So this week I had occasion to go into the exam room to have a look at what may be the cutest poodle puppy in Alaska: sweet, charming, ingratiating, energetic and cuddly - and extremely itchy. Though seeing him for the first time myself, I was re-checking the pup, who had not responded to his initial course of treatment.
Here I must point out that when re-checking a patient that another doc has seen, I (and probably most other doctors) have the opportunity to look absolutely golden, a paragon of diagnostic genius, because I often hit on the diagnosis that the other doc missed. HOWEVER: It cannot be over-emphasised that I am benefiting from the information gathered by the other doc, AS WELL AS the information about how the other doc's first treatment did (or did not) work. This gives me a significant advantage, and when I present any of these triumphs, I ask you not to view them as accruing entirely to my own skills. Sometimes it's just luck (or a damned good hunch), although more often I attribute these successes to having the benefit of more information than the first doc had - after all, response (or the lack of it) to therapy is often quite informative.
At any rate, the pup did indeed have a distinct rash on his belly, for which he had (reasonably enough) been given antibiotics. The owner reported absolutely NO improvement on his itchiness - in fact, if anything, he was worse - which gave me the valuable information that his skin condition was almost certainly not as a consequence of bacterial infection. There's no question that bacterial infections itch, often quite horribly, but had it been that, the pup would have gotten at least a little bit better on antibiotics.
I picked up my patient, who responded by squirming up the front of me, snuggling under my chin and licking at my jaw, all the while making sweet little puppy noises, something between little soft grunts and warbles of delight. I managed after a moment to corral him enough to lay him on his back in my left arm, the better to use my right hand to sort through his silky, curly belly fur to examine his lesions. Even the light passage of my fingers over his skin is enough to make him kick his back feet reflexively, the way many a dog will thump a foot when being belly-scratched. He has dozens of tiny red bumps scattered about, and patchy scabbed areas here and there where he has gone after himself with his back feet. Meanwhile, despite his itchiness, he can't quite bring himself to desist in his efforts to lick every square inch of exposed skin in the room, and turns his head to leave delicate puppy kisses all over my wrist. Sweet little man.
"Hmmm," I tell the owner. "Maybe let's do a comb-through to look for mites, and a skin scrape wouldn't be a bad idea either. Let me get some stuff." I return the pup to his owner - where he snuggles happily into her embrace and smiles, panting happily, at both of us. I nip out and get some slides with mineral oil on them, a flea comb, and a scalpel blade. I comb through the soft ripples of the puppy's coat, depositing the resultant debris into the mineral oil on one of the slides, and then coat the edge of my scalpel blade in the oil from the other slide. Using the flat edge of the blade, I carefully scrape a few of the lesions on his belly. For skin scrapes you go deep and wide, so I don't stop until I see a faint flush of red on the skin. The puppy seems absolutely delighted that someone ELSE is scratching his itchy tummy for him, and makes no protest.
The slides go under the microscope. The first one shows hair and dander and a few flakes of scabby debris, but nothing diagnostic. The second one, however, is a gold mine. Amongst the scattered curls of shed epidermis and the red dots of blood cells, I find the source of all our problems: a scabies mite.
These are disgusting little things, fat round little beasts with their legs pointing forward beside their tiny heads, and long hairlike structures sticking out at points along the wide curves of their posteriors. They burrow under the surface of the skin, sucking blood from their hosts, and not coincidentally causing little red bumps all over and quite a bit of itchiness. Their burrowing habits make them notoriously difficult to find on a skin scrape, but if you find one there's no doubt about your diagnosis.
I wash my hands copiously - scabies is a zoonotic disease, which means it's transferable to people, and I am simultaneously imagining creepy little monsters industriously excavating their way under my epidermis, and wondering why no one else in the puppy's household is itchy. Given his marked cuddliness, he's had ample opportunity to pass his mites along to everyone he's been in contact with. I return to the room, parasite book in hand (open to the scabies page), and show the owner the culprit.
"He has scabies," I tell her. "This is what they look like; if you want, I'll show you the one on the slide so you can see it for yourself." The owner considers this for a moment; sometimes seeing them alive and in motion creeps people out, so I usually offer the still photo before I offer the live show, but this owner is curious. I take her out and center our mite under the objective, where the owner looks at it for a long moment, doing its slow-motion crawl through the viscous medium of the mineral oil. She makes suitable noises, impressed but disgusted, and we return to the room.
"Are there any other pets in the house?" I ask her, since all would need to be treated at the same time. No, just this puppy, who has been in the home for a month, and itchy the entire time.
"This is transmissible to people," I warn her. "Clothes provide some protection, of course, but you'll want to wash the dog's bedding and so on, and consult your MD if any person gets itchy. You might also want to mention this to your breeder, since it's likely that he came up here with it - not a guarantee, but a likelihood - and the pets and people in the household of origin may need to be treated too."
