as the warm breath of a passing
host. Larvae stick to the hair coat and enter the body through mucous membranes.
Organisms migrate through tissues using spicules on their surface. Once at the
subcutaneous site, they feed on local tissues and after 3–4 weeks create a local
swelling with a breathing pore. After undergoing various larval stages they exit the
breathing pore, drop to the ground, and burrow into the soil to pupate.
iii. This disease has a seasonal occurrence during late summer to early fall in most
geographic locations. Most infestations involve the skin, but larvae can migrate to
the eye, trachea, pharynx, and/or upper respiratory tract. Neurologic signs occur
when migrating larvae in the respiratory tract gain access to the calvarium via
the cribriform plate, middle ear, or other foramen. Previous studies of cats with
confirmed CNS Cuterebra larvae myiasis were of indoor/outdoor cats presented
for depression, lethargy, or seizures during the months of July through September
(northern hemisphere). Neurologic examination revealed lateralizing intracranial
signs depending on where the larvae traveled. An important historical finding was
association with a recent upper respiratory infection, often with severe episodes of
sneezing, preceding development of neurologic signs.
96

Questions: 90, 91
90a 90b
90 A 6-year-old West Highland white

terrier dog was presented for the 90c
complaint of lethargy, weight loss, and
skin lesions. Dermatologic examination
revealed lesions on the foot pads (90a),
ears (90b), and perineal area (90c).
Laboratory evaluation of the dog
revealed a normochromic, normocytic,
non-regenerative anemia, elevated
serum alkaline phosphatase and alanine
aminotransferase, and elevated post-
prandial bile acid concentrations. ANA
testing was negative.
i. What differential diagnoses are ruled out based on the diagnostic testing?
ii. What differential diagnoses should be considered?
iii. Skin biopsy findings revealed the following: diffuse parakeratotic hyperkeratosis,
upper level epidermal edema (stratum spinosum and stratum granulosum),
vacuolation of keratinocytes, and epidermal hyperplasia. There was a mild
superficial perivascular infiltrate in the superficial dermis composed primarily
of neutrophils, mast cells, and plasma cells. The pathologist commented that it
showed the classic ‘red, white, and blue’ of ‘X’ disease. Ultrasound of the liver
revealed a small liver with a hyperechoic, reticular pattern surrounding hypoechoic
areas (‘honeycomb’ pattern). What is the most likely diagnosis?
91 Briefly describe the use of interferon (IFN) therapy in veterinary dermatology.
97

Answers: 90, 91
90 i. PF, zinc-responsive skin disease, generic dog food dermatitis. Dogs with these
disorders rarely have laboratory abnormalities and/or the clinical signs described
for this patient.
ii. SLE, hepatocutaneous syndrome (superficial necrolytic dermatitis, metabolic
epidermal necrosis), drug eruption.
iii. Hepatocutaneous syndrome. This is a cutaneous manifestation of a systemic
disease. Dogs with liver disease, chronic gastrointestinal disorders, glucagonoma,
diabetes mellitus, and pancreatic tumors may develop this unique pattern of skin
disease. It has also been reported in dogs on long-term anticonvulsant therapy (e.g.
phenobarbital). The pathogenesis is unknown but is related to degeneration of
keratinocytes in the upper levels of the epidermis. Nutritional imbalance is suspected.
There is no specific treatment for the skin lesions; however, supplementation with
high-quality protein (1 egg yolk/4.5 kg), zinc sulfate (10 mg/kg q24h), and fatty
acids may be beneficial. Alternatively, infusions of amino acids (500 ml of a 10%
solution) IV via a central catheter over 8–10 hours every 7–10 days may be helpful.
If there is no response after 4–5 treatments, it is unlikely the patient will improve.
If there is resolution of lesions, amino acid therapy is administered as needed.
One author (KM) has observed mild resolution of skin lesions in dogs where the
underlying metabolic disorder was treated. In most cases, however, the appearance
of lesions is associated with severe disease, and most dogs die or are euthanized
within 1 year of diagnosis.
91 IFNs are glycoproteins. They are divided into two major groups: type I (IFN-α,
IFNω, and IFN-β) and type II (IFN-γ). IFNs are naturally produced and have
antiviral, antitumor, and multiple immunomodulatory effects. Recombinant feline
IFN omega (rFeIFN-ω) and recombinant canine IFN gamma (CaIFN-γ) have
been used for the treatment of dogs with AD; both showed benefit in dogs as
an alternative option to immunotherapy. Currently, rCaIFN-γ is licensed for use
in Japan for the treatment of AD. rFeIFN-ω has been used to treat a wide range
of skin diseases in cats including herpes infection, retrovirus infection, plasma
cell pododermatitis, pox virus, feline acne, chronic gingivostomatitis, and pre-
operatively and postoperatively in the treatment of feline fibrosarcoma.
98

Questions: 92, 93
92 An 11-year-old female spayed 92
cat with a 5-year history of chronic
recurrent bilateral Malassezia otitis
externa was presented for examination.
The most recent episode of otitis had
been present for several months and
the owner reported the right ear being
most affected (odor, copious exudate,
presumed pruritus). The cat was
presented for examination because of
progressive ataxia of 1 months’ duration.
Neurologic examination revealed
decreased sensation on the right side of
the face consistent with right facial nerve
paralysis. In addition, the ataxia was
consistent with right-sided vestibular disease. The owner also reported that the cat’s
purr and meow had changed over the previous month; this was a major concern.
Cytologic examination of ear exudate revealed septic inflammation (neutrophils
and cocci). The tympanic membrane was not visible on otoscopic examination after
cleaning the ear canal. The ear canal appeared to end abruptly.
i. What are the two most likely differential diagnoses? Based on the information
provided, which one is most likely?
ii. Imaging of the skull is indicated. The three imaging modalities that could be
used in this case are conventional radiographs, CT, and MRI. Briefly discuss key
advantages and disadvantages of these three imaging tools.
iii. CT was performed (92, post contrast). What are the key findings? Do any
explain the change in the cat’s vocalizations?
iv. A biopsy of the mass was obtained from soft tissue on the right side of the cat’s
face. The histologic findings were compatible with an adenocarcinoma. What are
the treatment options and prognosis?
93 What organisms comprise the Staphylococcus intermedius group (SIG) of

bacterial pathogens, and what is the practical significance of this reclassification?
99
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Answers: 92, 93
92 i. Vestibular disease due to otitis media and vestibular disease due to neoplasia.
Given the history of chronic ear disease, chronic bilateral otitis media is highly
suspect; however, the current clinical signs are most likely due to a tumor. Evidence
for a tumor includes the age of the cat, acute onset of unilateral worsening, and
inability to visualize the tympanic membrane post cleaning with an ‘abrupt’ ending
suggestive of a space-occupying lesion. Changes in the cat’s vocalizations are also
suggestive of a mass compressing the vocal cords or nerve damage.
ii. CT and MRI are superior to conventional radiography because both provide
tomographic images (i.e. slices of the patient). Superimposition of images is
avoided using CT and there are enhanced radiographic opacities; conventional
radiography only allows for five radiographic opacities. CT allows for larger gray
scale and enhancing of contrast between structures. CT allows for visualization of
bony structures and radiotherapy treatment planning, if indicated. MRI provides
superior soft tissue detail and is the modality of choice for the CNS. One major
disadvantage is that there can be geometric distortion of structures, which is
problematic for planning radiotherapy treatment.
iii. Large mass extending from the base of the right ear through the right bulla
and through the cranium on the right side, creating a mass effect on the caudal
pharynx. This most likely explains the changes in the cat’s vocalizations. Right
otitis media is also noted.
iv. Tumors of the ear tend to be locally invasive and tend not to metastasize. A
retrospective review revealed that the most common malignant ear tumors in
dogs and cats were ceruminous gland adenocarcinoma, SCC, and carcinoma of
undetermined origin. In cats, the prognosis was very poor if neurologic signs were
present, if the diagnosis was an SCC or carcinoma, and/or if there was invasion of
local tissues.
93 The SIG is comprised of S. pseudintermedius, S. delphini, and S. intermedius

based on multilocus sequence analysis. Since the first description in 1976,
S. intermedius has been considered the primary pathogen of canine pyoderma. In
this new classification scheme, the primary pathogen of dogs is S. pseudintermedius.
From a practical perspective, microbiology laboratories will report culture
isolates and sensitivities as ‘SIG’. Specific identification of SIG species requires
molecular testing and is not performed regularly for clinical isolates. Isolates
previously identified as Staphylococcus intermedius, but now believed to be S.
pseudintermedius, are designated in the literature as [pseud]intermedius.
100

Questions: 94, 95
94 A 13-year-old male castrated Devon Rex 94
cat presented for rapidly progressive hair
loss and increased grooming behavior. The
cat was almost completely alopecic on the
ventral abdomen, with a ‘shiny’ appearance
to the skin. Waxy, dark debris was noted
in the inguinal region and around the claw
folds of all four paws (94). Since the cat’s last
examination 6 months ago, it had lost 1.6 kg.
The owner reported that the cat seemed to be
eating slightly less and had been more lethargic
recently. The cat did not have any previous
history of dermatologic abnormalities, it lived
indoors, and received year-round flea and tick
preventive.
i. Based on the history provided and clinical
presentation, what differential diagnoses
should be considered? What would be your
recommendations for initial diagnostic work-
up?
ii. Skin biopsy revealed moderate acanthosis of the epidermis. Dermal inflammation
was absent. Most of the hair follicles were in telogen and appeared miniaturized.
Abdominal ultrasound revealed a severely mottled pancreas, giving the appearance
of an infiltrative process. Given these findings, what is your diagnosis?
iii. With regard to the skin, what is a common secondary complication of this
condition?
95 Dog breeds are defined by their conformation and hair coat. The latter has
important biological functions and important animal bond functions (i.e. health
and emotional benefits from petting the dog). Diseases of the hair follicles impact
on both the health of the dog and its appearance.
i. What is a Dermatoscope?
ii. It is commonly believed that puppies ‘lose’ their puppy coat. It is now known
that there are distinct morphologic changes that occur in the hair coat of dogs as
they mature. Describe these changes.
iii. What percentage of hair follicles is in telogen in a dog’s hair coat?
101

Answers: 94, 95
94 i. The almost complete alopecia and ‘shiny’ appearance of the skin suggest para-
neoplastic alopecia; however, this syndrome can appear very similar to hyperadreno-
corticism. The owner should be questioned regarding any history of corticosteroid
administration. Skin scraping would be indicated to look for feline demodicosis,
a common secondary complication of iatrogenic hyperadrenocorticism. Because of the
systemic signs noted (weight loss, lethargy, decreased appetite) additional diagnostics
include CBC, serum biochemistry, and urinalysis. Abdominal ultrasound, CT, or MRI
is recommended because of the possibility of paraneoplastic alopecia. This condition is
reported most commonly with a variety of visceral neoplastic processes, often involving
the pancreas. Imaging helps assess whether a solitary tumor or diffuse disease is present.
ii. Paraneoplastic alopecia.
iii. Secondary Malassezia overgrowth, reported more so with this condition
compared with other internal disease processes. This may contribute to the
frequent reports of overgrooming in these animals. In this cat, large numbers of
yeast organisms were noted on cytology from the inguinal region and around the
claw folds. However, yeast overgrowth is a common finding in Devon Rex cats; it
may have been present historically but not deemed problematic as the cat showed
no dermatologic abnormalities until the development of paraneoplastic alopecia.
95 i. A portable external microscope that produces high-quality, high-magnification

(300X) digital images. It is used for producing live color images of the hair and
skin. It is commonly used in human medicine to examine moles.
ii. Hair coat changes were followed in puppies from 10–28 weeks of age using a
Dermatoscope and histologic examination of hair follicles via skin biopsy. Three
breeds were examined: poodles, Labrador retrievers, Siberian huskies. Results
revealed that puppies ‘gain an adult hair coat’ rather than ‘lose their puppy coat’.
Over time, the mean number of hair follicles per hair follicle unit increased in all three
breeds. In Siberian husky puppies, the growing follicles were predominantly those
that produced smaller diameter hair shafts and were curved. This would account for
the adult coat, which contains a high number of twisted hair shafts creating a dense
undercoat. Labrador retriever puppies had fewer hair follicles per unit than Siberian
husky puppies, but the diameter and degree of curvature were similar. As the puppies
matured, hairs developed into straight, large diameter hair shafts. This corresponds to
the dense coarse hair coat typical of this breed. In poodles, only minimal changes were
noted in the diameter and curvature of the hair shafts. In this breed, the changes in the
adult hair coat are the result of an increase in the number of hair follicles.
iii. Varies from 50% to >90% depending on the season. One study found that >50%
of hair follicles in Labrador retrievers and Siberian husky dogs were in telogen at 28
weeks. In contrast, <10% of poodle dogs had hair follicles in telogen. Observations
of >10% of hair follicles in telogen in poodles may suggest a disease state.
102

Questions: 96, 97
96 A 2-year-old male castrated bulldog 96
presented for severe erythema and
moderate pruritus of all four paws,
the face, and ventrum (96). The owner
also reported that patchy alopecia over
the dorsum appeared to be progressing
to involve more body areas. Clinical
signs initially began when the dog
was approximately 1 year of age. The
only treatment administered had been
oral prednisone at a tapering anti-
inflammatory dose and oral cephalexin
(25 mg/kg q12h for 14 days).
i. What are the possible differential
diagnoses for this patient?
ii. Multiple deep skin scrapings identified
large numbers of Demodex canis mites
of all life stages from all four paws, the
face, dorsum, and ventrum. How is this
form of demodicosis classified?
iii. What are the treatment options for this disease? Note label and off-label options.
97 Compared with dogs, the ear pinnae 97

of cats are consistent in size and shape.
Haired skin covers both the convex
and concave surfaces and between
them is the auricular cartilage, which
gives shape to the pinna. This cat (97)
was found as a stray and presented
for examination for the complaint of
‘progressively droopy ears’.
i. What type of cartilage is found in the
ear?
ii. What breed of cat has naturally
droopy ears?
iii. List common differential diagnoses
for damage to ear cartilage of cats.
103

Answers: 96, 97
96 i. Demodicosis, bacterial pyoderma, dermatophytosis, cutaneous adverse
reaction to food, AD.
ii. Juvenile-onset generalized demodicosis.
iii. Based on an evidence-based review, several treatment options are deemed
efficacious for canine generalized demodicosis. Amitraz dips, currently the only
treatment labeled for canine generalized demodicosis, is efficacious at 0.025–
0.06% applied once every 7–14 days. In the USA, the product is licensed for use at
0.025% applied once every 14 days. Studies have shown increased efficacy when
applied at a higher concentration and/or more frequently. Metaflumizone-amitraz
was also labeled for the treatment of canine generalized demodicosis when applied
topically once monthly. Additional studies found improved efficacy when the
product was applied every 14 days. (Note: At the time of publication production of
this product has been discontinued in the USA.) Topical moxidectin-imidacloprid
has also shown efficacy with weekly application, particularly in patients with more
mild disease. Ivermectin has been used effectively since the mid-1980s (0.3–0.6
mg/kg PO q2h). Milbemycin oxime has shown efficacy when administered PO
(1–2 mg/kg q24h); however, more rapid and complete response was reported at the
higher dosing regimen. Moxidectin (0.2–0.5 mg/kg PO q24h) also demonstrates
good efficacy for generalized demodicosis in the dog. Evidence exists to suggest
doramectin (0.6 mg/kg SC once every 7 days) as another treatment option.
97 i. Elastic cartilage. This cartilage provides for greater flexibility so that it can
withstand greater bending.
ii. Scottish fold. The ear abnormality is the result of a dominant gene mutation that
makes the cartilage fold, resulting in pinnae that bend forward.
iii. Trauma, aural hematoma, tumors, hypercortisolemia. Excluding trauma, the
most common cause of damage to ear cartilage is an aural hematoma. Acute aural
hematomas are easily diagnosed by clinical examination; aspiration of the fluctuant
mass will reveal blood, confirming the diagnosis. Untreated and/or recurrent aural
hematomas can cause permanent curling fibrosis and deformity of the ear cartilage.
‘Droopy ears’ are a clinical manifestation of hypercortisolemia caused by naturally
occurring adrenal disease or as a result of exogenous corticosteroid administration.
It is presumed to be due to weakening of the cartilage and/or collagen. ‘Droopy
ears’ are an increasingly recognized adverse effect of cats receiving potent inhaled
glucocorticoids for respiratory disease (e.g. feline asthma).
104

Questions: 98, 99
German shepherd dog presented
for the lesions shown (98). The
lesions have been recurrent for
2 years. Skin scrapings and hair
trichogram have been negative
for Demodex mites. Impression
smears have revealed cocci and
yeast and the lesions respond
slowly to concurrent systemic
antibiotic and antifungal therapy, but always recur. Culture and sensitivity of
the lesions revealed that bacterial resistance was not a complicating factor.
Close examination of the lesions reveals odor, pain, erythema, and swelling and
crusting of the lips and perioral area. Hairs are trapped in exudate and the lips are
depigmented. The dog has a regional lymphadenopathy and a history of dysuria.
i. Describe the clinical distinctions between mucocutaneous pyoderma and
bacterial intertrigo (lip fold pyoderma).
ii. What other differential diagnoses need to be considered in this case?
iii. What key histologic criteria would help differentiate the major differential
diagnoses?
99 For management of AD, what are 99

the options for humane antipruritic
therapy while awaiting a noticeable
benefit from immunotherapy (99)?
105

Answers: 98, 99
98 i. Mucocutaneous pyoderma and fold pyoderma are clinically very distinctive.
The latter is recognized by its location between appositional folds. The folds create a
moist, warm environment where bacterial and yeast overgrowth can occur. Lesions
rarely extend past the folds. Fold pyoderma is very common. Mucocutaneous
pyoderma is less common and does not start in folds nor are the lesions limited to
this area. Lesions are symmetrical; the first signs are swelling and erythema followed
by crusting, fissuring, and erosions. Lesions often extend to the nasal planum and
lips and may involve other mucocutaneous areas such as the prepuce and perineal
regions. Facial rubbing can occur and salivary staining is common.
ii. Lupus erythematosus, pemphigus, adverse drug reactions, lymphoma,
candidiasis, mucous membrane pemphigoid, cutaneous lymphoma, oral pain (e.g.
dental disease).
iii. Key findings: lupus – moderate lichenoid inflammatory infiltrate and basal
cell degeneration; pemphgius – subepidermal pustules with acantholysis; mucous
membrane pemphigoid – subepidermal clefting; cutaneous lymphoma – tropism of
neoplastic lymphocytes for the epidermis and mucous membranes; candidiasis –
presence of abundant yeast organisms on special stains; mucocutaneous pyoderma –
dermal perivascular to lichenoid infiltrate that does not obscure the basement
membrane. Mucocutaneous pyoderma can be difficult to distinguish from lupus as
one retrospective study found both to have very similar histologic findings.
99 Bathing to remove allergens, bathing with antimicrobial shampoos to minimize

or manage concurrent pruritic microbial overgrowth. Focal application of steroids
to intensely pruritic areas (e.g. periocular ophthalmic glucocorticoids, otic
glucocorticoids). Essential fatty acid supplements can be helpful, but their action is
slow in onset. There is still much controversy about the benefit of antihistamines;
as of yet there is inconclusive evidence that they help acute or chronic flares.
Essential fatty acids and antihistamines are sometimes used in chronic cases for
their steroid-sparing effect. Systemic drugs include cyclosporine (modified), oral
prednisone, pentoxifylline, misoprostol, and Chinese herbal extract (steroid
sparing). Chinese herbal extracts and other organic compounds may or may not
list all of the ingredients. Anecdotally, one of the compounds, liquorice, may have
steroid effects; one dog receiving this compound developed calcinosis cutis.
106

Questions: 100, 101
100 A direct mount from a fungal 100
culture colony is shown (100). The
culture was from a cat with skin lesions
and the colony grew within 7 days of
inoculation on to DTM. The gross
colony was pale and a red color change
developed around it as it was growing.
i. Brief examination of this wet mount
reveals two obvious reasons why this is
not a pathogen. List them.
ii. Where would the cat have contacted this organism?
101a 101b
101 A 3-year-old female spayed foxhound-cross dog presents for diffuse, severe
crusting dermatosis of several weeks’ duration. The owner reports that despite
having a ravenous appetite, the dog has also lost weight during the same time
period. On physical examination, you note that there is diffuse crusting and silvery-
white adherent scaling over the dog’s entire body, with thickening of the underlying
affected skin and areas of alopecia. Intradermal nodules are also palpated along the
pinnae, ears (101a), extremities, and muzzle. Peripheral lymph nodes all palpated
enlarged and cranial organomegaly is noted on abdominal palpation. The dog
is walking somewhat abnormally; palpation of the limbs identifies swollen and
painful joints. There is moderate muscle wasting, most noticeable over the epaxial
muscles and hindlimbs.
i. What questions do you have for this owner regarding other pertinent history?
ii. What are your differential diagnoses for this patient?
iii. Cytology from under one of the crusting lesions reveals multiple amastigotes
within the cytoplasm of many macrophages (101b). Given this finding, what is
your diagnosis? Had cytology failed to identify the disease process, what other
diagnostic tests may be considered given the clinical suspicion?
iv. How is this disease managed?
107

Answers: 100, 101
100 i. The hyphae and conidia are pigmented and the conidia have transverse and
horizontal septa. This colony is most consistent with an Alternaria sp. of fungus.
This is commonly confused with macroconidia of Microsporum canis.
ii. Alternaria spp. are common plant pathogens and are the cause of a wide range
of leaf, flower, blossom, and fruit disease. The cat could have contacted this spore
inside or outside the house. Also, this spore is commonly found on skin scrapings
or surface cytology.
101 i. Travel history, to rule in/out possible infectious diseases. Are any other dogs
affected (do they have other pets?). Does the owner have any signs of dermatologic
or systemic illness that coincides with the disease development in the dog. Any
other history including previous drug administration, history of any dermatologic
abnormalities, or signs of illness other than what has been noted recently.
ii. Immune-mediated disease (SLE, PF), epitheliotropic cutaneous lymphoma,
dermatophytosis, leishmaniasis, zinc-responsive skin disease, sebaceous adenitis.
iii. Leishmaniasis (Leishmania infantum). This is a protozoal disease transmitted by
biting sand flies (Phlebotomus in Old World, Lutzomyia in New World) and possibly
other biting insect vectors. It has been reported in the Mediterranean countries with
Europe, Africa, South America, and Asia most commonly reported. More recently,
the disease has been reported in the USA where it is now considered to be endemic,
particularly in foxhound and foxhound-cross dogs. It is an uncommon disease in
dogs and rare in cats. When organisms are present on cytology or histopathology
and clinical signs are supportive, this finding is diagnostic for the disease. When
organisms are not readily present, diagnosis can be confirmed with appropriate
serologic evaluation. High titers (e.g. 1/320, 1/640, or 1/1,280) are diagnostic.
Cross-reactivity with other infectious diseases has not been reported. If borderline
or low titers are noted and there remains clinical suspicion for the disease, lymph
node and/or bone marrow aspirates may be helpful for identifying the organisms;
amastigotes may still be difficult to find, especially on lymph node aspirate.
iv. The most commonly used treatment protocol is administration of meglumine
antimonite (100 mg/kg SC q24h for 4 weeks) along with allopurinol by mouth
twice daily for at least 6 months. Treatment efficacy may be monitored via repeated
clinical examinations to assess response to treatment as well as repeated qPCR to
monitor parasitic load.
108

Questions: 102, 103
102a 102b
102 A 9-month-old male castrated Labrador retriever dog presented for extensive
lesions involving the entire oral cavity (102a). Over the last 4 months, a single
‘wart’-like lesion had progressed to what is shown. Lesions were present on
both the inner and outer labial surfaces bilaterally, along the tongue, hard and
soft palates, and extending up the nasal philtrum. The masses did not affect the
dog’s ability to eat or play; however, lesions were easily traumatized. The owner’s
complaint at the time of the visit was “my home looks like a crime scene” due to
the amount of bleeding that occurred whenever the lesions were traumatized or
the dog shook its head. In addition, the owner reported a foul odor from the dog’s
mouth.
i. What is your clinical diagnosis?
ii. What immediate concerns do you have regarding this dog’s overall health?
iii. What are possible treatment options? This is the dog after treatment (102b).
103 What is silver sulfadiazine (AgSD)?
109

Answers: 102, 103
102 i. Severe oral papillomatosis (rare).
ii. Although the exact mechanism resulting in either spontaneous regression
or spread of papillomas is not known, spontaneous regression is suspected to
be associated with the presence of CD4+ and CD8+ lymphocytes. In this case,
regression had not occurred after several months, raising serious concerns about
a defect in the dog’s immune response. Humoral immunity may also be affected;
severe papillomatosis has been reported in beagles with IgA deficiency.
iii. In this case, surgical debulking is needed: cold steel, cryosurgery, or electrosurgery
using a carbon dioxide laser. Recombinant canine oral papillomavirus vaccination
has been beneficial for disease prophylaxis as well as for treatment of oral
papillomatosis in dogs; however, caution is warranted as cutaneous neoplasms
may form at the injection site, albeit years later. One study reported on the efficacy
of azithromycin therapy for regression of canine oral papillomatosis; a dose
of 10 mg/kg daily led to a decrease in clinical scores of the papillomas. Other
treatment options include systemic chemotherapy with single-agent vincristine,
cyclophosphamide, or doxorubicin. Administration of interferon has been
investigated; however, at low oral doses treatment has not been highly effective.
In people, the use of immunostimulants such as imiquimod has been beneficial;
the medication causes cytokine induction and stimulation of the humoral and cell-
mediated immune systems that leads to papilloma regression. Cimetidine, which
also acts as an immunostimulant, has had some success as an adjunct treatment
for various papillomavirus conditions in people. Anecdotally, topical imiquimod
5% cream (applied q24–48h until lesions regress) has been beneficial in dogs. Also,
cimetidine (20–30 mg/kg q12h) has been efficacious in many cases of papillomatosis
in dogs. This dog responded to a combination of surgical debulking, imiquimod
cream for several months, and cimetidine. Ultimately, the lesions recurred and the
owner elected euthanasia as permanent remission could not be induced.
103 A combination of silver and sulfadiazine. It is a water soluble cream that

has broad-spectrum antibacterial activity. AgSD serves as a reservoir of silver in
the wound and slowly releases silver ions. The proposed mechanism of action is
that AgSD binds to cell DNA, resulting in membrane damage. The binding of
AgSD to the base pairs in the bacterial DNA helix inhibits transcription, leading
to inhibition of bacterial growth. Currently, AgSD is used widely as a cream or as
compounded drops to treat a wide range of infections in veterinary dermatology,
especially multidrug-resistant Pseudomonas ear infections. The use of silver in
nanotechnology is being explored, as nanotechnology can change the chemical,
physical, and optical properties of silver and offer new biomedical options.
110

Questions: 104, 105
104 A Wood’s lamp is a common diagnostic tool in small animal dermatology.
i. When was the lamp invented, and when was it first used?
ii. What are the physics behind the use of the Wood’s lamp?
iii. What is the most common use of this tool in veterinary dermatology?
105 A 3-year-old female spayed goldendoodle 105

dog presented for severe hindlimb swelling (105),
progressive cutaneous bruising, and fever. The
dog also had a recent history of gastrointestinal
upset (including hematochezia and hematemesis)
following an episode of dietary indiscretion
approximately 1 week prior to the development of
skin lesions. She had been treated by her primary
care veterinarian with various anti-emetics and
metronidazole. On physical examination, the
dog was diffusely erythematous and severely
pruritic; several areas of self-trauma were noted,
particularly along the cervical region. Multiple
areas of diffuse ecchymotic hemorrhage were
identified; diascopy was performed, which did
not identify blanching of the skin. CBC revealed
peripheral eosinophilia. The only abnormality
noted on serum biochemistries was moderate
hypoalbuminemia.
i. What other diagnostics would you consider
performing for this patient?
ii. A skin biopsy of this patient showed severe superficial and deep, perivascular
to diffuse eosinophilic dermatitis. Several degranulating eosinophils were noted
around collagen fibers forming ‘flame figures’. Dermal edema was noted to be
moderate and many vessels were markedly dilated. What is the diagnosis based on
the biopsy and clinical findings?
iii. What is this condition, and what has been reported about it in dogs?
111

Answers: 104, 105
104 i. 1903 by Robert W Wood. The first 104
description of its use for diagnosis of fungal
infections was in 1925.
ii. It emits long-wave radiation generated from
a high-pressure mercury arc. The lamp contains
a compound filter made of barium silicate with
9% nickel oxide (called the Wood’s filter), which
blocks all light rays except for those between
320 and 400 nm with a peak at 354 nm.
iii. As a screening tool for detection of Micro
sporum canis infections (104). Other dermatophyte species that fluoresce a bright
green color include M. distorum and M. audouinni. Trichophyton schoeleinni
organisms fluoresce a dull blue and some variants of M. gypsum will fluoresce a
dull yellow. M. canis is the predominant veterinary pathogen that fluoresces. The
compound that causes fluorescence in Microsporum species is a pteridine.
105 i. Clotting times (prothrombin time and partial prothrombin time, buccal
mucosal bleeding time), skin biopsy if there are no contraindications, FNA of
affected area.
ii. Eosinophilic dermatitis (eosinophilic cellulitis, Wells-like syndrome).
iii. Wells syndrome is another term for eosinophilic cellulitis in people. In dogs,
the disease process is considered to be rare; it is suspected to be due to a severe
hypersensitivity reaction, as seasonality has been noted in several reported cases. A
retrospective study identified three different groups of dogs with similar histologic
features on skin biopsy. The first group was composed of dogs previously treated
for gastrointestinal illness prior to the development of skin lesions. The second
group had concurrent gastrointestinal illness at the time of cutaneous lesion
development. The third group had solely cutaneous lesions in the absence of
gastrointestinal illness. Between groups one and two, previous exposure to
various medications, gastrointestinal upset (vomiting and/or diarrhea, often with
hematemesis and/or hematochezia), and hypoalbuminemia were common findings.
Possible drug reaction or association is suspected to be a potential cause of disease
development. Dogs can recover from the condition if treatment is initiated as soon
as possible; typically, high anti-inflammatory to low immunosuppressive doses of
corticosteroids is beneficial plus supportive care for any concurrent gastrointestinal
illness. Monitoring for sepsis and dehydration is imperative.
112

Questions: 106, 107
106 A 1.5-year-old cat was presented 106
for acute intense pruritus of the caudal
dorsum and medial aspect of the
hindlimbs (106). Physical examination
revealed multifocal areas of patchy
alopecia on the dorsal lumbosacral
region and complete hair loss on the
entire caudal ventrum and inguinal
areas. The cat was very sensitive to touch
anywhere around its hindquarters. The
owner reported that the cat had no access to other animals and lived on the seventh
floor of an apartment building but did occasionally sit on the outdoor patio. The
owner moved into this apartment 5 months ago and the pruritus began within 4–6
weeks of the move. Skin scraping was negative for mites and flea combing did not
reveal any live fleas or flea feces.
i. Based on the physical examination findings, what condition do you initially
choose to treat?
ii. How can you explain your treatment plan to the owner?
107 A 3-year-old male neutered mixed- 107

breed dog presents with non-pruritic
bilateral symmetrical alopecia along
the trunk and proximal extremities of 4
months’ duration. Clinical examination
shows the blue hairs to be affected (107).
Alopecia is predominantly restricted to
the dorsolateral trunk and proximal
extremities. Other cutaneous findings
include comedones and dry, non-
adherent scales in areas of hair loss. Skin scrapings, skin cytology, dermatophyte
culture, CBC, and serum chemistries are all negative or within laboratory reported
normal ranges.
i. Are there any additional questions you would like answered?
ii. What is the most likely diagnosis, and how does it develop?
iii. What diagnostic test(s) would confirm your clinical suspicion?
113

Answers: 106, 107
106 i. Flea allergy dermatitis/hypersensitivity.
ii. Some owners find it hard to believe that fleas are the underlying cause when no
fleas are found on physical examination. Knowledge of the flea life cycle may help.
A host is required for food and protection; fleas spend their entire adult life on their
host. Eggs are laid on the animal and fall into the environment where they go through
three larval and one pupal stage. Fleas can remain in the pupal stage for over 100
days. If the owner’s apartment had previously housed animals who were infested
with fleas, the cat may have provided the right stimuli (temperature, vibration,
carbon dioxide) to cause emergence of the adult fleas, leading to infestation.
Flea-allergic animals often develop highly effective grooming skills to remove
parasites that are causing them intense discomfort. This helps explain why a flea-allergic
animal will often have no fleas. The reaction of the cat to touch on the hindquarters
further demonstrates the extreme sensitivity that fleas can cause. One study found
that approximately 40% of cats responded to flea control measures alone even when
obvious evidence of fleas was absent. Flea control medications are generally safe and
well tolerated, making the downsides to treatment very few. Response to judicious
application of monthly flea control medication for at least 3 months in combination
with environmental control will help to confirm the diagnosis.
107 i. Is the dog polyuric, polydipsic, polyphagic? Constantly panting? Gained

weight? When was the dog neutered? Are other animals in the household similarly
affected? Any littermates similarly affected? Affirmative answers to questions 1–3
might suggest hyperadrenocorticism (atypical age of onset for endogenous disease).
Weight gain could suggest hypothyroidism. Castration-responsive dermatosis is rare
but plausible. Although dermatophyte culture was ‘negative’, similarly affected pets
would raise suspicion of a false-negative test result. Familial history of a similar
problem among littermates or parents would suggest an inherited skin disease.
ii. CDA, a genetic alopecic condition of ‘dilute’ (blue or fawn) coat colors.
Affected dogs are born with a normal coat, but thinning and alopecia progress
as they mature. Alopecia begins with color dilute hairs along the dorsal back and
progresses down the lateral trunk. Secondary bacterial folliculitis, generalized
scaling, comedone formation, and hyperpigmentation are common sequelae.
Regrown hairs are usually deformed. A genetic defect (D locus of color dilute gene)
causing follicular and melanin dysplasia results in dysplastic hair shafts. Although
most common in Doberman pinscher dogs, any breed can be affected.
iii. A trichogram shows melanin clumping and distortion of hair shaft anatomy.
Aggregated macromelanosomes in the basal cell layer of the epidermis and follicular
epithelium, hair matrix cells, hair shaft, and sebaceous glands, with varying degrees
of follicular dysplasia and cystic follicles, may be seen on skin biopsy.
114

Questions: 108, 109
108a 108b
108 An 8-year-old female spayed 108c

cocker spaniel dog is presented for a
3-year history of bilateral otitis externa.
Physical examination reveals a mild
waxy discharge bilaterally. There is
resistance to opening the dog’s mouth
for oral examination, which appears 12
largely normal. Otic examination is
normal other than the presence of a white material deep to the tympanic membrane,
which appears intact. CT of the skull is performed (108a–c).
i. What are the imaging findings?
ii. What are the differential diagnoses and associated pathophysiology?
iii. What are the recommendations for intervention, possible complications, and
the prognosis?
109 A 4-year-old male castrated Scottish terrier dog 109

presents for the patch of alopecia shown (107). The
owners do not report pruritus, monthly spot-on
topical flea control is used year round, and the dog
does not have any other dermatologic abnormalities.
Based on the appearance of the lesion, what questions
should be asked of the owners?
115

Answers: 108, 109
108 i. Both tympanic bullae are expanded with thin and partially disrupted bony
margins. There is extensive new bone proliferation, most prominent medial and
ventral to the bulla and along the retroarticular process to the temporal bone. Both
bullae are filled with enhancing soft tissue material.
ii. Bilateral aural cholesteatoma, bilateral severe chronic otitis media, or neoplasia.
Aural cholesteatomas are epidermoid cysts forming within the middle ear. They
are composed of keratin debris surrounded by keratinizing stratified squamous
epithelium. These can be congenital or acquired; they are most often reported as a
complication of chronic otitis media/externa in dogs. Once the cyst is formed it can
expand with accumulation of keratin debris and/or sebaceous material, resulting
in various degrees of inflammatory response.
iii. Curative-intent treatment involves surgical excision of the cholesteatoma. Surgical
approach is based on extent of disease, but often total ear canal ablation and lateral
bulla osteotomy and/or ventral bulla osteotomy are considered. Complications
include facial nerve injury, excessive hemorrhage, abscess, and seroma formation.
Recurrence after surgery is reported in 50% of dogs. Risk factors for recurrence
include inability to open the mouth or neurologic signs on admission, and temporal
bone lysis on CT. Median survival time of dogs with neurologic signs or inability
to open the mouth is 16 months. Encroachment of the temporomandibular joint as
documented on the CT scans in this patient likely accounts for the difficulty opening
her mouth, and contributes to the guarded prognosis.
109 The region of alopecia is very well demarcated. An important question to ask
is when they last remembered the dog to have hair in this area and whether or
not the hair coat has been clipped since. This pattern is common in post-clipping
alopecia. Other differentials include endocrine alopecia, superficial bacterial
pyoderma, demodicosis, and dermatophytosis, but the well-demarcated nature of
the alopecic region makes these highly unlikely. This dog had a surgical repair of
a cranial cruciate ligament rupture 2 years prior to presentation. At the time of
surgery, an epidural had been administered for pain control. While the area clipped
for surgery regrew hair normally, the epidural site remained alopecic. This is a
cosmetic condition, which may be permanent or transient in nature; it can take
upwards of 18 months or longer for some dogs to completely regrow their hair
coat. No treatment is required.
116

Questions: 110, 111
110 An 8-year-old female spayed mixed- 110a
breed dog presented for recurrent
bacterial pyoderma of several months’
duration. The owner also noted that
the dog appeared to be gaining weight
recently and was slightly lethargic. On
closer examination, these lesions were
noted multifocally along the abdomen
and trunk (110a). Routine CBC showed
thrombocytosis and lymphopenia.
Serum biochemistries showed severely
elevated alkaline phosphatase and mild
elevations in alanine aminotransferase and cholesterol. The dog had no history of
any previous medical abnormalities, including dermatologic problems.
i. What is the most likely diagnosis for this patient?
ii. What cutaneous manifestations are associated with this disease process?

