Diagnostic test question

[kanabeans]

My dog has been drinking and urinating a lot so I took her to the vet. She didn't have a UTI and had very diluted urine. They took blood to run a CBC and some other stuff. It came back with a high cortisol. No signs of kidney failure or diabetes. So the vet ran another test and on the invoice it says "Code: 2703 MISC. - Antech Resting Cortisol". I had a voicemail from the vet tech saying that this test came back normal and that the next step is to do an abdominal u/s.

I'm not sure what the Antech Resting Cortisol test is or means, does this mean she could still have cushings? Does it help determine if the issue is related to the pituitary gland or the renal glands or liver?

Unfortunately my vet is out of the office until July 4th so I think the earliest I can talk to her is next Saturday. I will call on Monday to see if there is another vet in the office that can answer my questions, but until then I was hoping somebody in the cyber world might have some answers for me. Thanks!

Tests results from last week:

Entire test results:

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[Harley PoMMom]

Hi and welcome to you and your girl!

I have manually approved your membership so there is no need to respond to the email that is automatically sent to you for validation.

Cushing's is when a dog's system produces excessive amounts of cortisol. I am pasting a post from one of Administrators, Glynda, who has explained Cushing's disease so well:


Hi Lauri,

If as dog has pituitary dependent cushing's, the adrenals can be normal size, if early on in the disease, but most often, both glands are equally enlarged. If an adrenal tumor is involved, unless there are bilateral tumors which is very rare, only one adrenal gland is enlarged and the other is either much smaller or completely atrophied. I'll try to explain how this whole mess works and how cushing's screws up a perfect communication system.

Picture this. The pituitary gland is just hanging around in a dog's head with a cortisol meter in it's hand waiting for it to beep. When that meter beeps, the pituitary gland says, "oh it's time for more cortisol and releases acth hormone. The adrenal glands get jolted awake by the acth and obeys the pituitary gland by releasing a good shot of cortisol. That's how it works in a perfect world in a normal dog.

If a dog has a pituitary tumor, the pituitary gland gets all screwed up in the head and can no longer operate the meter correctly. The tumor is evil, like that little devil that stands on your shoulder and tells you to do bad things. :D Well, the evil tumor tells the pituitary "hey we need more cortisol dummy" and the pituitary says duh, okay boss and keeps releasing a steady stream of acth. The adrenal glands have no idea what is going on up in the head so they just do what they are being told to do and release cortisol in response. So now we have the pituitary gland that is dumping acth like crazy and the adrenal glands are dumping cortisol like crazy. So after this mayhem goes on for a while, the dog is floating in a sea of acth and even worse, a sea of cortisol and then all heck breaks loose. The dog starts peeing everywhere, drinking like crazy, panting (like me going up one flight of stairs) losing hair (like me under stress), sucking up food like crazy (call me Hoover), develops a pot belly (like me, a big fat sea cow after chinese sodium overload) and thinning skin that bruises easily (yeah, yeah, yeah also like me). No, I don't have cushing's, I'm just old and infirm with a huge appetite. :D

If a dog has an adrenal tumor, the adrenal tumor could care less about the pituitary gland and lets loose a whole bunch of cortisol and/or one or more of whatever sex hormones it darn well feels like dumping. Remember that the pituitary gland is perfectly healthy and is operating that meter just fine. When the adrenal tumor releases cortisol, the meter never beeps so the pituitary gland is thinking "cool we got cortisol so I'll just hang around here and do nothing. Well that's just great but the adrenal gland that doesn't have a tumor is sitting around on it's butt doing nothing while its evil twin is over there going "bwaahaaaahaaa, I don't need no stinkin acth. It starts shooting out adrenal steroids like it's a gatling gun and with so much cortisol in the blood, it effectively turns off the pituitary gland. So the pituitary gland goes idle, there is no more acth to jolt the poor normal adrenal gland and it starts to shrivel up and atrophy from lack of use. Kinda like most of the muscles in my body. :(

So that's my story and I hope it helps you understand why most of us cushparents are screwed up in the head. It's the evil pituitary and adrenal glands' fault.

Now a bit of information about the tests for Cushing's: the two tests most used for diagnosing Cushing's are the low-dose dexamethasone suppression (LDDS) and the ACTH stimulation. With the LDDS test there are 3 blood draws and it takes 8 hours; a baseline/resting, a 4 hour blood draw, and an 8 hour blood draw. First is the baseline/resting number, then dexamethasone is injected and blood is drawn at the 4 hour mark and then the 8 hour mark. In a normal dog the dog's pituitary gland will perceive that there is a steroid and shut off its stimulatory message to the adrenal glands and suppression is seen at the 8 hour mark. With a dog that has Cushing's no suppression is seen at the 8 hour mark.

In the ACTH stimulation test two blood draws are taken; one is the baseline/pre number and the 2nd one is the post number. After the pre blood draw is done a stimulating agent, usually Cortrosyn, is injected and 1 hour later the second blood draw is done. Dog's with Cushing's normally will have a exaggerated post response to the Cortrosyn.

Cushing's can not be diagnosed or ruled out with just the resting cortisol taken, so with your girl I am confused with the voicemail the vet tech left for you. :confused: A resting cortisol can be used when Addison's is suspected, Addison's is when a dog's cortisol is too low.

Cushing's is a slow progressing disease so one does have time to get a confirmed diagnosis. Cushing's is also treatable but success in treatment is dependent on keen owner observation and a knowledgeable vet with experience at treating Cushing's.

Getting copies of all tests that were done on your girl and posting any abnormal values here would be a great help to us. Is your girl taking any other herbs/supplements/medications? Does she have any other health issues? How old is she and how much does she weigh?

Please know we are here to help in any way we can so do not hesitate to ask all the questions you want. ;)

Hugs, Lori

[kanabeans]

Thank you for your reply!

So the resting cortisol test is kinda pointless? :(

Would the LDDS and/or the ACTH stimulation test be the next best step? Or an u/s? Or do all 3 need to be done eventually? Could she still have cushings with the resting cortisol within "normal range"?

Her only sx at the moment is the excessive eating and drinking. Is it possible she has a UTI but the urine is so diluted that it couldn't pick up the bacteria? But then I guess if that were the case she wouldn't have elevated cortisol would she? When they test the urine they do it similar to an amnio I guess, where they use u/s or something where they can also see inside and said they were no stones.

ETA: She weighs 18.4 lbs and is a schnauzer poodle mix from what we can tell.
My dog has a complicated history and so this is not going to go over well with my husband who is not much of a dog person.

Jan 2012 - diagnosed with luxating patellas
April 2012 - had one eye with a dilated pupil and no vision, started a course of steroids and regained some vision back in that eye within 12 hours. Vet put her on a long course of steroids for 4 months (low dose). She was concerned it could be degenerative brain disease. She never deteriorated and we weaned her off the steroids.
Nov 2012 - she started having early morning episodes of vomiting bile. Vet suggested feeding her right before bedtime and that seemed to help.
Dec 2012 - Started having accidents in house with foul smell. Diagnosed with a UTI
Late Dec 2012/early Jan 2013 - A few weeks after finishing the antibiotics for the UTI she had blood in her urine. There were no other sx. Diagnosed with crystals and started her on S/O food.
Jan/Feb 2013 - she started having soft stools with blood, diagnosed with some bacteria overgrowth (from what I recall a bacteria that is normally found in the stool). Did tylan powder for one month. ETA: The vet said that the bacteria overgrowth could be caused by stress.

All was good until about 2 weeks ago when I noticed the increase in drinking/peeing. Another symptom was accidents while sleeping and dribbling on the floor.

Despite all this she acts like a 1 year old puppy, very energetic and playful. She was a rescue so I'm not sure of her age but with the estimate given she's about 6 years old, but could be older. She is the best dog anybody could ask for, she's wonderful with my girls, loves people, super smart..... Breaks my heart that she has such a hard time and I don't want to lose her.

[kanabeans]

Forgot to add... she is a schnauzer poodle mix, weighs 18.4 lbs, no supplements, and on Urinary S/O food.

I will try to get the vet's office to email me a copy of the bloodwork results.

[kanabeans]

I guess I'm also confused as to why her cortisol was elevated in the first bloodwork (CBC, thyroid, and other stuff) and within normal range in the resting cortisol test.

[labblab]

Hello from me! Resting cortisols can vary greatly from day-to-day, even hour-to-hour, in all dogs whether or not they have Cushing's. Cortisol tends to rise and fall within daily circadian cycles, and other external factors (such as stress) can cause the level to rise at the time of a test even when there is nothing physiologically wrong. As Lori has said, abnormally low resting cortisols can point to the possibility of Addison's, but the reverse is not true: the resting cortisol for a Cushpup may fall anywhere within a normal/elevated range and it requires specialized diagnostics of adrenal response (the ACTH stimulation test or the LDDS) in order to gauge whether there is an abnormality present. Here's a quote that may help:


Q: Where does the resting serum cortisol test fit in?

A: Resting cortisol concentrations are not useful for diagnosing Cushing’s Syndrome. In fact, resting cortisol levels in dogs with known Cushing’s Syndrome overlap 50% of the time with normal dogs. However, resting cortisol levels are very useful as a diagnostic aid in ruling in or ruling out Addison’s disease. If a resting cortisol is > 2 µg/dl (>55 nmol/L), Addison’s disease is very unlikely. Conversely, a resting cortisol < 2 µg/dl (<55 nmol/L) supports the diagnosis of Addison’s disease and an ACTH stimulation test is recommended to confirm the diagnosis.

http://www.antechdiagnostics.com/Main/ANTECHInsights/October-2012-12.aspx


Marianne

[Harley PoMMom]

So the resting cortisol test is kinda pointless? :(

Would the LDDS and/or the ACTH stimulation test be the next best step? Or an u/s? Or do all 3 need to be done eventually? Could she still have cushings with the resting cortisol within "normal range"?

The resting cortisol is pretty useless when trying to diagnose Cushing's.

Cushing's can be difficult to diagnose and is frequently misdiagnosed as other illnesses have the same symptoms. There just isn't one test that is conclusive, so a vet has to rely on more than one diagnostic and validation test. Strong and obvious symptoms do play a huge part of making a Cushing diagnosis.

Since her only symptoms are increases in drinking and urinating, has diabetes been ruled?


Her only sx at the moment is the excessive eating and drinking. Is it possible she has a UTI but the urine is so diluted that it couldn't pick up the bacteria? But then I guess if that were the case she wouldn't have elevated cortisol would she? When they test the urine they do it similar to an amnio I guess, where they use u/s or something where they can also see inside and said they were no stones.

When a dog has diluted urine a regular urinalysis may not pick up any bacteria, an urine culture and sensitivity test should be performed so the exact bacteria can be known and the correct antibiotic will be prescribed.

Using the free catch method to collect the urine is usually alright but having a ultrasound guided cystocentesis can be a better way because they are capturing the urine right from the bladder.


Jan 2012 - diagnosed with luxating patellas
April 2012 - had one eye with a dilated pupil and no vision, started a course of steroids and regained some vision back in that eye within 12 hours. Vet put her on a long course of steroids for 4 months (low dose). She was concerned it could be degenerative brain disease. She never deteriorated and we weaned her off the steroids.
Nov 2012 - she started having early morning episodes of vomiting bile. Vet suggested feeding her right before bedtime and that seemed to help.
Dec 2012 - Started having accidents in house with foul smell. Diagnosed with a UTI
Late Dec 2012/early Jan 2013 - A few weeks after finishing the antibiotics for the UTI she had blood in her urine. There were no other sx. Diagnosed with crystals and started her on S/O food.
Jan/Feb 2013 - she started having soft stools with blood, diagnosed with some bacteria overgrowth (from what I recall a bacteria that is normally found in the stool). Did tylan powder for one month. ETA: The vet said that the bacteria overgrowth could be caused by stress.

Did the vet diagnose the reason for her short term blindness?

Is the type of crystals known? And what is her urine specific gravity (USG)?


All was good until about 2 weeks ago when I noticed the increase in drinking/peeing. Another symptom was accidents while sleeping and dribbling on the floor.

