20TH ANNIVERSARY Vol. 21, No.

12 December 1999

CE Refereed Peer Review

Chronic Bacterial Skin

FOCAL POINT
★ Proper culture and biopsy
collection procedures for
cytologic and histopathologic
examination of samples are
critical to accurately identify
the causative agent in cats with
chronic bacterial skin infections.
KEY FACTS
■ An accurate list of potential
diagnostic differentials should
be sent to the microbiology
laboratory along with the
Infections 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, and
histopathologic staining properties. Successful treatment depends on accurate identification of
the causative organism using appropriate techniques for collecting and preparing samples for
analysis. Antibiotic therapy is best selected on the basis of sensitivity testing. Because results
may be unknown for several weeks, however, therapy with antibiotics that have a history of
success against a specific organism should be initiated in the interim.

E
valuation of cats with chronic skin lesions and/or draining tracts that are
samples to ensure that samples
unresponsive to routine therapy is a challenge. Diagnostic differentials for
are handled properly and
these problems include unusual or fastidious bacteria, fungi, foreign bod-
appropriate stains are used to
ies, parasites, neoplasia, claw regrowth following onychectomy, and immunolog-
maximize the reliability of culture
ic diseases (see Diagnostic Differentials for Chronic Draining Lesions in Cats).
results.
Signalment, history (including travel), response to previous medications, and
physical examination findings may help limit the list of possibilities. A logical
■ Biopsy specimens should
approach to the diagnostic workup and some specialized techniques are neces-
be examined with special
sary to confirm the diagnosis. This article reviews the important causes of drain-
histopathologic stains and
ing tracts and discusses the diagnostic procedures and therapeutic options for
submitted for macerated tissue
cats with chronic draining tracts caused by bacterial agents.
culture to improve diagnostic
accuracy.
SIGNALMENT AND HISTORY
Because some disorders have a predilection for certain breeds or genders, sig-
■ Aerobic, anaerobic, and
nalment alone may be helpful in limiting the diagnostic differentials. For exam-
facultative anaerobic bacteria
ple, pseudomycetoma has thus far been described only in Persians. Sporotri-
have been recovered from feline
chosis and cryptococcosis are predominant in male cats. Age may also be
abscesses.
important because very young or very old immunocompromised cats with con-
current illness may be at increased risk for bacterial and fungal infections.
■ Even with the best techniques
Because prior therapy or surgery can alter a lesion’s clinical appearance, clients
and intentions, a diagnosis may
should describe how lesions appeared when they first developed. An orderly ac-
still be based on response to
count of changes in the type, quantity, and color of exudation; presence or ab-
therapy.
sence of granules in the exudate; character of the odor; and distribution of the
lesions 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
Compendium December 1999 20TH ANNIVERSARY Small Animal/Exotics

