Which one is it?

[Cute Cookie]

My 11 yr old Shih Tzu Cookie began acting strangely a little over a month ago. I have visited my local vet, but they are not very proactive and it took a visit to an out-of-town vet to suggest Cushing's, or, because most of her basic tests returned in the normal range atypical Cushing's. At the out of town visit, dry eye and a very deep corneal ulcer were also diagnosed, so she is now also seeing an eye specialist who has suggested SARDS.
In my research, I have found more common symptoms with the onset of Sards (some blindness, could be the ulcer, small growths, head tremors, increased seasonal allergies not being helped my her meds). She does not appear to have any hair loss, but was on cyclosporin for almost a year and I have read that it can thicken her coat. She has all other observable symptoms.
What is the difference in the two diseases? How do I find out?

[StarDeb55]

Welcome to you & Cookie! The current line of thought for Cushing's & SARDS is that their is a relationship, but the experts aren't exactly sure what it is. The following link is from our important information section concerning SARDS. I think it will have some good information for you. The important information & resource section has tons of information on Cushing's, so you might want to take a look.

Has any actual diagnostic testing been done for Cushing's, such as a low dose dex test or ACTH? How long has Cookie been off cyclosporin? I ask because my first cushpup, Barkley, was also on cyclo for severe allergies. Cyclo is a major immune system suppressant, & that may be contributing to the corneal ulcer issues.

http://www.k9cushings.com/forum/showthread.php?t=213

Debbie

[sunimist]

Hi and welcome! Don't have but a minute now, but wanted to give you this link on SARDS. Hope it helps.
http://www.k9cushings.com/forum/showthread.php?t=213

Here is the link to our resourses and information page. Lots of good and helpful information here.
http://www.k9cushings.com/forum/forumdisplay.php?f=10

I have no expierence with SARDS, but others will be along shortly to give you more information.

Shelba and Suni~~

Sorry. Debbie and I were typing at the same time.

[Cute Cookie]

Thanks Debbie. I have seen that article about the Iowa tests. If it is SARDS, I will most likely accept the blindness, I just want my sweet dog’s personality and health back. Cookie had the ACTH Stim test and it was within normal – Atypical Cushing’s was then suggested. She is having the low dose dex test tomorrow morning.
Cookie began Cyclosporine 25mg every other day end of September. It was a miracle drug for her allergies. She also began this treatment with Ketoconozole which she took for about a month and then again in April/May. I don’t recall exactly when we upped her 25 mg dose to every day, but by June 2 her allergies were so bad that we upped it again to 50 mg every day. What I assumed were problems associated with the allergies and her lack of relaxation due to the constant scratching began around this time. I returned to the vet on June 19 because of her increased water, indoor accidents and other odd behavior. He took her off the cyclosporine and prescribed Temaril which we began on the 22. We (and Cookie) were away from this environment for 12 days and took the opportunity to see a vet in Atlanta to review her strange behavior. The ulcer coincidentally showed up on the day we had the appointment scheduled. This vet immediately diagnosed the dry eye and after several other tests including the ACTH told me to research/pursue the Cushing’s when I returned home.
My local vet has told me they use melatonin for Cushing’s treatment, but I just read that it is very bad for dry eye.
Mabry

[StarDeb55]

If you are using Temaril-P, that could very well be the problem The "P" is for prednisone. Long term use of steroids may induce what is termed iatrogenic Cushing's. The only thing that can be done is to slowly wean the pup off the steroids. How long have you been using the Temaril? Believe I know what a struggle it is when a pup has severe allergies, Barkley had horrible allergies, along with dry eye. He was a Lhasa/Shih Tzu mix. I agree the cyclo worked wonders for him.

You may want to hold up on the low dose that is scheduled. You can do both the low dose along with the full adrenal panel from UTK in one test. Take a look at the listing from the following link for adrenal panel, combined dex suppression. You want to check part "H" of the PDF. If you think you want to do this, you do need to wait as the samples need to be overnighted to the Univ. of Tenn., Knoxville, & there is no one in the lab to accept samples on the weekends.

http://www.vet.utk.edu/diagnostic/endocrinology/index.php

Debbie

[Cute Cookie]

Thanks...I will see if I can reschedule...didn't even think of that.
Also, she was only on the prednisone for less than a week so I don't suspect it to have much affect on her condition.

