Bob, 12 year-old Yorkie with possible Cushings

[ademas]

Hello.

My (nearly) 12 year-old yorkie became extremely ill in Nov. of 2010 when he was diagnosed with both diabetes and hypothyroid disease. We really thought we were going to lose him. His BUN tests were horrible, and we expected renal failure.

For nearly six weeks he wouldn't eat or drink, and we kept him going with IV hydration, Pedialyte, and feeding him blended foods with a small baster. Surprisingly, his kidney function returned to normal, and after a few months, both his diabetes and thyroid condition became regulated (much thanks to the wonderful people over at the K9 Diabetes Forum).

Fast forward to now. He's had some hair loss on his shoulders and back, which I kind of assumed had a lot to do with both his health challenges and the needles used for IV hydration and insulin, as well as his thyroid condition.

Last week he became ill, and I took him to a new vet. This vet suspects Cushing's Disease, based mostly on his hair loss, skin, and pot belly appearance. She (the vet) started with a full blood panel, which came back relatively good, all things considered. She said she was expecting the results to "scream Cushing's", but that they really didn't. The only anomalies were slightly elevated white cells and pancreatic enzymes, which didn't alarm her, but warranted a course of Amoxicillin to fight any slight infection that was going on, specifically if it might be pancreatitis.

The next step the doctor would like to take is the ACTH Stim. test. Is this the next logical step to take? I'm not asking due to the cost ($244), but because I read about the urine test that can be done to rule out Cushing's Disease, and I want to appear that I know what I'm talking about.

If it is, indeed, Cushing's Disease, what is generally the step following diagnosis? What type of further testing needs to be done? What medication do they normally start with? What frequency of ongoing testing?

I wish I could say money is no object, but--of course--in the real world, my resources are not without limits. I've paid for the last vet visit, and have the money set aside for the ACTH test, and I also have $2,000 set aside in my pet emergency fund. I'm older, and live on a fixed income, but I have some play there, too, as I normally manage to set aside $300-$400 per month to savings. All of this is above and beyond the diabetes supplies and thyroid medication that Bob is already on.

I felt like I was in a pretty good place (financially) to address most any emergency that might come up, but now I'm beginning to wonder.

Well, now I'm rambling. That's what happens when you get old. =) There are a couple of questions in there--specifically about the protocol of tests to diagnose, then the protocol of treatment. I sure appreciate and welcome any input.

Thank you.

[k9diabetes]

Saying hi to you and Bob, who is already a member at K9diabetes! :)

Natalie

[ademas]

Thanks, Natalie, for steering me over here.

You were a godsend to both Bob and I in those early, drama-filled months.

Thank you. :)

[Cyn719]

Hi

Welcome to you and Bob....so sorry for the reasons you are here but so glad you found us. The members here are fantastic and will be by soon to give you advice and ask you questions that will help them give you their opinions. If you can post your test results .....basically the abnormal results, Bobs weight and anything else you can tell us it ill really help.

Hang in there...it's a lot but you are doing a great job:)

[frijole]

Welcome! You might be old ;) but you are asking all the right questions! :D BTW I'm old too. I would normally say to ask for the UC:CR (urine test) to rule out cushings. I'd like to ask those smarter than me to chime in as to whether diabetes could have an affect on the test results (dilute urine).

You mentioned that the blood panel was mostly normal. I noted you did NOT mention either of the liver enzymes being elevated. Cush dogs almost always have high liver values - where normal is 150 a cush dog can be as high as 1000 to 2000. Also cush dogs have abnormally huge appetites and/or thirst. Hair loss is one of many symptoms cush dogs have. My family has had several diabetic dogs and they all had round tummies.

My concern with testing your dog for cushings is that you really have to perform multiple tests to get a firm diagnosis and my first inclination is that your dog does not have it. But I am not a vet. I just don't want you to spend money on test that might not be needed.

Looking forward to thoughts from other members. Glad you found us. Kim

[Harley PoMMom]

Hi and welcome to you and your sweet boy!

