If it's not Cushing's, then what is it?

[momofbug]

Hello all, I am glad I found you! My sweet Swedish Vallhund Bug, who is ~9.5, has been exhibiting signs of Cushing's for some time now. (Sadly I just didn't really realize it.) She has been shedding like crazy for over 5 months, drinking water like there's no tomorrow, sleeping downstairs rather than upstairs with her people (it's cooler down there), has little interest in playing, has a BIG appetite (no, really, she will stand at the refrigerator and beg for veggies – her favorite treat!) and has developed a potbellied/bloated look.

To give some background on Bug: she has a (remote) history of bladder stones, is spayed (she was ~ 2 yrs old), is on DES (1mg once a week for incontinence), and eats Hills ZD food. She has also developed a few lipomas on her chest and belly over the past year (or less).

She had some lab-work done last May and her liver numbers were a bit elevated. At that point the vet (not one we normally see) had mentioned Cushing’s. We followed up with our regular vet and she dismissed the idea, as Bug really didn’t have any other symptoms. Fast forward to now with all her symptoms. An abdominal ultrasound revealed: “the liver is generally enlarged and diffusely hyperechoic with an occasional, small (4-7m) hypoechoic nodule.” In the gallbladder/biliary tract: “small amount of hyperechoic and non-shadowing material in the gallbladder lumen. No cystic or bile duct distension is present.” Urine sample seems fine but will elaborate if needed. Now for her lab-work:

MCH 26.5 pg (H) 21.9 - 26.1

Platelets 466 K/uL (H) 143 - 448

ALKP 187 U/L (H) 5 - 160

ALT 178 U/L (H) 18 - 121

BUN/UREA 8mg/dL (L) 9 - 31

Chloride 105 mmol/L (L) 108 - 119

CREA 0.4 mg/dL (L) 0.5 - 1.5

An ACTH was performed – I was told she is on the high end of normal. Her results are as follows:

Pre-ATCH 4.9 ug/dL (Pre-ATCH cortisol values 2 – 6)
Post-ATCH 20.0 us/dL (Post-ATCH cortisol 6 – 18, also listed Equivocal post-ATCH cortisol 18 – 22)

She will start Denamarin tonight for the elevated liver numbers, will take for 30 days then recheck. All of this being said, what do you guys think?? Could her symptoms be due to liver issues or possible Cushing’s? Thank you in advance for your thoughts and time!

Heather

[Harley PoMMom]

Hi and welcome to you and your girl!

Sorry, I have only a moment to post but wanted to welcome you both and type a quick comment.

Diagnosing Cushing's can be very challenging because not one test can accurately identify it so multiple testing is needed to validate a diagnosis for Cushing's. The two tests that are generally used to diagnose Cushing's are the low-dose dexamethasone suppression (LDDS) and the ACTH stimulation test. There are pros and cons with either of those tests, the LDDS is considered the gold standard test for Cushing's, however a false positive result can be created if there is a non-adrenal illness is present when the test is performed. With the ACTH stim test, a false negative result may happen.

I see that an ultrasound was done, were the adrenal glands visualized?

I'll try to get back later.

Hugs, Lori

[momofbug]

I would like to add the abnormal labs from May 2014 for reference:

Platelet 505 range 148 - 484 K/uL

Plateletcrit .048 range 0.14 - 0.46%

ALT 210 range 10 - 100 U/L

Bilirubin Total 1.4 range 0.0 - 0.9 mg/dL

The vet (whom we love and trust) suggested hepatic biopsies if the numbers don't improve after 30 days on Denamarin, OR consider trying Anipryl.

Thanks again for your thoughts,
Heather

[momofbug]

Hi Lori,

Thank you! I know this is difficult to diagnose so I'm glad I have you (all) to run things by. Yes, the adrenal glands were visualized in the ultrasound and were noted as "normal". That is what is confusing to me, but in researching I've found it can be difficult to get a good look. Would it be safe to say her adrenal's are OK since it was listed as "normal"? ::so confused::

I don't want any false negatives, or false positives for that matter, but given her symptoms I'm racking my brain to figure out what else it could be... I asked the vet if the DES could be causing the elevated liver numbers and she agreed possibly, offering to change her med. I've opted to keep her on the DES for now, hoping the liver supplement will help.

[Harley PoMMom]

With elevations in the Bilirubin and ALT along with the findings from the ultrasound, I am inclined to believe that this would be more indicative to a liver issue than Cushing's.

Has the vet mentioned about performing a bile acid test to check the function of the liver?

Hugs, Lori

[momofbug]

Thank you, Lori. The vet did suggest a bile acids test. I will definitely follow up with her on that when I take Bug in for recheck. Thanks again, I really appreciate your input!

[Harley PoMMom]

Let us know how it goes, ok?

[molly muffin]

Hi, I don't think I've said hello to you yet. :)

I agree with Lori, it does sound like something is up with the liver and a bile acid test is exactly the next thing to look into.

Definitely hoping that this can be figured out soon.

Welcome!

[momofbug]

Thank you, I will be sure to keep you posted; we should know more in a couple weeks. For now, Bug's energy level is up, so I'm hopeful that's a sign the Denamarin is working.

[molly muffin]

How is Bug doing? Did you ever get the follow up bile acid test?

[momofbug]

Hello all, just wanted to give a quick update on Bug. She had follow up lab work done today - everything looks good with the exception of her ALT which is still elevated at 175 U/L (range 10 - 125). The vet suggested following up in 6 months, no need to continue the liver supplement. I didn't inquire about the bile acids test - is that something I should do still? She seems to be doing well and is acting more like herself. Thanks for your input!

[molly muffin]

The ALT hasn't come down too much, just a few points and while that is good, you want it to come down more.

I'm not sure why they said to discontinue liver supplements. Liver supplements are good any time there is a problem with the liver. Most of our furbabies are on them for the rest of their lives and you are supporting the liver by using them. Since liver is the primary concern right now, I'd probably continue the supplements.

I'd probably do the bile acid as that would be the next step before considering a biopsy if the ALT doesn't come down.

While the vet suggested 6 month retesting, I'd probably go no longer than 3 months at most before retesting as things can sure change fast and you want to know if anything is getting better or getting worse.

[momofbug]

Thank you Sharlene, I will be sure to follow up with the vet in 3 months and contact her this week about resuming the liver supplement. I thought it was odd she didn't recommend continuing the supplement, especially since it did help.

[molly muffin]

Did you restart the liver supplements?