New member who needs help - (Lilah) 8 y/o female maltese.

[Rachel]

I do not know if my dog has cushings, and would like any info. you may have.
Lilah is a 8 y/o female maltese. I run a full chemistry panel yearly on both my dogs to make sure they are healthy. Here is her history.
2007: all labs WNL except trigycerides 360 high.
2008: ALT 253 high, ALKP 129 (upper limits of normal), CHOL 388 high, TRIG 604 high
*vet thought she needed to be put on low fat diet, so we switched foods- she was not concerned about liver values.
2009: ALT 381 high, ALKP 50 WNL, TRIG 156 upper limits of normal, CHOL 218 WNL
*vet was still not concerned with ALT.
*switched food 10-2010 from S.D. low fat to Royal Canine LF digestive formula
11-2010: ALT 892 almost 9 X NL, AST 57 high, GGT 19 high, ALK PHOS 149 upper limits of normal, CHOL 330 high, TRIG 103 WNL, catoxalate crystals in her urine, 30+protein and SG of gr'er than 1.050.

Looking back I wish I would have done something about the labs, but my vet was not concerned because she was non-symptomatic. I have taken this into my own hands and went to an internal medicine specialist in Nov 2010. She did an u/s which showed a healthy appearing liver and the rest was quite unremarkable. I asked her about the possibility of cushings then, but she did not agree. She said that she did not look like a cushings dog and the ALKP was not grossly elevated. We did a bile acid test which came back elevated (I can not remember the values). We did a liver bx, which did not show any remarkable liver damage, even though we know it is there. Her symptoms are vague: dry, thin, flaky skin (no itching), darkening of the skin, slightly thinning hair (it used to matt up, but does not now), course hair texture, ravenous appetite, black-heads on tail and pubic area, random night panting, and elevated labs (especially cholesterol- which I read is specific to cushings). I noticed her urinating a lot on walks, but the vet thought it was only her marking her territory. The specialist diagnosed Lilah with immune mediated hepatitis and put her on denamarin once a day and ursodiol twice a day.
After a month on her meds we rechecked ALT and it came down to 705. I was very happy.
I brought her back in last wed to check her progress, and was very discouraged to find the labs elevated again. ALT 812 high, and ALKP now 212. She had also gained weight. She went from 9.6 to 11.3 in two months. I did increase her food slightly from 1 cup to 1 1/3 cups because she was always so hungry and tried to get my other maltese's food. It is definitely fat and not fluid because you can pinch it. She is a thick dog, she does not have the thin spindly legs you typically see with a cushings dog. This visit I asked my regular vet again about the possibility of cushings and she actually entertained the idea. She is faxing the info to the specialist and we are waiting to hear back from her. Lilah sleeps all day, and is lazy acting like a typical senior dog. She does not have increased thirst that I can notice. I'm at a standstill and don't know what to do. Any thought would be appreciated. She is my baby. Thank You, Rachel

[Harley PoMMom]

Hi and welcome from me and my boy, Harley! Was any thyroid problems ruled out?

[Rachel]

TSH and Blood Glucose are WNL.

[frijole]

I would have asked the same question Lori did. Interesting. What I find interesting is that the ALT is more elevated than the ALKP. My dog never had elevated ALT - only alk phos. I think that it is typically the alkp that is a more elevated with alt somewhat elevated in cush dogs.

Does your dog have a round tummy? Real round? Or is she just thick? Not all cush dogs have the thirst issue - mine never did but she would head butt trash cans to get to food. When she ate she never took a breath or even chewed it - she inhaled it. Does that sound like your dog?

There are other diseases that mimic cushing's and the testing to get a firm dx takes time - more than one test. My 2nd dog was diagnosed with cushing's a year ago and I wasn't concerned since I had treated a dog for over 4 yrs with it. Well... she had 5 false positives for cushing's and we put her on the meds for it. Bad move. And I should have known that even though her tummy was round and appetite (at the time, not now) was in line with cushing's ... there were alot of other symptoms that did not match up.

Thousands of dollars later - we believe she has an adrenal tumor (not cushing's though) that sends signals that intermittently look like cushing's. It is the strangest thing.

