Rufus has a two-month history of licking excessively underneath his tail. The owners have also noted that he strains when defecating, with traces of frank blood noted in his stool. He has no previous history of skin disease or allergies.
Andrew Simpson, DVM, MS, DACVD
VCA Aurora Animal Hospital, Aurora IL
Subjective
Rufus, a 5 Y MN German shepherd dog, has a two-month history of licking excessively underneath his tail. The owners have also noted that he strains when defecating, with traces of frank blood noted in his stool. He has no previous history of skin disease or allergies.
Objective
T (axillary): 98̊ F
P: 88 bpm
R: 36 bpm
mm: pink, moist
CRT: 1-2 seconds
On general physical examination the following were noted: heart and lungs auscult clearly in all fields, lymph nodes palpate normally, abdomen is soft and non-painful; ears, eyes, nose are all clear with no discharge or inflammation.
Dermatologic examination revealed severe, crateriform ulcerations and deep draining tracts affecting the skin around the anus with mild amount of purulent exudate.
Differential diagnoses consisted of perianal fistulas (perianal sinuses), anal sac abscessation, perianal neoplasia (i.e. squamous cell carcinoma, anal sac adenocarcinoma, perianal adenoma), atypical bacterial infection, deep mycosis, and mucocutneous lupus erythematosus.
Diagnostics
Under heavy sedation (dexmedetomidine + hydromorphone IV) rectal examination showed severely thickened perianal tissue but both anal sacs were empty and no masses were noted. No overt hemorrhage or melena was present. The hair was clipped and the area was gently lavaged with diluted chlorhexidine solution. Samples for cytology were also collected and stained with DiffQuick.
Skin cytology revealed numerous degenerative neutrophils, few macrophages, with no infectious organisms noted.
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