Cushing's or maybe not please help so stressed

[Dream]

Hello, I am new here my furbaby Lily is a 9yr old Carine Terrier and I need some advise I am very frustrated. I will try and keep this as short as possible. Her medical issues started in 2009 with what I thought was an eye infection turned out she wasn't making any tears. 3yrs later two ophthalmogist lots of eye medication and money and it didn't help, so she is pretty much blind now. 2012 Lily started with excessive drinking and peeing had an ultrasound of abdomen which vet said was normal except for small adrenal glands also had bloodwork done at the time and all labs were normal. Vet told us it was kidney failure or cancer and just keep her comfortable-quality of life. In 2014 she stopped eating had no energy so off to vet we went thinking this was the end, they did x-ray of liver which was normal and took more bloodwork, Lily was then diagnosed with hypothyroid and was put on Levothyroxine. She seemed to be doing a little better with the meds, then 2015 she developed what vet is calling a Staph infection on her stomach so on antibiotics for two weeks. It went away until she finished the antibiotics and it came back. I decided to take her for a second opinion and that vet thought she was overweight even though she was not eating very well. In sept 2015 Lily started limping on her back leg took her to vet they said she had a buldging disk and put her on anti-inflammatory, pain meds and steroids for two weeks. She seemed to do much better and can now walk. December they repeated her thyroid and did a CBC panel where they said her liver levels were high so they put her on liver supplements Denamarin and wanted a urine sample. I brought in the urine and she had blood in her urine and it was very diluted which I new due to the excessive drinking and peeing. Lily then went back on antibiotics and I needed to bring in another urine sample when she was done with the meds. There was no blood in her urine at that time it was still very diluted. That is when the vet said she thought it may be cushings disease. She now wants another ultrasound and more bloodwork and said she would also refer me to an internal specialist. As of 2 days ago I noticed a large lump on left side of Lily's body between her ribs and her hip that I need to call the vet for. My questions is first does this sound like Cushings disease or something else that my vet may be missing. Would Lily still be doing somewhat ok after all these years or would it have progressed more quickly. When is it ok to just let her be and give her the best rest of life she has without the guilt of not doing more? So Confused thanks for listening.

[Harley PoMMom]

Hi and welcome to you and Lily!

I am sorry your dear girl is going through so much right now and I sure do understand your confusion and anguish.

We love details and you've done a fabulous job of providing them to us but, of course, I have some more questions. :o Could you get copies of all tests that were done on Lily and post those results here? With respect to the blood chemistry and CBC, you need only post the highs and lows and please include the normal reference ranges. Were any diagnostic tests performed on Lily, and if so, could you post those results too? Is Lily's urinating and drinking still increased?

An ultrasound of a dog with Cushing's generally shows a change in the size of the adrenal glands: dogs with the adrenal type of Cushing's have one adrenal gland that is larger than the other; dogs with the pituitary form of Cushing's have bilateral enlarged adrenal glands. The majority of Cush dogs have a ravenous appetite, pee rivers, and drink buckets upon buckets of water, and these symptoms do not wax and wane. So with Lily's adrenals being on the small size and her inappetence a Cushing's diangosis is questionable.

When a dog has diluted urine a regular urine test may not pick up the bacteria so an urine culture and sensitivities test is recommended.

Cushing's moves at a snail's pace so one does have time to get a confirmed diagnosis for their pet. The sole purpose of treatment is to remedy problematic symptoms, the medications used for Cushing's do not to cure it. So if a dog doesn't show any obvious Cushing's symptoms I don't know how one would be able judge how the treatment is working.

Cushing's is probably the most difficult canine disease to diagnose. Physical symptoms associated with Cushing's are shared by many other diseases, blood and urine abnormalities are shared with other other diseases and the diagnostic tests to measure circulating cortisol are flawed and can yield false positive results in the face of non adrenal illnesses or even stress. All of these things make it very challenging to correctly diagnose Cushing's which makes it one of the most misdiagnosed canine diseases. There isn't one test that can accurately identify it so multiple tests are needed to validate a diagnosis for Cushing's. Unfortunately the experience acquired by a general practitioner in vet school is woefully inadequate to provide the hands on experience and extensive understanding of the endocrine system, both of which are required to safely and effectively diagnose and direct treatment of any endocrine disorder, including Cushing's; however, an Internal medicine specialists receive this kind of training, so I think the recommendation to see an Internal Specialist is a really good idea.

