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  1. #1

    Default Dog Diagnosed and feeling unsure about diagnosis and treatment

    Hello,

    My dog, Winston, a 12 yr (almost 13yr) old pit/chow/boxer mix was diagnosed with Cushing's last week. I had actually suspected it for close to 3 years now but each time I asked any general vet if that's possible they seem to be convinced his problems were due to a GI issue or disease. Two weeks ago my dog became listless and I took him to the ER where they took his vitals. He had a high respiratory rate and was running a fever. When I finally met with an ER doctor she asked me his acute symptoms (one bout of diarrhea earlier that afternoon but really nothing else other than feeling too weak to walk and the fever and refused to eat). I then went over his changes and symptoms historically and she said, "He looks like a Cushing's dog" then told me she suggested they do full lab work (CBC, Urinalysis and Culture in case it was a UTI) and an ultrasound. Well bloodwork showed show abnormal numbers and ultrasound found that his small intestine was thickened (has been for a while), his bladder was partially distended, liver was inflamed and both adrenal glands were enlarged. His last ultrasound prior to this was back in March 2018 that showed normal adrenal size and everything else was normal except for the thickened small intestine.

    Anyway, long story short, he was given fluids, pain medication because his abdomen hurt upon palpation and I decided to take him home rather than hospitalize him. They also gave me Metrodizanole (?) to take home. The following morning his poop was completely normal and thereafter so I did not give him the metrodizanole. A few days later I had an appointment with an Internist at a vet speciality hospital. The internist seemed young (think she just completed her residency this past year) and immediately wanted to test for Cushing's disease. She didn't mention any other possibilities. Just immediately went off on the whiteboard and explaining cushion's and the two tests. Her recommendation was the ACTH stem test and a cPL (?) test for pancreatitis. She explained why she preferred ACTH over LDDS, but I can't remember why that is now. So they took him and the following day the results came back and she confirmed his diagnosis as positive for Cushing's.

    Here's where I'm beginning to question the diagnosis now, even though I suspected it for years. She told me it was a complex disease to diagnose. So the fact that I literally got a diagnosis based on just the ACTH stim test has me questioning everything and maybe feel like she's not begin thorough enough to find out what is really wrong with him. So I asked her why she was so confident just from that test and she said it's also because of his clinical signs and symptoms, his ultrasound showing two enlarged adrenal glands combined with the ACTH stim test which was positive and when all those are combined there is high confidence of Cushing's. Am I being paranoid now? Now I'm worried there are actually other problems and maybe it's not Cushing's. Sometimes I wonder whether he is simply just Hypothyroid? His symptoms are:

    -Ravenous Appetite (3 years now)
    -Distended Abdomen (3 years now)
    -Loss of hair on his tail, around his neck and around shoulders where his harness sits, a bit on the underside of his belly and underside of his thighs (gradual loss of -hair over the last 3 years)
    -The hair all along spine to where the tail meets is very rough in texture (just started this summer)
    -Increased thirst (just started this summer - vet blamed it to UTI)
    -He is NOT incontinent, no house accidents, can hold it in up to 8 hours
    -A hell of a lot of muscle mass loss. He's gotten very bony, can see and feel his ribs. The vet gave his body score a 3...but his appetite is through the roof and we feed him the same amount as he always had before, maybe if not more and have had a hard time getting him to put on weight. His spine has been sticking out severely for a couple of years now. It was one of the first symptoms along with the slow loss of hair on his tail.
    -His skin used to be pink/whitish and now has varying degrees of black spots (3 years now)
    -Oily dandruff (1 year now)
    -Strange clusters of tiny black scabs developing under the arm pits (just this summer)
    -weird skin nodules across his body (popped up over the last 3 years)
    -He DOES not pant but his breathing, always closed mouth and through his nose, sounds labored (started a year ago) when he's sleeping at night and snores now.
    -Sleeps all day long, lost interest in long walks, does not hang with his people anymore, stays in the bedroom, only shows excitement when treats or food is involved. (for a while now)

    Should I be questioning my dog's diagnosis?? Does this sound familiar? Does it seem odd that after just one visit and one test with the Internist that the diagnosis is confirmed??

    Thanks everyone.
    Last edited by Winston's Mom; 12-11-2018 at 10:24 PM.