tured until it is time to collect the appropriate

Diagnostic Differentials for diagnostic specimens. Focal areas of alopecia
Chronic Draining Lesions in Cats may also provide clues about the presence of re-
solving or possibly very early lesions. Hair sur-
Bacterial causes ■ Histoplasmosis rounding a puncture wound or necrotic tissue
■ Aerobic or facultative capsulatum can sometimes be easily removed because such
anaerobic ■ Coccidioides immitis lesions disrupt the blood supply to the hair.
—Pasteurella ■ Dermatophytosis
DIAGNOSTIC EVALUATION
—Staphylococcus ■ Miscellaneous fungal
A methodic approach greatly aids in making
—Streptococcus infections (molds) a diagnosis when higher-order bacteria are sus-
—Nocardia ■ Pythium insidiosum? pected (see Potential Diagnostic Procedures). A
—Opportunistic complete blood count, serum biochemistry
Mycobacterium Miscellaneous causes profile, and urinalysis are helpful to identify
—Mycobacterium ■ Foreign body systemic disorders (e.g., diabetes mellitus) that
may predispose a cat to chronic infections.
—Streptomyces ■ Joint disease
Testing for feline leukemia virus (FeLV) anti-
—L-Form bacteria ■ Dermoid sinus gen and feline immunodeficiency virus (FIV)
—Mycoplasma ■ Neoplasia (with or without antibody is essential for any cat with a chronic
■ Anaerobic a bacterial component) disease. A thyroid hormone assay (thyroxine)
—Fusobacterium ■ Immunologic (systemic may be indicated in cats older than 4 years of
—Bacteroides illnesses) age. The essential dermatologic database in-
cludes aseptic collection of specimens for bacte-
—Actinomyces ■ Parasites (cuterebra,
rial and fungal cultures; cytologic evaluation of
larval migrans) scrapings, aspirates, or exudate from the le-
Fungal causes ■ Claw regrowth following sions; and histopathologic examination of bi-
■ Sporothrix schenckii onychectomy opsy tissue samples. Focal draining lesions may
■ Cryptococcus neoformans ■ Panniculitis be examined radiographically for radiopaque
■ Blastomyces dermatitidis ■ Aseptic abscessation foreign bodies, tooth fragments, projectile for-
eign bodies, and osteomyelitis. Fistulography
using iodinated contrast material is often help-
a propensity to fight with other cats, thereby increasing ful to define the source, direction, and extent of a
their risk for bite-wound abscesses and puncture in- draining tract. Electron microscopy of a tissue sample is
juries or exposure to immunosuppressive viral diseases. sometimes indicated when L-form bacteria are suspect-
The health status of other in-contact animals (and peo- ed. Cytologic or histologic examination of aspiration
ple) may help to define contagious or possibly zoonotic and/or biopsy samples of regional draining lymph
causes. A thorough medical history allows clinicians to nodes can also aid diagnosis.
better define the list of potential diagnostic differentials Culture and biopsy collection procedures are best
and limits the number of unnecessary tests. performed with the patient under general anesthesia.
Microbiologic culture and susceptibility testing are the
PHYSICAL EXAMINATION basis for diagnosis in many cases. When possible, all
Because of the zoonotic potential of some of the oral and parenteral antibiotics should be discontinued 2
causative organisms (especially Sporothrix schenckii), to 3 days before culturing; this ensures that residual an-
protective gloves should be worn during the physical tibiotic in the tissue does not suppress bacterial growth
examination. In addition, palpation of a painful lesion in the cultured sample. A microtip culturette swab may
may cause a patient to become aggressive, so caution is be used to collect material from deep inside fistulous
advised. Palpation of the regional and peripheral lymph tracts; however, this method often provides insufficient
nodes may help to better determine the extent of the organisms for culture. Samples taken from open drain-
disease. Crusted lesions are often difficult to identify ing tracts may be contaminated with secondary bacteri-
because of the amount of hair present; gentle palpation al opportunists, which can confuse interpretation of
of the skin surface may help to discover such lesions. culture results. Aseptically collected, deep biopsy sam-
During palpation, a fluctuant pocket of fluid or exu- ples usually provide more accurate culture results.
date may be identified—the lesion should not be rup- Specimens for cytologic examination should be ob-

