Auggie Pheno or Cushings? (12 y/o American Bulldog)

[asgparrish]

Auggie is my 12 year old rescued American Bulldog. To make a long story short he had what we believe was an unspecified seasonal allergic reaction that caused severe lung congestion last Oct. The treatment or vet recommended caused immediate improvement and Auggie seemed cured within a week. In mid March Auggie seemed to e breathing heavily again and we took him back to our vet who gave him the same medications as in Oct. Within a week Auggie showed no noticeable improvement so I took him to another vet for a second opinion. His X rays were horrible - almost completely opaque and obscured the heart. We did a full blood panel (he had had one in Dec. when he had his bi annual check up) with a special component to try to see if his heart was enlarged. The X rays were sent to a special Pet X Ray place for review - all came back within normal limits or inconclusive. We were referred to the local specialty clinic. They dis an abdominal ultrasound and an adrenal mass was found on his left adrenal gland (less than 3 cm). An ACTH test was done and sent to the U of TN. The results show elevated sex hormones but not cortisol. After extensive research and a two week course of meds to stabilize his blood pressure (which tested normal on several occasions) treatment I decided to have Augs surgery done at NC State's vet hospital. His consult was Thurs. and he was supposed to have his surgery today. Yesterday they did tests to make sure his blood wouldn't over coagulate and did a blood gas panel (the only test he has done poorly on - he got a 68 out of 100). In other words adrenal mass aside and low blood oxygenation he's healthy as a horse. They did a CT scan this AM and the senior resident who would be doing the surgery (under the supervision of a senior on staff vet) called and said that she is not certain he has a pheno tumor. She thinks he has Cushings and wants to do more tests. She said that the adrenal mass wasn't really large enough to determine if it was a pheno or just a small mass based on the CT Scan (though his left adrenal gland is smaller than his right). I questioned her and reminded her that his tests showed elevated sex hormones only, he has no liver enlargement, no elevated cortisol, no hair issues, no loss of muscle tone or abdominal distention. She said he could still have Cushings. Does this seem normal? Has anyone ever had this sort of mixed diagnosis at such a late stage? I don't want to put Augs under the knife for no reason but this last minute backing out of the resident has me worried that either I've missed something about his condition and test results or she's simply not very knowledgeable. Everyone else seems to think it's a pheno.
Any input would be appreciated!

Tammy

[mytil]

Hi Tammy,

Welcome to our site - I am sorry you and Auggie are going through this.

Firstly, IMO should there be any doubt regarding the diagnosis of the mass, I too would delay the surgery.

What type of med was given to Auggie earlier on to relieve his congestion? Was it prednisone based?

Unfortunately, a lot of dogs do not follow the "normal rules" of the cushing's book and we have seen some unique cases here over the years.

When you get the chance, post the results of the ACTH and panel sent to UnivTN - that way we can have a better look at the actual numbers.

Terry

[lulusmom]

Hi Tammy and welcome to you and Auggie (I love that name).

I don't have a lot of time to type my usual novel but I wanted to take the time to tell you that because a CT scan gives a surgeon a much more accurate view of the adrenal gland, it wouldn't be that odd to have a change in diagnosis based on what the surgeon is seeing on the ct scan. Pheos, as well as adrenal tumors, are not always that easy to visualize and even with a ct scan, they often aren't 100% sure of what their dealing with until they open the dog up. It could very well be that the mass on Auggie's adrenal is a pheo but it's not causing any problems. I've read a lot about pheos and was surprised to learn that pheos are found in a really high percentage of dogs at necropsy but they were not the cause of death.

The surgery Auggie was scheduled for is the most difficult canine surgery there is and it is best left to a board certified surgeon who has lots of experience. The fact that a resident is performing surgery, makes me nervous. Have you asked how many adrenal surgeries this resident has performed? Give the high risk associated with this kind of surgery, I wholeheartedly agree with Terry that if there is any doubt at all, it's much better to delay the surgery and do more testing.

We have a few folks here who have a lot of experience with adrenal tumors and adrenalectomies so I hope they will be by to share their valuable information with you.

Glynda

[frijole]

Tammy,

I might be able to save you time and money. :D My dog Annie has a pheochromocytoma and I have spent enough money in coming to this diagnosis to buy a new car. I cannot tell you how insane the last year has been. The journey started a year ago and we thought she had cushing's. She showed positive results on 4 acth tests and 2 ldds tests for cushings. FYI my dog does not have cushings. She has elevated cortisol that is coming from her body dealing with the pheo.

She also has periodic bouts of high blood pressure. They come and go and are usually not a big deal. I do have her on enalapril to treat this.

Pheos are strange and most aren't discovered until after the dogs have passed and so there isn't alot of documentation on them relative to treatment. The surgery is highly complicated and if you read about it you will see that the likelihood of complications after the surgery is high. Like Glynda, I would only let a very highly experienced vet do the surgery.

