Hi! I’m new to Cushing’s & really need some advice.

[Larkberly]

My name is Kim & my 6-yr old Shih-tzu/Maltese mix is Archie. My vet has suspected Archie has had Cushing’s Disease since he was 3, even though that is extremely young. A little background on Archie because he’s not your usual pup: I got Archie when he was just 8 weeks old. He was a “gift” from my brother. From the first day Archie & I met, I knew he wasn’t your “normal” pup. He nipped at me the first time I picked him up but I thought it was just him being nervous & a puppy but I have learned that Archie does not like to be touched. You can’t pet him for more than a few seconds & pretty much only under the chin before he will growl & give you a warning air-nip. I have never been able to check his paws or ears or pet him like a real dog. You can’t touch him while sleeping or he wakes up snarling & biting. He has to be sedated to go to the vets office & has to be “knocked out” for blood draws & X-rays. But I know Archie loves me & is generally happy...he follows me everywhere, sits at my feet & comes to me for his 10 seconds of under chin pets. He’s always happy to see friends, the groomer and the vet-just don’t try to pet him. Neither my vet nor I can figure out the behavior but it’s just Archie...or so I thought. Since Archie was very young he’s had problems-eye, ear & skin infections, heavy panting day & night. And when he was 2 he hurt his leg & it never fully healed right. We thought maybe early arthritis but as time passed more symptoms-panting got worse, he was thirsty all the time & peeing up a storm, his hunger has gone through the roof, he’s got a pot belly & more skin infections. Also, he rubs & scratches his face constantly. We’ve changed foods, giving Apoquel & the Cadia injections & he still itches all the time. At this time he was 3 & my vet mentioned Cushing’s but said he was young. Fast forward to this past year..another skin infection & my vet said we need to run some tests...his liver enzymes were very high (ALP was 1149) & he has protein in his urine. Now my vet seriously suspects Cushing’s but because of cost of testing & his behavior problems she doesn’t think testing should be done. A few weeks later he went to the groomers (where he has to be muzzled & my groomer wears chain mail gloves to “groom” him) & when he came home he was in terrible pain. The groomer thought she cut his nail too far as that’s when he yelped but 2 days later he was worse & we went to the vet. It was his neck & shoulder on the same “leg” he had hurt in the past. Archie was put on Carprofen, Gabapentin & Hydrocodone to help with pain & we started laser therapy. Luckily Archie was being pretty sedated so for laser therapy we only had to muzzle him & use a towel over his head for eye protection & to help keep him still. Since this has happened Archie has started pooping in the house. It’s like he doesn’t even know he has to go until it’s happening. He hadn’t been going on his normal morning walk because of his neck injury & I thought that was part of it but when we tried going back to normal routine he would still poop in house. It happens when he’s barking or running around...you know, something that puts pressure on his “pooper”. (Sorry, not using official terminology). It’s now been 2 1/2 months since Archie’s neck injury & he’s doing better as far as his pain but he falls down & stumbles a lot and he’s doing better about the pooping but still has an accident in the house a couple times a week. We’ve stopped the gabapentin & hydrocodone. We are weaning down from the Carprofen but he still needs it at times. I asked my vet if all this could be related to Cushing’s & she thought a lot of it was. But she doesn’t want to test Archie for Cushing’s yet for a few reasons 1) his behavior issues make him a bad candidate for the ACTH test because he has to be sedated & it would throw off the test 2) the cost..I’m already over $15K in the last year on his vet bills. She said when he starts urinating in the house then we should consider testing/medicating. We retested his urine & his numbers went down (1.053, ph 6, 3+ protein in July to 1.020, ph 5.5, 1+ protein in September). I feel so lost & confused. I read many dogs are on medication with fewer symptoms than Archie but I also understand that there are a lot of potential side effects with the medication. I don’t know what to do, should I get a second opinion? But how will Archie react to a stranger? Any advice would be appreciated. And thank you for taking the time to read my ridiculously long post.