So I am glad you have found a specialist to help you. Just keep yourself open to all of the possibilities because it might be something else altogether.

Have you done a sonogram on a high resolution machine? Might be worth doing with the IMS. Biggest bang for the buck in my opinion.

Good luck and do keep us posted. Kim

[Harley PoMMom]

If I was having a thyroid panel done on my pup I would have it send out to Dr. Jean Dodds. IMO, she is an expert in thyroid issues.


Another significant problem is diagnostic over reliance on the canine endogenous TSH test. This test in the dog, unlike the equivalent one in humans, is only ~70% predictive, with a 20-40% discordancy rate (both false positives and false negatives occur).This is quoted from an article by Dr. Dodds and can be found here:
http://www.k9cushings.com/forum/showpost.php?p=23229&postcount=1

Dr. Dodds website: http://www.itsfortheanimals.com/HEMOPET.HTM

Love and hugs,
Lori

[Rachel]

Lilah's T4 was 1.8 and has consistently been in the normal range since 2007. I don't think she has any thyroid problems.

Have you ever heard of a cushings dog having severely elevated ALT with only slightly elevated ALK PHOS? I guess that is my question. Do you think that doing a ACTH test is something I should do?

To answer your question: Lilah's tummy is not overly round, but is full. She eats so fast she almost chokes on her food. She grunts and makes a lot of noise like she is starving to death. My male maltese has prednisone induced cushings. My little Sampson has a severe case of lymphectasia and the pred is one of the meds that keep him stabilized. Every time I try to ween him down he bottoms out on me. So I am familiar with the typical "look" of a cushings dog. What made me start questioning all this was the way Lilah's skin is dry and flaky like Sampson's. I am grasping at straws and trying to find out what is causing the markedly elevated labs so I can properly treat the disease. Ya'll are great, thanks for the support!

[Rachel]

I also forgot to tell you that I do and teach ultrasound for a living. Not only did the vet do an ultrasound, but so did I on a great machine. The adrenal were about 4mm with the typical "peanut" shape.

[frijole]

There are lots of reasons why ALT could be elevated - anything from a bacterial infection to cancer... so I think you are smart to check into it. I read that it is not uncommon for ALT to be 3 to 4 times normal but that it is when it remains high that you should look into it.

Great - if you did an ultrasound - were the adrenals the same size? Were they enlarged (one or both)? You already said the liver was not enlarged which would possibly be a sign of cushing's. Did you see any tumors or anything of note? Bladder look ok? Did the vet do the ultrasound?

The problem with the acth test is that if anything else is going on it could effect the result and show up as a false positive. This is why you can't diagnose cushing's from a single test. I would probably have the vet do the UC:CR urine test. It can not diagnose cushing's but it can rule it out. Cheapest, fastest way to get a 'no'. If it's a no you'll save alot of money and time. If it doesn't rule out cushings' then you could do the acth or the ldds tests.

Kim

[Rachel]

I read the UC:CR urine test can be false positive in liver disease and immune-mediated diseases. With her ALT at 820, I considered that liver disease and assumed it would not be accurate.

Yes, the vet also did an ultrasound. No tumors were seen, bladder was unremarkable. Both adrenals gland were the same size and according to the vet WNL for size. Liver had a slight increased echogenicity, which is the brightness. No enlargement was noted.

What about the low dose dexamethasone suppression test?
Thanks,
Rachel

[labblab]

Hi Rachel, and welcome!

If it were my dog and I was proceeding with diagnostics based more upon concern over lab abnormalities than classic Cushing's symptoms, I would opt for an ACTH before performing an LDDS. This is because the ACTH is the more "specific" test for Cushing's -- meaning that it is less likely than the LDDS to return a false positive result in the face of other, nonadrenal illnesses.

The LDDS is a more "sensitive" test -- meaning that it is less likely to miss diagnosing Cushing's in a dog that truly has the disease. But for a dog lacking a typical symptom profile, I think the greater danger lies in falsely assuming that Cushing's is the cause of lab abnormalities when, in fact, some other illness or issue is at play.

Just my two cents worth!

Marianne

[lulusmom]

Hi Rachel and welcome to you and Lilah.

