A four-year-old neutered male Saint Bernard dog weighing 54.9 kg presented for evaluation to the Fox Valley Animal Referral Center emergency service with the chief complaint of severe, recurrent epistaxis of 1 week duration. The patient had been treated by the primary care veterinarian with cold compressing and amoxicillin trihydrate/clavulanate potassium (unknown amount) (Clavamox ; Pfizer Animal Health, New York, NY, USA), which was unsuccessful. The patient was up-to-date with vaccinations. Laboratory evaluation performed by the primary care veterinarian revealed a normal complete blood cell count, normal biochemistry panel, and negative heartworm enzyme-linked immunoassay (ELISA) (SNAP  4Dx  Plus Test, Idexx Laboratories, Westbrook, ME, USA). Blastomycosis urine antigen testing (MiraVista Laboratory, Indianapolis, IN, USA) was performed due to the endemic region and was negative. No abnormalities were noted on three view thoracic radiographs. Prothrombin and partial thromboplastin were within the reference range.
Physical examination at the time of presentation was unremarkable except for bilateral linear nasal philtrum ulcerations. Upon further questioning the owners reported that these lesions had been present since the patient was 1 to 2 years of age and the hemorrhage came from these sites, not from inside the nostril itself.
The patient was admitted to the hospital and started on prednisone (0.5 mg/kg per os (PO) every 12 hours) (West-Ward Pharmaceutical Corp, Eatontown, NY, USA) and tacrolimus 0.1% (small amount applied topically to the nose every 12 hours) (Protopic ; Astellas Pharma, LLC, Northbrook, IL, USA) for systemic and topical immunosuppression. Additional laboratory evaluation included a buccal mucosal bleeding time which was within the normal range. No further hemorrhage was noted and the patient was discharged.
Three severe arterial hemorrhages occurred at home following discharge and a weight loss of 2.7 kg was noted even though the patient was reported to be eating well. The owners also reported lethargy and a change in attitude at home as the patient was less interactive and playful. The patient represented 1 week later to the emergency service. At presentation the patient was administered acepromazine (0.02 mg/kg intravenously once) (PromAce ; Boehringer Ingelheim, Ridgefield, CT, USA) and a cold water/dilute epinephrine (Epinephrine injection, USP; Hospira Inc., Verna, India) compress was applied with a towel to control severe hemorrhage.
Laboratory evaluation was performed. Serum biochemistry analysis revealed a high alanine aminotransferase (ALT) (371 U/L; reference range 10-100 U/L), elevated gamma-glutamyl transferase (GGT) (20 U/L; reference range 0-7 U/L), elevated blood urea nitrogen (BUN) (43 mg/dL; reference range 7-27 mg/dL), and anemia (hematocrit [HCT] 25.7%; reference range 37.1%-61.7%). The remainder of the serum biochemistry and electrolyte panel was unremarkable.
Abdominal ultrasound was performed at the owner's request due to weight loss. Results were unremarkable except for a solitary, small (5 mm) nodule on the spleen suspected to be a benign process (extramedullary hematopoiesis).
The patient was hospitalized, and topical and oral therapy was continued as previously described. The patient continued to have severe hemorrhage from his nasal philtrum intermittently. Surgery was suggested for a definitive treatment in this patient as the owners were considering humane euthanasia due to continued hemorrhage, weight loss, anemia, and change in attitude. Four days after his second admission to the hospital, the patient was anesthetized and taken to surgery.
The ulcerated part of the nasal philtrum and floor of the nares were sharply excised with a margin of healthy tissue 1 cm deep. Hemorrhage was controlled with cautery. The lower remaining philtrum and lip tissues were undermined and closed in two layers to create a new philtrum area by apposing the dorsal and ventral margins (Figure 2). The excised portion was submitted for histopathology. Anesthetic recovery was routine. 
The topical tacrolimus was discontinued for 1 week and the prednisone was decreased to 0.25 mg/kg PO every 12 hours due to adverse clinical signs including polydypsia, polyuria, and muscle wasting. An Elizabethan collar was used to prevent self-trauma to the surgery site. Tramadol (Amneal Pharmaceuticals, Glasgow, KY, USA) was started at 4 mg/kg PO every 12 hours for pain control and amoxicillin trihydrate/clavulanate potassium (19.6 mg/kg PO every 12 hours) was started for infection prevention. Cyclosporine (Atopica ; Novartis Animal Health, Greensboro, NC, USA) was started at 4 mg/kg PO every 24 hours for further immunosuppression and as an alternative to prednisone for immunosuppression in this patient. Pentoxifylline (Teva Pharmaceuticals, Sellersville, PA, USA) was started at 9.8 mg/kg PO every 12 hours to improve red blood cell deformability and reduce blood viscosity decreasing platelet aggregation and thrombus formation.
The patient was hospitalized for an additional 5 days prior to discharge (Figure 3). No further hemorrhage was noted from the nasal philtrum. 
Histopathology revealed large arterioles and arteries in the submucosa with infiltrates of plasma cells, macrophages, and cellular debris. Within the arterioles there was spindle cell proliferation with an extracellular matrix deposition resulting in intimal thickening and stenosis of the arteries and arterioles consistent with dermal arteritis of the nasal philtrum.
The patient was rechecked 10 days post-discharge and topical tacrolimus was resumed. Prednisone was weaned and discontinued. Fish oil (AllerG-3; Vetoquinol SA, Lure Cedex, France) supplementation was started at 3.9 mg/kg PO every 24 hours and Vitamin E (Nature Made ; Pharmavite, Mission Hills, CA, USA) was started at 7.8 mg/kg PO every 24 hours for anti-oxidant properties and has been previously noted in the literature to be useful in these patients. The cyclosporine was continued.
The patient remained clinically normal and was re-evaluated at 3 months postoperatively. The patient had returned to his normal attitude. The ulcerated areas of his nasal philtrum remained absent but there was mild depigmentation laterally on the right side. This was suspected to be scar tissue based on the location of the surgical incision. Laboratory evaluation with complete blood count, serum biochemistry panel, and total thyroxine were all within normal limits (Marshfield Laboratories, Marshfield, WI, USA). Cyclosporine was decreased to 2.9 mg/kg PO every 24 hours.
The patient was evaluated over the phone, email, and through the referring veterinarian (Figure 4). Cyclosporine wean was continued. At the time of this publication, the patient is on pentoxifylline, vitamin E, fish oil, and topical tacrolimus. The cyclosporine dose is 0.98 mg/kg PO every 24 hours currently and the plan is for a recheck at the 1 year postoperative date. The cyclosporine will be continued.