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Thread: Flynn 11 y/o Foxie Cross - Right adrenalectomy- Good Bye Flynny We will miss you

  1. #1
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    Default Flynn 11 y/o Foxie Cross - Right adrenalectomy- Good Bye Flynny We will miss you

    Hi – I would like to introduce myself and my beautiful boy Flynn, he is a just turned 11 year old Foxie cross. I rescued him from wandering on a busy road when he was approx 6 mths old. No-one claimed him so he ended up mine and I love him to bits

    Our problems started last November when he suddenly collapsed, he has doggie day care with my parents while I am at work so they rushed him to the vet. He perked up with IV fluids but an ultrasound scan showed a large liver mass. Bloods slowed very elevated liver tests with ALT and ALP off the scale. A biopsy was done which was benign and we rushed him to the specialist vets and he went on and had a 650g mass removed, histology showed a masive low grade hepatocellular cancer which we were upset about as the initial biopsy was negative but his surgeon said this tumour has a very low chance of recurrence. YAY. He hated the pet hospital and cried the whole two days he was there. Of note, a preop CT scan showed two nodules on the other side of his liver. They were biopsied, and are benign. The surgeon said if there had not been benign he would most likely not have operated.

    Prior to this, Flynn had nondescript symptoms that included weight gain we thought because of his ravenous appetite so put him on a diet, less energy, panting when stressed ie if we were eating, lipomas removed a year prior but mainly all back again, pot belly, shaky like a lot of foxies and he has always done this but it is much more pronounced, not so good at jumping, occasional diarrhea. He seems in discomfort, hangs his head when in back of the car and no, its not my driving! He does have a history of arthritis in his hips (from all those years of pogo jumping I think) plus when he was about six he injured his back, just above shoulder area. I am unsure whether this discomfort is due to that or some other cause. Vet did get a positive pain result when stretching his legs back to test. Apart from the diarrhea which has settled these symptoms have not gone away with the surgery.

    He recovered from his operation, but not as good as I thought he would. So we were back to the specialists vet (3 hr drive from us) in January after blood sample showed liver enzymes still elevated, protein in urine, high blood pressure plus all the other symptoms listed above. His vet suspected Cushing’s disease and did the LDDST, which was negative and apparently he suppressed nicely. She asked for cortisol/creatinine urine test to be done once we were home. Which we did but unfortunately the local vet wrote the wrong thing on the form! At this appointment Ultrasound was repeated, the nodules seen previously were rebiopsied and negative again, they mentioned adrenals on the large side of normal.

    We went back last week for further review when we found out the wrong test had been done on his urine.. he had protein/creatinine instead! Blood shows liver tests still high but slightly less than January, still protein in urine. Now we have a new specialist vet, so yet another scan shows only very minimal change in liver nodules but enlarged adrenal glands on both sides. They still think he has cushing’s and they whisked him off for a cortisol/creatinine urine test (via stab into his bladder), BP was high but not surprisingly as he so stressed out being there!!

    So we are still in limbo here… waiting for vet to call me this week with the cortisol/creatinine result, although I am kinda kicking myself for allowing them to do that to him while he was stressed AND did they have to stick him with a needle to get the urine? I have read that he should be calm when he has this test.

    He does have a lot of symptoms of cushings but not the some of the common ones like hair loss and excessive drinking/urination. Sorry I do not have his lab results to type in, I will get copies. But if this cortisol/creat is positive do you think I need to ask for more testing before starting any treatment? Thank you for reading my novel

    Trish and Flynn

  2. #2
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    Default Re: Advice please on appropriate testing

    Hi Trish,

    Welcome to you and Flynn! Sorry for the reasons that brought you here but glad you found us.

    You are correct that the UC:CR (Urinary Cortisol/Creatinine Ratio Test) should be done at home because of this being less stressful on the pet. Any kind of stress or illness can cause elevations in the UC:CR results. Also, any chronic health issue may cause the adrenals to be enlarged.

    A confirmed diagnosis of Cushing's is not only based on test results but also on strong clinical symptoms displayed by one's pet. If Flynn is not showing obvious signs such as excessive water consumption, increased urination, and increased appetite, than I would not pursue any more tests for Cushing's Disease.

    You mentioned that a UPC (Urine Protein-Creatinine Ratio) test was performed, could you post the results from this tests and all abnormalities listed from his senior wellness panel (CBC/Chemistry Blood Panel.)

