Sophielu - new to forum

[sophielusmom]

Hello all!! Wondering if anyone can confirm that Cushing's is possible with completely normal Chemistry Profile & CBC results?? My 10 1/2 yr old Sheltie is drinking excessively & urinating large amounts. She is hypothyroid and has been regulated on .2mg am and .1mg pm of ThyroCare for about a year (prior to that .2mg am and pm since 2006). Her urine is dilute after 8 hr water fast at 1.010. A Urine Prot:Creatinine ratio result of .3 put her at borderline for early kidney disease. Vet wants to do Urine Cort:Crest and ATCH Stem test, but she has just pu/pd, a bit of pacing in pm and a touch of rear end weakness (she is sensitive on palpation in her lumbar spine). I guess I might be in a bit of denial, but with totally normal blood work.....really, could it be as bad as Cushing's? She will have a thyroid monitor end of the week to be sure she is not needing a medication reduction on the ThyroCare. Thoughts?

[labblab]

Hello and welcome! I have just a moment to post, but I would definitely await the results of the thyroid monitoring before moving onward. Blood abnormalities commonly exhibited by Cushpups include elevations in ALKP, ALT, cholesterol and triglycerides. Although most all dogs with Cushing's present with at least an elevation in ALKP, I believe there are some rare exceptions. One of our other staffers knows more about this situation (normal liver enzyme levels in untreated Cushpups), and I will ask her to stop by here to comment.

Marianne

[Squirt's Mom]

Hi and welcome to you and your baby! :)

A quick note to let you know I added "Sophielu" to the title of your thread. We have another thread titled "New to forum" so I wanted you to be able to see yours more clearly. ;) If you would like the title changed to something else, just let a moderator or administrator know and we will take care of it for you.

We typically see elevations in liver enzymes, especially the ALP (ALKP) and CHOL, and often others as well. However, I guess it would be possible to have normal labs and still have Cushing's - tho I would think that would mean it was found very, very early.

I am wondering why she was deprived water for the UC:CR - don't recall ever hearing of that before. The UC:CR can rule out Cushing's if it is normal; however if it is abnormal that does NOT mean Cushing's, only that something is off and further testing is needed.

Hypothyroidism can mimic Cushing's as can other conditions like diabetes, kidney and liver disease, among others. Since you already know she had low thyroid function, I would opt for a full thyroid panel now before further cush testing just to make sure that organ is well controlled.

Cushing's sounds worse than it is for the vast majority of pups. It is not necessarily a death sentence. Our babies can and DO live out their normal lifespan and beyond with proper care, passing from things unrelated to this disease. You can read some real horror stories online - I know, I think I found and read most of them when my Squirt was first diagnosed and I was sick by the time I found our family here. If it turns out that your baby girl does indeed have Cushing's, you have found the very best place to land. We will be by your side every step of the way...you will never be alone. You and your baby girl are now part of our family and even if she does not have Cushing's, we will want to hear from you and know how things are going.

Hang in there!
Hugs,
Leslie and the gang

EDITED TO ADD - I am not the learned staff member Marianne mentioned. ;)

[lulusmom]

Hi and welcome to you and Sophielu.

As Marianne and Leslie have mentioned, most dogs with cushing's do have common lab abnormalities associated with the disease, most notably the alkaline phosphatase liver enzyme. Dogs are the only species on earth that has a steroid induced alk phos isoenzyme, however, a small percentage of dogs are missing that genetic marker so some dogs who are ultimately diagnosed with cushing's have normal alk phos value. That could partially explain the normal liver values but completely normal blood chemistry and complete blood count is not consistent with cushing's. I personally would put any cushing's test on the back burner until other more likely causes have been ruled out. The most likely causes based on what you've told us is over supplementation of thyroid hormone or diabetes insipidus. A full thyroid panel is an excellent idea and then I would suggest a trial with desmopressin drops. Diabetes Insipidus is rare and it is also very rare that I am compelled to mention it to members. I saw your post and DI is the first thing that came to mind as Sophielu fits the profile. I've provided a link to a Canine Diabetes Insipidus power point presentation that is quite informative. Desmopressin drops are not cheap but worth every penny if it resolves pu/pd. I've dealt with chronic pu/pd and it's not fun. If Sophielu is in fact not concentrating her urine due to a decrease in ADH, an antidiuretic hormone, Desmopressin drops will be effective and you should see improvement rather quickly.

http://www.slideworld.com/slideshow.aspx/Diabetes-Insipidus-in-Canines-ppt-879871

I'm keeping fingers and paws crossed that the solution is as simple as reducing the Thyrocare dose.