The UC:CR is a non-invasive and easy test that can rule out Cushing's but when other non-adrenal illnesses are present the results can be abnormal.

Regarding the diabetes, was there difficulty in getting the diabetes controlled? Many of the symptoms of diabetes are shared with Cushing's such as a pot-bellied appearance, excessive drinking and urinating, and elevated liver enzymes.

Usually if pancreatitis is suspected a spec cPL test is performed to confirm the pancreatitis, has one been done?

Illnesses such as uncontrolled diabetes and pancreatitis will create false positives results on any of the Cushing's tests so I would recommend having these health issues managed before any testing is done. Once the diabetes and pancreatitis is under control I would suggest having an ACTH stimulation test done and then possibly an ultrasound but only if your boy is displaying some strong Cushing symptoms.

The two medicines that are usually rx'd are Trilostane/ Vetoryl and Lysodren/Mitotane. These are strong drugs and should only be given to dogs that have a confirmed diagnosis of Cushing's.

Please know we are here to help in any way we can so do not hesitate to ask any and all questions.

Here are some handy links about Trilostane/ Vetoryl and Lysodren/Mitotane: Lysodren loading Instructions and related tips. (http://www.k9cushings.com/forum/showthread.php?t=181) and Trilostane/Vetoryl Information and Resources. (http://www.k9cushings.com/forum/showthread.php?t=185
)

Love and hugs,
Lori

[ademas]

Thank you for the welcome!

I don't have the test results from the blood panel. It was taken last Friday, and the vet called me on Saturday. All she really said was that things looked surprisingly good, with the exception of the elevated white cells and pancreatic enzymes. I definitely think she would have mentioned liver enzymes if they were out-of-whack, and I know I would have zoomed in on that.

I'll be out that way tomorrow, so I'll try to stop by and get a copy of the test results.

Bob was at 8 lbs. on the nose last Friday.

Aside from the hair loss, pot belly, and some change in skin pigmentation (which has cleared up considerably with the thyroid medication), he hasn't displayed the other symptoms. His water intake seems normal. When he does drink more, it's almost a given that his BG is running high. He doesn't have "accidents". His appetite is generally good, but not ferocious. No excessive panting at all.

If I can get those blood work results tomorrow, I'll post more detail.

Thanks again!

Craig

[ademas]

Regarding the diabetes, was there difficulty in getting the diabetes controlled? Many of the symptoms of diabetes are shared with Cushing's such as a pot-bellied appearance, excessive drinking and urinating, and elevated liver enzymes.

Usually if pancreatitis is suspected a spec cPL test is performed to confirm the pancreatitis, has one been done?

Illnesses such as uncontrolled diabetes and pancreatitis will create false positives results on any of the Cushing's tests so I would recommend having these health issues managed before any testing is done. Once the diabetes and pancreatitis is under control I would suggest having an ACTH stimulation test done and then possibly an ultrasound but only if your boy is displaying some strong Cushing symptoms.



Thank you for the good information. Initially, yes, it was very hard to get his blood sugar under control, but he has been very well regulated for many months now. His BG on the blood panel was 100, and he's been extremely stable in the upper-double-digits to the mid-100's for a long time.

He's never had pancreatitis that we know of, but the fact that his white blood cells were up, along with his pancreatic enzymes, she (the vet) thought it wise to start the Amoxicillin, just in case. In retrospect, I should have questioned her a little more on this, but there it is.

Thanks again,

Craig

[Harley PoMMom]

He's never had pancreatitis that we know of, but the fact that his white blood cells were up, along with his pancreatic enzymes, she (the vet) thought it wise to start the Amoxicillin, just in case. In retrospect, I should have questioned her a little more on this, but there it is.

Thanks again,

Craig

Hi Craig,

My boy, Harley, had pancreatitis which was diagnosed from an ultrasound and confirmed with the spec PL test.

I once had his lipase and amylase, the pancreas enzymes, tested along with a spec PL test and the amylase and lipase were normal while the spec PL results were in the 400's (0-200.) Harley never did display any signs of pancreatitis but his spec PL test results always confirmed that he had it.

