Cushing diagnostic confusion.

[Sara's dad]

Hi everyone!

As most of you, i found this forum while searching informations about this disease.
Is about my dog, an rescued metis retriever that we own for about 21 months. As is it a rescued dog, the real age is unknown. The vet suggest that is about 6 yo.Anyway, we love her as all of our other family members and want to do the best for her. Because a big part of her life was on the streets, she got some phobias -for water, for other dog companion, for more then 1 year we could not take her out for walk. The reason i mention all those problems is because she was a stresses dog.
Now she trust us 100%, we can manipulate water around her , she finally follow us to walk outside, only problem to solve is about other dogs fear.

Her weight was 66 lbs little overweight it, but she was very sedentary. I did managed her food intake qty and now she is 61.About 2 months ago i noticed some symmetrical hair loss on the body. Went to a vet and they immediately said that this is a sign of Cushing disease. So asked to make the ACTH stimulation blood test. The result were:

Pre ACTH 1.60micrograms/dL
Post ACTH 23.22micrograms/dL
Vet said that Sara has 100% Cushing Syndrome.
As i was very curious about this condition, i start reading myself on internet then went to do also a full biochem blood test. After getting the results i became confused as all the parameters including ALP /ALT are in normal range. Asking the vet about this issue, she said ALP/ALT has no relevance at all as long ACTH is positive.
When asking about more test to know the origin of HAC - PH or AD she gave me a shocking reply that we will found it out after we start the treatment....:eek::confused: So at this point i'm very confused.
I will do everything to give the correct treatment but after reading many informations including this great forum i have the feeling that i'm on the wrong path about the treatment to follow.

So, at this point the only clinically signs are: hair loss and that ACTH result. Sara has energy, dos not drink more water then should, she eats well but do not act like a dog didn't eat for days. I really don't want to stress my baby with chemicals if i'm not 100% sure she need them.

Your suggestions are very welcomed. Thank you!

[molly muffin]

Hello and welcome to the forum. What was the normal range on the ACTH test?
There was nothing out of range on the CBC?
The LDDS test that you asked about us the gold standard for diagnosing Cushing's. The ACTH shows to you where the cortisol level is at.
With no symptoms other than hair loss I would want an LDDS. If anything else is going on you can get a positive on the ACTH test. So I'd say I want that done and if that is positive since hair loss has started you could do a low dose of medication.

So glad you found us and really glad you gave that sweetie a good home.

[mytil]

What angels you and your family are for taking in Sara!!!! She is a very lucky girl. Love her smiling photo (avatar).

I have a sec but am wondering if thyroid issues have been ruled out.

Terry

[labblab]

Absolutely, I would not yet start treatment since, like you, I believe there are many question marks about the diagnosis. In the absence of any abnormalities in Sara's regular blood panels and with her only symptom being hair loss, I would not start Cushing's treatment regardless of the ACTH result. Until we know what the "normal" range was for your lab, we cannot know how highly elevated Sara's ACTH was. But from the number you have given us, I am guessing it is only a mild departure from normal.

As Sharlene says, you could opt for an LDDS test. But the LDDS is actually even more likely than the ACTH to return a "false positive" in the face of illness or physical stress. So with the total absence of symptoms other than hair loss, I don't know that I'd feel any more comfortable with starting treatment even if an LDDS was positive, either.

Like Terry, I am wondering whether Sara's thyroid function (T4) was well within normal range on her blood panel? Low thyroid can cause skin and coat problems, too.

I am also puzzled by your vet's comment that you will wait until after treatment is started to further investigate whether a pituitary or adrenal tumor is involved. Why wait? Cushing's is a disease that progresses very slowly. Even if Sara has Cushing's, you have time to assess the situation carefully. Plus, trilostane treatment itself enlarges the adrenal glands, which is one of the ways in which you would be seeking confirmation of a pituitary tumor in the first place. After taking trilostane, you can't know whether the enlargement was present beforehand, or whether it was just caused by the drug.

If Sara was mine, I would not rush into treatment. I would take a wait-and-see approach to see whether other external symptoms emerge, and I would repeat her basic lab panels in a couple of months to see whether any new irregularities emerge that are consistent with Cushing's. Of course, none of this explains or helps with the hair loss. But I still would not yet start treatment based on that one symptom alone.

Marianne

[Sara's dad]

Thanks for you replies and suggestions. As we had no idea about Cushing we let the vet chose what type of blood test to be done. So, at this point only biochemistry and ACTH stimulation were done. Now after reading more informations on this forum i will do the ACTH and LDDS to find out the exact cause of her condition.

In case of treatment it will be difficult to find the drugs on our local market. i'll have to find a way to get it from outside but noticed that is not easy...in UK they ask for local Vet prescription and not accept one from other country:confused:

Anyway, thank you very much for your support. Hope to find the best way for our beloved Sara.