Labrador retriever dog presented
for a solitary hyperpigmented mass
on the cranial thoracic region of the
dorsum (111). The dermal mass was
approximately 2 cm in diameter,
hyperpigmented, well circumscribed,
and somewhat soft on palpation. No
other clinical signs were reported by the
owners and no other lesions were found
on physical examination of the dog.
ii. On FNA of the mass, a moderate amount of local hemorrhage was noted. Within
a few minutes, the dog developed urticaria, edema, and erythema surrounding the
mass. Given this additional history, what is the most likely diagnosis for the mass?
iii. Which breeds are predisposed to this type of cutaneous mass?
117

Answers: 110, 111
110 i. Hyperadrenocorticism. Because 110b
the dog had no previous history of
glucocorticoid administration, spon
taneous hyperadrenocorticism is most
likely. Pituitary-dependent hyper
adrenocorticism accounts for approxi-
mately 85% of canine hyperadrenocor-
ticism cases (pituitary microadenomas)
and 15% are due to a functional
adrenal tumor. Other possible causes
include ectopic ACTH secretion or
ectopic/hyperactive eutopic adrenocortical receptors, but these are extremely rare
occurrences in dogs.
ii. Alopecia, typically bilaterally symmetrical and sparing the head and extremities.
Failure to regrow hair following shaving or grooming is also reported. Alopecia
is due to steroid-induced atrophy of the hair follicle and pilosebaceous unit.
Comedone formation may be noted, particularly around the mammae and dorsal
and ventral midlines. Keratin plugged follicles occur due to accumulation of
debris in an atrophic follicle, or may be secondary to demodicosis or bacterial
pyoderma. Recurrent bacterial pyoderma in a dog with no prior history may be
the only presenting sign when ‘classic’ clinical signs (i.e. polyuria/polydipsia) are
absent. Skin infections may be further complicated by seborrhea. Unless there are
secondary pruritic triggers (e.g. pyoderma, Malassezia overgrowth) pruritus is
uncommon; inflammation is masked by excess circulating corticosteroids. Other
dermatologic abnormalities include thin, atonic skin (110b), calcinosis cutis and
milia, hyperpigmentation, phlebectasia, and bruising.
111 i. Neoplasia (basal cell carcinoma, hair follicle tumor, apocrine gland tumor,
hemangioma, hemangiosarcoma, MCT, cutaneous lymphoma, plasmacytoma,
melanoma); non-neoplastic mass including local hemorrhage, foreign body
reaction, or, less likely, infectious etiologies.
ii. MCT. The adverse reaction exhibited by the dog following aspiration is known
as Darier’s sign.
iii. Australian cattle dog, beagle, Boston terrier, boxer, bullmastiff, bull terrier,
cocker spaniel, dachshund, English bulldog, fox terrier, golden retriever, Labrador
retriever, pug, Rhodesian ridgeback, schnauzer, shar-pei, Staffordshire terrier,
Weimaraner. In these breeds, the disease usually presents as a solitary cutaneous
mass; however, the following dog breeds most frequently present with multiple
tumors: boxer, golden retriever, pug, shar-pei, and Weimaraner.
118

Questions: 112, 113
112 i. How is hyperadrenocorticism definitively diagnosed in the dog?
ii. What treatment options are available for consideration?
113 An owner whose hobby is sled dog 113a

racing presented one of 10 dogs for
examination. The owner reported that
all dogs were showing similar clinical
signs and this dog was representative
of the entire group (113a). The dogs
showed moderate to severe pruritus
and self-trauma of 1 year’s duration.
There were no cats on the premises.
The owner reported that she was also
pruritic. The dogs live with the owner
and have full access to her home through 113b
a dog door. The dog door leads to an
outdoor pen that contains doghouses.
The owner uses straw for bedding and
changes it weekly. All dogs receive
monthly spot-on flea control. Skin
scrapings were negative for Demodex
mites. Cytology of the excoriated areas
revealed overgrowth of Malassezia and
neutrophils with intracellular cocci.
Flea combing did not identify any fleas;
however, this organism (113b) was 113c
found under a mat of hair.
ii. What is the organism in 113c?
iii. What is the most likely cause of the
dog’s pruritus? What are the treatment
options?
119

Answers: 112, 113
112 i. Screening tests include urine cortisol–creatinine ratio, ACTH stimulation test,
and low-dose dexamethasone suppression test. Low-dose dexamethasone suppression
tests can determine ‘is this hyperadrenocorticism’ and ‘what is the etiology’. Lack of
suppression for the entire 8-hour test period is compatible with hyperadrenocorticism;
in 60–65% of dogs with pituitary-dependent hyperadrenocorticism, the 4-hour plasma
cortisol concentration will suppress, but then ‘escape’ by 8 hours. Suppression should not
occur in dogs with functional adrenal tumors. If suppression does not occur at either time
point, a high-dose dexamethasone suppression test may be performed to differentiate.
Desmopressin stimulation has been described as a potentially useful differentiating test.
More commonly, advanced imaging techniques (abdominal ultrasound, CT, MRI) are
utilized to evaluate the adrenal glands. CT or MRI may be used to evaluate the pituitary
gland, particularly when neurologic abnormalities are reported.
ii. Trilostane and mitotane administration are medical options for dogs with PDH.
Ketoconazole decreases steroidogenesis by inhibiting the cytochrome p-450 enzyme
system; it has been effective in some dogs. Selegiline, bromocriptine, and cyproheptadine
have all been evaluated as treatment options, but are not effective. Adrenalectomy is
the treatment of choice for adrenal tumors as it may offer the potential for cure. Other
options include pituitary radiation therapy and hypophysectomy; these options may
be considered in patients with neurologic abnormalities.
113 i. Louse nit. The major differential for this organism is a Cheyletiella egg;
however, these are not tightly glued to the hairs and are smaller.
ii. A human louse, Phthirus pubis. This would explain the owner’s pruritus but not
the dog’s, since lice are species specific.
iii. Combined bacterial and yeast infections are likely contributing to the dog’s pruritus;
however, the underlying trigger is louse infestation. Dogs can be infested by two lice
species: sucking louse (Linognathus setosus) and biting louse (Trichodectes canis).
Louse infestations are most common in situations of overcrowding and poor hygiene.
In this case, the bedding should be changed more frequently to minimize mechanical
transmission. Lice spend their entire life cycle on the host and only live for 1–2 days off
the host; attention to possible objects that could allow for fomite transmission (straw
bedding, rugs, blankets) is necessary. Treat all in-contact animals. Louse nits need to
be removed from the hair coat or else reinfestation can occur. Clipping the hair coat
of long-haired animals is effective, as is aggressive bathing to loosen nits. Anecdotally,
vinegar and water rinses 1:1 have been used to soften the cement attachment to the
hairs. Aggressively bathe dogs to remove nits and apply a whole body insecticide rinse.
Spot-on products (e.g. fipronil, selamectin, imidacloprid) have been used successfully
to treat individual animal infestations, but are not recommended for multi-animal
outbreaks or in animals with dense hair coats.
120

Questions: 114, 115
114 What is the difference between acanthosis, acantholysis, and acantholytic cell?
115 Immunohistochemical markers are used to aid the pathologist in identifying

the specific cell type involved in a disease process. Specific cell types possess
patterns of immunohistochemical staining (typically reported as positive or
negative), which identify the various cell types involved. This process is used
most frequently for neoplastic processes to determine the cell or tissue of origin
(from personal communication, Texas A&M University College of Veterinary
Medicine and Biomedical Sciences Pathology Department). Match the following
immunohistochemical cell markers with the cell type identified:
i: c-kit A: all leukocytes

ii: CD1 B: striated muscle, smooth muscle
iii: CD3 C: neurons, neuroendocrine cells including Schwann
and Merkel’s cells
iv: CD11b/d D: epithelium
v: CD11a/CD18 E: dendritic cells
vi: CD20/CD79a F: basement membrane
vii: CD45 G: mesenchymal cells including fibroblasts, endothelial
cells, myoepithelial cells, smooth and skeletal muscle,
melanocytes, and various inflammatory cells
viii: collagen IV H: macrophages
ix: cytokeratin I: leukocytes except erythroid cells and plasma cells
x: desmin J: mast cells
xi: melan A K: skeletal muscle
xii: myoglobulin L: T cells
xiii: neuron-specific enolase M: melanocytes
xiv: synaptophysin N: neuroendocrine cells
xv: vimentin O: B cells
121

Answers: 114, 115
114a
114b 114c
114 Acanthosis refers to an increase in the thickness of the stratum spinosum

of the epidermis (114a). It is a common finding in inflammatory skin diseases.
Acantholysis refers to disruption and separation of the keratinocytes (arrows) of
the epidermis in the stratum spinosum. It is caused by lysis of the intercellular
cement. It is most commonly observed in pustular diseases, particularly severe
bacterial pyoderma and PF, where it is a hallmark feature of the disease (114b).
Acantholytic cell refers to the individual separated cells that result from the process
of acantholysis. In severe bacterial pyoderma, cells tend to be seen singly or in
small groups. In PF, these cells are commonly observed in rafts or groups. The dark
blue cells shown (114c) are an example of a raft of cells. These cells can be readily
observed on skin cytology from a pustule in a patient with PF.
115 i. = J; ii. = E; iii. = L; iv. = H; v. = A; vi. = O; vii. = I; viii. = F; ix. = D; x. = B;

xi. = M; xii. = K; xiii. = C; xiv. = N; xv. = G.
122

Questions: 116, 117
116 A 6-year-old male castrated DLH 116a
cat presents for management of a
chronic allergic skin disease. The cat
is morbidly obese, weighing 10.45 kg
(23 pounds) and with a body condition
score of 9/9. The cat has previously been
managed with injectable long-acting
corticosteroid administration due to the
owner’s inability to administer pills to
the animal. Recently, the cat has become diabetic and requires insulin in addition
to dietary management for diabetes mellitus (DM). On physical examination, the
cat has a large indolent ulcer involving the upper lip bilaterally (116a) as well as
multiple eosinophilic plaques along the ventral abdomen. The cat is moderately
pruritic and has developed self-induced alopecia along the most caudal portion of
the ventral abdomen (the only portion of the abdomen the cat can reach).
i. What are the options for controlling the immediate pruritus in this animal?
ii. With regard to long-term management of the allergic skin disease, what options
may be considered and what difficulties do you face diagnostically with this
patient?
117a 117b
117 Glucocorticoids are commonly used in veterinary dermatology.

i. What are the common side-effects of long-term topical glucocorticoid use (117a, b)?
ii. What are the common side-effects of systemic glucocorticoid use?
123

Answers: 116, 117
116 i. Corticosteroid administration is 116b
not a viable option given the history and
development of DM; insulin resistance
is a potential complication. Antibiotic
administration may be beneficial; many
of these lesions respond well to antibiotic
administration alone. If antibiotic
administration does not alleviate the
cat’s pruritus, additional therapy with
cyclosporine is the next best option.
Although DM is a reported cyclosporine
side-effect, it does appear to be less diabetogenic compared with corticosteroids.
ii. Skin scraping and cytology should be performed to rule out generalized demodicosis
and secondary infections, respectively, as complicating factors. Assuming the cat is
receiving year-round adulticide flea prevention, a diet trial would also be indicated;
however, this may be difficult with concurrent DM. Therefore, treatment should be
aimed at managing presumed AD. This could include administration of fatty acids
and antihistamines (adjunct or sole therapy) and cyclosporine or pursuing allergy
testing and ASIT. (Note complications with cyclosporine above.) If the cat’s appetite
decreases with cyclosporine administration (fairly common albeit transient adverse
effect), development of hepatic lipidosis would be a concern. ASIT would be the
safest option long term. A weight loss plan should be recommended for the cat; DM
may be transient due to the previous steroid administration. In this cat, ASIT was
pursued based on the IDT shown here (116b).
117 i. Scaling of the skin, thinning of the skin, focal alopecia, focal hyper
pigmentation, easily bruised skin, easily torn skin, telangiectasia, follicular
inclusion cysts, comedones, calcinosis cutis or milia formation, focal drug reaction
to the commercial product or base, depigmentation of skin, elevations of serum
chemistry parameters, blunting of ACTH stimulation test.
ii. Polyuria, polydipsia, polyphagia, weight gain, panting, muscle weakness,
muscle wasting, joint laxity/injury, inappropriate urination, depression, behavior
changes, iatrogenic hyperadrenocorticism, cystitis, ‘silent’ urinary tract infections,
gastric ulceration, vomiting, diarrhea, liver and metabolic changes (e.g. diabetes
mellitus), hair loss, calcinosis cutis, scaling of the skin, skin infections (bacterial,
dermatophytosis), demodicosis, comedones. Less commonly, steroid-related
aggression and mood changes can occur in dogs.
124

Questions: 118, 119
118a 118b
118 This lesion (118a) was found on the dorsum of a 3-year-old dog during an
annual examination. The owner was unaware of the lesion. It was removed via
excisional biopsy and a photomicrograph of the skin biopsy is shown (118b).
i. What are the diagnosis and prognosis?
ii. How does the site affect the prognosis?
iii. What is the most recent non-interventional therapy?
119a 119b
119 A 14-year-old male castrated cat presented for

lethargy, decreased appetite, and weight loss of 3
months’ duration. The owner also noted that the
cat was losing a large amount of hair, particularly
along the ventrum and limbs (119a). Large sheets
of exfoliated scale were present throughout the
skin, particularly in areas of near complete alopecia
(119b).
i. What diagnostic tests are indicated, and why?
ii. What are your differential diagnoses based on the clinical appearance?
iii. What neoplastic processes have been implicated in association with this clinical
appearance?
125

Answers: 118, 119
118 i. Dermal melanocytoma, the most common melanocytic tumor of dogs. They
are usually solitary, circumscribed, brown to black, and alopecic. The size varies
from 0.5–4.0 cm. The prognosis is good if wide surgical margins are obtained.
ii. Canine melanocytic lesions can occur anywhere on the body. They occur more
commonly in darkly pigmented dogs. Clinically, it can be difficult to differentiate
between a benign and a malignant melanoma; however, location of the lesion may
be important. The vast majority of oral melanomas and approximately two-thirds
of melanomas from the digits are malignant. In contrast, most melanomas from
the skin are benign. Recently, a malignant melanoma from the perianal region of
the dog was reported; this is a very unusual location for a melanoma.
iii. The licensure of a DNA vaccine for dogs with oral melanoma in 2010. The vaccine
contains a DNA plasmid containing a gene for human tyrosinase, a protein found on
both human and canine melanoma cancer cells. In a study involving 58 dogs with
stage II or stage III oral melanoma, dogs receiving the vaccine post surgical debulking
had a significantly longer survival time than did control dogs. Side-effects included
minimal to mild pain at the site of injection, and a single dog developed vitiligo.
119 i. CBC, serum biochemistry, and urinalysis to determine whether obvious

metabolic abnormalities exist. Ultrasound, CT, or MRI of the abdomen for
structural abnormalities or masses. Skin biopsy to determine if clinical findings
are due to a primary dermatologic problem or if skin changes are associated with
cutaneous manifestation of a systemic disease.
ii. Paraneoplastic alopecia, superficial necrolytic dermatitis (although typically, less
alopecia is present), hyperadrenocorticism, feline thymoma-associated exfoliative
dermatitis, dermatophytosis, PF, cutaneous epitheliotropic T-cell lymphoma, SLE,
EM, demodicosis.
iii. The most likely diagnosis is paraneoplastic alopecia. The ‘shiny’ appearance
of the skin (associated with complete alopecia in the absence of inflammation)
with large amounts of scale is visually distinctive. The pattern of hair loss is
also supportive of the disease. This type of paraneoplastic syndrome may be
associated with any underlying visceral neoplasia; however, pancreatic cancer
is most frequently reported. Hepatocellular carcinoma has also been associated
with feline paraneoplastic alopecia. The combination of alopecia on the face
and moderate exfoliative dermatitis is supportive of feline thymoma-associated
exfoliative dermatitis and cutaneous epithelial T-cell lymphoma. These conditions
typically have a more diffuse pattern of scaling and alopecia compared with cats
with paraneoplastic alopecia; the distribution of alopecia is typically ventral. The
prognosis for cases of feline paraneoplastic alopecia is poor.
126

Questions: 120, 121
120 A 3-year-old female spayed mixed- 120a
breed dog presented for multiple
erythematous, nodular skin lesions
affecting the haired skin of the muzzle,
flanks, and ventral abdomen as well as
several mucocutaneous junctions (eye
lids, vulva, lips) (120a). The nodules
were minimally pruritic, raised with an
umbilicated center, and primarily non-
ulcerated at the time of presentation.
i. What are the differential diagnoses
for this patient?
ii. Skin biopsy of the lesions revealed ‘focally extensive areas of severe infiltration
of neutrophils and macrophages with fewer eosinophils and lymphocytes in the
dermis. The infiltration extends from the superficial to deep dermis and focally
into the subcutaneous adipose tissue. In several sections within the nodular
aggregation of pyogranulomatous inflammation, there are few extracellular and
intrahistiocytic, round to crescent-shaped, non-staining 5–20 µm diameter yeast
with occasional narrow-based budding. Yeasts are surrounded by a clear, 5–10 µm
wide capsule giving the organisms a ‘soap bubble’ appearance. The organisms are
noted to be refractile.’ What is the diagnosis for this patient?
iii. How does this organism differ with regard to canine and feline infection?
121a 121b
121 These two 6-week-old kittens are littermates (121a). The abdomen of the
black kitten, approximately 1 month later, is shown (121b). What is the diagnosis?
127

Answers: 120, 121
120 i. Infectious: deep fungal including 120b
blastomycosis, cryptococcosis, histo-
plasmosis, coccidioidomycosis; atypical
bacterial including botryomycosis,
myco bacterial infection, nocardiosis,
actinomycosis, canine leproid granu-
loma; inflammatory: cutaneous histio-
cytosis, sterile pyogranuloma/granuloma
syndrome; neoplasia: cutaneous epi
theliotropic T-cell lymphoma.
ii. Cryptococcosis (120b shows organisms from an impression smear).
iii. Disease is acquired from the environment via inhalation of infective spores
or yeast organisms. It is not considered to be contagious or zoonotic. In dogs, it
occurs in individuals typically <4 years old. Major organs involved are the nasal
cavity, CNS, and eyes. CNS signs include meningitis, meningoencephalitis, head
tilt, nystagmus, paresis, ataxia, circling, and seizures. Ocular changes include optic
neuritis, retinal hemorrhage, blindness, anterior uveitis, and periorbital swelling.
The nasal cavity can be involved but respiratory signs are often subclinical or
very mild; rhinosinusitis is not typically reported in the dog. Cutaneous lesions
are considered to be a marker of disseminated disease. Cryptococcosis is more
common in young cats. Common signs include sneezing, mucopurulent nasal
discharge, mandibular lymphadenopathy, and possibly otitis media. CNS signs are
variable and include depression, changes in behavior and temperament, seizures,
circling, vestibular signs, and blindness. Ocular changes are a sentinel sign of CNS
involvement. Compared with dogs, where cutaneous signs are less common, cats
often present with papules and nodules, particularly involving the nasal planum.
121 Congenital hypotrichosis. This condition is due to a lack of adnexa in the

regions where they are normally found. It is a rare condition, which is noted at
birth or shortly thereafter. It is believed to be caused by a spontaneous genetic
mutation. This mutation has been reported in kittens before, but with concurrent
congenital oligodontia of both the deciduous and permanent teeth. It has also
been reported in a litter of Birman kittens that had concurrent thymic aplasia.
This kitten had normal deciduous and permanent teeth. Long-term management
required additional moisturizing of the skin by the owners and careful restriction
of the kitten from excessively sunny areas to prevent solar-induced actinic damage.
128

Questions: 122, 123
122a 122b
122 A 7-year-old female spayed beagle dog presented for a 3-month progressive
history of severe pruritus and excessive scaling. The dog was pruritic to the
point that massive self-trauma was present in the form of linear excoriation and
erosions (122a). The owner had noted that the dog’s nose was beginning to turn
pink compared with its normal black appearance (122b). Previous treatment for
ectoparasites and infections had not been beneficial.
i. A biopsy of the skin showed neoplastic round cells infiltrating the dermis,
epidermis, and follicular epithelium. The cells were round with a single large central
nucleus and a moderate amount of basophilic cytoplasm. The cells frequently
formed small aggregates or microabscesses within the epidermis. Neoplastic cells
were positive for CD3 on immunohistochemistry. Based on this description, what
is your diagnosis for this patient?
ii. Three forms of this disease exist in dogs. What are they?
iii. In most cases, diagnosis of this disease is uncomplicated based on biopsy and
immunohistochemistry results (when performed). At times, however, particularly
in the earlier phases of disease, diagnosis might not be quite as concrete. What
other options are available for testing to confirm a diagnostic suspicion?
123 Ketoconazole, itraconazole, fluconazole, and terbinafine are antifungal drugs

commonly used in veterinary dermatology to treat superficial to deep fungal
diseases or yeast infections. For each drug, what is the mechanism of action?
129

Answers: 122, 123
122 i. Cutaneous epitheliotropic T-cell lymphoma.
ii. Mycosis fungoides, pagetoid reticulosis, Sézary syndrome. Clinically, mycosis
fungoides cannot be distinguished from pagetoid reticulosis; the difference is based
on histopathologic evaluation. In either case, the disease is generalized with localized
cases reported far less frequently. Sézary syndrome is a form in which neoplastic
lymphocytes are also found in peripheral lymph nodes and peripheral blood.
Although lesions clinically are identical, extracutaneous neoplastic lymphocytes
are not noted with the other two forms. Since all three forms appear clinically
identical in dogs, the disease might be better classified with regard to subtype based
on appearance: exfoliative erythroderma, plaques/nodules, ulcerative disease of
the oral mucosa, and mucocutaneous forms.
iii. One option is to take advantage of the fact that clonality (expansion of
neoplastic cells from the same clonal population of cells) is a hallmark of
malignancy; heterogeneity of cells implies reactivity as opposed to malignancy.
Canine lymphoma and other lymphoid neoplasias can be diagnosed based on
the detection of clonal rearrangements of antigen receptor genes, specifically the
T-cell receptor genes (CD3 region). A PCR assay has been developed to identify
gene rearrangements for the specific lymphoid neoplasia (immunoglobulin
rearrangement for B-cell leukemias and T-cell receptor gene rearrangements in
T-cell leukemia lymphoma). A recent study identified increased expression of
retinoic acid receptors and retinoid X receptors via immunohistochemistry from
lymphoma tissue, whereas non-neoplastic lymphoid tissue did not show the same
increased level of expression. This finding may also help differentiate lymphoma
from other lymphoproliferative disease.
123 Ketoconazole, itraconazole, and fluconazole are azole antibiotics. Their

mechanism of action is to inhibit cytochrome P450 and the conversion of
lanosterol to ergosterol, causing accumulation of C14 methylated steroids. They
also inhibit intracellular triglyceride and phospholipid biosynthesis, cell wall chitin
synthesis, and oxidative and peroxidative enzymes. Terbinafine is an allylamine
antifungal drug that inhibits fungal growth by disrupting sterol biosynthesis. It
inhibits the formation of ergosterol by inhibiting squalene epoxidase, the enzyme
responsible for converting squalene to an ergosterol precursor. Deficiency of
ergosterol compromises cell wall integrity and results in impaired growth and/
or death of the fungal pathogen. In mammals, biosynthesis of cholesterol uses the
same squalene epoxidase; however, terbinafine shows a markedly lower binding
affinity for mammalian enzymes.
130

Questions: 124, 125
124a 124b
124 Foot pad hyperkeratosis is a 124c

common dermatologic problem or
complaint. In addition to the history and
general physical examination, careful
examination of the hyperkeratosis can
help narrow the differential diagnosis.
i. This dog (124a) is otherwise healthy.
The lesions seen are present on all paws.
What is the most likely differential
diagnosis, and what other clinical signs could be present to support the working
diagnosis?
ii. This dog (124b) is 7 years old and the primary complaints are ‘slowing down’
and ‘reluctance to move quickly’. The owners report that the dog had been normal
until approximately 9 months ago. The dog’s heart rate, respiration, and body
temperature are within normal limits. The medical record reveals a 20% increase
in body weight over the last year. The hyperkeratosis is limited to the foot pads.
Exudation and odor are absent. What are possible differential diagnoses?
iii. This dog (124c) is 10 years old and the primary complaint was lameness. In
addition, physical examination revealed weight loss and the owner confirmed that
the dog had been depressed and anorectic for the last several weeks. What are
likely differential diagnoses?
125 Most active ingredients in shampoos remain constant despite reformulations

and renaming of veterinary products. Tailoring treatment recommendations
for a specific patient or disease requires a thorough understanding of the active
ingredients.
i. With regard to antibacterial antiseptics, what ingredients are options?
ii. What recommendations for antipruritic therapy may be used when infections
are absent?
131

Answers: 124, 125
124 i. The lesion shown is classic digital hyperkeratosis. This is common in dogs
with disorders of keratinization, particularly cocker spaniel dogs. The nose should
be examined to look for concurrent nasal hyperkeratosis. Hyperkeratosis around
the mammae presenting as ‘fronds’ is a common concurrent clinical finding.
ii. The most likely are those that involve an underlying medical disease.
Musculoskeletal pain can change a dog’s gait and lead to abnormal foot pad
keratinization. In this case there are long fronds of keratin on the foot pads growing
in all directions. The lack of exudation and odor make immune-mediated diseases
or infection less likely. The vague history of decreased activity and weight gain
makes hypothyroidism suspect. Foot pad changes are also common in dogs with
hepatocutaneous syndrome. Other possible causes include vitamin A-responsive
skin disease, fatty acid deficiency, and zinc-responsive skin disease.
iii. Include, but are not limited to: immune-mediated diseases (pemphigus complex),
metabolic (hepatocutaneous syndrome), severe irritant reaction, infection (bacterial
or fungal), or possibly demodicosis. In most cases of primary bacterial or demodectic
pododermatitis there is more exudation and swelling and less hyperkeratosis. Severe
dermatophyte infection with M. gypseum can cause severe pedal dermatitis, but would not
account for the weight loss and signs of systemic illness. These foot pads are representative
of the hyperkeratosis and fissuring seen in cases of hepatocutaneous syndrome.
125 i. Common ingredients include chlorhexidine, benzoyl peroxide, acetic acid/boric

acid, tris-EDTA, ethyl lactate. All of these ingredients are antiseptics, meaning their
intrinsic properties allow for killing of microbial organisms. Several recent studies have
evaluated the efficacy of these various antimicrobials. Two studies found chlorhexidine
to be most effective when compared with other topical antimicrobials including benzoyl
peroxide. Another study found in-vitro efficacy of acetic and boric acids to be very low.
ii. If the patient is historically prone to infection development, bathing with antiseptic
shampoos should still be part of the long-term management protocol. One study
evaluated the effects of conventional shampooing versus whirlpool therapy, with and
without shampoo; the study showed decreased pruritus scores in patients treated with
whirlpooling regardless of whether shampoo was used or not. This demonstrates the
inherent benefits of topical therapy in dogs. Another study evaluated the efficacy of
using ultrapure soft water with shampoo for controlling pruritus; dogs treated showed
improvement in TEWL, indicating improved skin barrier recovery. In one patient
who was intensely pruritic post bathing with tap water, when the same shampoo
was used with well water or distilled water the dog was not pruritic. Anecdotally,
colloidal oatmeal and pramoxine may be beneficial for pruritus; shampoo therapy
tends to provide short-term relief to pruritic patients. Longer relief may occur if these
ingredients are incorporated into leave-on lotions or conditioners.
132

Questions: 126, 127
126 A 9-year-old female spayed black 126a
dog presented for a 6-month history of
non-pruritic nodular skin disease that
had not responded to previous anti
biotic administration or topical bathing.
The owner reported that the lesions
had primarily affected the muzzle,
dorsal head, and various other regions
of the dog’s body on haired surfaces
(126a). Nodules were not exudative
but were alopecic, variably sized, and
erythematous. 126b
i. What are the differentials and recom
mended diagnostic tests?
ii. Histopathology from one of the
nodules is shown (126b). The dermato
pathology report identified a nodular
to diffuse infiltration of primarily
histiocytes, small lymphocytes, and
neutrophils extending through the
middle dermis and subcutis. Lesions
typically tracked along adnexal struc
tures to the superficial dermis in a linear/tubular formation. Infiltration was
frequently centered on blood vessels, but was only minimally vasoinvasive. No
organisms were identified on special stains. Based on this report, what is the
diagnosis for this patient?
iii. What treatment options should be considered for this patient?
iv. How would you counsel the owner regarding the prognosis?
127 Note the lesion shown on this 127

cat’s face (127). The owner reports a
slow onset of the lesion and a lack of
pruritus. This is an indoor/outdoor cat
of unknown age. How would you work
up this case?
133

Answers: 126, 127
126 i. Infectious (actinomycosis, nocardiosis, bacterial pseudomycetoma, oppor
tunistic mycobacterial infection, dermatophytic kerion, blastomycosis, histo
plasmosis, coccidioidomycosis, cryptococcosis, sporotrichosis, other opportunistic
fungal infection, pythiosis, lagenidiosis, protothecosis, leishmaniasis); inflammatory
(sterile granuloma and pyogranuloma syndrome, reactive histiocytosis, cutaneous
xanthoma, canine sarcoidosis); neoplasia (cutaneous T-cell lymphoma, mast
cell tumor, metastatic neoplasia). The most important diagnostics include skin
biopsy with special stains and bacterial culture for aerobic and atypical bacterial
organisms such as Mycobacterium, Nocardia, and Actinomyces spp. Additional
diagnostic testing should include CBC, serum biochemistry, urinalysis, thoracic
radiographs, and CT/MRI depending on findings.
ii. Reactive histiocytosis.
iii. For solitary lesions, surgical excision is successful; however, this does not prevent
development of new lesions. Topical corticosteroids may be used for localized
disease. For widespread nodules, tetracycline/doxycycline and niacinamide is often
effective. It may be administered alone or combined with vitamin E and fatty acid
supplementation. Response to corticosteroid administration is variable, but may
be as high as 50% in cases with the cutaneous form of disease. In more refractory
cases, cyclosporine (modified) or leflunomide can be effective. Immunosuppressive
dosing is recommended (initially) and then tapered to the lowest effective dose.
iv. Although the disease typically does not progress (e.g. the cutaneous form does
not become systemic), the prognosis for durable remission is guarded. This is due
to the waxing and waning nature of the disease and need for long-term treatment.
If tetracycline/doxycycline and niacinamide is successful, side-effects may be
minimal long term, lending to a more favorable prognosis.
127 Wear gloves when handling this patient as many of the possible differential
diagnoses are zoonotic. Key initial diagnostic tests include: skin scrapings, hair
pluckings, impression smears, Wood’s lamp examination, and bacterial culture
and sensitivity. Slow-onset lesions can be neoplastic and a skin biopsy is indicated.
Medical diagnostics should include screening for FeLV and FIV since the cat
goes outside. This cat proved to be FeLV and FIV positive. D. cati mites were
found at the lesion site and from hair trichograms distant to the lesion. Skin
biopsy and special stains ruled out neoplasia and microbial infections. Except
for finding Demodex mites on the biopsy, the only other significant finding was
supportive infection. Bacterial culture revealed a methicillin-resistant SIG. This
was an unexpected finding since the cat had no prior history of antibiotic therapy.
Treatment with topical mupirocin ointment and oral milbemycin for demodicosis
resulted in marked improvement but not resolution of the lesion.
134

