12-year-old Cairn: Atypical Cushing's?

[drcd279]

Hello all! So glad to have found this forum. In July, I noticed my 12-year-old Cairn terrier, Mandy, drinking excessive amounts of water. My first fear was kidney issues or diabetes. I took her to the vet and they performed a blood panel. She had slightly elevated levels of ALP (226) and ALT (150), as well as a high BUN (41). All other items in the panel were within normal range, including glucose (109, though in January of this year, it was 84).

Her urine sample revealed that it was concentrated, not diluted, so this confused the vet. I then had the LDDS test performed, and my vet called me yesterday to say that Mandy does not have Cushing's. Yet, since my initial noticing of her first symptom of excessive water intake, Mandy has also developed (or, in hindsight actually, I've probably just noticed now that I'm more knowledgeable about Cushing's symptoms) the following symptoms:


Potbelly and water retention
Panting
Excessive hunger (her thirst is better now that she's on a wet dog food, but I suspect that is the only reason why, as it has more moisture content)
Increase in fatty tumors
Slight but noticeable symmetical hair loss on her underside


I don't think my vet has much experience in Cushing's - period. She suggested Mandy's panting might be related to allergies. I'm sorry, but I cannot accept that ALL those symptoms are the result of ragweed or something. Then I started reading about atypical Cushing's, wherein other hormone levels are out of whack, but the dogs test negative in traditional Cushing's diagnosis tests.

I read that Cushingnoid pups' bodies are flooded with excess cortisol, which inadvertently helps with chronic issues like allergies and arthritis, because the cortisol calms these problems, though it causes a host of other issues. Mandy has pretty much all the symptoms of Cushing's but I've noticed she is still licking her paws (she has always had atopic dermatitis caused by some allergen that is most active in late summer through fall). So it seems to me that if Mandy had regular Cushing's, her paw licking would likely cease. It continues!

I've been reading everything I can about atypical Cushing's and/or adrenal fatigue or whatever veterinary science is calling it. Most websites recommend trying melatonin and lignans. I gave her her first full dose of melatonin last night and she woke up her usual, perky self as opposed to the somewhat groggy puppy I've seen since her symptoms got worse. I'm trying to not misplace my optimism, but I want to try SOMETHING to help my dog. I can't stand to see her laying next to me on the couch, panting and looking so uncomfortable despite it being a cool 73 degrees in the house.

So I guess my questions for anyone who might be able to offer any insight would be:


Am I probably correct in assuming this is atypical, based on her symptoms and the negative LDDS test? I am not asking anyone to tell me definitively of course, but I'm wondering if this assumption has any validity. I am currently unemployed (at the worst possible time), otherwise I would not hesitate to get the ultrasound performed immediately.
Did anyone find that melatonin and lignans worked well? I ordered 20mg HMR lignans from Amazon. I've read varying reports on how much to give. Some say 1mg per 1lb bodyweight. Mandy is around 17 pounds currently (though some of that is water retention). When I initially suspected Cushing's, I tried her on Adrenal Harmony, an herbal blend. This actually seemed to make her worse so I stopped it.
I read that wet food is better for Cushing's dogs (and is generally agreed to be better for dogs in general, if you can afford the higher costs) so I've put her on Instinct chicken formula. She loves it and it hasn't caused any bowel problems! Anyone found that this helps in atypical cases? I just worry that having been on dry food her whole life up until now, her kidneys may be having a difficult time with all the protein, though it seems to me this is closer to the natural diet of a dog?
Does anyone know how I would go about getting a full endocrine panel sent to UTK Veterinary College? Would my vet have to agree to do this? I may be able to swing paying for this as opposed to the ultrasound, but I don't know how to get the bloodwork to them.

If you read through all of this, god bless you. I am just so worried about my puppy. I have had her since I was 18 and I'm now 30. If she were 15, I would likely not be investing all this time, energy, and money into researching and resolving, but my baby is 12 and still has a lot of spunk and love of life left in her. Who am I kidding, I would probably do this if she were 15, but what I'm trying to say is that I really do think she could be around for a few more years if I find a way to help her. I just want her to have the best quality of life possible. Any and all thoughts on this would most definitely be appreciated. Thanks for your time. -David

[labblab]

Hello and welcome to you and your sweet Mandy! I have only a moment available to post right now, but wanted you to know that we are very glad you've joined us, and additional info will be provided throughout the day.

