New member looking for insight - Patches has passed

[Patches]

Hello everyone,

My name is Jennifer and I have a 15 year old Shih Tzu, Patches. I will give a brief overview initially.

Patches has been having skin problems for a couple of years, also diagnosed with Hypothyroidism around the same time. He is currently on medication for that. Likely in and around the same time frame the vet started mentioning the possibility of Cushing's, his liver counts have been elevated also. They are unsure if this is just normal for him as they are elevated every time we test his blood.

Through our many discussions surrounding Cushings, I did as much research as I could, but never came across this site until recently. We did test his urine way back which was inconclusive. At that time with the information I had, I decided not to test for Cushings because all I had been told and read was that even all the testing may not give us a clear result, beyond that if we did all the testing and began treatment, that could be more dangerous that letting him be, as the medications could result in Addisons which could kill him. He was not really exhibiting serious symptoms and vet seemed to understand and support my decision, given the age of Patches.

Patches has been getting recurring skin infections for some time likely close to that 2 year mark, to which I have just been using IsaDerm, when he has a breakout. This has been working fine, and the vet never warned me about any side effects of this (which I now now can exacerbate Cushings and damage the liver). I was just trying to keep him off Antibiotics. Up until about 3 months ago, Patches has been living a pretty happy and spoiled life. At 15 he was still able to take hour long walks and often referred to as prancing or puppy-like. He was experiencing some good days and bad days in regards to arthritic pain. So really, I figured why upset the balance and traumatize him with testing and put him on medications that could potentially make him very ill, and possibly even kill him. If he seemed happy and comfortable at this age, that is really the goal, isn't it?

Things changed pretty rapidly a few months ago, he started having some really bad paw problems, which I initially thought was due to road salt exposure. We have been trying to get it cleared up with antibiotics, creams, baths, etc. Nothing is working and it is very painful for him. I have seen specialists and they are attributing the undiagnosed Cushing's to having damaged his immune system and that is why he is not healing. I was about to go and do the low dose testing, but changed my mind again after reading some threads on here. I read that the testing can cause further stress and may even traumatize... then when medications started, the dog did not react well... causing further problems. End result being they stopped treatment to make the dog comfortable. After I read this, I changed my mind again. This was part of my thought process before and so I just ended up with the same decision.

Patches is 15 and a half now, so about 90 in people years as he is a small dog and only about 15 to 16 lbs. He is really struggling now though. He has stopped barking completely (was still pretty yappy until about 3 months ago). He is not eating much, sleeping all the time, and walks are out of the question because of his feet. We have done 3 courses of antibiotics, he is a week off the final one and his paws are looking pretty bad again and he is back in pain.

My question is, do you think I should go ahead and test. He has classic symptoms... About a year ago, I was trying to treat holistically, giving him melatonin and flax... but I was unsure of how much to give him. Do you think it would be ok to treat him with these things without doing all the testing or would it hurt him? Do you think is could help? Or should I test, just to get a positive and then treat holistically? I am really against putting him on chemo medications.

Any insight would be so appreciated

Cheers,

Jennifer

[labblab]

Hello Jennifer, and welcome to you and Patches. I apologize that I have only a moment to post right now, but I wanted to let you know that I’ve moved your thread to our main “Questions and Discussion” forum. This way, our members will be more likely to see your questions and stop by to talk with you. I’ll try to return, myself, tomorrow. But in the meantime, welcome to you both!

Marianne

[Squirt's Mom]

Hi Jennifer, welcome to you and Patches!

First off, the IsaDerm is a corticosteroid cream which can cause a form of Cushing's called Iatrogenic that is caused by steroid use and "cured" by weaning off the steroid. So that would be my first step - find a non-steroidal treatment for his skin asap.

Second, I would find a derm vet if one is in your area and have his skin tested for Calcinosis cutis - IF that is the culprit instead of recurrent infections you can pretty much be assured he does have Cushing's. CC can be caused by other things but the vast majority of the time Cushing's is behind CC. This test is a simple skin scrape so it isn't as stressful as blood draws and injections which are required for the LDDS and ACTH.

