Maggie: Now, Calcinosis Cutis, End stage of Cushing's?

[Maggie]

Hello I have a 7 year old Boxer named Maggie who we think has Cushings. Back ground: We started started noticing Maggie was having problems a few months ago now looking at it there were so many signs before that.
She has always been what we tease as a walking med bill with demodex as a pup and skin allergies. She took shots till we moved to Okinawa 2008 (she was age 5 at 57lbs then). She could not get the injection meds there so we let her go off them and her skin was good. We blamed it on the climate change. She did not even need benedryl for mild flares...amazing for this dog:) There she started getting very bad uti's that were re current and did not react to many of the antibiotics. We did the clean needle catch going thru her abdomen and she still took a long time to get over it.
Last year in June we took our glasses off and realized she was overweight big time. She was 73 lbs so we took her in to the vet. We looked into thyroid issues because she was drinking alot and eating everything. She never got into the garbage before and was doing this now. She would eat bars of soap even...anything she could get to she did. The tests came back as one high and one was low. (she also had surg and had seven "skintags" that were very dark removed) So no thyro issues no canx. Dr. said she just need to get more exercise. In Japan our yard was like 10x20 and her yard wsa over half acre in the states so we agreed must be lack of excercise and over eating. Put her on diet food and from July to November she only lost 3lbs:(
Nov 2010 we moved back here to the states and Maggie just started looking potbellied instead of fat all over. Her water intake was so obsessive she was always trying to get into toilets and peeing... she had her first accident in the house this month and is waking up in the middle of the night to wiz 2-3 times. She started getting some red marks in her skin on the shoulder blades. For some reason I looked in her mouth and there is was a large mass attached to the gum line. I took her to the vet and they did a panel on her. We were informed to her demise that she was now classified as a senior at not even 8:( We scheduled a surgery to take the mass out and biopsy it.
At this time March 2011 she was potbellied, ravenous hungry, way over board on water, no shine at all to her coat, she was getting dark spots in all of her white areas, very lathargic, hair is thinning...never has come back from the 7 tag removal sites, hind legs are weaker she kind of dragges her back paws (looks like she is stubbing her toes), the skin on her belly is thin and flaky, her skull is so bony and her hips and shoulders are more promenantmaybe from belly sagging) lastly the crusty bad hair/skin on her shoulders was growing by the week. I started web browsing and came up with melanoma and Cushings as possible culprits. We did the surgery on her mouth two weeks ago and it was not cancer. Her levels of liver enz were thru the roof but she did not have anything with that to look at problems like liver failure. They corelated with the increased levels (a couple other things were increased also)in diseases like Cushings.
This week I took her in for post op and her skin "rash" that was getting worse by the day...literally now it was bigger than my hand and getting hard with discoloration..losing hair too. Doc did skin scrape and it started to bleed results are no demodex/ mange said she it was a "deep pyoderma" infection of the skin and she is on anti biotics for at least a month to six weeks. Again this can corelate to Cushings she said. We are already in about a $1000 this month and can not afford the testing along with the meds for cushings. We are at the point that we are going to assume it is cushings and treat the symptoms as much as possible. The doc can not obviously put her on the lysoderm and high end drugs with out confirmation but were are, I think, discussing possibly melatonin or ?Anipryl (which ever it is that is the lowest med for cush sympt)
Has anyone out there just provided the most love and patience for thier dog whilst letting life take its course? We wish we were able to do surg drugs or what ever it takes but that is not feasible in our situation and from what I read in most cases it does not prolong the life? We love our girl she is my companion as my husband is milit and does his thing all over the world. She has as much character as either one of our kids and we consider her as much. I just am at a loss as to what to do to make life easier for her. We are also considering the real meat real food diet as maybe she will get better nutrition that way so if you know any advice on that one it would be greatly appreciated.

[jrepac]

Wow...sounds like you and Maggie have been thru a lot. Given all the other things you have done for Maggie, i don't understand why your vet would not have done a simple test called a UC:CR..urine cortisol to creatine ratio test. It's inexpensive and can rule out Cushings (but not confirm it). If you get a "positive" result, meaning that Cushings is possible, well you can do a few different tests if you choose to. I'm an advocate of the ACTH test, which is helpful (around $200) and an ultrasound is good, if you can afford it (price varies greatly). The ultrasound can help rule out adrenal based cushings.

