Faith Ann - New member with Atypical questions

[Faith Ann Mom]

I am new and I just learning to navigate here. I read your post with great interest. My beloved dog Faith Ann has been diagnosed with Atypical Cushings. She had an Adrenal Panel in 5/13 & 2/14 at UTK. Her baseline were normal, and Post ACTH as follows:
POST ACTH - May 2013 - Feb 2014 - Range
Cortisol ng/ml 2013: 202.3 - 2014: 205.9 - (65.0 - 174.6)
Androstenedione 2013: 0.87 - 2014: 1.62 - (0.27 - 3.97)
Estradiol pg/ml 2013: 82.2 - 2014: 77.7 - (27.9 - 69.2)
Progesterone 2013: 1.70 - 2014: 1.58 - (0.10 - 1.50)
17OH Progesterone 2013: 1.47 - 2014: 1.22 - (0.40 - 1.62)
Aldosterone pg/ml 2013: 110.6 - 2014: 50.4 - (72.9 - 398.5)

Last year, May 2013, UTK Lab Dr. Eiler attached to the results the Treatment Option Considerations with this Comments: "Some vets may consider items 2-5 from Treatment Options if symptomatic". Items 2 to 5 were the Recommendations for Lignans & Melatonin protocol for Atypical Cushings. Since May 2013 to the present time Faith 12+ y/o 69 lbs Lab/Chow was placed on 40 mg HMR Lignan once a day and 6 mg Melatonin twice a day.
The 2013 results and the 2014 results, are not much different. The Estradiol is lower this year and Aldosterone is much lower this year, and the liver enzymes are much much better this year. There is some improvement. The test results this year came with no Recommendation. I wrote Dr. Eiler/UtK Lab asking for his Recommendation like he did last year and he answered that UTK does not make recommendations. I scanned the 2013 results with his Comments & Recommendations and emailed it to him to refresh his memory. I don't know if he would reverse himself and give a recommendation this year. I was disappointed because UTK are the champions on Atypical Cushings research. Reading your posts I see some of you are communicating with Dr Oliver, is he still at UTK? How can I contact him for some guidance? My vet does not want to treat my dog with Lysodren because the cortisol is marginal. I need someone give me a good advice based on their experience or tell me how I can contact Dr. Oliver. Thank you and God bless you all for being such wonderful caring parents for your beloved dogs.
Faith Ann Mom

[labblab]

Hello and welcome to you and Faith Ann! I noticed you had posted this reply on another member's thread, and I have taken the liberty of copying it and also placing it here so as to create a new thread that is your very own. This way, it will be easier for our members to reply to you directly. We are really glad you've found us!

Marianne

[addy]

Hi and Welcome,

I only have a moment so sorry this is so short. Dr. Oliver passed away some years ago so perhaps things are being handled differently now at UTK. I am surprised they did not make any recommendations as they had previously done in the past. It has been awhile since I checked their recommendation worksheet. They used to recommend a maintenance dose of lysodren. If the cortisol is creeping up are you seeing new symptoms and any new abnormal blood work. If you are not seeing any new symptoms nor any changes in blood work that may be why your vet is taking the route of not adding a maintenance dose of lysodren. It was always my understanding that If a dog has elevated cortisol, the dog has Cushings, not atypical. On the old reports they also used to make a comment at the bottom about cortisol and hormones. Does your old report have any notations? When my Zoe had her original UTK panel her cortisol was extremely elevated and that remark was noted at the bottom. On some dog's reports they would remark "moderatley elevated cortisol. Do they mention anything about the cortisol at all on the 2013 report?

Sorry- have to run. Hang in there.

[addy]

One more thought- usually a UTK panel is done when a dog has Cushings symptoms but testing does not indicate a Cushing diagnosis- ie- ACTH or low dose dex test is normal or inconclusive-


Just wondered about the hows and why of seeking out the original diagnosis:)

[Faith Ann Mom]

I am new here. I would like to have Dr. Oliver contact information, email or telephone. My beloved Faith is a female Lab/Chow 13+ y/o. Her Adrenal panel & LDDS Cortisol after 8 months on HMR Lignan & Melatonin on 2/10/14, was as follows:

Baseline & Normal Range:

Cortisol 49.0 (2.1 - 58.8)
Androstenedione 0.37 (0.05 - 0.57)
Estradiol 81.5 (30.8 - 69.9)
Progesterone 0.44 (0.03 - 0.49)
17OH Progesterone 0.17 (0.08 - 0.77)
Aldosterone 11.4 (11 - 139.9)


POST ACTH & Normal Range:

Cortisol 205.9 (65.0 - 174.6)
Androstenedione 1.62 (0.27 - 3.97)
Estradiol 77.7 (27.9 - 69.2)
Progesterone 1.58 (0.10- 1.50)
17OH Progesterone 1.22 (0.40 - 1.62)
Aldosterone 50.4 (72.9 - 398.5)

Results: Indicate presence of increased adrenal activity (Marginal).


