Maggie - Miniature Labradoodle - 11 years old - New Cushings diagnosis

[Shaun]

Hello everyone from the UK!,

My miniature labradoodle Maggie has been diagnosed with Cushing's last week. She's actually 11 on 6th June, next week.

Maggie's main clinical symptom has been the loss of her coat, from here shoulders right along the dorsal part of her back and along the upper surface of her tail. She's lost hair at friction points, where here harness sits, collar and she has a couple of symmetrical patches at the medial area of her hind legs. There has been no increase in drinking, urination, no pot belly (she has some comedones on her chest), no lethargy. Only other observation is that i've noticed here shaking when something she's worried about is happening, going to the vets, groomers, getting in the car, having a bath etc.

I first noticed Maggie had a moth eaten tail in December last year (2022) and took her to the vets, initial thoughts were thyroid, but because Maggie has always been an itchy dog the suggestion of allergies was raised. Cushing's was discussed but because the hairloss hadn't progressed to the point it is now and that there were no other symptoms it was dismissed. Blood tests were performed and Maggie's TT4 was low normal 16 (range 13-51), she also had elevated liver enzymes (ALT- 165 U/L & ALKP - 640 U/L). A full thyroid panel was performed and the elevated liver enzymes were passed off as 'increased to being an older dog'. The full blood panel showed her freeT4 and TSH levels to be normal, so thyroid was ruled out. The vet suggested Apoquel for Maggie's condition as she believed it was a dermatological issue, which i didn't agree with so decided to get a second opininion.

The new vet agreed her thyroid was fine, and suggested an ACTH stimulation test, this came back as normal and the vet was 'pretty sure it wasn't Cushings'. We then did skin scrapes to check for demodex, nothing seen, we did a 6 week isolated hypoallergenic food change (she went on a novel protein made from insects lol) and that didn't help. Whilst all this was going on i was building up my knowledge on Cushings, testing protocols etc and went back to see the vet. The practice normally just uses ACTH stimulation to check for Cushing's (which i found odd given the accuracy and specificity), so i asked them to perform a LDDST which they agreed to.

The results from the LDDST came back as positive for Cushing's, to say i was gutted is the understatement of the century as i suspected this from the outset and feel we could've done this 6 months ago. I'll get Maggie's test results from the vets and post them here but i can summarise that whilst there was some suppression it wasn't enough to be normal and the lab suggested this was reflective of ADH Cushing's (again this has added a further level of worry and concern due to the lower number of cases of adrenal based Cushing's and the potential prognosis).

A final urine cortisol creatinine ratio test was performed and again this has shown elevated cortisol levels (i'm not sure of the units being used in this test but the vet was saying that <34 is normal but Maggie's was 45).

A diagnosis of Cushing's has been made and she's started today on Vetoryl 30mg once a day (Maggie weighs 15.2Kg).

We're closely monitoring Maggie for any side effects, tbh i've read a fair bit about this drug and it's frightened me. To say it's been an emotional rollercoaster ride is an understatement, in my mind this was going to end up being Alopecia X, a cosmetic but non life threatening condition that we would adapt to and to have this diagnosis of ADH has been deeply upsetting.

Strangely, i was treating Maggie's coat with a natural lotion for Alopecia X/Black Skin Disease called Dermacton (it's made in the UK) and here coat has started to regrow.

Many thanks for reading and for all of the resources made available to people who've been down this unfortunate path.

Looking forward to any comments, observations or questions.

Cheers,

Shaun

[labblab]

Hello, Shaun, and welcome to both you and Maggie! We surely do understand the worry and anxiety associated with a Cushing’s diagnosis. In the absence of one truly definitive diagnostic test, the effort to consolidate lab results and clinical observations can be both stressful and perplexing. In Maggie’s case, I can understand why it’s taken some time to try to sort things out. She does exhibit some consistent lab abnormalities as well as the skin and coat issues. However, it is by far the exception rather than the rule for a Cushing’s dog to lack *any* of the hallmark outward symptoms of excessive hunger, thirst, and urination, pot belly, hind end weakness, exercise intolerance, etc. Is her urine dilute? I’m assuming not, given her normal level of thirst and urination. So that’s another head-scratcher.

