Purpose of Differential Diagnoses: Rant About Quality Of Life Versus Quantity, And Differential Diagnoses

So Jasmine recently broke out with a third skin infection in quite a short time.

This time it was a nasty bacterial folliculitis (inflammation of hair follicles) around the base of her tail.

She lost a bunch of fur which left her with bald patches. The infection now seems to have cleared up with antibiotics and topical treatment, and even though her vet warned us that further hair loss might still occur, we are hoping that won’t be the case.

Taking care of the infection is only the first step though.

Purpose of Differential Diagnoses: Rant About Quality Of Life Versus Quantity, And Differential Diagnoses

Why?

Now we have to figure out what is going on allowing these infections to happen.

Most bacterial skin infections in dogs are secondary to another disease such as parasitism, allergies, endocrine (hormonal) disorders or abnormalities in the immune system.

Parasites (fleas, mange …) have been ruled out. That leaves us with allergies, hormonal issues or immune system issues. Wow, such lovely choices, so hard to pick!

Allergies?

Of course, the first conclusion to jump to are allergies.

They are extremely common and Jasmine’s allergy spot blood test is a long list of things she’s allergic to. We are controlling her food allergies with a custom home-cooked diet. Controlling exposure to environmental allergens is another story, particularly since she tested positive for so many of them, including pollens and grasses.

Allergy shots are an option with a limited number of allergens.

Approximately half the dogs receiving immunotherapy will have an excellent response. About 25% will have a so-so response. About 25% will not have any response at all.

Viva of Kenzo the Hovawart is responding to the treatment very well. She has tested positive to dust mite allergy only though.

The more offending substances, the lesser the chance the treatment will work and the higher the likelihood of complications.

Limiting exposure?

That leaves supportive treatments and limiting exposure. But Jasmine is allergic to a whole bunch of grasses too.

This brings me to the question of quality of life versus quantity.

Her vet loves Jasmine and has her best interest in mind. However, with the main, however logical, suggestion being eliminating exposure to hay/grass—not only what she gets into but even whom she sees, what would become of Jasmine’s life?

“If she was my dog she would not see grass or hay fever,” he noted.

Say what? How would one even remotely manage something like that short of locking her in a clean room? I’m sure there are plenty of couch-potato dogs out there who’d be perfectly happy with such a plan.

Jasmine is an outdoor dog!

She loves her family and her den, but what she really lives for is spending time outside. Taking that away from her would be a fate worse than death!

I still clearly remember the look on her face when after her surgeries she could not go for her walks. The disappointment that quickly turned into resignation. The profound sadness in her eyes.

Come to think of it, I believe that for her there isn’t a choice between the quality and quantity of life. If she was deprived of her time outside, she would die of sadness within a month! I am sure of that.

So what happens from here? Are we going to manage her outbreaks until things finally get out of control?

What if it’s not allergies?

We are not convinced that her skin issues do stem from allergies, and if so, there is no real proof that the grasses are at the root of it.

It is winter now and there is snow on the ground!

Yes, she has allergies. But she is not an itchy dog! She doesn’t spend her days in agony scratching and licking herself. In fact, my observation is that she doesn’t get itchy until something is already brewing.

There is no discernible pattern to anything. I’ve been charting details about the weather, air quality, and locations she’s been to, for a long time now. There is no pattern! (To be on the safe side, we are now tracking eye redness as well.)

However logical, allergies are not adding up to us.

It walks like a duck, it quacks like a duck … what if it isn’t a duck?

What else could it be?

Differential diagnosis, please!

I have to give our vet all the credit in the world. As convinced as he is that it is allergies, he is still listening to what we are saying.

So while we are implementing all the reasonable suggestions to minimize Jasmine’s exposure to allergens, we will also be working on differential diagnosis.

If it wasn’t allergies, what would it be?

Yes, allergies are extremely common, but they are also most commonly over-diagnosed.

If I had allergies and broke my leg—could I pin the broken leg on the allergies?

Well, possibly, if I sneezed hard enough to fall off a balcony …

We are not saying that allergies cannot be at the root of the problem. But we are not feeling it.