But, really no need to let your pup suffer with these symptoms; it sounds a lot like Cushings, but you need to be certain. And, the monthly meds are not outrageously expensive. Brand name Anipryl, frankly, is not cheap; the generic is about 1/3 of the cost, if you can find it, however. But, it does not help all dogs, only a certain percentage respond to treatment (only 20-30% respond well, where others may have partial to no response); efficacy depends on where the pituitary tumor is located (assuming you are dealing with pituitary and not adrenal based Cushings).

Anipryl is a bit of a crapshoot; a few of us had some good luck with it (myself included), but you should speak to your vet first about the tests, before worrying about the meds. In my case, I was dealing w/mild symptoms and other elevated hormones in an older dog, so treating with Anipryl + Melatonin + Lignans made sense and provided considerable relief from the symptoms you mention. We were on Anipryl (generic) for a little over 2 years, before she unexpectedly passed on :(...but again, do have a serious chat w/your vet and don't rule out testing & treatment...it will make a big difference in your Boxer's quality of life...

Jeff & Angel Mandy

[StarDeb55]

Welcome to you & Maggie! I'm very sorry to hear about all of the problems Maggie has been having over the past several years. From your description of all of Maggie's symptoms, it certainly sounds like Cushing's is a definite possibility.

When it comes to the diagnostic testing, we all know the financial strain that getting a confirmed diagnosis can cost. This doesn't even address the emotional toll of watching your pup decline.


from what I read in most cases it does not prolong the life?
If you have been reading this nonsense about treatment will only give a pup about 2 years, it's absolute hogwash. My first boy, Barkley, was successfully treated with lysodren for nearly 8 years, crossing the bridge at 15. We have a number of other members whose pups have been successfully treated with both trilostane & lysodren from 3-6 years or more. I will tell you that anipryl is only effective in about 15% of pups with Cushing's. For anipryl to work, the lesion that causes the problem must be in a specific location in the brain, the pars intermedia. Melatonin is normally used in conjunction with lignans to treat atypical Cushing's, but melatonin, I'm pretty sure, has a mild cortisol lowering effect.

When it comes to testing, there is a simple, inexpensive screening test, the urine cortisol:creatinine ratio. If this test is negative, it means you absolutely aren't dealing with Cushing's, a positive means that Cushing's is a possibility further testing required.

I can't address the costs involved with Trilostane as I have never used the drug. I will tell you that once you get a confirmed diagnosis, & the pup on a stable dose of lysodren, costs will go way down. It's just getting to that point that is the really rough road, as I said. I know from experience as I have been down the Cushing's road twice in about the past 12 years.

I'm going to post 2 links from our important information section for you, the first one is information about anipryl, the second is information about where you might seek help with the financial costs of getting your pup in treatment. I would also suggest you take a look at the important information section as there are a huge number of links that will lead you to just about any information you might want concerning Cushing's.

No matter what your decision is, please keep us posted. We are here to help you & Maggie any way we can.

http://www.k9cushings.com/forum/showthread.php?t=224
http://www.k9cushings.com/forum/showthread.php?t=212

Debbie

[Maggie]

This was to post for all but went only in one reply will repost to end of thread.

[labblab]

Welcome from me, too!

Jeff and Debbie have already covered the bases really well. I agree with them that the first, cheapest, and easiest test to perform would be the urine UC:CR test. I also want to add that if Maggie does turn out to suffer from Cushing's and you and your vet wish to consider trilostane as a treatment, it is possible that you MIGHT be able to lower the treatment monitoring cost somewhat. What I am going to write about now will likely sound like Greek to you, because it involves the monitoring testing that is required if a dog is treated with either Lysodren or trilostane -- and you are still grappling with upfront diagnostic issues right now. But since you are worried about treatment costs, here is some info that you may want to offer to your vet for consideration down the road.

