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CONSIDER THIS CASE | Previous topical treatments included: UÊ iomÞVinÊÃÕlv>Ìi UÊ ÃovlÕ«Ài`oniÊ >ViÌ>ÌiÊ >n`Ê ÌiÌÀ>V>iniÊ hÞ`ÀoVhlo- ride (NeoPredef, pfizerah.com) UÊ Þ`ÀoVoÀÌiÃoniÊVÀi>m UÊ iVon>âoliÊniÌÀ>ÌiÊÓ¯Ê>n`ÊmiVon>âoliÉVhloÀhiÝi- `iniÊ }lÕVon>ÌiÊÓ¯Ê Ãh>m«ooÊ >l>ÃiLÊ Ãh>m«oo]Ê tevaanimalhealth.com). All medications had minimal effect. The best results were achieved after initial application of hydrocorti- sone cream. At presentation, the dog was receiving cephalexin and chlorpheniramine. PHYSICAL EXAMINATION The dog was extremely pruritic and rubbed his face on the carpet constantly. Additional clinical signs included: UÊ oÌhi>ÌinÊ>««i>À>nViÊh>iÀÊVo>Ì® UÊ lo«iVi>ÊÛinÌÀÕmÊ>n`Êhin`limLî UÊ ÀÞÌhim>]Ê VÀÕÃÌÃ]Ê >n`Ê h>iÀÊ `iÃVoloÀ>ÌionÊ inÌiÀ- digital areas) UÊ1lViÀ>ÌionÃ]Ê iÀÞÌhim>]Ê >n`Ê VÀÕÃÌÃÊ «>lm>ÀÊ >n`Ê plantar surfaces of interdigital areas) UÊ Þ«iÀkiÀ>ÌoÃiÃ]Ê ÕlViÀ>ÌionÃ]Ê >n`Ê viÃÃÕÀiÃÊ vooÌ- pads). The dog was alert and responsive to stimuli. Body condition score was 3.5/9. The dog was nonvisual and a prosthetic global implant was noted in the right eye (OD). Corneal scarring and a minimal menace response were noted in the left eye (OS). DIAGNOSIS Laboratory Analysis A CBC, serum biochemical profile, and urinalysis were submitted for in-house testing. The results of the CBC and urinalysis were unremarkable. The cytologist reported the presence of occasional target cells, which can be associated with liver disease. The serum biochemical profile revealed normal serum albumin, mild hyperglycemia, mild to moderate increase in alanine aminotransferase, marked increase in alkaline phosphatase, and a mild increase in total bilirubin (Table). The sample was also mildly lipemic with slight hemolysis. Table. Pertinent Results: Serum Biochemical Profile Variable Alanine aminotransferase (mg/dL) Alkaline phosphatase (mg/dL) Blood urea nitrogen (mg/dL) Glucose (mg/dL) Total bilirubin (mg/dL) Result Reference Interval 305 1263 11 181 1.2 10–90 11–140 8-24 75–125 0.2–0.6 Dermatologic Tests Dermatologic tests included deep skin scrapings, Wood’s lamp evaluation, and tape-preparation cytol- ogy stained with Diff Quik and Gram’s stain. The skin scrape provided no evidence to suggest demodicosis. The cutaneous cytology demonstrated gram-positive cocci with no evidence of yeast. The Wood’s lamp examination was negative, and the der- matophyte culture could not rule out dermatophytosis until complete. Differential Diagnoses Erythematous & Ulcerative Dermatoses of the Feet Atopy Bacterial pyoderma Demodicosis Dermatophytosis Drug reaction Erythema multiforme Food allergy Malassezia infection Mucocutaneous candidiasis Pemphigus foliaceus Systemic lupus erythematosus Toxic epidermal necrolysis Hyperkeratotic Footpads Bacterial or yeast dermatitis Cutaneous epitheliotropic lymphoma Demodicosis Dermatophytosis Drug eruption Generic food dermatosis Hepatocutaneous syndrome Pemphigus foliaceus Systemic lupus erythematosus Zinc-responsive dermatosis Diagnostic Imaging Radiography and abdominal ultrasound were indi- cated due to the elevated liver enzymes and bilirubin. The dog was discharged with cephalexin (22 mg/kg PO Q 12 H) and chlorpheniramine (4 mg PO Q 12 H) with instructions to return the following day for the imaging studies. Based on the results of imaging, an adrenocorticotropic hormone (ACTH)-stimulation test and/or skin biopsy of the feet were potential consid- erations. Radiography The next morning, the dog was sedated with butorph- >nolÊä°£Êm}Ék}Ê ®Ê>n`ÊÀ>`io}À>«hÃÊovÊÌhiÊ>L`ominÊ were taken. The radiographs showed irregularity in shape of the ventral margin of the liver and focal cau- dal displacement of the right aspect of the transverse colon (Figure 1, page 41). Ultrasonography 1lÌÀ>ÃoÕn`ÊovÊÌhiÊliÛiÀÊÃhoÜi`Ê>ÊÃiÛiÀilÞÊiÀÀi}Õl>ÀÊ shape with nodular, coarse parenchyma. Hypoechoic nodules ranging in size from 0.4 cm to 2.2 cm were seen diffusely in all liver lobes, which coalesced to form a reticular, “honeycomb” appearance. A well circumscribed mass (3.3 cm × 3 cm) with a normal hepatic echogenicity was found in the right liver (Figure 2, page 41). A small, hypoechoic nodule in the caudal cortex of the left kidney (6.5 mm × 4.2 mm) produced distal July/August 2011 Today’s Veterinary Practice 39 Hepatocutaneous Syndrome in a Shiba Inu