New member Quincy's mom--testing questions

[qsmom]

Hi all, I am a new member. My husband and I have a 9 year old neutered male Boston Terrier, Quincy. He's a terrific dog--AKC CGC, certified Therapy Dog, agility champion (CPE CS-ATCH) and AKC Advanced Trick Dog and, believe it or not, a professional model. Aside from some orthopedic issues (since resolved), he's always been in excellent health.

Several months ago, I noticed that he seemed to be drinking a little more than usual, and begging for food a bit more than before. He's peeing a little more often, but not alarmingly so. He's always had seasonal alopecia (we live in upstate NY, where the sun doesn't shine most of the winter...), but it always grows back. This year, he seems to have a lot of hair loss across his tummy and beneath his stubby tail, but too soon to know if it will grow back. He's as active as ever, alert and able to learn new things.

After reading about BTs as a breed, I learned of the susceptibility to and symptoms of Cushings, so we took him to the vet last month. His initial bloodwork came back with an ALP of 142, slightly high. Vet recommended second test 1 mo. later. That just came back yesterday at 224. Now our vet, who is conventional/allopathic (but whom we like very much) is suggesting LDDS rather than UC:CR. I get that, but I'm scared about the test, and wonder whether it is appropriate given the fact the vet sees no other indicators, either in bloodwork or clinical symptoms.

I'd like to know what you all think about the LDDS test--does it pose a risk? Is it worthwhile doing at this point? I doubt his symptoms justify the dangerous drugs yet, even if it is Cushings. Just scared...

Thanks so much for any advice you can offer.

[Squirt's Mom]

Hi and welcome to you and Quincy! :)

If I were you and all I was seeing was a little increase in drinking I'm not sure I would pursue the testing at this point unless I was willing to start treatment. We typically see a ravenous appetite - and I mean they literally think they are starving 24/7 even after eating a full meal. The drinking and urination is copious, often with loss of house training. Our cush babies pant for no reason, even when it is very cool. They seek out cool places to lay. They develop a pot belly and the skin begins to darken as if bruised. They often become restless and are less interactive than they once were. They exhibit exercise intolerance and have trouble jumping when they didn't before. The ALP values we see are typically 100's if not 1000's of points over normal, not slightly elevated and we also see other lab changes in other liver values as well as others.

The LDDS poses little risk. Blood is drawn then an agent, dexamethasone, is injected and two more draws are made over an 8 hour period to see if the adrenals can suppress normally. If they cannot, then Cushing's is a possibility. However, with so few signs in evidence I think I would opt for an abdominal ultrasound first myself. They should be able to see the adrenals as well as many other organs. In Cushing's the adrenal glands will be enlarged, either both or one depending on whether the disease is adrenal or pituitary driven.

It is true that BT are one of the breeds that seem to be over-represented in Cushing's but not all Bostons develop the disease. If Quincy does have Cushing's it could be that he is in the very early stages. But bear in mind that Cushing's is one of, if not THE, most difficult canine condition to correctly diagnose. Many other diseases/conditions share the same signs and can cause false-positives on the cush tests - another reason I would want the US first. My own Squirt was diagnosed with Cushing's but an US showed a tumor on her spleen and once it was removed her cortisol returned to normal. ;)

It is perfectly normal to be afraid when we first start learning about Cushing's but as one who has worked with special needs dogs for some time now, Cushing's is one disease I would choose to deal with over many, many others our babies can have. It is manageable and with proper treatment our babies can live out their normal life-span and beyond. You have found the very best place to be to learn about this disease and how to cope with it SHOULD it become a reality for your sweet baby boy.

I'm glad you found us and look forward to learning more soon!
Hugs,
Leslie

[molly muffin]

Hello and welcome from me too.

Leslie has made some good points. Cushings is hard to diagnose. So, first everything is normal other than the ALP?
Ultrasound is a good bang for your buck option. You can also have an ACTH test, which rather than like an LDDS which sees if the glands can suppress, the ACTH acts more like a sponge dump, in that you see where the baseline is, an injection is given and you test an hour later to see how much cortisol is now in the body from the adrenal glands.

All test have the ability to have false positives if anything else is going on, and one reason that Leslie probably mentioned the ultrasound, as it is non invasive and can show you what the internal organs look like. Once my dog starting having symptoms I did a baseline ultrasound which was spendy to start off with, but then we did follow up comparison ultrasounds to check for changes, which weren't as expensive as the initial one.

The LDDS is not a dangerous test that I have ever heard. And if you are looking for early detection and peace of mind, then it might be something that you want to have done. That is a personal decision and one for you to discuss with your vet. My vet also wanted LDDS as soon as my dogs ALP started going up, and I did have it done and it was negative at that time.

[qsmom]

Thank you so much Leslie. My thought was, even if he does have Cush, if it's in the very early stages, we would probably opt not to treat yet, unless withholding treatment might put him at risk for us not being prepared to head off related conditions (e.g. pancreatitis). Our vet suggested ultrasound if the LDDS came back positive, to help determine if PD vs. adrenal. Would adrenal glands be enlarged on ultrasound in PD?
I'm thinking that if we do the LDDS and it comes back positive, I may look for an internist with a specialty in endocrinology. We live not far from Cornell Veterinary School, so that might be an option.

[qsmom]

Hi Sharlene, thank you for responding. I did specifically ask the vet if there were any other abnormalities in Quincy's bloodwork and she said no, so it's just the ALP. He had a full thyroid panel done last April; that was OK back then. Our vet suggested ultrasound IF the LDDS came back positive, to determine PD vs. adrenal. She is able to do the ultrasound without sedation, so maybe less expensive, tho' we have insurance (thank God!). I'm glad to hear LDDS is not dangerous. Our vet said we can take him home between blood draws, so that might be less stressful for him. At this point, I'm most concerned about getting an accurate Dx, which from everything I've read here, is a considerable challenge.

