Henry, 11yr old mini schnauzer - inconclusive results?

[minischnauz]

Hello,

I’ve been reading the forums for a couple of weeks now – so glad you guys are here! I could use some help interpreting the results I just got and where to go from here.. This will be long so I apologize in advance. :)

Henry is an 11-year-old miniature schnauzer. He is 27 pounds (not overweight, just big for a mini!) He has been pretty healthy all his life (knock on wood). But the week of July 16th, he was a little “off” – a little lethargic, wasn’t excited about food, but would eventually eat. A couple of days later, he started leaving his food, so I started him on a bland diet. In the middle of the week, he started having diarrhea, though he had plenty of appetite for the bland diet and seemed to get back to normal energy levels. By Saturday, July 21, the diarrhea was worse, so he went into the vet. They did blood work and the abnormal numbers were (ref range numbers in parenthesis):
TP 8.8 (5.2-8.2)
ALB 4.0 (2.2-3.9)
GLOB 4.7 (25-4.5)
ALT 223 (10-125)
ALKP 936 (23-212)
TBIL 3.3 (0.0-0.9)

They sent him home with Metronidazole and Famotidine and were going to refer him for an ultrasound.

Sunday morning, 7/22, he was not himself – wouldn’t eat anything, vomited, was whining and panting. So off to the emergency vet we went. They ended up keeping him overnight for fluids and IV meds. By the next morning he was eating and ready to come home (and has been fine since). The bloodwork when he went in showed 3 abnormal levels:
ALT 126 (10-118)
ALKP 1774 (20-150)
LYM .96- (1.00-4.80)

They did an xray and ultrasound, too, and the only thing the vet discussed as possibly being an issue was a “moderately enlarged” liver (no adrenal masses found). He suggested testing for Cushings.

Went back to the regular vet to discuss Cushings testing on 7/30/18. He drew more blood work and these were the elevated levels:
ALT 166 (10-125)
ALKP 1292 (23-212)

Cushings test was performed on 8/1/18 and just got the results yesterday:

Cortisol, Baseline: 196 (15-110 nmol/L)
Cortisol low dose dex 4h: 14 (0-30 nmol/L)
Cortisol low dose dex 8h: 103 (0-30 nmol/L)
Cortisol 1hr post ACTH: 537 (220-550 nmol/L)

Notes: “Here is a mixed message with loss of suppression of cortisol but a high-normal response to ACTH-stimulation. One possibility is that this dog does not have hyperadrenocorticism and the elevated result reflects a stress response to non-adrenal illness. More likely is that this dog has pituitary dependent hyperadrenocorticism. Any decision regarding a diagnosis of hyperadrenocorticism will weigh heavily on the confidence of clinical signs.”

So, this means this is probably Cushings, right? But I don’t think he is showing any clinical signs! No potbelly, no skin issues, no excessive panting, no accidents in the house (yet), his energy is great. Of course, since then I have noticed him drinking more than he usually does, but that is not saying much because he never drank a lot of water. I have been measuring and he is drinking about 2 cups a day (today, more like 3), but I don’t think this is excessive for his size. What would be an excessive water amount for a 27 lb dog?

I started him on Denosyl last week (that was what the vet sold), though I am ordering Denamarin for next month. The e-vet also suggested switching to Royal Canin LF, which I have done. (I’m not crazy about the ingredients but Henry loves it and seems to be doing well on it, so he will stay on it for now.)

I spoke with the vet and she says the Cushings results are inconclusive, suggesting that we not treat right now, as he is not showing symptoms and because there could be a different underlying issue. She recommends just watching him and seeing how he does.

Thoughts? I agree with not treating if the signs aren’t there, but is there something else I should be doing or looking for? I don’t want to put him through excessive testing because any vet visit really stresses him out. He hates going there. But at the same time, I don’t want to be negligent if there is something obvious that I should be doing or testing for. Do these results scream something else to you? And when would symptoms be enough to start treating? Is the water-drinking itself cause for concern?

Not sure if this could be a factor, but the last month was very stressful for him, starting with July 4th, which never seemed to end. He’s become so fearful of fireworks that I had to get a Xanax prescription for him this year. It worked for a few nights, when fireworks were further away and more sporadic, but when the neighbors started setting them off on the 4th itself, it didn’t work and he worked himself into quite a state. And then I had work done on the house, which was loud, and he hates loud noises now. And then all of the vet appointments (did I mention he hates going to the vet?) Could all of this stress be affecting things?

I apologize again for the length – thank you for reading! And I would really appreciate any thoughts you might have as to test results and where to go from here.

Thank you!
Julie

[labblab]

Hello, Julie, and welcome to you and Henry! Thank you so much for writing such a thorough introduction to your sweet boy’s issues. My time is running short this morning, so I’ll need to return later before I can write a lengthier reply. But I wanted to at least let you know how glad we are that you’ve joined us. So stay tuned for more!

Marianne

[Harley PoMMom]

Hi Julie,

Welcome to you and Henry from me as well! I am so sorry your boy is having some issues and we will help in any way we can.

For me, Henry's case does not scream Cushing's. Normal drinking for a non-cush dog is 1 ounce per 1 pound of body weight so for Henry's weight of 27 lbs, that would be 3.375 cups, so no he isn't drinking excessively. Miniature schnauzer are predisposed to pancreatitis and his symptoms along with the some of the abnormal lab values are commonly seen with pancreatitis. My recommendation would be to have a Spec cPL test performed to see if pancreatitis is in play here. Were his triglycerides and cholesterol checked?

