Macy My Mini Schnauzer

[als20781]

Hello. My name is Amanda and I am a pet parent to a 16 pound, 10 year old Miniature Schnauzer. I am looking for advice on what to do about my dog being diagnosed with Cushing’s disease and is now taking Vetoryl. I went out of the country for a month between Oct/Nov of 2014 which my dog stayed with my parents and her dad (my ex-husband). When I returned I was told that for the past week she had been vomiting once a day. I took her to the vet on 11/24/14 and after blood work and several tests; she was diagnosed with Cushing’s disease. I was also told that she had bladder stones that needed to be surgically removed. At this point I am considering a second opinion because she doesn’t have any of the signs associated with Cushing’s and she is not having problems with urination and they are insistent on the surgery. Against my gut feeling, I started her on Vetoryl 10mg twice a day on 12/03/14. By the first of February 2015 Macy was experiencing the following: decreased appetite, lethargy, weakness, shaking and diarrhea. I spoke with the vet and they told me to stop giving her the Vetoryl . She was seen on 2/9/15 and after several test and blood work, they were not able to find out what was causing her symptoms. They put her on an antibiotic (Clavamox) and said to start the Vetoryl again after 3 days. She finished her antibiotic and she has perked up some, still not all that keen on eating though. She went in yesterday 3/12/15 for a re-check of her Cushing’s disease and bloodwork. I was told that her Cushing’s was under control but that her liver enzymes were elevated 3 times what they were on 2/9/15. They asked that I bring her in today 3/13/15 for an ultrasound on her abdomen. I just feel like she is having all these issue as a result of the Vetoryl. Can anyone please advise? I can send you test results; I just need to know what to look for on the paper work. Thank you in advance from a very worried pet parent!

Amanda

[labblab]

Welcome Amanda!

YIKES, YIKES, and TRIPLE YIKES!!! I have only a moment to post right now, but there are so many worrisome aspects to Macy's diagnosis and treatment that I want to at least get a quick note written. First, vomiting is not a symptom that is at all typical of Cushng's, so if that was the only abnormality at the time of diagnosis it does not even fit the profile of the disease. Secondly, the diagnostic blood tests can be skewed in the presence of other concurrent illnesses. So, for instance, whatever was making Macy ill enough to vomit daily might have falsely affected the Cushing's test so that it came back "positive" even if Macy did not have Cushing's at all. Thirdly, even assuming that Macy does have Cushing's, there should have been interim monitoring ACTH tests performed long before February in order to determine whether or not her cortisol was being maintained within a safe and proper level by the Vetoryl.

All in all, if she were mine, I would not restart the Vetoryl again until all these diagnostics are better sorted out. When you return to the vet today, please ask for printed copies of all her previous test and laboratory reports. Once you have those in hand, we can talk with your further about the specific things to take a look at.

Thanks in advance for this additional info!
Marianne

[Harley PoMMom]

Hi Amanda,

Welcome to you and your girl! Vomiting is not a symptom of Cushing's, what other symptoms did your girl display that led the vet to test for Cushing's? Also, if you would get copies of all tests that were performed on your girl and post those values that are abnormal that would be great...e.g...ALT 150 U/L (5-50)...thanks! We are especially interested in the results of all tests that were done to diagnose and monitor the Cushing's.

My boy, Bear, had 2 surgeries for oxalate stones and they can become painful. How were her bladder stones diagnosed? Were the Cushing's test/s performed when she was having symptoms of those bladder stones?

Decreased appetite, lethargy, weakness, shaking and diarrhea are symptoms that cortisol has dropped too low, so I am glad that the Vetoryl was stopped. I'm assuming that an ACTH stimulation test was performed, and if so, could you post those results for us? Were her electrolytes checked too?

