Annie, 15.5 yo Westie, adrenal mass (pheo?) - Annie is at the Bridge

[Wagger]

I have been reading many of the threads the past few weeks (sometimes bawling my eyes out), trying to figure out what's been going on with Annie, my very charming (and willful ) Westie, who is 15 years & 9 months old.

I am so grateful to all of you for sharing your experiences, knowledge, and hearts. I was particularly intrigued by frijole's Annie, and my biggest hope is to be able to bring my Annie some relief to revive her spunk and see her wag her tail more. Excuse me for the novel-length 1st post, but I wanted to cram everything I could!

In a nutshell, Annie has a mass on her right adrenal gland, but apparently it is not secreting cortisol because her LDDS test does not indicate Cushing's. Based on more recent symptoms, I strongly suspect she has a pheochromocytoma, but today we saw a veterinary internal medicine specialist who thinks it's more likely that the tumor is not secreting anything and Annie's symptoms are more likely unrelated (a brain tumor or canine cognitive disorder)The doc suggested Anipryl, but backed off when I pointed out that IF it is a pheo, an MAOI in contraindicated (yes, I've been doing my homework! We both agree that Annie is not a good candidate for surgery due to her age, but I am going ahead with a CT scan of her abdomen and head on Thurs in the hopes that we can have a more definitive diagnosis and can manage symptoms and improve quality of life for whatever time Annie has left. Also will do a urine catecholomine test, which doc said if it's positive it could be non-pheo causes, but if it's negative, that would rule out a pheo.

Symptoms
She's been having many of the standard Cushing's symptoms, (started to notice on-and-off since last fall, but has been getting markedly worse since early July): recurrent skin infections, extreme hunger & thirst, potty accidents in the house, waking/pacing/anxious in the middle of the night, lethargic, bouts of panting, restlessness, can't seem to get comfortable, smacking her lips/licking, etc. I thought she was just getting old. She also doesn't wag her tail anymore (since last winter), but it still works -- she holds it out when we're walking outside and wags it when saying "hi" to strangers at the vet (my hubby says her wagger is broken)

More recently (July/Aug) - Annie also breathes hard sometimes when she's sleeping. She has head & whole body muscle twitches. Rubs face all over carpet, furniture, people & chews feet until bloody (so she's been wearing the cone of shame pretty much since April/eye surgery). Since July, she's had 2 bouts of no eating/vomiting bile, which is rare for her, although she's had a lifelong issue with "sensitive stomach" & allergies.

History
* In early April, Annie developed a corneal ulcer that was down to the last layer and about to perforate. Our vet had me put in eyedrops every 1-2 hours until we could consult with the only animal ophthalmologist in Hawaii, but thankfully, all was well (except my wallet) after a corneal pedicle graft. She was diagnosed with dry eye and I've been putting Tacrolimis ointment in her eyes since (we tried cyclosporine first, but she had a reaction that turned her into an evil-looking red-masked racoon from hell).
* In May, we suffered the heartbreaking loss of Annie's adopted sister, Ursa-bug (16 year old Shih-Tzu), who probably had Canine Cognitive Disorder.
* In June Annie had several teeth extracted and a benign growth removed from her skin (forehead). She healed very quickly from both surgeries, but the hair on the leg that was shaved in April has not really grown back (we call it her "chicken leg").
* June 28-July 9: We could not get rid of recurrent skin infections (medicated baths 2x/week & antibiotics), so doc put her on 10-day steroid dose and changed her food to Royal Canin Hydrolyzed Protein (HP)(over the course of 1 week) (previously ate Wellness CORE, reduced fat)
* July 15: Annie was sleeping next to me in the middle of the night and she suddenly yelped/screamed and started shaking all over for 2-3 minutes. Then she quieted down and seemed okay & went back to sleep. I thought maybe she had a bad dream, but after reading about pheos, this seemed like a sudden release of adrenaline?
* July 13-18: ravenously hungry, waking up at 2-3a crying, pacing, restless. Also urping yellow bile 2 or 3 times. I took her in to the vet on 7/18 and they do bloodwork. Diagnosis as after-effects of steroids.
* July 22-26: Stomach making noises, won't eat, & urping yellow bile. Doc gives her a shot for nausea on 7/26 and 4-day dose of Cerenia pills (anti nausea); change food (over 1 week) to Hills Venison & potato.
* Early August: 2a pacing, crying, won't settle. Feed her at 5a and she eats, but continues to act the same way. I'm concerned whether Annie is in pain or has Cushing's. Doc schedules LDDS test, ultrasound, x-rays. Ultrasound results below; x-ray does not reveal any apparent arthritis or spinal degeneration that would cause pain.
* Last night, she woke me up and I brought her downstairs where she emptied her water bowl and then threw up a few minutes later. It was 3:30a (6 hours since she'd last eaten), so I thought she was going to urp water/bile, but instead it was a thick, soupy brown "kibble stew" all over the carpet! Luckily, I did not wake up the household steamcleaning in the middle of the night, but there was no way to clean it otherwise. It seemed to make Annie feel much better, though, and she proceeded to try and "help" me with clean up duty!