[Cute Cookie]

Hi Debbie,
I rescheduled for Monday. Thank you very much for mentioning that. So I have this correct, I opened the PDF, scrolled to Adrenal Panel (Combined Dex Supp / ACTH Stim) for dogs, #3 adrenal function, “H” Adrenal Panel with Combined Dex Supp/ACTH Stim Test for Dogs. So this is all three tests? She had an ACTH Stim test in Atlanta (out-of-town vet), it was in the normal range, possible atypical suggested. I am looking at the results but do not understand them. It says Cortisol Pre - 1.5 and then Cortisol 2 - 5.4.
My next question, can a low dose dex test be done at a variety of labs but only U of Tenn does the full adrenal panel? I am wondering if my local vet was going to do the low dose dex test elsewhere. I read under the forum the advantage of doing the full adrenal panel was because of the break of time needed if you split them up. I also spoke with the eye vet, we are going to hold off on the retina testing (SARDS) because of the severity of the ulcer and that she can still see out of her good eye, he says it affects both eyes. He suggested a pituitary gland tumor was another possibility. Will the U of Tenn tests address pituitary gland issues?

[StarDeb55]

I had this wonderful reply all typed for you, could have sworn I hit submit, but I guess I didn't, so I will try, again.


I opened the PDF, scrolled to Adrenal Panel (Combined Dex Supp / ACTH Stim) for dogs, #3 adrenal function, “H” Adrenal Panel with Combined Dex Supp/ACTH Stim Test for Dogs. So this is all three tests?
I believe that is correct, but to be on the safe side, I would suggest either you or your vet contact the UTK lab directly. Let them know that you wanted to do a low dose dex + full adrenal panel, & is this the panel order you need.


I am looking at the results but do not understand them. It says Cortisol Pre - 1.5 and then Cortisol 2 - 5.4.
This ACTH is within normal range.



My next question, can a low dose dex test be done at a variety of labs but only U of Tenn does the full adrenal panel? I am wondering if my local vet was going to do the low dose dex test elsewhere.
Correct, most any vet reference lab can do the testing for an ACTH, low dose dex, or high dose dex. As far as we know, UTK is the only lab in the country that is doing the full adrenal panel testing. I'm not sure what benefit a low dose dex is going to be with a normal range ACTH. IMO, I would ask your vet the reasoning for going ahead with an low dose, in light of the normal ACTH. You might also run this by the UTK lab.


He suggested a pituitary gland tumor was another possibility. Will the U of Tenn tests address pituitary gland issues?

Approximately 85% of pups diagnosed with Cushing's have a pit tumor, therefore statistically it's more than likely that is what Cookie's problem is. The only 2 ways to diagnose what type of Cushing's are through the low dose dex test which sometimes will not tell you which type. All you can determine is that the pup does have Cushing's. The other way is through an abdominal ultrasound on a high resolution machine which will take a look at the adrenal glands, along with all other internal organs.

Hope this helps.
Debbie

[lulusmom]

Hi and a belated welcome to you and Cookie.

Debbie has provided you with a lot of good information and answers to your questions but as someone that is coming in on the tailend of things, I have a lot more questions than answers for you. To make sure I was asking those questions in an order that makes sense to you and everybody else, I've posted my comments in blue within the body of your various posts below.


My 11 yr old Shih Tzu Cookie began acting strangely a little over a month ago. I have visited my local vet, but they are not very proactive and it took a visit to an out-of-town vet to suggest Cushing's, or, because most of her basic tests returned in the normal range atypical Cushing's. At the out of town visit, dry eye and a very deep corneal ulcer were also diagnosed, so she is now also seeing an eye specialist who has suggested SARDS.

Has Cookie experienced allergies her entire life or did her skin problems come on suddenly? Can you explain what you mean by acting strangely?

In my research, I have found more common symptoms with the onset of Sards (some blindness, could be the ulcer, small growths, head tremors, increased seasonal allergies not being helped my her meds). She does not appear to have any hair loss, but was on cyclosporin for almost a year and I have read that it can thicken her coat. She has all other observable symptoms.

Aside from blindness and common symptoms associated with cushing’s, I have never heard of the other symptoms you have listed as being associated with SARD’s. I’d be very interested in reading any reference material you may have for my own edification. I’ve done a lot of reading about SARD’s and unfortunately, it seems to be a mysterious condition that is not always accompanied by symptoms, before or after blindness. Can you please explain the other observable symptoms you mention?




Thanks Debbie. I have seen that article about the Iowa tests. If it is SARDS, I will most likely accept the blindness, I just want my sweet dog’s personality and health back. Cookie had the ACTH Stim test and it was within normal – Atypical Cushing’s was then suggested. She is having the low dose dex test tomorrow morning.
Cookie began Cyclosporine 25mg every other day end of September. It was a miracle drug for her allergies. She also began this treatment with Ketoconozole which she took for about a month and then again in April/May. I don’t recall exactly when we upped her 25 mg dose to every day, but by June 2 her allergies were so bad that we upped it again to 50 mg every day.

Ketoconazole is an antifungal that is also sometimes prescribed for cushing’s. Was this drug prescribed because Cookie’s skin issues involved yeast/fungus? There have been studies that show if Ketoconazole is given in conjunction with cyclosporine, the dose of cyclosporine can be reduced, thereby making treatment more affordable. Perhaps this was the reason by Ketoconazole was added to the treatment regimen????.

