Newbie - Possible Cushings?

[Yorkieluv]

Hi,
I am new on this forum I am hoping for any advice on Cushings. My Yorkie had been asking for more and more food and had developed a little potbelly. She seemed to be drinking more that usual but not a huge amount. She had been having accidents during the night. I took her to the vet, who wanted to test for Cushings. I got the lab results today and would be grateful for any comments on these results.

TDDS LAB REPORT
BIOCHEMISTRY
Canine Profile

Total protein 63 g/L (54.0 - 77.0)
Albumin 34 g/L (26.0 - 40.0)
Globulin 29 g/L (20 - 47)
Sodium 151 mmol/L (139 -154 )
Potassium 5.0 mmol/L (3.5 - 6.0)
Na:K ratio 30 (25.0 - 35.0)
Chloride 109 mmol/L (99 - 125)
Total calcium 2.24 mmol/L (2.0 - 3.0)
Phosphate * 1.70 mmol/L High (0.8 - 1.6)
Urea * 11.9 mmol/L High ( 2.0 -9.0)
Creatine 64 umol/L (40 - 106)
Alk Phos * 238 U/L High (0.0 - 25.0)
ALT * 29 U/L High (0 - 25)
GLDH * 18 U/L High (0 - 10.0)
Total biliruben 0 umol/L (0 - 9.0)
Bile acids * 11 umol/L High (0 - 10.0)
Glucose NO OXF RECEIVED
CK * 375 U/L High (0 - 190)
Cholesterol * 10.0 mmol/L High (3.8 - 7.0)
Triglycerides * 4.6 mmol/L High (0.45 - 1.9)
Amylase 922 U/L (0 - 1800)
Lipase 39 U/L (0 - 150)
SERUM SLIGHTLY LIPAEMIC
HAEMATOLOGY
RBC * 8.59 x10^12/L High (5.0 - 8.5)
Hb * 19.3 g/dl High (12.0 - 18.0)
HCT * 62.7 % High (37.0 - 55.0)
MCV 73.0 fl (60.0 - 80.0)
MCH 22.5 pg (19.0 - 26.0)
MCHC 30.8 g/dl (30.8 - 37.0)
RDW 17.7 % (12.9 - 17.8)
Platelets 361 x10^9/L (160 - 500)
WBC * 5.45 x10^9/L Low (6.0 - 15.0)
Neutrophils 3.95 x10^9/L (3.0 - 11.5)
Lymphocytes 1.10 x10^9/L (1.0 - 4.8)
Monocytes 0.24 x10^9/L (0 -1.3)
Eosinophils 0.16 x10^9/L (0 - 1.25)
Basophilis 0.00 x10^9/L (0 - 0.2)
Reticulocyte % 1.3 %
Reticulocyte count 111.67 x10^9/L
Platelet comment PLATELET COUNT APPEARS NORMAL IN FILM.
RBC comment SLIGHT POLYCHROMASIA. SLIGHT ANISOCYTOSIS.
Leukocyte comment LEUKOCYTE MORPHOLOGY UNREMARKABLE

MICROBIOLOGY
Urine creatinine 14.45 nmol/L

ENDOCRINOLOGY
Basal cotisol 118 nmol/L ( <125 )
Cortisol Post ACTH 146 nmol/L ( <800 )
Urine cortisol 241 nmol/L
Urine cortisol : creatinin 16.7 (<20 )
Total T4 22 nmol/L (13.5 - 50)
cTSH .16 ng/ml (0.0 - 0.6)

CLINICAL COMMENTS
Serum lipaemia may be artefactually elevating CK , bile acids and phosphate.
Elevations in liver results are mild - moderte - ALP is moderately elevated in contrast to mild elevation in ALT, which may represent a steroid influence (I note your clinical suspicion of Cushing's syndrome), but other causes such as primary hepatobiliary disease are not excluded.

There is mild hypercholesterolaemia - was this a starved sample? Fasting hyperglycaemia may lend support for Cushings disease or other endocrine disease - has glucose been checked in house?