Usually the periodic monitoring testing involves relatively expensive ACTH stim testing. However, here is a link to an article published last fall in the Journal of the Veterinary Medical Association that discusses a novel trilostane monitoring option involving measurement of baseline cortisol only (rather than performing a full ACTH stimulation test). This approach is largely experimental, and I have not heard of any vets beyond the article's author (Dr. Audrey Cook) who are using this technique. But as you will see, depending upon the results of the dog's baseline cortisol, the author believes it may be possible to make certain monitoring decisions in the absence of ACTH stimulation. Here's the article link:

http://avmajournals.avma.org/doi/abs/10.2460/javma.237.7.801

I do believe that this experimental research advises that baseline cortisol monitoring has the potential to be sufficient only in the event that the result falls within a fairly narrow range and all symptoms are resolved. So Maggie would likely still need monitoring ACTH tests at times. However, if you should reach the point of considering trilostane treatment for Maggie, your vet might want to contact Dr. Cook directly for additional feedback regarding this experimental approach.

Marianne

[StarDeb55]

I forgot to add on this morning's post to you that you can cut the cost of either medication down quite a bit by using a compounding pharmacy, if your vet would not have a problem with that, compared to using a brand name drug.

Debbie

[jmac]

Hello-

I just have one more thought for you. Is Care Credit an option? It's a special credit card that some vets take where you have the option of making payments with no interest. I have used it a couple of times in extremely expensive situations with my dogs. Here is the website: http://www.carecredit.com/

My dog, Hannah, is on Anipryl right now (we have been on it for three weeks) and it was the first thing my vet suggested as well, as it is low risk. It was about $75 for two months for us (but Hannah only weighs 11 lbs.). He said he would not treat with something else without further testing. He did a low dose dexamethasone blood test (I think it was about $260) but we also just had an ultrasound done ($465) to see what else was going on. It is really important to try to distinguish between adrenal and pituitary forms. I also thought that there wasn't much hope in helping Hannah, but after joining two groups online, I have found that is not true. I have also found that the most expensive time might be in the diagnosis of Cushing's, but it sounds as though many dogs can be managed on medication at a relatively low cost.

You have to do what is right for you and your dog, but I am fairly new to all of this as well, and just wanted to chime in with my two cents.

Good luck to you!
Julie

[Maggie]

I have posted here a couple weeks ago and I appreciate all the advice I got before, however; now I have been looking around for the answer to "What are the end stages or signs that the end is near". I keep comming up with people asking questions to that question...labs, medicine dosing, etc.
I just want to know the end stages...
Maggie has been diagnosed with Cush (yesterday) thru symptoms and a biopsy confirming calcinosis cutis (which from what they say is a direct hit for the disease) I honestly think it was found too late as her begining symptoms started while we were in Japan and the vets checked her thyroid and then said she just needs a diet...obviously when we look back she had all the earmarkers and that was over a year ago.
So as far as a blood panel I have it but as for all the testing that everyone seems to do I will not be diong it. (I know there are diff kinds of Cush but I think we are past finding out to help her live more years. I think all we can do it help her feel better for what she has left) There is with out a doubt she has it and it is bad now. Her case of calcinosis cutis started in a patch inbetween her shoulder blades and now rides her shoulders like a saddle it has started or grown now down her back and at her waist. It is so fast growing that there is major noticable difference almost every other day. This started about 6 weeks ago and now there are spots that are 4 times thicker than normal skin and when the docs manipulate that area it bleeds. We treated it first with antibiotics and they did not work. We just got the biopsy results yesterday. Our doc said he has never seen anything like it and that it is bad. (his previous partner was a derm so he has seen a lot)
Maggie started throwing up Thursday afternoon (48 hrs) and has not kept anything related to food down. Now she is keeping some fluids for a bit so I am giving her pedialite to help keep her as hydrated as possible. She is not even keeping brown rice down. Her stool has turned very dark (like the texture and color of a un cooked drk choc brownie mix -assuming blood) but now that she is not eating there is not much to check. There is also alot of mucus in the stool now that was not there 2 days ago. She can still walk around and this morning before she got sick again she looked like we were on an upswing. She still wants to eat and drink she just cant keep it down. She moves into what ever room I am in and is perfectly mobile except for once in a while stubbing her back toes.
On Monday we are going to start I think vetoryl. Assuming she makes it thru the rest of the weekend...fingers crossed. The vet said they are using that more now because it does not seem cause as much damage as the lysoderm can.
My question again from any of those that know...Is she in the final stages? Is there any purpose to giving her meds now? I would rather put her down then have her live this misserably not being able to eat and puking umteen times a day. Eventually that will kill her on its own. Honesty please and no sugar coating because I feel that you can not deal with what is in front of you if you do not know the whole picture.
Thank you in advance, Maggie and Mommy

