New member, please help, is it Cushings?

[CBJ@RVA]

I'm hoping someone can help me. My dog (Charlie, 12 yrs old) has been having leg tremors/shaking for almost a month. Charlie is lucid before, during, and after these episodes. The episodes happen about every 5 minutes or so and last only a few seconds. The longest one I have witnessed lasted 7 seconds. The tremors/shaking do not fit the "textbook" examples of what would be considered a seizure. Physical exam at vets office was normal. Blood tests were normal except thyroid levels were low. Urinalysis was not done because his bladder was empty at time of visit. Charlie was prescribed medication for his thyroid and referred to a neurologist. Charlie had an MRI ,spinal tap and chest x-ray on Monday. Results were normal. Glucose levels were checked twice on Monday because neurologist suspected shaking could be from low blood sugar, but those results were also normal. Physical neurological exam was normal. Neurologist prescribed an anticonvulsant (Levetiracetam 250mg three times a day) to see if it would stop the tremors. The medication made Charlie worse. When Charlie would have a tremor he could no longer keep his balance and would fall over. He also fell down a few stairs. Luckily I was there when it happened and he did not get hurt. I stopped giving him the medication after 2 doses. Within 24 hours he was back to where he was before the anticonvulsant medication. Both my vet and the neurologist casually mentioned Cushings could be the problem. The neurologist suggested the following tests: (1)Abdominal ultrasound (2)Urinalysis
(3)+/-ACTH Stimualtion test (4)Echocardiogram (5)More fasting blood glucose measurements

I started researching Cushings because I didn't know much about it. I saw that the UCCR urine test is part of the tests done to determine Cushings. Not wanting to put Charlie through another stressful vet visit this week I called my vet to see if I could bring in a urine sample for the UCCR test. The receptionist said she had never heard of the test and she only knew of the 8 hour blood test for Cushings. She said she would ask our vet and call me back. That was yesterday morning and as of 5pm today I haven't received a return call. Is this urine test not a "common" test done by veterinarians? Is it only done by specialists in internal medicine practices?

Here is some background on Charlie and what has been going on with him in addition to the tremors. Charlie has always been an inactive dog, even when he was younger. He mainly likes to lay in his bed and look out the window, or in the warmer months hang out on our screen porch. So it is hard to say if he is less active than normal. Charlie has never been food crazy. He gets fed twice a day. Sometimes, especially when the weather is hot, he might skip a meal. He has always been a slow eater. He will pick out a few pieces of food, carry them to a different spot, then eat them. He could take 10 minutes to finish a meal. For the past 6 weeks or so he has been begging for his breakfast and dinner. He puts his head in his dish and doesn't look up until he is finished. A few times last year he got into the garbage. It was surprising because he had never attempted this before. I read that one of the first signs of Cushings is consuming more water and it could start long before other symptoms show up. Charlie has not been drinking more water than usual, but he does drink more than our other dog. He is not going to the water dish frequently, but when he does he takes a big drink. So I am confused as to whether or not the amount he drinks is normal. Perhaps it hasn't seemed excessive because he has been drinking that way for a long time.? Charlie has had skin issues in the past and he has also had problems with yeast in his years. Currently, his skin and ears are ok. If not for the tremors/shaking we would not of suspected anything was wrong. Which leads me to ask, can tremors/shaking be a sign of Cushings? I did see a post on the forum about tremors, but it was related to medication. Has anyone had their dog experience the type of tremors/shaking that Charlie is having being diagnosed with Cushings? I have read muscle weakness is a sign of Cushings, but Charlie is still able to walk, run and jump up on furniture.

I don't know what my next step should be. Should he have an abdominal ultrasound first, or the ACTH test, or just start with the UCCR urine test? Does anyone on here even think Cushings is a possibility? A big thank you to anyone that is still reading this!

