14 year-old Shih Tzu With Recent Cushing's Diagnosis

Hi Julie,

Dogs with primary liver disease have more abnormalities than just ALT and ALKP. Did your vet do a complete chemistry and cbc or did he just do a snap test inhouse? If comprehensive testing was done, can you post all abnormalities? As far as symptoms associated with primary liver disease, dogs don't usually have any symptoms until most of the liver has shut down, usually 75%.

Based on everything you just posted, it sure doesn't sound like Hannah ever had cushing's and in the absence of any symptoms associated with cushing's, I sure wouldn't pursue any diagnostics to rule it out at this point. To answer your question about the LDDS, yes it is more likely to yield a false positive results if there is something else going on with a dog. This would include any non adrenal illness, whether chronic or transient, and stress. So could Hannah's results have been a false positive? Absolutely.

I personally would find an ultrasound more useful than a bile acid test. If liver enzymes are elevated, chances are bile acids are going to be high. FYI, most dogs with cushing's have mildly high bile acids but some have elevations as high as 50.

Glynda

Julie, I'm not around much any more, so I have gone back & read your last several posts. If you don't mind, could you post Hannah's last 3-5 hemoglobin/hematocrits, & the dates they were done. Actually, I would like to see the complete CBC, if possible. I'm looking for drops in WBC, along with platelet counts, besides the H&H. I just don't have the time to go back & re-read the whole thread at the moment. Post how ever many you can find, along with the dates they were done.

I read where the vet apparently feels there is a concern for possible lymphoma. Believe me, I have plenty of experience with that one, too, unfortunately. At any point in time over the past 3-4 months, have either you or the vet felt any swollen glands on Hannah? The normal places to find them would be in & around the lower jaw/neck, or in behind her elbows or knees. When Barkley got sick, I never actually thought to check for swollen glands. All I can tell you is B was "off", the main symptom was a lack of appetite. This was the cushing's boy who never lost that voracious appetite even with him being well controlled by lysodren. He would have eaten until he popped, if I let him, so I knew something was really wrong. After going back & forth between his derm vet & GP vet for 2 weeks, not getting a straight answer from either of them, I threw up my hands, basically told both of them, "I'm spending a bucket of $$$ for both of you to figure out what's going on, & this boy is literally dying in front of me." After I pitched that fit with the derm vet, we got sent to an IMS. She felt multiple swollen nodes on physical exam, & wanted to keep B for an ultrasound & fine needle aspirate of one of the nodes. The ultrasound told the tale, multiple swollen lymph nodes throughout his abdomen. A fine needle aspirate was done on the node in behind his knee, & 24hour later, the verdict was lymphoma. I don't want to worry you to death, but on the remote chance this is lymphoma, there is not a lot of time. On the slim chance it is lymphoma, I can offer you some help with your options.

I'm telling you B's story as it's my long-winded way of saying that I agree with Glynda that an ultrasound would be the best bet, IMO.

Debbie

You learn something new all the time on here. If a dog that has elevated liver ALT's and ALP's is going to test high on a bile acid test, then I guess that wouldn't rule out liver disease after all. arggghhh
I agree, over all, frustrating.

hugs,
Sharlene

THANK YOU, THANK YOU, THANK YOU for your thoughts!!! I am now going to talk to the vet to see if they think I should just do the ultrasound first.

Debbie, I will post results below. Thanks so much for sharing all your thoughts. I honestly think he threw out lymphoma as just an example, but who knows. I have felt nothing abnormal on Hannah. I just checked after I read your post and had my mom check too since she was over. She's with her a lot too, and hasn't noticed anything either.

She has had other abnormal results as well, some of them only since the Hemoglobin and Hematocrit (MCV, MCH, MPV) and Platelets have been high for years.

I will post results in order. I don't have Wednesday's results yet. They usually mail me a copy when I'm not there to pick it up. I just know he said ALKP was 860 something and I think ALT was 260.

I will try to mark "HIGH" with red and "LOW" with blue.

