Beagle just diagnosed, but needs surgery

[Balego]

Hello
I am new here. Our 9 1/2 yr old beagle was scheduled to have his second TPLO for a torn cruciate ligament in his knee last week. His first TPLO was in November 2013.
His pre-op bloodwork this time showed elevated liver enzymes, indicating possible Cushings. He then had the low dose 8 hr test to confirm, (sorry, can't remember the name of the test) , and then he had an ultrasound. Although he shows NO symptoms of Cushings, he apparently does have pituitary Cushings.

We have to treat the Cushings before he can have his surgery, and in the meantime he is in pain, and being kept in a large Xpen to limit his movements.

I am concerned about the treatment, the side effects, and of course, the cost. I do have his blood test results, and am awaiting the results to be emailed to me from his ultrasound.

I guess we are just feeling a little overwhelmed and worried, and we didn't expect this setback when we scheduled his surgery. We knew that the possiblity of his second knee tearing was great, so were prepared. But we weren't prepared to hear that we cannot fix his knee because he has Cushings that needs to be treated first!

Thanks for listening.

[judymaggie]

Welcome from another beagle parent! My almost 12 year old beagle, Abbie, is my second Cushing's pup (my first also a beagle). Our in-house experts (who have much more Cushing's knowledge than I do) will be along. If your beagle (name?) has no Cushing's symptoms, then I am very confused about the vet's insistence on treatment before surgery. Is it the surgeon who is requiring this or your vet?

When you get a chance, please post the abnormal (high or low) lab results as well as the 8 hour Cushing's test (LDDS) which would have three numbers. Please include the ranges for each test as they vary from lab to lab. As soon as you get the ultrasound results, please post those as well. Easiest way to do all this is just list the info in your post, i.e., "ALT 681 (14-500)".

[Wrighton]

Welcome to the group. There is so much good information here.

I really can't help about information re Cushings, but my Icy was in the middle of testing for Cushings when she found a deer irresistible and in spite of ice covered snow, she took after it. She when through the ice and tore her CCL. Our vet operated seven weeks ago and she goes to PT still, but she is walking with only a slight limp. She had no trouble with the surgery. Of course, she had pain, but canine style she kept on keeping on.

As to whether or not she has Cushings ... The jury is still out after a myriad of tests. She, too, is relatively symptom free. I've received great support and help here.

Gail

[Dixie'sMom]

Hello and welcome to you and your beagle from me and my hound dogs. :) As those above have said, the others will be along soon to welcome you to our family and to go over any tests you may have had done to diagnose the cushings and to look at the blood work with the elevated liver values.

More times than not, the treatment for Cushing's can wait until other issues are treated, so the lab tests should give some clues as to why your vet is pushing for treatment before the surgery.

Again,welcome and I look forward to getting to know you and your sweet pup. :)

[Balego]

Hello
Thank you for the welcome. Our beagle is named Baxter.
My vet, when he got the blood test results from the pre op blood work, called us about his suspicion of Cushings due to Baxters high liver enzymes, which were ALP 3,198. All other blood work was normal. He said he didn't think it would affect the surgery, and scheduled the low dose dexamethasone test. We had that done one week before our surgery date. The result of that test was; Cortisol -baseline: 238, cortisol 4 hour: 245, and 8 hour: 197.

When he informed the surgeon, (who is a mobile surgeon) of this, the surgeon refused to do the TPLO on a dog with Cushings, and cancelled the surgery. We then took Baxter for an ultrasound. The results showed both adrenal glands the same size, maybe slightly enlarged, liver only slightly rounded, some sludge in the gall bladder, but basically that everything else looked okay. Baxter does have a rather large lipoma on his lower left abdomen, which showed in the ultrasound as a fatty tumour. We had wanted to get that taken care of a couple of years ago, but Baxter tore his ACL at that time, so we had to deal with that instead. I do not yet have the results on paper of the ultrasound, but the above was what the vet who did the ultrasound told us, and that it was pituitary rather than adrenal Cushings.
Baxter shows no symptoms whatsoever. He healed perfectly from his first TPLO, and until he tore the second ACL, he was back to acting like a pup, with no pain or slowness. Apparently liver enzymes were not included in the bloodwork for his last surgery, so we have no idea if he was
Cushingoid then.

Because he doesn't exhibit symptoms, if he didn't need this surgery, we would possibly not treat for Cushings. But we apparently don't have a choice? I haven't yet gotten far enough to learn what kind of side effects or even which drug will be used. The vet said one of the two drugs that are normally used would work quicker, although it needs more fiddling to get the dose right? Sorry, I can't remember the name as I type this. I am waiting for all the info and pricing so we can make a decision which way to go. I confess, I am very confused by all of this.

