Excessive Adaptive Responses

Anaphylactic shock occurs in sensitized animals after exposure to antigens in sensitizing vaccines or drugs, ingestion of foods, or insect bites. Clinical signs occur within seconds to minutes after exposure to the allergen. In most domestic animals, the lungs are the primary target organs, and the portal-mesenteric vasculature is a secondary target; this is reversed in dogs. Mast cell degranulation in the pulmonary vasculature causes constriction of bronchial airways or pulmonary veins and pooling of blood and edema in the pulmonary vascular bed, which results in severe respiratory distress. Mast cell degranulation in the portosystemic vasculature causes venous dilatation and pooling of blood in the intestines and liver.

Clinical signs can be localized or generalized and include restlessness and excitement, pruritus around the head or site of exposure, facial edema, salivation, lacrimation, vomiting, abdominal pain, diarrhea, dyspnea, cyanosis, shock, incoordination, collapse, convulsions, and death. In dogs, the major organ affected by anaphylactic shock is the liver, and signs are associated with constriction of hepatic veins, which results in portal hypertension and visceral pooling of blood. GI signs rather than respiratory signs are more apt to be seen in dogs. Supportive therapy, in addition to treating respiratory distress, consists of the administration of epinephrine (both locally and systemically as needed). IV fluids for the treatment of shock, antihistamines (systemically for severe acute anaphylaxis or orally as a means to control chronic signs of allergy or milder allergic signs), and corticosteroids if needed. Ancillary support of blood pressure and respiration may be necessary.

Urticarial reactions (hives or angioedematous plaques) of the skin and subcutaneous tissue and acute edema of the lips, conjunctiva, and skin of the face (facial-conjunctival angioedema) are less severe forms of Type I hypersensitivity. Hives are the least severe reaction and may not be associated with other clinical abnormalities. Facial-conjunctival edema is more severe and can be associated with mild to moderately severe systemic anaphylaxis. These reactions usually follow administration of vaccines or drugs, ingestion of certain foods, or insect bites. Urticarial reactions and facial-conjunctival edema occur in most species and usually resolve spontaneously within 24 hr. Not all urticarial reactions are mediated by Type I hypersensitivity. (Also see Urticaria.)

Milk allergy occurs occasionally in cows and less frequently in mares. This occurs when a cow makes IgE autoantibodies to its own milk components, notably casein. When intramammary pressure rises, these milk proteins gain access to the circulation and induce a Type I hypersensitivity. The reaction can be localized or systemic. Recovery occurs once the animal is milked.

Allergic rhinitis, manifest by serous nasal discharge and sneezing, is less common in domestic animals than in people. Often, it is seasonal, correlating with pollen exposure. Nonseasonal rhinitis may be associated with exposure to ubiquitous allergens, such as molds, danders, bedding, and feeds. Recurrent airway obstruction in horses (see Recurrent Airway Obstruction in Horses) is probably a reaction to chronic exposure to molds present in moldy hay and poorly ventilated stables. Summer snuffles is a seasonal allergic rhinitis occurring commonly in Guernsey or Jersey cattle placed on certain types of flowering pastures in late summer and early autumn. Allergic rhinitis can be diagnosed tentatively by the following: 1) identification of eosinophils in the nasal exudate, 2) demonstration of a favorable response to antihistamines, 3) disappearance of signs when the offending allergen is removed, or 4) occasionally, its seasonal nature. Skin testing is not an accurate means to diagnose nasal allergies in animals.

Chronic allergic bronchitis has been characterized in dogs. A dry, harsh, hacking cough that is easily precipitated by exertion or by pressure on the trachea is a characteristic clinical sign. The disease may be seasonal or occur year-round. Usually, it is not associated with other signs of illness. The bronchial exudate is rich in eosinophils and free of bacteria. Chest radiographs are normal, and there may or may not be a low-grade peripheral eosinophilia. The condition is treated with bronchodilators and expectorants (aminophylline and potassium iodide or guaifenesin). Glucocorticoids will alleviate clinical signs, especially when their use can be limited to certain seasons or to low-dose, alternate-day therapy. Avoidance of the offending allergen(s) usually is not possible.

Allergic bronchiolitis is most common in cats. It is manifest by a low-grade cough, wheezing, some dyspnea, and increased peribronchiolar density on radiographs, and it may be mistaken for other conditions (allergic asthma or lungworm disease). Early in the course of the disease, clinical signs can be modified by antihistamine therapy, but if the disease increases in severity, moderate to high dosages of corticosteroids may be necessary. The offending allergen usually is not identified.

