幼年波斯猫外用含有氯倍他索的乳液后出现医源性皮质醇...

王帆

Iatrogenic hypercortisolism in a Persian kitten after topical application of a skin lotion containing clobetasol

幼年波斯猫外用含有氯倍他索的乳液后出现医源性皮质醇增多症

作者：Deepa Chirayath and Sahla Shaheena

翻译：王羽迪

Hypercortisolism is a rare endocrine disorder in cats. This report describes the clinicopathological findings and successful management of iatrogenic hypercortisolism in a Persian kitten. The disorder was presumed to be a consequence of prolonged topical application of a lotion containing clobetasol.

皮质醇增多症是一种罕见的猫内分泌疾病。本报告描述了幼年波斯猫的医源性皮质醇增多症，其临床病理学结果和成功的治疗。推测该疾病是长期外用含有氯倍他索乳液的结果。

Introduction

简介

Hypercortisolism (HC) is a multisystemic clinical syndrome resulting from a prolonged increase in circulating glucocorticoid concentrations. Generally cats are regarded as being less susceptible to the deleterious effects of glucocorticoids than dogs. This might be due to  the decreased density and lower binding affinity of glucocorticoid receptors in the skin and liver of cats.Iatrogenic hypercortisolism can occur as an adverse effect of exogenous glucocorticoid supplementation. This report describes a rare case of iatrogenic hypercortisolism in a kitten that occurred as a consequence of prolonged application of a topical lotion containing clobetasol.

皮质醇增多症(HC)是一种多系统临床综合征，由循环中糖皮质激素浓度长期升高引起。一般来说，猫被认为比犬更不容易受到糖皮质激素的有害影响。这可能是因为猫皮肤和肝脏中糖皮质激素受体的密度降低和结合亲和力降低。医源性皮质醇增多症可有外源性糖皮质激素补充剂副作用导致。这份报告描述了一个罕见的幼猫医源性皮质醇增多症的病例，该病例是由于长期外用含有氯倍他索的乳液而发生的。

History  

病史

A 3.5-month-old male kitten weighing 1.3 kg was presented at the University Veterinary Hospital for the complaint of extensive alopecia. The kitten had been treated for pruritus and localised alopecia one month previously with Wokazole Plus lotion (ofloxacin 0.1% w/v, miconazole 2% w/v, clobetasol 0.025% w/v and zinc sulfate 3% w/v; Vetoquinol; Mumbai, India). As a result of the initial reduction in pruritus, the owner applied the lotion liberally  all over the body of the kitten, twice daily. By about one month, the kitten had become almost completely alopecic, while continuing to exhibit a good appetite.

一只3.5个月大的雄性幼猫，体重 1.3 公斤，因大面积脱毛而到大学兽医医院就诊。1个月前，幼猫因瘙痒和局部脱毛使用过Wokazole Plus乳液治疗（氧氟沙星0.1% w/v、咪康唑2% w/v、氯倍他索 0.025% w/v和硫酸锌 3% w/v）。由于最初的瘙痒减轻，主人每天两次将乳液大量涂抹在幼猫全身。大约一个月后，幼猫几乎完全脱毛，但仍然食欲良好。

Physical examination and observations

体格检查和观察

On examination, the animal was found to be dull and lethargic. It had a pendulous abdomen and exhibited marked alopecia, scaling and atrophy of the skin (Figure 1a). Milky-white, hazy deposits were present in the anterior chamber of both eyes, more so in the left eye (Figure 1b). Right lateral radiography revealed the presence of hepatomegaly (Figure 2).

经检查，发现该动物精神沉郁和嗜睡。表现为腹部下垂，明显可见脱毛、皮屑和皮肤萎缩（图 1a）。双眼前房中存在乳白色、朦胧的沉积物，左眼更明显（图1b）。右侧位 X线片显示肝脏肿大（图 2）。

Figure 1. Kitten with hypercortisolism. (a) External morphology showing generalised alopecia, marked scale, cutaneous atrophy and pendulous abdomen. (b) Close-up of eye showing lipid within the aqueous humour.

图1。患有皮质醇增多症的幼猫。(a) 外观可见全身脱毛、明显的皮屑、皮肤萎缩和腹部下垂。(b) 眼部房水内脂质特写。

Figure 2. Right lateral radiograph of a kitten with hypercortisolism, showing hepatomegaly

图2。一只患有皮质醇增多症的幼猫的右侧位X线片，显示肝脏肿大。

Blood was collected from a cephalic vein for laboratory analysis. Haematological study revealed leucocytosis, lymphopaenia, granulocytosis monocytosis, anaemia, macrocytosis, hypochromia and anisocytosis. The serum was creamy in colour and the lipid profifile revealed abnormally high levels of triglycerides. Venous blood gas analysis revealed high glucose and lactate, low potassium and normal creatinine levels (Table S1).

从头静脉采集血液用于实验室分析。 血液学研究显示白细胞增多症、淋巴细胞减少症、粒细胞增多症、单核细胞增多症、贫血、大红细胞增多症、血红蛋白减少和红细胞大小不一。 血清呈奶油色，脂质显示甘油三酯水平异常高。 静脉血气分析显示高葡萄糖和乳酸、低钾和正常肌酐水平（表 S1）。

The clinical and biochemical changes indicated an endocrinopathy. The serum total T4 level was found to be  in the normal range. Iatrogenic hypercortisolaemia was  suspected and the kitten underwent an ACTH stimulation  test, where 125 µg synthetic ACTH (Acton Prolongatum,  Ferring; Mumbai, India) was administered intramuscularly. Plasma cortisol levels pre- and post-ACTH were 0.16 µg/dL and 0.5 µg/dL, respectively (reference range 7–25 µg/dL) which was consistent with adrenal suppression and supported a diagnosis of iatrogenic hypercortisolism.  

