5 Year Old Shih Tzu with Cushings Diagnosis

[Fighting Bee]

Hi all,

First off, I'm so glad to have found this website. The information is incredibly helpful and I've already learned a lot just from browsing.

I am looking for advice on how to proceed with my 5 year old shih tzu Zeke.

Background - Last Saturday (6/4), Zeke had a routine vet visit as he was due for some vaccinations. I did not take him in for any specific problems, although I did ask about flaking on his back that's been an on-again, off-again problem for years. Other than that, he has seemed to be in good health. The vet recommended a blood test based on his age. Well, the blood test came back as having an elevated liver enzyme level, indicating the possibility of Cushings. We decided to do a urine test, which also came back abnormal. The vet then recommended an x-ray of Zeke's abdomen, which we did on Wednesday, 6/8. According to the vet, everything looked fine in the x-ray. So we then did the 8-hour blood test, which came back as positive for Cushings. The vet stated that the growth was on his pituitary gland.

All of this has happened in less than a week. I am in shock right now. Zeke hasn't exhibited any symptoms of Cushings - no increased thirst or hunger. No potbelly. The vet even commented on how healthy and strong he looked when she saw him last Saturday. Zeke did have one accident in the house a few months ago, but I believe it was because I got distracted with the kids and couldn't attend to him in time.

There are 2 vets in this practice. The one that I talked to on Friday thinks that we should take a wait and see approach - when Zeke starts showing symptoms of Cushings, we should start treatment. Her recommended course of treatment is trilostane, with lysodren being a second, less favorable option. She seemed fairly confident in his diagnosis as well as in her thought that he should still live a normal lifespan that is of high quality if we don't treat right away.

Her colleague will be calling us on Tuesday to give her opinion. This second vet is apparently an advocate of treating the disease now and not waiting for symptoms to occur.

I am really confused and would love any advice as to how to proceed. The vet said she didn't see a reason to do an ultrasound or any other testing at this point. Should I get another opinion?

If we don't treat right away, could we be causing more harm to Zeke or making it harder to keep his symptoms at bay once they begin? Does his young age make a difference as to whether he should be treated? Are there any questions I should be asking the vet?

Sorry for all of the questions and for this message being all over the place. It's been a stressful week worrying about the diagnosis and what it means for Zeke both now and for the future.

Here are his test results:

Initial Bloodwork (I'll just include counts that were marked as High or Low on the report):
HGB 18.6 (High)
Neutrophil SEG 56 (Low)
Lymphocytes 37 (High)
Alk. Phosphatase 180 (High)

Urine Cortisol/Creatinine:
Urine Cortisol 41.3
Urine Creatinine 282.3
Ratio 46

Dexemethasone Suppression:
Pre Dex 16.4
Post 4 Hr Dex 2.0
Post 8 Hr Dex 13.7

Again, any advice would be greatly appreciated!

Leah

[frijole]

Leah,

Welcome aboard! I am so glad you posted. I would not even think about treating a dog with no signs of cushings. There are too many cases that are misdiagnosed. Even the intl experts agree - you don't treat a dog without symptoms (Feldman is a leader in the field and recently wrote an article on it written for vets)

180 alk phos is hardly elevated. Most of us have dogs with readings between 1000 and 2000! It would be helpful if you could put the ranges for normal next to the items that were abnormal. We have a lab tech who can offer better advice than me but she'll ask for it! :)

I have two experiences with diagnosing cushing's. The first was spot on and my dog was treated with lysodren successfully for 4 1/2 yrs. She passed away last year unrelated to cushing's at 16 1/2. My other dog was misdiagnosed. And I had experience! She had 5 false readings on the acth test and 2 on the ldds test (the one you had done). There are many reasons why a dog might have elevated liver enzymes. Like I said - yours is a really low number.

It could be that you caught it early but if you wanted to rule out cushings I would have a sonogram done as well as an acth test. But remember - the tests can be wrong if anything else is going on.

If you have no symptoms you really don't need to do a thing. Just keep an eye out for changes and retest. I hope this helps!! Kim

[lulusmom]

Hi and welcome to the forum.

Cushing's is a difficult disease to wrap your arms and your head around so walking around in a state of confusion after receiving a diagnosis is the norm. Speaking of diagnosis, clinical signs play a huge role in confirming a diagnosis so since Zeke is asymptomatic, I don't believe a diagnosis can be confirmed at this point in time. I also believe that the first vet you spoke to on Friday has the right idea in his wait and see approach.