Moderator's Note: I have merged your update on Maggie into Maggie's primary thread. We normally like to keep all posts on a pup in a single thread as it is easier for other members to refer back to the pup's history, when needed.

[StarDeb55]

I am so very sorry to hear that Maggie is doing so much worse. I'm going to post a link that may give you some of the information you're looking for. From your description of Maggie's symptom right now, this really sounds to me like she may have pancreatitis. Our babies are extremely prone to pancreatitis because of the liver, pancreas and other other organs being damaged by the excessive amounts of cortisol. Pancreatitis, no matter what the cause, is a life threatening situation, left untreated, & it is very painful. IMO, it's imperative that you get in touch with your vet, or take Maggie to an ER clinic to be examined.

When it comes to the calcinosis cutis, you're correct, it's development is absolutely diagnostic for Cushing's. One of our moderators, Sabre's mom (Angela), dealt with CC in her pup, Sabre. I will PM her & ask her to drop by, but it won't be until sometime tonight as she is in New Zealand.

http://www.k9cushings.com/forum/showthread.php?t=195

Debbie

[labblab]

I, too, am so terribly sorry that Maggie is doing so poorly. The calcinosis cutis is, in and of itself, a major treatment challenge. But it does sound as though some other issue is acutely affecting Maggie right now, and as Debbie says, it may indeed be life-threatening if it is pancreatitis or some type of internal bleeding.

In further answer to your question as to the final stages of Cushing's -- there is no single pathway that every Cushpup will follow. This is because dogs don't die of "Cushing's" per se, but rather from the effects of any one of a number of system or organ failures that untreated elevated cortisol can cause. So just as it says in the link that Debbie supplied, over time, untreated Cushing's can result in such serious conditions as kidney failure, heart failure, pancreatitis, or infections (or serious liver changes), etc. So the specific issue that becomes life-threatening may differ from one Cushpup to another, and the symptoms will depend upon which particular organ or system failure is involved.

Is your vet aware of Maggie's condition right now? I know that finances are a big issue for you, but even a simple blood draw and fecal sample could help identify the nature of Maggie's acute illness right now -- for instance, whether her kidney, pancreas, or liver are severely compromised, and whether there is blood in her stool. And then you could better judge your treatment options. In honesty, I do not believe that you will want to start trilostane while Maggie is acutely ill like this. If she cannot eat and drink, and if you do not know the status of her kidney, pancreas, and liver -- you may be risking more harm than good by asking her system to handle the addition of the trilostane right at the moment. Once stabilized, the trilostane may still be an option. But I think you first have to find out what is making her so immediately ill.

Again, I am so sorry that she is doing so poorly. Please keep us updated, OK? And please be sure to give her some hugs for us. Poor sweet girl!!

Marianne

[lulusmom]

To answer your question, the end stage of cushing's takes a very, very long time and it is not pretty. Most dogs end up dying from a compromised immune systems which leaves them open to massive infection. If the massive infections doesn't kill them, organ failure will.

Cushing's is a very slow to progress disease and it is not uncommon for dogs to go undiagnosed for two or three years. Most people interpret a cushdog's symptom as simple aging and it's not until the dog usually has other stuff going on like, pancreatitis or diabetes, that the red flags start going up for a vet. This sounds like what may be happening with Maggie.