Can you tell us what skin condition Cookie has been diagnosed with and was she diagnosed by a veterinary dermatologist? Were skin scrapings, biopsies and cultures done to rule out and rule in various conditions?

Was Cookie still on Ketoconazole at the time the ACTH stimulation test was done? If so, the acth stim test would most definitely be skewed for diagnostic purposes. A dog with pituitary dependent cushing’s is usually producing too much cortisol, which by the way is the natural form of the steroid, prednisone, which is prescribed for severe allergies. A dog with uncontrolled cushing’s can have allergies as well as arthritis but neither may be apparent to the pet owner because the cortisol is keeping them in check. Once a treatment such as Ketoconazole is administered and the cortisol is reduced, these conditions are unmasked. Skin conditions can become much worse and arthritis pain becomes apparent. Did Cookie’s skin problems and itching increase after you started giving her Ketoconazole? Is she still on this drug?

What I assumed were problems associated with the allergies and her lack of relaxation due to the constant scratching began around this time. I returned to the vet on June 19 because of her increased water, indoor accidents and other odd behavior.

He took her off the cyclosporine and prescribed Temaril which we began on the 22. We (and Cookie) were away from this environment for 12 days and took the opportunity to see a vet in Atlanta to review her strange behavior.

FYI, Cyclosporine can cause urinary tract infections. Did your vet do a urinalysis and culture to rule this out? Aside from having accidents in the house, which is common with any number conditions, what strange behavior are you seeing at this point in time?

The ulcer coincidentally showed up on the day we had the appointment scheduled. This vet immediately diagnosed the dry eye and after several other tests including the ACTH told me to research/pursue the Cushing’s when I returned home.

Exactly what tests were done that led this vet to believe Cushing’s was involved? If he/she did a complete blood chemistry, he may have seen the common abnormalities that are usually seen in cushing’s. Unfortunately, a lot of those abnormalities are also seen in non cushingoid dogs that are being treated with cyclosporine. Cyclosporine can cause increase in liver enzymes, ALT & ALK, increase in cholesterol and triglycerides. These are all abnormalities that can point to cushing’s as well. Can you please get your hands on any bloodwork and urinalysis that were done and post the results here?

Can you tell me what drugs Cookie was on at the time the ACTH stim test was done? We are now looking at two drugs, Ketoconazole and Temaril, that can skew the results, of an acth stim test. If she was on neither at the time of the acth stim test, how long had it been since her last dose of either drug?

My local vet has told me they use melatonin for Cushing’s treatment, but I just read that it is very bad for dry eye.

I’m not familiar with this melatonin side effect but if true, could be a real concern to many of us whose dogs have or have had dry eye/conjunctivitis and have treated concurrently with melatonin for atypical cushing’s. There is so much information out there and so little of my brain is storing the useful tidbits anymore. Can you please let me know where I can find this information so I can bookmark for future reference?


Hi Debbie,
I rescheduled for Monday. Thank you very much for mentioning that. So I have this correct, I opened the PDF, scrolled to Adrenal Panel (Combined Dex Supp / ACTH Stim) for dogs, #3 adrenal function, “H” Adrenal Panel with Combined Dex Supp/ACTH Stim Test for Dogs. So this is all three tests? She had an ACTH Stim test in Atlanta (out-of-town vet), it was in the normal range, possible atypical suggested. I am looking at the results but do not understand them. It says Cortisol Pre - 1.5 and then Cortisol 2 - 5.4.

As I mentioned earlier, if Cookie was receiving any treatment like Ketoconazole or Temaril P at the time this acth stim test was done, the results would be skewed and you might as well have flushed the money down the toilet if your vet ran this for diagnostic purposes. If Cookie was not receiving either of these drugs for at least three to four days before the stim test then I would be more concerned that Cookie’s acth stim results are looking more like a dog that might have addison’s disease rather than cushing’s. With a pre stimulation draw of less than 2 ug/dl and only 5.4 ug/dl after injection of a stimulating agent, it looks as though Cookie doesn’t have much cortisol in reserve. This could be explained away if Cookie was taking Ketoconazole at the time.

My next question, can a low dose dex test be done at a variety of labs but only U of Tenn does the full adrenal panel? I am wondering if my local vet was going to do the low dose dex test elsewhere. I read under the forum the advantage of doing the full adrenal panel was because of the break of time needed if you split them up. I also spoke with the eye vet, we are going to hold off on the retina testing (SARDS) because of the severity of the ulcer and that she can still see out of her good eye, he says it affects both eyes.