  2. #2
    Join Date
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    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    Here's where I'm beginning to question the diagnosis now, even though I suspected it for years. She told me it was a complex disease to diagnose. So the fact that I literally got a diagnosis based on just the ACTH stim test has me questioning everything and maybe feel like she's not begin thorough enough to find out what is really wrong with him. So I asked her why she was so confident just from that test and she said it's also because of his clinical signs and symptoms, his ultrasound showing two enlarged adrenal glands...
    Hello, and welcome to you and Winston! We’re really glad you’ve found us. In honesty, what your specialist has told you sounds accurate to me. Unfortunately, there is no way to know with certainty that Cushing’s is the “correct” diagnosis for any dog. Different puzzle pieces have to be considered, and if enough indicators point to Cushing’s, then confidence in the diagnosis increases. Winston does seem to check off a lot of the Cushing’s “boxes,” with the ACTH stimulation test being the final puzzle piece. There are only two lab tests that are specifically diagnostic for Cushing’s: the ACTH and the LDDS. And the ACTH is actually the more “specific” of those two tests, meaning it is less likely to return a “false positive” in the event that some other illness or injury is actually at play instead of Cushing’s. Perhaps that’s why the specialist preferred it in Winston’s circumstance.

    So short of also performing an LDDS, there really is no other specialized testing available at this point. Having said that, we can review a few aspects of Winson’s previous testing in order to see how the puzzle pieces fit. When you took him to the ER, you mention that he exhibited certain lab abnormalities. Can you tell us more about them? Cushpups typically have elevated levels of ALKP — sometimes huge elevations — as well as higher levels of other liver markers, as well. Cholesterol, triglycerides, and platelets may also be high, and irregularities in certain white blood cell counts can occur. Urine is typically dilute, with low specific gravity. And you mention hypothyroidism — is Winston’s thyroid level within normal range? Low thyroid readings can be secondary to Cushing’s and rebound once cortisol levels are well-controlled, or hypothyroidism can be a genuine problem in its own right. It’s true that hypothyroidism could be responsible for some of Winston’s issues, so knowing more about his thyroid status will be helpful to us.

    Once we know more about any of these other possible clinical abnormalities, we can better judge the likelihood that Cushing’s is at play. However, given the ultrasound results in addition to the other testing and symptoms that we already know about, I’m guessing your specialist is giving you an accurate assessment thus far of the diagnostic challenges/realities associated with Cushing’s. Have you discussed treatment options yet, should you decide to proceed with that?

    Marianne

  3. #3

    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    So happy to have found this forum! Here are my dog's lab results. FYI, the labs results that they emailed me from the ER (CBC and UA) look totally different format wise from what I'm used to seeing from my regular vet's office. Those typically include more footnotes and information. Also, I don't see any thyroid value in any of these tests.

    CBC Panel I'm posting what was outside normal range - or results I'm unsure of..

    ALT 154 10-125 U/L
    ALKP 330 23-212 U/L
    CHOL 510 110-320 mg/dL
    Cl 108 109-122 mmol/L
    MCV 60.1 61.6-73.5 fL
    MCH 21.1 21.2-25.9 pg
    WBC * 19.09 5.05-16.76 K/μL
    NEU * 16.74 2.95-11.64 K/μL

    There was no range for these...I don't really understand what this means or what it is?
    %NEU * 87.6 - %
    %LYM * 9.0 - %
    %MONO * 3.1 - %
    %EOS * 0.2 - %
    %BASO * 0.1 - %

    EOS * 0.03 0.06-1.23

    Urinalysis
    (there were no normal ranges for reference..so i don't know what this all means? but specific gravity and PH had a green line marker on some scale - i guess that's good?)
    COLLECTION METHOD CYSTOCENTESIS -
    COLOR YELLOW -
    CLARITY CLEAR -
    SPECIFIC GRAVITY 1.025 -
    GLUCOSE NEGATIVE -
    BILIRUBIN NEGATIVE -
    KETONES NEGATIVE -
    BLOOD 2+ -
    PH 8.0 -
    PROTEIN 2+ -
    UROBILINOGEN NORMAL -
    WBC 2-5 0-5 HPF
    RBC 20-30 - HPF
    BACTERIA NONE SEEN -
    EPI CELL RARE (0-1) -
    MUCUS NONE SEEN -
    CASTS NONE SEEN -
    CRYSTALS NONE SEEN -
    SOURCE URINE_CYSTO -

