Systemic lupus erythematosus (SLE)
Question: Dear Dr. Mike,
My dog is a German Shepherd, born June 3, 1998. My vet says his labs are suggestive of lupus. His ANA is 10,248. His platelet count is 62. His absolute polys are 10620. On protein electrophoresis, his total protein is 8.2, albumin is 2.3, Alpha 1 is 0.46, alpha 2 0.87, beta is 2.85, and gamma is 1.71. His Coombs Direct was negative. On his superchem/cbc (I don't believe this one - I'm a diabetic on an insulin pump for 9 years) his glucose is 6 (we're talking dead here - I'm basically unconscious at 35, but that's what the report says), total protein is 8.6, AST(SGOT) is 70, Phosphorous is 13.1, Cloride is 91, A/G is 8.5, globulin is 5.8, magnesium is 1.4. His absolute lymphs are 448, and I think everything else is normal. Urinalysis shows 30 mg/dl protein.
His symptoms are fever of 103-104 F for 4 weeks. Weight dropped from 85 to 67 pounds from April 1 to June 22. Lethargic. Poor balance. Legs look weak. Limps.
I am taking him to the University of Florida Vet school next week for more testing. He has a history of shifting lameness. My questions relate to a fight he had with a pit bull on April 1. His weight loss started after he had a fight resulting in about 30 or 35 stitches. Could the fight or the treatment have triggered something that looks like lupus? He was treated with Domitor/Torb - .80/.70 cc I.V. His wounds were flushed with dilute Nolvasan. I'm not sure what this means, but his record says 3-0 PDS for SI Closure of lacerations. He had Ceph 500 x 2 PO bid x 7 days. He seemed to recover fully in about 3 weeks, but by the end of May, he looked awful. The pit bull had some funny looking stuff on his nose that may have been discoid lupus. Could this have been "transplanted" into my dog in the fight resulting in SLE?
If it is lupus, what is the prognosis (in general, of course)? Does he have weeks? Years? It's only a $150 dog, but to my kids, its a million bucks or more. He is really sweet, and we are obviously concerened.
Thanks for any opinion you can give me.
Sam Mc and Family
I am hopeful that the veterinarians are the University of Florida were able to help your shepherd but it still seemed like it would be useful to answer some of your questions as well as I can, just in case.
The blood sugar level is probably low due to sample handling. Red blood cells continue to use the sugar in the serum for energy until they are separated from the blood (until it is centrifuged and the serum taken off). This often causes low glucose levels in serum that is not promptly separated. This can also affect potassium levels some but shouldn't affect most other chemistry tests and doesn't affect titers for any disorders that I know of.
German shepherds seem to be prone to systemic lupus erythematosus (SLE). The titer is pretty high so the probability of this disorder being present would also seem to be pretty high. The diagnosis of SLE is made based on the presence of clinical signs and the positive ANA test. In general, the diagnosis becomes more likely if at least one of the "major" signs of SLE are present, which include arthritis affecting more than one joint, kidney disease (glomerulonephritis), skin disease not from another cause, anemia with a positive Coomb's test and low platelet counts. If two of these major signs are present or if at least two "minor" signs are present then SLE is also likely. The minor signs include fever, pleuritis, heart muscle inflammation, muscular weakness and neurologic disorders.
Since your dog has low platelet counts, arthritis or muscular weakness affecting more than one leg, fever and poor balance, there are enough clinical signs to make SLE very likely.
SLE is not considered to be contagious. However, dogs with SLE may not show clinical signs until there is an initiating factor, such as a bacterial or viral infection, a drug reaction, cancer or some event that has a big impact on the immune system. So in this sense, the fight with the pit bull could have led to the clinical signs developing because an infection was possible and drug reactions to the medications used for treatment are possible initiating factors. In a few instances, these things create an immune reaction that really isn't lupus and that can be controlled by successfully managing the underlying problem, such as withdrawing the drug or controlling the infection. It would take some luck for that to be the case, though.
SLE has a variable prognosis. If there is an initiating factor and it can be controlled there is a good chance of regaining a state in which the disease is still present but it isn't causing much problem -- which was the situation prior to the recent problems, probably. There may be future relapses but they can often be controlled, too. If there isn't an obvious underlying cause the prognosis is not as good. In general, it is usually possible to control the disease for at least some time using immunosuppressive medications but eventually these usually lead to complications of their own and so dogs with SLE that must be constantly medicated tend to have shorter lifespans than dogs without this problem. It seems possible to keep dogs pretty comfortable during their lifetime in many cases, however.