FOCAL ALOPECIA ■ SYSTEMIC DISORDERS ■ RADIOGRAPHY

Small Animal/Exotics 20TH ANNIVERSARY Compendium December 1999

tained after aseptic micro- Specimens for macerated

Potential Diagnostic Procedures
biologic culture specimens tissue culture are collected af-
have been collected. Direct- ■ Tests for feline leukemia virus and feline ter histopathology samples
impression samples, swab- immunodeficiency virus have been obtained. The skin
collected samples, or im- ■ Complete blood count should be gently cleansed
prints from tissue collected with a topical disinfectant
■ Serum chemistry profile
for biopsy can be applied (e.g., povidone–iodine, chlor-
to a clean glass slide. Slides ■ Urinalysis hexidine gluconate); residual
should be heat-fixed before ■ Thyroid profile scrub is removed with 70%
staining with a modified ■ Cytologic examination of exudate and tissue grains isopropyl alcohol, and the
Wright’s stain. Gram’s stain- —Gram’s stain skin surface is allowed to air
ing may help identify organ- —Modified Wright’s stain dry. This prevents disinfec-
isms in highly exudative tant from being dispersed
—Fite–Faraco stain (acid-fast)
samples. In addition, fine- into the tissue to be cultured.
needle aspiration samples ■ Fine-needle aspiration of regional lymph nodes Appropriate sample sites in-
should be collected from re- ■ Aerobic, anaerobic, and fungal cultures clude intact skin over a fluc-
gional lymph nodes, stained, —Swab-collected sample tuant pocket, a primary lesion
and examined in a similar —Aseptically collected tissue sample (macerated (e.g., a pustule), or chronic
manner. tissue culture) granulomatous tissue. The
Primary lesions (e.g., pus- sample should be collected by
—Fine-needle aspiration of exudate from closed
tules, vesicles) should be se- surgical excision (deep le-
lected for biopsy if possible. wounds sions) or punch biopsy (more
The skin should not be ■ Biopsy and histopathology with special stains superficial lesions); placed in
cleansed before collecting —Punch samples of superficial lesions a dry, sterile petri dish; and
histopathologic samples be- —Surgical ellipse of deep lesions shipped on cold packs. Sterile
cause the skin surface may saline should not be added to
contain subtle but impor- the samples because it en-
tant changes. A 6-mm, full-thickness skin sample courages overgrowth of surface contaminants and may
should be collected through any crust and exudate. For lead to severe tissue autolysis. Vacutainers should not be
larger, deeper lesions or lesions in which the leading used to ship samples because their sterility is not guaran-
margin is important, surgical excisional biopsy may be teed after the seal is broken. Samples for anaerobic culture
more appropriate. An elliptic incision made with the should be submitted in appropriate anaerobic culture
long axis perpendicular to the leading edge of the lesion medium or culturette tubes. Even in appropriate contain-
ensures that the pathologist will process the tissue in a ers, anaerobic bacteria are fragile and should be processed
standardized format that will yield the most accurate immediately to prevent false-negative results. The micro-
results. Several specimens should be submitted from biology laboratory can provide additional information
representative lesions, including, if possible, early and about its preferred specimen transport protocol.
late stages of the disease process. Tissue imprints for cy- Swab-collected samples can be used for culture if sur-
tologic evaluation should be made on clean glass slides face contamination during sample collection is avoided.
before the biopsy specimen is placed in formalin fixa- Surgical preparation of the intact skin followed by a
tive. It is important to include a history and differential small stab incision or fine-needle aspiration usually
diagnosis list for the pathologist to ensure that appro- yields an appropriate sample from a fluctuant pocket.
priate stains are used. This technique can also be used for intact pustules or
Macerated tissue culture is the preferred method for vesicles; if a swab is merely inserted into the opening of
specimens from patients with chronic, poorly respon- a fistulous tract, culture results may be erroneous be-
sive lesions. The maceration process involves mincing cause of contamination with surface bacteria. The like-
the tissue before plating it onto appropriate agar. Bacte- lihood of obtaining accurate diagnostic microbiologic
rial colonies trapped in fibrous or granulomatous tissue culture results is directly proportional to the quality of
and intracellular bacteria are more likely to be recov- the sample collection techniques employed.
ered by this method. Not all commercial veterinary lab-
oratories are familiar with this procedure; thus it is im- CAUSES
portant to talk to the microbiologist before submitting Routine Abscess
such specimens. Subcutaneous abscesses are common in cats, and the