11/6/12
ALB-2.9 g/dL (2.2-3.9)
ALKP-772 U/L(23-212) H
ALT-240 U/L (10-100) H
ALKP-772 U/L (23-212)H
BUN/UREA-19 mg/dL (7-27)
Chloride-120 mmol/L (109-122)
CREA-1.1 mg/dL (0.5-1.8)
GLU-111 mg/dL (70-143)
Potassium-4.7 mmol/L (3.5-5.8)
Sodium-162 mmol/dL (144-160) H
TP-6.1 g/dL (5.2-8.2)
GLOB-3.2 g/dL (2.5-4.5)
ALB/GLOB-0.9 (no range given)
BUN/CREA-17 (no range given)
Na/K-34 (no range given)
OSM cal-323 mmol/kg (no range given)
HCT-39.7 % (37.3-61.7)
HGB-14.3 g/dL (13.1-20.5)
MCHC-36 g/dL (32-37.9)
WBC-12.72 K/uL (5.05-16.76)
LYMPHS-4.23 K/uL (1.05-5.1)
% LYMPHS -33.3%
MONOS-0.7 K/uL (0.16-1.12)
% MONOS-5.5%
NEUT-7.24 K/uL- (2.95-11.64)
%NEUT-56.8%
EOS-0.53 K/uL (0.06-1.23)
%EOS-4.2%
BASO-0.02 K/uL (0-0.1)
%BASO-0.2%
PLT-614 (148-484) H
Retics-86.8 K/uL (10-110)
%Retics-1.3%
RBC-6.94 M/uL- (5.65-8.87)
[COLOR=MCV-57.2 fL (61.6-73.5) L
MCH-20.6 pg (21.2-25.9) L
RDW-21% (13.6-21.7)[/COLOR]
MPV-8.5 fL (8.7-13.2) L[/COLOR]
PDW-10.2 fL (9.1-19.4)
PCT-0.52% (0.14-0.46) H


10/4/12 (My vet ran a test in house and also sent it out to IDEXX Labs at no charge. Here are the IDEXX results)
WBC-12.9 (5.7-16.3 K/uL)
RBC-7.10 (5.5-8.5 M/uL)
HGB-15.0 (12-18 g/dL)
HCT-42.4 (37-55%)
MCH-21.1 (19.5-26.0 pg)
%Reticulocyte-1.1 ( -%)
Neutrophil SEG-56.0 (60-77%) L
Lymphocytes-35.6 (12-30%) L[/COLOR]
Monocytes-3.8 (3-10%)
Eosinophil-4.5 (2-10%)
Basophil-0.1 (0-1%)
Auto Platelet-674 (164-510 K/uL) H
*There is some info about Absolute neutrophil, lymphocyte, etc. if you want it.
*In the remarks it says "slide reviewed microscopically; no parasites seen)

Here are the results for 10/4 from my vet office:
RBC-7.06 M/uL (5.65-8.87)
HCT-39.8% (37.3-61.7)
HGB-14.1 g/dL (13.1-20.5)
MCH-20.0 (21.2-25.9) L
MCHC-35.4 g/dL (32.0-37.9)
RDW-21.0% (13.6-21.7)
%Retic-1.2 (no range given)
Retic-85.4 K/uL(10-110)
WBC-12.49 K/uL (5.05-16.76)
% NEU-55.9% (no range given)
%LYM-34.4% (no range given)
%MONO-5.3% (no range given)
%EOS-4.2% (no range given)
%BASO-0.2% (no range given)
NEU-6.97 K/uL (2.95-11.64)
LYM-4.30 K/uL (1.05-5.10)
MONO-0.66 K/uL (0.16-1.12)
EOS-0.53 K/uL (0.16-1.12)
BASO-0.03 K/uL (0.00-0.10)
PLT-614 K/uL (148-484) H
MPV-8.2 fL (8.7-13.2) L
PDW-9.9 fL (9.1-19.4)
PCT-0.50% (0.14-0.46) H
GLU 109 mg/dL (70-143)
BUN-17 m/dL (7-27)
CREA -1.2 mg/dL (0.5-1.8)
BUN/CREA-14 (no range given)
TP-6.1 g/dL (5.2-8.2)
ALB-2.9 g/dL (2.2-3.9)
GLOB-3.2 g/dL (2.5-4.5)
ALB/GLOB-0.9 (no range given)
ALT-89 U/L (10-100)
ALKP-471 U/L (23-212) H
Na-151 mmol/L (144-160)
K-5.9mmol/L (3.5-5.8) H
Na/K-26 (no range given)
Cl-118 mmol/L (109-122)
Osm CAlc-304 mmol/L (no range given)

