Duffy - Cushing Testing

[ls1012]

Hi All,
My 10 year old Havanese has some of the symptoms of Cushing's. Heavy panting, exercise intolerance (he use to walk with me two miles up to a few months ago) now he can barely do 1/3 mile..... I do not force him and it has been very hot and so now I am just letting him go in the yard to go potty and right back in unless I go swimming in the pool I take him in and that seems to keep him cool for a while.

He also has a dry cough, especial after he barks he will cough. I video'd it and took it to my Vet to see. They said definitely a cough. So we started with X-Ray (Slightly collapsed trachea) followed by an Ultrasound of abdomen and heart. Abdomen shows the same as last few years. Liver is enlarged and heart echo showed slight mitral valve leak with slight thickening. Rest of heart ultrasound is normal. Cardio Vet said Mitral Valve leak to mild to treat at this point- re-check in 6 months. ALT and ALKP have been a little high for a few years. Now they are higher. (359 and 414) Denamarine does not seem to be holding enzymes down as well as it was last few years. Cushing's test on last Friday.

The results from Cortisol Serial 2 ACTH are as follows:
Pre
Post
Cortisol Sample 1 - 11 (High) (Lab comments said it should be between 1 and 5)
Cortisol Sample 2 - 7.5
Which test is the Resting Cortisol? I would think Sample 1 would be but it appears his levels went down if that were the case? Would that make sense?

Also what is IATROGENIC HYPERADRENALCORTICISM? It says it should be between 1 and 5 with little to no increase in post cortisol levels.
HYPOADRENALCORTISM- Resting cortisol is usually sub normal and less than 1. With no increase after ACTH.

Can someone help me with understanding these tests results? My Vet is on vacation and the other Vet in the practice sent me these results. My Vet will not be back until next week and I am a bit nervous until I can speak to her.

We go back this Friday for Bile tests on the Liver.
Any help with understanding this test is appreciated!
Thanks Much,
Lynn

[labblab]

Hello Lynn, and welcome to you and your boy. I apologize that I can’t write as lengthy a reply as I’d like right now, but I can start with a couple of quick thoughts. First, it is very unlikely that an ACTH would give a result where the first (resting) cortisol reading is significantly higher than the second (stimulated) reading. My best guess is that the two test tubes were accidentally reversed and/or mislabeled in conjunction with the lab submission and analysis. The other possibility is that the stimulating agent was ineffective. However, given the two numbers that were listed, I’d guess that the samples were simply reversed. If this were the case, then the result would still be negative for Cushing’s because I feel certain that 11 would fall within the normal range for a diagnostic post-ACTH test.

Iatrogenic Cushing’s refers to development of the syndrome secondary to a dog being given supplemental steroids such as prednisone. Dogs who are given steroids for sufficiently long periods of time can see disruption in their normal adrenal activity, and the development of the same symptoms that result from naturally occurring Cushing’s. The cure is simply to wean the dog off the steroids.

Hypoadrenalcorticism refers to Addison’s Disease, or the situation where the adrenal glands are not producing enough hormones (as opposed to producing too much).

So, turning back to your test results, we’re not exactly sure what happened that led to this odd result. If the samples were simply reversed, it is a negative result for Cushing’s. If the stimulating agent was ineffective, however, then the test was not accurate. Even when conducted correctly, one drawback to the ACTH is that it produces a fair number of “false negatives,” especially in the presence of an adrenal tumor (as opposed to a pituitary tumor). There is another blood test, the LDDS, that is less likely to miss making the diagnosis in a dog who does have the disease. So depending upon the outcome of the bile acid test, one alternative might be to retest with a LDDS. Another, different option might be to conduct an abdominal ultrasound in order to actually view the status of the adrenal glands, as well as the liver and other internal organs. The imaging might help provide additional clues as to what is at the root of your boy’s problems.

Marianne

[ls1012]

Thank you Marianne. I am suspicious as they changed the name of the lab work from another patients name to mine so what you are saying may be exactly right. I am not even sure they have the correct blood work for my dog. I am going to call my Vet's partner who gave me these results today as my Vet is away. I am a bit annoyed as I asked for the LDDS test as that is what the Cardio Vet recommended and for some reason they did not want to give it. Duffy is going back Friday for Liver Bile tests as his Ultrasound shows an enlarged liver and his ALKP and ALT is high again. Denamarine was working well but it seems it is not holding them down as well now (359 and 414). I am sure i will be back tomorrow with more questions after I speak to the Vet. I am learning even with dogs you have to be your own health advocate. Thanks again!