When increases in drinking and urinating diabetes and/or an UTI are the first causes that I would think of to be the culprit for those symptoms. Excessive drinking and urinating are signs of Cushing's, and I mean that the dog drinks buckets and buckets of water and is peeing lakes. Along with the polyuria and polydipsia a ravenous appetite, hair loss, thin skin, and muscle atrophy are the usual symptoms when a dog has Cushing's, does your girl display any of these?


Despite all this she acts like a 1 year old puppy, very energetic and playful. She was a rescue so I'm not sure of her age but with the estimate given she's about 6 years old, but could be older. She is the best dog anybody could ask for, she's wonderful with my girls, loves people, super smart..... Breaks my heart that she has such a hard time and I don't want to lose her.

She sure sounds like a sweetheart and your love for her is evident. If it turns out that she truly does have Cushing's it is a treatable disease and with treatment most if not all clinical Cushing's symptoms can be resolved.


I guess I'm also confused as to why her cortisol was elevated in the first bloodwork (CBC, thyroid, and other stuff) and within normal range in the resting cortisol test.

Assessing the resting cortisol is not usually included with a regular CBC/chemistry blood panel. Dogs with Cushing's can have a resting cortisol within the normal reference ranges but their post number is generally elevated, and the post can only be known with a ACTH stimulation test. Did her chemistry panel show any high values? High elevations in the ALP and cholesterol and sometimes a moderate high level in the ALT are some of the usual values found on a chemistry panel when a dog has Cushing's.

If this were me, I would want diabetes to be ruled out along with having an urine culture and sensitivity test done to make sure no bacteria is present that can be attributing to an UTI which could be the cause for the increased drinking/urination.

I am sorry for the reasons that brought you here but so glad you found us, we will help in any way we can.

Hugs, Lori

[kanabeans]

Hello from me! Resting cortisols can vary greatly from day-to-day, even hour-to-hour, in all dogs whether or not they have Cushing's. Cortisol tends to rise and fall within daily circadian cycles, and other external factors (such as stress) can cause the level to rise at the time of a test even when there is nothing physiologically wrong. As Lori has said, abnormally low resting cortisols can point to the possibility of Addison's, but the reverse is not true: the resting cortisol for a Cushpup may fall anywhere within a normal/elevated range and it requires specialized diagnostics of adrenal response (the ACTH stimulation test or the LDDS) in order to gauge whether there is an abnormality present. Here's a quote that may help:



Marianne

I forgot to mention that the first set of blood tests (CBC, thyroid, etc)... the same blood work that came back showing elevated cortisol came from the same blood draw the vet sent the next for the resting cortisol test.

I'm kind of frustrated that she did this useless test (resting cortisol), I'm on a limited budget which she knows and don't have money to throw around on useless tests. It was $122 for the resting cortisol test. Why would she find this info useful?

[kanabeans]

The resting cortisol is pretty useless when trying to diagnose Cushing's.

Cushing's can be difficult to diagnose and is frequently misdiagnosed as other illnesses have the same symptoms. There just isn't one test that is conclusive, so a vet has to rely on more than one diagnostic and validation test. Strong and obvious symptoms do play a huge part of making a Cushing diagnosis.

Since her only symptoms are increases in drinking and urinating, has diabetes been ruled?

The vet's first set of blood tests ruled out diabetes. I will try and get all the results emailed to me tomorrow to look at.


When a dog has diluted urine a regular urinalysis may not pick up any bacteria, an urine culture and sensitivity test should be performed so the exact bacteria can be known and the correct antibiotic will be prescribed.

Using the free catch method to collect the urine is usually alright but having a ultrasound guided cystocentesis can be a better way because they are capturing the urine right from the bladder.

They used u/s guided cystocentesis to get the urine.


Did the vet diagnose the reason for her short term blindness?

There was no definitive diagnosis for the blindness. She still has limited vision in that eye. IIRC there was some hemorrhaging in the back of the eye when I took her to the vet and the vet said it was possible it could have been an injury to the head. Sadly I have small kids who play the Wii and I remember she got wacked in the head once when she walked behind them when they were bowling. :(

Is the type of crystals known? And what is her urine specific gravity (USG)?

I don't know but I will find out.


When increases in drinking and urinating diabetes and/or an UTI are the first causes that I would think of to be the culprit for those symptoms. Excessive drinking and urinating are signs of Cushing's, and I mean that the dog drinks buckets and buckets of water and is peeing lakes. Along with the polyuria and polydipsia a ravenous appetite, hair loss, thin skin, and muscle atrophy are the usual symptoms when a dog has Cushing's, does your girl display any of these?

She is drinking and peeing more than the 1 ounce per pound that is suggested. I haven't measured but if I were to hazard a guess as to how much I would say about 25-30 ounces a day at most. After I took her to the vet on Thursday I stopped trying to monitor/limit her to the 18/20 oz a day (vet said not to limit) and just let her have as much water as she wants she actually slowed down on her drinking. She still drinks more than 18 ounces but nowhere near how bad it was before. She's also peeing a lot in relation to the amount she is drinking.


She sure sounds like a sweetheart and your love for her is evident. If it turns out that she truly does have Cushing's it is a treatable disease and with treatment most if not all clinical Cushing's symptoms can be resolved.



Assessing the resting cortisol is not usually included with a regular CBC/chemistry blood panel. Dogs with Cushing's can have a resting cortisol within the normal reference ranges but their post number is generally elevated, and the post can only be known with a ACTH stimulation test. Did her chemistry panel show any high values? High elevations in the ALP and cholesterol and sometimes a moderate high level in the ALT are some of the usual values found on a chemistry panel when a dog has Cushing's.

According to one of the tests the vet did she had elevated cortisol, I don't know which test it was.

If this were me, I would want diabetes to be ruled out along with having an urine culture and sensitivity test done to make sure no bacteria is present that can be attributing to an UTI which could be the cause for the increased drinking/urination.

I am sorry for the reasons that brought you here but so glad you found us, we will help in any way we can.

Hugs, Lori

Thank you for your kind words, I put my answers in bold as I'm not very good at separating quotes.

[labblab]

I forgot to mention that the first set of blood tests (CBC, thyroid, etc)... the same blood work that came back showing elevated cortisol came from the same blood draw the vet sent the next for the resting cortisol test...

I'm kind of frustrated that she did this useless test (resting cortisol), I'm on a limited budget which she knows and don't have money to throw around on useless tests. It was $122 for the resting cortisol test. Why would she find this info useful?
I am confused, because it sounds as though you are saying there was a reading for cortisol on the first set of basic tests? That would be very unusual -- cortisol is typically always a special add-on test. So I am guessing there must have been some confusion as to exactly what abnormality was being reported to you from the first set of tests.

That question aside, I would directly ask your vet about the purpose of the special resting cortisol test. If it was supposedly to check for Cushing's, you deserve a refund or a credit applied towards a genuinely diagnostic test such as an ACTH or LDDS.

Also, diabetes and thyroid function can be checked via that first basic blood chemistry panel. If both "Glucose" and "T4" are within normal range, you can probably rule those out as being the source of the problems.

Marianne

Edited to add: I see we were both posting at the same time and that diabetes has been ruled out.

[goldengirl88]

Wow I thought my vet was a robber. I too would want full credit for an ACTH test like Marianne said that was ridiculous to do that when you are so limited on funds too. I am so sorry this happened to you. Blessings
Patti

[kanabeans]

Thanks guys, if this is truly the case, I'll be very disappointed in my vet. I love her, as does my dog and I trust her. She knows my budget constraints so I'm praying that perhaps it's just marked wrong on the invoice or I misunderstood something. I'll definitely get to the bottom of it tomorrow.

[goldengirl88]

Don't put any blame on yourself. Just know no matter how much you love your vet, animal practices are big money now. Just remember to trust yourself and not put blind faith in anyone. Who knows maybe she is unfamiliar with the protocol for Cushings?? Blessings
Patti

[labblab]

I agree with Patti that I hope you won't blame yourself, and also that perhaps your vet is just not that familiar with Cushing's testing and was hoping to save you some money. No vet can know everything about every disease or disorder, so I would say that I would reserve my judgement about the testing until you have the chance to talk it over with her directly. I think the manner in which she chooses to proceed from this point forward can do a lot to remedy the situation.

Marianne

[goldengirl88]

Maybe if you try to be really nice about it she will give you credit for towards an ACTH?

[kanabeans]

For the moment I'm just going to put the test results that are high/abnormal. When I have more time I'll put all of them if needed.


CBC
Platelet count: 419 (normal is 170-400)
Platelet Est: Increased
ALK Phosphatase: 450 (normal is 5-131)
Triglyceride: 585 (normal is 29-291)

Cystcentesis
Appearance: cloudy
Specific Gravity: 1.013 (low) - normal is 1.015-1.050
pH: 8 (high) normal is 5.5-7


ETA: I see it now, the cortisole sample from Saturday (Zoasis - Cortisol) says 4 g/dL

I have some stuff to do but I'll put the results more clearly in a bit.

[kanabeans]

So perhaps I misunderstood the vet and that the first set of bloodworm didn't test cortisol at all, perhaps the 2nd test was to check the cortisol because the alk phosphatase was high. So it could be her liver? :(

[kanabeans]

Thinking out loud here, but I have wondered if she has colitis, especially when the tylan powder she was on seemed to help her. I read online that one of the many causes of high alk phosphatase can be colitis.

Her platelets aren't high enough for it to be cancer can it? :(

[labblab]

Perhaps there is a liver issue, but we're still left with the problem that a resting cortisol is not used to diagnose liver problems and, regardless of the value, does not rule out Cushing's and Cushing's can be associated with elevated values of ALKP and cholesterol/triglycerides. If Cushing's is suspected, you are still in need of one of the blood tests that are diagnostic of the disease: the ACTH stimulation test or the LDDS.

That is what needs to be clarified with the vet -- what was the value of the resting cortisol when it cannot be used to rule Cushing's in or out?

Marianne

[kanabeans]

Perhaps there is a liver issue, but we're still left with the problem that a resting cortisol is not used to diagnose liver problems and, regardless of the value, does not rule out Cushing's and Cushing's can be associated with elevated values of ALKP and cholesterol/triglycerides. If Cushing's is suspected, you are still in need of one of the blood tests that are diagnostic of the disease: the ACTH stimulation test or the LDDS.

That is what needs to be clarified with the vet -- what was the value of the resting cortisol when it cannot be used to rule Cushing's in or out?

Marianne

So they want to do an u/s next.... which would be a better next step the ACTH, LDDS, or the u/s? I can get a referral from the vet's office to an internal medicine vet here in town where I live.

[kanabeans]

Entire test results:

Page 1
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Page 2
http://i1278.photobucket.com/albums/y501/migster2020/maggieresultspg2_zps0234101b.jpg

Page 3
http://i1278.photobucket.com/albums/y501/migster2020/maggieresultspg3_zpsad272b40.jpg

[kanabeans]

And adding a picture of her and all her sweetness, she's the black pup

http://i1278.photobucket.com/albums/y501/migster2020/magmiss_zpsea7c76a3.jpg

[goldengirl88]

As Marianne stated the high triglycerides and alkp can be signs of Cushings. I know you are going to get an ACTH to determine what her numbers are. I would also get her on a liver supplement such as Denamarin, S Adensoyl, Milk Thistle, Hepato Support. Also I would be addressing the high triglycerides as Cushings dogs have a lot of fat mobilized in their systems, and you do not want to deal with pancreatitis. I use fish oil to bring Tipper's down, get a good brand that has less mercury etc. in like Nordic or Kronch. Be careful how much you use as it too is a fat even though it is an unsaturated one it is still adding more fat to the diet. I hope you get credit towards your ACTH from that other test. I also noticed that the gravity test on the urine was a little low. I almost forgot! What a darling picture of your baby, so cute!Blessings
Patti

[kanabeans]

As Marianne stated the high triglycerides and alkp can be signs of Cushings. I know you are going to get an ACTH to determine what her numbers are. I would also get her on a liver supplement such as Denamarin, S Adensoyl, Milk Thistle, Hepato Support. Also I would be addressing the high triglycerides as Cushings dogs have a lot of fat mobilized in their systems, and you do not want to deal with pancreatitis. I use fish oil to bring Tipper's down, get a good brand that has less mercury etc. in like Nordic or Kronch. Be careful how much you use as it too is a fat even though it is an unsaturated one it is still adding more fat to the diet. I hope you get credit towards your ACTH from that other test. I also noticed that the gravity test on the urine was a little low. I almost forgot! What a darling picture of your baby, so cute!Blessings
Patti

Thank you for your help, I'll bring it up to the vet.

