Diagnosis

[Frankiedoo]

Thank you for allowing me to join. Our almost 10 year old goldendoodle was diagnosed with PDH. It was a process getting here for sure. She was diagnosed in April 2020 with hypothyroidism. Her energy level improved and she lost the weight she had gained. However, her PUPD and appetite increased. I thought maybe she was over medicated, but she was not. Fast forward to August, I just knew something more was wrong. She had a mildly elevated ALT and steadily rising, but normal ALP. Her cholesterol was high, too. Her hair was thinning on her back end. She had an ultrasound and all looked good except for an ever so slightly enlarged liver. Her urinalysis came back with very dilute urine and she was losing protein. Her sdma and kidney numbers were normal. Her albumin and BUN were slightly low. We started on benazepril and a renal diet. I insisted on urine cortisol creatine test. It was sky high. She had the LDDS which confirmed Cushing’s. She is almost 60 pounds. She started on 20 mg of vetyrol 2X daily. We had a complication as she had a mast cell tumor on her leg. Thankfully it was low grade with clean margins. We started the vetyrol 2 weeks before surgery and had acth stim. Her levels were still high and her symptoms were no better. She has been on 30 mg 2X daily for the last 3 weeks. Her pupd is a little better but not normal. She’s still hungry!! I’m not sure if part of it is the low protein food. She had a urinalysis and acth stim yesterday. We expect to hear all results tomorrow. She has never had accidents, just drinks a lot with large volume of urine.

I appreciate any and all help/advice. Her last acth 3 weeks ago was 6.5 post and 5.1 pre.

Happy Holidays!
Amy

[labblab]

Hello Amy, and welcome to you and your boy! I’m afraid it’ll likely be tomorrow before I’m able to write a more thorough reply. But I wanted to at least have the chance to welcome you, and also to let you know that I’ve moved your thread here, to our main Questions & Discussion forum. People are more likely to see your thread here, and to have the chance to respond.

In the meantime, we’re really glad you’ve found us! And I look forward to having the chance to add more tomorrow.

Marianne

[Frankiedoo]

Thank you so much! My Frankie is a girl and she is excited, too.

Happy Holidays!

[labblab]

Oops, I’m so sorry about that!! You had written “she” and “her” so many times, but I still decided to make Frankie a boy, regardless. DUH! Anyway, so glad to have both you girls with us ;-)))))

[Frankiedoo]

LDDS
Pre - 5.0
Post 4 hours - 1.7
Post 8 hours - 3.3

*pre treatment

[Frankiedoo]

So apparently her levels increased on acth from xmas eve. Have you e er heard of this happening? Internal medicine doc wants to try 40 mg 2 x daily for 2 weeks. If no better, perform another ultrasound and additional work up.
Acth
Pre 6.6
Post 8.5

[labblab]

Just wanted you to know that I’ve not forgotten you, but today has turned out to be another crazy busy day for me. I promise I will make it back again tomorrow. Overall, though, it sounds as if your vet is making reasonable suggestions. But more to follow...

Marianne

[Frankiedoo]

Thank you so much. I guess I’m just baffled by the increase based on already having started vetyrol. However, she did have mast cell tumor surgery 3 weeks ago. I hate that I can’t go in with her. She’s also on benazepril and thyoroxine. I want her off the thyroid meds. She did have the full assay so it’s confusing. If not Cushing’s,then what? She has so many Cushing’s symptoms.
PUPD (no accidents)
Increased hunger
Very Dilute urine
Thinning fur near tush
Stress leukogram
High cholesterol
Low bun
Proteinuria
Mildly elevated alt
Alp is normal but has gone from 8 to 160 in a year or so
Shaky legs sometimes

I would like her to have another ultrasound and retest blood.

[Squirt's Mom]

Hi Amy and welcome to you and Frankie!

These are my thoughts which others may not agree with but that is the good thing about forums like ours - you are presented with information from more than one source that may make a light bulb come on for you. ;)

I have some concerns about the diagnosis. Cortisol will rise naturally in response to any stress, internal or external. My first pup was diagnosed based on the LDDS, HDDS, ACTH, and UTK panel but the ultrasound found a tumor on her spleen. Once that was removed all her tests returned to normal. She did eventually develop conventional Cushing's but at the time of those tests she did not have the disease - it was the tumor that caused false positives on all the testing.