Eosinophilic bronchopneumopathy occurs most frequently in dogs but has been recognized in all species. It is associated with diffuse inflammatory infiltrates in the lungs and a pronounced peripheral eosinophilia; frequently, the serum globulins are increased. Unlike in allergic bronchitis, affected animals are often dyspneic or tire easily with exercise. Diffuse bronchial exudate contains numerous eosinophils. The specific offending allergen is rarely identified. Glucocorticoids are the treatment of choice. A similar syndrome is also associated with resident or migratory parasitic infections of the lungs in young animals.

Allergic asthma occurs most frequently in cats, in which the signs are similar to those in people. It occurs more frequently in summer and after going outdoors; individual attacks can be transient and mild, or protracted and severe (status asthmaticus). Mild attacks may manifest as wheezing and coughing; in severe attacks, there may be expiratory dyspnea, hyperinflation of the lungs, aerophagia, cyanosis, and frantic attempts to obtain air.

Intestinal allergies (food allergies) are principally seen in dogs and cats, particularly kittens. (Also see Food Allergy and see Adverse Reaction to Foods.) Allergic gastritis is manifest by vomiting, which occurs 1 to >12 times weekly, within 1–2 hr of eating. The vomitus may be tinged with bile. In cats, vomiting may be the sole sign; dogs may also have intermittent loose feces. Cats and dogs with allergic gastritis are usually healthy except for vomiting, although there can be loss of weight and coat condition in severe cases. Allergic enteritis is associated with a mild inflammation of the small intestine but with little or no eosinophilia. Feces usually are normal in volume and frequency but vary from semiformed to watery. They may be extremely odorous, especially in cats. Affected animals may be excessively thin despite good appetite. Skin lesions and poor coat are commonly associated with food allergies in cats but less commonly in dogs. The allergy often develops after episodes of viral, bacterial, or protozoal enteritis (a phenomenon known as allergic breakthrough). Eosinophilic enteritis, the most severe form of allergic intestinal disease, manifests by moderate to severe inflammation of the intestines and a pronounced eosinophilia. Diarrhea, weight loss, and poor coat condition are usually evident. The prevalence of allergic colitis is greater in cats than in dogs, although in general it is not common. In dogs, it is often associated with frequent defecation and soft, mucus-laden and sometimes bloody feces; in cats, it most frequently manifests by more normal feces coated or spotted with fresh blood. (For diagnosis and treatment of food allergies, see Food Allergy.)

Atopic dermatitis (see Atopic Dermatitis) is a complex pruritic, chronic skin disorder that occurs in many species but has been studied mostly in dogs. Some animals with atopic dermatitis may have a genetic predisposition that leads to excessive production of reaginic (IgE) antibodies. It has been estimated that ~10% of all dogs suffer from atopy, with a breed predisposition in terriers, Dalmatians, and retrievers. Atopic dermatitis of dogs often is triggered by inhaled allergens, eg, house dust mites, pollens, molds, and danders. Atopic dogs often chew at their feet and axillae. Excessive sweating is especially noticeable in hairless areas. The severity of the skin lesions are greatly increased by licking, scratching, flea infestation, and secondary bacterial or yeast infection. Atopic skin lesions in cats are either miliary (small scabs) and widespread, or larger and more localized. Localized lesions are often pruritic.

In cats, food allergens probably are a more common cause of skin lesions than are inhaled allergens. Sweet itch (see Biting Midges) is a seasonal allergic dermatitis of horses associated with certain insect bites, especially night-feeding Culicoides. Intensely pruritic lesions appear along the dorsum from the ears to tail head and perianal area. Similar allergic skin reactions to insect bites can be seen around the ears and face of cats and dogs. (For diagnosis and treatment, see Atopic Dermatitis.)

The production of autoantibodies against erythrocyte or platelet antigens leads to anemia and thrombocytopenia, the most common Type II reactions. Antibody and complement attach to RBCs either directly or indirectly via an absorbed antigen and then mediate RBC destruction, resulting in a severe, life-threatening anemia. Concurrent thrombocytopenia is found in 60% of cases. IMHA can be associated with systemic lupus erythematosus or with lymphoreticular malignancies. Drugs or infections may trigger episodes of hemolytic anemia or thrombocytopenia in many species. More often than not, the initiating cause is unknown.

