5 year old Frenchie, elevated ALT, skin lesions— I suspect Cushing's, what to do next

[turtlesmom]

Hi All—

The love of my life, Turtle, is a French Bulldog who is 5 years old. He has been in exceptional health his whole life until the last few months where things just seem off. Some symptoms:

1. Rising ALT. 2 months ago was at 300, this was tested after he ingested dark chocolate and had to go to emergency room. 1 month ago at recheck was 550. Yesterday was 1300!! Urine Acid Bile Test=normal

2. Loss of hair around abdomen where his harness was.

3. Very recent development of hard callous like skin abrasions on top of his neck. They are white except where irritated and have bled and scabbed. (Just read that there is something called calcinosis cutis associated with Cushings, this sounds extremely similar to what Turtle has and makes way more sense than just one day his harness that he has worn for years suddenly irritated him)

4. Drinks excessively and urinates often

5. In last 3 months has been losing ability to jump seems related to hind legs becoming weak. Needs me to lift him into bed and onto couch. Previously would impress people with how high he could jump.

6. Skin seems thin and stays if I pinch it...

7. Perhaps reduction in muscle, sometimes he just seems more boney

8. Otherwise, acting like normal self, good appetite, a bit more aloof, I just think he is not feeling well :(


Anyways I am supposed to go to the vet on monday for an ultrasound related to the 1300 ALT level. And after having done some reading I very much believe that my dog has Cushing's and am wondering what tests I need to ask for and what to do next. Also do I need to see a special type of vet (one that specializes in endocrinology)? Basically I want to get the best care for my animal and am feeling lost.

Thank you very much!

[labblab]

Hello and welcome, although I am so sorry for the reasons that have brought you here. In honesty, if you have access to a specialty dermatologist, that might be the best diagnostic referral source for Turtle. In conjunction with all the other classic symptoms, if a biopsy of those white skin spots shows calcinosis cutis, I don't think you need to go a whole lot further in confirming a Cushing's diagnosis. In this situation, an alternative explanation for the calcinosis would be very rare and surprising (assuming Turtle has not been treated with steroids recently). And you will want to get going with treatment of Turtle's skin and the Cushing's as quickly as possible so as to keep those lesions from worsening. I don't want to alarm you, but in terms of quality of life issues, calcinosis cutis can be one of the most important Cushing's symptoms to manage as it can worsen very quickly. And for some reason, bulldogs and boxers seem to be over-represented here as far as manifesting CC.

An ultrasound remains a good place to start in order to view the status of the adrenal glands so as to gain info as to whether the Cushing's is pituitary or adrenal in nature, and also to rule out any other contributing issues with internal organs. And you may want to also request an ACTH stimulating test. It is a blood test that is used to diagnose Cushing's, but also to monitor treatment effectiveness down the road. So even if Turtle is diagnosed via skin biopsy, it would still be helpful to have a baseline pre-treatment ACTH in place by which to judge medication effects.

Please do keep us updated, OK?

Marianne

[turtlesmom]

Thanks so much Marianne.

I will request a ATCH test tomorrow when I bring him in for the ultrasound. Do you know if it is a fasting test?

I also will call a pet dermatologist. This has been so stressful. I just want my little guy better. It feels good though that I seem to have a name for what is going on.

[Budsters Mom]

Hello and welcome from me too.:)

You are off to a great start with Marianne, so I'm mainly here to welcome you to the group. We will do all we can to help. The more that we can find out about your sweet Turtle, the more guidance we will be able to give you.

Most of us were scared and feeling lost when we stumbled upon this group. That is especially true for me. The more you're able to learn, the more empowered you will become. The fear doesn't totally go away, but it does get better.:) please feel free to ask any and all questions.

[Harley PoMMom]

I will request a ATCH test tomorrow when I bring him in for the ultrasound. Do you know if it is a fasting test?



Most times when a dog is having an ultrasound done fasting is required, and when the ACTH stimulation test is used for diagnosing Cushing's some labs do prefer that the dog be fasted.

Hugs, Lori

[molly muffin]

I just want to pop in and say hello and welcome to the forum.

How did the ultrasound and testing go? Hope all is well.

Sharlene and Molly Muffin

[spdd]

Welcome to the forum. I echo Sharlene's comment - how did the testing go?