SURGICAL EXCISIONAL BIOPSY ■ MACERATED TISSUE CULTURE ■ ANAEROBIC CULTURE SAMPLES

Compendium December 1999 20TH ANNIVERSARY
treatment of routine bite-
wound abscesses is fairly
straightforward and reward-
ing. Bacteria are often inocu-
lated through the skin via
bite or claw wounds or for-
eign bodies. Because cat skin
is very elastic, these puncture
wounds seal over rapidly and
abscessation occurs in 2 to 4
days. Aerobic, anaerobic, and
facultative anaerobic bacteria
have been recovered from fe- Figure 1—An adult cat exhibiting ulcerative to necrotic der- granules, often referred to as
line abscesses. In a recent matitis. These lesions are not pathognomonic for any of the sulfur granules, that are com-
study of flora isolated from etiologic agents discussed in the text. Nocardia was cultured posed of colonies of the or-
feline cutaneous abscesses, from a biopsy sample.
9.7% of the cultured speci-
mens contained only obligate anaerobes, with Fusobac-
terium species and Bacteroides species isolated most fre-
quently.1 Approximately 16% of the cultures contained
1
both obligate and facultative anaerobic bacteria. Other
frequently isolated organisms include Pasteurella multoci-
da, Peptococcus species, Clostridium species, Staphylococcus
species, and Streptococcus species.1,2
Therapy for feline subcutaneous abscesses usually
consists of surgical debridement to establish ventral
drainage and copious lavage with saline or dilute
(0.15%) chlorhexidine solution.3 Broad-spectrum an-
tibiotics that are effective against anaerobic bacteria are
good choices for empiric therapy.1 Because most anaer-
obic infections are polymicrobial, response to treatment
with antibiotics directed against the anaerobic compo-
nent is often equal to or better than that with combina-
tion antibiotic treatment. Treatment with penicillin or
amoxicillin for 7 to 14 days is usually adequate. If peni-
cillin resistance is suspected or cytologic examination
reveals many gram-positive cocci, amoxicillin–clavulan-
ic acid may be an effective alternative.2 Other antibi-
otics that have been used successfully to treat anaerobic
infections include metronidazole, clindamycin, and ce-
foxitin.
Nocardiosis
Recurrent or nonhealing abscesses should prompt
concern about the presence of immunosuppressive dis-
eases (e.g., FIV, FeLV) or unusual infectious agents. No-
cardia organisms are soil-borne, aerobic, branching, fil-
amentous, gram-positive bacteria.4–7 A differentiating
staining characteristic is the propensity for this organ-
ism to be partially acid-fast.8 Nocardia organisms are
saprophytic and can enter the body through soil inocu-
lation of wounds or by inhalation or ingestion.5,7,9 No-
cardia asteroides is the species most commonly isolated
ACID-FASTNESS ■ LYMPHADENOPATHY ■ SULFUR GRANULES
Small Animal/Exotics
from canine and feline cuta-
neous lesions.5,9,10
The clinical findings asso-
ciated with Nocardia infection
are not unique and include
abscessation with fistulous
tracts, cellulitis, nodular der-
matitis, or multifocal ulcera-
tions5,9 (Figure 1). Localized
regional lymphadenopathy
may also be present.9 The ex-
udate may contain yellowish
ganism.4,9 These granules can
be gently crushed between
two glass slides and stained with Gram’s stain and mod-
ified Fite–Faraco stain (acid-fast) to provide a tentative
diagnosis of nocardiosis.7 Histopathology may be help-
ful, although Nocardia organisms are often difficult to
identify even with special staining techniques.
Aerobic swab samples of the exudate and any obvious
granules should be submitted for microbiologic cul-
ture.5 Anaerobic specimens should also be submitted
because infections with Actinomyces species and other
resistant anaerobic bacteria are important diagnostic
differentials for lesions of this type. Macerated tissue
cultures can be more productive than swab specimens
in recovering Nocardia from these patients.4 Nocardia
grows well on blood agar and Sabouraud dextrose agar.7
Löwenstein-Jensen agar (used to detect Mycobacterium
species) may be used to isolate Nocardia when other
culture samples are negative.
Nocardia species show variable antimicrobial sus-
ceptibility patterns. Apparent in vitro susceptibility and
actual in vivo efficacy do not always correlate well for
humans with Nocardia infections4,7,11; thus empiric an-
tibiotic selection is usually made for cats with nocardio-
sis. Potentiated sulfa drugs have long been considered
the treatment of choice, and enrofloxacin, amoxi-
cillin–clavulanic acid, minocycline, chloramphenicol,
erythromycin, imipenem, clarithromycin, amikacin,
and combinations thereof have also reportedly been
successful in treating nocardiosis5–7,9–12; however, many
of the Nocardia isolates from our recent patients have
shown clinical resistance to most of these drugs. In sev-
eral cases, rapid resolution of lesions was achieved with
parenteral amikacin therapy after extended treatment
with several different oral antibiotics had failed.
Oral antimicrobial therapy should be continued for
at least 1 month after complete clinical remission has
been achieved. If amikacin is used for a prolonged
Small Animal/Exotics 20TH ANNIVERSARY Compendium December 1999