Unless Bob is displaying strong clinical symptoms of Cushing's, if it were me, I would not pursue any tests for Cushing's.

Please do keep us updated on your sweet boy and wishing you both the best of luck.

Love and hugs,
Lori

[Squirt's Mom]

Hi Craig,

I agree with Lori - unless strong cushing's signs become obvious, I wouldn't pursue the testing. Kate Connick has a great list of signs seen in cush pups -

Kate Connick*
http://www.kateconnick.com/library/cushingsdisease.html


The most common symptoms include:
• increased/excessive water consumption (polydipsia)
• increased/excessive urination (polyuria)
• urinary accidents in previously housetrained dogs
• increased/excessive appetite (polyphagia)
• appearance of food stealing/guarding, begging, trash dumping, etc.
• sagging, bloated, pot-bellied appearance
• weight gain or its appearance, due to fat redistribution
• loss of muscle mass, giving the appearance of weight loss
• bony, skull-like appearance of head
• exercise intolerance, lethargy, general or hind-leg weakness
• new reluctance to jump on furniture or people
• excess panting, seeking cool surfaces to rest on
• symmetrically thinning hair or baldness (alopecia) on torso
• other coat changes like dullness, dryness
• slow regrowth of hair after clipping
• thin, wrinkled, fragile, and/or darkly pigmented skin
• easily damaged/bruised skin that heals slowly
• hard, calcified lumps in the skin (calcinosis cutis)
• susceptibility to infections (especially skin and urinary)
• diabetes, pancreatitis, seizures

Hugs,
Leslie and the gang

[ademas]

You mentioned that the blood panel was mostly normal. I noted you did NOT mention either of the liver enzymes being elevated. Cush dogs almost always have high liver values - where normal is 150 a cush dog can be as high as 1000 to 2000. Also cush dogs have abnormally huge appetites and/or thirst. Hair loss is one of many symptoms cush dogs have. My family has had several diabetic dogs and they all had round tummies.


I picked up labs today, but I'm not really sure what any of them mean.

His ALK Phosphatase is only 26, and his ALT (SGPT) is only 29; his AST (SGOT) is on the high end of the normal range at 55.

What other tests would be useful here? I have all of the results now.

Craig

[ademas]

Here are the HIGHS and LOWS from Bob's blood work. Everything else was WNL.

CHEM

CK 501 (10-200 U/L) HIGH
LIPASE 794 (100-750 U/L) HIGH
ALBUMIN 1.7 (2.5-4.0 g/dL) LOW
TOTAL PROTEIN 3.3 (5.1 - 7.8 g/dL) LOW
GLOBULIN 1.6 (2.1 - 4.5 g/dL) LOW
CHOLESTEROL 101 (112 - 328 mg/dL) LOW
CALCIUM 5.7 (8.2 - 12.4 mg/dL) LOW

TCO2 (BICARBONATE) 16 (17 - 24 mEq/L) LOW
CHLORIDE 118 (105 - 115 mEq/L) HIGH
B/C RATIO 42.5 HIGH

CBC STANDARD

WBC 22.8 (5.7 - 16.3 K/uL) HIGH
HGB 18.5 (12 - 18 g/dL) HIGH
NEUTROPHIL SEG 83 (60 - 77%) HIGH
LYMPHOCYTES 10 (12 - 30%) LOW
EOSINOPHIL 0 (2 - 10%) LOW
AUTO PLATELET 558 (164 - 510 K/uL) HIGH*
*SLIDE REVIEWED MICROSCOPICALLY; NO PARASITES SEEN; PLATELETS APPEAR INCREASED.

ABSOLUTE NEUTROPHIL SEG 18924 (3000 - 11500 /uL) HIGH
ABSOLUTE MONOCYTE 1368 (150 - 1350 /uL) HIGH
ABSOLUTE EOSINOPHIL 0 (100 - 1250 /uL) LOW

[frijole]

Craig, Thank you for posting those results - they help a great deal... I see no way that your dog has cushings. So don't do any testing for it... We have a med tech here with 30+ yrs experience. I'm going to point her to this thread and get her opinion. She is great and I'm sure she will be able to offer you some ideas as to what to do next. Hang in there. Her name is Deb by the way. Kim

[k9diabetes]

Here are some links that can fill you in on what these various chem values measure.