[Sara's dad]

Our update is that today got blood sample test for LDDS.Whithin 4hours will go for first sample and then later 4 for the second.
If the basal blood qty is enough will pay also for a T4 panel tests. I still hope is not cushing.I will pray for that.

[Sara's dad]

Here are the biochem blood tests result:
ALT 38.99 (normal range 10-60)
ALB 26.9 (23-40)
AST 24.77 (0-50)
CHOL 211.24 (110-320)
CRE 1.06 (1.06-1.8)
ALP 29.14 (23-212)
GGT 5.67 (0-7)
GLU 89.27 (74-143)
K 4.23 (3 5-5.5)
TP 6.93 (5.2-8.0)
TRIG 44.15 (10-100)
UREE 19.51 (14.98-50.78)

Hematology
Lym# 3.12 (0.83-4.69)
Mon# .30 (.14-1.97)
Neu# 3.11 (3.62-11.32)
Eos# 0.57 (0.04-1.56)
Bas# 0.0 (0.0-0.12)

Only Neu# are out of range.

[molly muffin]

Let's see what the LDDS and ACTH look like and definitely have thyroid checked. No need to worry about the vetroyl just yet.

Those are very good blood results!

[labblab]

Yes, those really are good results, and in my own mind, they really do make Cushing's seem less likely regardless of that mildly elevated ACTH stim test and no matter how the LDDS turns out. Dogs with Cushing's typically exhibit certain types of abnormalities on their blood panels, and we just are not seeing them here. Once again, with loss of hair largely being the only symptom, I would not rush into treatment, regardless.

Marianne

[lulusmom]

I wholeheartedly agree with Marianne but if your vet is pushing you to do diagnostics for cushing's and you want to rule out cushing's, I would recommend that you do a UC:CR. It's a relatively inexpensive urine test. If the ratio is within normal range, you can rule out cushings. If the ratio is high, cushing's could be possible but additional testing such as the acth stimulation test and/or LDDS test would need to be done. The urine specimen must be collected while Sara in a relaxed atmophere as the slightest bit of stress, such as being in a vet's office, can increase cortisol levels. Therefore, you need to collect the urine specimen, preferrably the first pee of the day before any medications and food. Get the urine sample to the vet as soon as you can but if you can't get it there before an hour or two, keep it refrigerated until you can get there. Is Sara on any medications?

Glynda

[labblab]

Hey Glynda, so great to see you here!! :)

Yep, I agree the UC:CR would have been a good place to start. But the vet has already done an ACTH stim test which turned out to be:

Pre: 1.6
Post: 23.2

We don't know the normal range for that lab, but I am guessing that although technically "positive" for Cushing's, it is likely only a mild elevation. But this is why the vet wants to start treament. Based on this result, I'm thinking the LDDS may turn out positive, too. But even if so, is this truly Cushing's or instead severe stress at the time of testing, or something altogether different that is elevating cortisol?? That is a big question, I think...:confused:

Marianne

[Sara's dad]

Sorry I didn't write down the ACTH normal range lab. Here they are:

Pre ACTH 2.00-6.00ug/dL
Post ACT >22ug/dL -> Cushing.

Sara results:
Pre ACTH 1.6ug/dL
Post ACTH 23.7ug/dL



As her blood panel looks almost perfect , i'm also thinking very serious that ACHT could be false positive because of the stress she is facing when going to vet. She's temperament is not as normal dog. She scares even at the smallest dog she notice in the park. So any places she goes and don't feel safe stress her very much.
I'm on the same line with all of you, drug treatment is the last option for me ,only if i'm 100% sure Sara has cushing with many clinical symptoms and all test concluding this condition.
I'm not that crazy to "poison" my dearest Sara as long she just show hair loss.

Just finished last blood sample (8hours). I'll keep you informed the result. Fingers crossed for her!


Once again , thank you very much for your support. This forum is the best source I found for cushing disease and all Thanks God I found you. God Bless this community!:)

[lulusmom]

Please see my comments below in blue


About 2 months ago i noticed some symmetrical hair loss on the body. Went to a vet and they immediately said that this is a sign of Cushing disease.

Yes, it is a symptom of cushing's but it's also a symptom of other diseases as well. Where exactly is Sara losing her coat and did your vet do a skin scraping to rule out parasites?

So asked to make the ACTH stimulation blood test. The result were:

Pre ACTH 1.60micrograms/dL
Post ACTH 23.22micrograms/dL
Vet said that Sara has 100% Cushing Syndrome.

It is apparent that your vet is not well versed in diagnosing cushing's. There is no way an experienced vet assessing a dog who presents with hair loss and no other symptoms associated with cushings, and whose blood chemistry and cbc is void of the usual abnormalities seen in cushing's, would confirm a diagnosis cushing's syndrome diagnosis and proclaim there is no doubt about the diagnosis and it is 100% accurate. There are huge doubts about the diagnosis and if this facts above aren't enough, let's throw in the fact that Sara is extremely stressed out at the vet's office, making the only piece of evidence your vet used to confirm a diagnosis extremely suspect for false positive result. Yes, it's less likely to yield a false positive than an LDDS test but it's not impossible in the face of extreme stress.