course of therapy, careful monitoring cause deep-seated infections are com-

of renal function is necessary and mon. The prognosis for patients with
treatment after resolution of lesions actinomycosis is guarded. Even with
should continue only for an addi- appropriate treatment, relapses are
tional 2 weeks. Serum urea nitrogen common and some patients may re-
and creatinine levels should be check- quire continuous, lifelong antibiotic
ed at least once weekly during ami- therapy to control lesions.8
kacin therapy. Urinalyses (collected
by cystocentesis) are also warranted Streptomycosis
to detect changes in specific gravity Streptomyces griseus is a gram-posi-
and check for casts. Because antibiot- tive, filamentous, aerobic bacterium
ic susceptibility patterns of Nocardia that has rarely been isolated from
species are variable, prognosis is cats.14 The clinical appearance of le-
guarded.7 sions is similar to that of Nocardia or
Actinomyces lesions, except that any
Actinomycosis granules are black rather than yellow.
Actinomyces species are anaerobic, Identification of the organism in cul-
gram-positive, branching, filamen- ture is the key to diagnosis, and ap-
tous bacteria found in the oral cavity propriate antibiotic therapy is based
of animals. Infection with Actino- Figure 2—Caudal view of an adult cat’s on the results of susceptibility testing.
myces hordeovulneris commonly oc- hindlimb. Hemorrhagic to necrotic papu-
curs in association with traumatic lar lesions with draining tracts are visible. Mycobacterium Infections
injury in which plant awns (e.g., fox- A diagnosis of Nocardia infection was Opportunistic Mycobacterium
tails) disrupt mucosal barriers.13 Soli- made on biopsy culture, whereas multiple Opportunistic mycobacterial gran-
tary or multiple abscesses with drain- swab cultures were negative. Similar le- ulomas (atypical mycobacteria) can
ing tracts may be present and cannot sions can be seen with opportunistic My- be caused by a number of Mycobac-
cobacterium infections.
be distinguished from other causes terium species, including fortuitum,
8
by clinical appearance alone. Similar smegmatis, chelonei, xenopi, thermore-
to Nocardia infection, granules can sometimes be iden- sistible, phlei, vaccae, and ulcerans.15–21 These facultative
4,8
tified in the serosanguineous exudate. Diagnosis is pathogens are ubiquitous in the environment. Although
confirmed by identification of Actinomyces species in the method of inoculation into the skin and subcuta-
anaerobic culture. A large quantity of exudate and neous tissue is unknown, the most likely routes are trauma,
granules (3 ml, if possible) should be submitted because foreign-body penetration, and fight wounds.21 Oppor-
isolation of these organisms can be difficult. Samples of tunistic mycobacteria most commonly cause chronic,
tissue for macerated culture are also helpful. Bacterial nonhealing, granulomatous panniculitis with a fistulous,
culture plates should be held for longer than usual be- exudative reaction of the skin and deeper tissues.18 The
cause growth of Actinomyces may take 2 to 4 weeks. Histo- lesions often target the inguinal region and hindquarters
pathologic examination may be suggestive of actinomy- of cats.15,17,18 Nodules and deeper draining tracts may or
cosis, but other causes of chronic dermatitis that may may not be present. M. smegmatis infection sometimes
be difficult to isolate by microbial culture (e.g., fungi, produces multifocal areas of necrosis that leave small ul-
Mycobacterium) should be eliminated. The presence of cerations in the skin surface (Figure 2). Lesions consis-
acid-fastness may distinguish Nocardia species from tent with opportunistic mycobacteria are not unique
Actinomyces species—the latter are never acid-fast.5,8 compared with the bacterial infections discussed previ-
Treatment of actinomycosis usually involves surgical ously, except that tissue grains do not form. Although
debridement and debulking prior to antibiotic therapy.8 regional lymphadenopathy can occur, clinical signs of
A careful search should be made for plant awns if a pa- systemic illness are generally absent and disseminated
tient resides in or has traveled to regions in which they disease is uncommon.15,18
are found. Penicillin drugs are the empiric treatment of The patient’s history usually reveals a poor response
choice, although other drugs may be indicated based to antibacterial therapy or spontaneous waxing and
on sensitivity testing.4,5,8 Amoxicillin, minocycline, ery- waning of lesions. Attempts to surgically excise oppor-
thromycin, and clindamycin are reasonable alternatives. tunistic mycobacterial lesions usually fail22; suture lines
Antimicrobial treatment should continue for at least 1 often dehisce, and infection recurs at and around the
month after complete clinical remission is achieved be- surgical site. Preliminary research has suggested that