    ACTH STIM RESULTS:

    Time 1 PRE CORTISOL SAMPLE 1
    5.4 (HIGH) 1.0-5.0 ug/dL

    Time 2 POST CORTISOL SAMPLE 2
    21.7 (HIGH) 8.0-17.0 ug/dL

    HYPERADRENOCORTICISM (HAC): Post ACTH results greater than 20 ug/dL
    (dog) and greater than 15 ug/dL (cat) are consistent with HAC.

    NOTE: ACTH results should always be interpreted in light of clinical
    signs. False positive results may occur with stress or non-adrenal
    illness. In addition, exogenous steroids may be measured by the assay
    and result in falsely elevated cortisol levels. Because of wide
    variability, resting (basal) cortisol should not be used to rule-out
    or diagnose HAC.

    IATROGENIC HYPERADRENOCORTICISM: Resting cortisol is usually between
    1-5 ug/dL with little to no increase in the post-ACTH cortisol level.

    HYPOADRENOCORTICISM (HOC): Resting cortisol is usually subnormal
    (less than 1 ug/dL) or low normal with no increase after ACTH.

    POST-LYSODREN: Pre & post cortisol levels after Lysodren loading or
    while on maintenance Lysodren should be between 1-5 ug/dL.

    POST-TRILOSTANE: Pre & post cortisol levels between 1.5-9.1 ug/dL
    indicate optimal control.

    cPL
    Chemistry
    12/4/18 (Order Received)
    12/4/18 7:35 AM (Last Updated)

    Spec cPL 264 0 - 200 ug/L H

    Serum Spec cPL concentration is increased and pancreatic inflammation is
    possible. Consider additional diagnostics and/or treatment if clinical signs
    or other evidence of disease exist. Recheck cPL in 2-3 weeks.

  4. #4

    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    Additionally, the specialist also just days later diagnosed him with Pneumonia. Also a bit puzzled...I did mention that there was one afternoon we were in the car and we heard him have 3 small coughs in a row. We weren't even sure if they were coughs or sneezes honestly. Just a random thing that happened. A few days later he sneezed when we walked out of our unit to go for our morning walk. After his sneeze I saw cloudy discharge from one nostril. I also described his breathing sometimes sounded wet at times, like he had boogers in his nose even though he had a runny nose for a while but it was clear except for that one time he sneezed. So I brought him in for a chest x-ray. She came back into the room and immediately said, "he has a little pneumonia" and immediately put him on Baytril. A few days later when I received an email with a summary of the visit and radiology report of the chest X-ray it mentioned "wet cough" which I never said and it said the X-ray was consistent with a case of Pneumonia, but then it also mentioned about considering PTE since the dog is Cushing's? My dog has had no other symptoms since then - now I'm questioning the Pneumonia diagnosis. I never know how much faith and confidence I should be putting into vets now ever since I spent the last 3 years of several vets telling me Winston could have this or could have that, or not looking further into abnormal lab work. *sigh*

  5. #5
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    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    Yeah, I sure do understand why you have a lot of reservations and questions about the whole diagnostic process. I tend to question most everything I’m told, myself (needless to say, that makes me not-the-most-popular patient and pet-parent on the block...;-). But definitely keeping in mind that I am not a vet myself, here’s some observations.

    Several lab abnormalities are consistent with Cushing’s: elevated ALT, ALKP, cholesterol, overall white blood cell count, and neutrophils; low eosinophils. At 1.025, the specific gravity of Winston’s urine would probably be considered only moderately concentrated and somewhat below a preferred range. The presence of both blood and protein in his urine can also be associated with Cushing’s-related changes in his kidneys. Also, I’m guessing the possibility of the PTE was mentioned because there seems to be a higher risk of blood clots forming in Cushing’s patients. Cushpups are also more vulnerable to infections, in general, and that could account for the vet’s decision to treat any possible pneumonia or respiratory infection with an antibiotic. Last but not least, Winston’s cPL was a little bit elevated, but I don’t know whether the vet didn’t feel as though his clinical symptoms warranted additional concern in that regard.

