Buddy, The Mighty Lizard Hunter - Suspected Pituitary Macro Tumor

[Budsters Mom]

Buddy, My 10-year-old large Yorkie has recently been diagnosed with Pituitary dependent Cushing's. After $1600 in tests and vet bills, this Diagnosis was confirmed. His illness came on very suddenly, although he's probably had Cushings for several years, Although I didn't know it. A few weeks ago he had a restless night and then woke up vomiting the next day. He also was so weak he was practically unable to stand. His back legs were wobbly and would not hold him up. After taking him to the vet and having numerous tests including blood work and x-rays, we were referred to the emergency hospital for a ultrasound. His liver was so large that they thought he had a tumor. It was difficult to see his other organs. Buddy was stabilized and set home. He was able to eat a meal normally in the hospital and kept it down. Cushing's was suspected by both hospitals. We left with the referral to specialty hospital for a neurology consultation. Due to the extreme weakness in his hind limbs, a consultation was needed to see if Buddy was even a candidate for Cushings treatment. In the meantime Buddy became Stronger and was able to move easier, but still very wobbly. The neurologist gave Buddy clearance to go ahead and have Cushing's testing. He was given the low dose eight hour test a few days later at his regular vet. That is when pituitary dependent Cushing's was confirmed. Five days ago trilostane treatment was started. Buddy weighs 16 pounds and is on 20 mg once per day. He is not fat, just a large Yorky. He has been having many stomach upsets since treatment started. He has had a gassy, sour stomach but hasn't vomited and has eaten normally. Right now it's 4:24 AM and he's been up with an upset stomach all night And hasn't been able to settle. I'm going to call the vet in the morning. Have any of you tried giving your Cushing dogs Pepto-Bismol? Do your dogs get upset stomachs with trilostane? Does it eventually go away once they adjust to the medication? I have to take Buddy back for another blood test to check his levels 7 to 10 days after starting the medication. Can anybody give me any help or insight in the meantime? It would greatly be appreciated. Thank you.

[Squirt's Mom]

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[Squirt's Mom]

Hi Mom and welcome to you and Buddy!

Something many of us use to help with tummy upsets is Pepcid AC - be sure it is the AC form only - not time released, fast acting, etc, just plain Pepcid AC. Tagamet is another one used. Generic Pepcid AC is Famotidine; generic Tagamet is Cimetidine. Most stores have their own brands under the generic names that will save a few pennies. Do call your vet tho and let them know how the Trilostane (Vetoryl) is affecting sweet Buddy.

If you don't have them, get copies of the actual tests results so far and post them here in Buddy's thread. That will help us, help you.

We are a Lysodren (MItotane) house so I will let our Trilo parents talk to you about that. But I will tell you that any time the diagnostic tests for Cushing's are given while another illness is present, it makes the diagnosis suspect because so many things can cause the tests to give false-positives and share the same signs as Cushing's. Also, Cushing's does not come on suddenly....it is a very slowly progressing condition. So seeing all those tests done before starting treatment will be beneficial. Also, the more detail you can tell us about Buddy the better. We LOVE details! See all the questions that follow?

Is he having any issues with his vision?

Is he neutered?

Does he have any other health issues that you are aware of?

Is he on any other meds, supplements, herbs, etc? If so, what?

How is his appetite?

Any loose stools or diarrhea since starting the Trilo?

What signs were you seeing before the diagnosis and have they lessened, gotten stronger or are they about the same since starting treatment?

Here is a link to our Helpful Resources section that will give you a lot of info on Trilostane (Vetoryl) - http://www.k9cushings.com/forum/showthread.php?t=185

I'm glad you found us and want you to know it is always safe to cry, or talk, share your fears and hopes, even scream here. You and Buddy have a new family now and we will be with you every step of the way. Keep your chin up and keep reading and talking to us. I'm very glad you and Buddy are here!

Hugs,
Leslie and the gang

[addy]

His illness came on very suddenly, although he's probably had Cushings for several years, Although I didn't know it. A few weeks ago he had a restless night and then woke up vomiting the next day. He also was so weak he was practically unable to stand. His back legs were wobbly and would not hold him up. After taking him to the vet and having numerous tests including blood work and x-rays, we were referred to the emergency hospital for a ultrasound. His liver was so large that they thought he had a tumor. It was difficult to see his other organs.

