Dani

[Dani]

Hi there,

This is my first post regarding Dani, my 12.5 yr old female dachshund/Chihuahua mix. Dani weighs 19 lbs and her weight has remained consistent. Since mid-March, her thirst has become excessive and consequently she asks to go out more often. She’s also had several accidents in the house, something that she had never done before. And in the last month, her appetite is through the roof, though I am not feeding her more. To my knowledge, the only other sign of Cushing’s (I think) would be a small amount of flaky dandruff appearing on her back. I don’t see any thinning of fur or sores. She is not on any medication, but I do give her glucosamine and fish oil.

I contacted my vet who did a urinalysis and complete blood work up on 4/7/18. Here are the results that are out of range of normal:

ALT 14 U/L (range 18-121)
Platelets 532 K/uL (range 143-448)

Diabetes mellitus has been ruled out, though the vet said that the possibility of diabetes insipidus remains.

As a note, Dani’s creatinine levels (from 4/7/18 and 6/2/17) were 0.8 mg/dL (range 0.5 – 1.5) The note on the labs indicates: “Both SDMA and creatinine are within the reference interval which indicates kidney function is likely good.”

I had read on the forum and elsewhere that a normal creatinine level almost assuredly rules out Cushing’s (I hope I have that information correct).

The vet said that Dani’s urine is very dilute (sp Gravity 1.021) so she suggested doing the ACTH, which was done on 4/23/18. Results:
Pre-ACTH 8.0 ug/dL (range 2-6)
Post-ACTH 20.3 ug/dL (range 6-18)

The IDEXX report indicates that a post-ACTH level of 18-22 would be considered ‘equivocal’.

Because this test was basically inconclusive per the report and because Dani continued to show the symptoms described above, the LDDS was ordered to be done on 4/26/18. Results:
Pre-dex 3.7 ug/dL (range 1.0 – 6.0)
4 hrs post dex <1.0 ug/dL The interpretation lists anything <1 as ‘normal’
8 hrs post dex 1.3 ug/dL Range is 1.0 – 1.5 and is considered ‘inconclusive’

My vet consulted with the internist at the lab who then recommended coming back in 2-4 months for a repeat of the ACTH. If the symptoms get worse, then I should go in at 2 months, if symptoms remain the same, then at 4 months.

Except for the excessive thirst and hunger, I’m not sure if anything so far points to Cushing’s. But something is definitely not right. Aside from what my vet has already suggested about repeating the ACTH, do you have any ideas? Should we consider an ultrasound? My vet is very easy to work with and will consider any ideas or suggestions that I might bring to her. If the symptoms progress/become worse, at what point do I consider seeing a specialist? Are we on the right track with pursuing the follow-up ACTH? My head is spinning with all of this….

Thank you so much for your time,
Becky

[Squirt's Mom]

Hi and welcome to you and Dani! :)

Her vet seems to be on the ball and has the bases covered pretty good! Which is a good thing to see! :) The one thing that concerns me with waiting is the skin - there is a complication with Cushing's called Calcinosis cutis that can be very hard to get rid of and can cause the pup discomfort. So I think my next step would be to see a veterinary dermatologist if one is available to you. If not, I would ask Dani's vet who could do a skin test for the CC. There are other causes for CC but they are very rarely seen. The majority of cases are caused by Cushing's so a positive test for CC pretty much locks in a Cushing's diagnosis. So that would be my immediate focus.

As one who wanted to be as thorough as possible when my Squirt was going thru the testing phase, I did every test available and am glad I did because the ultrasound found a tumor on her spleen. Had we not had that test done things could have gotten nasty quickly so I always recommend the ultrasound. Another test we did was the full adrenal panel at the University of Tennessee in Knoxville (UTK). It picks up not only cortisol but the intermediate, or sex, hormones as well. Those hormones can cause the same signs as cortisol. When a pup has elevated intermediates but normal cortisol that is called Atypical Cushing's and is often an indication that true Cushing's with elevated cortisol is developing. So those are two more things to consider and discuss with her vet from my point of view. ;)

You did a great job supplying information - that helps us help you. :) I'm glad you found us and look forward to learning more as time passes!

Hugs,
Leslie

[Dani]

Hi Leslie,

Thank you for the warm welcome and information!


