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FELINE- Chronic Bacterial Skin Infections in Cats

FELINE- Chronic Bacterial Skin Infections in Cats

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20TH ANNIVERSARYVol. 21, No. 12December 1999
Refereed Peer Review
FOCAL POINTKEY FACTS
5
Proper culture and biopsycollection procedures forcytologic and histopathologicexamination of samples arecritical to accurately identifythe causative agent in cats withchronic bacterial skin infections.
Chronic Bacterial SkinInfections in Cats
Texas A&M University 
Robert A. Kennis, DVM Alice M. Wolf, DVM
ABSTRACT:
Many chronic skin lesions appear similar clinically; thus it is important to recog-nize their differing cytologic and morphologic characteristics, culture requirements, andhistopathologic staining properties. Successful treatment depends on accurate identification ofthe causative organism using appropriate techniques for collecting and preparing samples foranalysis. Antibiotic therapy is best selected on the basis of sensitivity testing. Because resultsmay be unknown for several weeks, however, therapy with antibiotics that have a history ofsuccess against a specific organism should be initiated in the interim.
E
valuation of cats with chronic skin lesions and/or draining tracts that areunresponsive to routine therapy is a challenge. Diagnostic differentials forthese problems include unusual or fastidious bacteria, fungi, foreign bod-ies, parasites, neoplasia, claw regrowth following onychectomy, and immunolog-ic diseases (see Diagnostic Differentials for Chronic Draining Lesions in Cats).Signalment, history (including travel), response to previous medications, andphysical examination findings may help limit the list of possibilities. A logicalapproach to the diagnostic workup and some specialized techniques are neces-sary to confirm the diagnosis. This article reviews the important causes of drain-ing tracts and discusses the diagnostic procedures and therapeutic options forcats with chronic draining tracts caused by bacterial agents.
SIGNALMENT AND HISTORY
Because some disorders have a predilection for certain breeds or genders, sig-nalment alone may be helpful in limiting the diagnostic differentials. For exam-ple, pseudomycetoma has thus far been described only in Persians. Sporotri-chosis and cryptococcosis are predominant in male cats. Age may also beimportant because very young or very old immunocompromised cats with con-current illness may be at increased risk for bacterial and fungal infections.Because prior therapy or surgery can alter a lesions clinical appearance, clientsshould describe how lesions appeared when they first developed. An orderly ac-count of changes in the type, quantity, and color of exudation; presence or ab-sence of granules in the exudate; character of the odor; and distribution of thelesions must be obtained. Any previous treatment attempts should be assessed,including medications, dosages, length of therapy, and apparent response.Clients should be asked whether their cats are allowed outdoors. Some cats have
CE
s
An accurate list of potentialdiagnostic differentials shouldbe sent to the microbiologylaboratory along with thesamples to ensure that samplesare handled properly andappropriate stains are used tomaximize the reliability of cultureresults.
s
Biopsy specimens shouldbe examined with specialhistopathologic stains andsubmitted for macerated tissueculture to improve diagnosticaccuracy.
s
Aerobic, anaerobic, andfacultative anaerobic bacteriahave been recovered from felineabscesses.
s
Even with the best techniquesand intentions, a diagnosis maystill be based on response totherapy.
 
