Pierre, 8 y/o Yorkie, awaiting diagnosis

[weezandrico]

Hello, all!

First of all, I am new to the forum, so my apologies if I commit any forum faux-pas (such as starting this thread)!

My husband Adam and I are the parents of Pierre, an 8.5 year old, 17 pound Yorkie. We are awaiting the results of his LDDS test tomorrow to hopefully confirm whether his Cushing's is adrenal or pituitary. We are also parents to a 2 year old Yorkie mix named Gomez, who is healthy as a horse and ADORES his brother.

Pierre has already undergone his physical exam, urine analysis and culture, X-rays, and CBC. Below are his results (as we are aware of at the moment):

Urinalysis: No diabetes, no blood or crystals, extremely dilute.

CBC: Liver levels off the charts (900 something, I think he said?) and high triglycerides, otherwise, levels are normal.

Physical exam/X-Rays: Enlarged liver and heart.

What tipped us off was that Pierre began to ask to go outside in the middle of the night about a month and a half ago, and had an accident in his crate one day (I'm usually not a fan of crate training animals, but he has been somewhat neurotic since birth, and prefers the safety of his "house" when we are gone) after only 3 hours. He has had several allergy issues since age 2 (wheat, corn, soy, flea saliva, grass, pine, human dander...the list goes on!) and we took him to see the doctor for a pre-emptive allergy shot, as we were getting ready for a short trip, and my mother (who watches him and Gomez) is not the best at keeping things out of his reach. He was also prescribed 10 days worth of Prednisone as a booster, as he had been many times in the past.

The next morning, we woke up to discover he had urinated in our bed overnight-totally in his sleep, which is something he had never done before (even while on steroids). We rushed him back in to the doctor, who suggested a CBC and detailed urinalysis upon completion of the Prednisone to rule out Cushing's. We waited until he finished his rounds and lo and behold, both of those tests plus his X-rays just short of confirmed what we already thought.

Aside from his EXTREME food addiction (which has been an issue for years, as he lived with 3 other dogs at one point) and his extreme thirst (also an issue from almost day one-it's almost as if he forgets to drink water all day and then gulps it down) and the frequent urination, there have been no other symptoms! No hair loss, lethargy, or decreased activity. He did have one seizure in the car on the way home from his second vet appointment in two days-the first I have ever seen him have-but I would be willing to bet that it was stress induced.

I'm hoping that someone can confirm that we caught it early enough for a good prognosis while we wait for our LDDS results. I am concerned, however, as the doctor we have been seeing at our large practice is just a general practitioner, and not an internist. When I asked if the LDDS test would zero in on the type of Cushing's (I've read that it generally does-hopefully I'm not wrong), he told me that if he has it, whether it is AD or PD is "irrelevant as far as treatment is concerned." For the most part, this is 100% contradictory to what I've learned so far. Should I be as worried as I am? Money is no object for us as far as testing, diagnosis, and treatment go-I don't have much, but I will sell my car if I have to. I just want to do what's best for Pierre-and Gomez NEEDS his big brother to be around for as long as he can. Any help/advice is greatly appreciated. I can already tell that this site and forum have been nothing short of lifesavers for many people and their babies. Thank you again!

Jill

[addy]

Hi and Welcome,

Sorry I only have a moment and with the holiday weekend here in the States, quite a few members are out and about. I am sure more will be along to welcome you. Regarding some quick thoughts:

Perhaps your vet thinks it does not matter pituitary verses adrenal as he feels the treatment is the same because you would not consider adrenal surgery. Otherwise I'm not sure why he made the statement he did. You need to make sure if possible to work with a vet with experience treating many dogs, not just a few.

What exactly did the xray's confirm, the enlarged heart? Alkp in the 900's is not off the charts, we see pups in the 2000's.If you could possible round up all your tests and post the abnormal readings along with the lab's normal range, that would would be a good start.

What did the vet say about the enlarged heart? Any more info you can provide about that also would be good.

Also, what was the allergy shot? Steriods can do funny things. Just because Pierre never had a problem with them before does not exactly rule out steroids were not causing a problem now. I assume the urine culture showed nothing either, right?