Questions: 128, 129
128 A 10-year-old female spayed DSH cat 128
presented for a non-pruritic cutaneous lesion on
the dorsal cervical region. The owner had noted
the lesion while she was petting the cat a few days
prior to examination. The cat did not seem to be
bothered by the lesion; there was no evidence of
pruritus or self-induced alopecia. No evidence of
systemic illness was reported by the owner. On
closer examination, there were three small (1–2
mm diameter) plaque-like papules present on the
dorsal neck near the base of the skull. The masses
were discrete, firm, and tan in appearance. The
surface was alopecic; however, broad hair loss
was not present surrounding the masses.
i. Cytology from an aspirate of the masses is shown
(128). What is the diagnosis for this patient?
ii. How are these masses classified in cats with regard to histologic interpretation?
iii. What is the typical biological behavior of these cutaneous masses in cats?
129 A 7-year-old female spayed German 129

shepherd dog was presented for recurrent
skin infections over approximately the
last 8 months. According to the owners,
the dog had no history of skin disease
prior to this. Pruritus was noted to be
mild to moderate and primarily focused
on the ventral abdomen where lesions
were noted (129). The owners reported
that several courses of antibiotics had
been administered along with different shampoos; however, the treatments had not
resolved the lesions. Otherwise, the dog seemed overall in good general health. She had
gained weight (total of 2.7 kg [6 lb]) over the past 8 months and seemed less energetic;
however, the owners attributed this to her age.
i. Based on the history provided by the owners, what dermatologic diagnostics
should be performed?
ii. What are a few possible reasons for the recurrent skin infections in this patient?
iii. What additional diagnostics may be considered?
iv. With regard to this patient, what treatment recommendations would you make?
135

Answers: 128, 129
128 i. Mast cell tumor (MCT).
ii. As mastocytic or atypical poorly granulated MCTs. The mastocytic type is
subclassified as well-differentiated or pleomorphic. Prognostic indicators are not as well
defined for feline cutaneous MCTs as they have been for dogs. A recent study evaluated
potential markers to determine their prognostic value for feline cutaneous MCTs. It
was determined that multiple masses, pleomorphic phenotype, and high mitotic index
all correlated with an unfavorable outcome. Immunohistochemistry factors including
KIT (CD117) expression, telomerase expression, and proliferation index (MIB-1/Ki67
index) were also evaluated. Increased KIT immunoreactivity and Ki67 index also was
associated with increased morbidity. A previous study also identified KIT expression to
be potentially helpful in identifying mast cell origin; however, there did not appear to be
a difference in KIT expression and MCT phenotype. Further evaluation is warranted.
iii. In general, most feline cutaneous MCTs are considered to be benign neoplasms
with a low rate of local recurrence. The presence of multiple cutaneous MCTs
has been associated with decreased overall survival time compared with cats with
solitary masses. Involvement of regional lymph nodes or spleen is also associated
with more severe disease. Solitary cutaneous MCTs without lymph node
involvement typically present as benign disease with a relatively extended survival
time. Median survival time is markedly decreased in cats with multiple cutaneous
masses, evidence of tumor recurrence following surgical removal, and/or lymph
node or splenic involvement. The prognosis is guarded for these animals.
129 i. Skin scrapings, skin cytology, possible dermatophyte culture, bacterial

culture and susceptibility.
ii. (1) Bacterial resistance; (2) underlying illness leading to secondary bacterial
infections: possibilities include any metabolic (renal insufficiency, hepatic disease),
endocrine (hypothyroidism, hyperadrenocorticism), or neoplastic process.
iii. CBC, serum biochemistries, urinalysis.
iv. Treatment of the infection should be two-fold. If the owners are willing and able,
topical control should be initiated with an antiseptic shampoo. Chlorhexidine would
be a good agent to use, either alone or in combination with other antiseptics (e.g.
phytosphingosine, miconazole or ketoconazole if yeast are also noted on cytology,
or tris-EDTA). To get good contact with the skin, it may be beneficial to clip the hair
coat short as this dog’s coat is rather dense; good penetration through the fur may
not be possible. Based on the results of culture and susceptibility, if an appropriate
antibiotic can be used, it should be prescribed for a minimum of 3–4 weeks. The typical
recommendation is to treat at least 1 week past the point of clinical resolution. This
takes a minimum of 3 weeks for superficial skin infections and may take longer. With
the growing prevalence of bacterial resistance, antibiotic choices are often limited.
136

Questions: 130, 131
130a 130b
130 An 8-year-old male castrated shar

pei dog presented for a 2-month history
of progressive skin lesions. Initially,
the dog had a swollen, thickened and
erythematous lesion over the left hindlimb; 130c
the lesion measured approximately 9
cm in diameter and extended over the
tarsus (130a). More recently, the lesion
had grown in size and had a sticky,
viscous exudate on the ulcerated surface.
Additional lesions had also developed over
the trunk, medial thighs, and head. Mild
pruritus was evident and the dog was non-
weight bearing on the left hindlimb.
i. What is the most likely explanation
for the sticky, viscous exudate noted by the owners?
ii. Histologic findings from a skin biopsy of the mass are shown (130b, c).
Histopathologic interpretation showed a poorly demarcated, non-encapsulated,
invasive neoplastic mass extending through the entire dermis. The mass was
composed of closely to widely spaced round cells in sheets; the cells had
variably distinct borders and moderate to large amounts of cytoplasm. Smaller
cells contained fine basophilic granules; most cells were larger with wispy and
vesiculated cytoplasm. Nuclei were round to oval with multiple nucleoli. Mitotic
index was high. Lymphatics were dilated with neoplastic cells. Several eosinophils
were admixed with neoplastic cells. Given the description, what special stain is
recommended to confirm the diagnosis?
iii. Uncontrolled cellular proliferation is a key feature of neoplasia. Measurements
of cellular proliferation have been used in human and veterinary medicine to
predict behaviors of tumors. What proliferation markers have been evaluated for
this canine neoplasia?
131 What is phytosphingosine?
137

Answers: 130, 131
130 i. Mucin. Cutaneous mucinosis is considered to be ‘normal’ in the shar pei
breed.
ii. MCT (grade III based on the cellular and nuclear morphology). Toluidine blue
stain would better identify mast cell granules.
iii. In veterinary medicine, proliferation markers that have been evaluated for
canine MCTs include staining for argyrophilic nucleolar organizer regions
(AgNORs) and immunohistochemistry for proliferating cell nuclear antigen
(PCNA) and Ki67. AgNORs are widely used as a measurement of tumor kinetics
and metabolic activity; they identify areas in the nucleus associated with proteins
and ribosomal RNA transcription. Higher AgNOR counts are associated with
increased mortality, local recurrence, and metastasis for canine MCTs. PCNA
interacts with DNA polymerases and has maximal expression during the synthesis
phase of the cell cycle. Although studies have shown association between PCNA
expression and increased mortality in canine MCTs, expression has not been
proven as a prognostic indicator independent of histologic tumor grade (i.e.
higher grade tumors have a tendency towards increased PCNA expression by
default [increased mitotic index etc.]). Ki67 is a nuclear protein; it is expressed
in all phases of the active cell cycle; however, inactive cells do not express this
protein. Cells positive for Ki67 are actively involved in the cell cycle (known as the
growth fraction) and are considered to be a measure of proliferation. For canine
MCTs, increased Ki67 expression is associated with increased mortality, rate of
local recurrence, and metastasis. KIT (also known as CD117) is a stem cell factor
receptor associated with MCT development in dogs. It is encoded by the proto-
oncogene c-kit. Expression of KIT has been associated with histologic grade of
MCTs; increased KIT expression is noted with higher grade tumors along with
increased expression of Ki67 and AgNORs.
131 A plant-based sphingosine molecule. Sphingosines are incorporated into

the intercellular lipid bilayer that forms the epidermal barrier of the stratum
corneum by forming ceramides. Newer shampoos and ear cleaners incorporate
phytosphingosine into their products. These products may be beneficial for
seborrheic skin conditions (keratoplastic function) and may improve barrier
function with regard to ‘normalizing’ the epidermis. Claims have also been made
for mild antimicrobial and antipruritic actions; this may be due to the improvement
in barrier function.
138

Question: 132
132 A 6-year-old female spayed bassett hound dog presented for evaluation of
chronic and recurrent bilateral ear infections of at least 8 months’ duration. Previous
treatments with topical and systemic medications did not resolve the clinical signs.
The dog had moderate otic pruritus on physical examination and vocalized loudly
when the ears were manipulated. Otoscopic examination revealed a large amount of
green malodorous purulent exudate with visible ulceration along the length of the
canal. Cytology from both ears showed large numbers of mixed bacterial organisms
(primarily rods with large numbers of cocci admixed) and neutrophils.
i. What are possible reasons for the persistence of the bacterial ear infection?
ii. CT identified fluid opacity in both tympanic bullae. Myringotomy and canal
irrigation were performed. Culture was obtained prior to irrigation; results and
susceptibility profile are shown:
Pseudomonas Pseudomonas
aeruginosa aeruginosa Enterococcus
Antibiotic (strain 1) (strain 2) spp.
Concentration (mg/ml) and susceptibility
Penicillin G 2S
Piperacillin <8 S <8 S
Piperacillin/tazobactam <8 S <8 S
Ticarcillin <16 S <16 S
Ticarcillin/clavulanate <16 S <16 S
Cefotaxime >64 R 32 I
Ceftazidime <8 S <8 S
Amikacin 32 I 8S
Gentamicin 8 I SS
Tobramycin 4 S 4S
Ciprofloxacin >4 R <0.5 S 1S
Aztreonam <8 S
Cefepime 8 S <4 S
Ceftizoxime 64 R 128 R
Imipenem <4 S <4 S
Ofloxacin >8 R <1 S
Cefpodoxime >8 R >8 R
Levofloxacin >8 R <1 S <=1 S
Rifampin >=4 R
R = resistant; S = susceptible; I = intermediate susceptibility
What type of organism is Pseudomonas spp.?

iii. What is the general susceptibility of Enterococcus spp. to cephalosporin
antibiotics?
iv. What recommendations for management should be considered?
139

Answer: 132
132 i. Occlusion, resistant organism, middle ear disease. Occlusion may be due
to the presence of a mass (benign, neoplastic) or stenosis of the canal (excessive
proliferation, swelling and edema, ‘normal’ conformation of the breed). Resistant
organisms commonly encountered include multidrug-resistant Pseudomonas spp.
or methicillin-resistant Staphylococcus spp. Otitis media may be caused by a mass
proximal to the tympanic membrane or infection in the tympanic bulla. Sterile
processes such as primary secretory otitis media may contribute to middle ear
involvement; noted most commonly in Cavalier King Charles spaniel dogs.
ii. A gram-negative rod-shaped bacterial organism, found ubiquitously in
nature. Pseudomonas spp. have been associated with severe otitis externa
in dogs. Pseudomonas otitis can persist and recur for a variety of reasons
including antimicrobial resistance, multiple strains of Pseudomonas with varying
susceptibility profiles, and the influence of other factors such as occlusion, otitis
media, or underlying inflammatory skin and ear disease. Pseudomonas isolates
from the ears of dogs are frequently resistant to a variety of antibiotic agents.
Fluoroquinolone resistance is noted commonly, especially in patients with
chronic disease. When culture and susceptibility reveals mixed bacterial infection,
treatment can be challenging.
iii. Intrinsically resistant.
iv. Because of the presence of both otitis externa and otitis media, topical and
systemic treatment is recommended. Treatment needs to be based on the
susceptibility profile of the organisms involved in the infection. Of the antibiotics
evaluated, only injectable options are available to which all organisms are
susceptible. Various options exist regarding topical treatment. Although ones
listed as ‘resistant’ would not be recommended, those listed with ‘intermediate’
susceptibility would still be a viable option. A significantly higher MIC can
be achieved in local tissues compared with serum. Continued irrigation of the
canal with an antiseptic ear cleaner is recommended to inhibit microbial growth.
Products containing tris-EDTA are typically beneficial in gram-negative infections,
which require calcium and magnesium for formation of a viable bacterial cell wall.
Given the highly resistant nature of this infection, the owner should be instructed
to wear gloves when manipulating and treating the ear canals, especially if open
wounds are present. Although additional investigation with regard to efficacy is
necessary, bacteriophage therapy may be a viable treatment option to avoid further
complications of resistance development.
140

Questions: 133, 134
133a 133b
133 A 1-year-old female spayed Persian

cat is presented for diffuse alopecia
and excessive scaling. The owner states
that ‘this absolutely is NOT ringworm’
because she knows what ringworm
looks like and the condition did not
respond to two lime sulfur dip applications. Also, none of the other seven cats or
four dogs appear to have any dermatologic abnormalities.
i. You obtain a sample for a trichogram and this is observed (133a). What is your
diagnosis?
ii. On examining a cytology sample, you find this (133b). Describe the abnormalities
seen on the sample.
iii. What is known about the disease in this breed of cat?
134 Various options exist for the administration of ASIT. These include conventional
subcutaneous injectable immunotherapy, sublingual immunotherapy, and mucosal
(intranasal) immunotherapy; the latter has been evaluated for the treatment of
feline experimental asthma. Currently, there is no standardized protocol for
immunotherapy administration. Frequency of administration, volume, and
induction protocols differ greatly between practitioners.
i. What is rush immunotherapy?
ii. In what diseases and species has rush immunotherapy been evaluated?
iii. What potential side-effects are associated with this type of immunotherapy
administration? What is the general recommendation for administration when this
option is pursued?
141

Answers: 133, 134
133 i. Dermatophytosis.
ii. There are numerous fungal hyphae elements visible within the hair shaft, causing
distortion of the normal architecture; this leads to weakening of the hair shaft,
making the infected hairs prone to breakage. This manifests clinically as alopecia.
The round structures on the outside of the hair shaft are ectothrix spores. These
are the infective agents of dermatophytosis.
iii. Persian cats appear to be predisposed to the development of dermatophytosis.
Compared with other cat breeds, Persian cats will frequently become severely
infected with a generalized form of the disease and many will remain chronically
culture positive for Microsporum canis either due to an inability to mount
effective cell-mediated immunity and/or because they are fomite carriers. These
cats can appear clinically normal, making them a source of exposure to other cats,
susceptible animals, and/or people. It is uncertain whether this breed predisposition
is due to a genetic anomaly or other underlying factors. A similar finding has been
reported in Yorkshire terrier dogs, another breed that appears predisposed to be
chronically culture positive for M. canis. Jack Russell terriers have anecdotally
been reported to be predisposed to Trichophyton spp. infections.
134 i. Abbreviated course of allergen administration. It has been utilized most

frequently with immunotherapy injections; however, intranasal rush immuno
therapy has also been studied. The induction period is shortened to one to several
days compared with the normal several weeks. Gradually increasing amounts of
allergen are administered, as with standard induction, but typically with fewer
levels or gradations (i.e. fewer injections administered during rush versus standard
induction).
ii. It is used in people with certain allergic diseases and considered to be safe and
effective. In dogs it has been evaluated for the treatment of AD and found to
be effective. Rush immunotherapy has been evaluated for the treatment of both
asthma and AD in cats.
iii. Increased pruritus at the site of injection, urticaria and angioedema, and
anaphylaxis. Because of the accelerated induction administration, side-effects
tend to be more common with rush immunotherapy, therefore it is recommended
that rush induction is performed in a hospital setting under close monitoring so
that any adverse reactions can be identified and addressed immediately. Rush
immunotherapy may be beneficial for clients who are not able to administer
injections frequently (e.g. incapable or unwilling to administer every-other-day
injections) or where time is a factor.
142

Questions: 135, 136
135a
135 Shar pei dogs originated in China and for years were used as guard and
hunting dogs (135a). During the Cultural Revolution, dog ownership was highly
taxed and the breed neared extinction until a small group of dogs were rescued in
the 1970s and taken to other countries.
i. How has the breed standard been modified? What genetic abnormality has been
magnified?
ii. What skin diseases are common in this breed as a result of these changes?
136 What are the major classes of compounds used for animal flea control? What
are their modes of action?
143

Answers: 135, 136
135 i. Introduction into the western 135b
world resulted in strong selection for
the ‘wrinkled skin phenotype’. The
intentional change has been a result of
selecting for dogs that have increased
hyaluronan (HA) deposition in the skin.
Selection of dogs that retain their skin
folds into adulthood has altered the
phenotype to the more heavily wrinkled
‘meat mouth’. The meat mouthed
phenotypes (heavily padded muzzles) have 2–5 times higher serum levels of HA
compared with other breeds and the term hyaluronanosis has been proposed as
a name for this condition. HA is synthesized at the plasma membrane by three
HA synthases (HAS1, HAS2, HAS3); HAS2 is the rate-limiting enzyme. It is
overexpressed in dermal fibroblasts of this breed compared with other breeds,
suggesting a regulatory mutation as a cause of hyaluronanosis.
ii. Clinically, these dogs seem predisposed to AD, recurrent microbial overgrowth,
and demodicosis. Conditions related to excessive mucin deposition, such as chronic
otitis externa (135b) due to stenotic ear canals, are common. Another common
skin disease is the appearance of vesicles of varying size caused by mucin exuding
from the dermis. These are easily diagnosed by gently stabbing or aspirating a
lesion and noting the stringy, viscous nature of the fluid (similar to joint fluid,
which also has a high concentration of HA).
136 Neonicotinoids (imidacloprid, nitenpyram, dinotefuran) act as agonists at

polysynaptic nicotinic acetylcholine receptors and result in paralysis and death of
adult fleas. Phenylpyrazole (fipronil) binds at the GABA-gated chloride channel
causing excessive neuronal stimulation, paralysis, and death of adult fleas.
Avermectins and semi-synthetic avermectins (moxidectin, selamectin) bind to
receptors on glutamate-gated chloride channels leading to flaccid paralysis and
death. Semicarbazone (metaflumizone) works by blocking voltage-dependent
sodium channels leading to the blockage of nerve impulses causing paralysis and
death. Pyrethrins and pyrethyroids work by affecting voltage-dependent sodium
channels of neurons and causing paralysis. Spinosyns (spinosad, spinetoram) are
non-antibacterial tetracyclic macrolides; they cause excitation of insect nervous
systems leading to involuntary muscle contractions, tremors, paralysis, and death.
They also have effects on GABA receptor function, which may contribute to the
mechanism of action.
144

Questions: 137, 138
137 A 4-year-old female cat presented 137
for this lesion seen on the neck (137).
The cat was an indoor cat with no prior
history of skin disease. The owners
reported that the skin lesion seemed to
appear suddenly; however, on further
questioning the owners reported that
the cat had resented petting on the head
and neck for the past several weeks. At
the time of admission, the lesion had
been partially obscured by the hair coat
and its margins and extent delineated
by palpation. The lesion under the
remaining hair coat felt hard, hairs were easily epilated and, although the margins
of the lesion could be elevated, the crust was tightly adhered to the skin. No pain
on palpation could be elicited. Clipping of the hair coat revealed the full extent of
the lesion.
i. What is the medical term for the thick yellow adherent crust?
ii. What are possible differential diagnoses?
138 This dog presented with oral and 138

mucocutaneous ulcerations (138).
i. What are the major immune-
mediated differential diagnoses for a
dog presenting with mucocutaneous
ulcerations?
ii. What are the major non-immune-
mediated differential diagnoses for a dog
presenting with oral mucocutaneous
ulcerations?
iii. The diagnosis is most often
confirmed via biopsy. What is the
optimum procedure for obtaining a
biopsy from ulcerative lesions?
145

Answers: 137, 138
137 i. Eschar, a general term used to describe a slough of dead tissue on the surface
of the skin.
ii. Differential diagnoses are difficult due to lack of information. History suggests
the onset was several weeks prior to presentation; the appearance of the lesion
supports that hypothesis. Strictly from the clinical appearance of the lesion, radiant
thermal burn is a major differential diagnosis. These are common in cats that
sit near heat stoves or fireplaces; close enough for tissue damage but far enough
from immediate danger of a burn. Sun bathing in geographic regions with intense
direct sunlight or repeated sleeping on electronic equipment that generates heat
can also cause radiant thermal injuries of varying severity. Given the location, it is
important to determine if the cat had received injections in this area or if spot-on
topical flea products had been applied. Injection reactions that are irritating are
likely to cause acute ulcerative lesions noticed by owners. Spot-on flea control
products typically do not cause irritant reactions, but are associated with focal
areas of non-inflammatory hair loss occasionally preceded by erythema. Grooming
of this area is possible; if a topical caustic agent had contacted the hair coat and
skin, it seems likely the cat would have been presented earlier for oral/tongue
lesions. There are cases of eschar lesions in people caused by Bartonella henselae
and rickettsial diseases post tick bite.
138 i. Bullous pemphigoid, epidermolysis bullosa acquista, pemphigus vulgaris,

paraneoplastic pemphigus, EM, SLE, drug reaction, linear IgA bullous dermatosis,
TEN.
ii. Renal failure should be ruled out at the time of presentation. Irritant reactions
can cause oral ulceration; this can often be determined from the history or pattern
of the ulcerations. Foreign body reaction (e.g. mechanical removal of plant material
[burrs] from hair coat by chewing) can cause oral ulceration. It is important to rule
out infectious causes of oral ulceration (e.g. viral, candidiasis); oral ulceration due
to infection is rare and the host is likely to be immunocompromised.
iii. If oral ulcerations are present, it is important to look for intact vesicles and/or
bullae; these are the primary lesions that lead to ulcerations. If vesicles are small,
they can be harvested with a large skin biopsy punch (>6 mm); however, care
must be taken not to rupture the lesion. If bullae are present, these lesions can be
collected via elliptical incision. If no primary lesions can be found, an elliptical
incision that extends from ‘normal’ to ‘ulcerated’ tissue should be submitted. The
most valuable area of the biopsy will be the junctional area between the ulcer and
‘normal’ tissue.
146

Questions: 139, 140
139a 139b
139 Note the nasal depigmentation in both of these cats (139a, b). What are
possible differential diagnoses?
140 A 10-year-old female spayed shih tzu 140

dog presented for non-healing wounds
and draining tracts over the dorsum.
The owner had noted the matting of
the hair coat approximately 1 week ago
and assumed that the dog needed to
be groomed. The dog had no history of
prior skin disease. On examination, there
was a thick, dried purulent exudate on
the dorsum, with matted hair within the
crusts. When the crusts were lifted, the skin
beneath was eroded and fresh exudation
was present. The dog was notably painful
when the skin was palpated. The hair coat
was clipped; multiple draining lesions
were seen once the matted hair and crusts
were removed (140). The owner also
reported that the dog has been coughing
for the past week and her appetite was somewhat decreased. On palpation, the
submandibular, prescapular, and popliteal lymph nodes are approximately three
times larger than they should be bilaterally.
i. What diagnostics do you recommend for this patient?
ii. What are your differential diagnoses with regard to the draining lesions on the
dorsum of this dog?
147

Answers: 139, 140
139 The number of differential diagnoses 139c
is limited because depigmentation is not
a common skin problem in cats. Any
inflammatory reaction that damages
the epidermis and basal cells containing
melanocytes can lead to depigmentation.
In general, depigmentation can result
from glucocorticoids, inflammation
(although hyperpigmentation is more
common), post trauma, neoplasia,
immune-mediated diseases, or leuko
derma (congenital, hereditary). Depigmentation has been reported in association
with rhinitis in cats. Close inspection of the nose in both cats reveals a lack of active
inflammation, making it difficult to identify the underlying cause. Depigmentation
of the nose is a hallmark of lupus; however, cutaneous lupus is still not well
documented in cats. Vitiligo has been reported as a breed-associated disease in
Siamese cats. Nasal depigmentation in dogs can be a sign of lupus; however,
inflammation is typically present (139c).
140 i. Deep skin scraping, cytology, and culture and susceptibility are recommended.
Skin biopsy may be indicated depending on the results of these initial diagnostics.
In general, draining tracts are indicative of a deep, infiltrative disease process (e.g.
deep bacterial infection, fungal infection, sterile inflammatory response, neoplasia).
When draining tracts or nodules are present in any patient with skin disease, skin
biopsy is recommended along with culture and susceptibility. For this patient, a
CBC, serum biochemistry, and urinalysis are indicated because of the presence
of systemic signs. The peripheral lymph nodes should be aspirated and thoracic
radiographs considered because of the owner’s report of coughing.
ii. The presence of draining tracts indicates a deep, infiltrative disease process
involving the skin. Differential diagnoses include infection (deep bacterial
infection including atypical infection [mycobacterial, nocardiosis, actinomycosis];
fungal infection including blastomycosis, coccidioidomycosis, histoplasmosis,
sporotrichosis, opportunistic fungal disease and/or kerion reaction), inflammatory
conditions (sterile granuloma/pyogranuloma syndrome, sterile nodular panniculitis,
SLE, vasculitis), and neoplasia (MCT, cutaneous lymphoma, metastatic neoplasia).
Depending on the history, drug eruption, topical irritant reaction, post-grooming
furunculosis, and thermal burn should also be considered. In this case, skin
scrapings revealed Demodex canis mites. This was a case of adult-onset generalized
demodicosis secondary to lymphoma.
148

Questions: 141, 142
141 A 4-year-old female spayed boxer 141a
dog is presented for a mass on the
medial aspect of the right pinna (141a).
i. What are your differential diagnoses
for the lesion?
ii. Histopathologic examination of the
mass showed ‘multiple long papillary
projections covered by a massive
amount of partially parakeratotic scale crust. The epithelial cells covering the
papillae are markedly hyperplastic and exhibit normal maturation. Occasional
ballooning regeneration is present in the basal cell layer. Many of the cells have
pale blue cytoplasm and occasional koilocytes with cytoplasmic clearing are
evident. Cells rarely contain pale basophilic intranuclear inclusion bodies’. What
is the diagnosis based on the clinical signs and histologic findings?
iii. This disease has several forms or clinical syndromes in the dog. Describe them.
142 A 5-year-old female spayed mixed- 142

breed dog presents with an acute onset
of skin lesions. Lesions developed in
the third week of cephalexin treatment
for a bacterial pyoderma. Small 1–2
mm erosions/ulcers are symmetrically
distributed on the hard palate and on
the lips. Skin lesions are most severe on
the ventral abdomen. Numerous and
coalescing, polycyclic rings of erythema
are diffusely distributed on the ventral
thorax, abdomen, and flanks (142). Additionally, there are small erosions at the
mucocutaneous junction of several mammae and the anal ring. A skin tag on the
ventral chest is not affected. There are no findings suggestive of internal disease.
In addition to the cephalexin, the dog received chlorhexidine shampoo, an oral
ivermectin-based heartworm preventive and a topical imidacloprid-containing flea
preventive administered 21 days ago. Results of a CBC and serum chemistries are
within normal range. A skin biopsy of several erythematous rings shows cell-poor
interface dermatitis with multiple apoptotic keratinocytes in all cell layers of the
epidermis, satellitosis, and parakeratotic hyperkeratosis.
i. Based on the historical, clinical, and histopathologic findings, what is the most
likely diagnosis?
ii. What in the history is compatible with your likely diagnosis?
iii. How would you treat this dog?
149
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Answers: 141, 142
141 i. Exophytic viral papilloma, non- 141b
viral squamous papilloma.
ii. Exophytic viral papilloma.
iii. Oral papillomatosis (141b) is usually
a self-limiting but contagious viral
disease; however, lesions may persist or
progress to other body regions. Ocular
papillomas are related to oral papillomas,
and are considerably less common.
Lesions typically are confined to the
conjunctiva, cornea, and eyelid margins.
Canine genital papilloma is presumed
to be similar to oral papillomatosis because the lesions are contagious. Cutaneous
papillomas are typically solitary lesions induced by a subtype of papillomavirus. These
masses are caused by a papillomavirus that is different from the virus which causes
oral papillomatosis in the dog. Lesions are most common in dogs <2 years of age,
but they can occur in any age dog. Cutaneous inverted papilloma is a rare endophytic
variant of the more common cutaneous exophytic papilloma. Multiple papillomas of
the foot pad are found primarily in adult dogs; however, it is not confirmed if lesions
are due to a papilloma virus. Papillomavirus-associated pigmented plaques have been
described primarily in miniature schnauzer and pug dogs. This form of papillomavirus
has shown potential for malignant transformation.
142 i. EM, a T lymphocyte-mediated reaction against individual keratinocytes

resulting in cell death (apoptosis). EM is an uncommon idiosyncratic cutaneous
reaction pattern having multiple forms of bizarre patterns of erythema with
mucosal and cutaneous ulceration.
ii. Idiosyncratic drug reactions or eruptions can look like and mimic many other
dermatoses. The index of suspicion is heightened based on the temporal history
(timing of drug administration until observed lesions) and distribution of lesions
(especially in non-haired or sparsely haired body regions including the oral cavity).
iii. Search for an underlying trigger of EM and remove it, if possible. Given the
onset of clinical lesions during the prescribed course of cephalexin, this antibiotic
is highly suspect. Chlorhexidine likely was not involved in the disease process
because not all of the bathed skin was affected. Likewise, the use of this topical
treatment likely did not cause the oral lesions. Nevertheless, it is prudent to
discontinue all previously administered medications where applicable. Since this
patient did not have systemic signs associated with the adverse drug reaction, no
other treatments were prescribed and all the clinical lesions resolved 2 weeks after
drug withdrawal.
150

Questions: 143, 144
143a
143b
143 Feline ‘chin acne’ is a clinical reaction pattern in cats (143a, b). The number
of sebaceous glands on the chin of cats is increased; territory marking is exhibited
by facial rubbing on objects. Chin acne occurs when there is inflammation and
plugging of hair follicles. There are a number of diagnostic approaches to feline
chin acne, but one approach is similar to that of canine pyoderma: simple (acute
and/or first time) or complex (chronic and/or recurrent).
i. What are the common differential diagnoses for a cat with a first time occurrence
of chin acne regardless of age?
ii. What are the common differential diagnoses for a cat with chronic or recurrent
episodes of chin acne regardless of age? What diagnostic tests are indicated?
144 What is the name of the biting louse of dogs found only in warm climates, and
what is the name of the biting louse of cats?
151

Answers: 143, 144
143c 143d
143 i. Mild plugging can be due to a

mild keratinization disorder or facial
rubbing. Differentials for lesions that
are more extensive (143a) include der-
matophytosis, demodicosis, Malas
sezia and/or bacterial disease, and acute
dental pain.
ii. Includes chin rubbing due to pruritus
from AD, food allergy, and chronic
dental pain. Clinical presentation usually includes alopecia, swelling, exudation,
papules, pustules, and/or furuncules (143b). Clinical clues that the cat may have
facial pruritus or pain include blunted whiskers and skin lesions on the face and/or
ears. Foreign body reactions can cause chronic chin acne, most commonly keratin
from ruptured hair follicles, plant material, or insect bites (embedded stingers).
Chronic recurrent chin acne can also be caused by keratinization disorders. These
cats will develop lesions at a young age; lesions worsen as a result of inflammation,
follicular rupture, and granulation tissue (143c). Skin biopsy may reveal extensive
dilated comedones and furunculosis, which are difficult to treat due to the cystic
nature of the lesions (143d). Core diagnostics (skin scraping, impression cytology,
DTM fungal culture) are recommended initially. Food trials and allergy testing are
needed to confirm pruritus as an underlying trigger. Biopsy may be warranted in
more difficult cases.
144 Heterodoxus spiniger (dog louse) and Felicola subrostratus (cat louse).
152

Questions: 145, 146
145a 145b
145 A 3-year-old male Labrador retriever 145c

dog from the Midwestern region of the
USA was presented for the problem
of lameness, depression, and cough.
Examination of the dog revealed that
the lameness was associated with lesions
on the paws (145a). A radiograph of the
thorax was obtained (145b). Cytology
from purulent exudate from the margins
of a paw lesion was examined (145c).
i. What is the diagnosis?
ii. What are the current treatment recommendations for this disease?
iii. Besides clinical signs, how is response to therapy monitored?
146 The ventrum of a 3-year-old 146

mixed-breed dog that presented for
the complaint of pruritus and ‘scabs’ is
shown (146).
i. What is the name of the lesion shown
(arrow)?
ii. Impression smears and bacterial cul
tures confirm that this is bacterial pyo
derma. What is this type of pyoderma
commonly referred to as?
iii. Although these lesions are classic
and typical of bacterial pyoderma, what other diseases need to be considered?
153

Answers: 145, 146
145 i. Fungal pneumonia due to blastomycosis with dissemination to the skin.
Blastomyces dermatitidis is a dimorphic fungus that exists in the environment
as a saprophyte; when it is inhaled it transforms into a yeast. This organism is
found predominantly in North America (endemic to the Midwestern region) but
has been identified in Africa, India, Europe, and Central America. Dogs used for
duck and raccoon hunting are at greater risk, possibly because the organism is
common near waterways, especially near beaver dams. The mode of transmission
is via inhalation; dogs are more susceptible than people. This organism has low
zoonotic risk; infections in both owners and dogs are considered to be coincidental
exposure from the same source. However, traumatic inoculation can occur (e.g.
pathologists performing necropsy of an infected host).
ii. Itraconazole is the first-line treatment for non-life-threatening systemic mycoses
without CNS involvement. If there is ocular and/or CNS involvement, fluconazole
is recommended (improved penetration through the blood–brain and blood–
ocular barriers). A comparison of itraconazole versus fluconazole did not reveal
a significant difference with respect to remission or relapse rate. Treatment with
fluconaozle was longer but less expensive than with itraconazole.
iii. Treatment is monitored by urine antigen tests for blastomycosis. The sensitivity
of this test is 93.5% in urine and 87.0% in serum. Treatment continues until there
are two negative tests.
146 i. Epidermal collarette. This lesion is considered a ‘hallmark’ of bacterial

pyoderma.
ii. Superficial spreading pyoderma, also known as ‘exfoliative superficial pyoderma’.
This is a clinical name for a superficial bacterial infection of the skin characterized
by the presence of large epidermal collarettes that spread across the skin with an
advancing margin consisting of a raised crust. Typically, the surrounding skin is
erythematous. This is the most common form of superficial pyoderma in the dog. In
long-haired dogs (e.g. collies and Shetland sheep dogs), these lesions often develop
on the trunk and become large (6–10 cm in diameter), accompanied by large areas
of secondary hair loss. These lesions are seen commonly in dogs with complex
bacterial pyoderma, particularly in dogs with underlying AD. ‘Older’ textbooks
referred to these lesions as ‘bacterial hypersensitivity’ due to their pruritic nature
and occurrence in dogs with underlying pruritic diseases. The mechanism of lesion
development is believed to be associated with a staphylococcal exfoliative toxin
that causes loss of keratinotcyte cell–cell adhesion in the superficial epidermis.
Exfoliative toxins have been identified in Staphylococcus pseudintermedius;
injection of these toxins into mice creates characteristic skin exfoliation.
iii. PF, EM, sterile eosinophilic pustulosis, pustular dermatphytosis, demodicosis.
154

