Yohnny 11 year old Shih-tzu with Cushing-like problems

Dear group,

Am so happy to have found you. I need some help. I am still healing and getting back on my feet after losing my other dog to heart failure and other health issues and now faced with another health problem with his brother Yohnny. It is a little overwhelming so am looking for support and guidance.

My boy Yohnny has high cortisol but the LDDS test did not show Cushings. Vet says he is a mystery and she does not know what to do other than do the LDDS test again. He has enormous apitite, thin fur, and now recently it seems his breathing has changed.

He has symptoms that made my vet think he may have cushings - enourmous appetite, thin fur, pot belly. Did LDDS test but came back negative. So he does not have cushings my vet says.
She has also done abdominal ultrasound and all looked normal.

About the same time this happened he also also was diagnosed with a tumor in his testicle ( he has had Cryptorchidism all his life) so they removed both his testicles - no metstases.

He is obsessed about food and when we go out all he wants to do is eat poop. I have him onleash and have to walk right next to him to stop him from eating dog poop. I miss it somethimes bcs he knows I don't like it so he is sneaky. which means I have to de-worm him often. bc god knows what is in the tummy of his.

I have hear stresss can cause high kortisol. I know I was super stressed during my other dogs ickness and death, do you guys think he is stressed? He does not act strees, but he is a low key dog so it is hard to say.

He also has athritis. Has take caartegen shots but other than that he is fine. I just find him not so happy and more reserved.

Sorry if this post is all over the place. I do have results from tests but cannot find a way to post them.

Hello, and welcome to you and little Yohnny. First of all, I’m so sorry about your loss of Yohnny’s brother. It seems terribly unfair that you are faced with all of this new worry at a time when your heart is already hurting so badly. But we’ll do our best to offer our thoughts and suggestions in our effort to help.

As far as posting lab results, the easiest thing for you to do is just go ahead and type any abnormal results directly in a reply here. We only need to see results that are too high or too low, along with the normal reference range for that particular value. It’ll also help if you’ll type in the three cortisol values that made up the LDDS test.

When you say that Yohnny’s cortisol level is high, I’m guessing that his resting, or baseline, cortisol level was high on his LDDS. That would be the first of the three values. However, you’re correct that a high baseline cortisol level cannot be used alone to diagnose Cushing’s. Just the stress of being at the vet and being tested can raise that value, for instance. And yes, while Yohnny may have been reacting to your own stress during his brother’s illness, I don’t think that type of transitory stress would produce all the ongoing symptoms you are describing.

I have a couple of suggestions to offer to you. If you live outside of North America, though, I’m not sure whether or not the first suggestion is possible for you. It would be to conduct an alternative diagnostic blood test: an ACTH stimulation test. We understand that the injectable substance needed to conduct this test can be difficult to obtain in other parts of the world right now. But this is why I’m making the suggestion. Here’s an excerpt from an article about interpretation of the LDDS written by a noted American endocrinologist, Dr. David Bruyette:

Quote:

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When interpreting LDDS test results, first evaluate the eight-hour post-dexamethasone 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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So if Yohnny is in the early stages of Cushing’s, there’s a small possibility that the LDDS is simply not yet registering the disease. Another possibility is that Yohnny may be suffering from the effects of elevations in adrenal/sex hormones other than cortisol. I wouldn’t know whether or not his testicular tumor might play into this or not. However, there has been much conjecture in recent years about the presence and significance of other elevated adrenal hormones. The name that’s been given to this situation is “Atypical Cushing’s.” Many questions remain and more research is needed. The vet school at the University of Tennessee at Knoxville has taken the lead in related research here in the U.S., and they will process blood samples submitted from elsewhere. However, again, the testing agent that’s required is the one that’s used in the ACTH stimulation test. For your information, though, here’s a thread on our Resources forum that discusses “Atypical Cushing’s.”

https://www.k9cushings.com/forum/sho...Hyperestrinism

Given Yohnny’s very puzzling situation, one last suggestion I can offer is to talk with your own vet about the possibility of consulting directly with Dr. Bruyette about any other diagnostic options. Your vet may have other specialists with whom he/she can talk, but Dr. Bruyette has a worldwide reputation re: his Cushing’s expertise, and has now established a consulting service whereby he will review case studies submitted by other vets at a reasonable cost. Here’s the homepage for his consulting service:

https://www.veterinarydiagnosticinvestigation.com/

So in closing, it’ll help us if you can first tell us more about any specific abnormal lab results. And in the meantime, once again, welcome!

