一例猫嗜酸性肉芽肿复合物的新临床表现

王帆

Novel presentation of eosinophilic granuloma complex in a cat

一例猫嗜酸性肉芽肿复合物的新临床表现

作者：Kaitlin P Hopke and Sandra J Sargent

 

翻译：施尧医生

 

Abstract

摘要

Case summary A 9-year-old neutered male domestic shorthair cat was presented for multiple deep lesions on all four limbs and a nodule on the right pinna. The limb lesions ranged from nodules with necrotic surfaces to full-thickness ulcerations with exposure of muscles and tendons. The cat lived indoors only in a single-pet household and had no prior history of trauma. The owner reported that the lesions appeared abruptly and that the cat was not apparently painful or pruritic. Histopathology of the limb lesions and pinnal nodule confirmed severe lesions of the eosinophilic granuloma complex. Resolution of lesions was achieved with a combination of antibiotics, prednisolone, topical therapies, diet change and ciclosporin.

Relevance and novel information This case report demonstrates a severe, aggressive presentation of eosinophilic granuloma complex. It will expose practitioners to atypical clinical signs of this commonly diagnosed disease.

病例总结：一只九岁已去势雄性家养短毛猫因四肢多发性深部病变和右耳廓的结节就诊。四肢病变包括表面坏死的结节和暴露肌肉和肌腱的全层溃疡。患猫严格室内饲养，家中没有其他宠物并且之前没有外伤史。主人描述病变是突然出现的，且患猫没有明显的疼痛或瘙痒的表现。四肢病变和耳廓结节的组织病理确认为严重的嗜酸性肉芽肿复合物。通过联合使用抗生素、泼尼松龙、外部治疗、改变饮食和环孢菌素，病变已经痊愈。

相关性和新信息：该病例报告阐述了一种严重的、具有侵袭性的嗜酸性肉芽肿复合物的表现。本病例很好的向从业者展现出这种常见病的不典型临床表现。

 

Keywords: Eosinophilic granuloma complex; EGC; feline eosinophilic dermatoses; feline allergic disease; feline cutaneous reaction patterns; hypersensitivity disorder

关键字：嗜酸性肉芽肿复合物；EGC；猫嗜酸性皮肤病；猫过敏性疾病；猫皮肤反应模式；过敏性疾病

 

Introduction

引言

Feline eosinophilic granuloma complex (EGC) is a common finding in veterinary dermatology. It comprises a group of reaction patterns that affects the skin, oral cavity and mucocutaneous junctions of cats. EGC can be caused by a variety of factors but is most commonly thought to be the cutaneous manifestation of feline allergic disease. The three primary clinical lesions of EGC include indolent (also referred to as eosinophilic or rodent) ulcer, eosinophilic plaque and eosinophilic granuloma. All three lesion types share an inflammatory etiology and a pathogenesis involving an influx of eosinophils into dermal tissues. This case describes an unusually severe clinical presentation of EGC that does not fit into one of the aforementioned clinical entities. Despite the novel appearance, the lesions responded to the therapies traditionally used to treat EGC.

猫嗜酸性肉芽肿复合物（EGC）是兽医皮肤病学中的一种常见临床表现。它由一系列影响猫皮肤、口腔和皮肤黏膜交界处的反应模式组成。EGC可由很多病因引起，但是猫过敏性疾病被认为是最常见的病因。EGC的三个主要临床病变表现包括无痛性（也称之为嗜酸性或惰性）溃疡、嗜酸性斑块和嗜酸性肉芽肿。这三种病变的病因学都是炎症反应，且病理变化都涉及嗜酸性粒细胞浸润真皮组织。本病例描述了一种EGC不常见的、严重的临床表现，并且与上文提到的三种病变都不符合。尽管是一种新临床表现，但该病变对EGC的传统治疗有反应。

 

Case description

病例描述

A 9-year-old neutered male domestic shorthair cat was presented for evaluation of full-thickness wounds on its limbs and a nodular lesion on the right convex pinna. These lesions developed acutely and did not appear to affect the cat. Historically, the cat only suffered from occasional pruritus manifested by licking and secondary mild hypotrichosis. The cat received an injection of cefovecin and a dose of topical fluralaner prior to referral.

