Calcinosis cutis treatment? Help! Cushing's uncertain, diagnosis uncertain :(

[mistyB]

Hello,
I am hoping for some advice from anyone who has dealt with calcinosis cutis –we do not yet know if our girl has Cushing’s or not.
The history: Back in November, I noticed that our 12 year old (13 this June) French Bulldog, Mimi, had a strange spot on her head, it looked thick and dark, but did not seem infected or paining in her in any way, so I just kept an eye on it at first. Then I noticed two spots on her neck that looked sore, and when I touched them, the hair could be pulled right off the skin. I made a vet apt. and the vet suspected a bacterial infection. Mimi was put on oral antibiotics with an antibiotic topical cream as well. She had the two spots on the neck that were red and sore looking with hair that could be peeled off in clumps. One spot on her back that was just a little red. And the weird crusty spot on her head that didn’t look at all like the other three, but could also at that point have the hair peeled off at the edges.

The two week antibiotic treatment cleared the two neck spots and the back spot right up. The skin became pink and healthy, hair grew back on those three spots (somewhat slowly) and they are still perfectly healed to this day. The spot on her head didn’t respond at all and actually was getting worse. We went back to the vet and a longer course of oral antibiotics was prescribed, as well as continuing the topical antibiotic. She was on antibiotics for another month, and at the end of them, I took her back because I saw no improvement –the head spot was larger, and very crusty. The areas that weren’t dark and crusty were almost scaled.

Our vet took biopsies and the biopsy result showed the spot was calcinosis cutis. At that point, our vet had Mimi come in for a full blood panel and a fungus test. She talked to us a bit about Cushing’s Disease. And gave us DMSO gel to treat the spot. At the time we went in for the full blood panel (May 2nd), there was a new spot on Mimi’s head that I was afraid might be another of these, although on that day the new head spot was just a little red and a slight bit of roughness to the skin.

Once the blood test results were in, we had a long talk with our vet. She is perplexed. Mimi’s blood tests are 100% normal and show none of the indicators she was looking for to support Cushing’s as a diagnosis. Mimi has no other symptoms of Cushing’s –no pot belly, she doesn’t drink or urinate or eat any more frequently than she ever did, no hair loss other than the spots, and no weight gain (in fact, she had lost a bit of weight)

At this point, the vet consulted with the lab doctor who diagnosed the calcinosis on the biopsy, and he looked at the results again, as well as had another diagnostician at his lab look, and they are positive it’s calcinosis cutis. Our vet also spoke with some sort of canine disease specialist who said if Mimi has the calcinosis, it’s almost a guarantee she has Cushing’s.

Our vet is hesitant to do the further testing (suppression test?) for Cushing’s right at this moment for a couple of reasons –one, we don’t have the fungal test results back yet, and she wants to rule that out first. Two, when Mimi first presented with the four original spots, the antibiotic topical had a steroid in it, because the head spot was itching Mimi. She only had the topical applied for about 5 weeks, and the vet thinks this would be an abnormally short time for an exterior source of steroid to be the problem, but she wanted to see how the head spot did with just the DMSO first. Just in case the head spot, like the other three spots Mimi originally had, were just a bacterial infection, but the steroid cause the head spot to become calcinosis. Which we know is a long shot, since the head spot never did look like the three that healed, even before any topical.

So, I have been treating the head spot with DMSO since May 2nd. Also treating the new head spot. The original spot pretty much looks the same, it is a large scale, and occasionally seems to spread a bit at the edges (I’ll notice a bit of hair peel at the edges). It has never seemed to hurt her at all, and she doesn’t mind when I apply the DMSO to it.

The new spot, which was just a reddened bit of skin on May 2nd, is now as large as the original spot (about 2 inches), and became very swollen and oozy and horrible in the last two days. I couldn’t even put the DMSO on it this morning or yesterday morning, as it is actually hurting Mimi. She yipped yesterday morning when I tried, and I have never heard her yip in my life. She is very stoic. Last night I bathed her and gently put a warm washcloth on the new spot. Large chunks of the hair in that area came right off and it just looked so oozy, raw and sore that I put a piece of A&D ointment covered gauze on it after her bath.

We’re at a loss as to what is the best way to proceed. I’m trying to get Mimi in to the vet today to show her how much worse the new spot has become.

For anyone who has used DMSO –is it normal for spots to continue to worsen? How long until the gel has a positive effect?

Does anyone else have a dog who had absolutely no Cushing's symptoms except the calcinosis cutis?

This is so horrible, we have no idea how to help our dog, we're not even sure what is actually wrong with her :(

[labblab]

Hello and welcome, although I am so sorry about Mimi's skin problems. We indeed have had other folks who have battled CC, and one of our current members, Renee, is an expert and I'm betting she'll soon be by to talk with you.