Ultrasound - 8/11/15
Last week, an ultrasound revealed an adrenal gland mass (the gland was partially obscured, so they could not see it all, but the US report says it's "at least 1.9 x 3.0 cm). The left adrenal gland is normal. The liver is mind to moderately enlarged and mildly diffusely mottled in echogenicity. No focal hepatic parenchymal abnormalities are detected and no evidence of hepatic lymphadenomagaly is seen. Both kidneys contain cortical cysts, the largest of which is approx 1.9 cm in diameter. ... A scant volume of anechoic peritoneal fluid is present.

LDDS
Cortisol Sample 1, Baseline (0H): 2.6 (ref range 1.5-5.0)
Cortisol Sample 2, Dex (4 hr): 1.0 (ref range 0.0-1.4)
Cortisol Sample 3, Dex (8hr): <1.0 (ref range 0.0-1.4)

Bloodwork - not "normal" & compared to past 2 results
Alk Phosphatase: 161 (8/6/15), 217 (7/8/15), 90 (4/8/15), ref range 5-131
BUN: 34 (8/6), 30 (7/8), 34 (4/8) ref range 6-31
Potassium: 6.5 (8/6), 5.0 (7/8), 5.0 (4/8) ref range 3.6-5.5
Na/K Ratio: 22 (8/6), 30 (7/8), 31 (4/8) ref range 27-38
Platelet Count: 674 (8/6), 272 (7/8), 429 (4/8) ref range 170-400

[Squirt's Mom]

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[labblab]

Hello and welcome to you and Annie! I am sorry that I have only a moment to post right now, but I will return later today and add a more comprehensive reply. But I wanted you to know that we are very glad you have joined us, and we will do our best to offer as much info and support as we can.

Marianne

[labblab]

Hello and I'm back again, although I'm afraid I don't have a great deal of insight to offer.

Thank you so much for your very comprehensive summary of Annie's history and symptoms. Unfortunately, I will be the first to admit that I don't know much about pheos, but as soon as I finish this note, I am going to send off a message to one of our members, Trish, who is a medical professional herself and very experienced with pheos due to treatment for her own dog. I'm hoping Trish will be able to stop by and give us her thoughts.

Given Annie's symptom profile, I confess to being hugely surprised that her LDDS test was normal. If for no other reason, I might have thought that her acute illness right now would have elevated her cortisol level even if Cushing's itself was not involved. I am somewhat puzzled by your vet ascribing all of her symptoms to the possibility of a brain tumor or cognitive disorder. That could explain things like lethargy and panting and restlessness. But I don't know how that would explain her acute GI disturbance, or chronic physical ailments like unresolved skin infections. Regardless, since you will be having the CT scans of her head and abdomen, it sounds as though you should have additional diagnostic info available on Thursday. We will definitely be interested, as well!

So in the meantime, I wish I could be more directly helpful. But as I say, I will send a note off to Trish, and I will anxiously await the CT results alongside you.

