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Thread: Cushing's Crisis over Christmas still not good

  1. #1
    Join Date
    Jan 2014
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    Unhappy Cushing's Crisis over Christmas still not good

    Hi,
    My name is Allison, and my dog is Samson. He is a 13-ish Schipperke/Pomeranian mix (we think) that I rescued 7 years ago. I first had Samson tested (low dose dex and ultrasound) in the summer of 2013 after he exhibited months of depression (shortly after the sudden death of our other dog), and then started developing the usual Cushing's symptoms of thirst, frequent urination and crazy hunger. His test results suggested Cushing's but I was advised to wait to treat and have him tested again by three vets (one an endocrinologist) because his results were very mild.

    I had him tested again in early December 2013. His ultrasound showed both adrenal glands were enlarged, his liver was enlarged and had a "node" on it, and his kidneys were enlarged. His dex suppression test (I left the results with the endocrinologist) showed that he had Cushing's but they were unable to determine which type. Shortly after the test, Samson developed chronic diarrhea which was believed to be from stress, and was given flagyl and then tilan (which finally got it under control.)

    Samson began to act strange on the Friday before Christmas--refusing to eat his food, not taking treats, so I took him to the vet and she gave him a mild antibiotic. He didn't improved over the weekend, so I returned and asked for blood work and a BP measure. They said his BP was normal.

    I received a call the next morning saying to get him to the ER because he was in possible kidney failure. His Alk Phos was 1875 and his BUN/creatinine was elevated etc.

    The ER gave him fluids and his kidney function improved immediately, however, they did a dopler blood pressure and said his BP was 250! They said he probably has pancreatitis, and possibly liver and kidney disease. So they kept him for 2.5 days. They also got him on trilostane 2x per day and BP meds.

    Since Christmas we have had another emergency because (apparently) due to the high amount of BP meds (he was on two) his BP dropped so low that he had a fainting episode (which looked to me more like a seizure), and he spent two more days in the ER.

    We have since adjusted his meds twice and he still is not the same. I understand it takes time for the meds to get in his system, but he is only eating chicken and rice (after he began refusing the canned food), and has now gone from chronic diarrhea to constipation. He doesn't want to walk or go outside except for brief moments. He is going off alone in the house, and sleeping on a dog bed which he always refused to use in the past. Samson is getting the ACTH stim test tomorrow and having his BP rechecked.

    I guess I am just looking for advice from other people who are going through this. I was told Samson's case is more complex than usual (and I was also told all Cushing's is complex) so we are using a specialist. I want to make my guy comfortable and I just don't know what to do. I don't know if we waited too long to begin testing and treatment or what. We have committed to giving this guy a chance.

  2. #2
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    Default Re: Cushing's Crisis over Christmas still not good

    Hi Allison and welcome to you and Samson,

    I only have a minute to post but wanted to approve your message and ask a quick question. How much (mg) of Trilstane is Samson getting? Please take note of the instructions below so your post will not have to be approved.



    Moderator’s note: In order to complete your registration, you need to check your emailbox (or spam folder) for a communication from us. Once you respond to that email, your membership will be finalized, and anything that you post will become visible on the forum immediately. Until that time, your replies must be manually "approved" by a staff member before they are visible to the public -- so there may be a bit of delay between the time that you write your replies and the time that you actually see them.

    If you have already received and responded to the confirmatory email, please be patient. Your registration will be finalized shortly…Thanks!
    John (Roxee & Rozee's Dad)

  3. #3
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    Default Re: Cushing's Crisis over Christmas still not good

    Sorry about the registration issue. I guess I tried posting too quickly.

    Samson is about 19 pounds and is currently on 9 mg of Trilostane 2 times per day.

  4. #4
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    Default Re: Cushing's Crisis over Christmas still not good

    A rule of thumb and even by the makers of Trilostane is to not give cushings meds to a dog that is lethargic, won't eat or drink or has diarrhea.
    John (Roxee & Rozee's Dad)

  5. #5
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    Default Re: Cushing's Crisis over Christmas still not good

    Your registration has now been finalized, so you can go ahead and post freely. I will come back later to reply in greater detail, but there are several things about Samson's situation that are troubling, including the initial diagnostic testing as well as giving trilostane to a dog who may have primary kidney/liver disease (those are contraindications to the drug). We will do our very best to help you sort things out!

    Marianne

  6. #6
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    Default Re: Cushing's Crisis over Christmas still not good

    Hi and welcome to the forum.