[labblab]

Hmmmm...I am so sorry you and Baxter are having these problems. There seem to be two issues here. First, how much confidence do we have that Baxter truly has Cushing's? Secondly, is it really unsafe to proceed with the surgery, regardless?

This is my worry about the diagnosis -- the LDDS is vulnerable to "false positives" in the presence of other illnesses or extreme stress. If Baxter is experiencing a great deal of ongoing pain associated with his torn ligament, it seems reasonable to me to think that his LDDS response might be elevated right now for reasons other than Cushing's. Especially in the absence of any observable signs of Cushing's and nothing definitive on ultrasound, I would be very cautious about declaring him a Cushpup. If anything, I would want to do the opposite: perform the ligament repair and then retest to see whether the LDDS response has normalized.

It is true that you are left searching for an explanation for the elevated ALKP. Also, untreated Cushing's can make dogs more vulnerable to ligament tears in the first place and can slow healing. So as a preventative to future issues, lowering elevated cortisol can be a benefit to dogs in terms of this type of orthopedic issue. But you are right in the midst of an acute dilemma now that requires attention, and if I were you, I would want a better explanation as to why the surgeon is refusing to proceed. What is the specific current risk that is stopping him?

Also, what is his treatment expectation? How long does he plan to wait before he feels satisfied that the Cushing's is controlled? In the absence of any outward symptoms, how does he plan to judge treatment success anyway, especially since elevated liver enzymes may be slow to show any change? The monitoring blood test for Cushing's is the ACTH stimulation test. If you really do decide to give medication, you will want to first perform this test so you at least have a baseline cortisol level against which to judge the effect of the drug. The ACTH is also used diagnostically, and is a bit less vulnerable to false positives than is the LDDS. So there may be benefit to additionally performing that test, for both purposes.

All in all, I am very disturbed that you are being bullied into treatment without a more solid basis that the diagnosis is even correct. As I say, I would really pin the surgeon down with these additional questions. Do you have any alternatives at all as far as seeking a second surgical opinion?

Marianne

[Balego]

Hello Marianne
Thank you for your response. I am not convinced that Baxter has Cushings,but I am being told it is
Cushings because of the high cortisol. I asked if it could be anything else causing it, but even the vet who did the ultrasound (a different vet we were sent to for that), said it indicates Cushings because of the high cortisol. Matter of fact, we had actually dropped Baxter off for his surgery last Wednesday, and got a call an hour later saying the surgeon cancelled it. Our own vet clearly didn't think it would affect the surgery and that we could deal with it afterwards and scheduled us in, but the surgeon refused to touch Baxter when he showed up to do it and found out Bax was suspected Cushings.. The reason being apparently problems with healing, possible risk of infection. So we had to pick Baxter up, and our vet was able to get us in for the ultrasound in a neighbouring town that same afternoon..
We have not been able to speak with the surgeon. There are two mobile surgeons that work as a team, travelling around to the rural vet practises to perform these ortho surgeries. It was the other surgeon that did Baxters first tplo, not the one that was to do this present one.

I spoke with our vet yesterday, about what our next step is. He said he could ask on a vet online board other experts to see what they might say. But it seems we could use the drug to get the cortisol down, and throughout recovery until Baxter is all healed,then discontinue the drug.
We do like our vet, and had a very good experience last time with Baxters surgery. Also, his practise isn't out to make every dollar, he gives excellent care and is very conscientious about his clients financial situations. Going elsewhere would cost a couple thousand more and the reputation Of the these particular two surgeons is excellent. Unfortunately one of them won't touch Baxter with those high levels. And I have no idea yet what things will add up to with this Cushings and all the meds and testing that will be needed. My hubby just recently retired, and we are now on pensions so it's worrisome. We did set aside for a second tplo because we knew the chances of it being necessary were high. This other stuff blindsided us.

Can pain, and anxiety about car trips/vets, etc, cause such high cortisol readings?

And the thought of drugs and side effects do scare me.

[doxiesrock912]

Stress and pain certainly can raise cortisol. Illness can as well.
I would see if the other mobile vet willdo the surgery. In the absence of symptoms, knowledgeable vets do not treat Cushings.

Ligament tears are incredibly painful and I agree that this needs to be corrected first. Once Baxter is fully healed and pain free, then test for Cushings again to have an accurate reading.

Treating now based on numbers that are most likely high because of the injury and pain is dangerous. The ultrasound showed barely any change in Baxter's organs which further suggests that the high numbers are not only related to Cushings. Do watch the gallbladder sludge because that could indicate a different problem. Our Daisy Mae was on Urisidol for that.

The dose in medication will not be accurate at all. Getting the dosage correct is tricky when a dog is known to have Cushings, no way would I treat under these circumstances.

Your vet sounds good. Hopefully he can convince the mobile vet.