Marianne

[molly muffin]

Hello and welcome from me too.
If the tumor is a nodule only and not secreting anything, then her cortisol levels could be normal and she can obviously suppress when her body determines that there is enough cortisol present already.

It sounds like the episode with the yelp might have been a seizure or something else going on. Many of the symptoms do present like a pheo, and hopefully the testing will give you more to go on concerning that. I wonder about IBD causing the stomach upset or pancrease even. Given that 6 hours later the food wasn't adequately digested my first inclination is gastric upset with the possibility of IBD. I think that the CT scan you are planning will tell you more, but you're in a holding pattern trying to figure out what is going on with Annie.

Trish might indeed have some more insight as her Flynn has had both a pheo and IBD.

[Wagger]

Thank you so much for responses, and reading through my looong post! ... I realized later that I forgot to include my own name, Carole.

Yes, Marianne, I was very surprised to find out the LDDS was normal, I was so sure it would be Cushing's, although the vet did say it could be atypical.

And yes, molly muffin, Annie has always had intermittent issues with her tummy, so the recent bouts could be unrelated to the adrenal tumor, although she's never vomited food before, just bile. Also, when her tummy acted up before, it would be gurgling like hell and she'd be clearing the room with farts , but that hasn't been the case lately.

I have found some human pheo case studies and discussion boards and it seems that the excess release of catecholamines can cause decreased gastric motility, which seems to fit her latest bouts. However, I know I'm so desperate for answers that I'm probably grasping at anything (and it may not turn out to be a pheo!).

In any case, Annie has hardly eaten since her early Mon morning barf incident. She took a few bites of kibble yesterday (Tues) morning, then seemed utterly miserable -- uncomfortable, lip-smacking, moaning, refluxy ... I was worried, so stayed at home to watch her until she settled down. She wouldn't eat anything last night or this morning, so this morning I made her a batch of her usual "upset tummy food" -- rice porridge with some bits of boiled turkey. I know she'll eat it, but worried that it may make her feel worse again (and I really need to go in to the office today).

Annie has to fast after 8pm tonight for her CT scan tomorrow. I called the vet, but still waiting to hear back. I guess I'll go ahead and give her a few teaspoons this morning and a couple more small feedings when I get home and again just prior to 8pm.

It's nice to have someplace to come and ramble ... I worry so much about my poor Annie.

Carole

[Trish]

Hi Carole and Annie

My dog was diagnosed with a pheo back in 2012, he was 11 at the time so we went ahead and had the adrenalectomy. He is a fox terrier x. Many of the symptoms you are describing he also had, apart from the excessive thirst and hunger. He was also negative on LDDS testing. The tumour was on his right adrenal and was picked up on an ultrasound. They also went on and did a CT, so get better pictures. The suspected pheo because of the position of the tumour, in the medulla (middle) of the adrenal gland. He also had very high BP >200. Has Annie had a BP check? You are quite correct that this type of tumour does not secrete cortisol hence the negative LDDS. But they do secrete catchecholamines like adrenaline which can be intermittent so they get a spurt and if you read Frijole's Annies story, she had definite periods when heart would race, she would go pink and be really stressed looking. Flynn did not seem to have those, they thought he might be secreting a small amount continuously.

Unfortunately it can be hard to diagnose, there are blood tests and urine tests that some IMS are using, this explains it a bit more. We did not do these testing but another member Vicki who is treating her dogs Brando and Snuggles has, because of their ages she is treating medically http://www.ncbi.nlm.nih.gov/pubmed/23311717 so you might want to look up their thread. The adrenals are in such a tricky spot that it can be dangerous to poke a needle in to get a biopsy and a definitive result. Flunn has a nodule on his other adrenal, it is just over 1cm and when they did the surgery they did not think it looked cancerous so we have been monitoring it for nearly 3 years with only very minimal increase in size.

If BP is a problem and that really can make them feel yuck if it is consistently elevated then the drug of choice is phenoxybenzamine.

Hopefully after the CT we will have more answers as to the likliehood this is in fact a pheo then you will be able to move forward from there and get the most appropriate treatment in place.

My dog has also had liver tumours and had two big surgeries for those, the last one 18 months back, I think with him being 14 now I would be hard pressed to put him through surgery again.

