Comet, 7 y/o Golden - Diagnosis Help!

[amelia]

Hi All
I am a new member & would appreciate your input and/or suggestions. I have (2) Golden Retrievers, 7 and 11 - both male.
My 11 yr old was diagnosed in April 09 & has been on 50mg of Trilostane & doing relatively well.(discuss in another post).

So, having some experience with Cushings, I think my 7 yr old (Comet) may have it as well.

Symptoms-excessive thirst & excessive amounts of urinating, ravenous appetite, weight gain without food increase, about 8 months ago he had facial nerve paralysis (now gone) & he has minor ear yeast (which he never had before).
Annual routine tests results-urine specific gravity low 1.005 (1.015-1.050), cholesterol high 337 (92-324), all other blood work & thyroid were normal. So we were concerned about the urine & repeated the test, withholding water for 11 hrs & 12 hrs. His gravity increased to 1.014 (still below normal)
urine cortisol/creatinine ratio -12 (below 13-Cushings syndrome is highly unlikely.)
uninalysis - negative for UTI
Low Dose Dex - pre 5.7 / 4 hr-1.4 / 8hr-<1.0 (could be false positive results)

We were thinking maybe diabetes insipidus but since he was able to concentrate his urine (although still below normal) & his appetite, I think we are ruling that out. So, it looks like we are back to Cushings.

I have not had an ultrasound yet only because all the other tests were negative & if it is really the beginning of the disease, the US may not show anything yet.

Am I overlooking anything? I appreciate any suggestions. At my wits end!!! Thanks

[StarDeb55]

Welcome to You & your pack! I'm sorry to hear that you may be facing another Cushing's diagnosis. I do have a couple of comments on the results you have posted. First of all, to the best of my knowledge, a negative result on urine cortisol: creatinine ratio means that you have now totally ruled out Cushing's. The other things that make me not suspect Cushing's are only an abnormal cholesterol on the chemistry profile. Most cushpups have several elevated liver function tests at diagnosis, including the alkaline phosphatase, ALT, & cholesterol. The alk phos being elevated is the most common abnormality, & it's frequently what will point a vet toward looking at Cushing's. Even though the LDDS indicates a possible positive result, the low dose can yield a false positive result in the face of non-adrenal illness. This is why a positive result on the low dose needs to be confirmed by a second test. You're correct about a cushpup not being able to concentrate their urine, but I'm almost positive that a cushpup can't concentrate their urine under most circumstances. The fact that your pup did concentrate his urine when he was dehydrated, IMO, also rules that symptom out. Have regular diabetes & thyroid been ruled out?

I wanted to make a couple of further comments about the cortisol:creatinine ratio. My 2nd boy, Chewbacca, has shown a lot of typical Cushing's signs in the past year or so, including skin/hair issues, ravenous appetite, repeated ear infections, among others. I was so freaked out that he might have Cushing's as he might have been my 3rd cushpup, I insisted that a UCCR be done on him which came back negative. I have had 2 vets, my general practice vet & derm vet, assure me repeatedly that a negative UCCR means that Cushing's is absolutely not in the picture.

Hope this helps.

Debbie

PS- I see that you did say thyroid was normal, that leaves regular diabetes.

[labblab]

Low Dose Dex - pre 5.7 / 4 hr-1.4 / 8hr-<1.0 (could be false positive results)

Hi and welcome from me, too.

I can imagine how frustrating this diagnostic process has been for you, and how anxious you are to get to the bottom of Comet's problems. However, it appears to me as though the LDDS result that you posted above is strictly negative for Cushing's -- I am not seeing the possibility of a "false positive." The 8-hour sample is the one that determines the overall Cushing's diagnosis, and to be "positive," you are looking for a result greater than 1.4. Since Comet's 8-hour result was less than 1.0, his test result was not consistent with Cushing's. (The 4-hour result only has significance if the 8-hour result is greater than 1.4).

Here is an explanation of LDDS testing written by Dr. Edward Feldman:


Low Dose Dexamethasone Test (LDDS)
The protocol utilized for this test is obtaining plasma samples
for cortisol before and 4 and 8 hours after I.V. administration
of 0.01 mg/kg dexamethasone. The 8-hour plasma cortisol
is used as a screening test for hyperadrenocorticism, with
concentrations >1.4 μg/dl being consistent with (not confirming)
the diagnosis of Cushing's syndrome.
Since both the UC:CR and the LDDS results were inconsistent with Cushing's, it seems highly doubtful that elevated cortisol is the cause of Comet's symptoms. One other thought...I wonder whether Comet may be suffering from elevation of sex hormones or adrenal steroids OTHER than cortisol. This condition is labeled as "Atypical Cushing's," and is diagnosed by sending blood samples to the lab at the University of Tennessee at Knoxville for analysis. Here's a link that better explains this condition:

http://www.k9cushings.com/forum/showthread.php?t=198

UTK testing of a full adrenal panel includes an ACTH test as well, and the ACTH would be one last method by which you could test for conventional Cushing's via blood samples.