I have a real affinity for Maltese and have two boys myself. I'm about to take one in to have bloodwork done because he has become overly obsessed with food. He's 9 years old so he's at that age when he could have any number of things going on or he could just be a glutton like his mom in his old age. :D

Others have already asked most of the questions I would have but as usual, I still have more, plus a few comments which I've typed in blue text below:


I do not know if my dog has cushings, and would like any info. you may have.
Lilah is a 8 y/o female maltese. I run a full chemistry panel yearly on both my dogs to make sure they are healthy. Here is her history.
2007: all labs WNL except trigycerides 360 high.
2008: ALT 253 high, ALKP 129 (upper limits of normal), CHOL 388 high, TRIG 604 high
*vet thought she needed to be put on low fat diet, so we switched foods- she was not concerned about liver values.
2009: ALT 381 high, ALKP 50 WNL, TRIG 156 upper limits of normal, CHOL 218 WNL
*vet was still not concerned with ALT.
*switched food 10-2010 from S.D. low fat to Royal Canine LF digestive formula
11-2010: ALT 892 almost 9 X NL, AST 57 high, GGT 19 high, ALK PHOS 149 upper limits of normal, CHOL 330 high, TRIG 103 WNL, catoxalate crystals in her urine, 30+protein and SG of gr'er than 1.050.

Wow, that's some high protein and hugely high SG. This is definitely not normal. Did your vet mention these abnormalities, including the crystals in the urine? Have you had a more recent urinalysis done? Just a note....dogs with cushing's usually have low SG.

Looking back I wish I would have done something about the labs, but my vet was not concerned because she was non-symptomatic. I have taken this into my own hands and went to an internal medicine specialist in Nov 2010. She did an u/s which showed a healthy appearing liver and the rest was quite unremarkable. I asked her about the possibility of cushings then, but she did not agree. She said that she did not look like a cushings dog and the ALKP was not grossly elevated.

Dogs with cushing's normally have an enlarged liver and ALKP is usually much more elevated than ALT. If ALT is elevated at all, it's usually very mild. It is known that approximately 20% of dogs with cushing's will not have elevated ALKP because they are missing a gene that most dogs have that triggers ALKP in the face of steroids. I suppose it's possible that Lilah is one of those dogs but I'm not convinced. The liver enzyme elevations look more like primary liver disease to me but then, I'm not a vet nor a human medical professional. Insurance is my game

We did a bile acid test which came back elevated (I can not remember the values).

FYI, Maltese is a breed who are known to have high bile acids but it doesn't mean they have any problems. Depending on how high the post meal bile acids were, it could be normal for Lilah.

We did a liver bx, which did not show any remarkable liver damage, even though we know it is there.

A liver biopsy should be able to tell your vet if steroid hepatopathy common in cushing's is present. Did your vet mention anything about this?

Her symptoms are vague: dry, thin, flaky skin (no itching), darkening of the skin, slightly thinning hair (it used to matt up, but does not now), course hair texture, ravenous appetite, black-heads on tail and pubic area, random night panting, and elevated labs (especially cholesterol- which I read is specific to cushings).

The symptoms you mention can be associated with cushing's but they can be associated with other conditions as well. Cholesterol is usually mildly elevated on lab work for a cushdog but dogs with other conditions, including primary liver disease, can affect fat metabolism, causing elevated cholesterol. In my opinion, Lilah does not have classic cushing's blood and urine abnormalities. I believe in one of your subsequence posts you mention that the adrenals were normal (kidney shaped) and that the liver was of normal size. This is also not consistent with cushing's.

I noticed her urinating a lot on walks, but the vet thought it was only her marking her territory. The specialist diagnosed Lilah with immune mediated hepatitis and put her on denamarin once a day and ursodiol twice a day.

I had a tiny Maltese years ago, who I lost to sudden kidney failure and two years before that she had hepatitis and I would think Lilah would have more abnormalities on her bloodwork than what you've posted. Was albumin and bilirubin normal? Dogs with hepatitis usually don't have an appetite, yet you say Lilah is now food driven.

