Willow, 8 Year Old Bichon Frise, Newly Diagnosed

[willow2002]

Hi,

Willow and I are so happy that we found a place with so much information to help us with understanding Cushing's disease.

Willow is a 17lb, female Bichon Frise. What prompted me to take her to the vet was excess water drinking, panting, urination, loss of coat luster and some hyperpigmentation.

The vet started out with a blood panel. Here's the results:
ALB 4.6 (2.5-4.4 G.DL)
ALP 24 (20-150 U/L)
ALT 77 (10-118 U/L)
AMY 461 (200-1200 U/L)
TBIL 0.2 (0.1-0.6 MG/DL)
BUN 12 (7-25 MG/DL)
CA 11.9 (8.6-11.8 MG/DL)
PHOS 4.0 (2.9-8.6 MG/DL)
CRE 0.8 (0.3-1.4 MG/DL)
GLU 114 (60-110 MG/DL)
NA+ 149 (138-160 MMOL/L)
K+ 3.7 (3.7-5.8 MMOL/L)
TP 7.1 (5.4-8.2 G/DL)
GLOB 2.5 (2.3-5.2 G/DL)

He also did the low dose suppression test. Here's the results:
Baseline 199 (15-110 nmol/L)
4 Hour 29 (0-30 nmol/L)
8 Hour 137 (0-30 nmol/L)

She's been diagnosed with PDH. My vet would like to start her on Vetoryl using the 1 mg / kg approach.

Any thoughts or comments would be very much appreciated.

Thanks,
Leslie

[mytil]

Hi Leslie and welcome to our site, glad you found us.

Sorry but I do have a few questions.

Was the LDDS test the only one performed to diagnose Cushings? If not, please post the additional results - I say this because typically a ACTH test is performed and/or an abdominal ultrasound is done especially to determine if it is PDH or ADH (adrenal dependent).

I converted the nmol values to ug/dl values by dividing by 27.59 as most are familiar with these and you can read the LDDS results chart easier.

Baseline 199 (15-110 nmol/L) = 7.2 ug/dl
4 Hour 29 (0-30 nmol/L) = 1.05 ug/dl
8 Hour 137 (0-30 nmol/L) = 4.95 ug/dl

Here is a link to a flow chart for LDDS results - (there are others listed, but goto the LDDS chart) http://www.k9cushings.com/forum/showthread.php?t=217. You can see the results you have posted are indicative of a Cushing's diagnosis. The baseline does seem a bit high though. Was your girl unusually stressed or taking any other type of medication?

Here is the link to the Trilostane information - http://www.k9cushings.com/forum/showthread.php?t=185. I know others will chime on this as there are two schools of thoughts on the dosage protocols (of which does not indicate both are incorrect, it depends upon the dog and the vet).

Here is the link that describes more on the blood panel and what each one is - What do those Lab tests mean?
http://www.vetmed.wsu.edu/ClientED/lab.aspx

These values showed slight elevation but I am sure others will chime in shortly on these.

ALB 4.6 (2.5-4.4 G.DL)
CA 11.9 (8.6-11.8 MG/DL)

Terry

[willow2002]

The LDDS test was the only one performed. The specialist said that since she suppressed at 4 hours, but the value went up at 8 hours this was indicative of PDH.

Willow has not been taking any other medication. We did two courses of Rimadyl earlier this year for an inflamed disc in her back. So she took it for about a month. Other than that only her heartworm pill.

She does get a little stressed out going to the vet, but I wouldn't call it excessive.

Thanks,
Leslie

[lulusmom]

Hi Leslie and welcome to the forum.

I am sure that our lab tech expert, Debbie, will be by to give your opinion on Willow's blood chemistry but I don't see the usual abnormalities we see with cushing's. Typical abnormalities include increases in ALP, ALT , cholesterol, tryglycerides and a decreased or low-normal BUN. Glucose can also be elevated with cushing's but the mild elevations like Willows can also occur with stress. The most common reason for mild increase in albumin is slight dehydration and since there is a relationship between albumin and calcium, it isn't uncommon to see a slight increase in calcium if there is a slight increase in albumin.