Re her tummy, again we have been through this one. Having a bit of a flare up right now! I give him just one novel protein, lately he has been on vension but seems to not be agreeing with him anymore. I have taken him off that and just giving him chicken and rice to let it all settle down. I also give him half a tst of Metamucil dissolved in 50ml of water and poured over his dinner. Plus a probiotic and also metronidazole when he is real bad. Slippery elm bark can also settle them down, cerenia for nausea is also good. Also a small amount of pumpkin, I buy the actual vegetable boil and mash about a tablespoon for him but I know others buy unsweetened pumpkin in a can from the supermarket. It is important to get them to eat, when he goes totally off food I give him scrambled eggs and that always gets eaten, plus I add water to his meals so he is getting enough fluids as he has never been a big drinker. Has she had worming treatment?

The allergy symptoms are similar to Flynn, rubbing his face on the carpet. The best thing I have found for that is a drug called Apoquel, it is new and in low supply but ask your vet if that is available. make sure flea treatment is up to date as well.

Hope that helps, fingers crossed the CT gives us the answers but do ask for BP if that hasn't been done. Thanks Marianne for the heads up!

Trish

[Wagger]

Thank you so much for chiming in, Trish! I'm sorry to hear about Flynn's tummy flare and hope he feels better soon.

I did give Annie a tiny meal yesterday and 2 mini meals in the evening. She loves the rice porridge and seems to be doing ok.

The vet took Annie's blood pressure during Annie's last tummy flare up, but it was normal. She's never had worming treatment.

Many of her symptoms -- like drinking a lot of water, sundowning, appetite -- come and go day-to-day. The canine cognitive symptoms like going to the hinge side of the door and "lost" in the room only started in June-July (coinciding with the skin infections, hind leg weakness, etc). However, she has been constantly lethargic/depressed for many months now, which breaks my heart. She still loves to cuddle and be loved on, but I hardly ever see that spark that has been the essence of Annie.

Her IMS said they will monitor her BP throughout today while Annie is there for her CT scan. I'm a bit apprehensive because they have to put her under for that, but Dr. W reassured me that it'll be very light and only for short amount of time.

They're going to do the urine catecholamine test, but we are waiting for the lab to send the specimen kit (and her IMS said we can hold off and see what the CT scan results are).

Please send my sweet Annie some good vibes today for her CT scan.

Carole

[molly muffin]

Hi Carole, just popping in and checking to see how everything went with Annie today. How is she? How are you?

[Wagger]

Thank you so much, Sharlene, and everyone sending us prayers and positive energy today -- it worked!

Annie's IMS said she did great with the anesthesia, and her blood pressure was normal before, throughout, and after the CT scan.

CT scan was good news ... no evidence of any brain tumor or abnormalities in her head. "Within the right adrenal gland, there is a focal, large, approximately 2.3 cm diameter, heterogenously enhancing soft tissue dense mass. No conclusive evidence of tumor thrombus or other filling caudal vena cava. No abnormalities are detected in the gastrointestinal tract. Left adrenal gland, spleen, urinary bladder, or mesentary/peritoneum. No lymphadanomegaly is seen. Both kidney contain cysts, the largest approximately 2.3 cm.

So the mass in her adrenal gland is contained, with no evidence that it's invading neighboring veins or organs. Nothing to support whether it could be a pheo or not.

We'll be doing the urine test that may give us a better indication, but until then, our IMS is sticking with the canine cognitive disorder diagnosis. She gave us a prescription for Keppra, an anti-seizure med that she said in her experience, has shown better success with CCD than Anipryl -- and it's safe and result can be seen within a week.

I'm not quite sold on the CCD diagnosis, but then again, Annie IS nearly 16 years old. We'll see how it goes with the Keppra while we wait for further pheo-related testing ...

Other than her funky tummy, Annie's actually been doing ok otherwise the past few days ... sleeping peacefully through the night and hasn't been guzzling down water or panting/breathing hard.

I'll report back on her progress with the Keppra ...

Thanks again, and have a great weekend!
Carole