Please know we will help in any way we can, and do not hesitate to ask all the questions you want.

Hugs, Lori

[Dream]

Thanks for the information. I have another question regarding drinking and peeing. Lily is trained to go on pee pee pads so prior to 2010 she would average 30 a week once she started drinking a lot she went up to 100-150 a week and I had to buy her a water bowl with the water bottle attached so she would not run out while I was at work. After she went on thyroid meds she went back down to 50-100 pads a day and right now we can go through 50-100 a week. She weighs about 30lbs. She gets up every 3-4 hours a night to go pee. Not sure anymore if this is truly excessive just got used to it.

[Harley PoMMom]

Can you monitor her drinking by measuring it, on the average, a healthy dog drinks about 1 ounce of water per pound of body weight per day. Here's a handy spreadsheet to log water intake:


http://www.k9cushings.com/forum/showpost.php?p=59503&postcount=1

[Dream]

Thank you for helping. I am going to vet tonight to pick up refill on Lily's thyroid med and I will get a copy of her lab results will try and post them later. I am also going to get the number for the internal specialist.

[Dream]

I have lab results ALK phosphatase 155 red range 5-131, RBC 9.4 ref range 4.8-9.3, Hemoglobin. 21.9. Reference range 12.1-20.3, Monocytes 984 ref range 0-840 everything else was in normal range. Her urine test the specific gravity 1.008 ref range 1.015-1.050 everything else was normal. Please tell me what you think and if you need any other information. Thank you for being so helpful

[molly muffin]

Hello and welcome from me too.

Thyroid can also cause an increase in water intake and peeing. I'm with Lori, that with adrenal glands on the small side, that doesn't seem very cushing like.

I think before pursuing cushings testing, I'd make sure that the thyroid is stable, and she has been off antibiotics and any steroids for I'd guess about a month. Then see if the symptoms are still there and if so, progress on to an LDDS test. I'm rather thinking that her cortisol has been running high due to the issues she has had with her health and so I would also see if that dilute urine gets into range again. With the drinking from the thyroid, I'd expect that to be more dilute but with the thyroid stable, if that was the cause then it might get more concentrated.

Now I'm not saying that she doesn't or does have cushings, just that because it is so hard to diagnose, you want to rule out other things first.

Also, you said they mentioned kidney failure at one point? Does she have high BUN and Creatinine? It wasn't mentioned on your list of out of range items. I would expect to see high values in both, especially Creatinine if she had kidney failure.

Deep breaths.


The steroids also will cause an increase in drinking and peeing when she is on them and for a bit afterwards.

[Dream]

Thank you because that is how I feel the vets just don't seem to know and they want to keep doing the same tests over again. Her total T4 is 2.1 reference range being 0.8-3.5. Her bun/creatinine level is 10 reference range 4-27. She has been taking a liver supplement for about 2 months now and vet wants to repeat liver labs when she finishes the 3 month supply. Lily was home all day today and slept on the sofa and her pee pee pads were dry until she got up to see me now that would not be a cushings symptom.

[molly muffin]

okay so thyroid seems to be stable and in a good range. BUN/Creatine, looks good too, so I'm personally not thinking kidney failure.
It wouldn't hurt to repeat the liver tests once that supply is gone and see if it has helped.
Liver enzymes can take awhile to come down, if they do. Nothing is a given.
hmm, no you wouldn't think the pee pads would be dry. So, seems to be when she is moving around the most is when the peeing starts. Gets excited, etc.

[Harley PoMMom]

Is Lily getting her thyroid medication twice a day? And are her monitoring tests for the thyroid levels being performed 4-6 hours post pill?

[Dream]

Lily gets her thyroid meds twice a day and she gets her levels tested every 6 months now that she is stable. I will be doing more labs as soon as she finishes her liver supplements she still has another few weeks to go. I am not going to do anymore testing until we see where that brings us. Thank you for all of your help and advice now I have a plan that is reasonable. I wish you all the best and I will definitely be back if cushings disease becomes a 100% diagnosis.

