Lily - Westie on Vetoryl but maybe not Cushings

[EAD]

My 10 year old westie had recurrent urine infections this year, bloods checked January and July were all fine but in September showed raised ALT and ALP.

Checked for Cushings with ACTH test which showed positive so started her on 30mg Vetoryl.

Next ACTH was done and bloods, bloods showed ALT and ALP the same as before, Vetoryl was raised to 40mg per day.

Just did another ACTH (results back next week) and bloods, bloods showed ALT raised even higher and now vet is questioning if she is truly Cushingoid and if original results showed a false positive.

She was scanned after results of first ACTH and adrenal glands looked normal and no sign of tumour.

Vet wants to recheck bloods in the new year but said to continue with Vetoryl.

[Squirt's Mom]

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[Roxee's Dad]

Hi and welcome to you and your pup,

Was an LDDS test performed to confirm the cushings diagnosis? Cushings is difficult at best to get a confirmed diagnosis, the ACTH can produce a false positive, especially if their are other problems causing her cortisol to go high.

What were the results of the ACTH, What symptoms besides the high ALT and ALP did or does your dog have? Extreme thirst and hunger?

Currently on 40 mg of Vetoryl (Trilostane), how much does your dog weigh?

[EAD]

Hi John, No it was just a ACTH test, vet said none are totally accurate.

It was the recurrent urine infections led us to check her bloods which showed raised ALT and ALP. Maybe increased appetite too.

Dont know ALP figures but ALT was 130 something last month and today the ALT was 238.

Lily is a westie and weighs 8.7kgs.

[Roxee's Dad]

Lily is about 20 pounds ( 8.7kgs ) and is getting 40 mg of Vetoryl (Trilostane) That is about 2 mg per pound which may or may not be a bit high for a starting dose. Vetoryl does recommend starting at the lower end of the dosage, which is about 1 mg per pound vs the 2 mg per pound she is getting now.

Can you get copies of the results of the ACTH testing? I could be incorrect but it seems your vet is using the ALK / ALP results to monitor the Vetoryl treatment. It takes quite a while for cush treatment to lower the ALK / ALP. Many cush pups even after cushings is controlled remain with a high ALK / ALP.

We look forward to seeing the results of the ACTH testing that has been performed so far.

[Woodydog]

Hi and Welcome from me, you have came to the right place they are many angels here who will help you and Lily.

Where abouts are you

[Roxee's Dad]

Did your vet explain what to watch out for in case Lily's cortisol levels go too low?

Lethargy
Lack of appetite
diarrhea

[EAD]

Low cortisol levels haven't been mentioned.

She was started on 30mg per day after first ACTH test, then upped to 40mg after second test (results above 200).

Next test results as far as I know under 200 so kept on 40mg.

Vet adjusted the Vetoryl I believe based on the ACTH results but just said she would have expected the ALT and ALP to drop once Cushings stabilized.

I'm worried now continuing with Vetoryl if she maybe hasn't Cushings.

Could the Vetoryl cause the ALT to raise further.

I'm in Northern Ireland btw.

Thank you for replying xx

[Woodydog]

I tried to PM you, is your other dog called Alfie, and do you post on a rescue form DP, sorry if I,ve got that wrong, but I used to post on the same form a while back.

[EAD]

Yes that's me.......hello :)

[Woodydog]

Hello I posted on DP under Broonie look me up. I am so glad that you have found here it has save my sanity on more that one occasion. Sadly my dog just passed (not cushings) and this place have been wonderful.

I hope you get the answers and help for Lily :)

[EAD]

Thank you, thought we had things stabilized but now panicking we're down the wrong path and something else is going on. Wondering if I should start Lily on Zentonil to support liver, will speak to vet again in morning.

Sorry to hear about your dog.

Do you not post on DP anymore?

[Woodydog]

No not really but I do lurk everyday just to see what's going on it seems to have change a bit in the last year and a half. I remember reading about lily and her cushings. Please don't panic but do listen to there suggestions on here they really did help me although Woodys symptoms turned out not to be cushings but cancer.

If you can get copies of all Lily's test that will help figure out what is going on

Tracy

[EAD]

Yes it definitely has changed.

Few questions in my head....

Should we start liver supplement?
Should we stop Vetoryl until we confirm Cushings?

What other tests can help us diagnose it?

Worried I'm doing more harm than good atm.