[turtlesmom]

Hi all—

Thanks so much for your replies. I had to step back from the internet for a second because I was stressing myself out which I decided wasn't good for me or for little Turtle. So here is the summary of the last couple weeks:

1. Vet at first did not concur with my hypothesis of Cushing's due mainly to Turtle's liver levels which are very high on ALT (1300+) and normal on ALKP and due to the fact that Turtle's appetite had been severely reduced—basically his clinical presentation was not consistent with Cushings. He believed that some of the symptoms looked like Cushings because he had an underlying liver disease which then would elevate his cortisol levels. His questions really was are these symptoms secondary to liver disease. We were put on two strong antibiotics. Turtle's attitude and appetite immediately got much better and I felt much better and that perhaps the vet had been right. We still had not understood what the skin problem was and I thought it would clear.

He had test for lepto which came back negative although he basically was being treated for this scenario and responded positively, vet says lepto testing not the most accurate, he has continued on antibiotics because responded positively clinically

He also had ultrasound which showed slightly enlarged adrenals.


2. About one week later his skin got worse— it spread. We biopsied it and took a skin smear. Skin smear positive for fungus so was sent home with shampoo, vet believed that the fungus could be secondary to underlying problem and shampoo would prob not alleviate problem. A couple days ago, skin biopsy came back as calcinosis cutis.

Liver levels continue with elevated ALT (although slightly less but still over 1000) and ALKP still near normal.

He seems more depressed and in pain :(. His appetite seems fine but it seems like his mouth might be hurting him and I am not sure if he has sores there or what is going on. He is eating very slowly.

It almost seems like some of his cushing symptoms flare along with his calcinosis cutis, and I am not sure if somehow his skin could make even more cortisol be released...like he becomes more potbellied and coat more dry....

3. Tomorrow we are going to the vet for LDDS test and some other blood test. Tuesday he wants to biopsy the liver (liver was ultrasounded, nothing showed). The question the vet has and one I would like to ask here is if some underlying liver disease could be causing the Cushing's. He basically sees Turtle as an outlier and wants to figure out a little more I think.

I read on one thread that a tumor on a dog's spleen had caused cushing's and after removal cortisol levels went back down. I also read on PubMed an abstract for "Generalized calcinosis cutis associated with probable leptospirosis in a dog."

So I think the hypothesis is certainly a possible one. I just don't want my little bug to be in pain and his calcinosis cutis is very brutal and I would like it gone ASAP even though I know that is not possible...we are in it for the long haul.

So specific questions...

1. Do any of your dogs diagnosed with Cushings have elevated ALT and normal ALKP?

2. Have any of your dogs had Cushings secondary to underlying disease other than something specific to pituitary or adrenal glands like liver disease?

3. Are there any topical suggestions for calcinosis cutis? I have read about DMSO and then I saw this other study on humans about myo-inositol hexaphosphate-based cream (IP-6), wondering about any experiences on these. Tomorrow I talk to the vet about topicals for calcinosis cutis, he said there is one so we will see what it is, I just wish there was something to soothe him.

[frijole]

Hello. I've been here over 8 yrs and never seen a cush dog with normal alk phos and extremely high ALT. I'm concerned about the LDDS test because it is known to cause false positives (for cushings) in dogs with other illnesses present. So even if you get a positive on it you are no further ahead. My own dog had this happen several times and she had a rare non cushings adrenal tumor but it took me a year to figure it out and I had to go to a specialist/teaching university.

If your dog is ill from some other cause and it's body is fighting then it would be creating cortisol to fight the disease. Again my dog Annie had this happen to her. She didn't have skin issues though.

We have had many members that have had to fight calcinosis cutis and it is very difficult. The easiest way to locate their threads is to do a search of the forum for calcinosis cutis. Sorry I can't remember what the used to treat but I know it is a battle that can be won over time. Kim

[molly muffin]

Kim is right, ALKP is what you normally see with cushings.
Cushings is caused by an adrenal tumor or a pituitary tumor. Then there is Atypical cushings, cortisol is not eleveated, but intermediate sex hormones are. This can only be verified by Univ of Tenn testing. Introgenic cushings, is caused by a dog being steriods for a long period of time, symptoms usually resolve as the steriod use is decreased and finally removed all together.