CORTISOL LDDS

Baseline & Normal Range
Cortisol LDDS 49.9 (2.1 - 58.8)
4 hr Post Dex 53.3
6 hr Post Dex ---
8 hr Post Dex 33.1

Comments: Baseline cortisol is within the reference interval however there was no suppression of cortisol by dexamethasone at 4 hours and incomplete suppression at 8 hours. Results are suggestive of hyperadrenocorticism.

My concerns is that the conventional medication Lysodren put the dog at risk of Addison and Faith's 2/10/14 result Post ACTH Aldosterone was 50.4 which is below the normal range of (72.9 - 398.5). Last year, 5/1/13 (prior HMR Lignans & Melatonin Treatment) Post ACTH Aldosterone was 110.6.

I would like to contact Dr. Oliver. If any of you knows how to contact him please let me know.
Any comments or advice after reading these results will be highly appreciated.

On 5/1/13 prior to HMR Lignan & Melatonin the results were similar to 2/10/14: "Increased Adrenal Activity Marginal".
2013 POST ACTH Estradiol was 82.2 and this year was 77.7, (27.9 - 69.2) still a little bit above normal.
Last year POST ACTH Androstenedione was 0.87 and this year was 1.62 (0.27 - 3.97). The rest of the numbers were similar in 2013 and 2014.

Faith is also being treated for hypothyroidism with Levothyroxine.
I also read the Lysodren can trigger hypothyroidism.

Thank you very much,

[lulusmom]

Unfortunately Dr. Oliver passed away a number of years ago. We may be able to answer some of your questions but we will be in a much better position to do that if you can provide us with a bit more information. What symptoms did your girl have that prompted your vet to test for cushing's? Have you seen any improvement in those symptoms? Was an abdominal ultrasound ever done to rule out an adrenal tumor?

Glynda

[Faith Ann Mom]

Unfortunately Dr. Oliver passed away a number of years ago. We may be able to answer some of your questions but we will be in a much better position to do that if you can provide us with a bit more information. What symptoms did your girl have that prompted your vet to test for cushing's? Have you seen any improvement in those symptoms? Was an abdominal ultrasound ever done to rule out an adrenal tumor?

Glynda

I don't see and I can't find my respond to the ultrasound question I don't know where it went. While I get familiar with this, if you see my reply can you put it where it should be, so everybody can see it and comment.

I also want to reach the parents of dogs with Cushings and pain due arthritis and hip dysplasia.

One thing that puzzles me is that in the ACTH Adrenal Panel Faith's Cortisol result is marginal high, and her Aldosterone result below to normal, is that Adrenal Insufficiency which is treated with the hormone that cause iatrogenic Cushings? Correct me if I am wrong. In the Low Dexa Supp Test the results point to Cushings.


Forgive me that I keep writing to you but everytime I open this page you are the one that appears in the screen. I am sort of using this like an email instead of a forum. Thank you for your patience.

[Harley PoMMom]

I don't see and I can't find my respond to the ultrasound question I don't know where it went. While I get familiar with this, if you see my reply can you put it where it should be, so everybody can see it and comment.

I couldn't find the post with your response to the ultrasound question. As for writing long replies then having them disappear, that has happened to me also and can be frustrating, so here's a link that will explain what to do: Attention Members - How to stay logged in while typing long replies (http://www.k9cushings.com/forum/showthread.php?t=1329)


I also want to reach the parents of dogs with Cushings and pain due arthritis and hip dysplasia.

Some members have used Adequan for their arthritic dogs. Fish oil capsules may help, and also a supplement that has glucosamine, chondroitin and MSM. We do have a Thread where this is discussed: Joint support supplement (http://www.k9cushings.com/forum/showthread.php?t=5005)


One thing that puzzles me is that in the ACTH Adrenal Panel Faith's Cortisol result is marginal high, and her Aldosterone result below to normal, is that Adrenal Insufficiency which is treated with the hormone that cause iatrogenic Cushings? Correct me if I am wrong. In the Low Dexa Supp Test the results point to Cushings.

Is Faith taking any medication for high blood pressure?