Cushing's is a serious disease; however, it is also a very graded disease which means it progresses at a snail's pace so if a dog is not otherwise compromised, there is no rush to treat until overt symptoms become apparent. The goal of treatment is not to cure the disease because it is not curable, the goal is to alleviate symptoms that become troubling, not so much for the dog but for the pet owner. The drugs prescribed for cushing's are not benign and I would question the experience of any vet who advocates to treat a dog who is asymptomatic. If there is any question as to this fact, I have provided some excerpts below from papers published by world reknown endocrinologists:


A quote from lecture given by Dr. Edward C. Feldman, DVM, DACVIM Professor, School of Veterinary Medicine, University of California, Davis, Davis, CA. 81st Western Veterinary Conference. Title - Diagnosis & Treatment of Canine Cushing’s I: Diagnosis of Hyperadrenocorticism (Cushing’s Syndrome) in Dogs—Which Tests are Best? Edward C. Feldman, USA
http://wvc.omnibooksonline.com/data/papers/2009_V101.pdf


Dogs chronically exposed to excess cortisol usually develop a classic combination of clinical signs, some of which may be dramatic. These common signs include polydipsia, polyuria, polyphagia, abdominal enlargement, alopecia, pyoderma, panting, muscle weakness, thin skin, and lethargy. It must be remembered, however, that not all dogs with hyperadrenocorticism develop the same signs. From this long list of potential signs (plus others), most dogs exhibit several (but not all) of these problems. Hyperadrenocorticism is a clinical disorder, and animals afflicted with this disease must have at least some clinical signs or the diagnosis must be uestioned.

Quote from Dr. Rhett Nichols, DVM, ACVIM, that can be found in our Helpful Resources section, entitled Canine Cushing's Syndrome: Diagnosis and Treatment. http://www.k9cushings.com/forum/showthread.php?t=210&highlight=rhett


The most important criteria for making a diagnosis of Cushing’s syndrome or hyperadrenocorticism (HAC) is the patient must have signs and symptoms consistent with the disorder. The importance of signalment, history, and physical examination findings cannot be overstated. The predictive value for HAC based on a positive screening test result increases in direct proportion to the number and severity of clinical signs and biochemical changes occurring in the disease. A dog with at least three of the typical signs of hyperadrenocorticism (e.g., polyuria and polydipsia, panting, and polyphagia) and a positive LDDS or ACTH response test has Cushing’s syndrome until proven otherwise. If there are no clinical signs (e.g., a clinically normal dog with an elevated ALP) the patient either does not have the disorder or may have subclinical Cushing’s syndrome. In the latter case, a wait and see approach is advised whereby the patient is followed clinically and with laboratory testing over time. In the dog that has signs and symptoms of Cushing’s syndrome and the screening tests are negative, consider repeating the tests in 3 to 6 months or initiating a workup for atypical Cushing’s syndrome.

I hope this information helps alleviate any concerns you may have about not treating Zeke right now.

Can you advise if the Dex Test was the low dose dexamethasone or the high dose dexamethasone suppression test? If it is the low dose, your vet is correct that these results would be indicative of pituitary based disease; however, given that the abdominal ultrasound showed normal liver and adrenal glands and Zeke isn't symptomatic, the first thing I think about is the possibility that stress or a non adrenal illness is responsible for the high urine cortisol creatinine ratio and a false positive LDDS. Either way, I don't see how a diagnosis can possibly be confirmed based on the information you've provided.

Kim has already mentioned the mild elevation in ALK. We do see much higher elevations here and some scarey high in the 4,000 and 5,000's. Was any other urine tests done and if so were they normal...i.e., was USG normal and was a urine culture done to rule out a urinary tract infection. Was T4 included on the bloodwork and was it within normal range?

Most dogs are older when diagnosed but my first cushdog was one of the rare ones and diagnosed at 3 years old. Unlike Zeke, she was overtly symptomatic for months and months before being diagnosed by a very knowledgable internal medicine specialist.

A lot of dogs will have elevated liver enzymes on one test and will be normal on the next, which is why a lot of vets choose to redo bloodwork in 90 to 120 days to see where things stand. This is definitely the approach I would take if Zeke were mine.

Glynda

[Squirt's Mom]

Hi and welcome to you and Zeke, :)

Like the others, I think the first vet is on the mark with the wait and see approach. Without strong signs it is difficult to make a firm diagnosis and cold be dangerous to treat with either Trilostane or Lysodren.

My Squirt is one who was caught early when blood work for a dental was done in early '08. She had very mild signs so I took the time time learn all I could about Cushing's and to do very thorough testing on her. Even then, we didn't start Lysodren until this year because her signs did not manifest until then.

So take a deep breath and relax. You have been given a reprieve at the very least! ;)

Hugs,
Leslie and the gang

[littleone1]

Hi Leah,

Corky and I also want to welcome you and Zeke.

I also agree with the others about not starting treatment unless there are clinical signs. I'm really glad you found us.