Next I would want an abdominal ultrasound on a high resolution machine - which is non-invasive and doesn't usually require medication. If the dog cannot lay still then a mild sedative may be given but most pups can lay for the time needed. This test gives us the biggest bang for our buck because it lets us see the actual organs and any issues with them such as tumors, cysts, enlargement, etc.

And finally, I would seek out an IMS - Internal Medicine Specialist - to give Patches a good check up. From what you have shared I don't really see Cushing's - other than the possibility of the skin and exercise intolerance, which could be attributed to age, arthritis and his paw problem instead of Cushing's. Liver enzymes can be elevated for many reasons and liver diseases can cause cush signs. The elevated cortisol associated with Cushing's acts as a sort of "treatment" for inflammatory conditions like allergies and arthritis so the fact that arthritis is an issue would indicate the cortisol is not at the levels we typically see with this condition. That is not to say the arthritis rules Cushing's out - it just casts a shadow of doubt on the diagnosis anecdotally.

Yet you say he has classic Cushing's symptoms, called signs in animals. Here is a list of the most common signs we see in our cush babies -


Increased thirst and urination (polydipsia and polyuria, respectively)
Increased hunger
Increased panting
Pot-bellied abdomen
Obesity
Fat pads on the neck and shoulders
Recurrent infections of skin, ears, urinary tract, etc.
Loss of hair
Lack of energy
Inability to sleep (insomnia)
Muscle weakness
Infertility
Darkening of the skin
Appearance of blackheads on the skin
Thin skin
Bruising
Hard white scaly patches on the skin, elbows, etc. (associated with the disease calcinosis cutis)
Neurologic abnormalities (circling, behavioral changes, seizures, etc.)

If you aren't seeing several of these signs fairly strong that would cast another one of those shadows.

I want to assure you that the testing for Cushing's is not overly stressful for most dogs. If you have a pup who gets stressed just going to the vet or riding in a vehicle, then yes the testing could make that worse, especially if the pup requires frequent monitoring ACTHs. BUT there is a new protocol coming out for monitoring cortisol after treatment has begun that is much gentler on our babies and we have high hopes it proves out as well as it seems to doing so far. The drugs used to treat Cushing's are no more dangerous than aspirin when used correctly. If aspirin is misused it can cause serious damage, even death. But in the hands of a Cushing's savvy vet who follows the established, proven protocols and with an educated, observant pet parent our babies do very well on treatment, returning to a more normal life and usually living out their full life-span...and beyond due to the diligence of their moms and dads, and good vet care.

You are in the right place for that education, too.

It would help us give you more meaningful feedback if you could get copies of the testing done so far, like the one that shows the elevated liver enzymes, and post the abnormal results here along with the normal ranges and little letters that follow. It would look something like this when you type it:

ALP 350 125-300 ug/dl

We only need to see the abnormal values - those that are too high or too low.

However, 15 is a grand old age for a pup Patches size. Treating Cushing's does require more vet visits than usual and it does require powerful medications (NOT deadly medications ) so when presented with the decision of whether to test and treat or not you have to look at each individual pup. And you know Patches better than anyone. Simply getting him off the steroid cream might make a huge difference in the changes you are seeing. Seeing a specialist may present a solution for his feet not offered previously. An ultrasound may show his organs are in good shape for an old fellow. Diagnosing Cushing's is as much about ruling out other possibilities as it is ruling in the disease. So like I said in the beginning - I would start with those 3 steps before considering Cushing's testing like the LDDS or ACTH.

Regardless of what you choose to do, we will be with you all the way. You and Patches are now part of our little family here at K9C and you will never be alone again. Don't hesitate to ask questions, we will do our best to answer them. I'm glad you found us and look forward to learning more soon.