My little gal is almost 15 and she's had it for a year now. We have had our ups and downs but I elected not to do the surgery as I didn't want to lose her and she is living a relatively normal (aside from episodes) life.

Her symptoms come and go but they are trembling, inappetance, hind leg weakness/muscle wasting. Her story is very long but if you want a lesson in what NOT to do - read her thread. ;) Don't let a regular vet tell you this is cushings. Work with a specialist if there is one in your area. And don't feel you need to have surgery to give your dog a normal life.

Kim

[asgparrish]

Hi Guys,

Thanks for the supportive comments. We really need all of the help we can get!

Here's a little more on Auggie's condition.

His adrenal panel that went to the U of TN came back with "normal ATCH stim"

These are the other values I was given:
Cortisol (baseline) 38.7 Result (post ATCH) 121.4
Estradiol 78.8 (baseline) Result (post ATCH) 85.3
Androstenedione 2.43 (baseline) Result (post ATCH) 9.72
Progesterone 0.03 (baseline) Result (post ATCH) 1.87
Aldosterone 35.0 (Baseline) Result (post ATCH 89.9)

UTN's comments on the adrenal panel were: "The sex steroids are increased as indicated, so the tumor appears functional. Consider surgery or items 2-5 on the treatment option sheet attached...."

The adrenal panel was sent to UTN after an abdominal ultrasound by the local specialty clinic that we were referred to showed that Auggie's left adrenal glad was enlarged. This was also after a full blood panel had been done (his second full blood panel in 3 months - he had had a full workup in Dec. during his biannual regular checkup - the two blood panels showed no changes and no abnormalities).

The ultrasound also showed that Auggie's liver was smaller than expected but within the normal range for his breed (no enlargement due to disease - yeah!). They also thought based on the images that he mighthave a slightly prominent right ventricle and small left ventricle. He has also had an echocardiogram.

His blood pressure has been tested numerous times and has always come out within the normal limits except for 1 test on last Thurs. which was taken immediately after he had been exercised by the hospital staff and then it was a little high.

After the adrenal panel came back from UTN I researched surgeons in my area in an attempt to locate one with adrenal experience. The local specialty clinic wanted one of their guys to do the surgery (As if! he specializes in fractures and livers!Do they think I'm stupid?)

I tracked down the only vet clinic/hospital in the US that works only on endocrine disorders. They recommended that I go to NC State's vet hospital. I bugged a vet from Ask.com into posting an inquiry on a vet only information network and he received multiple responses from across the country that I should go to NC State - two of which said they personally knew of a case in which NC State had successfully removed large adrenal tumors. All of the vets agreed that since NC State is a large teaching hospital that they have more experience with adrenals, more equipment and more staff to monitor patients. Still not satisfied - I wrote to the head of the NC State Soft Tissue Surgery department (Dr. Mathews) and point blank asked him if he was the man to do this operation and if not to let me know who he felt was. I gave him (and all of the other vets) 6 states that I was willing to travel to in order to get the best treatment for Auggie.

Dr. Mathews was responsive and told me that they regularly work on adrenals including Phenos.

I secured a referral to NC State and on Dr. Mathews advice we started Auggie on 10mg of phenoxybenzamine 2x daily and scheduled the surgery for two weeks after we started the medication - dogs have to be on it for 2 weeks in order to stabilize their blood pressure for surgery. I am told that Phenos are notorious for spiking bp during surgery - in addition to reacting very badly to the normal anesthesia drugs (they have to have narcotic anesthesia). The phenoxybenzamine has been shown to reduce mortality from 48% to 13% for dogs undergoing surgery for phenos. BTW - we got the generic and it was still 330.00 for a 14 day supply - but well worth it if it really reduces the mortality rate that much.

I corresponded with Dr. Mathews several times and finally felt bad for taking u so much of his time that I asked if there was a vet tech I could ask basic questions. He gave me the info for the soft tissue dept. vet tech Stacy Meeks. I corresponded and spoke with Stacy on several occasions. I only found out that Dr. Mathews would not be preforming the procedure on 04/19th while speaking with Stacy - two days before our check in on 04/21st. I grilled Stacy on the history of the vets that were assigned to Auggie and she assured me that yes, both had done adrenals and that yes, they had pheno experience. Given that I had been told by two vets not to prolong the wait for the surgery unless necessary, the fact that we were 12 days into the med supply and the fact that I was told the vets were adrenal experienced I chose to move forward without Dr. Mathews. It's a highly respected teaching hospital - right?

