Friday, April 8, 2011

395. Do Skin Warts recur after excision? A case is reviewed 8 months later

Do Skin Warts recur after excision? A case is reviewed 8 months later
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 09 April, 2011


http://www.kongyuensing.com/folder5/20110330generalised-infected-warts-old-shih-tzu-singapore-toapayohvets.htm
has the pictures and updates.



April 8, 2011

"My uncle was so surprised and said: 'Your dog is so young and active," the wife said to me over the phone today when I asked what happened since 76 warts were excised by me 8 months ago. See: http://www.asiahomes.com/real_estate_tips/0816bluff.htm







"He is like a brand new dog a few days after the surgery. He behaved as if he was 6 years younger. Full of energy! It was not just my uncle who commented. Many friends were so surprised that my dog had become energised after the wart surgery!"

Today, the husband made an appointment specifically to consult me about the dog's right ear.

His first remark was that the 13-year-old male neutered Shih Tzu was a new dog after the warts were removed. I expected a half-dead lethargic old Shih Tzu but I was also surprised at the full coat and alertness.






The old Shih Tzu has been stressed by the painful eyes and right ear canal (filled with stinking pus) for at least 8 months. 10 viral skin warts came back and were frozen.

The couple will need to be diligent and educated to eliminate the stresses if his old companion is to live to a ripe old age in comfort and free from pain and itchiness. Follow up with the vet is advised after one month and subsequently.
The dog came in for a smelly right ear. I put a cotton bud and got a smear of dark brown pus at one end. The Shih Tzu winced in pain when the cotton bud touched the junction of the horizontal and vertical canal. He did not bite me. I smelt the brownish-yellow tip to check what type of bacteria or yeast infection it could be. This is not scientific as an ear discharge smear to check for yeast and bacteria would be done soon.

The smell was like some rotten flesh kept for some time. I asked my assistant and the owner to smell the tip as I waved it in front of their nose. The left ear was perfectly normal. "I ran out of your ear drops," the husband said.

There were 10 warts on the back spinal area (after I had the dog clipped bald. We thought it was 3 warts before clipping). 10/76 warts. Yet Vet 1 had told the owner: "The dog is old already. The warts are not serious. No point removing the warts. They will return back." I did say there is a possibility of recurrence too. The dog was 12 years old and a very high anaesthetic risk.

WHY DID THE OWNER SEEK A SECOND OPINION?
I asked the wife over the phone as Vet 1 had been their regular vet and they were a loyal client. "The dog was bleeding every day," the wife said. "A lot of blood. The dog was in pain. He was sleepy most of the day. I had to do something." In other words, the wife was very concerned and went into the internet to do research. Then the couple came to consult me.
WHAT DID I DO 8 MONTHS AGO?
Admitted: August 8, 2011, 2011, 9.3 kg, 38.1 C.
76 warts from head to toe literally.
R ear - rotten smelly skin. L eye - dry eye.



8 months ago, 76 warts were electro-excised under general anaesthesia
HIGH ANAESTHETIC RISK
It is not surprising that the family vet (Vet 1) did not want to perform surgery to excise the warts. He probably did not relish the blame and hassles if the old dog died on the operating table. So, over the 5- 6 years, the warts multiplied to number 76! The dog was lethargic most of the day. "What do you expect?" you would say. "He is an old dog!"

Anaesthesia & Surgery on Day 1 - August 11, 2011 and goes home on Day 2.
IV saline drip with Baytril 0.5 ml and Tolfedine 0.5 ml IV
Domitor 0.1 ml IV. Isoflurane gas maintenance. Electro-surgery. Excised 76 warts (a packet of warts given to the owner is still remembered).
2/0 absorbable stitches.
Baytril x 3 tablets, Trimethoprim and multivitamin for home.
The owner came 2 weeks later for antibiotics and no more news from the owner till today to consult about the smelly right ear. The wife was knowledgeable and had agreed that it was too risky to get the lateral ear canal resection surgery done. This surgery would have eliminated this recurring right ear infection (since 8 months ago, if you referred to my notes dated August 2010 (image below).

Procedures used to excise 76 warts
BLOOD TEST ON AUGUST 11, 2011
Liver enzymes high, urea high, creatinine low.
White Cell Count 19.8 (6-17)
Neutrophils 88% Abs 17.55
Lymphocytes 9.6% 1.90
Monocytes 1.1% 0.22
Eosinophils 0.71% 0.14
Basophils 0% 0
PCV, platelets, haemoglobin and RC etc - normal.

URINE TEST ON AUGUST 11, 2011
pH 6.5 (5-8)
SG 1.038 (1.005-1.030)
Protein trace
Blood negative
White blood cells 8
Bacteria Occasional
Crystal Calcium oxalate+

TODAY'S TREATMENT
Clipped bald. 10 warts. 2 most prominent between eyes and behind midline of eyes.
1. Right ear discharge sample. Stained exudate (fixative, air dry, S1, air dry, S2, air dry) to check for yeast and bacteria. Bacteria present. The owner had been giving his own ear drops for the past 8 months from some sources.

2. Irrigated the ear and bathed the dog after clipping the coat.

3. Froze 10 warts seen after clipping coat, 1 minute. Prominent one between eye. biggest cauliflower shaped at 4 mm x 4 mm. Others were much smaller appearing as small lumps under the skin. No need for sedative or anaesthesia.