Courtney

[labblab]

Hello Courtney, and welcome to you and Charlie! I have only a moment to post right now, but I wanted to make sure you know that we’re so glad you’ve found us. I have several thoughts that I want to offer, but it may be tomorrow before I will have enough time to write them out. My own Cushpup experienced tremoring/shivering episodes both prior to diagnosis and for a time period after treatment was begun. Whether or not they were similar to Charlie’s, we shall find out. I also had a nonCushpup who suffered from grand mal seizures of unknown origin and was successfully treated with phenobarbital. So I will be anxious to talk with you more about Charlie’s issues.

One quick question in advance: for how long a time has he been taking the thyroid supplement, and are his levels yet back within normal range. I do know that low thyroid levels are associated with seizure activity, but obviously the neurologist knows that, as well. So I’m guessing that low thyroid is not being a considered a cause at the moment?

Also, the UCCR could indeed be a reasonable starting place. You may already be aware that it can only serve as an initial gateway test. Elevated readings on that test are not limited to Cushing’s; normal readings on that test take Cushing’s off the table, however. So that may be a fine place to start, and a GP vet ought to be able to handle that test request.

OK, gotta run for now. But once again, welcome!
Marianne

[CBJ@RVA]

Thanks Marianne!

He has been on the thyroid supplement since February 8, 2018. I read that it can take 2 months or more for it to get into normal range. My GP vet said some studies suggest low thyroid levels can cause seizure activity, but she is not "on board" with that. She believes his tremors/shaking are being caused by something else yet to be determined.

Charlie gets extremely stressed going to the vet, so knowing that I could possibly rule out Cushings with the UCCR test is why I wanted to start there. We have spent over $3,500 the past two weeks on tests and still no answer. I just feel helpless right now and I really don't know what to do next. It doesn't help that our vet hasn't returned my call with a simple "yes" or "no" about the capability of performing the UCCR test.

Courtney

[labblab]

OK Courtney, here I am back again. First of all, I’m somewhat surprised that your vet expresses skepticism about a connection between hypothyroidism and seizure activity. Although not a commonly occurring side effect, I thought a link was pretty well established. At least, that was the case when my nonCushpup started having grand mal seizures a few years ago. I did a lot of research at that time, and hypothyroidism consistently came up as a possibility. So a comprehensive thyroid panel performed by the lab at Michigan State Univ. was one of the first tests my vet ordered. As it turned out, my girl’s thyroid function was normal, so that was the end of that. But still, I wonder why your vet disputes a link. Did the neurologist express an opinion about the possibility?

You mention that Charlie had a normal MRI. What portion of his body was imaged? If it was his head, a pituitary tumor responsible for Cushing’s should have been seen. If no pituitary tumor is present, then the only other cause of Cushing’s would be an adrenal tumor. I mention this because, if this is the case, an abdominal ultrasound as recommended by the neurologist might be the one test that could give you the biggest bang for your buck. Not only could you check the status of his adrenal glands, you’d also gain insight into the presence of any other internal abnormalities. And if Charlie has a normal pituitary gland as well as normal adrenal glands, then Cushing’s is basically off the list.

Returning to the UCCR, however, there ought to be no reason why your regular vet can’t submit a urine sample for analysis. Here’s a tip if you do decide to proceed with the test. We’re aware that some specialized endocrinologists recommend submitting a pooled sample for the most accurate result. What this means is that you combine samples taken on three successive mornings. The first pee of the morning is recommended, and the samples should remain refrigerated throughout the entire time period.

And finally, let’s return full circle to your question about a Charlie’s tremors. You describe his tremoring as occurring in his legs — as you’ll see, this is a bit different from what I observed with my Cushpup. I’m including here a reply that I previously posted elsewhere re: tremoring episodes.



Through the years, we have had other members who have worried over unexplained tremoring episodes. My own Cushpup, a Lab, suffered from intermittent involuntary tremoring episodes across his shoulder blades that made him look as though he was shivering. For him, the episodes happened most often when he was sitting down or at rest -- even when he was sleeping. Sometimes he would jerk himself awake, they were that severe. But just as is true for your boy, he would usually just stretch afterwards and never seemed to be in any particular pain or discomfort. The tremors began before he started trilostane treatment, worsened significantly when he first started the drug, and then ended up stopping entirely a few months down the road.