Marianne

Dear Marianne,

Thank you so much for your swift reply, your understanding and help and the warm welcome. It means a lot to me as I am feeling overwhelmed and sad.

Here are Yohnny's abnormal lab results:

Chemistry 11.102019
Creatinine 38 (44-159)
ALT 149 (10-125)
ALP 608 (23-212)

Urine 16.10.2019
Cortisol/Creatinine ratio 155.2 (<33)

Serum/urine 04.12.2019
Alkaline phosphatase 591 (14-147)
Cortisol/Creatine ratio 117.5 (<33)


LDDS test 13.11.2019
before admin 88.0
2nd sample 11.5
3rd sample 22.4
(24.8-124.2)
“Did not indicate hyperadrenocorticism”



—When you say that Yohnny’s cortisol level is high, I’m guessing that his resting, or baseline, cortisol level was high on his LDDS. That would be the first of the three values.

No they were not. As you can see 88.9.

Thank you for your suggestion to do ACTH test. Live in Sweden so I think this is possible here. I find it strange that my vet has not suggested this. Could there be a reason for this? She says that Yohnny is a mystery and the only thing she has suggested is another LDDS test in a month or two.

Thanks for the info on “Atypical Cushing’s.” and the tip about talking to my vet about the possibility of consulting directly with Dr. Bruyette. I will certainly talk to her about it.

Are there any other tests I should be asking for? Urinalysis? Super Chem Blood Test? What about the Ultrasound of adrenal glands?

In conjunction with removing his testicles the vet did do an abdominal ultrasound and said there was nothing irregular.

Thank you for any input you have or guidance.

with appreciation.
Amanda

Welcome from me too, Amanda. We suspected that my boy Gable had Cushing's for years, but the LDDS test did not confirm it. We got the diagnosis finally after the ACTH test.

Thank you Joan. And thank you for sharing your experience.
So is the ACTH test done for all the different kinds of Cushings?

Hi Amanda!

Welcome to you and Yhonny!

Yes the ACTH is used to test for Cushing's, both the pituitary based and the adrenal based forms. However, I would pursue the test for Atypical that Marinanne mentioned instead of the simple ACTH if it is available to you there.

I'm glad you found us and look forward to learning more as time passes!
Hugs,
Leslie

Hi Leslie and thanks for response and suggestion. Can I ask why you would do the test for Atypical? When talking with my vet I am going to need to explain why I am asking for this. Also, are there any other tests I should be asking for? Urinalysis? Super Chem Blood Test? What about the Ultrasound of adrenal glands? Thanks. Amanda

Hi Jayessi and a belated welcome to the group. I don't have much to add to the great information you've already received but wanted to ask about the urine cortisol creatinine ratio (UC:CR) and make a few comments. The ratio for both tests are quite high so I am wondering if you collected the urine specimen at home or whether your vet collected it? The reason for asking is that whenever I see a ratio that high, it's usually because the urine was not collected at home under relaxed conditions. If collected by the vet whether by free catch or cystocentesis, a high ratio is to be expected as even the stress of an office visit can cause a significant increase in circulating cortisol. If you did not collect the urine, the test result would be invalid and your vet should kindly refund or credit your account. I agree that if your dog has cushing's, the negative LDDS is likely because the disease had not progressed enough to break the communication between the pituitary and adrenal glands. An acth stimulation test is usually the next the step. However, it appears that it's been several months since the last LDDS so if the stimulating agent for the acth stimulation test is not available in Sweden, a repeat LDDS test could be done at any time. As far as testing for atypical cushing's, I am the odd person out and don't recommend spending the money on that. The reason is because the treatment for atypical cushing's is melatonin and lignans which is available over the counter in the US and can be given as a trial without an atypical diagnosis. These supplements may be available over the counter in Sweden and if so, you could actually try that regimen without incurring the cost of testing. Just be aware that if melatonin and lignans is effective, it can take several weeks to a few months to see any improvement. If no improvement in 4 months, chances are they aren't going to work. I know that what you are experiencing is frustrating and costly but it is not an uncommon experience. Many members have gone through the same thing.