We want Pierre to be around for a long time too, so if you can give us more specifics that would be great. Cushings is so hard to diagnose. We always just want to see if we can get the whole picture.;)

Sorry this is so short. Hang in there!!!!:):):):):):):):):)

[StarDeb55]

Jill, welcome to you & Pierre! The one thing in your introductory post that caught my eye was the use of prednisone for Pierre's allergies. Was Pierre on any pred or any allergy medication that might contain pred when his Low Dose Dex test was done? If he was, that test is totally invalid. A lot of allergy meds do contain pred as a component with one of the main ones being Temaril-P. Long term use of pred can cause a type of Cushing's called iatrogenic. The solution for this is to wean the pup off of pred.

Debbie

[weezandrico]

Addy (and Zoe and Koko),

Thank you so much for your reply!

Adam just dropped Pierre off a few minutes ago for his LDDS test-we asked for copies of his bloodwork and urinalysis, and they will hopefully be ready for us when we go to pick him up this afternoon/evening.

As far as his little (or big!) heart goes, the vet said it could be early congestive heart failure, which I guess sometimes is a package deal with Cushing's-but never having had an x-ray on it before, he also said it could have been enlarged for quite some time and never caused problem. So, we'll hope that's the case!

And the allergy shot I'm pretty sure was either Prednisone or Temaril-P...we go to a large practice because it's 24 hours with a great team of doctors, but they are pretty quick to prescribe steroids for basically any issue :(

I'll update later today after the LDDS and hopefully with some more specifics. Thank you for taking time to reply :)

[weezandrico]

Hi Debbie!

Thank you so much for your reply as well. As far as his LDDS test goes, he's taking it today, and he took his last pill (I can't remember now if it was Prednisone or Temaril) on July 1st-so we should be in the clear. His bloodwork was done on July 2nd, but our vet assured us that there wouldn't be enough left in his system to skew any results-we'll see about that, I guess!

[lulusmom]

Hi and welcome to you and Pierre.

Prednisone can cause symptoms that are commonly associated with cushing's so I would appreciate if you could clarify some timelines for us. What date was Pierre given the steroid injection and what date did you start giving him the Prednisone pills? I suspect your vet injected Pierre with Depo Medrol which is a long acting steroid, lasting anywhere from 8 to 12 weeks. If you added Prednisone on top of that before 8 weeks, Pierre was floating in steroids. At what point after you started the injection and pills did Pierre start peeing in the bed and asking to go out in the middle of the night? Dog with cushing's, who have lost the ability to concentrate their urine, are unable to go all day without drinking so Pierre's drinking behavior before the steroids does not sound like a dog with naturally occurring cushing's. My first cushdog, Lulu, always had a robust appetite but that appetite went from robust to insane. She was constantly begging for food, foraging everywhere for any crumb and stealing the other dogs' food. That doesn't sound like what you are seeing in Pierre but even so, Prednisone can also cause a huge increase in appetite.

The fact that your vet ran labs only one day after discontinuing prednisone, tells me that s/he has little experience with cushing's. Prednisone causes iatrogenic cushing's and symptoms resolve once treatment has been discontinued. I am at a loss to understand why your vet would do any testing for pituitary or adrenal cushing's when the more obvious problem is iatrogenic cushing's caused by prednisone. Labs done one day after steroids are not going to be normal and you are definitely going to see elevated ALKP and probably a few other abnormalities. If having accidents in the bed and elevated ALKP were what drove your vet to start testing for cushing's, I have even greater concerns with your vet's experience.

I'll be looking forward to hearing much more about your precious Pierre.

Glynda

[weezandrico]

Glynda,

That's exactly everything I'm worried about! He was given the injection on Monday, June 16th.

The peeing indoors/overnight started quite some time before the injection or the daily medication (probably mid to late April)-which is what worried us in the first place! His eating, drinking, and peeing (inside and outside) was DEFINITELY exacerbated when he was on the steroids-by the time he was at every other day on his pills, you could tell within the hour when he had taken one by his behavior (begging for food, scratching at the door where we keep it, gulping down water). That definitely makes me think his natural levels are already elevated to begin with-but maybe those "natural" levels are residual effects from the injection.

