Huck has Cushing's?

[huck1409]

I just found out that my 7.5 year old labradoodle, Huck, may have Cushing's. But I am concerned and confused about what the vet is telling me.

My husband and I were on vacation out of the country between 10/18-11/7. My husband's parents watched Huck while we were gone. While they know him well and have spent a lot of time with him, he was probably stressed and missing us while he was with them. He has never spent so long away from us. We got him back on Sunday, November 8, and that day, he had an accident on the couch while he was sitting right next to me. He is incredibly reliably housetrained, so I thought he might have a UTI, so we took him to the vet last Tuesday.

They tested his blood and his urine. He came back negative for a UTI, but his cortisol levels were elevated and his platelet count was also low. They then tested his cortisol:creatinine ratio, which was also concerning.

Today, he went back to the vet for a low dex test. They did that test, but they also wanted to retest his platelet count. When they took blood again, a huge baseball sized bruise developed. And the blood came back again with low platelets. They say this is concerning because low platelets are not consistent with Cushing's but instead autoimmune disorders, but they feel pretty confident he has Cushing's.

Having done some research on Cushing's, he has very few of the physical symptoms except one--he definitely has been developing a bit of a potbelly. I noticed it just before we left on vacation, but I didn't think anything of it because it is really not that bad. Besides the one accident in the house, he hasn't been having any more accidents, and he is not drinking a ton of water. He hasn't gained any weight; if anything, he's lost half a pound. He does seem ravenous, but then again, he always has! He is his lively, spirited, loving self. He does not look or act like a sick dog at all.

I know there is probably not much you all can tell me until the low dex test comes back, but I guess I'm just wondering if anyone has experienced low platelets around the time of a Cushing's diagnosis? Or are you aware of any other cause of the potbelly besides Cushing's? I am feeling incredibly worried and overwhelmed. I took him to the vet because he had ONE accident in the house, and now it seems like they are telling me multiple bad things are wrong with him :(

I am so glad to have found this forum and I really appreciate any advice you can give us!

[labblab]

Hello and welcome to you and Huck, although I'm very sorry he is having these worrisome issues. I am very glad you've found us, because we will do our best to try to help you sort through Huck's testing and the information you are receiving.

I do have to say, though, that regardless of the outcome of the LDDS, I think you still have some distance to travel to arrive at a valid Cushing's diagnosis. I am surprised to hear that your vets are so confident that Huck has Cushing's when, actually, he exhibits no consistent symptoms other than a possible pot belly. One urination accident is very, very different from the consistently excessive thirst and urination that characterizes so many Cushpups. Not every dog with Cushing's exhibits every possible symptom, but Huck has virtually no overt symptoms. Plus, Cushing's is associated with elevated platelets, not a decreased level.

Another testing concern is that apparently the vet performed the cortisol:creatinine on a urine sample obtained while Huck was there in the office? This is a major no-no, because that test is highly vulnerable to the effects of stress. In order to perform a valid UC:CR, most labs and specialists instruct the owner to obtain the first urine sample of the morning, at home, under as low-stress a scenario as possible. Best of all is to obtain a low-stress sample on three successive mornings and to pool them prior to analysis.

Aside from the platelets, were there any other abnormalities in Huck's general bloodwork? Most Cushpups exhibit moderate to extreme elevations in ALKP. In addition, many dogs have mild to moderate elevations in ALT, elevations in cholesterol, and a particular pattern of abnormality of white blood cells. How about Huck's urine -- was it dilute? If not, then that is also inconsistent with Cushing's.

I know you are anxiously awaiting the results of the LDDS. However, I do have to warn you that the LDDS is vulnerable to returning "false positives" in the presence of nonadrenal illness. In other words, if a dog has another serious illness or condition, he may have an elevated test result even in the event that Cushing's is not involved. Huck's big bruise and low platelet count really worries me, and I have to wonder whether the pot belly is related to some other illness or internal abnormality altogether. In honesty, if it was me, I would not trust a Cushing's diagnosis at this point, regardless of the result of the LDDS. I would want to pursue further diagnostics, such as perhaps an abdominal ultrasound in order to image his internal organs (including the adrenal glands) and also perhaps more specialized blood analysis.

Thanks in advance for any additional info you can provide about Huck's testing. And, of course, we will be anxious to hear the result of the LDDS. But for the reasons I've given above, I think there are several remaining questions no matter how the LDDS turns out.

Marianne

[labblab]

Forgot to add that I wonder whether Huck's pot belly could be the result of fluid build-up (or "ascites") in conjunction with something going on with his spleen or liver. Unlike Cushing's, an issue like that might also be more likely to be consistent with low platelets, I think...

[SandyH]

Sent you a PM

[huck1409]

Thank you so much for your incredibly thorough responses. I can't tell you how much I appreciate it. These are all such good ideas that I will be able to raise with our vet tomorrow. I will definitely make sure we get an ultrasound of his abdomen so we can see what's going on in there.