[Woodydog]

Have you done the LDDS test and an ultra sound (sorry if I've missed that)

I don't know enough about this disease to answer your questions but there is always someone around this board as we are all in different time zones that will help you anyway they can. I was like you when I first came her I was frantic with worry take big deep breath I'm sure someone will post with some answers to your questions

[Roxee's Dad]

Since Lily has already had the ACTH and ultrasound, the next test to confirm cushings would be the LDDS (8 hour test)

ACTH could very well be a false positive if another illness is present.
UltraSound did not show plump glands or any other abnormalities.
A UC/CR would be a good test as it could not confirm cushings, BUT could rule it out.
LDDS would be good to confirm the original diagnosis as in most cases it takes more than one test to confirm cushings.

[EAD]

No my vets haven't done a LDDS, just ACTH. She said none are 100% accurate.

She was scanned, I was told adrenal glands and bladder normal.

Thank you :)

[EAD]

Thank you John, we were both posting at the same time.

Adrenal glands looked similar size.

The problem we have now is Xmas holidays and getting samples to lab what with them being off on holidays.

Sample from ACTH test posted to lab today, hopefully get results after Xmas.

To do a LDDS test next week runs into new year holidays too.

What is UC/CR test?

[Roxee's Dad]

UC/CR is a Urine cortisol:creatinine ratio. Here is a link to some information on using it to rule out cushings.

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ArticleStandard/Article/detail/357729

[Roxee's Dad]

We have more information on diagnostic testing in our information and resources section too :)

http://www.k9cushings.com/forum/showthread.php?t=5427

[EAD]

Thank you John, have taken note of that.

Does anyone think it wise to stop Vetoryl until things are confirmed?

[Roxee's Dad]

Gosh, that is a very hard question to answer. Most would not even have started without more than 1 test to confirm. Without knowing the ACTH stim test results, I couldn't say one way or the other. BUT if Lily gets lethargic, doesn't want to eat or drink, diarrhea, or gets a bit wobbly, I would stop immediately.

Wanted to add that I am still a bit confused that the only real cushings symptom is ALP but no excessive appetite or thirst.

[EAD]

Thanks. She has been in great form lately and appetite very good.

Her ALT was raised as well as the ALP, I think the recurrent urine infections also made them think Cushings. Her appetite has definitely increased over this last year too but I'm not sure I can say its excessive.

[EAD]

Maybe she is definitely Cushingoid and theres another reason why the ALT continues to rise. Is that a possibility?

[lulusmom]

Yes, if ALT is rising, there is a very good possibility something else is going on. To answer an earlier question, it is highly unlikely that vetoryl is causing the increase in ALT.

I see the you live in Ireland I know that some of you folks have trouble getting copies of tests from your vet but it would really help us a lot if you try and post the high and low values on the latest bloodwork. Please include normal reference ranges. Can you also please get a copy of the original acth stim test that was done prior to starting treatment and post those results as well.

I see that you mentioned your vet increasing Vetoryl dose from 30mg to 40mg after the stim test came back high. I believe you mentioned 200. I am assuming that is the post stimulated number and that the reporting units are in nmol. We are used to seeing reporting unit ug/dl so I did the conversion and the post stim would be 7.25, which would have been within the therapeutic range but only if all symptoms had resolved. Exactly what symptoms did your dog have and what changes have you seen since starting treatment?

I do have concerns about the diagnosis, especially after reading that at one point your vet was doubting the diagnosis. It is curious that your vet is learned enough to know that none of the diagnostic tests can be relied on to be 100% accurate yet it seems s/he confirmed a diagnosis based on only one test and very few symptoms that are normally associated with cushing's. I really hope you are successful in getting those tests.

Glynda

[EAD]

Thank you Glynda for replying, my head is spinning atm.

The original problem was ongoing urine infections and when bloods checked both ALT and ALP raised.

She has had antibiotic injections and urine sent to lab this week showed it normal.

I will contact vets this morning re liver supplements and do my best to get results you mentioned.

Also will ask about doing other tests that might help (LDDS and UC/CR).

Is it questionable as to when to do UC/CR test, either at loading or maintenance dose?

Thank you.

[Woodydog]

Morning popping in to see how you and Lily are this morning. Have you called the vet today, how did it go ?

[EAD]

Hi :)

Vet dealing with Lily not in until Monday so will have to wait and speak to her then.

Getting blood and Acth results in about an hour so will post them here.

Gave Lily her Vetoryl this morning as normal, vet said to continue with it for the meantime as I suppose we can't say she doesn't have Cushings.

She has had 3 Acth tests done so far, first one prior to starting Vetoryl, next two after 10 says to check the meds.

If she didn't have Cushings would all the tests have looked like she has?

Does that even make sense to you all?

