Molly- Cushing with Calcinosis Cutis (Molly has passed)

[way2weary]

Hello to all. My story is about my Molly McGee. She is my eight year old Boston Terrier who was officially diagnosed with Cushings Disease on 3/3/15 after failing her Dexamethasone Suppression test. What brought us to the vet on 2/27/15 was what I now know is Calcinosis cutis that had ruptured. The smell was and still is horrific! These large hard leathery patched developed symetrically on both sides of her flank in less than a week's time with the largest one rupturing on day 7 or 8. Since then, there are smaller hard spots that have come up each with a mate in almost the exact same spot on the opposite side of her body. She was initially put on a 21 day regimen of Cephalexin 250 mg twice daily, but the vet added another week after seeing her yesterday for her ACTH Response Test. I know I just jumped ahead in the story, sorry about that. It is so difficult to keep my thoughts straight since this all happened so fast.

In hindsight, Molly has been showing signs for a few years. Ravenous appetite, extreme thirst, pendulous belly, etc. She was eating the others' food if I left the room and was gaining weight while Manny was losing it because he just let her eat his food. She was up to 25 or so pounds when I decided that she needed to be put on a calorie restricted diet and monitored closely so as not to bully the other 2 for their food. I added a canned filler to her food which was basically a pumpkin and veggie puree to 1/2 cup of kibble to help her feel more full. That worked wonders for her and over the course of 4 months she lost just over 6 pounds and is now a healthy 18.8 pounds. She still has/had her pot belly though, and she started to ask to be put up onto the bed which is pretty high. At first I just thought she was a little weak from the calorie restriction and maybe she was attention seeking. Over time, maybe 3 weeks to a month, she started to have difficulty jumping up onto the couch which is low to the ground in comparison. She started drinking even more water, longer and more frequent trips to the water bowl. Then within days, the hard patches began to appear. All said and done the extreme weakness, increased polydipsia, and calcinosis cutis all appeared over a 2 week period.

We visited the vet for the first time on 2/27/15. Immediately upon his exam in conjunction with our description of her other symptoms he mentioned the strong possibility of Cushing's Disease and that it was calcium deposits in her skin which is directly related to Cushings. Blood was drawn for a Senior Profile, and urine collected for a urinalysis. Here are the abnormal results that came back the following day:

Albumin-3.3 g/dL(3.4-4.2)
ALT-223 U/L(23-140)
ALK PHOS- 3212 U/L(1-142)
GGT- 253 U/L(0-8)
Glucose- 147 mg/dL(71-113)
BUN/Creat Ratio- 30.0(4.0-27.0)
NA- 144 mmol/L(145-156)
CL-100 mmol/L(107-120)
Total CO2-24 mmol/L(12-23)
Cholesterol- 465 mg/dL(138-332)
Lipase-158 U/L(17-152)

Lymph#- 0.9 K/uL(1.1-4.5)
Neut%-85.8 (42.0-84.0)
Lymph%-7.8 (14.0-45.0)
PLT- 634 K/uL(164-510)

Urine Protein- 1+
Heme- 1+
USG-1.005
BACT-1+
Cocci Observed

Poor Baby! Bad enough but a UTI to boot. Anyway we returned to the Vet on 3/4/15 for the Dexamethasone Suppression test to confirm the Diagnosis and to hopefully differentiate Pituitary vs Adrenal Cushings.

Pre- 7.5 ug/dL(1.0-6.5)
4 hr- 6.9 ug/dL(0.0-1.4)
8 hr- 6.7 ug/dL(0.0-1.4)