    And actually, that’s not quite the last thing — given Winston’s symptom profile, I’d be quite surprised if nobody has checked his thyroid status. It would appear as a “T4” reading on a blood chemistry panel. If the T4 level is out of range, then more involved blood testing can be done in order to better clarify whether a genuine thyroid issue exists. If his thyroid function truly hasn’t been evaluated at all yet, that’s one thing that I’d want to pursue further. As I said before, hypothyroidism doesn’t explain all his abnormalities, but it could play a role.

    So, bottom line, Winston really does check an awful lot of those Cushing’s “boxes.” At this stage, it does sound to me as though it’s a likely diagnosis and I would be considering treatment if he were my own dog and I felt as though the symptoms of the disease were really diminishing the quality of his life.

    Marianne

  6. #6

    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    Quote Originally Posted by labblab View Post
    Yeah, I sure do understand why you have a lot of reservations and questions about the whole diagnostic process. I tend to question most everything IÂ’m told, myself (needless to say, that makes me not-the-most-popular patient and pet-parent on the block...;-). But definitely keeping in mind that I am not a vet myself, hereÂ’s some observations.

    Several lab abnormalities are consistent with CushingÂ’s: elevated ALT, ALKP, cholesterol, overall white blood cell count, and neutrophils; low eosinophils. At 1.025, the specific gravity of WinstonÂ’s urine would probably be considered only moderately concentrated and somewhat below a preferred range. The presence of both blood and protein in his urine can also be associated with CushingÂ’s-related changes in his kidneys. Also, IÂ’m guessing the possibility of the PTE was mentioned because there seems to be a higher risk of blood clots forming in CushingÂ’s patients. Cushpups are also more vulnerable to infections, in general, and that could account for the vetÂ’s decision to treat any possible pneumonia or respiratory infection with an antibiotic. Last but not least, WinstonÂ’s cPL was a little bit elevated, but I donÂ’t know whether the vet didnÂ’t feel as though his clinical symptoms warranted additional concern in that regard.

    And actually, that’s not quite the last thing — given Winston’s symptom profile, I’d be quite surprised if nobody has checked his thyroid status. It would appear as a “T4” reading on a blood chemistry panel. If the T4 level is out of range, then more involved blood testing can be done in order to better clarify whether a genuine thyroid issue exists. If his thyroid function truly hasn’t been evaluated at all yet, that’s one thing that I’d want to pursue further. As I said before, hypothyroidism doesn’t explain all his abnormalities, but it could play a role.

    So, bottom line, Winston really does check an awful lot of those Cushing’s “boxes.” At this stage, it does sound to me as though it’s a likely diagnosis and I would be considering treatment if he were my own dog and I felt as though the symptoms of the disease were really diminishing the quality of his life.

    Marianne
    Marianne

    Glad I'm not the only one who scrutinizes a bit! In my mind, there are lots of little telltale signs that dog may not show when we are actually at the vet, behavior wise as well, and often times I'm not the best at always describing things. Additionally, I have this perception that because the vets see tons of dogs day in and day out that after a while the are just trying to move patients in and out throughout the day and do not spend as much time really talking things out with me. That being said, I want to believe the Cushing's Diagnosis but I also want to feel like other possibilities are being explored just to rule anything else out. I think the specialists very quick diagnosis was a surprise to me!

    I checked the the last CBC again and there isn't a T4 level there. I'm guessing because he came in sick so they assumed it would likely be low anyway but all three of his last CBC panels showed low T4 level. Each were with different vets. Two vets said it could be temp. caused by him being unwell. One of those vets did do some further testing on thyroid. Results were as follows:

    Total T4 0.7 1 - 4 μg/dL L
    Free T4 0.4 0.6 - 3.7 ng/dL L
    Free T4 (pmol/L) 5.1 7.7 - 47.6 pmol/L L

    cTSH 0.11 0.05 - 0.42 ng/mL

    She said because his TSH level was normal that he was not Hypothyroid. I also just found another test result during that same testing. It is Cortisol level. I don't know if it's in the blood or urine. Is this the Urine:Cortisol ratio that is initially used to rule out Cushing's??
    Endocrinology
    3/14/18 (Order Received)
    3/16/18 5:14 PM (Last Updated)
    TEST RESULT REFERENCE VALUE
    Cortisol 4 2 - 6 μg/dL