A veterinary opthomologist is the only person than can give you a definitive diagnosis of SARD’s so I’m happy to see that you have consulted with one. It is my understanding that SARD’s does affect both eyes so I am not sure why your opthomologist cannot examine Cookie’s other eye to rule SARD’s out or in. Can you clarify for us? We don’t have a lot of members who were able to help us understand more about the diagnostic process for SARD’s so I’m hoping you and Cookie can do that for us.

He suggested a pituitary gland tumor was another possibility. Will the U of Tenn tests address pituitary gland issues?



Again, I am so sorry for asking more questions than providing you with any useful information but Cookie’s case is very confusing. I can be easily confused so I appreciate your patience with me. :o It's just that the drugs she’s been given can cause some symptoms that overlap or are identical to those seen in cushing’s; plus, without timelines, there is no way to tell if it is a suspected medical condition or a drug that is the likely culprit for Cookie's symptoms as well as the abnormalities your vet is seeing in her bloodwork.

[StarDeb55]

Glynda, does the following answer any of your questions?


I returned to the vet on June 19 because of her increased water, indoor accidents and other odd behavior. He took her off the cyclosporine and prescribed Temaril which we began on the 22. Also, she was only on the prednisone for less than a week so I don't suspect it to have much affect on her condition.

It sounds to me that the cyclo was stopped on 6/19 & the Temaril-P was stopped less than a week later.

Debbie

[lulusmom]

Glynda, does the following answer any of your questions?

.

It sounds to me that the cyclo was stopped on 6/19 & the Temaril-P was stopped less than a week later.

Debbie

Debbie, I did see this information but we still don't know if the acth stim test was done while Cookie was on Temaril P and/or Ketoconazole. With the relatively low acth pre and post stim results, I tend to suspect that Cookie may have been on Keto when the stim test was done. One would think that if she were taking Temaril P at the time, the results would be skewed in the other direction.

[apollo6]

Welcome from Sonja and Apollo
You are going a million miles a minute.
First read what cushing is, symptoms are loss of hair, pot belly, skin liaisons, darkened skin, weak hind legs.
Then you need to distinguish which on it is, if it is, PHD,(pituitary gland), Adrenal( one gland is larger then the other) or Atypical.
Your little fur ball is dealing with a lot of other issues which need to be addressed.
The tests for cushings:
full blood panel-to determine elevated readings
ultrasound- to see if adrenal glands are enlarged, liver enlargement, pancreas's, and kidney problems.
Then get the ACHT STIM Test,
Go to an Internal medicine specialist(endocrinology) familiar with cushing's, after all this , look into treatment options. You will be asked questions by the senior members. You are not alone, and you don't have to make a decision right now.

[Cute Cookie]

Got the results of the low dose dex test. Vet says she has pituitary Cushing’s and has recommended Trilostane. Our suspicions, will keep it brief because everyone here knows them. Lethargy, loss of playfulness/greeting me, extreme neediness, panting, frequent peeing/accidents, increased thirst, VERY increased appetite, head tremors, legs slipping underneath her, can’t get comfortable, wart-like growths on skin, distended stomach, NO hair loss but dull, rough coat. The changes came on so suddenly (May ‘10) I knew it was not just old age (11).
Cookie has had allergies for 7 years. We used to split time between South GA and Chicago. The allergies went away when we were in Chicago. We moved to GA permanently 5 years ago and the allergies have been non-stop. When away from here, the allergies subside. We did everything to try to cure this. She had allergy tests (9/06) and most of the culprits were local. Shots (1 1/2 yrs) did nothing at all. New vet said that is she was prone to allergies she would eventually develop them in another climate so he put her on cyclosporine in 9/09, it was the miracle cure! She took Ketoconozle for yeast and cost (one month each, Sept, May), but vet did not want her to build up an immunity so kept her just on Cyclo. By 6/2 allergies so bad we upped cyclosporine, this also coincides with “Cushing's symptoms”. Discontinued Cyclo 6/20...scratching (in another climate)...Temaril for 6 days (6/22). Off Temaril (6/28) because of severe, deep, eye ulcer and dry eye (6/29). ACTH test (7/1) – normal, only drug was a Temaril on 6/28. During this time, multiple blood/urine tests, x-rays, mostly normal. Only points of interest, elevated white blood cells, elevated liver enzymes and enlarged liver.
I am going to a specialty eye vet for the ulcer, he said to check out SARDS because of her other issues. My research (surfing internet for HOURS) shows most dogs with SARDS have Cushing's, dogs with Cushing's don’t necessarily have SARDS. SARDS affects both eyes, her “good eye” still works, so for now we are waiting. We did not do the test because of the severity of her eye ulcer...still to be cured, next appt 7/15. BTW, the eye vet said he had not heard melatonin was bad for dry eye, I read it here (http://www.dogcancerblog.com/more-melatonin-and-dog-cancer/). He also suggested a pituitary tumor based on notes/conversation.
Vet in Atlanta suggested Cushing’s based on observable symptoms and blood/urine. I’m not sure how to read the test, can you make some suggestions? I don’t see an ALK, I do see elevated ALP which is 647+. ALT is 68.
All of this info has been an accumulation of various vets. I have not been able to find a local vet I am pleased with since I moved to S Georgia, so have been visiting a variety of out-of-town vets.

