Panicky mom of a possible Cushing pup

[JDG]

I took my 8 year old best buddy to the vet last week because he has had some loss of weight despite an increase in his food over the past few months or so. His tail and hind legs seem bony as well as the top of his head and back. I think his hair has lost his bushiness. Labs were taken. His liver enzymes were found elevated, (especially his alk phos ?). He then had an ultrasound done that suggested both of his adrenal glands to be enlarged. Yesterday he had LDDS testing. I am waiting for results of the latter testing. Cushings was mentioned as a possibility of all these findings but not yet diagnosed. I am feeling overwhelmed with all the info I'm hearing about. I don't know what to think about anything. I will welcome whatever anyone may be able to offer to get all this straight in my head so I can help my guy. I am reading that if the LDDS comes back positive, it could be false-positive. I don't understand. What else could cause those symptoms ? I also would like opinions on medications.

[labblab]

Hello and welcome!

I am so glad you have found us, but very sorry about your worries over your buddy! With the exception of weight loss, all of the symptoms that you have mentioned are indeed consistent with the pituitary form of Cushing's (which is the more common of the two types). Most Cushdogs have ravenous appetites, and also exhibit excessive thirst and urination. As a result, many Cushpups actually gain weight. However, my own Cushpup was an exception to that rule -- he was losing weight at the time that he was diagnosed, even though he was hungry all the time. How is your dog's appetite? Also, is he drinking and peeing a lot?

The fact that the ultrasound exhibited bilaterally enlarged adrenal glands is consistent with the pituitary form of Cushing's. With PDH (pituitary Cushing's), a tiny tumor on the pituitary gland (usually benign) messes up the communication between the pituitary and adrenal glands, and this results in the production of excess cortisol by both of the two adrenal glands. In adrenal Cushing's, it is a tumor on an adrenal gland itself which is the culprit -- and this will show up on ultrasound as a mass or enlargement of one adrenal alone.

Both of the two blood tests that are used to diagnose Cushing's -- the LDDS and also the ACTH -- have the potential to give "false positives" in the face of other nonadrenal illness. This is because the body can produce excess levels of cortisol for reasons other than Cushing's disease. Examples would be diabetes or pancreatitis. That is why the pattern of symptoms is equally as important to making a Cushing's diagnosis as are the blood test results. This is also a reason why an abdominal ultrasound is often recommended, as well -- in order to visualize the condition of the adrenal glands and also the other important internal organs. The ultrasound can help to "rule in" Cushing's and "rule out" disease stemming from other organs.

Since your dog's ultrasound is consistent with pituitary Cushing's and there are also several compatible symptoms, it does make sense to proceed with the LDDS blood test. But I would also be interested to hear about his appetite and thirst/urination. And if it turns out that he DOES have Cushing's, please do not despair. It is a disease that progresses slowly and can be managed quite successfully with appropriate medication.

Marianne

[ventilate]

Hi;
I just wanted to welcome you here. When my dog first got her diagnosis of Cushings, I cried, then I searched the net and found someone who recommended me here. This site is an excellent source of information and everyone here either has or had a dog with cushings. Nike my Giant schnauzer was diagnosed when she was 9 and lived till she was 13 so 4 years with cushings and did well. I lost her at 13 and GS are know to live 10-12 so she did very well. Can you tell us more about your dog, what breed is it? The low dose dex challenge is one of the main confirmatory tests although there are others that can be done if there is any question. Others here can help you out better than I can on what tests. We do like to see the test results so a bit of advice when you get the results please post them, as well the Alk Phos results. The actual numbers are more helpful then normal, or in the ball park, elevated or low...
Many dogs live their normal life span with cushings, My vet included told me my dog would probably live a couple years with cushings, but that would have been her normal lifespan. A lot of times the dogs are already in later stages of life when they are diagnosed. So if you get that speech, you can be prepared.
I just wanted to welcome you and let you know you are not alone and this forum is an excellent source of info and friendship.
Good luck with your pup
Sharon, Jagger and forever HRH Nike and DS Kenai

[JDG]

