help with diagnosis

[pugrescue]

My little diabetic pug Emmit has been thru so many tests the last month or so, and each one seems to point in a different direction. I am finally thinking Cushings may be a possibility, and 2 different vets have pretty much given up, just keep repeating....he has so many problems.

Emmitt is 11 yr old rescue pug we adopted in Apr/15. We took him directly from the ICU where he had been in for ketoacidosis, pancreatitis , diabetes. Siince then he has also been dx with collapsed trachea and slightly enlarged heart.

took a few months to regulate, a bit of a bear actually, but very very stable and good numbers now. He is my 3rd diabetic, I have been a member of K9 Diabetes for more than 6 yrs. Have 12 rescue pugs in all, many medical conditions, never had a Cushings dog.

All went pretty well till Dec 10 when Emmitt began a long period of diarrhea. Lost weight at an alarming rate, 20.5 lbs down to 17 in 3 wks. Had been checked for worms, vet thought (I concurred) EPI, he tested neg end of Dec. By mid Jan he was down to 16.2 lbs, not eating well, more diarrhea and vet said IBD. We already had him on that diet and meals 4X per day.....treated with Panacur and Tylan and flagyl, and poos finally cleared up.

Still not doing well, lost so much muscle mass. Tested for Addisons ACTH
Jan 15....
pre stim he was 1! (2-6 normal range)
post stim (norm 6-18) he was 22.. (18-22 possible cushings, >22 cushings) Not exactly what we were expecting.

I dismissed Cushings as he does not look like that, and has no outward signs of pot belly, excessive hunger, PU?PD etc. Do you think that since he has his diabetes in good control, that the drinking/urinating is more normal because of that?

Xrays done on Jan 20 to confirm mega-esophagus (caused by myasthenia gravis) showed enlarged liver. Now vet says liver cancer!! Just doesn't seem like that to me.
So I am hoping you can help with interpreting his blood work he had done last wk

These are the values out of range, normal range in brackets

WBC..........36.52 (6-17) has been high since adoption
neutrophils 32.15 (3-12) " " " " "
RBC....4.9 (5.5-8.5)
HGB ...10.6 (12-18)
HCT ... 32.65 (37-55)
ALP... 453 (20-150)
ALT... 377 (10-118)
BUN.... 38 (7-25)
NA 138 (138-160)
K.....5.3 (3.7-5.8)
ratio 26 (>29)

So to make a very long and agonizing story shorter, does anyone think it is worth doing a urine test for creatinine/cortisol ratio? Or am I out to lunch completely and just grasping at straws.

I know his liver values are high, but I have had several pugs with CAH, and none of them seemed like this. Have had ones with siezures etc from BA, but Emmitt does not even seem like a liver dog to me.

So after so much research, Cushings explains the high WBC incl Neutrophils, enlarged liver, diabetes, Addisons ACTH test which turned out to be a Cushings test instead LOL.....

He is eating well, feeling good most of the time, is regurgitating somewhat because of the mega-E & MG, but he is not ready to give up and neither am I!!

Any input is appreciated. Joan

[tank&kat]

Hi Joan,

It doesn't sound like Cushing's. I can't explain the exaggerated ACTH response. Hopefully someone here with more experience can help with that. Vets will generally not make a concurrent diagnosis of these two diseases unless symptoms are obvious and that doesn't seem to be the case with your boy, especially since he lost so much weight. Weight loss and diarrhea are not associated with Cushing's.

It can't hurt to do the UCC. It is a simple urine test. I personally wouldn't do it unless my dog had more symptoms. I hope you find out what's going on with him. It can be very frustrating when we don't know how to help our babies.

Katherine

[Renee]

Hello fellow pug mom!! :) 12 pugs at once? WOW! I have three at the moment and that is enough for me. Where are you located and what pug rescue are you working with? Just being curious. I am on the board and an active participant for polar pug rescue up in Alaska and have outreach with most of the pug rescues across the US. Pugs are just amazing, aren't they? My girl pug has cushings and has been on treatment since Dec. 2013.