We will see what his LDDS test says, I suppose, since he's been off of the pill steroid since June 30th (I was a day off in my earlier post). But if the shot has lingered like you're saying, which I would not be surprised about, I wonder how that will affect things...

I am pretty upset with our current vet, because we were concerned about all these things-especially a false positive after having been doped up for so long, and he was EXPLICITLY clear that it didn't matter, and that we had a long enough buffer period. That should have been my first red flag, instead of him telling us that it "didn't matter" whether the Cushing's was AD or PD (or iatrogenic). It's a lot to put a dog through unnecessarily, and a lot to put our wallets through unnecessarily as well! We'll definitely be taking Pierre to a specialist, pending the LDDS results today or tomorrow. I'm going to try to find out exactly what they used on 6.16 so I can do some research on that as well.

Thank you so much for your help!

[lulusmom]

I forgot to mention that if a dog is suspected of having iatrogenic cushing's, the LDDS test is not the test of choice as a false positive result is highly likely. In other words, your vet could be wasting more of your money on an inappropriate test. You may want to print out a copy of Dr. Mark Peterson's blog entitled "Prednisone and Cushing's Syndrome: Which Screening Test Is Best?" and share it with your vet. Dr. Peterson is a world renown endocrine specialist who helps educate veterinarians both on his blogs and through the many lectures he gives at veterinary conferences worldwide. I have provided a relevant excerpt from the blog as well as a link below:


Another important point: in this scenario, you want to use and ACTH stimulation test, not the low-dose suppression test. If another long discussion for me to explain the reason why that's the case, but you can get false-positive results in dogs with iatrogenic Cushing's disease so you do NOT want to use a low-dose dexamethasone suppression test in this dog, at least as your initial test.


http://endocrinevet.blogspot.com/2011/04/q-prednisone-and-cushings-syndrome.html

[weezandrico]

Wonderful -__-. That's exactly what I was afraid of :(

I'm going to print this out and take it in with me when we go to pick him up. Thank you so so so much for the link! I'll let you know how everything turns out. I honestly want to ask for another blood test and LDDS or ACTH to be performed at their expense once we resolve what exactly his injection was.

You have been a huge help, Glynda!

[molly muffin]

I just want to pop in and welcome you to the forum. Glynda, Deb, Addy, have all got you off to a good start with information and you can't ask for a more knowledgeable, been there, done that group, they've seen it all or if not all, then most of it. :)

It sounds like Pierre has been on and off steroids for a very long time due to his allergies. Poor boy. It's possible that the pred has contributing to the over all long term signs, drinking, eating, urinating like crazy.

Looking forward to seeing what sort of labs you have and could you post anything that is abnormal, out of range, along with the range, when you get results. That could be quite helpful.

Welcome again
Sharlene and molly muffin

[weezandrico]

Good evening, all!

I just want to thank everyone again for their replies, and the wealth of knowledge you've all shared!

We just picked Pierre up from his LDDS test, and aside from being a little p/oed at us for leaving him at the vet today, he seems to be doing fine :)

I was able to obtain a copy of his bloodwork/urinalysis. All levels except the ones below were normal:

SUPERCHEM:

Total Protein:
Normal: 5.0-7.4 g/dL
Pierre: 7.8 g/dL

Alkaline Phosphatase:
Normal: 5-131 ui/L
Pierre: 949 ui/L

Total Bilirubin:
Normal: .1-.3 mg/dL
Pierre: .6 mg/dL

Phosphorus:
Normal: 2.5-6 mg/dL
Pierre: 7.4 mg/dL

Calcium:
Normal: 8.9-11.4 mg/dL
Pierre: 5.9 mg/dL

Triglycerides:
Normal: 29-291 mg/dL
Pierre: 400 mg/dL

Lipase:
Normal: 77-695 ui/L
Pierre: 795 ui/L

CBC:

MCV:
Normal: 58-79 FL
Pierre: 84 FL

Differential:
Results: "Absolute ^"

URINALYSIS:

Specific Gravity:
Normal: 1.015-1.050
Pierre: 1.008

pH
Normal: 5.5-7.0
Pierre: 7.5

Phew! Hopefully, that all formats correctly. From what it looks like to me, nothing is "off the charts" per se, except for maybe his ALKP levels. And his WBC count is totally normal, which I assume is good? His red blood cells were on the lower end of the spectrum, but still normal.