Thank you so much for the quick support !!!
I will get copies of the testing results from the vet so I can share them and hopefully learn more about what the numbers mean.
I have heard elsewhere also that weight loss is not a usual sign of Cushings. I do wonder if it does relate to the muscle mass wasting? My pup's tail and hind legs quarters seem bony, like they lost a cushioning? I spent a lot of years trying to manage his tendency to gain weight. It is just the end of this past summer that he lost about 3-6 pounds without trying. I upped his food intake, he's gained a few pounds back, but the boniness has not changed. I do think his coat has thinned out.
My Shadow is a cocker spaniel mix. Don't think the typical cocker spaniel. My pup has the shape and long wavy hair of a cocker, just bigger. He was a rescue from Virginia and we'll never know what he is mixed with. His good weight is about 52 pounds. He has been obsessed with food since day 1 so I haven't noticed any extra appetite issues. He does drink a lot but always has. I do swear, however, that he could hold his bladder for 24 hours, so I haven't noticed new issues in this area at this time.

[Squirt's Mom]

Hi and welcome to you and your baby! :)

[QUOTE]I am reading that if the LDDS comes back positive, it could be false-positive. I don't understand.

As Marianne said, false positive can result from non-adrenal illnesses (Cushing's is an illness that involves the adrenals). My Squirt is a prime example. Based on five Cushing's tests - LDDS, HDDS, ACTH, ultrasound (2), and UTK panel - she was diagnosed with PDH (the pituitary form of Cushing's). However, after the second U/S I was told about a tumor on her spleen. After the tumor and 1/2 her spleen were removed her cortisol returned to normal and has remained within range since. That was in Sept. of '08. ;)

Cortisol is one of the body's natural defenses against stress of any kind - internal and external. Anytime the body is under stress, excess cortisol is released. The tests for Cushing's look for excess cortisol but cannot tell the difference between cortisol being released due to a non-adrenal illness and cortisol being released due to Cushing's. This is why is it so important not to rush into treatment.

What else could cause those symptoms?

Diabetes, hypothyroidism, liver or kidney disease to name a few.

Glad you found us and look forward to learning more as time passes!

Hugs,
Leslie and the gang

[frijole]

Please also get a copy of the ultrasound write up that was done and type in what it says. They are very helpful. Thank you! Kim

[JDG]

Oh I'm so lost :( The vet said that the LDDS test came back showing my pup has Cushings but he is unable to differentiate between pituitary and adrenal as the cause. We have to do another long test tomorrow- the HDDS. Another day of fasting. Another few days of extreme worrying.
I did get copies of his testing. I'm not sure how to read it all though.
AST - normal at 35
ALT - 230
ALK Phosph -1274
GGTP - 41
Chol - 487
Trigly - 396
Amylase -267 (low)
Urine - T4, 1.6 : pH 8.0 : (no ratios were done?), rest wnl
Ultrasound : L Adrenal 0.72cm R Adrenal 1.08cm
: Liver with diffuse increased but even echogenicity
: Assessment = bilateral adrenomegaly
Cortisol Serial 3
Sample 1 3.8
Sample 2 2.1
Sample 3 3.3

[labblab]

It is true that Shadow's LDDS results (and bloodwork results if those you have listed represent elevations) are consistent with Cushing's. Since the ultrasound shows bilaterally enlarged adrenal glands, I'm not exactly sure why your vet wants to perform a HDDS test. Bilaterally enlarged adrenals are consistent with pituitary Cushing's, so it would seem to me that you already have your likely answer in that regard. And I would think that ultrasound results would actually "trump" those from a HDDS, since the ultrasound is telling you about the actual appearance of the adrenal glands, including any masses or enlargements. But maybe your vet just wants to leave no stone unturned.

How long have you had Shadow? I only ask since you say that he has always been very hungry and thirsty. Since Cushing's is a slowly progressing disease, it is possible that he has actually suffered from some of the symptoms for quite some time.

Once again, please do not dispair over this diagnosis. Do you know whether your vet has treated other Cushing's dogs, and if so, which medication he tends to recommend?

Marianne

[JDG]

Oh I've had my Shadow since he was several weeks old. He is 8 now. He has certainly always been food oriented.
I think our vet will be offering Trilostan if it comes to that after the HDDS. I think the vet wants to be sure that its a pituitary issue.
I have to say, I am having a great deal of trouble understanding all the dicifering in all this testing. All the percentages, ratios, and false pos/neg possibilities are too much ! How can I be sure of this diagnosis ?