We have seen vets that confirm a diagnosis based on overt symptoms, bloodwork abnormalities and an LDDS but all were totally consistent with cushing's. Willow's bloodwork is, in my opinion is absolutely not consistent with cushing's and therefore, also in my non-expert opinion, your vet should have done additional testing, in particular, an abdominal ultrasound to take a look at the adrenals and the surrounding organs. The LDDS is considered by some to be the gold standard in testing for cushing's but is has it's issues, like all the other diagnostic tests, and is more likely to yield a false positive result in the face of non-adrenal illness. Cushing's is a difficult disease to diagnose and a lot of the symptoms associated with cushing's are shared with other conditions. I'm not saying that Willow doesn't have cushing's, I'm just saying that with blood work that wouldn't otherwise raise an eyebrow and no abdominal ultrasound to confirm the usual organ abnormalities consistent with cushing's, how can your vet be so certain that Willow doesn't have something else going on that has caused a false positive LDDS? :confused:

I am sorry for the circumstances that brought you here but I'm really glad that you found us. It's not an easy disease to wrap your head around and I discovered that this forum saved my sanity by supporting and educating me until I was able to comprehend a lot more. We're here to help you in any way we can by sharing our experiences and providing a wealth of reference material in our Resources forum. I highly recommend that you read all that you can in your spare time. Ha, spare time, who has much of that these days? :D Here's a link to some really great info for pet owners that are new to the disease. Let us know if you have any questions and we'll do our best to give you appropriate feedback.

http://www.k9cushings.com/forum/showthread.php?t=180

Glynda

[willow2002]

Again, thanks so much for your help. I talked to my vet and I'm going to set up an appointment to get an abdominal ultrasound done.

Leslie

[apollo6]

Welcome
the other members are right get the other tests. The ultrasound will show if both or only one adrenal gland is enlarged and if the other organs are enlarged-pancreas, liver, kidney.

You need to determine which form of cushing Willow has before you even think about any treatment.
Apollo is on Trilostane , but only after I did the full blood panel, the urinalysis, ultrasound, and ACHT STIM TEST. I went to another other specialist, because I did not like the option I was given. I read up on the medications before deciding on which one was best for Apollo. When you are that far late us know what the vet wants you to start and what dosage.
Many vets start our fur balls on to high dosages which can be bad. Apollo weighs 10lbs, I with the help of input from the members only started him on 10mg. and he has been doing fine. But because of hind leg weakness, the vet -internal medicine specialist decided to go up to 12.5 mg. compounded. Each case is different.
Hugs Sonja and Apollo
p.s. Willow is a cutie

[StarDeb55]

Leslie, I'm kind of late, but I would like to welcome you & Willow! I'm in total agreement with Glynda, there is nothing in Willow's general labwork that "screams" Cushing's. The typical abnormalities that Glynda mentioned, alk phos, ALT, cholestrol, are all liver function tests. With the excess production of cortisol by the adrenals putting stress on the liver since it has to process all of this cortisol, this will raise most of the liver enzymes. Frequently, an elevated alk phos is what will point a vet at Cushing's. Glynda has already explained the inherent problem with basing a diagnosis on a LDDS only, so I'm really glad to hear that you will be getting Willow in for an ultrasound. One thing about the ultrasound, you want to make sure that it's done on a high resolution machine so both adrenals are clearly visualized. Most general practice vets will not have this type of ultrasound.

Keep us posted.

Debbie

[willow2002]

We just got back from the ultrasound. My vet had me got to a specialist in the area because he said his equipment would not be adequate for looking at the adrenal glands.

The specialist said her adrenals are normal sized and no internal organs are enlarged.

I haven't had a chance to talk this over with my vet yet. But it seems to me that I should not start any meds and retest her in about 6 months.

As always any thoughts or help would be appreciated.