I admit, I was also concerned that the vet seemed so certain about the Cushing's. Tomorrow, I will ask for all the results of the tests they did so I can find out if some of those other levels you talked about were elevated. The point about the cortisol:creatinine ratio is especially well-taken--Huck hates the vet and I guarantee he was stressed when they took the urine sample.

Again, thank you so much. You've confirmed my suspicions that there's a lot left to get to the bottom of, and now I'm better equipped to make sure we get the right answers.

[molly muffin]

Hello and welcome to the forum. I just want to second what Marianne said, the low platelets needs to be looked into further and without symptoms of cushings I think the ultrasound gives the most bang for the buck at this point.

Losing half a pound isn't much of a worry since it might have happened while you where away. My dog loses weight every single time we go away. She just doesn't eat as well as she does when she is at home with her peoples.

[huck1409]

Update on Huck:

We got the results of the blood and low dex tests back yesterday. This time, Huck's platelets were not low. They were 278 with a reference range of 170-400. The vet says that platelet count is sometimes hard to test accurately because they can clump together and seem lower than they actually are. He is confident based on this test that Huck's platelets are fine. That still leaves the issue of the big bruise at the spot of the blood draw, but it's obviously possible that the vet tech stuck him badly during the low dex test.

In any case, the vet is still convinced Huck has Cushing's. Here are the test results:

ALKP 330 (normal 20-100)

LDDS:

Baseline 6.8 µg/dL
4 hours 1.1 µg/dL
8 hours 6.5 µg/dL

Everything else was normal.

The vet told me this is consistent with the pituitary form of Cushing's, but from what I read online, it seems like these results can't differentiate between the pituitary and the adrenal forms?

We are going to take Huck to an endocrinologist specialist. We live in Manhattan, and it seems like there are some great specialists here. I'm sure he will recommend an abdominal ultrasound.

Obviously we will wait for the specialist's view and also further confirmation of the Cushing's diagnosis, but my vet said he wouldn't even treat for Cushing's at this point since Huck is not really showing any of the physical symptoms. As I mentioned, he has a mild potbelly and he does seem maybe a little more hungry than usual (although he has always been an enthusiastic eater so if there's any difference, it's quite mild). I'd love to hear anyone's thoughts on whether they'd treat in this situation? Obviously I'd rather not medicate Huck until I absolutely have to, but I also want him to be as comfortable and happy as possible. What are the side effects of the drugs like?

[My sweet Ginger]

I don't know where they drew blood from on Huck but one day I saw a large bruise on my pup's neck which scared the heck out of me. It turned out they drew blood from her jugular vein the day before and it was gone after a few days.

[labblab]

Hi again, and thanks for returning and posting Huck's test results. Yes, his LDDS is indeed consistent with the pituitary form of Cushing's. This is because his four-hour value was less than 50% of his baseline reading.


If the eight-hour postdexamethasone administration cortisol concentration is above the reference range, then evaluate the baseline and four-hour postdexamethasone administration cortisol concentrations to see whether cortisol suppression occurred during the eight hours. If at least 50% cortisol concentration suppression is present at the four- or eight-hour time points, the definitive diagnosis is PDH and additional adrenal function tests are not needed.

http://veterinarymedicine.dvm360.com/clinquiz-interpreting-low-dose-dexamethasone-suppression-test-results

Elevation in the ALKP is also consistent with Cushing's, and we often see levels that are much, much higher than Huck's. However, given his very few overt symptoms, I'm really glad you are choosing to consult with a specialist. If he was my own dog, I don't believe I would choose to treat, either, without further input. Huck is in the prime of his life, so if be truly has Cushing's, I do think you may consider starting treatment somewhat sooner rather than later so as to minimize accumulated systemic damage caused by chronic elevation of circulating cortisol. But it would seem as though there are still some remaining diagnostic question marks, and I think an ultrasound would be a great place to start.

Marianne

[huck1409]

Thank you both for your responses! It is invaluable to have such experts weighing in.

Yes, it looks like the vet took blood from his jugular vein (sounds awful!) and that's what the bruise is from. It looks very scary but seems to be bothering me a lot more than him.

We are probably getting the ultrasound next week. I will post anything we learn. I agree that Huck is in the prime of his life! I'm expecting him to be around for years and years, so we want to make sure we are doing absolutely everything we can to keep this under control.

[molly muffin]

Hi, are you getting the ultrasound this week?

Just checking in to see how Huck is doing.

[huck1409]

First of all, happy thanksgiving to all that celebrate it.

Huck had his ultrasound today and they found a 1 cm mass on one of his adrenal glands. This is very upsetting to me because, based on our LDDS results, our vet had us convinced it was pituitary dependent Cushing's. And since Huck is not really displaying very many physical symptoms of Cushing's and his enzymes are not very elevated, we were planning not to start treatment yet.