Terri

[jmac]

Hello and welcome! My Shih Tzu, Hannah, who is 12 was diagnosed in March. She had some slight symptoms, but not necessarily anything terrible that I would have even contacted my vet about if her liver enzyme (Alk Phos) had not been really high on her routine blood test. I would recommend getting the ultrasound at some point. We had the Low Dex Suppression test done to diagnose hers. My vet also told me I could wait and see and do nothing, get an ultrasound to look at her adrenal glands (to try to see if it was the pituitary form), or try Anipryl (not necessarily as effective for many dogs, but the least risky, and it can treat the symptoms). We waited a little while and got advice on this forum, thought it over, and I decided to have the ultrasound done about 6 weeks later because it was driving me crazy. Her adrenals and liver (and everything else) looked normal. We did start on Anipryl, and although I don't notice a huge difference in her food and water intake (which were just slightly elevated), when the vet did another blood test one month into the meds, her liver value had dropped significantly. It seems to be doing something for her at this point. He does not want to treat with anything stronger unless she has significant symptoms because that is what you base so much of the treatment on. I would also go with the recommendation of your first vet. You don't want to harm the dog further with strong meds. I would possibly consider the ultrasound at some point to check out what things look like internally, or maybe get another test repeated in the future to see what it says. Some people do have an incorrect diagnosis, and since your dog is doing well, I would wait. Hannah also has no pot belly, hair loss, skin problems, etc. I would say that she began to eat more (getting into my other dog's dish and would bark or paw at us in the evening-this went on for months before I realized she was probably telling us she was hungry), and has had an increase in water intake and urinating, but not anything terrible. It is a lot to take in initially, and I was so sad and so worried about what was going to happen to my girl, but she is doing great and nothing has progressed. Her Alk Phos level was much higher than your dog-like 1700 or something, and my vet said she was still okay and he was not worried. Please take your time with this. There is no rush and your dog is not showing any symptoms. Pay attention to increased thirst, hunger, urinating, hair loss, skin problems, pot belly, etc. and if you see those things, then I would treat. You may want to look into Anipryl as well. Most info. says it is effective in about 25% of dogs with the pituitary form. At any rate, it seems to be working for Hannah, and we just buy the 10 mg pills, and she gets a half each morning, so it lasts two months. Good luck to you and please keep asking questions!

Sincerely,
Julie

[jmac]

One other question-Zeke isn't taking any steroids for allergies or anything, is he? That is one other thing that can cause things to be off. I agree with others...wait and retest. Best of luck to you!

[Fighting Bee]

Thank you all so much for your reassurance and advice (and the informative links, too)! This information has helped set my mind at ease that we are doing what’s best for Zeke. I am very hesitant to put him on meds when he doesn’t appear to have symptoms, for all of the reasons that you’ve all mentioned.

We will be talking to the second, “more aggressive” vet on Tuesday, but I believe we are going to monitor Zeke and see how he does in the next few months. I really like the suggestion of follow up blood work and an ultrasound, as well as Anipryl as an initial treatment option if/when we get to that point. I am also going to press our vet practice to make sure that there is nothing else going on with Zeke, as a few of his numbers are slightly off.

Regarding Zeke’s test results - he was given the low dose dexamethasone suppression test. No other urine tests were given. I don’t believe T4 was tested for, at least it doesn’t appear on the reports I was given. (Edited to add - he is not on steroids or any meds at this time).

Just to clarify, the reference ranges given on the reports are as follows:

Initial Blood work:
HGB 18.6 (High) Range: 12-18

Neutrophil SEG 56 (Low) Range: 60-77

Lymphocytes 37 (High) Range: 12-30

Alk. Phosphatase 180 (High) Range:10-150


Dexemethasone Suppression:
Pre Dex 16.4 Range: 1.0-6.0

Post 4 Hr Dex 2.0 Range: less than 1.5

Post 8 Hr Dex 13.7 Range: less than 1.5

Thanks again for your kind words and helpful advice. I wish the best for you and your precious pups.

[Squirt's Mom]

There are two dex suppression tests used in diagnosing Cushing's and the results are interpreted differently. Do you know if Zeke had the low dose dex or the high dose dex test?

My Squirt was on Selegeline (Anipryl) for about 9 months with good results. She was one of the rare cases in which this is true. Another factor was the fact that a tumor was found on her spleen that was causing her cortisol to be elevated. Once it was removed, her cortisol returned to normal. An abdominal ultrasound found the tumor so I highly recommend a good ultrasound on a high resolution machine.

Keep reading and talking! Educating yourself is very important when facing this condition. Ask any questions you may have and we will do our best to help you understand.

Hugs,
Leslie and the gang

[lulusmom]

Leslie, I had the same question about low dose vs high dose. Even though I knew it didn't make sense that it was a high dose because an acth stim wasn't done, I was't completely sure because I'm not used to seeing such a high 8 hour number. The member did respond and say that Zeke had the low dose dex test.

[Squirt's Mom]

Plain as day, too! :p