Based on your description, I do not personally feel that cushings is at play. Symptoms play a very strong role in the diagnostic phase and what you describe does not sound like cushings at all. I would suggest you don't waste any more money pursuing cushings at the moment, and focus elsewhere.

Do you have access to an internal medicine specialist in your area?

Besides the out of range bloodwork, and the severe bout of diarrhea / weight loss, what current symptoms are you trying to figure out? It sounds to me as though Emmitt may have had an acute, and long, bout of pancreatitis. Did you ever run bloodwork to check for pancreatitis? Pancreatitis can be both acute and chronic. It's possible he had an acute episode and it has become a chronic condition.

I sure wish you knew what was going on with Emmitt. There are some very smart people on this board, so I know more of them will be along to offer more ideas.

[labblab]

Besides the out of range bloodwork, and the severe bout of diarrhea / weight loss, what current symptoms are you trying to figure out? It sounds to me as though Emmitt may have had an acute, and long, bout of pancreatitis. Did you ever run bloodwork to check for pancreatitis? Pancreatitis can be both acute and chronic. It's possible he had an acute episode and it has become a chronic condition.

Hello, and welcome from me, too! Boy, your little boy has certainly been through an awful lot. How wonderful that you are showing him so much care and compassion. I do want to repeat what Rene has written above, because I also share her questions. It is true that there are aspects of Emmit's presentation that correspond with Cushing's ("stress" leukogram, vulnerability to pancreatitis and megaesophagus, elevated ALKP, etc.), but there are others that do not (diarrhea and weight loss, well-controlled diabetes, three-fold elevation in ALT, anemia, lack of overt Cushing's symptoms, etc.).

I have only a moment to post right now, but I believe my next step forward would be to request an abdominal ultrasound performed by a trained sonographer using high resolution equipment, if possible. You mention x-rays having been performed, but an ultrasound should give you more detailed info about liver abnormalities as well as the presence of other internal problems with the adrenal glands, pancreas, kidneys, spleen, etc.

I would put my money towards an ultrasound rather than a UC:CR because, in essence, the urine test will only be duplicating the more Cushing's-specific ACTH. You already know that Emmit is borderline positive on the ACTH, so there is every reason to think you'd also see elevation on the urine test. But the question is "why?" and the urine test won't provide any additional info in that regard.

I notice that Emmit is also somewhat anemic in addition to the white cell abnormalities. Do the vets think he is losing blood in conjunction with the diarrhea, or have they discussed the anemia at all?

Again, sorry that I don't have time to write more at the moment. But an ultrasound is truly the next diagnostic I would pursue.

Marianne

[pugrescue]

Thank you all for your input and expertise.

Renee....we adopt most of our pugs, and transport etc for DFWPR, Dallas ForthWorthPugRescue. They intake about 10 pugs per wk, a very good well organized group. We personally adopt only the "un-adoptable".

Emmitt has been tested for pancreatitis. When in ICU in Apr PCL was positive. Negative every time since. I may not have been clear, but the diarrhea has cleared up, and he is now gaining weight ( 1 lb in the last wk). I know that he does have mild chronic pancreatitis, and that is why we have him on a special low fat diet, and partly why we feed 4X per day.

I will look into the ultrasound and get that scheduled. I think what I am trying to "fix/change" is the dx of hepatic cancer. Hopefully the ultrasound will confirm my gut feeling that this is not cancer....many people would not want to find Cushings as the cause of his abnormal bloodwork & the enlarged liver....but I do as this is treatable.

In regards to his diabetes in tight control. I have read that many Cushings dogs are hard to regulate, but have not really studied in what regard. Emmitt was a bear to get where we are today. I have experience with difficult diabetic pugs in the past (currently have 2), but Emmitt took some real innovative means to stabilize. He gets 4 meals and 4 insulin shots of Novolin N per day at 6 hour intervals. There is no possibility that he can be regulated in tight control with the standard 12 hrs spread and 2 meals/injections per day.