[EAD]

Just reading back in my diary, I have a note that first Acth test was 650, second was 238 and I think third was under 200.

Waiting on results from yesterdays Acth.

Will post full results when I get them.

[EAD]

Ok have results.

Acth test 18/10/13

Cortisol pre Acth 236.0 nmol/L (Reference range 25.0125.0)
Cortisol post Acth 612.0 nmol/L (Reference range 125.0520.0)

Comments from lab

Results were consistant with hyperadrenocorticism where there are compatible clinical signs. Similar results maybe seen in animals with severe or stressful non-adrenal illness.

Bloods 20/12/13


ALP - 304 (20-150)
ALT - 238 (10-118)
AMY - 581 (200-1200)
TBIL - HEM (2-10)
BUN - 6.8 (2.5-8.9)
CA - 3.19 (2.15-2.95)
PHOS - 1.48 (0.94-2.13)
CRE - HEM (27-124)
GLU - 6.7 (3.3-6.1)
NA+ - 142 (138-160)
K+ - HEM (3.7-5.8)
TP - 84 (54-82)

QC OK
HEM 3+
LIP 1+
ICT 0

[lulusmom]

Thank you for posting the test results. I really do have concerns about the cushing's diagnosis. Dogs with cushing's have moderate to severe elevations in ALP with very mild elevation in ALT. This is not the pattern with Lily and while the ALT is not terribly high, I seriously doubt that cushing's has anything to do with it. The blood sample was also severely hemolyzed which can significantly impact some of those blood values. I believe Hemolysis of 3+ is pretty high so I would ask the vet if he really feels these test results are meaningful. Was Lily fasted for the test? Most often hemolysis happens during the blood draw or improper storage of the sample but there are also canine diseases that can cause this as well. Do you have copies of the original blood screening tests that were done by your vet to diagnose Lily? If not, can you get them and post those results?

It seems that your vet was grasping at straws to figure out why Lily is having chronic urinary tract infections. Was a urine culture done to specifically identify the types of bacteria in the urine so that appropriate antibiotics could be prescribed? Sorry for all the questions but the only thing that points to cushing's is the results of an acth stimulation test, which is not high enough to rule out nonadrenal illness as being the culprit. Stim tests do not tell you if the dog has pituitary cushing's or an adrenal tumor. Did your vet do an abdominal ultrasound, a high dose dexamethasone suppression test or an endogenous acth test to make that determination? An abdominal ultrasound is usually the test of choice for this as the appearance of the adrenal glands can make the distinction while validating a positive acth stim or ldds test. It also gives the vet a chance to check out the surrounding organs for the typical abnormalities caused by cushing's as well as identify problems completely unrelated to cushing's.

I'm sorry for all the questions but based on the information you've provided so far, I have concerns about the validity of a cushing's diagnosis and I also have questions about how much experience your vet has had with cushing's. You can't provide too much information so share as much as you can.

Glynda

P.S. A UC:CR is a diagnostic tool which is done before starting treatment to support a diagnosis. If the ratio is high, cushing's is a possibility but additional tests, like the acth stim test and ldds test would have to be done. At this point, I don't believe it makes much sense to do one.

[EAD]

Thank you again for the lengthy reply.

Lily also had bloods sent to the lab in England last week for titre testing and the lab emailed to say the sample was hemolyzed and it had to be redone on Monday past. The blood results I just posted were done in my own vets.....is it coincidental they both hemolyzed?

Don't have original blood results but will ask for them.

Lily was fasted for the test, only had her Vetoryl that morning.

No I don't believe a culture was done for the urine.

Lily had a scan done from which I was told her adrenal glands looked normal as did her bladder.

No other tests done.

Do you mean if bloods hemolyzed it can give wrong readings, ie could ALT not be raised as much as it shows?

[lulusmom]

You should talk to your vet about the hemolysis on both tests. This is usually a lab error but like I said before, it can also be caused by disease in rare cases. Hemolysis can affect many of the blood values but I'm not 100% sure it would skew the ALT value. I do know that in human studies, it does impact the ALP, which is the primary liver enzyme that is usually elevated in cushdogs. If you look at the test results you posted, you will see "Hem" next to TBIL, CRE and K+. This means that the hemolysis was so bad that they could not interpret values for TBIL (Total Bilirubin), (CRE) Creatinine and (K+) Potassium. These are all used to interpret kidney function so given Lily's PU/PD, I would want a lot of clarification from the vet as to why you've had two blood tests done that are so hemolyzed, rendering the last blood test useless for evaluating kidney function.