[Rebelsmom]

Your tests numbers along with the symptoms all seem to point to Cushings and I agree with Marianne that the ultrasound points it to Pituitary. It is nice that your vet wants to be sure, but it does seem like you have your answer.

Testing numbers are always difficult when you first start trying to figure it all out. What I did (other than asking questions here) was look up what each abbreviation was and want organ or gland it had to do with. This way I knew what to look for. When you get your test results they should also show a normal range for each number so you can see what is high or low and just how high and low it is.. Take a deep breath first everyone here is ready to help you understand and make sense of what you can't..

My Rebel has been on Trilo since March of 2010 and has done really well on it.. He went from being an unhappy, don't touch me dog back to my happy playful and lovable dog. He was 7 at the time of his diagnosis and we just celebrated his 9th a few months ago.

I would start keeping a journal for Shadow, that keeps his test results and you can write down any changes in his behavior or symptoms. This way you can keep track of what is going on and have dates of when this or that was started. I also write down in mine questions I want to ask his vet or people here.

[labblab]

Melissa has already given you some great suggestions. I just have a couple more thoughts to add. Unfortunately, unlike some other illnesses, there is no single test that is 100% accurate in diagnosing Cushing's. You and your vet are left with a bit of detective work: fitting in the puzzle pieces to see which symptoms and test results are consistent with Cushing's, and which point to a different ailment. Once you rule out other possible causes for symptoms and abnormalities, then Cushing's becomes more and more likely.

I am assuming that Shadow's blood glucose levels have been normal, so that rules out diabetes. I also see a "T4" result of 1.6 on your list of lab results. It is listed on the same line as "Urine," but I am guessing that it is instead a blood result for Shadow's thyroid function. I believe that 1.6, while on the lower end, still falls within normal range for dogs. Since you've not listed any lab values for kidney function that are abnormal (and the ultrasound didn't note any kidney problems), then Shadow's kidneys seem to be OK. Shadow does have elevated liver values, but both the elevations and the ultrasound report show liver abnormalities that are common with Cushing's. The ultrasound didn't indicate any masses or other gross abnormalities of the liver. Elevated cholesterol and triglycerides are also common with Cushing's.

So you're left with a dog who exhibits some symptoms, lab values, test results, and an ultrasound that are all consistent with Cushing's. Nothing in the testing thus far points instead to a different culprit. So the big question shifts to: is it time to treat? I grant you that the weight loss (rather than weight gain) is less common. But as I said earlier, my own Cushpup did the same thing -- and it was actually his weight loss that was initially causing me the most concern of all. He was losing all muscle mass in his rear end, and was starting to have trouble with the stairs and could no longer jump into the car.

I think the decision to treat comes from a combination of quality of life issues and also a desire to halt ongoing organ damage. Shadow's lab values indicate that, systemically, he is reflecting abnormalities that can be caused by elevated cortisol. And if he has Cushing's, the muscle wasting will only progress. So upon your vet's recommendation, you may decide that Cushing's is the most likely cause of Shadow's problems and go ahead and give treatment a try. You can always discontinue treatment if Shadow does not show improvement.

As Melissa and her Rebel are examples, we have many members whose dogs have done very well on trilostane. I have one cautionary note in that regard: our experience here is that it is best to start with a low dose and work upwards rather than the other way around. How much does Shadow weigh? Initial trilostane dosing is based upon a dog's weight, and the manufacturer of brandname Vetoryl recommends that a dog be started on a dose that does not exceed 1 mg. per pound of body weight.

I have been rambling here, so will close for now!
Marianne

[lulusmom]

I agree with Marianne about the HDDS test. The abdominal ultrasound and the HDDS are considered differentiation tests as both are used to differentiate between pituitary and adrenal based disease. As Marianne has mentioned, the ultrasound already shows bilateral enlargement of the adrenals which is consistent with pituitary based disease (PDH). This is no great surprise since 85% of dogs have PDH.

