Scarlett - possible macro tumor? - sweet Scarlett has passed

[Scarlett'sdad]

Scarlett is a 15 year old silky terrier, weighing 8.5 pounds. she weighed twelve pounds at diagnosis in August, 2009. She was urinating and drinking a lot, had a pot belly. Her blood panel showed an alt of 314, normal 5-107, alkp of 106, unusual since it it is usually elevated,. She had a pre acth of 13.8 ug/dl, a post acth of 26.5. Her low-dose dex was pre-dex 13.1 ug/dl, 8 post-dex 6.9 ug/dl. By May 2010, she wouldn't eat so I stopped the trilostane. I took her to a new vet who said she had stopped eating because the trilo had driven up her creatinine from 1.5 to 1.7, her bun was already 34 at the start and she felt it was time to just treat for high blood pressure and uti's as they came up. Scarlett also has ibd, bouts of pancreatitis and colitis, bulging disks in the back. What I am really curious about is that starting in May 2010 she began having tremors like I've seen discussed in threads here, hard to describe, they've gradually increased and they're up to about 4 an hour now. About a year ago she began pacing a little, it is more pronounced now. She became less interested in her walks, and would pull away when I would try to pet her. she would no longer sit on the sofa with me. In October, an emergency vet had increased her blood pressure meds and drove her kidney values way up, they are coming down with subq fluids daily and this has brought her appetite back, but really has had no affect on the tremors or pacing. A recent ultraound showd no enlargement of the adrenals, they are both the same size. I will post her current lab values below, do you think this could be a macro tumor?
AlkPhos 77 10-150
ALT 235 5-107
AST 33 5-55
CK 94 10-200
GGT 10 0-14
Albumin 4 2.5-4
TotProtein(TP) 7.3 5.1-7.8
Globulin 3.3 2.1-4.5
Tot Bilirubin 0.3 0-0.4
Dir Bilirubin 0.1 0.0-0.2
BUN 154 7-27
Creatinine 3.8
Cholesterol 162 112-328
Glucose 123 60-125
Calcium 12.8 8.2-12.4
Phosphorus 5.5 2.1-6.3
tc02- 17 17-24
Chloride 106 105-115
Potassium 5.5 4.0-5.6
Sodium 150 141-156
A/G ratio 1.2 0.6-1.6
B/C ratio 40.5
Ind bilirubin 0.2 0-0.3
NA/K ratio 27 27-40
Anion Gap 33 12-24
WBC 16.7 5.7-16.3
RBC 7.85 5.5-8.5
HGB 18.6 12-18
HCT (PCV) 52.4 37-55
MCV 67 60-77
MCH 23.7 19.5-26
MCHC 35.5 32-36
Nrbc
Neutrophils seg 92 60-77
Lymphocytes 4.8 12-30
Monocytes 2.9 3-10
Eosinophils 0.2 2-10
Basophils 0.1 0-1.0
(URINE - Urinalysis)
Collection Method (free catch, cysto, catether, etc.):catheter
specific gravity 1.013
Color yellow
Clarity clear
Glucose neg
Bilirubin neg
Ketones neg
Blood neg
pH 6.5
Protein trace less than 100 mg/dl
WBC none seen
RBC 0-2 0-5
Bacteria none
Epi Cells rare (0-1)
Mucous none
Casts none
Crystals none
Other: amorphous debris

[Squirt's Mom]

Hi and welcome to you and Scarlett! :)

If I am reading right, the treatment was stopped in May of 2010 and she has not been on any treatment for Cushing's since?


...she began having tremors like I've seen discussed in threads here, hard to describe, they've gradually increased and they're up to about 4 an hour now. About a year ago she began pacing a little, it is more pronounced now. She became less interested in her walks, and would pull away when I would try to pet her. she would no longer sit on the sofa with me.

These are all signs of uncontrolled cortisol but not necessarily a macro tumor. Was she diagnosed with the pituitary form or the adrenal form? With both adrenals the same size, I am assuming pituitary? I would expect both glands to be enlarged with a macro. ;) We have a thread started by a member whose baby did have a macro and others have contributed over time that may help you see if there are other signs present with Scarlett. You can find it here -

Macro tumor thread
http://www.k9cushings.com/forum/showthread.php?t=3567

We have some members here who have dealt with kidney issues and I am sure they will be along to talk to you soon. Meantime, some links that may help with the kidney issues -

http://pets.groups.yahoo.com/group/K9KIDNEYS/
http://dogaware.com/health/kidney.html

I'm glad you found us and look forward to learning more about Scarlett!
Hugs,
Leslie and the gang

[addy]

Hi and Welcome,

I am sorry to hear of Scarlett's problems. We have a link where members have discussed their experiences with macro tumors

http://www.k9cushings.com/forum/showthread.php?t=3567&highlight=macro+tumor

We have seen pups with macro tumors pace, circle, shiver, it is hard to say if that is what your are seeing.