Thanks,
Willow and Leslie

[Squirt's Mom]

Hi Leslie and welcome to you and Willow! :)

I'm Leslie, too! :D

My cush baby is Squirt and her story is a bit different - and one I think may help you.

She was also diagnosed with PDH - based on five tests. But a second ultrasound found a splenic tumor. Once the tumor and part of her spleen were removed, her cortisol returned to normal, making the original diagnosis of PDH questionable. We are currently waiting on her latest test results to get the final answer...hopefully. :rolleyes:

Here's the deal - cortisol is the body's natural response to stress, whether external or internal. The physiological stress of that tumor caused Squirt's cortisol to elevate, making every test she had come back positive. Her story is just one reason to take your time, have thorough testing done leaving no stone unturned. Cushing's is a slow progressing condition so you have time to make sure of what you are dealing with.

Based on the test results posted, my suggestion is to have her intermediate hormones tested before you start treatment, especially with Trilostane as it is known to elevate some or all of these hormones. Elevations in one or more of these other 5 hormones, but with normal cortisol results, is a form of Cushing's called Atypical. Atypical causes the same signs as true Cushing's (elevation in cortisol) but can only be tested thru the Uni. of TN in Knoxville (UTK). That is the only lab in the world that is testing for this form of Cushing's. It's treatment is different as well.

I'm glad you found us and hope to learn more about you both in the future. Keep in touch, keep reading and asking questions...we will be here to help you. You and Willow are family now and no longer alone on this journey.

Hang in there!
Hugs,
Leslie and the girls :D - always

[Casey's Mom]

Hello and welcome Willow and Leslie:)

There is a screening test you can do which is inexpensive called a urine cortisol creatinine ratio, which is a rule out test. You would collect urine from Sophia at home, preferably the first morning pee, & take it into the vet. A positive result indicates that Cushing's is possible but further diagnostics are required. A negative means you aren't dealing with Cushing's & you're done. Cushing's is probably the most difficult endocrine disorder to diagnose in our pups, so you want to make very sure you have a confirmed diagnosis before you start either medication, lysodren or vetoryl.

To further what Leslie said this is a slowly progressing disease and it is very important that you have a confirmed diagnosis before you begin treatment as the drugs could be quite harmful if used on pup who does not have cushings.

We are here for you so ask lots of questions okay?

Hugs,

[Squirt's Mom]

Mornin' Leslie,

How are you and Willow today? We would love to hear from you when you get a chance!

Hugs,
Leslie and the girls :D - always

[willow2002]

We're good today. Willow's getting used to her shaved belly. Her little sister Mazie (my 5 year old Bichon) was pretty mad that she didn't get to leave the house too yesterday. I keep trying to tell her that she doesn't really want to go where Willow is going. :)

I called my vet this morning to talk about the ultrasound results, but he's off today. The other vet is going to call me tomorrow, so I'll keep you updated.

Thanks for asking. Have a great day everyone.

Leslie, Willow & Mazie

[apollo6]

We'll be waiting to hear from you.

[willow2002]

Hello everyone! I hope you're having a good evening.

I talked to my vet today. Since Willow's symptoms are not excessive (not affecting her quality of life) and in light of her blood panel and ultrasound results, we are not going to start any medication at this point. We're going to retest her in 6 months and see if there has been any changes in her LDDS numbers and blood work.

Have a great weekend.
Leslie, Willow and Mazie

[gpgscott]

Hi Leslie,

Waiting for a period and retesting is a pretty common approach at this point given your situation. It will probably be harder on you than on Willow.

Try not to obsess too much and please continue to update us with her condition during the wait.

Best to you both. Scott

[willow2002]

I do have a few questions. With PDH how often does the pituitary tumor grow large enough to cause neurological problems or be cancerous? Can Cushing's be caused by environmental factors? I live in a small condo development (about 70 units) and there have been about 3 cases of Cushing's that I know of which seems like a high percentage.