This is very strange....I'm usually harping about vets not doing enough testing but now I'm about to tell you that your vet has done a pretty good job of covering the bases and I believe he has the results he needs to confirm a PDH diagnosis. :) However, if your vet is adamant about running yet another test to make absolutely sure that you are dealing with PDH, please tell him to test the endogenous acth concentration as opposed to the HDDS. The HDDS is rarely done anymore because if a dog fails to suppress on the LDDS test, there is a really good possibility that he will suppress on the HDDS which would tell your vet nothing. I know this is all Greek to you but if your vet is cushing's savvy, he'll understand. If he doesn't, it might help a lot if you share the link below with him. this is the continuing education page for veterinarians sponsored by Dechra, the manufacturer of Vetoryl (Trilostane). Answers to questions are provided by reknown and very well published endocrine specialists so the credentials are solid and their knowledge of the disease is unquestionable:

http://www.dechrace.com/top10_diagnosing.html

Glynda

[JDG]

So the HDDS testing from yesterday came back inconclusive for PDH vs AT. It is totally up to me if I want to try to treat with medication. The vet doesn't seem to think my Shad has enough of the classic signs for Cushings or rather that all the pieces don't fit neatly. I may take him to a specialist (internist) on Tuesday.


The HDDS results are as follows:
pre/ cortisol sample 1 3.7
post 1 (4 hr) 0.7
post 2 (8 hr) 2.4

[JDG]

Today we see an internist at a Boston Animal Hospital (Angell's). A bit nervous but hoping to get some answers.

[labblab]

I am really glad you are seeing the internist. You will not have to make any decisions with which you are not comfortable, but I hope it will be helpful to gain yet another perspective on things. I will be very interested to hear what the internist recommends.

Good luck to sweet Shadow today,
Marianne

P.S. I just went back through your thread to see that Shadow weighs about 52 pounds. If the internist does indeed recommend treating with trilostane, I hope he/she won't recommend a starting dose any greater than 60 mg. We've learned from direct conversations with Dechra (manufacterer of brandname Vetoryl) that they have revised their guidelines to reflect initial dosing no greater than approx. 1 mg. per pound of a dog's body weight. The technical reps at Dechra are happy to talk to vets and owners alike about their revised recommendations.

[Snoopy&Rummer_Mom]

Hi and welcome. Well, the ladies here have offered you great advise. But from someone who is going through the process of definitely determining if my Wheaten has Cushings, here you will find so much support and most importantly you will be able to just breath. When I was told there was a possibility my dog has Cushings I was panicking too.

The one thing I want to offer is that one thing I have learned is that not only is the blood work important but also the "physical" symptoms. Some of Rummer's blood work are not consistent with Cushings yet she has almost every symptom for Cushings. So testing is important as well as a Cushings savvy vet. Good luck with the specialist in Boston.

[JDG]

Well, the specialist says Shadow has the paperwork of Cushings but she's not sure the symptoms fit. She wants us to go back in a month for a recheck, repeat labs, and another ultrasound. She thinks we should hold off on meds at least until then.
The internist said it is hard to make a diagnosis at times because other things may make the paperwork look like Cushings. She also mentioned the possibility of a liver biopsy in the future, if needed. She did say the high liver enzymes don't need to be treated right now. I don't understand that one.

[JDG]

Is anyone familiar with Denosyl and/or Ursodiol ? My pup was just started on them for high liver enzymes, as well as high cholesterol and such.

MODERATOR NOTE: I have merged your latest post concerning high liver enzymes with Shadow's original thread. We like to keep all info about each pup in their own thread. That way it is easy for members to look back through the history if needed.

[Squirt's Mom]

Hi,

Good to hear from you again! :)

How has Shadow been doing? Any follow up testing for Cushing's or on the liver itself?

We've had members on those meds but I haven't used them myself. I'm sure others will be along soon to share their experiences with you, tho.

Hugs,
Leslie and the gang

[Harley PoMMom]

Just wondering, was a bile acid test done?

[JDG]

No, no one has mentioned a bile acid test. We are still not even sure what's going on with my Shadow :( There has been no change with his liver enzymes so the internist recommended these 2 new meds. I asked about the milk thistle and Sam-E but this is what she wants him to have. Expensive too. I hope it helps.

