Hi everyone. My name is Jen and I have a 12 1/2 year old Boston Terrier named Jigsaw. She is my love (as I'm sure you all feel the same way about you kids, thats why we are meeting here). Here is her story, and please any input is openly welcome. Let me apologize now for it is a lengthy story.
Last January she developed what looked like vasculitis bilaterally on her ears, crusty, flaky, and would bleed. They were affected identically. We did a full blood workup and everything looked good, only her BUN was a a bit under the low normals. Instead of doing a biopsy, we decided to treat her with Tacrolimus topically first and monitor response. I thought I saw a little improvement after a month, but decided to add in pentoxifylline as well. After adding this I did see noticeable improvement, but never completely resolved. I realize that not all vasculitis cases completely resolve so at that time I was ok with what it looked like.
In late April, I noticed that she started drinking a little more and asking to go out as well. I continued to monitor and was increasingly getting concerned as time went on about diabetes, kidney, or cushings.
At the beginning of May, I went to my vet and expressed my concerns, and we did a first morning urinalysis and she had some protein, no ketones, with a specific gravity of 1.012. Oh crap. Stopped the Pentoxifylline. So diabetes is ruled out, but now kidney or Cushings. The next 3 mornings we did specific gravities and all 1.012.
Retrospectively, I was thinking about her haircoat... (she has always had hairloss due to a worked up diagnosis of Adrenal Gland Sex Hormone Imbalance when she was 9 months old) and realized that her haircoat had become brittle, losing more hair on her thighs, and she was still brown in Spring, I live in Oregon we don't see the sun until July (of course she is a sun worshiper so she is always brown in the summer and then black in the winter).
Now I was sure she was Cushnoid, right? We did bloodwork again, BUN again just under low normal, Glucose of course was normal, ALT, Alk Phos were NORMAL. What? How can that be? I was sure she was cushnoid. She did not have the classic signs of a pot belly, but.... By the time we did bloodwork, finally got the results interpreted, and spoke to the vet (after 4 days), she was just starting to show some muscle weakness in her hindquarters, a little bit confused, her water consumption really amped up, along with trips outside almost on the hour, oh and the stance... shifting her weight to the front due to her weakness in the hindquarters, certainly she is cushnoid. My vet said, I don't know, her bloodwork looks good, you need to go to the internist.
The internist had an opening 2 weeks later, and by that time her symptoms had really worsened. She couldn't jump up on the couch, she was wobbly, seemed like senility had really set in. We went over her history, and she too thought she was cushnoid. Good but not good. She said even though she did not have the classic pot belly and the elevated ALT and Alk Phos, 5% of patients will not. We did a LDD and sure enough, we confirmed Cushings. I felt ok about the diagnosis because I knew that with medication, she could have a good quality of life. She had been on Lysodren (mitotane) for 4 1/2 years with the Sex Hormone Imbalance with it never helping her hair regrowth, so I was advised to discontinue it slowly and monitor response. No change, so she has been off it for 7 years. For the Cushings, the internist advised me to try Trilostane, it being a better drug of choice, and of course I'm on board! Here we go!
She started the Trilostane 8mg bid, by the 10th day that evening, she started kinda a grunt, reverse sneezing thing, with slightly open mouth breathing. Odd, had never heard of this being a side effect, but regardless I was 2 hours away from Emergency and 1:30am so I gave her Pred, bummer because she was suppose to have her stim that morning. Two hours after giving her the Pred the symptoms went away, didn't matter though she was going to be at the internist front steps first thing that morning. Of course she showed no signs of the breathing issue, and I think they thought I was overreacting and maybe I was just seeing reverse sneezing or something...uh nope! Of course I had to wait another week for the stim and was advised to restart the Trilostane, so I did. Everything was going fine for the first 4 days and then the breathing thing started again along with hard sneezing, clear liquid drips from her left nostril, trembling, and lethargy. She was of course still eating! They asked me to videotape it, so I did. They were thinking maybe with her cortisol level decreasing, it was maybe allergies getting stirred up, maybe a tooth root abscess, a foreign body, tumor maybe.... I was advised to continue the Trilostane. I relunctantly continued with her symptoms worsening, and then her stim test. After seeing her for the stim test, the internist came out and added another possibility for the nose issue...aspergillis. Her thought was because it was only 1 nostril, and her lungs and heart sounded good. The slightly open mouth breathing was because she couldn't breathe out her nose. The other possibilities are still there, but she just added that to the list.
So her stim came back 2.2. I was advised to decrease to 6.4mg bid due to the results being on the low side of normal. I did but she continued to worsen. Two days later, I talked to the tech, and said I have to stop, she is miserable. Her drainage is a bit green now. The tech said continue until I get an answer from the doctor, I just couldn't!!! I stopped it that night. Thankfully the next day, another tech called and said discontinue for 3-4 days, monitor, and then restart the Trilostane at 4.8mg bid. After the discontinuation she amazingly got back to her old self a little bit each day. I couldn't believe the turnaround in her. By day 2 off of the meds, she had no nasal drainage, no lethargy, no sneezing, she was sunbathing again, waking me in the morning by standing on my chest and stretching, being all lovey. Thank god my girlie is back. I emailed the internist and explained the miraculous change in her and explained how reluctant I was at starting her back at 4.8mg, so she said try 3.2mg bid instead and if the symptoms return decrease to 1.6mg bid. I just couldn't bring myself to start at 3.2mg, I thought I'll start her low at 1.6mg and then if no symptoms, I'll increase to the recommended 3.2mg, etc.
I started her on the 1.6mg and the first 11 days, she was doing great. She was acting totally normal with no symptoms, until day 12. She started slowly with the nasal drip, then the green gunk, the sneezing, and now lethargy again. So far, no trembling. She had a stim today and hoping within the next 1/2 hour to have the results. I have decided to discontinue the Trilostane and monitor her response until she is back to her normal self again. I haven't spoken to the internist yet, but does anyone have any experience in using Trilostane on such a low dose? And has anyone ever dosed every other day?
I do realize that the nasal thing is not a side effect directly linked to the Trilostane, but indirectly causing this to occur. I suspect a tumor, I pray I'm wrong, but whatever it is, it seems to like the over abundance of corticosteroids she produces when off the Trilostane.
Oh and back to the Vasculitis with her ears... I don't think so! Since being treated with the Trilostane, her ears have improved with no Pentoxifylline and every other day application of Tacrolimus. So obviously she had calcinosis cutis with her ears not vasculitis. Hindsight is always 20/20, but if I had biopsied the ear, we would have known in January what the ears were, and then been able to look directly into the Cushings. With the Trilostane the water consumption and urination is back to normal as well, and her haircoat is already becoming soft again. I need to find a balance, and if anyone has suggestions or comments, please do.
As far as working up the nose issue, I don't mind spending the money, but with her being depressed and not herself, I can't even imagine putting her under anesthetic for a CT and rhinoscopy. What do you all think?
Thanks for the feedback!