Forgive me that I keep writing to you but everytime I open this page you are the one that appears in the screen. I am sort of using this like an email instead of a forum. Thank you for your patience.

We truly understand how overwhelming this can be and are here to help you in any way we can. No apology is needed, ok? ;)

Hugs, Lori

[frijole]

I too would like to know if an ultrasound was done to rule out an adrenal tumor. Thank you, Kim

[lulusmom]

I asked about an abdominal ultrasound because adrenal tumors can cause low aldosterone. What I completely forgot to ask is what symptoms does Faith Ann have that lead your vet to pursue a cushing's diagnosis, whether typical or atypical?

Glynda

[Faith Ann Mom]

I asked about an abdominal ultrasound because adrenal tumors can cause low aldosterone. What I completely forgot to ask is what symptoms does Faith Ann have that lead your vet to pursue a cushing's diagnosis, whether typical or atypical?

Glynda

FAITH SYMPTOMS:
PU/PD, WEIGHT GAIN, HER BEAUTIFUL COAT DID NOT GROW BACK AFTER MY SON PARTIALLY SHAVED HER, I STOP HIM ON TIME BEFORE HE TOTALLY SHAVED HER. HAIR FLUFFY TAIL IS GONE. SHE ALSO HAD HIP DYSPLASIA AND I WAS CONSIDERING STEM CELL THERAPY.

The Vet ordered a comprehensive blood test and ACTH, Urinalysis, Urine/Creatinine Ratio.
ACTH WAS NEGATIVE FOR CUSHINGS. Urine Cortisol result was 5.5 (5 - 55) LOW-END NORMAL. Urine Creatinine was 46.1 (100 -500) LOW. CORTISOL/CREATININE RATIO WAS 37 (HIGH). Urinalysis Specific Gravity 1.009 (1.015 -1.050) LOW. URINE PH 6.5 (5.5 - 7.0) NORMAL. HIGH ALK-P, HIGH ALT, NORMAL AST AND NORMAL GGTP.

Her thyroid results were slowly getting better but her symptoms persisted.

On Nov 10 2011 she had the DEXA SUPP TEST CORTISOL SERIAL 4 and came up NEGATIVE FOR CUSHINGS.

On November 20, 2011 she had the Abdominal Ultrasound, which was negative for adrenal tumor. I will put the Ultrasound findings, conclusions & recommendations at the end.

Since the symptoms persisted and cushings was ruled out with ACTH & DEXA SUPP TEST we attributed the symptoms to the hypothyroidism.

All 2012 we were adjusting the Levothyroxine dosage, was either to high or to low. On December 2012 she got a comprehensive blood test and got a normal thyroid panel result but the symptoms PU/PD, no hair regrowth, loss hair in the tail remained.

On March 2013 she had another comprehensive blood test and her thyroid was normal, but still ALK-P high, PU/PD, Urine Specific Gravity low. I started doing some research and found Univ of TN.

On 4/25/13 we sent the blood samples to Univ of TN and I posted those results, which were "Increased Adrenal Activity Marginal" and she started the Melatoning 6mg twice a day and HMR Lignans 40 mg once a day.

On 8/13/13 we send blood samples for a premium comprehensive Thryoid Panel to University of Michigan who specializes in Thyroid. Univ of TN referred us to Michigan State Univ for Thyroid testing. All the Ts all the Free Ts, antibodies, etc. etc. were normal just the Free T3 a little bit above the normal range.

On Feb 2014 we repeated the ACTH this time combined with Low Dexam Suppression Test and I already posted the results.

THIS IS THE ULTRASOUND RESULT OF 11/20/11:
HYSTORY:
Elevated liver enzymes. ACTH Stim NORMAL. Considering Stem Cell Therapy (for her hip dysplasia pain).
FINDINGS:
The abdominal ultrasound is performed on 18 November 2011.
The urinary bladder is enlarged and the contents are anechoic. The bladder wall thickness is normal. The liver is uniformly enlarged and mildly hyperechoic compared to the falciform fat. The splenic architecture is normal. The gallbladder contents are anechoic. The small bowell, stomach, colon wall and prancreas are within normal limits. There is no intra-abdominal lymphadenopathy. THE CAUDAL POLE OF THE RIGHT ADRENAL GLAND MEASURES 0.64 CM IN WIDTH AND THE CAUDAL POLE OF THE LEFT ADRENAL GLAND MEASURES 0.56 CM IN WIDTH.
CONCLUSION:
Hyperechoic uniformly enlarged liver. Differentials are steroid hepatopathy, fatty infiltration, chronic hepatitis and less likely lymphosarcoma.
RECOMMENDATIONS:
FOLLOW-UP TESTING FOR PITUITARY DEPENDENT ATYPICAL HYPERADRENOCORTICISM (STEROID HORMONE PROFILES), FURTHER EVALUATE FOR NON-ADRENAL DISEASE AND POSSIBLE LIVER BIOPSY OR FINE NEEDLE ASPIRATE IF APPROPRIATE.[/B]