9/14/12:
RBC-6.24 M/uL (5.65-8.87)
HCT-34.2% (37.3-61.7) L
HGB-12.4 g/dL (13.1-20.5) L
MCV-54.8 fL (61.6-73.5) L
MCH-19.9 pg (21.2-25.9) L
MCHC-36.3 g/dL (32.0-37.9)
RDW-19.8% (13.6-21.7)
%RETIC-0.5% (no range given)
RETIC-31.2 K/uL (10.0-110.0)
WBC-13.31K/uL (5.05-16.76)
%NEU-67.4%
%LYM-23.8%
%MONO-4.8%
%EOS-3.8%
%BASP-0.2%
NEU-8.98 K/uL (2.95-11.64)
LYM-3.17 K/uL (1.05-5.10)
MONO-0.64 K/uL (0.16-1.12)
EOS-0.50 K/uL (0.06-1.23)
BASO-0.02 K/uL ( 0.00-0.10)
PLT-610 K/uL (148-484) H
MPV-8.4 fL (8.7-13.2) L
PDW-10.5 fL (9.1-19.4)
PCT-0.52% (0.14-.46 ) H
GLU-97 mg/gL (70-143)
BUN-17 mg/dL (7-27)
CREA 1.1 mg/dL (0.5-1.8)
BUN/CREA-15 (no range given)
TP-6.0 g/dL (5.2-8.2)
ALB-2.6 g/dL (2.2-3.9)
GLOB-3.4 g/dL (2.5-4.5)
ALB/GLOB-0.8 (no range given)
ALT-78 U/L (10-100)
ALKP-326 U/L (23-212) H
NA-153 mmol/L (144-160)
K-5.5 mmol/L (3.5-5.8)
Na/K-28 (no range given)
Cl-14 mmol/L (109-122) H
Osm Calc-306 mmol/L (no range given)


8/8/12 (same ranges-I don't have the full print out on this one)
RBC-6.60 M/uL
HCT-36.9% (37.3-61.7)L
HGB-13.7 g/dL
MCV-55.9 fL (61.6-73.5) L
MCH-20.8 pg (21.2-25.9) L
MCHC-37.1
RDW-18.7%
%RETIC-0.4%
RETIC-25.1
WBC-13.04
*Skipping cell % and types*
PLT-610 K/uL (148-484) H
MPV-8.6 fL (8.7-13.2) L
PDW-10.1
PCT-0.47% (0.14-0.46)H
GLU-96
BUN-23
CREA-1.2
BUN/CREA- 19
TP-5.9
ALB-2.7
GLOB-3.2
ALB/GLOB-0.8
ALT-49
ALKP-250 (23-212)
Na-156
K-5.5
Na/K-28
CL-119 (109-122) H
Osm Calc-314


4/9/12
RBC-6.78 M/uL (5.65-8.87)
HCT-39.5% (37.3-61.7)
HGB-14.4 g/dL (13.1-20.5)
MCV-58.3 fL (61.6-73.5) L
MCH-21.2 pg (21.2-25.9)
MCHC-36.5 g/dL (32.0-37.9
RDW-19.3 % (13.6-21.7)
%RETIC-1.0% (no range given)
RETIC-66.4 K/uL (10.0-110.0)
WBC-11.22 K/uL (5.05-16.76)
*I'm skipping the percent/type of each cell (let me know if you need it*
PLT-558 K/uL (148-484) H
MPV-9.3fL (8.7-13.2)
PDW-10.9 fL (9.1-19.4)
PCT-0.52% (0.14-0.46) H
GLU-94 mg/dL (70-143)
BUN-21 mg/dL (7-27)
CREA-1.2 mg/dL (0.5-1.8)
BUN/CREA-18 (no range given)
TP-6.7 g/dL (5.2-8.2)
ALB-3.0 g/dL (2.2-3.9)
GLOB-3.7 g/dL (2.5-4.5)
ALB/GLOB-0.8 (no range given)
ALT-81 U/L (10-100)
ALKP-186 (23-212)
NA-151 mmol/L (144-160)
K-5.3 mmol/L (3.5-5.8)
Na/K-28 (no range given)
Cl-117 mmol/L (109-122)
Osm Cacl-303 mmol/kg (no range given)