It does sound to me as though your vet is doing a very careful and thorough job of trying to sort out the diagnostics. Obviously, we are most familiar here with CC secondary to the elevated cortisol of Cushing's. But one of our staffers, Glynda, has searched out these three articles that document cases that were instead associated with systemic infections. So I think it's a good thing that your vet has been pursuing the blood panels and fungal test. In the absence of any Cushing's symptoms, it does lead one to believe that there is likely a cause other than Cushing's in Mimi's case. FYI, here are those articles:

http://www.jaaha.org/doi/abs/10.5326/15473317-35-5-368?journalCode=aaha

http://www.ncbi.nlm.nih.gov/pubmed/16359308

http://www.ncbi.nlm.nih.gov/pubmed/19037918

Regardless of cause, I know your focus right now is on speeding the healthy process. So as I say, do check back and I'm sure Renee will be stopping by to help.

Marianne

[Harley PoMMom]

Hi and welcome to you and Mimi!

I have manually approved your membership so now all your posts will be seen right away. Also, please just disregard the validation email that was sent to you from k9cushings.

Gosh I am so sorry your sweet girl is going through so much right now and I do understand how worried you must be. Getting that biopsy performed to confirm the calcinosis cutis was very important so I'm glad to see that was done. Now, that calcinosis cutis (CC) sure is a bugger to get under control and unfortunately it gets worse before it gets better.

We do have members dealing with CC with their dogs and are having success with treating it, however, the dogs with CC were diagnosed with Cushing's. I've been a member of this forum for around 7 years and I don't recall a dog that had CC and did not have Cushing's. And with those cushdogs that do have CC getting that elevated cortisol down to the therapeutic ranges is critical in getting control of that CC.

Symptoms of Cushing's can be different for each individual dog so even though Mimi is not experiencing the common clinical signs of Cushing's does not guarantee that she does not have it. As far as the tests for Cushing's, there are two that are usually performed, the ACTH stimulation and the low-dose dexamethasone (LDDS), the LDDS is considered the "gold standard" test to diagnose Cushing's. With Mimi having CC I wouldn't recommend having the LDDS performed because when a non-adrenal illness is present it can cause the LDDS to yield a false positive result. Instead I would advise having an ACTH stimulation test performed to see if her cortisol is elevated as it is less likely to yield a false positive result in the face of a non-adrenal illness.

Our resident CC expert is Renee and I am sure she will be along shortly but in the meantime you can take a look at Renee's album where she posted pictures of her Tobey with various stages of CC, here's a link to her album: http://www.k9cushings.com/forum/album.php?albumid=805, also I'm including a link to her thread where you will find the treatments she used to get that CC under control: http://www.k9cushings.com/forum/showthread.php?t=5908

I am sure am sorry for the reasons that brought you here but sure glad you found us and we will help in any way we can.

Hugs, Lori

[Renee]

Hello and welcome, although I am so very sorry you are dealing with the dreaded CC. My pug Tobey has cushings and has had CC since the fall of 2013. Her lesions are cleared up right now, but she still has them internally.

I am very glad you had a biopsy done, as this is the only true way to diagnose CC. However, I think your vet is very smart to wonder how the use of topical steroid would impact the biopsy results. Has your vet reached out to the lab that did the biopsy to get their feedback? I highly doubt you would want to put your girl through another biopsy, but one has to wonder how the results were impacted. Five weeks of use on the topical sounds like it would be long enough to change the character of the lesions and possibly impact their composition.

The fact that the other spots healed up with antibiotic use is very interesting as well. In traditional CC, which is caused by excessive cortisol, nothing will 'heal' the lesions expect for lowering the cortisol in the body. This usually takes months and months. As a reference, it took a solid 6+ months for my pug's CC to heal, once we got her cortisol lowered and into the proper range. That said, your physical descriptions of the lesions sound very much like CC, which has me perplexed!

While CC is generally presumptive for cushings, there is that very small minority of dogs that can develop CC for reasons other than cushings. Other sources of stress, such as kidney/renal disease, thyroid disfunction, increased serum calcium or phosphate levels, or even just the extreme stress from the other bacterial infections. I would think this is exceedingly rare - but certainly possible. Is there a chance that your pup has calcinosis circumcripta, rather than calcinosis cutis? The difference is that the circumscripta version is much more likely to develop due to short term stress and heals on it's own within a few months. CC, on the other hand, generally will not heal until the underlying cause is identified and addressed. Whatever is causing the CC will continue on and more and more lesions will develop.

If you are interesting in ruling out cushings, you could have your vet run a UC/CR test. It's a simple urine test that can help to rule out excessive cortisol. I do also wonder if it's possible that your pup has elevated sex hormones, rather than cortisol? This is known as atypical cushings. Of course, the complete absence of symptoms does make me really scratch my head! I do agree with Lori in regards to running an ACTH. And, while you are at it, you may consider running the ACTH through the University of Tennessee (experts do I have the correct university?) to have them check the sex hormones as well.

I'm hoping a few other experts will stop by with other ideas. In the mean time, I will definitely be doing some more thinking!

[mistyB]

Hello to all,

I'm not sure if the vet ran a UC/CR test, I will ask her today -we have an appointment this afternoon. I know she took urine and tests were run, I'm just not sure which ones. She did check Mimi's thyroid and ruled it out.

