New Member and unsure of Cushings

[China13]

Hi I am Tina and my rat terrier Holley Jane is 11. Thank you for accepting me into your group. Holly Jane just had her teeth cleaned and the vet said the pre blood work (that they do before the cleaning) might possibly mean "Cushings".

They did an ACTH test while she was there and the results were Cortisol - Pre ACTH 12, Cortisol - post ACTH 10.2

The vet's email went on to say "Holley Jane's ACTH test was equivocal; this means that her resting cortisol was high but when stimulated the adrenal gland did not make any more cortisol. This can happen when the cushing' disease is due to an adrenal tumor. In some cases it is possible to surgically remove an adrenal tumor so further testing to see if the Cushing's is caused by pituitary gland or adrenal gland is recommended."

I want to do what is best for my baby, but do not want unnecessary testing or meds if not really needed. She has absolutely no symptoms, other than being over weight she weighs 16 pounds). I am at a loss at what I should do. Any suggestions would be appreciated. Thank you so much.

[Squirt's Mom]

Hi and welcome to you and your baby!

I am assuming the ACTH was done prior to the dental or that second number would more than likely have been quite high and making the results invalid because the stress from the dental would skew an ACTH. IF I were going to have another test done it would be the LDDS or abdominal ultrasound (or both) as those tests can help determine if it is the pituitary or adrenal form. However in light of no signs I don't think I would pursue testing at all right now. I would simply watch and if signs started appearing later on then look at testing again then. Just so you know, here is a list of some of the signs of Cushing's:


Increased thirst and urination (polydipsia and polyuria, respectively)
Urinating at night or having accidents
Increased hunger
Increased panting
Pot-bellied abdomen
Obesity
Fat pads on the neck and shoulders
Loss of hair
Lack of energy
Muscle weakness
Infertility
Darkening of the skin
Thin skin
Bruising
Hard, white scaly patches on the skin, elbows, etc. (associated with the disease calcinosis cutis)

I certainly wouldn't even be thinking of surgery right now since it isn't certain she has the disease much less what form.

Can you tell us if Holley has any other health issues? Is she taking any medications?

I'm glad you found us and look forward to learning more about your sweet girl soon!
Hugs,
Leslie

[labblab]

Hello Tina, and welcome to you and little Holley Jane! I’m afraid I don’t have time right now to add as lengthy a reply as I would wish. But I do want to let you know how glad we are that you’ve joined us, and to assure you that I’ll return to add more either this evening or tomorrow.

However, I can’t leave without first reassuring you that, under the circumstances you’ve described, you can take plenty of time to think things through prior to proceeding with more testing. Your vet has made quite a quantum leap from seeing a few lab normalities to warning you that your asymptomatic dog may benefit from very expensive and very risky adrenal surgery. WHAT???? There are a whole lot of steps and considerations in between, not the least of which is that your dog’s ACTH results are within the normal range for a dog who does not have Cushing’s. I understand what your vet is referring to in terms of “false negatives” on the ACTH, and we’ll talk about that some more. But overall, there are a whole lot of puzzle pieces that we need to fill in before you assume that your dog even has Cushing’s at all.

So I’ll be back to talk more. In the meantime, though, it’ll help us a great deal if you can obtain and post the exact numbers that were abnormal on Holley Janes’s pre-anesthesia labwork. I’m betting that the prime issue will be some elevations in her liver markers: the ALKP, and perhaps also her ALT. Also, can you tell us about any other illnesses or issues in her prior health history. Finally, let’s confirm that you’re not seeing any overt Cushing’s symptoms at all, such as excessive thirst/urination/hunger, skin or coat problems, pot belly, hind end muscle weakness, excercise intolerance, seeking out cool spots for resting? Sorry for so many questions, but this info will be a big help to us as we offer our thoughts and suggestions.

Thanks in advance, and once again, welcome!
Marianne

[labblab]

P.S. I see that Leslie and I were typing at the same time, so I apologize for any duplication. But I think both she and I are on the same track — there’s a lot more info that we’d like to find out!

[China13]

Thank you Marianne,
I was feeling very pushed from the vets office. It is a very large practice and I never get to see the same vet so I feel like he doesn't really know us. Here are the abnormal numbers from the blood work. RBC 9.02, Hematocrit. 59.5, MCH. 21.5, Reticulocytes. 162, Chloride. 105, Total Protein 8.1, Globulin. 4.3, ALT. 135,ALP. 630. Creatine Kinase 463. These were all listed in red on the results given to me as be out of range. Everything else they did was within the normal range. She has been in good health most of her life aside from a few bouts of pancreatitis during her 11 years. I was terrible about over feeding her. She would alway have chicken breast, or tuna or cheese if I wanted to her to eat her kibble. She was on Science Diet for most of her life until a few years ago I changed to The Honest Kitchen in addition to all the extras. I am disabled so sit most of the day in a recliner and she is right beside me doing the same thing. She doesn't get a lot of exercise unless a squirrel happens in the back yard. There are none of the other symptoms mentioned. She does get very stressed out going to the vet so they not see her like she normally is. I am so happy to have found this group. She is my everything an I want the best for her, but do not want to put her through tests that are not needed right now. Thank you for all your help - and for being there. Always, Tina and Holley Jane

[labblab]

Hi Tina! I finally made it back here to you again — sorry for the delay! By the way, I love your photo of Holley Jane. What a cutie pie — no wonder she’s so precious to you.