On this first one, it's a really good one but on my screen at least it looks blank when you first load it up because their html coding is bad. So if you see a blank panel on the right, scroll down to find the actual document.

http://www.vetmed.wsu.edu/ClientED/lab.aspx

http://www.petplace.com/dogs/understanding-blood-work-the-biochemical-profile-for-dogs-2/page1.aspx

http://www.petplace.com/dogs/understanding-blood-work-the-biochemical-profile-for-dogs-2/page1.aspx



Creatinine kinase (CK) is released into the blood from damaged muscle. Elevation of creatinine kinase therefore suggests damage to muscle including heart muscle.


Those don't cover Lipase separately but it's discussed under Amylase in the WSU article as both are pancreatic enzymes .

This isn't the picture of a dog with Cushing's disease that I'm aware of.

Given the low cholesterol and the high CK, I wonder if the vet isn't seeing boniness and loss of muscle mass and that's what is triggering the Cushing's question. While Cushing's can cause those things, so can other conditions and there does not seem to be any classic symptoms of Cushing's in his bloodwork or his blood sugar. Perhaps he's on a high dose of insulin for his size, but his blood sugar is very well controlled.

So I wonder if there might be a GI / food absorption problem - pancreatic insuffiency, IBD... something that's preventing him from absorbing his food so the body has been turning on itself.

Does he seem to be getting bony and losing muscle? (probably hard to tell in an 8 pound dog... )

Natalie

[frijole]

Craig - I got word to Deb and she will be researching your case so hang on while she checks out the numbers.

She did mention that the high WBC & absolute neutrophil count indicate the presence of infection. Did the vet say anything about a possible infection? Was a UTI ruled out? Any problems with diarrhea or vomiting that might indicate a GI tract infection?

Thanks!
Kim

[ademas]

Thanks for the links, Natalie.

I found another on my own, and the CK was the first thing that jumped out at me--made me wonder about heart disease.

Also, I think I read somewhere that the low calcium can be an indicator of Cushing's, although I don't know that it says all that much in the absence of other indicators.

It is hard to say on the bony butt. A few years ago, he was a portly 11 lbs. His body shape completely changed when he got sick in Nov. 2010, mainly because he lost so much weight, and then when he put some back on, it was on a much healthier diet.

Kim, yes--I took Bob in because he didn't feel well. He hadn't eaten well for a day--which isn't like him--and I had pulled way back on his insulin to compensate. He also had what appeared to be a hot spot developing, but it turns out it was nothing.

In short, I was torn between watching him for another day, but since it was Friday, I really didn't want to be stuck with a sick pup for the weekend without knowing what was going on. The vet wasn't sure what was going on either, but wanted to start him on a course of Amoxicillin just to be safe. He's been on it since Saturday now, and he's back to his old self.

Thanks for the great input! I really appreciate it.

[Squirt's Mom]

Hi Craig,

If that B/C ratio is the BUN/creatinine ratio, which I think it is, then the kidney function need to be questioned, too. Tho usually to have a high ratio, either the BUN, the creatinine or both are high and I don't see those values listed.

*IF* this is the BUN/creatinine ratio, that could indicate renal insufficiency. The kidneys don't give any warning they are in trouble until they are about 75% damaged, which they don't recover from easily, if at all.

I think if Bob were mine, I would ask for a referral to an IMS and have them go over the test to date then check him out further if needed. I just do not see anything that says typical Cushing's.

Hopefully, our resident lab tech will be along soon to give her input on this but I think the pancreas and kidneys need to be looked at for sure.

Hugs,
Leslie and the gang

[ademas]

Hi Craig,

If that B/C ratio is the BUN/creatinine ratio, which I think it is, then the kidney function need to be questioned, too. Tho usually to have a high ratio, either the BUN, the creatinine or both are high and I don't see those values listed.