On Wed. 04/20th I got a call from NC State asking me if I wanted to postpone the surgery until Dr. Mathews would be back the following week. I started to grill them about why they would ask that - were the vets I had been assigned not really adrenal experienced? They assured me that they were only asking because it had come to their attention that I had been corresponding with Dr. Mathews. They didn't want me to drive 2.5 hours to the hospital and be under the impression he would be doing the surgery (he is out all week on vacation). I told them I had covered all of that with Stacy the day before and I was willing to proceed based on the fact that Auggie was to have 2 experienced adrenal surgeons (Dr. Keiri Jermyn - a senior faculty member and surgeon, Dr. Mila Freire - a 4th year resident that would be assisting - both of whom I was told on numerous occasions were adrenal experienced - even with phenos). There would also be a 3rd year vet student observing (Austin). I also said that I would reschedule if the information I had been given was incorrect and that Dr. Mathews was the better option. They assured me I was in good hands already.

During check in at NC State on Thurs. 04/21st I even asked the receptionist if the vets assigned to Auggie had adrenal experience - she told me they did. I asked Mila to her face if she had pheno/adrenal experience. She told me she did. I never got the chance to meet Dr. Kieri Jermyn and ask her.

I admit that I was not totally happy with the consult with Mila - she seemed a little under informed to me - but then I did date a vet for four years and I tend to be VERY picky about who I let treat my pets. I felt I might have been letting my anxiety over the operation get the best of me so I said nothing.

Auggie was taken for his CT scan at around 11:00 the next morning. A CT scan usually takes about 45 minutes. Mila didn't call me until almost 2:00 (Auggie had now been under anesthesia for 1.5-2 hrs. more than necessary by my estimation and we all know that phenos dogs don't due well with anesthesia - in fact Mila had told me the day before that they are so concerned about the anesthesia time that they use staples to close because they are quicker than sutures). Mila then told me that she really didn't feel comfortable going forward with the surgery based on the CT scan results alone. She suggested we test him for Cushings. OK, is it just me or isn't that what his ATCH test was for??? I reminded her that his tests results came back positive for sex hormones and that he showed no elevated cortisol. She said he could still have Cushings. I reminded her that his liver is not enlarged. She said he could still have Cushings. I told her he has no hair loss/ any hair issues and no abdominal distension. She insisted that he could still have Cushings. She then went on to say that once he had been tested for Cushings that she would "have to have an internist interpret the results because she wasn't an internist and wouldn't be able to understand it". OK maybe it's me - but if she couldn't read/interpret the ATCH test (or even the comments of it being a sex hormone tumor) why did they schedule my dog for surgery on a weekend when all of the internal medicine people were on vacation??? At this point I decided that I had no confidence in Mila and that she was def. not the person to do one of vetdoms most difficult surgical procedures on my dog. I told her to wake him up and cancel the surgery (after all she didn't want to do it based on the CT scan).

My husband drove back to the hospital today and got Augs. So here we are - all this prep and we are back to square one - or at least set back for 2 more weeks as Augs will have to go back on the blood pressure med. before another surgery can be attempted.

Am I the only one that thinks Mila is wrong about think Auggie has Cushings when he has NO SIGNS of Cushings? Everything thus far has pointed straight at a pheno. All the other vets think it's a pheno... We've done virtually every test under the sun and all point to a pheno not Cushings - Am I crazy?

Disheartened, discouraged and completely confused

Tammy

[asgparrish]

He was given Theophylline to help him breathe during both episodes of breathing difficulty (though he only had congestion in the Oct. episode) He also received Lasix for water retention (though he only received one or two doeses during each of the episodes). I don't know if either is prednisone based but I don't believe they are.

[addy]

Hi Tammy,

I can understand why you feel disheartened and confused. When we have a good internist or really good vet it makes life so much easier.

I am hoping Kim will be along to read your post as you know, she has been through a lot with her Annie. Fired a few vets too;);)

I am here to hold your hand and offer a shoulder if you need one.

Hugs,
Addy

[frijole]

:D Dang right I fired a few vets... I am on like the 4th or 5th and I live in a small town. You want to talk about clueless... if you have a few free days, read Annie's thread... on second thought... I'd hate to put anyone thru that. ;) Trust me I understand what you are going thru. That is why I posted what I did telling you not to let them tell you this is cushing's. You are obviously schooled in this since you know that the test showed no elevated cortisol and therefore no cushing's.

Elevated sex hormones can be classified as 'atypical cushings' and trust me... some thought that might be what Annie has however if you read about pheochromocytomas you will learn that they secrete adrenalin (thus the episodes of high BP that are intermittent) and sex hormones (thus the elevated levels and cushing-like symptoms).