[Faith Ann Mom]

I couldn't find the post with your response to the ultrasound question. As for writing long replies then having them disappear, that has happened to me also and can be frustrating, so here's a link that will explain what to do: Attention Members - How to stay logged in while typing long replies (http://www.k9cushings.com/forum/showthread.php?t=1329)



Some members have used Adequan for their arthritic dogs. Fish oil capsules may help, and also a supplement that has glucosamine, chondroitin and MSM. We do have a Thread where this is discussed: Joint support supplement (http://www.k9cushings.com/forum/showthread.php?t=5005)



Is Faith taking any medication for high blood pressure?



We truly understand how overwhelming this can be and are here to help you in any way we can. No apology is needed, ok? ;)

Hugs, Lori


No, Faith is not taking high blood pressure medication, but the Vet never takes her blood pressure. I have an appointment on March 5 and I will make sure she takes her blood pressure. I want to be more educated for March 5 appointment. I know the Vet wants to start Faith on Lysodren, but with the very low Aldosterone and the fact that Lysodren can unmask the arthritis pain makes me skeptical. I post again the ultrasound results. That one was in 2011. Shall I do another Ultrasound?

I read a study by a registered nurse: LOW-DOSE CORTISOL REPLACEMENT AS A NOVEL TREATMENT FOR CANINE CUSHING'S DISEASE.

Here is the link. Please tell me if you know about it and what do you think.

http://www.petcarebooks.com/pdf/Atypical-Cushings-treatment.pdf

Thank you so much for your help.

[Faith Ann Mom]

Hello and welcome to you and Faith Ann! I noticed you had posted this reply on another member's thread, and I have taken the liberty of copying it and also placing it here so as to create a new thread that is your very own. This way, it will be easier for our members to reply to you directly. We are really glad you've found us!

Marianne

Marianne, you are so sweet and kind. Thank you so much.

[Faith Ann Mom]

Does your old report have any notations? When my Zoe had her original UTK panel her cortisol was extremely elevated and that remark was noted at the bottom. On some dog's reports they would remark "moderatley elevated cortisol. Do they mention anything about the cortisol at all on the 2013 report?
r
The 5/1/13 ACTH REPORT signed by Dr. Hugo Eiler at the botton said:
RESULT: "Indicate presence of increased adrenal activity Marginal. COMMENTS: Although, estradiol may contribute to clinical signs it is not a good indicator of adrenal activity, since it is also secreted by peripheral tissues (adipose, skin); in this case the source is not known. Treatment options are attached for your consideration. Some vets MAY CONSIDER ITEMS 2-5, IF SYMPTOMATIC.

NOTE: Items 2-5 are items listed on the attached Treatment Option Considerations Steroid Profiles in the Diagnosis of Atypical Cushing's Disease.

On 2/7/14 ACTH TENTATIVE REPORT signed by Dr. Hugo Eiler at the botton said:
Dear Dr. Bramson: Could you please clarify the protocol used in this combined Desamethasone suppression/ACTH test. Colum labels are tentative until we get additional information from you.
In our protocol, the sequence of testing is: baseline; then dexamethasone injection, then sample at 4h, then sample at 8h; then inject ACTH, then collect final sample 1 h after ACTH.
Attached is what was written on each tube by your people (except accession number 14-713 written by us); which is not clear to me (what was done). This information is needed for adrenal interpretation.
With his handwriting: BIG STAR SIGN "LDDST SAME DAY AS THYROID 1/29. ACTH FOLLOWING DAY 1/30.

The 2/10/14 ACTH FINAL REPORT signed by Dr Hugo Eiler at the botton said:
RESULT: "Indicate presence of increased adrenal activity (Marginal).
COMMENTS: (History: PUPD; >ALK-P; Hypothroidism). Compared with previous panel (13-3064; 5/1/13) the number of elevated values decreased from 5 to 4; moreover some elevated values are slightly lower/higher than before, which may be in part, a random effect.
Note. Dr. Bramson: LDDST & Thyroid samples were collected 1/29/14; samples for panel-ACTH Test were collected the following day (1/30/14).