[labblab]

Kim, welcome to you and little Archie. There’s no need at all to apologize for the length of your post. We like to gain as much background info as possible, and Archie’s history is definitely quite complicated so the more we know, the better. In honesty, his medical history is complicated enough that I want to take a little more time to think things over before offering my own suggestions. I didn’t want to waste any more time before welcoming you, though! We’re very glad you’ve found us, and I’ll be back again a bit later on to write more. So stay tuned!

Marianne

[Larkberly]

Thank you, Marianne. Just knowing someone out there is listening & willing to help means the world. Believe me-I’m staying tuned...

[labblab]

Hi again, Kim! First of all, it sounds as though Archie has presented a lot of both medical and behavioral challenges during these past six years, and bless you for taking such good care of him. Your vet is correct that his anxiety/aggression issues do complicate the initial process of testing for Cushing’s, and would also make the treatment monitoring process more stressful for everybody involved if he does indeed have the disease. Many of his symptoms are consistent with Cushing’s, but some are not such as the new problem of pooping in the house.

Aside from the elevated ALKP and the urine abnormalities, has his other labwork remained within normal range? How about thyroid and blood glucose levels? Either diabetes or thyroid abnormalities could also explain some of Archie’s issues, so that’s why I ask.

As far as Cushing’s diagnostics, it’s true that both of the two diagnostic blood tests can be skewed inaccurately by anxiety and/or chemical sedation. However, there is one preliminary “gateway” urine test that you could discuss with your vet. It would involve you gathering urine samples at home, if that would be possible. It’s called a Urine Cortisol/Creatinine ratio (UC:CR), and although it cannot definitively establish Cushing’s, it can pretty definitively rule it out if the results fall within normal range. Once again, stress will skew the results, so that’s why the urine sample is best obtained at home in as stress-free environment as possible. One sample can be analyzed on its own, but a more accurate result is obtained by pooling samples obtained on three successive mornings. I don’t know whether Archie would object to you trying to catch a sample in a cup, but it might be worth a try.

If Cushing’s was deemed a possibility after the UC:CR, then the next steps do become somewhat murky given Archie’s aversion to being handled or blood-tested. Given Archie’s complicated presentation, I do believe you would be well-served to seek a consultation with an internal medicine specialist. This is a vet who has received advanced training in involved illnesses, and his/her expertise could help you sort out which testing would be of greatest value. You may find such a vet in a private specialty practice, or definitely in conjunction with a vet school if you happen to live in an area near a vet school.

If Archie does have Cushing’s, the two most widely effective treatments do require monitoring blood testing. But additionally, there is one medication — Anipryl — that does not require followup bloodwork. If you Google it, you’ll see that it is prescribed for dogs suffering from either Cushing’s or canine cognitive dysfunction. It only seems to help relieve symptoms in a limited number of Cushpups, but in Archie’s case, it might be worth a try. Heck, it might even ease some of his behavioral stress, as well.

Having mentioned Anipryl, it occurs to me that your own vet might want to make contact with a national endocrinology expert who consults out of California. His name is Dr. David Bruyette, and for many years he was the medical director of a VCA facility in Los Angeles. He’s a Cushing’s expert, and has consulted with pharmaceutical manufacturers re: multiple medications including Anipryl. Dr. Bruyette now heads a private veterinary medical consulting firm, and could probably offer advice to your vet without having to personally examine or test Archie. Undoubtedly a fee would be involved, but in Archie’s case, I believe it could be money very well spent. Here’s a link to Dr. Bruyette’s website:

https://www.veterinarydiagnosticinvestigation.com/about-us

OK, that’s about all I can think of for right now! But I’ll continue to mull things over and see if there are other suggestions I can come up with. And hopefully some other folks will drop by, too, with their welcomes :-).

Marianne

[Squirt's Mom]

Hi Kim,

Just popping in to say WELCOME! to you and Archie.

