1. 11-year old Cavalier King Charles Author: Ross Bond Editor: David Lloyd © European Society of Veterinary Dermatology

2. 11 year-old Cavalier King Charles spaniel Entire male Progressive skin disease of 3 weeks duration Owner reported reluctance to walk and interdigital dermatitis Now “blisters” on perineum and scrotum Left mouse to activate screen History and presenting clinical signs - 1

3. Dog reportedly depressed Thirst and appetite considered normal Skin lesions progressively more severe Moderate pedal and perineal pruritus Left mouse to activate screen History and presenting clinical signs – 2

4. Clinical findings on referral Peri-oral crusts and fissures

5. Clinical findings on referral Linear preputial lesion; erythema; erosion, crust

6. Clinical findings on referral Interdigital erythema and exudation

7. 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. How would you approach this case?

8. Principle differential diagnoses Metabolic epidermal necrosis (superficial necrolytic dermatitis) Pemphigus foliaceus Diagnostic Tests Skin scrapings Skin biopsy Haematological and biochemical profiles Urinalysis Case investigation

9. No evidence of parasites and fungal elements on microscopy Elevated alkaline phosphatase, alanine aminotransferase, glucose, cholesterol Mild lymphopenia and eosinopenia Urinalysis unremarkable Results

10. Skin biopsy specimens showed Compact diffuse parakeratosis and hydropic degeneration of the upper epidermis Mild acanthosis and sparse mononuclear cell infiltrate in the upper dermis Results

11. What is your diagnosis? Do the investigations permit a definitive diagnosis? Are there any additional investigations which you think may need to be done?

12. Diagnosis Metabolic epidermal necrosis Historical and clinical features suggestive, supported by histopathology Laboratory tests support a metabolic disorder

13. Further tests Post-prandial bile acids were elevated, consistent with hepatobiliary dysfunction Abdominal ultrasonography showed diffuse hepatic disease

14. How would you deal with this case? What is your prognosis? How will you advise the owner? What treatment would you consider?

15. 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

16. Symptomatic therapy only Systemic and / or topical antibacterial therapy Nutritional supplementation with high protein diets helpful in some cases Glucocorticoids generally contra-indicated owing to the metabolic disease Specific therapy for hepatic or pancreatic disease is ideal but seldom possible Therapy

17. 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 hypo-aminoacidemia (present in this case) Comment

18. 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 Comment

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