We never did figure out what caused them. Through the years, other members here have reported similar issues with their dogs under a variety of circumstances: some using trilostane, some using Lysodren (another medication), and also dogs not yet being treated at all. For this reason, it has been hard to point to a single "trigger." It is true that tremors are now listed as a possible side effect of trilostane. But I've always wondered whether such tremors more often just somehow relate to rapidly changing cortisol levels. But the good news is that they didn't really seem to bother my dog at all -- it was ME who was going crazy trying to figure them out!

I see I’ve written quite a bit here, so I’ll go ahead and end this reply for now. But please continue to ask additional questions. I must confess that Cushing’s is not the first thing that would have come to my own mind in relation to Charlie’s tremoring. But since it’s being considered, I do think the UCCR could be the easiest and least expensive place to start. However, I also agree with the neurologist that an ultrasound would be very high on my general diagnostic list.

Marianne

[Squirt's Mom]

Hi Courtney, welcome to you and Charlie!

Marianne has gotten you off to a great start, as usual, and I don't have much to add. But I do have a few questions. What breed(s) is Charlie an what color is he? Certain breeds are prone to conditions that cause tremors as are white dogs, usually small white dogs. I may be grasping at straws but you never know! ;)

I would like to add that you consider finding another vet or sticking solely with the IMS at least until Charlie has a confirmed diagnosis. His current vet doesn't seem to be very cush savvy and that can bring unnecessary risks when dealing with this disease - in both the diagnostic and treatment phase. For them not to know about the UC:CR and that seizures are associated with thyroid issues is alarming to me. Of course, we don't know for sure that Charlie is cushinoid just yet but something is going on and I would want a vet who was on the ball.

Most of all, know that you are Charlie are now part of our little family here at K9C. You will never be alone; we will walk with you every step of the way on his journey. Never hesitate to ask questions or just talk when needed - we DO understand.

Hugs,
Leslie

[CBJ@RVA]

Charlie’s tremors seem to be occurring in just his legs. They happen when he is standing and sitting. So far we have not noticed it happening when he is lying down or sleeping. Thats not to say they definitely don’t happen then. The tremors are short in duration so it would be easy to miss if he is in a resting position. When the tremors happen you can tell it throws him off balance and he usually steps out of it, if that makes any sense. I have taken several videos of his episodes and showed both our GP vet and the neurologist. The episodes do not appear to be actual seizures. However, our vet said that doesn’t mean they aren’t seizures. Very frustrating.

Charlie had a brain MRI. The neurologist said the MRI was normal. No visible tumors, no evidence of stroke, a normal looking brain. I read somewhere, not on this forum, if the pituitary tumor is small it might be missed on an MRI. I read this after speaking with the neurologist so I did not question him specifically about a pituitary tumor. I did mention to the neurologist about our GP vet commenting on seizure activity in dogs with low thyroid levels, and not being convinced on the subject. He said he would agree with that and also feels like the tremors are unrelated.

Charlie is a poodle/havanese mix. He is more of a miniature poodle size vs havanese size. He weighs 23 lbs and is not a bit overweight. He is a white dog with black ears and a black spot on his back. I have read that poodles are one of the breeds where you are more likely to encounter seizures and Cushings. I have never read/heard about tremors being more common in white dogs. This is very interesting information.

At this point I just feel so desperate for an answer.

Courtney

[labblab]

Courtney, if you Google “White Dog Shaker Syndrome,” you’ll find what Leslie was talking about. Given your description of Charlie, it’s not a perfect match since WDSS typically involves full body tremors. However, it still may offer food for thought.

I will tell you that from our experience here, seizures are not a common side effect of Cushing’s. When they do occur in conjunction with the disease, most frequently it is due to an enlarged pituitary tumor that is placing pressure on other areas of the brain. Based on the MRI, that seems highly unlikely to be present for you guys. Also, I’ve not noticed any particular association at all between seizures and poodles suffering from Cushing’s.

