Corgi diagnosed today w Cushing's - Sadie has passed

[Alsarve]

Ok, gonna try some numbers. Got a 2 hr nap, please excuse my sleep deprived brain. Sadie is finally sleeping comfortably in her favorite spot, the cold hard bathroom floor.
HEMATOLOGY
L Hemoglobin 13 (13.4-20.7)
H Reticulocyte 133 (10-110) comment: appropriateness of regenerative response should be evaluated due to degree of anemia and reticulocytosis.
H Neutrophils 13439 (2940-12670)
H Platelets 531 (143-448) comment: platelets clumped on blood film
Polychromasia & Anisocytosis are both "slight"
Slide reviewed microscopically, no parasites found.

[labblab]

Great, that’s an excellent start! These first results relate to blood cell counts (often labeled as “CBC” summaries). You should also have a page of blood chemistries (“Chem” panels), and also any specialized Cushing’s tests. But you’ve typed these cell counts just as we need to see them. Good job ;-).

Marianne

[Alsarve]

H Glucose 126 (53-114)mg/dL
H ALT 208 (18-121) U/L
H ALP 3539 (5-160) U/L
H GGT 23 (0-13) U/L

Sorry for so many posts. Have to post stuff before I fall asleep and erase stuff ��

[Alsarve]

Ok, looks like everything was normal in the urinalysis. Last thing on this paperwork is her cortisol.
H Cortisol 14.3 (2-6) ug/dl
Total T4 1 (1-4) ug/do

Remarks at the end of this bloodwork, which was done 11/14/18.
Both SDMA and Creatinine are within reference levels which indicate kidney function is likely good.

Her test for cushings, cant remember the initials, was the 8 hr test, done on 11/28/18. Sent into Michigan State and interpreted by Kent Refsal, DVM PhD, Professor Endocrinology.

Cortisol Baseline 135 (15-110) nmol/L
Cortisol low dose dex 4h 90 (0-30) nmol/L
" " " dex 8h 67 (0-30) nmol/L

Interpretation: There is incomplete cortisol suppression in response to administration of dexamethasone. These results support a diagnosis of hyperadrenocorticism, provided that the clinical signs and other test abnormalities are consistent. The extent of suppression of cortisol at 8h suggests this is more likely to be pituitary dependent hyperadrenocorticism. There is recognition of false positive adrenal function test results as a stress response to non-adrenal illness. Are there clinical features that do not fit well with hyperadrenocorticism?

[Alsarve]

I also had bloodwork run on her Aug 28th at another vet because she was vomiting and off her food, just not right. Here are some of the numbers to compare, from Aug to Nov 2018.

Glucose 121 mg/dl 70-143
ALT 144 U/L 10-125. HIGH
ALKP >2000 U/L 23-212 HIGH
This bloodwork wasnt quite as thorough. At this Sadie was panting but not all the time. And just started to show the muscle weakness a little more. Evidently I was wrong about the adrenal or pituitary part. Ok time for another quick snooze before Sadie's dose at 9pm. Thanks ladies! ❤

[labblab]

Okey Dokey, thanks so much for typing in all this info. Sadie does indeed exhibit some lab abnormalities that are consistent with Cushing’s: elevated neutrophils and platelets in terms of cell counts, and elevated liver markers on her chemistry panel. Her glucose is slightly elevated and her thyroid is low-normal, both of which can be associated with the high cortisol of Cushing’s. Her 8-hour LDDS test is indeed consistent with the pituitary form of Cushing’s. However, please note this important part of the LDDS interpretation:

These results support a diagnosis of hyperadrenocorticism, provided that the clinical signs and other test abnormalities are consistent... There is recognition of false positive adrenal function test results as a stress response to non-adrenal illness. Are there clinical features that do not fit well with hyperadrenocorticism?