The one thing that concerns me with waiting is the skin - there is a complication with Cushing's called Calcinosis cutis that can be very hard to get rid of and can cause the pup discomfort. So I think my next step would be to see a veterinary dermatologist if one is available to you. If not, I would ask Dani's vet who could do a skin test for the CC. There are other causes for CC but they are very rarely seen. The majority of cases are caused by Cushing's so a positive test for CC pretty much locks in a Cushing's diagnosis.


I do have a question regarding the skin issue. Right now, all I'm seeing is a bit of flaky white dandruff. Dani has had that before and although I've never had it checked by a dermatologist, her regular vet said that it's dry skin and to use a moisturizing shampoo. That seemed to do the trick. I checked Dani over pretty good and I don't see any other skin issues. So my question is, if we do the skin testing 'too soon' -- that is before any additional skin issues appear -- will the test result in a false negative even if she does have CC?

Edited to add: By the same token, is it possible to do the full adrenal panel too soon? I just don't know at what point I should start with these next steps.

Thank you,
Becky

[Squirt's Mom]

I'm not sure if timing will have an effect on testing for CC or not. If her skin has cleared with the shampoo then CC is unlikely I would think. Here is a link about CC anyway - https://dermvettacoma.com/calcinosis-cutis/

As for the UTK panel, I don't think it can be done too early when signs or other indicators are present tho as the disease progresses in a diagnosed dog those intermediate hormones can rise. The UTK panel is the only test to show those hormones tho. The good thing about Cushing's is that there is rarely a need to rush into treatment so waiting would be alright. Just keep an eye on her for any changes, any increase in signs or new ones showing up, and take her in for followup then. My main worry was the skin and if that has cleared then my mind is eased a bit. ;)

[Dani]

Thank you for the link. I'll watch for additional symptoms.

I made an appointment for an ultrasound for 5/25/18. I'll let you know what they find.

- Becky

[labblab]

Hello Becky, and welcome to you and Dani from me, too! Leslie has really covered the bases, so I just have a couple additional thoughts to add as we await the ultrasound results. First, you had made this comment earlier:


As a note, Dani’s creatinine levels (from 4/7/18 and 6/2/17) were 0.8 mg/dL (range 0.5 – 1.5) The note on the labs indicates: “Both SDMA and creatinine are within the reference interval which indicates kidney function is likely good.”

I had read on the forum and elsewhere that a normal creatinine level almost assuredly rules out Cushing’s (I hope I have that information correct).

I just want to clarify that there is a difference between the creatinine level on a blood test and the result of a urine cortisol to creatinine ratio (UC:CR). Creatinine on a blood test relates solely to kidney function. So in terms of her kidneys, it’s great that Dani’s creatinine and SDMA results were normal. But those results do not confirm or rule out Cushing’s. Turning to the UC:CR, creatinine is measured, but only as sort of a “control,” — it’s the cortisol level in relation to the creatinine that is really of interest. If an abnormally high level of cortisol is present in the urine, Cushing’s may be a cause. If the cortisol level is within range, Cushing’s is extremely unlikely. Given Dani’s results on the ACTH and LDDS, I’m guessing that a UC:CR performed at the same time would likely have given similar results: right at the top of the normal range or edging a bit over.

So the ultrasound will indeed be of interest. Also, I agree that if you do perform another ACTH further down the line, it might be of interest to have the blood samples sent to Tennessee for their analysis of her complete adrenal profile. On your end, the testing protocol remains just the same as for the prior ACTH. It’s just that the blood is sent to a different lab for analysis, and the testing will cost a bit more this time around. But the info you gain may be useful. The only downside might be that the exact numbers for Dani’s cortisol would not be directly comparable to the ACTH test performed by a different lab. By that, I mean the normal reference range will probably differ, so you won’t have a direct comparison, apples-to-apples, as to how the exact numbers for her cortisol may have changed. But you’ll still know whether her cortisol is within, or instead above, the normal range, and that is the most important thing. I hope that makes sense!

Last but not least, what you’re describing in terms of skin issues does not sound like CC. If you were to perform a biopsy, it would need to be a sample of cells from an active skin lesion. Since all Dani is suffering from is flakey dandruff, there would be nothing to sample. And again, this doesn’t sound to me like CC, anyway. So I think you can relax on that front.

Please do let us know how the ultrasound turns out, and we can go from there. And once again, welcome!

Marianne

[Dani]

Hi Marianne,

Thank you for the information.