I can quickly answer two questions for you, though. First, the blood analysis that UTK provides is based upon an ACTH stimulation test performed by your own vet. The ACTH involves first drawing a baseline blood level (just as was the case with the LDDS). Then a stimulating agent is administered, and one hour later a second blood sample is drawn. Your vet then sends these two tubes of blood to the UTK lab where they will perform a full adrenal panel. This involves measuring the "pre" and "post" levels of other adrenal hormones in addition to cortisol. UTK actually charges a fairly modest amount for the analysis -- the biggest part of the expense is the cost of the ACTH stimulation performed by your vet. We can talk more about this later, though.

Secondly, here's a link to UTK's specific recommendations re: lignans.

https://vetmed.tennessee.edu/vmc/dls/endocrinology/Documents/LIGNANS%20INFORMATION.pdf

Sorry to make this intro so brief, but once again, we're very glad you've found us!

Marianne

[drcd279]

Thanks -- when I brought up the idea of sending the samples off to the UTK college the vet tech reacted as if it were just out of the question. I guess she has never done it before. I told her that UTK is the only place in the country that can offer a full adrenal panel.

I may have to switch vets if she won't accommodate this. I'm terrified that the longer I wait, the worse off my dog will be. I would never forgive myself if she developed SARDS and went blind.

Are there any special shipping methods the vet has to use in order to get it to UTK? I suppose it would be no different than the method they use to ship samples to local testing companies, but it has to go much further.

[Harley PoMMom]

Are there any special shipping methods the vet has to use in order to get it to UTK? I suppose it would be no different than the method they use to ship samples to local testing companies, but it has to go much further.

Yes, the The University of Tennessee lab is very specific about the handling, and here's a handy link where you can find that information: http://www.vet.utk.edu/diagnostic/endocrinology/pdf/endo_tests_info_07.pdf

What is very important to know is the standardized percentage of SDG or HMR in the product you are giving. SDG is the active component of the lignan. And the recommended starting doses:
Suggested doses: SDG lignan; one milligram/lb B. Wt./day. HMR lignan; 10-40 mg/day for small to large dogs. This comes from the UTK treatment option sheet: http://www.vet.utk.edu/diagnostic/endocrinology/pdf/TreatmentInfoAtypicalCushings201107.pdf

As an example: If one 30 mg capsule contains 20% flax lignan extract (standardized).

30 mg capsule = 20% lignans.

20% is 1/5 of 100% (or 100 divided by 20 = 5).

30 mg divided by 5 = 6 mg lignans.

Each 30 mg capsule would contain 6 mg lignans.

Mandy weighs 17 pounds so she would need around 3 (6mg) capsules which is 18mg and is just a tad above her weight.

Also, the melatonin, it needs to be the regular kind, not the fast-acting or rapid releasing type.

With this type of treatment improvement in symptoms can take up to 6 months to be seen, I know this is not what one wants to hear. Cushing's, whether it is Atypical or Spontaneous, requires a lot of patience. :eek:;)

Regarding the diet; there really isn't a "set" diet, a diet needs to be tailored to that individual dog's needs and health issues. However, dogs with Cushing's do lose muscle mass so their feed should have a high quality protein.

And yes, Mandy could have Atypical Cushing's or it could be that she is in the very early stages of Spontaneous Cushing's. Dog's with Atypical Cushing's generally have the same symptoms of a dog with Spontaneous Cushing's.

We have a good bit of information about Atypical Cushing's in out Helpful Resource Forum so here's a handy link to that info: http://www.k9cushings.com/forum/showthread.php?t=198

If you have any questions please do ask them. ;)

Lori

[labblab]

I'm terrified that the longer I wait, the worse off my dog will be. I would never forgive myself if she developed SARDS and went blind.

Lori has supplied you with a ton of helpful info. I just wanted to pop in to add that SARDS is not a condition that you really have any control over. The causative mechanism is still poorly understood, but it currently seems as though in dogs suffering from SARDS, hormonal elevations and Cushing's-like symptoms accompany the blindness as opposed to being the cause of the blindness. Right now, it is impossible to predict which dogs will suffer from SARDS and there is no way to prevent or cure it. So even though you may feel anxious to proceed with hormonal testing for other reasons, it would not have any bearing on preventing SARDS.