On Feb 2014 Tentative & Final Reports Dr Eiler does not mention Items 2-5 like he did last year on the 5/1/13 Report or any Items listed on the attached Treatment Option Considerations. I emailed Dr. Eiler and asked him for his recommendation and he told me to address that question to my Vet.

I sent him another email and told him that I had read his comments about the UTK protocol and the protocol used by "Dr Bramson's people" and his remarks on the Tentative Report of 2/7/14 and on the Final Report of 2/10/14 that says "LDDST SAME DAY AS THYROID 1/29. ACTH FOLLOWING DAY 1/30.
I asked him what those remarks/comments mean and if in his opinion the results were accurate or not accurate due to the collection method and handling of the samples and if the ACTH/LDDS should be repeated and have not receive a response yet. I think I have the right to know, the tests are very expensive and Faith's case is a complex case and needs reliable results.

On 2/10/14 LDDS FINAL REPORT Dr Eiler wrote:
HISTORY: PU/PD, elevated ALK-P, hypothyroidism,
COMMENTS: Baseline cortisol is within reference interval however there was no suppression of cortisol by dexamethasone at 4 hours and incomplete suppression at 8 hours. Results are suggestive of hyperadrenocorticism.
Made no recommendation.

I enclose a studio by a registered nurse "LOW-DOSE CORTISOL REPLACEMENT AS A NOVEL TREATMENT FOR CANINE CUSHING'S DISEASE. Here is the link:

http://www.petcarebooks.com/pdf/Atypical-Cushings-treatment.pdf

Have you heard about it?

Thank you so much for helping me.

[Faith Ann Mom]

FAITH'S ADDITIONAL SYMPTOMS:
Weakness & Shaking in the hindquaters. One time when she was resting on her side, the shaking was on her back legs, front legs, abdomen. I started massaging her abdomen and it felts like she had a vibrator inside. Then I proceed to massage her head to confort her and I felt the same thing like she had a vibrator inside her head.

LEAKING MY LEGS EXCESSIVELY, leaking my purse and sometimes leaking the metal cabinet.

MAKING LOVE TO MY PURSE simulating she is the male in a sexual intercourse.

GLUCOSE LITTLE BIT HIGHER THAN NORMAL: 131 (84- 120) on the chemistry test of 1/30/14, same collection day of the ACTH &/or the LDDS tests. First time her glucose was higher than normal. The Vet says that could be the fear/anxiety for the two consecutive testing days at the clinic for adrenal panel, thryoid, chemistry, etc.

I CHANGED HER FOOD FROM WELLNESS FOR SENIOR to ORIJEN FOR SENIOR made 80 % of with free-run chicken and turkey, wild-caught fish and nest-laid eggs, 20% of fruit, vegetables & botanicals and 0% grain, potato or GMO.

I BOUGHT INSTINCT GRAIN-FREE BISCUITS by NATURE'S VARIETY, made with chicken, garbanzo bean flour, cranberries and other natural ingredients. Hopefully the glucose will go back to normal with the new diet. I will test her again in one week and I will get a glucometer this Friday.

REDUCED WEIGHT from 70 to 66.6 lbs (3 1/2 lbs). I don't know if is due to the new diet and treats.

REDUCED APPETITE FOR FOOD OR TREAT. I don't know is because she does not like the new food or the new treats with no carbo or because the food is more protein and makes her feel full or satisfied for a longer period of time. She is not begging for too many treats like before. [/B]

It looks like Faith is an atypical Atypical Cushings dog and maybe the reason I don't get too many responses.

My heart is full to the ones are taking the time to help me with this unusual atypical case of Atypical Cushings which has puzzled my Vet and I don't get a treatment option recommendation from Univ of TN.

Sorry about my grammar. English is my second language.

Thank you, Thank you.

Faith Ann's mom

[lulusmom]

First let me say that if English is your second language, I admire you because you've done a beautiful job of communicating things to us.

Since the ultrasound was done quite a long time ago, if you can afford it, having another one done now might show some changes in the adrenal glands that might help in figuring out what is causing Faith Ann's problems.

We are aware of the Caroline Levin and Alfred Plechner theory of adrenal exhaustion and we don't put much stock in it. If this theory is so great why haven't sanctioned controlled studies been done. This is a highly controversial issue. I personally have only seen one member whose dog was being treated according to Dr. Plechner's recommendation and it was a nightmare. The dog had been on steroids for years, developed diabetes and appeared to be insulin resistant. Every time the owner tried to wean the dog off of Medrol, because the steroid had effectively shut down he adrenal glands, which were no longer functioning. I don't know what happened to that do as the member quit posting. It was horrible to see that happen.

