Calcinosis cutis... where do I go from here?

[annziemarie]

Our dog has confirmed calcinosis cutis/suspected Cushing's and I just want to know what our options may be before we talk to the vet.

A little history: Lucy had a dental abscess mid-October and we had her put under anesthesia on 10/19 for dental work. She had a total of 9 teeth removed. She was on amoxicillin for about one week, but was switched to clindamycin after the surgery and took it for two weeks. She went for a follow up with the vet three weeks post-op and had no issues.

About a week after her last follow up she started forming red spots in her groin and armpit areas. We tried treating the spots at home for a period of time with Benadryl/cone/clothing but it continued to get worse, to the point where she was bleeding and oozing, with large white scabby areas present. We brought her back to the vet on 11/28. They did not know what was wrong at that time but prescribed a new antibiotic and gave her a steroid shot, and advised us to call if she didn't improve. After a week her condition had not improved noticeably and we brought her back again. She was put under anesthesia for a skin biopsy, had an ultrasound, and was sent home with prednisone, an additional antibiotic, a medicated shampoo and topical cream.

We now have the biopsy results which show calcinosis cutis. The ultrasound showed no tumors, but she does have a huge liver, contributing to her pot belly. Her liver enzymes have also been very high for the last two years. We did have Lucy tested for Cushing's two years ago when she started having increased thirst and urination in the house. Her results did not indicate Cushing's at that time and we ended up treating her for Lyme disease. I would say the urination in the house decreased, but never resolved fully. She now has all the symptoms of Cushing's aside from maybe an increased appetite - she seems to be eating less, but maybe this is from so many antibiotics - so I am sure she has it. I am hesitant to pay for more testing but I don't think the vet will treat the condition without confirmation and if I understand correctly her skin will not improve unless we treat the Cushing's. I am also very concerned about how difficult it seems to treat calcinosis cutis in particular. It looks like the Cushing's is commonly treated with chemotherapy drugs but I am pregnant and not sure if this is an option for us practically or financially. On the other hand, I don't want the dog to be uncomfortable if there is something we can do about it. She still has a good quality of life, aside from this skin condition.

So... I guess I don't have a specific question but would love to know what our future might look like. We are waiting for a call back from the vet and are working on weaning her off the prednisone as quickly as possible. She just started it Saturday so it may be another few days. I want to know what treatment options may be and have realistic expectations. We have already spent probably $2500 to get to this point and the prospect of more testing and expensive treatments is stressing me out.

[judymaggie]

Hi and welcome to you and Lucy! I am so sorry that you are going through a rough patch with Lucy. I do not have personal experience with calcinosis cutis but have learned, from other members, that it is a very difficult issue to manage. It is almost always seen when a dog has been diagnosed with Cushing's; however, it can occasionally occur in dogs without Cushing's.

As a first step in determining whether or not Lucy has Cushing's, I would suggest that your vet conduct a UCCR (urine creatinine:cortisol ratio) urine test. It is inexpensive and, if negative, then Lucy would not have Cushing's. If positive, then Lucy might have Cushing's and you would need to proceed with additional testing. I would have to agree with your vet that treatment for Cushing's not be started until a definitive diagnosis is made.

A couple of issues: it is very important that Lucy be completely weaned off of prednisone so that any testing results are not skewed. I think it is a good idea to have a waiting period -- others will be along who can better address how long the break should be once the prednisone is stopped.

Also, did the ultrasound report address what Lucy's adrenal glands looked like? If considering Cushing's, they are usually either both enlarged or one enlarged. It would also help us if you would provide us with any high or low lab results from recent tests. You need only type the name of the test, the result and the range, i.e.:

ALT 200 (H)(range 12-118).

Has a urinalysis been done? If so, please post any abnormal results (in particular, the specific gravity) as well as whether there is protein in her urine.

If Lucy does, indeed, have Cushing's, your concerns about handling either Vetoryl or Lysodren when you are pregnant are valid. It is possible to dose using protective gloves or, if possible, have someone else dose Lucy.

Before I close, I did want to provide you with the link to the thread from our "in-house" Cushing's expert, Renee:

http://www.k9cushings.com/forum/showthread.php?t=5908&highlight=calcinosis+cutis

It is a long thread but you would be able to learn quite a bit about CC from Renee's experience and guidance.