Hi again, Amanda. I’m going to jump back in and give you a quote from an article published by a researcher at University of Tennessee at Knoxville that perhaps best answers your question about testing for “Atypical Cushing’s.” As you’ll see, Dr. Oliver is describing dogs who exhibit Cushing’s-like symptoms and also elevated cortisol on urine creatinine: cortisol tests, but who test negative for elevated cortisol on the LDDS and ACTH stimulation test for cortisol alone.

Quote:

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HYPERESTRINISM IN DOGS
Jack W. Oliver, D.V.M., Ph.D.
Director, Clinical Endocrinology Service
The University of Tennessee

The Clinical Endocrinology Service at the University of Tennessee utilizes steroid hormone profiling in the diagnosis of adrenal disease. Many of the cases received have had preliminary diagnostic workups with either ACTH stimulation or low dose dexamethasone suppression testing that has been negative, but signs of Cushing's disease persist. Many of these atypical Cushing's-like cases will have abnormal levels of adrenal intermediate steroids and sex hormones. Included in the atypical cases are a considerable number of dogs that have hyperestrinism (elevated estradiol levels), with and without increased levels of other steroids. The dogs with hyperestrinism typically present with some or all of the following clinical signs: “Cushingoid” appearance, presence of chronically elevated levels (usually extremely elevated) of serum alkaline phosphatase, hepatomegaly, steroid hepatopathy on biopsy, PU/PD, dilute urine, panting, haircoat problems and skin biopsies that indicate presence of an endocrinopathy. The talk will focus on case presentations that associate clinical signs presented by dogs with primary hyperestrinism (elevated serum estradiol levels), including the association of high estradiol with increased alkaline phosphatase, and the fact that sex steroids can cause elevated cortisol/creatinine ratios. Treatment concerns will be addressed, such as mitotane and trilostane resistance. Other potential treatments for hyperestrinism will be discussed.

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Unfortunately, Dr. Oliver passed away a few years ago. But other researchers at Univ. of Tennessee are still carrying on related research.

https://vetmed.tennessee.edu/vmc/dls...s/default.aspx

Also, there’s a lot of other helpful information, on this thread:

https://www.k9cushings.com/forum/sho...Hyperestrinism

As far as other additional testing for Yohnny, you’ve mentioned that an abdominal ultrasound has already been done? If so, we’d hope that the adrenal glands were seen on that scan. Sometimes during the early stages of Cushing’s, the glands may still look normal, though. As far as other testing, a urinalysis can be very helpful — Cushing’s dogs typically exhibit very dilute urine with low specific gravity.

Marianne

I see that Glynda and I were typing at the same time, and I just wanted to add this note. She’s absolutely right that there are still a lot of question marks about the meaningfulness of an “Atypical Cushing’s” diagnosis, and the added expense of the more involved blood test may not be worth it for many people. The added problem for you is that a blood sample would have to be shipped to the U.S., if that’s even possible. However, given Yohnny’s puzzling situation, I just wanted you to know about the research that’s been done thus far.

If your vet can indeed get the necessary ACTH stimulating agent, then a basic test of Yohnny’s cortisol response probably remains your best bet. If not, a repeat LDDS may be the next best option.

I hope I haven’t confused you with all this extra information. Please feel free to ask any more questions that we may have brought to your mind!

Marianne

Hi Lulusmom and thank you so much for taking the time to write.

Regarding the urine cortisol creatinine ratio (UC:CR). I collected them myself at home on our regular morning walk. I am pretty sure he was not stressed.

I am seeing vet next week so trying to get info and come prepared when I talk to her.

Basically why it has been several months is that the vet does not really understand what is wrong with Yohnny. Because I read a little about the LDDS test Iand saw it is not 100% test I asked her about this. But she said no if he has cushings it should show on the test. She has not discussed ACTH test or any other test with me. So I am wondering if I should look for another vet?

I will consider everyone's input so I am glad you are giving yours about testing for atypical cushing's, even though others don't agree. At this point I am gathering as much info as I can.

Again, thank you.