Hi and Welcome,

Yes, Trilostane/Vetoryl can cause an upset stomachFDA report of a study when first approving the drug"

[QUOTE]Adverse Reactions: Adverse reactions are reported here using the entire enrolled population of 75 dogs. Five dogs were withdrawn because of adverse reactions including lethargy, anorexia/inappetence, not drinking, vomiting, diarrhea, and muscle tremors.

The most common adverse reactions were vomiting (17.3 %), lethargy (17.3%), diarrhea/loose stools (14.7%), and anorexia (6.7%). Other adverse reactions were: nocturia, upset stomach, corneal ulcer, cough, persistent estrus, vaginal discharge and vulvar swelling in a spayed female, hypoadrenocorticism, electrolyte imbalance (elevated potassium with or without decreased sodium), collapse and seizure, shaking, constipation, scratching, weight gain, and weight loss.

Conclusions: Trilostane was effective in lowering post-ACTH stimulation cortisol levels and improving clinical signs in dogs with pituitary- and adrenal-dependent hyperadrenocorticism. The most comment adverse reactions were vomiting, lethargy, diarrhea, and anorexia.

But I am concerned. I know it is hard to write down everything and/or remember but could you round up copies of any blood work done and post abnormal findings? Cushings does not come on suddenly and should not he used in dogs with primary liver disease. Are the vets saying Cushings is the cause of the enlarged liver? Did the neurologist say the leg problems are soley due to muscle wasting from Cushings? It just feels like a part of the puzzle is missing.

Glad you found us

[Simba's Mom]

Hi and welcome to you and Buddy, take some deep breaths, we are here for you..Those tummy issues can be hard to deal with, the cush parents here have some great ideas..My Simba has tummy issues too, I feed him more small meals then 2 bigger ones, seems to help with him...also when he has flare ups, I make an egg for him, seems to settle things down...He eats turkey foods, seems to be better for him...its sometimes a guessing game to see what works for our cush pups, just keeping asking and you will get lots of info from this site, and a hand to hold along the way! Sending hugs!

[Budsters Mom]

I have been trying to post an update to answer some of the questions that were asked of me and post test information. I am new to this site as of early this morning. I checked my email like I was supposed to and connected to login properly. My post still is not showing up. I am obviously doing something wrong. Please bear with me if it ends up being posted a couple of times. As I'm going to try to do it again. Thank you for understanding.


Hello again. My name is Kathy. Thank you for being willing to help us and for your outpouring of love and support. Before Buddy was diagnosed with Cushings, I had never heard of it before. This is my very first forum I found you out of desperation. But he is not only the light of my life, he is also my best friend. The thought of not being able to help him weighs heavily on my mind and heart. You asked for details, so here goes!

First, I'd like to answer some of your questions. Buddy is neutered he was neutered at six months. He has always had many allergies. They have shown in various skin issues ,allergies to food and environmental sneezing, runnynose and wheezing allergies. They have practically been nonexistent the last couple of years. They returned in full force after starting Trilo. Could this be due to a drop in his cortisol levels? Other then these issues, he has been basically healthy. His allergies have been controlled by an occasional dose of Benadryl.

About a year ago I noticed that he was slowing down. He was no longer able to jump up on the cedar chest to see out. I made an ADA approved ramp For him to use instead. He needs to be able to get to the window for his job, which is guard duty. He takes it very seriously. Lizard hunting is another important job. About six months ago but he started having trouble getting up the ramp. One he made it up there, he would have a hard time getting down and would freeze. He would stay there until someone came to help him down. I finally had to end up taking down the ramp. Right around that same time I noticed that but he could no longer get through his doggie door Or go up one small step to get back into the house. His beautiful hair started thinning about a year ago. I wasn't overly concerned because he always had so much of it. It now takes a long time for his hair to grow back in after grooming and I have to be very careful when I groom him. The doctor said that Buddy skin was thin? That was something that I hadn't noticed. Although he was showing mobility issues, I Thought these concerns were due to normal aging. Buddy up until becoming really ill, was always happy an active, happy, little guy. He started drinking more water the last few years. In fact, lots of it. He would drain most of a bowl and then Be drinking again a few minutes later. When he urinates, It's as if a dam has burst. I don't know where he puts it all! So far, there hasn't been any accidents in the house. Buddy's appetite is normal. No matter how upset his stomach is or how bad his allergies are, he always eats!
There has been no more vomiting, diarrhea or loose stools since starting Trilo. His stomach is very's upset most of the time now And allergies remain a problem, specifically wheezing , sneezing and runny nose. I don't have copies of all of his recent tests. I will ask for them when I return to the vet in a few days. Attached is what I have:

March 4, 2013. Pet emergency and specialty center

Medical record for Buddy 1:00 PM
Clinical history-
Betty presented for multiple episodes of vomiting and ataxia. Ate well Saturday p.m. Sunday a.m. Vomited, then vomited water when offered. Vomited a total of 8 to 10 times during Sunday. Owner gave Benadryl 12.5 mg, to try to help with nausea. No vomiting since 11 PM. Drink small amounts this a.m. and have kept it down. Yesterday at time of vomiting became ataxic. owner feels it is improved today. Urinated today a.m. Normal stool yesterday. No c/s.

pmh Of allergic run to vax, Only gets rabies now. On blue Buffalo salmon.

At rdvm today: hct 49.5, neu 11.48 bands suspect, wbc 13.81, plt 305 bun 41, alkp >2000, ggt 10, chol 392, na 143, rest wnl

rads at rdvm: Good and detail, Large liver extending the last rib, enlarged spleen. Large bladder, Feces in colon. Soft tissue density dorsal to stomach on lateral view (r/o Stomach pushed by liver vs mass effect vs other). Thoracic view diffuse interstitial pattern.

Referred here for ultrasound

Physical examination
BP 120, Temperature 102.9, Pulse 150, Respiration 60, Weight 7.273 kg, 16.00 lb, 0.38 m2

1. GEN APPR:BAR, Appears hydrated
2. EENT:MM Pink and moist CRT< 2 sec PERL
3. CARDIOVASC: NSR, GRADE 1-2/6 murmur ausculted, ausculted, Good pulse quality, no pulse deficits.
4. RESPIRATORY: Panting, lung sounds clear
5. ABDOMEN: Tens on palpation, hepatomegaly Palpable, difficult to palpate deeply. Rectal formed stool.
6. MUSC.SKEL: Ambulatory times 4.BCS. 7/9. Walks with stiff gate, primarily appears to be due to right hind limb. No obvious instability. No reaction to back palpation.
7. NERVOUS: PLR intact. CP deficits both hind limbs. Hyper reflexive reflexes in hindlimbs. Intact anal and tall tone.
8. GENITAL/URIN: Normal
9. INTEGUMENT: Normal
10. LYMPH NODES: Normal

PROBLEMS IDENTIFIED
-Mild hypothermia r/o stress, Infection, inflammation, Neoplasia, other
-Vomiting multiple times r/o Metabolic, endocrine, pancreatitis, Neoplasia , Fb obstruction, toxin, other
-Ataxic gait/CP Deficit/hyper reflexes r/o 13 – 13 Myelopathy ( ivdd, neoplasia, fxr, luxation), toxin, discospondylitis, discospondylosis , other
-Distended abdomen r/o hepatomegaly,Cushings, asites, Neoplasia, other
-bun r/o pre renal, renal, post renal, other
-elevated alkp, ggt, hepatomegaly, r/o endocrine hepatopathy, vacuolar hepatopathy, inflammatory hepatopathy,neoplasia, other
-Increased soft tissue density dorsal to stomach r/o mass effect, secondary to hepatomegaly, ingesta, other

DIAGNOSTIC TREATMENT PLAN
Met with Mrs. J and examined buddy. Discussed PE and rad/bloodwork concerns. Discussed ataxia appears to be more a Peripheral neuropathy rather than central. (As good mentation, alert, cn intact). Recommend USG to evaluate azotemia. BP to evaluate again for possible hypertension. It was normal the first time at 120. AUS Ideal to evaluate liver and abnormal appearance of stomach on rads. Would recommend spinal rads or advanced imaging to better evaluate spine. At this time plan to Ward OBS while awaiting AUS and will use this to help make decision in case mass etc. is found. She understands will not be done until late this afternoon plan approved.

CLINICIANS PROGRESS NOTES
BP 120
Neg. glucose, small bilirubin, neg blood, ph 6, protein 100

4:30 PM
Back from AUS. Initially vocalizing and appears stressed in cage but quiets down. CP deficits remain but is able to emulate on hind limbs. Still no evidence of back pain. Offered z/d diet- Ate very eagerly.