I am sorry for all these questions but the more information we know about you girl the better our feedback can be, ok?
Please know we will help in any way we can so do not hesitate to ask all the questions you want. ;)

Hugs, Lori

[als20781]

Hello to you both Marianne and Lori and thank you so much for getting back to me so quickly. I had hoped to respond sooner with the info requested, however I don’t have it all yet. I had requested yesterday, Macy’s chart info from November when she was first diagnosed with Cushing’s, but all they gave me where just a summary of what had happened. I have emailed the vet and requested that they send me her CBC/Chemistry panel. I hope that is correct in what I need. Until I receive it I am just going to post a quick summary of what they gave me.

History: Macy presented to internal medicine service on 11/19/14 for evaluation on chronic intermittent vomiting that began on 11/3/14. Macy vomits once per day approximately 5 days a week. When she vomits, it is always partially digested food. Macy vomits early afternoon most days. Other than vomiting, Macy has been bright and has maintained a good appetite and has normal bowel movements. (Note: Macy stopped vomiting 3 days before seeing the vet; we kept the appointment to be on the safe side.)
Physical Examination: Macy’s temp, heart rate and respiratory rate were normal. She weighs 16.5 lbs. and is in a generous body condition score (8/9). Temperature 100.6F, Pulse 96 bpm, Respiration 24 bpm. Mucous membranes: Pigmented, CRT: <2 seconds.
Complete Blood Count: Macy has increased total plasma proteins (namely fibrinogen) that suggest an acute inflammatory process. High fibrinogen can also be seen with Cushing’s disease. She also has a high eosinophil count, which can be seen with allergic &/or parasitic infections.
Blood Chemistry Profile: Macy has an elevation in liver enzyme. Macy also has a high globulin level, which indicates acute inflammation. A bile sample was collected for cytology and culture. There are no cytologic abnormalities. Macy’s Bile results reveal no bacterial growth. An ACTH stimulation test was performed to investigate whether or not Macy has Cushing’s disease. Her response is consistent with Cushing’s disease.
Urinalysis: Macy has marginally concentrated urine (USG: 1.020). There is also protein (3+) which is likely related to Macy’s bladder stones that were found today.
Urine Culture: Macy has evidence of inflammation and bladder stones. Preliminary results reveal no bacterial growth.
Abdominal Radiographs: Large, hyperechoic lever (no nodules), large spleen, gallbladder walls appear normal thickness, normal pancreas ( no evidence of current pancreatitis), adrenal glands normal size, changes in the appearance ( strations) of the stomach and intestinal wall, normal thickness, multiple stones in bladder, mineralization in the kidneys.
At this time, the primary cause for Macy’s vomiting is still unknown. There is evidence of an acute inflammatory process occurring at the moment. Possibilities include inflammatory bowel disease, ulcers, a chronic low grade pancreatitis, intestinal parasites, &/or pain (potentially from the bladder stones).
That basically sums up everything that happened on the day she was diagnosed with Cushing’s. As soon as I receive the CBC/Chemistry, I will post the numbers. Thank you again for all your help.

Amanda

[Squirt's Mom]

If you have not stopped the Vetoryl, please do so til things can be sorted out a bit more. ;)

[als20781]

Sorry for the delay. I have had a hard time getting the results from the vet. Here is Macy's CBC from 11/19/14 when she was diagnosed with Cushing's.
11/19/14
WBC 8.5
RBC 6.01
HGB 15.2
HCT 44.3
MCV 73.7
MCH 25.3
MCHC 34.3 L
RDW 12.3
TPP 8.5 H
SEGS% 56
LYMPH% 16
MONOS % 7
EOS% 16H
BASOS % 5H
ABS SEG 4.76
ABS LYM 1.36
ABS MON .6
ABS EOS 1.36H
ABS BAS .43H
PLT EST ADEQ.
PLT CNT 328
MPV 16.10H

Please let me know if you need anything else and I will look on the report for it. Thank you so much.

[Squirt's Mom]

If you would, please edit your post to include the normal ranges for each value listed. We really only need to see those that are too high or too low so that may save you a bit of typing. ;)

[als20781]

Sorry about that. I have re-typed it with the ranges and only what is low or high. I have also included another set of values that I missed in the last post.