I know that only I can make the decision as to whether or not to do an ultrasound and/or adrenal panel, but I'm trying to figure out if there is enough justification at this point to pursue either. If we do the u/s now and it shows as normal, is it safe to assume that all is clear or is it also a possibility that a very small tumor (or something else) wouldn't yet show? I do have to say that as anyone who has lost a dog knows, it's easy to get a little crazy when anything seems out of the ordinary. I don't want to spend money needlessly, but at the same time I want do whatever is necessary to ensure that Dani has the healthiest life possible.

Thanks again,
Becky

[Dani]

We went for the ultrasound today and I can't tell you how I wish I would have been wrong about everything, but I wasn't. Dani has a lot of stuff going on. I'll list the abnormal stuff here just as it's written on the report.

Adrenals: Right adrenal-normal size and shape. Left adrenal cranial pole is normal, however, the caudal pole is slightly larger.

Liver: Mildly enlarged in size, abnormal architecture due to several poorly defined hypoechoic nodules; overall slightly increased echogenicity.

Gall bladder: Normal walls with a small quantity of hyperechoic sludge in the lumen.

Spleen: Normal size, shape and echogenicity; however there is a singular (1.5cm x 1cm) poorly defined hypoechoic nodule.

Kidneys: Both ~4cm. Normal size range is 4cm for toy breeds, 5 cm for small breeds. Poor architecture due to decreased cortico-medullary distinction and increased overall echogenicity.


Recommendations:
Liver: Non-specific hepatic changes. Tissue sampling or recheck imaging is required for a definitive diagnosis.

Spleen: Similar lesion noted in the spleen. Same course of action as advised with the liver is recommended.

Kidneys: Advanced age related fibrosis seen in both kidneys.