[ls1012]

Hi Marianne,

I am totally confused at this point. From everything i have read online and on this site (such as what you posted) the 1st cortisol level is supposed to be lower than the second cortisol level after they inject him. My Vet's partner is telling me that his level is supposed to go lower and if it went higher it would mean his body can't process the cortisol. I said well why is the pre level highlighted as HIGH (11) when it is supposed to be between 1 and 5? She said it could be high for lots of reasons including stress. OK, great answer. Doesn't solve a darn thing and don't think I even buy in to it.

Evidently there was confusion as to whose blood it was and she also explained to me the names on the vial was the correct name but the names inside the bags were wrong hence the name change on the lab notes. Also, I asked her why the blood work when we did not request it and she said because they made a mistake and did it.... In any case if this is true and it is my dogs blood work it shows his phosphorous is low (probably due to the home cooked diet they had me put him on that they said would help his liver issues but I don't see much of a change after a year or so now)..... However, I did some research and did see low phosphorous can cause breathing problems which could be a part of my boys problem.... In any case they sold me a new supplement vitamin holistic in powder form that should help the low phosphorous.

Which brings me to my next question. Has anyone here tried the pre-prepared raw diet? Maybe that would be a better solution for him. I am going to have to do some research on that.

I am thoroughly disgusted that my little Havanese is suffering and no one can seem to pinpoint the problem. Apparently who knows if my Vet even got the blood work right.... The cardio doc suggested the LDDS to begin with due to the panting and the ravenous appetite. There is an Emergency/Specialty Hospital by me that is very good. They did minor surgery on Duffy when his anal glands were impacted and also diagnosed a scratched cornea when his old Vet said he did not have one and referred me to an eye specialist who was wonderful. They specialize in oncology etc but do have a general internist on call and they told me I can bring him through ER tonight and they would have to take him. They said they may keep him over night but would work with me to try and find out what is going on. I took some videos of his labored breathing and coughing with my cell phone to show to them.

I am at a loss. I don't know what else to do. We have gone to the cardio doc- my regular vet. Nothing to really explain the breathing problem or the liver problem. As soon as he walks even inside in the AC he breathes heavy. If he gets excited forget it. The breathing and panting is horrendous. (you are talking a dog that walked two miles with me) up to two months ago. Other than that he has vomited twice in the last two days. I am not all that concerned about that as it has been a pattern on and off for several years with him. He sometimes does that on and off and then it stops. Like he hadn't vomited for over a month to Sunday. They attribute it to his high liver enzymes and enlarged liver although we do not know what is causing the enlarged liver. I have a Bile Acid Test scheduled with my Vet this Friday but I think she is about to not be my Vet anymore after todays ordeal. Maybe the specialty clinic can do it.

I am sorry to ramble but I am disgusted and sad.

Any advice or knowledge with any of these issues would be greatly appreciated. I do not know what to do at this point. I think we will pack ourselves up after I am done with work and take him to the ER/Specialty hospital. i called Pet Plan Insurance to see if he would be covered for the same issues and they said as long as it is a covered issue whether it be a 2nd or 3rd opinion he is covered. TG for Pet Plan. I would never be without it again....

Thanks for listening. - Lynn

[labblab]

I’m afraid your vet is flat-out wrong in maintaining that the expectation is for a diagnostic post-ACTH level to be lower than a pre-ACTH, regardless of whether a dog has Cushing’s or not. As you’ll see from the interpretation protocol given by IDEXX labs, for a normal dog without Cushing’s, here are the expected results:

Pre-ACTH: 2 - 6 ug/dL
Post-ACTH: 6 - 18 ug/dL

For a dog with Cushing’s, the expected post-ACTH result is even higher.

http://www.idexx.fi/pdf/en_ie/smalla...n-protocol.pdf

And per noted endocrinologist, Dr. Mark Peterson:

In normal dogs, administration of ACTH produces a rise in serum cortisol to values usually >10 μg/dl (>300 nmol/L). In contrast, dogs with Cushing’s syndrome (because of the increased thickness of the adrenal cortex) tend to have an exaggerated cortisol response to ACTH administration, with post-ACTH serum cortisol rising to concentrations >20 μg/dl (>600 nmol/L).