Lily should never be fasted for a stim test as Vetoryl is not properly absorbed without food. I now have another concern because the results of the the last stim tests are most likely inaccurate and the post stimulated cortisol could be much lower than the test results. This is another red flag that perhaps your vet has limited experience with cushing's and does not have a good understanding of the drug s/he prescribed (Vetoryl). Normal adrenal glands on imaging increases my concern about a misdiagnosis. What did the ultrasound findings have to say about the appearance of the liver?

With respect to the urine tests, not all antibiotics address all bacteria so without a culture and sensitivity test to match the antibiotic with the bacteria, it is possible that the UTI's are recurring because they were never really remedied with an appropriate antibiotic. Most vets do the basic urine test by dipstick inhouse so if your vet did send a urine specimen to a lab, it's possible he did order a culture so just confirm this with him. Can you get a copy of the urine tests also. I would be most interested in the urine specific gravity. Dogs with cushing's who have PU/PD have low specific gravity.

Since you are asking your vet for copies of more tests, can you ask for the latest copy of a complete blood count (CBC) as well?

Glynda

[EAD]

Hi Glynda, that was latest blood results I posted, are they not complete?

Urine has nearly always been sent to the lab, I think I remember them mentioning staph but not sure. Antibiotics used have been Xeden and Convenia injection.

Liver was never mentioned after the scan, just adrenal glands and bladder.

I've always been told to fast her.

Goodness my head is spinning, so much to think about.

[lulusmom]

What you posted was a blood chemistry. A complete blood count is different. Rather than me completely confusing you by trying to explain the difference, I've included the url below to a site that explains it. Your vet should have the radiologists abdominal ultrasound interpretation so just ask for a copy and then you can share it with us.

http://www.veterinarypartner.com/Content.plx?A=1630

It sounds like your vet pulled out the big guns with Xeden and Convenia as both are broad spectrum antimicrobials that are usually used for UTI's when there is no response to other antbiotics. Hopefully, between the two, Lily's UTI has completely resolved. I would still like to know what her urine specific gravity was when she was diagnosed.

With respect to fasting, I'm giving a url below to Dr. Mark Peterson's blog for veterinarians who want to learn more about the various endocrine disorders. Please either print out this page for your vet or provide him with the url. Do not fast Lily for any more acth stimulation tests as 1) it renders the results useless and 2) places the dog at risk should a vet use these inaccurate numbers to support an increase in dosing. The first point Dr. Peterson makes under "Four Important Points Here" is,


First, trilostane should always be given together with food. It has been shown that feeding immediately after the administration of the drug significantly increases its absorption

http://endocrinevet.blogspot.com/2013/11/protocol-for-acth-stimulation-testing.html

Pet owners' spinning head syndrome is quite common in canine cushing's. We've all been there and it does take a while for the fog to clear and for things to start making sense. Try not to drive yourself crazy trying to absorb everything at once. It's a convoluted matter that's really difficult to wrap your head around and that includes a good number of gp vets so cut yourself some slack and we'll help you learn as we go.

Glynda

[EAD]

Thank you Glynda again :)

I have a list of questions for my vets tomorrow, not sure how they're going to take all this querying but I will be asking.

Can i ask another couple of questions please?

When you ask for Urine Specific Gravity details......do you mean from back at the very start of year when first urine infection or latest problems last month?

Also if Lily doesn't have Cushings, does it mean something else is raising Cortisol in her body and the Vetoryl is reducing it or am I not understanding it right?

On a daily basis Vetoryl is given with food.

Do I continue with Vetoryl in meantime?

Will be at vets tomorrow as I'm hoping to get an appt to take another one of my dogs (Rottie x) for repeat blood tests. Her last results showed raised ALT which vet thought was due to strong antibiotics she was on for infected toe and ongoing Onsior.

Different dog (Scottish Terrier) also had bloods done last month, showed raised ALP, vet tested for Cushings as he also had skin infection but came back negative. Need to check those again.

[lulusmom]

If your vet takes exception to your asking questions in an attempt to better understand cushing's so that you can be a better advocate for your dog, then you may want to consider finding a vet who acts in the best interest of his patients, not his ego. Vets are human and not all are created equal. Many of us can you tell you that first hand as our dogs were the ones who paid the price for their ignorance and our own. I'd never heard of cushing's and apparently neither did my vet. It was not until I took my dog to an internal medicine specialist that she was diagnosed at least one year after she became symptomatic. We've seen more case studies on this site than most vet general practitioners will see in their lifetime and the key to safely and effectively restoring a good quality of life to a cushdog is an experienced vet and an educated pet owner. It is when one or both of those are missing that dogs get into trouble. You are Lily's voice so make it heard.