PERFORMANCE COUNTS
This is a rare case of generalised warts in Singapore. The warts multiplied and spread over a period of 5-6 years. Why?
Food fed - home-cooked chicken and dog treats and canned Caesar. Sometimes diarrhoea, the wife said.
Given k/d canned and dry (last 2 months). Stools well formed and no diarrhoea.

OVERALL
Need to treat right ear infection and dry eyes if the dog is going to live longer with no pain and discomfort. Warts must be frozen when they are small. 10 very small warts were frozen without the need for anaesthetic and sedative as this dog was OK with the freezing. The biggest one was around 4mm x 5 mm between and above the eyes in the midline as shown below.


8 months ago. Under general anaesthesia and for around one hour, the 76 warts were excised by electro-surgery!
8 months later. The wart above and between the eye has recurred but was hidden by the hairs. Clipping exposed this wart. This was deep frozen.





Small warts <4mm x 4mm can be frozen and usually they will disappear 7-14 days later. Note that the large wart above the left ear (as in 8 months ago) has not recurred! So, the owner was happy with the outcome. But the war can be lost if one battle is won if the owner is not vigilant to get small warts excised.


PHONE ADVICE TO THE WIFE - REDUCE STRESS AS WARTS ARE SAID TO BE VIRAL AND GROW WHEN IMMUNE SYSTEM IS DONE.

A very busy working couple. I told them I do consult on Sundays and other days by appointment only. Fortunately, the dog's 10 warts discovered early - can be frozen. Only 10 small ones. The husband did not want a blood test as advised. Here are instructions given for this dog:

1. EYE CARE TO BE DONE DAILY (2 types of eye drops and Atopica) to prevent dog going blind with dry eyes 2 years later. Put dog on table. Teach mum how to do it if couple goes overseas for 2 weeks.

2. NO DIRECT WIPING OF EYEBALL by husband to clear pus around eyelids. Close the eyelids first after applying eye drops, I advised.

3. RIGHT EAR INFECTION MUST BE DILIGENTLY CONTROLLED AND FOLLOWED UP WITH THE VET. Rotten flesh smelly pus. Should be able to cure this one soon. Should review with the vet (me) 4 weeks later.

Warts do come back and can be frozen if detected early. Warts had caused pain and infection if left for several years (WCC high in Day 1). Owners are happy with the outcome. If the dog had died under anaesthesia, it would be bad for the vet. So, it is understandable that Vet 1 was reluctant to do surgery. Too many large warts, deep freezing is impractical.

A rare case in Singapore. Many older dogs have a few skin warts but this old Shih Tzu had 76 warts. The warts started with a few over the back area some 5 years ago, according to the wife. Then more and more appeared. The family vet would not want to excise them saying that the warts would come back again. So, no point removing them. The dog started rubbing his infected warts onto the floor and bloodied the apartment. "The Shih Tzu just could not stop scratching the large wart above his left ear. I have to do something," the wife checked the internet and contacted me.

What causes these warts? They are believed to be caused by papilloma viruses. Poor immune system in very young and old dogs lead to wart formation. What is the cure? Reduce the stresses.
PERFORMANCE counts in the veterinary practice. This case needs the owner to take care and follow up with the vet monthly or regularly. It had been 8 months since I saw the dog. I said diplomatically to the wife that an old dog needs more care than a young one and that stress due to pain and infection must be reduced considerably to prevent wart formation in old age. Also, good nutrition and no dry feed (urine crystals). The dog has a very good coat and skin and I presume k/d diet and some home-cooked food were sufficient.

RETROSPECTIVE REVIEW. In hindsight, I should have operated the dog after 24 hours as he was lethargic. Sometimes I want to save the owner some money by doing a same-day operation as in closed pyometra and urinary stone cases. It may not be wise to take such a risk as many dog owners never really forgive and never forget if the dog passes away on the operating table. Deaths of pets on the operating table are very highly emotional events even for the vet and his or her staff.

GET YOUR DOG WARTS EXCISED BY YOUR VET WHEN THE WARTS ARE SMALLER.
This case has a happy ending but owners are advised that skin warts in their dogs are best removed when they are few in number and are smaller. Happy endings are not always the case in high anaesthetic risky old and sick dogs with warts!
A YOUNG MAN WITH FOOT WARTS
Skin warts occur mainly in very young and old dogs as both groups have a much lower immune system. What about young people?

Do people get the cauliflower skin warts? I remember this young man in his early 20s in National Service. His shoes were damp from military training.

At first he had one and then more foot warts presented below his feet as he had to wear his boots for military service. Moe warts kept appearing on his hand as well. I can't remember how many he had. I advised him to see the doctor who made him an appointment with the surgeon as these warts seem to thrive and spread.

Like many young Singaporean males hooked onto the online gaming, he did not have sufficient rest. He would go online gaming till past 3 am every day.

He ate noodles most of the time. He saw the doctor who removed some warts. He reduced his online gaming of WOW II and other games. Slept more hours and earlier. I got him a freezing solution. He applied on the remaining two warts. Now he has no warts recurring. It seems that the warts are best excised early as they seem to spread to nearby skin areas. How he got the skin warts, I don't know. Now he has no warts at all and that is a relief for him as such warts can be quite painful.

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