It is good that you have the option of dealing with the veterinary school. It is often best to be working with a specialist in internal medicine when working with a disease such as SLE. Most general veterinary practices don't deal with this on a frequent basis so the veterinary school staff is very likely to have more experience with the condition.
I hope that things have improved since you wrote and I apologize again for the long delay in getting back to you.
Mike Richards, DVM 7/24/2001
Discoid lupus is an immune mediated skin disease that is probably related to systemic lupus erythematosus (SLE) but instead of affecting the whole body as SLE does, it primarily affects the nose and face. As far as I know, there is no known cause of this problem but it does seem more frequent in dogs of the German shepherd, collie, Brittany spaniel. Shetland sheepdog, Siberian husky and German shorthaired pointer breeds.
The disease normally starts as loss of pigment around the nose. There may be scabby sores or just scaling of the nasal tissue. The surface of the nose may change from its typical cobblestoned appearance to a smooth surface. As this disease progresses it can cause deep sores on the borders of the nose where it meets normal skin and the sores start to progress up the bridge of the nose. Some dogs seem to be really bothered by this condition and others show little reaction to the sores.
Ultraviolet light seems to make the sores worse, so the disease may appear to be seasonal. It is more common in areas in which exposure to ultraviolet light is increased, such as high altitudes. If the depigmentation leads to sunburn, squamous cell carcinoma becomes more likely than in other dogs. Topical sunscreens can be very beneficial, although it is hard to get dogs to leave them on. Keeping the dog in during the peak sunlight hours is probably the most effective way to prevent excessive exposure to UV light.
Treatment depends on the severity of the disease. In many cases, topical treatment will be all that is necessary, using a corticosteroid ointment (Panalog, Synalar and others). It is usually necessary to use a fairly potent corticosteroid. Vitamin E supplementation is sometimes beneficial but can take several months to show much effect. Severe cases require treatment with corticosteroids. It is possible that other immunosuppressive therapy such as gold salts or azathioprine (Immuran) could be beneficial but this is rarely necessary to consider. In people, this condition is often responsive to antimalarial medications but I do not know if this is safe or effective therapy for dogs.
Michael Richards, DVM
This is a rare disease of the immune system. In this disease, the immune system forms antibodies against the nuclear component of its own cells. This can cause a variety of effects but the most common ones are arthritis, kidney disease, skin disease and blood disorders (anemia and/or decreased in platelet numbers). A great number of other effects and side effects of this disease can occur so it is hard to rule in or rule out when faced with a multi-systemic disease. In general, this disease is not considered to be present unless testing to determine if antibodies against the nuclear elements of the cells are present (positive ANA test) AND clinical signs of at least two of the common disorders are present. Even then, it is hard to be sure that this disease is actually the problem. Some drug reactions and cancers can produce almost identical clinical signs and many problems produce some of the clinical signs. Treatment usually involves the use of immunosuppressive medications, most commonly corticosteroids such as prednisone. Often, a second immunosuppressive agent must also be used. Azathioprine, cyclophosphamide and cyclosporine are examples of these medications. Lupus is not curable but it is often possible for a dog to live with it successfully. Some of the disorders that resemble lupus are curable, especially if a cause can be identified. Continuous monitoring of patients suspected of having lupus should be part of the treatment, due to the possibility of another problem, the multitude of side effects that can occur and the potential for problems from the medications used to treat it.
Mike Richards, DVM
Question: My K-9 is a long haired male neutered G/S 6.5 years old 90 lbs. After seeing the dog the vet. suspected SLE, due to his platelet count being low and skin conditions. A battery of tests were conducted including ANA test, all have been normal. His platelets have been in and around the 150's. I have also noticed a slow down in his drive. All these things have transpired since June. The vet is confident he has SLE but is unsure how to proceed, should he treat it conservatively as SLE or not at all and monitor the dog. Some say because he is a working dog, and it is early in the diagnosis, treat him for SLE, he stands a better chance of continuing to work then. The other choice is to do nothing and see what develops. The bad thing about that is if he worsens he will be removed from service. Would the proper thing to do be to refer it to a Specialist to review. Wait a month and retest the blood? Start treatment conservatively? Is there a test that will clear this up? I know that I am not giving you much medically, but I believe the vet has made all the right moves. Any advice you can offer would be greatly apprieciated. My supervisors will be making a decision soon as to Deiter's future, I just want to help make the right one! Thank you! James-
Answer: Systemic lupus erythematosus (SLE) is very hard to diagnose with certainty.