Bingo! Pituitary Dependent Hyperadrenocorticism.(WELL APPARENTLY NOT TRUE ACCORDING TO MOLLY'S REGULAR VET WHO SAID THAT HER RESULTS DO NOT PROVE NOR DISPROVE PDH -UPDATE 3/13/15) Thanks to reading the posts here and other information given to me from my vet, printed and websites, I decided on Lysodren and to start treatment on Saturday 3/7/15 since her chances of having anything bad happen during the first 2 days of loading seemed minimal. Armed with my script for Lysodren(250 mg twice a day with meals) and a bottle of (10) 5mg Prednisone tablets for rescue if needed, we were on our way. I began treatment Saturday morning with a cup of food, which she devourved, licking the bowl and floor afterward. While she was eating I called her name and clapped to get her attention which she ignored, completely focused on her meal. Saturday night, Sunday morning, Sunday night, and Monday morning went exactly the same. Uneventful, statis quo. I spoke with the vet early Monday afternoon, updated him and assured him that there were no signs or symptoms that were odd or unusual. We agreed to talk again in the morning.

That afternoon she began to seem a little "off" for lack of a better word, and the water bowl was not empty as usual. I was on high alert, but she seemed fine otherwise. That evening when I gave her her antibiotic wrapped in cheese she spit it out. This is a dog who never ever refused a treat. So I had to give her the antibiotic by hand this time. An hour later, at dinner she dug in with her usual enthusiasm and I thought- false alarm. However, much to my surprise when I called her name she stopped and looked up at me, again something she has never done! At the end of the meal there was food left in the bowl and she didn't clean up the floor! Is it really possible that her induction phase was complete after only 2.5 days? I skipped dosing her that night and called the vet in the morning. That was yesterday 3/10. We went to the vet yesterday afternoon for her ACTH Response Test and are currently waiting for those results which are expected back by this afternoon. I am anxious for the results to see where we are at. I know we need to keep Cortisone levels below 5 ug/dL if we are to get the CC under control and my vet is in agreement with that number. I will update as I get results. Thanks for allowing me to document our story here.

[Dixie'sMom]

Hi and Welcome to you and Molly McGee! I enjoyed reading your story, although I am sad that Molly is having problems. You could be our poster child for educating yourself properly and doing things the right way the first time. I'm so impressed!

Now let's hope that sweet Molly's ACTH goes well and she can go right into maintenance and her symptoms (especially that skin) improves. I'll be following along to see how things go and I look forward to getting to know you both. Welcome to our family!

[way2weary]

Although I did not get the numbers from Molly's ACTH Test the message left by the vet's office was that Molly's cortisol levels are not under control and to start with loading again. My question to you all is does the dose I gave her last night count as the complete 3rd day or is it Day 1 again? I am going to call this morning to get the actual results to see where we are at. I'm confused a little because A. This dog has never ever walked away from food and B. She was drinking normal amounts of water too. Anyone else have a similar experience with a false sign of completed induction? I don't want to be wrong again at $215 per test but I don't want her to go into Addisonian crisis either.

[Squirt's Mom]

Hi and welcome to you and Molly! :)

For many years we have been telling folk that Lyso lasts for 48 hours - each pill works in the body for 48 hours so to wait a day or two after stopping the load to have the ACTH done in order to get more accurate reading on what the dose had actually done. ie, the ACTH give the day of or the day after stopping may return with a higher post # than what it would have been if the test had been given the next day. Not all vet follow this time schedule tho. Since the ACTH was done soon after her last dose, you will need to keep a close eye on her just in case her cortisol continues to fall and gets too low. It sounds like you stopped in time, tho - VERY good job observing during the load! :cool::cool::cool: She may not be loaded which means you will be out an additional bill for another ACTH soon BUT that bill is nothing compared to the ones that would ensue were she to crash and need hospitalization. ;)

As for which day it is for the load, that doesn't really matter. We have seen pups load in 3 days and we have seen pups take literally months to load. Some vets will give a set number of days to load without telling the parent anything further and all too often the dog is over dosed. The correct way is just what you did - give the med twice a day and WATCH carefully for the signs that indicate the load is achieved. And you did that very well, Mom. So pat yourself on the back for that no matter what the ACTH results are - you did it right. It is always better to be over cautious with these drugs than over confident. ;)

I must say I am shocked there was no mention of investigating the liver further with those elevated enzymes. That would have been my first direction to look for causes of problems. It is expected to see high ALP and some elevation in the other liver values - but not always and NOT at those levels Molly returned. That GGT took my breath away to be honest. Our IMS explained to me that the ALP tells us how hard the liver is working and represents living cells. The other liver values however tell us more about damage and disease and represent dying cells. At the least I would have wanted an abdominal ultrasound and probably a bile acid test to make sure things there were ok and just reacting to the excess cortisol and not presenting with additional issues.