IMHA occurs in several clinical forms: peracute, acute or subacute, chronic, cold agglutinin disease, and red cell aplasia. Most cases are treatable, but relapses are common. (Also see Immune-mediated Hemolytic Anemia.)

Peracute IMHA is seen mainly in middle-aged, larger breeds of dogs. Affected dogs are acutely depressed and have a rapid decrease in PCV within 24–48 hr with bilirubinemia, variable icterus, and sometimes hemoglobinuria. Initially, the anemia is nonresponsive, but it may respond within 3–5 days. Thrombocytopenia may also be present. Antiglobulin tests are often negative, and spherocytes may or may not be present, but tube or slide agglutination of RBCs is marked. The autoagglutination is not dispersed by saline dilution, hence the term hemolytic anemia with in-saline agglutinins. The serum usually contains autoantibodies that cause agglutination of most donor RBCs. The prognosis of peracute IMHA is poor even with prompt and vigorous therapy. The most effective therapy involves immediate use of high dosages of glucocorticoids plus cyclophosphamide, together with a compatible blood transfusion. If incompatible blood must be used, the animal should first be heparinized and maintained on heparin for 10 days. Even without transfusion, heparinization may be beneficial for the first 2 wk or more. Bovine hemoglobin blood substitute and human immunoglobulins can be used as supportive therapy until immunosuppressive treatment reduces the destruction of RBCs.

Acute IMHA is the most common form of the disease, with a breed predilection in Cocker Spaniels. Initial signs are pallor, fatigue, and less commonly, icterus. Hepatosplenomegaly is a prominent sign. The WBC count may be increased due to bone marrow hyperplasia. Autoagglutination of RBCs is uncommon, and the antiglobulin test is generally positive. These animals usually respond well to glucocorticoid therapy. If a favorable response is not seen within 7–10 days, cytotoxic drugs (cyclophosphamide or azathioprine) should be added to the regimen.

Chronic IMHA differs from the acute form in that the PCV falls to a constant level and remains there for weeks or months. The bone marrow is either normal or hyperresponsive, and the antiglobulin test is often negative. Chronic IMHA is relatively more common in cats than in dogs. Usually, the anemia is responsive early in the course of disease but responds minimally or not at all by the time it becomes severe. Initial treatment is with glucocorticoids; if there is no response within 2 wk, cytotoxic drugs may be added to the regimen.

Cold agglutinin disease is an IMHA of dogs and horses. Its cause is usually unknown but may be secondary to infection, other autoimmune diseases, or neoplasia. The IgM autoantibodies can be agglutinating or nonagglutinating. Complete agglutination does not occur at body temperature but only when the blood is chilled; thus, it is more frequent in colder climates and seasons. Initial signs may be of a hemolytic disease; in the agglutinating type, vascular blockage may lead to necrosis of the nose, tips of the ears and tail, digits, scrotum, and prepuce. Diagnosis is based on a reversible autoagglutination that occurs only at 4°C. The direct antiglobulin reaction is usually negative for IgG, frequently positive for C3, and usually positive for IgM if the reaction is performed in the cold. Mortality is high. In the absence of an obvious initiating cause such as infection or neoplasia, the disease is best controlled with high doses of glucocorticoids in combination with cyclophosphamide.

Red cell aplasia (see Primary Bone Marrow Diseases) is most common in dogs. It occurs in two forms, one in postweanling to adolescent puppies and the other in adults. Unlike in IMHA, the bone marrow shows a selective depression of erythroid elements; granulocytes and platelets are unaffected. Therefore, the peripheral anemia is unresponsive. The immune attack is directed against erythroid stem cells, and the antiglobulin test is usually negative. Treatment is usually as for chronic IMHA, but recovery may be very slow.

Immune-mediated thrombocytopenia is common in dogs. It occurs more often in females than males. The most frequent clinical signs are hemorrhages of the skin and mucous membranes. Melena, epistaxis, and hematuria may be accompanying features and can cause profound anemia. Hemolytic anemia and thrombocytopenia sometimes occur together. Immune-mediated thrombocytopenia usually is diagnosed on the basis of low peripheral platelet counts despite a pronounced megakaryocytosis in the marrow. Occasionally, megakaryocytes may be selectively absent from the marrow. Tests for antiplatelet antibodies are difficult to conduct, so diagnosis is usually made on clinical presentation and response to therapy. (Also see Primary Immune-mediated Thrombocytopenia.)