Haemogram is largely unremarkable - neutrophils are lower than expected for Cushings disease ( which usually produces a 'stress' leukogram of neutrophilia with lymphpaeria ), but it does not exclude it. Given your clinical picture, ACTH stimulation may be useful. Monitoring liver enzymes and futher liver investigations (e.g. abdominal imaging, bile acid stimulation ) may also be considered.

__________________________________________________

My Yorkie had not eaten for 11-12hrs when they did the above tests. I asked my vet to check for diabetes, but she did not do so, as far as I can see.

My vet intends to do a SHAP test and, on Monday morning, she will scan my Yorkie's tummy area (looking for a mass), her liver and her adrenals. My Yorkie is 13 and a half years old.

Any advice would be very welcome. I am so worried about my baby.

[Harley PoMMom]

ENDOCRINOLOGY
Basal cotisol 118 nmol/L ( <125 )
Cortisol Post ACTH 146 nmol/L ( <800 )
Urine cortisol 241 nmol/L
Urine cortisol : creatinin 16.7 (<20 )


The result I bolded is the urine cortisol:creatinine ratio (UC:CR) test and is commonly used as a screening test for Cushing's. When the results are negative, such as your dear girl's are, it highly unlikely that she has Cushing's.

Now, from her blood work it does not seem that her glucose was tested, which is odd because it is generally done on a chemistry panel. And diabetes would be something I would want ruled out.

I have a question regarding the Alk Phos (alkaline phosphatase), although it is marked high, those reference ranges are not the ones we are used to seeing so could you double check that for me. Since the Alk Phos and the ALT (alanine aminotransferase), which are both liver enzymes, are elevated having an ultrasound sounds like the right move to me.

Hugs, Lori

[Yorkieluv]

The result I bolded is the urine cortisol:creatinine ratio (UC:CR) test and is commonly used as a screening test for Cushing's. When the results are negative, such as your dear girl's are, it highly unlikely that she has Cushing's.

Now, from her blood work it does not seem that her glucose was tested, which is odd because it is generally done on a chemistry panel. And diabetes would be something I would want ruled out.

I have a question regarding the Alk Phos (alkaline phosphatase), although it is marked high, those reference ranges are not the ones we are used to seeing so could you double check that for me. Since the Alk Phos and the ALT (alanine aminotransferase), which are both liver enzymes, are elevated having an ultrasound sounds like the right move to me.

Hugs, Lori



Hi Lori

Thank you so much for your reply.

I will ask my vet about the Alk Phos. range and see if there has been a typing error perhaps? It seems a huge difference. I will ask, once again for the diabetes blood test to be done. She goes in on Monday and I thought I would starve her for 12 hrs before the Ultra sound scan. Would that be correct? Also, wouldn't the diabetes blood test be more useful if she was starved for 12hrs before taking the blood? I don't know much about this sort of thing, but it makes sense to me?

I asked the vet to have a UC:CR test done and I took in the urine, which I collected from Toots first thing in the morning (when she had been calm and relaxed all night.) I was worried that she would have a false high due to the extreme stress she feels when going to the vet. The vet did not want to do this test as she said that test is often incorrect and a waste of money. I told her to humour me and to just do it!

I know little about this illnes, but I am trying to find out as much as I can. Do you know what this SHAP test is - I cannot find any such test on the web?

The vet said she spoke to the lab that did the tests, and they said that they have seen similiar results with a dog found to have adrenal cushiings? Are they just ignoring the UC:CR!!? I must say I find the results of the tests very confusing.

I really appreciate your help and I will find out about the Alt Phos. on Monday.

luv
Yvonne

[lulusmom]

Hi Yvonne and a belated welcome to you and Toots.

I concur with Lori that the huge red flag in all the results you posted was the urine cortisol creatinine ratio (UC:CR) which is normal. As Lori mentioned, you can pretty much rule out cushing's with normal results so yes, your vet(s) appears to be ignoring that very important fact. Your vet's concern with the accuracy of a UC:CR would only be legitimate if the ratio were high. The reason for this is that non-adrenal illness or stress can yield a high ratio so if the ratio is high, you would still need to do additional testing such as the acth stimulation test or LDDS. If the ratio is normal, however, this test is definitely worth the cost because with a normal result, a vet normally would start looking at possible non-adrenal illnesses that could explain the lab abnormalities and mild symptoms you've reported.