一只九岁已去势雄性家养短毛猫因肢体的全层溃疡灶和右耳廓凸面的结节病变就诊。病变突然出现但对患猫似乎没有影响。通过病史可知，患猫偶尔表现出瘙痒（舔舐）并有继发的轻度少毛症。患猫在转诊前注射过一针头孢维星和外用一次氟雷拉纳。

 

Physical examination revealed a nodule on the right forelimb with an ulcerated necrotic surface and adjacent full-thickness ulceration. The lateral left carpus had multiple full-thickness ulcerations with muscle and tendon exposed. Both hocks had similar lesions comprised of deep ulcerations. The left metacarpal pad had a central erosion, while the third digital pad was mildly swollen with pigmentary change. A purpuric macule also was noted on the lateral aspect of the right metacarpal pad. The left metatarsal pad had one erosion present. A semisoft nodule was located at the base of the convex right pinna (Figure 1). All body systems other than dermatological were found to be unremarkable.

体格检查发现右前肢有一结节，表面溃疡坏死，周围全层溃疡灶。左腕关节侧面有多处深层溃疡灶且已暴露肌肉和肌腱。双侧跗关节有相似的深层溃疡灶。左爪垫中央有一糜烂灶，第三趾垫轻度肿胀伴有色素改变。右脚掌侧面有一紫色斑点。左跖骨垫有一糜烂。右耳廓凸面的基部有一处半柔软的结节（图1）。除了皮肤，其他器官没有发现明显病变。

 

Figure 1 Initial presentation: (a) nodule on right forelimb; (b) full-thickness ulceration on left carpus; (c) full-thickness ulceration on left forelimb; (d) left carpus; (e) ulcerated lesion on right hock; (f) metacarpal pad discoloration; and (g) right pinnal nodule

图1 首诊表现：（a）右前肢的结节；（b）左侧腕关节全层溃疡；（c）左前肢全层溃疡；（d）左侧腕关节；（e）右侧肘关节溃疡；（f）爪垫色素改变；（g）右耳廓结节

 

A preliminary list of differential diagnoses based on the history and clinical presentation included infection (viral, bacterial, fungal, mycobacterial) and neoplasia. Initial diagnostics included a chemistry panel, complete blood count (CBC), cytology, aerobic and fungal cultures, and histopathology. Cytology of an impression smear from the forelimb lesions revealed mixed inflammatory cells, including neutrophils and macrophages without obvious infectious organisms. The chemistry panel was within normal limits. The CBC revealed eosinophilia (3562/μl, range 0–1500/μl). Deep tissue culture showed no aerobic growth after 72 h. Fungal culture of deep tissue obtained via biopsy revealed no growth of pathogenic fungus after 3 weeks.

基于病史和临床表现，最初的鉴别诊断包括感染（病毒、细菌、真菌、分枝杆菌）和肿瘤。初步检查包括生化、全血细胞计数（CBC）、细胞学、需氧和真菌培养，以及组织病理学检查。前肢病变的细胞学压片可见混合的炎性细胞，包括中性粒细胞和巨噬细胞，但未见明显病原微生物。生化指标都在正常范围内。CBC提示嗜酸性粒细胞增多症（3562/μl，参考范围是0-1500/μl）。深层组织需氧培养72小时后未见微生物生长。对深层组织活检取样，进行真菌培养3周后未见真菌生长。

 

Skin biopsies were performed to obtain samples of the affected areas using 6 mm punches. Three samples were collected from the lesions on the forelimbs and a fourth sample was obtained from the right pinnal nodule. Histopathological examination revealed necroulcerative and severe, multifocal eosinophilic dermatitis (Figure 2). A second opinion was requested due to the initial diagnosis being seemingly inconsistent with the clinical presentation. A second pathologist reported severe ulcerative and necrotizing eosinophilic dermatitis, consistent with severe lesions of the eosinophilic granuloma complex. This pathologist did make note of the fact that there were also lymphocytes amongst the eosinophils, so lymphoma could be a differential, although this was less likely.

