皮肤是猫咪健康状况的标志-全身性疾病的皮肤表现（5）

王帆

皮肤是猫咪健康状况的标志

SKIN AS A MARKER OF GENERAL FELINE HEALTH

全身性疾病的皮肤表现

Cutaneous manifestations of systemic disease

作者：Linda J Vogelnest

翻译：何梦婷  校对：王帆

皮肤糜烂和溃疡的患猫

The cat with skin erosions and ulceration

除了具有特征性临床表现的嗜酸性斑块以外, 非瘙痒自损产生的皮肤糜烂和溃疡，在猫中罕见。缺失的表皮上覆盖坚硬的结痂, 但是，猫的理毛行为通常会限制结痂形成。这种皮肤表现通常在诊断上没有难度，因为皮肤活检组织病理学检查能发现许多病因。

Aside from eosinophilic plaques with their characteristic clinical appearance, prominent skin erosions and ulceration that are not readily explained by self-trauma from pruritus are relatively rare in the cat. Firm adherent crusts may overlie these epidermal defects; however, cat grooming behaviour will often restrict crust formation. This cutaneous presentation is often less diagnostically challenging, as skin biopsies for histopathology are conclusive for many causes.

通常需要考虑全身性疾病（图8）. 一些已经讨论过的疾病，包括细菌性脓皮病和利什曼原虫病，有时可能会出现明显的糜烂至溃疡（请参见前面关于“脱毛、红斑、皮屑和/或局灶性结痂的患猫”的讨论。）

There are often systemic disease considerations (Figure 8). Some diseases already discussed, including bacterial pyoderma and leishmaniosis, may at times present with prominent erosion

through to ulceration (see earlier discussion of ‘the cat with alopecia, erythema, scaling and/or focal crusting’).

图8一只猫腹部多灶性糜烂和溃疡伴发不适。浅表细胞学检查、血液学、生化和尿液分析均未发现明显异常。拒绝进行皮肤活检。多形红斑、副肿瘤性天疱疮、药物反应（无近期病史）、皮肤血管炎和系统性红斑狼疮均为考虑因素。

Figure 8 Multifocal erosions and ulceration on the clipped ventral abdomen of a cat presenting with concurrent malaise. Superficial cytology and screening haemtology, biochemistry and urinalysis revealed no explanatory abnormal findings. Skin biopsies were declined. Erythema multiforme, paraneoplastic pemphigus, drug reactions (no recent history), cutaneous vasculitis and systemic lupus erythematosus were all considerations

皮肤虚弱

Skin fragility

皮肤虚弱是猫中的一种综合征，有多种潜在病因。它导致皮肤撕裂，甚至轻微的皮肤创伤，产生大面积的皮肤撕脱/溃疡。

Skin fragility is a syndrome reported in cats with multiple potential causes. It results in skin tearing associated with even minor skin trauma, producing large regions of skin avulsion/ ulceration.

皮质醇增多症

Hypercortisolism

自发性肾上腺皮质机能亢进在猫中很罕见，中年到老年猫患病，并与垂体（最常见）或肾上腺肿瘤有关。在临床上猫比犬更能耐受高皮质醇水平，因此犬疾病最常见各种各样的全身症状（多尿、多食、体重减轻），除非并发糖尿病，否则通常不存在症状。猫的医源性高皮质醇血症与可注射的、口服的和外用的糖皮质激素有关。

Spontaneous hyperadrenocorticism is rare in cats, affecting middle-aged to older individuals, and associated with pituitary (most commonly) or adrenal neoplasia. Cats are more clinically tolerant of high cortisol levels than dogs, so most common systemic signs of canine disease (polyuria, polyphagia, weight loss) are variable, and often absent unless there is concurrent diabetes mellitus. Iatrogenic hypercortisolaemia in the cat has been associated with injectable, oral and topical glucocorticoids.

据报道，大约50%的自发性病例发生皮肤变化，大多数是医源性病例，包括各种形式脱毛、皮肤变薄、虚弱和容易瘀伤。耳廓的特征性卷曲和脱毛也可能发生，特别是在医源性疾病中。

Skin changes are reported in approximately 50% of spontaneously occurring cases, and most iatrogenic cases，and include variable alopecia，and thin，fragile and easily bruised skin. Characteristic curling and alopecia of the ear pinnae may also occur, particularly in iatrogenic disease.