Animals with immune-mediated thrombocytopenia that show only petechial and ecchymotic hemorrhages, with no significant blood loss and megakaryocytes in the marrow, may be treated initially with glucocorticoids. The clinical signs should abate and the platelet count begin to rise after 5–7 days. If the platelet count has not increased significantly by 7–10 days, cyclophosphamide, azathioprine, or vincristine can be added to the glucocorticoid regimen. In animals with megakaryocytes in the marrow and severe blood loss, a more rapid response to therapy is desirable. Such animals are treated with a single injection of vincristine combined with daily glucocorticoids; a favorable response usually occurs after 3–5 days. If the blood loss is life-threatening, platelet-rich whole blood should be administered. If the platelet count has risen by day 7, remission is maintained on glucocorticoids alone. If there is no response after 7 days, a second dose of vincristine is given. If the platelet count is still low after 2 wk, vincristine is discontinued and either cyclophosphamide or azathioprine is added. Animals with thrombocytopenia and no megakaryocytes respond much more slowly to glucocorticoids, or to glucocorticoids and vincristine. Preferred treatment for these animals is with prednisolone and cyclophosphamide, and a response should not be expected earlier than 1–2 wk after beginning therapy. Therapy may be discontinued in most animals with immune-mediated thrombocytopenia 1–3 mo after the platelet count returns to normal. Some animals have a persistent thrombocytopenia despite drug therapy, or they can be maintained in remission only with chronic high-dose treatment. The alternatives are to allow the animal to live with the thrombocytopenia if signs are minimal or to use longterm combination drug therapy with glucocorticoids and either vincristine, azathioprine, or cyclophosphamide. Splenectomy is seldom curative by itself but may allow use of lower and safer dosages of immunosuppressive drugs.

In these diseases, affected animals make autoantibodies against the intracellular cement proteins in the epidermis. This promotes local proteolysis, leading to separation of the epidermal cells (acantholysis) and development of vesicles within the skin. Although not strictly a Type II disease, it is best considered here.

Pemphigus foliaceus is the most common of these diseases, occurring more often in dogs than in cats and horses. It is characterized by the development of erosions, ulcerations, and thick encrustations of the skin and mucocutaneous junctions. The absence of lesions in the mouth, and the widespread thick, crusty nature of the skin lesions, tend to differentiate pemphigus foliaceus from the much rarer pemphigus vulgaris. Autoantibodies in the skin react with intracellular cement (desmoglein), resulting in its degradation and separation of the cornified and uncornified cell layers. Immunosuppression is required to treat the disease. High doses of glucocorticoids are used initially, but low-dose, alternate-day therapy is used once the disease is under control. More potent immunosuppressive drugs such as cyclophosphamide or azathioprine may be used with glucocorticoids in cases unresponsive to steroids. Animals that respond poorly to initial therapy, or require high dosages of drugs to control lesions, have a poor longterm prognosis.

Pemphigus vulgaris is a much less common autoimmune skin disease than pemphigus foliaceus. It is characterized by vesicle formation along the mucocutaneous junctions of the mouth, anus, prepuce, and vulva, and in the oral cavity. Other areas of the skin are only mildly involved. Because the epidermis of animals is relatively thin (compared with human skin), these blisters rupture rapidly and form erosions; consequently, characteristic bullae are seldom seen. The vesicles develop as a result of suprabasilar acantholysis. Secondary bacterial infection often complicates the lesions, and if untreated, the disease is often fatal. It is treated with high doses of glucocorticoids alone or in combination with other drugs such as cyclophosphamide, azathioprine, or gold salts. Pemphigus vulgaris is difficult to maintain in remission, and the longterm prognosis of affected animals is fair to poor.

Bullous pemphigoid is a rare canine skin disease recognized most often in Collies and Doberman Pinschers. Lesions are often widespread but tend to be concentrated in the groin. The involved skin resembles a severe scald. Bullae also develop; they are subepidermal and may be full of eosinophils. Autoantibodies to the basal lamina can be detected in immunohistopathologic sections. The treatment of choice is prednisolone and azathioprine used in combination; remission is frequent, but continual drug therapy at relatively high dosages may be required to keep the disease under control. The longterm prognosis is poor.