2/15/12--Abnormal Results:
MCV-59.7 (61.6-73.5) L
MCH-21.1 (21.2-25.9) L
BASO-0.13 (-0.00-0.10) H
ALKP-437 (23-212) H
Other info. that may be helpful:
RBC-7.07 (5.65-8.87)
HCT-42.2 (37.3-61.7)
HGB-14.9 (13.1-20.5)
WBC-10.80 (5.05-16.76)

I also have results for 1/19/12 and a few from 2011. It took me about an hour to type this, so I need a break. ;) Let me know if you need more though, and I'd be happy to keep typing.

Thanks again SO MUCH!

Julie & Hannah

Julie, there was a very significant drop in Hannah's hemoglobin, 2 grams between April & mid Sept. Subsequent CBC s show that her hemoglobin has recovered quite nicely, so she is definitely not anemic at the present time. Was anything unusual going on in the above time period? Did you notice if Hannah may have had blood in her stool during this timeframe? I'm thinking that she might have had something like colitis with some slow bleeding in her GI tract that dropped her hemoglobin, but she may not have shown signs of being overtly ill. Since her hemoglobin has recovered, I don't think it's anything to worry about, but please double check with the vet. With lymphoma, Hannah would have probably shown a decreased WBC count & platelet count, she shows neither. With Barkley, I had the derm vet telling me he was anemic, the GP vet than asks if the derm vet said anything about B being leukopenic which is fancy word for low WBC. An overall depression of blood cells produced in the bone marrow is frequently indicative of a malignant process of some type. Hannah is not showing this.

To show you the beauty of the ultrasound, when Harley had his diagnostic US to confirm his Cushing's diagnosis, the report comes back that he has a dilated bile duct, along with bile sludge. The IMS explained that at some point Harley probably had a gall stone or stones block his bile duct, they managed to clear on their own, & Harley never got sick enough for me to notice anything amiss. The information about the bile duct ended up being very important about a year later when Harley had repeated episodes of vomiting bile colored material over several days, ended up at the vet on IV fluid overnight, & after reviewing Harley's chart, his GP vet decided that this episode was related to this bile duct issue.

Debbie

Thank you so much for the info., Debbie. I have scoured these results and looked for patterns and tried to make sense of them. Unfortunately, I can't. I can't think of anything different going on during the time the hemoglobin and hematocrit were low. We did check a fecal during that time because I was worried maybe she was bleeding (even though everything looked normal) and it was totally normal. After my vet saw the low hemoglobin and wanted to monitor it, I looked back at all of her blood work and noticed that in back in Jan. of 2012 her hemoglobin was low, but he never mentioned it. It was normal again on her Feb. blood work. Sometimes I think he forgets what we're even monitoring because it has gone from her liver to having a kidney value off once, to the possible anemia, and now to the ALT. We don't know why it recovered, but I'm glad it did...other than the new problem with the ALT.

Do you think it is weird that the ALT was suddenly high 4 weeks after being normal (and she has NEVER had an abnormal ALT level)? I am so surprised at the change. Also, the ALKP has been steadily rising too, despite her being on Denamarin. It worries me that it isn't helping anymore. Do you think that could mean anything?

I read online that dogs with Cushing's can have high platelet levels. I saw this in two or three places. Has anyone else heard of this? It doesn't seem like a common thing I read on here. I realize that we wonder if she does indeed have Cushing's, but if she does, maybe that is why it is elevated.

Hannah did have an ultrasound in April of 2011 , after the LDDS test suggested Cushing's. It was totally normal. Her liver looked normal as did her adrenal glands, although they still thought she could have early Cushing's disease. I guess if we do the ultrasound, even if there isn't some terrible mass, maybe they will see a change. My vet was talking about bile duct stuff, but thought that two weeks of antibiotics and metronidazole would clear that up and it didn't.