AMIKACIN THERAPY ■ PLANT AWNS ■ SURGICAL DEBRIDEMENT AND DEBULKING

Compendium December 1999 20TH ANNIVERSARY Small Animal/Exotics

very aggressive debulking in disease, the prognosis for pa-

conjunction with appropriate
antibiotic therapy may be cura-
tive.23 However, antibiotic ther-
apy alone may be successful
and is much less disfiguring.
Diagnosing opportunistic my-
cobacteriosis can be challenging
because these organisms may be
difficult to find in affected tis-
sues. Histopathologic examina-
tion reveals pyogranulomatous
inflammation. Such special Figure 3—Multifocal to coalescing ulcerative lesions with cats. 15 These infections are
stains as Fite–Faraco (acid-fast) minimal exudation. A diagnosis can best be made with apparently acquired through
may reveal a few organisms in fat surgical debridement and macerated tissue culture.
vacuoles of the panniculus, but
definitive diagnosis is based on bacterial culture.17,18 Be-
cause these organisms are deep within the skin, aseptically
collected biopsy samples submitted for macerated tissue
culture are most likely to produce positive results (Figure
3). Opportunistic mycobacteria can grow on blood agar,
but less fastidious organisms may overgrow the plates and
obscure the diagnosis. Such culture media as Löwenstein-
Jensen should be used when an atypical mycobacterium is
suspected. Colonies of opportunistic mycobacterial species
usually appear in culture in approximately 7 days, much
faster than what is seen with Mycobacterium avium or clas-
17
sic tuberculosis-causing species. Cultures should be re-
tained, however, because growth of some opportunistic
8,18
Mycobacterium species may not occur for 3 to 4 weeks.
In vitro mycobacterial susceptibility testing can be per-
formed by some specialized laboratories and is recom-
mended where available. However, the results of these tests
may take several weeks and treatment should not be de-
layed in the interim. Because therapy may last several
months, the best drug should be selected first. We and
others have had success using fluorinated quinolone an-
tibiotics at higher-than-labeled dosages (enrofloxacin, 5 to
10 mg/kg orally twice daily) until 1 month beyond clinical
remission.18,22 Treatment with clofazimine (Lamprene®,
Novartis, East Hanover, NJ) has also been successful in
several patients that were not responsive to other
agents20,24; this product is not approved for use in cats and
temporarily (i.e., until medication is discontinued) stains
tissue orange–yellow during treatment. Hepatopathy,
corneal pigmentation, gastrointestinal distress, pruritus, seb- may take 6 weeks or longer.24 Intradermal testing for a
orrhea sicca, and systemic illness have also been associated
with clofazimine use.8,20 Azithromycin, amikacin, and
21
doxycycline have been used with occasional success. Crit-
ical evaluation of the success rates with different therapeu-
tic protocols is difficult because spontaneous remission has
16
also been reported. Because of the variable antibiotic sus-
ceptibility and chronic waxing and waning nature of the
tients with opportunistic my-
cobacterial infection is general-
ly guarded.
Cutaneous
Mycobacteriosis
(“Classic Tuberculosis”)
Mycobacterium bovis, My-
cobacterium tuberculosis, or
Mycobacterium microti can
cause classic tuberculosis in
contact with infected small-
mammal prey. M. avium, an-
other slow-growing mycobacterial pathogen, is consid-
ered a soil saprophyte.15,25 Siamese cats appear to be
predisposed to M. avium infection.15,18,19,25
Clinical signs in cats with classic tuberculosis are
highly variable. Abscesses, soft nodules, plaques, or ul-
cerations with exudation have been reported.15 These
lesions most often occur on the face, head, neck, shoul-
ders, distal limbs, or other common sites of bite
wounds.15,24 Most patients have systemic signs of illness,
including anorexia, fever, lymphadenopathy, anemia,
and icterus. 15,18,19,25,26 Radiographs may reveal hep-
atomegaly or splenomegaly, abdominal masses, or lung
involvement15,18—findings that may be helpful in dif-
ferentiating classic tuberculosis from opportunistic my-
cobacterium or feline leprosy. There have been only
two reported cases of M. microti infection to date, and
both patients had pneumonia.15
Confirming a diagnosis of tuberculosis can be diffi-
cult because few organisms may be present in the le-
sions. Histopathology may identify intracellular, acid-
fast, rod-shaped bacteria within a granulomatous tissue
reaction in the dermis or subcutis.27 Aerobic swab cul-
tures from exudate and biopsy tissue samples of skin
and lymph node(s) should be submitted for culture.
These organisms require a special culture medium that
is high in lipid content, such as Ogawa egg-yolk medi-
um, Stonebrink’s medium, or Löwenstein-Jensen agar.
Growth of classic tuberculosis organisms in culture can
be exceedingly slow, and identification of the organism
delayed hypersensitivity reaction has not been success-
ful in diagnosing cats with tuberculosis.15 Polymerase
chain reaction techniques have been developed to iden-
tify the DNA of tuberculosis-causing organisms in the
skin of dogs and humans,28 but no reports have been pub-
lished on the accuracy of this procedure for cats. Inocu-
lation of organisms from tuberculosis cultures in guinea