11/19/14
CBC

MCHC 34.3 L (34.5-36.3)
TPP 8.5 H (5.7-7.9)
EOS% 16H (0-7)
BASOS % 5H (0-1.3)
ABS EOS 1.36H (0-.85)
ABS BAS .43H (0-.2)
MPV 16.10H (7.8-12.4)

11/19/14
Plasma

ALBUM 3.0L (3.2-4.1)
GLOB 3.6H (2-3.2)
ALK PHO 282 H (15-164)
CHLOR 103L (109-117)
AN GAP 24.0H (13-22)
BLOOD, ANY SPECI CORTSOL: 7.2 NG/ML
BLOOD, ANY SPECI CORT PA: 324.6 NG/ML

Thank you.

[Barb]

What food is Macy eating and was there a change in food when you were away?

[Harley PoMMom]

BLOOD, ANY SPECI CORTSOL: 7.2 NG/ML
BLOOD, ANY SPECI CORT PA: 324.6 NG/ML

Thank you.

Can you double check those numbers (especially the 7.2), it looks like those results are from an ACTH stimulation test, is there a reference to an ACTH stimulation test on Macy's paper work?

I see also noted is that chronic pancreatitis may be the culprit for her vomiting, has the IMS mentioned having a Spec cPL test performed to see if she does indeed have pancreatitis?

[als20781]

Macy's food changed right before I left. She had been on Hills Science Diet R/D since October 2011. In September 2014 she was changed to Hills Science Diet W/D, but there was a couple of weeks there where they tried four different kinds to see which one she liked. The W/D was one of them, another was Royal Satiety I will have to find out what the other two were.

That was an typo error on the Cortisol. It is 72.1 ng/ml. I will also have to ask about the pancreatitis. On the discharge papers they gave me that day it states: No evidence of current pancreatitis. However on here CBC from the same day it states: Chronic Mild Pancreatitis.

Thank you.

[als20781]

I also can't find any reference to the ACTH stem test. Is there a way that I can attach Macy's CBC report?

I also should mention that in October of 2011 Macy was diagnosed with Evans Syndrome. She has been in remission since 2012 and as far as I know, she has not any more issues with that.

[Harley PoMMom]

I'm pretty sure those results are from an ACTH stimulation test, but just to make absolutely sure I suggest calling her IMS and asking her that question.

I never heard of Evans Syndrome, had to look that up and found:
Evans Syndrome refers to a condition in which the following two conditions exist at the same time – Immune mediated thrombocytopenia (ITP) and Immune mediated hemolytic anemia (IMHA). Both of these are complex diseases that result in destruction of the platelets (thrombocytopenia) and red blood cells (anemia). http://www.petplace.com/article/dogs/dr-debras-faqs-and-posts/ask-dr-debra-common-questions/what-is-evans-syndrome-in-dogs-- Is that description correct?

Cushing's disease can cause just the opposite, it increases the number of red blood cells and/or increases platelets.

[labblab]

I also feel confident those are the results of a diagnostic ACTH, and if so, this is how the results would convert to units of ug/dL (with which many of us are more familiar):

Pre-ACTH cortisol level: 7.2
Post-ACTH cortisol level: 32.5

So it is true that this result would be consistent with Cushing's. But in the face of no corresponding external symptoms (vomiting is definitely not typical), Macy's history of Evan's Syndrome, and the likely presence of an active, unidentified inflammatory process, I am very puzzled that the specialist would leap to a Cushing's diagnosis (and treatment) so quickly. It is a given that the ACTH can be skewed by the presence of other illnesses, returning a "false positive" even when a dog does not have the disease. So with so many other question marks about Macy's situation, my personal opinion is that they were very hasty in putting her on the Vetoryl. And if she appears healthier off the drug than while taking it, that doubles my suspicions that her issues may not be Cushing-related at all.