What this is saying is that this test may show elevated cortisol readings when something other than Cushing’s is the true cause. The body can produce high amounts of circulating cortisol in response to the stress of other illnesses or injuries, as well. That’s why you want to make sure that actual observable symptoms of Cushing’s are also present, in conjunction with the elevated cortisol. And that’s where I worry a bit about Sadie’s diagnosis. This is what you’ve told us about her symptoms.

Almost forgot. No hair or skin issues that I have found. Appetite has gone down, water consumption up just a little. Pants pretty much non stop unless sleeping. Pot belly. Gets worn out super easy, just from walking.

Most all Cushpups exhibit excessive thirst/urination that translates into abnormally dilute urine with a low specific gravity, yet apparently Sadie’s urinalysis was normal. Her lack of appetite is also worrisome, and contrary to the norm for Cushing’s. The fact that all three of her liver markers are elevated can be associated with Cushing’s, but it might also indicate a problem that is more specific to the liver. So I’m not wanting to raise unnecessary questions in your mind about the diagnosis, but I do think some questions are there. If you don’t see improvement while taking the trilostane, and especially if things worsen, I’d stop the medication and rethink things. Although it would mean extra cost, an abdominal ultrasound might give you the most bang for your buck in terms of additional diagnostics. The imaging would allow you to see whether there are problems with Sadie’s liver or other internal organs that could account for her illness, aside from or in addition to Cushing’s.

So bottom line, please do keep us updated as to how she’s doing!
Marianne

[Alsarve]

The vet also did a radiographic of her abdomen (I know that's not the same as an ultrasound just forgot to add it in with the other info).
It says radiographic shows markedly enlarged liver and inflammation in the upper GI tract (duodenum and pancreas). Distended cranial abdomen and tenderness on cranial abdomen palpation.
My vet said it doesn't matter if I give Sadie her Trilostane with a meal or not. Does anyone think maybe my vet doesn't have enough experience w Cushing's?
Sadie didnt want to eat this morning, so I cooked her up a little venison burger so she would have something to have her meds with. Any thoughts guys?

[Alsarve]

Thank you guys. Sadie passed in my arms about 20 mins ago. glad she had some yummy meat before she crossed over that rainbow bridge.

[Squirt's Mom]

Trilostane MUST be given with a meal, not snack, meal. It is a fat soluble drug and without food the body will not absorb and use it. However, with Sadie not wanting to eat I would not be giving the Vetoryl. I continue to find the diagnosis suspicious especially in light of the liver enzymes. In your shoes I would ask for an abdominal ultrasound and liver testing. But that is me. My first cush pup came back with false-positives on ALL her testing because of a tumor on her spleen. When the tumor was removed her cortisol returned to normal. She did eventually develop conventional Cushing's. My second dog diagnosed with Cushing's had many pre-existing conditions and a necropsy (autopsy in animals) following her death proved she never had Cushing's. So I am highly cautious when the dog does not present as a typical cush pup and Sadie does not. I wouldn't rush into treating Cushing's right now but would want further, in depth, testing myself.

[labblab]

Sadie’s lack of appetite is a real concern to me. If she were my dog, I would not feel comfortable continuing to give her the trilostrane under these circumstances. For one thing, I wonder whether she might be suffering from pancreatitis — that could account for the lack of appetite and also pain (panting). Or a primary liver/gallbladder issue could be a problem.

As far as the food, your vet is incorrect that it’s OK to give trilostane on an empty stomach. The manufacturer is very specific that food is required for the medication to be properly absorbed. Plus, giving on an empty stomach could increase the likelihood of tummy upset.

Bear in mind that I am not a vet, but I don’t feel good about your vet’s advice right now. I’m sorry about the expense involved, but if Sadie was my own dog, I’d ask for a referral for a consultation with a specialist in internal medicine. I’d simply say that Sadie’s lack of appetite is a real worry for you, and you want to make sure there’s nothing else going on before continuing treatment. In reality, I simply don’t think it’s safe to give trilostane to a dog while it’s not eating and the source of apparent pain is unknown.

Marianne