Marianne

[Squirt's Mom]

Hi and welcome to you and Mandy! :)

I just LOVE Cairns! My Squirt was half Cairn and half Longhaired Chihuahua - she had the spirit of the terrier tho thru and thru! :p

Squirt started out as Atypical and for several years we treated successfully with the melatonin and lignans, her intermediates coming down. In time, her cortisol did start to elevate bringing into the conventional Cushing's state. Most Atypical pups do eventually become conventional (or spontaneous), requiring the addition of Lysodren, or Vetoryl (Trilostane) in some cases. My next statement is sometimes seen as controversial but I take it as fact - UTK does not recommend Vetoryl for Atypical pups because this drug has been shown to cause elevations in the intermediate hormones so Lyso is their drug of choice if/when the cortisol starts to rise. I actually prefer Lyso so that worked out just fine with me. (You will also find me to be the oddball in preferring Lyso over Vetoryl. ;):D ) The controversy comes in because most pups with conventional Cushing's (meaning the cortisol is elevated from the beginning) also have elevated intermediate hormones so many vets simply do not believe in Atypical and some who do accept that form don't think it matters which drug is chosen if the cortisol rises in an Atypical pup. I trust UTK and their research so I stuck with their recommendations and tell those who are dealing with Atypical the same - Lyso over Vetoryl in my book for these pups. ;)

I also want to let you know that Cushing's is one of, if not THE, most difficult canine condition to correctly diagnose so I am never comfortable with making a diagnosis, positive or negative, based solely on one test. The signs in this disease are as important as the test results and the signs you have posted are certainly in keeping with Cushing's - conventional Cushing's. My Squirt did not display the hunger until her cortisol started to rise; in fact, that was the thing that let me know what was happening. So I would consider the ACTH and an abdominal ultrasound. The LDDS is considered the gold standard but just about nothing is 100% in this disease. ;)

Another point is that you may have caught this at an early stage. If that is the case, these signs are going to get stronger and stronger over the next little while and then a repeat LDDS may well come back with a different result.

And....if you could get the actual results of the LDDS and post it here that would be great. It is rare that a vet misinterprets this test but it does happen. Most labs will note on the paperwork if the results are consistent but not always. So you may want to let the gurus here take a look at the results.

Finally, I am glad you are here and want you to know that you and Mandy now have a new family. One who will be with you from here on out, every step of the way. Never hesitate to ask questions - if we don't know we will help you research to see what we can learn. You are no longer alone.

Hugs,
Leslie and the gang

[Allison]

David, hi.

Welcome to the forum! I can't offer a lot of advice. When we adopted our senior dog, his Cushings was already being well-managed and we just had to follow the prescribed treatments. Instead we fought a battle with pancreatisis. If I were to say anything though is I agree with you about having a vet you trust. A disease is hard enough to deal with; you need to know your vet will be of help.

That said, you've come to the perfect place! You and Mandy have a special relationship. There are a lot of experts here who can help as you figure out how to best help Mandy. They'll want to see test results and have lots of questions. But they'll have a lot of sound guidance to offer.

[drcd279]

Thank you guys for replying and your nice words of support. I am working on getting the LDDS results emailed to me from my vet. I can also post her blood work.

I actually took her off the lignans yesterday. She started retaining a lot of water and seemed to be constipated (I was giving her 20mg HMR lignans). After being off of them for 24 hours, she started pooping (and not to be gross, but a LOT of poop), so I think the lignans were causing that. Lori, thank you for explaining the dosage to me.

My question going forward is this: what would be more worthwhile as far as getting this diagnosed goes? I am unemployed but I will begin working in two weeks, but it's just substitute teaching so I have no idea if it will be steady enough. I say this because though money is tight, I think I can swing either 1) the ultrasound or 2) ACHT/stim test and adrenal panel from UTK.