I believe I’d specifically ask the neurologist whether he felt as though he had an adequate image of Charlie’s pituitary gland. If so, you really are left solely with an adrenal tumor as a possibility. I would want to know if that’s why the neurologist is advocating for an ultrasound as his first diagnostic. There are various types of adrenal tumors, which in turn can affect the production of various adrenal hormone levels in addition to, or instead of, cortisol. Abnormalities in those hormones may also be associated with seizure activity, I guess. So perhaps that may be part of the big picture that the neurologist is looking at...

Marianne

[molly muffin]

Hello and welcome from me too.
If your vet can't do the UC;CR and yes it is a common enough test, then I'd ask if the IMS could do it. A full urinalysis also might show something. That would be a good starting spot and not as expensive as some other test could be.

The UC:CR Could rule out cushing or high cortisol High cortisol itself, whether from cushings or something else, can cause weakening of muscles, tendons, etc.
These are my initial thoughts and probably what my next step would be based on all blood work other than thyroid being normal.

Lets throw in, a urinaysis to check for concentration and any possible bacteria.

How are Charlies teeth? We've found that teeth bacterial infections can cause issues in other areas of the bodies too. This is really looking for anything that might be off, but some areas to think about and check out if nothing comes of any other tests.

[CBJ@RVA]

[QUOTE=molly muffin;
How are Charlies teeth? We've found that teeth bacterial infections can cause issues in other areas of the bodies too. This is really looking for anything that might be off, but some areas to think about and check out if nothing comes of any other tests.[/QUOTE]

Charlie's teeth are terrible. He has had dental problems since he was a puppy. He was born with a significant under-bite, which has made any benefit he could gain from dental chews, etc. almost impossible. He hates having his teeth brushed too. Its been almost 3 years since the vet cleaned his teeth. I know poor dental hygiene can cause other problems in the body, particularly kidney. I will bring this up to our vet on our next visit.

Courtney

[CBJ@RVA]

"Update"

I spoke on the phone with the neurologist and asked if he felt he had an adequate image of the pituitary gland. I told him I was concerned about Cushing's disease. He said he definitely had a good image and even went back and viewed it again to make certain. He said it looked completely normal, not even borderline enlarged. However, he did add that the MRI couldn't completely rule out pituitary dependent Cushing's.

Yesterday evening I took Charlie back to our GP vet to discuss our next step. I had her do a urinalysis and a fecal exam. Fecal exam was clear. Urinalysis specific gravity was consistent with what she sees in Cushing's dogs. (sorry I didn't get a copy or specific numbers) No infection present or indication of kidney disease. The blood work he had done on 2/7/18 (CBC/Chemistry/T4/FreeT4) showed low thyroid and his alkaline phosphate was elevated, 242 UL (5-160 U/L). The vet said she has Cushing's dogs whose numbers are way higher than 242. (600-800 range) Dogs with low thyroid can also have elevated ALP. The rest of his blood work was normal/unremarkable. Charlie does have a yeast infection in both ears, which I had suspected.

My vet and the neurologist both feel Charlie should have an abdominal ultrasound before doing the UCCR urine test or the LDDS test. The reason for this is because Charlie is having unexplained episodic tremors/spasms in his legs. My vet said even if Charlie has Cushing's disease she feels there is something else causing the tremors. I made an appointment with the IMS on March 6 for the ultrasound.

Courtney

[Squirt's Mom]

Cushing's can be caused by either a tumor on the pituitary gland or one or both of the adrenal glands, which sit just on top of the kidneys. So the US would be the best next step. And we see ALP (ALKP) values in the 1000's in many of our cush pups so what has shown up for Charlie is indeed a very mild elevation. ;)

Do let us know how things are going and especially what is learned from the US.

Hugs,
Leslie

[molly muffin]

An ultrasound can give a lot of bang for the buck.
As he has teeth issues, did they take a good look at his mouth to make sure no infection there?

Usually with cushings, we do see a low specific gravity in the urine so that is probably what the vet meant by consistent with cushings.