I have never heard of a SHAP test but suspect you mean SNAP test which can be any number of inhouse tests developed by IDEXX Laboratories. I believe in Toots' case, your vet is going to do a SNAP acth stimulation test. I personally would question the wisdom of ignoring the normal UC:CR and incurring the cost of an acth stim test, which is not cheap. At this point, I definitely think an abdominal ultrasound is a good next step but if it were my dog, in lieu of the acth stim test, I would want a standard urine analysis with urine culture to rule out possible urinary tract infection and to check urine specific gravity. Dogs with cushing's, who drink and pee too much, have lost their ability to concentrate their urine and dilute urine has abnormally low urine specific gravity.

I'm sorry for the reasons that brought you here but am glad you found us. We'll do whatever we can to help you be the best advocate you can be for Toots.

Glynda

[Yorkieluv]

Hi Yvonne and a belated welcome to you and Toots.

I concur with Lori that the huge red flag in all the results you posted was the urine cortisol creatinine ratio (UC:CR) which is normal. As Lori mentioned, you can pretty much rule out cushing's with normal results so yes, your vet(s) appears to be ignoring that very important fact. Your vet's concern with the accuracy of a UC:CR would only be legitimate if the ratio were high. The reason for this is that non-adrenal illness or stress can yield a high ratio so if the ratio is high, you would still need to do additional testing such as the acth stimulation test or LDDS. If the ratio is normal, however, this test is definitely worth the cost because with a normal result, a vet normally would start looking at possible non-adrenal illnesses that could explain the lab abnormalities and mild symptoms you've reported.

I have never heard of a SHAP test but suspect you mean SNAP test which can be any number of inhouse tests developed by IDEXX Laboratories. I believe in Toots' case, your vet is going to do a SNAP acth stimulation test. I personally would question the wisdom of ignoring the normal UC:CR and incurring the cost of an acth stim test, which is not cheap. At this point, I definitely think an abdominal ultrasound is a good next step but if it were my dog, in lieu of the acth stim test, I would want a standard urine analysis with urine culture to rule out possible urinary tract infection and to check urine specific gravity. Dogs with cushing's, who drink and pee too much, have lost their ability to concentrate their urine and dilute urine has abnormally low urine specific gravity.

I'm sorry for the reasons that brought you here but am glad you found us. We'll do whatever we can to help you be the best advocate you can be for Toots.

Glynda

Hi Glynda,

Thanks so much for the welcome and for all the information you have given.

Re Tootsy's tests, the protocol for ACTH stim tests appeared to be followed, ie blood taken, injection given and two hours later, more blood taken. It appears that your response is saying that the results that I have posted on the Forum may not be consistent with the ACTH stim test. Indeed, at the head of the results sheet, the acronym TDDS appears. As I am not qualified to comment, may I ask what you think this apparent anomaly means?

If the ultrasound shows positive results for a tumour, should the urine test still be requested?

I am so pleased I was referred to this Forum. Many thanks again for everyone's kind assistance.

Yvonne.

[molly muffin]

Hello and welcome,

So they have already done an ACTH test and it looks like everything involving cortisol is negative and Thyroid is also normal.

ENDOCRINOLOGY
Basal cotisol 118 nmol/L ( <125 )
Cortisol Post ACTH 146 nmol/L ( <800 )
Urine cortisol 241 nmol/L
Urine cortisol : creatinin 16.7 (<20 )

That leaves having the glucose checked and having an ultrasound to take a look at various organs.
That is what I'd do next and see what it shows.

Yes you do want to fast before an ultrasound as food can obscure viewing of the organs.

Welcome again

[Yorkieluv]

Hello and welcome,

So they have already done an ACTH test and it looks like everything involving cortisol is negative and Thyroid is also normal.

ENDOCRINOLOGY
Basal cotisol 118 nmol/L ( <125 )
Cortisol Post ACTH 146 nmol/L ( <800 )
Urine cortisol 241 nmol/L
Urine cortisol : creatinin 16.7 (<20 )

That leaves having the glucose checked and having an ultrasound to take a look at various organs.
That is what I'd do next and see what it shows.

Yes you do want to fast before an ultrasound as food can obscure viewing of the organs.