I'm torn about which one to do because although I do think the adrenal panel from UTK might confirm/rule out atypical cushing's, I feel I may end up just doing the ultrasound anyway. On the other hand, if I get the ultrasound and it is inconclusive, at that point I think I would feel compelled to do the UTK panel testing. If I do the ultrasound and the vet notices enlarged adrenal glands, it still might not tell me which "kind" of Cushing's she has. Any advice as to which one I should try first? I really appreciate you guys reading this and offering your thoughts. I am the only one on earth who is going to advocate for my girl and I want her to have the best quality of life for however long I have left with her. It's so stressful trying to help her but also being under a financial strain.

[Squirt's Mom]

If I had to choose between the two I would go with the ACHT/stim test and adrenal panel from UTK. Then when I had saved up enough, the US. ;)

You're doing a good job, mom! Keep your chin up!
Hugs,
Leslie and the gang

[drcd279]

Thanks for the advice, Leslie! I'm actually a dog dad though ;)

I am taking her on Wednesday to get the ACHT stim test and panel sent to UTK. If you or anyone who has done this knows... do I have to pay UTK ahead of time? I've been asking my vet so many questions lately that I don't want to bug her again, but I'm wondering how UTK will accept the panel and perform the analysis if they haven't received payment. Does the vet pay and then charge me in the bill? Just want to make sure there are no hold-ups.

[labblab]

I would expect that your local vet will charge you the entire amount, including the UTK lab fee. Then he/she will end up forwarding the appropriate portion of the payment to UTK. Good luck!

Marianne

[Harley PoMMom]

When I had the UTK adrenal panel done my vet charged me than they forwarded the payment to UTK.

One very, very important thing, those blood samples have to performed and shipped according to UTK protocols.

Hugs, Lori

[drcd279]

One very, very important thing, those blood samples have to performed and shipped according to UTK protocols.

I actually called UTK just to make sure I knew which protocol my vet was going to be following and I printed it out for her...which I think offended her because they had already faxed her the protocols. When I dropped Mandy off today she disappeared into the back and I only dealt with the vet techs... did not speak to me afterward either. I actually think I've made her feel somewhat uncomfortable because I refused to accept her non-diagnosis after Mandy tested negative on LDDS test. I think some vets (and doctors) don't like it when patients/clients "play doctor" and do research. Sorry not sorry...I love my dog and will advocate for her until her last day on earth.

If the adrenal panel comes back to show that her sex hormones are elevated I will be glad I did this research and paid the extra money to send it to UTK. It actually wasn't as bad as I thought it would be. I was prepared to get a $500+ bill but it was around $300. Just a bit of advice for anyone reading this considering using UTK: call their laboratory finance department before you get the testing done. Their finance lady told me she would let my vet know how to get a cheaper rate on the overnight shipping to UTK. Mine cost around $50. I'm not sure if she convinced my vet to do it in whatever way was recommended to be cheaper or not... really doesn't matter to me, but just thought I'd put that on here in case it might help someone else.

Thank you to everyone who has responded to this thread. I appreciate your advice, comments, and tips more than you know. I feel kind of alone in this because some of my family members would never go this far for "just a dog" -- I subscribe to the belief that all living things deserve respect, preservation, and care. Dogs especially ;) I also think when you get a dog, you make a commitment to provide the best care you can give to him or her for their entire lifespan, not just when they are young.

[Harley PoMMom]

Well, poo poo on the vet :) I think it is wonderful that you are educating yourself and that you are an excellent advocate for your sweet girl ;)

Hugs, Lori

[Squirt's Mom]

One of my favorites came to mind reading your post. Our babies are never "just" anything - mine are my children as much as my daughter was. I always feel sorry for those who don't comprehend the depth of love we feel for our babies - how much they miss out on! "Just a dog"? Never....

JUST A DOG

From time to time, people tell me, "lighten up, it's just a dog,"
or "that's a lot of money for just a dog."

They don't understand the distance travelled, the time spent,
or the costs involved for "just a dog."

Some of my proudest moments have come about with "just a dog."

Many hours have passed and my only company was "just a dog,"
but I did not once feel slighted.

Some of my saddest moments have been brought aobut by
"just a dog," and in those days of darkness, the gentle touch
of "just a dog" gave me comfort and reason to overcome the day.

If you, too, think it's "just a dog," then you probably understand
phrases like "just a friend," "just a sunrise," or "just a promise."

"Just a dog" brings into my life the very essence of friendship,
trust, and pure unbridled joy.
"Just a dog" brings out the compassion and patience
that make me a better person.
Because of "just a dog" I will rise early, take long walks and look
longingly to the future.

