Meet Yvette - 10yr old Rottie

[Julie & Yvette]

Hi everyone,

I am new here. I have a (i think) 10 yr old Rottweiler - she came from the SPCA 6 yrs ago and they told us she was "about 4". We've had a rough couple of months, and I was hoping to see if anyone has any advice for me. Here's her story (sorry, this is going to be long):

Background - she was very overweight when we got her - 112 lbs. We put her on a diet and she's maintained a good/slightly thin weight of a little over 80 lbs on about 3-4 cups of dry IAMS per day. The vet wanted her slightly on the thin side due to a previous torn ACL injury. A few years ago she started leaking urine and was put on DES (Proin didn't work out initially). Ever since around that time she has been drinking a lot - but no accidents in the house even when we are gone at work all day. We attributed the drinking to the new medication.


The bigger issues started 2 months ago...

- We noticed blood in her urine - there would be drops of blood on the floor after she got up. We took her right to the vet. She ran bloodwork and took an X Ray. Everything came back pretty normal. She was put on antibiotics and switched from DES back to Proin to see if it was a side effect of DES. After about a week the blood dissapeared.

- About 2 weeks later we gave her a raw beef bone. She's gotten diarrhea from them in the past, so it didn't surprise me too much when she ended up with diarrhea the next day. We started feeding her just boiled chicken and rice for a few days thinking it was from the bone and would go away soon. It was slowly getting more solid but she kept straining to poop and there was blood in the stool. 6 days after the bone we tried feeding her kibble for dinner and she puked it all up along with the breakfast of chicken and rice she had that morning. Back to the vet she went.

- The vet said it was not due to the bone. After a week long of various tests, including more bloodwork, urine tests, an ultrasound, and a dexamethasone suppression test we got a diagnosis of Cushings due to a small adrenal gland tumor. By this time she weighed in at 71 lbs - way too skinny. She was started on Trilostane and we switched her food to a mixture of Innova Large Breed Senior kibble + Wellness wet food.

- 3 days after starting the Trilostane was her worst day. We had let her out at 1am the night before and she was trotting around just fine. We we woke up at 9am in the morning her front elbow was completely swollen and she couldn't put any weight on it. We took her to the emergency vet (it was a Sunday) who x rayed the leg and ran a bunch of tests and couldn't find anything wrong with her except slightly anemic and slightly high white blood cell count and the fact that she looked sick. She said the joint looked really good, tested negative for lyme, blood glucose good, electrolyte levels/ratios were normal. She gave her shots of pain killers, anti-inflamitory, and antibiotics and sent us home. By the time we got home she was completely unresponsive - wouldn't even lift her head for a treat. We went right back to the ER and she was admitted and put on fluids overnight. That was a very scary day for us, but by morning she had perked up and was even putting just a little bit of weight on that front leg. The ER vet thinks it was the pain killer that zonked her out.

- The next day she went back to our regular vet. They reviewed all the tests shes gone through and talked with the person who did the ultrasound and and internal specialist. Now she had some concerns about the Cushings diagnosis - some things didn't fit: the adrenal gland without the tumor was normal size (not small), her liver didn't look like a Cushings liver (it was slightly scarred and small, not enlarged), and she has no problem holding her urine for a full day while we are away from home. She took her off the Trilostane (even if she does have Cushings this could have been a bad reaction to it). She went back on a round of antibiotics, pain killers, and we were told to try to get her to walk on the leg if she would tolerate it.

- Her front leg seemed to be slowly improving, but about 3-4 days later she started having issues with her back legs sliding out from under her and trouble getting up. I'm not sure if this is due to the extra stress from babying her front leg or if something is going on that is hurting all her joints.

- This week (1.5 weeks after the ER Sunday) she had a followup. She's back up to 75 lbs so that is very encouraging. We got her boots with rubber non-slip soles and she is walking a decent amount better in those, but is still pretty sore in both that front and the back legs. At this point we have her on no medication and are in wait and see mode (we even stopped the Proin after that ER visit and she's not leaking yet). She is much improved since the bad Sunday, but still not near the happy healthy dog she was a few months ago.

Other symptoms she has that look like Cushings:
- panting a lot
- thinning fur/some hair loss
- dandruff


I guess my question is is there anything else we should be doing for her at this point? Is this in fact Cushings? We used to give her glucosamine and Fish Oil but stopped when all this started happening - should we start those up again?

Thank you!

[Roxee's Dad]

Hi Julie :) Welcome to you and Yvette.

It sure sounds like Yvette has been through much over the last few weeks :( Do you have the results of her cushings test? ACTH and or LDDS. If not, please ask your vet for a copy, they should be happy to provide that information to you.