[judymaggie]

Hi! I am not going to be as nice as Valerie ... if your vet gave you this advice:


it seems we could use the drug to get the cortisol down, and throughout recovery until Baxter is all healed,then discontinue the drug.

then he needs to do some studying about Cushing's. This is not even close to how this disease is treated.

One route you might take now is to ask your vet to request a urine cortisol:creatinine ratio (UCCR) test. This involves your getting a urine sample from your dog, preferably the first one after he gets up, into the vet and he would send the sample away for this test. It is not expensive. If the results are negative, then Baxter does not have Cushing's. If the results are positive, then Baxter might have Cushing's and further tests would be recommended.

[labblab]

Boy, I really don't know what to advise you to do at this point, as I think the surgeon is being very unreasonable and may actually be placing Baxter at risk by dictating the commencement of treatment at a time when Baxter is obviously in pain and in need of intervention.

As a surgeon, I'm afraid he is not very familiar with the actual ins and outs of Cushing's treatment. Yes, in an ideal world, Baxter's cortisol level would be lowered prior to surgery -- IF he actually has Cushing's and IF you had more time. But even if Baxter has Cushing's, it may not be safe to lower his cortisol tremendously overnight. There are dosing protocols in place that take time to achieve. Depending upon the drug of choice, it can take 1-2 months to arrive at an optimal dose. Does he intend to let Baxter suffer all that time? It just does not make sense to me. And if the surgeon is unaware that nonadrenal illness or injury can return a "false positive" on the LDDS, he is truly undereducated regarding Cushing's diagnostics. :( :(

The best suggestion I can make is to request an ACTH stimulation blood test. Maybe (fingers crossed!) it will come out negative for Cushing's. If not, you will have a baseline cortisol value to work from in terms of treatment (your LDDS results cannot be used for this purpose). And although your GP vet's suggestion is unconventional, I realize he is desperately trying to figure out a way to pacify the surgeon enough to go forward with the procedure. However, unless Baxter's Cushing's is confirmed, treatment really is just not a good option. I would ask for an ACTH stimulation test and see how it turns out. :o :( :(

Marianne

[Balego]

Valerie, Judy and Marianne, Gail, everyone, thank you for your input. Your comments really helped my husband and I understand more what we are up against. As it happened, as we were discussing what to do, our vet phoned. We expressed all of our concerns, and requested the ACTH test. We also talked about Baxters' need to have his knee repaired asap and our vet agreed to speak with the surgeon that performed the last TPLO about moving ahead with the surgery. We were able to lay all of our concerns on the table, and our vet really listened to what we had to say.

He agrees that Baxter shouldn't have to suffer with pain and that the most important issue right now is getting that knee repaired.
He will speak with the surgeon today sometime, and all we can hope is that the surgeon will be willing to go ahead and do the tplo.

It is a difficult position to be in, to know that these two surgeons are probably the best around here and that we are hesitant to trust anyone else to do a TPLO on Baxter, yet be forced to push them to do something they don't think is safe to do. But we simply cannot sit here and watch Baxter struggle to walk and to be in pain, when five weeks ago he was happy and running around like a big goofy puppy.

If, in the end, Baxter does have Cushings for sure, we can handle that. Although we hope he doesn't, I suppose it is better than something else that might be worse causing his high cortisol, lurking inside him!

In his 9 1/2 years, he has never been sick. He does have a mild heart murmer, he does have a lipoma, he has a couple of skin tags, he blew out both knees. But not once has he had even one 'off' day.

[labblab]

I am SO glad you were able to have this discussion with your vet! And if it turns out that the other surgeon is willing to proceed immediately, I would actually defer on the ACTH for the moment. Although it is less vulnerable, it can also be skewed by the same nonadrenal factors as can the LDDS. If you can have the surgery now, I would wait until Baxter is out of pain before pursuing any additional Cushing's diagnostics.

Marianne

[Balego]

Good point, Marianne, thank you! I will mention this when our vet calls.

[MilliesGrandma]

Wow, I feel for you dealing with competing issues. Our newf (who does not have cushings) is currently undergoing chemotherapy for lymphoma and leukemia. During his second round of chemo he ruptured his ACL completely. We were faced with deciding what course to take. Chemo severely effects healing as it kills rapidly dividing cells (both the bad ones and the healing ones). Without knowing if the chemo would work we were reluctant to put him through surgery, and the resultant recovery period. Dilemma! We decided to keep going with the round he was in and see where he was at during the break between rounds. Surprisingly he has been managing fine. He's hobbling a bit but it doesn't seem to be overly bothering him. We were told by several vets that the worst of the pain is when the ruptures happens but that it settles down within a day or so. Once it's ruptured, it's ruptured. Fortunately, he has achieved remission for both cancers but has to finish the chemo protocol. So we keep going, and he manages on a day to day basis.
He has a daily dose of tramadol to ensure he is comfortable. We will probably do a brace for him as surgery probably isn't a good option for him given the circumstances.