My Zoe has IBD and colitis and is on Trilostane but does not have the kidney issues yet or high blood pressure. we have not yet experienced the tremors. If I understand you correctly, Scarlett has been off Trilostane since May 2010 and we have no ideas what her cortisol levels now are?

[Scarlett'sdad]

Off trilostane since May 2010, and no idea what cortisol levels are now.. Will have to ask for it to be included on blood work I am having done this week. What screen includes this, I am afraid I am rather late in the game of checking on these things myself.

[frijole]

I don't think she ever had cushings. That alk phos level is so low (normal) and it is the ALT that is elevated. Looks like diabetes was ruled out. How about hypothyroidism?

Please read the report for the ultrasound and see if there is any mention of tumors on any other organs. When I read your comments I thought perhaps she has a pheochromocytoma (one type of adrenal tumor)... My Annie had one and was misdiagnosed with cushings. She had high blood pressure (intermittently), loss of appetite/weight, intermittent episodes of full body shaking, loss of muscle mass in hind legs. She had all sorts of false positives on cushings tests. Sounded exactly like your gal. But I would have thought they'd have picked up on the tumor on the ultrasound. (note sometimes they do miss things though) She had a big tummy but it wasn't really her tummy it was enlarged liver and heart.

How yellow is Scarlett's urine? If it is normal looking - based on the alk phos reading I would cease worrying about cushings and a macro.

File this away in case you need it in the future - these tumors are rare and often not diagnosed until after death. My girl lived with hers for 2 + years. Surgery can be an option depending on location and size.

Kim

[molly muffin]

Hello Scarlets dad and welcome to you and Scarlet.

Cortisol levels are checked with an ACTH test.

Are you seeing an internal medicine specialist too? Since I see that there have been several issues with kidney's, etc.

This is a link to a site that can help you understand your different readings on blood tests, etc.

http://www.acreaturecomfort.com/caninebloodwork.htm

Just remember, none of us end up here because everything is okay. We come in knowing not nearly enough and then the homework starts. :)
We are also a really Good support group for going through these things as everyone is either in the same boat as you, or been in the boat before, so all worries, fears and hopes are shared. :)

Sharlene and Molly Muffin

[frijole]

Off trilostane since May 2010, and no idea what cortisol levels are now.. Will have to ask for it to be included on blood work I am having done this week. What screen includes this, I am afraid I am rather late in the game of checking on these things myself.

If she were mine I would do an acth test at this point because it is a very expensive test and I feel you would be wasting money. Cush dogs have alk phos levels in the thousands and Scarlett's is normal. I truly believe it is something else.

Have you tried going to a specialist? That's what I ended up doing (after wasting thousands and thousands at my regular vet who was lost).

Kim

[Roxee's Dad]

Hi and a little belated welcome from me too.

After reading your first post, while the ACTH test was high normal, it doesn't seem that it was that high, but indications of excessive thirst and urination could lead one to believe she has cushings. There are many underlying conditions that could have caused her cortisol to be high. You mentioned she had UTI's and pancreatitis, bulging disc and colitis all of which could raise cortisol levels.

Was Scarlet on any type of steroids during or before the ACTH testing, that led to the diagnosis of cushing's? I do agree with the others and would have her cortisol checked via an ACTH test. If her cortisol is too low because of an adreanal malfunction, and she has UTI and pancreatitis and even a buldging disc, these could be causing her pain thereby the "tremors". Also noticed her WBC is just a tad over normal which could mean she is fighting an infection although their could be other reasons for this.

It would appear that her cushings symptoms have not returned since stopping the Trilo in 2010? No excessive drinking, urinating, appetite?
I wouldn't jump to a macro conclusion just yet.

I am a firm believer in using a Internal Medicine Specialist when it comes to more complicated diagnosis in our senior pups. Please do let us know the results of her upcoming bloodwork.

We are one big family here and are pulling hard for you and Scarlett.

