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