Questions: 147, 148
147a
147 A 5-year-old male neutered Labrador retriever dog with an incompletely

excised peripheral nerve sheath tumor of the distal limb is presented after the
second week of a 4-week definitive-intent radiation therapy protocol (an attempt
to sterilize the tumor field and kill any residual neoplastic cells, leading to an
effective ‘cure’ of the nerve sheath tumor) for the problem of erythema, pruritus,
and varying degrees of desquamation of the skin in the treatment field (147a). The
owners are concerned about how they should be managing him at home.
i. How does progressive radiation dermatitis present in the patient?
ii. What treatment strategies are used to prevent progressive radiation dermatitis?
148 A 4-year-old male neutered Cavalier King Charles spaniel (CKCS) presents with
moderate neck pain and a slight left-sided head tilt of 2 weeks’ duration. The dog
also ‘guards’ or ‘protects’ his neck and will occasionally spontaneously vocalize.
The dog scratches his neck and ears frequently, but pruritus is absent elsewhere
on the body. Recently, the owner thinks the dog has developed impaired hearing.
The dog has no previous history of ear disease. Clinical examination reveals the
dog to have neck pain along with a slightly diminished left-sided menace response.
Mentation, cranial nerve reflexes other than menace response, postural reactions,
and conscious proprioception are normal. No skin lesions are present. From gross
inspection, the ears are free of odor and discharge.
i. Based on the available information, what are the possible locations of the lesion
or abnormality that is causing the dog’s presenting signs.
ii. Otic examination shows the epithelium to be smooth and intact with no
purulent, ceruminous, or hemorrhagic discharge. No visible mass is present in
either canal. The left tympanic membrane is opaque and bulging laterally into the
external canal. Given the patient’s signs, are there other diagnostics you would like
performed?
155

Answers: 147, 148
147 i. Early radiation dermatitis manifests as 147b
erythema, pruritus, and scaly dry desquamation.
Advanced radiation dermatitis manifests as moist
desquamation and necrosis in extreme cases
(147b).
ii. There is no gold-standard approach in the
prevention and management of progressive
radiation dermatitis. Practice tends to be institu
tion and site specific. Veterinary and human
clinical trials have evaluated the efficacy of various
treatment recommendations, but results have been
mixed. As preventives, aloe vera and vitamin E
topical ointments/gels, oral zinc and pentoxifylline
supplementation, topical corticosteroid, and
sucralfate creams are frequently prescribed. A
small randomized study (20 human patients)
did show statistical benefit using a topical cream
containing hyaluronic acid, glycyrrhetinic acid, and anti-protease and antioxidant
compounds during therapy; however, patient numbers were too small to fully
evaluate the potential benefit of this therapy.
148 i. Facial nerve, cervical spine, and/or external, middle and/or inner ear.
ii. MRI of the brain, foramen magnum region, cervical neck, and bullae is indicated
to exclude Chiari-like malformation/syringomyelia and primary secretory otitis
media. Both of these conditions are thought to be hereditary in CKCSs. Canine
Chiari-like malformation occurs when a portion of the cerebellum descends
through the foramen magnum, resulting in abnormal flow and pressures in CSF.
Syringomyelia is the condition caused by these dynamic changes in CSF leading
to excessive cystic fluid accumulation within the spinal cord (‘syrinx’ formation),
which can be visualized with advanced imaging modalities. Common clinical
signs associated with Chiara-like malformation/syringomyelia in dogs include
cervical hyperesthesia, pericervical pruritus seen as scratching, diminished menace
response, facial nerve deficits, proprioceptive deficits, and seizures. Some CKCSs
may remain asymptomatic in spite of documented imaging abnormalities.
156

Questions: 149, 150
149
149 A 16-week-old male intact Shih tzu puppy presented with a 1-month history of
progressive skin problems. Clinical signs were noted shortly following administration
of the second series of vaccinations. The owner described swelling and redness,
which began around both eyes and progressed to include the muzzle and chin (149).
The dog was noted to be severely pruritic/uncomfortable to the point of causing
traumatic ulcers and erosions along the affected regions. Although reported to be
a quiet puppy in general, the dog also appeared to be somewhat lethargic recently.
There had been no beneficial response noted to a 2-week course of oral antibiotics
or a tapering anti-inflammatory course of prednisone. On physical examination,
submandibular, prescapular, and popliteal lymph nodes were enlarged.
ii. What diagnostic recommendations should be made for this patient?
iii. Cytology of the lymph node aspirate showed suppurative inflammation without
any obvious infectious organisms. Biopsy of the skin on the muzzle showed diffuse
pyogranulomatous dermatitis and panniculitis. Special stains were all negative.
What is the diagnosis based on this information?
iv. How is the disease treated?
150 What is PSOM?
157

Answers: 149, 150
149 i. Demodicosis, deep pyoderma, dermatophytosis, angioedema, distemper,
juvenile cellulitis.
ii. Skin scrapings, impression smears of the exudates, fine needle aspirate of the
lymph nodes, possible culture and susceptibility. Dermatophytosis rarely causes
systemic signs and lymphadenopathy. In some cases skin biopsy may be needed to
confirm the diagnosis.
iii. Juvenile cellulitis.
iv. Juvenile cellulitis is treated with immunosuppressive doses of prednisone;
however, combination treatment with cyclosporine has been shown to be an effective
treatment for the disease. Lack of early recognition can lead to permanent scarring.
If a positive response is noted to appropriate therapy within 4–5 days of initiation,
the long-term prognosis is good. In severely affected dogs, permanent scarring may
be a noted consequence of the disease. Untreated, the disease can be fatal.
150 Primary secretory otitis media, a condition most commonly seen in Cavalier
King Charles spaniels (CKCSs). It occurs when an excessive amount of viscous
mucoid material fills the tympanic cavity, resulting in a bulging ipsilateral ear drum
and neurologic abnormalities including craniocervical pain, head tilt, ataxia, facial
nerve paresis/paralysis, nystagmus, and seizures. Scratching of the head/neck,
with or without otitis externa, and impaired hearing are other reported signs.
Mucus accumulation is thought to be secondary to poor drainage caused by a
pressure mismatch resulting from uncoordinated muscular movements between
the Eustachian tube and the pharynx. Removal of the mucus plug (150) followed
by bulla flushing after myringotomy (general anesthesia required) drastically
improves or resolves signs. Relapses are common, requiring repeated myringotomy
and bulla content evacuation. Insertion of tympanostomy tubes to improve
drainage of the bulla has been reported. MRI of the skull and neck is generally
recommended in CKCSs with clinical signs possibly attributed to PSOM or Chiari-
like malformation/syringomyelia since similar signs may be present with each
condition. Documentation of concurrent Chiari-like malformation/syringomyelia
abnormalities in a dog with PSOM is important as the patient’s signs may not
improve or resolve after solely removing the mucus plug from the middle ear.
150
158

Questions: 151, 152
151a 151b
151 A 5-year-old female spayed boxer dog was presented for the complaint of
lameness, depression, anorexia, and pain and exudation on the dorsum along the
interscapular area. Close inspection of the skin revealed a large focal area of matting
of the hair coat. After the area was clipped, a large number of intact pustules
(151a) was noted. Dermatologic examination revealed crusting of the foot pads
and a diffuse pustular eruption. Cytologic examination of the pustules is shown
(151b). The owner reported that this was the third time the dog had developed a
‘reaction’ in this area post application of a spot-on flea control product. The dog
had no prior history of skin disease. During the first episode the dog developed
only a mild area of erythema approximately 14 days after application. After the
second application, the reaction occurred much sooner (within 7 days) and was
limited to a focal area. This time the lesions developed within 48 hours and the dog
was febrile with a more widespread distribution of skin lesions.
i. What are the cells shown in 151b?
ii. Bacterial culture was negative. A skin biopsy of the area revealed intracorneal
pustules with large numbers of acantholytic keratinocytes. Areas of acantholysis
extended into the hair follicles. Special stains were negative for any infectious
agents. What is the most likely diagnosis?
152 i. What strategies are used to manage radiation dermatitis (see also case 147)?
ii. What is the typical time course and doses at which radiation dermatitis presents?
159
www.Ebook777.com
Answers: 151, 152
151 i. Acantholytic keratinocytes.
ii. The most likely diagnosis is PF. In this case, the underlying trigger was a spot-
on flea control product containing metaflumizone–amitraz. This product has been
associated with pustular acantholytic dermatitis in dogs, suggesting a contact drug-
triggered PF. In a study of metaflumizone–amitraz-associated pustular acantholytic
dermatitis in 22 dogs, the authors confirmed a PF-like drug reaction at the site of
flea control application.
152 i. The treatment site should be clean, dry, and protected from trauma and
irritation. The site can be managed with warm water soaks or gentle washing with
a mild soap and patting dry. Hydrophilic moisturizing creams provide rapid relief
for early dry desquamation and minor irritation. Topical corticosteroid ointments
(e.g. hydrocortisone, triamcinolone) are beneficial for pruritus, but should be
discontinued if moist desquamation develops. Once moist desquamation develops,
longer more frequent soaks should be used for natural debridement. Non-
stick, non-occlusive, and/or hydrogel wound dressings should be used. If moist
desquamation develops with >5–10 Gy remaining, debridement soaks should be
continued and radiation withheld until new skin islets are visualized.
ii. Erythema is variable and closely related to radiation effects (vasodilation) on
vessels. Epidermal changes are based on radiodepletion of cellular compartments
with germinal and stem cells being at greatest risk of injury. Based on turnover
time of canine epidermis (approximately 21 days), progression from dry to moist
desquamation is seen about 2–3 weeks after starting radiotherapy. Although skin
tolerance experiences a significant volume and dose rate accumulation effect,
erythema and dry desquamation typically present at cumulative doses around 20–30
Gy with progression to moist desquamation around 40–50 Gy when administered
in 2 Gy fractions. Epidermal appendages start to display transient loss in function
early and may progress to permanent loss if doses are sufficient. After cumulative
doses of about 10–12 Gy administered in 2 Gy fractions, sebaceous gland and hair
follicle dysfunction is observed.
160

Questions: 153, 154
153
153 This 6-year-old female spayed cat was presented for the complaint of persistent
scaling. The owners had adopted the cat 1 year ago. It lived indoors and there were
no other pets in the household. On questioning, the owners reported a gradual
development of scaling over the last year and moderate pruritus. Except for the
skin lesions, physical examination was unremarkable. Dermatologic examination
revealed diffuse scaling throughout the hair coat including along the ventrum and
legs (153). Some of the hairs were pierced by scales. A small area of the hair coat
was clipped and scales were adhered to the skin. No other lesions were noted.
Although previously recommended at routine health visits, the owners declined
flea control because the cat lived indoors.
i. Given the above information, what is the most likely clinical diagnosis?
ii. How would you confirm your clinical diagnosis?
iii. When cats are presented for an examination, increased scaling is often observed.
What are possible causes?
154 What is known about the relationship between vitamin D and AD in the dog?
161

Answers: 153, 154
153 i. Superficial bacterial pyoderma with or without concurrent Malassezia
overgrowth. Another highly suspect disease would be Cheyletiella spp. because of
the excessive scaling and pruritus.
ii. Impression smears using glass slides and/or clear acetate tape preparations can
be used to identify bacteria and yeast.
iii. Common causes are fear and stress. In the case of fear, adrenaline results in
piloerection and shedding hairs and scales adjacent to the hairs and skin. If the
owner reports the cat has ‘dry skin’ at home, fear would not explain persistent
scaling in its home environment. On the other hand, many more cats with true
dermatologic problems have had their scaling attributed to ‘humidity or dry hair
coat’. The theory is that cats spend large portions of the day sunbathing or nestled
up against a heating duct and this heat results in ‘dry skin’. Sunbathing and heat
seeking behavior are universally present in this species, yet only a small number of
cats exhibit this problem. This becomes problematic when trying to determine the
time line (start of the disease) and/or seasonality. Other common causes of scaling
include lack of grooming due to obesity or osteoarthritis.
154 Vitamin D is increasingly being recognized as an immune modulator in humans.

Increasing evidence suggests the potential for vitamin D to inhibit Th2 responses.
Furthermore, evidence suggests that vitamin D might promote cathelicidin
expression on the skin; cathelicidins are important in skin defense mechanisms
against microbial infections (e.g. bacterial infections). Vitamin D supplementation
has been shown to provide significant improvement in lesion scores in a small
group of children with winter-related AD. Further research is needed, but these
findings suggest a possible role for vitamin D with regard to allergies in humans.
In dogs, there has been little work investigating the potential role for vitamin
D in allergies. A recent study measured serum 25-hydroxyvitamin D [25(OH)D]
concentrations in dogs receiving anti-inflammatory prednisone for the treatment
of AD and compared these levels with those of healthy dogs. The dogs treated
with prednisone did not have significantly different levels of 25(OH)D compared
with the healthy dogs. However, dogs with a suboptimal response to prednisone
were found to have significantly lower levels of 25(OH)D compared with dogs
that had marked improvement. The study also compared 25(OH)D levels between
dogs that responded well to cyclosporine with suboptimal responders and found
no significant differences. Further studies are needed to investigate the relationship
between vitamin D and response to steroids in atopic dogs and/or if it can be used
as an adjuvant treatment for canine AD.
162

Questions: 155, 156
155a 155b
155 A 7-year-old male castrated Boston terrier dog presented for multifocal
erythema and hair loss of several months’ duration (155a, b). The owner also
reported that the dog would frequently have episodes of exercise intolerance,
fatigue, frequent panting, and near respiratory distress with noticeable inspiratory
stridor. The owner also felt that the dog’s head had changed from how it used to
look; the eyes appeared to be bulging more than usual. On examination, the dog’s
skin was noted to be thin and atonic.
i. What is canine acromegaly (hypersomatotropism)?
ii. What is the typical signalment?
iii. Which of the dog’s clinical signs are compatible with this diagnosis?
156 A 3-year-old female spayed Labrador retriever dog was presented with
multifocal, progressive, non-pruritic areas of alopecia on the head, neck, and legs.
The lesions were not specific to any particular condition and it was determined that
a skin biopsy from the affected areas would likely provide the best information to
identify the condition affecting this patient.
i. Which areas for biopsy should be collected from this patient?
ii. How should the skin biopsies be collected?
iii. What should be done with the collected skin biopsies?
163

Answers: 155, 156
155 i. An excess of circulating growth hormone, often caused by an increase in
circulating progesterone. The disease may develop following prolonged adminis
tration of progestins, especially medroxyprogesterone acetate, or in intact older
female dogs during diestrus. Rarely, acromegaly may be caused by a growth
hormone-secreting tumor of the pituitary gland.
ii. Middle-aged to older intact female dogs.
iii. The most commonly reported clinical signs include inspiratory respiratory
distress and stridor. This is due to the increase in soft tissue in the oropharyngeal and
orolaryngeal areas. On physical examination, this patient had a severely elongated
and thickened soft palate. Patients with acromegaly may also have increased body
size, often noted as enlargement of the limbs, feet, head, and abdomen. In this
dog’s case, the broader head explained the bulging eyes noted by the owner. In
typical cases the skin becomes thickened and more folded, particularly around
the head, extremities, and neck. This is due to connective tissue proliferation in
the dermis and deposition of hyaluronates leading to interstitial edema formation.
This feature was not noted on skin biopsy from this dog; rather, epidermal atrophy
was reported, a feature common to many endocrine dermatopathies.
156 i. Fully developed lesions or early developing lesions are preferred; ‘older’
lesions are less diagnostic.
ii. Do not shave, wash, or scrub lesions as this could remove diagnostic material.
Gently clip adjacent hairs without touching the skin or removing crusts or scales.
Subcutaneous injection of anesthetic is necessary unless the dog is sedated. Collect
specimens from the center of lesions when using a punch biopsy. For transitional
areas, use an elliptical excision that spans affected and non-affected skin; orient
the ellipse parallel to hair growth. In biopsies collected from areas of alopecia, it
is important to mark a line parallel to the direction of the hair growth (156). This
helps the pathologist orient biopsies to be trimmed for histologic examination.
iii. Gently blot the specimen to remove blood and immediately place in a solution
with 10% neutral buffered formalin, with the ratio of tissue to formalin at least
1:10. Punch biopsies can be placed directly in formalin; excisional biopsies must be
placed on a piece of wooden tongue depressor or cardboard to avoid curling and
folding of specimens. Larger punch biopsies should not be placed in a specimen
mesh/cassette; this can distort specimens. Formalin only penetrates 1 cm of tissues.
Specimens >1 cm should be trimmed to allow proper fixation. After fixing for
24 hours, a smaller container with less
formalin can be used to submit samples. 156
164

Questions: 157, 158
157 With regard to the dog in case 155:
i. How is canine acromegaly diagnosed?
ii. How is the disease typically treated?
158a 158b
158c 158d
158 The term ‘pyoderma’ literally means ‘pus in the skin’. By convention, when
the term ‘pyoderma’ is used in veterinary dermatology it is assumed to be referring
to bacterial skin infections caused by Staphylococcus spp. Bacterial pyoderma can
be classified by a variety of schemes. One scheme is based on whether or not an
underlying trigger can be identified: secondary or primary (i.e. idiopathic). Another
scheme classifies the infection based on the underlying etiology (Staphylococcus
spp., Nocardia). The most common scheme used in clinical practice is classification
by depth of pyoderma: superficial or deep.
i. What clinical manifestations of bacterial pyoderma are demonstrated in these
four images (158a–d)?
ii. What is difficult about the classification of intertrigo and pyotraumatic
dermatitis?
165

Answers: 157, 158
157 i. A tentative diagnosis is made based on 157
supportive history and clinical signs in an intact,
cycling female dog. This dog did not have the
expected signalment. Documentation of increased
serum growth hormone is required to diagnose
the condition definitively. Currently, there are no
commercially available assays to detect circulating
growth hormone in the dog. Increased insulin-like
growth factor is consistent with a diagnosis of
acromegaly and may be used as a marker of disease.
An adrenal hormone panel may document increased
progesterone hormone; this was elevated in this patient.
ii. In most cases where progesterone-induced acromegaly is proven or suspected,
withdrawal of exogenous progestin therapy and/or ovariohysterectomy are
curative. Clinical signs associated with the excess circulating growth hormone,
including tissue proliferation, are typically reversible. Medical management with
aglepristone is a viable treatment option. In atypical cases, work-up for pituitary
neoplasia should be pursued and treated. Because this dog had clinical signs of
increased growth hormone and an elevation in insulin-like growth factor and
progesterone, pituitary neoplasia was suspected. The dog responded well to
mitotane administration, with near complete resolution of clinical signs (157).
158 i. (158a) impetigo, (158b) spreading pyoderma, (158c) folliculitis, (158d)

deep pyoderma.
ii. These two clinical presentations can appear clinically and/or histologically as either
superficial or deep pyoderma, depending on the etiology and chronicity. Intertrigo is
caused by moisture, maceration, and chronic friction from appositional areas. These
lesions are often managed similarly to focal areas of superficial pyoderma. Histologically,
epidermal lesions consist of severe erosion and/or ulcerations with exudation. Superficial
crusts contain neutrophils and serum and are often colonized by bacteria. Necrosis
may extend into the dermis and there may be mild to moderate neutrophilic or
lymphoplasmacytic infiltration. Pyotraumatic dermatitis has two clinical presentations
with different histologic findings: (1) epidermal lesions consisting of severe erosion,
ulceration, and exudation. Superficial crusts contain degenerating neutrophils and are
often colonized by gram-positive bacteria. The adjacent epidermis may be spongiotic.
Necrosis and inflammation may extend into the dermis with a lymphoplasmacytic
infiltrate with or without eosinophils; (2) in addition to the findings described above,
deep folliculitis, follicular rupture, and diffuse inflammation in the deep dermis can also
be seen. Coalescence of ruptured furuncles is a common finding. The underlying trigger
for both forms of pyotraumatic dermatitis is usually a hypersensitivity reaction.
166

Questions: 159, 160
159 A cat rescue organization asked for assistance 159
with recurrent Otodectes spp. infestations. The
rescue facility’s admission of cats was limited
and based solely on space availability. During
admission, cats were screened for diseases, housed
in individual cages in an isolation room for 14
days, vaccinated for feline upper respiratory
diseases and panleukopenia, and prophylactically
administered a single application of selamectin.
After this period, if room was available, cats
were moved to large open floor adoption rooms
appropriately furnished for cats. If room was not available, cats remained in
individual cages until such space was available. A careful investigation of the facility,
the cats, and medical records revealed that Otodectes infestations were occurring
only in rooms where cats were allowed to co-mingle. In addition, there was no
evidence that cats with clinical ear mite infestations received treatment other than
one application of selamectin. Clinical signs varied from typical brown-black debris
to severe pruritus, as shown here (159). The rescue facility director is concerned
about environmental infestation of the group housing rooms with Otodectes spp.
What is the likelihood that cats are being reinfested from the environment?
160 A 4-month-old cat was presented 160

for the problem of hair loss and
crusting on the ears. Skin scrapings,
flea combings, and ear swabs were
negative for parasites. A Wood’s lamp
examination of hairs plucked from
skin lesions revealed intrafollicular
bright green fluorescence of the hair
bulbs. A direct examination is shown
(160). A DTM plate was inoculated via
toothbrush fungal culture technique. Further questioning revealed that this was
a single cat household and the cat had only been in the home for 3 days prior
to presentation. Because the kitten was not yet litter box trained, the kitten was
confined to a small room in the home.
i. Can you make a definitive diagnosis at this point? If so, what is it?
ii. The owner is unwilling to commit to your treatment recommendations pending
confirmation of the fungal culture. What recommendations are important to make
during the 7–14 day incubation period?
167

Answers: 159, 160
159 It is possible. The survival of O. cynotis mites off the host has been studied
under both natural and laboratory conditions. At 10°C (50°F) and 95% relative
humidity mites were able to survive in the laboratory for 15–17 days; however,
at 34°C (93.2°F), survival was only 5–6 days. Female mites survived longer
than males. In natural conditions, mites could live off the host for 12 days at
temperatures ranging from 12–14°C (53.6–57.2°F) and relative humidity between
57% and 83%. Looking at both experimental and field conditions, mites can live
off the host over a wide range of temperature (10–34°C [50–93.2°F]) and humidity
(57–95%). Animal facilities will most likely experience a range of temperature
and humidity that will allow for survival of mites off host for at least a few days.
Mites and debris are most likely to collect in areas where cats sleep or frequent,
making these areas ‘hot spots’ for transmission. In this situation, all the rooms
were cleaned, disinfected, and then treated with an environmental product
labeled for control of fleas. Cat beds and perching posts were cleaned or removed
depending on their composition. While rooms were being treated, cats were moved
to individual cages, their ears were cleaned and treated appropriately, and all were
retreated with a spot-on therapy for flea control with dual efficacy against ear
mites (e.g. selamectin, imidacloprid plus moxidectin).
160 i. Yes, Microsporum canis dermatophytosis. This is the only fungal pathogen
of importance in veterinary medicine that fluoresces. The finding of fluorescing
hairs alone is not diagnostic of a dermatophyte infection; however, microscopic
examination of hairs and identification of ectothrix spores is definitive. Note the
prominent cuffs of spores around the hair shaft. Wood’s lamp examinations are
most time- and cost-efficient as a screening tool when examining suspect skin
lesions, especially in cats.
ii. First, pending confirmation of the culture, the owner should confine the kitten to
a room that can be easily cleaned to prevent spore deposition in the environment.
Spores do not proliferate in the environment, but their presence can complicate
post-treatment fungal cultures and potentially be a risk factor for susceptible hosts.
Second, the owner should mechanically clean the room daily and wash areas with
detergent to remove infective material. Disinfectants are used to eliminate spores
not removed via cleaning. Third, the owner should be encouraged to start topical
therapy to minimize spread of spores in the environment. Fourth, any other health
issues should be addressed (e.g. intestinal parasites, vaccinations, diet). Fifth, the
owner should be instructed to use common sense and good hand hygiene after
handling the kitten. Dermatophytosis is a zoonotic disease.
168

Questions: 161, 162
161
161 A 5-year-old male neutered mixed-breed dog presents for loss of nails and
mild intermittent lameness. Initially the dog lost a single nail on the left front
paw, but after several weeks the owners report multiple missing nails from all the
paws. Clinical examination finds a generally healthy dog with problems limited
to the nails. Onychorrhexis, onychodystrophy, onycholysis, onychomadesis, and
onychalgia without purulent paronychia are seen from various and multiple claws/
digits on each paw (161). The dog eats an over-the-counter commercial diet and
receives monthly flea and heartworm prevention. No other animals are in the
household.
i. Define onychorrhexis, onychodystrophy, onycholysis, onychomadesis, onychalgia,
and paronychia.
ii. List some differential diagnoses for single claw abnormalities on a paw as
opposed to when multiple nails from more than one paw are affected?
iii. If distal digit amputation (P3 removal) for biopsy is performed in a dog, what
affected digit(s) would be the best one to remove?
iv. What is symmetrical lupoid onychodystrophy (SLO)?
162 The diagnosis of Microsporum canis dermatophytosis was confirmed in the

cat in case 160.
i. What treatment options should now be considered?
ii. Which topical antifungal agents have been shown to be consistently efficacious
as sole or adjuvant topical therapy?
169

Answers: 161, 162
161 i.
• Onychorrhexis: brittle, splitting, or fragmenting claw along the long axis of the claw.
• Onychodystrophy: malformed claw.
• Onycholysis: claw separating from the underlying dermis (corium).
• Onychomadesis: when a claw has sloughed from the digit (P3).
• Onychalgia: pain associated with the claw.
• Paronychia: inflammation of the claw fold and surrounding soft tissue.
ii. Single claw: trauma, infection, foreign body, neoplasia. Multiple claws: genetic,
nutritional, autoimmune/immune-mediated disease, endocrine/metabolic, neoplasia.
iii. Since the forelimbs bear more weight than the hindlimbs, a rear digit is preferred
for P3 amputation over a forepaw digit. Likewise, any digit other than digit 3 or
4 is recommended as these digits bear more weight than others. Alternatively, if a
dewclaw is affected, it should be removed as it bears no weight at all.
iv. An uncommon condition limited to the nails in otherwise healthy dogs with no
other skin lesions. It occurs most often in young to middle-aged dogs of all breeds, with
German shepherd dogs, rottweilers, schnauzers, and Norwegian Gordon and English
setter dogs overrepresented. This dermatopathy is believed to be immune mediated.
Initially, 1–2 nails are sloughed (often deemed the result of trauma) with others from
multiple paws following suit weeks to months later, resulting in variable lameness.
As nails attempt to regrow, they tend to be brittle, frayed, soft, and/or malformed.
Secondary bacterial and yeast paronychia accentuates these abnormalities.
162 i. Selection of a systemic antifungal drug and treatment dosing interval.

The most commonly used antifungal agents are itraconazole, terbinafine, and
fluconazole. Griseofulvin is fungistatic, but its use has become limited due to the
availability of drugs that are safer and more effective. It is teratogenic and can
be associated with bone marrow suppression. If griseofulvin is used, cats should
be tested for FIV and FeLV, which have been associated with a higher risk of
bone marrow suppression. Itraconazole is very effective against dermatophytosis.
Terbinafine is an allylamine antifungal agent and is also effective against
dermatophytes. Fluconazole has efficacy against dermatophytosis; one author has
used 10 mg/kg q24h with success. Reported side-effects of azoles and allylamines
include occasional vomiting and elevated liver enzymes. Dosing interval is another
treatment option that needs to be decided. Both itraconazole and terbinafine have
been shown to have residual activity in the skin; treatment has been successful with
daily administration until the pet is cured or when used in a pulse therapy format
(week on/week off). The major advantage of pulse therapy is client compliance and
the clinical observation that cats may have less anorexia and gastrointestinal upset.
ii. In-vitro and in-vivo studies have regularly shown that enilconazole, lime sulfur,
and miconazole-based products are consistently antifungal.
170

Questions: 163, 164
163a 163b
163 An 8-year-old male neutered

beagle dog presented on emergency 163c
for evaluation of a ventral cervical
wound of unknown duration. The dog
had been lost for several days prior
to presentation. Initial emergency
stabilization and triage were performed,
and the dog was hemodynamically
stable. Radiographs of the cervical
region and thoracic cavity were un
remarkable other than free gas along
the fascial planes of the cervical region.
The patient was sedated and the wound
examined (163a). The head is to the
right of the image.
i. Describe the wound based on the
wound classification system.
ii. How would you manage this wound?
iii. Initial wound triage was performed and this device was placed onto the
wound (163b, c). What is this device, and what are the mechanisms of action and
recommended settings?
164 A dog weighing 32 kg presents severely depressed, inappetent and with

severely crusted skin lesions. You diagnose PF and the only injectable steroid
available in your clinic is dexamethasone. What is the equivalent calculated dose
of dexamethasone compared with ‘immunosuppressive prednisone’? Based on this
duration of action, when is the soonest you can start prednisone therapy?
171

Answers: 163, 164
163 i. A class III, contaminated or dirty wound. Wound classification is based
on level of contamination and exposure time. Class I is a clean wound or <6
hours duration; class II has significant contamination, or 6–12 hours duration;
class III contains gross contamination or >12 hours duration. Critical level of
contamination for infected wounds is >105 organisms/gram of tissue.
ii. Assess the patient to confirm hemodynamic stability. Thorough physical
and directed (orthopedic, neurologic) examinations should be performed prior
to sedation. The fur surrounding the wound should be widely clipped; sterile
lubricant can be placed in the wound to prevent fur adherence. Debridement of
devitalized tissue should be performed using sharp dissection; questionable areas
should be left, as their appearance can appear worse initially due to vasospasm
and hemodynamic compromise. The wound should be thoroughly lavaged
using copious amounts of isotonic solution (lactated Ringer’s solution) under
moderate pressure. Ideal pressure is 8 psi, which can be generated using a needle
(18–20 guage) connected to an intravenous fluid line and pressure bag inflated
to 300 mmHg. Submit wound tissue or swab for aerobic and anaerobic bacterial
culture and susceptibility analysis. Cover the wound with a sterile dressing and
debridement bandage.
iii. A vacuum-assisted closure device, which produces a negative-pressure wound
environment with the goals of removing wound fluid, improving tissue circulation,
enhancing granulation tissue formation, and increasing bacterial clearance.
The system consists of sterile open-cell foam, egress suction tubing, and an
occlusive adhesive covering, connected to a suction device. Intermittent suction is
recommended at -125 mmHg with a 5 minute ON, 2 minute OFF cycle.
164 Care must be taken when consulting textbooks regarding conversion. It is

common for textbooks and on-line sources to list the ‘relative anti-inflammatory
potency’ and the ‘equivalent dose’. The relative anti-inflammatory potency of
prednisone is 4 compared with 20–30 for dexamethasone. It is common to use on-
line calculators to make conversions and, given this range of 20–30, the equivalent
dose can vary. The most common equivalent dose (mg) for dexamethasone is 0.75
for 5 mg prednisone. So the dog’s total dose of prednisone is 128 mg (4 mg/kg x
32 kg) or 24 mg of dexamethasone (0.75 mg x 32 kg). Dexamethasone has a long
duration of action, with a half-life of >48 hours. Theoretically, prednisone therapy
can start in 48 hours.
172

Questions: 165, 166
165 With regard to case 163, what other options exist for the management of
contaminated wounds?
166a 166b
166 A 3-year-old male castrated Rottweiler-cross dog presented for depigmentation

of the nasal planum, muzzle (166a), hair around the eyes (166b), and nails on all
four paws. According to the owner, the depigmentation was gradually occurring
over the last several months. None of the lesion sites were noted to be pruritic or
painful. The nails were firmly attached at the claw fold; however, the nails had
lost their normal black pigment. On examination, the nasal planum maintained
its normal cobblestone appearance, but it had changed to a mottled gray-pink
color (the owner reported the nose was black). Several white hairs were noted in
the periocular areas as well as the muzzle. The remainder of the dog’s coat was
normal.
i. Based on the clinical appearance, what is the most likely diagnosis?
ii. How is this diagnosis confirmed? What are the defining features?
iii. In what breeds of dogs is this condition common?
iv. What is the treatment for the condition?
173

Answers: 165, 166
165 (1) Local antiseptics such as dilute chlorhexidine (0.005%) have excellent
immediate and persistent antimicrobial activity with limited toxicity at dilute
concentrations. (2) Tris-EDTA alone or in combination with antimicrobials such
as aminoglycosides allows for high local concentrations with limited systemic
absorption. Tris-EDTA causes disruption of bacterial cell walls and enhances
activity of topical antimicrobials. (3) Sugar/honey’s proposed mechanisms include
decreasing inflammatory edema, attracting tissue macrophages to cleanse the
wound, provision of local energy source, and antibacterial properties related to the
liberation of hydrogen peroxide. (4) The proposed physiologic effects of hyperbaric
O2 include enhanced or improved oxygen delivery to cells, antimicrobial effects,
stimulation of phagocytosis, stimulation of fibroblasts, modulation of neutrophils,
and angiogenesis. (5) Silver’s proposed mechanisms of action include potent
antimicrobial properties of silver ion, anti-inflammatory biochemical properties
(decrease matrix metalloproteinase activity), and increasing wound calcium
(increases epithelialization).
166 i. Idiopathic vitiligo; focal depigmentation and concurrent leukotrichia are

highly characteristic.
ii. Diagnosis is based on clinical appearance and biopsy confirmation.
Histopathology typically shows a marked reduction or complete absence of
epidermal melanocytes and melanin. Often, melanin can be seen as fine granular
particles in the superficial dermis or, more often, engulfed in the small to moderate
numbers of dermal melanophages seen in the biopsy specimen.
iii. The disease is uncommon, but it has been reported in Belgian Tervuren,
Rottweiler, German shepherd, and Doberman pinscher dogs. In cats, the condition
is rare and most commonly reported in Siamese cats.
iv. There is no treatment; it is a cosmetic condition. Affected animals should be
protected from excessive sun exposure. Infant-safe sunscreen can be applied to
the affected skin to prevent secondary burn injury and actinic changes. Because
of the cosmetic issues, this disease has a much greater impact on the quality of
life in people; treatment consists of minimizing lesions and repigmentation of the
skin. For people options include medical (topical corticosteroids, systemic steroids,
or other immunomodulatory medications, phototherapy, photochemotherapy,
laser therapy) and surgical treatments (skin grafting, melanocyte suspension
transplantation). Other alternative options include make-up to camouflage the area,
psychotherapy for emotional issues associated with this disease, depigmentation
(skin lightening) to allow for a more generally cosmetic appearance, and alternative
therapies such as herbal/Chinese supplements.
174