That being said. Anything going on in the body, can cause the adrenal glands to kick in and create cortisol at high levels. If this continues for a long period of time, you will see the same signs as cushings, but it isn't cushings. You can have the enlarged liver and adrenal glands, skin problems, and anything else associated with high cortisol. Once the underlying reason for the cortisol being produced is addressed and corrected, then the cortisol should return to normal and symptoms clear up. I think that is probably what is going on with Turtle. If that is true, then an LDDS can produce a positive for cushings, due to the body producing all the cortisol, and be incorrect.
I think due to the high ALT, looking at liver problems as the underlying cause, is a good idea. Taking a close look at gall bladder, kidney's, pancrease, spleen is also a good idea.

Hope this helps.
Sharlene and Molly Muffin

[goldengirl88]

Hi just wanted to stop by and welcome you to the forum. I hope your Turtle gets his diagnostic done and that you are able to get a diagnosis on him. Blessings
Patti

[turtlesmom]

Test results in, confirmed Cushings, although still waiting on liver biopsy I guess to make sure not secondary to liver disease. Tests:

Aug 29, 2013:

ALT 525 (ref 12-118)
ALKP 95 (5-131)


October 2, 2013:

ALT 1367 (12-118)
ALKP 414 (ref 5-131)
protein in urine, cholesterol high= 436 (ref 92-324)


October 21, 2013

ALT 1016 (12-118)
ALKP 645 (50131)

other abnormalities in bloodwork on a few dates I am not reporting here such a BUN/creatine and platelet count, etc.


Results of LDDS test
Pre 6.4 (ref 1-5)
Post1 7.0 (ref 0-1.4)
Post2 7.1 (ref 0-1.4)

[turtlesmom]

I also got DMSO gel from the vet. I am going to take photos of his skin and watch it. I will upload them to my album here.

Here is today, pre-tx:

http://www.k9cushings.com/forum/picture.php?albumid=758&pictureid=5617

[molly muffin]

Hi :) How is Turtle doing? Is the DMSO helping? Just wanted to check in on you.

Sharlene and Molly Muffin

[molly muffin]

I saw your post that the cc is getting better. Hope the MRSA gets cleared up soon too.

You mentioned that you have seen a decrease in appetite, this is pretty normal when on trilostane. Even for dogs who have always loved their food, the high cortisol makes them feel even more hungry and that goes away with treatment.

Glad to hear from you.
Sharlene and Molly Muffin

[turtlesmom]

Thanks Sharlene!

The strange thing is that the reduced appetite was actually before the trilostane, now after two weeks on trilostane it is coming back which is good. It might be due to skin or MRSA...or maybe stomach upset due to antibiotics. Vet was initially worried wasn't Cushings because of this and his abnormally high ALT (1300+ with ref range being something like 10-100) and that Cushings symptoms were secondary to underlying disease but it seems that actually Cushings is primary and Turtle just is a little bit strange. But luckily he is responding really well to trilostane. He has been on it two weeks. 14mg twice a day (every 12 hours, compounded at diamondback pharmacy). He is around 28 pounds (his weight fluctuates lately between 27-29 lbs).

I might copy paste my other post here so all info is consolidated here. I feel like I have learned a lot.

ACTH Stim a couple days ago:

(pre) Cortisol Sample 1: 5.3 ref range 1.0-5.0
(post) Cortisol Sample 2: 3.7 ref range 8.0-17.0

****Per test result paper:
Post-Trilostane: Pre and Post cortisol levels between 1.5-9.1 ug/dL indicate optimal control
Hypoadrenocorticism: Resting cortisol is usually subnormal (less than 1 ug/dL) or low normal with no increase after ACTH
Hyperadrenocorticism (Cushings): indicated by Post ACTH greater than 20 ug/dL

my vet was very pleased with results, I am super pleased with turtle's clinical results, he has more pep in his step, we went on longest walk in month yesterday, he is begging for food again, just better all around, he has a better complexion if this is possible

also blood work a week ago had his ALT reduced to 300
which while still elevated it hasn't been there since the end of August so I was stoked :) things are trending in the right direction

[turtlesmom]

What I have learned about Calcinosis Cutis

Copy/Pasting what I wrote from other post, basically this is how I have been treating Turtle's Calcinosis Cutis which has been the worst part so far of Cushings for my doggy:

Hi—

I just read through your thread. I basically have been in the midst of this for the last few weeks. My dog, Turtle, has severe calcinosis cutis (he has also never been on steroids and was diagnosed with PDH cushing's). It is insane how fast it spread. Basically in one month it spread over most of his back. It is the most horrible thing. Anyways for the first time it is starting to look better and I have read anything and everything I could. These are what we have done for treatment of the CC:

1. Twice daily DMSO (90% gel).
It is hard for me to know how much it helps the skin, although I do believe it has been helpful. However, I do know that it greatly helped Turtle's pain. It would relax him a lot about 10-15 minutes after I put it on. For that alone I believe it has been helpful. I have read that there are worries about serum calcium levels when DMSO is used on CC dogs over large areas, however, my vet is not worried about this and when his electrolytes were checked everything was normal.