其他皮肤虚弱表现

Other skin fragility presentations

各有一例多中心性毛囊淋巴瘤、弥漫性组织胞浆菌病和肝脂质增多症患猫中，也有类似的皮肤虚弱报道，但在这些疾病中的发病机理尚未确定。皮肤虚弱（图9）是缅甸猫的鉴别诊断，其他猫偶见。与其他获得性皮肤虚弱的表现不同，它表现在年轻猫。

Similar skin fragility has been reported in single cats with multicentric follicular lymphoma,disseminated histoplasmosis and hepatic lipidosis, although the pathogenesis in those conditions has not been determined. Cutaneous asthenia (Figure 9) is a differential reported in the Burmese cat, and sporadically in other cats. In contrast to other presentations of acquired skin fragility, it should be apparent from a young age.

图9患皮肤衰弱的喜马拉雅猫-猫先天性皮肤虚弱。(a)不规则疤痕和局灶溃疡性病变。（b）图中的猫显示出不同位置的病变，显示了由小的皮肤创伤引起的大面积溃疡，这是典型的皮肤脆弱综合征。

Figure 9 Himalayan cat with cutaneous asthenia – a congenital cause of feline skin fragility. (a) Irregular scarred and focally ulcerated lesions. (b) The cat pictured at a different presentation, showing large areas of ulceration produced by minimal skin trauma, as is typical with skin fragility syndrome.

德文卷毛猫乳头状瘤病毒感染与原位鳞状细胞癌

Papillomavirus infection and SCC in situ in Devon Rex cats

在不同品种的中老年猫中，原位鳞状细胞癌病变被认为是局灶的或多灶性黑色素皮屑性斑块，发展为溃疡性和结痂性斑块和结节。至少某些形式与乳头瘤病毒感染有关，然而，潜在的全身性疾病是非典型的。据报道，德文卷毛猫患有一种严重侵袭性的原位鳞状细胞癌（图10），表现为从幼年开始发展的进行性病变。这种疾病与乳头状瘤病毒相关鳞状细胞癌的内部转移有关。

SCC in situ lesions are well recognised in middle-aged to older cats of varying breeds as localised single or multifocal melanotic scaly plaques, progressing to ulcerative and crusted plaques and nodules. At least some forms are associated with papillomavirus infection; however, underlying systemic illness is atypical. An aggressive severe form of SCC in situ is reported in Devon Rex cats (Figure 10), which presents with progressive lesions that develop from a young age; this condition has been associated with internal metastasis of papillomavirus-associated SCC.

图10 一只10岁德文卷毛猫的原位鳞状细胞癌，与乳头状瘤病毒感染相关。(a)颈部持续性多灶性结痂，伴轻度局灶性红斑。(b)前肢内侧界限清晰的糜烂性和结痂性病变

Figure 10 Squamous cell carcinoma in situ, associated with papillomavirus infection, in a 10-year-old Devon Rex. (a) Persistent multifocal areas of adherent crusting, with mild focal erythema, on the neck. (b) Well-demarcated erosive and crusting lesions on the medial forelimbs

除了嗜酸性斑块外，猫相对罕见非瘙痒自损性皮肤糜烂和溃疡。

Aside from eosinophilic plaques, prominent skin erosions and ulceration that are not readily explained by self-trauma from pruritus are relatively rare in the cat.

副肿瘤性天疱疮

Paraneoplastic pemphigus

据报道，一只猫在手术切除胸腺瘤后3.5周发生了严重的糜烂和溃疡性皮肤病，与副肿瘤性天疱疮相一致。腹部、大腿内侧和耳廓有大面积病变。在患有胸腺瘤的人、犬和猫上发现重症肌无力先于皮肤表现发生。重症肌无力和皮肤病变在几个月后消失，推测这两种疾病都是与胸腺瘤切除前释放的自身抗体引起的副肿瘤性疾病有关。

A severely erosive and ulcerative dermatosis consistent with paraneoplastic pemphigus is reported in one cat, occurring 3.5 weeks after surgical removal of thymoma. Extensive lesions were present on the ventral abdomen, inner thighs and ear pinnae. Myasthenia gravis, which has been recognised in humans, dogs and cats with thymomas, preceded the skin signs. The myasthenia gravis and skin lesions resolved after several months, and it was presumed that both were paraneoplastic diseases due to autoantibodies released prior to excision of the thymoma.