ETA: She's scheduled for an u/s tomorrow. I think this is a good decision to get a good look at her organs before moving forward with the stim tests.

[kanabeans]

Exactly one year ago my dog had surgery to get her teeth cleaned and a cracked tooth pull, they (a different vet) did blood work prior and cleared her for surgery.

I had the old vet's office email me those results because I wanted to compare and there are some results that are out of the normal range.

BUN 8.4 (normal range 9.0-29.0)
ALP 236 (normal range 0-140)

RDW% 19.9 (Normal Range 12.0-17.5
HGB 21.1 (NR 12.0-18.0)
MCHC 39.6 (NR 32.0-38.5)
RBC 8.64 (NR 5.50 - 8.50)

The old vet's office ok'ed her for surgery and her ALP was high then and nobody said anything to me. Why wouldn't they tell me that there were results out of the normal range?

[labblab]

So they want to do an u/s next.... which would be a better next step the ACTH, LDDS, or the u/s? I can get a referral from the vet's office to an internal medicine vet here in town where I live.
I am so sorry for my delay in replying to your question, but I've been thinking it over and am afraid there is no easy answer. (Also, I've not had a chance to look over the other specific lab results you've posted, so I'm writing this as sort of a "general" response).

The trouble is, there is not one single "best" test for Cushing's, and all of the diagnostics do carry an expense. When an ultrasound is performed and interpreted by a experienced professional, it can provide a lot of useful information about the status of a number of internal organs in addition to the adrenal glands. So we often say, "you get a lot of bang for your buck" with an ultrasound. It may reveal abnormalities consistent with Cushing's, or it may reveal unrelated problems that could account for overt symptoms. However, there is always the chance that nothing remarkable at all will be viewed on ultrasound, even when a dog does have Cushing's. If a dog has an adrenal growth or tumor, that is very likely to be seen. But if the Cushing's is caused by a pituitary tumor instead, both adrenal glands may be enlarged or they both may be of normal size -- a certain percentage of pituitary Cushpups don't exhibit adrenal abnormalities on ultrasound.

Turning to the diagnostic blood tests instead, both the LDDS and the ACTH have pros and cons. The LDDS has an added advantage of sometimes being able to point to the pituitary form of the disease, but it is also the test that is most likely to return a "false positive" in the face of other nonadrenal disease. A "positive" on an ACTH is more trust-worthy, but the ACTH is more likely to return a "false negative," meaning it is more likely to miss making the diagnosis even when a dog has the disease. So the decision as to which blood test to use may hinge on the overall symptom profile (in other words, how likely does it seem that Cushing's is the problem), and does the dog suffer from any other health problems that are likely to skew the test. If you have a dog with classic symptoms and no other known issues, the LDDS may be the best place to start. If you have a dog with questionable symptoms and another illness (like diabetes, for instance), then the ACTH may be the more conservative route to go out of reluctance to mistakenly diagnose and treat a dog for Cushing's when he/she doesn't really have the disease at all.

So, I've written a book here and still probably not given you a lot of help. In summary, I know I'm asking you to repeat yourself, but can you please list for us very specifically any/all current symptoms that point to Cushing's? And are there any other known illnesses at play? This info can help with making a decision as to what to do next.

(And oh, I wanted to double-check myself when I keep telling you that a resting cortisol cannot be used to rule out Cushing's. Just for the heck of it, I randomly looked at the LDDS results for three dogs here who have just been diagnosed with Cushing's. All three were "positive" for the disease on the subsequent blood draws, but the initial resting cortisol was well within normal range. If the only thing that had been tested was the resting cortisol, the disease would have gone undiagnosed).

Marianne

[kanabeans]

I am so sorry for my delay in replying to your question, but I've been thinking it over and am afraid there is no easy answer. (Also, I've not had a chance to look over the other specific lab results you've posted, so I'm writing this as sort of a "general" response).

The trouble is, there is not one single "best" test for Cushing's, and all of the diagnostics do carry an expense. When an ultrasound is performed and interpreted by a experienced professional, it can provide a lot of useful information about the status of a number of internal organs in addition to the adrenal glands. So we often say, "you get a lot of bang for your buck" with an ultrasound. It may reveal abnormalities consistent with Cushing's, or it may reveal unrelated problems that could account for overt symptoms. However, there is always the chance that nothing remarkable at all will be viewed on ultrasound, even when a dog does have Cushing's. If a dog has an adrenal growth or tumor, that is very likely to be seen. But if the Cushing's is caused by a pituitary tumor instead, both adrenal glands may be enlarged or they both may be of normal size -- a certain percentage of pituitary Cushpups don't exhibit adrenal abnormalities on ultrasound.

Turning to the diagnostic blood tests instead, both the LDDS and the ACTH have pros and cons. The LDDS has an added advantage of sometimes being able to point to the pituitary form of the disease, but it is also the test that is most likely to return a "false positive" in the face of other nonadrenal disease. A "positive" on an ACTH is more trust-worthy, but the ACTH is more likely to return a "false negative," meaning it is more likely to miss making the diagnosis even when a dog has the disease. So the decision as to which blood test to use may hinge on the overall symptom profile (in other words, how likely does it seem that Cushing's is the problem), and does the dog suffer from any other health problems that are likely to skew the test. If you have a dog with classic symptoms and no other known issues, the LDDS may be the best place to start. If you have a dog with questionable symptoms and another illness (like diabetes, for instance), then the ACTH may be the more conservative route to go out of reluctance to mistakenly diagnose and treat a dog for Cushing's when he/she doesn't really have the disease at all.

So, I've written a book here and still probably not given you a lot of help. In summary, I know I'm asking you to repeat yourself, but can you please list for us very specifically any/all current symptoms that point to Cushing's? And are there any other known illnesses at play? This info can help with making a decision as to what to do next.

(And oh, I wanted to double-check myself when I keep telling you that a resting cortisol cannot be used to rule out Cushing's. Just for the heck of it, I randomly looked at the LDDS results for three dogs here who have just been diagnosed with Cushing's. All three were "positive" for the disease on the subsequent blood draws, but the initial resting cortisol was well within normal range. If the only thing that had been tested was the resting cortisol, the disease would have gone undiagnosed).

Marianne

Thanks for your reply Marianne,

Her current sx are drinking and peeing a lot. She has had a few accidents in the house, usually when she is laying down sleeping b/c I find she has pee'd on herself (back leg is wet). She also has had dribbling pee around the house.

After reading online I found another sx that makes me think it is cushings and that is her back legs tremble at times. This isn't something that is always present.

Other problems she has right now is licking her bottom a lot (rectum) and stopping and looking at it frequently.

Otherwise she's her usual self. Nothing out of the ordinary at all. Full of energy and playful, eating fine, etc...

ETA: I feel comfortable at this point doing the u/s and I'm okay with it. It think it's a good test to do and doesn't mean we won't do the stim tests. Dh is surprisingly more on board with this than I thought he would be and if I have to cut corners in other areas to save money for this I will.

[molly muffin]

Hi, she is a real cutie. Love the picture. Have they done a Urine culture test recently? The peeing/leaking, licking can be symptoms of a UTI and if it has gone unchecked, I'd do a skin scraping of where she is licking to check for a yeast infection.

So glad to hear that she is full of energy and playful!

Sharlene and molly muffin

[Harley PoMMom]

Exactly one year ago my dog had surgery to get her teeth cleaned and a cracked tooth pull, they (a different vet) did blood work prior and cleared her for surgery.

I had the old vet's office email me those results because I wanted to compare and there are some results that are out of the normal range.

BUN 8.4 (normal range 9.0-29.0)
ALP 236 (normal range 0-140)

RDW% 19.9 (Normal Range 12.0-17.5
HGB 21.1 (NR 12.0-18.0)
MCHC 39.6 (NR 32.0-38.5)
RBC 8.64 (NR 5.50 - 8.50)

The old vet's office ok'ed her for surgery and her ALP was high then and nobody said anything to me. Why wouldn't they tell me that there were results out of the normal range?

The vet should of mentioned that those values were abnormal. An elevated ALP does not mean that there is liver damage, many other things can cause the ALP levels to increase; certain medications, any gut issues, thyroid problems, these are just a few that I can think of off the top of my head.

When ever my furbabies have blood work done at the vets, they automatically make copies of the results for me to take home and analyse, I keep the copies in a folder ;) This way when the vet does call me to discuss the results I have a list of questions ready for the vet to answer. Also if an emergency would arise and I had to take one of my babes to an emergency clinic I would have that folder to take along for the doc to look at.

Hugs, Lori

[goldengirl88]

That would have been my suggestion to that their is a UTI problem.

[kanabeans]

Maggie had an abdominal u/s yesterday, the u/s tech gave me false hopes that everything looked normal to her but that we'd have to wait on the radiologist's reading. The vet called me to tell me just now that something didn't look right on the u/s, something about how the u/s tech says that it's a picture of the right adrenal gland looks but that the radiologist says it looks just like the left and were they certain that it was actually the right adrenal gland?. But that the left adrenal gland looked smaller which is consistent with an adrenal tumor and that there was what looked to possibly be a mass. Which doesn't make sense if they think the right one looks like the left. She's young but surgery sounds risky and from I've found online doesn't seem to prolong life more than 3 years.

I'm really confused. Anyway, they can't be 100% certain and offered to redo the u/s at no charge on Tuesday. So I have to wait in misery and put my dog through an NPO again for another u/s. I have to try to keep it together for my girls' sake and it is so hard.

[Harley PoMMom]

Oh shoot, sorry to hear that the u/s has to be redone, glad that they are doing it free of charge.

Yes, an adrenalectomy is a serious surgery and one needs to find a very competent surgeon who has experience doing this type of operation. We do have some members whose dogs have gone through an adrenalectomy and the operation was successful, I am sure they will be along to share their opinions and advice.

Since I can not offer any words of wisdom regarding an adrenalectomy, I am here for you with tons of moral support, we are some of the best hand holders ;)

Hugs, Lori

[goldengirl88]

So sorry to hear you have to have another US. I hope they are able to give you a more definitive answer on what was seen on the adrenal gland. I hope it all turns out to be nothing. My Tipper has an adrenal tumor and we have to have a US every three months. It is not fun, but something that must be done. Blessings
Patti

[kanabeans]

So sorry to hear you have to have another US. I hope they are able to give you a more definitive answer on what was seen on the adrenal gland. I hope it all turns out to be nothing. My Tipper has an adrenal tumor and we have to have a US every three months. It is not fun, but something that must be done. Blessings
Patti

I read Tipper's story, so he has an adrenal tumor? And you think it's because of past doses of prednisone? Maggie has had small prescriptions of prednisone years ago for allergies, and then she was on it for 4 months back in 2012 but it was a very low dose. I can't help but blame myself that I was giving her something that would later make her sick. The vet claims it has nothing to do with the steroids but doesn't give me much comfort. She never seemed to be the same after those 4 months of prednisone. :(

[goldengirl88]

Tipper had lots of prednisone as a puppy because of terrible allergies that were at times life threatening emergencies. Dr. Peterson the well known endocrinologist discussed this in detail with my Vet. He feels her history with this predisposed her to it. My vet told me that in their circles they all have known for years how bad it is. That's all I can tell you is what they told me and I do believe it. Tipper has an adrenal tumor and a pituitary tumor also. I am so sorry you are going thru this, it is not easy, but you will make it just like all of us have. With the help and support of this forum you will do well. Blessings
Patti

[kanabeans]

Tipper had lots of prednisone as a puppy because of terrible allergies that were at times life threatening emergencies. Dr. Peterson the well know endocrinologist discussed this in detail with my Vet. He feels her history with this predisposed her to it. My vet told me that in their circles they all have known for years how bad it is. That's all I can tell you is what they told me and I do believe it. Tipper has an adrenal tumor and a pituitary tumor also. I am so sorry you are going thru this, it is not easy, but you will make it just like all of us have. With the help and support of this forum you will do well. Blessings
Patti

Can I ask what treatment you are doing for him? I don't think surgery is an option for us, seems risky and pricy. So would we just give her medicine for cushings and keep her as comfortable as possible? How long can they live with an adrenal tumor?

