Molly, 13 yr, shih tzu - lhasa aspo - Molly has passed

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Originally Posted by molly muffin

LDDS Test results

Cor1 - Cortisol (base) 79 30 - 300 range nmol/L
Cor34 - Cortisol (DEXA) - 4 hrs <27.59
Cor38 - Cortisol (DEXA) - 8 hrs <27.59

Interpretation for low-dose DEXA:

Normal dogs: Serum cortisol suppresses to <40 nmol/L for the 8-h interval.
Adrenocortical hyperfunction: dogs with HAC do not suppress to <40nmol/L for the full 8 hours. In ~60% of dogs with pituitary tumores, there is suppression to <50% baseline values or <40 nmol/L at 3 or 4 hours.

converted to ug/dl division by 27.59

Cor1 - Cortisol (base) 1.051
Cor34 - Cortisol - 4hrs <1
Cor38 - 8hrs <1

Sharlene

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Sharlene, can you double-check the lab report for Molly's LDDS? It looks like she had 79 nmol/L for the baseline cortisol, but I'm confused by the "Cor34" and "Cor38" lines. I'm assuming those reflect the 4-hour and 8-hour results, but I'm thrown somewhat by the notation. If the lab did not not give specific numbers for her 4-hour and 8-hour results, but instead the report is just indicating that they were both less that 27.59 nmol/L (or less than 1 ug/dl), then those results are not consistent with Cushing's. I just want to double-check that I am interpreting the report correctly.

Marianne

Yes I think you are interpreting that correctly Marianne.
The cor34 = 4 hour, cor38 = 8 hour (I don't now what they actually mean other than the 4 and 8 hours draw)

and yes the number on the result is is is <27.59 or as I did the conversion <1

I didn't think it looked like cushings on that result either. Yes, the ultrasound shows results which could be consistent with cushings (liver, adrnal gland slight enlargement) and the ACTH results are consistent with cushings. This one is not. What about the urine gravity, that doesn't appear to be diluted to me either.

I find this just very weird and confusing.

:( Sharlene, whose boat is acting a bit tipsy right now.

I received a response from Dr. Peterson on his blog and if there are any new studies that show it may be beneficial to treat asymptomatic dogs, Dr. Peterson isn't aware of them. Because we've had so many members with dogs who are asymptomatic but have high alkp, I included a question about that as well: Hopefully his response will set some minds at ease.

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I am not a proponent of treating dogs with asymtomatic Cushing's disease, unless they have secondary hypertension or proteinuria.

Low dose trilostane may be helpful, but I am not aware of any studies that even suggest that, let alone prove that to be the case. With any drug, we have to weight the concerns of side effects.

In general, most dogs with Cushing's syndrome develop a high alkaline phosphatase, with is "induced" to rise because of the cortisol excess. In other words, the fact that this liver (and bone) enzyme is high only means that it is a marker for Cushing's and does not reflect liver damage. So to me, that is not a reason to treat, especially since this value rarely normalizes after successful treatment with trilostane or mitotane.

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Glynda, I'm confused by Dr. Peterson's comment that elevated ALKP is only a "marker" in Cushpups. Just as is the case for Molly, we've repeatedly seen ultrasound reports that note liver enlargement and hyperechoic (fatty) changes in dogs suspected of Cushing's. It seems to me that these represent genuine physical abnormalities resulting from the disease. But not life-threatening, so maybe that is what he means -- that generally there are no serious changes to the liver?

And Sharlene, I am totally stumped right alongside you. I am baffled by Molly's contradictory test results -- especially the conflicting ACTH and LDDS results. In an article discussing interpretation of LDDS results, Dr. Peterson tells us that a "negative" LDDS is very reliable. Only a very small percentage of Cushpups do not return a positive result:

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When interpreting LDDS test results, first evaluate the eight-hour postdexamethasone administration cortisol concentration. If it is above the reference range, the dog probably has hyperadrenocorticism (false positive results may occur in dogs with nonadrenal illness). If it is within the reference range, either the dog does not have hyperadrenocorticism or there is a 5% to 10% chance that the dog has PDH. (The dog may have early pituitary disease and the pituitary gland is still responding to a pharmacologic dose of dexamethasone by decreasing ACTH production, thereby reducing serum cortisol concentrations.) In those cases, an ACTH stimulation test is warranted.

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As you can see, he does suggest moving on to an ACTH for a symptomatic dog who has a negative LDDS, but a positive ACTH would then result from a scenario where the dog is suffering from PDH. So what do we do with the finding that Molly may have only one mildly enlarged adrenal? Is the ultrasound missing enlargement in the other gland, too?

It does seem to me that there are still enough remaining question marks that I would be hesitant to start treating. A trace amount of protein was noted in Molly's urinalysis, but I don't believe that would yet constitute "proteinuria" that would warrant immediate Cushing's treatment with so many questions left unanswered.