Welcome again


Thank you so much for the welcome and for your help.

Will a 12 hrs fast be sufficient for the scan?

[Yorkieluv]

Hi Yvonne and a belated welcome to you and Toots.

I concur with Lori that the huge red flag in all the results you posted was the urine cortisol creatinine ratio (UC:CR) which is normal. As Lori mentioned, you can pretty much rule out cushing's with normal results so yes, your vet(s) appears to be ignoring that very important fact. Your vet's concern with the accuracy of a UC:CR would only be legitimate if the ratio were high. The reason for this is that non-adrenal illness or stress can yield a high ratio so if the ratio is high, you would still need to do additional testing such as the acth stimulation test or LDDS. If the ratio is normal, however, this test is definitely worth the cost because with a normal result, a vet normally would start looking at possible non-adrenal illnesses that could explain the lab abnormalities and mild symptoms you've reported.

I have never heard of a SHAP test but suspect you mean SNAP test which can be any number of inhouse tests developed by IDEXX Laboratories. I believe in Toots' case, your vet is going to do a SNAP acth stimulation test. I personally would question the wisdom of ignoring the normal UC:CR and incurring the cost of an acth stim test, which is not cheap. At this point, I definitely think an abdominal ultrasound is a good next step but if it were my dog, in lieu of the acth stim test, I would want a standard urine analysis with urine culture to rule out possible urinary tract infection and to check urine specific gravity. Dogs with cushing's, who drink and pee too much, have lost their ability to concentrate their urine and dilute urine has abnormally low urine specific gravity.

I'm sorry for the reasons that brought you here but am glad you found us. We'll do whatever we can to help you be the best advocate you can be for Toots.

Glynda

Hi Glynda

I have just been informed that there is 'SHAP' Test in the UK - I thought you might be interested in the details .

SHAP Profile (Cort. x 2, OHP x 2)

Adrenal sex hormone status is investigated using standard ACTH stim test.

17 - OH -Progesterone (OHP) has been identified as a sensitive marker and this, along with cortisol, is measured before and after the ACTH administration.

The lab told the vet that they suspect possible adrenal involvement and I assume this is why they are doing this particular test. The lab have the pre- and post-ACTH blood collected and I would presume that this is what will be used.

Yvonne.

[molly muffin]

What were the results of the SHAP test?

[lulusmom]

Hi, Yvonne, and thank you for clarifying about the SHAP test. I had no idea this lab test even existed but I was finally able to find it offered by a lab in the UK. I'm therefore not sure that particular test is available in the U.S. which would explain my ignorance. If a hormonal imbalance is suspected here in the states, most vets request a full adrenal panel that is only done by the University of Tennessee Knoxville (UTK). While the SHAP test provides pre and post cortisol and 17-OH-Progesterone (OHP), the UTK panel provides those two as well as androstenedione, estradiol and progesterone. I was able to determine that NationWide Specialist Labs in the UK offers the SHAP test as well as a full canine adrenal panel that include the same adrenal hormones as UTK. This is all very good information for future reference so thank you for my continuing education. ;)

With respect to your question about the acth stimulation test, I apologize for confusing you. I did not intend to question whether the test results you posted was for a legitimate acth stimulation test. What I should have said is that if the UC:CR was done before the acth stimulation test, I questioned the wisdom of incurring the cost of an acth stimulation test given that the UC:CR was normal. I made the assumption that the UC:CR was done first as that is the usual progression of the diagnostic phase. What was the timing of these two tests? Sharlene has already asked you for the results of the SHAP test and I would be very interested in seeing them as well. The information you posted previously was not the actual results so you would need to either get a copy of the actual results from the vet or you could call them and have them read you the results.

Glynda

[Yorkieluv]

Hi,

I have been told that the SHAP tests were all within normal range! The vet said that they are now sure that Toots does not have Cushings. She tells me that she wants to do the tests, once again, in three months time?!! I don't understand this - are they thinking of liver problems or cancer that they may have missed? I hate to put my poor little dog through those blood tests, once more. She was very upset by the whole thing.