[Scarlett'sdad]

Thanks for all your replies. Scarlett's being put on the extra high blood pressure medicine that drove her creatinine up from 2.2 to 4.6, and BUN from 74 to 154 was done under the supervision of a board-certified internal medicine specialist at the large, open 24 hours clinic I went to (my regular vet is not open nights). He was so fixated on lowering her blood pressure (which apparently was just elevated that high by being stressed and excited) led to him wrecking her kidneys, so I think I will stick with my regular vet for the moment. Scarlett's thirst, excessive urination had returned by late April 2010 even being on 60 mg trilostane at 12 pounds weight. My current vet, who I started with in may 2010 as I didn't want to up the trilo again, said that with a BUN of 35 and creatinine of 1.7, was early kidney failure causing those symptoms. Scarlett had taken steroids for itchy skin as late as 2007, but not in close proximity to her Cushing's diagnosis.

[addy]

My current vet, who I started with in may 2010 as I didn't want to up the trilo again, said that with a BUN of 35 and creatinine of 1.7, was early kidney failure causing those symptoms. Scarlett had taken steroids for itchy skin as late as 2007, but not in close proximity to her Cushing's diagnosis.

If I am not mistaken I believe Vetoryl is to be used with caution with dogs having kidney disease so I can understand your vet's reluctance at that point. Did anyone ever talk about different forms of diabetes?

I am so sorry your specialist was not good, it happens. Sometimes they fixate on one thing and forget the whole picture. My Zoe did not have huge ALT numbers and when I questioned an endocrinologist about it, he said that does not mean she does not have Cushings but her cortisol and other intermediate hormones were significantly increased.

Hopefully others will also be by soon to weigh in with opinions and advice.

[labblab]

Welcome from me, too.

From looking through Scarlett's labwork, it really seems to me as though her kidney issues may take priority over everything else right now. As you know, her values were already elevated prior to the ER visit. And even though her creatinine has come down a little bit from its peak, it is still elevated and her BUN is highly abnormal.

Can I ask what prompted the ER visit, and why you feel as though it was medication that caused the spike in her renal values? Uncontrolled blood pressure can wreak havoc on the kidneys, so I am wondering whether it is possible that it was high blood pressure that was associated with the spike rather than the meds.

But regardless of the cause, abnormal kidney function can cause a host of symptoms including excessive thirst and urination, lethargy, depression and seizures. And since both of the diagnostic Cushing's blood tests (ACTH and LDDS) can be skewed by the presence of other, nonadrenal illess, I'm not sure how trustworthy their results would be in the face of Scarlett's current renal abnormality.

Has Scarlett been on the Sub-Q fluids consistently since October? Does your vet have a gameplan as far as maintaining them indefinitely? Are you making any dietary changes or instituting other means of kidney support? I really do think it seems more likely that Scarlett's immediate problems are associated more with the kidney issues than with a macro.

Marianne

[molly muffin]

Oh my gosh! I can certainly see why you would want to stick with your own vet. We are more use to the exact opposite situation in general with cushings. I am sure that was a very distressing incident to you and Scarlet. I don't know if it was the medicine or whether it was a kidney issue, but either way, it is associated with that ER hospital and the specialist.

I actually agree with Marianne that the kidney is the most important issue right now. What did the kidney show on the ultrasound, did they look at that? When I look at my ultrasound report it does talk abut the kidneys too, so maybe yours does also.

Poor little Scarlet and you. Sounds like you have both been through the wringer the last few years.
It is however, your diligence and love for Scarlet that has gotten her to this point even, because the things you mention can have very serious consequences. You are obviously doing a very good job.

Sharlene and Molly Muffin

[Scarlett'sdad]

I think it was the increase in the BP meds, both at the hospital and at home for a week after because my regular vet said since her BP was likely not really elevated except at the stressful moment it was taken, the lack of sufficient blood flow to the kidneys caused the problem. She had gone up only from 1.7 to 2.2 creatinine between May 2010 and October 22 2012 (they took her blood upon admission to the clinic) and it was 3.9 on release two days later and 4.6 after a week at home. I feel pretty guilty for allowing this treatment to happen, but I was swayed by the internist's board certification and talk of a stroke, sudden blindness or a blood clot in the lungs. She went into the hospital due to an attempt to feed a lower phosphorus diet causing a recurrence of her pancreatitis - I know beef is really bad for having phosphorus, but her home cooked beef/sweet potato loaf is all she can eat without real digestive trouble - I have tried everything, believe me. I just wanted her to get some IV fluids to avoid dehydration,but they took her BP and things went downhill form there.

[molly muffin]

I am so sorry that you went through that. You must have been so scared for her. I'm sure you probably still are.

So back to your original question of could this behaviour signify a macro tumor. I would not say a definite yes to that until the kidney issue is fully addressed and you can see if the behaviour changes as the bun and other lab results become more normal. These are things that could also be associated with the kidney issue that scarlet is having currently.

