PMC8417874_01
Initial physical examination of a 4-year-old intact male French bulldog. Severe ulcerations involving the inner aspect of the hind legs (A) and ulcerations of the interdigital region (B) and the footpads (C). Ulcerations, erosions and depigmentation of the perianal region (D) and thick crusty material covering the scrotum (E). Purpuric macules and patches were present on the caudal aspects of the thighs (F). Epidermis was sloughing off around the ulcerative lesions (G). Slight depigmentation was visible on the upper lip (H).
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F1
Severe extensive ulcerations were present bilaterally on the inner aspect of the hind legs (Figure 1A), between the digits (Figure 1B) and footpads (Figure 1C). The perianal region was eroded and depigmented (Figure 1D). A thick, adherent crusty plaque covered the scrotum which was almost completely ulcerated (Figure 1E). Large poorly-defined purpuric macules and patches were noted on the caudal aspect of the thigh (Figure 1F). Major epidermal detachment (Figure 1G), very painful necrotizing lesions, and a pseudo-Nikolsky sign epidermal detachment obtained by gentle pressure to the erythematous skin, were apparent together with slight mucocutaneous depigmentation (Figure 1H). Histological examination revealed severe extensive multifocal epidermal necrosis with multifocal epidermal detachment and necrotic material within flaccid vesicles (Supplementary Figure 1A). Some extension of ulcerations to the hair follicles was noted (Supplementary Figure 1B). Slight heterogeneous perivascular dermatitis with lymphocytes, neutrophils and plasma cells was observed (Supplementary Figure 1C). Some mild multifocal septal panniculitis was present (Supplementary Figure 1D).
Schematic diagram describing timeline clinical, diagnostic and treatments features of suspected drug-associated (immune mediated) reaction in a 4-year-old male French bulldog. SPI, Staphylococcus pseudintermedius.
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F2
By day two, an improvement was already apparent, the skin had started healing and granulation tissue was observed (Supplementary Figure 2). Marbofloxacin was maintained based on the sensitivity results received on day 15, 3 days after presentation (Figure 2).
Clinical examination after 3 weeks. Healing was complete along the distal limbs (A), crusty inflammatory lesions were observed on the back of the left thigh (B) and the extremities, particularly around the claws (C). Onychomadesis was observed on digits II and IV of the left hind foot (D).
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F3
Localized perionyxis (Supplementary Figure 3A), with dark crusts and suppurative oozing, was noted. Crusted granulation tissue was apparent on the caudal side of the distal limbs but no oozing was noted (Supplementary Figure 3B). After 3 weeks from starting doxycycline, the improvement was excellent, the distal limbs had completely healed (Figure 3A) but some crusty and inflammatory lesions were observed on the back of the thigh (Figure 3B) and the extremities, particularly around the claws (Figure 3C). Onychomadesis was observed on digits II and IV of the left hind foot (Figure 3D).