The "major" signs of SLE are arthritis affecting multiple joints, without evidence of cartilage erosion, multiple painful muscles, skin sores with bullae (blisters), increased protein in the urine, immune-mediated hemolytic anemia (IMHA), decreased platelet numbers (thrombocytopenia) and decreased white blood cell count.
The "minor" signs of SLE are fevers for no apparent reason, oral ulcers, inflammation of the pleura (the lining of the chest cavity) or pericardium (lining around the heart), heart muscle inflammation, enlarged lymph nodes, dementia and seizures.
Most dogs with SLE will test positive on anti-nuclear antibody (ANA) testing. Even a weak positive ANA is considered significant in dogs. Not all dogs with SLE have positive ANA tests, though.
To make a diagnosis of SLE in dogs, the recommended criteria are: the presence of two major signs and a positive ANA test OR one major sign, two minor signs and a positive ANA test OR two major signs that aren't explained by another condition even if there isn't a positive ANA test.
German shepherds are prone to discoid lupus, which looks like SLE but is usually confined to the face, especially the area around the nose. Dogs with discoid lupus usually have negative ANA tests. They also get phemphigus, which is another immune mediated disease.
I don't think of platelet counts in the 150,000 range as being low but it is apparent from answering questions on line that many vets do.
Due to the significance of the diagnosis in a working dog, I do think that it is worthwhile to get the opinion of a specialist. In this case, it is probably acceptable to consider a board certified dermatologist or an internal medicine specialist.
Hope this helps some.
Mike Richards, DVM 9/15/2000
Question: Dear Dr. Richards,
I have had a biopsy done on my German Shepherd and found out that she does in fact have Discoid Lupus. My question now relates to treatment. The clinic I took her to told me that the pathologist said that my dog's case is very mild and in the very beginning stages so they suggested I go for the lowest type of treatment. I went by the clinic the other day and what they are telling me to give her is 4 capsules of Tetracycline 250 mg. each day (2 capsules 2 times a day) and also Vitamin E, Vitamin B and some fish oil capsules also twice a day. I have no problem with the vitamin supplements but I am concerned about giving her so many antibiotics for the rest of her life. I am not much for medications even for myself and I don't feel comfortable giving my dog so many pills each day. My question, therefore, is...Is it absolutely necessary for her to take the Tetracycline or are there other options. Can I just give her the vitamins and not the Tetracycline?
I would appreciate any advice or referral you can give me.
Thank you, Sheryl
It helps a lot when thinking of the use of tetracyline to think of it as an immune modulator with minimal side effects rather than an antibiotic. The effects it has on the immune system are probably why tetracycline can be helpful in cases of discoid lupus rather than its antibiotic effect. When compared to other drugs with immune system effects it is very unlikely to cause problems, except for causing vomiting in some patients.
Another medication sometimes used for discoid lupus is niacinamide. At the present time I think it is usually used at the same time as tetracycline, with both medications dosed at about 250mg (small dog) or 500mg (large dog) three times a day. It is also relatively unlikely to cause serious side effects, when compared to medications such as corticocsteroids but it also causes vomiting in a fair number of dogs.
Discoid lupus can often be treated with topical medications. A sunblocker can be helpful. You have to use a waterproof one and it should have an SPF of 30 or greater. Some dogs do better with oral supplementation of Vitamin E, usually 400 to 800 IU per day. Keeping affected dogs indoors helps a lot, too.
Topical application of a potent corticosteroid, like fluocinolone acetonide or betamethasone dipropionate applied twice daily will often control the symptoms of discoid lupus and is preferable to using oral or injectable corticosteroids.
It would really surprise me if the vitamins and fatty acid supplementation would work alone but it might, if you also use sunblock and try to avoid exposure to the sun, too. Topical corticosteroids work for many dogs and the combination of these things and tetracycline and niacinamide works for most dogs.
Mike Richards, DVM 7/14/2000
Q: Dr. Mike, I am almost positive my 1-year-old Alaskan Malamute dog has discoid lupus, and so is my vet. His symptoms, which include severe lesions on his nose and lips, point directly at this disorder. We did one lab test--it was negative. However, biopsies were taken only from the lips, not the nasal region, and the lab doctors were unable to come up with any kind of ironclad diagnosis (they found several bacterial infections, which I understand can be a secondary problem seen often with lupus), and suggested that a follow-up test be done with biopsies from both tissues for comparison. My vet also said that these tests can often be false-positive or false-negative.
For the time being, we are treating him with Panalog for his nasal and lip lesions, which become very bad if I go even a couple of days without using the Panalog. If he doesn't improve, which I'm sure he won't (he hasn't with antibiotic treatment in the last 6 months, why should he now?) we'll do another test, so I anticipate that a lupus diagnosis is impending. Another clue: his litter brother was diagnosed with SLE at the age of 4 months.