a propensity to fight with other cats, thereby increasingtheir risk for bite-wound abscesses and puncture in- juries or exposure to immunosuppressive viral diseases.The health status of other in-contact animals (and peo-ple) may help to define contagious or possibly zoonoticcauses. A thorough medical history allows clinicians tobetter define the list of potential diagnostic differentialsand limits the number of unnecessary tests.
PHYSICAL EXAMINATION
Because of the zoonotic potential of some of thecausative organisms (especially 
Sporothrix schenckii 
),protective gloves should be worn during the physicalexamination. In addition, palpation of a painful lesionmay cause a patient to become aggressive, so caution isadvised. Palpation of the regional and peripheral lymphnodes may help to better determine the extent of thedisease. Crusted lesions are often difficult to identify because of the amount of hair present; gentle palpationof the skin surface may help to discover such lesions.During palpation, a fluctuant pocket of fluid or exu-date may be identified
the lesion should not be rup-tured until it is time to collect the appropriatediagnostic specimens. Focal areas of alopeciamay also provide clues about the presence of re-solving or possibly very early lesions. Hair sur-rounding a puncture wound or necrotic tissuecan sometimes be easily removed because suchlesions disrupt the blood supply to the hair.
DIAGNOSTIC EVALUATION
 A methodic approach greatly aids in makinga diagnosis when higher-order bacteria are sus-pected (see Potential Diagnostic Procedures). A complete blood count, serum biochemistry profile, and urinalysis are helpful to identify systemic disorders (e.g., diabetes mellitus) thatmay predispose a cat to chronic infections.Testing for feline leukemia virus (FeLV) anti-gen and feline immunodeficiency virus (FIV)antibody is essential for any cat with a chronicdisease. A thyroid hormone assay (thyroxine)may be indicated in cats older than 4 years of age. The essential dermatologic database in-cludes aseptic collection of specimens for bacte-rial and fungal cultures; cytologic evaluation of scrapings, aspirates, or exudate from the le-sions; and histopathologic examination of bi-opsy tissue samples. Focal draining lesions may be examined radiographically for radiopaqueforeign bodies, tooth fragments, projectile for-eign bodies, and osteomyelitis. Fistulography using iodinated contrast material is often help-ful to define the source, direction, and extent of adraining tract. Electron microscopy of a tissue sample issometimes indicated when
L
-form bacteria are suspect-ed. Cytologic or histologic examination of aspirationand/or biopsy samples of regional draining lymphnodes can also aid diagnosis.Culture and biopsy collection procedures are bestperformed with the patient under general anesthesia.Microbiologic culture and susceptibility testing are thebasis for diagnosis in many cases. When possible, alloral and parenteral antibiotics should be discontinued 2to 3 days before culturing; this ensures that residual an-tibiotic in the tissue does not suppress bacterial growthin the cultured sample. A microtip culturette swab may be used to collect material from deep inside fistuloustracts; however, this method often provides insufficientorganisms for culture. Samples taken from open drain-ing tracts may be contaminated with secondary bacteri-al opportunists, which can confuse interpretation of culture results. Aseptically collected, deep biopsy sam-ples usually provide more accurate culture results.Specimens for cytologic examination should be ob-
Compendium 
December 199920TH ANNIVERSARYSmall Animal/Exotics
FOCAL ALOPECIA
s
SYSTEMIC DISORDERS
s
RADIOGRAPHY
Bacterial causes
s
Aerobic or facultativeanaerobic
Pasteurella 
Staphylococcus 
Streptococcus 
Nocardia 
Opportunistic
Mycobacterium 
Mycobacterium 
Streptomyces 
L
-Form bacteria
Mycoplasma 
s
Anaerobic
Fusobacterium 
Bacteroides 
Actinomyces 
Fungal causes
s
Sporothrix schenckii 
s
Cryptococcus neoformans 
s
Blastomyces dermatitidis 
s
Histoplasmosis capsulatum 
s
Coccidioides immitis 
s
Dermatophytosis 
s
Miscellaneous fungalinfections (molds)
s
Pythium insidiosum 
?
Miscellaneous causes
s
Foreign body
s
Joint disease
s
Dermoid sinus
s
Neoplasia (with or withouta bacterial component)
s
Immunologic (systemicillnesses)
s
Parasites (cuterebra,larval migrans)
s
Claw regrowth followingonychectomy
s
Panniculitis
s
Aseptic abscessation
Diagnostic Differentials forChronic Draining Lesions in Cats
 