We ask a lot of questions for a reason. According to your prior posts, Maggie was not properly diagnosed and because of that your vet was not willing to treat with anything but Anipryl. Anipryl is a waste of money, especially when the cushing's has progressed to the point of causing calcinosis cutis as severe as what you are describing. It is not too late to get a proper diagnosis and start effective treatment but you cannot do either of those things without first dealing with whatever is happening right now. Any underlying illness will skew the diagnostic tests for cushing's. Plus, you should never give Trilostane or Lysodren to a dog that is sick and Maggie is definitely sick.

I agree with Debbie that it sounds like Maggie has pancreatitis and if that is the case, it can be treated. Has your vet seen Maggie and given you a definitive diagnosis of what is causing the apparent gastrointestinal issues?

My second cushdog was a rescue who we adopted. There was no doubt in my mind that he had cushing's as he was one raging infection. His eyes were bleeding, his ears were oozing black stuff down his face, his mouth was full of abscesses, his coat was sparse, the muscle wasting was so severe that he trembled constantly and would fall over frequently. He also developed a rare symptoms of cushing's called psuedomyotonia which never resolve complete and left him with a stiff and wide stanced gait. His belly was bigger than anything I'd ever seen because his liver and bladder were so incredibly huge. There is no doubt in my mind that Jojo had cushing's for many years and what I was looking at could be reversed with treatment. If not for the fact that I was intimately familiar with canine cushing's, Jojo would have been dead or euthanized by the shelter over three years ago.

I hope Jojo's story helps you better understand that cushing's doesn't take a dog's life overnight. Yes, it can cause serious complications like pancreatitis, diabetes and chronic infections but that doesn't mean a dog is in the end stages of the disease. There is every reason to believe that if Maggie does have cushing's and you can get her over her gastrointestinal problems, you can start treatment and she'll get much better and have a great quality of life just like my two cushdogs and many others here.

I realize that it is frustrating to get questions in response to your questions but it really does help us provide you with more meaningful feedback if you can share as much medical information as possible, including posting test results. We really are here to help you and Maggie in any way we can. I hope I've answered your question about the end stages of the disease but more importantly, I hope that I've provided you with enough information to give you every reason to hope that a lot can be done to give Maggie a good quality of life and keep her with you for a lot longer.

[Sabre's Mum]

A belated welcome to you and Maggie.

My head is not fully "on to it" at the moment as I have just worked a 12 hour night shift but I will try to piece together a brief reply ... (which will hopefully make sense!)

Our Sabre has calcinosis cutis and even after treatment with Lysodren some went away but the larger plates remained. To be honest, without treatment the calcinosis cutis will only get worse and infections will become very difficult to manage. When you do treat, I will warn you that it will get worse before it gets better .... but it does get better. Sabre lost a lot of hair and had a number of plates of calcinosis cutis on his back. With treatment we finally arrested any further growths and his hair grew back within 6 months.

The main thing in the start is to try and stop any infections. We did this by a number of methods (not all at once) .... oatmeal shampoo, betadine on the bad areas, epiotic to scuff off skin on top of the calcinosis cutis, antibiotics when we saw an infection starting ...

There is another dog here ... Mocha who was treated with Trilostane. Here is a photo before treatment

http://www.k9cushings.com/forum/album.php?albumid=251&pictureid=1943

and after 2 months of treatment

http://www.k9cushings.com/forum/album.php?albumid=251&pictureid=2062

In my research three years ago when Sabre was diagnosed I found out that basically calcinosis cutis is virtually pathognomonic for Canine Cushing's syndrome. There are a few cases reported for which other diseases are the reason but I think this number is under 10 cases (sorry I don't have time to search ... I recall about four cases).

If you have any further queries please ask away .... I will try to get back on as soon as I can ... around sleep and work.

Angela and Flynn

[labblab]

Me again...:o I just want to make sure you notice that you also have new replies from Debbie and me on the bottom of the first page of your thread. I also wanted to add one more thought: if you have in fact received the definite diognosis of calcinosis cutis from a skin biopsy, then I agree with Debbie and Angela that it seems certain that Maggie does indeed suffer from Cushing's. So with limited finances, I would probably not put any more money into diagnostic Cushing's testing, but instead towards identifying the source of Maggie's current acute illness.

