Duke-5 1/2 year old male Vizsla newly diagnosed

[Duke's Mom]

Hi group—this is a VERY long first post sorry…

I’m the mom and breeder of Duke a 5 ½ year old intact male vizsla. We are in the early stages of diagnosing HAC and trying to identify pituitary origin (which I believe he has) vs adrenal vs atypical vs stress induced….all different things the vet generalist or the vet radiologist that did the u/s have hypothesized.

So her is Duke’s lengthy background that lead up to my deciding he had Cushing’s Disease (HAC) and asking for him to be tested….I’m a RN and a very good diagnostician.

10+ months ago Duke developed a non-healing irritated area on his hip surrounded by hair loss in the area, he was seen by the vet and it was thought to be insignificant. The hair loss was blamed on licking the area, something we had never seen him do but accepted the explanation. When it had not resolved after 4 months , including treatment x1 with systemic antibiotics, the area remained inflamed but not tender and the hair breakage/loss remained we decided it was time to have the irritated hard bump removed – January 2017. Prior to removal, Duke had pre-op blood work and his rabies and DPT boosters done 2 weeks apart from each other and both before the surgery- I feel the immunizations may have has a role in starting his HAC. The bump and irritation was only in the skin and the pathology came back as “comedones”. Post removal of the irritated area Duke healed very poorly and developed a wound infection, reacted to the absorbable stitches and removed then himself (now it did itch and bother him) reopening the wound. It was sutured closed again with a less reactive material, was treated with two different antibiotics for the wound infection and took over 3 months to heal from a small excision in the skin. Data points…comedones, delayed wound healing, compromised immune system/infection not responsive to normal treatment. While healing from his excision Duke started to lose LOTS of hair. First around his neck and fore-chest, then in front of his ears, we thought this was from the inflatable donuts rubbing his hair off. He also started to drink LOTS of water, we thought this was because the inflatable donuts (2 of them) made him warm. The hair loss continued and we thought he was having an allergic reaction to his collar now that he did not have hair around his neck.
Jump ahead a few months....the polydipsia, polyuria continued and progressed even after getting out of the donuts, the hair loss also progressed and Duke had a bald belly, chest, and very thin hair around his neck and in front of his ears, any areas where he had lost hair remained patchy or bald with no regrowth. 3/2017 Duke’s dog mom died from hemangiosarcoma and the dog dynamics changed. Duke is a VERY sensitive dog, as are most vizslas are. 4/2017 Duke’s polyuria and polydipsia increased within a month of his mom dying, the hair loss continued, he started to have diarrhea and occasionally frank blood in his stool, developed insomnia waking multiple time to drink and pee at night, we saw behavioral changes with increased aggitation and he was always starving. Duke was treated x2 with flagyl for the diarrhea and the vets (every time we went in a different vet in the practice saw him so there was no continuity of care) seemed unconcerned.
The polydipsia, polyuria, polyphagia and insomnia continued and we now were not getting any sleep x 6 weeks. Duke also developed a thick hard non-tender , thickly crusted area between his shoulders that I decided was a calcinosis cutis and swollen glands in his neck. I put together a detailed history and summary of my findings and presented it to one of the vets and said I wanted him tested for HAC with a LDDT. I also said that I needed one vet to step up and take charge of Duke's case because the lack of continuity of care had prevented them from seeing what I was presenting in his clinical case summary…..
So on the test results…

1/17/17 pre-op panel—everything WNL
Key values
ALT 66 (12-118)
Alk Phos 59 (5-131)
BUN 15 (6-31)
Crt 0.7 (0.5-1.6)
Glucose 96 (70-138)
WBC 6.8 (4.0-15.5)
Neturophils 78%
Plt 229 (170-400)

5/19/2017—Cushing’s testing , and other requested blood work—listing mostly the abnormal values.. He had a complete chem panel, thyroid, UA, CBC, & LDDT
Chem and CBC:
ALT 144 H (12-118)
GGT 14 H (1-12)
Alk Phos 108 (5-131)
Bun 13 (6-31)
Glucose 104 (70-138)
Cholesterol 263 (92-324)
Precision PSL 92 (24-140)
WBC 10.6 (4.0-15.5)
Neutrophils 81%
Plt 373 (170-400)

Thyroid
Total T4 1.2 ( 0.8-3.5)
Free T4 26.2 (8-40)

UA
SG 1.002 L (1.015-1.050)
PH 8.0 H (5.5-7.0)
Struvite crystals 0-1
Fat Droplets 4-10
Other Sperm
Everything else neg

LDDT Cortisol Serial 3 (8 hour test)
Sample 1 5.3 H (1.0-5.0)
Sample 2 Dex 1.6 H (0.0-1.4) 4 hr post
Sample 3 Dex 2.6 H (0.0-1.4) 8 hr post

The vet called these “border line values” and said possibly adrenal. She suggested a HDDT and IMS consult. I told her from my reading I felt quite sure these values were consistent with PDH and wanted to start treating now as such. The insominia and thus our not sleeping was impacting all of us and we could not continue this was much longer.