Myasthenia gravis is an autoimmune disease in which autoantibodies directed against the acetylcholine receptors on muscle cells cause receptor degradation or blockage and so block neuromuscular transmission. The disease is characterized by extreme generalized muscle weakness, which is accentuated by mild exercise. Megaesophagus due to paralysis of esophageal muscles is a frequent primary or accompanying complaint in dogs. Thymomas are often associated with myasthenia gravis in people but are uncommon in domestic species. Administration of a short-acting anticholinesterase (edrophonium chloride) produces a dramatic increase in muscle strength. Treatment is with a long-acting anticholinesterase. Chronic immunosuppressive drug therapy for this disease is logical. Autoantibodies to the acetylcholine receptors can be detected in the serum of affected animals by an indirect immunohistopathologic assay using normal muscle as a substrate.

This lesion is caused by immune complexes that form within the bloodstream and are filtered out in the glomeruli (see Glomerular Disease in Small Animals). In effect, the insoluble complexes collect on the glomerular basement membrane. Depending on their size, they may be deposited on the subendothelial or subepithelial surface of the membrane. Secondary glomerulonephritis occurs as a sequela of chronic infectious, neoplastic, or immunologic disorders. Animals with idiopathic glomerulonephritis (>50% of cases) usually have signs of renal disease, whereas secondary glomerulonephritis is often a relatively minor part of a more serious disease.

When inhaled antigens meet circulating antibodies in the walls of the alveoli, immune complexes form in the alveolar walls and trigger acute inflammation. Hypersensitivity pneumonitis is most common in large animals exposed over a long time to antigenic dusts. The most potent antigens of this type are those contained in the spores of thermophilic actinomycetes from moldy hay. Inhalation of these spores causes farmer’s lung disease in people and a similar condition in cattle (see Hypersensitivity Pneumonitis in Cattle). Hypersensitivity pneumonitis is characterized by the onset of respiratory distress 4–6 hr after exposure to moldy hay. The most effective treatment is removal of the source of the antigen; otherwise, corticosteroid therapy may help.

This complex autoimmune disease occurs in dogs, is rare in cats, and has been reported in large animals. It has two consistent immunologic features: immune complex disease and a tendency to produce multiple autoantibodies. Clinically, it reflects a combination of Type II and III mechanisms. Antibodies to nucleic acids are the diagnostic hallmark of SLE, but in many individuals, antibodies to RBCs, platelets, lymphocytes, clotting factors, immunoglobulin (rheumatoid factors), and thyroglobulin are also present. The presence of autoantibodies to nucleic acids, antinuclear antibodies (ANA), can be diagnostic of the disease. Either the immune complex or the autoantibody component of the disease tends to predominate in a given animal. Immune complex deposition around small blood vessels may lead to synovitis, dermal reactions, oral erosions and ulcers, myositis, neuritis, meningitis, arteritis, myelopathy, glomerulonephritis, or pleuritis. Glomerulonephritis is one of the major life-threatening complications of SLE in cats but not in dogs. Psychosis, a major sign of SLE in people, is also seen in animals with SLE. Autoimmune hemolytic anemia or thrombocytopenia, or both, are the most common presentations of SLE in animals.

SLE is characterized by the presence of ANA, and tests for these or the associated lupus cells may help in diagnosis. However, some healthy animals may have ANA, and not all animals with SLE have detectable ANA in their blood. Diagnosis of SLE must therefore be based on the entire clinical syndrome—not just on the presence or absence of ANA.

SLE usually can be treated with glucocorticoids. Initially, they are used in high daily doses, and when remission occurs, alternate-day, low-dose therapy is used. Drug treatment should be continued for 2–3 mo after all clinical signs have resolved. Cyclophosphamide or azathioprine, or both, are used in combination with glucocorticoids in animals with SLE that is difficult to control with glucocorticoids alone.

Vasculitis mediated by immune complexes occurs in animals, especially dogs and horses. Lesions are most prevalent in the dermis of the distal limbs and mucous membranes of the mouth, particularly the palate and tongue (dogs) and lips (horses). Involvement of the nose, ears, eyelids, cornea, and anus is less common. Early lesions develop as reddened areas that rapidly form shallow erosions. A scab quickly forms over dermal erosions. Limb edema is common in horses and a less frequent but equally striking sign in dogs. Vasculitis is a feature of SLE in some animals but most often is idiopathic. Drug-induced vasculitis has been well recognized in dogs. The vasculitis is detected on histopathologic and immunohistopathologic examination of superficial and deep biopsies taken from the margins of lesions.