Telecom with Mrs. J, updated on urine, BP and AUS, overall fairly good results as no obvious masses and hepatomegaly is suspected secondary to endocrinopathy. Would recommend follow-up with rdvm For testings for Cushings At a future date.ataxia and increased reflexes are still concerns – possibly could have thrown a clot, could relate to Cushing's this way but otherwise may be a separate problem. (13-13 myelopathy, neoplasia, other). Can do pain meds and activity restriction trial, next diagnostic step would be spinal rads but discuss limitations of rads. Discuss signs can progress, worsen, it occurs would recommend more advanced imaging, consider sx or neuro consult if this occur. Mrs. J. approves final rads, will monitor at home follow up with our RDVM. Discussed activity restriction.

Two views spinal rads: No obvious bony lesion. Subjective disk space narrowing T 10-11-12

Tgh Tramadol ( Elect to hold off on NSAIDs given high suspicion of Cushing/other hepatopathy )

CLINICIANS PROGRESS NOTES 2:37 PM
ABDOMINAL ULTRASOUND
-Liver-diffusely hyperechoic ( same eghogenicity as spleen) With mild Mottling and ill defined hypoechoic regions. Subjectively plump based on degree of overhang over midline gastric axis, recommend rads to delineate hepatic margins, prominent hepatic vasculature, no
discrete masses or nodules.
-Gallbladder- Gallbladder filled with significant amount of moderate eghogenic debris with possible early organization, bile duct WN L
-Stomach- Normal rugal folds, multiple Pinpoint hyperechoic foci in muscularis; small intestinal segments evaluated have normal architectural layer definition, multiple full pinpoint hyperechoic foci in muscular is, all segments(0.35cm).
-Pancreas-Homogeneous texture and smooth capsule in sections evaluated; R pancreas 0.56
-Spleen-Homogeneous echotexture, normal echogenicity, focal hypoechoic nodule within Parenchyma.
-Kidneys- right:4.25 cm- ragged corticomedullary Definition, hypoechoic cortical, cyst containing a pinpoint hyperechoic density that shadows (ie:mineral); left: 4.8 cm, attenuated corticomedullary definition; No pelvic dilation, mineralization of diverticuli bilat
-Adrenal glands-right 0.52 cm, left 0.69cm (Normal average cat 0.43 cm, normal canine <0.75 cm);
-Urinary bladder-Unremarkable
-Prostate – WN L
-Lymph nodes:meds enteric and sublumbar LN WNL
-No asites
FINDINGS
>hepatopathy And liver changes – r/o : endocrine hepatopathy , vacuolar hepatopathy, inflammatory hepatopathy, less likely Infiltrative dz
>hepatic vessels midly prominent – R/O: R sided Heart failure, fluid overload
> Multiple pinpoint hyperechoic foci in muscularis of stomach and intestines – consistent with Mildly dilated lymphatics r/o: Transient Gastrointestinitis or inflammatory bowel disease "these are most likely", Infiltrative DZ, other
> Mild soft tissue mineralization and kidneys

TENTATIVE DIAGNOSIS
Open for ataxia
Enlarged liver

DIET- Normal diet
RECOMMENDATIONS
Summary:
Buddy presented for ultrasound evaluation after his liver looked large on x-rays at your family veterinarian after multiple episodes about vomiting. Ultrasound evaluations of his liver was most consistent with changes secondary to An endocrine disease such as Cushing's as well as G.I. changes most likely secondary to Gastrointestinitis. He has eaten well in the hospital with no further vomiting.

He does have a wobbly gait in his hindlimbs and abnormal reflexes which are most consistent with the spinal issues such as a disc or blood clot among other causes. Spinal x-rays did not show any obvious bony lesions. We are sending him home with pain medication and recommend activity restriction as we discussed if these signs persist or worsen, advanced imaging and even surgery may be recommended.

Please keep buddy confined to a crate or small room. No running, jumping or playing. He should go outside on a leash for bathroom purposes only.

Please monitor buddy for any progressive difficulty using his hindlimbs, vomiting, in appetence, diarrhea, coughing or any other abnormalities. If these occur please recheck immediately with your family veterinarian or the PESC if after hours.

Everybody is doing well with no further vomiting and eating and walking please recheck with your veterinarian in two days. Recheck sooner if problems occur.

END OF MEDICAL RECORD

I don't have copies of the low dose eight hour Cushings test that determined Pituitary Dependent Cushings, as of yet.
Below are the test results I do have.