As i was very curious about this condition, i start reading myself on internet then went to do also a full biochem blood test. After getting the results i became confused as all the parameters including ALP /ALT are in normal range. Asking the vet about this issue, she said ALP/ALT has no relevance at all as long ACTH is positive.

Again your vet is showing her ignorance; however, I will defend her a tiny bit here. Canines are the only species on earth to have a steroid triggered Alkaline Phosphatase liver enzyme; however, there is a very, very small number of dogs who are missing that genetic marker. Therefore, it is possible that a dog with cushing's could have a normal Alkp on the blood chemistry but you would still probably see other abnormalities in the blood chemistry as well as the cbc. What did your vet say about the low Neutrophil on the cbc?

When asking about more test to know the origin of HAC - PH or AD she gave me a shocking reply that we will found it out after we start the treatment....:eek::confused: So at this point i'm very confused.

Well that pretty much cinches it......your vet is completely clueless and you should be more than confused. I don't even know how to respond to that ridiculous statement so I'll just let it be.

I will do everything to give the correct treatment but after reading many informations including this great forum i have the feeling that i'm on the wrong path about the treatment to follow.

So, at this point the only clinically signs are: hair loss and that ACTH result. Sara has energy, dos not drink more water then should, she eats well but do not act like a dog didn't eat for days. I really don't want to stress my baby with chemicals if i'm not 100% sure she need them.

I totally agree with you. While your vet may be 100% sure she needs treatment, based on what you've told us, I'm 100% sure that your vet doesn't know what she is doing. I'm also 100% sure that Sara has a great advocate in you. Good job of being proactive in Sara's care.


When I posted before, I did not know that you had already committed to the LDDS test. I agree with Marianne that the LDDS could yield a false positive result due to Sara's high anxiety in the vet's office but nevertheless, with the lack of any other symptoms and the usual lab abnormalities, I would not start treatment.

Glynda

[Sara's dad]

Hi everyone! just want to share my happiness with you.

My girl Sara is a cushing free dog!:)

Here are the results for LDDS and T Panel:

LDDS

Bazar cortisol - 1.72ug/dL
Corstisol ->4 hours <1 ug/dL
Corstisol -> 8 hours <1ug/dL

Thyroid

Cholesterol 207 mg/dL (130-386)
TSH 0.06 ng/mL (< 0.5)
T4 total canine 1.7ug/dL (1.5- 4.5)


So after these 2 results i'm 100% sure my baby is not a cushing dog.

The hair loss pattern looks similar to cushing but is caused by other reason! I'll have to check for skin affection or any allergen reason.

Last week my vet was informing me that Sara has cushing and start looking for drug treatment. Thanks God I did want to read myself about this condition and found this place otherwise my dog was doomed!:mad:
As a lesson for everybody, do not trust only the first conclusion you get from your vet. Always try to inform yourselves from other sources , go and ask other vets opinions, search internet and do all the tests you can before start any treatment.

Sara has a problem with hair loss, but she is a healthy dog after doing all these tests. I will look to find out the real reason of her condition and keep you informed. Any personal experience shared can help a lot when others will find themselves in same situation.

Promise to keep you updated.;)

[Budsters Mom]

YAAAAAYYYY!!!! Great news thanks for sharing! :D:D:D

[labblab]

Bazar cortisol - 1.72ug/dL
Corstisol ->4 hours <1 ug/dL
Corstisol -> 8 hours <1ug/dL
Cristian, can you clarify these LDDS results for us? For the 4-hour and 8-hour results, we need both Sara's actual test numbers and also the normal range. I can't tell whether the <1 ug/dl is what she tested at, or whether that is the normal range. So we need two numbers for both of those lines.

Marianne

[Sara's dad]

Cristian, can you clarify these LDDS results for us? For the 4-hour and 8-hour results, we need both Sara's actual test numbers and also the normal range. I can't tell whether the <1 ug/dl is what she tested at, or whether that is the normal range. So we need two numbers for both of those lines.

Marianne


So, at 4 and 8 hours the cortisol level was identical meaning less then 1ug/dL

Official interpretation of lab:

If cortisol level is <1.5ug/dL on both 4 & 8 then dog is healty

If:
a. Cortisol 8h>1,5ug/dL , 4h >1,5ug/dL & >50% of bazal level---> Cushing syndrome AD or PD - need extra tests
b. Cortisol 8h>1,5ug/dL , 4h <1,5ug/dL or <50% of bazal level---> Cushing syndrome of PD nature

So my baby has 1.7 bazal then 4h and 8h <1.;)
This means she is cushing free!