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

So Jasmine 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.

Why?

It’s important to figure out what is 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.

(source: Lowchens Australia)

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 is allergies.

Allergies in dogs are prevalent. Further, Jasmine’s allergy spot blood test was a long list of things she was allergic to. We were controlling her food allergies with a custom home-cooked diet. Controlling exposure to environmental allergens was another story, though, mainly since she tested positive for 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.
(source: Veterinary Partner)

Viva of Kenzo the Hovawart responded to the treatment very well. She tested positive for 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 left supportive treatments and limiting exposure. But Jasmine was allergic to a whole bunch of grasses too. This brings up the question of quality of life versus quantity.

Her vet loved Jasmine and had her best interest in mind. However, with the principal, however logical, suggestion to eliminate exposure to hay/grass—not only what she got into but even whom she saw, what would become of Jasmine’s life?

“If she were my dog, she would not see grass or hay fever,” the veterinarian noted.

Say what? How would one even remotely manage something like that short of locking their dog 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 was an outdoor dog!

She loved her family and her den, but what she lived for was spending time outside. Taking that away from her would be a fate worse than death!

I clearly remember the look on Jasmine’s face when she could not go for her walks after her surgeriesappointment quickly turned into resignation. There was a prof for heround sadness in her eyes.

I believe that for her, there wasn’t a choice between the quality and quantity of life. If she were deprived of her time outside, she would die of sadness within a month!

So where to go from there? Should we just manage her outbreaks until things finally get out of control?

What if it wasn’t allergies?

We were not convinced that her skin issues stemmed from allergies. And if so, there was no actual proof that the grasses were at the root of it.

Her folliculitis came on where there was snow on the ground!

Yes, Jasmine had allergies. But she was not an itchy dog! She didn’t spend her days in agony scratching and licking herself. My observation was that she didn’t get itchy until something was already brewing.

There was no discernible pattern to anything. I’d been charting details about the weather, air quality, and locations she’s been to for a long time. There was no pattern!

However logical, allergies were not adding up to us.

It walks like a duck, and 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 was that it was allergies, he was still implemented we were saying.

So while we were implementing all the reasonable suggestions towerenimize Jasmine’s exposure to allergens, we was working on a differential diagnosis.

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

As common as allergies in dogs are, 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 …

Jasmine had several other issues, Perhaps the answer lied there. On the other hand, maybe we were missing something perfectly simple. That was a mistake we didn’t want to make. Look one way and miss a truck hurtling at us from another direction.

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 pimple. 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 before Jasmine’s dental and stem cell treatment. But, still, it didn’t seem to be anything to worry about, and it self-resolved.

In the meantime, Jasmine got moist pododermatitis on her foot (bacteria confirmed with cytology). It was believed to have started due to self-trauma due to allergies. We were buying that one, as her toes seemed to have been an issue. That has been 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 a small bald patch was left.

And then, the recent major break-out of folliculitis around her tail base led to substantial hair loss and bald patches. Staph and Dermatophilosis found. Antibiotics took care of it.

However, then Jasmine started paying attention to her left flank this time. I found a ain, pretty much precisely the same area a flank previously. However, it looked drier, more like a scrape than a bite this time. I used Dermacool, and it didn’t seem to bother her for the time being.

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

Previously diagnosed issues included:

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

Previously undiagnosed issues:

episodes of pacing and panting going on progressively, improved with TCVM
new licking at front feet and scratching at front elbows with marked episodes

She was not itchy otherwise. Also, were tctually itchy, or were they burning, tingling – how would one know?

Other notes:

her coat had been very fine, reddish tint, and her nails wore off easily
since Jasmine was shaved for her surgeries, the undercoat overtook the top coat (the first winter, she grew virtually undercoat only)
her coat got smelly easily after being wet (even after a bath); it didn’t dry well
her feet smelled bad sometimes
licking of private parts

When emailing with one of my veterinary friends, I noticed one thing: Jasmine’s T4 levels the year prior were 36 in August and 42 in September on half the dose. Then, suddenly they dropped to 14.

After revisiting how were managed Jasmine’s hypothyroidism, she became infection-free.

Related articles:
Common Dog Misdiagnoses: Skin Issues