2. Once daily bath with Ketochlor shampoo.
When my vet took smear samples of Turtle's skin there was a lot of yeast (for this reason I would suggest NOT using oatmeal based shampoo as I believe it agitates yeast problems). I leave the shampoo on for the recommended 10 minutes. I use a bowl of water and shampoo to lather it on outside of the bath, set the timer for 10 min, and then put him in the shower when the timer goes off.

Cushing's dogs and CC skin is very susceptible to secondary (bacterial and fungal) infections. The two active ingredients of Ketochlor are Chlorhexidine Gluconate and Ketoconazole. Oddly, Ketoconazole is taken orally to treat Cushings. However, both work to combat fungus and bacterial infections. I believe the daily shampoo has been really helpful. It also helps in debriding the wound.

3. At the very beginning, they took a sample and looked for MRSA (bacterial infection). They did not find any. However, three weeks later they took another sample to test for MRSA because his skin was smelling very bad and it tested positive for MRSA. So we had to change to an extreme oral antibiotic (he had previously been on amoxicilan and zeniquin). He is now taking Chlorephenicol.

4. When he started Trilostane (Vetrotyl) for his Cushings, his CC did stop spreading. However it definitely looked worse before better, like it is rising out of the skin or something. He is now 2 weeks in to Trilostane and his ability to heal himself is greatly improved. He is doing much better and I finally can see some light at the end of the tunnel. I would try to get your dog on Trilostane as fast as possible. There is talk about Lysodren being better for CC than Trilostane. I do not know about this, the reality is that there are very few actual studies on CC in veterinary journals that I can find, so that hypothesis is anecdotal. When my vet consulted local vet dermatologist on the question, the derm said he never treated CC with lysodren, that trilostane has been effective. Given the risk profile of the two drugs for me it was easy to choose, other people may have different opinions. Additionally, Turtle's appetite has been greatly reduced and we are not really sure why this is since this is the opposite of a Cushing's dog. I have wondered if it had to do with his skin issues and resulting pain. But basically we don't know...and my dog had always been a voracious eater.

5. I have been using some medical grade manuka honey at night on his wounds, this is not on Vet's advice but after learning about MRSA, I read studies that it can help. Again, I am not sure if it is helping or not.



Other than that I just have to say that CC is the worst. It has been excruciating to watch my dog in pain every day and realize that there is very little I could do about it (and trust me I combed for an answer— humans also get calcinosis and there is very little they can do, it is very unfortunate)

Basically you have to treat the underlying Cushings and be mindful of secondary infections to the skin. Also, you have to realize that the last thing to be healed will be the skin.

He hasn't been too itchy which is lucky. I dress him in hoodies for his walks and if/when he does start to itch, but we have been going through piles and piles of towels in this house.

[goldengirl88]

I also use Manuka honey as my Tipper has acid reflux at times. I give it to her daily. I was told by the vets that her esophagus is in wonderful shape with no lesions from the acid, because of using this. This is wonderful stuff and is used for burn victims etc. in other places in the world. Sorry you baby ahs this going on with the CC I know that has to be hard to watch. Blessings
Patti

[addy]

I think you did a great job of summing it up:)

Ketochlor did wonders for my pup as well, she had mild cc with bacteria and yeast, lost all her hair just about, then it started on her ears, I also used Douxo wipes on places I could not put the ketochlor (above collar area) and her ears, also made sure I cleaned her ears once a week with an ear wash and then finally was able to cut back on that as well.

Good job!

[turtlesmom]

I hate this beast that is Cushings.

Everytime I start to think Turtle is better, he sort of does a few steps back.

I have some questions that some people might be able to help me with. It seems like vetrotyl is working well per lab results and symptom reduction. His calcinosis cutis is better but spread a bit, it is seriously almost everywhere :( well, everywhere on his back, with a tiny patch on his face and on his chest, his name is turtle and now he has a shell...