[Squirt's Mom]

Would adrenal glands be enlarged on ultrasound in PD?

In the adrenal based form we typically see one gland enlarged and the other smaller or even atrophied. In the pituitary form we usually see both glands enlarged. So the US can give a good clue IF Cushing's is in play and if so which type. The LDDS can determine which form as well. I personally prefer to start with the US as it is less invasive and generally less stressful for the pup. Plus it is the one test that gives us the biggest bang for the buck by letting us see many of the other organs and their status.

[qsmom]

That is excellent info. I may ask our vet to switch to the US test first, since it seems less stressful. Thank you!

[qsmom]

Hello everyone,

Well, we had an abdominal ultrasound this morning. It showed slight (but clinically significant) bilateral enlargement of adrenals. No other abnormalities noted on scan. Board Cert. Radiologist said findings are suggestive of Cushings. I am trying so hard not to panic. The next step is the LDDS test on Thursday 2/1. Once that comes back, if it shows Cushings, is there any other diagnostic test or tests we should do to be absolutely sure? Once we have a Dx, then I have to think long and hard about whether to start Rx. Quincy's symptoms are so mild (some hair loss on his belly, mild thirst, and some begging for food).

[Squirt's Mom]

I'm glad the US didn't find any problems! That in itself makes the test worth the cost! ;) I wanted the ACTH performed before starting treatment so we would have a baseline to compare to when we started monitoring treatment. Squirt had the LDDS and the ACTH along with the US. She also had the full adrenal panel that looks at intermediate hormones but that was because I am a bit anal at times. :D I think the US, LDDS, and ACTH will tell you what you need to know.

[qsmom]

I'm glad the US didn't find any problems! That in itself makes the test worth the cost! ;) I wanted the ACTH performed before starting treatment so we would have a baseline to compare to when we started monitoring treatment. Squirt had the LDDS and the ACTH along with the US. She also had the full adrenal panel that looks at intermediate hormones but that was because I am a bit anal at times. :D I think the US, LDDS, and ACTH will tell you what you need to know.

Thank you, that is useful info!

[molly muffin]

We also had the LDDS, ACTH and US. We did the intermediary test too (other sexual hormones) but that was solely due to a negative on the LDDS and a positive on the ACTH. I think the LDDS and see what that shows will give you and idea and then if you want to follow up with an ACTH after you see what the LDDS shows, you could do so.

[qsmom]

Well, things have taken a turn with Quincy. He had a second LDDS in mid-March that was completely normal. Our vet suggested an ACTH and full adrenal panel at University of Tennessee Knoxville. That just came back with a post-stim of 28, so it looks like a positive test. Again, I am trying not to panic. Quincy has no symptoms other than elevated ALKP (830's) and hair loss along his belly and trunk. He's an agility dog, so we take him to a chiropractor once a month; she says he has mild loss of muscle tone along his rear spine.

Both of his vets (conventional and chiro) are suggesting we start with HMR lignans and Melatonin to see if that helps. He's on milk thistle (Denamarin didn't help). I'd like to know everyone's experience, if any, with lignans and melatonin, and what steps to take next (e.g. repeat abdominal ultrasound?) Thanks.

[Squirt's Mom]

Melatonin and lignans are the combination used to treat a form of Cushing's called Atypical in which the cortisol is NORMAL but two or more of the intermediate hormones are elevated. Since you had a sample sent to UTK you should have gotten a report listing all the hormones tested - like estradiol, progesterone, and aldosterone to name a few. Could you share those results as well? If the cortisol is elevated then the melatonin and lignans will do little to nothing for it - that combo only works on those intermediate hormones. However if the cortisol is elevated that can cause the other hormones to elevate as well. Most conventional cush pups (with elevated cortisol) do have elevations in many if not all of the hormones. My Squirt started out as Atypical and was on the melatonin/lignans combo for quite a while before her cortisol started rising. The combo did help until the cortisol started rising and then her appetite kicked in BIG time. She has always been a Miss Piggy but her appetite was unbelievable when the coritsol kicked in! At that point we added Lysodren to her lignans and melatonin and she did very well for the rest of her life.

How is his appetite? Any increase or decrease in that area? Any pot belly, panting for no reason, changes in skin as is darker and thinner, is he heat intolerant? Has the hair loss worsened since your first post? Without more signs I would be very hesitant to start any treatment. The lignans and melatonin won't hurt anything but don't expect them to lower the cortisol. Does Quincy get stressed at the vet in general or riding in a car? A dog that is stressed for other reasons can return an elevated cortisol reading that is completely unrelated to Cushing's.

And then there's Molly, Sharlene's dog (Molly Muffin) - negative LDDS several times yet did have Cushing's. Here is a link to Molly's journey; you can read it and see if anything seems familiar to Quincy's journey so far. https://www.k9cushings.com/forum/showthread.php?4333-Molly-13-yr-shih-tzu-lhasa-aspo-Molly-has-passed

But if I were in your shoes I would hold off on starting Lysodren or Trilostane either one until the signs were stronger and other labs showed more of an indication of Cushing's like changes in neutrophils and monocytes, increases in glucose, cholesterol as well as the liver enzymes (we typically see ALP in the 1000's). Others may come along and say they would start treatment. :) But don't rush....based on what you have shared so far I still say he is in the early stages IF this indeed really is Cushing's.