Visiting Veterinarian : Coming full circle
"Michelle, I have a question," the boy said, pulling my sleeve. "What's the matter with Truffle's feet?" Good question, I thought. Wish I knew the answer. I had been taking care of Truffle since she was just a tiny ball of chocolate Labrador puppy fluff, almost 13 years ago. This fall her owner came into the office. "I dunno what's wrong with Truffle," she said. "She just isn't herself." Mom went on to describe vague symptoms - intermittent shivering, low energy, trouble getting up and negotiating stairs. I gave Truffle a good once over. She had lost weight and was starting to show her age. "Oh, she's also been chewing on her feet," mom added.
I picked up a paw and examined it carefully. "Look here," I prompted. "She has sores between the pads." Three of her four feet were affected. I had seen this kind of lesion plenty of times before. "Anything new in the environment?" I asked. "Carpets? Floor cleaners? Construction in the house?" Feet like these usually result from contact with allergens or irritants like fiberglass insulation, sand, chemical disinfectants, lawn treatments. There were a million things that could do it. Her mother could not think of anything. "Well, I'm sure they hurt." I concluded. "Maybe that's why she's shivering and reluctant to walk. Let's treat it symptomatically and see how she does." Truffle went home with antibiotics, pain medication, and topical sprays.
A week later Truffle returned. "She seemed better at first, but she's shivering again and her feet are very red," her mother reported. "I just have this sense something is really wrong." One thing I have learned is to never discount an owner's observations. "Let's run some tests," I agreed. I, too, had the feeling that the problem was more than simple tender tootsies...only we docs like to call this "clinical impression" instead of "mothers' intuition." Sure enough, blood work indicated a few abnormalities, but they were as vague as her symptoms. "These could indicate anything from serious liver disease to benign aging changes," I said, as we considered our next steps.
Over the next few weeks we ran more tests. Bacterial and fungal cultures. Impression smears looking for yeast infection. We treated empirically with corticosteroids. Her feet got worse and worse. They were now bright red and weeping. We tried different antibiotics and shampoos. We soaked her feet. Nothing helped.
"Michelle, I have a question," the young boy said, pulling my sleeve. "What's wrong with Truffle's feet?"
I smiled ruefully. "I don't know yet, honey."
Earlier that week I had finally advised getting a biopsy. "I've never seen feet like this that didn't respond to the standard treatments," I had said while injecting a local anesthetic into one of Truffle's poor, oozing paws. "Maybe she has some kind of autoimmune disease." We sent the biopsy sample to the lab, took chest and abdominal radiographs, and photographs of her paws that I posted on the Veterinary Information Network Dermatology boards. Then we waited. Two days later we had a diagnosis.
Hepatocutaneous syndrome is an uncommon condition causing skin lesions like Truffle's. It is associated with some type of underlying systemic disease, usually chronic liver disease or pancreatic cancer. Also known as superficial necrolytic dermatitis, the syndrome was first described in a human patient in 1942, and in a dog in 1986. No one knows the exact pathogenesis, but somehow, as a result of metabolic imbalances caused by the primary disease, the levels of amino acids in the body drop and skin lesions result. There appears to be a predisposition among Shetland sheepdogs, West Highland white terriers, cocker spaniels, and Scotties. Seen most often in older dogs, lesions are usually reported on the footpads, feet, along the lips, legs, nose, face, muzzle, and genitalia. Often there are no obvious signs of systemic illness when the skin lesions first appear. Definitive diagnosis is based on biopsy and identifying the underlying liver or pancreatic disease. Truffle's X-rays had not revealed any tumors, but often an abdominal ultrasound is needed for definitive diagnosis. "What's the prognosis?" Truffle's family asked, pondering the idea of more testing. "And what would treatment entail?"
Treatment for hepatocutaneous syndrome has many aspects. We would treat the amino acid deficiency with weekly eight-hour intravenous infusions of special solutions, along with oral supplements. We would also treat secondary bacterial, yeast, or fungal infections with appropriate medications and continue drugs for pain. And finally we would identify and, if possible, treat the underlying problem, such as surgically removing a tumor.
The statistics did not look good. The underlying disease is often not curable and many dogs continue to be so painful they can barely walk. Most survive only a few months from the time of diagnosis. The family thanked me for the information and told me they would need time to talk it over.
It was raining the next Sunday. My black and white striped umbrella made a stark contrast against the grey morning as I walked up the path to Truffle's house. Gathered around her where she lay on her cozy dog bed were mom, dad, the young boy who had pulled my sleeve, and his brother. I explained how we would proceed, step by step, that we were going to spare Truffle any further suffering now that we knew she had a terminal disease.
As I drew up the injection, Mom reminded me that I was the one who had led them to Truffle, having told them about a litter of puppies almost 13 years ago. "It comes full circle," she said, as the family said good-bye. And isn't that what this time of year is really all about? Being with the ones we love through the hard times as well as the good, through the circle of life and of death, of darkness and of light.