对患病区域使用6mm皮肤打孔活检取样。前肢病变采集了3个样品，右耳廓的结节采集了1个样品。组织病理学提示坏死溃疡，严重的、多灶性嗜酸性粒细胞性皮炎（图2）。由于初步诊断结果跟临床表现不符合所以申请第二次判读。第二位临床病理学家报告结果是严重的、坏死溃疡性、嗜酸性粒细胞性皮炎，符合嗜酸性肉芽肿复合物特征。这位病理学家还备注除了嗜酸性粒细胞，还可见淋巴细胞，虽然不太可能，但淋巴瘤也要列入鉴别诊断。

 

Figure 2 (a) Ulcerative dermatitis with necrosis of the underlying dermis, and heavy dermal infiltrates of eosinophils; (b) dermal infiltrates of eosinophils, inflammatory mast cells and small lymphocytes, with mild-to-moderate edema and mucinosis; and (c) ‘flame figures’ (arrows), consisting of collagen bundles surrounded by degranulated eosinophils, which, in turn, are surrounded by macrophages and multinucleated giant cells. The bars in (a), (b) and (c) are 600 μm, 60 μm and 60 μm, respectively

图2（a）溃疡性皮炎伴有真皮层坏死和真皮层嗜酸性粒细胞大量浸润；（b）真皮嗜酸性粒细胞、炎性肥大细胞和小淋巴细胞浸润，并伴有轻度到中度水肿和黏蛋白增多；（c）‘火焰征’（箭头），由胶原纤维束和周围退行性的嗜酸性粒细胞组成，嗜酸性粒细胞周围又被巨噬细胞和多核巨细胞包围。图（a）（b）（c）的比例尺分别是600μm，60μm和60μm。

 

Treatments prescribed at presentation (prior to histopathology or culture results) included pradofloxacin (6 mg/kg/day [Veraflox; Bayer]) and sublingual buprenorphine (0.01 mg/kg q12h). Antibiotics were prescribed due to the severe clinical appearance and large amount of tissue necrosis evident on presentation. Pradofloxacin was considered an appropriate antibiotic choice based on mycobacterial infection being a differential. Buprenorphine was prescribed for analgesia post-biopsy procedure. After all diagnostic results were reviewed, prednisolone was added to the regimen at 2 mg/kg q24h. The pradofloxacin course was completed but not refilled. A food trial was also initiated with a hydrolyzed salmon prescription diet (Blue Natural Veterinary Diet HF).

在诊断结果（组织病理和培养结果）出来前的治疗包括普多沙星（6mg/kg/天）还有舌下给予丁丙诺啡（0.01mg/kg q12h）。由于临床表现很严重以及大量组织出现坏死因此给予抗生素治疗。使用普多沙星作为抗生素治疗是考虑到鉴别诊断里有分枝杆菌感染的可能。丁丙诺啡作为活检后的镇痛药使用。在所有诊断结果出来后，治疗方案中增加泼尼松龙，以2 mg/kg q24h的用法使用。普多沙星第一个疗程完成后停药。此外还使用了含有水解鲑鱼肉的处方粮（Blue Natural Veterinary Diet HF）进行食物限制试验。

 

Additional diagnostics were performed to rule out underlying systemic causes of the dermatologic abnormalities. Thoracic radiographs revealed no evidence of intrathoracic disease. Abdominal ultrasound showed mild cystic sand (deemed likely incidental) and prominent medial iliac lymph nodes. The radiologist noted this lymphadenopathy may be normal or mildly reactive to the cutaneous lesions in the hindlimbs, with no additional diagnostics (such as fine-needle aspirate) deemed necessary. A urinalysis was submitted due to the cystic sand finding, and was unremarkable. Retroviral testing confirmed the cat was negative for feline leukemia virus and feline immunodeficiency virus. A lymphoma panel (PCR for antigen receptor rearrangement [PARR]) was recommended but was ultimately declined by the owner.

其他的附加检查用来排除潜在的系统性疾病所引起的皮肤异常。胸部X线片提示没有胸腔内疾病。腹部超声提示轻度的膀胱内结晶（被认为是偶然发现）以及髂内淋巴结明显。影像医师指出该淋巴结肿大可能是正常的也可能是由于后肢皮肤病变造成的轻度反应性的淋巴结，不需要进行其他检查（如细针抽吸）。由于发现了膀胱内结晶因而进行了尿液分析，但结果没有明显异常。逆转录病毒测试证实该猫猫白血病病毒和猫艾滋病病毒阴性。建议主人进行抗原受体重排的PCR检测(PARR)来排除淋巴瘤，但主人拒绝该项检查。

 

The cat was re-evaluated 2 weeks later. The lesions were stable: there was no worsening of existing lesions and no new lesions. Four-week follow-up showed improvement of all limb lesions. Weight loss was noted but was accounted for by the owner not feeding an adequate amount of the new diet. A gradual steroid taper was initiated. Topical application of a spray containing hypochlorous acid (Vetericyn; Innovacyn) to the lesions was recommended. A chemistry panel with CBC was repeated. The eosinophil count normalized, but there was a mild lymphopenia present (855 μ/ml). This abnor- mality was attributed to the use of the steroid.