[Cute Cookie]

wow, ya'll are quick. It took me a bit to get up last post.
Cookie was on Cyclopsorine from September 11, '09 until June 19, '10. In that time she went from 25 mg every other day, to every day (not sure when) and then it was upped to 50 mg every day on June 2, '10.
She was on Temaril from June 22-28. Two pills for three days, then one for three and had just been reduced to every other day which she took June 28.

[Cute Cookie]

One more, she was on the ketoconozole the beginning of May, don't know exactly when I took her off, but recall it being third week of May.

[Roxee's Dad]

Just a quick question: Are or were you using Temaril or Temaril P?

Temaril P does contain steroids and may contribute to cushing's like symptoms.

[Cute Cookie]

She was on Temaril P, but only for a 6 day period. All of her symptoms were evident far before the Temaril P use. I suspect that her ACTH test may have returned normal because of the medicine (it was done 4 days after she stopped the Temaril P).
Working on getting a copy of my test results, I am having a lot of problems with my local vet. I am also trying to get an internal medicine specialist referral from them - ends up they are in the same building as my eye specialist!

[lulusmom]

Hi Cookie's Mom (or Dad) :D

I see that you've provided more information for us as well as asked a few questions. If I weren't so burned out at the moment, I'd post my normal novel but will save that for tomorrow. Just wanted to let you know that I haven't forgotten about you and am checking in when I can. In the meantime, I will tell you that I think it's a great idea to get Cookie in to see an internal medicine specialist and how fortuitous that you happen to have an IMS in your eye specialist's building.

Glynda

[lulusmom]

Hi again,

I think my brain has had sufficient rest to put two sentences together without confusing you. :D See my comments in blue below:


Got the results of the low dose dex test. Vet says she has pituitary Cushing’s and has recommended Trilostane.

Can you please get the results and post them here? There should be three numbers; a pre or baseline draw, a four hour draw and an eight hour draw. The LDDS does not differentiate between pituitary based disease (PDH) or an adrenal tumor (AT); however, with 80% to 85% of dogs having PDH, the odds are that your vet's diagnosis is correct.

Our suspicions, will keep it brief because everyone here knows them. Lethargy, loss of playfulness/greeting me, extreme neediness, panting, frequent peeing/accidents, increased thirst, VERY increased appetite, head tremors, legs slipping underneath her, can’t get comfortable, wart-like growths on skin, distended stomach, NO hair loss but dull, rough coat. The changes came on so suddenly (May ‘10) I knew it was not just old age (11).

Everything you've listed is a symptom that can be associated with cushing's and while every dog is different, I don't think most have symptoms that come on as suddenly as Cookie's have.

Cookie has had allergies for 7 years. We used to split time between South GA and Chicago. The allergies went away when we were in Chicago. We moved to GA permanently 5 years ago and the allergies have been non-stop. When away from here, the allergies subside. We did everything to try to cure this. She had allergy tests (9/06) and most of the culprits were local. Shots (1 1/2 yrs) did nothing at all. New vet said that is she was prone to allergies she would eventually develop them in another climate so he put her on cyclosporine in 9/09, it was the miracle cure! She took Ketoconozle for yeast and cost (one month each, Sept, May), but vet did not want her to build up an immunity so kept her just on Cyclo. By 6/2 allergies so bad we upped cyclosporine, this also coincides with “Cushing's symptoms”. Discontinued Cyclo 6/20...scratching (in another climate)...Temaril for 6 days (6/22). Off Temaril (6/28) because of severe, deep, eye ulcer and dry eye (6/29). ACTH test (7/1) – normal, only drug was a Temaril on 6/28. During this time, multiple blood/urine tests, x-rays, mostly normal. Only points of interest, elevated white blood cells, elevated liver enzymes and enlarged liver.

I definitely think that the Temaril P was responsible for skewing the results of the ACTH stim test. As I previously mentioned, both the pre and post stim results were rather low, especially for a dog suspected of having cushings. When you administer oral or topic steroids, the adrenals glands can slow down and depending on the length of treatment, the adrenals can completely stop producing cortisol. Even though Cookie was only on Temaril P for a short time, it could have been long enough to see a drop in cortisol.