Sharlene and Molly muffin

[Scarlett'sdad]

Scarlett has been to another clinic where she has had a much better experience with a board certified internist, this vet works closely with her regular vet and is totally up to speed on the blood pressure issue. The tremors have lessened, they may be a result of Canine Cognitive Dysfunction - even when her values were still pretty good, she had some symptoms of it. After three days hospitilization, her creatinine has gone back up but she has been helped by the daignosis of a liver infection; she was discharged 1/17 with ursodiol 75 mg once daily, denamarin 90 mg once daily, sevelemar phos binder 200 mg twice a day. She wouldn't eat her regular diet this morning, since she just had a recheck this past thursday I called the 24 hr clinic and got some Science Diet canned Liver diet. any experience here with this diet or those liver medications? It does certainly look as though she never had Cushing's. Thanks so much for the help, in the middle of the night it is helpful to just browse here and the kidney forums for info/support.

[Scarlett'sdad]

Scarlett apparently never had Cushing's but took Triolstane from Sept 2009 to April 2010 after being misdiagnosed as so having. At the bottom of this post I have listed all the things she is dealing with, but we had had a great month after the addition of B-vitamin complex at 25 mg twice a day, Ursodiol and Denamrin for her liver, and Sevelemar as a phosphorus binder. The labs I am posting from 2/14 showed no hint to me or the vet that she was about to get stuck against furniture Sunday morning 2/17, press her head against the wall, and hardly be able to walk. Her tremors and pacing have returned after stopping for a month following the three medicine and vitamin additions listed above. The vet suspects that the pneumonia has stopped her from compensating for a brain tumor, but with her kidneys as bad as they are I am reluctant to have an MRI done. Any ideas on anything else it might be?
Larry/Scarlett 15 y/o Silky Terrier Central CA
Neurologic deficits, chronic active pancreatitis, pneumonia, IBD, CRF, Mitral valve/Tricuspid valve disease, High blood pressure, T3-L3 myelopathy, increased liver enzymes
Budesonide,Pepcid,Ursodiol,Sevelemar,Cyclosporine, Denamarin,Clavamox for the following week,buprenex for a few days then back to Tramadol,Amlodopine
ALB 3.9 g/dL 2.5-4.0 235 5-107
ALKP 115 U/L 10-150
ALT 142 U/L 5-107 High
AST 28 U/L 5-55
BUN/UREA 119 mg/dL 7-27 High
CA 11.8 mg/dL 8.2-12.4
CHLORIDE 101 mEq/L 105-115 Low
CHOL 148 mg/dL 112-328
CK 75 U/L 10-200
CREA 3.4 mg/dL 0.4-1.8 High
DBIL 0.1 mg/dL 0.0-0.2
GGT 13 U/L 0-14
GLU 119 mg/dL 60-125
PHOS 4.0 mg/dL 2.1-6.3
POTASSIUM 5.2 mEq/L 4.0-5.6
SODIUM 144 mEq/L 141-156
TBIL 0.1 mg/dL 0.0-0.4
TP 7.1 g/dL 5.1-7.8
GLOB 3.2 g/dL 2.1-4.5
ANION GAP 29 mEq/L 12-24 High
BICARB 19 mEq/L 17-24
IBIL 0.0 mg/dL 0-0.3
A/G Ratio 1.2 0.6-1.6
B/C Ratio 35 High
Na/K Ratio 28 27-40

Hematology Results
HCT 46.1 % 37-55
HGB 16.3 g/dL 12-18
MCHC 35.4 g/dL 32-36
WBC 20.0 K/uL 5.7-16.3 High
LYMPHS 6.9% 12-30 Low
MONOS 4.7 % 3-10
EOS 0.1 % 2-10
BASO 0.0 0-1
RBC 6.71 M/uL 5.5-8.5
MCV 69fL 60-77
MCH 24.3 pg 19.5-26
NEUT SEG 88.3 60-77 High
PLATELETS 425 K u/L 164-510
RETIC CNT 0.5 %
ABS BASO 0 u/L 0-100
ABS EOS 20 /uL 100-1250 Low
ABS LYMPHS 1380 /uL 1000-4800
ABS MONOS 940 /uL 150-1350
ABS RET 34 K/uL 10-110

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

[Scarlett'sdad]

Scarlett died yesterday, April 12, 2013. The neurological deficits turned out to be GME. The symptoms were kept mild for the first eleven months she had it, because she was taking cyclosporine for her atopy (she was such a fighter, she had so many problems to deal with, I forgot to list that one; despite that she kept part of her spirit until the end). The symptoms of depression and excessive circling prior to urinating, pacing at night were thought to be related to her kidney failure or just canine cognitive dysfunction. When the severe symptoms emeged, she could not walk unaided within a week. She shivered constantly the two hours a day she was awake . Despite the addition of prednisone for inlammmation, and mirtazapine for appetite, she would not eat and things went rapidly downhill. Thanks for all the concern and help shown here, my heart is broken. I wish many healthy days for all of you and your babies.