5/20/17-- Duke was started on Vetorly 1mg/lb dosage—70 mg I decided to give the medication at night with his third meal since we were given no guidance (and my research regarding the peak effect made sense regarding helping the insomnia). 4-5 days in we saw a decline in the polyuria and polydipsia , although still not down to normal, there was no noticeable change however in the insomnia or hunger. Duke was also started on Baytril x 2 weeks for an unknown infection d/t the swollen lymph nodes/glands in his neck.

14 days after starting treatment Duke had his first ACTH stim test (we moved his medication to AM x 6 days before the test) and then in the afternoon AFTER the test he had an ultrasound. Below are the results. He also developed and eye infection and was started on Tobramycin for that.

6/1/17 ACTH stim test on Vetoryl
Sample 1 4.5 (1.0-5.0)
Sample 2 9.0 (8.0-17.0)

The vet said levels were fine no change needed. I sited the Vetoryl drugs dosage guidelines regarding ACTH stim test and a dog still showing multiple symptoms of Cushing’s (poly x3 + insomnia)… this seemed to be new info for the vet. She said to increase him from 70 mg to 90 mg/day, dogs weight is 70 lbs.

6/1/17 Ultrasound
Comments : edited
there are bilaterally enlarged nodular shaped adrenal glands. The left adrenal measures .86 cm and the right adrenal gland measures .87 cm and normal adrenal glands measure up to .74 cm in thickness..
Diagnosis/differentials:
The changes in the liver could be most consistent with a mild vacuolar hepatopathy with biliary stasis and r/o cholangiohepatitis and there is gastroenteritis and mild pancreatitis most likely due to dietary causes and r/o inflammatory bowel disease with bacterial overgrowth/dysbiosis. The adrenal findings are most consistent with Cushing's disease (pituitary dependent) and r/o stress hypertrophy.

Current Treatment
Vetoryl 90 mg QD-at night with food 1-2 hours before bed, melatonin 6 mg BID, Omega 3-6-9 FA 2 caps BID, probiotic (Vet’ Best Gas Buster) BID, D-Mannose 500 mg BID- bladder and renal flushing and support, Acetylator 2 caps BID-GI and bowel support supplement, Cell Advance 800 2 caps BID-immune support supplement, Theanine 100 mg TID.

So here is what I know….my dog most likely has PDH and IBD, as I suspected. There is a question the vets are bring up if this is really Cushing’s or stress induced HAC. They also discussed atypical before the u/s report came in and because he is not neutered, I’m ignoring most of this. Duke is not currently managed symptom wise.

Next step is IMS consult and holistic vet consult. I do not plan on using the Royal Canine Hydrolyzed Protein Diet that was suggested but will explore other high quality diets including raw. Right now he eats Wild Calling White Fish and rotates through a few other of their exotics—he also eats lots of fresh fruit he picks from our trees- citrus, figs, stone fruit…and lots of people food my husband shares with him. So far we are over $2000.00 into getting this disease under control with no vet insurance.

I’m very open to thought and ideas regarding treatment, diet and how to manage the insomnia the hardest problem to live with.

[labblab]

Hello and welcome, although I'm surely sorry about Duke's ongoing issues. Thank you so much for giving us such a complete summary of his health history and current status. I'm afraid I must give a briefer reply than I'd like (I must soon head off for some dental work -- YUCK!). But here are a few "first" thoughts in kind of a jumbled fashion.

You are correct that Duke's LDDS result was consistent with PDH, as are his bilaterally enlarged adrenal glands. However, one concern with both those results are that other physical ailments can result in "false positives," as well. If the body is stressed by some condition other than Cushing's, the adrenals may be prodded into working overtime and produce those same results. It is true that Duke exhibits certain symptoms of Cushing's. However, it is quite unusual for his ALKP to fall within normal range. And the fact that he had a number of ongoing issues at the time of testing (inflammatory bowel, possible pancreatitis, possible liver/gallbladder abnormalities, enlarged lymph nodes, etc.) makes the overall diagnosis more worrisome to me. So I am guessing this is why your vets are still puzzling over things, and I have to agree that question marks remain for me, as well.

However, since you've already started Vetoryl, here are some thoughts about that. You are correct in your understanding that a post-ACTH of 9 ug/dL is still too high if symptoms remain uncontrolled. However, that is the case after a dog has been treated for a full month. As I understand it, Duke was first tested (as recommended) after two weeks of treatment. Dechra's current recommendation is not to make any dosing increases until the first thirty days have passed. This is because cortisol levels typically continue to drift downward during the first month, even on an unchanged dose. So I actually would not have increased his dose, either. Duke will be due for another ACTH at that thirty-day mark, and it will be important to see how much further his cortisol has dropped on the higher dose.