*IF* this is the BUN/creatinine ratio, that could indicate renal insufficiency. The kidneys don't give any warning they are in trouble until they are about 75% damaged, which they don't recover from easily, if at all.


Thanks, Leslie.

I hadn't gotten around to that B/C ratio information yet. His BUN is 17, smack in the middle of normal range (7 - 27 mg/dL) and his Creatinine 0.4 (0.4 = 1.8 mg/dL), if that information helps.

[frijole]

Thanks for the additional information. Hopefully Deb will see this as I know she was doing some research for you. Kim

[StarDeb55]

Craig, I'm the Deb that Kim mentioned. I think several of the other members have already mentioned this, but it bears repeating, the liver function values, alk phos, ALT, cholesterol, & AST, being within normal range & not elevated, point the finger completely away from cushing's. We see alk phos elevation in just about every pup who is a member of this group, sometimes the elevations can be into the thousands.

Please don't concentrate on heart problems due to the elevated CK. This enzyme is concentrated in muscles anywhere, so if there is any kind of muscle problem, it will elevate the CK. For example, in a person who has had some type of generalized trauma, say a car accident, there CK will be elevated. To pinpoint the elevated CK being from the heart, one has to do a CKMB, the MB fraction is limited to heart muscle. Unfortunately, I do not think CKMB testing is available for our pups. The other heart related lab test is a troponin. Again, I don't think it's available for canines.

What raises red flags for me are the elevated WBC & absolute neutrophil count. This is clearly indicating some type of bacterial infection. Since the amoxicillin appears to have helped, I do think there was some type of infection. It's unfortunate that your vet felt that even a simple UA was not warranted. Now, the low calcium, albumin, & elevated B/C ratio are hugely concerning. Calcium regulation is controlled by several things including the parathyroid & kidneys. At any point was a urine collected, & was there any protein present in the urine. If this hasn't been done, I think it's warranted. The other thing I would like to see is the phosphorous level even if it's normal. If memory serves, calcium & phosphorous were in opposite of each other, meaning when the calcium goes down, the phosphorous goes up. A lot of this regulation is controlled by the kidneys. The not eating episodes might be attributed to a high phos level as this can make a pup feel pretty crummy. I think it's an excellent idea to get a referral to an IMS, take all of these labs with you, & let them sort this out. My huge concern is that Bob might possibly be showing signs of early kidney disease which can be treated, when caught early.

Sorry it took awhile to get back to you, but I have some personal issues going on right now that have been absorbing my time. Hope my input has been helpful, not too technical, & not too confusing.

Debbie

[ademas]

Thank you, Debbie.

Yes, urine was taken at the same time as the blood work. It was negative for protein (negative for everything).

Phosphorous was 4.8 (2.1 - 6.3 mg/dL).

I also faxed the full results to my regular vet. She's steering me towards not pursuing anything in regards to Cushing's, as well. It's her opinion that it was likely a slight bout of pancreatitis, and that we caught it early.

Thank you so much for the feedback.

Craig

[StarDeb55]

I still think a cPL test may be warranted. Lori has stated on more than one occasion that with her Harley, his lipase/amylase values were normal, he was feeling fine, & his cPL results were very elevated. With the diabetes, I think the cPL results might be very useful.

Debbie

[Squirt's Mom]

Hi Craig,

I agree - checking out the pancreas is important. Here's why - when that organ gets inflamed it gets in a very, very bad mood and starts spreading it's poison throughout the body. When inflamed, the pancreas releases enzymes that damage not only itself but organs that are connected to it or near to it - which are quite a few! The pancreas truly likes to share its misery with everyone - and it can do some awful damage which some pups cannot overcome. So having the cPL done would be wise.

I am so glad that Cushing's is off the burner! ~~whew~~ So many times once that term has been bandied about, folks tend to get tunnel vision in spite of evidence to the contrary. :)

Now, just because you aren't dealing with Cushing's, we would still love to hear how Bob is doing so do check in from time to time and let us hear from you.

Hugs,
Leslie and the gang