Glynda

P.S. to Leslie. The vet did a water deprivation test to challenge the kidney's ability to concentrate the urine. The vet ran a urine protein creatinine ratio and is contemplating doing a urine cortisol creatinine ratio. When dealing with so much pee, we members do tend to get our UP's and UC's mixed up on occasion. :D

[labblab]

Thanks, Glynda! :)

[Squirt's Mom]

ahhhh....Thanks for the explanation, Glynda! :):cool:

[Renee]

Just popping in to say that my dog is that rare cushings dog that DOES NOT have elevated Alkphos. This really threw my vet for a loop while we were coming to the diagnosis, but it can and does happen, just as Glynda said.

[sophielusmom]

Thank you so much everyone!! I had postponed her thyroid monitor for two reasons...I needed to have her son checked (he is hypothyroid, on meds 4 weeks now) and because she developed pu/PD and has family history of kidney disease I worked her up for that thinking the thyroid was probably stable and the kidneys were an issue. Now I am wondering if I jumped the gun. I had considered poss DI as well. I will post again once the thyroid monitor is in. In the meantime, we are hugging a lot and doing our best to tolerate the peeing;-)

[sophielusmom]

My almost 11 yr old Sheltie Sophie was diagnosed Friday with pituitary tumor following ACTH Stim test ( which showed high basal cortisol and high cortisol response) & follow up ultrasound which showed very large left adrenal gland and borderline large right adrenal gland and no evidence of tumors in the abdomen. Sophie has normal bloodworm, except a mild anemia. She is PU/PD and has weakness, lethargy and muscle tremors/trembling, occasional panting. She does not have skin issues, pot belly or ravenous appetite. I am concerned about starting Trilostane as I understand a decrease in appetite is one way that response is monitored. But, Sophie cannot afford a decrease in appetite...I am currently hand feeding at least half of every meal despite her being on Mirtazapine to stimulate appetite. Can anyone speak about a Cushing's dog with poor appetite and Trilostane?

[doxiesrock912]

Unless Daisy is off, she usually has a great appetite.
I would also be concerned about a dog that already has a loss of appetite. Have they ruled out other issues and if not, I would insist that they do so.

Loss of appetite is not a symptom of Cushings and could indicate that something else is going on.

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about appetite and Trilostane into Sophielu’s original thread. We normally like to keep all posts about each pup in a single thread as it makes it easier for members to refer back to the pup's history when needed. Thanks!

[addy]

Hi and Welcome,

I have just a moment but my Zoe did not have elevated liver values when she was first diagnosed. A year later I questioned Dr. Peterson, a world renowned endocrinologist about that and he told me not all Cush pups will have elevated liver values and that doesn't mean Zoe did not have Cushings.

I just thought I would mention our telephone conversation as if seemed pertinent here.

[lulusmom]

I would be very concerned about starting cushing's treatment in any dog that is anorexic. This is not common in cushing's unless there is an another underlying problem that is making the dog sick. If that were the case with Sophielu, I would expect to see some blood chemistry abnormalities. Normal liver enzymes are less of a concern for me. It is the complete absence of any other abnormalities that is disconcerting. When I look at the information you have provided so far, my first suspect is a pheochromocytoma and here are the reasons why:

1. Clinical signs: Sophielu's symptoms are more consistent with a pheo than cushing's. Her anorexia and episodic panting are big red flags. Dogs with cushing's don't have episodic symptoms as their adrenal glands are constantly secreting huge amounts of cortisol and/or other adrenal hormones. They are polyphagic and will drive you crazy begging for food and their panting is pretty constant. Dogs with pheos are anorexic and their panting is in response to the episodic release of catecholamines. Here is an excerpt from a DVM360 article written by Dr. Jana Gordon setting forth possible clinical signs associated with a pheo:


Clinical Signs

These tumors may be an incidental finding and in a previous report was found in up to 60% of dogs at necropsy so most animals with pheochormocytomas exhibit no clinical signs.7,8 In animals with signs, they may be non-specific and intermittent. Signs include lethargy, weight loss, anorexia, panting, polydispia, polyuria, abdominal distention, and collapse.1 Additional clinical findings may include pale mucous membranes, tachycardia and hypertension.1

2. Normal blood labs with exception of mild anemia. This is not typical of cushing's but is very typical finding in a dog with a pheo. See excerpt from same article:


General Laboratory Findings

Routine laboratory abnormalities are uncommon but may include a non-regenerative anemia of chronic disease, regenerative anemia (if hemorrhage), hyperglycemia, and elevated liver enzymes.1 Proteinuria and variable concentration might be found on urinalysis due to the effects of catecholamines on hypertension and vasopressin secretion, respectively.1

3. Ultrasound findings: There is no mention of any liver abnormalities that one would see if a dog has cushing's. Liver is usually enlarged and is hyperechoic, meaning the contrast is brighter. The fact that liver enzymes are normal means Sophielu could be one of few dogs who do not have the steroid induced alkp isoenzyme due to a missing gene but that doesn't mean that the effects of excess steroids would not be seen on imaging. Can you please look at the ultrasound findings and let us know what it says about the liver?

Dogs with adrenal dependent cushing's have a tumor in the adrenal cortex which over secretes cortisol, independent of what the pituitary is telling the adrenal glands to do. Since the pituitary gland is healthy, it recognizes enough circulating cortisol in the blood and quits sending signals to the adrenal glands to release cortisol. Because the contralateral adrenal gland is no longer getting the message, it shrinks up from lack of use. This is not the scenario that was seen on Sophielu's ultrasound. She has one very large adrenal gland and one that is borderline enlarged. This would be suggestive of a dog that either has both an adrenal tumor and a pituitary tumor, which is very rare. It would be more common in a dog with a pheo, especially a dog whose labs and symptoms are more commonly associated with a pheo than cushing's.

4. Hypertension: About 50% of dogs with cushing's will have hypertension at diagnosis but it is very, very common finding in a dog with a pheochromocytoma, especially a dog who is symptomatic. Did your vet check Sophielu's blood pressure? I almost hate to ask that question because general practitioners don't usually have the right equipment nor take the time to make sure multiple readings are taken under the least stressful condition possible.

5. ACTH stimulation test: While a stim test is less likely to yield a false positive result than the LDDS test, I would think it would be more likely in a dog with a pheo. These dogs intermittently secrete catecholamines also known as epinephrine/norepinephrine which is adrenaline so it makes sense that if a pheo is dumping adrenaline, the pituitary will pick up on that and tell the adrenal glands to dump cortisol in response. That's just my layperson's deduction based on my research and a few case studies on this site. We've had a member or two who have had positive diagnostics for cushing's but were later diagnosed with a pheo. Can you please post the actual results of Sophielu's acth stim test?

Here is the url to the DVM360 article I referenced above:

http://veterinarycalendar.dvm360.com/avhc/content/printContentPopup.jsp?id=766820

If Sophielu were my dog, there is no way I would start treatment without a second and very experienced opinion. I would ask for a referral to an internal medicine specialist. If this is something you would entertain, and I hope you do, if you let us know your approximate location, we may have members who can give you a name. You can also search for one yourself at www.acvim.org

Glynda

[pansywags]

I can't speak to trilostane because we never medicated but my Cushing's dog had a poor appetite. She had a pituitary macroadenoma and it was a struggle to get her to eat and arrest wasting (she was a picky, whimsical eater throughout her life). An arsenal of yummy/stinky toppings and hand feeding helped in getting some food in. UC Davis told me they would not consider putting her on meds due to her suppressed appetite (this was prior to CT scan confirmation of the macro and other masses).