[lulusmom]

Tipper had lots of prednisone as a puppy because of terrible allergies that were at times life threatening emergencies. Dr. Peterson the well know endocrinologist discussed this in detail with my Vet. He feels her history with this predisposed her to it.

Patti, did Dr. Peterson tell you that chronic use of prednisone when Tipper was a puppy predisposed her to an adrenal tumor? If so, did he explain how that happens? If not, do you think you could ask him?

[goldengirl88]

Yes he did say this, but I have no explanation for it. He told my vet who told me and I guess my vet did not ask for an explanation.

[Trish]

Hi
So sorry to hear about the ambiguous ultrasound report. There is nothing more nerve wracking than the time waiting confirmation of a diagnosis and having to redo the ultrasound is right up there! Just checking this has been done on a high definition machine? I would also be tempted to ask for a specialist to do it as it seems to have been a tricky scan for the ultrasound tech? If it has just been done at the local vet, I think I would be inclined to go to a specialist. Sorry if I have read that wrong and you have already done this.

I think you should give yourself a break with the blame game too, from what I have read (and I have read extensively on adrenal tumours, as my dog has undergone adrenalectomy) there are no clear cut causes for this disease. Even if you review the human literature on adrenal tumours they are also still in the dark as to potential causes. There are some tenuous links they know that either children or adults in midlife are more at risk, plus there are a few rare genetic diseases that could lead to adrenal tumour but rarely. Plus smoking, :p and I would say it is pretty safe to assume Maggie is a non-smoker :) She is so cute by the way!

The mean survival time (MST) for my dogs adrenal tumour was 15months following adrenalectomy. We are now at 20 months and still going strong. I always refuse to look at those numbers on prognosis as my boy Flynn is not a number or a statistic and in my opinion those predictions are always made to be broken!

I think as hard as it is, one step at a time for now. Get a clear ultrasound, check they are doing it on a good machine and then we take it from there once the final report comes in. Hope you get to relax a little with Maggie and have some fun over the weekend. :)
Trish

[goldengirl88]

In answer to your question I take Tipper every three months to have an Ultra Sound done so we can see if there is any growth with the tumor. For almost a year she had no growth at all then the last US she had a miniscule amount of growth. We are due back at the end of July. No one knows for certain what the cause of Cushing's is, but Dr. Peterson is the top Endocrinologist and has the only clinic in the world ( well did 2 years ago) for this, so what he says you can take to the bank. I am sure he would never tell my vet that Tipper was predisposed to this from the prednisone use if it were not so, what would be the point in him doing so? Please do not blame yourself as I have too. Just so you know Tipper had high amounts of this, so that is different than your dogs situation. We were in a bad situation and it was the only thing that would help her. She even got anaphylaxis in which her throat swelled. She did grow out of the allergies, and then when her cortisol was managed a little of the allergy stuff came back, but not even like when she was a puppy. If your dog is not showing symptoms from the tumor maybe you want to talk to your Dr. and see what they think about monitoring it. The only other resolution is surgery and maybe that is an option. Your best served to discuss this with a surgeon and IMS to get the full rundown. Then make your own decision on what you feel is best knowing your dog and your situation. You will get thru this like the rest of us are doing. We are all in this together. Blessings
Patti

[Trish]

We all know excessive use of steroids can cause iatrogenic cushings. But there are no direct links, that I can see, that steroids cause adrenal tumours. Even in Dr Peterson's (who we all recognise as an expert) own blogs or articles, I can see no literature to link to this assertation. Dr Peterson does provide links to current research in this area on one of his blogs from 2012. The first shows adrenal size returning to normal after stopping the steroids. Plus another that shows work being done to look at cause of adrenal tumour development.

If you are able to provide anything studies that show the opposite we would be interested to see them.

Source: Mark Petersons blog. http://endocrinevet.blogspot.co.nz/2013/09/top-endocrine-publications-of-2012_4.html
Effect of glucocorticoid administration on adrenal gland size and sonographic appearance in beagle dogs.

Pey P (http://www.ncbi.nlm.nih.gov/pubmed?term=Pey%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22092685)1, Daminet S (http://www.ncbi.nlm.nih.gov/pubmed?term=Daminet%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22092685), Smets PM (http://www.ncbi.nlm.nih.gov/pubmed?term=Smets%20PM%5BAuthor%5D&cauthor=true&cauthor_uid=22092685), Duchateau L (http://www.ncbi.nlm.nih.gov/pubmed?term=Duchateau%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22092685), Travetti O (http://www.ncbi.nlm.nih.gov/pubmed?term=Travetti%20O%5BAuthor%5D&cauthor=true&cauthor_uid=22092685), Saunders JH (http://www.ncbi.nlm.nih.gov/pubmed?term=Saunders%20JH%5BAuthor%5D&cauthor=true&cauthor_uid=22092685).


1Department of Medical Imaging of Domestic Animals and Orthopedics of Small Animals, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium. Pascaline.Pey@UGent.be



Abstract

Our aim was to evaluate the influence of glucocorticoids on the adrenal gland using ultrasonography. Eleven healthy beagles were used in a prospective placebo-controlled study. All dogs received hydrocortisone at 10 mg/kg twice a day per os for 4 months or a gelatin capsule twice a day per os as a placebo. Clinical and endocrinologic examination of the dogs and ultrasonographic evaluation of adrenal echogenicity, shape, and measurement of the length and height of the cranial and caudal pole were performed at baseline (TO), at 1 (T1) and 4 months (T4) after the beginning of treatment, and 2 months after the end of the treatment including 1 month of tapering and 1 month without treatment (T6). The dogs were assigned randomly to the glucocorticoid (n = 6) and placebo groups (n = 5). At T1, the difference between the two groups for the height of the cranial and caudal pole was not ultrasonographically remarkable despite a statistically significant difference (P = 0.0165 and P = 0.0206). Decreased height and length of entire gland were observed at T4 (P < 0.0001, P = 0.0015, and P = 0.0035, respectively). Percentages of atrophy were variable between dogs. Both adrenal glands regained normal size and shape 1 month after cessation of glucocorticoid administration. As not all dogs developed marked adrenal gland atrophy and the degree of atrophy varied widely between individuals, ultrasonography cannot be the technique of choice to detect iatrogenic hypercortisolism. Ultrasonographic changes are reversible within 1 month after the end of glucocorticoid administration

AND

Mol Cell Endocrinol. (http://www.ncbi.nlm.nih.gov/pubmed/22100615#) 2012 Mar 31;351(1):78-86. doi: 10.1016/j.mce.2011.09.045. Epub 2011 Nov 11.
Animal models of adrenocortical tumorigenesis.

Beuschlein F (http://www.ncbi.nlm.nih.gov/pubmed?term=Beuschlein%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22100615)1, Galac S (http://www.ncbi.nlm.nih.gov/pubmed?term=Galac%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22100615), Wilson DB (http://www.ncbi.nlm.nih.gov/pubmed?term=Wilson%20DB%5BAuthor%5D&cauthor=true&cauthor_uid=22100615).
1Endocrine Research Unit, Medizinische Klinik Campus Innenstadt, Klinikum der LMU, Ziemssenstr. 1, D-80336 Munich, Germany.


Abstract

Over the past decade, research on human adrenocortical neoplasia has been dominated by gene expression profiling of tumor specimens and by analysis of genetic disorders associated with a predisposition to these tumors. Although these studies have identified key genes and associated signaling pathways that are dysregulated in adrenocortical neoplasms, the molecular events accounting for the frequent occurrence of benign tumors and low rate of malignant transformation remain unknown. Moreover, the prognosis for patients with adrenocortical carcinoma remains poor, so new medical treatments are needed. Naturally occurring and genetically engineered animal models afford a means to investigate adrenocortical tumorigenesis and to develop novel therapeutics. This comparative review highlights adrenocortical tumor models useful for either mechanistic studies or preclinical testing. Three model species - mouse, ferret, and dog - are reviewed, and their relevance to adrenocortical tumors in humans is discussed.

[goldengirl88]

I think this has gotten off the path. The statement from my vet to me was that Dr. Peterson said Tipper's use of prednisone predisposed her to Cushing's, not specifically to an adrenal tumor, but to Cushings. Tipper has both pituitary and adrenal tumors . My vet said that vets have known for years how bad these steroids are. Those were the statements made. Also I want to add that Dr. Peterson said this based on only diagnosing Tipper with PDH, Tipper's adrenal tumor was not found until after that time. So argue away as I do believe her Cushing's was caused by what Dr. Peterson said.

[molly muffin]

Hmm, well I don't know about any predisposition or not when it comes to cushings, so I'm going to set that aside for now. I hope that at some point, some where, there will be more research done into causes of cushings, as it effects dogs, horses and humans.

What is most important is dealing with what is now and that is I think your vet is going to have another ultrasound done at no charge to you to see if there really is anything on the adrenal gland?

Now keep in mind that you may have a nodule on the adrenal gland that isn't secreting and doesn't grow. That is what we are hoping for Tipper, that is what I am hoping for my Molly too. Trish's Flynn, had a pheo tumor which is a different type of tumor and had the surgery. As you can see from all of this, no one persons experience is going to be exactly the same and not all tumors are created equal, so there are a few more things to find out before you can really move forward and decide on treatment plans.

Sharlene and molly muffin

[kanabeans]

Sorry, I didn't mean to cause a debate, I just feel guilty and wonder if it could have something to do with the prednisone, mostly because it seems like ever since she was on the prednisone for 4 months she became a different dog.

[kanabeans]

Hi
So sorry to hear about the ambiguous ultrasound report. There is nothing more nerve wracking than the time waiting confirmation of a diagnosis and having to redo the ultrasound is right up there! Just checking this has been done on a high definition machine? I would also be tempted to ask for a specialist to do it as it seems to have been a tricky scan for the ultrasound tech? If it has just been done at the local vet, I think I would be inclined to go to a specialist. Sorry if I have read that wrong and you have already done this.

I don't know if it was done on a high definition machine. It was in the vet's office by the vet tech. Perhaps the vet will do the redo u/s? Not sure if I had mentioned it earlier but the vet tech said she had a lot of gas and it was difficult to get shots because of it.

I think you should give yourself a break with the blame game too, from what I have read (and I have read extensively on adrenal tumours, as my dog has undergone adrenalectomy) there are no clear cut causes for this disease. Even if you review the human literature on adrenal tumours they are also still in the dark as to potential causes. There are some tenuous links they know that either children or adults in midlife are more at risk, plus there are a few rare genetic diseases that could lead to adrenal tumour but rarely. Plus smoking, :p and I would say it is pretty safe to assume Maggie is a non-smoker :) She is so cute by the way!

Definitely not a smoker, not even 2nd hand.

The mean survival time (MST) for my dogs adrenal tumour was 15months following adrenalectomy. We are now at 20 months and still going strong. I always refuse to look at those numbers on prognosis as my boy Flynn is not a number or a statistic and in my opinion those predictions are always made to be broken!

I think as hard as it is, one step at a time for now. Get a clear ultrasound, check they are doing it on a good machine and then we take it from there once the final report comes in. Hope you get to relax a little with Maggie and have some fun over the weekend. :)
Trish

Thank you for your post.

[kanabeans]

I had asked the vet tech last week if it were possible that the urine would be too diluted to detect a UTI and she said that it wouldn't matter if the urine was diluted. She also said they don't send it out for a culture. Does anybody know if diluted urine could cause it hard to test for a UTI in the office? Maggie does have a hx of UTIs.

[Trish]

Hi

With dilute urine the bacteria may not always be seen when they test it, so for those dogs it pays to send a sample where they do a proper culture. The test takes a few days as they drop some urine on a culture plate and wait a couple of days to see if any bacteria grow. Then they can test various antibiotics against the bacteria to make sure if it does need treatment they use the right one.

I would ask them about the machine they use for ultrasound. I know my vet also has an ultrasound scanner but he always sends us to the IMS for our checkup scans. He said his scanner is good enough for the routine stuff they need to scan in general practice, like checking pregnant dogs etc but it does not give the definition required when these adrenal tumours are suspected.

