Vasculitis and skin infection.

Hey Dr. Marie,
We've got a doberman with a hard-to-diagnose skin issue. Usually starts with a cyst/furuncle of some kind and EXPLODES into a bad skin infection that takes months to heal. The word we're using to describe her condition now is "cellulitis" or our current vet mentioned "vasculitis," but that doesn't answer HOW this all starts. She has been to 4 different veterinary offices in Illinois and Wisconsin and seen a total of 12 different vets concerning this recurring issue. Haven't yet taken her to a dermatologist as there isn't one within 200 miles of us but I feel like that future appointment is almost inevitable.

She's had an annual recurring skin problem since Sept. 2012 (even a small, quick to resolve occurrence in Aug. 2011) - starts with a small bump/cyst/lump/furuncle and then morphs into an out-of-control infection that lasts for several months. Usually she eventually gets better, but this year, it will be 6 months at Thanksgiving that she's been struggling with this year's blow-up.

She has been crate-bound since early August. Her two rear feet and 'shins' are swollen, bleeding and oozing constantly. When she lays down to rest, it seems that clotting starts to happen (good), but the skin in those areas is so brittle, shiny, and thin-looking from the infection/disease/affliction that when she stands up, the skin bursts open and there's just blood oozing everywhere (bad).

History: Year 1 flare-up started with an interdigital cyst between the front paw toes (not pads). Started in September and cleared up in Dec./Jan. Year 2 started April 8, 2013 on her rear left hock/upper thigh and spread down that leg and all the way up to beneath her tail. Cleared up some time in Aug/Sept. but still has scarring at the origin point (white, dry, hard skin where hair does not grow). Year 3 started June 2014 as an interdigital cyst between the right rear toes and has grown to 'infect' the other foot. It has gotten to a point where she holds her right rear foot up in the air and only walks using three legs. The swelling/edema was really bad and the only thing that helps the swelling is steroids (has helped all three occurrences). This year she's also got a bad rash that's appeared in her armpits and abdominal area.

Most vets have treated only the symptoms and didn't even attempt to figure out the cause. That means most of the time the diagnoses and prescription were: infection=antibiotics, steroid shot, steroid pills, betadine soaks, ointments, sprays, and painkillers. This is the year we really got sick of it and said, "Look, this seems to be occurring EVERY year. Can we please figure out what it is so we can help prevent or control it?"

One of the more recent vets, after 3.5 months of Sofie making weekly or bi-weekly office visits for steroid and antibiotic refills finally gave up and said, "I can't help this dog."

At that point (late August of this year), we started to do our own veterinary/clinical online research since we felt like no normal vets could help Sofie. We found that there are blood tests, biopsies, and other lab diagnostics that can be done to help determine a cause (I cannot believe no previous vet had even mentioned this or thought to do this....). We felt that her affliction could be a number of different things, most of which can be further investigated through testing.

Our newest vet, a skin specialist but not a dermatologist, saw Sofie's awful, bloody condition and could probably see the frustration on our faces and immediately did an on-site blood panel and same-day biopsy surgery on three different sites (two bad spots, one normal skin spot). He said that thyroid came back low but could be due to Sofie's body fighting off this ongoing infection, she had a BUN of 7 (kind of low) and has monocytosis. She has not had a full thyroid panel (not sure how it's different from a regular blood test; should we request one?). Biopsy lab results came in about 5 days later and note "deep bacterial infection is suspected," "suspected vasculitus, and deep necrosis." No mention of autoimmune diseases in biopsy report. Skin scrapings have all come back negative. Cytology slide examinations are now showing that the previous bacterial infection has cleared up, however Sofie is just not getting better - she's not healing.

Pills she's on currently: Orbax antibiotic, dexamethasone, thyroxine

Next Thursday (Oct. 30) we're taking her in to have blood drawn to do a serum/blood allergy test at the same new vet that did the blood testing. From my understanding, an intradermal test would require 1) her to be off steroids (currently on dexamethasone pills) and 2) a dermatologist facility. That's why we're opting for a serum test instead, although I do understand that I.D. test tends to be more accurate. Can't imagine her being off steroids for long enough to have one done.

What she's eating: Last week, we transitioned her off NutriSource Seafood Select over 7 days and onto Acana Singles Pork & Butternut Squash just to see if it helps, although she's had these flare-ups on many different kinds of food over the years. I did a huge spreadsheet of all ingredients in every food she's eaten to make sure she wasn't receiving a meat protein she'd been exposed to before (now, if she's got a 'peas' problem, that would stink b/c peas are in EVERYTHING!)

She is a HUGE pill-spitter-outter so we need to crush her pills and mix them with something. Currently that's plain non-fat Land o' Lakes yogurt and hard boiled eggs. I realize that we're adding food to a LID, but it's either that or she doesn't get her meds I'm open for any creative ideas on how to get a pill-hating dog to eat pills on a LID. It was recommended by a fellow doberman owner to stop the eggs and switch to canned pumpkin as pumpkin is an ingredient in the Acana food and eggs are not.