Sorry that I am not providing any answers here :o. Like you, I am baffled for the moment...

Marianne

Well include me as stumped. :o

Just to cover all the bases - can you confirm that the ultrasound of the adrenals was done on a high resolution machine and that they were able to view both adrenals?

I ask this because my Annie had 2 false positive ldds tests and a host of false pos. acth tests as a result of an adrenal tumor that was not caught on the first ultrasound we did. Her urine was concentrated as well.

Not sure if this helps but at least you know you aren't alone! Kim

Didnt Dr. Peterson have a case study where he said non adrenal disease can also enlarge the adrenal glands? It was the case study of the young collie. I remember being upset because I wondered if Zoe's colitis flare was responsible for her enlarged adrenals.

Addy, I think it's true that the adrenals can enlarge in the presence of any chronic condition that stimulates excess pumping of cortisol. That's why the symptom profile is so critical when arriving at a Cushing's diagnosis. If Cushing's sympoms are absent and/or symptoms are present that are inconsistent with Cushing's, you'd want to do further investigation.

Marianne

Thanks everyone for answering and posting your thoughts. It's a confusing
situtation that's for sure.

I asked about the High Density ultrasound. They said they didn't know what I meant by that
but that their machine could see everything. They did present sizes in cm for all the organs
so I am assuming they were able to see enough to measure.


I'll post her abnormal ultrasound results (abnormal only) and test histories
again, so noone has to go scrolling through pages to find the
information.

Ultrasound July 2012:

Liver: mildly enlarged, diffusely hyperechoic and margins rounded
gall bladder: moderate amount of echogenic debris present
stomach: moderate gas
left kidney: hyperechoic speckling in the cortex and mild derease in corticomedullary definition
left adrenal gland: mildly enlarged with caudal pole larger than the cranial pole
Urinary bladder wall: mildly thickened at the apex, although lumen is not fully distended.
Mucosa: mildly hyperchoic and irregular and two small calculi present
right kidney: similar in apperearance to the left kidney - small non obstructive calculi present
right adrenal gland: upper reference of size to mildly enlarged
lymph nodes: mildly enlarged

Test Histories:


ALT - 54 (10 - 118) May 2010
ALP - 518 (20 - 150) May 2010

Albumin 46.7 (26 - 44) April 2011
Protein 78 (51 - 72) April 2011
ALT - 110 (6 - 118) April 2011
ALP - 764 (5 - 141) April 2011


Albumin 44.1 (26 - 44) (barely out of range) March 2012
Protein 76 (51 - 72) March 2012
ALT - 139 (6 - 118) March 2012
ALP - 1121 (5 - 141)

ALT - 152 (6 - 118) June 2012
ALP - 1003 (5 - 141) June 2012

Albumin 46.8 (26 - 44) August 2012
Protein 74 (51 - 72)
ALT - 144 (6 - 118) August 2012
ALP - 1054 (5 - 141) August 2012

and finally Urine gravity 1.038 August 2012

this could be because I couldn't get her to drink much that morning
after not eating.
trace protein
small amount blood

I think she might have a UTI and we're still waiting on the results of the
culture/sensitivity test to come back.

So, what could be making her ACTH go up like a cushings dog and her LDDS show
normal dog results. I'm rather worried about something like liver disease, but I
thought I read somewhere that any joint issue could also cause high cortisol results.
Does anyone know if that is true? Not sure it would show high on ACTH though.

Her abnormal values seem to be up and down too.

I'm stumped. The good thing is that Molly doesn't know a thing about this
and is running around the house with a shoe in her mouth, which I need to
go retreive. She won't chew it but she will try to fit her entire
body inside of it. (this does not by the way, work).

Hugs everyone and thanks so much,

Sharlene and Molly Muffin

Hi Sharlene,

Thanks for always checking in on my little Hannah. I appreciate your kind words and encouragement.

I have no advice for you, unfortunately. Hannah has never had an ACTH test, but my IMS does not recommend them unless she is using a drug to treat Cushing's. She doesn't feel that there is enough valuable information.

Hannah has had really high ALKP levels in the past and they dropped dramatically after taking Denamarin. She has been on it for about 6 months now. Her ALT has never been high though. I think that infection can cause liver values to be high, but I don't know if that is just ALKP or also ALT. I know sometimes if a dog has a dental infection and gets it taken care of, the liver values can return to normal. Again, not sure if this is one or both.

I'm sure others will be along to help you out soon though. I love the story about Molly with the shoe. So funny! I love that she tries to get in it. What a little cutie! Sounds like she is quite happy too, and that certainly is most important! :)

Julie & Hannah

Hi Sharlene,

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So, what could be making her ACTH go up like a cushings dog and her LDDS show normal dog results.

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I think she might have a UTI and we're still waiting on the results of the culture/sensitivity test to come back.

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May be the answer. Sometimes infections or other abnormalities can cause a higher than normal Cortisol reading.