Diesel

[DieselsMom]

Hi Everyone,

I've been lurking and reading for awhile based on suspicions and now it's been confirmed -- he has Cushings. An ultrasound is scheduled for next Thursday, but he stresses at the vet and will probably need to be sedated -- something he doesn't handle well. He's a Boston Terrier with significant breathing issues.

I noticed in other threads that you all are so great in giving your time going over labs and I'm hoping you'll help me too! I don't have his Oct 2017 labwork with me, but I know his ALP was 400 at that time. The current labs were done on 3/28/18 and the following are the abnormal readings:

Anion Gap 24.8 H range 9-22
Cholesterol 382 H range 92-317
Triglyderides 438 H range 29-291
ALP 611.3 H range 5.0-131.0
CALP 488.0 H range 0-40

T4 0.8 L range 1.0 - 3.5

HCB 18.3 H range 12.0-18.0
MCV 76.0 H range 59.0-75.0


LDDS was done on 4/5/2018

Baseline Cort 2.5
4 hour 1.6 (appears to be in normal range)
8 hour 2.1 H normal range is <1.0

Interpretation:

1. Look at 8 hour result first. Normal dogs will have serum cortisol concentrations less than 1.0. Dogs with PDH/adrenal tumors will have 8 hour results > 1.4. Cortisol concentrations between 1.0 and 1.4 are inconclusive.
2. Look at 4 hour result. (after reviewing 8-hour result that supports diagnosis of hyperadrenocorticism). Supportive of PHD if 4 hour result is less than 50% of baseline or < 1.4. Suppression does not occur in dogs with adrenal tumors and about 40% of dogs with PDH.

Any help deciphering will be greatly appreciated!!

[Squirt's Mom]

I have just a second right now but did want to let you know I have manually approved your post so members can see it and start replying as they can. One of our Admins will more than likely get this fixed so all your replies will automatically clear but just in case, check your spam or junk folder for an email from K9Cushings to which you can reply and free up your account.

I'm glad you found us and will be checking in later. Sit tight! I am sure others will be along soon to chat and help with your questions.
Hugs,
Leslie

[DieselsMom]

I have just a second right now but did want to let you know I have manually approved your post so members can see it and start replying as they can. One of our Admins will more than likely get this fixed so all your replies will automatically clear but just in case, check your spam or junk folder for an email from K9Cushings to which you can reply and free up your account.

I'm glad you found us and will be checking in later. Sit tight! I am sure others will be along soon to chat and help with your questions.
Hugs,
Leslie

Thanks Leslie! Oops, looks like my mom turned into mon in my user's name. Anyway I can change that?

Thanks,
Cindi

[labblab]

Hi Cindi, your username has now been revised ;-).

Welcome from me, too! And I’ll be back to write more tomorrow.

Marianne

[DieselsMom]

Hi Cindi, your username has now been revised ;-).

Welcome from me, too! And I’ll be back to write more tomorrow.

Marianne

Thank you!

[molly muffin]

Hi Cindi and welcome to the forum.

The LDDS does seem to point toward pituitary cushings. It is interesting that they show both a ALP and a CALP. We don't usually see a CALP, but it is ALKP results due to cortisteroid (or high cortisol) Which this is quite indicative of since it is high along with the general ALP.

Was the blood test done after a meal or was it a fasted blood test? That could make a difference in the trig and cholesterol results, but you might want to try to get on a diet with lower fat content, but a good protein.

My next question is how much does he weigh and was medication/treatment plan discussed? If the recommendation is to use vetroyl, make sure to start at no more than a 1mg/1lb ratio. Give with food, check cortisol levels about 14 days after starting.

If the recommendation is to use lysodren, then we can discuss that protocol also.

[labblab]

OK, I’m back again, too! Thanks for posting all these test results, and yup, they do seem to be consistent with Cushing’s. As Sharlene says, the CALP result is not one we usually see — I even had to look it up. But also as she says, it registers high ALP specifically associated with corticosteroids, so that does seem diagnostically significant.

I think, though, that the LDDS results are inconclusive as to whether pituitary or adrenal Cushing’s is the cause since neither Diesel’s 4 or 8 hour result were less than 50% of the baseline value nor less than 1.4. So I’m assuming this is one reason why the ultrasound has been recommended — to get a good view of his adrenal glands. Here’s a link that helps explain how you interpret LDDS results, generally:

http://veterinarymedicine.dvm360.com/clinquiz-interpreting-low-dose-dexamethasone-suppression-test-results


LDDS was done on 4/5/2018

Baseline Cort 2.5
4 hour 1.6 (appears to be in normal range)
8 hour 2.1 H normal range is <1.0

Interpretation:

1. Look at 8 hour result first. Normal dogs will have serum cortisol concentrations less than 1.0. Dogs with PDH/adrenal tumors will have 8 hour results > 1.4. Cortisol concentrations between 1.0 and 1.4 are inconclusive.
2. Look at 4 hour result. (after reviewing 8-hour result that supports diagnosis of hyperadrenocorticism). Supportive of PHD if 4 hour result is less than 50% of baseline or < 1.4. Suppression does not occur in dogs with adrenal tumors and about 40% of dogs with PDH.
We’ll certainly be anxious to know how the ultrasound goes, and what results are obtained. So please do continue to update us.