Trish :)

[molly muffin]

It has been said many times on the forum here by various members that the urine Has to be cultured if it is very dilute as they just can't get a good enough reading otherwise.
Lets see what shows up on the next ultrasound. A couple things you will want them to find out is if there is a difference over all in size between the two glands, left and right, one abnormally smaller than the other for instance and the size of any possible tumor. Not all adrenal nodules are secreting tumors, and one way to determine if it is or isn't, is by looking to see if one is larger than the other.
If the adrenal glands themselves are about the same size, then it is more likely to be benign, or non-secreting.

Don't worry about starting debates, there is a lot of information and opinions and it's always good to have healthy discussions and figure things out.

Sharlene and molly muffin

[kanabeans]

Ok, I'm ready to get off this emotional roller coaster already....

Today we had Maggie's 2nd u/s to try and get a better pic. It was a high resolution u/s and this time the vet did it herself and they actually let me stay in the room and hold Maggie. If I learned one thing today, it's that Maggie sneezes anytime they get to 'close' to her adrenal glands. The vet said for some reason she has a lot of dogs that do that. Very weird.

So according to the vet everything looks normal, pictures were much better this time around and no gas. She said adrenal glands look the same size and normal and no masses. Of course this is what the vet tech said last week so I'm not going to get too excited until we get the report back from the radiologist.

At this time the vet doesn't think Maggie has cushings, and I actually brought up the possibility of the UTI test being negative because the urine was too diluted, which was something she wanted to suggest to me actually. However, the culture would be $200 and I don't know how much further I can go while keeping my husband on board. I truly feel that Maggie has cushings and would much rather spend that $200 towards the stim tests.

The vet seems to think she doesn't have cushings because her adrenal glands look fine and her resting cortisol was normal. I pointed out to her that the cortisol fluctuates throughout the day and we could have just got it at a low point... which she concurred with me but said that all the dogs she's diagnosed with cushings always had high resting cortisol too. She said it's possible Maggie's cushings is atypical. I would be more than happy to agree with her opinion that Maggie doesn't have cushings if she wasn't symptomatic. The excessive drinking and peeing, and I pointed out how her back legs tremble which the vet tech noticed as well.

So at this point she prescribed an antibiotic for a possible UTI to see if that resolves Maggies symptoms. I did ask if she had an infection, if that could raise Maggies ALP and she said no. I could have sworn though I read online that the raised liver enzymes could be caused by an infection.

I'm really frustrated and becoming disheartened that my vet may not know what she's talking about. She said she'd be okay to do the stim test if that's what I wanted but the fact that her info/advice/opinion isn't accurate (to what I've been told/read on this forum and read online) concerns me.

[Renee]

I am going to jump in here, although I have been fairly absent because I have been very busy in my work and personal life.

Please shell out the money for the culture to be done. There are many reasons for this, but maybe the most important is that you could be invalidating all other tests to follow due to a pesky UTI. A UTI can skew the results of the cushings tests, meaning you'll be wasting more money.

I speak from personal experience with my pug on the UTI's. We had them going, chronically, for nearly over a year. At one point, the bacteria had progressed to MRSP (closely related to MRSA), and could only be treated with a specially compounded abx, which took 8 weeks to clear up. We were getting cultures every 6-8 weeks for nearly a year. Point here is, if I had never done the culture, I would have never known what bacteria was present, nor would I have known what abx would kill it, and she would have never been able to get better. When you throw broad spectrum abx at a UTI, you are taking a gamble that it can kill the bacteria present. It may or may not. I went down your road for 2 months before I smartened up. By that time, my Tobey had taken so much clavamox I could have started my own pharmacy. Guess what? First culture done showed that her bacteria was resistant to clavamox. What a waste of time!!

With cushings diagnosis, it is always one thing at a time, and first things first is to rule out all other possibilities. A UTI may sound fairly harmless, but it really can cause a host of problems, especially if it is an aggressive bacteria.

[kanabeans]

I am going to jump in here, although I have been fairly absent because I have been very busy in my work and personal life.

Please shell out the money for the culture to be done. There are many reasons for this, but maybe the most important is that you could be invalidating all other tests to follow due to a pesky UTI. A UTI can skew the results of the cushings tests, meaning you'll be wasting more money.

I speak from personal experience with my pug on the UTI's. We had them going, chronically, for nearly over a year. At one point, the bacteria had progressed to MRSP (closely related to MRSA), and could only be treated with a specially compounded abx, which took 8 weeks to clear up. We were getting cultures every 6-8 weeks for nearly a year. Point here is, if I had never done the culture, I would have never known what bacteria was present, nor would I have known what abx would kill it, and she would have never been able to get better. When you throw broad spectrum abx at a UTI, you are taking a gamble that it can kill the bacteria present. It may or may not. I went down your road for 2 months before I smartened up. By that time, my Tobey had taken so much clavamox I could have started my own pharmacy. Guess what? First culture done showed that her bacteria was resistant to clavamox. What a waste of time!!

With cushings diagnosis, it is always one thing at a time, and first things first is to rule out all other possibilities. A UTI may sound fairly harmless, but it really can cause a host of problems, especially if it is an aggressive bacteria.

So would a UTI cause elevated ALP? A

And if she had cushings of the pituitary gland would her adrenal glands be enlarged (one or both)?

[molly muffin]

Hi, I've been thinking about this. She had crystals and is on SO food, and I know that is when my molly's ALP started to go up.

So, to recap, her symptoms are drinking excessively and peeing, leaking. Now has this been going on for Only 2 - 3 weeks? Not before? How much more water is she drinking exactly?

And is she still licking at her bottom?

See these are the things that make me think, UTI, yeast infection maybe around her bottom area, rather than cushings. Cushings happens when there is either a pituitary or adrenal gland tumor, and usually the symptoms come on very slowly. Her back legs shaking, might be from the luxating patelsas.

Can they get any kind of skin scrap to test from the area she is licking? to check for yeast? which might be bothering her if she also had a UTI.

Here is the good thing. If it is cushings, it progresses slowly and you'll have time to do testing in the future if needed. If it is UTI and/or yeast infection, then it could be cleared up now and everything return to normal.

Maybe if there wasn't so many tests and expenses coming all at once, bham, bham, bham, then you're husband would be more okay with it too.

Those are my initial thoughts.

Sharlene and molly muffin

[kanabeans]

Hi, I've been thinking about this. She had crystals and is on SO food, and I know that is when my molly's ALP started to go up.

So, to recap, her symptoms are drinking excessively and peeing, leaking. Now has this been going on for Only 2 - 3 weeks? Not before? How much more water is she drinking exactly?

I would say the peeing and leaking has gradually been building up. I remember last year she had a few instances where it would happen but I just figured it was because nobody let her out when she needed to go. But the peeing and leaking has gotten worse in the last 2-3 weeks when her drinking became excessive. I haven't kept an exact measurement but her bowl holds about 18 oz and she drinks up to a bowl and a half to 2 bowls of it. ETA: she weighs 18.4 lbs

And is she still licking at her bottom?

When she had her first u/s last week they expressed her anal glands and that has seemed to help with that.

See these are the things that make me think, UTI, yeast infection maybe around her bottom area, rather than cushings. Cushings happens when there is either a pituitary or adrenal gland tumor, and usually the symptoms come on very slowly. Her back legs shaking, might be from the luxating patelsas.

I didn't think the back legs shaking could come from luxating patellas... maybe that's possible.

Can they get any kind of skin scrap to test from the area she is licking? to check for yeast? which might be bothering her if she also had a UTI.

Here is the good thing. If it is cushings, it progresses slowly and you'll have time to do testing in the future if needed. If it is UTI and/or yeast infection, then it could be cleared up now and everything return to normal.

Maybe if there wasn't so many tests and expenses coming all at once, bham, bham, bham, then you're husband would be more okay with it too.

Those are my initial thoughts.

I think you're right and at this time I will take a more serious consideration to the possibility it's a UTI. The vet prescribed 100mg of simplicef once a day for 14 days. I already started her on it, so would it be okay to finish it out and then pursue the culture. My vet says that she's not even sure that it would grow anything that diluted even in a culture. Is it possible to reduce her water intake and try to get a more concentrated amount of urine?

[B]Do you know if the adrenal glands are always enlarged (one or both) with cushings and that normal sized adrenal glands means it's not cushings?



Sharlene and molly muffin

I put my responses in bold, I have a hard time with the breaking up the quote. Thank you for your post. :)

[Harley PoMMom]

With the pituitary type of Cushing's both adrenal glands will be enlarged, now if this is in the early stages of Cushing's the adrenal glands could be of normal size.

Typically with adrenal cushing's, one adrenal gland has a tumor and is significantly enlarged and the other gland is either normal size or atrophied to some degree.

Hugs, Lori

[kanabeans]

With the pituitary type of Cushing's both adrenal glands will be enlarged, now if this is in the early stages of Cushing's the adrenal glands could be of normal size.

Typically with adrenal cushing's, one adrenal gland has a tumor and is significantly enlarged and the other gland is either normal size or atrophied to some degree.

Hugs, Lori

Ok, thank you. So if we get the report back from the radiologist tomorrow that they are of normal size then I will definitely look further into the possibility of an UTI.

[molly muffin]

Yes, molly's leg shakes on the side she has the luxating patella. So I know that is possible. Not all the time, but that is the cause. It isn't on the side without the luxating patella.

Sharlene and molly muffin

[kanabeans]

Yes, molly's leg shakes on the side she has the luxating patella. So I know that is possible. Not all the time, but that is the cause. It isn't on the side without the luxating patella.

Sharlene and molly muffin

Interesting, and something I didn't consider.

If it turns out she doesn't have cushings, I swear this dog is shortening my life with these scares. A couple of years ago I was worried she had degenerative brain disease, and then the time she was peeing blood and I thought it was her kidneys failing but it turned out to be a UTI, now this. I'm a wreck.

[molly muffin]

It does make for an emotional roller-coaster as you already noted. :)
Molly has a crystal problem too and she was at one point urinating blood, yep, it was a bad UTI.
Now this luxating patella thing has come up, as a grade 2, not enough to do surgery but still a worry.

I feel sometimes as thought, she does something, I react, or this happens, I react and never know what will be going on the next day, so I do sympathize and understand what you mean.
yet here we are loving them so much and trying to do whatever we can to make their lives better.

It packs a real whallop some days though.
Sharlene and molly muffin

[Trish]

Hi - pleased to hear the new scan looked better!! Hopefully the radiologist agree's with your vets assessment and we can put the adrenal tumour diagnosis in a box. I totally agree with Renee in getting a proper culture done, gosh that does sound expensive for that test though.

I think with all the confusion you are experiencing I would be tempted to go see an IMS, might cost more for appointment but sometimes it can actually save you money by the specialist sorting it all out and then cutting down on some of the testing by your vet? Just a thought, fingers crossed for good report tomorrow.

[kanabeans]

Tipper's mom mentioned this up thread:


I would also get her on a liver supplement such as Denamarin, S Adensoyl, Milk Thistle, Hepato Support. Also I would be addressing the high triglycerides as Cushings dogs have a lot of fat mobilized in their systems, and you do not want to deal with pancreatitis. I use fish oil to bring Tipper's down, get a good brand that has less mercury etc. in like Nordic or Kronch.

Are Denamarin, S Adensoyl, Milk Thistle, Hepato Support all liver supplements and I need to pick one? Or should I look into getting her on all of those?

And do you use regular over the counter human fish oil or is there one made specifically for dogs?

[kanabeans]

It does make for an emotional roller-coaster as you already noted. :)
Molly has a crystal problem too and she was at one point urinating blood, yep, it was a bad UTI.
Now this luxating patella thing has come up, as a grade 2, not enough to do surgery but still a worry.

I feel sometimes as thought, she does something, I react, or this happens, I react and never know what will be going on the next day, so I do sympathize and understand what you mean.
yet here we are loving them so much and trying to do whatever we can to make their lives better.

It packs a real whallop some days though.
Sharlene and molly muffin

Thanks Sharlene, I spent last night reading through Molly's story and it sounds like you have had it more rough than I have with that emotional roller coaster. Looking through all these posts just make me sad to think of all the moms and dads worried about their furbabies and the furbabies that are dealing with cushings. :(

[kanabeans]

Hi - pleased to hear the new scan looked better!! Hopefully the radiologist agree's with your vets assessment and we can put the adrenal tumour diagnosis in a box. I totally agree with Renee in getting a proper culture done, gosh that does sound expensive for that test though.