In the meantime there will be many more experienced members to welcome you and help you to better understand what may be going on with Yvette, my first thought is that she may not have cushings. It is a bit difficult to diagnose, so the test results will be a big help.

On a final note, I manually approved your post. Please check your e-mail and / or your spam folder for a message from K9cushings and follow instructions to finalize your membership approval.

[Roxee's Dad]

Hi, just me again.:o

I also wanted to ask if the cushings test was performed while she had an illness, like the diarrhea? often times our pups cortisol levels will increase during an illness, thereby giving a false positive on a cushings test.

Typically our cush pups:
Have a ravenous appetite
Drink tons of water
Excessive urination
hair loss
are just a few of the symptoms.

[Julie & Yvette]

I don't have the test results (other than the vet said it confirmed Cushings) - I'll try to get those for you.

At the time of the test the diarrhea was gone, but she still had soft, bloody stool.

All of your typical symptoms seem to apply to her:
- Ravenous appetitie - she's always scarfed down her food. Recently we've been giving her bigger meals and she doesn't always finish them right away, but she'll be back in an hour to get the rest. She always wants to eat.
- Drink tons of water - yep, but its ever since she started DES so could be from that?
- Excessive urination - she doen't have to go out often, she's fine with 3 times/day, but she does seem to pee for a long time when she goes
- Hair loss - started about a year ago around where her collar rubs around her neck and she now has a few balding spots on her sides as well


Also, I clicked the email link. Thanks for approving my post!

[mytil]

Hi Julie,

(I have approved your membership so there is no need to reply to any email confirmations from K9c).

Welcome from me too.

I would be very suspicious about the Cushing's diagnosis. Through all the testing at the various ER and vet visits, did anyone give her any prednisone?

IMO, to make this sort of diagnosis and then give this very strong medicine and then come back and say I am not so sure of this diagnosis raises my concerns about the vet's experience. This medicine is not like aspirin.

The blood in the urine could have been the result of a UTI. The bone issue can be that she has some blockage and getting sick like this is not a normal symptom of Cushing's.

I would most certainly seek the advice of a specialist - one who has treated Cushing's and knows the ins and outs thoroughly. Check these links - http://www.k9cushings.com/forum/showthread.php?t=182 and http://www.k9cushings.com/forum/showthread.php?t=183

Please keep us posted.
Terry

PS - can you let us know what pain killer she was on AND what was the dose of Trilostane you were giving her?

[mytil]

Hi again,

I am back, I only a few minutes to write up something and had to get off line.

The reason why I mentioned prednisone was because this is given if the cortisol levels fall too low (and of course the Cushing's meds have been stopped). At the ER vet, did they know your girl was on Trilostane and did they mention anything about cortisol levels falling too low to you? Falling too low can be dangerous for your dog.

All of your typical symptoms seem to apply to her:
- Ravenous appetitie - she's always scarfed down her food. Recently we've been giving her bigger meals and she doesn't always finish them right away, but she'll be back in an hour to get the rest. She always wants to eat.

By being ravenous, this means literally hoovering food and getting into trash cans or anywhere to find food. With her leaving some this really is not the ravenous behavior of high cortisol

Looking forward to those test results
Terry

[lulusmom]

Hi and welcome to the forum.

Based on the details so far, I would definitely question whether Yvette has cushing's. It appears that she was having nonadrenal issues which apparently were still unresolved at the time some of the testing was done. Bloody, soft stool is not normal and any number of GI issues can cause false positive low dose dex results as well as contribute to some of the same blood abnormalities we see in cushing's.

It would be a great help if you can round up all of the testing that your vet did to make a diagnosis and post the results here. With respect to the blood chemistry and cbc, we only need the abnormal values and please include the normal reference ranges. I will be interested to see if the bloodwork includes the T4 thyroid hormone as some of Yvette's symptoms, including the hair loss pattern, are consistent with hypothyroidism.

I agree with Terry about the appetite. An uncontrolled cushdog, won't leave a bowl until it's empty and licked clean. My two cushdogs, prior to treatment, left their dishes looking like they were right out of the dishwasher. :D Cushdogs lose the ability to concentrate their urine, which is why they pee and drink huge volumes. If they don't drink enough, they can dehydrate and it can turn into a very dangerous situation rather quickly. If Yvette can hold her urine all day, I highly doubt that her kidneys have lost their ability to concentrate. Your vet should have checked the urine specific gravity (USG), which is almost always low in a cushdog. If USG was within normal range, that would be another piece of evidence that would support the doubts I have about an accurate diagnosis.