So for me and folks like me, it's not "just a dog"
but an embodiment of all the hopes and dreams of the future,
the fond memories of the past, and the pure joy of the moment.

"Just a dog" brings out what's good in me and diverts my thoughts
away from myself and the worries of the day.

I hope that someday they can understand that its' not "just a dog"
but the thing that gives me humanity and keeps me from being
"just a man" or "just a woman."

So the next time you hear the phrase "just a dog,"
just smile,
because they "just don't understand."

~Unknown Author~

We are the blessed because we do understand, because we do know what it's like to share such a love. Oh yes, we are certainly the most blessed of all.

Hugs,
Leslie and the gang

[Joan2517]

Hi and welcome from me, too. Tough, if your vet get offended. They don't always know as much as they think they do, and you have every right to question and double check. That is what I should have done with my Lena. I found this forum too late to back up my concerns with the knowledge I have now.

It won't happen again!

[molly muffin]

Hello from me too. Educating yourself and knowledge is the best thing you can do to help your girl. A vet should not be intimidated or upset by a knowledgeable pet owner, it allows you to have frank discussions and make the best decisions possible. I think you are doing an excellent job of learning and being proactive. Good job dad!!

[drcd279]

Hi guys - After waiting almost two weeks, I got the results from UTK for Mandy. I am perplexed by the results:

Cortisol
Baseline: 2.2
Post ACTH 1hr: 15.7
Post ACTH 2hr: 13.5

Androstenedione
Baseline: 0.09
Post ACTH 1hr: .33
Post ACTH 2hr: .17

Estradiol
Baseline: 40.8
Post ACTH 1hr: 39.2
Post ACTH 2hr: 40.3

Progesterone
Baseline: <0.20
Post ACTH 1hr: 1.27
Post ACTH 2hr: .91

17 OH Progesterone
Baseline: <0.08
Post ACTH 1hr: 1.72** Only one to be slightly above reference range
Post ACTH 2hr: 1.11

Testosterone
Baseline: <15.0
Post ACTH 1hr: <15.0
Post ACTH 2hr: <15.0

UTK Vet comments: Overall, values are within reference range. Post ACTH 17-OH-P elevation is marginal, nonsignificant (early stage HAC?). Retesting in 6-8 months off melatonin is a consideration if still exhibiting HAC symptoms.

So, either the melatonin I've been giving her each night is suppressing her numbers, or she is just in early stages..?? Yet I would think even early stages Cushing's would show slight elevations in these numbers?? I'm really confused and was hoping this test would provide a more definitive diagnosis. I'm not sure I want to now invest in an ultrasound if that would be inconclusive as well. This is very frustrating. Any thoughts?

[labblab]

Well, given these results in combination with the earlier "negative" LDDS and Mandy's ability to concentrate her urine -- I truly doubt that she is suffering from overproduction of adrenal hormones associated with Cushing's of either type. At this stage, I think the possible value of an ultrasound would be to investigate whether there is any other obvious growth or abnormality that could account for her symptoms. But for now, I think you've come to the end of the road with Cushing's.

I suppose it might be possible that she could suffer from a type of adrenal tumor that stimulates production of hormones other than those associated with Cushing's. There is a rare type of adrenal tumor called a pheochromocytoma which can stimulate overproduction of epinephrine, nor-epinephrine and/or dopamine, and dogs suffering from this condition can exhibit symptoms that mimic Cushing's, and often on an intermittent basis when bursts of these hormones are released. We have had a few cases of pheochromocytoma among our members here through the years, but as I say, it is a rare type of tumor. More likely might be some other internal organ abnormality.

How is she currently doing in terms of outward symptoms? If the melatonin seems to be helping her for any reason, it probably does no harm to continue it. I do think an ultrasound would be the next most reasonable diagnostic step. But my sense of urgency about moving forward would greatly depending on how her symptoms are either remitting or progressing.