I have been giving Annie melatonin (3 mg a.m. and 3 mg pm) for about 6 months and that has helped with the hairloss and it calms her down. You could certainly do that. I buy it at the health food store. I haven't tried lignans but it too helps reduce the sex hormones. (these are on the Univ of Tenn sheet as recommended treatment options I am sure)

If you start on the melatonin you might want to start with 1/2 dosage and one time a day and ramp it up. That way Auggie wouldn't be too drowsy. It worked for Annie. (She weighs around 15 lbs)

I can't remember what you said the symptoms are that you are dealing with. Lastly I take Annie in for weekly acupuncture and it has absolutely helped her. It helps keep her calm.

Hang in there. Are you thinking of contacting the Doc that was on vacation? You sure did your homework before hand. I'd be pretty upset if my dog was under anethesia and they pulled that one. I bet they didn't have the experience you required. Wow.

Kim

[StarDeb55]

Tammy, I want to offer you & Auggie a late welcome! I have been reading & can't offer you any firsthand experience with adrenal surgery, other than what you have already been told. I do think you made the right decision to cancel as all of this "flip-flopping" by the vets who were going to operate would have initially freaked me out, then I would have gotten mad.

The only other thing I will tell you is that neither theophylline or Lasix is steroid based. Theophylline is simply to help dilate the bronchial passages to ease breathing. I've taken it myself when my asthma has been major bad in the past. Lasix is simply a diuretic that is frequently used to help control blood pressure. I take it daily.

Debbie

[asgparrish]

Thanks Addy, Kim and Debbie

I appreciate you taking the time to read my posts - especially since I can be rather long winded : )

Yes, I will be contacting Dr. Mathews when he returns from vacation. I doubt he'll be able to tell me much of anything that will make me feel Mila isn't an idiot but I do want to hear any possible explanation he can give me for her sudden about face on Auggie's diagnosis without (in my opinion) any evidence to support it. He is after all the dept. head and he should know about what happened if for no other reason than to prevent it from happening in the future.

I'll have to hear what he says before I will decide if I will go back to NCSU or if I will try to pull some strings and get into the U of TN.

I guess I am torn between being angry at the last minute change of heart with Mila (I suspect she was in way over her head) and being relieved that she didn't try to go forward anyway and kill Auggie in the process. I'm ticked that she set back Augs treatment more than anything - though I can say that I'm not thrilled that her decision wasted 330.00 worth of meds, narcotic anesthesia fees, 2 nights boarding for Augs, 4 + tanks of gas, 2 days of my vacation time and other misc. expenses. Then again - still more grateful she didn't kill my big guy.

I did start Auggie on melatonin and lignans (yes, the U of TN recommends them both) but he's only been on them a few weeks. Having the tumor removed should stop the pheno issues so he probably doesn't need them but it never hurts to err on the side of safety.

The only worrisome symptom that Augs has is labored breathing - that's what started all of this. He does also sleep a lot (but then he is at least 12 and a bulldog). and he has very recently developed extreme thirst.

I too have fired more than one vet! I guess that after dating a vet that graduated with honors from a top vet school I became very picky and better able to judge the quality of the care I was getting (I don't miss the guy but I really hated having to find a new vet when we broke up! LOL)

In fact, Auggie has 3 vets - His primary vet is about an hour away (I told you I was picky) He has a back up vet that is local - for emergencies and/or second opinions and he has a vet that is certified in acupuncture/Chinese/holistic medicine.

Thanks again for all of your support and insight!

Tammy

[Buffaloe]

Hi Tammy,

You have certainly been through a long and difficult process to this point with Augie. There's nothing simple about adrenal tumors/pheochromocytomas.

My dog was finally diagnosed with a very large, malignant cortical adrenal tumor in 2006 at the age of 12. She had a very successful adrenalectomy. We were blessed with a very skilled and experienced board certified surgeon who was assisted by another wonderful bc surgeon.

We had a combination ACTH/LDDS test which included a full adrenal panel analyzed by UTK. The written results we received were not definitive and were confusing. I followed up with Dr. Jack Oliver via e-mail. After going back and forth, he eventually told me, "based on the test results, it is likely Shiloh has a primary adrenal tumor." This was instrumental in our lengthy diagnosis. You might want to follow up with Dr. Oliver in a similar manner.

Our initial consultation was with a wonderful board certified surgeon who interned under our surgeon and worked at his facility. She had performed several adrenalectomies and wanted to operate on Shiloh. I elected to wait two weeks until Dr. G. returned from vacation in Germany. He owns two wonderful facilities here in Phoenix and has performed scores of successful adrenalectomies. Everybody told me he was as talented as any surgeon in the country.

I think you exercised excellent judgment in not proceeding with Augie's surgery. It sounds to me like you should wait for Dr. Matthews and work with him. I don't think there is any big hurry. Following up with Dr. Oliver at Tennessee might be of some value to you. I know it's tough but just hang in there. I know you will do the best you possibly can for Augie.

Ken