多形红斑复合物和中毒性表皮坏死

Erythema multiforme complex and toxic epidermal necrosis

多形红斑（EM）的特征是多灶性角质形成细胞死亡（细胞凋亡），导致皮肤和粘膜多灶红斑至溃烂区域融合。从轻度的红斑病变到全层溃疡，其严重程度很大，影响到局部至大面积皮肤和粘膜区域。可能出现典型的“靶点”病变，包括周围扩散的红斑和中央清晰的斑点。通常并发萎靡和发热。根据病变的严重程度和分布以及是否存在全身性疾病的症状，将其分为轻度EM或重度EM。猫（和犬）的EM与人类不同，在人上EM通常与疱疹病毒感染有关，在较小程度上与药物反应有关。虽然在犬上偶见报告与感染相关（细菌、肺孢子虫、细小病毒、疱疹病毒），但是许多病例是特发性的。犬中更严重的疾病，以及猫中报告的大多数EM病例均与药物有关。

Erythema multiforme (EM) is characterised by multifocal keratinocyte death (apoptosis), resulting in multifocal to coalescing areas of erythema to ulceration of the skin and mucosa. There is a spectrum of severity, from mild erythematous lesions to full thickness ulceration, affecting localised to extensive skin and mucosal areas. Classical ‘target’ lesions, consisting of erythematous macules that spread peripherally and clear centrally, may be present. Concurrent malaise and pyrexia are common. Subclassification as EM minor or EM major is based on the severity and distribution of lesions, and the presence or absence of signs of systemic illness. Disease in cats (and dogs) may vary to that in humans, where EM is most often associated with herpesviral infections, and to a lesser extent with drug reactions. Occasional infectious associations are reported in dogs (bacteria, Pneumocystis species, parvovirus, her-pesvirus), although many cases are idiopathic. More severe disease in dogs, and most cases of EM reported in cats, have been drug associated.

中毒性表皮坏死（TEN）被认为是一种单独的疾病，在猫中很少报道，并且与人类十分相似。其特征是角质形成细胞凋亡影响皮肤和粘膜的全层表皮/上皮细胞，并导致广泛的皮肤和粘膜坏死。TEN通常是由于药物反应引起，是一种危及生命的疾病。

Toxic epidermal necrosis (TEN) is considered a separate disease that is reported rarely in cats, and appears similar to human TEN. It is characterised by keratinocyte apoptosis affecting the full thickness epidermis/epithelium of skin and mucosae, and resulting in widespread areas of skin and mucosal necrosis. TEN is most often caused by drug reactions, and is a life-threatening disease.

EM和TEN的诊断是通过皮肤活检的组织病理学改变，与一致的临床症状得以证实。诊断应及时彻底调查潜在的药物诱因和/或潜在的感染性疾病。消除疾病的诱因能够使疾病得到解决，并且对预后很重要。

Diagnosis of EM and TEN is confirmed by histopathological changes on skin biopsies, in association with consistent clinical signs. Diagnosis should prompt a thorough investigation for potential drug triggers and/or underlying infectious diseases. Removal of disease triggers may lead to disease resolution, and is important prognostically.

对于皮肤糜烂和溃疡的患猫，要密切关注潜在的全身性疾病。

Underlying systemic disease is a very relevant consideration for the cat with skin erosions and ulceration.

诊断方法：皮肤糜烂和溃疡 Diagnostics: skin erosions and ulceration 对于这种皮肤表现，重点关注潜在的全身性疾病，重点要先进行全面的病史调查包括近期的整体健康状况和用药史，以及对其他器官疾病的全面体格检查。必须进行皮肤表面细胞学检查，判断是否存在病变产生的或使疾病加重的活跃的继发细菌感染。皮肤活检通常对此表现有提示意义，从不同病变中采集多个样本，并注意在任何溃疡区域的边界带上完整的皮肤，这将最大程度地提高其诊断价值。无论是否存在其他提示全身性疾病的异常表现，在皮肤活检前也应该进行实验室检查。 Underlying systemic disease is a very relevant consideration for this cutaneous presentation, and a comprehensive history including recent general health and drug therapies, and a full body physical examination screening for other organ disease, are important initial steps. Skin surface cytology is necessary to screen for active secondary bacterial infections that produce the lesions or contribute to their severity. Skin biopsies are often indicated with this presentation; collecting multiple samples from a range of lesions, taking care to include intact skin at the borders of any ulcerated areas, will maximise their diagnostic value. Laboratory screening will also often be indicated prior to biopsy collection, irrespective of the presence or absence of other abnormalities suggesting systemic disease.

龙医生