In my mind, the discrepancy in Maggie’s ACTH and LDDS/UCCR results is also less than ideal in terms of diagnostics. You’re exactly right that the ACTH is more prone to returning “false negatives” in genuinely Cushinoid dogs, especially in the presence of adrenal tumors. However, on the flip side, the LDDS is more vulnerable to returning “false positives” in dogs who don’t truly have Cushing’s, but for whom some other issue is elevating cortisol levels. So in the absence of the most common observable Cushing’s symptoms, I’m feeling somewhat dodgy about the actual underlying diagnosis.

In honesty, given Maggie’s age, even if she truly does have Cushing’s, I’m not sure I’d even begin treatment at this point if her only observable issue is the hair loss. Medication cannot cure Cushing’s, it can only relieve symptoms. And if she doesn’t exhibit observable discomfort or behavioral abnormality, I’m not sure what your treatment goal will be. It’ll be hard to monitor the therapeutic effect of the Vetoryl if there are no symptoms to be relieved other than coat/skin, especially since coat and skin can take months to resolve. Cushing’s is typically a slowly developing syndrome that can indeed cause systemic internal damage over time. That’s why I generally endorse treatment for younger dogs. But I consider it more on a case-by-case basis for older dogs. Given the fact she’s part Lab, I’m guessing Maggie is already entering her senior years such that insuring her immediate comfort is perhaps the highest item on the priority list. And the stress of the lab monitoring and potential side effects from the medication may outweigh the value gained from current treatment given her lack of symptoms.

Now that I’ve probably thrown your rollercoaster off into another ditch with my diagnostic doubts, I will say that her Vetoryl dose does seem appropriate for her weight. I’m also sure you’ll be watching her like a hawk for the development of any unwanted side effects. Please bear in mind that I am not a vet myself. But if she does indeed suffer any ill effects from the medication, I would really think twice about pursuing treatment right now if she were my own.

Marianne

[Harley PoMMom]

Hi Shaun,

Welcome to you and Maggie from me as well! I sure am sorry for the reasons that brought you here but so glad you found your way here.
I agree with everything Marianne has said, the one suggestion I have would be to have an ultrasound performed, this allows the vet to get a good look at those internal organs to see there is anything else going on.

Please do not hesitate to ask all the questions you want and do know that we will help in any way we can.

Lori

[labblab]

I’m so glad Lori has suggested an ultrasound! I totally agree with her that, under these circumstances, it could really help clarify the path forward. You’d get a definite answer about the presence or absence of an adrenal tumor, and it also can help establish the health of Maggie’s other internal organs. If an ultrasound is an option for you, I’d really encourage you to consider it.

[Shaun]

Hi both,

Many thanks for your warm welcome, replies and thoughts which i'll respond to below.

I spoke to the vets yesterday to have all the lab results sent over so hopefully will have them today (they were having email issues yesterday).

As mentioned, she doesn't display any of the hallmark signs for Cushing's beyond her coat, but there are some signs that could be indicative of it. At the moment, the vet is going on the lab results, primarily the LDDS test (which wouldn't have been done if i hadn't asked about it) and the UCCR test. I mentioned her occasional panting and tremor but this may just be a senior dog thing. Maggie's urine isn't dilute and she can leave food in her bowl all day, in fact i'd say her appetite is diminished somewhat as we've seen before over the warmer months.

Marianne, you asked about treatment goals given her age etc, well the vet has suggested that we may just have picked up on Maggie's symptoms early and if left untreated she will go on to develop more of the classic symptoms. There has also been a suggestion that if Maggie does have an adrenal tumour, which as we know all start benign, it may stop or delay it becoming malignant. Lastly, there's the less important (but one we'd hope for) that here coat would recover over the coming months.

To sum up on this, we want to enjoy Maggie for a long as possible but with overarching context that she should never be suffering and she'd be enjoying a good quality of life.

Regarding the option of an ultrasound, it's been discussed. One of the other vets has said he's the only person at the practice who could find the adrenals, but i wasn't sure of beyond measurement what we'd expect to get out of it. He suggested he probably wouldn't be able to see any lesions and we'd probably be left with the same treatment choice. I could always ask for Maggie to be referred to a clinic with better imaging equipment/experience, which may be an option. Maggie would need to be sedated for any of this which is another concern.