Her eyes pop open wide. "I just went to my doctor," she says. "He told me I was taking too much Tylenol and it was causing a rash. I didn't want to say anything," she confides in a lower voice, leaning forward in a slightly conspiratorial way, "but the rash itches like crazy! Do you think this could be the same thing?" She deposits her puppy on the table and pulls up the front of her turtleneck. Oh, my. I can't imagine how uncomfortable she's been. Her chest and abdomen are entirely covered in little red bumps. Covered.
"Well, I'm not allowed to diagnose people, so I won't guarantee it, but those certainly LOOK like scabies lesions," I tell her, forestalling her as she is about to pull down one of her bra cups to show me more lesions. "You need to check in with your MD about treatment; it won't do much good to treat the puppy if you don't get treated also."
"What do you mean?" she asks.
"Because you can give it back to him, pretty easily, in fact. The very first time I diagnosed scabies, a client came in with her cat and told me she thought the cat had scabies. Well, who comes in saying a thing like that?" I ask rhetorically. "So naturally I asked her why she thought that, and she said that SHE had had scabies - she was a hairdresser and had gotten it from a client - and she thought she'd given it to her cat. Turns out she was right. The cat had one tiny scab on her side, but I scraped it and lo and behold, I found my very first scabies mite. So we treated the cat and I told her to follow up with her MD to be sure they didn't just merry-go-round it back and forth between them. Same thing here. We'll treat your puppy with something that will last three to four weeks, but you need to get rid of it on you and any other itchy family member."
"It's pretty much just me, " the owner says. "He sleeps here," she adds, patting her bespeckled sternum. "In bed with me."
I go get a topical treatment of selamectin for the puppy, which we will follow up twice (in part because she's about to take the puppy to California with her for a few weeks, where he may have some heart worm exposure.) I apply the first dose to the puppy - the most difficult move of the exam, since holding still is NOT in this puppy's repertoire - and decant him back into this carrier (with some difficulty, since he has marked jack-in-the-box skills, and is inclined to pop out of the top of the carrier like a cork out of a champagne bottle).
"Go see your MD and tell him your puppy has scabies, and that you saw the mite with your own eyes," I admonish her. "Let him know we're treating the puppy, but you need to be treated at the same time. Oh, and I'd strip your bedding and launder it, too," I add.
"Great. My down comforter," the client says.
"Sorry!" I tell her, wincing. "I know it's a pain - but at least we have a diagnosis," I add, in a hopeful, cheery tone, trying to end things on an upbeat note. Immediately after which I go back and wash my hands again (twice), visions of scabies mites dancing in my head. Maybe I should wash them three times. Yeah. That's the ticket. Oh, crap, my pinkie itches. There's a red spot on it. A red itchy spot. Maybe washing four or five times would be better. Did I touch my head before I washed my hands? I hope not. Having mites burrowing in the thickets of my hair may not be the LAST thing I need, but it's definitely in the bottom ten.
It seems to be the week for creepy-crawlies, however. I was just in the fabric store when what should happen but that I run into another client of mine. She spies me and wades through the bolts of fabric to tell me cheerfully that her pet is feeling MUCH better, thanks so much - and so is she. It takes me a moment - I saw her a week ago - but then I recall that she had a dog that she suspected of having chyletiella, the "walking dandruff" mite and another zoonotic parasite. She suspected this in part because the dog had a prior history of it, and because she was herself covered in bites (which she pulled up her shirt to show me, without any greater hint of modesty than the scabies client had had. Oh, well; I AM a doctor, and a girl; I suspect they'd be more circumspect with a male doc, but for me it's no more than I see every week in the locker room.) This client also had some concern (fostered by her MD) that her rash might be secondary to some medication she was taking, but had been much more mite-suspicious than the other client, perhaps in part because we'd mentioned the zoonotic potential to her on the first go-round.
"Oh!" I tell the client. "I'm SO glad you're feeling better - both of you!" In truth I'm delighted to learn that I've alleviated not only the dogs' suffering but the owners' as well, although it's always uncomfortable for me to be treading on the edges of human diagnosis. Legally humans are the only species on earth that I'm not allowed to diagnose or treat, and I want to stay well clear of that line. On the other hand, it's entirely reasonable that I have more acquaintance with zoonoses than most MDs do. Comparative medicine is my stock in trade, besides which (and here put on your surprised faces) being a human myself and therefore subject to the risks of zoonoses on my own account, I'm a bit more conversant with them than your average MD has any need to be. Still, I try always to be very clear that I am NOT diagnosing the client, but offering a suggestion which they can take to their MD for follow-up. Some clients are darkly pleased that I've come up with an answer their own doc has missed, leading me to wonder if there's a bit of an adversarial relationship there, but perhaps it's just frustration on the part of the client. Lord knows I may have frustrated a client or two in my time, although I try hard not to.
Meanwhile although my pinkie bump is gone and no longer itchy, I'm obsessively suspicious of every itch and scratch my own dogs have essayed in the past three days. If they scratch more than twice I'm sorting through their coats microscopically, on the hunt for mobile dandruff. None of that - but is that a red bump....?