患猫两周后复查。病变稳定：现有病变没有继续恶化也未见新病变出现。4周后回访可知所有肢体病变得到改善，体重出现下降但主要由于动物主人没有喂足够量的处方粮。激素开始逐渐减半剂量，且建议对病变外用含有次氯酸的喷剂。复查了生化和CBC，嗜酸性粒细胞数恢复正常，但是有轻度的淋巴细胞减少症（855μ/ml），这种异常是由于激素的使用所造成的。

 

Unfortunately, the client failed to bring the cat in for the next scheduled recheck and discontinued the prednisolone when the supply was finished. When the cat did return for re-evaluation, it had several new lesions (primarily foot pads and pinna). The original lesions were heavily crusted with underlying purulent discharge (Figure 3). Cytology revealed cocci and therefore a culture was submitted. The steroid was resumed and a cefovecin injection (Convenia; Zoetis) was administered. Cefovecin was chosen due to its documented efficacy in treating staphylococcal infections and ease of administration in the cat. The client was instructed to soak the affected feet in dilute chlorhexidine solution once daily.

不幸的是，动物主人没有在后续的复诊时间带患猫复查且泼尼松龙吃完后就停药了。当患猫来院再次复查时出现了几处新病变（主要是爪垫和耳廓），原病变结痂，结痂下有脓性分泌物（图3）。细胞学可见球菌因此进行了细菌培养。重新开始使用激素并且注射一针头孢维星。之所以使用头孢维星是因为其对球菌的有效性以及对猫使用方便。指导客户把患猫患病的爪子浸泡在稀释后的氯己定溶液中，每天一次。

Aerobic culture from the cat’s limb lesions revealed heavy growth of methicillin-resistant Staphylococcus pseudintermedius, sensitive to only amikacin and chloramphenicol. An extended susceptibility panel was performed and the only antibiotic options were linezolid, vancomycin and rifampicin. Vancomycin was not chosen due to its cost and route of administration (injectable). Rifampin was also a poor choice due to its known adverse effects in cats. Owing to limited systemic antibiotic options, a pharmacologist was consulted. He voiced reluctance to use chloramphenicol owing to potential bone marrow suppression and instead recommended linezolid. Linezolid is typically well tolerated in cats, is easily administered and is fast-acting. The cat was started on linezolid at 10mg/kg q24h for 30 days. Mupirocin was also applied topically to affected areas, q12h, and prednisolone was continued.

患猫病变的需氧培养结果提示耐甲氧西林的假中间型葡萄球菌大量生长，对阿米卡星和氯霉素敏感。扩大了药敏实验范围后结果只有利奈唑胺、万古霉素和利福平可以使用。万古霉素由于其高昂的价格和使用方式（注射）没有被采用。利福平由于对猫的副作用也不是个好选择。由于可使用的全身性抗生素很有限，因此专门请教了药理学家。他不建议使用氯霉素因为其骨髓抑制作用，因而他推荐使用利奈唑胺。猫对利奈唑胺耐受性较好，使用简单且快速起效。患猫按照10mg/kg q24h的剂量，连用30天。此外还每天外用莫匹罗星两次，并继续使用泼尼松龙。

 

The 2-week recheck showed improvement of all limb and foot pad lesions. Repeat blood work showed neutrophilia (17,513/μl), lymphopenia (1055/μl) and eosinophilia (2100/μl). The nodule at the base of the right pinna was larger than previously noted. Fine-needle aspirate and cytology of the nodule showed eosinophils (1+) and occasional neutrophils.

两周后复查可见所有肢体和爪垫的病变均有改善。复查血像提示中性粒细胞增多症（17513/μl），淋巴细胞减少症（1055/μl）和嗜酸性粒细胞增多症（2100/μl）。右耳廓基部的结节较上次增大。对结节进行细针抽吸后细胞学检查可见嗜酸性粒细胞（1+）和偶见中性粒细胞。

 

The pinnal nodule continued to grow and rupture intermittently (Figure 4). The client was concerned with quality of life as the cat was required to wear an Elizabethan collar and yet still excessively bled from the pinnal mass. At this time, the cat was started on ciclosporin (Atopica; Elanco) at 7 mg/kg q24h. The prednisolone was gradually tapered over the course of 4 weeks.