Now having said all of that I do understand that in the beginning when we are so completely confused, it's hard to ask for answers when we don't even understand why we're asking the question. I want you to understand those list of questions you have for your vet so let's see if we can prepare you a bit better.

None of us here are vets but we like to look over the shoulder of vets. Believe it or not, members have saved lives here because misdiagnoses is not uncommon and some vets take little to no time to educate themselves about serious drug they are prescribing. Let's try to start at day one when your vet told you he suspected cushing's. I believe that was in September when the liver enzymes, ALT and ALKP were elevated. The results of that specific blood chemistry is what I'd like to see. If a complete blood count was not included in that test, your vet should have ordered one as well as a urinalysis. These are all routine tests that are done to check for the usual abnormalities associated with cushing's.

I would like to see the results of the urinalysis your vet did once he suspected cushing's. With Lily's only symptom being frequent urinary tract infections, getting a fresh urinalysis would have been key. Dogs with cushing's drink and pee buckets because their kidney lose their ability to concentrate the urine. They don't pee more because they are drinking more. They drink more because they pee too much and if they don't drink, they will become dehydrated very quickly. Excessive drinking and peeing is what is called polyuria/polydipsia (PU/PD and in order to make sure a dog has PU/PD a vet needs to do a routine urinalysis to check the urine specific gravity, which in a cushdog is usually less than 1.015. Urine appearance is also usually clear as it is dilute. When Lily was diagnosed, was she noticably drinking and pee a lot, having accident in the house and did you notice that her pee was clear and odorless?

The stress of non adrenal illness can increase circulating cortisol in the blood. Severe anxiety can also raise cortisol levels causing false positive results on the acth stim tests. Primary liver disease, tumors on internal organs, cancer, diabetes and a host of other problems can elevate cortisol and some share the same symptoms and blood abnormalities on lab tests. This is why symptoms are such a huge component of a diagnosis, which is the reason why I'm raising so many questions about Lily's history. Based on the information you have provided, she does not present as the usual cushingoid dog. Chronic UTI is a symptom of cushing's but that is rarely the only symptom when dogs are diagnosed. Lily's adrenal glands were normal on imaging and no mention of the liver, which is usually enlarged with cushing's. There are two tests that were done that were severely hemolyzed, raising questions as to the validity of those tests. Hopefully the blood tests done in September were not affected by hemolysis. All of these things have left a big question mark over my head.

If Lily does not have cushing's, she should not be taking Vetoryl. Healthy dogs have been dosed with Vetoryl in studies with no adverse effects but Lily is not a test subject. These dogs were being routinely tested according to protocol and part of that protocol is that the acth stimulation test is done three to five hours after dosing WITH A MEAL. Lily is not being tested according to protocol, which places her at risk of overdose if your vet continues to increase her dose based on results of acth stim tests that are not accurate due to fasting. The drug is not well absorbed into the gi tract without food so there is no way to determine the appropriateness of the dose. Vetoryl is always given with food and especially before an acth stim test.

I believe I mentioned another member here whose dog did not have the usual symptoms we see in a cushdog but her vet started treatment with Vetoryl. Her dog didn't have pu/pd before treatment but it wasn't long after treatment that her dog started drinking and peeing like nobody's business. She withheld treatment and it resolved. Her dog didn't have cushing's and ultimately passed away from cancer. If you are going to see your vet tomorrow, talk to him about withholding Vetoryl to see if Lily's PU/PD improves. Never go behind your vet's back.

Glynda

P.S. Here is a url to another page on Dr. Mark Peterson's blog regarding the ACTH stim test. You will note that a few pet owners have asked questions about fasting their dogs because their vets have insisted they be fasted. Please also pay attention to what he has to say about the stimulating agent cortrosyn. Your vet may not know that you don't have to use the entire vial for smaller dogs. You can split the vial and save the remainder for future tests. Dr. Peterson explains how to do that. This is also one you should print out for your vet. http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

[EAD]

Feel that things are getting a bit clearer in my head but so wish I had came onto this forum when it all first happened :(

I have printed details to show vet and have a list of questions.

Her urine was a lightish yellow colour, dont recall much odour.

It was one of the nurses gave me the results yesterday which I assume was ok for her to do but hope I dont meet with resistance from the vet tomorrow....if so I wont be happy.

Thank you so much for taking the time to post such lengthy replies :)

[EAD]

Ok had chat with my vet, won't get copies of results until tomorrow but we have agreed to take Lily off the Vetoryl for the meantime, said it won't do her any harm.