How is Molly doing today? Still eating and drinking ok? How are her stools? Let us know how things are going and what the ACTH results are when you get them. I am sure others will be along to chat with you soon, too.

Hugs,
Leslie and the gang

[way2weary]

Here are Molly's ACTH Response Test Results:

Pre-cortisol- 8.5ug/dL(1.0-6.5)
Post-Cortisol-46.2ug/dL(6.5-18.0)

Not good, I know. She failed the test miserably. Obviously, I over interpreted the signs but better safe than sorry. The thing that worries me about these results is that her pre-cortisol level after 2.5 days on Lysodren is higher than before we started treatment. Different lab, but identical reference ranges. I got some Milk Thistle today which I will start tonight to help with her liver enzyme issues hopefully.

She is doing well otherwise. Bright eyed and relatively active, ie happy to see me when I come home. Her appetite is voracious again and her trips to the water bowl are as long as ever. She has no signs of being "loaded" so far. We are currently on our 5th day of treatment having had 9 doses, the 10th will be tonight at dinner. Fingers crossed we can get through this weekend without any incidents or crisis. Heck, I'll be happy to get through this Friday the 13th. ;)

[molly muffin]

We all have our fingers crossed for a successful load. It does seem to just hit all at once. They are ravenous one day and then the next boom, they stop and look up at you or drink less water and that's it, they are loaded.

yea, weird about the pre cortisol being higher than when started lysodren.

you're doing good!

[judymaggie]

A belated welcome to you and Molly! Sorry I didn't chime in earlier -- I am also a "Lysodren Mom". :D I think you did exactly the right thing in alerting your vet to Molly's subtle changes even though the ACTH numbers did not bear out her having reached loading. It is those subtle changes that are so easy to miss.

I don't see that Molly had an ACTH prior to the one on 3/10 so we really can't compare "apples to apples" with regard to her cortisol levels. The difference in the pre-cortisol on the LDDS and the ACTH could be due to Molly's anxiety level.

I would second Leslie's suggestion to consider having an ultrasound done as well as bile acid tests. An ultrasound can give you so much information about all of her organs. It is important to make sure that the ultrasound is done by a well-trained technician and conducted with a high resolution machine. The majority of the time this means having the test and interpretation done by an internal medicine specialist.

You have a lot to deal with and are doing a great job!

[way2weary]

When I spoke with my Vet yesterday we discussed doing the abdominal ultrasound at a future date. When I got her initial Dex results I was told she had PDH, apparently the vet who was covering for mine that day was wrong. Given her numbers, I did think that there had to be greater suppression to prove PDH than Molly's numbers. I am certain he told me she was PDH. My vet said yesterday her numbers do not prove PDH but they don't rule it out either. Either way, we both agreed that the top priority right now for Molly is to get her cortisol levels under control. I brought up her GGT result again, but he seems unconcerned about it even though her numbers are about 30x normal. He still believes all her liver enzyme results are due to her cortisol levels and the fact that she is full blown Cushings. I am not so sure. Her belly is bigger than ever and she seems to have some difficulty breathing while laying down just due to the sheer size of it pushing up against her diaphragm. It was rather warm here yesterday and I have to put a shirt on her to keep the other 2 pups from constantly licking her CC lesions, I think both may have contributed to her extra panting. She is not having any difficulty now while she is sleeping in the cool of the night.

I picked up some Milk Thistle yesterday but I'm not sure how to give it to her. Not so much the dosage, but physically how to I get her to take it? I tried to give her a small bowl of water with it in there but she took one smell and walked away. I'm thinking maybe in her food would be more successful. I'd appreciate others' suggestions and descriptions of how they give it to their dogs.