We've also touched on adrenalectomy, but again with no real firm diagnosis beyond the lab results and clinical presentation, it's a non starter given the risks, age and general prognosis.

One aspect i need to explore further is treatment with Melatonin, Maggie has always been super anxious, we can't put her in kennels anymore due to the state she gets herself in, so maybe she always has had elevated cortisol levels. She suffers serious separation anxiety and if i'm not there she's looking for me and won't settle. When i mention Melatonin to the vet she suggested it was more experimental and more popular in the US but Vetoryl is the more appropriate route.

Thanks again for the suggestions, will come back here when i get the lab data.

Shaun

[labblab]

Dear Shaun,

Thanks so much for all this additional information. We’ll definitely be interested in seeing those lab results when you get them. To save you effort, you need only post any abnormal results from general blood panels (along with the normal range), as well as the results from the specific Cushing’s diagnostic tests.

I’ll repeat once again that I’m not a vet, but after receiving this additional information, I’m going to prod you a bit more about a couple of considerations. First and foremost, the fact that Maggie exhibits such a high level of anxiety when separated from you or away from home concerns me in terms of the validity of both the LDDS and the UCCR. Turning first to the UCCR, if the urine sample was obtained while she was at the vet, the results are most surely skewed upward and likely unreliable. We’ve been told that the urine sample must be obtained in the most stress free environment possible — meaning at home under normal conditions. Ideally, the first pee of the day is gathered on three successive mornings and pooled and refrigerated. That pooled sample is then taken in for analysis. Perhaps that was all done for Maggie, but if not — if the sample was obtained at the vet — I don’t think the results can be trusted.

Turning to the LDDS, I have the same worry that her high level of stress may have affected the results. As we discussed earlier, the LDDS is the more sensitive of the two diagnostic blood tests. This means that if a dog truly has Cushing’s, it’s less likely than the ACTH to return a negative result. However, it is the least *specific* of the two tests. This means that it is more likely to return a false positive when a factor other than Cushing’s is elevating cortisol. And a high level of stress alone could be such a factor. So learning about Maggie’s anxiety makes *me* more anxious about the validity of that test result, especially in the absence of virtually all observable Cushing’s symptoms.

As for adrenal tumors, my own understanding is that Vetoryl has no benefit in terms of lessening the size of the tumors nor affecting malignancy or growth. An older drug used to treat Cushing’s, Lysodren, does sometimes have an actual physiological affect on tumor growth. That’s because its method of action is to actually erode layers of the adrenal cortex. That is not the case with Vetoryl, and I’m unfamiliar with any effect on adrenal Cushing’s other than simply symptom relief.

And that brings us back to symptoms. Again, I’m very worried about giving Maggie Vetoryl in the absence of symptoms. With no excessive thirst or appetite, it will be virtually impossible for you to gain early warning about a possible medication overdose. One of the first signs is a dramatic speedy loss of appetite or thirst. You’ll still be able to watch for vomiting, diarrhea or extreme lethargy. But that also means that Maggie can become more seriously ill from an overdose before you’ve had a chance to identify the issue.

As you can see, I remain quite worried about you starting treatment at this stage of her diagnostics. Based on what your vets have told you, she’d definitely need to have any ultrasound performed at a specialty clinic that has advanced imaging equipment and interpretation. But under those conditions, any adrenal tumors should be able to be directly visualized, as well as any growths or abnormalities in her other organs. So I still think that would be worth consideration.

I’ll go ahead and close and await those lab results. I know I can be very long-winded, so thanks very much for bearing with me!

Marianne

[Shaun]

Turning first to the UCCR, if the urine sample was obtained while she was at the vet, the results are most surely skewed upward and likely unreliable. We’ve been told that the urine sample must be obtained in the most stress free environment possible — meaning at home under normal conditions. Ideally, the first pee of the day is gathered on three successive mornings and pooled and refrigerated. That pooled sample is then taken in for analysis. Perhaps that was all done for Maggie, but if not — if the sample was obtained at the vet — I don’t think the results can be trusted.