Results of Acth test done on Friday said all looked ok.

Going to start her on Zentonil for liver support.

She did say she felt we had been hasty in starting treatment.

Questioned blood hemolysed, said she wasn't overly concerned about that and didn't feel that would affect ALT reading.

She did say they have trouble sometimes getting blood from Lily.

So monitor her over holidays and redo bloods in new year and also an Acid bile test.

'Think' I feel a bit happier with what we're doing.

[lulusmom]

I am very happy to read your update this morning. I think you and your vet have come up with a good plan. Put cushing's on hold and Enjoy the holidays. I'm hoping and praying that Lily's drinking and peeing normalizes in which case you can probably put cushing's on hold forever.

Glynda

P.S. I'm glad your vet explained why she wasn't concerned about the hemolysis; however, I do hope they find a way to do future blood draws that don't impair the specimen. Vet techs usually do the blood draws so your vet may want to share this video with her techs. It shows a technique that is good when you are dealing with difficult, fidgety dogs.

https://www.atdove.org/videos/Procedure/Blood-Draw-Lateral-Saphenous

[EAD]

Thanks Glynda :)

I know they had trouble getting blood from her leg so took it from the neck and it flowed out very quickly.

We will see how things are in the new year and do appropriate tests then.

Goodness this dog ownership is an emotional rollercoaster at time.

[lulusmom]

My cushdogs were 4.5 lbs and 6.5 lbs and were too small to take blood from the leg so they always had a lot of bruising on their neck after every blood draw.

I always thought pet ownership was challenging at times until my first dog was diagnosed with cushing's. What I thought was challenging was a drop in the bucket in comparison to the challenges of cushing's. Funny thing is, we've all survived it. We may have a nervous tic here and there and not a lot of hair left, but by golly, we're still here. :D

Glynda

[EAD]

Hi there, I am back with various results from my vets.

Urine test at lab 7/10/13

Sample Type - Plain
Colour - Yellow
Appearance - Cloudy
USG - 1.031
PH - 7.0
Protein +
Glucose – Neg
Ketones – Neg
Bilirubin – Neg
Blood/Haem – Neg

White Cells – 10-50
Red Cells – 5-10
Epithelial cells – None seen
Casts – None seen
Crystals – Frequent struvite (??? Word I cant make out) phosphate crystals
Urine culture - >0?5 cfu/ml staphyloccus pseudintermedius

There is a whole page of various antibiotic details, will type these out if needed.

Blood Test 17/10/13

ALB 36 (25-44)
ALP 208 (20-150)
ALT 129 (10-118)
AMY
TBI
BUN
CA 2.82 (2.15-2.95)
PHOS 1.61 (0.94-2.13)
CRE 91 (27-124)
GLU 6.8 (3.3-6.1)
NA+ 143 (138-160)
K+ 4.6 (3.7-5.8)
TP 72 (54-82)
GLOB 36 (23-52)
QC OK
HEM 1+
LIP 3+
ICT 0

Acth test 18/10/13

Cortisol pre Acth 236.0 nmol/L (Reference range 25.0125.0)
Cortisol post Acth 612.0 nmol/L (Reference range 125.0520.0)

Comments from lab

Results were consistant with hyperadrenocorticism where there are compatible clinical signs. Similar results maybe seen in animals with severe or stressful non-adrenal illness.

Acth Test 7/11/13

Cortisol pre Acth 150
Cortisol post Acth 238

Urine Test 16/12/13

Sample Type - Plain
Colour - Yellow
Appearance - Clear
USG - 1.039
PH – 5.0
Protein + +
Glucose – Neg
Ketones – Neg
Bilirubin – Neg
Blood/Haem – Neg

White Cells – <5
Red Cells – None seen
Epithelial cells – None seen
Casts – None seen
Crystals – None seen
Urine culture – No bacteria growth

Bloods 20/12/13


ALP - 304 (20-150)
ALT - 238 (10-118)
AMY - 581 (200-1200)
TBIL - HEM (2-10)
BUN - 6.8 (2.5-8.9)
CA - 3.19 (2.15-2.95)
PHOS - 1.48 (0.94-2.13)
CRE - HEM (27-124)
GLU - 6.7 (3.3-6.1)
NA+ - 142 (138-160)
K+ - HEM (3.7-5.8)
TP - 84 (54-82)

QC OK
HEM 3+
LIP 1+
ICT 0

We have tried to enjoy Xmas and not stress too much, it wont help the situation. Hope you all had a lovely xmas and new year too.