The rapidly escalating liver values even while taking Vetoryl would worry me that there is a different inflammatory/illness process going on that is significantly affecting her liver. If she were my dog, I do believe I would seek a second opinion to try to get to the bottom of things, and I would not resume the Vetoryl in the meantime.

Can you please try to get us the results of the recent ACTH monitoring test and also these recent abnormal lab values? Is she still off the Vetoryl, and how is she behaving now?

Marianne

[als20781]

That is correct on the Evans Syndrome. I didn’t realize that Cushing’s caused the oppistite. I wish the vet had told me that, it would have made me even more nervous about starting the Vetoryl. She almost died from Evan’s in 2011. The night that she was admitted they had to do an emergency blood transfusion and she was in ICU for a week. After she was well enough to come home, she was still on the medicine for a year because her blood platelets keep attacking and destroying themselves. I don’t want her to take anything that could flare that back up again.

I have posted the most recent ACTH monitoring and labs from 3/12/15. Before, it said BLOOD-ng/ml. The most recent says SERUM-ug/dl, as you mentioned.

Thank you for your opinion on getting a second opinion. I have felt since November that I should and the only reason that I didn’t is that they did an amazing job when she was diagnosed with Evans…but now I don’t feel that way. She use to have the same Dr. all the time and he left the practice last year and since then I never have the same person overseeing Macy and it makes me very nervous. I feel like they don’t listen to what I tell them about her and if they do, they either don’t relay it to the next person or misconstrue it.

Macy is still on the Vetoryl. She seems okay with the exception that when she became lethargic in 02/2015 she stopped eating dry food. She will eat just fine but still refuses to eat dry. I have to mix it with wet or chicken broth now. Other than that she seems fine. She was on the Vetoryl a little over two months when she became lethargic , not interested, etc. and I keep waiting for that to happen again as she continues the medicine. However, she also seemed fine other than the vomiting when she was diagnosed with Cushing’s. Had it not been for me taking her in for the vomiting I would have never thought anything else could be wrong.

03/12/2015
CBC

MCHC 33.1 L (34.5-36.3)
TPP Comment (5.7-7.9)
EOS% 9.50H (0-7)
BASOS % 0.800 (0-1.3)
ABS EOS 1.00H (0-.85)
ABS BAS 0.08 (0-.2)
MPV 14.00H (7.8-12.4)
PLT EST INC
PLT CNT 443H (147-423)


03/12/2015
Plasma
BUN 33H (8-32)
ALBUM 3.1L (3.2-4.1)
GLOB 3.5H (2-3.2)
ALK PHO 1396 H (15-164)
CHLOR 102L (109-117)
AN GAP 28.0H (13-22)
TBILI 0.0L (.2-.5)
SERUM, ANY SPECI CORTSOL: 4.8 UG/DL
SERUM, ANY SPECI CORT PA: 6.0L UG/DL

Please let me know if you need anymore info. Thank you!

[als20781]

Hello. Can you tell me how Macy's most recent blood work compared to her initial blood work back in November when she was diagnosed?

Thank you! :)

[labblab]

I am so sorry that your last reply was overlooked with no responses! I am literally headed out the door, so it will be later today before I will be back home and able to add some thoughts. But I just wanted to let you know that you have not been forgotten!

Marianne

[Squirt's Mom]

To get the two testing times together for comparison -

November -


11/19/14
CBC

MCHC 34.3 L (34.5-36.3)
TPP 8.5 H (5.7-7.9)
EOS% 16H (0-7)
BASOS % 5H (0-1.3)
ABS EOS 1.36H (0-.85)
ABS BAS .43H (0-.2)
MPV 16.10H (7.8-12.4)

11/19/14
Plasma

ALBUM 3.0L (3.2-4.1)
GLOB 3.6H (2-3.2)
ALK PHO 282 H (15-164)
CHLOR 103L (109-117)
AN GAP 24.0H (13-22)
BLOOD, ANY SPECI CORTSOL: 7.2 NG/ML
BLOOD, ANY SPECI CORT PA: 324.6 NG/ML