After a month on her meds we rechecked ALT and it came down to 705. I was very happy.
I brought her back in last wed to check her progress, and was very discouraged to find the labs elevated again. ALT 812 high, and ALKP now 212. She had also gained weight. She went from 9.6 to 11.3 in two months. I did increase her food slightly from 1 cup to 1 1/3 cups because she was always so hungry and tried to get my other maltese's food. It is definitely fat and not fluid because you can pinch it. She is a thick dog, she does not have the thin spindly legs you typically see with a cushings dog. This visit I asked my regular vet again about the possibility of cushings and she actually entertained the idea. She is faxing the info to the specialist and we are waiting to hear back from her. Lilah sleeps all day, and is lazy acting like a typical senior dog. She does not have increased thirst that I can notice. I'm at a standstill and don't know what to do. Any thought would be appreciated. She is my baby. Thank You, Rachel

Aside from the liver support and ursodiol, is Lilah taking any other medication?

I wish I had more answers than questions but perhaps more clarification from you will help us offer up more helpful information for you.

I'm sure sorry about the reasons you had to find us but I'm glad you did.

Glynda

[Rachel]

Thanks Glynda! You answered many of my questions.

Lilah's direct and indirect bilirubin are normal as well as albumin. Vet did not mention anything about steroid hepatopathy in bx results.
The only meds she is on is denamarin and ursidiol.

What do you think about the Royal Canine LF digestive formula. I switched her from S.D. low fat in oct. 2010. This was approx. 4 weeks before the grossly abnormal blood work was taken. Like I said before it has been steadily on the rise for 3 years now so I don't know if the food has say so. Vet was uninpressed.

Lilah has very vague symptoms. No vomiting, no diarrhea, and a great big appetite. She sleeps all day (but my husbands works nights so she cuddles in the bed with him) but she loves walks and playing too. This is all to crazy and is making me anxiety ridden!

[lulusmom]

I think there are much better food out there than Royal Canin LF. The ingredients gross me out but most of the prescription diets do. I have no idea why these companies cannot make a prescription diet with quality ingredients instead of the disgusting by products and cheap fillers. Check out the first six ingredients. Even the gelatin is a by-product.

Water sufficient for processing, pork by-products, pork liver, corn grits, rice flour, chicken by-products, gelatin by-products

Now having expressed my opinion, I also believe that prescription diets serve a purpose when a dog's physical ailment really does call for a special diet. I'm not sure about Royal Canin but I've heard from a number of people with overweight dogs that Hills prescription weight formula worked great. Most switched diets when their dog lost the weight they needed. Is Lilah on this food for her weight or another suspected issue?

[Rachel]

We put her on the low S.D low fat because of the high triglycerides and when her liver enzymes started creeping up. My other dog was on the Royal Canin LF digestive and the vet said that was a better quality food so for simplicity to switch her over and feed them both the same food.

[lulusmom]

I did notice that the fat content is extremely low in this food and it has made a difference in lowering the triglycerides. With such low fat, I believe that may be the reason you are seeing dry flaky skin and the change in coat. Do your own research and see if you can find a commercial brand with better quality ingredients with acceptable levels of fat. Hopefully, there are other members who are dealing with high triglycerides who can share their experience.

Glynda

[Rachel]

Ya'll have been so great and are full of info! Here's what the liver bx said, vacuolar hepatopathy, mild, portal to panlobular. The degree of vacuolar hepatopathy is quite mild and may be incidental. Potential differential diagnoses for gyycogen accumulation include high levels of endogenous glucocorticoids. Now the vet wants to do a ACTH stimulation test to rule-out cushings. The ACTH stim test is $251.50. The low dose dexamethasone test is $159.00. Which one would be more effective in ruling this out? Thanks, Rachel

[labblab]

Hi Rachel, and welcome!

If it were my dog and I was proceeding with diagnostics based more upon concern over lab abnormalities than classic Cushing's symptoms, I would opt for an ACTH before performing an LDDS. This is because the ACTH is the more "specific" test for Cushing's -- meaning that it is less likely than the LDDS to return a false positive result in the face of other, nonadrenal illnesses.