[EAD]

Just bumping this back up if someone has any thoughts :)

[molly muffin]

I am glad that you are trying to enjoy the holidays and not stress out. I wonder if the serious infection that she had would have affected her liver values and now that this is clear of her system (per last urinalysis) if this would not start to get her liver numbers back down.
Cushings is a slow progressing disease, so the good thing is that normally one does have time to find out if there is something else going on, other than cushings.
I think any dog whose liver values start to go up, can benefit from being on a liver supplement. It often takes much longer for values to go down than it does for them to go up. Very unfair in the nerve wrecking scenerio.

Hopefully Glynda or one of the other admins that is very familiar with lab results will stop by and comment too.

People have been in and out over the holiday season.

Hang in there.
Hugs,
Sharlene and Molly Muffin

[EAD]

Thank you Sharlene for replying :)

My head feels like it is going to explode as there is so much stuff to ponder and all the time I am worried time is passing and something serious is going on that we're missing.

My other two dogs have raised liver readings too so sticking my head in the sand would sort out the stress levels but I cant do that.

Meantime im reading things I dont really understand half the time :confused:

[molly muffin]

My dogs liver enzymes started to go up when she was first diagnosed with crystals. I don't Know if there is any correlation between the two or not, I just know that the occurred at the same time.
I think they told me that they start to worry when the ALT is 3 times what it should be. I tend to worry sooner though. The biggest help that I think so far we have gotten the most bang for the buck on, is the ultrasound to look at all the internal organs and this should be done at least yearly.
We have high ACTH, which can be high if there is another cronic or serious disease, like liver, etc, and then our LDDS tests have been negative. Every dog is different and I certainly understand you wanting to get this figured out.
We did go to an IMS in addition to the GP vet and they work together.

hugs,
Sharlene and Molly Muffin

[lulusmom]

Thank you for posting the additional test results. I had already commented on the more recent blood chemistry to I'll stick to the earlier urinalysis and blood values. The first thing I noticed is that Lily's urine is concentrated and USG is definitely normal which is not consistent with cushing's. The second and most important observation was the type of bacteria identified. Staphylococcus Pseudintermedius (MRSI) is a strain that is resistant to the usual antibiotics prescribed for veterinary use. This is the reason there was a whole page of information on antibiotics. I also have concerns that Lily is a breed that is genetically predisposed to hyperlipidemia. I realize that your vet has trouble with blood draws on Lily which could cause hemolysis but I also would be concerned that Lily may have hyperlipidemia, which can also increase liver enzymes. Unfortunately, the results you posted don't have cholesterol or triglycerides, both of which are usually very high if a dog has hyperlipidemia. Can you recheck your paperwork and see if you can find those listed anywhere? If Lily does have hyperlipidemia, diet needs to be modified to low fat.

A good friend who adopted one of my little chihuahua rescues is dealing with this bacteria. In addition to crusty lesions on the dog's body, she has a recurrent cyst between her toes that becomes very swollen, very infected and very painful. A culture finally identified this bacteria six months ago. The vet put her on a different type of antibiotic and it cleared up but now it's back again. This could certainly explain Lily's recurrent UTI's. I've not done much research on this bacteria but I think you and your other pets could become infected. This is something you should ask your vet.

So to recap, a highly resistant bacteria is identified in Lily's urine; liver enzymes are mildly elevated, which could be attributed to the urinary tract infection or possible hyperlipidemia; Lily has no symptoms associated with cushing's and a borderline acth stim test could very well be a false positive. If Lily were my dog, I would be questioning the cushing's diagnosis and would talk to the vet about putting cushing's on the back burner, ruling out hyperlipidemia, getting Lily on liver support with a follow-up recheck of liver values.

Glynda

[EAD]

Thank you again Sharlene and Glynda :)

From what I can see on Lilys last urine results there are no crystals but both ALP and ALT are higher than before.

I dont see anything on results about cholesterol or triglycerides unfortunately. Would they be on a CBC which I dont think we have for Lily?

We stopped the Vetoryl I think it was 23rd December I have been giving Lily Zentonil (liver supplement) since 13th December.

Vet said to wait 4 weeks from last bloods (20th December) before rechecking which would be 17th January.

Will mention hyperlipidemia to my vets.

Does the vet choose the antibiotic best suited to the bacteria specified by the lab?

[lulusmom]

Cholesterol and triglycerides are part of the blood chemistry and yes, your vet should have chosen an appropriate antibiotic but if she is unfamiliar with MRSI, she should consult with a board certified veterinary dermatologist to see what their experience has been, and which treatment regimen seems to be most effective. I must have missed your post about starting treatment with Zentonil. That's good to hear and I'm also glad to hear that your vet will be doing follow-up blood work later this month. I'll be interested in seeing the results.