Cushing's is one of the most difficult canine diseases to diagnose, which makes it one of the most misdiagnosed diseases. I haven't been around here as long as some but in my time here, I don't ever recall seeing a Rottie with cushing's. They are just not a breed that screams or even whispers cushing's to me, so I'm automatically very interested to know what tests were done and under what conditions.

I'm sure sorry for the reasons that brought you here but I'm glad you found us. We're here to help you and Yvette in any way we can.

Glynda

[Julie & Yvette]

She has not been given prednisone (I'm pretty sure) - the only day I think that might have been a concern was the day she was at the ER. That day the ER vet knew that she had just started Trilostane and checked her potassium sodium ratio and said it was normal. She said because that was normal it wasn't an effect of the Trilostane and I should keep giving it to her. I didn't and waited until I could talk to my regular vet who told me to keep her off of it. I know she was worried about cortisol levels potentially low at the ER, but with the slew of tests that have been done I honestly don't remember if she was tested for that after the fact - I do know she was taken off the Trilostane.

I have very high confidence in the experience of my regular vet. She has been amazing through this whole ordeal. She did not prescribe the Trilostane until after urine tests, bloodwork, dexamethasone suppression test all showed positive AND they found a tumor on her adrenal gland in the ultrasound. All of her symptoms at the time seemed to fit as well. I'm here though because I want to get as much information as I can from those of you that live with this everyday.

For the food - I think shes been taking a break recently because she eats so fast she ends up almost puking it back up. She starts coughing a bit after eating and needs to wait for her stomach to settle a bit before going back for more. She seriously just inhales the food.

The UTI does sound plausible. I'm sure the bone has caused some of these symptoms as well - but the x rays at the time showed no blockage.

The trilostane dose was 15mg twice per day.
For the pain killers the ER gave her (sorry if this is spelled wrong its tough to read this writing): Buprenix 0.5 mg (1ml) 1M. Polyflex 700mg IM. Then we got sent home with Clavamox and Tramadol. The tramadol didn't seem to bother her, but the shots certainly did.

I'm going to go read through your links now.

Thank you!

[Julie & Yvette]

Oh, also everytime she has had her urine tested it was very dilute and not concentrated. Looking at her urine they are pretty confused at how she is able to hold it.

[Julie & Yvette]

I found the CBC results from her ER visit if these are helpful. I have no idea how to read any of this, but there actually are a whole bunch that were out of the normal range. Here are the ones that are off with normal ranges in parenthesis:

WBC = 23.29 (normal = 6-17)
LYM = 0.23 (1-4.8)
GRA = 21.98 (3-12)
LY% = 1.0% (12-30)
MO% = 5.1% (2-4)
GR% = 93.9% (62-87)
HCG = 10.9 g/dl (12-18)
HCT = 34.39% (37-55)
MCV = 59 (60-77)
MCH = 18.8 pg (19.5-24.5)

I don't see anything that says "T4" on this sheet, but she also had bloodwork done at the regular vets (last year and this year) - I don't have the results of those here.

A couple of other symptoms that I should mention that may or may not be related:
- she's been picking at a sore on her back leg - it wasn't getting better so its been bandaged for a few days and she's leaving it alone now.
- she was shaved for the ultrasound and at the ER for the fluids and her fur doesn't seem to be growing back in those spots yet.

[frijole]

I know its frustrating trying to figure out all of this - many of us have been down similar paths where we thought we had answers only to learn things weren't as we thought... to really help we need to see the blood panel results that include the liver enzymes as well as the actual tests done to dx cushings.

I had a mystery dog - took me 2 years to figure out what was wrong with her (and I had already treated another dog for cushings so was experienced!). This dog, Annie was diagnosed with cushings. The drug didn't work and we did test after test - she had like 7 cushing tests that came back positive. Guess what ? She didn't have cushings.

I share this simply because she had a small tumor on her adrenal gland too and it was a very rare thing that is usually not diagnosed until after death. Another member had a tumor on the spleen that caused a false positive on the cush tests... It is very very common to see false positives because other illnesses skew results.

Your dog very well could have cushings but like Glynda said - a cush dog just doesn't eat alot and often - a cush dog will never ever walk away from food until it is all gone and they will search the floor like a vacuum cleaner looking for food and head butt very large trash cans in order to score more food. When we talk about drinking lots of water we are talking buckets.

I didn't get my answers until I went to a specialist. I wasted a lot of precious time and lord knows money... so if you can get test results and share as much as you can about Yvette's journey it will be very helpful. Our goal is to help you find the answers so Yvette can be treated for whatever it is that ails her.