You will see a few blogs from pet owners who think Caroline Levin saved their dogs who were diagnosed with SARDS after going blind suddenly. The fact of the matter is that many of these dogs have cushing-like symptoms before or after blindness and all usually have some form of hyperadrenal activity and there is no research showing that this phenomenon has anything to do with so-called adrenal exhaustion. There is no scientific explanation as to why this happens in SARDS but it is known that most of these dogs will see a resolution of symptoms within months without any treatment. Caroline Levin is a registered nurse, I believe with a background in human opthamology. She is not an expert on canine steroids and her studies are her own and not accepted by the veterinary community at large. She and Dr. Plechner and the alternative medicine vets who support them would do well to pool their resources to get scientific proof of their theory. I've included a link below to another thread with discussions on this issue.

http://www.k9cushings.com/forum/showthread.php?t=3869

[lulusmom]

I think you are absolutely correct. I don't think you are getting many responses from members because when you put all the test results together, they are conflicting and don't really support a solid diagnosis of typical or atypical cushing's. I sure don't know how to explain that but I'll share some of my thoughts with you.

Loss of Coat: Faith Ann is a Chow mix which is a Nordic, also called Northern breed. Nordic breeds seem to be genetically predisposed to coat issues, primarily alopecia X, also called follicular dysplasia. One study, which I've provided below, was done to show the efficacy of Trilostane to regrow coats in Pomeranians indicates that the sex hormone, 170H Progesterone is the marker for adrenal dysfunction. I haven't read that study in a while but as I recall, all test dogs had elevated 170H Progesterone yet aside from the loss of coat, they had no other clinical problems. From my experience that hormone is almost always elevated in dogs with atypical cushing's, yet Faith Ann's is normal, as is her Progesterone and Androstenedione which is also quite odd; however, the abdominal ultrasound done in 2011 showed normal adrenal glands which raises great suspicion that Faith Ann's problem is not adrenal based. I've also included a link to a great paper authored by Dr. Ellen Behrend, entitled Atypical Cushing’s Syndrome in Dogs: Arguments For and Against. Atypical Cushing's, as a legitimate disease, is not widely accepted in the veterinary community at large and Dr. Behrend's paper will give you a very good idea as to why that is.

811

My cushdog, Lulu, was a Pomeranian, also a Nordic breed. She was diagnosed with hypothyroidism after I had her cut down for the summer and her coat never grew back. She was diagnosed with cushing's a year later and by that time, her torso was pretty much bald and her once pink skin was gray. Neither Lysodren or Trilostane grew hair for her so she wore sweaters in the winter months. When I switched her treatment from Trilostane to Lysodren, we did a UTK panel to see what her sex steroids looked like. Almost all were off the charts yet she didn't become symptomatic again until her post stimulated cortisol was well above normal, which I believe was 25 ug/dl. I'm on the fence about atypical cushing's even if a UTK panel shows a lot more than marginal hyperadrenal activity. Faith Ann has marginal activity so I personally don't think she has atypical cushing's but you and your vet need to figure that out. All I can do is give you some credible reference material to help you learn about the condition.

http://www.2ndchance.info/cushingsbehrend2010.pdf

Low stimulated Aldosterone on UTK panel: If the UTK panel showed increased activity in Androstenedione, Progesterone and/or 17OH Progesterone, I'd be more inclined to think a low post stimulated Aldosterone might be caused by an adrenal tumor but the results of the abdominal ultrasound you posted doesn't support an adrenal tumor. Healthy dogs can have low Aldosterone levels which is supported by the article below. I've included the url for the article as well as a relevant excerpt. I'm not saying that Faith Ann is healthy, I'm saying that because this abnormality is not uncommon in healthy dogs, a vet would have a very hard time associating a low stimulated Aldosterone level with adrenal disease when other tests don't support it.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2808283/

Tests for plasma aldosterone levels (either basal or stimulated) are not easily available and may be unreliable (some healthy dogs may have low aldosterone levels), so this assay currently does not have widespread clinical use in canine hypoadrenocorticism

Elevated Estradiol: This is another very difficult interpretation when there is such little evidence of hyperadrenal activity. A good number of healthy dogs have elevated Estrodiol and studies show that it is not uncommon and doesn't cause any clinical problems for a dog. When Estradiol is the primary steroid that is elevated, UTK calls this syndrome hyperestrinism. Unfortunately aside from Dr. Oliver's little write up on the UTK site, I've been unable to find any informaton on hyperestrinism. Conversely, I found a renown expert, Dr. Mark Peterson, whose responses on his vet blog tend to make me think he may not support the hyperestrinism theory. I've included a link to one of his blogs where he is responding to a vet about an Alaskan Malamute (also a Nordic breed) with atypical cushing's.

