1. Crusting of muzzle and perineum in a Cavalier King Charles spaniel Author: Ross BondEditor: David Lloyd © European Society of Veterinary Dermatology

2. History | Signs | Differentials | Tests | Therapy | Notes Click to reveal the text on this screen Click the forward arrow to jump to the next screen History - 1 11 year-old entire male Cavalier King Charles spaniel Progressive skin disease of 3 weeks duration Owner reported reluctance to walk and interdigital dermatitis. Now “blisters” on perineum and scrotum History

3. History | Signs | Differentials | Tests | Therapy | Notes History - 2 Dog reportedly depressed Skin lesions progressively more severe Thirst and appetite considered normal Moderate pedal and perineal pruritus History

4. History | Signs | Differentials | Tests | Therapy | Notes Peri-oral crusts and fissures Clinical signs - 1 Signs

5. History | Signs | Differentials | Tests | Therapy | Notes Clinical signs - 2 Signs Linear preputial lesion; erythema, erosion, crust

6. History | Signs | Differentials | Tests | Therapy | Notes Clinical signs - 3 Signs Interdigital erythema and exudation

7. History | Signs | Differentials | Tests | Therapy | Notes How would you approach this case? Signs What are the next steps you would take? Make a list of your principle differential diagnoses List any samples you would collect List any tests you would perform to assist in making a definitive diagnosis

8. History | Signs | Differentials | Tests | Therapy | Notes Case investigation Differentials Principle differential diagnoses Metabolic epidermal necrosis (superficial necrolytic dermatitis, hepatocutaneous syndrome, necrolytic migratory erythema) Pemphigus foliaceus

9. History | Signs | Differentials | Tests | Therapy | Notes Tests - 1 Tests Diagnostic tests Skin scrapings Skin biopsy Haematological and biochemical profiles Urinalysis

10. History | Signs | Differentials | Tests | Therapy | Notes Tests - 2 Tests No evidence of parasites and fungal elements on microscopy Elevated alkaline phosphatase, alanine aminotransferase, glucose, cholesterol Mild lymphopenia and eosinopenia Urinalysis unremarkable

11. History | Signs | Differentials | Tests | Therapy | Notes Tests - 3 Skin biopsies showed compact diffuse parakeratosis and hydropic degeneration of the upper epidermis Mild acanthosis and sparse mononuclear cell infiltrate in the upper dermis Tests

12. History | Signs | Differentials | Tests | Therapy | Notes What is your diagnosis? Do the investigations permit a definitive diagnosis? Are there any additional investigations which you think may need to be done? Tests

13. History | Signs | Differentials | Tests | Therapy | Notes Diagnosis Metabolic epidermal necrosis Historical and clinical features suggestive, supported by biopsy results Laboratory tests support a metabolic disorder Tests

14. History | Signs | Differentials | Tests | Therapy | Notes Further tests Post-prandial bile acids were elevated, consistent with hepatobiliary dysfunction Abdominal ultrasonography showed diffuse hepatic disease Tests

15. History | Signs | Differentials | Tests | Therapy | Notes How would you deal with this case? What is your prognosis? How will you advise the owner? What treatment would you consider? Therapy

16. History | Signs | Differentials | Tests | Therapy | Notes Prognosis Prognosis is poor Many cases are difficult to manage and require euthanasia, either because of the severe skin disease or due to hepatic disease or pancreatic neoplasia Therapy

17. History | Signs | Differentials | Tests | Therapy | Notes Therapy - 1 Therapy Symptomatic therapy only Systemic and / or topical antibacterial therapy Nutritional supplementation with high protein diets are helpful in some cases

18. History | Signs | Differentials | Tests | Therapy | Notes Therapy - 2 Glucocorticoids are generally contra-indicated due to the metabolic disease Specific therapy for hepatic or pancreatic disease is ideal but seldom possible Therapy

19. History | Signs | Differentials | Tests | Therapy | Notes Comment - 1 Notes Most dogs have associated hepatic disease (vacuolar alteration or cirrhosis); a few have pancreatic glucagonomas Some dogs become diabetic The cause of the hepatic and skin disease is unknown Skin lesions may reflect hypoaminoacidemia (present in this case)

20. History | Signs | Differentials | Tests | Therapy | Notes Comment - 2 Notes The periorificial lesions plus footpad hyperkeratosis are the usual findings Often confused with autoimmune diseases Ultrasound may allow visualisation of pancreatic neoplasia or metastases in rare cases, and distinguish from liver disease Bile acid assays useful for assessment of hepatic function

21. History | Signs | Differentials | Tests | Therapy | Notes Review Notes If you would like to review this case, please use the navigation buttons below