If we sound skeptical about the diagnosis it is to protect you and Yvette from lost time, money, stress, etc based on the many years we've helped others... and trust me, this disease is tricky to diagnose and is very often misdiagnosed.

Glad you found us and look forward to learning more. Hang in there - the best thing you can do is what you are doing and that is get involved, ask questions and be her voice. Kim

[Julie & Yvette]

Hi again. Sorry for the delay - I've had my hands full with a diabetic cat the past week. I have copies of all the test results now.

On 3/30 she had bloodwork - this was just after we saw blood in her urine. Here are the results that were not normal:

ALK PHOSPHATASE = 439 (reference range = 10-150)
ALT (SGPT) = 142 (5-107)
AST (SGOT) = 128 (5-55)
CK = 488 (10-200)
LIPASE = 1410 (100-750)
T4 = 0.7 (1.0-4.0)
WBC = 18 (5.7-16.3)
RBC = 5.27 (5.5-8.5)
HGB = 11.5 (12-18)
HCT = 34.5 (37-55%)
NEUTROPHIL SEG = 82 (60-77%)
LYMPHOCYTES = 9 (12-30%)
EOSINOPHIL = 1 (2-10%)
AUTO PLATELET = 517 (164-510)
POLYCHROMASIA = slight
ANISOCYTOSIS = slight
ABSOLUTE NEUTROPHIL SEG = 14,760 (3,000-11,500)
ABSOLUTE MONOCYTE = 1440 (150-1350)

[Julie & Yvette]

On April 17th she had the ultrasound - that was the week before the ER Sunday.

Comments from the ultrasound:

Liver/Gallbladder: Liver small and slightly hypoechoic, though size best determined via radiographs

Kidneys/Bladder: Both kidneys mild diverticular calcifications

Adrendal Glands: Right adrendal large rounded hypoechoic tumor. left adrenal enlarged with retnetion of general shape, but cranial pole more rounded.

Additional comments: No free abdominal fluid

Assessment: Hepatic changes may be consistent with chronic active hepatitis, chirrosis, mvd. adrenal mass right, R/O functional vs nonfunctional, adenoma vs adenocarcinoma vs less likely phaeochromocytoma, left adrenal hyperplasia, r/o pdh vs benign

Recommendations: recommend urine cortisol/creatinine, ldds. If negative for Cushing's recommend liver biopsy with preop clotting profile.

[Julie & Yvette]

The urine test:

Urine Cortisol = 8.6
Urine Creatinine = 37.4
Urine Cortisol/Creat Ratio = 72

[Julie & Yvette]

Dexamethasone Suppression Test:

Pre Dexamethasone = 5.2 (reference range = 1-6)
Post 4 hr dex = 3.3 (<1.5)
Post 8 hr dex = 5.7 (<1.5)

[Julie & Yvette]

Currently we have her off all medications, but we're giving her fish oil and glucosamine like we always have.

She has been gaining some weight (she's at 76 lbs now), but it looks like a little bit of a pot belly to me. She is slowly starting to walk better, but she still seems pretty miserable and just wants to lay there. The fur that was shaved for the ultrasound has not grown back. Yesterday, she started not wanting to eat as much.

Whew, that was a lot of info - any advice on where to go from here?

Thank you!

[labblab]

Hi Julie,

I am so sorry that nobody has yet had the chance to reply to you about Yvette's test results! I am heading out of the house myself, but I promise I'll come back later and add some thoughts. And I'm hoping that you'll also get some feedback from other folks today, too.

Until later,
Marianne

[labblab]

OK, I'm back again, but feeling as though I still need to take more time to look over all of Yvette's info. Her situation definitely seems complicated :o.

One thing that I did notice on the 3/30 lab report was an elevated result for lipase. Has anybody mentioned pancreatitis as a possible cause for the ongoing GI/weight issues? I have a nonCushpup who suffered from intermittent episodes of vomiting and diarrhea over the span of a couple of months, and it was only through some specialized blood testing that we discovered she was suffering from pancreatitis. Dogs with Cushing's do have an increased vulnerability for pancreatitis. So it could be the case that Yvette does indeed have Cushing's, but the clinical picture (lack of ravenous appetite, for instance) could have been muddied by some smoldering pancreatitis. But another possibility is that pancreatitis at the time of the Cushing's testing could have affected the test results. Just a couple of thoughts to throw out.

Also, I noticed that her T4 (thyroid) level was abnormally low. Again, it would take some specialized blood testing to explore whether hypothyroidism is a genuine problem for Yvette. But if so, that could also account for some of her physical issues. Has any comment been made about her thyroid?

Again, these are just a couple of quick thoughts. I'll try to stop back again later on...