I think with all the confusion you are experiencing I would be tempted to go see an IMS, might cost more for appointment but sometimes it can actually save you money by the specialist sorting it all out and then cutting down on some of the testing by your vet? Just a thought, fingers crossed for good report tomorrow.

Thank you for the advice, we will look into an IMS if this antibiotic does nothing. I would love to find a good one in my area that people have had good experiences with. I did call one place last week but they require a referral from the regular vet. Is the norm?

I'm not going to get my hopes up yet, also I read online that with PDC the adrenal glands can still be normal size. My gut is telling me it's cushings, but maybe we are lucky and it's just a UTI. If she wasn't symptomatic I'd be less concerned but in addition to the eating and drinking she also is a little piggy with food. Prior to being on steroids she was a 'dainty' eater and would only eat when we would eat dinner, her food would sit in her bowl. After the 4 months of steroids she changed to the kind of dog that scarfs down her food as soon as you put it in her bowl. I was hoping this would go away after we stopped the steroids but it didn't. And she is the kind of dog that walks the kitchen floors looking for crumbs. Maybe the steroids just taught her bad habits? I don't know.

[Harley PoMMom]

Are Denamarin, S Adensoyl, Milk Thistle, Hepato Support all liver supplements and I need to pick one? Or should I look into getting her on all of those?

Yep, they are all liver supplements; denamarin has both S-Adenosylmethionine (SAMe) and silybin, milk thistle contains Silymarin and silybin, hepato support's ingredients are silymarin and silybinin, different Vitamin B's and some other things.

I'm not positive but I think Sharlene (molly muffin) uses hepato support for Molly and has had success with it.


And do you use regular over the counter human fish oil or is there one made specifically for dogs?

From what I have read the ratio between the EPA/DHA is what is important, wild salmon or krill oil are usually recommended. With salmon oil it is crucial to buy the oil that is from wild salmon and not from farm raised salmon because the wild salmon's primary diet is krill. Human grade fish oil can be used. The dogaware site has a lot of info regarding fish oil, here's an excerpt from there and a link to the article:
I don't recommend any particular brand of fish oil. The ConsumerLab.com review of Fish Oil/Omega-3 Supplements done in 2008 showed that "all were fresh and contained their claimed amounts of EPA and DHA . . . None of the products were found to contain detectable levels of mercury [over 10 ppb (parts per billion). . . . ). In addition, none of the products contained unsafe levels of lead or PCBs." However, an updated report in 2012 found, "Trace levels of PCBs were found in every product (as PCBs are ubiquitous in water), but two supplements exceeded contaminations limits for PCBs. Mercury was not detected in any of the products." Some people prefer to get molecularly distilled fish oil, which is fine, but I don't think it's necessary (note that the term "pharmaceutical grade" does not have a legal definition). If you prefer liquid fish oil, be sure to buy products in dark bottles and keep them refrigerated. Don't buy more than you will use in a couple of months, as fish oil will become rancid over time when exposed to light, heat, or air. See K9RawDiet.com for some good brands (this site belongs to a friend of mine).

Fish Oil or Salmon Oil (http://dogaware.com/diet/supplements.html#fishoil)

Hugs, Lori

[molly muffin]

I have been using Heppato Support supplements, I'm going to give the S Adensoyl 100 a try, since it contains both sam-e, milk thistle and b viatamins.

Sharlene and molly muffin

[kanabeans]

Finally got the results from the u/s. My gut was right, u/s shows that the right adrenal gland is larger than the left, this time they say no sign of a mass. :confused:

So they think PDC, which isn't it supposed to be both are enlarged or not enlarged with PDC?

Next step is the Low Dose Dex Test scheduled for Thursday.

I asked my vet if she's ever treated dogs with cushings and she said she's had a few dogs diagnosed with it but the owners chose not to treat because they were very old dogs. She knows an IM vet that she works with at times (actually works at her office) and said that she actually already called her and that it was the IMS that recommended the LDDT over the other one, don't remember the name. The vet said any time I'm unsure I can ask her to call/check with the IMS. I think for now we will keep it this way since the IMS is quite far and Maggie is already familiar with our vet and office. She said that any time I wanted to go to the IMS she would be fine referring me.

I love my vet and I feel like she loves Maggie more than any vet could love an animal that is not there own. She actually called me today on her day off from own to talk about Maggie.

Some questions I forgot to ask the vet, does Maggie need to fast or have no water prior to the LDDT? (I will call to confirm this next Wednesday when the vet is back from vacation)

Are there any bad side affects I need to be on the look out for or any potential complications after the LDDT?

Will we be able to conclusively diagnose Maggie with cushings after the LDDT and the u/s results?

If it is adrenal dependent and we decide not to operate is the treatment for ADC and PDC pretty much the same otherwise in terms of medication?

Thank you for all your help!

[Harley PoMMom]

Maggie's only symptoms are increased drinking/urination, right? Even with the u/s findings I'm still not convinced that a Cushing's diagnosis is likely. Sweet Maggie sure has had her share of health issues, which could attribute to enlarged adrenal glands.

If this were me, and with Maggie's history with UTI's and crystals, I would have an urine culture and sensitivity test done before having an LDDS test performed because both of these issues could create a false positive result in the LDDS test.

This is only my opinion and I am sure others will be along to share theirs.




Her only sx at the moment is the excessive eating and drinking. Is it possible she has a UTI but the urine is so diluted that it couldn't pick up the bacteria?
ETA: She weighs 18.4 lbs and is a schnauzer poodle mix from what we can tell.
My dog has a complicated history and so this is not going to go over well with my husband who is not much of a dog person.

Jan 2012 - diagnosed with luxating patellas
April 2012 - had one eye with a dilated pupil and no vision, started a course of steroids and regained some vision back in that eye within 12 hours. Vet put her on a long course of steroids for 4 months (low dose). She was concerned it could be degenerative brain disease. She never deteriorated and we weaned her off the steroids.
Nov 2012 - she started having early morning episodes of vomiting bile. Vet suggested feeding her right before bedtime and that seemed to help.
Dec 2012 - Started having accidents in house with foul smell. Diagnosed with a UTI
Late Dec 2012/early Jan 2013 - A few weeks after finishing the antibiotics for the UTI she had blood in her urine. There were no other sx. Diagnosed with crystals and started her on S/O food.
Jan/Feb 2013 - she started having soft stools with blood, diagnosed with some bacteria overgrowth (from what I recall a bacteria that is normally found in the stool). Did tylan powder for one month. ETA: The vet said that the bacteria overgrowth could be caused by stress.

All was good until about 2 weeks ago when I noticed the increase in drinking/peeing. Another symptom was accidents while sleeping and dribbling on the floor.

Despite all this she acts like a 1 year old puppy, very energetic and playful. She was a rescue so I'm not sure of her age but with the estimate given she's about 6 years old, but could be older. She is the best dog anybody could ask for, she's wonderful with my girls, loves people, super smart..... Breaks my heart that she has such a hard time and I don't want to lose her.


Finally got the results from the u/s. My gut was right, u/s shows that the right adrenal gland is larger than the left, this time they say no sign of a mass. :confused:

So they think PDC, which isn't it supposed to be both are enlarged or not enlarged with PDC?

With the pituitary type both adrenal glands are enlarged, if the Cushing's is in the early stages both may be of normal size.



Some questions I forgot to ask the vet, does Maggie need to fast or have no water prior to the LDDT? (I will call to confirm this next Wednesday when the vet is back from vacation)

Usually for the LDDS test a dog is fasted but is allowed water.


Are there any bad side affects I need to be on the look out for or any potential complications after the LDDT?

Her drinking may increase, some dogs have become a bit lethargic/sleepy and some dogs get somewhat antsy, all dogs are different and can react differently. :)


Will we be able to conclusively diagnose Maggie with cushings after the LDDT and the u/s results?

I still would have an urine culture and sensitivity test done before performing the LDDS test.


If it is adrenal dependent and we decide not to operate is the treatment for ADC and PDC pretty much the same otherwise in terms of medication?

Thank you for all your help!

If treating with Trilostane, yes, the treatment is basically the same.

By the way, Maggie sure is a beautiful girl!!!

Hugs, Lori

[Renee]

I just want to reiterate, again, the importance of getting any potential UTI / bacteria squared away before doing any further cushings tests. Please do the culture and sensitivity before you move on to the LDDS.

As for adrenal size, my pug has PDH, and her adrenals are both enlarged, with one slightly larger than the other.

[kanabeans]

Thank you Lori for your reply and insight. So you think it's still possible she could have a UTI that would cause one adrenal gland to be enlarged? Her sx of drinking and peeing is something new but there have been times (I think it happened 2 times in the last 11 months) where she dribbled pee and wet herself in her sleep. Looking back now I realize that it could be related to whatever is going on with her now. Could she have had a UTI for that long and not get worse health wise (kidney infection, temperature, etc...)? How sick are dogs with cushings at the time of diagnosing? Aside from the large consumption of water and peeing Maggie acts pretty normal. She may fatigue a little faster than before but I just figured it's because she's getting older. She still plays like a puppy.

I suppose it would be good to do the urine culture just to cover all our bases. This is just the worst timing as I'm going out of town in about 2 weeks and then when we get back we're going on a trip (was gonna take Maggie with us).

So perhaps urine culture test first and then the LDDT.... are vets usually capable of doing the LDDT or would the specialist be better? I called a few specialists and it's $120 just for a consult.

Also, how often is it that a dog has cushings but not an elevated resting cortisol? I realize that we could have just caught her at a low point with her cortisol... but just curious.

So many questions and possibilities going through my brain and it's exhausting.

[molly muffin]

I think it can be quite common for the resting coritisol to be within range.

Yes a regular vet can administer the LDDS test.

Normally you'd expect a UTI to get worse, but it just depends I think on what is causing it.

I'd still think you could take Maggie with you on a trip, nothing here should affect that, you can take any meds needed with you.

Sharlene and molly muffin

[kanabeans]

The vet suggested stopping the antibiotic now since she no longer thinks it's a UTI. I've given her 3 doses of the simplicef and now that you guys say she still could have a UTI should I continue giving it to her? She is supposed to get another dose tonight. She's on 100 mg once a day for 14 days.

I'm certain I'll do the culture now just to be on the safe side, but if I continue giving her the antibiotic it may not grow anything if she did have a UTI. By the time we get the culture she'll have been on the antibiotic for almost a week.

I can't call the office because they're closed already and the vet we see is on vacation til Wednesday.

[kanabeans]

I think it can be quite common for the resting coritisol to be within range.

Yes a regular vet can administer the LDDS test.

Normally you'd expect a UTI to get worse, but it just depends I think on what is causing it.

I'd still think you could take Maggie with you on a trip, nothing here should affect that, you can take any meds needed with you.

Sharlene and molly muffin

I know, I would much rather just stay home though and take care of her and get this resolved.

[Renee]

Just a question, maybe you already answered it... was her bladder looked at during the ultrasound? Any presence of stones in the bladder or kidneys, or other abnormalities?

And, no one would fault you for wanting to stay home and take care of this! I took 2 weeks off from work when we first started the cushings meds. We totally understand!

[kanabeans]

Just a question, maybe you already answered it... was her bladder looked at during the ultrasound? Any presence of stones in the bladder or kidneys, or other abnormalities?

And, no one would fault you for wanting to stay home and take care of this! I took 2 weeks off from work when we first started the cushings meds. We totally understand!

They looked at it during the u/s and it is fine.... I'm assuming anyway since the vet had nothing to report from it (radiologist's report) and I know they looked at it because she showed it to me while doing the u/s and said it looked fine.

[Trish]

Hi

Pleased to hear no mass was seen in the adrenals. I was not sure if the glands were different in size so did a quick google, this study is a bit old from 1997 but outlines a study they did measuring adrenal glands in dogs with no known disease. It seems there is a difference in size in the adrenals. I have copied the most relevant part below for your info.

Ultrasonographic adrenal gland measurements in dogs without evidence of adrenal disease
http://www.ncbi.nlm.nih.gov/pubmed/9238781
"In dogs where both adrenal gland lengths were measured (n = 74), the right adrenal gland length was less than that of the left in 46 dogs, equal to the left in one dog, and greater than the length of the left in 27 dogs."