Can anyone tell me how long after a dose of Lysodren is she in danger of an Addisonian type reaction. My worry is that something will happen while I'm at work and she is alone. I dose her at 8 am when I get home from work and again at 7:30 pm before I leave for work. I can keep an eye on her throughout to day and for roughly 45 minutes at night until I leave for work. I worry about her all night long, fearful that I will come home to a deceased Molly because I wasn't there to give Prednisone. Will it happen that fast or is it a gradual thing? I am heading into my 5 night on schedule starting tonight(Saturday 3/14/15) and would appreciate any information from the more experienced Cushing's moms so that hopefully I can stop worrying so much about not being here with her. Obviously, I can't be the only one with a Cush dog who has to work.

This morning's dose will be her 11th dose of 250 mg and the start of her 6th day of loading. I hope we are inching closer to the end of her induction phase and not barreling towards the cliff. Thanks for listening, and I look forward to receiving some assistance with my questions from this awesome group of people.

[Squirt's Mom]

Sweetheart, with those liver numbers I would not be treating Cushing's at all right now but rather putting my money and efforts into those liver values and having an ultrasound and bile acid test done. Here is why - my Squirt was diagnosed with PDH based on FIVE tests - LDDS, HDDS, ACTH, UTK panel, and two ultrasounds. BUT after the second US I was told about a tumor on her spleen. Once it was removed, her cortisol returned to normal and the diagnosis of PDH was null and void. And her numbers were no where near as high as Molly's are. ;)

[labblab]

Well, I am going to straddle both fences here and say that both Cushing's and possible liver/gall bladder complications may require treatment in their own right. If Molly's horrible skin issues are indeed calcinosis cutis, then I don't think you want to abandon the Cushing's treatment. But I have to agree that those GGT numbers are much higher than what we typically see with Cushing's alone. I really do think that an abdominal ultrasound could be very important as far as identifying additional issues that may be contributing to the overall problem.

Just as an example, Cushpups may have increased vulnerability to gallbladder mucoceles which can raise levels of all the liver-related blood markers.

http://veterinarycalendar.dvm360.com/managing-gallbladder-mucoceles-proceedings?rel=canonical

As for your worry about leaving Molly alone overnight, I surely do understand that. But if she is perfectly fine when you leave, I would not expect her to become life-threateningly ill during the time period you are away. If her cortisol drops too low, she may certainly feel yuckky and even throw up or have diarrhea. But you would certainly be aware of that just as soon as you are home again, and then you can take appropriate steps.

Just as a general caution to all our readers, if you think your dog is crashing and you can take him/her in to the vet or emergency service directly, it is better not to give prednisone beforehand. Prednisone will skew any test of cortisol for at least 24 hours, so that eliminates the vet's ability to check the cortisol level right at a time when you urgently want to know what it is. Of course, if you cannot take the dog in to be seen right away, then for safety's sake, you will want to go ahead and give the prednisone at home. But don't just give it as a knee-jerk response, I guess is what I am trying to say.

Marianne

[Renee]

I think the ultrasound would be invaluable at this point.

If she has something else going on that is raising the cortisol, then the CC could be caused by that, and not traditional cushings at all. We assume that CC is from cushings, but cushings is in essence excess cortisol. If something else is elevating cortisol, even if it's not cushings, then it makes sense that CC could come up.

[way2weary]