Providing that my dog is diagnosed with lupus, which my vet seems fairly certain he will be at some point, I have three questions:
How often does discoid lupus develop into SLE in dogs? I can find virtually no research on lupus in canines, and I am concerned that we could have a much more serious problem on our hands (and paws!) in the future. Is this something I should be concerned about?
Will it help to tattoo my dog's nose when he's healed enough to make that possible? I've read that vets often tattoo dogs' noses who have "collie nose", and that it protects the dog from ultraviolet light damage from the sun, easing his symptoms. Since lupus can make my dog more sensitive to sun exposure, is this a good option for someone like me?
Where can I get my hands on some veterinary research on the subject? Is any being done (read that published) currently? I'm desperate for more in-depth info.
Thank you very much.
A: I am under the impression that discoid lupus does not usually lead to systemic lupus erythematosus. I checked this out in several veterinary texts, including Rhea Morgan's "Textbook of Small Animal Medicine" and Nelson and Couto's "Essentials of Small Animal Internal Medicine" and Muller, Kirk and Scott's book "Small Animal Dermatology". They support that impression.
According to Dr. Nelson's text, systemic lupus usually has to have a positive ANA (anti-nuclear antibody) test AND at least two of the following problems may be considered positive for SLE: peripheral blood cytopenia, oligoarthritis or polyarthritis, glomerulonephritis, focal or multifocal central nervous system signs, dermatitis, polymyositis, myasthenia gravis or vasculitis.
If the above signs develop, ANA testing would obviously be a good idea.
Discoid lupus is a much more benign disease that does most commonly affect the nose and the area around it. It has to be distinguished from other conditions that affect this area, including phemphigus erythematosus, phemphigus foliaceous, drug eruption, bacterial folliculitis, ringworm, contact dermatitis, SLE, Vogt-Koyanagi-Harada-like syndrome and several other conditions.
Skin biopsies can be very helpful in distinguishing between these conditions.
Malamutes may have a predilection to the Vogt-Koyanagi-Harada-like syndrome and therefore, it has to be considered more carefully than some of the other differentials. This disease normally causes uveitis (inflammation of the eyes) as well as dermatologic signs. Most of the time, there is little visible skin disease other than pigment loss but some dogs with this condition do show the kinds of symptoms you describe (skin eruptions, etc.).
I couldn't find an answer to your question about tattooing for discoid lupus. This has been done for nasal solar dermatitis, which may be a variant of discoid lupus or might even be discoid lupus, so it seems possible that it might help. We have had good luck treating discoid lupus so we haven't resorted to this. I am not familiar enough with this personally to offer an opinion on how useful it might be.
The easiest way to find references is to get one of the books (your vet might have one or more of them) and copy down the literature references in them. They will give more literature references and eventually you have a good set --- but they are older references. I think that the University of Guelph, Canada and Cornell University have many of their library references online and you might be able to find them on the web.
Good luck with this.
Mike Richards, DVM (additional reply to the letter on SLE)-I do think it is possible to miss SLE early on and diagnose discoid lupus instead. It is good that the ANA test was negative.
peripheral blood cytopenia = general depression of all blood cells oligoarthritis, polyarthritis = arthritis in many, or all, joints glomerulonephritis = a kidney disease - increased drinking, urinating and weight loss central nervous system signs == anything that suggests nerve disease, such as loss of balance, walking in circles, etc. dermatitis = skin disease polymyositis = muscular pain in more than one muscle group vasculitis = inflammation of blood vessels (possible bruising, blood loss) (sorry -- I forgot about the technical nature of the terms)
I do not mind if people copy what I write and take it to their vet. Most vets will be OK about this, some will probably not be. There are differing opinions about much of what I cover in these messages -- and I am just stating mine.
Malamutes are also more prone to the Vogt-Koyanagi-Harada- like syndrome than other breeds.
I have not used Panalog or other topical corticosteroids with much success. I'd be pretty happy if it was enough to control this sort of condition. I have used Vitamin E (not a great deal of success but seemed to be helpful sometimes) and oral corticosteroids. We did have one dog that did pretty well just with zinc oxide on its nose -- it didn't lick it off nearly as fast as it seemed like it could have.
We have seen seasonal return of pigment in a couple of dogs but I am not certain we were actually treating discoid lupus in any of these patients because we did not confirm a diagnosis through biopsy.Mike Richards, DVM
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...