Questions: 167, 168
167
167 A 3-year-old male castrated German shepherd dog is presented for management
of year-round chronic otic pruritus (167). You perform ear swab cytology today
and only shed keratinocytes and a mild amount of ceruminous debris are noted.
Otoscopic examination reveals external ear canals of approximately normal
diameter with moderately erythematous canal walls and medial pinnae. Both
tympanic membranes are intact. The pruritus is only partially responsive to
antimicrobial therapy. Regarding the ears, previous treatment of overt infections is
helpful and clinical signs recur shortly after therapy has been discontinued.
i. What is the most likely underlying trigger? What other diagnostics would you
consider for this patient?
ii. What are your recommendations to control the otic pruritus?
168 A 12-year-old male intact Labrador retriever dog is presented with a 14-day
history of acute, non-progressive head tilt. The dog is a working dog, lives largely
outside, and is used for hunting, but has not been hunting in the last 3 months.
On presentation the dog is bright and interactive and has a normal physical
examination except for mild black debris in the external ear canal on both sides.
Neurologic examination is normal except for a left head tilt, severe vestibular
ataxia with falling to the left, and a rotary nystagmus. The owner has not treated
the dog since the onset of the clinical signs and is unaware of any trauma.
i. Based on the findings listed, what is the lesion localization?
ii. What are your top seven differential diagnoses for this patient?
175

Answers: 167, 168
167 i. An allergy. Identification of the underlying allergy is indicated. Two probable
causes are food allergy or environmental allergies. A diet trial (novel protein/
carbohydrate commercial product, hydrolyzed diet, home-cooked novel protein
diet) for at least 6–8 weeks is indicated. If the results of dietary manipulation
and subsequent challenge do not provide appreciable benefit, work-up for
environmental allergies should be discussed with the owner. Immunotherapy may
be a beneficial consideration for the dog given his young age. If the pruritus is
localized to the ears, immunotherapy (year-round) should be discussed from a
cost-to-benefit standpoint compared with medications that may be needed only
intermittently and may be restricted to topical products.
ii. Symptomatic treatment until the cause of the allergic otitis can be identified. This
may include antiseptic cleaners and an otic medication containing glucocorticoids.
Topical tacrolimus treatment was evaluated in atopic and non-atopic beagle dogs
in one study and found to be well tolerated with minimal side-effects.
168 i. This patient is exhibiting signs of vestibular dysfunction. The vestibular

system has three main components: vestibular nerve, vestibular nucleus (in the
rostral medulla oblongata), and cerebellum (flocculonodular lobe). Lesions are
classified as peripheral (involve the receptors or the vestibular nerve) or central
(involve the medulla or cerebellum). Central lesions can be subdivided into medulla
or cerebellar localization. There are three hallmark signs of medulla localization in
veterinary species: paresis, proprioceptive deficits, and mentation changes. Diseases
affecting the cerebellum may also show proprioceptive deficits, but hypermetria
and intention tremors are often also present. Paresis and proprioceptive deficits
occur because of disruption of the descending upper motor neuron or ascending
sensory tracts, respectively, coursing through the brainstem. These tracts are
paired; therefore, if an animal has a left head tilt, a left hemiparesis and/or left side
proprioceptive deficit would be expected. Mentation changes occur with damage
to the reticular activating system, which maintains the level of consciousness;
therefore, damage can result in the animal being obtunded, stuporous, or comatose.
Patients with central disease can have one or more of these findings; however,
if any of these findings are present, central localization should be assumed. The
direction or phase of nystagmus or the presence of other cranial nerve deficits is
not a consideration when localizing a lesion. This dog has a normal neurologic
examination except for a left head tilt, nystagmus, and ataxia, which indicates a
left peripheral vestibular lesion.
ii. Otitis interna, trauma, foreign body, hypothyroidism, neuritis (immune
mediated versus infectious), neoplasia (e.g. lymphoma, nerve sheath tumor), and,
less commonly, idiopathic vestibular disease due to the lack of improvement.
176

Questions: 169, 170
169 A 3-year-old male castrated pug- 169
cross dog presented for severe pruritus
of 1-year duration. The dog had caused
marked self-traumatic lesions including
excoriations and erosions over the
lateral aspects of both forelimbs from the
elbow to the shoulder blades and along
the dorsal cervical region. The lesions
were hyperpigmented in the center and
surrounded by an erythematous border
(169). The lesions had not responded to
appropriate infection control (for both
bacterial infection and yeast overgrowth)
and effective flea and mite control had
ruled out ectoparasite infestation. The
dog had not benefitted from a strict novel protein diet trial and did not improve
when corticosteroids were administered, even when administered at high anti-
inflammatory/low immunosuppressive doses.
i. Based on the clinical appearance of the lesions, what are proposed differential
ii. Skin biopsy samples revealed ‘epidermal hyperplasia and acanthosis, diffuse,
marked, chronic, with hypergranulosis, pigmentation of the basal layers and
orthokeratotic hyperkeratosis’ consistent with chronic self-trauma. No evidence
of vasculitis was detected on multiple biopsy samples. MRI was pursued, which
showed Chiari-like malformation and moderate syringomyelia. What are Chiari-
like malformation and syringomyelia?
iii. How does this abnormal finding relate to the cutaneous lesions noted in the
patient?
170 Desmosomes are 170

adhesion molecules present
in all layers of the epi
dermis. These structures
are responsible for cell-to-
cell adhesion of epidermal
keratinocytes.
i. What molecules are incorporated into the desmosomal unit (170)?
ii. What is the difference between a desmosome, a hemidesmosome, and a
corneodesmosome?
177

Answers: 169, 170
169 i. Vasculitis/vasculopathy, immune-mediate disease (PF, eosinophilic pustulosis,
linear acantholytic pustular dermatosis, lupus), allergic skin disease, neuropathy,
neoplasia (cutaneous epitheliotropic T-cell lymphoma).
ii. Occipital bone hypoplasia, which results in a portion of the cerebellum
descending through the foramen magnum. This malformation results in abnormal
CSF flow through the spinal canal. Syringomyelia describes cystic accumulation of
fluid or cavitation within the spinal cord.
iii. There are several classifications of pruritus including neurogenic pruritus, which
is caused directly by diseases of central structures in the CNS, and neuropathic
pruritus, which is caused by damage to the afferent fibers of the peripheral nerves
or spinal cord, which transmit pruritus to the skin. Although the exact pathogenesis
of pruritus due to Chiari-like malformation and syringomyelia remains unclear, it
is suspected that the malformation leads to damage of the dorsal horn and crossing
of the spinothalamic fibers, and results in interference of processing of sensory
information to and from the skin. This interference causes paraesthesia and
resultant scratching. Whether the scratching is due to pain or pruritus is unclear, as
these two sensations are very closely related. Cervical/cranial hyperesthesia is seen
in approximately 86% of dogs with Chiari-like malformation and syringomyelia,
whereas scratching is seen in approximately 62%.
170 i. The desmosomal unit is composed of two compartments: the intracellular plaque
and the extracellular core. Plakoglobin and plakophilin bind to intermediate filaments in
the intracellular portion of the cell and then bind on the opposite side to desmoplakin.
These structures make up the inner dense plaque of the desmosome. Desmoplakin binds
to desmocollin and desmoglein, which also bind to each other, to span the extracellular
space, forming the core of the desmosome. Different forms of the various molecules are
expressed in different layers of the epidermis. Basal cells primarily express desmoglein
2 and 3 and desmocollin II. Cells in the spinous layer express both desmoglein 1 and 3
and desmocollins I, II, and III. In more superficial layers of the epidermis, desmoglein 1
is expressed in greater abundance compared with desmoglein 3. Desmoplakin I and II
molecules are expressed in all layers of the epidermis.
ii. A desmosome is responsible for anchoring two neighboring keratinocytes together.
They are present in all layers of the epidermis, but are most prominent in the
stratum spinosum (desmosomes give this layer its characteristic ‘spiny’ appearance).
A hemidesmosome anchors basal keratinocytes to the basement membrane. They
provide a structural link between the extracellular matrix molecules (plectin, integrin,
bullous pemphigoid antigens) and keratin intermediate filaments. Corneodesmosomes
are modified versions of normal desmosomes and are important for maintaining
effective and appropriate desquamation of the stratum corneum cells.
178

Questions: 171, 172
171a
171 A 4-year-old Persian cat was presented for the problem of acute onset of
fever, lethargy, and anorexia of 2 days’ duration. At the time of examination, the
skin was markedly erythematous, painful with even minimal manipulation, and
easily torn. During the examination the cat struggled; the skin on the dorsal, neck
avulsed from the neck to the dorsal thoracolumbar area. A positive Nikolsky’s
sign was elicited. Prior to this episode the only abnormality was an eosinophilic
granuloma on the lip. The lesion had been only minimally responsive to previously
administered glucocorticoids. Prior to referral a diet change had occurred and the
cat developed diarrhea, presumably from the diet change. Tylosin powder had
been administered to control the diarrhea. A 6-mm skin biopsy was obtained; the
biopsy site expanded to 25 mm after sampling due to the extreme fragility of the
skin (171a).
i. What are the differential diagnoses for the skin disease?
ii. What is a Nikolsky’s sign?
iii. The histologic description of the skin biopsy showed hydropic degeneration of
basal epidermal cells, full-thickness coagulation necrosis of the epidermis, minimal
inflammation, and separation of the dermal–epidermal junction. What is the
diagnosis, and how is this disease managed? What is the prognosis?
172 Desmosomes have important implications in certain dermatologic diseases.

In which diseases of dogs and cats do desmosome functions (or dysfunction)
contribute to the pathogenesis? What is the pathogenesis of these conditions as it
relates to desmosome molecules?
179
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Answers: 171, 172
171 i. Inherited collagen defect (i.e. 171b
EDS), idiopathic skin fragility syndrome,
hyperadrenocorticism. This case is com
plicated by the fact that the cat shows signs
of systemic illness; the differential diagnosis
list should be expanded to include drug
eruption, TEN, and EM.
ii. Nikolsky’s sign is elicited by applying
pressure to the edge of a vesicle, bulla, or patch
of skin. It is positive when the outer layer of
the skin is easily rubbed off or pushed away. A positive ‘Nikolsky’s sign’ indicates poor
cell cohesion; it is often seen in pemphigus, TEN, EM, or drug reactions.
iii. TEN. Wound management and supportive care are necessary. The prognosis
is considered poor to guarded. In this case, TEN was presumed due to tylosin
administration. Because of the extreme fragility of the skin, a large defect was created
when the hair coat was clipped (171b). To prevent further tearing of the skin, sterile
wound bandages were applied and secured with surgical stockinet material. Withdrawal
of tylosin resulted in return of the cat’s appetite within 24 hours. Silver sulfadiazine was
used to control wound infection. Over the next 6 months the cat’s wounds contracted;
the only defect post resolution was contraction of the skin between the ears.
172 The most common diseases are the pemphigus complex of diseases (PF,
pemphigus vulgaris, paraneoplastic pemphigus). The acantholytic feature of these
diseases is due to targeted autoantibodies against various components of the
desmosome molecules, leading to detachment of the desmosomes and separation
of keratinocytes from neighboring cells. For pemphigus vulgaris, desmoglein 3 has
been identified as the major autoantigen in dogs as well as in people. The same
molecule has also been implicated as one of the autoantigens in paraneoplastic
pemphigus along with other plakins including envoplakin and periplakin. In
people, desmoglein 1 is the major autoantigen in PF. Recently, desmocollin I
has been identified as one of the major autoantigens in PF in the dog. Darier’s
disease is a rare genodermatosis that has been reported in both people and dogs.
The condition presents as hyperplastic skin with crusted and scaly plaques.
Desmosomes are rare or absent; cleft formation and detachment of keratinocytes
occur in multiple layers of the epidermis. Trichophyton spp. dermatophytes and
Staphylococcus pseudintermedius bacterial organisms each produce proteolytic
enzymes that can disrupt the adhesive properties of desmosomes. This is seen in
superficial pustular dermatophytosis and bullous impetigo exfoliative pyoderma;
both conditions have been reported in dogs.
180

Questions: 173, 174
173 A 5-year-old male Yorkshire 173
terrier dog presented for depression,
lethargy, anorexia, and lameness of 5
days’ duration. Prior to presentation,
the dog was healthy and had no
previous medical problems. Physical
examination revealed an elevated rectal
temperature, petechial and ecchymotic
hemorrhages over the body, peripheral
lymphadenopathy, cough, and the facial
lesions shown (173). Examination of
the mouth revealed pale gums, wide
spread petechial hemorrhages, ulcers, erosions, and vesicles. In addition, there
were central areas of necrosis and ulceration on the foot pads. The dog was not
receiving any medications and flea and tick control consisted of manual removal
of fleas and ticks by the owner.
i. What are the most common viral tick-borne pathogens and their current
geographic distributions?
ii. What are the most common bacterial tick-borne pathogens and their current
common geographic distributions?
iii. What are the most common protozoan tick-borne pathogens and their current
geographic distribution?
iv. What is a ‘dry ice tick trap’ and a ‘tick drag’?
174 An IDT is performed on a 3-year-old male castrated Labrador retriever dog

with a history and clinical signs consistent with AD. Twenty-five minutes after
the test is complete the dog has very strong positive reactions to house dust mites
(D. farinae) and storage mites (Acarus and Lepidoglyphus spp.). At the time of
discharge, the dog does not have any erythema or lingering wheal formation from
the IDT. Approximately 6 hours after discharge, the owner calls and reports that
at the site of the IDT there are multiple focal areas of erythema and swelling; the
dog is intensely pruritic.
i. How do you explain to the owner what has happened?
ii. What is the typical approach to treatment? How do you manage this?
181

Answers: 173, 174
173 i. Tick-borne encephalitis (central Europe), louping ill virus (GB, Ireland).
ii. Borrelia spp. (USA, Europe, Asia, Japan, Canada, Africa, Brazil), Anaplasma
spp. (USA, Europe, South America, Africa, Middle East, Southeast Asia), Rickettsia
spp. (USA, Latin America, Central and South America, Europe, Africa, India, parts
of South East Asia).
iii. Babesia spp. (Europe, tropical and subtropical regions, USA, parts of Africa,
Japan), Hepatozoon spp. (southern Europe, Japan, Thailand, Philippines, India,
Africa, Middle East, South America, southern USA).
iv. Both are used to decrease the population of ticks in a small area without using
pesticides. A dry ice tick trap is one of many non-pesticide methods for local control
of ticks in the environment and it takes advantage of the tick’s natural attraction
to carbon dioxide. The edge of a square wooden board is covered with strips of
masking tape or duck tape sticky side up. One kilogram of dry ice is placed in a
plastic bucket with 10–20 holes punched near the bottom. The bucket is placed on
the board and ticks are trapped in the sticky tape. The trap will last for approximately
2–3 hours. For a tick drag, light colored flannel cloth is dragged across vegetation
where ticks may be waiting for a host. The ticks will attach themselves to the cloth.
After ‘dragging the area’, the cloth can be burned or sprayed with an insecticide.
174 i. This dog is experiencing a late-phase reaction to the allergens injected during
the IDT. This late-phase reaction is IgE mediated and is thought to be caused by
mast cell degranulation, chemoattraction, and inflammatory cell infiltration. In
human studies it has been shown that the incidence of late-phase reaction increases
with increasing concentration of injected allergen. In people, if an individual has a
late-phase reaction, it is believed to be associated with a higher degree of allergen
hypersensitivity. One study showed that 40% of atopic dogs had late-phase
reactions after intradermal injection of house dust mite allergen.
ii. It is important to prevent self-trauma to the affected area from biting, licking,
chewing, and scratching, so an Elizabethan collar or shirt may be used. If the
clinical signs are mild, cold compressing may provide some temporary relief.
Topical corticosteroids (sprays, gels, lotions) may help ease the erythema and
pruritus. If that does not provide relief, a short course of an anti-inflammatory
dose of oral corticosteroids (prednisone or prednisolone) can be considered. The
authors routinely ask owners to take digital pictures if any late-phase reactions
are seen after discharge. The late-phase reaction provides additional information
about the IDT and can help with the formulation of immunotherapy.
182

Questions: 175, 176
175a 175b
175 A 6-year-old male castrated Devon Rex cat presents for persistent waxy
debris on the skin and overgrooming of all four limbs (175a, b). Skin cytology is
performed and numerous yeast organisms are noted from around the nail folds.
Although the owners have not reported overt signs of otitis externa, you notice on
physical examination that both external ear canals contain a large amount of dark
brown, waxy debris. Similar organisms are noted on ear swab cytology.
i. What breeds of cats are noted for Malassezia overgrowth of the skin and ear
canals?
ii. What species of Malassezia have been reported in cats?
iii. How is the disease condition managed typically?
176a 176b
176 This fungal culture plate (176a) was inoculated 18 days ago from a cat
undergoing both systemic and topical treatment for dermatophytosis. Note the
lack of growth in the center and the ring of fungal growth on the margins of the
plate. Cytologic examination of the growth is shown (176b). The growth on this
plate was subcultured onto Sabouraud’s dextrose agar, incubated at 37°C, and
confirmed to be M. canis. What was happening with the treatment culture?
183

Answers: 175, 176
175 i. Although any cat with signs of otitis externa may have overgrowth of
Malassezia on cytology, certain breeds tend to be more prone to this superficial
mycosis. Devon Rex cats and Sphynx cats have a higher likelihood of Malassezia
overgrowth when compared with other domestic cat breeds. When similar breeds
are assessed (e.g. Devon versus Cornish Rex cats), the Devon Rex still shows
higher prevalence of Malassezia overgrowth. Both Devon Rex and Sphynx cats are
prone to primary cornification defects (primary seborrhea), which likely accounts
for concurrent Malassezia overgrowth; more cutaneous nutrients serve as an ideal
environment for microbial overgrowth. Although earlier reports implied that
concurrent disease states (e.g. diabetes mellitus, hyperthyroidism) increased the
likelihood of Malassezia overgrowth, a more recent study could not substantiate this
claim. This study did, however, corroborate the association of feline paraneoplastic
alopecia and cutaneous Malassezia overgrowth irrespective of breed.
ii. M. pachydermatis, M. sympodialis, M. globosa, M. furfur, M. nana, M. slooffiae,
M. obtusa, and M. restricta.
iii. Although topical therapy with antifungal rinses and anti-seborrheic agents can be
beneficial, this is difficult in many cats, making treatment less effective. Itraconazole
administration has been effective; response to therapy supports a diagnosis of
Malassezia overgrowth in these cats in a similar fashion to the response to treatment
of the disease in dogs. Other azole derivatives or terbinafine may also be effective.
176 This is a very common finding in toothbrush cultures obtained from animals
receiving topical therapy. First, growth of the dermatophyte is often delayed
because of treatment. Second, both gross and microscopic growth are altered
in appearance. In this case, the plates were inoculated from the center outwards
towards the margins of the plate. Growth was inhibited in the center of the plate
due to trace amounts of topical antifungal solution alone or on infective spores
being deposited onto the plate. As the inoculation moved to the margins of the
plate, trace solution and/or infective spores not covered in antifungal solution were
deposited on the plate and allowed to grow. Lack of sporulation is a common
finding in animals undergoing treatment, especially in the later stages of therapy.
The arrow is identifying the swollen end of a hypha where a dermatophyte
macroconidium is trying to develop. This thickened ‘finger-like’ projection is
typical of M. canis colonies incubated at suboptimal temperatures or exposed to
antifungal therapies.
184

Questions: 177, 178
177 The tail of an atopic golden 177
retriever dog is shown (177). What is
unusual about the tail, and what do you
suspect is the cause?
178 A 6-year-old male castrated American 178a

bulldog was presented for a 6-month
history of progressive nodular skin
disease (178a, b). The owner reported
that nodules initially presented over
the limbs and head but have spread to
involve most body regions. Lesions begin
as firm nodules that enlarge, ulcerate,
and become exudative and matted with
a thick adherent crust. Multiple courses
of systemic antibiotics had not been
beneficial. Although oral corticosteroids 178b
(anti-inflammatory dose) seemed to result
in a slight reduction in lesion size, the
nodules never completely regressed. The
dog had a history of traveling out of the
local region prior to lesion development;
however, other household dogs had not
been similarly affected. More recently, the dog had developed clinical signs of systemic
illness including gastrointestinal upset and decreased activity. Pruritus was not a reported
feature; however, the owner felt the dog was painful where nodules were present.
ii. What diagnostic testing would you recommend?
iii. Skin biopsy of the nodules showed sheets of neoplastic round cells with diffuse and
perivascular distribution. Occasional small aggregates of neoplastic cells were found
within the epidermis. The cells had large round to oval nuclei with multiple large nucleoli
and a moderate amount of pale cytoplasm. Mitotic index was high. The cells infiltrated
into follicular, apocrine gland, and sebaceous epithelium. Immunohistochemical staining
was positive for CD3 in the neoplastic cells. Given this report, what is the diagnosis?
iv. What treatment options are available for this condition, and what is the prognosis?
185

Answers: 177, 178
177 It is exhibiting hypertrichosis. The most common cause of hypertrichosis in
dogs is cyclosporine administration. At the time of presentation, the dog had been
receiving 5 mg/kg cyclosporine q24h for 2 years for management of AD. If this is
the only clinical abnormality noted, likely no change in therapy is necessary.
178 i. Infectious (deep fungal including blastomycosis, cryptococcosis, histo

plasmosis, coccidioidomycosis; opportunistic fungal, eumycotic mycetoma,
derma to
phytic pseudomycetoma; atypical bacteria including botryomycosis,
mycobacterial infection, nocardiosis, actinomycosis, canine leproid granuloma,
L-form infection); inflammatory (cutaneous histiocytosis, sterile pyogranuloma/
granuloma syndrome); neoplasia (cutaneous epitheliotropic T-cell lymphoma,
MCT).
ii. Cytologic impression and FNA, routine aerobic bacterial cultures, and cultures
for atypical bacterial infections. Laboratory personnel should be alerted to the
possible contagious nature of the organism (particularly for deep fungal mycoses).
Skin biopsy is recommended as this will most rapidly differentiate infectious versus
neoplastic diseases.
iii. Epitheliotropic T-cell lymphoma.
iv. Various treatment protocols have been tried, but few have reported good efficacy.
In general, the prognosis is poor, with mean survival time from diagnosis of months
to 2 years. Palliative options include supplementation with high concentrations of
linoleic acid or administration of corticosteroids (e.g. prednisone or prednisolone).
A recent study demonstrated the presence of retinoid receptors in tumors of dogs
diagnosed with cutaneous lymphoma; although not thoroughly investigated,
retinoid receptor binding drugs may be beneficial. Lomustine (CCNU) is an
alkylating agent that has been one of the more promising treatment options for
canine cutaneous lymphoma. Higher dosing protocols have increased efficacy, with
a response rate of 78–83% reported. The effect of this treatment on survival has
not been reported. Lymphoma in both dogs and people is a highly radiosensitive
neoplasia. Newer radiation delivery systems may allow this possibility to be a
more favorable option, as treatment can be tailored to the individual patient while
minimizing damage to surrounding normal tissues.
186

Questions: 179, 180
179 Owners are often frustrated by cases of generalized demodicosis that ‘fail to
resolve’ with the treatment that has been prescribed. There is a small population
of dogs that will have chronic demodicosis (i.e. dogs that apparently cure but
continually relapse) due to an impaired skin immune system. Excluding these dogs,
when presented with a case of ‘refractory demodicosis’, what other reasons should
be discussed with the owner and investigated?
180a 180b
180 A 5-year-old male neutered basset hound dog was presented for the problem
of persistent otic pruritus (>1 year) manifested by ‘ear flapping’ (180a). The dog
had no other clinical signs of skin disease. Otic examination revealed diffuse
erythema from the ear pinnae to the tympanic membrane. Initial otic cytology was
unremarkable and did not reveal any inflammatory cells or organisms. The owners
had cleaned the dog’s ears daily since it was a puppy. The owners declined further
diagnostics. Because of the possibility that either the ear cleaning procedure and/
or a topical ear cleaner might be causing a local allergic/irritant reaction, all ear
cleaning was discontinued for 14 days. Approximately 10 days after the initial visit,
the owners presented the dog because of increasing ear pruritus, odor, and marked
ceruminous exudate. Ear swab cytology revealed too many to count Malassezia
organisms. The dog was sedated, the ears cleaned, and a treatment protocol of oral
ketoconazole (5 mg/kg q24h for 21 days) and topical ear steroids (dexamethasone
and propylene glycol) and topical miconazole solution was prescribed. The dog
was re-examined at the end of treatment and the owners reported a marked
reduction in ear pruritus, but persistence of a ceruminous exudate. Repeat ear
cytology is shown (180b). Identify the organisms.
187

Answers: 179, 180
179 Common reasons for treatment ‘failure’ with generalized demodicosis include:
• Failure to address concurrent bacterial pyoderma. Bacterial pyoderma (super
ficial or deep) is frequently noted concurrently with generalized demodicosis.
If infection is not addressed, Demodex mites will persist. It is difficult for
treatment to reach therapeutic concentrations in the skin when a large amount
of purulent material is also present.
• Failure to prescribe an adequate dose of miticide medication. For example,
ivermectin is commonly used for the treatment of demodicosis; however, the
dosage needs to be much higher than for other parasitic infestations. Dosage
for heartworm prevention is approximately 0.6 mg/kg once every 30 days; for
sarcoptic mange it is 0.2–0.3 mg/kg PO or SC once every 7–14 days for 6–8
weeks; for demodicosis it is 0.3–0.6 mg/kg q24h for average treatment duration
of 7 months.
• Failure to treat long enough. The goal of treatment is to achieve 2–3 consecutive
negative skin scrapings, 2–4 weeks apart. Negative skin scraping means no
mites of any life stage present, either alive or dead.
• Failure to identify and address concurrent medical disease. This is particularly
true for cases of adult-onset generalized demodicosis.
• Premature discontinuation of treatment by owners. When the dog ‘looks better’
owners may think treatment can be discontinued. It is important to educate
owners from the beginning that their dog will reach a clinical cure much sooner
than it will reach a parasitic cure.
• Failure to identify a concurrent disease causing immunosuppression, or concurrent
illness being treated with immunosuppressant therapy (e.g. neoplasia).
180 Candida in large numbers with smaller numbers of Malassezia. Malasssezia

are bottle-shaped, thick-walled, up to 5 µm in length, and reproduce by monopolar
budding on a broad base. M. pachydermatis is the only member of the genus
that grows on Sabouraud dextrose agar without lipid supplementation. Candida
pseudohyphae show distinct points of constriction often resembling sausage links.
They have narrow base budding, making it easy to distinguish from Malassezia.
Candida blastoconidia, or yeast-like cells, are larger than Malassezia. In this case,
a culture isolated both Malassezia and Candida (C. tropicalis); susceptibility testing
revealed that both organisms were susceptible to all antifungal drugs tested. Candida
spp. are common commensals of animals, often found at the mucosal junctions.
Candidiasis is often observed in immunocompromised individuals. During the
work-up of this case it was found that the dog had autoimmune hemolytic anemia.
188

Questions: 181, 182
181 A 5-year-old male neutered Labrador retriever dog with an incompletely
excised grade II mast cell tumor of the distal limb was presented for consultation.
The owners were considering definitive radiation therapy treatment (attempt to
sterilize the tumor field, with the goal of curing residual microscopic neoplasia,
with typical treatment dose amounts exceeding 45 Gy within 3–4 weeks) and
wanted an insight into the cutaneous toxicity associated with treatment.
i. What is the normal progression of acute radiation-induced skin reactions?
ii. What is the basic pathobiology of radiation-induced injury to the skin?
182
182 A 6-year-old female spayed samoyed dog presents with a progressive history
of non-pruritic skin and ‘hair that has been falling out, often in clumps’. No other
signs of systemic illness are reported. On physical examination there is partial to
complete alopecia primarily affecting the truncal region (182). All of the head and
all four limbs have been spared. The skin underlying alopecia appears normal with
no evidence of inflammatory changes. The hair coat is sparse; what hair remains has
a ‘wooly’ appearance. Skin scrapings are negative on multiple sites sampled. Surface
skin cytology does not reveal any infection or microbial overgrowth.
i. Multiple skin biopsy specimens are obtained from normal and affected areas.
The affected regions show epidermis of a normal thickness with moderate
hyperpigmentation. Most of the hair follicles are in haired telogen; however, many
show an excess amount of trichilemmal keratinization that is consistent with ‘flame
follicle’ appearance. Based on this description, what is the diagnosis for this patient?
ii. What is the current proposed pathogenesis of this disease in dogs?
iii. What options are there for managing the condition?
189

Answers: 181, 182
181 i. Erythema, dry desquamation, hyper- 181
pigmentation, moist desquamation, skin
necrosis (181).
ii. Hierarchical organization exists within the
germinal components of the basal and suprabasal
layers of the epithelia. A single stem cell in the basal
layer of the epidermis is surrounded by a column of
daughter or transient amplifying cells (progenitor
cells), which continue through the maturation/
cornification process. The radiosensitivity of cells
in these layers decreases during the maturation process, leaving them less prone to
injury and toxicity effects; cells at most risk are those in the germinal (basal) layer
or stem cells. The preferential depletion of cells in the stem cell and early progenitor
cell compartments results in a progressive decline in the number of cells available
for terminal differentiation (fewer cells becoming fully cornified keratinocytes). This
can eventually have a negative impact on the protective barrier function of the skin,
leaving the patient at risk for secondary complications (e.g. infections, dehydration,
solar injury). Barrier function is maintained until post-mitotic cells are lost through
continuing normal cell turnover.
182 i. Alopecia X (or hair cycle arrest).

ii. The exact pathogenesis is not known. The disease presents with bilaterally symmetrical,
non-inflammatory hair loss resembling the appearance of ‘endocrine alopecia’, in which
the head and limbs are spared. There appears to be a genetic influence, as this disease
is seen almost exclusively in Nordic dog breeds with plush double coats (samoyed,
pomeranian, keeshond); familial association has also been documented. Several studies
have failed to identify the causative gene. Estrogen receptor presence does not appear
to be associated with the disease and antagonism of the receptors does not appear to
influence hair regrowth. Based on response to treatment trials, there is suspicion that
abnormal adrenal function may be involved; however, this has not been well documented.
iii. In some dogs where adrenal hormone abnormalities have been documented,
treatment with either mitotane or trilostane has resulted in hair regrowth. Treatment
risks include development of hypoadrenocorticism and/or adrenal necrosis. Monitoring
is necessary to evaluate treatment efficacy and adverse reactions. In patients without
any evidence of systemic illness and no other abnormalities other than hair loss, it is
questionable whether this aggressive treatment is necessary. Many clinicians consider
alopecia X (different from atypical hyperadrenocorticism) a cosmetic disease. Melatonin
supplementation (3–6 mg/dog q12–24h) has been beneficial in some patients; side-effects
may include sedation. ‘Sweater therapy’ has been helpful for some dogs and their owners.
190

Questions: 183, 184
183 i. What determines the severity of radiation-induced injury (see also case 181)?
ii. What determines the rate at which acute injury occurs?
184a
184b
184 The axillary area of a 6-year-old female spayed mixed-breed dog is shown (184a).
The dog lives indoors. The lesions shown develop in late August through October
and are pruritic. The owners report only mild facial and otic pruritus, but are most
concerned about the recurrent axillary lesions. The clinical signs began when the
dog was 1 year of age and consistently resolve once the weather becomes cold. In
the past, the clinical signs have been well managed by systemic glucocorticoids, but
the owners are reluctant to administer them due to annoying side-effects (polyuria,
polydipsia). The dog receives year-round flea and tick control and skin scrapings are
negative. Skin cytology from an impression smear is shown (184b).
i. What is the interpretation of the skin cytology?
ii. What is the cause of the dog’s recurrent skin lesions?
iii. What are important points to discuss with the client regarding specialized
diagnostic testing?
191

Answers: 183, 184
183 i. The severity depends both on the extent of stem and progenitor cell depletion
(how many cells are lost from the germinal layer and do not mature/complete the
cornification process) and the length of delay of maturation from stem cell to
fully differentiated keratinocyte. Severity of injury increases with dose (how much
total radiation is delivered to the site, measured in Gy), but dose fractionation
(breaking up the total dose into smaller units to be delivered over an extended
time period) can decrease the adverse effects by allowing regeneration of the stem
cell and progenitor cell compartments over the course of radiotherapy. In essence,
this allows for the skin to recover. Dose fraction schedules are considerably more
coarse (larger units of radiation delivered in fewer treatment sessions) in veterinary
medicine compared with our human counterparts (smaller units delivered more
frequently).
ii. It is predominantly independent of dose and more determined by loss of cells
from the terminally differentiated compartment. The more cells that are destroyed
from the germinal cell layers, the higher is the likelihood that radiation-induced
skin injury will occur. This can happen both with comparatively low radiation
delivery doses (e.g. 15 Gy) as well as with high (e.g. 45Gy) doses.
184 i. Bacterial pyoderma. The presence of neutrophils is compelling evidence that

the cocci are more than bacterial overgrowth.
ii. Seasonal AD. The newly proposed diagnostic criteria for AD include: onset of
signs under 3 years of age; dog living mostly indoors; glucocorticoid-responsive
pruritus; pruritus that precedes development of lesions; affected front feet; affected
ear pinnae; non-affected ear margins; non-affected dorsolumbar area. In a dog
with recurrent seasonal pruritus occurring in the fall (autumn), the two most
common differential diagnoses would be seasonal AD and fleas. Administration of
year-round flea prevention makes the latter possibility less likely.
iii. In general, diagnosis of AD is clinical; allergy testing is performed to identify
allergens for ASIT. Testing is usually limited to 50–60 allergens. Removal of a
weed or tree from the dog’s immediate home will not prevent exposure to the
allergen. Pollen particles are airborne and can travel hundreds of miles. Reasons
for ASIT in dogs with seasonal atopy include: clinical signs cannot be managed
medically; failure to respond to therapy regardless of the severity of the pruritus;
therapy is contraindicated (e.g. diabetic dog and steroids); effective therapy alters
performance or behavior (e.g. steroid aggression, antihistamines, sleepiness or
hyperactivity). Other key points to stress are that ASIT is year-round and currently
presumed to be lifelong therapy; it can take 3–12 months to see maximum benefit.
192

Questions: 185, 186
185 A 7-year-old female spayed mixed-breed 185a
boxer dog presents for crusting skin lesions
and ear margins that bleed easily during
normal activity. The dog had been acquired
from a rescue organization several months
prior to presentation, therefore her previous
history is unknown. At the time of adoption,
the dog was diagnosed with heartworm
disease and numerous microfilaria were noted
on a blood smear. The dog has since been
treated for the microfilariasis and appears
to be in good overall health. On physical 185b
examination, both pinnae are noted to be
crusted and scalloped along with margins
(185a); the ear tips bleed with minimal
manipulation. The tip of the nose is irregular,
with erosions and loss of normal cobblestone
architecture (185b). The tip of the tail is
also crusted and alopecic. There is a near
complete absence of claws on all digits of all
four paws (185c). Based on the distribution
of skin lesions, you make a clinical diagnosis
of vasculitis/vasculopathy. 185c
i. There are a number of causes of
vasculitis/vasculopathy in the dog. List
several infectious etiologies that can cause
vasculitis.
ii. List several non-infectious etiologies for
vasculitis.
iii. How might you manage the clinical
signs in this dog?
186 The process of skin formation involves a series of highly regulated events
in order to form a functional epidermal barrier. Defects or abnormalities in the
process cause decreased barrier function and can contribute to several dermatologic
disease states.
i. Name the four layers of the epidermis.
ii. How do ‘keratinization’ and ‘cornification’ differ?
iii. Describe the cellular events involved in cornification.
193