    It does sound as though your boy has a lot going on. My first thought was what was the ER thinking by giving a very sick dog on IV fluids Vetoryl and why weren't they able to confirm a pancreatitis diagnosis by doing a do a simple Spec cPL. I've been through the drill with two of my dogs and most recently, my mother's dog. It would help us immensely if you could round up all of the testing that has been done since you retested Samson in December. With respect to the blood chemistry and complete blood count (CBC), we need only see the highs and lows, and please include the normal reference ranges. I'm a huge Pom lover and have had two Poms with cushing's, both of whom have passed.

    The LDDS test may not have provided a clue as to whether you are dealing with pituitary (PDH) or adrenal dependent disease but the abdominal ultrasound did. If a dog has PDH, both adrenal glands will be enlarged, or depending on progression of the disease, they could be normal. Samson had two enlarged adrenals which is indicative of PDH, which is the diagnosis most cushdogs have.

    Having test results would help understand the er vet's suspicion of kidney disease but severe elevation in ALKP and a high BUN/Creatinine ratio is not unusual for a dog with cushing's. Nor would it be unusual for a dog with pancreatitis. A high ratio is indicative of low creatinine or high BUN. Dehydration from pancreatitis and frequent urination caused by Diabetes Mellitus or Cushing's can cause high BUN resulting in a high ratio. I'd be more concerned with a low ratio as that is indicative of high creatinine or low BUN. When both creatinine and BUN are elevated, that's when I start to get nervous. With respect to the high ALKP, dogs are the only species that have a steroid induced isoenzyme so if Samson has cushing's, his ALKP would probably had been elevated prior to becoming sick; however, there is another ALKP enzyme that comes from the gut so the elevation in ALKP is probably being triggered by two sources, cushing's and pancreatitis.

    Most dogs with cushing's have enlarged livers due to fat accumulation as a result of cortisol's effect on fat metabolism. This does't mean a dog has primary liver disease. When the pancreas is seriously inflamed, it can also affect the liver and kidneys because they are so close in proximity. This could explain the enlarged kidneys.

    Is your specialist a board certified internal medicine specialist? If so, was Samson being treated by this specialist before he ended up in the ER with suspected pancreatitis? Either way, has the specialist sat down with you to explain exactly what Samson's issues at this point in time? John already mentioned that it is not a good idea to give a sick dog Vetoryl and a cushdog that is not eating normally, should be considered sick.

    Your response will really be helpful in our ability to provide you with meaningful feedback.

    I'm sorry for the circumstances that brought you here but I'm very glad that you found us. We'll all try to help you figure out what is going on with Samson, and the more information you can provide, the better.

    Glynda

  7. #7
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    Jan 2014
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    Colorado
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    Default Re: Cushing's Crisis over Christmas still not good

    Thank you all for your quick responses! I am so glad I found this website.

    I will round up all of Samson's test results when I take him in tomorrow for the ACTH test. I read on the trilostane website that you are not supposed to give trilostane to dogs with kidney or liver disease so I did raise my eyebrows at this. I will ask the doctor why they proceeded with this course (she is board certified and has an excellent reputation.) I know that his kidney numbers responded quickly to the fluids so they did feel that dehydration caused theelevation in his kidney numbers.

    I found some notes I wrote after the CBC he had when I was told to rush him to the ER: ALK Phosp was 1800 now (up from 475 in summer 2013). I don't understand my BUN/Creatinine notes because they look like I wrote BUN/Creatinine 96 and 2.5 which is unclear to me. The vet also wrote "Cyto?" on the records. Phospate was 6.6 and calcium was elevated. His platelets were over 200,000. I will get more info tomorrow.

    I also know what his platelet count was on Friday 1/3/14: 192,000. They had to repeat it because on 1/2/14 when he "fainted" they said it was 45,000 and wouldn't let him come home. Luckily it must have been a mis-read the first time. His sugar was slightly elevated but not enough for them to say "diabetes." His BP was low for him --140. This poor dog has had so many blood tests

    I was not taking Samson to a specialist prior to the problems he had over Christmas. I would have gone the route of the specialist even if Samson hadn't gone into crisis. We had just done the LDD and the ultrasound and I was waiting to get a referral but my vet was on vacation.

    Although Samson refuses to eat dry food or canned vet formula, he eats chicken and rice with vigor. He was never a picky eater until Christmas. He is still constipated so I plan to slowly switch him to a lower fat Wellness canned formula and off the chicken/rice. He is sleeping a lot, and carrying his tail down. He shakes a lot--especially when lying down and when standing in place (I understand this can be a Cushing's symptom.)