Marianne

[Julie & Yvette]

Thank you for the response.

I don't think we've heard anything about either pancreatitis or possible thyroid issues (but I could be wrong, we've gone through a lot with her recently). Are there other signs we should be looking for with either of those?

[Somesie]

Hey there, Julie. I can't help with interpreting test results, as I'm pretty new to this game myself, but I thought I would welcome you and let you know that you've definitely come to the right place for support and information.

We have been in the process of trying to find out what's wrong with our boy for several months now, and are kind of in the same wait-and-see place that you are right now, so I especially sympathize. Our vet 100% confirmed Jordan has Cushing's syndrome and prescribed Vetoryl, but thanks to the people here, I saw some red flags in her diagnosis that I otherwise would not have known to question. We've since been to a specialist who reviewed the myriad of tests he's had done, plus did a(nother) ultrasound, and declared that he does not, in fact, have Cushing's.

The diagnostic process has been very frustrating, and at times I've found myself trying to rationalize his test results to make them fit the Cushing's diagnosis, just so that we could have a confirmed problem and a clear solution. Of course, with such serious medications involved, that was definitely not the way to go, and I'm glad I had all of the voices of this forum to help guide me through. Even if they did guide me right into this holding pattern!

One thing I wanted to mention to you in this regard, in case you've not yet read it elsewhere, is that Cushing's progresses very slowly, so if that's truly what your baby girl has, then you're not really hurting her by taking a step back to re-evaluate and be 100% sure of the diagnosis before moving forward with meds. And, of course, if it turns out not to be Cushing's, then you did her a big favor by not medicating incorrectly.

The only other thing I can add is with regard to the ultrasound results. I've learned from experience that ultrasound is only as good as the equipment it's performed with, and (especially) the expertise of the operator. Having been present for both of Jordan's, I would have told you after the first one that I was 100% confident in the diagnosis that his adrenal gland was enlarged with a tumor. After witnessing the second one, however, done by the specialist...just...wow, Julie. It was a night and day difference, visible even to me, with no medical background at all, in the level of expertise of this doc versus the first one. I say all of this not to insult your current vet, but just to concur with what others have mentioned...Cushing's is very tough to diagnose, and unfortunately easy to misdiagnose. So, it's up to us to do exactly as you've been doing....learning as much as you can so that you can properly advocate for your girl.

I truly hope you get some answers soon, so that you both get some relief!! I'll be following your situation and will definitely keep you both in my thoughts! Jordan sends a big sloppy Boxer smooch your way!! :p

Best,
Jenn

[labblab]

Back again to elaborate a little more about testing for thyroid issues and pancreatitis. First, the thyroid. Yvette's T4 on the 3/30 bloodwork was 0.7 with the normal range being 1.0 - 4.0. So I would think her low T4 level would warrant a more complete thyroid panel. Upon measuring additional thyroid factors such as Free T4 and TSH levels, you will gain a better idea as to whether Yvette suffers from true hypothyroidism or whether her low thyroid level is more likely secondary to another condition or illness (such as Cushing's). Or upon retesting, you might instead find that there actually isn't any real concern at all about that T4 reading at all.

As far as the elevated lipase, it looks like Yvette's level was about double the normal value. While this doesn't necessarily confirm pancreatitis, I think it would raise the question for a dog who has had GI distress and is suffering from weight loss. The most definitive test for pancreatitis in dogs is the cPL blood test. It can reveal pancreatitis in a dog who doesn't even have an elevated lipase level at all -- that was the case with my own dog last spring.

Both these panels (thyroid and the cPL) just involve a simple blood draw. However, the blood must be analyzed by a lab that can perform the specialized tests. Your vet should be able to access such a lab with no difficulty, though. As I said earlier, neither of these issues may explain all that is going on with Yvette. But based on those earlier lab results, I'd think they would warrant further discussion with your vet.

Marianne

[StarDeb55]

Marianne has asked me to stop in & look at your girl's labwork. I'm a medical lab tech with 30+ years experience, so I'm kind of use to looking at these numbers. Marianne has done a very good job in offering feedback on the labs already. I would agree with her that the very elevated lipase may be pointing at pancreatitis, but the definitive test to make the diagnosis is the cPL test. The other thing I noticed is an elevated WBC count, along with an elevated absolute granulocyte count. This is indicative of a bacterial infection. Granulocytes are a specific type of WBC that fight bacterial infections. Did the vet say anything about an infection or was your girl put on antibiotics? If any of the Cushing's diagnostics were done during this timeframe, those results could be questionable as any non-adrenal illness such as pancreatitis can yield a false positive result on the Cushing's tests.

Debbie