Also, in terms of long-term treatment, it would likely be better either to switch to morning dosing or to twice-daily dosing (in which case you divide the daily dosing in half). I understand that the insomnia is an issue for you, but by dosing only once daily at night, it may well be the case that the drug's effectiveness has worn off by the next morning, so Duke's cortisol level is rebounding again all throughout the waking day. If that's the case, he will remain symptomatic. Also, you will always have to jockey his dosing schedule in advance of ACTH testing. Twice daily dosing would seem to be the better option in his situation.

Last but not least, if it were me, I would definitely give the Royal Canin a try. I know the ingredients sound awful and I wouldn't necessarily want to feed it long-term. But given Duke's intestinal issues, I would want to try to settle his inflammation ASAP. The Royal Canin is specifically recommended as an initial elimination diet, and that's where I'd start. Given the range of what he is eating now, there's no telling whether his condition is being worsened by an allergic food reaction or an inability to properly process something he's scavaging. And as far as your husband -- I would tell him in no uncertain terms to lay off the people food! You may not be able to totally monitor Duke's fruit intake in the yard, but your husband can certainly stop contributing to Duke's digestive woes!

Last but not least, I think consultation with an IMS would be a very good idea. I think there are enough question marks about Duke's overall picture that you'd benefit from having a specialist take a look.

Marianne

[DoxieMama]

Hello and welcome from me, too, though I apparently have less time before I must head out so my reply will be even shorter than Marianne's. Besides, she covered all the jumbled thoughts my pre-caffeinated brain has this morning anyway. I sure hope you can get Duke's digestive issues under control, and look forward to learning more about him.

Shana

[Joan2517]

Wow! Welcome from me, too. A very informative post! I am pretty sure that my Gable is part Vizsla and he has stomach issues as well. He is also very sensitive, takes things very much to heart. He's my big baby...

I just wanted to say hello and to welcome you to the forum.

[Duke's Mom]

My poor boy we can’t seem to find the right vet to get him on a good treatment plan and feeling better.

After initially starting on the Vetoryl in May and having the ACTH stim test 2 weeks later to check treatment response and a ultrasound that showed many things including enlarged adrenal glands we were sent to (the wrong) IMS. The IMS said she did not feel Duke has Cushing’s despite the lab results, and all his symptoms. She did a battery of test – all normal- malabsorption, more extensive liver test, bile acid test, fecal for ova / parasites, urine culture….. B/P and even repeated part of the ultrasound exam. She said she felt the Vet Radiologist that did the ultrasound “over calls things”, the IMS said she considers adrenal glands normal up to 0.9 CM so using her definition of normal he no longer has enlarged adrenal glands. What is the normal size for a medium-large dog? She wanted to do many more tests but at over $1500 for the first visit and everything being “normal” things were not making sense. She was pushing hard to do a CT scan (they have one there) but I said if needed, I’d prefer a MRI which I feel is better for soft tissue (but they can’t bill and collect for that since they don’t have one), she suggested that could be done after the CT--- we did neither. She had me stop the Vetorly, start on a strict “hypoallergenic hydrolyzed protein diet” and start Panacure x10 days event though stool was clear and put him on Tramadol for pain. She said she felt Duke has IBS and “you cannot have inflammation with Cushing’s” so the fact that she sees signs of intestinal inflammation means he does NOT have Cushing’s. (Not sure I agreed or believe clinically with this statement but I did go along with her POC) What experience do other have regarding GI problems in Dogs with Cushing’s- untreated—can such absolute statement ever be made?

We followed her orders--stopped treating the Cushing’s and started on a hydrolyzed chicken hypoallergenic food and treats (he is chicken sensitive but I was told he would tolerate this). Within one week after transitioning fully to the new food he was much worse, passing red jelly mucous, strainging with hind legs shaking when he would go to the bathroom, again and again. We switched to a hypoallergenic vegetarian hydrolyzed soy food next and this too he did not tolerate—no need for details . Mean time the skin lesion on his back has spread and grown 4 fold in 1 month, insomnia continues, as do all his other symptoms. Duke was started on Flagyl following the Panacure and the IMS wants him on the Flagyl x30 days “to reset his system”. The IMS said she wanted to do 6-8 punch biopsies including of normal skin to see what is going on with his skin lesion, that she felt was a lipid condition not CC. At this point I canceled that appointment and knew it was time to find as new specialist. I also cooked Duke ground lean turkey-oatmeal-rice-and butternut squash--- stool and tummy is much better!