Vasculitis is treated by withdrawal of offending drugs and, if necessary, by immunosuppressive drug therapy. Glucocorticoids used alone or in combination with other agents such as azathioprine or cyclophosphamide are usually used to treat non-drug-induced cases.

This rare disease of domestic animals is caused by deposition of immune complexes and inflammation in walls of small and medium-sized arteries. Among farm animals, it is most common in pigs, usually associated with erysipelas and streptococcal infections, and is attributed to a Type III reaction to these bacteria or to their vaccines. It has been reported in cats, although it may be mistaken for the noneffusive form of feline infectious peritonitis.

Purpura hemorrhagica of horses is a severe nonthrombocytopenic purpura (see Primary Immune-mediated Thrombocytopenia) that often follows a Streptococcus equi respiratory infection; it is mediated by immune complexes of antibody and streptococcal antigen deposited in vascular basement membranes.

Anterior uveitis ("blue-eye," see Anterior Uvea) is an immune complex–mediated reaction that frequently occurs in the recovery stage of infectious canine hepatitis (see Infectious Canine Hepatitis). It results from the reaction of serum antibodies with uveal endothelial cells infected with canine adenovirus 1. Similarly, severe equine recurrent uveitis (see Equine Recurrent Uveitis) is associated with immunologic reactions to Leptospira or Onchocerca spp. This periodic ophthalmia results from autoimmune attack. Antibodies against some serovars of Leptospira can cross-react with retinal antigens and so trigger severe ophthalmia. Uveitis caused by Toxoplasma and feline infectious peritonitis virus infections of cats may also have an immunologic basis.

T cell–mediated granulomatous reactions may also occur around persistent infectious foci. These reactions to microorganisms such as mycobacteria, Coccidioides spp, Blastomyces spp, and Histoplasma spp, and possibly feline infectious peritonitis virus, may be a result of chronic cell-mediated immune reactions and localized macrophage activation. Although cell-mediated immunity effectively controls these types of infections in most animals, for poorly understood reasons, these same mechanisms are only partially effective in others. These granulomatous reactions are characterized by the development of a fibrous stroma and an infiltration of macrophages, giant cells, and lymphocytes around the persistent antigen.

Lymphocytic choriomeningitis, a viral infection of mice (see Viral Infections), results from the destruction of virus-infected cells by T cells, leading to CNS damage and a choriomeningitis.

Old-dog encephalitis (see Canine Distemper) may also result from cell-mediated immune mechanisms directed against cells persistently infected with canine distemper virus. The initiating canine distemper virus infection is usually clinically inapparent and may precede the development of encephalitis by many years.

Allergic contact hypersensitivity results from chemicals reacting with and modifying normal dermal proteins. The modified proteins trigger a cell-mediated immune response, which causes inflammation and damages the skin (eg, poison oak and poison ivy reactions in people). This reaction has been described in dogs, cattle, and horses and usually occurs as a result of contact with sensitizing chemicals incorporated in plastic food dishes, plastic collars, and drugs placed on the skin.

Autoimmune thyroiditis in dogs is characterized by destruction of the thyroid gland by an autoimmune process that has both humoral (Type II) and cell-mediated (Type IV) components. It is particularly prevalent in Doberman Pinschers, Beagles, Golden Retrievers, and Akitas. Hypothyroidism (see Hypothyroidism) may be the sole manifestation of the disease or may be a clinical or subclinical component of a broader autoimmune disorder such as systemic lupus erythematosus or panendocrinopathy.

Autoimmune adrenalitis has been reported in dogs. The adrenal glands are slowly destroyed by a plasmacytic-lymphocytic infiltrate. When sufficient glandular tissue is destroyed, the dogs develop Addison syndrome (adrenocortical insufficiency, see Hypoadrenocorticism). The condition is sometimes associated with autoimmune thyroiditis (see above).

Keratitis sicca is a "dry eye" syndrome that occurs in dogs. It can occur in either a primary form or secondary to chronic use of sulfonamides. It results from immune-mediated destruction of the lacrimal glands and is similar to Sjögren syndrome of people. Affected dogs may respond favorably to cyclosporine eye drops.