CATALYST DX (March 4, 2013)
Below are the items that fell beyond the normal range
BUN 41mg. 7-27 HIGH
ALKP greater than 2000 UL 23-212 HIGH
GGT 10 U/L 0-7 HIGH
CHOL 392 mg. 110-130 HIGH
NA 143 mmol/L 144-160 LOW

PROCYTE DX (MARCH 4, 2013)
items out of normal range
NEU 11.48 K 2.95-11.64 HIGH
BAND - Suspect Presence
MONO 1.13K 0.16-1.12 HIGH


This is all I have for now. The doctor called me this evening to check on Buddy. She said to continue the Trilo, giving Buddy time to adjust to it. Upset stomach's are common when initializing treatment. Watch for vomiting and diarrhea. Let her know if he stops eating. As for Buddy's allergy symptoms recurring, that means Cortisol levels are dropping, which is what we want. Treat the runny nose, sneezing, wheezing etc. with Benadryl 3 times per day. Once Buddy is breathing better, he may be able to rest. Benadryl causes drowiness, which is good also. We go in Wed. or Thurs. for a blood test to see if Buddy's Cortisol levels are coming down. That is 7-10 days after initializing treatment. Adjustments may need to be made at that time.

Thank you for reading this....Kathy and Buddy

[Harley PoMMom]

Hi Kathy,

I only have a moment to post but I wanted to welcome you back and I will let the Administrators know that you need approval so please be patient with us...Thanks so much.

Love and hugs,
Lori

[addy]

so perhaps Buddy had a transient gastric episode along with an acute clot or disk problem with his back legs which is why he suddenly seemed ill, subsequently they found Cushings while checking everything out? That would seem to fill in the puzzle. At least that was how I read it but I am by no means an expert so hopefully after the holiday, one of our administrators will come along and read through it all.

Dropping Buddy's cortsiol will make his allergies flare up, he was self medicating with the higher cortisol, keeping them in check. It is not unusual for them to feel under the weather while their cortisol drops if they have other issues the higher cortisol was helping them with.

Recommend USG to evaluate azotemia

I am hoping someone else can dechiper what they are saying about the kidneys and their thought on the protein in the urine. I am not clear on that.

[Budsters Mom]

Hello again,
For those of you who are not independently wealthy, how do you pay for it all? I am terribly frustrated! Buddy is having an ACTH test on Wednesday To determine if the trilostane is reducing his cortisol levels. They do the first one 7 to 10 days after initializing treatment. This leaves me with a bill of approximately $2000 since the beginning of March. I work in a local public school district. This is my 21st year with the district. I love what I do, but I don't bring home anywhere near two grand in an entire month! I only work nine months out of the year! The $2000 does not include the cost of His meds. It only includes tests and vet bills. These tests have to be done regularly. I am feeling very stressed!

Update:
During the neurology consultation, I found out that buddy did not appear to have a disc problem in his back, causing his hind leg weakness. It could've been caused by a stroke. A $3000 MRI would determine if he had had a stroke. Even if he did have a stroke, there is nothing I can do about that anyway. The doctor said to go ahead and test for Cushing's, that Buddy was stable enough. She said that his hind leg weakness could be due to Cushings Deterioration. She also said that he didn't appear to be in any pain. So yes, Cushing's was tested and found And treatment with Trilo was started. Buddy's stomach has finally began to settle. His allergies,however are going haywire! I know baby steps. Several people including family members has suggested that I put buddy down. That is not something that I'm willing to do even though the bills are continuing to pile up. He has given me 10 years of unconditional love. Illness is not a time to abandon him and I won't do that! Thank you for giving me a safe place to vent.

By the way, When I called the vet to get a quote for Wednesday's test, I also asked for copies of all of Buddy's tests. I'll pick them up on Wednesday.
Hugs, Kathy and Buddy

[Harley PoMMom]

The initial cost expense is during the diagnostic phase and when a dog becomes stabilized on treatment the cost does go down considerably.

Here is a post from one of Administrators, Glynda, where she details another cost saving method:

Hi Kelly

The reason why the acth stim test is so expensive is because the stimulating agent, cortrosyn, is ridiculously expensive. There is good news for those with smaller dogs because studies show that while instructions on the .25 mg (250 mcg) vial is to inject the entire vial, only 5 mcg per kg of weight is necessary for an accurate result. While Java isn't small, her weight is still low enough to get two stim tests out of one vial. If you do the math, she'd need a bit over 113 mcg so your vet could just split the vial exactly in half.

I have provided the url to instructions on how to split, reconsititute and store for future use. This info is brought to us by a highly published and well respected endocrine specialist, Dr. Mark Peterson. Either give the url to your vet or print out the article for him and ask for a revised quote.

http://endocrinevet.blogspot.com/201...cortrosyn.html

Glynda

Having the Trilostane compounded is a money saver too.