Answers: 185, 186
185 i. Septic vasculitis: deep bacterial pyoderma, Rocky Mountain spotted fever,
ehrlichiosis, and Erysipelothrix rhusiopathiae in dogs. Neutrophilic immunologic
vasculitis is considered to be a non-infectious cause of vasculitis in dogs; however,
the condition may be precipitated by viral diseases or leishmaniasis. Vasculopathy
of greyhound dogs (‘Alabama rot’) is due to a shiga-like toxin produced by
Escherichia coli O157:H7 found in raw diets fed to racing greyhounds. Vasculitis
has also been reported in a dog with disseminated histoplasmosis. The severe
heartworm disease may also have contributed to the vasculitis/vasculopathy lesions
seen in this dog; if thrombi from microfilarial death form, they could potentially
become lodged in smaller vessels, leading to development of cutaneous lesions.
ii. SLE, rheumatoid arthritis, paraneoplastic syndromes, cryoglobulinemia/
cryofibrinogenemia, drug reactions, ischemic dermatopathy of Jack Russell terrier
dogs, dermatomyositis, familial vasculopathy of German shepherd dogs, post-
rabies vaccine induced.
iii. Treat infections if identified. Lesions are mild and may be managed with a combination
of tetracycline or doxycycline and niacinamide. Pentoxifylline is also an option. If lesions
worsen, more aggressive immunosuppressive therapy (prednisone) can be used.
186 i. From deep to superficial: strata basale, spinosum, granulosum, and corneum.
ii. ‘Keratinization’ is a series of genetically programed events through which
keratinocytes in the basal layer of the epidermis differentiate, mature, and die,
producing the cornified layer of the epidermis (stratum corneum). ‘Cornification’
includes keratinization and all of the steps in the formation of the cornified
epidermal envelope.
iii. In keratinization, epidermal cells mature from basal cells to flattened, dead
corneocytes. During maturation, structural proteins and lipids are expressed. In
the basal layer, cells are active with high mitotic ability. On leaving the basal layer,
they lose mitotic ability and progress to terminally differentiated corneocytes. In
the spinous layer, lamellar granules contain precursors to lipids, proteins, free fatty
acids, and enzymes; these contents will form the cornified envelope. In the granular
layer, lamellar granules fuse with the cell membrane. Contents are exocytosed
and utilized in cornified envelope formation. Keratohyalin granules containing
profilaggrin, loricrin, and keratin filaments are formed in this layer and go on to
form the cornified envelope. Protein accounts for 90% of the cornified envelope;
these covalently cross-linked polymers are insoluble, lending to the protective
epidermal barrier. Lipid accounts for the other 10%; extruded contents of lamellar
granules (ceramides, free fatty acids, cholesterol) interdigitate with intracellular
lipids to adhere the structure to corneocytes and complete the epidermal barrier.
194

Questions: 187, 188
187 A current controversy in the literature is what should be the correct term to
describe cats with allergic skin disease caused by something other than fleas or
food. Some argue that the term feline ‘atopic dermatitis’ is inaccurate and a more
appropriate term should be used. What are the arguments for and against this
controversy?
188
188 A 4-year-old male castrated pug dog is presented to your clinic. The owner
reports she came home from work to find the dog’s head and neck ‘swollen and
red’ (188). The dog is currently not receiving any medication except for routine
flea, tick, and heartworm preventives and there have been no recent vaccinations.
The dog has access to the inside of the home and, via a dog door, an outside
fenced yard. Except for being intensely pruritic, the dog is otherwise healthy. The
subcutaneous masses are firm, but pit and blanch with gentle pressure/palpation.
i. What is the most likely diagnosis? What is the prognosis?
ii. How is this condition manifested?
iii. How do you treat this condition?
195

Answers: 187, 188
187 The term ‘feline AD’ was first introduced into the literature in 1982. It was used
to describe a group of pruritic cats in which intradermal testing for environmental
allergens was positive and in which other causes of pruritus (external parasites,
infections, flea allergy, food allergy) had been ruled out. In essence, the disease was
diagnosed as it is in dogs and people: a clinical diagnosis based on exclusion. In
dogs, AD is defined as ‘a genetically predisposed inflammatory and pruritic allergic
skin disease with characteristic clinical features associated with IgE antibodies
most commonly directed against environmental allergens’. IgE has been implicated
with regard to development of AD and other allergic skin diseases in cats; however,
others argue that this involvement in the development of disease has not been
firmly established. The heterogeneity of the feline IgE molecule and lack of positive
allergy tests in approximately 35% of cats with a clinical diagnosis of AD are
cited as reasons why this disease in cats should have a different terminology.
Proposed alternative names include ‘feline non-flea/non-food allergic dermatitis’
and ‘feline non-flea/non-food hypersensitivity dermatosis’. Whatever name is
eventually deemed the most appropriate, cats with AD appear to respond similarly
to dogs with regard to medical management of the disease as well as response to
immunotherapy.
188 i. Urticaria and angioedema. Because the lesions are limited to the skin, the
prognosis is excellent.
ii. Anaphylaxis can manifest as localized or generalized reactions. Localized ana
phylaxis has signs restricted to a specific tissue or organ, usually at epithelial
surfaces. Typically, these reactions include pruritus, urticaria, and angioedema.
Maculopapular eruptions and erythroderma can also be seen. These lesions are often
found on the ventral abdomen since a thick hair coat can hide lesions on the rest of
the body. Generalized anaphylaxis is a systemic hypersensitivity reaction resulting
in a shock-like state and involving multiple organ systems. Clinical signs can also
include vomiting, diarrhea, urination, respiratory distress, tachycardia, and collapse.
A generalized anaphylactic reaction can be fatal if rapid treatment is not initiated.
iii. For a local reaction, antihistamines may be all that is necessary. The animal should
be washed or bathed if a topical product (shampoo, spray, gel, ointment) is the inciting
cause. If urticaria and/or angioedema is present, glucocorticoids are indicated until signs
of the reaction subside. For a generalized anaphylactic reaction, any suspect medication
or product must be stopped, oxygen (if respiratory signs are evident) and intravenous
fluid therapy should be provided, and glucocorticoid and epinephrine therapy initiated.
Careful monitoring of heart rate, respiratory rate, blood pressure, temperature, and
urinary output may be required for many hours. With successful intense intervention
and supportive care, improvement is typically seen within 1–3 hours.
196

Questions: 189, 190
189a
189 These are hairs from a trichogram of a cat (189a). What is the diagnosis?
190
190 A 15-year-old indoor–outdoor cat from a sunny climate has a history of

SCC of the ears; 5 years ago the lesions were treated via bilateral partial cosmetic
pinnectomy. The cat is now presented for erythematous crusted lesions in the pre-
auricular areas and on the nasal planum (190). The cat is receiving year-round
flea control. Otic examination of the remaining ear canal is within normal limits.
Dermatophyte culture is pending. Impression smears of the lesions are non-
diagnostic. Skin biopsy of a lesion from the pre-auricular area reveals findings
compatible with actinic dermatitis and from the nose the diagnosis is compatible
with SCC.
i. What are the treatment options for feline SCC of the nose, ears, and skin? Which
is best?
ii. What is Bowen’s disease? What is a key clinical feature?
iii. What is imiquimod?
197

Answers: 189, 190
189b
189 Dermatophytosis. Note the large cuff of ectothrix spores surrounding the
hair shaft. The margin of the hair shaft is irregular compared with a normal hair
(189b).
190 i. Aggressive surgical excision of the affected tissue; this is the best treatment
option when available. Surgical removal of nasal lesions is an option depending on
the extent of the lesion and whether the lips are involved. Alternative or adjunct
therapies include radiation, photodynamic therapy, cryotherapy, and intralesional
injection of chemotherapeutic drugs (5-fluorouracil).
ii. Bowen’s disease or multicentric SCC in situ (MSCCIS) is an uncommon skin
disease in cats. It is characterized by multifocal lesions over the head, neck,
dorsal thorax, abdomen, and limbs. Lesions are found in haired skin and darkly
pigmented skin and are not solar induced. Lesions can be treated with surgical
excision. Systemic chemotherapy has shown little benefit. There is some evidence
to suggest that bowenoid in situ carcinomas may involve a viral origin.
iii. Imiquimod (an imidazoquinoline amine) is a topical immune modulator that
has antiviral and antitumor activity in animals and people. Imiquimod has been
used to treat cats with MSCCIS. In one study, 12 cats were treated with 5%
imiquimod cream; initial lesions responded in all cats. New lesions developed in
8/12 cats; again lesions responded to imiquimod cream. Adverse effects included
local erythema, temporary worsening of lesions, increased liver enzymes, rare
neutropenia and vomiting. In a single case report, a cat with both actinic changes
and SCC of the pinnae was treated with imiquimod 5% cream; lesions resolved
after 12 weeks of therapy. Similar side-effects were seen within the first 3 weeks
of therapy. Imiquimod may be an option for therapy for cats with actinic changes,
MSCCIS, or SCC when surgery or radiation is not an option.
198

Questions: 191, 192
191 i. What are the most common cutaneous clinical signs associated with feline
hyperthyroidism?
ii. How are these clinical signs manifested based on the pathogenesis of hyper
thyroidism?
192
192 A cat was presented for this lesion on its face (192). The owner was unable to
offer any history. Cytologic findings were non-diagnostic and a skin biopsy specimen
was submitted for examination. The microscopic report stated: ‘The epidermis is
multifocally hyperplastic and ulcerated. Keratinocytes in the epidermis at the margins
of the ulcerations are swollen and have enlarged nuclei with pale basophilic glassy
intranuclear inclusions and marginating chromatin. The follicular epithelium of hair
follicles at sites of ulceration is necrotic, and disassociated aggregates of follicular
epithelial cells are brightly eosinophilic and necrotic and adjacent follicular epithelial
cells are swollen and have enlarged nuclei with pale basophilic glassy inclusions
and marginating chromatin. In the dermis beneath the ulcerations and surrounding
necrotic follicles there are scattered mast cells, macrophages, neutrophils, and
karyorrhectic debris. Occasional sebaceous glands are also necrotic and nuclei contain
viral inclusions’. The morphologic diagnosis was necrotizing and ulcerative dermatitis
with intraepithelial intranuclear viral inclusions.
i. What are possible differential diagnoses for the lesions in this cat?
ii. What is the diagnosis based on the macroscopic and microscopic findings?
iii. What other signs might the cat display with this diagnosis?
iv. How might you manage this case?
199
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Answers: 191, 192
191 i. Hair coat changes are a common finding 191
in cats with hyperthyroidism. Common
clinical signs include patchy alopecia, matted
hair, decreased grooming behavior, greasy
seborrhea, or a generally unkempt hair coat.
Excess dander (191) and long, thick claws
may also be seen in some cats. Symmetrical
non-inflammatory alopecia is not typically
associated with hyperthyroidism. Decreased
grooming and unkempt coat can possibly lead to secondary bacterial pyoderma,
although this is typically less common in cats than dogs. As with other internal
diseases, cats with hyperthyroidism may develop outbreaks of Demodex cati mites.
ii. Increased protein synthesis and metabolism has been implicated in many clinical
symptoms of hyperthyroidism, including cutaneous changes. Epidermal turnover
rate can be increased, leading to increased dander, sebaceous gland secretion, and
nail growth. In humans, increased vasodilation and generation of heat have also been
reported with hyperthyroidism; cats are often noted to have warm skin, particularly
in alopecic areas. Changes in internal health, due to any etiology in any species, can
affect the cutaneous microflora, leading to other concurrent dermatoses. Bacterial
pyoderma and demodicosis are most frequently reported as secondary findings.
192 i. Include infections (e.g. pyoderma, dermatophytosis, dimorphic fungi),

cutaneous parasites (e.g. demodicosis), allergic skin disease (flea allergy, cutaneous
adverse food reaction, AD), viral-related dermatitis (e.g. herpesvirus), autoimmune
dermatoses (e.g. PF), and neoplasia (e.g. SCC, cutaneous lymphoma).
ii. Herpesvirus 1-associated dermatitis (feline rhinotracheitis virus). Intranuclear
viral inclusion bodies are seen with herpesvirus. Other viruses affecting the skin of
cats, such as pox and papilloma, have intracytoplasmic viral inclusions.
iii. In addition to ulcerative papules on periocular and perinasal skin, cats with
Herpesvirus 1-associated dermatitis might present with depression, lethargy,
anorexia, fever, conjunctivitis, and repeated sneezing episodes. Keratitis, muco
purulent ocular and nasal discharge, crusting of nares, and oral ulcers may also be
seen. Rarely, cutaneous skin ulcers distant from the face and oral cavity may be
seen. Affected cats often have a history of upper respiratory disease.
iv. Oral famciclovir (adult cat, 125 mg PO q8–12h; kitten, 25–40 mg/kg PO q8–12h)
has shown the most promise for this skin disease. Systemic clindamycin, doxycycline,
or amoxicillin–clavulanate may be coadministered with famciclovir for chronic
‘snufflers’. Anecdotally, docosanol 10% cream applied topically to early skin lesions
may reduce the extent and severity of disease. Topical ophthalmic medication (e.g.
lubrication, antibiotics) is used commonly for keratitis and conjunctivitis.
200

Questions: 193, 194
193a 193b
1
5
4 2
8
3 9
6
193 Diagrams of a canine hair follicle are shown (193a, b).

i. Identify the structures labeled 1–9. Is this a primary or secondary hair?
ii. What are the three tightly regulated phases of hair growth in the dog?
iii. On a skin biopsy report, luminal folliculitis is described. What structures are
involved in luminal folliculitis, and what are your differential diagnoses when this
type of inflammation is reported?
194 What non-surgical method can be tried to remove a subcutaneous bot fly?
201

Answers: 193, 194
193 i. 1 = infundibulum; 2 = isthmus; 3 = inferior segment; 4 = arrector pili muscle;
5 = sebaceous gland; 6 = epitrichial (sweat) gland; 7 = inner root sheath; 8 = outer
root sheath; 9 = dermal papilla. This is a primary hair. Although secondary hairs
can have associated sebaceous glands, only primary hairs will have an arrector pili
muscle and an epitrichial (sweat) gland.
ii. Anagen is the phase of active growth where hair shafts are produced. This is
followed by catagen, the phase of regression. During catagen there is cessation of
mitotic activity of the matrix cells as well as apoptosis in the inferior portion of the
hair follicle. Telogen is the resting phase of the hair follicle, when the inner root
sheath is replaced by trichilemmal keratin and is reduced to about one-third of its
former length; the hair is retained in the follicle as a dead hair.
iii. Luminal folliculitis is inflammation of the hair follicle with involvement of the
follicular lumen. This pattern is the most commonly recognized type of follicular
inflammation and is characterized by the presence of intraluminal inflammatory
cells, typically neutrophils and/or eosinophils. Luminal folliculitis begins as mural
folliculitis or inflammation of the wall of the hair follicle. However, in mural
folliculitis, the inflammatory cells remain within the wall of the hair follicle and
do not invade the hair follicle lumen. Differentials include bacterial folliculitis
or furunculosis, dermatophytosis, demodicosis, sterile eosinophilic pustulosis,
Pelodera nematodes, and sterile eosinophilic pinnal folliculitis.
194 The goal of treatment is to remove the bot fly. Spontaneous extrusion can
occur and can also be ‘encouraged’. Occlusion of the central pore with petroleum
jelly, oil, or honey may trigger the parasite to back out of the hole. This ‘home
remedy’ has been used in people with success and by one of the authors for a
bot fly located in the medial canthus of a kitten. Surgical removal is the most
commonly used technique for Cuterebra larvae removal. Surgical extraction
requires making a large enough incision to extract the organism without damaging
it. It can be difficult to extract bot fly larvae because their surface spines anchor
them to surrounding tissue. Careful removal is important because any remaining
tissue from the larva can cause an intense foreign body reaction. Anecdotal reports
of anaphylaxis during removal have been reported.
202

Questions: 195, 196
195 In dogs, three species of Demodex mites have been identified. D. canis is the
most common species of Demodex in the dog; these mites live in hair follicles, may
cause localized or generalized disease, and may present in either juvenile- or adult-
onset scenarios. D. cornei is a short-bodied mite that lives in the most superficial
layer of the epidermis (stratum corneum); this mite has only been reported as a
concurrent infestation with D. canis.
i. What is the third species of Demodex mite reported in the dog?
ii. Where does this mite reside in relation to the skin?
iii. How does the disease present clinically?
iv. What breed of dog has this been reported in most commonly?

German shepherd-cross dog presented for
multifocal raised erythematous masses.
The owners reported that these lesions
had been present for the past several
years and previous treatments (several
courses of systemic antibiotics, topical
corticosteroids, bathing) did not appear
beneficial. The lesions seemed to wax
and wane; however, the owners felt more
nodules had developed over the past
few years. The masses did not appear to cause the dog discomfort; they were neither
painful nor pruritic and the dog appeared to otherwise be in good general health.
On physical examination, multifocal to coalescing raised, erythematous nodules were
noted along the dorsum, trunk, and lateral aspects of the hindlimbs (196). The lesions
were firm and a bit waxy on the surface.
i. Based solely on the clinical appearance, what are the differential diagnoses for
this patient?
ii. The pathologist reports a nodular to diffuse granulomatous reaction, but
comments that lymphocytes are oddly missing. Of your differential diagnoses, and
considering the history, what disease is most suspect?
203

Answers: 195, 196
195 i. Demodex injai (195). 195
ii. This mite also lives in hair follicles;
however, it occupies the space from the
follicular opening to the level of and
including the sebaceous glands.
iii. Although this mite does not appear
to be common, it seems to be associated
with dorsal greasy seborrhea. Erythema
and scaling may also be present.
Pruritus is variably present. Sebaceous
hyperplasia may be a concurrent
feature.
iv. Wire-haired fox terriers; in general,
terrier breeds may be predisposed to this
mite. Ivermectin (0.3–0.4 mg/kg q24h
for 2–7 months) has been reported to
be effective for treatment of D. injai as indicated by two consecutive negative skin
scrapes.
196 i. Infectious (bacterial including deep pyoderma, atypical bacterial infection

with Mycobacteria, Nocardia, Actinomyces, L-form infection, botryomycosis;
fungal including dermatophytic mycetoma, blastomycosis, histoplasmosis,
coccidioidomycosis, cryptococcosis, sporotrichosis), non-infectious inflammatory
(reactive histiocytosis, sterile granuloma/pyogranuloma syndrome, sarcoidosis),
neoplasia (multiple follicular tumors, cutaneous lymphoma, mast cell tumor,
hamartoma).
ii. Sarcoidosis, a nodular inflammatory disease of uncertain etiology. In people, it
is thought that the disease may be related to mycobacterial infections (particular
tuberculosis) since mycobacterial DNA has been identified in granulomatous
sarcoidosis lesions. Histopathology of the lesions lacks the lymphocytic component
that is noted with other granulomatous skin diseases; they are often described
as ‘naked’ granulomas due to this appearance of biopsy specimens. Lesions are
described as multifocal granulomas composed of epithelioid macrophages without
a peripheral accumulation of lymphocytes and without peripheral palisading. The
disease to date has been reported in people, horses, and dogs. Human and equine
sarcoidosis may be noted to have systemic organ involvement; to date, only the
cutaneous form of the disease has been reported in dogs.
204

Questions: 197, 198
197a 197b
197 A 10-year-old male castrated English springer spaniel dog presented for
multiple erythematous skin lesions. The owner reported that the dog had a
several year history of waxing and waning non-pruritic lesions that had increased
in severity over the past 2 years. On clinical examination, there were multifocal
erythematous plaques on the concave surfaces of both pinnae (197a), the external
ear canals, the ventral abdominal, and the preputial and perineal regions (197b).
Several smaller erythematous papules were noted in the same regions. The plaques
had a corrugated and somewhat waxy-scaly surface.
ii. Biopsy results showed an irregularly acanthotic epidermis with several deep
projections (rete ridges) into the dermis and focal areas of parakeratosis, several
intraepidermal pustules containing eosinophils and neutrophils, and mild dermal
lichenoid inflammation composed of predominantly lymphocytes and plasma
cells. Given this description, what is your most likely diagnosis?
iii. What is known or suspected about the pathogenesis of this condition?
198 A 2-year-old female spayed West Highland white terrier dog, recently
diagnosed with AD, is receiving subcutaneous allergen immunotherapy. The dog
has completed the induction phase of therapy and the owners have re-ordered
the maintenance vial. The dog is receiving 1.0 ml of allergen (20,000 PNUs/ml)
subcutaneously once every 7 days. The owners report that the dog is pruritic for
approximately 24 hours after receiving the allergen. The pruritus is focal at first,
but after a few hours the dog exhibits more widespread pruritus involving all four
paws. What are the options for making the dog more comfortable?
205

Answers: 197, 198
197 i. Lichenoid dermatosis, primary seborrhea, actinic keratosis, atypical
presentation of bacterial pyoderma, allergic skin disease.
ii. Psoriasiform-lichenoid dermatosis.
iii. This rare disease, typified by erythematous plaque lesions that are non-
pruritic, most frequently affects the anatomic locations described in this case. The
condition is most common in English springer spaniel dogs; breed predilection
suggests a genetic/heritability component with regard to pathogenesis. The exact
etiology is not known. The condition was first described in 1986. It has since
been proposed that the condition may represent a distinctive reaction to superficial
staphylococcal infection, possibly genetically programed. A case series described
similar lesions in three dogs treated with cyclosporine for various inflammatory
skin disorders, although these dogs were not spaniels. Although the lesions share
similar characteristics on histopathology, psoriasiform-lichenoid dermatosis is
not a true counterpart to psoriasis in humans. Although it is suspected to have a
genetic component, psoriasiform-lichenoid dermatosis is not an immune-mediated
condition, as is noted in people. The lesions in this dog responded well to treatment
with oral antibiotics (doxycycline, 5 mg/kg q12h) for 30 days plus topical bathing
with an antimicrobial shampoo as maintenance; at recheck, plaques were not
present and only mild lacy hyperpigmentation remained. (Note: This disease does
not appear to be as common as was once described in the literature. This may be
due to breeders actively removing affected individuals or other unknown factors.)
198 Includes reducing the volume of allergens injected (often to a known volume
that did not cause any adverse effects), increasing the number of days between
injections, adding oral antihistamine therapy or low-dose glucocorticoid therapy, or
adding in topical treatments (e.g. glucocorticoid sprays, antipruritic shampoos). The
best option for this patient would be to start with a lower volume of allergen mixture
per injection by either reducing the injection volume to the last volume at which the
dog did not react, or decreasing the volume by 25% if the client cannot remember. If
the dog continues to have ‘flares’ involved with immunotherapy administration, the
volume of allergen can be reduced by decrements of 25% until the dog is comfortable,
with the plan then slowly to attempt increased volumes. In some cases it is not
the volume of allergen that is problematic, but the interval between injections. In
most patients the interval is eventually increased to every 14–21 days. Successful
immunotherapy with longer intervals is uncommon. An indication that the interval
between injections needs to be shortened is a patient that is doing well but becomes
pruritic shortly after the allergen injection. Management of allergy patients receiving
immunotherapy via injections often requires changes in the volume of allergen being
administered per injection, the time between injections, or both.
206

Questions: 199, 200
199a 199b
199 A 5-year-old female spayed collie dog was presented for the problems of
depression, anorexia, and drooling. Physical examination revealed mild periocular
erythema and hair loss, mucocutaneous ulcerations, oral ulcers and vesicles
extending into the caudal pharynx, and ulcerative annular and serpiginous lesions
in the axillary and inguinal regions (199a, b). The owner reported that the dog had
been depressed and intermittently anorexic for the last 2 weeks.
ii. Skin biopsy revealed the following: lymphocytic interface dermatitis and follicu
litis with vesiculation at the dermal–epidermal junction. What is the diagnosis, and
how is this condition treated?
200 A 5-year-old male castrated retired 200

racing greyhound dog was presented
for lameness on all four paws, but
worse on the forepaws. Examination
revealed several circumscribed areas
of hyperkeratosis located centrally on
multiple digital pads (200). Palpation
of the lesions was painful.
i. What is this lesion?
ii. What is the etiology?
iii. Describe the histologic features of
this condition.
iv. How is this treated or managed?
207

Answers: 199, 200
199 i. Bullous pemphigoid, pemphigus vulgaris, paraneoplastic pemphigus, SLE, EM,
drug reaction, TEN, neoplasia, opportunistic infection, resistant bacterial infection.
ii. VCLE (of collie dogs and Shetland sheepdogs). This is not a new disease; in fact,
the disease and its breed predilection have long been reported in the literature by
various names. When the disease was first described in the early 1970s it was termed
‘hidradenitis suppurativa’ with a known breed predilection for collies, Shetland
sheepdogs, and their crosses. In the early 1980s it was reclassified as a clinical
variant of bullous pemphigoid. Over time this disease was renamed ‘idiopathic
ulcerative dermatosis of collies and Shetland sheepdogs’. The current name change
to VCLE represents findings that support this disease as being a variant of CLE.
There is some evidence that this disease may be exacerbated by sunlight and
affected individuals often have lesions that worsen in the summer months and
regress in the winter. Routine ANA tests are negative, but specialized testing has
identified autoantibodies. This disease waxes and wanes and durable remission
can be difficult to obtain. Corticosteroids are frequently utilized in management
of the disease, typically at immunosuppressive doses. Cyclosporine may be an
option in some dogs. Depending on the location of the lesions, topical tacrolimus
or potentiated glucocorticoids may be used. Sun avoidance is recommended.
200 i. Paw-pad keratoma (paw-pad corn, or callus). Synonyms include keratoderma,

tyloma, and tylosis.
ii. This lesion occurs almost exclusively in racing or retired greyhound dogs and other
related sight hounds. Evidence supports a mechanical etiology; weight-bearing digits on
the forelimbs appear to be most commonly affected, supporting the influence of repeated
trauma, particularly during racing. Foreign body penetration may also lead to corn
formation; surgical exploration and diagnostic imaging (e.g. radiography) have found
imbedded plant material, metal, and grit within various corn lesions in greyhounds.
iii. Lesions are typically characterized by well-demarcated, dome-shaped, conical
or cylindrical mounds of compact hyperkeratosis. The keratin projects above the
skin surface and frequently also extends downwards, forming a depression in the
epidermis, a feature unique to paw-pad keratoma. Exaggerated digitated surface
configuration (rete ridge formation) is also typically noted on histopathology. In
most cases, inflammation is mild to absent unless acute trauma or fissuring is evident.
iv. Surgical excision is the treatment of choice for paw-pad corns; however, the rate
of recurrence is fairly high. Techniques include laser removal, physical extrusion,
curettage, and removal of the firm center. Soft padded bandages or boots may
minimize further trauma to the area. Distal digital ostectomy (removal of the distal
phalanx) has been beneficial in some cases; however, this may not prove favorable
when multiple digits on multiple paws are involved.
208

Questions: 201, 202
201a 201b
201 A 3-year-old DSH cat presented for a 1-year history of progressive lameness.
The cat lived indoors and there were no other cats in the home. Physical examination
was normal except for lesions on the foot pads (201a). Large ulcerative masses
were present on both front paws. The owner had reported that when the lameness
first started the foot pads were soft and ‘puffy’ (201b). The foot pad lesions waxed
and waned, often becoming ulcerative.
i. Cytologic aspirate of a foot pad revealed a mixed inflammatory infiltrate with
plasma cells. A skin biopsy was obtained and was consistent with feline plasma cell
pododermatitis (PCD). Although the history and physical examination findings alone
were highly suggestive of PCD, at the time of presentation, this disease presents with
a wide range of clinical signs. What other differential diagnoses need to be ruled out?
ii. What are the common clinical characteristics of this disease, and what is known
about the etiology?
202 A 6-year-old rough coated collie 202

dog presents with acute severe pruritus
of the entire ventrum. Pruritic, alopecic,
and erythematous regions include the
elbows and the margins of the ear
pinnae. You perform skin scrapes,
which are negative for mites. The
owner notes that the dog spends about
50% of its time outside and that he has
seen foxes in the area lately. The owner
reports that recently he has developed
a pruritic rash, and in fact lifts his shirt up to show you that it is mainly on his
abdomen and forearms (202).
i. Based on your strong suspicion, you elect to treat empirically for what disease?
ii. What treatment options are available for this dog? What concerns do you have
related to the breed of dog and the possible treatments?
209
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Answers: 201, 202
201 i. Pemphigus, lupus erythematosus, chemical or physical trauma, infection
or sterile pyogranuloma, eosinophilic lesions, neoplasia (mastocytoma, lympho
sarcoma), foreign body reaction.
ii. PCD has only been reported in cats and there is no recognized sex, breed, or
age predilection. The etiology is unknown, but it has very characteristic clinical
manifestations. It begins as a soft spongy swelling on one, but usually on multiple foot
pads, with the central carpal and metarsal foot pads most commonly affected. In some
cases the foot pads will have a violaceous color and may have striations present (see
197b). Pain is variable with the initial foot pad swelling. Most cats are asymptomatic
for a long period of time, but usually become lame once lesions become ulcerative.
Large ulcerated proliferative masses, as occurred in this case, are not typical. Cats
can present with concurrent plasma cell stomatitis or swellings on the bridge of their
nose and nasal planum. A hypergammaglobulinemia (polyclonal gammopathy), tissue
infiltration with plasma cells, and response to immunomodulatory drugs strongly
support an immune-mediated etiology. In one study, several of the cats were FIV
positive, but the relationship between PCD and FIV is yet unknown. PCD may be a
reaction pattern to a yet unidentified antigen, as there has been at least one report of
plasma cell infiltrate causing nasal swelling in a cat without concurrent paw lesions.
202 i. Sarcoptes scabiei.

ii. Weekly dips with 2–3% lime sulfur are very effective. Other treatment options include
milbemycin oxime, selamectin, moxidectin, ivermectin, and topical fipronil. Treatment
should continue for two complete life cycles of the mite (6 weeks total). Amitraz dips
are also effective, but may be associated with sedation, ataxia, and bradycardia. While
systemic treatment options are very effective, there is particular concern with the use of
avermectins in collies. Collie dogs that are homozygous for a mutation in the ABCB1
gene (also known as the MDR1 gene) accumulate high levels of ivermectin in the CNS.
Ivermectin is a macrocyclic lactone. This class of drugs works through potentiation of
GABA-gated chloride ion channels. GABA-gated chloride channels exist throughout the
peripheral nervous system of arthropods and nematodes, and potentiation of them causes
inhibition of neurologic activity. In mammals, GABA-gated channels exist only within
the CNS. The ABCB1 gene encodes P-glycoprotein, a transmembrane protein pump
that is responsible for the efflux of xenobiotics from the intracellular space and is a major
component of the blood–brain barrier. The majority of collie dogs carry at least one copy
of a deletion mutation (nt228[del4])in the ABCB1 gene. Dogs that are homozygous for
this mutation are unable to efflux ivermectin and experience neurotoxicity at low doses
of ivermectin (0.1 mg/kg). Affected collies may also be more susceptible to neurotoxicity
with other macrocyclic lactones (e.g. milbemycin, selamectin, moxidectin), although
studies have shown that selamectin and moxidectin have wide safety profiles even in
ivermectin-sensitive collies. PCR testing for the nt228(del4) gene mutation is available.
210

Questions: 203, 204
203 A 12-year-old female spayed mixed-breed dog presented for severe, acute
swelling of both pinnae. The owner reported that the dog had been shaking her
head frequently for the past 2 days; the swelling was noted only on the day of
presentation.
i. Given the history, clinical description of the ear, and acute presentation, what is
the most likely diagnosis for this patient?
ii. What diagnostic tests and treatment options should be recommended?
iii. Although there can be several causes, what is the most common underlying
cause for this condition?
204a 204b
204 The ventral abdomen of a 5-year-old cat is shown (204a). The lesion has been
treated repeatedly with methylprednisolone acetate (20 mg/cat SC). Initially, the
lesion resolved for 3–6 months, but recently the interval between lesion recurrence
has decreased to 1–2 months. Close inspection of the lesion reveals that it is
intensely pruritic (cat observed to self-traumatize lesion), erosive, exudative, and
raised. Further dermatologic examination reveals blunted whiskers, hair loss on the
chin, mild ceruminous otitis externa, and scaling on the hair coat. Skin scrapings,
flea combings, and dermatophyte culture are negative. Impression smears of the
lesion are shown (204b).
i. What is the clinical diagnosis of this lesion?
ii. How is this lesion treated?
211

Answers: 203, 204
203 i. Aural hematoma. 203
ii. Drainage and repair of the hematoma
should be discussed with the owner.
Numerous options exist: surgical correc
tion, cannulation (203), suction drain
placement, punch biopsy technique, and
laser technique. The prognosis is good for
any of the treatment options. If drainage
is not accomplished, the hematoma will
eventually coagulate and organize making surgical repair much more difficult.
Scarring is a common side-effect of untreated aural hematomas. Ear swab cytology
should be performed to evaluate organisms in the ear canal. Otoscopic evaluation
should also be performed.
iii. Otitis externa. This may be due to any of several factors including allergic
disease, endocrinopathies, parasites, neoplasia, foreign body, or cornification
defects. Secondary bacterial and/or yeast overgrowth are/is commonly noted.
These should be diagnosed and treated accordingly. Otitis externa should be
managed aggressively to aid the healing of aural hematomas; oral prednisone or
prednisolone may be administered for the first few days to reduce inflammation.
If ear infections and/or aural hematomas are recurrent, the underlying etiology of
otitis externa should be identified and a long-term management plan formulated.
In cats, Otodectes infestation is the most common underlying etiology; allergic
disease is most common in dogs. Underlying allergies are commonly overlooked as
a cause of aural hematomas in dogs.
204 i. Eosinophilic plaque.

ii. Eosinophilic plaques are now recognized to be the ‘hot spots’ of cats with a similar
pathogenesis. An intensely pruritic event initiates self-trauma at a focal area, which
rapidly becomes exudative, creating an ‘itch–scratch’ trigger. Secondary bacterial
and yeast colonization are very common and underrecognized complicating
factors contributing to the pruritus. Impression smears of these lesions may reveal
predominantly eosinophilic inflammation with intracellular and/or extracellular
bacteria and yeast. This is in contrast to what is seen in cases of canine pyoderma,
in which neutrophilic exudate predominates. Treatment for the lesion alone includes
a 21–30-day course of antibiotics (potentiated sulfa antibiotics, cephalosporins,
clindamycin). If yeast are present, itraconazole, fluconazole, or terbinafine can be
administered and/or the cat can be treated with a topical antibacterial/antifungal
shampoo. Many cats with these lesions will respond to antibiotic therapy alone.
Topical antimicrobial therapy may be beneficial if the cat will tolerate it.
212

