Erythema multiforme or TEN (toxic epidermal necrolysis – toxic shock syndrome)

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Marina-Ştefania Stroe, DVM

Marina-Ştefania Stroe, DVM

Romania

History

Dog, half breed, M, intact, 4 years old, unvaccinated and without treatment for intestinal parasites, fleas and ticks, 10.2 kg.

The main concern was the ophthalmologic problem.

Three weeks ago he had problems with the hind limbs and he had difficulty in moving. Previous treatments: meloxicam, gentamicin, steroidal anti-inflammatory.

The possibility of ingestion of a toxic (plant / substance) is not excluded.

Clinical exam

-white mucous membranes, no lesions in the oral cavity;

-necroses in the auricular pavilions with a visible marginal line, foreskin necrosis, yellow crusts and areas of necrosis predominantly on the posterior limbs, tail, dry-looking fur, which is easily detached;

-after detachment, the skin is denuded, ulcerated, very painful on palpation;

-cutaneous hyperesthesia;

-minimal normal auricular secretion;

-corneal erosions, dry eyes, agglutinated secretions at this level;

-faded cardiac noise; imperceptible pulse;

-rectal examination: doughy feces consistency, normal color;

-abdomen in tension;

-blood pressure (indirect oscilometric metod): 138/102 (112 mmHg).

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TESTS

-Chest and abdomen rx and ultrasonography: free fluid; enlarged spleen.

-Ultrasound guided abdominal puncture: yellowish ascitic fluid, orange tint, after spinning small, white deposit. Protein: 1 g / 100 ml.

-Blood tests: low red blood cell counts, thrombocytopenia, leukocytosis, granulocytosis; elevated liver transaminases, bilirubin and amylase normal values, normal kidney parameters.

-Bleeding time: normal.

-Negative tests for infectious diseases.

-Abdomenocentesis: 335 ml of ascitic fluid and cytological exam: MODIFIED TRANSSUDAT WITH ERYTHROCYTE POLLUTION

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Fig 10

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Fig 9

Fig. 9: Cutaneous cytology, direct impression smear from necroses of the pinnae (Fig.10): nonsegmentated immature young neutrophils, lymphocytes, few macrophages in whose cytoplasm are found bacilli, bacterial population predominantly represented by bacilli, but also cocci, oxyphilic cell matrix

Fig. 11: Cutaneous cytology, direct impression smear from yellow scale, tail (Fig. 12): neutrophils in all stages: mature segmented, degenerative stage, but also young with eukromatic nucleus and evident nucleoli, macrophages with basophilic cytoplasm, slightly vacuolized, eucromatic nucleus, nucleic streamming, erythrocyte infiltrate.

Fig. 14: Tape prep from yellow scale, hind limb

keratinocytes on the surface of which are attached cocci, degenerate inflammatory cells

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Fig 11

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Fig. 13: Trichogram – hair with normal structure, some hair with degraded cuticle, rap A / T: 4/6, follicular cast, negative for demodex and dermatophytes.

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Fig 14

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Fig 13

Superficial and deep skin scrapes: negative.

 

 

 

 

 

 

 

 

 

 

 

 

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Fig 15

Fig. 15:

-Direct and consensual pupil reflex present;

-Reduced visual acuity;

– Schirmmer test 0 mm / min;

-Florescein test: Positive

Diagnosis: OU Corneal melting ulcer F +

Diagnosis and other differentials

Blood smear, cell morphology: moderate, hypochromic, regenerative anemia,; leukocytosis, neutrophilia, moderate non-specific cellular toxic status, eosinopenia, lymphopenia. In this case, the leukogram (neutrophilia, eosinopenia and lymphopenia) may suggest treatment with corticosteroids, stress, hyperadrenocorticism, severe inflammation (chronic) with various etiologies (viral, bacterial, fungal).

Skin biopsy: histopathological aspects advocate for hyperkeratosis with paracheratosis and chronic inflammatory response involving the epidermis, jonctional area and superficial epidermis.

Final diagnosis

Histopathological aspects may show Erythema multiforme or TEN (toxic epidermal necrolysis – toxic shock syndrome), which is a late reaction, surprised in a chronic, secondary phase due to fibroblast proliferation.

 

The toxic shock syndrome may be a reaction to drugs, chemicals or food

 

Treatment

Enrofloxacin (dose: 5 mg / kg) at 12h po;

Amoxicillin and clavulanic acid (dose: 20 mg / kg) at 12h po;

Furosemide (dose: 5 mg / kg) at 12h iv;

Tramadol (dose: 2mg / kg) at 12h iv;

Parenteral nutrition;

Bathing (chlorhexidine);

Acetylcysteine, Tobrex, Corneregel 6-7 times / day (lack of tears).

 

Luba Gancheva