[frijole]

I am so sorry. May Scarlett RIP and run free of pain. Kim

[molly muffin]

Oh no. I am so sorry to hear that Scarlett has passed. What a fighter she was. You and her both fought for her for the longest time and through the greatest of trials. The love you have for her will live on forever in your heart. There is no greater tribute to a live lived than one filled with love as her's was.
I know you are heartbroken. :( My condolences on your loss.
hugs,
Sharlene

[Bo's Mom]

I am so terribly sorry to hear about sweet little Scarlett. Prayers of strength and peace be with you now and in the days/years to come.

[doxiesrock912]

I'm so sorry to hear about Scarlett.
I wish that our furlets could talk sometimes and tell us what is wrong.

[mytil]

I am so incredibly sorry for your loss - I know how heartbreaking it is. We are all here for you!

Sending healing (((hugs))) and always remembering your Scarlett.
Terry

[Fellasmom]

I'm new to this board but just wanted to say I'm so very sorry for your loss.It's such a horrific loss and so many don't understand that they aren't "just"pets but family members.When I lost my dog several years ago,I kept telling myself how lucky I was to have had her for so long.She loved me so much and brought so much joy to my life.I don't think they ever really leave us.They stay in our hearts and I swear some of their personality comes through in our next furbabies.I still see her everywhere and you will too.My thoughts and prayers are with you.

[Boriss McCall]

I am so sorry for your loss.
hugs..

[scoora]

I am so sorry for the loss of your sweet Scarlett. My thoughts and prayers are with you.

[Jenny & Judi in MN]

I'm so very sorry. They love us so much. Judi

[SoggyDoggy]

I'm so sorry to hear sweet Scarlett has passed. Our thoughts are with you.

[Budsters Mom]

I am so sorry to hear about your darling little fur baby. My thoughts and prayers are with you.

Hugs, Kathy

[Sabre's Mum]

I am sorry for your loss. Rest in peace lil Scarlett.

Angela and Flynn

[milosmom]

also offering condolences and know that your sweet scarlett is in great company and will have lots of new friends to play with.sending you healing prayers for your broken heart...patty(milo)meka xoxox

[Mel-Tia]

Sorry to hear about Scarlett

Run free little girlie, hope the sun is shining on you now

Mel and my Angel Tia
Xxxxxx

[Simba's Mom]

So sorry to hear about Scarlett, what a fighter your fur baby was...sending hugs of comfort.. Keep those good memories alive and Scarlett will always be in your heart...

[Fellasmom]

Larry,
Thank you so much for a such your sweet words on Fella's memory post.I was just new myself on this board when I recall reading about the passing of your sweet Scarlett.Little did I know,I would be faced with the same heartbreak 7 days later.Such an awful heartwrenching loss to go through.I too feel huge amounts of guilt most days.But I know in my heart that there isn't anything that we wouldn't have done for our loved ones and we do what we think is going to give them the best possible chance of a good quality of life.

I just read Scarlett's story.She was lucky she had such a wonderful dad!I bet she loved the homemade meatloaf!:).

I still don't know what happened,as my Fella was described as a "perfect surgical candidate" and my little boy flew through the surgery with no complications...and he died the next day:confused:.I too think of him everyday and second guess myself.But as you said,they loved us so much that they would hate to see us in so much pain,guilt and confusion.The guilt can sometimes overshadow the absolutely wonderful life that we shared with them.I try very hard to let go of the guilt and remember how much I loved him and all the wonderful things we shared the past 10 1/2 yrs.Your sweet Scarlett and my Fella meant the world to us and I hate to focus so much time on the "end" because that was such a tiny portion of their lives!It's all those years of love and companionshiop that are so much more deserving of our time and energy.I try really hard to remind myself of that but admittedly,it's a work in progress because the guilt and second guessing does have a way of rearing it's ugly head again!:)

I hope the pain lessens one day for us.Adopting Romeo is a bittersweet decision but I am hopeful that it will ease some of the pain and emptiness I feel.I hope Scarlett and Fella are running free and healthy again!:).I hope your guilt lessens in time as well as it sounds like you did everything you possibly could for your sweet girl and all your decisions were based on your love for her.I will keep you and Scarlett in my thoughts and thanks for your kind words and understanding.
Patty