So, yes, your vet is correct that stress can elevate cortisol levels. But that doesn’t change the nature or expectation of the results from an ACTH stimulation test. It is named a stimulation test for a reason — because the injection stimulates the production of cortisol as opposed to suppressing it. On the other hand, the LDDS is a suppression test, and involves an entirely different physiological mechanism. Perhaps your vet is confusing the two tests, but that’s not a comforting thought. So I still think there was something wrong with your dog’s ACTH test.

I can’t disagree with your desire to get a second opinion from an internist. Cushing’s may still be a possibility, but something else may be involved , too. Aside from the panting, exercise intolerance, and liver abnormalities, does he exhibit any other outward symptoms that are typical of Cushing’s such as excessive thirst and urination, excessive hunger, skin and coat problems, pot belly, seeking cool spots, hindend muscle weakness, etc.?

Marianne

[ls1012]

Thank you Marianne. Yes, he exhibits excessive hunger to the point of crying when it is time to eat and gulps it down and looks for more. He has a slight pot belly and always seeking out cool spots. Either where he can feel the AC in the summer or the tile floors. He will cuddle with me when it is very cold in the winter just for a while and then get up and move. He also has the dark marks on his belly that he did not have. I realize there may be something else wrong and it may or may not be Cushing's but I would like to at least rule out Cushing's as my Cardio Vet said that would be a good place to start because of his panting and excessive hunger etc. Right now all I am getting is - "it could be this and it could be that" but I am just spinning in circles with "maybe" which is not helping my dog or my pocketbook, more importantly my dog..... The only one who seemed to know what he was talking about was the Cardio Vet as after the EKG and Ultrasound diagnosed slight mitral valve thickening and leakage but not severe enough to be treated. (No fluid in abdomen on x-ray) Re-check in 6 months. If it is not Cushing's then we need to move on to the next test. Bronchial scope tests for the breathing was also recommended as a possibility? But I don't want to skip something that is not an invasive test before we move on to more invasive tests. I don't want to miss something because of ignorance or mistakes. If my Vet does not know the difference between an ACTH and LDDS test I do not feel comfortable returning to them......

[labblab]

I can only imagine how frustrating and upsetting this is for you! Out of curiosity, did the vet explain why they ran an ACTH instead of the LDDS that you requested? That really doesn’t make any sense to me because the stimulating agent for the ACTH can sometimes be hard to acquire and is quite expensive. Cynical person that I am, I wonder if they had some of that agent left over from another dog and wanted to go ahead and use it and bill for it. I know it’s all water under the bridge now, but there’s a lot that’s puzzling about how they handled things.

One thing you might do is just book a regular appointment with an internist as opposed to going through the ER approach which would likely be a lot more expensive than just an office visit. You may need a referral for the internist, but your regular vet ought to be bending over backwards to help you get some answers right now. Perhaps the cardio vet could recommend an internist to you?

I totally understand and agree that you’d like to start with the less invasive stuff first, and a LDDS might be a good first step. I feel like your old practice owes you that test since that’s what you requested. But heck, who knows if they’d mess that up, too. So maybe it would be worth it to have a preliminary consultation with an internist and arrange a LDDS through him/her if they agree that it’s a reasonable place to start.

Marianne

[Joan2517]

What about just testing his cortisol level like we did with Gable? That gave us the diagnosis after years of trying to find it.

[labblab]

Hey Joan, in quickly looking back, it was an ACTH stimulation test that ended up diagnosing Gable:

Okay, well Gable's ACTH results are in:

Cortisol Sample 1: 5.1 HIGH / ref range: 1.0 - 5.0
Cortisol Sample 2: 23.8 HIGH / ref range: 8.0 - 17.0

So his result demonstrated the pattern we’d expect from a Cushing’s dog. His post-ACTH was elevated above the range we would have expected for a dog without the disease. I sure wish I thought that Lynn’s little boy’s ACTH was conducted properly, but I just don’t know. Plus, if I’m recalling correctly, Gable had tested negative on LDDS tests prior to finally getting this positive on the ACTH. So it just goes to show that sometimes multiple testing is necessary to finally get to the bottom of things.

Marianne

[Joan2517]

You're right, Marianne. We did it before he started the Vetoryl. I mixed it up with the pre-pill testing. And yes, Gable tested negative on two LDDS tests prior.