Questions: 205, 206
205
205 A 7-year-old male neutered yellow Labrador retriever dog presents with
multiple, partially alopecic, raised, freely moveable, non-adhered, palpably
fluctuant nodules with associated draining tracts on the trunk (205). Lesions have
been present for 2 weeks. The owner reports lesions quickly develop and come
to a ‘head’, after which they drain with a glossy yellow-brown material. Nodules
are painful to the touch. The dog is moderately depressed, slightly febrile, and has
generalized peripheral lymphadenopathy. However, the owner reports the dog is
eating, drinking, urinating, and defecating normally. Cytologic impression smears
of exudate from the lesions do not reveal bacteria or yeast.
i. List the differential diagnoses for these draining nodular lesions.
ii. What diagnostic tests are needed to confirm the diagnosis?
iii. What is the most probable diagnosis given the character of the oily discharge?
206 Glucocorticoid administration has been associated with what life-threatening

side-effect in cats?
213

Answers: 205, 206
205 i. Inflammatory/infectious (deep staphylococcal pyoderma, nocardiosis,
actino mycosis, L-form bacteriosis, mycobacteriosis, subcutaneous mycoses),
inflam matory/non-infectious (foreign body, cutaneous/follicular cyst, sterile
nodular panniculitis, histiocytic disease), and neoplasia.
ii. Deep incisional or excisional wedge biopsies of nodules for histopathology
and culture. If possible, select nodules with an intact surface epithelium to
avoid superficial microbial contamination. Special stains (e.g. PAS, GMS, acid-
fast) and polarized light examination of tissue should be requested to exclude
microorganisms and foreign bodies, respectively. Fine-needle aspirate cytology of
nodules can be misleading depending on the developmental stage of the nodule.
iii. Sterile nodular panniculitis (SNP). The nature of the discharge is suggestive of
saponification of the panniculus. Adipose tissue is fragile and prone to traumatic,
ischemic, and inflammatory insults. Injury to lipocytes causes release of lipids,
which are degraded into inflammation-inducing free fatty acids. Consequently, an
oxidative inflammatory cascade results in a pyogranulomatous to granulomatous
tissue response. Panniculitis has been associated with physicochemical factors
(trauma, injections, foreign bodies), infections, nutritional disorders (vitamin
E deficiency), immunologic conditions (lupus), and pancreatic disorders
(inflammation, neoplasia). When a specific etiology cannot be identified, the
disease is termed SNP; infectious agents must be ruled out because treatment for
SNP involves immunosuppressive/immunomodulatory agents.
206 Congestive heart failure (CHF). Glucocorticoids, particularly methyl

prednisolone acetate, can be a trigger for the development of CHF in cats with
‘compensated or asymptomatic’ hypertrophic cardiomyopathy. In one study
CHF developed within 1–19 days of administration of glucocorticoids in a small
number of cases. In approximately half of the cats in this report, CHF was cured
and morphologic cardiac changes partially or completely resolved. The temporal
association between corticosteroid administration, the initial diagnosis of CHF,
and the clinical course of the disease suggests that this may be a unique form of
CHF called ‘corticosteroid-associated CHF’. Overall this condition is rare.
214

Questions: 207, 208
207a
207 A 5-year-old male intact golden retriever dog presented for halitosis, excessive
salivation, and difficulty eating. The owners had noticed multiple masses along the
gingiva and tongue within 2 days of presentation (207a). The dog was otherwise
feeling fairly well. The owners reported no decrease in his energy during a hunting
trip the previous weekend.
i. What are your differentials for this patient?
ii. What diagnostic tests what would you recommend for this dog?
208 i. What are bacteriophages?

ii. What is their potential for use?
iii. What is known about their use in veterinary dermatology?
215

Answers: 207, 208
207b
207 i. The lesions appear to be proliferative to nodular with ulceration frequently

covered by a mucoid, membranous layer. Differentials should include those for
both nodules (infections – including deep fungal mycoses, opportunistic fungal
infections, bacterial, viral; inflammatory – foreign body reaction, chemical or
thermal burn injury; neoplasia – amelanotic melanoma, SCC, soft tissue sarcoma)
and necrotizing diseases (drug eruption, foreign body reaction, chemical or thermal
burn, immune-mediated diseases – lupus, pemphigus vulgaris).
ii. Biopsy would allow for identification of any neoplastic or possibly infectious
etiology. Tissue culture may be indicated to confirm or refute the presence of an
infectious organism. In this dog, a more thorough history and physical examination
were obtained. There was no history of previous medications, making drug eruption
an unlikely diagnosis. No history of burn or chemical insult was apparent. The
owner again mentioned the hunting trip the weekend prior to presentation. On
closer examination, several prickly heads of a Burdock plant (burrs) were found
stuck throughout the tail and fur of the feet (207b). Sedated examination of the oral
cavity revealed numerous fine burr particles embedded throughout the lesions on
the tongue and gingiva. Foreign body granuloma was confirmed on biopsy. Surgical
debridement and removal of the burrs from the dog’s coat led to complete resolution.
208 i. Viruses that infect bacterial organisms. Subsequently, they can potentially
kill and lyse the bacteria they infect, but do not kill or infect cells belonging to
humans or animals.
ii. Bacteriophages have been beneficial for the treatment of various bacterial
diseases; the use of bacteriophages is a potential intervention for treatment of
multidrug-resistant bacteria.
iii. Two studies evaluated the use of bacteriophage therapy for Pseudomonas otitis
externa in dogs, and the results were promising. Treatment with bacteriophages
for cutaneous burns has also been documented in a mouse model; the possibility
for translation to other animal species exists.
216

Questions: 209, 210
209a 209b
209 A 6-month-old dog presented with linear white scars (209a) on the trunk.
There was no history of excessive trauma. Close examination of the scars revealed
atrophic irregular tissue that was easily torn. The dog also had a history of chronic
hygroma formation on the elbows (note lesion on the right forelimb [209b]). The
skin was hyperextensible (209b).
i. What is the difference between cutaneous asthenia, dermatosparaxis, and Ehlers–
Danlos syndrome (EDS)?
ii. What is the diagnosis in this patient?
iii. What other clinical signs commonly occur in this disease?
iv. How do you confirm the diagnosis?
210
210 A 4-year-old male castrated DSH cat presented with an acute swelling on
the nose. The owner reported that the lesion had developed over the last week.
Physical examination was otherwise normal.
i. Biopsy of the nose is shown (210). What is the diagnosis for this cat?
ii. What treatment options may be considered for this patient?
217

Answers: 209, 210
209 i. Cutaneous asthenia describes disorders that involve both collagen and
elastin. Dermatosparaxis describes disorders caused by a type I procollagen-N-
peptidase mutation. EDS is a heterogenous group of connective tissue disorders
characterized by reduced tensile strength of affected tissue. The latter is recognized
by skin hyperextensibility, joint hypermobility, and tissue fragility.
ii. EDS, a heritable disease. Spontaneous disease occurrence has been reported in
people, rabbits, dogs, cats, horses, and cattle. In dogs and cats, both dominant and
recessive forms of inheritance occur.
iii. Widening of the bridge of the nose, subcutaneous hematomas, elbow hygromas,
hernias, joint laxity, microcornea, sclerocornea, lens luxation, cataracts.
iv. History and clinical signs; diagnosis by biopsy can be difficult as tissue can
appear normal. When changes are present, histologic findings include alterations
in arrangement, length, and staining characteristics of collagen fibers. Masson’s
trichrome stain will show abnormalities of collagen. There is no effective treatment
for this disease; control focuses primarily on managing symptoms. As the skin
is easily torn, care must be taken to prevent/minimize secondary infections.
Delayed wound healing is problematic. People report significant joint pain, joint
dislocations, muscle cramps, fatigue, and headache. Because of the rarity of the
disease in animals, little is known about the quality of life of affected dogs and
cats. Breeding from these animals is not recommended.
210 i. Plasma cell infiltrate. There is marked perivascular to diffuse dermal

infiltration with plasma cells, occasional Mott cells, and small lymphocytes. A few
neutrophils are also present. Feline plasma cell pododermatitis commonly presents
with this same histopathology finding; however, plasma cell infiltrate has also been
reported in a cat with nasal lesions in the absence of paw-pad disease.
ii. The exact pathogenesis of this condition in cats is not known, but the presence of
plasma cells, hypergammaglobulinemia on serum chemistry analysis, and response to
treatment are suggestive of an immune-mediated etiology. The condition is generally
responsive to corticosteroid administration. Prednisolone (4 mg/kg q24h) is generally
needed to induce remission; response is typically seen within 2–3 weeks of starting
therapy, at which time the dose should be reduced. Doxycycline has also been shown
to be beneficial in most cats with this disease; 5–10 mg/kg q12–24h typically brings
resolution within 1–2 months. Oral suspension should be administered due to the
potential for esophageal stricture with this medication. Cyclosporine (5–10 mg/kg
q24h) is another option for treatment; most cats respond well. In some patients,
treatment may be discontinued following resolution without relapse in clinical signs.
Other patients require life long treatment to maintain remission.
218

Questions: 211, 212
211a 211b
211 A cat was presented for the complaint of ‘itchy twitchy ears’. Close inspection
of the ears revealed these small black specks (211a).
i. This organism was removed from the cat’s ear (211b). Identify this parasite.
ii. What is the natural host, and how did the cat acquire this organism?
212 A four-year-old female spayed pug 212

dog presents for chronic ear infection
of several weeks’ duration. Until this
event, the dog had no prior history
of skin disease. Physical examination
reveals a large amount of ceruminous
debris in both external canals (212).
Otoscopic examination is attempted;
however, the canal lumen is extremely
stenotic, less than 25% of the normal
diameter. As can be seen in the image,
there is a large amount of redundant folding near the canal opening. Palpation of
the ear canals is painful to the dog; both canals feel thickened. The remainder of
the physical examination is normal, except for an excessive amount of exfoliated
scale along the body. The owner reports that this has been a historic finding for the
dog, but has not prompted her to seek treatment.
i. What is the likely primary cause of this dog’s chronic ear infections?
ii. What is the progression of ear disease in these patients?
iii. What dog breeds are predisposed to this problem?
219
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Answers: 211, 212
211c
211 i. Spilopsyllus cuniculi (European rabbit flea). It is differentiated from cat

and dog fleas by the almost vertical position of its genal comb and rounded ends
of the spines, compared with the horizontal position and sharp points found on
Ctenocephalides felis (211c).
ii. Rabbits. It is acquired by cats or dogs from rabbit burrows. It can cause severe
irritation on the pinnae of cats. It can also carry and transmit myxomatosis.
212 i. A cornification disorder. This is supported by the proliferative tissue in the

ears as well as the excessive scaling along the rest of the dog’s coat.
ii. Failure of epithelial migration begins the process of external ear canal pathology.
This creates an increased amount of debris in the canal (cerumen, exfoliated skin
cells) as self-cleaning is impaired. Edema formation follows, which allows for
increased moisture in the canals. The combination of increased humidity and debris
serves as an ideal environment for microbial overgrowth. Glandular hyperplasia
further increases the ceruminous debris present. Redundant folding follows, giving
the ear canal the appearance of corrugated cardboard. The combination of edema
and redundant folding can markedly decrease the canal diameter, causing stenosis.
The tissue may eventually become fibrotic, followed by calcification/ossification.
This is indicative of end-stage ear disease. At this point, medical management is
not possible.
iii. Spaniel breeds in general, particularly cocker spaniel and springer spaniel dogs.
West Highland white terrier and Bassett hound dogs are also commonly affected.
220

Questions: 213, 214
213 A 2-year-old male castrated cocker 213
spaniel dog was presented for progressive
alopecia, erythema, and crusting of the
periocular skin bilaterally (213). The
owner reported mild facial pruritus. The
only other medical problem was a prior
diagnosis of keratoconjunctivitis sicca
for which the dog has been receiving
topical eye drops. No other dermatologic
abnormalities were identified on physical
examination other than the bilaterally
symmetrical periocular alopecia, erythema, and crusting.
i. Based on the clinical appearance of the lesions, what differential diagnoses
should be considered?
ii. What initial diagnostic tests should be recommended?
214a 214b
214 A 9-month-old male castrated Labrador retriever dog presented for mild
swelling, erythema, and depigmentation along the front of the muzzle (214a) and
lips (214b) of approximately 2 weeks’ duration. The dog was otherwise healthy.
Physical examination did not reveal any other abnormal findings. No other mucous
membranes or haired skin were affected other than what is shown.
i. What additional questions should be asked of the owner with regard to the
history and progression of the disease?
ii. What are your differential diagnoses for this patient? What initial diagnostic
tests are indicated?
221

Answers: 213, 214
213 i. Dermatophytosis, demodicosis, allergic skin disease (including cutaneous
adverse reaction to food and AD), drug reaction, PF, ocular discomfort leading to
secondary trauma to the periocular skin.
ii. Wood’s lamp evaluation and DTM culture should be performed for
dermatophytes. Deep skin scraping and/or hair plucks should be obtained to
look for Demodex mites. Cytologic evaluation of the skin should be carried
out to look for microbial overgrowth. A repeat Schirmer tear test and ocular
examination should be performed to determine if the cause of the discomfort is
ocular. Depending on the findings of these core diagnostic tests, skin biopsy may
be necessary to obtain a definitive diagnosis.
In this case, all core dermatologic diagnostics tests were negative. On question
ing the owner further, she reported that the dog’s cyclosporine ophthalmic
ointment had been changed several weeks prior to the skin lesion development.
The medication had been compounded in a corn oil base as opposed to the dog’s
normal aqueous drops. Reformulation of the medication into an aqueous base
resulted in complete resolution of the dermatologic abnormalities.
214 i. What is the dog’s vaccination history? What other medications are being
administered, either by prescription or over the counter? What is the dog’s
environment? What toys, dishes, blankets, or other objects come into contact
with the dog’s mouth and face? Are other animals affected? Has there been any
remodeling in the home? Does anyone have any hobbies that involve volatile
chemicals? Is the dog pruritic? What about littermates?
ii. Include early stages of juvenile cellulitis (lack of lymph node swelling and
signs of systemic illness would make this less likely), contact irritation, and drug
reaction. Although this is not a commonly affected breed and the dog is very
young, uveodermatologic syndrome should also be considered, although it is fairly
unlikely. Because of this possibility, a thorough ocular examination should be part
of the initial diagnostic evaluation. Other tests include cytology, dermatophyte
culture, skin scrapings, and possible biopsy. In this case, the owner mentioned that
the dog had been given a new rubber ball to play with shortly before clinical signs
developed. After removing all other rubber toys and the new ball, clinical signs
resolved completely; contact irritation/hypersensitivity was diagnosed.
222

Questions: 215, 216
215a 215b
215 A 13-year-old cocker spaniel dog presented for a history of excessive crusting
and lameness. The dog also was noted to have been febrile for the past month and
more lethargic than usual. Treatment for presumed Lyme’s disease (doxycycline)
had been prescribed by the primary care veterinarian approximately 3 weeks
prior to presentation. On questioning the owners, they reported that the dog had
always been excessively scaly and had an oily coat; however, crusting seemed
to have increased markedly within the past 2 weeks. On physical examination,
thick mounded crusts were present on the nasal planum, foot pads of all four feet,
concave surface of the pinnae, and around the vulva (215a). Similar crusted lesions
were also present multifocally along the haired skin of the dorsum, ventrum, and
flanks.
i. Given the history and physical examination findings, what are the differential
ii. Cytology from under a crusted skin lesion on the flank is shown (215b). What
is the most likely diagnosis given this finding? What findings on a histopathology
report would confirm the cytologic suspicion?
iii. What is the difference between drug-induced, drug-triggered, and naturally
occurring PF?
216 i. What is IVIG?

ii. What is its proposed mechanism of action?
iii. What diseases has it been used to treat?
223

Answers: 215, 216
215 i. Primary disorder of keratinization (seborrhea), but does not explain the
lethargy or lameness. The thick crusting along with lesions on the non-haired skin
(foot pads, mucous membranes) increases suspicion of an autoimmune skin disease
(particularly PF) or metabolic abnormality (superficial necrolytic dermatitis, zinc
deficiency). Neoplasia (e.g. cutaneous lymphoma) would seem less likely given
the symmetrical nature of the lesions; however, this should be considered in an
older patient. The recent antibiotic administration would also add cutaneous drug
eruption to the differential list.
ii. PF. Note the large numbers of acantholytic keratinocytes forming small groups
or ‘rafts’ within a neutrophilic background. Histopathologic findings, including
subcorneal pustules containing large numbers of neutrophils and acantholytic
keratinocytes, support the diagnosis. Eosinophils may also be present in variable
numbers. Infectious organisms would not be identified.
iii. Naturally occurring PF is the most common form of PF reported in domestic
animal species; this form of the disease develops in the absence of any known
trigger. Drug-induced PF mimics the natural disease, but it goes into remission
with removal of the offending drug. Drug-triggered PF is also associated with drug
administration, but does not go into remission with removal of the drug. It is
suspected that the drug acts more to trigger the patient’s natural predisposition
towards development of PF. In dogs, this type of PF has most recently been
associated with the administration of topical metaflumizone-amitraz.
216 i. Intravenous immunoglobulin. The current formulation is a highly purified

infusion of human IgG antibodies.
ii. Suppression of inflammation by modulating the Th2 pathway. Other mechanisms
of immunomodulation, although not fully understood, include neutralization of
autoantibodies, inhibition of complement binding and activation, and suppression
of pathogenic cytokines.
iii. In the dog, IVIG infusions have been used for the treatment of immune-
mediated hemolytic anemia, cutaneous drug reactions, PF, and immune-mediated
thrombocytopenia.
224

Questions: 217, 218
217
Cmax (peak) Peak/MIC (Type 1)
T>MIC (Type 2)
24-h AUC/MIC
Concentration (mg/ml)
(Type 3)
Area under the curve:
AUC ‘amount of drug’
MIC = how much antibiotic
is required to inhibit growth
MIC
T>MIC
Time (hours)
217 i. What is the difference between pharmacokinetics (PK) and pharmacodynamics

(PD) with respect to antibiotic therapy?
ii. Three PK parameters are used to quantify the activity of an antibiotic (217).
Which ones are they, and how are they used to classify antibiotics when combined
with MIC?
218a 218b
218 A 5-year-old intact male golden retriever dog presented for a history of chronic,
non-seasonal pruritic dermatitis of approximately 3 years’ duration. The owners
felt that the severity of disease had been slowly progressive, but had remained
confined to the feet. The dog was reported to be moderately pruritic, with a fair
amount of time spent licking and chewing at his feet (218a). Salivary staining and
moderate interdigital erythema was noted on both the dorsal and ventral aspects
of all four feet.
i. An acetate tape impression of the feet is shown (218b). What are these organisms?
ii. With regard to treatment recommendations, what is the evidence for and against
various options for control of this disease?
225

Answers: 217, 218
217 i. PK refers to the time course of antimicrobial concentrations in the body
and PD to the relationship between those concentrations and the antimicrobial
effect. MIC is an indicator of the potency of an antibiotic, but does not provide
information about the time course of antibiotic activity.
ii. The three PK parameters that are most important are peak serum concentration
(Cmax), trough serum concentration (Cmin), and the serum concentration time
course (area under the curve [AUC]). When these are integrated with the MIC,
the killing activity of antibiotics can be divided into time-dependent killing,
concentration-dependent killing, and prolonged persistent effects. Antibiotics are
classified into three general categories based on pattern of activity. Type I antibiotics
(e.g. aminoglycosides, fluoroquinolones) are concentration dependent and therefore
the goal of therapy is to have a dosing regimen that maximizes concentration, because
the higher the concentration the more extensive and faster the degree of killing. The
best predictors of this are the 24-hour AUC/MIC ratio and Cmax/MIC ratio. Type II
antibiotics (e.g. beta-lactams, erythromycin, linezolid) have almost the opposite set
of properties. The ideal dosing regimen is one that maximizes duration of exposure.
The T>MIC (the percentage of time antimicrobial concentrations exceed the MIC)
is the best predictor of this. For beta-lactams and erythromycin, maximum killing
is seen when the time above the MIC is at least 70% of the dosing interval. Type
III antibiotics (e.g. vancomycin, tetracycline, azithromycin) have mixed properties
of time-dependent killing and moderate persistent effects. For these drugs the ideal
dosing regimen maximizes the amount of drug received. The 24-hour AUC/MIC
ratio is the parameter that correlates with efficacy.
218 i. Malassezia spp.; yeast organisms.

ii. Systematic reviews have evaluated various treatment options for Malassezia
dermatitis in dogs. Based on the data, there is good evidence to recommend a
sole topical treatment (2% miconazole nitrate and 2% chlorhexidine gluconate
shampoo twice weekly for 3 weeks). Fair evidence exists for recommending oral
ketoconazole (5–10 mg/kg q24h for 3 weeks) or oral itraconazole (5 mg/kg on
2 consecutive days of a week for 3 weeks), especially when topical treatment is
impractical or impossible. There is insufficient evidence to recommend either
oral terbinafine or various other topical treatments (miconazole, enilconazole,
chlorhexidine, piroctone olamine, benzalkonium chloride) for treatment of
Malassezia dermatitis in dogs. Although anecdotal reports exist with regard
to other treatment options, more stringent and controlled studies need to be
performed to further validate these therapeutic ‘recommendations’.
226

Questions: 219, 220
219 A 6-year-old male castrated DSH 219a
cat presented for intense pruritus,
exudative skin lesions, and progressive
alopecia. The ventral abdomen was
the most severely affected area (219a);
however, the owner had also noted
that the cat’s lip appeared swollen.
The cat spent 6 months of the year in
Florida, USA, and the other 6 months
in Wisconsin. No medications had
been administered to the cat, including
ectoparasite prevention.
for the lesions seen on this cat?
ii. Cytology of the lesion on the ventral abdomen showed a large number of both
eosinophils and neutrophils. Several coccoid bacteria, primarily in pairs or small
clusters and often located intracellularly, were also seen. What are your treatment
recommendations for this cat?
220a 220b
220 A 10-year-old mixed-breed dog treated

for lymphoma developed mild to moderate
pruritus, erythema, and excessive scaling over
the last several months. The lesions shown
were present extensively over the dorsum (220a). In addition, the dog had severe
facial excoriations. Skin scrapings revealed large numbers of mites and eggs per
high-power field (220b).
i. What is the diagnosis?
ii. What recommendations will you make to the ward staff?
227

Answers: 219, 220
219 i. Parasites (fleas, Demodex 219b
gatoi), infection (bacterial pyoderma,
dermatophytosis), allergy (flea allergy
dermatitis, cutaneous adverse reaction
to food, environmental allergy).
Abdominal and urinary tract pain
would also be differentials for the
lesions noted on the ventral abdomen.
ii. Since the cat is not currently receiving
any ectoparasite prevention, initiating
appropriate adulticide flea prevention is indicated. There is clinical and cytologic
evidence of bacterial pyoderma, therefore appropriate antimicrobial therapy
is recommended. Amoxicillin–clavulanate, cefadroxil, cefovecin, clindamycin,
ormetoprim–sulfadimethoxine, or trimethoprim–sulfonamide are all effective for
feline bacterial pyoderma. Based on response to the aforementioned treatments, a
lime sulfur trial for Demodex gatoi and additional work-up for underlying allergic
disease would be the next steps. This cat responded markedly to a single injection
of cefovecin sodium and flea prevention using selamectin (219b). Repeated
injection and maintenance of monthly flea prevention led to complete remission
and no relapse of skin lesions.
220 i. Cheyletiella infestation. This is a severe infestation; it is uncommon to find

large numbers of mites and eggs per high-power field. The mite causes dorsal
scaling and mild to moderate pruritus in dogs, cats, and rabbits. The entire life
cycle (approximately 35 days) is spent on the host. The mites do not burrow but
rather move freely on the surface of the skin and deposit eggs on the hairs.
ii. This is a highly contagious disease and presents a risk to other dogs or cats
housed in the ward that day. In this case, the risk is increased due to the large
number of mites. Mites can live in the environment for short periods of time; they
are very mobile. Transmission occurs via direct contact, environmental exposure,
or by ward staff. If possible, move the dog to isolation. The cage and area where
the dog was housed should be grossly cleaned and treated with an environmental
insecticide labeled as effective against fleas. Ward staff need to be informed of the
zoonotic risk and instructed to seek medical attention if they develop a pruritic
rash. All staff should change their uniforms and laboratory coats and place them
in a plastic bag until washed. Anyone handling the dog should wear gloves and
disposable gowns. The owners need to be informed of the risk and educated about
the treatment of their pet and other pets at home.
228

Questions: 221, 222
221a 221b
221 A 4-year-old female spayed

Labrador retriever dog presented for
excessive scaling and hair loss (221a).
The owners had adopted the dog as a
young adult; severe scaling was present
at the time of adoption; however, it was
attributed to poor nutrition since the dog was obtained from a rescue facility. The
dog’s clinical signs did not improve with antimicrobial therapy (systemic antibiotic
administration) or corticosteroid administration. The owners reported the dog to
be only mildly pruritic. On physical examination, large scales were present over the
entire body with scaling worse along the limbs and trunk. The scales were tan–white
in color and were either free in the hair coat or adhered to the skin in sheets. Hair loss
was more noticeable in areas with excessive scaling. The skin beneath the exfoliative
dermatitis was normal in appearance; ulcers and inflammation were absent. The
nasal planum, foot pads, and mucocutaneous junctions were not affected.
ii. A skin biopsy from a region of excessive scale is shown (221b). What are the
key findings?
iii. What is the diagnosis?
iv. What forms of this disease have been reported in the dog?
222 What options are there for 222

environmental flea control (222)?
229
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Answers: 221, 222
221 i. Cornification defect; differentials include severe primary seborrhea,
ichthyosis, epidermal dysplasia, nutritional deficiency/responsive dermatosis
(vitamin A, zinc, fatty acid).
ii. Marked compact/laminated superficial orthokeratotic hyperkeratosis and
follicular keratosis; the remainder of the epidermis is of normal thickness. Dermal
inflammation is not noted.
iii. Ichthyosis.
iv. Ichthyosis is used to describe a group of genetic skin diseases characterized
by generalized scaling. The disease results from an abnormality in keratinocyte
differentiation or cornification. The scaling is a result of either increased
keratinocyte proliferation or decreased corneocyte desquamation. Although
several forms of the disease exist in humans, only a few have been genetically
characterized in the dog. All forms in the dog have been reported or suspected to
be inherited as an autosomal recessive trait. A mutation in keratin 10 causes an
epidermolytic form of ichthyosis in the Norfolk terrier. Non-epidermolytic forms
of ichthyosis are more common in dogs. A mutation in transglutaminase-1 causes
ichthyosis in Jack Russell terriers. In golden retriever dogs, genetic ichthyosis due
to a PNPLA1 mutation associated with an autosomal recessive mode of inheritance
has been reported. This disease is an animal model for human autosomal recessive
congenital ichthyosis. Ichthyosis is also seen in other breeds of dogs; however, the
genetic characterization has not yet been determined.
222 Mechanical removal of flea eggs and larvae can be done via regular and
thorough vacuuming of the environment. Indoor environments can be sprayed
with methoprene or pyriproxifen; these insect growth hormone analogs stop the
development of flea eggs and larvae. Methoprene is degraded by UV light so it
should only be used indoors. Pyriproxifen is more UV stable and can be used both
indoors and outdoors; it remains in the environment for 2–4 months. Lufenuron is
an insect development inhibitor that interferes with chitin biosynthesis. It is both
ovicidal and larvicidal. It is very safe for mammals; it concentrates in fat and is
slowly released into the blood stream. Sodium polyborate powder kills larvae and
eggs by desiccation and is very effective for carpeted areas. It can last for up to 1
year; however, carpets cannot be steam cleaned during this period. Flea control in
the outdoor environment involves removal of leaves and mulch from shaded areas,
limiting pets access to damp dark areas, and keeping free roaming mammals (cats,
dogs, wild small mammals) from living in or around homes and sheds. Pyriproxifen
can be sprayed outdoors to control larvae. Steinernema carpocapsae are nematodes
that eat flea larvae. They come in a powder that is sprinkled over organic debris or
in a vial that can be attached to a garden hose and sprayed over the yard.
230

Questions: 223, 224
223a 223b
223 A 6-month-old Great Dane puppy was presented for the problem of pruritus
(223a). The owner reported that the pruritus had developed gradually over the last
3 months. The puppy’s vaccination history was current and the owner administered
monthly spot-on flea control. The skin was thickened, erythematous, and scaly.
There was no evidence of a bacterial pyoderma (i.e. papules, pustules, epidermal
collarettes). The puppy was depressed, febrile, lame, and had lymphadenopathy.
Skin scrapings were negative for Demodex mites. Skin impression smears revealed
large numbers of shed nucleated keratinocytes, but no bacteria or yeast were
observed. CBC and serum chemistries were within reported laboratory normal
ranges for the dog’s age. A FNA of the lymph nodes was compatible with reactive
lymph nodes. A skin biopsy was obtained.
i. The key findings of the skin biopsy are shown (223b). The pathologist
commented that this finding was diffuse and extended into the hair follicles. What
is the diagnosis?
ii. What are the three types of this condition?
iii. What is the treatment?
224 A 2-year-old cat presented for the problem 224

of multiple melanomas of the ears. Close
examination of the ears revealed that lesions
were limited to the pinna and periauricular skin.
A large number of darkly pigmented cysts were
present (224). On rupture of the cysts, darkly
pigmented, often slightly granular, material
exuded out. Once the cyst was ruptured and
evacuated the pigmentation disappeared. This is
a classic presentation of what condition?
231

Answers: 223, 224
223 i. Zinc-responsive skin disease. The key finding in the skin biopsy is
parakeratotic hyperkeratosis. In zinc-responsive skin diseases this abnormality is
widespread and since it involves changes in epidermopoiesis, changes extend into
the hair follicles, which can be a key diagnostic feature.
ii. Syndrome I occurs in northern or sled dog breeds (e.g. husky, malamute, akita); a
genetic defect in zinc absorption is suspected. These dogs present with symmetrical
crusted lesions that vary in severity from focal to widespread, with an older age of
onset (1–3 years of age). Syndrome II is the result of zinc-deficient diets or diets high
in phytates (high plant/grain) and/or calcium. A third syndrome is acrodermatitis,
originally described in bull terriers. This rare, inherited autosomal recessive
metabolic disease starts at 6–8 weeks of age and is only partially responsive to
treatment. Dogs develop crusted skin, growth abnormalities, decreased immune
function with chronic diarrhea, and bronchopneumonia. More recently, another
breed-related zinc-responsive skin disease has been reported in a litter of Pharaoh
hound puppies. Three of five puppies developed severe generalized erythematous
and crusted papules with pruritus, marked exfoliation, and erythema of the foot
pads. The puppies were inappetent, lethargic, and had retarded growth. Affected
puppies were administered intravenous zinc supplementation at 3–4 week intervals
to control skin lesions. The dogs were followed for over 2 years; they had stunted
growth and enamel hypoplasia of permanent dentition.
iii. Feed a complete and balanced diet and supplement the dog with zinc gluconate,
zinc sulfate, or zinc methionine.
224 Feline ceruminous cystomatosis (also known as apocrine hidrocystomas),

which can occur in the ears and/or around the eyelids of cats. These masses are
referred to as apocrine hidrocystomas, especially when they occur around the
eyelids. Lesions are characterized by single to multiple punctate nodules to vesicles
in the external ear canal and inner pinna. These lesions are dark blue, brown, or
black and can be mistaken for melanocytic or vascular neoplasms. The literature
reports this to be an ‘old age change’ and a disease of older cats, but the lesions
are observed frequently in younger cats. These lesions are classic, as rupture of the
cysts reveals a black-brown liquid, often with a grainy texture. Diagnosis is clinical;
however, biopsy is recommended to rule out melanoma. Skin biopsy reveals cystic
glands grouped in clusters. The lesions are best treated via laser surgery or with
silver nitrate. Successful treatment using surgical debulking followed by chemical
ablation with 20% trichloroacetic acid (used in plastic surgery for cosmetic
chemical peels) has been reported.
232

Questions: 225, 226
225 i. What is the difference between cyclosporine and cyclosporine (modified)?

How does this difference relate to veterinary medicine?
ii. What diseases has cyclosporine been used to treat?
iii. What are the most common clinical side-effects associated with cyclosporine
administration?
226
226 A 21-year-old female spayed DSH cat presented for crusting lesions on
the haired skin of the bridge of the nose. The cat had numerous other medical
illnesses for which she was being managed, but there was no previous history of
skin disease. The lesions were not noted to be overly pruritic or uncomfortable.
They were confined strictly to the facial location shown (226). What are your
differential diagnoses for this patient?
233

Answers: 225, 226
225 i. Cyclosporine (modified) is a 225
microemulsion formulation of cyclosporine.
The modified form is absorbed more
effectively and predictably in small animals,
leading to enhanced bioavailability. The non-
modified form is influenced by a number of
factors, including bile flow, presence of food,
and gastrointestinal motility, with regard to
systemic absorption.
ii. Canine and feline AD, sebaceous adenitis,
perianal fistulae, feline eosinophilic skin
lesions, feline pseudopelade, sterile nodular
panniculitis, CLE, cutaneous reactive histiocytosis, vaccine-induced ischemic
dermatopathy, juvenile cellulitis, variable response for PF and PE.
iii. Vomiting, diarrhea, nausea, anorexia, gingival hyperplasia (225), hypertrichosis.
Diabetes mellitus has been reported rarely in dogs administered cyclosporine for AD; a
recent study documented disturbances in glucose metabolism. Blood work abnormalities,
including elevations in alkaline phosphatase, alanine aminotransferase, and cholesterol,
have been reported by the manufacturer; however, these changes are rarely associated
with clinical signs of disease. Other uncommon to rare side-effects in dogs and cats
include bacterial infection, bone marrow suppression, hirsutism and excessive shedding,
hepatitis, lymphoma and lymphoproliferative disorders, neosporosis, nephropathy,
nocardiosis, papillomatosis, seizures, sodium retention, and toxoplasmosis.
226 Include dermatophytosis and demodicosis (although this is a fairly atypical

location) because of the concurrent medical illnesses and age of this patient. Other
differentials include PF, superficial bacterial pyoderma, drug reaction, foreign body
reaction, trauma, mosquito bite hypersensitivity with secondary self-trauma, less
likely deep fungal disease (such as cryptococcosis), and neoplasia. In this patient,
cytology from under the crust revealed a moderate number of cocci bacteria.
Superficial pyoderma was suspected due to previous foreign body reaction/trauma
after the cat had inadvertently come into contact with a cactus in the house.
234

Questions: 227, 228
227 A 4-year-old 227a 227b
male castrated collie
dog was presented for
chronic skin lesions
on the face, tail, and
distal extremities of
all four limbs. The
lesions consisted of
crusting along the
bridge of the nose
along with scarring
alopecia of the muz
zle and periocular regions (227a), ulceration with
crusting, depigmentation and scar formation 227c
involving the nasal planum (227b), and scarring
alopecia with erythema along the distal aspect of
all four limbs (227c). The owner had obtained the
dog from a rescue organization and was told that
numerous other dogs from the same litter were
similarly affected.
i. What is the most likely diagnosis in this patient?
What other differential diagnoses would you consider
if this dog was a 16-week-old puppy? What if the
lesions were present in a different dog breed? What if
only the facial lesions were present in this dog?
ii. What other clinical signs may be associated with this condition?
228 In-house cytologic evaluation is an important part of daily dermatologic practice.