Hugs,
Leslie

[molly muffin]

Hello and welcome to you and Patches. Shih tzu's are so funny and adorable. Just love them. My molly was shihtzu/llasho mixed.

hmmm, you can use a non steroid, antibacterial on the skin issues. do they look like sores, red and angry? You can post a picture to your album here if you want to show us.

Is anything else elevated? It sounds like they want to do an ACTH test to check for cushings, not a bad option. At worst, they can get spastic for up to 48 hours after it, not all dogs react like that though. My molly did, she would become a ball of energy after testing. It doesn't hurt them though. Used appopriately, the meds can be fine for cushings. You just need to know the protocols for both dosage and followup testing and as Leslie mentioned they are now introducing in the US a new follow up testing option.

His other bloodwork is fine? Kidneys, liver, blood sugar, etc?

We look forward to hearing more about Patches. Welcome again

[Patches]

Hi Leslie,

Sorry for my delay in reply, things have been pretty crazy and every time I start a reply, I getting interrupted. So here goes again!

First, I want to say thank you so very much for your incredibly detailed response! It is amazing to have a resource like with such a wealth of knowledge.

I will attempt to answer all your questions:

Patches has been off IsaDerm for about a month now but I just went through an entire large tube of it in a 2 month period. So great exposure this time around. Previously, a tube that size lasted about a year... I used this tube strictly for his feel, so I may have cause more damage to both his Cushing's, as well as thining of his paw pads :-(

I have seen a dermatologist and he says that the indication is high that Patches is Cushings positive. The piece I did not know was that the IsaDerm alone could cause a type of Cushings. So you say that its possible for that type to completely go away after the cream is discontinued? How long would it take to know that? (Although, now that I have gone through the Vet records listed below, it seems the Cushing's discussions began prior to the use of the IsaDerm cream).

The Dermatologist did do a skin scrap but he was looking for some kind of parasite, this came up negative. I have circled back with him and he said Patches does NOT have Calcinosis Cutis.

Based on your recommendation, I have gone ahead and booked an appointment with an Internal Medicine Specialist this coming Tuesday, I was lucky to get in so quickly due to a cancellation. They mentioned they would would want to do both an Abdonimal Ultrasound and one of the Cushing's tests the same day. Unless something changes based on the examination, I will probably let them go ahead with the Ultrasound but hold off on the Cushing's tests until we have all the other information and results. Would you agree with this strategy?

Answers to your Cushing symptom questions:

Increased thirst and urination (polydipsia and polyuria, respectively) -
after I began the thyroid medication 2 years ago, his thirst and appetite increased greatly. In terms of urination, he has always been able to hold it for long period without any accidents indoors. We did move to a new home 3 months ago (the exact time his paw problems began to be treated), at this time he went through a period where he did start having accidents in the house and at the vet office. I am unable to tell if that was strictly due to stress but I can say, they have now stopped completely.

Increased hunger -
while he was always ravenous before (an increased like crazy after the thyroid meds began), I am experiencing the exact opposite now since the paw problems/antibiotics began. I have trouble getting him to eat now, and have to change food often to entice him to eat, which causes huge stomach issues. He has lost A LOT of weight and is essentially skin and bones, which is scaring me.

Increased panting - NO

Pot-bellied abdomen -
somewhat I guess, the Dermatologist seems to think there is

Obesity - NO, he is under weight

Fat pads on the neck and shoulders - YES, several

Recurrent infections of skin, ears, urinary tract, etc. - RECURRENT SKIN INFECTIONS ONLY

Loss of hair -
somewhat I guess, GP and Dermatologist say yes and seem to think what they see is consistent with a Cushing's positive dog