http://endocrinevet.blogspot.com/2011/08/q-high-serum-estradiol-in-neutered-male.html

Estradiol is the only steroid that can be found outside the adrenal glands, in adipose (fatty) tissue which is why Lysodren and Trilostane aren't always effective if added to the atypical treatment regimen. The efficacy of Melatonin and Lignans is actually pretty low so with all things taken into consideration, I personally am not convinced that it has had anything to do with the changes noted between the two UTK panels.

LDDS Results: You asked for a comment on these results. The eight hour post dex number is within normal range so it is negative for cushing's. In my opinion, the comment that results are suggestive of hyperadrenocortism is irrelevant as long as the test is negative and no other tests support a diagnosis of hyperadrenocorticism.

If your vet is not a specialist, I would highly recommend you consider having Faith Ann seen by an internal medicine specialist. Do you live in the states? If so you can try to find a specialist in your area at www.acvim.org. If you tell us what city you are near, we may have members who can provide a name or two.

I apologize for the delay in getting this posted and I hope if nothing else, I've provided you with some food for thought and material to discuss with your vet.

Glynda

[lulusmom]

Hi again.

Thank goodness Marianne contacted me about my comments on the LDDS. You did not include the reporting units used by the lab and I assumed they were nmol/l. Can you confirm this for me? If not nmol, the results could be consistent with hyperadrenocorticism which could explain the comment that the results were suggestive of hyperadrenocorticism. I'll be checking back for your response.

Glynda

[goldengirl88]

I just had time to read your thread today. I commend you on all you are doing for your dog. It is unfortunate that this is such a complicated case. Glynda has done a great job helping you. Sometimes with Cushing's things are just not as straight forward as we would like. It seems you are doing a lot of diagnostic testing but not really coming to any concrete conclusions. I am not well versed in atypical Cushing's so In will leave that to the experts on here. I will however offer you unending support in your journey to help your baby. I hope you get some answers soon. Blessings
Patti

[labblab]

I apologize for being so slow to respond to your questions about Faith Ann, especially since you already had the appointment with the vet yesterday and were hoping for some feedback before then :o. Glynda has indeed given you some very helpful food for thought.

In relation to that LDDS test, she's right that it will be very helpful if you can find out the testing units. UTK is one of the few labs to report many results in units of ng/ml (instead of ug/dl which is more commonly used in the U.S., or nmol/l which is more commonly used in Europe).


CORTISOL LDDS

Baseline & Normal Range
Cortisol LDDS 49.9 (2.1 - 58.8)
4 hr Post Dex 53.3
6 hr Post Dex ---
8 hr Post Dex 33.1
If Faith Ann's results were indeed reported in units of ng/ml, then this would be the conversion to ug/dl:

Baseline: 4.99
4 hr Post Dex: 5.33
8 hr Post Dex: 3.31

Even though a normal range is not given for the 4 and 8 hour results, typically it is below approx. 1.4 or 1.5 ug/dl. So if this is an accurate reflection of Faith Ann's testing units, this would be a positive result for conventional Cushing's. Also, this pattern of results could appear with either pituitary or adrenal Cushing's. Coupled with the low aldosterone and marginally elevated cortisol post-ACTH, you might want to revisit the idea of another abdominal ultrasound prior to making a final treatment decision in order to see whether there have been any changes in the adrenal glands during the past 2 1/2 years that might finally herald an adrenal tumor.

Marianne

[Faith Ann Mom]

THANK YOU ALL FOR YOUR RESPONSES.

1. UTK FAITH'S LDDS' RESULTS UNITS ARE: ng/ml

2. THE ADVICE TO DO ANOTHER ULTRASOUND MAKES A LOT OF SENSE. I WILL DO THAT.

3. OTHER ISSUES FAITH HAS:
Faith has a SMALL BENIGN PERIANAL GROWTH (UNDER THE TAIL) that it is a little bit bigger now. I am concerned to go ahead with the that surgery due to her HIGH POTASSIUM and cardiac risk.
ARE THESE BENIGN GROWTH CAUSED BY HER HORMONAL IMBALANCES?