The first thing I want to stress is that we are not vets here, so the suggestions we make are not based on medical training. However, they are instead based on our years of experience with following the treatment journeys of all the members who have posted here. Over the years, we’ve had the opportunity to absorb a lot of research results and general information about both diagnosing and treating the disease. So given that as an introduction, here goes with my own thoughts about your situation.

One of the most important things we’ve learned is that there is no single definitive test for Cushing’s. The diagnosis really requires a combination of lab abnormalities, specialized test results, and also clinical symptoms. Thus far, we’ve only got one piece of the pie with Holley Jane. She does exhibit some lab abnormalities that may be consistent with Cushing’s, but so far she’s batting “zero” on the other two pieces: her diagnostic ACTH was normal, and she doesn’t exhibit observable symptoms.

Honing in on her ACTH for a moment, I don’t know why your vet is placing much value on her elevated pre-ACTH (resting baseline) cortisol reading. We’ve been told repeatedly by specialists that resting cortisol levels have no diagnostic value when it comes to Cushing’s. Stress alone can cause significantly elevated baseline readings. And if Holley Jane was tested when she was already hospitalized for a dental procedure, her stress level could easily have been through the roof. What is important diagnostically for Cushing’s is the post-ACTH cortisol level. And even though you’ve not given us the normal range for the lab that processed her result, I’m guessing that 10.2 falls within the normal range for a dog who does not have Cushing’s.

Your vet is correct that the ACTH is vulnerable to returning “false negatives” in dogs for whom their Cushing’s is caused by adrenal tumors as opposed to pituitary tumors. However, for a dog with absolutely no consistent observable symptoms, I’d think you’d more likely conclude that the ACTH is accurate this time — that Cushing’s isn’t actually present, and that those lab abnormalities have some other cause.

If it would give you some peace of mind, it’s true that there are other testing options that you can pursue. But I’m not sure to what end right now. Given Holley Jane’s lack of observable symptoms, it would be difficult to monitor the effects of medication. For the most part, and especially for senior dogs, treatment is typically offered to reduce the unwanted and uncomfortable observable symptoms that result from Cushing’s. There are a few exceptions. If a dog is outwardly asymptomatic but tests positive for Cushing’s and exhibits high blood pressure, protein in the urine, or elevated glucose levels, then most specialists recommend treatment to lower the cortisol level since it may be the root cause for those more serious internal systemic problems. Also, if an adrenal tumor is definitively identified, then it’s true that surgical removal can offer a complete cure for the Cushing’s and also eliminate the potential for tumor spread. However, that type of surgery is very expensive and very risky.

Further testing options that your vet may offer out are a different blood test (LDDS or Low Dose Dexamethasone Suppression Test), or an abdominal ultrasound. One drawback to the LDDS is the opposite of the ACTH: it’s more vulnerable to “false positives” if a dog is highly stressed or suffering from an illness other than Cushing’s. If your vet is truly concerned about the possibility of an adrenal tumor, than an abdominal ultrasound might be your best best. It is a noninvasive procedure that can offer useful information about the status of other internal organs in addition to the adrenal glands (liver, kidneys, spleen). For instance, you might find an alternative explanation for those abnormal lab values.

One other very simplistic testing possibility is a urine test that often serves as a gateway to further Cushing’s-specific diagnostics. It’s called a urine cortisol/creatinine ratio (UC:CR). The best way to conduct this test is for the owner to pool together a urine sample collected on three successive mornings at home — *not* at the vet’s office. This test is highly sensitive to stress, so you want the urine to be collected calmly at home. If the test result is elevated, it means that Cushing’s remains a possibility. However, if the result is within normal range, you can pretty much rule out Cushing’s with certainty.

So there you have the testing options of which I’m aware. Going full circle, though, I’d personally be hard-pressed to launch into extensive testing for a dog in Holley Jane’s current situation. If her lab abnormalities were nagging at me, I might consider that abdominal ultrasound in order to get a better picture of her overall organ health. And we do have another member who has just returned to us who had an asymptomatic dog for whom an adrenal tumor was indeed identified via ultrasound (“Remy’s Mom”). But right at the moment and in Holley Jane’s case, I’m not feeling as though Cushing’s treatment is a likely result or urgent issue.

Do let us know what you’re thinking yourself, though, and any additional info you get from the vet.
Marianne