I think relevant to your query where Maggie's right is larger, seems it is more common for the left to be longer but there is a significant proportion of dogs where the right is larger. I guess it is the actual difference in size, normal variation vs marked variation. So hopefully this finding in Maggie is not anything to be too concerned about, but I am sure your vet will be able to reassure you on that as they should have the actual sizes measured during the scan.

Re the UTI, if she was not overly symptomatic I agree with the vet and stop it and then retest later and get a proper culture done.

[molly muffin]

How is Maggie doing? Any more news?

hugs
Sharlene and molly muffin

[kanabeans]

How is Maggie doing? Any more news?

hugs
Sharlene and molly muffin

I just got the u/s results emailed to me and I'm going to post them. We were supposed to do the LDDT Thursday but I called and rescheduled and left a message for the vet to call me back in regards to ruling out a UTI before doing the LDDT. My gut tells me UTI, but gonna play it safe.

Maggie is doing good, her same old usual happy, playful, thirsty self. :)

[kanabeans]

Ultrasound results from July 3rd and July 8th. The July 8th u/s focuses more on the adrenal glands, the right in particular. I'm just going to post what seems to be abnormal or something I don't understand.

Liver:
Diffusely, severely hyperechoic and normal shape. No evidence of masses or nodules.

Liver: steroidal hepatopathy (consistent with cushing's disease, or idiopathic steroidal hepatopathy)

Right adrenal gland (caudal pole): Mildly enlarged (7.83 mm wide)

Left adrenal gland: 5mm wide; normal diameter.

No additional masses or nodules are seen in the image set.

The urinary bladder has very low volume and the measured wall thickness is heavily affect by this low volume. (is this because I took her for a walk while waiting for her u/s to happen and she pee'd?)

Interpretation: right adrenomegaly: not large enough to consider a functional carcinoma.

Differentials include hypertrophy (pituitary dependent) or an adenoma.

Functional testing necessary to confirm cushing's disease.

If positive, then consider pituitary dependent.
If negative, than probably benign adenoma causing adrenomegaly.
Then, liver fna for cytology of underlying liver disease.


Can anybody explain this to me in layman's terms?

[labblab]

Hey, I will take a stab at it! :)

There are changes in the liver that are consistent with increased steroid exposure. Cushing's would be a likely cause; if not Cushing's, then some other cause that is currently unknown.

The right adrenal gland shows enlargement that is not likely to be the result of a cancerous tumor of the type that would cause elevated secretion of cortisol. The more likely cause of the enlargement is either pituitary dependent Cushing's or a benign tumor.

If the LDDS is positive for Cushing's, then you will have a cause that would explain both the liver and the adrenal abnormalities. If the LDDS is negative, then the adrenal enlargement might be assumed to be due to a benign tumor that is not increasing cortisol production. And further diagnostics, like perhaps a biopsy ("fna" or fine needle aspiration), would be required to figure out what is causing the liver changes.

So to me, I do believe the LDDS is the next step. As far as a UTI, I do not believe a UTI would be the cause of either the liver or adrenal abnormalities. So to me, the only reason to hold off on the LDDS testing would be out of fear that an active UTI might skew the results. I have not been following your thread closely enough to know whether you have specific reason to believe that Maggie has a UTI right now. The flip side is that dogs with untreated Cushing's often suffer from chronic UTIs which may not grow a culture and you don't want to postpone the diagnostic testing forever (From the Veterinary Merck Manual: "Many dogs with hyperadrenocorticism show evidence of urinary tract infection without pyuria (positive culture)..."). If there is reason to suspect an active UTI and it fits into your timeframe to wait for a urine culture and sensitivity before moving forward, that would be the conservative route and would provide additional info to factor in. But if not, given the ultrasound report and the bloodwork abnormalities that are also consistent with Cushing's, I probably would be OK with proceeding on to the LDDS if Maggie were my dog. Just my two cents worth. ;)

Marianne

[molly muffin]

How are things with Maggie?

Sharlene and molly muffin

[molly muffin]

Checking in to see how things are going with Maggie.

hugs
Sharlene and molly muffin

[kanabeans]

Hi everyone,

Sorry I've been MIA, it's been a crazy last couple of weeks with traveling. I've finally scheduled Maggie's LDDT for Wednesday but I'm unsure about something. Her vet had initially said (when we had the test scheduled last month) that she didn't need to fast the night/morning before the LDDT. But I've found info online that states otherwise. My vet is rather new to cushings and diagnosing/treating so I just want to make sure we get this right the first time so I don't have to put Maggie through a repeat test like we had to with her ultrasound.

Thanks!

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about fasting for the LDDS into Maggie’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!

[labblab]

I think different labs may have different fasting requirements for a diagnostic LDDS. So if you really want to be certain, you can ask your vet's office which lab will be interpreting the results and then check the lab's own website (or call them) in order to find out their test requirements.

Marianne

[kanabeans]

Maggie had her Low Dose Dex Test yesterday and we got her results back today and I'm super confused. It came back negative for Cushings. The vet said there are about 5% of dogs who have PDH and have normal results. So it's possible she is one of the 5%. But I'm so confused, how could she have PDH with her right adrenal gland enlarged?

I had the vet email me her results:

Zoasis - Cortisol Serial 3 (DEX)

Time 1 - pre
Time 2 - 4 hour post
Time 3 - 8 hour post

Cortisol Sample one - 3.2...................NR: 1.0 - 5.0
Cortisol Sample two Dex - <1.0..........NR: 0.0 - 1.4
Cortisol Sample three Dex - 1.2...........NR: 0.0-1.4



Now what? The vet wasn't even sure what to do next and is going to consult with a specialist tomorrow. Not sure if I mentioned, but I started Maggie on Denamarin and I noticed about a week after she started that it did seem to help lower her thirstiness and water consumption. Not sure if that is a clue of anything. But her u/s showed an enlarged right adrenal gland and liver changes.

[molly muffin]

Welcome to my world. :) My molly has tested negative on 4 LDDS tests now, has a high ACTH, and a nodule on an adrenal gland.

Usually with a secreting adrenal tumor, they can't test negative on the LDDS, so they don't think ours is secreting. True, that 5% can test negative on an LDDS. My IMS didn't think they would consistently test negative though, but I wonder if maybe it has to do with location of the pituitary tumor. It is very confusing and I'm really interested to see what your IMS says, as mine and my vet are stumped by molly too.

We've been on this path now for years with no real difference.

hugs,
Sharlene and molly muffin

[kanabeans]

Re-posting her lab work and u/s results so nobody has to search through the thread.

JUNE 2014
CBC
Platelet count: 419 (normal is 170-400)
Platelet Est: Increased
ALK Phosphatase: 450 (normal is 5-131)
Triglyceride: 585 (normal is 29-291)

Cystcentesis
Appearance: cloudy
Specific Gravity: 1.013 (low) - normal is 1.015-1.050
pH: 8 (high) normal is 5.5-7


Ultrasound July 8, 2014

Left adrenal gland measures 5mm (normal)
Right adrenal gland measures 7.83mm (mildly enlarged)

Liver: steroidal hepatopathy (consistent with cushing's disease or idiopathic steroidal hepatopathy)

Also, if you recall Maggie had two u/s done, the first one the radiologist had difficulties with because the pics weren't good or something. There was conflicting info re: the right adrenal, first the report said that there looked to be a mass, then later in the report it said there was no picture of the adrenal.

The 2nd u/s results were attached to the 1st u/s results as an addendum. In the 1st results the say that the left adrenal gland was small, consistent with atrophy from functional contra-lateral tumor. But the addendum with the 2nd u/s results list the left adrenal measuring 5mm and is normal. So I'm not sure which one I should believe.

[kanabeans]

Welcome to my world. :) My molly has tested negative on 4 LDDS tests now, has a high ACTH, and a nodule on an adrenal gland.

Usually with a secreting adrenal tumor, they can't test negative on the LDDS, so they don't think ours is secreting. True, that 5% can test negative on an LDDS. My IMS didn't think they would consistently test negative though, but I wonder if maybe it has to do with location of the pituitary tumor. It is very confusing and I'm really interested to see what your IMS says, as mine and my vet are stumped by molly too.

We've been on this path now for years with no real difference.

hugs,
Sharlene and molly muffin

Well, we can all sit on the stumped bench together. LOL

Forgive my ignorance but what is a secreting adrenal tumor? Also, does Molly have sx of cushings like the increased thirst and urination? I forget....

[kanabeans]

Also did Molly have an u/s?

[molly muffin]

Yes molly has had a couple u/s. No she doesn't have symptoms of cushings, other than pot belly and on the ultrasound, enlarged adrenal glands bilateral (both enlarged) and enlarged liver, but outwardly, no signs. She doesn't eat too much, or drink too much, or pee too much, or have hair loss. Just that belly from the enlarged liver.
Secreting adrenal tumor, produces cortisol, ADH as opposed to PDH.

So, yep, stumped.
Sharlene and molly muffin

[Squirt's Mom]

There is a rarer tumor found on adrenal glands called a pheochromocytoma that does not secret cortisol so it is not a tumor associated with Cushing's even tho it is on the adrenal glands. A pheo would be a NON-secreting adrenal tumor.

The sneaky part of Cushing's is this - any stress can cause the cortisol to rise as a normal response to the stress. The tests for Cushing's can only tell us that excess cortisol is present but not WHY it is present. So a pup with a pheo tumor or other tumor can test positive even tho they do not actually have Cushing's. My Squirt tested positive when it was really a tumor on her spleen causing the cortisol to rise - and she had five positive tests. The LDDS, HDDS, ACTH, UTK panel and two ultrasounds. Cushing's is not an easy disease to diagnose. ;)

[kanabeans]

There is a rarer tumor found on adrenal glands called a pheochromocytoma that does not secret cortisol so it is not a tumor associated with Cushing's even tho it is on the adrenal glands. A pheo would be a NON-secreting adrenal tumor.

The sneaky part of Cushing's is this - any stress can cause the cortisol to rise as a normal response to the stress. The tests for Cushing's can only tell us that excess cortisol is present but not WHY it is present. So a pup with a pheo tumor or other tumor can test positive even tho they do not actually have Cushing's. My Squirt tested positive when it was really a tumor on her spleen causing the cortisol to rise - and she had five positive tests. The LDDS, HDDS, ACTH, UTK panel and two ultrasounds. Cushing's is not an easy disease to diagnose. ;)

So you are saying it could pheo?

I did some searching on it, as I'm not very familiar with what a pheo tumor is. It says it can rapidly metastasize, Maggie has been showing symptoms for the past year now. Her ALP was elevated slightly in July of 2013. So when they say rapidly metastasizes, how rapid is it that? I would think that if her ALP was elevated, albeit slightly, a year ago and sx were somewhat present, wouldn't the tumor show up on an u/s by now?

Naturally I wouldn't want to be a pheo tumor and I will run it by the vet, but I don't know how much it fits Maggie's profile/sx/progression. Also, the only sx I see from her currently is:

Started in June 2014 - frequent drinking/urination

Started perhaps this past spring - I find her stamina is not as strong when playing but she is still very playful and wants/initiates play frequently throughout the day

Started maybe almost a year ago but I thought maybe she was just getting old - her back legs tremble at times.

Increased appetite - started ever since she was taken off the steroids almost 2 years ago.

Dribbling pee and peeing in her sleep - this happened once about a year ago and then it seems to have gradually increased (probably along with her increase in thirst) and I chalked it up to her not being taken out when she was supposed to. This is better since being on the denamarin and she isn't as thirsty. Although she did have an accident when we brought her home from the vet after her LDDT, I suspect she didn't drink much while she was there and then they gave her a ton of water before I came to pick her up and she had to go. She peed right in front of us on the floor.

[Squirt's Mom]

So you are saying it could pheo?

No, I was explaining that there are adrenal tumors that are non-secreting in response to your question asking what a secreting adrenal tumor meant. In Cushing's, the tumor on the gland(s) secrets a hormone - cortisol. A pheo on the other hand is an adrenal tumor that does not secret cortisol.

We have had a few members here who's pups turned out to have pheo's and not Cushing's. Here are some of the threads.