    I am very worried and a bit frustrated because he has had so many tests in the last month, and I don't feel like we are getting to the bottom of this. If all else fails, I will get a referral, take time off, and I will drive up into Fort Collins, CO to CSU to find out what I can.

  8. #8
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    Default Re: Cushing's Crisis over Christmas still not good

    Unfortunately, the numbers you posted are difficult to assess without the normal references ranges so it should make more sense when you get the actual tests and post the results. Keep in mind I'm not a vet, I'm just an educated pet owner and special needs rescuer who has spent much time going over abnormal blood and urine tests with vets. I can tell you that most of the abnormalities you mention can be explained by cushing's, pancreatitis and dehydration from pancreatitis.

    Now that I know that Samson did not see the specialist until after the emergency, I have to assume that the specialist has all of the records from your gp vet and the er, right? I suspect she probably did additional testing as well??? If she is a board certified internal medicine specialist, she should have been able to get to the bottom of things; she should have explained in detail what is going on with Samson and you most certainly should not be forced to contemplate taking Samson to CSU for answers. She should be able to sit down with you and explain exactly what is going on with Samson and answer all of your questions. Once you post the results and we've had a chance to digest them a bit, maybe we can put a list of questions together for your discussions with her. When you see the specialist tomorrow, a lot of questions could be answered if she will just tell you 1) if kidney and liver disease have been ruled out; 2) does she believe that Samson's crisis was caused by pancreatitis and 3) is cushing's the only diagnosis at this time or are there other issues, and if so, what are they.

    One of my cushdogs had serious muscle wasting caused by cushing's and he not only had constant tremors in his hindquarters, he would fall over if he tried to lift his leg to pee. His rear end was noticeably boney. I know it's difficult to visualize muscle wasting in a Pom with a full coat but if you feel their spine, down to the hips you can tell if there has been a lot of muscle loss. Have you noticed this in Samson?

  9. #9
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    Jan 2014
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    Colorado
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    Default Re: Cushing's Crisis over Christmas still not good

    Thank you for helping me put together questions to ask. She is a board certified internal medicine specialist. Her practice is at the same place as the ER (it is both an ER and a specialist facility.) This will be my first direct consult with her (I have spoken over the phone to her but not in-person to this point, and it has been frustrating. I believe it is because the previous events were "emergencies" and not treatments so I spoke to whichever doctor was on call.)

    Samson has very little hair left at this point --just fuzz and a few random tufts (Samson without his hair...) and he does have muscle loss in his hind-quarters to some degree. He also has the drooping tummy.

    You know, I failed to mention earlier that when Samson was first suspected of Cushing's I took him to a holistic vet. She seemed more concerned with his thyroid symptoms than anything else (did a free t-4 test on him and his thyroid showed low.) She put him on a hefty dose of thyroid meds which was against my regular vet's wishes.

    Although Samson initially appeared to show improvement (had energy, depression went away), my regular vet said that thyroid meds can make a dog that is ill feel better even if it isn't curing anything. He said that thyroid numbers can get funky with Cushing's as a 2ndary concern, and the meds can cause BP problems, and that he didn't even agree with the particular thyroid test she ran. So I removed S from the thyroid pills about three weeks prior to his episode. His hair (which was already getting thin) really started going after that. I will mention this to the internal med doc too (they know he was on thyroid meds in the past.) The holistic vet has recently moved her practice to a swanky ski village.

  10. #10
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    Default Re: Cushing's Crisis over Christmas still not good

    If you saw my avatar pic, you'll see Lulu. That pic was taken when she still had some fuzz left. The picture below was taken later, after her skin turned black. She still had a bit of tuft left but that pretty much went away too. She did have primary hypothyroidism as well as cushing's so she had two strikes against her. It was purely cosmetic so I just made sure she had plenty of sweaters and onsies to keep her warm.

    I'm hoping that you can sit down and talk at length to the specialist and get a lot of questions answered. Take a notepad with you and take copious notes because if you don't, you'll forget most of what she tells you. If you don't understand what she is telling you, ask her to draw a picture if you have to. You both need to be on the same page to make sure that Samson's treatment is administered safely and effectively. It takes teamwork.

    Glynda

    P.S. Was it the specialist who directed the staff to administer Trilostane while Samson was so ill? If so, I would have great concerns with that decision and would question her knowledge of the drug. If she didn't order Trilostane, she should be taking issue with the ER staff.

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