Adrenals: Often when one pole of the adrenal is larger than the other, a benign mass is suspected. Advise recheck imaging, tissue sampling or further testing (Adrenal Panel)

~~~~~~~~~~~~~~~~~~~~~~~~~~

So that is where we are right now. I'm taking Dani in on 6/23/18 for the 8 hour LDDS and the blood samples will be sent to University of TN for the full adrenal panel. I'm not sure how I'm going to make it until that date, but somehow we'll make it through.

Any advice or comments would be most appreciated.

Becky

[Squirt's Mom]

I mentioned my Squirt having a tumor on her spleen earlier but here is the rest of the story, as they say.

She went for pre-dental bloodwork and the cortisol came back high so that started us on the Cushing's testing track. When she had the ultrasound done that tumor was found. Her ACTH was high, her LDDS indicated Cushing's, the HDDS told us it was the pituitary form....BUT after that tumor was removed her cortisol returned to normal. The tumor had caused the cortisol to rise naturally in response to the stress. Once the stressor was removed, the cortisol level dropped naturally. In our dogs as well as our own bodies, any time we are stressed our cortisol rises. It is supposed to do that - it is one of the "fight or flight" hormones. So stay on top of the liver, spleen and adrenals making sure they are fine and nothing is going on with them that could cause false-positives on the testing. The LDDS is notorious for giving inaccurate results if there is any other condition/disease/stress going on. That is what the tumor on Squirt's spleen caused - false-positives on all her tests. ;) Just food for thought based on my experience.

Let us know what the next steps are and how the adrenal panel and LDDS come out. Keep in touch regardless. You and Dani are family ya know.
Hugs,
Leslie

[labblab]

Yes, given Dani's ultrasound results, I think Leslie's point is well taken. It's not unusual for Cushpups to exhibit some organ abnormalities on ultrasounds. However, it sounds as though there's the possibility of tumors or masses being present in one or more of her organs. I think your first priority would be to find out if that's the case or not. Repeat imaging has been suggested and would certainly be far less invasive than actual tissue biopsy. Do you know if the "recheck" meant another ultrasound or perhaps an MRI now, or was the suggestion instead to wait a while and then repeat the ultrasound to see whether or not there are any changes over time?

The thing is, I'd think you'd really need to try to get more clarification about the organ abnormalities in order to accurately assess the likely cause or significance of any elevated adrenal hormone production that may be present. If Dani's previous LDDS had been "positive" for Cushing's, it exhibited a pattern of suppression that would have been consistent with a pituitary tumor as opposed to an adrenal tumor. But the ultrasound report is now speculating about a possible adrenal tumor. However, aside from the one enlarged adrenal pole, the glands themselves are of normal size. Normally with Cushing's, one or both glands themselves are enlarged. So there are question marks about this, and also the possibility of liver and spleen masses.

You asked earlier whether it might be time to consult with a specialist. Honestly, I think you are there. I think I would want to do that before any more testing is done of any type, including the LDDS. Unless the LDDS is being planned to be run in conjunction with an ACTH stimulation test as well, UTenn would not be able to complete a full adrenal panel. The LDDS and the ACTH are two different types of tests. The LDDS is a suppression test and the ACTH is a stimulation test. The full adrenal panel that we've been talking about relates to blood samples taken after the ACTH stimulating agent has been injected. I do believe it is possible for both tests to be performed in a single day, along with samples being sent to UTenn. But I'd want to make sure that it really makes sense to run all those tests at the same time, or whether there'd be a more desirable way to proceed given the information revealed in the ultrasound.

It may be the case that no tumors are present at all. But as I say, I'd want further clarification as to what the best "next step" might be. Your general practice vet may already have been investigating all this herself. But as I say, I'm thinking this would be the time when an actual in-office consultation with a specialist might be of value. It might mean more expense to you now, but it may save you unnecessary expense down the road, and also give you more peace of mind in terms of an overall game plan.

Marianne

[Dani]

Thank you Marianne and Leslie. Lots of good information. I've decided that it's time to get a specialist involved. There's just too much going on and frankly my head is a bit jumbled. I'll contact my vet to get a recommendation. Do either of you have experience with the specialists at Blue Pearl?

[Squirt's Mom]

Sorry, I'm not familiar with them. I think getting an IMS (Internal Medicine Specialist) involved is a great idea. Here's a link from our Helpful Resource section that can help you find an IMS close to you - http://www.k9cushings.com/forum/showthread.php?182-Finding-an-Internal-Medicine-Specialist-Vet-(ACVIM)-(N-America-and-other-countries)

[labblab]

I believe Blue Pearl is a chain of specialty clinics around the country. The specialty practice where my own Cushpup was diagnosed was originally an independent group. However, they are now part of Blue Pearl. As is the case with most things like that, I’m guessing that experiences will vary depending upon which individual vet within the practice a person ends up seeing. But I felt as though my dog originally received excellent care and we’ve since been back, now that it’s Blue Pearl, to see an orthopedist with our younger dog. Again, I thought we received a quality consultation.

Marianne

[Dani]

Thank you for the link. I appreciate all of your help with this.

[Dani]

Thanks so much for taking the time to help me with this. I'll contact my vet after the long weekend and get her input. Enjoy the rest of your weekend.

[molly muffin]

Hello from me too.

It is never too early to get an IMS on board and in the loop. That way you have an established relationship, whether or not cushings ever is a factor. As dogs get older, more issues can arise and having an IMS in your corner early can be a benefit as they will know Dani and be familiar with all aspects of her health and issues. I never regretted finding a good IMS. It took me a couple tries to get the one that I felt most comfortable with and that worked well with me for my molly. Molly has been gone for over a year and a half now but I still have a good relationship with that IMS and when I needed a referral with a rescue for getting another dog, she was the one I went to.

Here at our IMS's clinic, which is an ER, because they did the initial Ultrasound, they only charged me 70 for each follow up comparison ultrasound and I had them done regular. Molly had some benign masses, that never became anything but it's always good to be able to to do those comparsions for peace of mind.

If Dani's urine is dilute did they do a culture to check for a UTI? sometimes with dilute urine an infection doesn't show up as well as it does in normally concentrated urine.

[Dani]

Hi Sharlene,

Thank you for the welcome and information. I don't believe Dani's regular vet did a culture. There were a ton of tests done, but I don't believe a culture was a part of that. I'll check with her to be sure, but I would think that's a pretty basic thing to check for or at least I would hope she'd consider a UTI as a possibility.

- Becky

[Dani]

I just wanted to come back to give you the courtesy of a reply and the good news that the specialist says this is not leaning towards Cushing's at all. He ordered a urine culture (not sure why it hadn't been done before) and a B12/Folate workup. The results of both of those will be back in 5-7 days. We're still working on an answer as to what is causing her symptoms.

Thank you SO very much for your time and information.

Kind regards,
Becky

[labblab]

Dear Becky,

Thanks so much for this update! I’m so glad you’ve consulted the specialist, and surely hope you’ll soon have some answers. Please give little Dani a pat for us, and truly, we’ll remain interested in knowing how things turn out for you girls, regardless of whether or not Cushing’s is a part of the picture ;-).

Best wishes to you both!
Marianne