Anyway, will call the clinic schedule the U/S and report back.

Thanks again for your help, nothing like hearing from those that have been there done that.

Joan

[Renee]

Yes, I know DFWPR very well. I have donated to them over the years and been in touch with a few people over there. :) What an amazing organization and one that really sets the standard for a lot of us.

I agree with Marianne - a high quality ultra-sound may give you the most information going forward.

[molly muffin]

I just want to say hello and welcome. The others have covered everything that I would want to cover.
What I can say in regards to the higher ACTH post, after the very low pre, is that a dog with any kind of chronic illness is naturally prone to storing and producing greater amounts of cortisol This does not necessarily mean cushings though, and there is where symptoms come into play in trying to figure out if cushings is in fact a possibility. I'm really not inclined to think so at this point, but that doesn't mean it can be completely ruled out.

I do think the ultrasound will give you most bang for the buck and it would be my next step too. Chronic pancreatis, can be a real bugger too and hopefully it won't be flaring up again anytime soon.

What a sweetheart, to personally adopt the adoptable. I have a great deal of respect for you just for that right there. You aren't alone on this forum either, in taking in those who otherwise would have no other options. We have a few who do the same. It always brings a smile to my face and a tear to my eye.

[tank&kat]

Joan,

I noticed you mentioned that Emmit gets 4 meals and 4 insulin shots of Novolin N per day at 6 hour intervals. No diabetic dog should have this many injections per day. The norm is 2 with 3 times a day being very rare. I see that he weighs 16 pounds. How many units of insulin? I don't have much experience with diabetes. I am just learning so I want to refer you to the facebook group and the K9diabetes group to see if the people there can also help with this part. There are a few who have experience with diabetes and Cushing's in the fb group.

Pancreatitis can cause consistently high blood glucose levels which could be why you are having to give 4 shots a day. I can appreciate you not wanting a diagnosis of cancer for your boy. No one wants to see that happen. I believe the people in one of these groups can help you examine further why you are having such a hard time regulating glycemic control.


https://www.facebook.com/groups/89435412886/

http://www.k9diabetes.com/forum/

Katherine

[Renee]

I want to refer you to the facebook group and the K9diabetes group to see if the people there can also help with this part. There are a few who have experience with diabetes and Cushing's in the fb group.




https://www.facebook.com/groups/89435412886/

http://www.k9diabetes.com/forum/

Katherine

Her original post says she's been a member over on K9Diabetes for the last 6 years. :)

[tank&kat]

Her original post says she's been a member over on K9Diabetes for the last 6 years. :)

I have a bad habit of scanning when I read. Sometimes I miss little details or big ones lol. The info I got was from a member in the facebook group. She instantly said that it was not normal for a dog to have 4 shots a day.

[Haleth]

Just a quick reply: Hello! My Haleth had hepatocellular carcinoma (diagnosed July 2014) and and I can tell you it was nearly invisible beforehand. As with most dogs with spleen cancer, you first find out about it when the tumor bursts. That's what happened to us! Even a normal senior wellness exam didn't show anything alarming 2-3 months before the rupture. So I would get the ultrasound done STAT even if it is to rule tumors out. If it does turn out to be a tumor; it doesn't matter in the short run if it's cancer, because even benign cancers can rupture. Very dangerous and something you want to catch. If it is hepatocellular carcinoma I can tell you that it is an indolent cancer and most dogs live 4+ years after diagnosis. So a much better prognosis than hemangiosarcoma. It's also a cancer that only reliably responds to surgery, so again you want the tumor out of there, if there is one and the dog can handle the surgery. I'll also second getting in touch with an Internal Medicine specialist; ours has been invaluable since we rushed Haleth to our local emergency/referral centre that night in July.