Marianne

[DieselsMom]

Hi Cindi and welcome to the forum.

The LDDS does seem to point toward pituitary cushings. It is interesting that they show both a ALP and a CALP. We don't usually see a CALP, but it is ALKP results due to cortisteroid (or high cortisol) Which this is quite indicative of since it is high along with the general ALP.

Was the blood test done after a meal or was it a fasted blood test? That could make a difference in the trig and cholesterol results, but you might want to try to get on a diet with lower fat content, but a good protein.

My next question is how much does he weigh and was medication/treatment plan discussed? If the recommendation is to use vetroyl, make sure to start at no more than a 1mg/1lb ratio. Give with food, check cortisol levels about 14 days after starting.

If the recommendation is to use lysodren, then we can discuss that protocol also.

The blood test was not fasting, it was done around 8 pm, so he had eaten. He weighs 36lbs. Nothing was discussed other than to schedule the ultrasound. I've been feeding Nutrisca kibble because it doesn't have any of his allergerns, but he prefers The Honest Kitchen. I've been trying to feed THK more often.

He has trouble sleeping, mostly getting comfortable. He frequently falls asleep sitting up. He'll lay down, moan and then sit up until he can't do it anymore and he finally lays down. But he's up and down all night. Is there anything I can do to help him sleep?

Thanks!

[DieselsMom]

OK, I’m back again, too! Thanks for posting all these test results, and yup, they do seem to be consistent with Cushing’s. As Sharlene says, the CALP result is not one we usually see — I even had to look it up. But also as she says, it registers high ALP specifically associated with corticosteroids, so that does seem diagnostically significant.

I think, though, that the LDDS results are inconclusive as to whether pituitary or adrenal Cushing’s is the cause since neither Diesel’s 4 or 8 hour result were less than 50% of the baseline value nor less than 1.4. So I’m assuming this is one reason why the ultrasound has been recommended — to get a good view of his adrenal glands. Here’s a link that helps explain how you interpret LDDS results, generally:

http://veterinarymedicine.dvm360.com/clinquiz-interpreting-low-dose-dexamethasone-suppression-test-results


We’ll certainly be anxious to know how the ultrasound goes, and what results are obtained. So please do continue to update us.

Marianne

I definitely will! Thanks!

[DieselsMom]

Wow, I can't believe it's been almost exactly a year since I've posted. It's been a crazy year. Diesel is hanging in there, but having some problems. His ultrasound showed slight enlargement of his adrenals (no mass), the vet says that was indicative of PDH. He's taking 10 mg of Vetoryl twice a day. He's always been sensitive to meds so we have to be careful of dosing. After one Stim test last fall the vet said he was borderline (sorry, I don't have the test results). The vet increased his dose to 15 mg twice a day and switched him to a compounded Trilostane. Diesel was ok for a couple of weeks and then gradually stopped eating. He lost a total of 7 lbs. He was overweight but now looks boney. We stopped the compounded and went back to the 10/10 Vetoryl thinking it was the other medication that caused the problem. He had 3 spots about the size of a half dollar where the fur stood up and then fell out; along with a pus like substance. Fur is slowly growing back. His eating didn't improve much after going back on the Vetoryl, we started Pepcid because he acted hungry but after a few bites would walk away. Unfortunately the Pepcid didn't seem to make a difference. I finallly switched him to Nexium with great success -- he's finally eating again; although a topper is needed to get him to eat more than a couple of bites at a time. Even the toppers didn't work before starting Nexium.
He had another stim test on 3/28 and I have the results but haven't been able to talk with the vet yet (his dad is dying and he's out of town).
I'll try to post the results below, if I don't mess it up. :D But I have a couple questions before I try. Diesel frequently feels cold to the touch and shivers -- so I put a sweater on him and cover him up -- it helps. Is that the cushings? His thyroid came back slightly low this time (.8 with normal range starting at 1), but was normal in January and this has been going on since last fall. In about the same time frame, I think he's having peripheral vision loss because he jerks back when someone comes up on his side or he's smelling in the yard and walks up next to something -- is that caused by the cushings?
I occasionally give him a Melatonin before bed to help him sleep, but he seems groggy the next morning too. Oh and I frequently have to take him outside to pee before bed. In the past he's used the doggie door as needed, but now I wonder if the reduced eye sight is why he doesn't go out at night by himself anymore. Yard is fenced with 6 foot chainlink.