Obviously the adrenal tumor throws that out the window and is very discouraging. But maybe this is good news in some way? Maybe we can just have surgery and get rid of it altogether? Huck is only 7.5 and in very good health otherwise. But obviously the thought of the surgery is very scary. Has anyone on here had a successful surgery to remove an adrenal tumor?

The ultrasound specialist said he did not think the tumor was malignant based on the way the rest of the adrenal looks, but obviously we don't know for sure.

[molly muffin]

The surgery can be scary true. We have had members go through surgery successfully.

One of our members Trish, whose dog had surgery made up a list for others considering it to discuss with the surgeon, etc. As follows:


Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

My dog has a small nodule on her adrenal gland, which the specialist thinks is benign and not secreting. It didn't show up till a couple years after her cortisol had been high.

Normally with a secreting adrenal tumor they don't suppress at all on the LDDS test. It will be high at 4 hours and 8 hours. Hucks test showed suppression at 4 hours and then nonsuppresion at 8 hours, which is why your vet doesn't think it is the adrenal nodule causing the cortisol problem.

That isn't to say the adrenal nodule isn't or won't become a problem though. They can grow and become invasive into other body parts.

Have you spoken to a surgeon yet or what are your current thoughts?

[huck1409]

Thank you for responding, and thank you for that list of questions!! I will print this out and bring it with me. We have an appointment with one surgeon tomorrow and another next week. We wanted to check both out and see who we felt more comfortable with.

Both our vet and the specialist who did the ultrasound (who has a background in internal medicine) seem convinced we should take the adrenal mass out. But I am definitely not feeling so good about such an intense and risky surgery. Huck is only 7, and in incredibly good health. If I didn't know his cortisol levels were elevated, I would think there was nothing wrong with him. He is as lively, bright-eyed, and loving as ever. The only physical symptoms of Cushing's are a potbelly and a bit of increased hunger, but he's always loved food. No weight gain (he's at a perfect weight). No excessive drinking or urination. No coat or skin issues. No lethargy. Basically, his quality of life seems excellent to me right now. I am so scared to do the surgery and potentially lose him at such a young age when he is in such good health. But I also want him with me for a long, long time (before all this happened I was convinced he would live another decade), so I'm scared not to do the surgery and have the mass start causing more problems soon.

I had raised with our vet the possibility that Huck has both a pituitary tumor and an adrenal tumor. The vet seems convinced that there is only an adrenal tumor because only one adrenal is enlarged, and he would have expected both adrenals to be enlarged if there was also a pituitary tumor causing problems. But I spoke with my friend who is an internal medicine doctor (who treats Cushing's in humans), and he mentioned that 10% of humans have nodes on their adrenals that are not causing any problems. I really don't want to go through the surgery if this is just a benign "node" that is not secreting. Do you think I should push for a brain scan to try to see if there is also a pituitary tumor before I consider surgery?

Part of me wants to wait and see if Huck starts developing worse symptoms before we think about the surgery. But the other part of me thinks that his best chance of making it through the surgery with no complications is NOW, when he is young and healthy. I think I may try to ask some of these questions of an internal medicine specialist when I'm at the hospital tomorrow seeing the surgeon.

[huck1409]

We saw a specialist surgeon last night to further discuss what to do about Huck's adrenal tumor. The specialist--who knew more about Cushing's and adrenalectomies than I ever thought possible--did his own ultrasound, and disagreed that Huck had an adrenal tumor. In fact, he told us that Huck's right adrenal is perfectly normal (not enlarged at all), and Huck's left adrenal is also normal but has a small "node" on the end. He characterized it as a "node" rather than a "tumor," and doesn't believe it is secreting cortisol. He says definitely no surgery (at least until the node grows or otherwise starts causing problems). I am extremely relieved about that!

He suspects pituitary Cushing's, which is consistent with the LDDS test results. However, he said that it is a mystery as to why Huck's adrenal glands weren't more swollen. If Huck has a pituitary tumor, he would expect both adrenals to be enlarged--and neither really is. He referred us to an internal medicine specialist to try to get to the bottom of this. I'm obviously going to wait to see what the internal medicine specialist says, but now I'm wondering if Huck has Cushing's at all. He has the pot belly and intense hunger, but no other clinical signs. His cortisol is definitely elevated (and his ALKP enzyme), and the LDDS test was consistent with Cushing's, but why aren't his adrenal glands swollen?

This has been such a roller coaster. I hope we can get some answers soon! Could it be a problem with his liver or kidneys instead? I really hope we are not looking in the wrong place. We have great insurance so cost is not a problem. Can anyone think of any other tests they'd do to try to either confirm Cushing's or figure out what else is going on?

[labblab]

Just wanted to pop back to say that we've been told that a certain percentage of dogs with pituitary Cushing's do not exhibit swollen adrenals on ultrasound. Apparently this is a more likely result when the imaging is performed during the early stages of the disease.

Marianne

[molly muffin]

Hope you and Huck are both doing well and had a good holiday season