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162 DISC
Veterinary Dermatology 2000, 11, 7580

Case report
A case of diet-related lymphocytic mural folliculitis in a cat
JAN DECLERCQ
Poortersstraat 16, B8510 Marke, Belgium
(Received 31 October 1998; accepted 5 February 1999)

Abstract A 5-year-old cat developed a raised hair coat and adherent crusting lesions involving the skin of the
head, dorsal neck and abdomen. Erosions were present on the lips and eyelids. The footpads were dry and
scaly. Histopathology revealed inltrative lymphocytic folliculitis, moderate lymphocytic inltration into the
epidermis and apoptotic epidermal cells. A restricted diet as the only therapy resulted in gradual resolution of
the skin lesions. Despite an improvement in the dermatological condition, the cat increasingly lost all appetite
and marked weight loss occurred. The cat died 4 months after presentation. Post-mortem revealed a
perforated gastric ulcer and a mild to moderate inammatory bowel disease. The clinical course of lesion
resolution in this cat suggested a diet-related pathogenesis. The late nding of intestinal disease in a patient
with diet-related skin disease is still interesting and needs to be evaluated by further case studies.
Keywords: cat, crusting and erosions, diet, lymphocytic mural folliculitis.

INTRODUCTION
Lymphocytic mural folliculitis (LMF) is a rare and
newly recognized group of skin diseases in dogs and
cats, unied by inammatory inltration into the
follicular outer rooth sheath, generally at and above
the level of the follicular isthmus. The predominate
inammatory cells are lymphocytes and histiocytes.1,2 Currently ve types are recognized in the
cat: dermatophyte-associated, feline sebaceous adenitis, pseudopelade-like, early or prodromal epitheliotropic T-cell lymphoma and an idiopathic group
of diverse diseases.
Clinical and histopathological features of two types
of LMF have been described in a previous report.3
One type revealed mural folliculitis at the level of the
follicular isthmus and has been characterized as
pseudopelade-like or feline alopecia areata-like dermatosis.4 The other type showed mural folliculitis
with surface epidermal lesions characterized by
moderate lymphocytic inltration and focal transepithelial apoptosis. In the reported cat with this form,
there was a benecial clinical response to an
elimination diet.
The purpose of this report is to describe a similar
case of diet-related LMF and to conrm the existence
of this subtype in the feline.
CASE REPORT
A 5-year-old, female, neutered domestic short-haired
cat was referred with a 2-month history of progressive skin disease. Patches of crusting had developed
# 2000 Blackwell Science Ltd

on the head, dorsal neck and trunk. The lesions were

not pruritic. The skin lesions appeared 1 month after
changing the animal to a specially formulated lowcalorie diet for weight reduction. Prior treatment with
corticosteroids (1 mg kg71 daily for 10 days) and a
change to the original diet of commercial cat food
and cooked sh, had produced no improvement. No
other abnormalities were reported.
Physical examination revealed an obese cat (6.3 kg)
and extensive skin disease. The hair coat was raised.
The ear canals contained a scaly debris. The head and
dorsal neck showed patches of thickened skin covered
with adherent crusts and matted hairs (Figs 1 & 2).
Focal and less severe lesions were present on the
dorsal trunk. Crusts and erosions were seen on the
lips and eyelids. The abdomen was erythematous and
was covered with adherent crusts in an almost linear
conguration (Fig. 3). The footpads were dry and scaly.
Dierential diagnoses that were considered at that
time were demodicosis, dermatophytosis, pemphigus
foliaceus, lupus, drug reaction, erythema multiforme,
giant cell dermatosis, exfoliative dermatitis and
thymoma, epitheliotrophic lymphoma, and dietrelated LMF.
Skin scrapings were negative for parasites. Fungal
cultures of the skin were negative. Impression smears
from the skin beneath crusts were characterized by
lymphocytic inammation. The cat was feline leukaemia virus (FeLV) negative. Radiology of the
thorax did not reveal abnormalities. Several skin
biopsies from aected areas revealed a thick,
hyperkeratotic (orthokeratotic and parakeratotic)
epidermis. There was marked mural lymphocytic
folliculitis at the level of the follicular infundibulum
75

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76

J. Declercq

Figure 1. Photograph taken at the rst

presentation. Notice raised hair coat, patches
with adherent crusts on the head, and crusts on
the nasal planum.

Figure 2. Photograph taken at rst presentation.

The hair coat was clipped to allow visualization of
heavy crusting on the preauricular and perioral
region and on the dorsal neck.

Figure 3. Detail of the abdomen. The hair coat

was clipped to allow visualization of erythema
and crusting in an almost linear conguration.

and isthmus, excessive keratin in the hair follicles,

and sebaceous gland atrophy (Fig. 4). The epidermis
showed spongiosis, moderate lymphocytic inltration
and scattered apoptotic keratinocytes. The dermis
revealed a supercial and perifollicular inltrate
# 2000 Blackwell Science Ltd, Veterinary Dermatology, 11, 7580

composed of lymphocytes and histiocytes and fewer

mast cells, plasma cells and neutrophils.
The most probable diagnosis was diet-related
LMF. The owner was instructed to feed an elimination diet of raw horse meat.