I can't agree more with Marianne's suggestion to see an IMS - in particular Dr. Bruyette if possible. Her comment about thyroid issues is very important as well since hyPERthyroidism often causes aggressive behavior in dogs.

There is one more test that sedation would not interfere with and that is an abdominal ultrasound. One done with a high resolution machine so the adrenal glands are more likely to be seen. Their condition can give a good idea if Cushing's is in play plus it would allow a peek at many other internal organs to see how they look and if any tumors are present. There is a type of adrenal tumor that has nothing to do with Cushing's called a Pheochromocytoma. These tumors mimic Cushing's and other conditions because they all share the same signs. Here are some of the clinical presentations possible with a Pheo and a link for you to read:


Clinical signs associated with pheochromo-cytoma are often vague and intermittent, and may mimic more common disorders such as hyperadrenocortisism, diabetes mellitus, hepatic or renal disease, or other neoplasms. Clinical signs frequently observed include weakness, collapse, lethargy, anorexia, vomiting, panting, weight loss, anxiety, restlessness, polyuria, polydipsia, diarrhea, abdominal distention, hind limb edema, epistaxis, seizures or acute blindness.

https://www.addl.purdue.edu/newsletters/2007/Spring/CP.htm

Several years ago, one of our Admins had a pup with a pheo and it took ages to get the correct diagnosis. Here is the link to Annie's story. If you see anything in either the link above from Purdue or Annie's story below, please let Archie's vet know asap.

https://www.k9cushings.com/forum/showthread.php?933-My-Annie-15-1-2-pheochromocytoma-Annie-is-now-an-angel-running-free

I'm glad you found us and look forward to learning more about you and your sweet, yes sweet! :D, baby boy.

Hugs
Leslie

[lulusmom]

Hi, Kim, and a belated welcome to you. Marianne and Leslie have given you some good information but I wanted to share some information on acth stimulation test results as it relates to sedation. We had a member a few years ago who provides foster and hospice care for unadoptable dogs. One was a dog suspected of having cushing's. Her symptoms were many, severe and she was combative and very aggressive, making it difficult to do any testing. We've been around for a very long time and this was the first time I didn't have a definitive answer as to whether sedation would skew the results of an acth stimulation test. I therefore wrote to a well known and highly published internal medicine specialist, Dr. Mark Peterson. He advised that sedation can cause an increase in resting cortisol but the post stimulated cortisol would not be effected. You are in a very difficult situation as diagnostic tests, as well as treatment monitoring tests, are not going be easy for you or Archie. Looking at the results of the last two urine tests, their is a marked decrease in USG. I believe your vet feels that if Archie has cushing's, his urine will continue to be less concentrated and he will eventually start having accidents in the house and drinking tons of water to stay hydrated. This is usually when cushing's becomes a lot more problematic for pet owners. Given what you have been dealing with since Archie was a puppy, I have to believe that you have an enormous capacity to love him as well as a huge measure of intestinal fortitude and ingenuity in working around his behavioral issues for many years. I am therefore not as concerned about your ability to handle cushing's. Cushing's is a very graded disease, progressing at a snail's pace so waiting until Archie becomes a lot more symptomatic will not harm him. However, because Shih-tzus are a breed that are more likely experience a rare skin disorder called calcinosis cutis, can you tell us if your vet has done a punch biopsy or scraping to determine the type of skin problem that is plaguing Archie? Lastly, I wanted to mention that my last cushdog rubbed his face constantly on his bedding and furniture. He was a tiny Pomeranian I bailed out of my local shelter so I didn't know his history. He was a walking poster dog for cushing's and his mouth was a mess. I thought the rubbing would get better after all of his teeth were removed but it didn't. Long story short, he had severe hypertension which can give dogs a massive headache so please make sure your vet monitors his blood pressure. Given that he had 3+ protein in his urine, high blood pressure would be suspect. Having said that, taking Archie's blood pressure would present a huge problem and I have no idea how sedation would affect the results.