Just starting

[Urses]

My 7 year old German Shepherd has recently been exhibiting most if not all of the symptoms. I can't help but blame myself. I had a vet that pushed Apoquel instead of prednisone for her recurring ear and skin issues. I left for different reasons but I also didn't want to go near Apoquel for immune system suppression. She has seen a new vet and prednisone wouldnt be used much. Last week she began peeing inside and drinking a lot of water. My vet feels its progeressed too much and is doing a dexamethasone suppression test in the morning. I feel I know the results already because she has nearly every symptom, loss of fur, increased appetite, lethargy, thin skin on her belly, pot belly, open sores, insomnia. I can never forgive myself for doing this to someone I love. Shes all I have. If it is iatrogenic is there a way to reverse this or keep her around for more than two or three years? I will post my results when I get them. Thank you.

[Harley PoMMom]

Hi and welcome to you and your sweet girl!

I've only a moment to post, sorry, but did want to take time to greet you both. I have a couple of questions. Did her symptoms seem to have started suddenly? Did she have any blood work done, and if so, could you post those values that are abnormal with the normal reference ranges?

Iatrogenic is when Cushing's develops from steroid use, was your girl on some kind of steroid?

I apologize for this post being so short and will try to get back later, in the meantime some of our members will probably be by to welcome you and share their advice and experiences as well.

Hugs, Lori

[Urses]

Thank you for the response and I understand being busy. For about 6 or 7 months I noticed she just looked older very quickly. She did not have any of these symptoms. She had a belly rash over the winter that wouldn't go away and lesions in between her toes. She also had what appeared to be striae under her bottom lips, one on each side. Her appetite was normal, drinking sleeping were all fine. But the stomach rash would not go away and it wasn't until last week when everything happened at once. She has had prednisone off and on over a year or so just to help calm the stomach rash. She had a dose of prednisone the week before I noticed the increased drinking and peeing.

[labblab]

Hello and welcome from me, too! Does your vet think your girl's symptoms have been caused by the prednisone use? If so, this would indeed be considered to be "Iatrogenic" Cushing's, but the good news is that all symptoms would be expected to resolve once the prednisone use is permanently discontinued. In that sense, the treatment is very simple. One huge consideration, however, is that if Iatrogenic Cushing's is suspected, the LDDS is not the proper diagnostic blood test to perform. You would instead want to perform an ACTH stimulation test:


[The ACTH stimulation test is] the gold standard for diagnosis of iatrogenic HAC and monitoring of patients with HAC once they have started treatment.
It may be the case, however, that your vet doesn't actually think the prednisone is the culprit and is wanting to test for naturally occurring Cushing's. In that case, the LDDS would be appropriate.


The ACVIM panel considers the LDDST as the screening test of choice, unless latrogenic HAC is suspected.

But I'm wondering whether your girl's symptoms have been consistently present for a period of time, or have they only appeared recently in conjunction with prednisone dosing.

Thanks so much for any additional info you can share about her specific prednisone/symptom history.

Marianne

[Urses]

Thank you. I will ask tomorrow about the ACTH test and I will be getting a second opinion at internal medicine place in Akron soon. I think that the symptoms may have been there and slowly progressing and this last dose may have been enough to make them very noticeable. I just don't want to be too far down the road that this is permanent. I dont have the blood test with me but I will get it as well as the test tomorrow. She had said the only thing noticeable on the blood test was a slightly elevated liver enzyme.

[labblab]

Can you give us more specifics about the prednisone?

His long ago did she start taking it?
How often did/does she take it?
What is her weight, and what dose of pred has she been getting?

Thanks!
Marianne

[Urses]

Over the last two or three years not very often from what I can recall. I've gone through receipts and it would be scattered. She always had a bad infection in her ear mostly yeast and it would require a couple trips to the vet. She would get a seasonal allergy where her feet would get itchy and her stomach resulting in a rash. She might get prednisone three to four times a year at maybe a weeks worth (20mg twice a day for 5 days, then 20mg once a day for 5 days, then every other day) when she may have been heavier at 95 lbs. I dont know the dosage because shes recently been down to 80lbs in 2017. (I've cut back on how much she eats because I was giving her too much at her heavier weight.

Yesterday she didn't seem as lethargic and was pulling me on the leash. Other than some longer naps she seemed to be acting like her old self. Still drinking a lot and peeing though yesterday and this morning

Edit: I also want to thank you for asking about her. I kind of feel on an island here.Not many people know about it so I don't have anyone to talk about this. Especially as this is so frightening.