耳廓结节持续增大且会间歇性破溃（图4）。动物主人担心患猫佩戴伊丽莎白圈会影响生活质量并且对肿物仍大量出血感到担忧。此时，患猫开始以7mg/kg q24h的剂量使用环孢菌素。泼尼松龙在4周内逐渐减半剂量。

 

 

Figure 3 (a) Exacerbation of pad lesions after steroid discontinuation; and (b) crusting of lesions with underlying purulent discharge

图3（a）激素停用后爪垫病变恶化；（b）病变结痂且结痂下可见脓性分泌物 。

 

Figure 4 Enlargement of pinnal nodule

图4 耳廓结节增大

 

Surgical excision of the pinnal nodule was pursued due to lack of improvement with medical management. Owing to the size of the mass and the limited skin available for closure, a pinnectomy was performed (Figure 5). Although this same nodule was biopsied 4 months earlier, it was suspected to be a different entity than EGC. Therefore, the entire pinna was submitted. Histopathological examination confirmed cutaneous hemangiosarcoma. The surgical margins were clean but narrow (1–2 mm). Repeat metastatic work-up (thoracic radiographs, abdominal ultrasound) was recommended, along with an oncology consultation. The owner declined further diagnostics.

由于药物治疗没有改善耳廓结节，因此采取外科切除的方法。考虑到肿物的体积以及可缝合的皮肤有限，因此选择了耳廓切除术（图5）。尽管这个结节在4个月前被活检过，但仍认为其并不是EGC。因此，决定切除整个耳廓。组织病理学检查确诊为皮肤血管肉瘤。手术边缘干净但是比较窄（1-2mm）。建议进行肿瘤转移筛查（胸部X线片，腹部超声）并与肿瘤医师会诊。主人拒绝进行下一步检查。

 

 

Figure 5 Fourteen days post-pinnectomy

图5 耳廓切除术术后14天

 

At the recheck 6 months after referral, the pinnectomy lesion was healed and the forelimb lesions were significantly improved (Figure 6). The foot pad lesions resolved. The slowest healing lesions were the erosions on the hocks, but even these had granulation tissue. The delayed improvement of these lesions was attributed to their location (directly over the hocks) and the potential glucocorticoid effects on wound healing. Blood work showed persistent neutrophilia (9828/μl), lymphopenia (550/μl) and hyperglycemia (226mg/dl). The fructosamine level was normal (282 μmol/L), indicating no diabetes mellitus.

转诊后6个月进行了复查，手术切除部位已经愈合而且前肢病变明显改善（图6）。爪垫病变已经恢复。肘关节的糜烂病变愈合的最慢，但是也出现了肉芽组织。延迟愈合是因为病变的部位（在肘关节正上方）以及糖皮质激素对伤口愈合的影响。血检提示持续的中性粒细胞增多症（9828/μl），淋巴细胞减少症（550/μl）和高血糖（226mg/dl）。果糖胺水平正常（282μmol/L），证明患猫没有糖尿病。

 

Figure 6 (a) Residual lesion on right forelimb after 6 months of therapy; (b) healing metacarpal pad after 6 months of therapy; and (c) right distal forelimb 9 months after initial presentation

图6 （a）治疗6个月后右前肢残留的病变；（b）治疗6个月后正在恢复的爪垫；（c）治疗9个月后的右前肢远端

 

Over the next 3 months, the cat’s lesions continued to improve and the prednisolone was gradually tapered. At the 9-month recheck, the left forelimb was completely free of lesions and the right forelimb had only residual scarring in the previous lesion site. The healing of the hock lesions was progressing. The cat remained on a low dose of prednisolone (0.1mg/kg q48h), as well as ciclosporin (7mg/kg q24h). The cat continued to have fluralaner applied every 3 months and continued to eat solely the prescription hydrolyzed salmon diet (the owner declined challenging the diet).