Lack of energy -
YES, he sleeps ALL the time, but we have stopped all exercise since the paw problems. I live in Canada where the winters can be harsh and so there is much salt on the roads. He also does not seem to have much energy and has lost much muscle in his hind legs so I really don't know if he could tolerate a walk or not. He also has trouble walking due to the paws. I just put little booties on him every time he goes in the back yard as to not further damage his feet as the yard is full of snow and ice, which thankfully is melting now. He can still go up and down the stairs but it is a large undertaking for him. I block the stairs when I am away as I do not want him to fall. When I am home, I try to ensure he doesn't do the stairs as they do think he has IVDD but he sneaks it in every now and then, god bless his determination

Inability to sleep (insomnia) - NO, but prior to the paw issues, there did seem to be some of this... he was waking me up every night, barking so I would take him outside. Now he doesn't even seem to ever really move. I have to pick him up. He will just stay in one spot. Also, he never barks anymore, ever... so wondering if there is something in his throat making him not want to bark....

Muscle weakness - YES

Infertility - he is fixed

Darkening of the skin - need further direction on what this means, but I do think I have noticed some of this...

Appearance of blackheads on the skin - Dermatologist says YES

Thin skin - I don't know

Bruising -
There have been 2 instances where he has had excessive bruising on his chest, near his neck. I have no idea what it was. I have pictures of this, showed the vet and they had no idea what it could be either. This sprung up very quickly both times and took about 2 weeks to fade away. At it's worst, the colours were purple and black. (I can post pictures, but I tried to find where to do that, and I don't seem to have a button to post pictures. Also, it's says I can't post any attachments, so maybe that's why??) Please let me know if or how I am able to do this?

Hard white scaly patches on the skin, elbows, etc. (associated with the disease Calcinosis Cutis) -
NO, the recurrent skin infections are being called: superficial PYODERMA (this is painful for him)

Neurologic abnormalities (circling, behavioral changes, seizures, etc.) -
None of the ones you mention, but the has been mention by my GP that he may have Alzheimers or Dementia - he can sometimes be found staring at walls or odd things like the toilet for extended periods. This is off and on. Right now he just sleeps most of the time.

In case it's helpful, he has lost most of his hearing (loud sounds only, this also seems to have better and worse episodes); he also has some cloudiness in his eyes and can not see as clearly as he used to, he needs light. (I know this is normal aging stuff)

In the past week or two, his nose is dry and rough... I am not sure if this is due to me wiping him and drying him off (due to clean up wet food) or maybe it's an indication of dehydration? He is not drinking as much. (Vet visit this week, thankfully)

Blood test result & vet analysis for the past couple years:

Sept 2015: (first mention of Cushing's by VET)
-UREA: 11.5 - HIGH (Normal range: 2.5 to 9.6)
-ALT: 108 - OK (N 10 to 125)
-ALKP: 1118 - HIGH (N 12 to 212)

Dec 2016
SAP: 6.46 (N 5 - 131) (other liver values WNL)
BUN: 11.2 (N <11.1), creat is 79 (N 44 to 141)
Mild thromocytosis
U/a sg 1.012
Urine Cortisol 16.82 (over 13 is consistent but not definitive for Cushing's)

Apr 2016 - skin lesions brought to attention of VET

July 2016 - 1st time IsaDerm was prescribed for skin lesions
T4: 22 - good
ALP: 717 - increased (may have bilary sludging)
WBC: 16.4 HIGH (N 4 to 15.5)
Platlets: 523 HIGH
Absolute Neutrophils: 11.81 HIGH
Absolute Monocyte: 1.15 HIGH
VET notes: ALP has been increased for SEVERAL YEARS - consider abdominal ultrasound

March 2017:
SAP: 2167 (N 5 to 160)
ALB: 25 (N 27 to 29)
HCT: 34%, RBC normal, MCV low, MCHC low
platlets - HIGH (persistent finding)
T4 - 10.1 (N 13 to 53), prev 22, 17
VET NOTES:
-new mass on back of neck - 2cm in diameter, skin mobile over it
-increasing SAP over time, high platelets (both consistent with Cushing's)
-mild low albumin, could be decreased intestinal absorption or liver disfunction (but glucose and BUN - ok)
-renal loss (can see proteinura w/Cushing's)
-low MCV (could be iron deficiency
-MCV, MCHC (can be hepatic failure - but glucose and BUN are ok)
-low T4, could be due to concurrent illness
Overall - other vet notes that findings are consistent with Cushing's and options are 1) further testing or 2) benign neglect is a VALID option at this stage