Thank you so much Marianne for this info. and follow up of my question. I am going to have to read it a few times as it is hard to wrap my brain around all those fancy words but it is something I can also show my vet. Will read the links too.

Yes, he did an abdominal ultrasound in conjunction with removing his testicles. But I am not sure if she actually looked at the adrenal glands because she has not written anything about it in the report. She may have said it to m but I do not remember. I will ask her. This is what she wrote in her US report (it as my translation of swedish so please excuse me if it does not make sense)

bladder moderately filled aneloic urine normal wall, spleen homogeneous parenchyma normal ecogenicity, kidney approximately 4.2 cm normal bark/marrow, ventricle empty normal wall, liver overview: homogeneous parenchyma normal echogenicity, gallbladder thin-walled anechoic bile, right kidney same as left, small intestine normal motility sparing filling. Summary no deviating findings

I am definitely going to ask for a urinalysis.

THANK YOU!!!

Noted Marianne. I really want to do all that is possible for my boy. Even though we are still reeling from nine months of serious vet bills during the his bother's illness.
I think I am going to try and sum up all the suggestions in a post in this thread that I will be talking to with the vet and would be really grateful if you can have a peek at it so that I hve understood correctly.
with deep gratitude. /amanda

I have one more though that I cannot understand. The vet said she had talked with experts at the Swedish veterinary university and also with IDEXX who do the LDDS test.
She said sshe thinks there is "no correlation between urine creatinine and blood creatine".

She noted that in the blood test they took for the LDDS test the cortisol was in normal range 88.9 (24.8-124.2) while in the two urine tests it was very high 115 and 117.5 (<33)

What could that mean?

I think it’s good that your vet has already consulted with specialists at the university as well as IDEXX. That shows that she’s both interested and willing to learn more about what may be going on with Yohnny. I’m not exactly sure as to why his urine cortisol test was high but his blood cortisol test was normal. However, we do know that they are measuring cortisol levels in two different ways, and the LDDS is the test that is more specific for Cushing’s. The LDDS is the test that is generally considered to be the best choice for testing for Cushing’s here in the U.S., too, even where the ACTH stimulation test is available. This is because the LDDS is less likely to miss diagnosing Cushing’s in dogs who truly have the disease (fewer “false negatives”). There are a few situations, though, when a Cushing’s dog will test negative on the LDDS but positive on the ACTH. That’s why, if you have the option to do an ACTH, it would be a good idea. However, if your vet has already talked with the vet school and IDEXX and the ACTH has not been mentioned to you, my guess is that there is difficulty in performing that test there in Sweden. IDEXX does provide analysis for the ACTH here in the U.S. So I’m assuming it would have been discussed with your vet if it’s also available in Sweden. But you’ll find out by asking your vet.

As far as the ultrasound, the adrenal glands can be hard to see clearly unless very high powered equipment is used. Many general practice vets here in the U.S. don’t have equipment that’s powerful enough, so referral has to be made to a specialist’s office. That may also be the case with your vet — she couldn’t see Yohnny’s adrenal glands very clearly on the earlier ultrasound. So that will be another thing to ask about: whether or not another ultrasound performed at another location might be helpful.

All in all, it sounds as though what your vet has done so far has been reasonable. The question will just be whether or not there are any additional tests available to you that might be helpful.

Marianne

Thank you Marianne. This is very helpful. Thing are getting clearer :)

/Amanda & Yohnny

Hi!

I was recommended to read up on this thread that discusses “Atypical Cushing’s.”

https://www.k9cushings.com/forum/sho...Hyperestrinism

But could not open any of the links in the first post of that thread.

Is it just me or are they not working anymore?

Thank you!

The links open for me. You might want to check your settings in your browser. Check the box allowing links/pop ups from websites visited and see if that helps.

I think I see what you mean — the links now all connect to the same homepage of the U of Tennessee veterinary school instead of to the individual articles that are listed :-(((((.

I’ll check on this today and try to reset those links as soon as possible!

Marianne

OK, I’ve now updated all the links in the first post in that thread. I suspect links in other replies on that thread will need updating, too. I’ll work on that later today. But at least the first post should now be OK!