Hi Marianne,

Regarding the UCCR test, it was just the one sample taken by me at home. She'd been in for the LDDS and i waited a further 24 hours as I know how stressed she'll have been (she'd been caged and rubbed some skin off her nose poor thing, she did this in the kennels too). So the sample was collected first this and sent to the lab. I'm still waiting for them to sort out their email problems but for this particular test they suggest Maggie had a measurement of 45 and <34 would be normal.

I've made an appointment for next Monday to go and see the vet about the ultrasound. They could do it in house which would be cheaper but there's a fantastic small pet hospital a few miles away from me, they have an internal medicine team with a specialist imagining experts. I'd need to weigh up the cost vs the outcome, as the vet may say the diagnosis is already proven.

Another thought, Maggie had the LDDS but according to the IDEXX testing protocols when there is a limited suppression observed it suggests a high does test to determine specificity. That may also be an option to consider to try and determine what's going on, but i think the ultrasound with measurements would be conclusive.

Thanks again for your help.

Shaun

[labblab]

You’re so very welcome, and I appreciate the fact that you’re not cross with me since I keep throwing more question marks your way! For what it’s worth, if the expense is not too daunting, I think the referral to the specialty clinic could turn out to be money very well spent. It sounds as though there’d be little value to having imaging done by your local vet due to their technical limitations. But any and all feedback from the internal medicine team could be quite valuable.

As far as the HDDS, I’d encourage you to put the money towards the ultrasound instead. If I understand that test correctly, its goal is to differentiate between pituitary vs. adrenal Cushing’s when the LDDS is inconclusive. However, I think one catch is that first you have to believe that the LDDS is correctly diagnosing Cushing’s, in general. If that is not the case, I don’t believe the HDDS is helpful. If I’m not mistaken, both a dog with one type of tumor as well as a dog without Cushing’s at all will return a certain HDDS result. So to be of diagnostic value, you have to first determine that the dog *does* truly have Cushing’s. And, of course, that’s what I’m worried about, especially hearing how stressed Maggie was during the day of the LDDS test.

Thanks again for the continuing info, and we’ll certainly await further updates.

[Shaun]

Hi Marianne,

The thinking on the HDDS test was that some dogs may be suppression resistant at the lower dosage and therefore be a false positive. Maggie's results indicated a drop but not far enough to be considered normal and this would suggest ATH. The vets have sent me the results by mail they've said as there IT issues are ongoing. My appointment about the ultrasound is on Monday evening.

Thanks again,

Shaun

[Shaun]

LDDST Results

Cortisol Baseline - 75.6 (reference range 25.0 - 125.0 nmol/L)

Cortisol 4hr Post Dex - 54.1 (reference range 25.0 - 125.0 nmol/L)

Cortisol 8hr Post Dex - 46.4 (reference range <=40.0 nmol/L) therefore Cushingoid

Clinical Pathologist Report - LDDST test results consistent with HAT where there are compatible clinical signs. Similar results can be seen with chronic stressful non-adrenal illness.

[Shaun]

Considerations to support the diagnosis - UCCR cortisol elevated, the LDDST above (possibly), increased ALT/ALKP liver enzymes, comedomes on ventral abdomen, hairloss along dorsum and lichenification. Skin scrape test negative. Some tremor observed in stressful situations.

Considerations against the diagnosis - ACTH test reported as Normal, no PU/PD,no polyphagia, no lethargy, has been an itchy dog since birth with consideration for allergies (most likely environmental as prescription food screening bore no discernable results). Cytopoint injection tried for pruritus, Bravecto Spot On treatment applied for any demodex or flea issues.

[Shaun]

ACTH Stimulation Test

Cortisol Baseline - 79.5 (Reference Value 25.0 - 125 nmol/L)

Cortisol Post ACTH - 452.0 (Reference Value 125.0 - 520.0 nmol/L)


Clinical Pathologist Report - The results are not currently consistent with Cushings. If there is a high index of clinical suspicion a low dose dexamethasone suppression test may still be helpful.

[Shaun]

Urine Cortisol: Creatinine Ratio Test

Result 45.5
Reference Value x10-6

Clinical Pathologist Report: If the urinary cortisol:creatinine ratio results are < 34 x 10-6, hyperadrenocorticism is unlikely. In dogs with clinical signs suggestive of Cushings further investigation via an ACTH stimulation test or LDDST is indicated.