Over the weekend Duke had a spontaneous rupture of a back foot toe tendon- no associated trauma as a cause—is this Cusings related?. Today we saw a Veterinary Dermatologist (figuring from there I could get referred to a new IMS). She reviewed his records, test results looked at him, his skin, hair loss and back lesions and said “He has Cushing’s” and the lesions on his back are calcinosis cutis I don’t need a biopsy to tell you what they are. She also indicated that when she does do a punch biopsy only one small sample from the lesion is needed not 6-8 biopsies but with his history of suture reactions and delayed healing she did not want to disturb his skin. She said the lesions can also be diagnosed (when they become large like these are) by x-ray where the calcium deposits will show-up. She said to get DMSO gel and apply it daily and most importantly we were referred to a new IMS who we will see in 2 days. She said he showed no signs of allergies (which I knew). I’m hoping this will be the right IMS and feeling like we also need to get a new vet generalist since so far nothing has gone right and I don’t think they have the comfort or experience with Cushing’s and from the start I had to ask for him to even be tested and even with the positive tests they still could not recognize the disease. Very frustrating and disappointing.

The really sad part of this is I know Duke is in pain. I did not know Cushing’s disease was painful, but 2 weeks ago I was speaking with a human endocrinologist about my dog and his probably Cushing’s diagnosis. She said when people get Cushing’s it almost instantly ages them 10 years- skeletal and organ wise and is very painful. Duke is and has clearly been in pain.

[Joan2517]

Poor Duke, but this Dermatologist sounds like she knows what she's talking about...maybe now he will get some relief. I hope the visit with the new IMS gives you more confidence in Duke's treatment.

[Carole Alexander]

Hi and welcome. Duke's case is very complicated and you are doing a superb job as his advocate. I can offer little by way of informed thinking about his situation except that you have to find an IMS in whom you have confidence and who can begin to pull all of the pieces together to form a treatment plan. There is however, excellent information on this forum about treating CC and many owners have effectively treated it. My best to you and Duke.

[molly muffin]

Hello and welcome from me too.

CC is a definite sign of high cortisol, causing calcium deposits and very hard to get rid of. All those calcium deposits that are there already need to pop through and can look much worse before they get better.
One of the keys we have found with cc involved is that the post ACTH test needs to be down to under 5.0ug to get control of the cc.

High cortisol over a period of time causes the weakening in tendon and ligament and can result in tears occuring. We see this quite often with an ACL tear for example.

Poppycock that you cannot have IBD and Cushings together. One of our very long term cushing furbabies Zoe who has now passed on, had both and we've had others. Pancreatis is also quite common with cushings.

I'd do the twice a day dosing of cushing meds, (as marianne suggested earlier where the total dose is split into two doses like 45mg am and 45mg pm for instance) and to try and get control of the stomach issue, a bland diet, small meals of mushy chicken and rice or beef and rice. You want to boil the rice till it's a mushy consistency and then feed several small meals a day till you can get that flare up down. This is often what is recommended for pancreatis which his pancrease was showing some inflammation so this could help both.

A good probiotic which I think you are already giving.

[Duke's Mom]

Saw the new IMS specialist today and I think she is very good! She had reviewed all of the records and tests we had done (I dropped them off yesterday) and said that the first LDDT done back in May was diagnostic for pituitary dependent HAC. She was puzzles (as have I been) why all the clear clinical signs were being ignored and the dog not being treated. They did an ACTH stim test today to see how bad his cortisol levels are and based on this will decide which drug to start him on—Lysodren if level are very bad since that should bring the disease under control faster, or Vetorly BID dosing if levels are not that bad. She asked if I wanted them to do an xray to see the calcium deposits in the skin lesions so that a conclusive diagnosis of CC could be made. We did the xray and the deposits were there—no trauma, no infection risk- yet the other IMS never suggested this—wow. She said that unless we were wanting to consider treatment options such as radiation therapy for the pituitary tumor at some point, there was no need or point in doing any imaging to see the tumor; it did not change the treatment plan and so it was not needed. We already had the U/S showing the enlarged adrenal glands as well. There was some discussion about due to his young age at disease onset, the prognosis long term is not as good because the tumor has more years to grow and he may develop other neurologic symptoms at some point. He still has normal B/P (this specialist does not charge an additional $57 to check the BP). She was fine with my continuing on the home cooked diet since he is doing much better on it. She mentioned a supplement called Balance-IT that completes the vitamin and mineral needs for dogs on home cooked diets, but suggested waiting another week or so before making any changes or additives. Hope to have test results tomorrow and be starting treatment and moving towards our boy feeling better. I will be asking her for a referral to a new vet generalist in short time that she can work with assuming things continue on this positive track. It was a 100% different experience and I’m kicking myself that I did not make a change or do something sooner when things seemed off and odd!

[Joan2517]

Great! It's such a relief when you find a vet you can trust and work with. Not having faith in your vet is stressful and nerve-wracking...and Cushing's is stressful enough.