PYOGRANULOMATOUS INFLAMMATION ■ IN VITRO MYCOBACTERIAL SUSCEPTIBILITY ■ CLOFAZIMINE

Small Animal/Exotics 20TH ANNIVERSARY Compendium December 1999

pigs results in death in 6 to remission. Spontaneous re-

8 weeks.
Therapy for M. bovis or M.
tuberculosis infection can be
attempted with combination
therapy protocols that include
rifampin, isoniazid, and etham-
butol, which are currently used
in humans and dogs. Fluoro-
quinolones (enrofloxacin and
ciprofloxacin) and combina-
tions of rifampin or enroflox-
acin with clarithromycin, clo-
fazimine, and doxycycline Figure 4—Symmetric, nodular, ulcerative draining lesions over cal environmental pressure
have been effective in some the carpi of an adult cat. Negative culture results and a rapid (e.g., chronic inflamma-
cats.15,19,26 However, because response to tetracycline antibiotic therapy led to a presump- tion).30 L-Forms retain the
of the significant potential tive diagnosis of L-form bacterial infection.
zoonotic health risks from
these two mycobacterial spe-
cies, euthanasia is often recommended. M. avium is a soil-
borne pathogen, and thus its zoonotic potential is limited
except in immunocompromised humans.19
Feline Leprosy
Feline leprosy is caused by Mycobacterium lepraemuri-
um transmitted by cat and rat bites or soil contami-
nation of wounds.8,15 This organism is poorly charac-
terized because of the difficulty in maintaining it in
culture for study. Most affected cats are younger than 5
years of age, and there is no breed or gender predilec-
29
tion for infection. M. lepraemurium lesions consist of
single or multiple soft, fleshy nodules that are non-
painful and may or may not ulcerate.15,29 These are usu-
ally located on the head and limbs but can occur any-
where on the body. 8 Regional lymphadenopathy is
common, but systemic signs of illness are unusual.
The diagnosis of feline leprosy is suspected on the
basis of clinical findings and identification of acid-fast
organisms in skin lesions. Scrapings from ulcerated le-
sions or aspiration of nodules may reveal large numbers
of thin, acid-fast bacilli.8 Histopathology demonstrates
granulomatous inflammation with acid-fast bacteria in
macrophages. Confirmation is made by identification
of M. lepraemurium in culture at a reference laboratory.
Ogawa egg-yolk medium is the preferred culture mate-
rial. Injection of cultures into guinea pigs may be per-
formed to rule out tuberculosis-causing bacteria.
Aggressive surgical excision of affected tissue is the
treatment of choice; however, complete excision is diffi-
cult, and recurrence of lesions is common. Clofazimine
should be used as an adjunctive treatment after surgery.
To ensure complete resolution, antileprosy therapy
should continue for several months after clinical
mission of this disease has
also been reported.29 There
is no evidence that M. lep-
raemurium is contagious to
humans.
L -Form Bacteria
L-Form bacteria are par-
tially or completely cell-
wall–deficient bacteria of a
common species that has
been altered as a result of lo-
same virulence characteris-
tics of the parent organism.
Their structure helps them
evade attacks by the immune system and avoid diges-
tion by lysosomal enzymes and makes them resistant to
many routinely used antibiotics. L-Forms can persist in
this state or revert to a cell-wall–containing form, a
characteristic that helps differentiate them from My-
coplasma species. When present, L-form infection can
spread as such from cat to cat by direct contact with in-
fectious exudate.
Clinical findings in patients with L-form bacterial in-
fections include abscessation and draining tracts that
are often located over and involve the joints30 (Figure
4). Fever, anorexia, and signs of systemic illness are usu-
ally present. A common clinical presentation is chronic
abscessation that is poorly responsive to drainage proce-
dures and antibiotics routinely used to treat feline bite-
wound abscesses. In the absence of effective treatment,
lesions often spread hematogeneously or by direct inoc-
ulation to other locations on the body. Radiographs of
affected joints often show bone lysis, collapse of joint
spaces, and periosteal proliferation.30
Cytologic examination of exudate from these lesions
usually reveals a pyogranulomatous response with large
numbers of macrophages along with the neutrophil
population.30 L-Form bacteria grow poorly (if at all) on
routine culture media and may be difficult to identify
even with the special techniques used to culture My-
coplasma species. Overgrowth of secondary invaders in
these draining lesions often confounds interpretation of
microbiologic culture results. Electron microscopy may
be required to definitively identify the organism(s).
A definitive diagnosis of L-form infection may be diffi-
cult to achieve and is often presumptive based on therapy
response. Treatment with tetracycline drugs usually pro-
duces dramatic improvement in affected patients within