Marianne

[molly muffin]

I agree with Marianne, I'd keep up the melatonin for now and next I'd have an ultrasound done to see if there is anything going on with any internal organs.
Normally to have Atypical, they want you have to have at least a couple of the sex hormones out of range.
The melatonin might be helping with them and keeping them in range, and if that is so, then keeping her on it would only be beneficial.
I think that getting confirm diagnosis with a lot of the dog issues out there is one of the hardest parts. Too many things all are tied together and have same symptoms. Thyroid, diabetest, liver, kidney, gall bladder. They all work together. An ultrasound might show if there is any sludge in the gall bladder for example. (most dogs do end up with some sludge as they get older my IMS said) But if it is there, then you want to know how much, etc.
If not cushings, then have to start looking at other options, so just throwing thoughts out there for you.

[drcd279]

Marianne - Thanks for the reply.

Mandy is still exhibiting symptoms. She pants a lot - even indoors, in cool temperatures. I wouldn't say it is constant panting, but seems excessive. Her belly is distended still, and though her excessive thirst has improved, like I said in an earlier post, that's more likely due to switching to wet dog food. She still seems very hungry.

She has also begun sneezing a little more frequently and her nose is somewhat runny. Just a clear mucus, nothing like what I saw when she had kennel cough years ago. No coughing, just sneezing and hard "sniffs" like she's trying to expel something. She sometimes paws at her nose, too.

I guess I will look at getting an ultrasound when I can. I hate that I have invested so much time, research, energy, and money into thinking it was either kind of Cushing's, only to end up back at the drawing board. It is all worth it for my puppy, but it just sucks that I have no idea how to treat her symptoms. I hate seeing her uncomfortable.

[drcd279]

Too many things all are tied together and have same symptoms. Thyroid, diabetest, liver, kidney, gall bladder. They all work together. An ultrasound might show if there is any sludge in the gall bladder for example

Thanks - yeah I guess I will look into that. I wonder if it could be an enlarged liver? I guess an ultrasound will have to rule that out. I wish I would have done it first now that I've spent all this money, but I guess that's always the case with the last thing you try... she is worth it, no matter what.

[molly muffin]

Since the ALP and ALT and BUN where the only things out of range in her January testing, liver could certainly be suspect, but you just don't know for sure without a visualization.
You could redo blood work to see if anything like the ALT has continued to go up and if any kidney functions are off or glucose. That would the only other thing that I could think of to look into.
I would retest blood about every 6 months when my dogs liver enzymes where off before other things went wrong. I think she was around 8 or so when those started to go up. Nothing else was out of range at that time and cushing tests where negative too.
It really is beyond frustrating when you are trying to figure out what is going on with them. Especially when you go down one path, thinking that is the issue, only to have to switch roads. We too did the Atypical testing based on negative LDDS test results.

[drcd279]

Hi guys...

Just wanted to provide an update if anyone cares...

After months of trying to get Mandy's issue diagnosed, I'm happy to say that (at least for now, anyway) it appears that she does not have Cushing's of either kind.

She did not test positive on the LDDS, the ACTH, and UTK ruled out atypical Cushing's for me. Today I had an ultrasound performed and was preparing for the worst... I thought sure my vet was going to call and tell me she had a tumor or something. They said her ultrasound was very normal.

Still does not explain the excessive drinking, the high ALT/ALP/BUN numbers, but the vet told me she thinks those numbers are mild in comparison to other cases she's seen and she'd just like to recheck again in a month or so. She told me she may have somehow endured an insult to the liver... the ONLY thing I can think of to explain that would be that she did get into the trashcan back in May and ate a wrapper and a bunch of Mike 'n Ikes I threw away... but that was so long ago. I don't know. Grateful that for now, whatever it is doesn't pose an immediate threat on her life. I have spent a fortune on all this testing, so it's disappointing to not be able to pinpoint what is going on, but every dime is worth it for my pup.

I want to thank you guys for your replies and words of support! It really means a lot to be able to connect with a community of people who understand my dedication to her. Some people just don't get it, like I said! ;)

[Joan2517]

So glad to hear that Mandy doesn't have Cushing's! Hopefully whatever it was will have passed and she'll be fine.

Good news is always welcome here~

[DoxieMama]

Glad you've at least ruled out Cushing's. Please do stop in and keep us updated on her progress. You're family, now. :)

[molly muffin]

Excellent news that Mandy doesn't have cushings. Hopefully on the follow up testing the liver enzymes will begin to come down. This can take time, but if it is an insult to the liver then it is very possible they will respond though time.