If you're still reading, thank you!! I'll try to be more present and thanks for your help.

ACTH STIMULATION

PRE-ACTH CORTISOL 3.8 ug/dL
POST ACTH CORTISOL 8.0 1 ug/dL

Comments:
1. ACTH Reference Range:
Canine:
2-6 Pre-ACTH (resting) cortisol
6-18 Post-ACTH cortisol
18-22 Equivocal post-ACTH cortisol
>22 Post-ACTH cortisol consistent with hyperadrenocorticism
<2 Post-ACTH cortisol consistent with hypoadrenocorticism
1-5 Desired pre- and post-ACTH cortisol on lysodren* therapy
1.5-6 Desired pre-and post-ACTH cortisol on trilostane* therapy

ACTH response test is only clearly positive (>22) in 30% of
dogs with hyperadrenocorticism (HAC); equivocally positive in
another 30% of dogs with HAC, and normal in 40 % of dogs with HAC.*
If the ACTH response test is normal and HAC is still suspected,
proceed with a low-dose dexamethasone suppression test.

Dogs with iatrogenic Cushing's disease will have flatline response
test results in the low end or below the normal reference range.

Both HAC and hypoadrenocorticism are rare diseases in cats.

*Recommendations for target cortisol levels on trilostane (Vetoryl*) therapy
vary. Per the manufacturer, pre- and post-ACTH cortisol levels of 6-9 ug/dL
(testing performed 4 hours post-trilostane) may be sufficient for some animals if
clinical signs are well controlled.

[labblab]

Welcome back to you and Diesel! I’m sorry, though, that he doesn’t seem to be feeling his best. One quick question for you — in looking back through your original posting, I’m not seeing how old he is. Just out of curiosity, can you tell us his age? That may have some bearing on the treatment decisions going forward.

In terms of these recent monitoring ACTH results, the interpretation notes are pretty consistent with what we’ve seen to be generally recommended. For Cushpups who are still experiencing unwanted symptoms of the disease, you’d probably want to see the cortisol dropped somewhat lower. However, for dogs who are doing well, Diesel’s level of cortisol is probably just fine. One thing we can be reassured about is that it’s not too low.

So the question here is, Diesel seems to be having some problems but are they due to a higher level of cortisol or are they due to something else, even perhaps aging? The fur loss and pus sound like a skin infection to me. I’ve had similar problems with my nonCushpup that we ended up treating successfully with medicated shampoo. But Cushing’s itself can leave dogs more vulnerable to skin infections.

What’s the status of Diesel’s thirst and urination? Are they normal at this point? How about other common Cushing’s symptoms such as panting, seeking out cool places, muscle loss in his hind end?

Diesel’s pickiness about eating is a big question mark. Excessive hunger is more commonly associated with Cushing’s, and when we hear about lack of appetite, our first worry is that cortisol may have been driven too low by the medication. However, that isn’t the case here. Combined with his shivering, grogginess, and his new reflex to be startled, I’m afraid I do have one worrisome thought. As a Boston terrier, he’s a breed that can be more vulnerable to brain inflammation caused by enlargement of the pituitary tumor that causes Cushing’s. Because of the flat face and skull, there’s greater risk that a pituitary tumor may end up placing pressure on the areas of the brain that control hunger, vision, etc.

I don’t wish to worry you unduly by telling you this, but I think it’s important for you to know that it’s a possibility. The only way to know for certain is to pursue imaging of the head — either CT or MRI — and this can be quite expensive. If this is indeed the problem, then surgery or radiation may be an option. But again, the treatment is quite expensive and may or may not be a good option depending upon the dog’s age and overall health. If this is the problem, you can likely expect to see a worsening of neurological problems such as increasing loss of coordination and aimless circling around, even pressing the head against hard objects like a wall.

But this may not be the problem at all. Hopefully, it’s not. However, given Diesel’s poor appetite, regardless of cause, I’d probably be hesitant to lower his cortisol any further. Anyway, these are my initial thoughts. Thanks in advance for any additional info. And again, welcome back!

Marianne

[DieselsMom]

Thanks for the reply Marianne.

Diesel is 9, will be 10 in August. He still drinks and pees a lot; has hind end weakness.

He's always had trouble sleeping. He has difficulty breathing when he's laying down because of his brachycephalic problems. He's had two palate resections with little success. The surgeon says Diesel has too much excess tissue and during his second surgery the surgeon found a lot of scar tissue that was making things worse.

His vet and I have discussed a CT but because Diesel hasn't done well with anesthesia in the past, the vet is hesitant to do it.

Do you know of dogs that have had trouble with the compounded Trilostane? I'm not sure if it was the increased dose or the ingredients that caused Diesel to stop eating when we tried the compounded meds before.

I ordered a thermometer from Amazon, but it's not accurate, so I need to get something different.

I weighed Diesel yesterday and he's lost another pound.

Cindi