Jasmine has a number of other issues going on, maybe the answer lies there. Maybe it’s something perfectly simple we are missing.

That is a mistake we don’t want to make. Look one way and miss a truck hurtling at us from the other direction.

If the push came to shove, what do you think would be more important to your dog? Quality of life or quantity?

How it went down

It started with Jasmine suddenly licking at her right flank one night mid-fall. I went to look and there was something that looked like a bug bite. I put on some Polysporin and it seemed to have done the trick. She left it alone again. Then came back to it. As we were seeing her TCVM vet, I had him look at it and he didn’t find anything suspicious about it.

Then it happened again just prior to her teeth cleaning and stem cell treatment. Again, it didn’t seem to be anything to worry about and it was fine again.

In the meantime, she got a moist pododermatitis on her foot (bacteria confirmed with cytology). It was believed to have started as a result of self-trauma due to allergies. We were buying that one, as her toes did seem to have been an issue off and on. Resolved with antibiotics.

Then at the end of  November, the thing on the flank flared up again and this time some fur was coming out as well. Saw the vet immediately. The conclusion was a superficial folliculitis to pyoderma believed to be a result of a romp through the burrs and brambles. It cleared with topical treatment, though there is a small bald patch left from it.

And then the recent major break out of folliculitis around her tail base, which led to substantial hair loss and bald patches. Staph and Dermatophilosis found. Seems now under control with antibiotics.

However, last night she suddenly started paying attention to her left flank this time. I found a tiny spot again, pretty much exactly the same area as the right flank previously, but looks drier, more like a scrape than a bite this time. Used Dermacool and it doesn’t seem to bother her for the time being.

But that’s how the right flank started originally too, very low key.

Previously diagnosed issues:

  • hypothyroidism – recent T4 21 (13-51 normal)
  • eosinophilic gastroenteritis
  • bilateral ACL tear
  • arthritis
  • history of muscle injuries
  • she had a history of skin issues prior to hypothyroid diagnosis

Previous not really diagnosed issues:

  • episodes of pacing and panting going on progressively for 5 years now, improved with TCVM
  • this year new licking at front feet and scratching at front elbows with marked episodes

She is not itchy otherwise. Also, are the feet actually itchy or are they burning, tingling – how would one know?

Other notes:

  • her coat has been very fine, reddish tint, and her nails wear off easily
  • since she’s been shaved for her surgeries the undercoat is overtaking the top coat (the first winter she grew virtually undercoat only)
  • her coat gets smelly easily after being wet (even after a bath); doesn’t dry well
  • her feet smell bad sometimes
  • licking of private parts

When emailing with Dr. Laci of VetLive I noticed one thing: last year Jasmine’s T4 levels were 36 in August and 42 in September on half the dose she is on now. This March suddenly they dropped to 14. They are now 20 with double the dose. Surely something seems to be going on there …?

Related articles:
Common Dog Misdiagnoses: Skin Issues

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Jana Rade

I am a graphic designer, dog health advocate, writer, and author. Jasmine, the Rottweiler of my life, was the largest female from her litter. We thought we were getting a healthy dog. Getting a puppy from a backyard breeder was our first mistake. Countless veterinary visits without a diagnosis or useful treatment later, I realized that I had to take Jasmine's health care in my own hands. I learned the hard way that merely seeing a vet is not always enough. There is more to finding a good vet than finding the closest clinic down the street. And, sadly, there is more to advocating for your dog's health than visiting a veterinarian. It should be enough, but it often is not. With Jasmine, it took five years to get a diagnosis. Unfortunately, other problems had snowballed for that in the meantime. Jasmine's health challenges became a crash course in understanding dog health issues and how to go about getting a proper diagnosis and treatment. I had to learn, and I had to learn fast. Helping others through my challenges and experience has become my mission and Jasmine's legacy. I now try to help people how to recognize and understand signs of illness in their dogs, how to work with their veterinarian, and when to seek a second opinion. My goal is to save others the steep curve of having to learn things the hard way as I did. That is the mission behind my blog and behind my writing. That is why I wrote Symptoms to Watch for in Your Dog, which has turned out being an award-winning guide to dog owners. What I'm trying to share encompasses 20 years of experience.

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