4. These are Faith's electrolytes results of Feb 2014 from the UTK Chemistry (collected on 1/31/14):

Potassium 5.3 mEg/L HIGH (3.1 - 4.8)
Magnesium 1.1 mmol/L HIGH (0.7 - 0.9)
Phosphorus 6.9 mg/dL HIGH (2.6 - 5.8)
Bicarbonate 22.0 mmol/L H/End NORMAL (14 - 22)
Sodium 148 mEg/L H/End NORMAL (142 -149)
Calcium 10.1 mg/dL L/End NORMAL (10.0 -11.9)
Chloride 110 mEg/L L/End NORMAL (109 - 117)
Creatinine 0.7 mg/dL NORMAL (0.4 - 1.2)
Urea Nitrogen 24 mg/dL NORMAL (8 - 32)
Creat Kinase 219 u/L NORMAL (49 -324)
Cholesterol 213 mg/dL NORMAL (148 - 337)
LIVER ENZYMES
ALT 178 u/L HIGH (21 - 97)
ALK-P 844 u/L HIGH (15 - 164)
AST 23 NORMAL (15 - 51)


Isn't Aldosterone the hormone that balances the electrolytes?

5. We live in Key West, Florida and THERE IS NOT A VET/INTERNIST IN KEY WEST and our Vet is the best we have in Key West. She told me that she does not know the answer for Faith's condition. She does not know if I should keep her on the HMR Lignan/Melatonin protocol or to change it to Lysodren or Trilostane.
I am concerned that Lysodren will UNMASK or make WORSE Faith's Arthritis and Hip Dysplasia Pain. Vet agreed with that.

6. With respect to the perianal growth the Vet says that bigger it becomes more difficult the removal and the recovery.
There is not answer or solution for the HIGH POTASSIUM.
SHOULD I GO AHEAD WITH THE REMOVAL OF THE BENIGN PERIANAL GROWTH NOW OR UNTIL THE POTASSIUM IS NORMAL?

7. Finally, Faith has been in HMR Lignang 40 mg once a day and Melatonin 6 mg twice a day since May 2013 and LATELY she is RELUCTANT to take them even if I wrap them with her favorite treat or food. She looked at me very sad and turn her head. It appears that Faith is telling me that this medicine is not good for her. It reminds me when my mother was refusing a medicine because it made her feel horrible and we insisted following the doctor's instructions and that very medicine caused her death.

I am confused in which order to proceed first or simultaneously? Ultrasound? Perianal Surgery? Balancing the Potassium? How? We do no know the cause of her high potassium. Stop Melatonin & HMR Lignans?.

What would you do in my place?

[Squirt's Mom]

Personally, I would look for the closest IMS to me and get Faith Ann in asap. If that is flat impossible, an ultrasound would be my next choice....but others may think differently from me. ;)

[doxiesrock912]

Your vet's admission scares the heck out of me. If Faith rides well in the car, it is worth taking the trip to an IMS who can then work with your vet to properly treat Faith Ann.

[labblab]

I am so sorry that you are stuck in such a hard place re: Faith Ann's care. Her situation is certainly complicated, and I don't fault your regular vet for not having all the answers herself. Sometimes cases are so complicated/confusing that even the experts are stumped. But I am wondering whether your regular vet has considered a telephone consultation, herself, with a specialist or the internal medicine team at University of Florida's vet school? Even if physical transportation to a specialist would be difficult, there is nothing to prohibit a telephone consultation on your vet's part and I'm somewhat surprised that she hasn't already pursued this since she is openly acknowledging that she doesn't know on her own how best to proceed.

This is only my personal, layperson's opinion, but I think I would opt for a repeat ultrasound as my first course of action. HOWEVER, the adrenal glands are very difficult to visualize on ultrasound, so you really need to have the procedure performed on state-of-the-art high resolution equipment, and the interpretation provided by a specialized radiologist or veterinarian. I am now wondering who performed the original ultrasound in 2011, and how accurate that image really was. That type of sophisticated equipment/analysis may not be available on Key West, and so that throws you back to the same problem: where can you find the closest specialized diagnostic center?

Unfortunately, I don't think any of us here are qualified to advise you re: the surgical risks associated with the high potassium or the possible significance of the low aldosterone. But again, I would think these are questions your vet should be bouncing off a specialist, herself (and *would* want to be bouncing off a specialist) before proceeding further. Is this anything you two have talked about -- the possibility of her calling somebody else herself?

Also, just wanted to add that since Faith Ann's LDDS results were indeed reported in ng/ml units, her response was consistent with conventional Cushing's of either pituitary or adrenal origin. So that partially clarifies one big question for us!

Marianne