Collection technique and processing of the sample can impact on the diagnostic
sensitivity of disease detection. Accurate interpretation of the cytologic sample can
be influenced by where the sample was collected from, how the sample was obtained,
and how it was processed prior to evaluation. Otitis externa is a common indication
to perform cytology evaluation; the presence or absence of organisms along with
what types of organism are seen (e.g. yeast, cocci bacteria, rod-shaped bacteria) will
influence the ‘next step’ diagnostically and therapeutically for many practitioners.
i. What is Diff-Quick® stain?
ii. What options are available with regard to fixation of an ear swab sample?
iii. What options are available for staining ear swabs using a Diff-Quick type of
stain?
235

Answers: 227, 228
227 i. The facial lesions are symmetrical, suggesting metabolic or immune-mediated
disease (e.g. pemphigus); however, breed and distribution make the most likely
diagnosis familial canine dermatomyositis. If the patient originally presented as a
young puppy and lesions were inflammatory, pediatric diseases such as demodicosis
and dermatophytosis would need to be ruled out prior to diagnostics (i.e. skin
biopsy) to confirm a suspicion of juvenile-onset ischemic dermatopathy; this
condition presents in very young dogs and without a specific breed association. If
the patient was an adult but of a different breed (non-collie or Shetland sheep dog),
other causes of ischemic dermatopathy should be considered including vaccination-
induced ischemic dermatopathy and idiopathic ischemic dermatopathy. Vaccination-
induced ischemic dermatopathy typically has a time course associated with recent
vaccination (within 4 months of presentation) and may be localized (at the site of
injection) or generalized. If strictly facial lesions are present, lupoid diseases (discoid
lupus in particular) would be an important differential diagnosis.
ii. Skeletal muscle atrophy (often most noticeable over the temporal muscles, trunk,
and extremities), dermatitis involving scarring alopecia, erythema and crusting over
all extremities (head, face, ears, tail, distal limbs, bony prominences), decreased
jaw tone, stiff gait, megaesophagus, difficulty breeding, and hyperreflexia have
been noted in more severely affected patients.
228 i. A Romanowsky stain variant based on modification of Wright–Giemsa

stain. It involves three different solutions into which a dried cytology sample is
immersed. The first solution is a fixative reagent, typically with an alcohol base
(methanol is most commonly used). The second solution is a xanthene dye (the
‘stain’), which stains the sample first eosinophilic. The third solution is a thiazine
dye (the ‘counterstain’), which stains aspects of the sample basophilic. Intrinsic
organism and cellular properties lead to variable appearance of the sample on
cytologic evaluation.
ii. Include heat fixing the sample to the slide prior to staining, or proceeding solely
with the first Diff-Quick solution after the sample has been allowed to air-dry.
iii. Include using the complete three-step process (fixative, stain, counterstain) or solely
the third solution (basophilic counterstain). In a study evaluating the different fixation
and staining methods for canine ear swab cytology, it was concluded that heat fixation
did not provide appreciable improvement of sample quality compared with non-heat
fixed samples. Also, it did not make much difference to cytology interpretation whether
the sample was prepared with the three-step method or whether the counterstain alone
was used. Inter-observer variation is still a factor in ear swab cytology interpretation,
regardless of what fixation and staining methods are utilized.
236

Questions: 229, 230
229 A 5-year-old male castrated 229a
an acute history of moderate to severe
pruritus and discomfort. The dog had
not eaten well that morning and had
been lethargic for the past 2 days. On
physical examination, the dog was
reluctant to move and appeared to be in
pain. Diffuse erythema and mild swell
ing were present periocularly (229a)
and on the medial aspects of the pinnae.
Erythematous macules were noted
along with occasional papules and
pustules and slightly raised plaques, 229b
the latter occasionally appearing
‘targetoid’, intermixed with normal
appearing serpiginous regions (229b).
Skin surrounding mucous membranes
was affected; however, non-haired skin
appeared normal. The dog had a rectal
temperature of 40.6oC (105.1oF). The
owners did not report anything unusual
with regard to the dog’s history; nothing
had changed within the past week and
the dog was not receiving any medications.
i. Based on the clinical appearance, what are your differential diagnoses for this
patient?
ii. Skin biopsy showed diffuse infiltration of the dermis (superficial and deep) with
large numbers of neutrophils, often clustering along the hair follicles. Occasional
neutrophilic infiltration crossed into the epidermis, forming small intraepidermal
pustules. Severe edema was present throughout the dermis. Based on this
information, what additional diagnostics are indicated?
iii. CBC showed marked peripheral neutrophilia. Provided your additional diag
nostics from Qii are negative, what is your diagnosis?
230 A i. What is the pathogenesis of the dermatomyositis diagnosed in case 227?

ii.What are the treatment options?
237

Answers: 229, 230
229 i. EM, bacterial pyoderma (superficial and/or deep), fungal infection (histo
plasmosis, cryptococcosis, sporotrichosis), neoplasia (cutaneous lymphoma, mast
cell tumor), canine eosinophilic dermatitis (Wells syndrome), sterile neutrophilic
dermatitis (Sweet’s syndrome), toxic shock syndrome, post-grooming furunculosis,
sterile erythroderma (typically seen only in miniature schnauzer dogs).
ii. CBC and serum biochemistries to screen for peripheral leukocyte abnormalities
and determine whether there is a known source of the fever; special stains (GMS,
PAS, Fite’s) to assess the presence of infectious organisms on skin biopsy samples;
bacterial and fungal cultures.
iii. Sterile neutrophilic dermatitis or Sweet’s syndrome. This disease may take a
form similar to EM in which macules, small papules, pustules, and slightly raised
plaques predominate, or more distinct nodular lesions may be present. Post-
grooming furunculosis and deep pyoderma must be ruled out. Sweet’s syndrome
in dogs tends to mimic the disease in people; sterile neutrophilic infiltration of the
skin is reported along with peripheral neutrophilia, and patients are often febrile.
Other body organs may also be infiltrated. Strictly, sterile neutrophilic infiltration
of the dermis and epidermis in the absence of extracutaneous signs may also occur.
230 i. Familial dermatomyositis is a congenital/hereditary disease most commonly

reported in collies and Shetland sheep dogs and their crosses. Other breeds may
show similar clinical signs, but the underlying cause (i.e. genetics) is different.
The condition develops due to ischemic injury to the skin and skeletal muscles.
The disease varies in severity. Previous work done with collies has documented an
autosomal dominant inheritance with incomplete penetrance. In Shetland sheep
dogs, a linkage to chromosome 35 has been documented in disease development.
Additional studies have identified numerous gene transcripts associated with
immune function, but have not determined specific autoantibodies or genetic
defects associated with familial dermatomyositis in Shetland sheep dogs.
ii. There is no cure for familial canine dermatomyositis because this is a
genetic disease. Pentoxifylline has been shown to be effective in many patients.
Supplementation with essential fatty acids and vitamin E may also be beneficial.
For either drug, it can take up to 3 months before any noticeable benefit is seen.
In more severe cases, prednisone is administered and then tapered to control flares
of the disease; long-term administration will worsen muscle atrophy. Management
should also include bathing to minimize crust formation and decrease the frequency
of secondary bacterial pyoderma, which commonly develops.
238

Questions: 231, 232
231a
231b
231c
231 Examination of skin cytology is an important diagnostic test. Skin cytology can
be collected using a glass microscope slide (231a), clear acetate tape preparation
(231b), or by scraping debris from under nails or skin folds with a skin-scraping
spatula (231c). Briefly describe how optimum specimens are obtained using each
of these three techniques.
232 Fleas can transmit a variety of infectious diseases. List at least three infectious
diseases that are transmitted by fleas.
239

Answers: 231, 232
231d
231
• Glass microscope slide. Always use a new glass microscope slide. Place the slide
directly over the target area and then place a thumb over the site and gently
press once only to avoid too thick a specimen. Take multiple samplings on
the same slide using different sites (231d). Samples from intact pustules are
obtained by gently rupturing the pustule with a sterile needle. Samples from
crusted lesions are obtained by lifting the crust and getting the sample from
beneath. The specimen must be allowed to dry completely before and after
staining. Adequately sampled specimens should show a clear ‘fingerprint’
(231d).
• Acetate tape. Press clear acetate tape over the target site, skip the ‘fixative step’
to avoid fogging tape, allow the specimen to dry before mounting, and mount
over a drop of immersion oil.
• Scraping technique. A skin-scraping spatula is used to collect material from
beneath nail beds, skin folds, areas of lichenification, or beneath crusts. Material
collected from these sites is spread over the surface of a glass microscope slide
before staining. This technique is especially useful for looking for yeast beneath
nail folds.
232 The most severe infection spread by fleas is Yersina pestis. In addition, they
can spread Rickettsia typhi (murine typhus, which is a worldwide zoonosis), R.
prowazekii (present in the USA and known as rural endemic typhus), R. felis (flea-
borne spotted fever), Bartonella henselae (cat scratch fever), Bartonella quintana
(trench fever; the primary host is the human louse but fleas can also spread this
disease). Fleas also act as hosts for the helminth parasites Dipylidium caninum
(tapeworms) and Hymenolepis diminuta.
240

Questions: 233, 234
233 A 7-year-old male castrated yellow 233
acute severe pruritus and appearance
of a large skin lesion (233). The owners
had noted the dog shaking his head a
bit more frequently for the past week.
However, the lesion was not present
prior to the owners going to bed the
night before presentation. No other
lesions were noted on examination.
for this patient based on clinical
appearance?
ii. Of the differential diagnoses, which
is most likely given the history?
iii. What diagnostic tests do you
recommend for this patient?
iv. With regard to ‘hot spots’, what is
the classification of this lesion?
v. What are the treatment options?
234 A 6-month-old kitten was presented for 234

evaluation of non-responsive unilateral otitis
externa. Initial ear swab cytology revealed neutro
phils, cocci, and yeast. Initial treatment for the
microbial overgrowth did not resolve the otitis.
Examination of the ear revealed proliferative,
erythematous necrotic tissue covering the proximal
pinna and vertical ear canal (234). The ear was
pruritic and painful. Skin biopsy revealed sharp
demarcation between normal and abnormal
tissue. There were scattered apoptotic appearing
keratinocytes within severely hyperplastic epi
thelium. The abnormalities also affected hair
follicles, which were dilated and filled with necrotic debris. Special stains revealed
CD3+ T cells and caspase-3-stained keratinocytes, consistent with keratinocyte
apoptosis by epidermal infiltrating T cells. What is the most likely diagnosis, and
how is this treated?
241

Answers: 233, 234
233 i. Pyotraumatic dermatitis, demodicosis, dermatophytosis, superficial pyo
derma, deep pyoderma, neoplasia (mast cell tumor, apocrine gland tumor,
cutaneous metastasis), drug eruption.
ii. Pyotraumatic dermatitis because of the acute onset of the lesion.
iii. Deep skin scraping, otoscopic examination, ear swab cytology to look for
evidence of otitis externa. Culture and susceptibility may be needed based on the
dog’s previous antibiotic exposure.
iv. ‘Hot spot’ (pyotraumatic dermatitis, acute moist dermatitis) is a common
example of acute superficial bacterial pyoderma. Histologically, there are two
presentations: superficial and deep pyoderma.
v. The hair coat needs to clipped and then cleansed with an antimicrobial topical
shampoo or scrub. The dog may need to be sedated as these lesions can be severely
pruritic and/or painful. These lesions are best treated with focal antimicrobial
therapy. Previous studies have advocated the use of systemic antibiotics; this
should be considered when evidence of spreading superficial pyoderma is also
present. With the increasing prevalence of resistant organisms and the overriding
focus on judicious antibiotic use, topical control alone may be sufficient in many
cases. Some animals may also require the addition of mechanical restraints
(e.g. Elizabethan collar, socks, shirts) to prevent scratching and further trauma.
Addressing the underlying cause of the pruritus/pain is also recommended to help
prevent further pyotraumatic dermatitis lesions from developing.
234 Proliferative and necrotizing otitis. This is a uniquely and visually distinctive
ear lesion. Lesions can occur in kittens between 2 and 6 months of age and may or
may not spontaneously regress by 12–24 months of age. The lesions may respond
to glucocorticoids or to tacrolimus; however, effective treatment is not always
possible. This disease is considered rare, but it may simply be unrecognized.
242

Questions: 235, 236
235 Four 6-mm punch biopsies from the skin 235
of the lateral trunk of a 6-year-old neutered
male standard poodle dog with hair coat
abnormalities (235) have been submitted for
dermatopathologic examination.
Histological report: the epidermis is normal
thickness and there is marked diffuse ortho
keratosis and follicular keratosis. Sebaceous
glands are diffusely absent. Adjacent to a few
follicles, at the level of the isthmus, are tiny
aggregates of lymphocytes, mast cells, and
macrophages. Hair follicles have a stretched
out appearance and occasional follicles have
an irregular outline and contain an irregular
dystrophic hair shaft. In one biopsy, several follicles are atrophic and are in non-
haired telogen.
Morphological diagnosis: diffuse sebaceous gland atrophy, with focal minimal
parafolliculitis, marked orthokeratosis, follicular keratosis, and multifocal hair
follicle atrophy.
i. What is the diagnosis based on the histopathologic description?
ii. Which breeds of dog are predisposed to this disease?
iii. What is the suspected mode of inheritance of this disease in standard poodle dogs?
iv. What other species has it been reported to affect?
236 A 4-year-old cat presented for the complaint 236

of ‘bumps’. Palpation of the skin followed by
clipping of the hair coat revealed multiple,
firm nodules on the lateral aspect of the thigh
(236). The lesions were non-painful when
manipulated. The medical record indicated that
the last time the cat was examined was at the
age of 1 year when it was vaccinated. When
asked about the onset of the masses, the owner
reported that they occurred suddenly and have
rapidly developed over the last 2 weeks. The cat
is otherwise healthy.
ii. What is the 3-2-1 rule?
iii. The skin biopsy is compatible with a sarcoma. What is the treatment?
243

Answers: 235, 236
235 i. Sebaceous adenitis (SA) given the relative absence of sebaceous glands and
aggregates of inflammation where these glands are normally found.
ii. Standard poodle, vizsla, samoyed, akita, and English springer spaniel dog breeds
are believed to be predisposed. Dachshunds, Belgian sheepdogs, and Havanese
breed dogs may be at increased risk for SA.
iii. An autosomal recessive mode of inheritance is strongly suspected.
iv. SA has been reported in dogs, cats, rabbits, horses, and humans.
236 i. The dermatologic problem is ‘tumor’ and there are three major causes:
infections, granulomas (sterile inflammatory), and neoplasia. The most common
infection in the cat is an abscess, but clinically these lesions are not compatible with
abscesses. Subcutaneous infections with opportunistic fungi can appear similarly;
however, lesions are usually slow to develop. Granulomatous reactions in cats are
uncommon. They can occur as a result of tick or flea bites, but these are usually
smaller in size and slower to develop. Pansteatitis as a result of poor diet can occur,
but these lesions are typically painful. The most likely cause is subcutaneous skin
tumor; injection-site sarcoma is most likely.
ii. The Vaccine Associated Feline Sarcoma Task Force (VAFSTF) recommends for
every mass that (a) persists for >3 months after injection, (b) becomes larger than
2 cm, and/or (c) increases in size 1 month after injection should be biopsied (3-2-1
rule). If fibrosarcoma is suspected, an incisional biopsy specimen is recommended
(not a Tru-cut); the tumor can be heterogenous and misdiagnosed as a granuloma
from small tissue samples.
iii. The mainstay of treatment is wide surgical excision with a goal of a 3–5 cm
macroscopic margin of healthy tissue and at least one fascial plane beneath the
tumor. Radical surgery greatly affects recurrence rate. Radiation therapy with or
without chemotherapy can follow. Cats with the best prognosis are those that
undergo aggressive surgery and are treated with multiple modalities.
244

Questions: 237, 238
237 Sebaceous adenitis (SA) is an inflam 237a
matory skin disease in which sebaceous
glands are specifically targeted, as
shown by the histopathology report in
case 235.
i. How is the histopathologic pattern
different in short-coated breeds of dogs
(237a) compared with standard poodle
dogs?
ii. List other diseases whose cellular
infiltrate might incidentally surround,
disrupt, or destroy sebaceous glands as
seen histopathologically.
iii. Describe what this dog’s skin might look like given the disease process.
238
6 7
8
5 3
1 2
238 A CT scan is frequently incorporated into the diagnostics for a dog or cat with
chronic and/or recurrent ear disease, particularly when middle ear involvement is
suspected. In general, the sensitivity and specificity of CT are much higher than
those of plain film radiography in cases of moderate to severe otitis. CT scans may
also be incorporated with virtual otoscopy to provide a more accurate image in a
non-invasive setting.
i. Is this CT scan (238) from a dog or a cat?
ii. Identify the labeled structures on the scan.
245

Answers: 237, 238
237 i. Short-coated dogs affected by 237b
SA, such as the vizsla, usually have
large discrete periadnexal nodules
composed of granulomatous to pyo
granulomatous inflammation cen-
tered where there should normally
be sebaceous glands (follicular isth-
mus). Inflammation at the isthmus
level tends to be less prominent in
standard poodles, especially during the late stages of disease.
ii. Demodicosis, dermatophytosis, leishmaniosis, reactive histiocytosis, sterile
granuloma/pyogranuloma syndrome, uveodermatologic syndrome, pseudopelade,
exfoliative cutaneous lupus erythematosus of the German shorthaired pointer,
epitheliotropic lymphoma. Other histopathologic findings and patient signalment
help discriminate these diseases from SA; however, clinical differentiation might be
required in select cases.
iii. Initially, standard poodle dogs with SA develop with excessive and adherent
white surface scale that is not overtly pruritic. Follicular seborrhea, manifested
comedones, and fronds of keratinous material protruding from follicular ostia/
openings and entrapping exiting hair shafts (237b) are also common findings. As
the disease progresses a dull, dry, brittle coat with broken hairs that is multifocal
to generalized is seen. Loss of the normal ‘crimp’ to the hair denotes an additional
change in coat quality. These lesions first arise on the muzzle, head, pinnae, neck,
and dorsolateral trunk before extending to other body areas. Papules, pustules,
crusts, and pruritus may be a feature when bacterial folliculitis is present.
238 i. Dog. The presence of pendulous pinnae on the scan identifies the animal as
a dog. Cats have a prominent bony shelf separating the tympanic bulla into two
distinct compartments.
ii. 1 = tympanic bulla; 2 = external ear canal (near the level of the vertical and
horizontal canal); 3 = tympanic membrane; 4 = trachea (outlined by radiopaque
endotracheal tube); 5 = inner ear ossicles; 6 = brain; 7 = temporal muscles; 8 =
pinna.
246

Questions: 239, 240
239 A 5-year-old female spayed Lab 239
rador retriever dog was evaluated for
lethargy, anorexia, and erythematous
skin lesions. At presentation, the
dog was febrile (40.7oC [105oF])
with dull mentation. When the hair
coat was clipped, well-circumscribed
erythematous lesions were present
over the entire body (239). There
were no lesions found on the mucous
membranes. Four days prior to the
development of the recent clinical signs, the dog chewed on bones from a turkey
carcass for several hours until the owners discarded the remains.
i. Based on the patient’s history and physical examination, what differentials
should be considered?
ii. What diagnostic tests are indicated in this patient?
iii. Blood cultures are positive and the laboratory’s preliminary findings identify a
small gram-positive anaerobic rod. Considering the history and clinical signs, what
is the most likely diagnosis, and what other comorbidities should be evaluated in
this patient?
iv. Your diagnosis is confirmed and a skin biopsy is needed. What would you
expect to find on skin biopsy?
v. What is the best treatment?
240 These lesions developed over a 240

1-month period (240). The owners
reported that the dog vocalized one
evening and within hours there was
marked swelling of the face. Within
days, a non-healing wound developed.
Skin biopsy of the tissue revealed
necrosis and no etiological agents.
Bacterial culture of the wound and
of tissue did not isolate any bacteria.
The lesions have progressed in spite of glucocorticoid therapy. What is a possible
inciting cause?
247

Answers: 239, 240
239 i. Vasculitis, thrombocytopenia/thrombopathia, coagulopathy, cutaneous
drug eruption.
ii. CBC, serum chemistry panel, skin biopsy, blood culture, and urine culture
should be considered if the dog is not in a hypercoagulable state.
iii. Erysipelothrix rhusiopathiae, which is the causative agent of diamond
skin disease in pigs. Erysipelothrix organisms are epitheliotropic and damage
endothelial cell barriers, leading to local cellulitis with edema. Wild birds and
mammals can also harbor E. rhusiopathiae, and thus are potential reservoirs of
the microorganism. It is likely that this patient acquired the bacteria while she
was chewing on a turkey carcass 4 days prior to the development of clinical signs.
During chewing, damage to the oral mucosa likely occurred, allowing translocation
of bacteria from the carrion.
iv. E. rhusiopathiae infection typically results in cellulitis with marked edema in
the upper and mid dermis, vascular dilatation, and neutrophilic, lymphocytic, and
eosinophilic inflammatory infiltrate in the upper and mid dermis.
v. Antibiotic therapy should be guided by results of blood and urine culture
susceptibility findings. If empiric antibiotic therapy is needed while cultures
are pending, or if cultures were not obtained, previous reports show that E.
rhusiopathiae is highly susceptible to penicillins and cephalosporins; these drugs
should be considered first-line therapy.
240 Envenomation by an insect or snake secreting a necrotizing toxin was suspected

to be the inciting cause after infectious agents were ruled out. The vocalization
was most likely the bite and the swelling the initial reaction. The progressive
necrosis suggests a dermonecrotic toxin. There are two spiders (recluse spider and
sixed-eyed sand spider) that are known to secrete a dermonecrotic agent called
sphingomyelinase D. Initial bites often start as a ‘halo’ with a vesicle and progress
to a black necrotic area. Lesions can become very large; in some cases systemic
signs can occur within 24–72 hours and include hemolysis, hematuria, fever, and
arthralgia.
248

Questions: 241, 242
241 A 4-year-old female spayed golden 241
retriever dog presented for acute onset
of lameness in all four feet. The dog
had been out running, swimming, and
hiking over the weekend; the weather
had been quite warm at the time. The
owner noted that over the next 2 days
the dog seemed to be limping, which
progressed to shifting limb lameness
and not wanting to walk, especially on
hard and uneven surfaces. The dog had
also been licking its paws more frequently, paying equal attention to the front and
rear paws. The dog was not receiving any medication other than topical flea and
heartworm prevention once monthly year round. She was otherwise healthy with
no previous dermatologic abnormalities. On physical examination, all four paws
had a similar appearance (241) with primarily the paw pads affected; only mild
interdigital erythema was noted on the haired skin. No other lesions were noted
on the dog; all mucous membranes appeared normal.
i. What are the differential diagnoses for the condition noted?
ii. Given the history and clinical appearance, what is the most likely diagnosis?
iii. What is the proposed mechanism for the disease in dogs?
242 A 3-year-old Labrador retriever dog was presented for the problem of year-
round pruritus. The dog was receiving year-round flea and tick control, skin scrapings
were negative, and contagious mites had been ruled out via a response to treatment
trial using ivermectin. At the time of initial presentation, the dog had clinical signs
consistent with bacterial pyoderma and yeast overgrowth was confirmed via skin
cytology. Culture and sensitivity isolated an SIG isolate susceptible to cephalexin.
After 30 days of cephalexin and oral ketoconazole, the pruritus persisted despite
resolution of clinical lesions associated with microbial overgrowth. At this point the
differential diagnoses were narrowed to food allergy and/or canine AD. The owner
completed a home-cooked food elimination trial using kangaroo meat, lentils, and
potatoes for 8 weeks. There was no change in pruritus during the diet or during the
re-introduction of the previous food. At this point the working diagnosis was AD
and an IDT was performed. Based on identification of several positive reactions,
the owner was given the options of sole medical therapy (i.e. cyclosporine) or
immunotherapy; the owner elected immunotherapy. What do you need to consider
when selecting allergens for immunotherapy?
249
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Answers: 241, 242
241 i. PF (confined to the paw pads), zinc-responsive skin disease, superficial
necrolytic dermatitis, split paw-pad syndrome, generic dog food dermatosis, drug
eruption.
ii. Split paw-pad syndrome.
iii. The exact etiology is unknown; however, an anatomic defect in paw-pad
cornification is suspected. The disease has a characteristic clinical appearance in
which the paw pad becomes split and then peels off much of the superficial layer,
leaving a defect in the pad and exposed lower epidermal layers. The adjacent
haired skin is generally unaffected. Dogs can heal normally or with irregular, lumpy
keratinized pads; the latter can cause chronic inflammatory changes. Trauma and
exposure to moisture may precipitate an episode of split paw-pad syndrome. Self-
trauma may exacerbate lesions; dogs will frequently pull off torn, ripped fragments
with their teeth.
242 IDT can identify reactions to all major allergen groups (trees, grasses, weeds,
indoor allergens). It is not possible or practical to include all allergens into the
ASIT prescription. Although the exact amount of allergen necessary to stimulate
an appropriate immunologic response is not known, most allergen prescriptions
contain 10–12 allergens. Flea bite hypersensitivity is best managed with flea
control rather than immunotherapy. Mold allergy cannot be discounted and there
may be regional variations. Management of mold allergy can often be addressed
via avoidance and environmental changes in addition to ASIT. Currently, the key
steps are to decrease humidity in the home, instruct clients not to house the dog in
areas typically high in molds (laundry rooms, bathrooms, basements, cellars), and
improve air filtration via furnace filters. Look for allergens that can be managed
strictly by avoidance (e.g. wool, feathers). Look for results that do not match the
exposure history. For example, if the dog has strong reactions to grasses, but is not
pruritic during the grass season, these allergens are less important to include in
the allergy prescription. Finally, review the laboratory results for cross-reactivity
between plant families. Selection of one or a few allergens from each botanical
group that showed positive reactions may suffice.
250

Questions: 243, 244
243 A 6-month-old male castrated mixed-breed dog presents for multifocal areas of
partial alopecia. The owners first noted a spot of hair missing on the top of the head;
however, three other areas have developed on the dog’s face within the past week.
You perform a deep skin scraping and identify Demodex canis.
i. Depending on the temperament of your patient as well as lesion location,
collecting a diagnostic sample with a deep skin scraping can at times be difficult.
What tools may be used for collecting a deep skin scraping?
ii. Other than deep skin scrapings, by what other methods can demodicosis be
diagnosed? Which methods tend to be most accurate?
iii. D. canis is known to be a ‘normal’ inhabitant of the canine skin. If Demodex
mites are found by one of the diagnostic methods discussed, how likely are they to
be pathogenic as opposed to ‘normal’?
244a 244b
244c
244 A 5-year-old mixed-breed dog
was presented for pustular lesions on
the face, ears, paw pads, and ventrum
(244a). Skin biopsy findings revealed
multifocal subcorneal intact (244b) and
non-intact (244c) pustules with large
numbers of acantholytic cells.
i. What is the most likely diagnosis in
this case?
ii. What other differential diagnoses
should be considered taking into consideration the biopsy findings?
iii. In cases of pustular dermatitis, how should skin biopsies be collected?
251

Answers: 243, 244
243 i. Shown in 243. A scalpel blade is commonly 243
used for collecting samples by means of deep
skin scraping. In mobile patients or for areas
of sensitive skin (e.g. periocular), laceration is
possible. This is true for both the patient and
the veterinarian; this technique is considered to
be a ‘high-risk factor’ for exposure to human
blood in the work place. A laboratory spatula
with a rounded tip is preferred; the tip is scraped
along the direction of hair growth with applied
pressure to obtain capillary ‘oozing’. This is the
authors’ preferred method.
ii. Exudative cytology, hair plucking, biopsy.
Exudative cytology is beneficial when deep pyoderma is present; mites are identified
by cytologic examination of debris. Hair plucking is useful for sampling areas that
are difficult to scrape (e.g. periocular tissue, muzzle); mites are present near the
base of hair shafts. Skin biopsy is recommended when demodicosis is suspected,
but cannot be found using less invasive tests.
iii. In healthy dogs, the prevalence of mites found should not exceed a threshold
of 5.4% of the population. If Demodex mites are found on skin scraping, they
should be considered important; repeated skin scrapings to confirm their presence
is indicated if the patient is ‘not clinical’ for skin disease to assure the finding was
not aberrant.
244 i. Pemphigus foliaceus.

ii. Occasionally, acantholytic cells can be observed in cases of dermatophytosis.
Acantholytic cells can be seen in cases of severe deep pyoderma or chronic pyoderma.
Special stains and fungal culture can be used to rule out dermatophytosis. To rule
out the possibility of the pustular lesions with acantholytic cells being due to a
chronic pyoderma, intact pustules should be collected and submitted for histologic
examination.
iii. They should be collected preferentially from areas with intact and early
developing pustules. If large pustules are present, a punch biopsy should be
avoided, because the rotation of the punch could result in disruption of the lesions.
In this case, and in cases of vesicular dermatitis, an excisional biopsy is preferred.
Chronic lesions with superficial crusts should also be submitted, preferentially
intact. If crusts slough from the adjacent skin, these should also be submitted
for histologic examination. Even though intact pustules are preferred, superficial
crusts can frequently assist in diagnosing PF.
252

Questions: 245, 246
245 A 2-year-old female spayed golden retriever 245a
dog was referred for the problem of recurrent
Pseudomonas bacterial pyoderma. Past pertinent
history revealed that the dog was diagnosed as
having ‘allergies’ at approximately 6 months of age.
The owners elected medical management and were
applying an unknown topical product to the skin.
At the time of presentation the dog had extensive
hair loss, self-trauma and raised erythematous
papules and plaques on the dorsum, neck, trunk,
and vulvar area (245a). The lesions were pruritic
and exudative at the margins. Culture confirmed
the bacteria as SIG (heavy growth) and
Pseudomonas spp. (scant growth). 245b
i. How do you interpret the Pseudo
monas isolation?
ii. Pseudomonas pyoderma has been
reported in dogs. What are the clinical
signs?
iii. A skin biopsy of the plaques was
obtained and the results are shown
(245b). What is the diagnosis, and what
are possible causes of this disease?
246a 246b
246 The oral cavity of a 6-year-old orange tabby cat is shown (246a). Note the
oral lesions in the mouth. The owner presented the cat for examination because of
excessive drooling, lack of appetite, and odor.
i. What are the most likely differential diagnoses?
ii. Touch preparation cytology of the cut edge of a biopsy specimen revealed these
cells (246b). What additional differential diagnosis can be considered?
253

Answers: 245, 246
245 i. It represents overgrowth of a transient organism.
ii. In a retrospective study, seven out of twenty dogs with Pseudomonas pyoderma
presented with deep pyoderma characterized by sudden onset of acute dorsal truncal
pain. Lesions consisted of erythematous papules, hemorrhagic bullae, ulcers, and
hemorrhagic crusts. The other dogs presented with more gradual onset of lesions
and histories of prior skin disease and multidrug antibiotic administration. In these
dogs, bacteria were not always noted on cytology; diagnosis was made via culture.
iii. Calcinosis cutis (CC). There is extensive replacement of the dermal collagen
by dark-staining material (dystrophic mineralization). The most common cause is
hypercortisolemia from either endogenous (adrenal gland disease) or exogenous
(glucocorticoid administration) sources. CC can occur via percutaneous pene
tration of calcium chloride or calcium-containing bone meal from landscaping
materials, most commonly observed in animals sleeping on supply bags. CC
can occur as a complication of intravenous or subcutaneous calcium chloride or
calcium gluconate therapy for hypoparathyroidism. Idiopathic CC has been seen
in puppies with severe illness. Calcinosis circumscripta is another condition in
which dystrophic mineralization of collagen occurs. In this disease, there is focal
deposition of mineral salts in a tumor-like presentation. The etiology is unknown,
but trauma is considered likely, as lesions are found on pressure points or sites of
previous trauma; it has also been found in the oral cavity with no easy explanation.
246 i. Include SCC, fibrosarcoma, and melanoma.

ii. This slide shows a full field of intense eosinophilic infiltrate. An additional
differential diagnosis to consider is an eosinophilic inflammatory lesion. The
diagnosis in this case was an eosinophilic granuloma complex-like lesion. The cat
received three injections of methylprednisolone acetate; the lesion resolved and did
not recur.
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*** Department of Veterinary Pathobiology

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Bacterial cases Nutrition cases

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2 i. The standard inoculum is 105 colony forming units/ml of the bacterium.

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4 A 9-month-old male neutered cat is recovering from panleukopenia. The

4 i. Dermatophytosis and anagen effluvium.

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6 i. Omega-3 fatty acids (e.g. docosahexaenoic acid [DHA] and eicosapentaenoic

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7 An 18-month-old female spayed Siamese cat was presented for evaluation of

Serum or tissue drug concentration

8 Define mutant prevention concentration (MPC) (8) and mutant selection

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8 MPC can be defined as the MIC (minimal concentration of antibiotic that

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9 A 5-year-old male neutered DSH

10 A 4-year-old female spayed Labra­ 10

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11 A 5-year-old female spayed Doberman

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12 An average of 13.6 microliters of blood per day or approximately 15.15 times

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14 Specimens for bacterial culture and susceptibility or cytologic examination are

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18 An indoor/outdoor cat has a compound fracture of the femur of unknown

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18 i. Myiasis is infestation of tissues by fly larvae of the order Diptera. It is a

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19 This 6-year-old male castrated

20 An extreme example of a common 20

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23 Two cats (23a) are presented for

24 Infectious skin diseases can be diagnosed via cytologic techniques, histo­

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25 What is real-time quantitative PCR (qPCR)?

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26 i. Pattern baldness. Cats have two common presentations of non-inflammatory

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30 Special stains are frequently used in histopathology to better identify a particular

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10 A 4-year-old female spayed Labra 10

24 Infectious skin diseases can be diagnosed via cytologic techniques, histo