ZOONOTIC HEALTH RISKS ■ CHRONIC ABSCESSATION ■ BONE LYSIS

 Compendium December 1999 20TH ANNIVERSARY Small Animal/Exotics

48 to 72 hours; this response provides presumptive evi-
dence of L-form infection but does not rule out the possi-
bility of Mycoplasma as the causative agent. Severe ortho-
pedic damage caused by intraarticular infection may
require surgical stabilization after the infection has been
controlled. We are aware of several cases in which L-form
infections spread from infected cats to veterinarians, so
these cats should be handled with care and their owners
warned about the potential
ND
PE IU
for zoonotic infection.
M
M’
tive diagnosis. The ultimate reason to find the cause is to
provide a reasonable prognosis and treatment plan to
owners. However, even with the best techniques and in-
tentions, a diagnosis may still be based on response to
therapy (e.g., as with L-form bacteria).
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and facultative anaerobic bacteria from feline subcutaneous
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2. White SD: Pyoderma in five cats. JAAHA 27:141–145,

20th

CO

1991.
S

1 9 7
9 - 1
9 9 9
ANNIVERSARY
A LookBack
The popularity of cats as
companion animals has
increased over the past two
decades. At the same time, the
overall quality of feline medical
care, including dermatology, has
improved. Better antibiotics,
advanced diagnostic tools, and
high-quality reference
laboratories have been essential
for such advances. The
subspecialty of
dermatopathology has improved
the quality of biopsy evaluation,
whereas tissue-staining
techniques have improved the
diagnostic evaluation of
formalin-fixed tissues. The next
decade should witness improved
bacterial sensitivity testing,
polymerase chain reaction
techniques to aid diagnosis, and
new classes of antibiotics. There
is also a need to develop a better
understanding of how to dose
currently available antibiotics to
achieve therapeutic tissue
concentrations for resistant
bacterial infections in cats.
(Photos: Drs. Kennis [left]
and Wolf.)
Mycoplasma
Mycoplasma species usual-
ly cause upper respiratory
disease and, rarely, nonero-
sive polyarthritis/tenosyno-
vitis in cats.31 There is one
report describing Myco-
plasma-like organisms as the
causative agent of chronic
abscesses and draining tracts
in cats.32 However, the clini-
cal location and appearance
of the lesions and the charac-
ter and cytologic appearance
of the exudate described in
these cats was typical of L-
form bacteria. No known
Mycoplasma species were re-
covered from these patients,
and the diagnosis was pre-
sumptive on the basis of re-
sponse to tetracycline thera-
py. Because both L-form and
Mycoplasma infections re-
spond to tetracycline, it is
unclear whether Mycoplasma
species are true dermatologic
pathogens or this report was
a case of mistaken identity.
SUMMARY
The diagnosis and treat-
ment of bacterial causes of
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be very difficult. Successful
treatment depends on accu-
rate diagnosis. The diagnos-
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this article, such as macerat-
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TETRACYCLINE DRUGS ■ POLYARTHRITIS ■ TENOSYNOVITIS

Small Animal/Exotics 20TH ANNIVERSARY
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Compendium December 1999
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About the Authors
Drs. Kennis and Wolf are affiliated with the Texas Veteri-
nary Medical Center, Department of Small Animal Med-
icine and Surgery, Texas A&M University, College Station,
Texas. Dr. Kennis is a Diplomate of the American College
of Veterinary Dermatology; Dr. Wolf is a Diplomate of the
American College of Veterinary Internal Medicine and the
American Board of Veterinary Practitioners.