Marianne

[Maggie]

Thank you everyone for your advice, insight, and compassion. It is greatly appreciated:):)

Maggie is still not keeping anything down not even just a small amount of rice in the palm of my hand. She has been like this since Thursday and I will call the vet again today. It will be a sick call as they are not open but I do not know what to do. Her food is not digesting at all. It looks as though it just sits in some part of her belly where there are no acids to break it down. Sometimes she will not throw up for at least 3 hours after eating and it still looks whole. She is being kind of stand-offish. I am sure she is miserable as I know I would be. Is it horrific to say that part of me wishes I would look over at her and she would be peacefully gone? I finally get that there is no exact end stage that someone can describe... thank you. Our golden retriever (8 years old) we had before we got Maggie died of cancer and there are def signs that they have lost the fight with that illness. We will see what the vet has to say. Thank you againg everyone.

[Maggie]

Mags is still not keeping rice down. She will eat what fits in the palm of my hand and even if she does not throw up for 3 hours it still looks undigested. Like it just sits there on her belly where there are no enzymes or acids to help it. I will call the vet again this morning and see what he says. Maggie is being a bit stand of ish which is totally understandable. I think it is horrific to say and even more so to feel but at times I wish I could look over and see her peacefully gone. No more pain or worries. I know she worries for us because my husband is away...military and she loves me and the kids like we are her babies and family. I honestly believe that she is embarrased to be puking on the carpet and feels bad about that too:) But who would want to throw up on tile and have it get in their fur?

I do now realize there is no real end stage like other diseases....thank you! Our golden retriever Norman who we had before Mags died of cancer and there were def end stages for him so I assumed there would be for Maggie. We will see what we can do for our girl and I will let you know what comes of it.

[lulusmom]

With Maggie throwing up undigested foods, the problem could be in her esophagus instead of her stomach. If at all possible, take the vomit with you to the vet. They can actually test the ph to determine where it's coming from.

[Maggie]

Spoke with the doc and he said that he does not think it is pancreatitus. He thinks this is the tip of the iceberg and there is much more going on. He restated that he has "never in his life" seen a case of the calcinosis as bad as hers and as agressive. He said it is its own type/ atypical form of cancer that the cells are mutating and he is pretty sure it is due to a tumor on the adrenals. He said he could and was more than happy to come in and see her but he would hate for her to spend all day on an iv...meaning that tomorrow he knew what he would suggest and we should spend the time with her. I think that everyone here is courageous and applaude all that you do for your babies. Unfortunatley, I think Maggie was not diagnosed early enough and the months we would get from more vet visits and poking and prodding would be for us. I am thinking about her and that she has got to be miserable. Yes, I would love more time with her to hold her land love her but that time would not be enjoyable continuously putting bandaids on every event that comes up. I am sorry to have to rationalize my decision it is a horribly hard one:( Thank you all for your advice and compassion it is very useful and helps greatly.:)

[labblab]

I do understand that the nature and extent of Maggie's calcinosis cutis involvement affects your decision. Although we have had success stories such as Angela's, we have had at least one other member whose dog was suffering terribly from extensive infected calcinosis cutis, and who also made the decision not to prolong treatment. Were it not for the calcinosis cutis, I would probably encourage you to try to proceed a bit further with GI diagnostics, at least so as to know what you are dealing with. But having lived with family members who have suffered terribly from skin disorders, I do recognize the extent to which such issues undermine quality of life. I remember my mother-in-law being told repeatedly by dermatologists: "Now, this condition is not going to kill you." And her tearful response was "Maybe not. But the constant pain and itching makes me wish I was dead." Sadly, I knew there were many moments when that was exactly true for her.

Since we cannot directly ask our dogs what their choices would be, the point arrives where we have to make the decision that we feel is the kindest and most loving one on behalf our dear companions. Again, I am so sorry about Maggie's illness and your own pain over her condition.

Many hugs,
Marianne

[Cindy Thoman]

I just want to say that my thoughts and prayers are with you and Maggie. You certainly have nothing to apologize for. You know Maggie better than any of us and I know you want what is best for her. Knowing that are angels are suffering is the worst feeling ever. Sometimes letting them go is the best option for everyone. We are here for you no matter what decision you make.

xoxo
Cindy, Alex and Bear