[annziemarie]

Thanks! She has had a lot of testing recently and I am not sure if a urinalysis was one of these tests. I know they did a pre-anesthesia blood panel and her liver numbers were very high. In the 1200's when normal is around 150 if I remember correctly. At the time we were dealing with the dental emergency so it was a problem to address at a later time.

I will ask if they looked at her adrenal glands during the ultrasound. Maybe I will just request a copy of all of her records.

[annziemarie]

Lucy will be retested for Cushing's in about 3 weeks after being off prednisone for two weeks. Does anyone know what I can do to care for her skin in the mean time? We have been bathing her 2x per week and applying anti-biotic ointment but I'm not sure if we are doing more harm than good. She sometimes will bleed after the baths but I am hoping they help keep her itching down as the CC is all over her belly.

We are redoing the low dose dex suppression test which showed she didn't have Cushing's two years ago, despite having a lot of the symptoms. I'm a little skeptical because of this. Does anyone have experience with false negatives on this test? Also, my vet prefers to treat Cushing's with Lysodren. Does anyone who treats with this drug have any advice? Do you buy wholesale through the vet or go through a pet pharmacy?

Sorry for asking so many questions and thanks so much for any help!

[Harley PoMMom]

Hi and a belated welcome to you Lucy!

I'm going to be lazy here and insert a post from our resident CC expert, Renee, to another member regarding the CC:


Hi and welcome. I am so sorry that you are dealing with CC. My pug was first diagnosed with CC in Oct of 2013. Before it was all said and done, she had open lesions from the top of her head to the base of her tail. She is now what I would call in 'remission'.

First, I'll just put this right out there - there is NO cure for CC other than bring the cortisol into proper therapeutic range and keeping it there long term. The proper range is a post of below 5 ug/dl. And, when I say long-term, I mean staying in range for months or for life. My pug stopped her meds for about a month during a bout of pancreatitis. In just 3 weeks, I saw lesions recurring.

There are things you can and should do to help manage the CC, but none of these items will cure it. They can help, that is all.

CC lesions are very susceptible to secondary infection, so I do suggest you run a course of abx on occasion, especially if things are looking particularly bad. In combination with the abx, I also suggest you add a high quality probiotic.

I did use tramadol for pain, as needed. I think they are painful. Or, at least they were painful for my pug.

You may be told that DMSO is a treatment. My personal belief is that it does nothing and is an outdated treatment. But, that is only my opinion, and there are those that have reported good results using DMSO. It will not cure the CC though, so don't think it will. It smells horrific and you'll need to wear gloves when using it. I used it on my pug for about 2 weeks then stopped. I could see it was doing nothing but making her uncomfortable and making my other pugs treat her like she had leprosy.

What I did find helpful for topical treatment was using tea compresses. Not tea tree oil! Just tea bags, like lipton or chamomile tea. I did clip the hair around the areas as well, to keep them open and exposed to air, and I did peal away the scabs that were ready to come off, otherwise they just rotted over the skin. I never covered the lesions up, although I understand covering them may be necessary to prevent your dog from itching them.

Another CC mom, Dawn, had success using a spray she purchased on amazon. I cannot recall the name, something like cetochlor? I think this helped keep infection down.

Some people have used weekly medicated baths. I'm not opposed to this. My personal choice was not to bathe my pug until her lesions were in a significant stage of improvement. I didn't think the sores needed anymore moisture and I didn't want anything else topical on them to irritate the skin more.

I actually think some time in the ocean may not be a bad idea, especially if the sores are crusty right now. If they are open and oozing, then I would not recommend it.

The lesions will bleed, crack, ooze, peel away, look raw and angry, then eventually start to dry out. When they begin to flake and dry out, I believe they are on their way to getting better. Also, keep in mind, they will get worse before getting better, and even as you bring the cortisol down, the lesions that are below the surface will continue to bust through and break open. This went on for about 6 months for us. Hopefully they will not be as angry as the ones that you may be dealing with now though.

Sorry I've typed so much. I'm working a lot right now, so I am not on all the time, but I always watch the CC threads.