    Please know we are here to help in any way we can so do not hesitate to ask any and all questions.

    Love and hugs,
    Lori

  3. #3
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    Default Re: Advice please on appropriate testing

    Hello and welcome from me, too!

    I agree with Lori. Even if Flynn does have an elevated UC:CR (either in relation the current sample or on a repeat sample taken at home), I would not move forward with Cushing's treatment based only on that result and the ultrasound. (And yes, you are right that he should NOT have been stressed when that sample was taken!).

    It does sound as though something is causing him discomfort, but it seems as if it could be something other than Cushing's. As Lori says, if you could post any abnormal results from previous blood/urine panels, that will give us a place to begin our detective work.

    I'm so glad you and your sweet boy have joined us!
    Marianne

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    Default Re: Advice please on appropriate testing

    Thanks so much for the replies, I did not hear from the vet today about his results and I certainly have a few questions to ask him when he calls. Working on getting Flynn's results to share with you and will post them soon... hope you and all the pups have a great day!

  5. #5
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    Default Re: Advice please on appropriate testing

    The worst part of dealing with an illness is always waiting for the vet to call.

    Hope everything is ok.

  6. #6
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    Default Re: Advice please on appropriate testing

    Hi all
    Thanks for comments to date: I still have not heard back from specialist... 2 weeks later! Despite emails and phone messages.

    I did visit his local vet today (his cat sister Nala had to be put down) and got some of his latest results.

    These were taken on 9th May.
    Full blood count normal including haemoglobin, rbc, wbc, platelets. only slight deviation is lymphocytes 0.9 (1-4.8)
    Comment from lab - erythrocytes show anisocytosis 1+, polychromatic cells occ, leukocytes morphology appears normal. There appear to be increased numbers of both large and giant platelets but numbers are normal. Lymphopenia suggests stress.

    Other bloods:
    CK 637 IU/l high (74-385)
    AST 65 IU/l high (18-51)
    ALT 357 IU/l high (23-88)
    ALP 683 IU/l high (13-87)
    CHOL 10.9 mmol/l high (13-87)
    creatinine 40 umol/l low (48-109)

    Bil, urea, S.TP, albumin, GLO, AGR, S.Ca, S.po4, amylase, na, K, NAK, S.chl, HAEMO all normal.
    Comment from lab: moderate elevations in ALP, ALT are more pronounced that what they would expect for age-related changes. could be due to liver disease (tumour recurrence ruled out on US and biopsy of two nodules). this can also be seen with endocrine disease and recommend checking glucose (my comment, previous tests had been in high end of normal range) gut disease and with corticosteroid response endogenous and exogenous. Hypercholesterolemia is a fairly non specific change which can be seen in post prandial samples (my comment, he was fasted for this test) with endocrine disorders eg diabetes, cushings and glomerular disease.

    I do not have copy of his January blood tests but these ALP and ALT results are improved since then, so I was heartened to see they had not worsened but still pretty high.

    Protein/creatinine urine test
    U.TPCAL 1.84 g/L
    U.Cre 13521 umol/l
    PRCR 1.21
    Lab comments: recent studies demonstrate that proteinuria is prognostic and the severity of proteinuria significantly correlates with renal survival times (JVIM 2007;21:906-916)
    Staging of renal disease as suggested by International Renal Interest Society for cats and dogs are as follows, with the provisos there should be no evidence of urinary tract inflammation or haemorrhage and that routine measurements of plasma proteins has ruled out any dysproteinemias. Staging should be done on at least 3 urine samples collected over a period of at least 2 weeks.

    Protein:Creatinine substage
    Dogs <0.2 non proteinuric
    0.2-0.5 borderline proteinuric
    >0.5 proteinuric
    I have no idea what that protein test shows!

    Assessment: (this bit was at bottom of same form... I think blood pressure?!)
    SAP 145 178 163 142 152
    MAP 110 121 112 107 101
    DIA 91 90 84 81 74



    His other tests:
    Dexamethose supppresion test was negative for cushings... apparently he suppressed nicely. ( I do not have actual result here)

    Costisol/Creat has been done but I have no result yet.

    Ultrasound ; 2 liver nodules that vet told me are common in older dogs - they have been biopsided twice and not a recurrence of his liver tumour as mentioned in above post. Bilateral enlarged adrenals.