临床和生化变化表明内分泌病。血清总T4水平在正常范围内。怀疑是医源性皮质醇增多症，幼猫接受了ACTH刺激试验，其中肌肉注射125 µg 合成ACTH，ACTH前后的血浆皮质醇水平分别为0.16 µg/dL和0.5µg/dL（参考范围7-25微克/分升），这与肾上腺抑制一致，支持医源性皮质醇增多症的诊断。

The owner was advised to stop topical application of Wokazole Plus lotion. Multivitamin drops (Mulmin, Juggat Pharma; Bangalore, India) were prescribed for administration at a dose of 1 mL per os once daily (containing 1,000 IU vitamin A). After one month, regrowth of hair had begun and the vitamin supplement was continued for an additional month. At the end of the second month, hair regrowth was complete (Figure 3). Lipidosis of the aqueous humour had resolved completely and the animal recovered uneventfully.

建议主人停止外用Wokazole Plus乳液。使用复合维生素液，剂量为1 mL/os，每日一次 (含1000 iu维生素A)。一个月后，毛发开始再生，维生素补充剂又持续了一个月。在第二个月末，毛发完全再生(图3)。房水脂质沉积改善，动物顺利恢复。

Figure 3. Kitten with hypercortisolism after two months of treatment showing complete fur regrowth.

图3经过两个月的治疗后，患有皮质醇增多症的幼猫毛发完全再生。

Discussion  

讨论

Wokazole Plus lotion contains 0.025% w/v clobetasol, which is a super-potent class I corticosteroid. Application of this corticosteroid to large areas of the skin results in  sufficient systemic absorption to cause adrenal suppression and some degree of hypercortisolism in people. Infants, young children and those with an impaired cutaneous barrier are at greater risk for medically significant adrenal suppression.  

Wokazole Plus乳液含有0.025% w/v氯倍他索，这是一种超强效的I类皮质类固醇。在人上，皮肤大面积使用此类皮质类固醇导致充分全身吸收，从而引起肾上腺抑制和一定程度的皮质醇增多症。婴儿、幼儿和皮肤屏障受损的动物医源性肾上腺抑制表现风险更大。

Spontaneous hypercortisolism is a disease of middle aged to older cats; however, iatrogenic hypercortisolism due to application of topical glucocorticoids could be especially likely in kittens due to their small size and thin skin. This case exhibited a constellation of clinical signs consistent with hypercortisolaemia such as pendulous abdomen, hepatomegaly, lipidosis of aqueous humour, alopecia and skin atrophy. Although the animal was dull and lethargic, it maintained good appetite. Laboratory evaluation revealed a stress leucogram, hyperglycaemia and hypertriglyceridaemia. The serum alkaline phosphatase level was normal and there was mild elevation of serum alanine transferase. An ACTH stimulation test, which can distinguish between iatrogenic and naturally  occurring hypercortisolaemia, showed low cortisol values both pre- and post-stimulation. These clinico-patho logical findings are consistent with the description of  feline hypercortisolism.

自发性皮质醇增多症是中老年猫的一种疾病；然而，由于幼猫体型小、皮肤薄，外用糖皮质激素导致医源性皮质醇增多症的可能性更大。该病例表现出一系列与皮质醇增多症相一致的临床症状，如腹部下垂、肝脏肿大、房水脂质沉积、脱毛和皮肤萎缩。虽然这只动物精神沉郁、嗜睡，但它仍保持着良好的食欲。实验室评估显示有应激性白细胞相、高血糖和高甘油三酯血症。血清碱性磷酸酶水平正常，血清丙氨酸转移酶轻度升高。ACTH刺激试验可以区分医源性和自发生皮质醇增多症，显示刺激前后皮质醇值均较低。这些临床病理结果与猫皮质醇增多症的描述一致。

Retinoids have been reported to be useful in reversing the impaired wound healing that results from hypercortisolaemia, and feline skin fragility secondary to high levels of glucocorticoids may be treated with vitamin A @ 800 IU/kg once daily. In the present case, the kitten recovered completely with cessation of topical steroid therapy and the administration of multivitamin drops that  contain vitamin A as a supportive therapy.  

据报道，维甲酸类药物有助于逆转因皮质醇增多症导致的伤口不愈合，高水平糖皮质激素导致的猫皮肤虚弱，可服用维生素A@800 IU/kg每日一次。在本病例中，幼猫在停止外用类固醇治疗和服用含有维生素A的复合维生素液作为支持疗法后完全康复。

In conclusion, topical products containing high-potency glucocorticoids should be used with caution in cats, and especially in kittens. Pet owners should be warned about the potential for adverse effects from application of topical products which may otherwise be viewed as benign by the general public.

总之，在猫上使用含有高效糖皮质激素的外用产品时应谨慎，尤其是在幼猫上。应提醒宠物主人，使用外用产品可能会产生副作用，否则公众可能会认为这些产品是温和的。

王超

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