Aug 2017:
ALT: 338 prev WNL
SAP: 1401 prev 2167
BUN: 13.4, prev N (N range <11.1)
Creat: 54
platelets: 585 HIGH (N 170 to 400)
ALT (SGPT): 338 HIGH (N 12 - 118)
Alkaline Phosphatase: 1401 HIGH (N 5 to 131)
T4: 6, prev 10 (both low)

Vet notes: elevated SAP, SLT & platelets are consistent with Cushing's

Oct 2017:
T4: 14 (N 10 to 45), low end of Normal

Long post, so sorry...

Jennifer & Patches

[Patches]

Hi Sharlene,

I have posted some blood work as a reply to Leslie's message.

I don't seem to have an option to be able to post pictures, not sure if a setting needs to be changed, if possible please advise how to do so?

He has been off the steroidal cream for over a month and I am instead using a Dermatological soap. He has been on and off antibiotics for 3 months, He is again in his first week of a new round of them after being off for about a week and a half. I think the key this time might be to keep him on them for a good 6 weeks solid with no breaks. Unless the new specialist says different. I had been trying to keep him off antibiotics but it seems that I have no choice at this point because his paws have been such a problem

I thank you for the info re: Cushings testing, I did not anticipate any side effects of the injection... but I really hadn't got that far yet. Nice to have advance info!

As you will see the blood results in the other posts show elevated levels for various things that do seem to be worsening over time. I do know his liver has been elevated for a long time now. I need to reach out to my previous vet for previous results. I know that those results would vary, meaning every once in a while he did mention elevated liver enzymes but then they would go back to normal. I know this vet has retired so I have to see if the person who took over the practice still has those records.

Not sure about kidney results, which test or acronym is that?

Based on Vet notes, it looks like glucose has been fine all along.

Looking forward to further insight from you all.

Cheers,
Jennifer

[molly muffin]

Hi Jennifer,

Did you ever get an ultrasound done? Due to the high AlP and the comment about possible sludging, you would want to have a look at the gallbladder, liver, kidneys, adrenal glands (for any signs of nodule, tumor that could cause the cushings, although Pituitary tumor that is small is the most common cause)

For kidney test you are looking for BUN and Creatinine. I see you have both listed in Aug 2017 test. BUN high by itself is not necessarily anything to be worried about. Do you have the normal range for Creatinine from the lab work?
You could have a full urinanlysis done, and have them check for possible protein in the urine. An even earlier test for kidney issues is an SDMA. So things to mention to the IMS when they see him tuesday.

I'd take copies of all test with you to the IMS, just in case they don't get them before your appt.

As far as darkening of the skin pigmentation, it could be that where you see a white skin before it is now darker. It's easiest to see on the belly if that is light colored.

As far as posting pictures. You should be able to do this under your profile. You might have to go into your profile and change setting to upload photos. Mine is on the left hand side under albums but i don't see that option on your profile. Do you see anything that says albumns on your profile?

[Patches]

Hi there,

Patches had his ultrasound and some blood work done today. Not all results are back but what we do know is that his liver is not in good shape, they seem to think it is something called Hepatocutaneous Syndrome. The IMS and Dermatologist will discuss further tomorrow and then I will hear more. I was sent home with a slew of medications for his liver.

Cushing's may be there, as his adrenal's are a bit swollen but I have been told by IMS he is not healthy enough to test or treat that at the moment.

Prognosis is not good.

Very sad day.

Jennifer

[Harley PoMMom]

Sending hugs.

[Squirt's Mom]

How is Patches feeling?