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Diet-related lymphocytic mural folliculitis in a cat

77

Figure 4. Biopsy showing inltrative mural

folliculitis.

Figure 5. Photograph taken at the second

presentation (1 month of elimination diet).
Alopecia and sloughing of crusts with matted hairs.

Figure 6. Detail of the head showing adherent

scaling of the skin.

The cat returned 1 month later. Physical examination revealed erythema, scaling, severe alopecia, and
extensive sloughing of crusts and matted hairs (Figs
57). The latter was interpreted as a healing sign of
the condition. During that time, the cat ate the diet

well for 15 days and then began to gradually refuse

the food. The body weight was 4.6 kg. In an attempt
to improve the cat's appetite, several other ingredients were recommended. The cat was only willing to
eat the cod-sh supplement.
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J. Declercq

Figure 7. Detail of the neck showing crusting,

erosions and thickened hypotonic skin.

Figure 8. Photograph taken at fourth

presentation (4 months of restricted diet)
demonstrating improvement of the skin and
regrowth of a dull hair coat. Notice the thin
body condition and wrinkled hypotonic skin.

Figure 9. Photomicrograph of section of intestine

with lymphocyte and plasma cell inltration.

The cat was examined 1.5 months after the second

admission. Despite an improvement in the dermatological condition, the owners complained of poor
appetite. Marked weight loss and intermittent vomiting indicated a serious ongoing disease process. The
# 2000 Blackwell Science Ltd, Veterinary Dermatology, 11, 7580

cat's body weight was 2.2 kg. No abnormalities were

detected on a complete examination. A diagnosis
could not be made and prednisolone 0.5 mg kg71
every other day was administered. The cat's condition
deteriorated and 1.5 months after the third admission

162 DISC
Diet-related lymphocytic mural folliculitis in a cat
the body weight was 1.8 kg. Hair regrowth was more
obvious and the hair coat was dull and scaly.
Thickened bowel loops were detected by abdominal
palpation and a diagnosis of intestinal disease was
made. Skin biopsies revealed marked hyperkeratosis,
less follicular and epidermal lymphocytic inltration,
lack of apoptosis, and the dermal inltrate had a
higher number of mast cells and melanophages as
opposed to the previous biopsies. Prednisolone 2 mg
kg71 divided twice daily was prescribed. The cat died
3 weeks after presentation. Post-mortem examination
revealed a perforated gastric ulcer and a mild to
moderate inammatory bowel disease (Fig. 9).
DISCUSSION
A form of lymphocytic mural folliculitis with the
most severe and extensive histopathologic changes
has been recognized in cats.1,2 Aected cats were
middle-aged to aged and systematically ill. The
lesions were diuse scaly alopecia with concurrent
lethargy. Complete physical evaluation was not
informative. Response to therapeutic protocols was
poor and cats were euthanized due to the ongoing
nature of illness.
A case of diet-related LMF has been reported in a
6-year-old cat.3 This cat presented with a 6-month
history of crusting of the face, the dorsal neck and
abdominal region. The hair coat was raised and
aected skin was covered with adherent crusts. In
addition, the ear canals were plugged with crusty
debris. The histological features were lymphocytic
mural folliculitis, moderate lymphocytic inltration
of the epidermis and scattered apoptotic epidermal
cells. The present case shares historical, clinical and
histopathological features with the previously described cat. The clinicopathologic features reported in
both cats were unlike previously described cases of
LMF. In addition to inltrative folliculitis, this entity
was characterized by inltration of the epidermis and
necrosis of epithelial cells. This additional pattern did

79

result in a more severe clinical presentation with

crusts and erosions rather than with alopecia and
scaling as described in other reported cases. In both
cats a diet was eective in resolving dermatological
signs: in one cat with the feeding of a novel protein
source (horse meat), in the other with the feeding of a
restricted diet (horse meat/cod-sh). Aside from food
hypersensitivity, dietary deciencies, and drug reaction to colouring agents in commercial food,5 foods
have not been proved to be aetiologic agents in skin
eruption in veterinary small animal medicine.
This cat died 4 months after presentation due to
progressive intestinal disease, despite improvement of
the dermatological condition. At initial consultation
reports of intestinal problems were lacking and
clinical signs such as poor appetite and weight loss
occurred 3 months after the onset of cutaneous
lesions. The clinical course of lesion resolution
suggested a diet-related pathogenesis. The late nding
of intestinal disease in a patient with a diet-related
skin disease is still interesting and needs to be
evaluated by further case studies.