Undoubtedly Temaril P also contributed to the elevation in liver enzymes. There have been studies that show that despite the short half life of both ALT and ALK after an insult to the liver, steroids can cause those elevations to persist for weeks after steroids are withdrawn. The study I remember involved eye drops administered to healthy dogs for two weeks. Bloodwork done four to six weeks later still showed elevated liver enzymes. By the way, ALK, ALP and ALKP are all laboratory acronyms/abbreviations for alkaline phosphatase

I am going to a specialty eye vet for the ulcer, he said to check out SARDS because of her other issues. My research (surfing internet for HOURS) shows most dogs with SARDS have Cushing's, dogs with Cushing's don’t necessarily have SARDS. SARDS affects both eyes, her “good eye” still works, so for now we are waiting. We did not do the test because of the severity of her eye ulcer...still to be cured, next appt 7/15. BTW, the eye vet said he had not heard melatonin was bad for dry eye, I read it here (http://www.dogcancerblog.com/more-melatonin-and-dog-cancer/).

My research on SARD's showed that some dogs amy show symptoms associated with cushing's often before going blind but almost all dogs do become symptomatic within a few months after the onset of blindness. I think that if pet owners of all SARD's dogs were to have a full adrenal panel done at Univ. of Tenn reasonably soon after the onset of blindness, most, if not all, dogs would have one or more elevated intermediate hormones; however, these elevations often times are temporary. This is why some vet that are knowledgable of SARD's may choose not to treat typical or atypical cushing's because a good number of these dogs will improve on their own with complete resolution of symptoms within four to six months. Having said all that, I'm not yet convinced that Cookie has SARD's at all but your veterinary opthamologist will be able to confirm this.

I checked out the link to the blog above and I think it rather weird that this Dr. Dressler seems to be the only person that thinks Melatonin is bad for dry eye. I also noticed that a number of comments from pet owners with dogs that were diagnosed with atypical cushing's took exception to a number of Dr. Dressler's unsubstantiated comments that were in direct conflict with treatment recommendations by Dr. Oliver and his staff at the University of Tennessee. It seems that Dr. Dressler tired of his own blog and quit responding a long time ago.

He also suggested a pituitary tumor based on notes/conversation.

As I mentioned above, the majority dogs with cushing's do have a pituitary tumor but the only way to determine this is if the results of the LDDS is consistent with PDH and if not, an abdominal ultrasound or a high dose dexamethasone suppression test (HDDS) is done to make this determination.

Vet in Atlanta suggested Cushing’s based on observable symptoms and blood/urine. I’m not sure how to read the test, can you make some suggestions? I don’t see an ALK, I do see elevated ALP which is 647+. ALT is 68.

If you have a way of scanning Cookie's bloodwork, you can email to me and I'll be happy to post the abnormalities for you. One of our Moderators, Debbie, is a lab technician of many years and she's invaluable in helping us all understand the results of labwork. Let me know and I'll PM you my email addy.

All of this info has been an accumulation of various vets. I have not been able to find a local vet I am pleased with since I moved to S Georgia, so have been visiting a variety of out-of-town vets.

I really do hope you can get Cookie in to see an internal medicine specialist so that he/she can sort out all of the tests, confirm a diagnosis and ultimately direct treatment if necessary. In the meantime, we'll all be looking forward to the results of the LDDS.

[Cute Cookie]

Hi Lulu's mom,
Thanks for the info. If you will give me an e-mail address, I would like to forward her low dose dex test and blood/urine work to you, there is a lot of “wording” on them I don’t understand. Low dose dex test results: Pre Dex (result 5.7 ref range 1.0-6.0 ug/dL) Post 4 hr (result 0.6 ref range less than 1.5 ug/dL) Post 8 hr (result 4.6 ref range less than 1.5 ug/dL).
I am getting uneasy because the vet ordered-in Trilotsane, 30 mg/day for a 20 (now) lb dog and is ready for me to pick it up. This medicine scares me, not to mention very expensive, and in several of the posts I have read I want to make sure it will do the trick and not harm her. I will know more after my eye vet apt. tomorrow morning, but I suspect her eye is not healing and she is going to have to have surgery. She has been on so many meds for her eye (none steroid – Ofloxacin, NeoPolyBac, Optimmune, Metacam, Hydroxyzine, Zeniquin, and a serum made from her blood) that I am nervous about adding another. Which brings up another question. How was your dog after the low dose dex test? Cookie is very god with vets. She was so anxious to get home, cried in the car, she drank an entire bowl of water, ate but was not ravenous, put her face in front of the a/c vent and crashed on the floor like she was dead for the rest of the evening. It was very strange.
Thank you.

[lulusmom]

I just PM'd you my email address. The LDDS test is an all day ordeal and even my Lulu, who makes herself at home wherever she goes, including the vet's office, was wiped out beyond belief the day they did the LDDS. She was also thirsty as all get out so, I'm not surprised that Cookie wanted out of there and was totally exhausted.