tained after aseptic micro-biologic culture specimenshave been collected. Direct-impression samples, swab-collected samples, or im-prints from tissue collectedfor biopsy can be appliedto a clean glass slide. Slidesshould be heat-fixed beforestaining with a modified Wright
s stain. Gram
s stain-ing may help identify organ-isms in highly exudativesamples. In addition, fine-needle aspiration samplesshould be collected from re-gional lymph nodes, stained,and examined in a similarmanner.Primary lesions (e.g., pus-tules, vesicles) should be se-lected for biopsy if possible.The skin should not becleansed before collectinghistopathologic samples be-cause the skin surface may contain subtle but impor-tant changes. A 6-mm, full-thickness skin sampleshould be collected through any crust and exudate. Forlarger, deeper lesions or lesions in which the leadingmargin is important, surgical excisional biopsy may bemore appropriate. An elliptic incision made with thelong axis perpendicular to the leading edge of the lesionensures that the pathologist will process the tissue in astandardized format that will yield the most accurateresults. Several specimens should be submitted fromrepresentative lesions, including, if possible, early andlate stages of the disease process. Tissue imprints for cy-tologic evaluation should be made on clean glass slidesbefore the biopsy specimen is placed in formalin fixa-tive. It is important to include a history and differentialdiagnosis list for the pathologist to ensure that appro-priate stains are used.Macerated tissue culture is the preferred method forspecimens from patients with chronic, poorly respon-sive lesions. The maceration process involves mincingthe tissue before plating it onto appropriate agar. Bacte-rial colonies trapped in fibrous or granulomatous tissueand intracellular bacteria are more likely to be recov-ered by this method. Not all commercial veterinary lab-oratories are familiar with this procedure; thus it is im-portant to talk to the microbiologist before submittingsuch specimens.Specimens for maceratedtissue culture are collected af-ter histopathology sampleshave been obtained. The skinshould be gently cleansed with a topical disinfectant(e.g., povidone
iodine, chlor-hexidine gluconate); residualscrub is removed with 70%isopropyl alcohol, and theskin surface is allowed to airdry. This prevents disinfec-tant from being dispersedinto the tissue to be cultured. Appropriate sample sites in-clude intact skin over a fluc-tuant pocket, a primary lesion(e.g., a pustule), or chronicgranulomatous tissue. Thesample should be collected by surgical excision (deep le-sions) or punch biopsy (moresuperficial lesions); placed ina dry, sterile petri dish; andshipped on cold packs. Sterilesaline should not be added tothe samples because it en-courages overgrowth of surface contaminants and may lead to severe tissue autolysis. Vacutainers should not beused to ship samples because their sterility is not guaran-teed after the seal is broken. Samples for anaerobic cultureshould be submitted in appropriate anaerobic culturemedium or culturette tubes. Even in appropriate contain-ers, anaerobic bacteria are fragile and should be processedimmediately to prevent false-negative results. The micro-biology laboratory can provide additional informationabout its preferred specimen transport protocol.Swab-collected samples can be used for culture if sur-face contamination during sample collection is avoided.Surgical preparation of the intact skin followed by asmall stab incision or fine-needle aspiration usually yields an appropriate sample from a fluctuant pocket.This technique can also be used for intact pustules orvesicles; if a swab is merely inserted into the opening of a fistulous tract, culture results may be erroneous be-cause of contamination with surface bacteria. The like-lihood of obtaining accurate diagnostic microbiologicculture results is directly proportional to the quality of the sample collection techniques employed.
CAUSESRoutine Abscess
Subcutaneous abscesses are common in cats, and the
Small Animal/Exotics20TH ANNIVERSARY
Compendium 
December 1999
SURGICAL EXCISIONAL BIOPSY
s
MACERATED TISSUE CULTURE
s
ANAEROBIC CULTURE SAMPLES
s
Tests for feline leukemia virus and felineimmunodeficiency virus
s
Complete blood count
s
Serum chemistry profile
s
Urinalysis
s
Thyroid profile
s
Cytologic examination of exudate and tissue grains
Gram
s stain
Modified Wright
s stain
Fite
Faraco stain (acid-fast)
s
Fine-needle aspiration of regional lymph nodes
s
Aerobic, anaerobic, and fungal cultures
Swab-collected sample
Aseptically collected tissue sample (maceratedtissue culture)
Fine-needle aspiration of exudate from closedwounds
s
Biopsy and histopathology with special stains
Punch samples of superficial lesions
Surgical ellipse of deep lesions
Potential Diagnostic Procedures

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