Thank you! It is working now :)

Here are results of Yohhny's bloodtest and urinalysis. Vet has decided to hand us over to the internal specialist at vet hospital and do abdomnial ultrasound there. Posting abnormal results below.

Any input much appreciated.

BLOOD CHEM

Creatinine 29 (44-133)
ALT (GBT) 152 (25-122)
Alkaline phosphatase 1092 (14-147)
GLDH 27 (1.18)
Cholesterol 12.6 (3.6-10.3)
Fructosamine 157 (177-314)
Thrombocytes 659 (143-448)
Eosinophils (absolute) 40 (70-1490)

URINALYSIS

Color dark yello
Clarity clear
Specific gravity 1.024
Ph 7.0
Urine protien 3+
Glucose neg
Ketones neg
Blood neg
Bilirubin 1+
Urobilinogen norm
Leukocyte neg
White Blood Cells <1/HPF
Red blood cells <1/HPF
Bacteria cocci none
Bacteria rods none
Squamous epit cells <1/HPF
Non-squamos eit cells <1/HPF

I’m very relieved to hear that Yohnny will now be evaluated by an internal medicine specialist, with a repeat ultrasound at the hospital. I am not a vet myself, so I am only guessing when I look at all his lab results. But I do wonder whether or not there might be a primary liver problem that is at the root of his symptoms. The elevations across all the liver markers, the low creatinine and fructosamine, and the bilirubin in the urine all suggest to me that there may be more abnormality in his liver function than you’d expect to see in Cushing’s. But once again, I’m far from an expert, and it will be very helpful to have a specialist’s opinion regarding the best diagnostic path forward.

Whatever you find out, please let us know. You and Yohnny are now part of our family, so we’ll be right beside you here to learn more, and to offer our support!

Marianne

Marianne posted while I was comparing labwork previously posted and I have to agree with what she said....my concern would be something going on with the liver. So I too am glad Yhonny is seeing an IMS and hope they will have a definitive answer plus viable solution to help your sweet boy start to feel more like himself. Please keep us updated on what you learn and how he is doing.

Hugs,
Leslie

PS...ditto to ya'll being part of the family now regardless!

Thank you Marianne. I am hoping to get some more answers soon and it is comforting to know a family here.

Dear Leslie. Thank you. I also hope this step will help us with our boy. I really appreciate your support. Hugs back. Amanda

Marianne. Quick question. I got an appointment with IMS but not until March 30. Should I be ok waiting until then? Just worried that whatever problems he has might get worse...

I do wish I could give you an accurate answer, but I cannot since I don’t really know what’s wrong. I know how frustrating it is to have to wait to see either a vet or a human doctor, for that matter! But I hope that in Yohnny’s case, the wait will be worth it. Are you seeing any outward changes right now, either for better or for worse? If he’s remaining pretty much stable, I’d hope that means that the wait will not be adding to his problems.

Marianne

Thank Marianne. I realize I was asking a question that is impossible for you to answer just based on the test results. I have not seen any changes so am just trying to breath and hope that I actually can go to the vet on the 30th now with pandemic situation. I hope you and yours are safe and ok. It is a hard situation.

Dear friends. Hope you and your pups are holding up during these difficult times.

After many months of not knowing what is wrong with him we get to see and internal medicine specialist tomorrow at one of Swedens largest vet hospitals.

Yohnny has suspected Cushings, although it is not diagnosed. He has done the LDDS-test but it was negative.

He has not done ACTH-test or abdominal ultrasound so that will be two things I will be asking vet about.

Is there anything else I should be asking about? I have a golden opportunity and don’t want to miss anything.

It has been suggested here that he might have underlying liver issues (Thanks Marianee and Leslie)

Thank you any other last minute input you have, and prayers. Hugs to you all and your pups.

Abnormal bloodtest results are:

Creatinine 29 (44-133)
ALT (GBT) 152 (25-122)
Alkaline phosphate 1092 (14-147)
GLDH 27 (1-18)
Cholesterol 12.6 (3.6-10.3)
Fructosamine 157 (177-314)
Thromocytes 659 (143-448)
Eosinophils 40 (70-1490)

Urinalysis:

Color dark yellow
Clarity clear
Specific gravity 1.024
Ph 7.0
Urine protien 3+
Glucose neg
Ketones neg
Blood neg
Bilirubin 1+
Urobilinogen norm
Leukocyte neg
White Blood Cells <1/HPF
Red blood cells <1/HPF
Bacteria cocci none
Bacteria rods none
Squamous epit cells <1/HPF
Non-squamos eit cells <1/HPF

I’m so relieved you’ll be seeing the specialist tomorrow!! I really don’t have any more suggestions to add, but I surely do wish you good luck with the appointment. Please stay very safe, yourselves, and we’ll be so anxious to hear what the specialist has to say.