[molly muffin]

Even if cushings doesn't become a 100% diagnosis, you can always pop in and give us an update or ask any questions. Never know when someone has been through something similiar and can offer their two cents. :)

[Dream]

Hello, i took Lily to vet yesterday for the lump on her side, we had to see a different vet than the one who originally thinks she has cushings, anyway the vet has no idea what the lump could be she said Lily didn't seem to be in any pain. Vet said X-ray wouldnthelp and a biopsy would probably show nothing and I should do an ultrasound or just watch it and see. I mention that I was giving her some carprofen but was worried that it would do more damage to her liver. The vet didn't think that was a problem because her levels were not that far off. This vet however recommended that I go to an ophthalmologist in our area that is doing implants in the dogs eyes that release medication for dry eyes because Lily doesn't make any tears. Has anyone here heard of this I don't think I am going to even look into it. Vet also wanted me to put her on free form snip tips by Bauer to help her hypothyroid skin. I didn't realize she even had a skin issue. I am just confused

[Dream]

I forgot to mention Lily's temp was 103.8 vet first said fever but looked in her chart and another temp read 103.0 so vet said she must run high is this even correct does anyone know thanks

[molly muffin]

Normal temperature for a dog is 101 to 102.5 degrees Fahrenheit.

Can they do a fine needle aspiration of the lump to see if it is fatty cells, like maybe for a lipoma? Many dogs get lipomas as they get older. Mine has them, and as long as they don't get too big or bother her, we have left them alone. Some have to removed because they get huge, are under muscle and can cause lameness in the dog, that sort of thing.

I haven't heard of the implants for dry eye. Interesting. Not sure if I would go that route or not though, I'd need to know a whole lot more about it.

[Dream]

Hello everyone, you are all so knowledgable here I just got Lily's lab back and need advice. I am reposting lab results from December before Lily wasn't on the liver supplement and then I will post results after being on liver supplements for 3months and also she is scheduled for an ultrasound in 2 weeks. Decembers labs ALK phosphatase 155 (ref range 5-131),RBC 9.4(ref range4.8-9.3),hemoglobin 21.9(ref range 12.1-20.3)monocytes 984(ref range0-840)all other labs were normal. Now for the February labs RBC 9.9 (ref range 4.8-9.3),hemoglobin 22.0(ref range 12.1-20.3),hematocrit 62 (ref range 36-60), platelet count 101 (ref range 170-400), monocytes 872 ( ref range 0-840), globulin 3.8 (ref range 1.6-3.6), ALK phosphatase 177 (ref range 5-131). Also her bun/creatinine went from 10 in dec to 27 in February (ref range 4-27), wbc was 10.9 up to12.3 still normal but went up everything else is normal. Seems she really has had a big change but not sure what it could be? Does anyone know? Thanks

[labblab]

Hello, and welcome back to you and Lily! I'm afraid I don't have a single answer to explain the different lab variabilities. The one I'm especially wondering about is the low platelet count. I don't know what might be going on to cause that. Have there been any changes in that lump on her side? Also, how has she been behaving?

I do think the ultrasound is a good idea. Also, you had spoken earlier about a referral to an internal medicine specialist -- I'd encourage you to follow through on that, as well. Having an expert looking over all these results may give you the peace of mind that all the puzzle pieces are being accounted for, and nothing is being overlooked.

Do keep us updated, OK?
Marianne

[Dream]

Thank you I will be looking into all of this in the next month

[Dream]

Hello, I got the results back from Lily's ultrasound and would like to run them by everyone. Looks like spleen, kidneys, adrenal glands, GI, pancreas, urinary are all normal. The Liver however is enlarged as it extends caudal to the gastric fundus. The liver is hypoechoic, the portal markings are more prominent than normal. The liver has a coarse texture throughout. The gall bladder and bile are normal. The vet first wanted to put her on milk thistle and a pill but I explained that she had been on liver supplement and her labs got worse so we stopped. The plan as written on the ultrasound is supportive care. With all symptoms and labs and now ultrasound I do not feel this is cushings disease but does mean liver disease but what stage? One more thing the vet never looked at her lump through the ultrasound even though i asked it be checked when I booked appointment and requested they look at it this morning when I brought her in. When she called be I asked about it and they didn't look so frustrated.

[molly muffin]

Hmm, they said the bile was normal. Are they planning to pursue any liver testing like the cpl?
Also I would have them make sure to look at that lump next time you go in.

[Dream]

So I have taken Lily to the internal specialist and they wanted to do a ACTH test the results are 4.5 and 12.3. The vet said that was negative for cushings but that she may have atypical cushings disease and that I should put Lily on Melatonin 3mgs at night for one month and then have her liver labs done again to see if they have come down. Now I read online that it could take 4 months to see results with melatonin? Also just wanted input does this sound right and does this treatment make sense?