Thank you again in advance for keeping up with us :)

[weezandrico]

Not sure if anyone is even still reading, but I should probably add that after his LDDS yesterday, Pierre was going to the bathroom twice as often as before...he woke me up 3 times last night, which was a record. Does anyone know if the Dexamethasone they use in the injection has physical steroid effects, or does it just mimic cortisol in the bloodstream?

[molly muffin]

just a quick note, we are still reading and i'll look at these values tonight hopefully and get back to you, but yes, after an LDDS or especially an ACTH, they can react like they've had a cortisol dump into their bodies. It usually only last around 48 hours or so and some dogs don't show any effects.
It is normal though, so don't worry.

Sharlene and molly muffin

[Harley PoMMom]

Could you do me a favor and check on Pierre's previous Superchem blood panels to see if the levels in the Total Bilirubin, and phosphorus have been trending up, and if the calcium has been trending downward, also, what has the levels in creatinine been doing?...Thanks!

Hugs, Lori

[weezandrico]

Hi Sharlene and Lori!

Sorry it's been so long-we've been waiting for his LDDS test results for FOUR days now. We finally got them, and he "passed." I haven't seen the actual paperwork yet as I just got the call, but our vet said that while his initial cortisol was high (abnormally high, but not extremely high), he did suppress at a "very good" rate at 4, 6, and 8 hours. While I'm relieved that he is suppressing, I'm also obviously afraid of a potentially false negative, and the possibility of several OTHER reasons for his symptoms and abnormal blood work.

Of course, the vet is telling us that his bloodwork and symptoms basically "confirm" Cushing's-but if that's the case, why did he suppress at all? He now wants us to do an ultrasound and possibly MRI. Aside from the fact that I don't want to spend thousands more dollars, I really don't want to put Pierre through anything unnecessarily. Aside from his appetite for food and water and diluted/frequent urine, he really does seem to be doing just fine.

We unfortunately don't have any blood work handy to compare, as he is only 8 and just started his routine panels this year. He did have ACL/luxating patella surgery in 2012, so I'm going to call his surgeon today and see if I can obtain a copy of his pre-op bloodwork to review.

Thank you for all of your help thus far :)

Jill and Pierre

[Harley PoMMom]

Once you get a copy of those LDDS test results please do post them here. The chances of a false negative with the LDDS test is low. Dr Peterson has stated this on his blog:
Compared with the ACTH stimulation test, the LDDST is much more sensitive in confirming Cushing's syndrome in dogs. The sensitivity of the LDDST is excellent, approximately 90% to 95% in dogs with pituitary-dependent hyperadrenocorticism (PDH) and virtually 100% in dogs with a cortisol-secreting adrenal tumor (1-3).

Thus, this test will fail to confirm hyperadrenocorticism in only about 5% of dogs with the disease. That's not too bad.

Here's a link to the whole article: Helpful Tips to Improve the Accuracy of the Low Dose Dexamethasone Suppression Test (http://endocrinevet.blogspot.com/2012/05/helpful-tips-to-improve-accuracy-of-low.html)

Ultrasounds are expensive but they also can be a useful diagnostic tool. An ultrasound can provide so much info and an "inside look" at all the internal organs, but, not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting it. It may reveal abnormalities that could account for Pierre's symptoms, however, there is always the chance that nothing remarkable will be viewed.

Sorry, I've probably been no help at all, but hopefully when the LDDS test and pre-op blood-work results are known we can figure out what's going on and provide more meaningful feedback.

Hugs, Lori

[molly muffin]

I agree with Lori, would really like to see those numbers to see what they show.

I too have a dog with no symptoms, but blood work looks like cushings and she suppresses on the LDDS. It kind of makes you go nuts trying to figure things out when then you get those kind of results.


Sharlene and molly muffin