Best wishes for finally getting some answers!
Marianne

Thank you, Marianne. I was originally scheduled for March 30 but the hospital called and wanted to re-schedule me to April 24th! Because of pandemic they had to only focus on emergency cases. I was devastated to have to wait another month after waiting so long already. I took a chance and called the other hospital we have and they booked me in tomorrow! I guess they are handle in things better? Anyway, I am just so relieved I got in. Thank you for your well-wishes. Will let you know when I have more info. /Amanda

Saw vet yesterday. No diagnosis yet. Vet sent a thyroid test along with new blood and urine tests. Ultrasound showed that both adrenal glands where enlarged (the left one slightly more) and that liver also was enlarged and had structural changed (reactive). Once vet has results next week we will no more. Now all I do is try and stay calm and enjoy my boy every chance I get.

Thanks so much for this interim report. Bilaterally enlarged adrenal glands and an enlarged liver can all be caused by Cushing’s, so perhaps we’re headed more directly down that road. We shall see!

Here is update on Yohnny:

(let me know if anything is unclear am translating swedish vet terms to english)

He has high liver values and proteinuria. Thyroids tests done came back negative.

Proteinuria show leakage in kidneys. Vet gave us Fortekor (hypertension medicine) which he started to take 2,5 mg per day today april 3.

He will go back in for his second LDDS test in two weeks as cushings is strongly suspected. They will also do a hypertension check-up and a Cystocentesis for protein/crea quote.

At this point they are trying to find out if he has atypical Cushings or Cushings that is in early stages.

Vet also mentioned some kind of hormon test (on hte blood) they could do - but we will wait to see what the result of the LDDS test is.

I asked vet if the proteinurea and kidney issues and the suspected cushings are part of the same problem or different issues - she said they where most probably seperate issues. But I have read that proteinurea and hypertension is commin in cushngs dogs. Isn't it?

Abnormal test results

Blood

Trombocyter-Sys 677 x10*9/l 148 - 484
ALP-Profil 16,6 ukat/l < 1,4
ALAT-Profil 2,3 ukat/l < 1,2
Cholesterol 13,1 mmol/l 3 - 10,3

Urine
U-Densitet-Profil 1,025 > 1,03 ulli
U-Volym 4 ml 5 10 ulli
U-Färg gul ulli
U-Protein 3 0 - 0
U-Protein/krea kvot 1,4 < 0,5

Ultra sound
Liver sightly enlarged with slightly rounded edges. Both adrenal glands moderatly (close to substantially) enlarged bilateral with normal echogenicity and no vascular invasion so suspect central hyperadrenocorticism, or possibly inflammation rather than other neoplasm.

Any thoughts or input much appreciated. Thank you.

Quote:

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Originally Posted by Jayessi

He will go back in for his second LDDS test in two weeks as cushings is strongly suspected. They will also do a hypertension check-up and a Cystocentesis for protein/crea quote.

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I strongly recommend that only the LDDS test be done at that time because this test is sensitive to stress, if those other procedures are performed this could add more anxiety to Yohnny which would make his cortisol rise and could make the LDDS yield a false positive. Is it possible for other things to be done at a another time?

Hugs, Lori

Hi Lori. That is a good point you make. Thank you. I will talk to vet about this. Your input is much apprieciated. /Amanda

Lori. Would you recommend I just go in with him for the LDDS tests and then take him home in between? That is what I did the first time (we have taken LDDS test one but it was negative) but now I took the option of leaving him there as they were going to do the other things too.

Quote:

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Originally Posted by Jayessi

Lori. Would you recommend I just go in with him for the LDDS tests and then take him home in between?

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Since you took him home between draws the first time the test was given I would definitely do that again.

Thank you Lori. /Amanda