I believe seeing how bad the new spot on Mimi's head has become, and how quickly, may cause her to want to test for Cushing's, (if the fungal tests come back as normal). We were hoping that the original calcinosis spot on Mimi's head was just a bacterial lesion that was having a rare reaction to being treated with a steroid antibiotic -but the new spot on her head has never been exposed to any sort of a steroid, and it is a mirror version of the first head calcinosis spot.

[mistyB]

Hi Renee,
I just wanted to clarify -I don't believe our vet thinks the antibiotic ointment affected the biopsy results -she has had the lab diagnosticians check and double check their results and they are sure the biopsy sample was calcinosis cutis. What she wonders is if the ointment we used on the head lesion actually caused it to become a calcinosis cutis.

It's just very weird, because what caused us to go to the vet were a total of four lesions on Mimi, two on the neck, one on the back, and one on the head. The three body lesions were all alike -smooth bright pink sore looking skin with the hair able to be peeled right off. The head lesion looked different from the rest. It was thick and crusty and the hair came out in clumps.

Apparently, the three body lesions really were a bacterial infection, because the antibiotics and steroid topical cream cleared them up in two weeks. The head lesion though, never got any better, and was found through biopsy to be a CC. Since we had treated that head lesion with an antibiotic steroid cream, our vet wondered if we actually caused the CC -if perhaps the head lesion was just a more advanced bacterial infection that reacted badly to the antibiotic cream.

However, Mimi now has an identical lesion on the other side of her head -it's new, it first appeared on May 1st as just a small rough red spot, but has become literally identical to the large, original head lesion in just two weeks. The new spot has never been exposed to any sort of antibiotic or external steroid source.

If I can work out how you post photos here, I will post a pic of each lesion...

[mistyB]

I made an album -it has photos of her two head lesions...

http://www.k9cushings.com/forum/album.php?albumid=1093

[Renee]

The new spot has never been exposed to any sort of antibiotic or external steroid source.


Except that her body has been exposed to steroids, through using the cream. It stands to reason that if you used a steroid cream on multiple places on her body, then she has absorbed the steroid and the CC may be iatragenic.

It is entirely possible that the CC was induced by a combination of the stress from large bacterial infections and the absorption of steroids through the use of the cream.

[Renee]

I just looked at your album. Your girl is absolutely precious. Yes, those lesions look very like CC.

I don't think the existence of the CC is in question - it's identifying the underlying cause. Preemptively, we almost always assume it's cushings. And, it may not hurt you to rule that in (or out), but it also may be worth considering if there are any other causes.

[mistyB]

I hope that's it! If it is iatrogenic, shouldn't the DMSO heal the lesions?

[mistyB]

Off to a vet appointment now -hopefully the fungal test results have come back...

[Renee]

I hope that's it! If it is iatrogenic, shouldn't the DMSO heal the lesions?

Personally, I am not a fan of DMSO in the treatment of 'traditional' (cushings-induced) CC -- however, there have been people here that have had success using it when the CC occurred iatragenically or when it was a mild case of CC.

I do want to make it very, very clear though - DMSO will not cure CC. Eliminating the underlying cause is the only true cure. There are things you can do to assist in healing and management.

If the CC was in fact induced by some other source than cushings, then my recommendation to you would be:

1. Continue on with a good abx, but no steroids
2. Add in a quality probiotic to counteract the stress of the abx
3. Try to reduce stress / build immune system
4. Keep the lesions clean and dry, if possible. When they stay dry, they aren't as easily infected.

Also, consider running the UC/CR test.

[mistyB]

Results of today's vet appt: Our vet was alarmed at how quickly the new head lesion has progressed. It makes her doubt an external steroid cause, since there has been no exposure for over a month. The fungal culture results are still not back. She is sending Mimi's entire case file to a specialist for consult, and depending on those results and the fungal results, she may send the extra biopsies she took initially to a more extensive lab facility. Also, she had not done a UC/CR urine test, she had tested for dilution, and Mimi's urine was not diluted, it was in fact a little concentrated. But she has asked me to gather a "stress free" first morning pee sample so she can run that test. Also alarming, weight loss continues, even though I've increased her food amount since the last visit. I feel our vet is being very proactive and doing what can be done; I just wish I knew what was wrong with our little girl :(

[mistyB]

She also prescribed mupirocin ointment antibiotic for evening ( and to continue dmso in morning)

[labblab]

Just want to repeat that I think your vet is doing all the right things. I know you still don't have answers, but I'm very impressed with the diagnostic chain that she's following. :o

Hang in there!

Marianne

[molly muffin]

Hello and welcome from me also.

Was there Anything on the blood test that was out of range high or low?

Will your vet be running a UC:CR test on the morning urine?

I certainly applaud your vet in going by the book to rule things out before jumping into cushings in light of no symptoms, other than the cc.

[Joan2517]

It does sound like you've got a great vet...that really helps! And her picture is adorable!

[Crazy Daisy]

I was skimming through and noticed iatrogenic cushings was mentioned. Is your pup on regular steriods? Our IMS recommended using DMSO as part of her treatment simply to help the CC heal a little faster... but other treatment has to be done to actually "cure" the CC I believe. I'm a newbie so I'm still learning. lol