She also had a radiograph in August to check her back. They did the side view and the one where she lied on her back. I distinctly remember the vet who did it telling me everything else looked normal internally too. (I know that a mass may go undetected on an x-ray, but it seems there was nothing totally abnormal in August).

These are the things I can say are true of Hannah:
-She is more "lethargic" the past year or so, but that could be due to age, and she definitely has her moments where she is active, looking for food in the kitchen or following me around the house.
-She does take long drinks-30 seconds at least, but between her and my other Shih Tzu they are not emptying the water bowls (we have two medium-sized ones).
-She does sometimes urinate for a long time too, but it isn't several times a day, usually...although she does have her days like that.
-She seems to have phases where she barks at us in the evenings, usually after she has eaten, and she seems to want more food. But then it will randomly stop for weeks at a time. I can't find a pattern.
-She has done some strange things in the last several months, like wander into closets and go into corners. I mentioned this to my vet but he didn't seem overly concerned and thought it could be dimentia. It has not gotten worse, and it seems to come and go as well. At times I have thought she was looking for food, but I have no idea.
-She has had more ear infections and skin infections in the past couple of years. I'm not sure if this is due simply to allergies, or again, if she does have Cushing's if it could be due to that.
-She does have weaker rear legs, but since having the back injury in Sept. of 2011 she has not done stairs or jumped on furniture, so I assume that makes them weaker too.
-She has had some trouble defecating on and off and has needed Lactulose or Mirolax to soften her stools. We have been unsure if it is because the stool is dry/hard or if it was due to her sore back. She didn't always go daily when she was younger, and now it seems like if she skips a day it is too tough to go. With daily short walks (a couple of blocks) I can usually get her to go. When she was on antibiotics I had to stop the Mirolax because the stool was too soft, so it will be interesting to see what happens now that she's finished.

I guess if anything, I have lots of records and info. on my thread and maybe at some point all of the dots will connect and we will figure out what is going on. At this point, I think I am going to look into the ultrasound and see what it shows.

Thank you again to everyone who has offered input and advice. I sincerely appreciate it.

Julie & Hannah

Keep the faith Julie, maybe the ultra sound will tell us something. I had the same thought as Glynda, that it sure does not seem like Hannah has Cushings.

Are her allergies any better?

Sending love and hugs to you and Hannah.

I am also wishing you another


HAPPY BIRTHDAY because it is tomorrow, right?


Enjoy!!!! (as much as you can)

Julie,

Lots of good advice going your way. FWIW I have never thought Hannah had cushings either. An ultrasound is how we determined what was causing Annie's issues. Is there a teaching school nearby? They tend to have better equipment and most don't charge as much (in my case $150 vs $500) and the people reading the film are very qualified.

Hugs,
Kim

Wow-does this recent array of postings take me back! Kudos to you Julie for typing all those test results. I am SURE you were cross eyed when you stopped. I can remember doing that. I am also struck by how much I seem to have "forgotten." All those tests, all those results, and all the funny words and figuring out what they mean. Cushing's......or trying to figure out just what is going on is so complicated. I want to go back to the 1960's!

I have nothing to add to what the others have said. I do admire your thoroughness and sensibility in taking into account Hannah's age when you consider your options.

I'll be here reading. Keep up the good work!
-Susan

Thanks again for all your thoughts. Kim, the University of MN is close. I could go there, but at this point I feel like it just probably makes sense to stick with my regular vet to avoid hard feelings and awkwardness. And we can afford the ultrasound; it just stinks to blow through money on vet stuff. Hopefully the ultrasound will be all we need to rule something in or out.

Yes, Addy, today is the big day!

My dogs collided in the hallway yesterday, head-on, and of course Hannah's eye was hurt. :eek: This time it wasn't scratched though, but all red, like a blood vessel burst. Luckily she wasn't showing any pain and her eye was wide open, so when I called the E clinic they said I didn't need to bring her in. It looks to be almost completely better this morning, thank God. I was also worried she hurt her back somehow, but she seems to be okay. I just need to get through the day without any disasters or injuries!!! :D

Thanks for checking on us!
Julie & Hannah