[Shaun]

Vet agrees it's not 100% confirmed so we've decided to hold off on the medication until her ultrasound is performed (date tbc). I also asked if we could try her on a low starting dose should the ATH diagnosis be positive as i don't think we should go straight in at a higher (but correct) dose if she was controlled with much lower amounts.

Will keep you updated :)

It's her 11th birthday tomorrow : )

PS I had her weighed whilst she was there and she was 13.70Kg, so she's lost a bit of weight since i'd last looked.

[labblab]

Shaun, thanks so much for all this additional data. It’s very helpful to see the actual numbers. You’d already done a very good job of summarizing them, though, and the numbers are indeed consistent with what you’d reported.

I must confess I’m relieved to hear that you’re holding off on starting the Vetoryl until after the ultrasound, especially in the face of Maggie’s weight loss. That is yet another symptom that is *not* consistent with Cushing’s, and therefore may indicate that there is some other underlying issue that is elevating her cortisol. In this situation, I truly think an ultrasound can be a very important diagnostic tool as long as the imaging and interpretation can be done by a specialized team. I wish you the best of luck in getting that worked out.

And I certainly wish sweet Maggie a very happy birthday tomorrow!!! I hope you’ll be able to put your worries aside for the day to have a joyful celebration. If you’re a worrier like me, that may not be easy. But you both deserve a day off, for certain!! Many happy wishes will be flowing from her K9C family here :-))))))

Marianne

[Shaun]

Shaun, thanks so much for all this additional data. It’s very helpful to see the actual numbers. You’d already done a very good job of summarizing them, though, and the numbers are indeed consistent with what you’d reported.

I must confess I’m relieved to hear that you’re holding off on starting the Vetoryl until after the ultrasound, especially in the face of Maggie’s weight loss. That is yet another symptom that is *not* consistent with Cushing’s, and therefore may indicate that there is some other underlying issue that is elevating her cortisol. In this situation, I truly think an ultrasound can be a very important diagnostic tool as long as the imaging and interpretation can be done by a specialized team. I wish you the best of luck in getting that worked out.

And I certainly wish sweet Maggie a very happy birthday tomorrow!!! I hope you’ll be able to put your worries aside for the day to have a joyful celebration. If you’re a worrier like me, that may not be easy. But you both deserve a day off, for certain!! Many happy wishes will be flowing from her K9C family here :-))))))

Marianne

Many thanks Marianne for your help and support. I've given Mags a cuddle from you and wished her Happy Birthday too : )

[Squirt's Mom]

Sounds like an EXCELLENT plan to hold off on starting treatment! An ultrasound saved my Squirt's life and prevented us from treating Cushing's with a very powerful drug when she didn't really have the disease. She had a tumor on her spleen. That tumor caused false positives on the LDDS, HDDS, ACTH, and UTK panel. Once the tumor and half her spleen were removed all those tests returned to normal. The tumor had caused her cortisol to rise NATURALLY and cause all the tests to show positive. That is the job of cortisol...to rise any time the body is under stress to help the organism cope. This is why it is so important to be as thorough as possible during the diagnostic phase to rule out other causes for elevated cortisol. Something as simple as a UTI or bout of colitis can cause the cortisol to rise and impact the tests, all the blood tests, for Cushing's. So the US is a great step to take right now. Please let us know what you learn from that!

Hugs,
Leslie

[Shaun]

Thanks Leslie for replying, that's exactly my thinking too. As mentioned, the only clinical symptom i'm seeing is Maggie's coat. As i said to the vet, if that was normal i wouldn't be even here. Your point about colitis is interesting, Maggie has been having bouts of constipation and then loose stools which correlate with this starting. It's the case now, she won't go for a while and then she has a couple (apologies for the grossness lol). Any idea how this could be tested if it can elevate cortisol? As i write this, it's 2.35pm in the UK and Maggie's breakfast remains untouched in her bowl...this doesn't sound like a typical Cushing's pup to me.

We're still waiting for the date for the US, will be following up on Monday.