Glynda

[EAD]

Thanks Glynda, will keep this updated :)

[EAD]

Just updating......

Lily had to get antibiotics last week for more problems with her urine.

She was back at vets today for blood tests which showed her ALT has dropped from 238 to 154 and her ALP has also dropped from 304 to 273.

Vet said she felt a bile acid test would not be worth doing atm.

Other than that Lily is bright enough and eating well.

We are going to continue with liver supplements and Hills food.

[doxiesrock912]

Great news!!!

[molly muffin]

That is really good news that her numbers are dropping and that she is doing so well.

Sharlene and Molly Muffin

[EAD]

I should have added she isn't being treated for Cushings atm, I took her off Vetoryl before Xmas, we are just monitoring her bloods.

[labblab]

Hi, I just noticed this morning that you had two separate ongoing threads re: your dog's progress. You'll see that I have merged them together, which may make things a little confusing right at the moment since the replies are interspersed depending upon the day and time they were posted. But this is the only way we can keep the info about your dog all consolidated in one spot. From now on, just keep coming back to this original thread to post new updates and to ask any new questions, OK? ;)

Marianne

[EAD]

Sorry if I have confused you but its two different dogs both with different problems.

Alfie is a Scottish terrier and Lily is a westie.

[labblab]

Oops! My mistake!! I'll go ahead and split the threads back up again! So sorry!

Also, I've taken the liberty of adding your dogs' names to the thread titles so that it will be easier for dumbies like me to realize that they are two separate dogs/threads. :o

Marianne

[molly muffin]

It's not easy having two dogs with issues. :( One can keep us on our toes, two you must be on the ceiling at times. :)

Yes, I think since the liver enzyme numbers are coming back into range without any treatment for vetroyl that maybe cushings wasn't the issue. The urine infection certainly looks suspect at this time, only time and continued monitoring of the liver numbers will tell for sure though.

Sharlene and Molly Muffin

[EAD]

Thanks Marianne :)

Two is worrying, three is very stressful.

My other dog Kyla (rottie x) has slightly elevated ALT, vet thinks due to strong antibiotics for infected toe and ongoing pain relief.

She is also now getting liver supplements.

Some days I am ready for the hills.

Lily has been having urine infections for quite a while, we just dont know if related to high liver readings.

[molly muffin]

I think that having urine infections, especially repeatedly, Would contribute to high liver readings, if you think of the liver as a filter for toxins, and what is going in and out of it when there is an infection could cause some damage. The good thing is and this might be what you are seeing, is that once infections are taken care of and not recurring, then the liver values should go down. I'm hopeful that this what you are experiencing with Lily now.

You'll have to see where the ALT ends up being once Kyla's infection is cleared up too.

Sharlene and Molly Muffin

[Trish]

I think that having urine infections, especially repeatedly, Would contribute to high liver readings, if you think of the liver as a filter for toxins, and what is going in and out of it when there is an infection could cause some damage.

Sharlene and Molly Muffin

Hi - I have not heard of UTI affecting liver values Sharlene :confused: The antibiotics could be responsible in some cases though. :)

[molly muffin]

When my Molly started getting UTI's from crystals, many years ago now, that is when her ALKP first up, then slowly the ALT went up a bit too. It was suspected she was cushings, yet she never has tested posted on the many LDDS tests that she has had. My vet at the time, told me that she thought the liver values were up because of the infections from the crystals, which molly has not had for awhile now. Her infections I think started around 6 years ago at least. Cushings was first mentioned almost 3 years ago.

So I'm going by that information. It could be the antibiotics that she was given, where the contributing factor and not the UTI itself, but there did some to be some correlation. Of course she hasn't had a UTI now for awhile and her liver enzymes continue to be outside normal ranges.

Anyway, so that is what I was going by. You could ask your vet if they think that there is any correlation between the two. I'd just continue to monitor them (liver enzymes) as mentioned and give liver support. If cushing symptoms kick in, then proceed to some cushing specific tests.

Sharlene and Molly Muffin

[EAD]

Vet isn't sure if Lilys uti and elevated liver readings are linked but continued use of antibiotics would make you wonder.

Lily has had her adrenal glands, bladder, kidneys and liver scanned. Apparently nothing overly concerning was seen.

Have to take another urine sample tomorrow to vets.

You mentioned Kyla above......her antibiotics finished way before Xmas and her ALT has went slightly higher since but hoping it will drop or stabilise now liver supplements are being given.