Comet's situation is really a puzzle. Once again, I'm so sorry that you are struggling with this. But I am really glad that you have found us!

Marianne

[labblab]

One other suggestion occurs to me. Was Comet's UC:CR performed using only a single day's urine sample? One of our members, Dr. David Bruyette, is a veterinary endocrinologist, and he has warned us that UC:CRs can be of questionable value unless a pooled sample is analyzed:


Urine cortisols can be a problem. Many studies have shown that the only way to accurately gauge urine cortisol levels is to obtain the first morning voided urine sample on 3 consecutive days and then pooling the urine to run a UCCR. When done in this fashion it is likely an accurate test. Otherwise there is likely too much day to day variation to make a single random cortisol very helpful.
If Comet's original test was not performed on a pooled sample, that would be one easy and inexpensive "retest" that you might wish to ask for. One tip: the pooled samples should be refrigerated until you are ready to deliver them to the vet for analysis.

Marianne

[Squirt's Mom]

Hi and welcome to you and Comet! :)

I have to agree with Marianne and the others....based on the test so far, true Cushing's is out of the picture. However, Atypical may be present.

The test you have had done test for cortisol levels only. The UTK (Uni. of TN in Knoxville) tests for 5 other hormones, called intermediate or sex hormones, that can cause the same signs as true Cushing's. Pups with Atypical do not have elevated cortisol yet present as if they do.

In addition to ruling out hypothyroidism and both diabetes, I would strongly suggest two more tests - the UTK panel and an abdominal ultrasound. These two tests will tell you a great deal more than whether Comet has elevated intermediate hormones.

Please keep in touch and let us know how Comet is doing and what you decide to do from here. Ya'll are family now and we will worry if we don't hear from you. :) We will be here to help you in any way we can so don't hesitate to ask questions or just talk if you need.

Hugs,
Leslie and the girls - always

[amelia]

Hi,
Thanks for your reply. The (2) additional urines were done on (2) different days, withholding water 11hrs & 12hrs & were refrigerated. Is that what you mean by pooled sample?
As far as the other elevated tests, that is not always the case. My other Cushing dog (Boomer) did NOT have an elevated ALT, liver or Alk Phos & he was initially a mystery too. In fact, his ALT Phos was never elevated. We went through months of testing before coming up with Cushings. They were first considering Lyme Disease since he tested positive & then later tested negative. (drove me nuts)

I am trying to eliminate the same thing I went through with Boomer now with Comet. Many months of testing & thousands of dollars later.

The only similar symptoms between the 2 boys are the excessive drinking & eating. Comet is not panting, no hair changes etc. The main issues that drove us with Boomer was protein in his urine on his annual routine test. Although his urine gravity was normal. Now with Comet, the concern was the low urine gravity. All other test are normal except high Cholesterol. I read the info on "Atypical Cushings" & he does not have any of those symptoms either.
Could it be whatever he has is so early on that he is not showing all the signs of that disease?

My vet referred me to an internist, who is also treating Boomer for Cushings. His next suggestion is to have the ultrasound to completely rule out Cushings & then we go from there. I am not really anxious to do the US, because I feel we may be missing some other illness & was trying to eliminate other things first. I decided to wait until the weather gets warmer to do the US, since they shave so much & it has been one COLD winter here in PA. And, I would be more open to the US if he showed more signs of Cushings. Also, as a Golden, we hate getting our hair shaved.

It's tough & I don't know what to do.

[jrepac]

the "pooled" sample is when you gather an equal amount of morning urine for each of 3 successive days and combine them...which will likely give you a more accurate reading in the UCCR test..

I feel your pain w/the rounds of testing; been there, done that.

still, your test results below seem to point away from Cushings...including the lack of higher Alk Phos, which I have become accustomed to

But the symptoms you describe are Cushings like...you should consider the UTK testing for Atypical Cushings (it is the ACTH w/full profile)...the other hormones, if elevated cause very similar symptoms...in my case, the cortisol level and 3/4 of the other hormones were well above average....plus, if Atypical is present, the treatment reccos are a bit different

Good luck~

Jeff

[ventilate]

I would not rule out DI. I had 2 dogs that both have DI. Nike was my cushings dog as well as DI ( lost her in Oct) and my other dog Kenai also has DI. Nike had the water dep test at the vets and she was able to concentrate to 1.014 I think and the IMS I was seeing said that was not enough and it was diagnosic for DI. I started her on the DDAVP drops and she concentrated to 1.020-1.030. Kenai we just tried the drops and he was at 1.002-1.003 and he concentrated to 1.025 I believe, on the ddavp.
Sharon

[O'Riley]

What is DI ?