[Cute Cookie]

Thanks...makes me feel better. I thought for sure she had taken a turn for the worse.

[lulusmom]

Cookie's mom emailed me Cookie's labwork and I'll try my best to posts everything that is pertinent. Even though Cookie's mom has already posted the results of the acth stim test, I'm including it again here so that all of the information is in one place.

ACTH - 7/2/10
Cortisol Pre = 1.5 ug/dl
Cortisol Post = 5.4 ug/dl

* Normal Response to ACTH 5.5 - 20.0 ug/dl


LDDS - 7/13/10
Pre (Baseline) 5.7 ug/dl
Post 4 hour 0.6 ug/dl
Post 8 hour 4.6 ug.dl

* Consistent with pituitary-dependent hypoeradrenocorticism (PDH)

Urinalysis - 6/29/10
Color - Yellow
Appearance - Cloudy
Specific Gravity - 1.030 Normal 1.015 - 1.050
PH - 5.5 Normal 5.5 - 7.0
Protein 1+ (HIGH)

Bloodwork 6/29/10
Unfortunately, I could not make out the CBC on the first 2/3rds of the page. I was able to read the blood chemistry and the only abnormality was elevated ALP
ALP 647 (29 - 158 ug/dl)
ALT, ALB, AMY, TBIL, BUN, CA, PHOS, CRE, GLU, NA+, K+, TP, GLOB all normal.

HEM 2+ LIP 3+ ICT 0

Hopefully, Debbie will be by to give us her thoughts.

Glynda

[Cute Cookie]

Thank you. Poor Cookie is in rough shape. The deeper part of her eye ulcer was not healing and so we opted for corneal graft surgery yesterday. Tough decision, but good thing because apparently it was getting worse and very close to rupturing. I told the vet that she had tested positive for Cushing’s and had read that Cushing’s dogs have problems recovering from eye problems like this. He does not suspect SARDS because she still has vision in her good eye, but said to keep watch on it and does not think testing is necessary at this time – in addition to the obvious reasons. She did not recover well from the anesthesia, it was horrible, she was up all night crying and there was nothing we could do to help her. We are back off to the eye vet again today, it has crusted over and we don’t want to mess with it. On that note, we have opted to hold off on starting the Tri for a week or so, she is on 7 new meds for her eye now and I don’t want to throw anything else into the mix. Keep your fingers crossed.

[BestBuddy]

Fingers are definitley crossed.

I don't think I would start the trilo until you get the eye problem sorted out, with so many meds for it it might just be too hard.

Corneal Ulcers are really painful and can be very hard to heal. My Buddy had a couple, one in each eye and had to have surgery to scrape the top of the ulcer(forget the name of the procedure at the moment) to help it heal.

Wishing you an Cookie good luck and good news hopefully soon.

Jenny

[Cute Cookie]

Best Buddy,
Glad to hear you've been through this too. Cookie's ulcer was too deep to do that procedure, she had an infection. I am VERY upset that my local vet did not catch this, or the dry eye, on her past two visits within a month. She actually had a piece of pig bladder graphed on to her eye. Once it heals they can trim the bladder back so she doesn't have as big of a blind spot. It is really weird looking.
We have pain pills now - hopefully we all get some sleep tonight!

[BestBuddy]

I do remember the pain Buddy was in so I am glad Cookie will be getting some relief in that regard.

know we were very lucky that Buddy's eyes healed with just the scraping of the ulcer and it was expected (Buddy was also diabetic) we would have to remove the worst eye so sometimes there can be better than expected results.

I hope that happens for you and Cookie too.

Jenny

[Cute Cookie]

I am going to ask the vet to re-fax this, it is very hard for me to read as well.

VEC 23.85 +
LYM 1.93
MON1.23
NEU 19.89 +
EDS 8.52
ERS 8.28
LY% 8.1 -
MD% 5.1 +
ME% 83.4
ED% 2.2
BA% 1.2
REC 5.79
HGB 13.1
MCT 38.66
MCV 67
MCH 22.6
MCHC 33.9
RDMc 15.5
PLT 450
PCT 8.42
MPV 9.1
PDMc 34.5

[Cute Cookie]

The surgery that Cookie had done, I quote “repair the ulcer using a collagen free graft (Acell) and a rotational conjunctival pedicle graft. The presence of the blood supply in the conjunctival graft will help us eliminate the bacterial infection. In addition, we placed a temporary tarsorraphy to help protect the eye”. What I understood of this is that she has a tiny piece of pigs bladder sewn on to her eye, this was done because the ulcer was so deep, down to the last layer of her eye, that no other procedures were safe. Once it heals, the bladder may be trimmed back, but she will always have a grey spot on her eye and some vision loss.
She appears to be healing well and a day after surgery the eye vet was pleased with both the success of the procedure and her response to the dry eye meds (which she is only getting in her good eye now). We did switch to the drops instead of ointment (my request) because I have a difficult time getting the ointment applied, however, after some posts I have read I am wondering if I should switch back?
I was very curious about some of the posts I saw on Barney’s page about dry eye going undiagnosed. In less than a month’s time, Cookie saw her local vet twice, I had mentioned that I suspected some vision loss but they did not diagnose the dry eye. The out-of-town vet saw her a week after her last local visit and spotted the dry eye (visually) immediately, which was confirmed in the test he did. So, what’s up with that?