March -


03/12/2015
CBC

MCHC 33.1 L (34.5-36.3)
TPP Comment (5.7-7.9)
EOS% 9.50H (0-7)
BASOS % 0.800 (0-1.3)
ABS EOS 1.00H (0-.85)
ABS BAS 0.08 (0-.2)
MPV 14.00H (7.8-12.4)
PLT EST INC
PLT CNT 443H (147-423)


03/12/2015
Plasma
BUN 33H (8-32)
ALBUM 3.1L (3.2-4.1)
GLOB 3.5H (2-3.2)
ALK PHO 1396 H (15-164)
CHLOR 102L (109-117)
AN GAP 28.0H (13-22)
TBILI 0.0L (.2-.5)
SERUM, ANY SPECI CORTSOL: 4.8 UG/DL
SERUM, ANY SPECI CORT PA: 6.0L UG/DL

[Harley PoMMom]

Dogs with Cushing's generally have high elevations in the ALP, mild increases in the ALT, mildly increased blood glucose concentration, and high blood cholesterol concentration can be seen.

On the complete blood count (CBC) dogs with Cushing's syndrome have what is called a "stress leukogram," which refers to a specific white blood cell distribution in the blood. This includes a high total white blood cell count with increased numbers of neutrophils and monocytes and decreased numbers of lymphocytes and eosinophils.

Now, on Macy's blood work panels it sure seems she doesn't follow the usual Cushing's abnormalities, and since all dogs are different some just do not follow these same rules! ;)

I don't know if we were told exactly what Cushing's sysmptoms Macy was/is displaying that led the vet to test for Cushing's in the first place?

Hugs, Lori

[labblab]

I'm so glad Lori had a chance to reply to you earlier today. I'm afraid I am not able to offer much additional assessment of these lab abnormalities, because as Lori has already pointed out, aside from the elevated ALK Phos and perhaps also the elevated platelets, these lab abnormalities are not what we typically see with Cushing's dogs.

I can comment on the continuing low albumin/high globulin values, because that is an issue I am currently investigating with one of my non-Cushpups right now. Those two values are interlinked, meaning that if either one of them is "off," it will throw off the other, as well, in the opposite direction. Different things can cause low albumin, and different things can also cause high globulin. But one of the causes of high globulin is an inflammatory process going on somewhere in the body due to either skin or internal issues of some sort. So this ongoing imbalance does correspond with your vets' earlier assessment of an unresolved inflammatory issue of some kind. I don't know whether or not bladder stones would fit the bill for causing Macy's elevated globulin, as well as the elevated "anion gap" (apparently urinary blockages can elevate that lab value).

Bottom line: since Macy has no overt classic Cushing's symptoms and her blood panel is atypical as well, this further fuels my recommendation that you seek a second opinion re: the Cushing's diagnosis. I still have to wonder whether something other than Cushing's was contributing to her elevated cortisol level at the time of the diagnostic ACTH.

Marianne

[als20781]

Hello everyone! Sorry for the delay in responding. I wanted to thank everyone for all their advice and help. Without you, I don't know how my dog would be doing today. I did seek a second opinion and from my understand, Macy does not have Cushing's Disease. Also, since being off the medicine for 5 weeks now, all of her abnormal levels have returned to normal and she is happy and healthy! Thank you again and I will keep you posted. She goes back in three months for another checkup. :)

With much love for all that you did!!!!
Amanda

[labblab]

Wow, Amanda, this is super news! :) :) :)

Thanks so very much for taking the time to come back and update us. We do worry about all our folks when we don't hear. And this is the best news of all -- that Macy is back to normal. ;)

Best wishes to you both, and don't hesitate to stop back by again if other questions come up or if you just want to say "Hi!"

Marianne

[Harley PoMMom]

YAAA!! Amanda, that is great news! Best wishes from me as well!

Hugs, Lori

[molly muffin]

That is wonderful to hear! Congratulations! Best wishes here too.