My other big concern is that if there's no current bacterial infection, why is she still bleeding? Why can't she just clot and get better? FYI, her parentage (VetGen DNA test results) shows her mother was vWD clear and her father was vWD carrier. We've not had her vWD tested as the breeder assured us she was fine - should we test her?

Our possible diagnosis ideas:
1) Hypothyroid issue
2) An allergy (food or environmental)
3) Folliculitus/problem with hair follicles getting plugged up and causing a lump (caused by an allergy???)
4) A guess diagnosis by a previous vet (no diagnostics done by him so I don't really put much stock in it) was SLE (systemic lupus) and pemphigus bullous (I'd personally lean more towards pemphigus foliaceus)
5) Interdigital furunculosis (what would be the cause?)
6) And some kind of blood clotting issue in addition to all this. Maybe vasculitis or cellulitus would fall under this option.

It's also our feeling that Sofie's affliction might be caused by not just ONE thing but a mix of things (ex: hypothyroid with an allergy to fish-related ingredients and hair follicle problems).

Have you ever heard of anything like this? What other steps could we take to try and help her while we wait for blood allergy testing results? What other tests SHOULD be performed by a vet (a valid question since it seems like most vets are stumped by skin issues)? Is there anything we can do - sprays or supplements - that can help her dry, brittle, bleeding feet start healing?

Also open for any skin specialist doctors in my area that'd be willing to talk on the phone via a phone consultation. I want to discuss Sofie's history with any future potential specialist/dermatologist before we take a day or two off work to bring her to a far away treatment center (we live in north central WI about 1.5 hours south of Lake Superior - 3.5 hrs from Minneapolis and 4 hours from Madison). Our new vet seems like he cares very much but we realize he's not a certified dermatologist. After our bad experience with vets, we'd really want to consult with them on the phone before we make a special road trip for them. Aurora, IL is also a second option as we have family that live in the Chicago suburbs. Either way, we'd need to take time off work to get her to a dermatologist.

I'm attaching some progression photos of Sofie's 2014 issue. I do not have any pics from the very onset from "day 1" in early June. When we first noticed it, it was just a small pink lump in between her toes. In hindsight, I wish we would have taken some photos! As you'll see, it's gotten progressively worse. Sofie and us thank you for any suggestions or advice you can give. She really wants to get better!
-Lorraine, Joe, and Sofie

Hey Dr. Marie,
Thank you so much for your prompt and thorough response! You've already provided more information for Sofie than the vets she's visited in the first 2.5 years of her life!

QUESTIONS:
We have decided that we can make a special dermatologist visit for Sofie and are hoping to be able to schedule an appointment in early November. Based on our location in north central WI (Phillips, WI), can you make a recommendation on what dermatology facility I should contact? I've heard mention of universities in both Minneapolis, MN and Madison, WI. My dad lives in the Chicagoland area and I'm sure there's options down there, too. At this stage, I want to be sure we contact the BEST possible specialist for her condition because I don't think she can stand another three months of pain (and we do have to consider that we can only take so much time off work before we run out of vacation days). Do you feel that a university facility would be her best bet or should I spend time seeking out a veterinary dermatologist specialist in private practice? Can you recommend any dermatologists specifically?

A question about lupus (SLE not DLE since DLE states that symptoms usually show on the face and nose): One of the symptoms of SLE is a fever that is unwavering even when antibiotics are administered. Looking through vet records, Sofie has never had a fever and her temperature readings haven't changed (gone down or up) even when she was started on a course of antibiotics. Have you heard of a dog with lupus that never had a fever?

FURTHER INFO:
If her vasculitis is the result of a drug reaction, it should be noted that Sofie received a whole host of vaccines in February 2014 all on the same day: 3 year rabies along with her DA2PP + LGP annual vaccines, bordatella, and a lyme disease shot. I suppose it could also be from one of the antibiotics or steroids she's been given more recently.

If her vasculitis is the result of her skin reacting to staphylococcus, it should also be noted that in a vet visit in July 2013 that a pathologist report for antibiotic susceptibility noted a "growth of large number of Staph aureus (non-meth resist) and low number of enterobacter." Cytology and biopsies this year haven't noted any staph bacteria.

As for tick-borne illness, our most recent vet did mention that as a possibility and she has been bitten by ticks on numerous occasions. Being in the northwoods of WI, we definitely are surrounded by ticks and do our best to check our dogs and remove them ASAP. However, those tiny deer ticks are about as big as a grain of sand and I'm sure sometimes they slip through unnoticed. If she's ultra-sensitive to tick bites and perhaps tick bites are what start this whole ordeal, I hate to say it but there's no getting away from ticks up here, at least that I know of. If she turns out to be a special needs dog that can't be around ticks, for her own health, she can't live in northern Wisconsin. Now, if she already has a tick-borne disease from a previous bite that's caused vasculitis, we can do our best to treat that.

Thank you again for your thoughts and advice.
- Lorraine, Joe & Sofie