[Harley PoMMom]

The Bile Acid Test is one that measures how the liver functions and performs.

The blood tests measure pre- and post- meal levels of bile acids, the acids stored by the gall bladder and secreted by the liver. If the levels are high, there may be a problem with the liver.

If a liver issue is being considered, IMO, I would ask to have this done.

[JDG]

Interesting about this bile acid test. They have spoke of a liver biopsy (of which I would like to avoid) but not this test. I will ask about it when he is seen next. Thank you.

[Bgoods]

Is anyone familiar with Denosyl and/or Ursodiol ? My pup was just started on them for high liver enzymes, as well as high cholesterol and such.

MODERATOR NOTE: I have merged your latest post concerning high liver enzymes with Shadow's original thread. We like to keep all info about each pup in their own thread. That way it is easy for members to look back through the history if needed.

In the continual monitoring of Rolo, our vet prescribed Ursodiol (Actigall) for Rolo because of the identification of some "sludge" in his gall bladder that was noted during a recent ultrasound. We priced it around here (common human pill actually) but we weren't able to get the right dosage at a reasonable cost and ended up she could order it from Wedgewood in a tiny tab. He gets it twice a day, and the UT doctors recommended continuing it through his radiation treatments (although they stopped Trilo). Rolo takes the Ursodiol and also Denamarin, which is a liver supplement. His liver enzymes had shot through the roof in the fall of last year. He also had high cholesterol and the Ursodiol may help somewhat with that.

[JDG]

The internist has also noticed something (sludge?) around Shadow's gallbladder. These 2 new meds are quite pricey -$180plus for a 6 week supply. The internist also said she thought his adrenal glands looked good, but his liver a bit abnormal (not sure what that means).
We go back in 5 weeks for follow-up labs and ultrasound.

[JDG]

I'm just confusing myself terribly. Shadow has had 3 ultrasounds over 3 months showing sludge. His liver enzymes have been getting worse despite the meds he takes to counteract it. It has now been recommended that he have his gallbladder removed along with a liver biopsy at the time. I'm a wreck How do I know this is the right thing to do ? Supposedly the biopsy would show more precisely if Shadow' abnormal labs could be from Cushings, as his previously testing was inconclusive for definity.
This is my best buddy. I owe him to do the right thing by him.
Any comments or suggestions ?

[Harley PoMMom]

If it were me, before a liver biopsy was done I would have a bile acid test performed. A bile acid test is a good indicator of how the liver is functioning.

[JDG]

I am wondering if I should have the liver biopsy done before going with the gallbladder removal ?:confused:

[lulusmom]

I would recommend that you discuss the gall bladder removal with Shadow's internal medicine specialist so that you understand the procedure and the need for it. Neither this or a liver biopsy is a benign procedure and both require anesthesia. If it were me, I would have the liver biopsy done while Shadow is under anesthesia for the gall bladder removal.

[JDG]

Yes, they wish to do the liver biopsy with the gallbladder removal. I just don't want to do the removal if its not necessary.

[JDG]

So Shadow will now have a Cushings diagnosis. His liver biopsy showed changes relating to Cushings. We have to wait 4 weeks for him to recover from his gallbladder surgery before starting treatment. His gallbladder was forming a mucocele so it was good to get it out now. I have some studying up to do on this complicated disease. I am wondering why his liver enzymes have stayed elevated despite the meds to counteract it.

[JDG]

Now that we know my Shadow has Cushings, I will need to read up on the when and how to treat it. We have to wait 4 weeks for him to heal from his gallbladder surgery before meeting with the internist again. At that time, we will go over options. I hope to have a good idea before I go in as to the possibilities.
This has been a very long several months from the time I noticed Shad's hair reduction and muscle mass loss, all the inconclusive lab testing, 4 ultrasounds, and this week's surgery.
Now that the liver biopsy showed the Cushings changes, we know what we're dealing with.
It bothers me that the meds used to lower Shad's liver enzymes have not worked. I am wondering if treating the Cushings will help lower the enzymes.