    Aside from Cushing's and Hypothyrodism concern, I'm now beginning to become considered about his Kidneys. Could he have early Kidney disease? Over the summer there was bacteria in his urine. It was a free catch and a culture was made with the free catch urine. His only UTI-like symptom was drinking more (which has not resolved since then). I'm wondering if the bacteria was already present in the pan from doing the free-catch and he was placed on unneccessary antibiotics and whether this all points to early-onset Kidney disease - most recently his back legs have gotten extremely weak.

    My overall hesitation and stress over the last week since his diagnosis has been treating him with Trilostane. I've heard that the adverse effects could be worse than the disease itself and the damage it can do would be irreversible. I'm having incredible anxiety over this, yet at the same time I want to improve the quality of my dog's life - the major symptoms that are most important to me on improving is bring his appetite back to normal, his energy level back to where it used to be and improving his muscle tone. I've looked into alternative methods, but I don't know how much affect they will truly have. My biggest fear is poisoning my dog with drugs and possibly affecting his own body's response to stress and illness if his cortisol is suppressed.

    The specialist recommended I switch his raw diet to a cooke one and that I only give him low fat food now, in addition to treat the Cushing's with Trilostane at a dose of 30mg 2x/day. He is currently 43lbs (19.7kg). I asked the vet if that dose was too high and she said it was a very low dose for him.

    My other hesitation with starting him right away is that in 5 days we will be traveling back to the east coast for the holidays. This means that we won't be here with the specialist to do the initial ACTH stim test after starting treatment with Trilostane. So a part of me wants to wait until we are back home after the New Year but now I'm wondering if my dog's situation is grave and whether or not me waiting another 3 weeks to begin could mean further deterioration in my dog's health. I should note that Winston will be traveling back with us and we could possibly do the ACTH stim test in New York but I don't know if that is wise or not?

    Should I call my regular vet and ask to do a proper Hypothyroid panel? I had read somewhere that there is a very specific test for this other than what my vet had done earlier in the year.

    Thanks for all your advice. I'm so new to this.
    -Olivia
    Last edited by Winston's Mom; 12-12-2018 at 06:49 PM.

  7. #7
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    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    Kudos to you for reading up on Vetoryl! I know it's scary starting your furbaby on treatment but we are here and will help in any way we can, we are the best hand holders!

    Adverse effects are usually only seen when the dog is started out at a too high a dose. Diarrhea, inappetence, lethargy are some ill side effects so if you should see any one of those symptoms the Vetoryl needs to be stopped, also, if Winston would start acting not like his "ole" self than you would need to stop the Vetoryl, remember you know Winston best so if he would act off in any way cease the Vetoryl.

    Muscle mass takes a long time to improve, that ravenous appetite should calm down within 2 weeks of treatment.

    Lori

  8. #8

    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    I am so so thankful that this group exists and that there is such a vast knowledge and first hand experience of Cushing's from actual dog owners and I think that is pure gold. I am very scared for my senior puppy but feel a bit better knowing you and everyone here is able to support me through this journey!

    Olivia

  9. #9
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    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    Hi and welcome to you and Winston from me as well!

    One question I have is; was pancreatitis confirmed, and if so, what were the results of that specific test?

    Lori

  10. #10

    Default Re: Dog Diagnosed and feeling unsure about diagnosis and treatment

    Quote Originally Posted by Harley PoMMom View Post
    Hi and welcome to you and Winston from me as well!

    One question I have is; was pancreatitis confirmed, and if so, what were the results of that specific test?

    Lori
    The specialist confirmed Pancreatitis. I asked her if it was just an acute episode or chronic and she said "chronic". I'm puzzled as to where she came to that conclusion.
    Results:
    cPL
    Chemistry
    12/4/18 (Order Received)
    12/4/18 7:35 AM (Last Updated)

    Spec cPL 264 0 - 200 ug/L H

    Serum Spec cPL concentration is increased and pancreatic inflammation is
    possible. Consider additional diagnostics and/or treatment if clinical signs
    or other evidence of disease exist. Recheck cPL in 2-3 weeks.

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