[StarDeb55]

My Harley fought a non-healing ulcer in his left eye for about 7 months or so, in & around the time his Cushing's was diagnosed. My GP vet had actually ran a tear test twice during this period which always came back normal. When the eye ulcerated for the 3rd time, we were sent to the eye specialist who immediately did a repeat tear test which came back severely abnormal. I seriously don't know how one can foul up a tear test unless the test tapes were bad, but that is another matter. Harley has been on cyclosporin drops since & has had no further problems.

Debbie

[Cute Cookie]

Hi.
It’s been awhile since I’ve been on here and a lot of things have happened. Cookie’s ulcerated eye healed, but she went totally blind in both eyes very quickly. The eye vet wants to check for retinal activity, but what’s the point when all of the possibilities have no cure? After consulting with several vets, none being neurologists, it was determined that Cookie has a brain tumor as opposed to Cushing’s. I can’t put her under for a CT or MRI, which is what a neurologist will do, she had a terrible recovery from the anesthesia when she was under for the eye surgery. She completed her medicine regime for her ulcerated eye and we put her back on cyclosporine for her terrible allergies, even at the max dose, it was not the miracle drug it had been a year ago. Cookie’s “issues” have become extremely difficult, everything from before but ten times worse. With the blindness, I thought her other senses would grow stronger. Not the case, she no longer responds when you call her or make noises, mostly they just confuse her and she runs around and bumps into things. She is very anxious and cannot settle down, she will get lost in a corner even though the house is familiar. She pants constantly and will have little head ticks – but no seizures that I am aware of yet, she is at my feet most of the day. Eventually she wears herself out and will take a little nap – it is a 24 hour thing. She has some difficulty walking, and jumping/playing are out of the question. All she wants is food, absolutely ravenous, but you must put it to her mouth to get her to eat – she doesn’t seem to be able to smell where it is and she drinks a lot of water, her face is always wet – she used to shake off excess water.
So, going with the assumption it is a brain tumor, we put her on prednisone to see if that would help with anything. It will be two weeks Friday. Although I have not noticed as many head ticks, all of her other symptoms seem to have grown stronger, and in addition she is having accidents in the house.
Since the symptoms of the two conditions are so similar, I am wondering if the diagnosis against Cushing’s is correct. I am assuming I can’t do another ACTH test because of the prednisone. I also thought of switching over to the Trilostane to see if that would help, how long does it take to see results? I am just not sure what to do and both Cookie and I are miserable.

[labblab]

I am so very sorry that Cookie is doing so poorly. Her difficulties have to be very hard on both of you!

I have only a few moments to post right now, but just wanted to tell you that this may not be an "either/or" situation. Cookie may indeed be suffering from pituitary Cushing's, and it may be the pituitary tumor itself that is enlarging and causing these neurological problems. So she can be experiencing both the symptoms of Cushing's, as well as problems from the expansion of the tumor that is causing the Cushing's. Most pituitary tumors remain very tiny. But in some cases, the tumors increase to a size that places pressure on other areas of the brain ("macrotumors"). The kinds of symptoms that you are describing are consistent with this type of tumor expansion. Here's a link that will tell you more about this condition:

http://www.k9cushings.com/forum/showthread.php?t=229

It would take an MRI or CT scan to diagnose the tumor. If this IS what is causing Cookie's neurological problems, then currently in the U.S. the one treatment intervention with the greatest potential for improvement would be repetitive radiation therapy spread over the course of approx. one month. Experimental surgical reduction of the tumor is also being tried in at least one center in California, and we have one member here whose dog underwent successful surgery. But both of these options are very serious understandings, and I am putting the cart ahead of the horse. Do take a look at the link above, and see if what you read seems to correspond with what is going on with Cookie right now. If so, then we can talk about this in greater detail.

Marianne

[littleone1]

I'm so sorry to hear what has been happening to Cookie. I wish I could give you some advice. If she doesn't have Cushings, you don't want to give her the meds for it. You might want to see an IMS or another vet to get a second opinion. If she's having accidents in the house, she might possibly have a UTI.

I'm sending positive thoughts and healing prayers that you will be able to get some of the issues resolved.

Terri