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

[Squirt's Mom]

Mornin',

You may find that once the gall bladder is out, Shadow's cortisol level returns to normal and all the Cushing's tests will come back as normal. The illness in the gall bladder could be the source of all the Cushing's indications you have seen so far. This was the case with my Squirt. She is Atypical but her cortisol returned to normal levels once that tumor was removed and it has remained within normal range since. So just because Shadow has had some iffy Cushing's tests, has shown some cush signs, and there are visible changes to the liver that does not mean he had Cushing's.

The liver is an amazing organ, taking lots of abuse then bouncing back. Because it is such a workhorse of an organ, it can show up on lab work with indications of the stress it has been under with elevated levels. Then once whatever has been stressing the liver is removed, those levels go back down. But as long as the organ is being asked to do extra work, those levels will remain higher than normal. BUT that does not mean Cushing's - it simply means the liver is working extra hard.

For now, if I were you, I would put Cushing's way back on the shelf of my mind. Until Shadow has this surgery, is off all meds resulting from the surgery (except any he may need to take for the rest of his life, if any), and he has had plenty of time to recoup there is no sense in doing any Cushing's tests. The odds are they would all be skewed giving inaccurate results which might lead to treating an illness that isn't really present. ;)

So for the next little while, you job is to get Shadow through and recovered from this surgery, learn how to help him live to fullest without the gall bladder with diet, supplements and/or herbs, and then a period of rest and fun for both of you. :) Then, and only then, we will start looking at the possibility of Cushing's if needed.

It is my sincerest hope that this surgery cures all the things you have been seeing in your sweet boy and that you have no further need of us. BUT that does not in any way mean that you can simply disappear. Oh, no! You and Shadow are family and we want to know all about the surgery, the recovery, and all the fun ya'll are having. We will want to hear from you often during this time...and for all time after. ;):)

Hugs,
Leslie and the gang

[JDG]

Shad had his f/u with the internist along with repeat liver enzymes. They say his enzymes, although far from normal, a bit improved since his gallbladder was removed a month ago. They recommend we wait 2 months for f/u before considering the Cushings meds. He continues on the 2 meds for the liver enzymes.
The idea behind waiting is that Shad does not show "clinical signs" of Cushings. He does have the thinner haircoat and the boniness to his head and hips but these are supposedly not clinically troublesome symptoms that give reason to starting Trilostane along with its possible side effects and costly labwork.
I do hope I'm doing this right for my buddy's sake !!!

[lulusmom]

For what it's worth, I believe you've made the right decision. I agree with your vet's plan of action.

[JDG]

It has been 3 months since Shadow's gallbladder removal. His liver enzymes remain unchanged. It has been recommended that he start Trilostane. He is starting a 30mg liquid dose, 1x per day.
I welcome any info or suggestions.

[frijole]

Hello! Quick question - reading back I saw that your vet said not to treat as there were no symptoms - which I vehemently agree with. What symptoms is your dog exhibiting? There is no need to treat a dog without symptoms. It is in fact discouraged by world renowned experts that specialize in treating cushings. Just checking.

Also what is your dog's weight? (checking dosage)

Thank you! Kim

[Harley PoMMom]

Is Shadow showing strong clinical signs of Cushing's such as excessive drinking/urinating and a ravenous appetite?

[JDG]

Well, Shadow's liver enzymes are still elevated. The medications we have been using to help lower the enzymes has not lowered them.
Although not a life-threatening symptom, his hair coat is so thin, especially his tail. He does seem more tired, lies around more. He also pants more but I don't know if that's just related to the summer heat as he has never been able to tolerate it being warm (in his long black fur coat!). Shad has also been noticed with a back leg tremor that I thought at first was nerves at the vet but I've noticed it at home at times now too.
So the internist said she recommends he start on the Trilostane because of the liver enzymes and the possibility that the Cushings is the cause of the tremors.
Shad has always been food oriented. He ended up in the hospital overnight last month after he knocked over a cabinet and found a leftover stash of jellybeans, candycorn, and peanutbutter fudge.
As far as the peeing goes, I often think he can go 24 hours without needing too. When he and his sister go out in the morning to do their morning deed he will often just sit on the deck waiting to come in as he knows when I open the door it's time for breakfast!

[JDG]

Oh and Shadow is 50 pounds.