Lori

[labblab]

OK, I’m finally back again! I’m so glad Lori has greeted you and I totally agree with her, and also with your vet:


I spoke with the vet and she says the Cushings results are inconclusive, suggesting that we not treat right now, as he is not showing symptoms and because there could be a different underlying issue. She recommends just watching him and seeing how he does.

Henry’s observable symptoms really are not consistent with Cushing’s at all: fairly rapid onset of lack of appetite, nausea, vomiting, diarrhea, etc. Acute GI issues such as these are not typical of Cushing’s, but as Lori has suggested, pancreatitis could be a culprit, as could some other type of inflammatory GI issue.

As the lab interpretation stated, bodily stress caused by nonadrenal illness can result in “false positives” on the Cushing’s blood tests. That’s why consideration of clinical symptoms is such an important part of a Cushing’s diagnosis. And right now, Henry’s symptoms really are not consistent with the disease.

If you want to be more proactive re: alternative diagnostics, I’d recommend requesting a referral to an internal medicine specialist if there is one in your area. A specialist like this can be better able to make differential diagnoses when symptoms are complicated or confusing. There may be a bit more up-front cost involved in seeing a specialist, but you may well save money in the long run by receiving more targeted guidance and testing. Having said all this, please do feel free to continue to ask us any questions about Cushing’s, however. We’ll continue to try to help in whatever way we’re able.

Marianne

[minischnauz]

Thank you, Marianne and Lori, for your welcome and your thoughts!

I'm looking through the test results that I've gathered from the last few weeks. I'm assuming cholesterol is CHOL, which was measured on 7/21, our first vet visit after the onset of his GI symptoms, and which was 249 mg/dL (110-320). I don't see that it was measured at the e-vet or at the follow up vet visit. Dumb question, but what would I be looking for, letter wise, to see if the triglycerides were measured?

They treated the GI episode as pancreatitis, even though the e-vet said that their test didn't come back positive for it (which they said can happen even if it is present), but since they didn't find anything else and schnauzers are prone to it, they gave him the meds for it and it cleared right up. Is there a possibility that the pancreatitis could still be an issue even if he is no longer showing any symptoms? Could pancreatitis be responsible for those elevated liver levels and cortisol levels? The e-vet seemed to be of the opinion that the enlarged liver and elevated liver enzymes could be pointing to Cushings but if the test came back negative, to let it go because otherwise he seemed to be ok. Of course, I didn't get a positive or a negative! :rolleyes:

Do Cushings dogs, then, usually have a normal cortisol baseline? And is it the high baseline that makes it seem like something else might be going on? Henry's baseline number seems really high to me and I'd hate to think that it is harming him in some way.

I will do some research to see if there is an internal medicine specialist nearby.

Thank you again!
Julie

[labblab]

The resting or baseline cortisol level really has no significance as a Cushing’s diagnostic. Stress alone can increase a baseline cortisol level. So if Henry was really stressed out just by being at the vet, for instance, that could account for a transitory elevation in the baseline reading. It appears that he had a combined LDDS/ACTH stimulation test. On both of those tests, it’s the subsequent readings that are meaningful in terms of a Cushing’s diagnosis. Henry tested “positive” for Cushing’s on the LDDS, but he was within high normal range on the ACTH. So the test results were contradictory, and this is the rub. The LDDS is more likely than the ACTH to return a “false positive” in the presence of illnesses other than Cushing’s. Since Henry’s ACTH was within normal range and he doesn’t exhibit outward symptoms consistent with Cushing’s — this is what is making the Cushing’s diagnosis more questionable.

As far as looking for an internal medicine specialist, take a look at this link and see if it may help you locate somebody in your area:

http://www.k9cushings.com/forum/showthread.php?182-Finding-an-Internal-Medicine-Specialist-Vet-(ACVIM)-(N-America-and-other-countries)

Oh, and if Henry’s cholesterol was within normal range, that’s yet another strike against Cushing’s as being the culprit. Cushpups often have elevated cholesterol levels.

Marianne

[minischnauz]

That was an incredibly helpful explanation, Marianne, thank you! And thank you for the link -- I will check that out now.

Julie

[Harley PoMMom]

Is there a possibility that the pancreatitis could still be an issue even if he is no longer showing any symptoms? Could pancreatitis be responsible for those elevated liver levels and cortisol levels?


My Harley had chronic pancreatitis but didn't have symptoms. We monitored him with the Spec cPL test and even with diet modifications his levels never returned to normal, that pancreas is a fickle organ! Triglycerides are usually abbreviated with TRIG or TG, that's awesome (and unusual!) that his cholesterol was normal!! Any non-adrenal illness can cause the cortisol to rise so even if Henry isn't showing any outward signs of pancreatitis the pancreas could still be inflamed which could elevate those liver enzymes and cortisol.

Lori

[minischnauz]

Thank you, Lori, that's very interesting and helpful. I didn't realize pancreatitis could be present without symptoms. Oddly, it doesn't look like the Triglycerides have been tested. That is something I will keep in mind.

You both have made me much more comfortable with the interpretation of the Cushings results and the decision not to treat right now. I think, as long as Henry is still doing well, I am going to give him a little break from testing and then go back to my vet to see if we should recheck anything. There is a very good animal hospital about an hour away from where I live, which I will look into a bit more as well.

Thank you again for your help!

Julie