[labblab]

You are so welcome :)! But you really don't need to thank us -- you and your sweet girl are part of our family now, so we will probably end up bugging you with even more questions than you want to answer! ;)

Thanks so much for this additional info about the prednisone, though. Given this info, I doubt very much that your dog suffers from the Iatrogenic form of Cushing's. It typically requires steroid dosing given continually over an extended period of time, which has not been the case for you. If your dog does have naturally occurring Cushing's, though, receiving a short course of prednisone could indeed trigger a temporary worsening of existing Cushing's symptoms simply because the circulating steroid level in the body has been jacked up even higher for a while.

So at this point, we'll await the results of today's testing and go from there. And don't worry, we'll be right here every step of the way!

Marianne

[Urses]

I'm just concerned her skin issues this last year or so have been an underlying steroid issue and we have been treating it occasionally with adose, and this last round pushed her over the edge.
Here now and she wants to do the ACTH at a different time

[molly muffin]

Hi and welcome from me too. Are they doing the LDDS today and then want to do an ACTH at a later time?

Have they ever done any skin biopsies to determine exactly what the rash is? That might be worth looking into.

Also there is a shampoo that a few people with different issues have used on their dogs successfully. Marrianne is one of those who have used them, i think they are called Douxo shampoos. I think that might be worth looking into and marianne can certainly tell you more about it.

That's good that he is showing more energy too. Did they check her for a UTI too? Might need to do a culture to find out for sure if her urine is dilute, but that is a possibility for the sudden onset of drinking/urinating more too.

[Urses]

Yes she was checked for a UTI and she doesn't have one. I've spent the summer using Douxo and it hasn't helped. I have an appointment with a dermatologist in two weeks. I dont kno if he will want to do a biopsy. Her symptoms have receded a little but the drinking and peeing haven't. Her skin has improved in some areas, if you can call it an improvement. She still has striae under her front legs but her stomach has become a little darker than normal. It isn't red anymore. Could it be the rash has just been her skin reacting to the steroids and we have been treating her occasionally with a dose of prednisone to calm it down? I cant even think thats what I have done.
I am still waiting for the LDDS results. I think she was off Saturday. I want to do the ACTH one soon just for peace of mind but she said thats more of a test to check if the dosage is correct. Will that specifically give me a determination if its iatrogenic? If it is iatrogenic do I just wait and see if she recovers on her own? Or if she is able to. I know once you start treatment you cant stop but it just seems counter intuitive to do nothing.

[Urses]

She called yesterday and said the LDDS test came up negative for Cushings. I didnt get a chance to get a copy with the numbers but I will post them when I can. While I know its not a 100% guarantee and theres still a long way to go, its a little measure of hope that maybe her adrenal gland is still working and she can fight this. My pup still has the symptoms and isnt very comfortable. Shes calling me today to set up the ACTH test next.

[labblab]

Well, that's interesting that the LDDS was negative. Please let us know what you find out from the ACTH next week, and then we'll brainstorm some more!

Marianne

[molly muffin]

I too think it will be interesting to see what the ACTH shows.

There is a small percentage of dogs 5% who will always test negative on the LDDS, even if they have high cortisol, so in this case I think an ACTH could be beneficial. They will also want to rule out if anything else is causing high cortisol, as this is a natural body response. Infections for example can cause an increase in cortisol.

[Urses]

Well she tested negative for the ACTH test. I ended up going to the dermatology place in Akron Ohio and he diagnosed her with deep/mucocutaneous pyoderma, bacterial pododermatitus and an earinfection.
Hes thinking it could be lupus erythmatosus, severe allergic skin disease, cutaneous vasculitis, erythema multiforme, or even a paraneoplastic disease.
We are going to try and get the infection under control and then go from there to try and figure out what is causing ti. Most likely since she is a German Shepherd, its lupus which can be controlled. I'll get the culture report in a week or so.
He wanted to use prednisone to get her itchiness under control and there was no way I was going near that.

[labblab]

Well, at least you know it's not Cushing's, but I'm surely sorry for all these continuing problems. Did the vet have any thoughts as to what might be causing the excessive thirst and urination since I'm guessing they are not typically symptoms of these various skin conditions, or even lupus unless there is kidney involvement...

I surely understand why you are reluctant about using prednisone, but if Cushing's has been ruled out, pred or a similar steroid may remain your best short-term treatment option for an auto-immune disorder.

I'm still wondering about the thirst and urination, however. Is it still the case that all of her regular bloodwork is still within normal range except for a liver elevation? Can you find out exactly what that liver elevation was? I dunno. You've already invested so much time and money in diagnostics :o, but it still might be worth it to bite one more bullet and take her to an IMS for one more opinion about all this. Somehow, it still seems as though there may be pieces missing from the puzzle...

Marianne