[frijole]

diabetes insipidus -

http://en.wikipedia.org/wiki/Diabetes_insipidus

http://www.indulgedfurries.com/petdiabetes/diabetes_insipidus.htm

[Harley PoMMom]

Diabetes insipidus
(DI) is a metabolic disorder characterized by excessive, extreme urination, and accompanied by undue thirst. It is either caused by impaired production of a hormone called ADH (anti-diuretic hormone) from the brain (central DI), or an impaired ability of the kidney to respond properly to the ADH (nephrogenic DI).

[amelia]

Hi
I appreciate all your info & suggestions. I contacted Dr. Oliver from Univ Of TN & spoke to him regarding Comet's symptoms. He agrees that it could be Atypcial Cushings. I have all the info & plan on seeing my vet tomorrow & request a blood sample to go to Univ of TN to test for this. I also asked him about DI & he thought that when we held water back on Comet, he was able to concentrate to 1.014 & if he had DI, he would not be able to concentrate at all.
Hopefully, after this panel of testing we will get a diagnosis. Will keep you updated. Thanks again!

[StarDeb55]

Just make sure that your vet sends the samples directly to UTK & not to the lab he normally uses. When the samples are sent to the regular lab, all they do is forward them to UTK, & they tack on extra charges because they have been involved in the handling.

Debbie

[amelia]

Comet Update-
He still remains a mystery! He had another low dose dex & SO NORMAL. All his blood is also normal. My vet does not think it is cushing or atypical cushings. We are discussing ultrasound to check kidneys & adrenals. But I told him I can't go all over the place & get nuts with all this testing. It is getting very expensive. I would like him to decide what his gut is telling him what is wrong & then I will test. I don't think he knows what it is.

I am collecting more urine samples to be tested, because his specific gravity is low. DI is still not out of the picture. But none of his symptoms totally point to one thing......drinking like crazy, ravenous appetite, urinating alot because of all the drinking, weight gain, low specific gravity, alot of ear wax (always had clean ears before) & alittle high cholesterol (327).

Oh, he said one possibility could be Psychogenic polydipsia & the weight gain could be unrelated. I can't feed him any less, he is always hungry. The vets are at a loss.

On another note, the oncologist checked the pigmented lesion & thinks as I did, it could be a melanoma. So now we are off to the surgeon. Melanomas on the body are 85% benign. It's more important to get this resolved & then we will be back to other problem.

When will it all end!!!

[O'Riley]

Amelia....thank you for the update. Can you refresh my memory about something? How/when was regular diabetes ruled out?

~Rosey

[amelia]

Regular diabetes was ruled out because his glucose is 82. Normal range 70-138. We are redoing the urine gravity testing now for diabetis inspidius. Very frustrating. Will let you know what happens.

[Harley PoMMom]

Could you do me a favor and post Comet's calcium numbers with the reference ranges, please. :)

Love and hugs,
Lori

[amelia]

Calcium 10.4 (range 9.8-11.7) curious, what are you looking for?

[Harley PoMMom]

If the calcium is in the high normal range than this could make a pup urinate and drink more...Hypercalcemia is also an indicator for other diseases but I see that Comet's is well within the normal ranges! YAAA!!! ;):)

Love and hugs,
Lori

[amelia]

Well, I took 4 urines to the vet yesterday to test again for the specific gravity. 3 were below normal & 1 was in the normal range. It was 1.031 & the range is 1.015 to 1.050 so if he can concentrate urine then it is not diabetes insipidus.
Now, I am back to square one!:(:(

I don't think we will do any further testing. We decided that either the drinking could be psychogenic & the eating unrelated OR it still could be Cushings but it is too early on to show up in the tests.

Before Boomer was diagnosed he always had a good appetite & liked to drank alot but it gradually increased & then the panting started....that's when he was diagnosed.

I read that a dog can have Cushings up to 5 years before it is actually diagnosed. This could be Comet's case & I probably wouldn't think anything of it except for my experience with Boomer.
I guess we will wait & see. I hate not having a definitive answer but we will retest in 6 months.

[amelia]

Good News! (for a change)
Comet's lesion was benign.

[labblab]

YAY!!!!!!!!!!!!!!!!!!!!!!!! That's such great news! :D :) :D :) :D

Thanks so much for letting us know!
Marianne

[MiniSchnauzerMom]

Wonderful news that Comet's lesion was benign! Good news always welcome and appreciated. :D :D

Louise

[amelia]

Thanks for all your good wishes......it paid off!