The LDDS is a more "sensitive" test -- meaning that it is less likely to miss diagnosing Cushing's in a dog that truly has the disease. But for a dog lacking a typical symptom profile, I think the greater danger lies in falsely assuming that Cushing's is the cause of lab abnormalities when, in fact, some other illness or issue is at play.

Just my two cents worth!

Marianne
Rachel, I know I'm quoting myself ;), but I don't know if you noticed by reply yesterday since it was posted at the bottom of the preceding page on your thread. Even though the ACTH is more expensive, I agree with your vet as to the ACTH being the diagnostic test of preference in this situation.

Marianne

[Rachel]

Thanks Maryann, I forgot about the prior post. I appreciate you reiterating it for me. :)

[Rachel]

Hey Guys! I did the ACTH stim test on Lilah last tues. Just got the results and they are abnormal. Please let me know what you think and tell me what I need to do now.
resting cortisol 22 mg/dl (normal range the vet gave me 2-6 ml/dl)
post cortisol 26 mg/dl (normal range 6-18 mg/dl) My vet said anything over 22 post ACTH indicated cushings.
Thank You, Rachel

[Rachel]

Hey Guys! I did the ACTH stim test on Lilah last tues. Just got the results and they are abnormal. Please let me know what you think and tell me what I need to do now.
resting: cortisol 22 mg/dl (normal range the vet gave me 2-6 mg/dl)
post: cortisol 26 mg/dl (normal range 6-18 mg/dl) My vet said anything over 22 post ACTH indicated cushings.
Thank You, Rachel

[Harley PoMMom]

Hi Rachel,

Glynda asked about the crystals in the urine, did you ask your vet about this? Urinary crystals can a symptom of portosystemic liver shunt in maltese.

http://www.vet.utk.edu/clinical/sacs/shunt/faq.php

Lori

[Rachel]

I did ask the IMS but she said that since she was almost 9 yrs old and these increase labs started in 2008 that PSLS was not an issue. THe IMS said that those present as pups.

[Harley PoMMom]

What are the clinical signs of a liver shunt?

Some animals show no signs until they are older, when they develop bladder and kidney infections and stones.

http://www.vet.utk.edu/clinical/sacs/shunt/faq.php

Lori

[Rachel]

I did look up the symptoms of a liver shunt, and she is not doing any of them. Main symptoms were letharic, lack of appetite, head pressing, etc. When I did her ultrasound I visualized the main portal vein as well as the rt and lt branches. All were flowing in the correct direction with normal velocities. I would think if there was a shunt the blood flow in the portal would be decreases and hard to visualize due to the shunted blood volume. At least that is what I find on ultrasound in human portal shunting. I can ask the IMS again what she thinks. It is nearly impossible to get her on the phone. Usually my vet calls her.

[Rachel]

I found this when I googled urine oxalate crystals and cushings...

Urine Crystals
Urine crystals form when the urine pH is abnormal. The most common crystal in dogs with Cushing’s is the calcium oxalate crystal, which forms is urine that is too acidic. As the Cushing’s disease affects the pituitary gland, kidney function is affected to the point where high levels of protein are being excreted. As the urine sits in the bladder, the protein induces the crystals to congregate, eventually forming stones that quickly become too large to pass through the urethra. The protein increase also creates an environment favorable to the growth of bacteria, and the stones give the bacteria a place to live. Soon, the dog has a painful urinary tract infection.

[Harley PoMMom]

I have 2 dogs; Harley has cushing's and kidney disease, I am not treating his cushing's because of his kidney disease. Harley has never had an UTI or kidney/bladder stones...knock on wood!

Now, my other dog, Bear, does not have Cushing's and has had 2 operations for the removal of oxalate stones from his bladder. :eek:

[lulusmom]

Hi Rachel,

It is true that portosystemic shunts are usually diagnosed at early ages but it is not unheard of in an older dog, especially an older Maltese. I suspect that Lori and I are thinking this could be a possibility for a number of reasons, which I will list below:

1. Maltese is a breed that is predisposed to hepatic encephalopathy
2. Lilah's urine specific gravity was extremely high and this is not normal for a dog with cushing's. Low USG is the norm in cushing's. Your IMS addressed the portosystemic shunt in her response but what did she say about the urinary crystals in general and the very high USG?
3. Dogs with cushing's can have high bile acids but usually not over 50. Anything over 75 usually rules out cushing's. Can you tell us what Lilah's bile acids were?
4. The common elevated liver enzyme pattern for a cushdog is high ALKP with mild ALT elevations. Lilah's ALK has been consistently normal but ALT has continued to increase. AST, also a liver enzyme usually parallels ALT and is rarely seen in cushing's. While you did not post the normal reference ranges, I would suspect that Lilah's ALT is more than a five fold increase and that is usually a tip off that primary liver issues may be involved. Plus, I seem to recall that a liver biopsy did not show steroid hepatopathy. How can that be? Please be sure to ask your vet about this particular point. It just isn't making any sense to me but then, I'm just a cushdog parent. :)

Dogs that are stressed or have non adrenal illnesses can have abnormally high resting cortisol but I don't think I've ever seen levels as high as 22. I Googled "high resting cortisol" and found an interesting abstract of a study done by the University of Utrecht. The very first sentence of this abstract was a remarkable piece of information I had never seen.


Dogs with portosystemic encephalopathy (PSE) are known to develop pituitary-dependent hyperadrenocorticism....

The summation of this study could certainly explain Lilah's high resting cortisol levels.


The presence of increased concentrations of free cortisol in these dogs indicates that their basal pituitary-adrenocortical activity was increased[/B], probably due to aberrant neurotransmission in brain centers associated with pituitary function, as a result of hepatic encephalopathy.

Why don't you print this abstract and share it with your IMS. As a veterinary professional she can easily access the entire PDF version of this study. You have nothing to lose by making absolutely certain that all of the bases are covered.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T62-47RSDYP-25&_user=10&_coverDate=10%2F31%2F1994&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1648685794&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=42a7d4b10681847adc4612fec5366370&searchtype=a

Glynda

[Rachel]

Here are Lilah's values...
pre-prandial bile acids: 11.3 (0.0-6.9 umol/L)
post prandial: 51.0 (0.0-14.9 umol/L)

ALT 820 (5-107 U/L)
ast 57 (5-55 U/L)

Here's what the liver bx said, "vacuolar hepatopathy, mild, portal to panlobular. The degree of vacuolar hepatopathy is quite mild and may be incidental. Potential differential diagnoses for gyycogen accumulation include high levels of endogenous glucocorticoids. It a dog that does not clinically present with hyperadrenocorticism this may be incidental". The biopsy results did not find any of the findings one would typically see with PSS. Based on the bx results there DID show a suspicion for steroid hepatopathy. The IMS did not mention cushings as a possibility because she thought Lilah had more symptoms of primary liver disease. I'm trying to be diligent, that's why I went ahead and ran the ACTH test. I will print this article and share with my vets. Anything else ya'll see that I am missing? Thanks bunches!!!! I truly appreciate your time, you are God sent!

[Rachel]

I am going to Nashville in march. Does anyone know of a liver specialist at Vanderbilt? I live in Ocean Springs, MS and travel to Mandeville, LA to see a IMS. I am limited...

[Rachel]

I found this on a PSS site:

Do all dogs with high bile acids have shunts?
Bile acids can be increased with any liver disease. Bile acids can also be mildly increased in normal dogs, particularly in some breeds (such as Maltese) where chemicals in their blood interfere with the test. Most dogs with liver shunts have fed bile acids over 100 (normal <15-20). If the bile acids are only mildly increased or the animal seems normal, many veterinarians will simply rerun the test in 3-4 weeks.
Lilah's post bile acid was 51

Can a shunt be diagnosed with a liver biopsy?
In animals with shunts, the liver is smaller than normal because it is atrophied from poor blood flow. On a liver biopsy, the tissues appear shrunken. Some of the vessels are very tiny, while others multiply in an attempt to improve the blood supply and drainage. These changes are called hepatic microvascular dysplasia. Hepatic microvascular dysplasia (HMD or MVD) can also occur in dogs without liver shunts; therefore, other tests are needed to be determine if a shunt is also present.

Lilah's results only showed mild vacuolar hepatopathy no other findings.

Any thoughts?