Thanks so much for your help,
Leslie, Willow & Mazie

[StarDeb55]

Leslie, when the tumor begins to enlarge, it's termed a macroadenoma. Size is the determining factor for micro vs. macroadenoma, & I believe macros have to be a minimum of 10 mm. in diameter. As far as I know, malignant brain tumors are pretty rare in canines. When it comes to environmental factors, probably not. Keep in mind that Cushing's is a disease of middle & old age for our pups. There are probably a lot more pups who have Cushing's than anyone is aware of as the symptoms are very easily passed off as aging. I think the following link will answer some of your questions in more detail.

http://dogtime.com/hyperadrenocorticism-canine-cancer-library.html

Debbie

[AlisonandMia]

I'll try to answer your questions as best I can:

I don't know in what percentage of dogs the pituitary tumor grows large enough to cause neuro problems. Various authorities seem to report different numbers. It does seem to be something that is seen more often in some breeds than others - in Boston Terriers and Boxers for example it seems to be something that sadly happens more often than not and on the other hand I don't believe we have ever seen a Mini-Schnauzer with a macro tumor (despite seeing quite a few Mini-Schnauzers here). With other breeds it seems to be much less predicable - but most don't end up with a macro tumor. Most macro tumors seem to make their presence felt within the first 1 or 2 years of diagnosis from what we have seen here.

This is purely speculation on my part, but I think it may not necessarily be just the size of the tumor that causes problems either (although it would have to be large, of course) but also possibly the direction in which it grows. My little dog turned out have a large macro tumor - which never caused her any problems! (She passed away from another totally unrelated brain tumor, and in the course of diagnosing that (CT scan) the macro pituitary tumor was seen.)

I don't believe these Cushing's-causing tumors are ever cancerous although I have heard of a dog with a pituitary cancer. That dog did not have Cushing's as a result as that cancerous tumor did not produce ACTH, the hormone that causes the adrenals to over-produce cortisol in Cushing's.)

I don't think any environmental cause for Cushing's has ever been suggested or found. It seems to me to be a mixture of genetics and bad luck, really. Some breeds are considerably more prone to the disease than others and it isn't that unusual for siblings to develop the disease at around the same age which suggests a strong genetic predisposition, too. It is said the smaller breeds are generally more prone to Cushing's so this may be why it would show up in dogs living in a condo complex. The disease is also, I would think, more likely to be more visible among better-off and dedicated pet owners as these owners are more likely to be willing and able to help their dogs whereas others may just have to (or choose to) quietly get rid of a troublesome pet who has taken to urinating indoors - which is a very common presenting symptom.

I think if I had a newly diagnosed Cushing's dog and I could afford it, I'd be looking into having a CT scan to see how big the pituitary tumor is - just so I could have some idea of what to expect. This is just my thinking though I'd definitely get vet advice on that one before forking out the $ though - and an anesthetic is required for the CT and that would have to be factored into any decision making as well, of course.

Alison

[lulusmom]

According to a lecture given by Dr. David Bruyette in 2008, approximately 30% of dogs diagnosed with hyperadrenocorticism have a micro tumor and 40% have a macrotumor. That's a surprisingly large number of dogs; however, the vast majority of dogs with a macro do not show any neurological signs. As Alison mentioned, there seems to be a predilection in certain breeds to have an enlarging macro that eventually causes neuro problems.

As far as environmental factors, who the heck knows. I believe we live in a toxic environment and I am personally seeing more and more cancer in my friends and family, most of whom have no family history of it. Cushing's is pretty rare in people and it is know that the cause in people 100% genetic; however, numerous studies have been done in dogs and no genetic mutations/markers could be identified. I wish some of the siblings we have seen here with cushing's had been in one of those studies. :( Nobody seems to know what causes canine cushing's but the experts believe it is a neuro degenerative disease that manifests itself as a dog gets older. That's all fine and good but one of my cushdogs was only 3 years old at diagnosis so what is a person to believe? I have two dogs with cushing's so I think I'll go with Alison's bad lucky theory. :D