My Molly passed away Sunday afternoon 07/10/16. She had been very well controlled on Lysodren and in fact we had just had her ACTH Stimulation done on that Friday afternoon because it seemed she was just a little "off". But we had just moved to a new home and my boyfriend left us, so I thought maybe the stress was too much for her and was throwing her more into Addison's. Her numbers were great, so I was relieved. She wasn't eating as well as usual, but was still playing ball, loving her daily walk and car ride. She was happy all the way up to her last minutes as best I can tell. Her breathing had become shallow and rapid. Open mouth breathing but not panting but she shared a little baked chicken with me before I needed to head off to bed. I work overnights so we sleep together during the day. I took a brief video of her breathing and texted her Vet who advised me to give he 5mg Prednisone since he still felt like she was acting Addison's in spite of her numbers. He told me to keep an eye on her and take her to the ER if her breathing worsened. She was cuddled up next to me when I fell asleep. I awoke 2 hours later to find her on the bathroom floor. She had gotten up and off the bed, lost control of her bowels at the foot of the bed and walked into the bathroom and died there. My belief is that she had a Pulmonary Embolus secondary to her Cushings. She made it just under 1.5 years after diagnosis and was happy the entire time. I would do it all again if I had to. I miss her terribly but she was a beautiful soul.

[Budsters Mom]

I am so very sorry for your loss.:o Thank you for returning to let us know.

Fly free Molly, Fly free!!

[DoxieMama]

I am so sorry for your loss. RIP sweet girl.

[Squirt's Mom]

Oh I am so sorry to hear about your precious Molly McGee. :( I know your heart is still hurting so very much and I am glad you came to tell us what happened in spite of that pain. You worked so hard to make her life wonderful and I know she is forever grateful for all you did on her behalf.

Please know we are here any time you wish to talk and would be honored to help celebrate Molly's life with you via your memories. You can also start a tribute or memorial thread to your precious girl in the In Loving Memory section anytime you are ready if you wish. Regardless, we are here with you should you need a soft place to fall.

Our deepest sympathies,
Leslie, Trinket, Sophie, Fox, and all our angels



FRIEND
I lost a treasured friend today
The little dog who used to lay
Her gentle head upon my knee
And shared her silent thoughts with me.

She’ll come no longer to my call
Retrieve no more her favourite ball
A voice far greater than my own
Has called her to his golden throne.

Although my eyes are filled with tears
I am thankful for the happy years
She spent down here with me
And for her love and loyalty.

When it is time for me to go
And join her there, this much I know
I shall not fear the transient dark
For she will greet me with a bark.

~Author Unknown

[Joan2517]

I am so, so sorry...that sounds like how my Lena died, except she was at the emergency clinic when she passed. You were blessed to have that year and a half with her. Molly knew how much you loved her and she loved you...and there is no greater love than that of our babies.

[spdd]

I am so sorry to read this. My sincerest condolences.

[Renee]

I am so sorry for your loss. Sail on fast and free beautiful Molly.

[judymaggie]

My heart goes out to you on the loss of your dear Molly -- try to get some peace of mind knowing that she is no longer in pain.

[CalliesMom]

I am so sorry for your loss of Molly. :(

[molly muffin]

My day sincerest condolences.
What a treasure they are but never long enough with us

[Joan2517]

Oh I am so sorry to hear about your precious Molly McGee. :( I know your heart is still hurting so very much and I am glad you came to tell us what happened in spite of that pain. You worked so hard to make her life wonderful and I know she is forever grateful for all you did on her behalf.

Please know we are here any time you wish to talk and would be honored to help celebrate Molly's life with you via your memories. You can also start a tribute or memorial thread to your precious girl in the In Loving Memory section anytime you are ready if you wish. Regardless, we are here with you should you need a soft place to fall.

Our deepest sympathies,
Leslie, Trinket, Sophie, Fox, and all our angels



FRIEND
I lost a treasured friend today
The little dog who used to lay
Her gentle head upon my knee
And shared her silent thoughts with me.

She’ll come no longer to my call
Retrieve no more her favourite ball
A voice far greater than my own
Has called her to his golden throne.

Although my eyes are filled with tears
I am thankful for the happy years
She spent down here with me
And for her love and loyalty.

When it is time for me to go
And join her there, this much I know
I shall not fear the transient dark
For she will greet me with a bark.

~Author Unknown



What a beautiful poem~

[Aunt Jana]

I'm so sorry you lost your girl. My condolences.

[Allison]

I'm sorry for your loss of Molly. You gave her a wonderful life, even extending it pass her diagnosis. Take care and we'll be thinking of you in the days ahead. Hugs.