接下来的三个月，患猫病变持续改善，泼尼松龙逐步减量。第9个月复查时，左前肢完全康复，右前肢的病变部位留下疤痕。肘关节的病变仍在愈合。患猫仍在服用低剂量泼尼松龙（0.1mg/kg q48h）和环孢菌素（7mg/kg q24h）。患猫每三个月使用氟雷拉纳驱虫并且一直坚持只吃含有水解鲑鱼肉的处方粮（主人拒绝更换饮食）。

 

Discussion

讨论

This case demonstrates a novel, aggressive presentation of EGC. The commonly recognized lesions associated with EGC include eosinophilic plaque, eosinophilic granuloma and indolent ulcer. Eosinophilic plaques are raised, well-demarcated erythematous lesions typically found on the ventral abdomen. Eosinophilic granulomas can appear as raised or nodular lesions in the oral cavity, on the lower lip or on the footpads. Pinpoint white particles representing eosinophil degranulation are often noted in the center of eosinophilic granulomas. Eosinophilic granulomas may also present as linear lesions on the caudal limbs. Indolent ulcers are well-circumscribed ulcers located on the upper lip adjacent to the maxillary canine teeth. The cat in this case presented with unique lesions involving full-thickness ulcerations of the limbs. One may argue that the nodular appearance of some of the lesions most closely resembles eosinophilic granulomas. However, the severe ulceration associated with the lesions has not been previously documented, to our knowledge.

本病例展现了一种新的，侵袭性的EGC表现。跟EGC相关的常见症状包括嗜酸性斑块、嗜酸性肉芽肿和无痛性溃疡。嗜酸性斑块是凸起的、界限清楚的皮肤发红病变，腹部是典型的常发部位。嗜酸性肉芽肿是凸起的或是结节样病变，口腔、下唇和爪垫是常发部位。在嗜酸性肉芽肿的中央可见白色的针尖大小微粒，这是典型嗜酸性粒细胞脱颗粒的表现。嗜酸性肉芽肿也可能以线性病变为表现形式，通常出现在肢体的尾侧。无痛性溃疡是边界清楚的溃疡灶，上唇的犬齿附近是常发部位。本病例中的猫出现了独特的病变，涉及肢体的全层溃疡。有人可能会认为某些病变的结节和嗜酸性肉芽肿很相似。然而，就我们目前所知，严重的溃疡灶还没有报道过。

 

EGC can resemble several other disease processes such as viral infections, bacterial or fungal infections, and neoplasia. The cat was retrovirus negative. Histopathology was not consistent with herpes or calici-viral infections. The deep tissue bacterial and fungal cultures were negative. Neoplasia was not noted on histopathology. There were, however, lymphocytes among the eosinophils in the biopsy specimens, suggesting perhaps an inflamed lymphoma. Ideally, a precautionary lymphoma panel (PARR) would have enabled us to distinguish between monoclonal neoplastic lymphoid cells and polyclonal, inflammatory lymphoid cells. However, the owner declined this additional testing. The final diagnosis was still reported as severe EGC by more than one pathologist.

EGC和某些疾病的进程很相似，例如：病毒、细菌或者真菌感染和肿瘤。患猫逆转录病毒检测阴性。组织病理学与疱疹病毒或者杯状病毒感染无关。深层组织细菌和真菌培养阴性。组织病理学检查不提示肿瘤。然而活检样本中的嗜酸性粒细胞周围有淋巴细胞，可能提示炎性淋巴瘤。理想情况下，进行PARR可以帮助我们来区分单克隆肿瘤性淋巴细胞、多克隆炎性淋巴细胞，然而主人拒绝该项检查。最终诊断结果是严重的EGC，这一结果由多名病理学家所认同。

 

The cutaneous hemangiosarcoma on the cat’s right pinna was an unexpected finding. The nodule was initially biopsied and diagnosed as part of the EGC. However, that one lesion continued to enlarge despite treatment and despite improvement of all other lesions. Cutaneous hemangiosarcomas in cats are infrequently reported. Aggressive surgical excision was elected due to the tumor affecting the cat’s quality of life and the knowledge that complete surgical excision is typically associated with a favorable prognosis. It is still unknown whether the hemangiosarcoma was always present but not represented in the initial biopsy, or if the neoplasia was a later development.