    So that is where we are with Flynn, he is good mostly. Active, daily walks which he loves. I still think he has some minor discomfort better with small dose of previcox daily, hangs his head in car, panting has mostly settled though still does this if stressed, hunger remains, weight gain settling with diet, does have pot belly, itchy knees.. he is always nibbling at them and recent balanitis. But he is not drinking excessively, not peeing excessively and no fur thinning.

    If anyone has any ideas I would love to hear them!

    Thanks
    Trish
    Last edited by Trish; 06-01-2012 at 07:24 AM.

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    Default Re: Advice please on appropriate testing

    I have just been reading the other posts, one about leg trembling struck me. Flynn has always been a bit of a twitchy dog, but since his surgery I have really noticed his back legs both tremble much, much more. Even if he is standing still, sometimes at rest too.
    Last edited by Trish; 06-01-2012 at 06:34 AM.

  8. #8
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    Default Re: Advice please on appropriate testing

    Hi Trish,

    I can't imagine why the specialist has not gotten back with you after two weeks of inquiries! That is really inexcusable!

    It is especially a shame because Flynn's situation does seem complex and confusing. I'm sure I'm not telling you anything that you don't already know, but aspects of his symptom profile are hard to "put together." Normally, you wouldn't expect the liver enzymes for a Cushpup to decrease without treatment. And there are certainly question marks about the evidence that he is leaking protein into his urine. I think protein in the urine can be due to primary kidney damage of some sort, or it can also be secondary to the effects of another condition including Cushing's. I know very little about the actual protocol for the renal testing that was done, but from the lab report it looks as though a series of urine samples are required to really validate the test results. So maybe some additional kidney evaluation is called for. Because even though it is an unsettled research question right now, some researchers think that excessive protein in the urine is not only an indicator of renal issues, it can also cause renal problems to worsen. Therefore, medication is recommended in some cases to try to decrease the amount of protein spillage. But I think Flynn would need more evaluation in that regard. And if it turns out that he does have Cushing's and any kidney involvement is secondary to the Cushing's, then the kidney issues may automatically be better controlled once he is treated for the high cortisol.

    It sounds as though the low dose dex test was performed back in January -- is that true? If so, and if the current UC:CR comes back consistent with the possibility of Cushing's (even though it was drawn by needle at the vet's ), I'm wondering about a repeat of the LDDS now that it is almost six months later. As Cushing's advances, those diagnostic test results can change over time and a "negative" can shift to a "positive." But the trade-off is that other, nonadrenal conditions can falsely skew the test results, too. So if Flynn does have some other issue flaring, that could give you a "false positive" on the LDDS.

    For all these reasons, I agree that you really need the input of a specialist to sort out the next step in terms of diagnostics. And if this current specialist continues to be this unresponsive to your needs, perhaps you need to try to shift to somebody else...

    Marianne

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    Default Re: Advice please on appropriate testing

    Hi Marianne
    Thank you for your reply

    Yes, his LDDS was done in January. I am going to get onto the phone again next week and stay there till I get to speak to the specialist It is so annoying, the surgeon who removed the liver tumour back in November was so good at calling me whenever results came through it is disappointing to have this trouble now. The specialist he saw is new to the country having come from California and his credentials are in the field of oncology so I think I will have to ask if there is another specialist we can see.

    I agree, getting to the bottom of his problems is going to require more testing but I just have to make sure they do the correct ones! I will post any updates and thanks again for the input.

    Trish

  10. #10
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    Default Re: Advice please on appropriate testing

    Hi all
    Just an update on Flynn, after 4 ultrasounds and a CT prior to his liver surgery last November he has been back to the specialists this week for his routine checkup. His latest ultrasound yesterday has shown a probable tumour in his adrenal gland. Most likely a pheochromocytoma, also looks like some clot into his vena cava and an enlarged lymph node. This would explain his hypertension and they have noted changes in his eyes and also proteinuria so he started on BP medication yesterday. One nodule in his liver that has been biopsied prior to his surgery and once after and has been benign both times has grown a little so that has been biopsied again and also the lymph node. I am waiting for them to call me with results. In himself he is pretty good, still very trembly in his back legs but no excessive drinking or urinating, boy is he hungry though. I have noticed increased panting. Thanks for your advice previously.
    Trish

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