Flynn-
http://www.k9cushings.com/forum/showthread.php?t=4242&highlight=pheo

Kenai -
http://www.k9cushings.com/forum/showthread.php?t=6058&highlight=pheo

Lola -
http://www.k9cushings.com/forum/showthread.php?t=6050&highlight=pheo&page=2

Annie -
http://www.k9cushings.com/forum/showthread.php?t=933

[kanabeans]

No, I was explaining that there are adrenal tumors that are non-secreting in response to your question asking what a secreting adrenal tumor meant. In Cushing's, the tumor on the gland(s) secrets a hormone - cortisol. A pheo on the other hand is an adrenal tumor that does not secret cortisol.

We have had a few members here who's pups turned out to have pheo's and not Cushing's. Here are some of the threads.

Flynn-
http://www.k9cushings.com/forum/showthread.php?t=4242&highlight=pheo

Kenai -
http://www.k9cushings.com/forum/showthread.php?t=6058&highlight=pheo

Lola -
http://www.k9cushings.com/forum/showthread.php?t=6050&highlight=pheo&page=2

Annie -
http://www.k9cushings.com/forum/showthread.php?t=933

So it's possible to have a tumor on the adrenal gland that wouldn't yet show up on an u/s, be non secreting but cause her to have the dx I cushings such as increase thirst/urination... Etc?

I'm still trying to wrap my head around all this and make sense of, I'm not doubting your idea as to an explanation. Just trying to understand the possibilities.

[kanabeans]

Another question, could liver disease cause one enlarged adrenal gland?

ETA: Another question, the radiologist noted that her liver had steroidal hepatopathy (consistent with cushings or idiopathic steroidal hepatopathy).

Could the liver changes seen on the u/s have been caused by her prolonged steroid use from 2012 and the liver doesn't recover or return to normal?

[lulusmom]

I just reread your thread and wanted to add my two cents worth on the Maggie's symptoms, lab abnormalities and adrenal tumors in general.

The way you describe Maggie's current symptoms make me wonder if what you are seeing are the overt symptoms most of us saw when our dogs were diagnosed or are you trying to make all the pieces fit with a cushing's diagnosis, also like some of us have done? You mentioned that Maggie's appetite increased two years ago after being on steroids. Does she whine and beg for food, forage for food, clean her bowl, other bowls and look for more? Has she gained weight? Have you noticed that her hips and spine in her hind quarters look and feel boney, like there is no muscle there? This is what you would usually see and feel in a dog who has had the disease long enough to experience significant muscle wasting. This would definitely account for hind leg weakness and trembling/tremoring. Dogs with cushing's drink and pee buckets and when it is at full tilt, accidents in the house are no longer accidents. Peeing outside is the accident. If cushing's is the cause for Maggie's frequent urination, it is not likely that you would see her water intake drop with denamarin. Cushdogs lose the ability to concentrate their urine so the water goes right through them. They therefore drink more water to stay hydrated due to the extreme water loss. If you see a drop in drinking, there should be a correlating drop in peeing.

Maggie is a Mini Schnauzer mix which may predispose her to idiopathic hypertriglyceridemia. It is not unusual to see elevated triglycerides and cholesterol in dogs with cushing's but those elevations are usually mild. Was Maggie fasted for at least 12 hours before these tests were done? If fasted, I don't think Maggie's elevations would be considered mild. FYI, elevated ALKP is associated with idiopathic hypertriglyceridemia.

A functional adrenal tumor is not predictable as to when or what hormones/steroids it's going to secrete. It can secrete cortisol, in which case you would expect the tumor to also be over secreting one or more of the sex hormones. However, it can also secrete sex hormones only, in which case the LDDS and ACTH stim tests would be normal. Sex hormones, also known as intermediate hormones can cause the same lab and organ abnormalities as well as the same physical symptoms that are associated with excess cortisol.

All of the tests for cushing's pretty much suck but if you do enough of them, one or two of them will end up validating another one. In Maggie's case, none of them validate each other. Aside from the elevated ALKP, which could be attributed to any number of conditions, including hypertriglyceridemia, I don't see cushing's. You've had two conflicting abdominal ultrasounds so which one do you deem the most accurate? If it's the last one, you have one mildly enlarged gland and one normal size gland which is not indicative of a cortisol secreting tumor. So could it be that Maggie is in the very early stages of pituitary dependent disease and the enlarged adrenal could simply be a nonfunctional tumor, which could explain the normal LDDS? If that were to be the case, I would take wait and see approach to see if symptoms worsened or maybe even redo the LDDS in three or four months. Or could it be that Maggie has a functional adrenal tumor that is secreting sex hormones only, in which case a UTK full panel would be a consideration. Hypertension is a concern in cushing's but is greater concern with adrenal tumors and pheochromocytomas. Did your vet check Maggie's blood pressure? It's not easy to take a dog's blood pressure but if an adrenal tumor is suspected, you really need to address possible hypertension.

At this point in time, if Maggie were my dog, I would probably collect a urine specimen (first pee of the morning) and have the vet recheck the urine specific gravity again, as well as do a urine cortisol:creatinine ratio (UC:CR).

[kanabeans]

The way you describe Maggie's current symptoms make me wonder if what you are seeing are the overt symptoms most of us saw when our dogs were diagnosed or are you trying to make all the pieces fit with a cushing's diagnosis, also like some of us have done?

It's possible, but I really don't think this is the case for us. I have had a feeling in my gut since last July/August 2013 that something was not right. That was when she first had her accident while sleeping. It's not imagined. Whether or not she is asleep or just peeing on her side, but it's happening while laying down because she will have urine soaking her back leg that she's laying on as well as her bed or the ground.


You mentioned that Maggie's appetite increased two years ago after being on steroids. Does she whine and beg for food, forage for food, clean her bowl, other bowls and look for more? Has she gained weight? Have you noticed that her hips and spine in her hind quarters look and feel boney, like there is no muscle there? This is what you would usually see and feel in a dog who has had the disease long enough to experience significant muscle wasting. This would definitely account for hind leg weakness and trembling/tremoring. Dogs with cushing's drink and pee buckets and when it is at full tilt, accidents in the house are no longer accidents. Peeing outside is the accident.

She doesn't whine for food, she does beg and she scarfs her food quickly as soon as it's served. When she wants food she will stand at her bowl and do a quick, sharp bark to let me know she wants food, even if it's not time for her to eat. She will scavenge the kitchen floor looking for food. She's not overly obnoxious when it comes to getting food though. She wasn't always like this, she used to be dainty with her food and eating, food would actually stay in her bowl for awhile before she'd eat it. She wouldn't eat her food unless we were eating at the table. We would go on trips with her and she usually wouldn't eat for the first few days (out of nerves perhaps). When she would be home without us I'd have to buy wet food to mix with her dry so she would eat. Now it's not a big deal to her, she'll eat no matter where she is no matter the situation.

As for muscle wasting, I'm not sure. She seems like she could be a little less muscular in the back legs but I'm not certain. I just know that her back legs tremble (vet tech even saw the trembling) and she doesn't play for as long as she used to. Her hair seems fine, she has no pot belly. She has gained about 1 1/2 - 2 lbs in the past 3 years, but I'm also pretty rigid as to not giving her people food and she is only allowed her suggested food serving amounts twice a day.


Maggie is a Mini Schnauzer mix which may predispose her to idiopathic hypertriglyceridemia. It is not unusual to see elevated triglycerides and cholesterol in dogs with cushing's but those elevations are usually mild. Was Maggie fasted for at least 12 hours before these tests were done? If fasted, I don't think Maggie's elevations would be considered mild. FYI, elevated ALKP is associated with idiopathic hypertriglyceridemia.

She wasn't fasted when they did the blood work for her ALP count, CBC, urine test, etc... She was only fasted for her ultrasounds and her LDDT. I will ask the vet about idiopathic hypertriglyceridemia.


A functional adrenal tumor is not predictable as to when or what hormones/steroids it's going to secrete. It can secrete cortisol, in which case you would expect the tumor to also be over secreting one or more of the sex hormones. However, it can also secrete sex hormones only, in which case the LDDS and ACTH stim tests would be normal. Sex hormones, also known as intermediate hormones can cause the same lab and organ abnormalities as well as the same physical symptoms that are associated with excess cortisol.

All of the tests for cushing's pretty much suck but if you do enough of them, one or two of them will end up validating another one. In Maggie's case, none of them validate each other. Aside from the elevated ALKP, which could be attributed to any number of conditions, including hypertriglyceridemia, I don't see cushing's. You've had two conflicting abdominal ultrasounds so which one do you deem the most accurate? If it's the last one, you have one mildly enlarged gland and one normal size gland which is not indicative of a cortisol secreting tumor. So could it be that Maggie is in the very early stages of pituitary dependent disease and the enlarged adrenal could simply be a nonfunctional tumor, which could explain the normal LDDS? If that were to be the case, I would take wait and see approach to see if symptoms worsened or maybe even redo the LDDS in three or four months. Or could it be that Maggie has a functional adrenal tumor that is secreting sex hormones only, in which case a UTK full panel would be a consideration. Hypertension is a concern in cushing's but is greater concern with adrenal tumors and pheochromocytomas. Did your vet check Maggie's blood pressure? It's not easy to take a dog's blood pressure but if an adrenal tumor is suspected, you really need to address possible hypertension.

I think the only test so far that doesn't make sense is the LDDT. Perhaps she is in the early stage of Pit cushings. She may have had her blood pressure taken at her check up in June at the old vet, I don't know if the new vet has taken it. The old vet never said anything about her BP so I assume it means she was in normal range.


At this point in time, if Maggie were my dog, I would probably collect a urine specimen (first pee of the morning) and have the vet recheck the urine specific gravity again, as well as do a urine cortisol:creatinine ratio (UC:CR).

Thank you for your insight and help. I really appreciate you taking the time to help me think this through.

[kanabeans]

Well, the vet called back. She spoke with an IM vet and that vet thinks Maggie should have the ACTH test. She said she could do it but thinks at this point it would probably be best to go to an IM vet in case that test is negative too.

[lulusmom]

The problem with the acth stim test is that if Maggie does have an adrenal tumor, there is a much higher chance of a false negative result. The reason for this is that the acth stim test is done to test the adrenal mass. With pituitary dependent disease, the adrenal glands become squishy with fat from the continued over secretion of cortisol. It is this squishy fat that causes the adrenals to enlarge and it's this squishy fat that is adrenal mass. Dogs with adrenal mass are much more sensitive to the acth hormone and will have an exaggerated response to acth stimulation. Dogs with a cortisol secreting adrenal tumor don't have much adrenal mass because the tumor secretes cortisol independent of acth. These dogs will often have a normal response to stimulation. Dogs with adrenal tumors that are not secreting cortisol will also have normal response. It is for those reasons that I personally would recheck the USG and have a UC:CR done.

We all have our own opinions based on our own knowledge and experiences so what I personally would do may be completely opposite of what other members would do. Nobody knows Maggie better than you so our goal is to give you lots of food for thought so that you can make more informed decisions for your girl.

Glynda

[kanabeans]

The problem with the acth stim test is that if Maggie does have an adrenal tumor, there is a much higher chance of a false negative result. The reason for this is that the acth stim test is done to test the adrenal mass. With pituitary dependent disease, the adrenal glands become squishy with fat from the continued over secretion of cortisol. It is this squishy fat that causes the adrenals to enlarge and it's this squishy fat that is adrenal mass. Dogs with adrenal mass are much more sensitive to the acth hormone and will have an exaggerated response to acth stimulation. Dogs with a cortisol secreting adrenal tumor don't have much adrenal mass because the tumor secretes cortisol independent of acth. These dogs will often have a normal response to stimulation. Dogs with adrenal tumors that are not secreting cortisol will also have normal response. It is for those reasons that I personally would recheck the USG and have a UC:CR done.

We all have our own opinions based on our own knowledge and experiences so what I personally would do may be completely opposite of what other members would do. Nobody knows Maggie better than you so our goal is to give you lots of food for thought so that you can make more informed decisions for your girl.

Glynda

I truly appreciate your thoughts and advice, you guys certainly know more about this than I do, and possibly more than my vet does. I will re-read through your post after getting my kids to bed to better understand what you are saying. Thank you again!