Take care,

Shaun

[Squirt's Mom]

Hey Shaun,

Here is a link telling about the testing for colitis...here in the US anyway. These are the things I learned with my Trinket who had rather severe colitis...blood in the stool is very common, stool (turds) usually have a long, thin tail (talk about TMI! :D ); the stool also has a very distinctive odor...once you have smelled it you never mistake it for anything again.

https://vcahospitals.com/know-your-pet/colitis-in-dogs

There is no test to determine if colitis, or any other condition, is causing elevated cortisol That is simply a known fact about cortisol, how it works, and how it can impact certain tests, like the LDDS, HDDS, and ACTH. FYI...the HDDS is an old test that is rarely used these days. It was often used to determine which form of Cushing's was in play - adrenal or pituitary - but the LDDS can often make that determination these days so the HDDS is not used much any more.

Oh! and a Happy Belated 11th Birthday to sweet Maggie! Give her an extra ear scritch from me for being late.
Hugs,
Leslie

[Shaun]

Hi Leslie,

Many thanks again for the info and link. I've not seen any blood in Maggie's stools thank goodness, but rather she'll go from being constipated to loose (with a mucus like membrane). It may be a dog equivalent of IBS, inflammation based (she's been on a number of diets to try and cure her itching). I did note that there was a condition called Stress Colitis, and Maggie is the most anxiety ridden dog going..it's got worse as she's got older with serious reactions (shaking) when at the vets or groomers and separation anxiety at the thought of being left. So that may have skewed her test results.

Either way, i hope the US will give us the diagnosis or not (hopefully the latter) and if she does need to start on medication I won't be starting on the 30mg per day that i have in front of me. We'll start low and see what she needs to control it.

I'll report back when we have a date from the vet.

Take care,

Shaun

PS Thanks for the birthday wishes, she's had a cuddle from you : )

[Shaun]

Hello,

Hope you're keeping well?

Maggie has now had her ultrasound, the results aren't clear cut it seems..comments welcome as ever.


Regards,

Shaun






Signalment: 11yo female neutered crossbreed dog 13.4kg

Sedation: butorphanol and medetomidine

History: Feb 2023 - hair loss, raised alkp/alt on bloods, ACTH stim test didn't support diagnosis of cushings. LDDS test did support diagnosis of cushings. Dispensed trilostane, but unsure if given.

Physical exam: Extensive alopecia and pigmentation over shoulders, back and flanks. Poor hair coat ventral abdomen. No comedones, Abdomen a little rounded but not overtly potbellied.

Thoracic ultrasound:

heart - subjectively unremarkable, all chambers and wall thicknesses in proportion, systolic function adequate
no pleural or pericardial effusions
lungs unremarkable in visible parts
no mass lesions in visible parts Abdominal ultrasound:
no effusion
major vessels: unremarkable
abdominal fat: unremarkable echogenicity
Liver:normal size, shape and echogenicity, vasculature unremarkable
portal vein: unremarkable, PV/Ao ratio 0.74 ( < 0.65 suggests EHPSS, >0.8 excludes EHPSS), hepatopetal flow in mesenteric, splenic and gastroduodenal veins
gallbladder and biliary tract: homogenous hyperechoic debris within gall bladder, occupying 50% of lumen, no acoustic shadowing
pancreas:unremarkable
stomach: unremarkable, wall 3 mm, normal 3 - 5mm
duodenum: unremarkable, wall 4.5mm, normal <20kg <5.1mm, 20 - 30kg <5.3mm, >30kg <6mm jejunum: unremarkable, wall 3mm, normal <20kg <4.1mm, 20 - 30kg <4.4mm, >30kg <4.7mm Ileum: unremarkable
ICCJ: unremarkable
Caecum: unremarkable
colon: unremarkable
spleen: unremarkable
Kidneys: unremarkable, left kidney 5.04cm, right kidney 5.3cm, Ao 8.2mm, Ao/kidney ratio 6.1/6.4 , normal 5.5 - 9.1
adrenals: left adrenal is abnormal - cranial pole is enlarged at 8.2mm across (normal <7.4mm across) although is normal shape, it contains two hyperechoic homogenous nodules, largest nodule sits more cranially and iis 6.8mm x 9.3mm, second nodule more caudal is 4.6mm. Caudal pole is 5.2 mm, right adrenal 6.7 mm (normal 7.4mm)
ureters: unremarkable
bladder: unremarkable
proximal urethra: unremarkable
jejunal, colic and other visceral lymph nodes: unremarkable
sublumbar lymph nodes: unremarkable