My bad I just read yours is a torn ligament not ruptured. Disregard my ramblings!

[judymaggie]

Hi! It sounds like you and your vet are on the same page and both excellent advocates for Baxter. Keeping fingers crossed that your vet can convince the surgeon to proceed with the surgery!

[Balego]

Good news. Our vet just called and said that the surgeon who did Baxters first tplo agreed to the surgery! He said because there isn't any symptoms (drinking and peeing) and that it isn't adrenal, he feels comfortable doing it. We are scheduled for April 22. Prayers that all goes well, and that there will be no complications!

Once we are past this surgery and all healed, we can revisit the possibility of Cushings. I am still going to be nervous until we reach the 8 week X-rays that will hopefully show good healing.

Thanks again for all your kind responses. :)

[judymaggie]

Woo-hoo!!! It is strange to be excited about an upcoming surgery but I am so glad that the surgeon is on board. I will definitely send prayers and good thoughts for a successful surgery and please be sure to get back to us as to the outcome as we are a bunch of worriers. ;)

[FemaleK9]

My Rosie and I send lots of healing mojo to Baxter, and hope he will be a happy dog again soon!

[Harley PoMMom]

Tons of prayers being said and sent for dear Baxter.

[Dixie'sMom]

EXCELLENT! That is great news!

I'm so glad that you have a vet who is willing to push for the best treatment for Baxter. Hopefully you won't have to deal with the Cushing's issue at all down the road, but if you do, then we will hold your hand.

Prayers coming your way for a successful surgery and rapid healing.

[Balego]

Thank you for the kind words and wishes! I will stick around here in the meantime, and for sure I will update on Baxter' condition. Thank you so much again!

[molly muffin]

Hoping Baxter is doing well and the surgery goes smoothly with a good recovery.

[Balego]

Thank you, Molly.
I am quite nervous about this whole thing. One week from today is will be his surgery date. Then 8 weeks until xray to show how much healing has taken place. I doubt I will breathe easily until then!

[kmwilliams6113]

Hope your Baxter has a successful surgery!

In the last week, our 9 year old dachshund Greta has suffered a collapsed disc in her neck, and she was diagnosed with cushings. Luckily, pain meds and rest seem to be improving her, and she didn't need immediate neurosurgery. But, as you are, we're in a little catch-22... do we get an anti-inflammatory prescribed that will heal the neck faster but cause problems with her untreated cushings, or do we just do rest, watch for increasing pain, and take a little bit slower of a healing time. And, normally dogs with IVDD issues must rest for 6-8 weeks (crate rest) to allow swelling to fully subside and the area around the disc to completely heal, so do we wait 2 months to start treating the cushings, and let it do what it will in the meantime (besides the extra natural steroids, which ironically may be keeping swelling in the neck down)? The neck pain is surely the most urgent and currently debilitating, but 2 more months of untreated cushings is a little scary too. It's a conundrum.

Have you and your vet decided how long post-surgery you will give Baxter before you start to address the cushings (if there)? Curious to know how you are balancing both.

[Balego]

Just a quick update on our Baxter. He had his surgery on Apr. 22. All went very well, he came out of the anesthetic very ' bright eyed' apparently, so they let us pick him up early. His first night was rough, as was to be expected, and although he is being a little clingy, his wound looks just fine and he is already using his leg. He has antibiotics for 14 days because of the suspected Cushings, rather than the usual five days. Just a precaution. The surgeon was very confident that Baxter should heal up just fine.

I find it amazing that the hair on his tummy is growing back so nicely, from his ultrasound three weeks ago. Is this not unusual for a
Cushings dog?
Kmwilliams, I know exactly where you're coming from, not knowing just what to think or what to do, and how things will turn out! At this point, I am going to just let Baxter get all healed from this tplo, and watch and see if or when any Cushings symptoms appear. I will probably still go ahead with further testings, but I really hesitate to treat until I have proof he has Cushings, and begins showing symptoms. I am still not convinced he is cushingoid. (I am typing this on my iPad while sitting inside Baxters Xpen. He needs so much comfort right now!) :)

[labblab]

WooHoo, thanks so much for your update and I'm so glad to hear that Baxter is safely home! :)

Yup, slow hair regrowth is typical of Cushing's so I'm with you -- as we discussed earlier, I still have question marks about his diagnosis, too, and will be interested to see if his numbers remain elevated even after he has healed. For right now, though, I'm just so happy to know the surgery is behind him.

Keep us in the loop, OK? ;)
Marianne

[judymaggie]

Great to hear that Baxter is home and healing! :D Thanks for putting our worries aside.

[molly muffin]

Heal first then see how things are. Great to hear he is doing so well and home recovering.

[Squirt's Mom]

Glad to hear he is home and all went well!