dermatology

Authors:

Tsvetan Velev¹, Anna Valerieva², Plamena Novakova², Elitsa Valerieva³, Elena Petkova², Tsvetelina Lazarova¹, Maria Staevska², Miroslav Todorov¹

Affiliations:

¹ Veterinary clinic “Blue Cross”, Pancharevo, Sofia, Bulgaria;  ² Department of Allergology, University Hospital “Alexandrovska”, Medical University of Sofia, Bulgaria; ³ Dr. Shterev Hospital, Sofia, Bulgaria;

Abstract

Juvenile cellulitis (also known as juvenile sterile granulomatous dermatitis and lymphadenitis, juvenile pyoderma or puppy strangles) is a rare sterile granulomatous disorder that commonly affects the face, pinnae and submandibular lymph nodes of young puppies between 3 weeks and 8 months old. The condition often manifests with prodromal symptoms and concurrent medication / vaccination might be mistaken for culprit of hypersensitivity reactions.

Herein, we report a rare case of canine juvenile cellulitis misinterpreted as meloxicam allergy. Early diagnosis and proper treatment of the condition is associated with a very good prognosis. It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favorable prognosis. Additional treatment includes topical medications (eg. antimycotics, antibiotics and steroids) along with antiseptic dressings. Awareness of this condition must be improved as the severity of juvenile cellulitis may lead to euthanasia, therefore it is of vital importance that the disease is considered and explored early, and proper treatment is initiated promptly

Key words: juvenile cellulitis, puppy strangles, canine drug allergy, misdiagnosis, autoimmune cellulitis, sterile granulomatous dermatitis, juvenile pyoderma

Introduction

Juvenile cellulitis (also known as juvenile sterile granulomatous dermatitis and lymphadenitis, juvenile pyoderma or puppy strangles) is a rare sterile granulomatous disorder that commonly affects the face, pinnae and submandibular lymph nodes of young puppies between 3 weeks and 8 months old (1). Clinical signs of juvenile cellulitis include fever, lymphadenopathy as well as bilaterally symmetric, pruritic lesions in the periocular areas, face, muzzle, pinnae and inguinal regions. Symptoms progress to crusting and alopecia. Lesions typically form fistulae that drain. A typical feature which also gave rise to the term “puppy strangles”, is submandibular lymphadenopathy. Apart from all these findings, affected dogs are usually active and in good general health (2,3).

Figure 1. Bilateral symmetric, pruritic granulomatous lesions of the muzzle and the periocular areas.

Case-presentation

A 14-week-old miniature Spitz-Pomeranian puppy (regularly vaccinated) spontaneously presented with left hind limb lameness and pain. A hypothesis of possible trauma resulted in intramuscular meloxicam application in two consecutive days with no clinical benefit. Dermatological symptoms occurred after 48 hours and were misinterpreted as meloxicam allergy: bilateral symmetric, pruritic lesions in the periocular areas, face, muzzle, pinnae and inguinal region. This lead to a prescription of antihistamine and low-dose corticosteroid treatment.

Thereafter, the puppy presented also with fever and mandibular lymphadenopathy. Dermatological symptoms progressed to crusting and alopecia, some pustules formed bloody abscesses and drained. Symptoms continued to worsen requiring to rule out various infectious diseases: canine distemper, leishmaniasis, anaplasmosis, babesiasis and toxoplasmosis, all of which resulted negative.

Blood tests were within reference ranges and non-conclusive of an infectious agent. Clinical presentation suggested a diagnosis of autoimmune juvenile cellulitis and high-dose systemic corticosteroid and antibiotic therapy was initiated with clear benefit in less than 12 hours: prednisolone 2 mg/kg + trimethoprim/sulfamethoxazole, together with ocal antiseptic care. Therapy was tapered in 35 days with no signs of a relapse. At the final check, the puppy is 17 months-old with normal development and in good general health.

Figure 2. Bloody abscess on the back (spontaneously drained within few days)

Discussion

The cause and pathogenesis of juvenile cellulitis are not yet fully understood. It was suggested that it is a systemic condition with primary lymphadenopathy resulting in secondary dermatological lesions with some extent of immune dysfunction as well as hereditary components (4). Inflammation in juvenile cellulites is pyogranulomatous with no culprit microorganisms. Cytological findings reveal a nonbacterial aetiology of the disease (5). Analysis of joint fluid often shows signs of sterile suppurative arthritis. Examination of aspirates of affected lymph nodes, pustules, abscesses and joint fluid rarely show any sign of bacterial growth. Biopsy of lesions usually demonstrate discrete or confluent granulomas and pyogranulomas consisting of clusters of large epithelioid macrophages with variably sized cores of neutrophils (6). It was also suggested that since juvenile cellulitis usually occurs at the age when dogs usually receive their first vaccinations with modified-live virus vaccines, there could be a possible pathogenic link between infection with vaccine or other viruses and the evolution of this disease. Data on this association is, however, insufficient. Definitive diagnosis is based on cytological and histopathological analysis as well as on typical findings on complete blood cell count (leucocytosis, neutrophilia, and normocytic-normochromic anaemia) (6).

Juvenile cellulitis is responsive to high-dose corticosteroids which are often prescribed along with antibiotics due to the risk of secondary bacterial infection (5). Rapid and aggressive therapy is recommended in order to maintain a favourable prognosis, to avoid scarring, and to reduce secondary infections (7). The major differential diagnosis includes: canine distemper, demodicosis, bacterial pyoderma, dermatophytosis or an adverse drug reaction, as in the case presented here. However, sterile pus on cytology and responsiveness to corticosteroid treatment differentiate infectious or drug-related causes from juvenile cellulitis. Since juvenile cellulitis is a relatively rare condition, it doesn’t usually come as the first diagnosis in mind and other more common conditions are considered (2). However, as the severity of juvenile cellulitis may lead to euthanasia, it is of vital importance that the disease is considered and explored early, and proper treatment is initiated (8). Juvenile cellulitis is very responsive to high-dose corticosteroids, usually prescribed along with (5). It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favourable prognosis. Additional treatment includes topical therapy (e.g. terbinafine, oflaxacin, ornidazole and clobestal) along with antiseptic dressings (7).

Figure 4. Dermatological changes of the penile skin.

Conclusion

We report a rare case of canine juvenile cellulitis misinterpreted as meloxicam allergy. If diagnosed early and treated properly the condition is associated with a very good prognosis. It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favourable prognosis. Additional treatment includes topical medications (e.g. antimycotics, antibiotics and steroids) along with antiseptic dressings. Juvenile cellulitis has a very good prognosis if diagnosed early and treated properly. Complete recovery is typical with a low chance of recurrence (9). Dogs’ condition usually improves markedly by the 14^th day after treatment start. Symptoms are reported to resolve completely within the fourth week (7).

Awareness of this condition must be improved as the severity of juvenile cellulitis may lead to euthanasia, therefore it is of vital importance that the disease is considered and explored early, and proper treatment is initiated promptly.

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