You say her ultrasound was normal except for the liver. In a cush pup we typically see changes with the adrenal glands. With PDH they will both be enlarged. So normal appearing adrenals aren't the norm with Cushing's. A cush pup almost always has high elevations in the ALP with mild elevations in the other liver values. Frankie's ALP is normal - again not the norm at all. In addition, the mast cell tumor could have skewed the LDDS just as the tumor on Squirt's spleen skewed all her tests.

Some of her signs are consistent with Cushing's however...but one thing that makes getting a sound Cushing's diagnosis so hard is that so many other conditions share the same signs and they can skew the tests for Cushing's. With her main issues being excess drinking and peeing in addition to the very dilute urine I am wondering about Diabetes insipidus. This is a rare form of diabetes that has nothing to do with blood sugar but rather with how the body processes water. None of the usual tests can pick this disease up and the test for it, a water deprivation test, is rather risky so if this is suspected the vet simply starts treatment (a nasal spray). If the treatment helps then there is the diagnosis.

I am also wondering why she is being treated for kidney disease if the SDMA was normal? Was the CREA elevated? Even then with a normal SDMA that pretty much rules out kidney disease. So why the renal diet and Benazepril? Low protein for renal disease is no longer recommended until the final stages...it is the phosphorus that needs to be watched instead. So if she is on a low protein diet as a renal diet that may well be causing the hunger as you suspect. With the normal SDMA I would stop that diet and the Benazepril (unless she also has heart issues?). I would get her on a high quality food with moderate proteins and fats.

As for the increasing values on the ACTH....are you giving the Vetory with a meal every time? And is the ACTH being performed 2-4 hours after the pill and meal? The vet isn't telling you to fast for the ACTH are they? If the drug is given with a meal and the test is done during the correct time frame following then in my mind the increasing cortisol could be 1) the dose is not yet correct and an increase is needed or 2) something else is going on that has not been discovered yet which takes me back to my concerns about the initial diagnosis of Cushing's. I would want the ultrasound and additional investigation in your shoes....but that desire is informed by my own experiences with misdiagnoses. ;)

I am glad you found us and look forward to learning more as time passes. Keep talking and asking questions! That's the best way to learn.
Hugs,
Leslie

[Frankiedoo]

Thank you so much. I feel the same way. She was started on benazepril and put on renal diet due to proteinuria. I would’ve thought the urine would be less dilute having been treated with vetyrol for over a month now. We are giving her vetyrol with her meal. The acth is done 4-6 hours, but we do 4 after her pills. She had the hunger before beginning the low protein diet. She had never been a very hungry dog before. She now tries to eat rabbit poop which she never did before.

I am so stressed and torn. She is seeing an internal medicine specialist but I just feel like something is missing here. Can she try the diabetes insipidus drops on all the other meds? Would you stop benazepril? Vetyrol? Or wait the few weeks. Should I tell the internal med doc I want ultrasound and bloodwork now? Her last bloodwork in December 3rd wasn’t very interesting. Do I go for another opinion?

Was your dog’s spleen mass benign? Did he have Cushing’s symptoms?

Thank you so much. I’m super stressed.

[Frankiedoo]

Her cholesterol and creative kinase are elevated too.

[Frankiedoo]

In may of 2020 her urinalysis was normal.

[labblab]

OK, I've finally made it back here and I'm so glad to see that Leslie has also stopped by. She makes several excellent points, and I agree that it's very helpful to take a look at things from every angle possible. Frankie does present some question marks, just as Leslie has noted. The elevated ALT but ALP still within normal range, and normally appearing adrenal glands are the two oddities that I also especially note. However, so many of her other symptoms are indeed consistent with Cushing's, so I do understand the basis for the diagnosis.

As for the benazepril and dietary restriction, you're right that Frankie's proteinuria is the basis for that treatment. Chronic proteinuria can end up harming the kidneys, and moderating the amount of dietary protein that's ingested can lessen the amount of protein that ends up spilling into the urine. Cushing's is a systemic illness that can cause proteinuria, so if Frankie truly has Cushing's, this is another reason why you want to directly treat the Cushing's -- in order to lessen or eliminate the underlying cause of the proteinuria. One probably dumb question, but have you compared the calorie count of the new renal food to her previous food? It may be the case that her ongoing hunger may be partly due to a lower calorie intake. I'm giving my non-Cush Lab some prescription GI food right now, and it has quite a few less calories per cup than does her regular food. So I'm needing to feed her more to make up for the difference.