Conclusions:

Adrenal glands - there are two nodules within the left adrenal gland and the gland is slightly enlarged.The right adrenal is normal size.
Gall bladder - there is homogenous hyperechoic debris filling 50% of the gall bladder lumen

Recommendations/plan/thoughts:

Adrenal nodules - non-mineralised nodules less than 2cm in diameter ( these ones comfortably are) may be benign nodular hyperplasia rather than neoplastic lesions. It is possible for them to be non-functional or cortisol secreting. Usually if a dog has adrenal dependant HAC and an adrenal nodule secreting cortisol then the contralateral adrenal gland would be small, whereas in Maggie it is normal sized so although we cant confirm it on the scan its less likely that she has adrenal dependant HAC. Having adrenal nodules obviously doesnt rule out pituitary dependant HAC and some dogs with PD HAC may have normal sized adrenal glands.

In summary - Maggie has two small adrenal nodules and mild enlargement of the left adrenal gland but the changes are not extensive enough to be sure that these are neoplastic nodules and even if they were we couldn't confirm if they were secreting cortisol.
Gall bladder - although debris is fairly common in older dogs and often incidental it does suggest a degree of biliary stasis. Ursodeoxycholic acid can be used to try to encourage bile flow.

Further testing - it may be worth testing more extensively for hyperthyroidism as mentioned in your history. I would advise the owner to monitor water intake and other signs of Cushings disease and repeat the ACTH or LDDST if symptoms develop..

[Harley PoMMom]

Hi Shaun!

Thanks so much for posting Maggie's ultrasound findings. In my opinion I really don't think Cushing's is the cause of Maggie's symptoms, dog's with this disease generally have an enlarged fatty liver and according to the ultrasound, Maggie's liver is neither enlarged nor fatty. Also her adrenal glands don't have the appearance of a dog with Cushing's, when a dog has pituitary dependent Cushing's both adrenal glands are being over stimulated so they both are most likely enlarged. With an adrenal tumor, one gland will be severely atrophied while the other one is enlarged.

The concern I have is the gallbladder which could be mucocele or cholestasis and I believe the medication Ursodiol is the common treatment.

Please do keep us updated!

Lori

[Squirt's Mom]

I agree with Lori...this is not the typical US report on a cush pup. The liver is seldom normal in appearance and as Lori said the adrenals don't fit with either the adrenal based form nor the pituitary form. So along with the signs I would put Cushing's on the back burner for now. I would ask them to look into the possibility of an adrenal tumor called a pheochromocytoma. It is not a common tumor. There are other non-cortisol secreting adrenal tumors as well. Here is a link on adrenal tumors -

https://petcureoncology.com/adrenal-tumors-in-dogs/

Hugs,
Leslie

[Shaun]

Thanks Lori, i appreciate your thoughts and opinion.

Regarding Maggie's gallbladder, the vet didn't even mention this and it was just when receiving the report i noted the comments. My understanding is that specialist would have mentioned it if she thought there was a mucocele as it would have been distinguishable from biliary sludge vs 'an organised structure' in the gallbladder lumen. Either way i plan to bring this up with her normal vet.

Regarding the Cushings, well i honestly don't know..there's obviously something adrenal based going on, given the abnormality, but given that her main clinical sign is her poor coat and alopecia it may be sex hormone related, as that is observed with benign hyperplasia.

I guess we'll take a breather for now and let my funds recover too ; )

Take care,

Shaun

[Shaun]

Hi Leslie,

Thank you for your thoughts on this, i appreciate it.

I think i looked at that link before, it frightened me a bit : )

I'm probably going to adopt the 'wait & see' approach, looking for any other symptoms that Maggie may have. At the moment she's happy and there's nothing much beyond her coat to report on (well apart from the tremor when she's going somewhere she doesn't like).

Given Maggie's age i don't think i'd want to put her through adrenalectomy surgery. Given the chance she may never leave the hospital and that she'd require medication post surgery.

Melatonin may be an option for her alopecia? I guess I'm going to just watch her like a hawk and pray it's benign and slow growing so that she see's out her remaining years without suffering.

Take care,

Shaun