Toots had the scan and they checked her liver, adrenals, kidneys, bowel and stomache. They found nothing suspicious at all. There was a very small cyst on one kidney, but they are not concerned about it. They said that the liver, kidneys and adrenals were a little bit larger than normal. They found the adrenals quite easily, which made them think that they are bigger than is normal. They said that they usually have difficulty in locating them and they found hers very easily.

Do you think I should leave it at that or is there more I should ask the vet to do? She never mentioned Atypical Cushings - is this still a significant possibily or do the tests rule out Cushings completely now?

Thank you all for all the support you have given me. I appreciate it so much.

[Yorkieluv]

I have just been sent the actual results, by email, and the lab says "not supportive of atypical Cushings disease"

[Squirt's Mom]

What lab is it that says that and what do you see anything on those results about estrodiol or progesterone? Curious because there is only one lab we know of that tests for Atypical Cushing's and that is the Uni. of Tennessee in Knoxville.

[Yorkieluv]

What lab is it that says that and what do you see anything on those results about estrodiol or progesterone? Curious because there is only one lab we know of that tests for Atypical Cushing's and that is the Uni. of Tennessee in Knoxville.

Hi,

I don't see results about estrodiol, but there are results for progesterone, both pre and post ACTH. I live in the UK and the tests were done by a specialist lab over here. Should there have been tests for estrodiol?

[molly muffin]

It could be that other places are putting in place tests for atypical now I don't know. I hadn't heard of the SHAP before either, so maybe it doesn't test estrodiol. But I do know that with atypical they like to see at least 2 sex hormones elevated and the cortisol to be normal.

I think what they want to do is to keep an eye on her levels and see if they start to trend upwards, which can happen, if it is caught early. What might not be in range now, might be in 3 months, 6 months, a year, etc.
So it's a good precautionary thing to do. I was testing my dog every few months for awhile since she didn't have high results on her cushing tests but liver enzymes were continuing to go up and we where also doing repeat ultrasounds to keep an eye on the organs. You just want to see where things go and catch it early and this is how they want to do it.

[Yorkieluv]

It could be that other places are putting in place tests for atypical now I don't know. I hadn't heard of the SHAP before either, so maybe it doesn't test estrodiol. But I do know that with atypical they like to see at least 2 sex hormones elevated and the cortisol to be normal.

I think what they want to do is to keep an eye on her levels and see if they start to trend upwards, which can happen, if it is caught early. What might not be in range now, might be in 3 months, 6 months, a year, etc.
So it's a good precautionary thing to do. I was testing my dog every few months for awhile since she didn't have high results on her cushing tests but liver enzymes were continuing to go up and we where also doing repeat ultrasounds to keep an eye on the organs. You just want to see where things go and catch it early and this is how they want to do it.

Thanks very much for this information. So what you are saying, if I understand you correctly, is that my Yorkie could still be developing Cushings and needs to have these tests every few months? Gosh, I had ruled out Cushings completely after the vet told me that she does not have it. This is why I couldn't understand why she wanted to carry on testing her. What are the benefits of catching it early? The vet said that the drugs for Cushings simply make the dog more comfortable and in no way cure the disease. Does this mean that as long as my Yorkie does not appear to have very uncomfortable symptoms, I can hold off giving her these toxic drugs?

Thanks again for your help.

Yvonne

[Harley PoMMom]

When that elevated cortisol is left uncontrolled over a long period of time it will cause damage to the internal organs and leaves the dog more susceptible to other health issues such as high blood pressure, proteinuria, and thromboembolism.

And yes, the medications used to treat Cushing's do not cure it but they aid in the lowering of that elevated cortisol which in turn slows down or halts the assault from high levels of cortisol and it abates clinical symptoms. So if your girl's cortisol is normal than treatment is not needed.

Hugs, Lori

[Yorkieluv]

When that elevated cortisol is left uncontrolled over a long period of time it will cause damage to the internal organs and leaves the dog more susceptible to other health issues such as high blood pressure, proteinuria, and thromboembolism.

And yes, the medications used to treat Cushing's do not cure it but they aid in the lowering of that elevated cortisol which in turn slows down or halts the assault from high levels of cortisol and it abates clinical symptoms. So if your girl's cortisol is normal than treatment is not needed.

Hugs, Lori

Thanks so much, Lori. for explaining this to me.

Luv
Yvonne