[labblab]

Welcome back to you and Lily! I'm really glad you had the chance to see the specialist, and it is interesting to learn that Lily's cortisol as tested by the ACTH is within the range of a normal dog. As you may already know from your reading here, though, it is possible that she may have elevations in other adrenal hormones other than cortisol and presumably that is what the specialist is considering. Those other hormones can also be tested via ACTH stimulation, but there is only one veterinary lab in the country that analyzes the complete panel: the University of Tennessee at Knoxville. I am assuming your specialist is wanting to spare you the cost of that additional testing, but is recommending the treatment that would be appropriate for "Atypical Cushing's" even in the absence of the actual test results. The treatment is generally benign, so I'm guessing he figures "why not give it a trial run."

The one thing I'm wondering about in that regard, however, is whether he has also recommended that Lily take another supplement, lignans, in addition to the melatonin. According to the treatment recommendations of UTK for dogs with "Atypical Cushing's," it is the combination of both supplements that offers the best chance for results. Here's a link to a thread on our Resources forum that lists several different articles, and if you scroll all the way to the bottom, you'll find some information that is specific to lignans.

http://www.k9cushings.com/forum/showthread.php?t=198

So if the specialist hasn't recommended lignans, you might want to ask him specifically about that. Also, was he able to do some diagnostics or offer an opinion re: that worrisome lump?

Marianne

[Dream]

The vet visit went like this: the lump on her side is what happens when dogs are overweight but she was not sure why one side was larger than the other and didn't think it was anything to worry about. She tested for cushions even though didn't really think it was because her liver was dark in color and her labs were did not indicate cushings. She then talked about possible infections or cancer and maybe do chest X-ray and mri of brain. She said it was definetly not liver disease but it could be SARDS. This actually made the most sense to me the symptoms are blindness, elevated ATL when all other labs were normal, and frequent diluted urine, she couldn't confirm because she couldn't see here retina because of scar tissue but of course there is a test I could do. When vet called with the results of ACTH test I asked what she thought and what would be the next step that's when she said atypical cushings don't know if she is just grasping at straws. I said Lily is 10yrs old she has been having issues for at least 4 yrs now and is still extremely stable so before I have to mortgage my house what can we do. That is when she said to try the melatonin. Sorry for the rant hope someone can make sense of this any advise would be greatly appreciated

[molly muffin]

Melatonin and lignans are the treatment for atypical which is when cortisol is normal as Lilly's is but at least 2 other sex hormones are elevated.

The University of Tennessee does say to give it 4 months on treatment and then test the sex hormones to see if they are normalizing and if you see any symptom decrease. The scar tissue unfortunately will not change on the eyes, my dog has these too from retinal bleeds caused by high blood pressure.

I'd try it. I did in fact try it but needed to bring down cortisol also so went ahead with trilostane. You don't need to do that at least, so one thing ruled out.

[Sadielove]

Welcome. Sorry to hear about your. Furbaby. I am not an experienced person on the site but a mom of a Cush baby and here to give others comfort that we are always here to listen and encourage.

[Dream]

Thanks for the info I will call the vet and find out about the lignin( probably not spelled correctly) and the testing at 4 months not one

[Harley PoMMom]

We have information about Atypical and a list of lignans recommended by the University of Tennessee which can be found in our Resource Forum, and here's a link to that info: http://www.k9cushings.com/forum/showthread.php?t=198

Hugs, Lori

[Dream]

Lily just had labs done tonight to check her liver levels after being one month or a little over on melatonin for atypical cushings they are also checking her thyroid. My question is would her thyroid levels be off as a result of the atypical cushings or is it a separate problem. Her original thyroid labs were on the low side by just a few points. Dr decided to treat with medication because she had no other answers we have since changed vets and now are here with atypical cushings so again just wondering if thyroid was ever really the problem and does it still need to be treated in addition to cushings? Thanks for all the help

[Dream]

Vet just called and it looks like Lily's ATL went from 156 to 138 on melatonin so that is good new and her thyroid levels are normal just have to hear back from the iMS

[Harley PoMMom]

That's great that Lily's ALT level went down!! Now, regarding her thyroid, is she being treated for hypothyroidism? Dogs with Cushing's may have sick euthyroid syndrome which is when a non-thyroid issue causes a low thyroid level, so I would image that a dog with Atypical Cushing's could also have an abnormal thyroid level.

Hugs, Lori

[molly muffin]

That is very good news! So glad to hear that it is helping her.