Unfortunately there is not one test that can accurately identify Cushing's. The two tests that are generally used to diagnose Cushing's is the ACTH and LDDS test, and both can yield erroneous results. The LDDS is the "gold standard" test however when a non-adrenal illness is present this can create a false positive result so in Lucy's case with the CC an ACTH stimulation test would probably be the best option for her.

The two drugs, Lysodren (Mitotane) and Vetoryl (Trilostane) are the medicines that are most rx'd when a Cushing diagnosis is confirmed.

We have members having successful treatment with either medication. IMO, one drug is no safer that the other. Adverse effects are minimal when the proper protocols are followed, the dog is monitored appropriately, and "owner observation" is always a crucial component of treatment.

Both Lysodren and Trilostane can be compounded or purchased at an online pharmacy with a prescription from the vet. One of our members posted that there is an app called GoodRX that may help locate the lowest price for generic and brand.: https://www.goodrx.com/

Please do not hesitate to ask all the questions you want, we are here to help in any way we can. ;)

Hugs, Lori

[annziemarie]

Lucy's cortisol levels after we thought she had loaded with the Lysodren were pre 7.2 and post 12.0... are these still too high for her calcinosis cutis to clear up? I understand it can take a while but now I'm worried we didn't properly load her.

The vet said her results were on the higher end of normal and started her on a maintenance dose. Her skin was looking a bit better for a while but she now has new spots flaring up so I'm feeling discouraged again :(

[labblab]

Welcome back to you and Lucy! It looks as though a lot has happened since we last spoke with you: Lucy must have tested positive on the diagnostic LDDS test, and you started a period of Lysodren loading. It will be great if you can fill us in on more specifics about all that -- what were the exact LDDS results, and what was the Lysodren dosing protocol that was followed for her load?

However, to cut to the chase, unfortunately your instincts are entirely correct. With a post-ACTH level of 12.0, Lucy was never adequately loaded and the shift to a maintenance phase was way premature. The desired therapeutic range for a dog treated with Lysodren is much lower than the normal range for a dog who does not have Cushing's at all. A dog taking Lysodren is considered to be loaded when the post-ACTH drops between 1-5 ug/dL. That lower range is doubly important for dogs suffering from calcinosis cutis. Shifting to a maintenance dose when the cortisol is higher than that is pretty much a guarantee that any semblance of cortisol control will be impossible to maintain, and Lucy's cortisol may continue to climb even higher. This may be the reason for seeing a worsening of her CC once again.

When you mentioned earlier that your vet prefers Lysodren, I had hoped this meant he has experience with using it successfully. However, I am very worried if your vet is unaware that there is a difference between desired ranges depending upon whether the ACTH is being used as an initial diagnostic test vs. as a monitoring test for Lysodren treatment. Anyway, here are two links that will tell you quite specifically what your Lysodren loading goal should be:

http://www.idexx.com.tw/pdf/zh_tw/smallanimal/snap/cortisol/cortisol-mitotane-protocol.pdf

http://www.k9cushings.com/forum/showthread.php?t=181

I really think you will need to print out these links and address this problem with your vet directly. :o

Marianne

[annziemarie]

Thanks so much for this information! I have printed it out and will go over it with Lucy's "dad" tonight. He is the one who spoke with them earlier today to fax me her lab results at work today and this was all I received. I will try to get a copy of everything else that has been done. I know after the LDDS they said she was "very cushingoid".

Sounds like she wasn't even close to being fully loaded? I was very nervous about the whole process and overdoing it so we may have jumped the gun in bringing her in for her test. She has never had a ravenous appetite and her water consumption is spotty.

The vet who instructed us on the maintenance dose was a different vet within the same practice so I am not sure of her experience with Lysodren. We will be calling to have a discussion tomorrow. Not what I want to be dealing with the month before giving birth...

[labblab]

Oh gosh, I can only imagine how many balls you are juggling right now. :o

Super big kudos to you and Lucy's dad for working so hard to take such good care of her! Just to clarify, you did nothing at all wrong by having Lucy tested to see where her cortisol level was. It's always better to be safe than sorry, especially if a dog doesn't exhibit bold obvious symptoms and loading status can be really hard to judge. But that's why the numbers themselves are so important. With a cortisol hanging at 12, you would simply continue loading, monitoring, and then retesting again. So you, yourself, didn't goof up at all.

Marianne