But today and yesterday I am mainly worried about his breathing that has become shallow and/or labored. He still went on his walk, but he zones out and generally seems lethargic. We are one month into vetrotyl at 14mg/twice a day and he is about 28-30lbs depending. His appetite has not been great for awhile and this was actually pre-trilostane.

I am now worried about macroadenoma.

And I am thinking about getting MRI since I know Frenchies have higher chance, things seem off. I have been reading Dawn's thread about laser radiation at Davis and since I am in SF I could do that if it comes to it. What do people think? Or is this sort of the normal course of getting better? Like seems like getting better and then just doesn't?

[addy]

Sorry to hear that Frenchie is feeling under the weather. If you are about one month in to treatment, have you had his cortisol rechecked? There should be another ACTH test at 30 days.

(
pre) Cortisol Sample 1: 5.3 ref range 1.0-5.0
(post) Cortisol Sample 2: 3.7 ref range 8.0-17.0

The cortisol can continue to drop. It looks like the mid Novemeber test results are above. He might be a bit too low now for him to feel great. My Zoe dropped down to post 1.9 and was not feeling well from that low of cortisol. Dechra states post can drop to 1.45 but some specialists think no lower than a post of 2ug/dl.

[molly muffin]

Yes, I agree with Addy, my first thought is that the cortisol might have dropped too low and I would get a another ACTH test to check as this is most likely to the be the culprit and should be eliminated first.

They say, and when I say they, I mean others on the forum have experienced that the cc can get worse and then start to get better. It is Usually one of the last things to clear up, symptom wise.

Hang in there. We know it is a tough road to travel.

hugs,
sharlene and molly muffin

[turtlesmom]

So I was concerned that Turtle had a macroadenoma and got him a MRI. He does here are the results, copy pasted from PDF:

MRI of the brain has been performed. T2W, T1W pre and post Gd, T2*W, FLAIR and PDW
transverse images, T1W post Gd and T2W sagittal images and T1W post Gd dorsal images.
Findings:
1. There is a slightly lobulated mass in the region of the pituitary gland that measures 1.5cm x
1.9cm x 1.5cm in size. The mass is post Gd hyperintense and pre Gd has some ventral
hyperintensity that corresponds with a region of FLAIR and T2W hyperintensity without loss of
T2*W signal. The mass is causing compression of the interthalamic adhesion and thalamus
bilaterally.
2. The ventricles are normal in appearance with bilateral symmetry, and CSF contained within
nulls appropriately on FLAIR.
3. The cerebellum is contained within the caudal fossa.
4. The cranial cervical spinal cord included is within normal limits.
5. There is a small volume of fluid (based on the presence of a meniscus) within the left tympanic
bulla without obvious alteration to the bulla wall. The external ears are within normal limits.
6. Ocular, retrobulbar and nasal structures included are normal for the breed.
Diagnostic interpretation:
1. Pituitary mass most suggestive of macro adenoma Ddx: meningioma.
2. Early left-sided otitis media vs. fluid retention.

[goldengirl88]

I am so sorry to hear this. No one ever wants to hear this diagnosis though it is in the back of our minds every second of every day. I will pray for you and your baby. Blessings
Patti

[turtlesmom]

Thanks Patti.

I am feeling okay mainly thanks to Dawn's thread. I am near Davis and will try to go there too.

Just found this very good review article on meningioma:

http://www.integratedveterinarypathologybyalexandrabrower .com/uploads/1/4/1/0/14103113/meningioma.pdf

[Trish]

Sorry to read this news about Turtle, I am pleased you already have a plan to work on though and hopefully you get an appointment to discuss this treatment further asap. xx

[molly muffin]

Good idea going to Davis to see what they think. Maybe Turtle would a good candidate for the radiation therapy too. Butter seems to be doing better after having had it.

hugs,
Sharlene and Molly Muffin

[Dawn Anderson]

Just wanted to pop in and see how little turtle is doing. Were you able to get to Davis ? Butters is doing so much better this last week , tumor is still shrinking.
When I was there in Dec , Dr Kent mentioned that he was working with a 5 year old french that also has a server case of CC like Butters. Really hoping that he was referring to Turtle. Please keep in touch have been thinking of you both often.

Take care
Dawn and Butters