REFERENCES
1. Gross, T.L., Stannard, A.A., Yager, J.A. An
anatomical classication of folliculitis. Veterinary
Dermatology 1997; 8: 14756.
2. Power, H.T. Newly recognized feline skin diseases.
Proceedings of the 14th AAVD/ACVD Meeting 1998
2930. San Antonio, USA.
3. Declercq, J. Lymphocytic mural folliculitis in two cats.
V1aams Diergeneeskundig Tijdschzift 1995; 64: 17780.
4. Power, H.T., Olivry, T., Woo, J., Moore, P.F. Novel
feline alopecia areata-like dermatosis: cytotoxic Tlymphocytes target the follicular isthmus. Proceedings
of the Third World Congress of Veterinary
Dermatology, 1996. p. 74. Edinburgh, UK.
5. Mason, K. Workshop Cutaneous drug eruptions. In:
Irhke, P. J., Mason, I. S., White, S. D., eds. Advances in
Veterinary Dermatology II Pergamon Press, Oxford,
1992: 450.

Resume Un chat age de 5 ans a presente un pelage et des croutes adherentes au niveau de la peau de la tete,
de la zone dorsale du cou et de l'abdomen. Des erosions etaient presentes sur les levres et les paupieres. Les
coussinets etaient secs et squameux. L'examen histopathologique a montre une folliculite lymphocytaire
inltrante, une inltration lymphocytaire moderee de l'epiderme et des cellules epidermiques apoptotiques. Un
regime d'elimination, sans autre therapeutique, a permis une guerison progressive des lesions cutanees. Malgre
l'amelioration des lesions cutanees, le chat a presente une dysorexie avec une perte de poids. Le chat est mort 4
mois apres la premiere visite. Une autopsie a montre un ulcere gastrique perforant et une inammation legere
a moderee des intestins. L'evolution des lesions suggere chez ce chat une pathogenese liee a l'alimentation.
L'observation tardive d'une enterite chez un patient avec une dermatose liee a l'alimentation est interessante et
doit etre evaluee par d'autres etudes cliniques. [Declercq, J. (Un cas de folliculite murale d'interface liee a
l'alimentation chez un chat.) Veterinary Dermatology 2000; 11: 7580.]
Resumen Un gato de 5 anos de edad desarrollo un pelaje con el pelo elevado, lesiones costrosas y adherentes
en la piel de la cabeza, cuello dorsal y abdomen. Se observaban erosiones en los labios y en los parpados. Las
almohadillas se encontraban secas y con escamas. La histopatolog a mostro una foliculitis linfoc tica
inltrativa, inltracion linfoc tica moderada en la epidermis y queratinocitos apoptoticos en la epidermis. Una
dieta restrictiva como terapia unica llevo a una resolucion gradual de las lesiones cutaneas. A pesar de una
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J. Declercq
mejor a en el aspecto dermatologico, el gato llego a perder el apetito y se produjo una evidente perdida de
peso. El gato murio 4 meses despues de la presentacion. El estudio post-mortem revelo una ulcera gastrica
perforada y enfermedad inamatoria intestinal leve a moderada. El curso cl nico de resolucion de la lesion en
este gato suger a una patogenia asociada a la dieta. El hallazgo nal de enfermedad intestinal en un paciente
con enfermedad cutanea asociada a la dieta sigue siendo interesante y requiere ser evaluada en casos cl nicos
posteriores. [Declercq, J. (Un caso de foliculitis mural asociada a la dieta en un gato.) Veterinary Dermatology
2000; 11: 7580.]
Zusammenfassung Eine funfjahrige Katze entwickelte ein abstehendes Haarkleid und adharente Krusten auf
der Haut von Kopf, dorsalem Hals und Abdomen. Erosionen waren an den Lippen und Augenlidern
vorhanden. Die Fussballen waren trocken und schuppig. Histopathologie ergab inltrative lymphozytare
Follikulitis, moderate lymphozytare Inltration in die Epidermis und apoptotische Epidermalzellen.
Graduelle Resolution der Hautlasionen erfolgte mit einer restriktiven Futterung als alleiniger Therapie.
Trotz einer Besserung der dermatologischen Symptomatik verlor die Katze zunehmend den Appetit und
deutlich an Gewicht. Vier Monate nach Vorstellung starb die Katze. Postmortale Untersuchung ergab ein
perforierendes Magengeschwur und leichte bis moderate entzundliche Darmerkrankung. Der klinische
Verlauf der Lasionsbesserung deutete auf eine mit dem Futter in Zusammenhang stehende Pathogenese. Der
spate Befund der Darmerkrankung bei einem Patienten mit einer mit dem Futter in Zusammenhang stehender
Hauterkrankung ist interessant und muss in weiteren Falluntersuchungen bewertet werden. [Declercq, J. (Ein
Fall von mit Futter in Zusammenhang gebrachter lymphozytarer, muraler Follikulitis bei der Katze.)
Veterinary Dermatology 2000; 11: 7580.]

# 2000 Blackwell Science Ltd, Veterinary Dermatology, 11, 7580