You mention that Frankie had a full thyroid panel performed before starting the supplement. I'm interested in hearing a little more about that. Sometimes the results of thyroid testing can suggest that a low thyroid reading is most likely secondary to another condition, such as Cushing's. Kind of like with the proteinuria, once the secondary condition is effectively controlled, the thyroid readings may end up normalizing. However, hypothyroidism can also be a primary problem in its own right, of course. But I'm just wondering whether Frankie's thyroid testing offered any clues in that regard. Over-supplementation of thyroid can cause excessive thirst and urination, so I'm wondering how recently Frankie's thyroid level was checked. I'm assuming along with this other recent bloodwork, but I just thought I'd mention that.

Returning to one of your original questions, yes, Vetoryl dosing can require significant adjustment both up and down. Even though there are indeed certain unanswered questions about Frankie's presentation, if she were my own dog, I believe I'd follow your vet's suggestion right now and try the two-week increase. As he says, if that doesn't improve her symptoms and her labwork, then I'm all for a repeat ultrasound and any additional diagnostics that your vet thinks may be helpful. Since her cortisol level has been trending upward instead of downward, I don't think you're putting her at risk by continuing with two more weeks of the medication. But if that doesn't improve the situation, I'd want to do more investigation, myself.

My heart goes out to you, because I know how worrying the uncertainty must be. And especially right now during the holidays and in the midst of all the other worry in the world, it's a very upsetting time to be facing these challenges with your sweet girl. But we'll stay right here by your side, so do continue to bounce off any more questions or thoughts that come to your mind.

Marianne

[Frankiedoo]

You are so kind and comforting. It took us a long time to get to the diagnosis in large part due to her presentation. Her thyroid was checked recently and is at the lower end of the therapeutic range. At first we thought her increased appetite was habitual due to change in schedule. Now that we are working from home, she doesn’t go to daycare much. In true goldendoodle form, she loves the people there most anyway. I have an appointment scheduled with a veterinary nutritionist in 2 weeks to see about diet accommodations. The change in her urinalysis changed this summer but I mentioned an increase in urination and drinking a year ago. She’s happy and still loves her walks, she just urinates large dilute quantities of urine and is hungrier than normal. Her legs tremor sometimes when sitting or standing but it doesn’t seem to bother her. She’s had so many tests, I’m just baffled. Maybe she does have nephrogenic diabetes insipidus and the polyphagia is due to protein loss. It’s not massive but not normal. We just upped her benazepril as she was on an extremely low dose. Her use is 10.06 at this point and proteinuria 3.0.

[Frankiedoo]

Her beautiful tail has thinned, too. Her coat is thinner but not awful.

[Frankiedoo]

We have definitely been feeding her more to compensate for calorie differential. In sdddition we add canned pumpkin, seeet potatoes, blueberries, green beans and carrots to her diet. We started feeding 3x a day yesterday which we think helped. We are trying to begin exercising her again now that her incision is healing. She mast cell tumor was subcutaneous on her hind thigh/leg.

I really can’t thank you enough for your encouragement.

[labblab]

It sounds like you are doing a wonderful job of taking care of Frankie! My avatar is of my sweet Cushpup Lab boy, Barkis. He passed away a number of years ago now, but I still remember clearly how upsetting it was to see the bald spots developing on his sides and haunches. He really suffered from hind-end weakness, too, prior to being treated with trilostane. Coincidentally, he also had a mast cell tumor successfully removed from his hind thigh, too. He developed the tumor several years prior to his Cushing’s diagnosis, so I don’t think the two were related at all, and he was never troubled with mast cell issues again after the removal. I’ll surely be keeping my fingers crossed that the Vetoryl dosing increase may finally make the difference in Frankie that you’re hoping for.

Marianne

[Frankiedoo]

Thank you so much Marianne. I would totally think Frankie’s is all kidney related except for the increased hunger which started before her food switch. That’s the only symptom that doesn’t fit anywhere. End of October she swallowed my socks which she hadn’t done since she was a puppy. She had an X-ray then which showed nothing on her spleen. She is recently hesitant to jump on the bed and doesn’t follow me as much. She wasn’t interested in playing in the snow either. Her legs sometimes tremoring is definitely upsetting although it is not every day. She does love her walks though. She’s also become very bossy. She still is drinking more and peeing large dilute volumes. Any other ideas?