患猫右耳廓的皮肤血管肉瘤是个意外发现。这个结节起初被活检诊断为EGC的一部分，但在治疗后其他病变均有改善的情况下，该病变持续增大。皮肤血管肉瘤在猫中并不常见。由于肿瘤影响患猫的生活质量且考虑到肿瘤完全切除的病例预后较好，本病例最终选择了激进的外科切除。目前仍不清楚该血管肉瘤是一开始就存在而没有被活检取到，还是之后才发展出来的。

 

Initial treatment of EGC involves addressing secondary infection and inflammation. Long-term management entails immunosuppression and control of the hypersensitivity response. A glucocorticoid was pre- scribed initially in order to provide rapid dampening of the immune response and reduction in the severe inflammation. Ciclosporin was later added in this case in the hope of being steroid-sparing and to allow for reduction and possibly discontinuation of the glucocorticoid. Common causes of EGC include flea, food and non-flea, non-food induced hypersensitivity dermatitis. Routine application of fluralaner addressed a potential flea allergy, while a strict prescription diet trial addressed a potential food allergy. The client was educated about skin and/or serum tests for environmental allergies and formulation of allergen-specific immunotherapy. However, the cat responded to the food trial and immunosuppression so that further allergy work- up was temporarily postponed.

EGC的初始治疗涉及控制继发感染和抗炎。长期管理包括免疫抑制剂的使用和过敏反应的控制。一开始使用糖皮质激素是为了快速抑制免疫反应和减轻严重的炎症反应。后来使用环孢菌素是为了减少糖皮质激素的用量，有可能的话甚至可以停用糖皮质激素。常见的引起EGC的病因包括：跳蚤、食物以及非跳蚤非食物诱导的过敏性皮肤病。定期使用氟雷拉纳驱虫可以控制潜在的跳蚤过敏，严格饲喂处方粮可以控制潜在的食物过敏。此外还对客户进行了皮肤和/或血清环境过敏原检测以及过敏原特异性免疫治疗计划的相关教育。然而，患猫对食物限制试验和免疫抑制剂有反应，因此后续的过敏管理方案暂缓进行。

 

The antibiotic choice of linezolid may be received with some controversy. The International Society for Companion Animal Infectious Diseases lists linezolid as a ‘third-tier’ antimicrobial agent. In some countries in Europe (including France), the use of third-tier antibiotics is prohibited by law, as such molecules are reserved exclusively for the treatment of humans and not animals. However, it is important to note that linezolid is not prohibited universally and is permitted for use in animals in the USA (where this case was clinically managed). Its use should be reserved for cases in which first- and second-tier antimicrobials are not appropriate and culture indicates susceptibility. Both of these criteria were met in this case. An independent expert on antimicrobial resistance was consulted on this case. This expert suggested linezolid owing to its favorable pharmacokinetics, safety profile in cats and lack of documented resistance in bacteria isolated from animals (M Papich, 2019, personal communication). Therefore, there was no violation of responsible antimicrobial stewardship in the treatment of this case.

使用利奈唑胺作为抗生素治疗可能会引起争议。国际伴侣动物传染病协会把利奈唑胺列为第三线抗生素。在欧洲的某些国家（包括法国），法律禁止使用第三线抗生素，因为这些药物只能被用于治疗人类疾病而非动物。然而，利奈唑胺并非全球性禁用，在美国批准用于动物（本病例是用于临床治疗）。利奈唑胺应该在已知一线和二线抗生素无效且培养结果显示对利奈唑胺敏感时使用。本病例符合以上所有标准。一位抗生素耐药性方面的专家也参与了本病例的会诊。这位专家因为利奈唑胺优秀的药代动力学、对猫的安全性好以及从动物身上分离的细菌没有一种对其耐药而建议使用（M Papich,2019, personal communication）。因此，本病例在治疗过程中没有违背抗生素药物管理的原则。

 

Conclusions

结论

This case introduces a presentation of EGC that has not been previously documented. It expands our knowledge of this common dermatologic condition. It also stresses the need for a thorough work-up and management of allergies in feline patients presenting with severe skin lesions.

本病例介绍了之前从未报道过的EGC临床表现，扩展了我们对这种常见皮肤病的认知。本病例还强调了对表现出严重皮肤病变的猫进行完整的诊断流程和过敏管理的必要性。

 

 

sharrow许

这个病例有种打开了一个新大门的感觉

逗号

龙医生

袁丽娟

害怕，正有一个足垫溃疡的嗜酸性肉芽肿病例