Pookie - Dog not eating and has Cushing's

[fkhan]

Hello,

My baby Pookie, which is a 15 ½ year old Pekingese has been suffering from Cushing’s for a year. The vet advised not to treat until the water and food intake excessively increased. She started of with panting and has had acth, low & high dose dex. The vet feels it’s pituitary based. Recently, I took her in because I wanted to start Trilostane with her, but her Kidney values were high after the Vet did another ACTCH test. They also found a minor UTI, which I’m hoping her Kidneys were high. After this test, my Pookie was excessively panting and listless/lethargic. Brought her to the ER for IV’s and antibiotics and her Kidneys got normal again. Now the main concern is her weakness and her lack of appetite. She doesn’t eat much at all and I’ve been feeding her Gerber baby food by syringe. Before the recent ACTH test, Pookie was doing pretty good. I had her on melatonin, lignans, ginkgo, adrenal harmony, fish oil, and denamarin advanced for her liver. Now I’m extremely worried about her and hate Cushing’s. I just started to give her the supplements she has been used to, because she has been off of them for 10 days. Maybe these supplements were helping her all this time, but I want to do everything I can for her. Her right eye is red too, which has got me worried. The vet gave antibiotics for the eye, but it didn’t change anything. Luckily, I have been on vacation this week and have been able to help my Pookie get by. She was running before the ACTH test and after that, Pookie went downhill. I don’t know if it was Adrenal fatigue, Macroadenoma possibility (loss of appetite and red eye), or her being off her supplements. She has been through so much the past 10 days and was going to have an MRI done, but held off to give her a break. Any clues, suggestions, or feedback would be appreciative. Pookie has a half sister who is older and is doing just fine. Pookie sleeps well, but her weakness and loss of appetite has me very concerned. I know she is old, but her blood tests are pretty good given the circumstances. She has always been a strong girl, and still carries herself outside to pee, but it’s challenging for her. I know that day may come for me to put her down, but if it’s Cushing’s that’s causing this or Old Age, I don’t want to put her down if something can help her. Sorry for all this info,
FK

[Harley PoMMom]

Hi and welcome to you and Pookie!

I am so sorry your precious girl is not feeling well, and I understand how worried you must be about her. Getting her to eat, I believe, is the most important thing right now. Baby food is good as long as it doesn't contain any onion or onion powder. Another thing you may try is boneless, skinless chicken breast (baked, boiled) mixed with some very mushy rice, if she doesn't like the chicken you could give her lean hamburger instead.

Could you post the results of all tests that were performed on Pookie? We need only see those values that are marked abnormal with their reference ranges and units of measurement...as an example ALT 150 (5-50 U/L)...thanks! Has the vet mentioned about performing a SDMA test for the kidneys? If not, I do recommend having this test done.

Please know we will help in any way we can, and if you have any questions don't hesitate to ask them.

Lori

PS...Here's a link to a thread regarding inappetence in dogs: https://www.k9cushings.com/forum/sho...etence-in-dogs

[fkhan]

Just got back from the vet and her blood looks good, but they think it's a Macroadenoma. I'm preparing for the end, but don't want to. Her ACTH base was 181 and post was 494

[Harley PoMMom]

Just got back from the vet and her blood looks good, but they think it's a Macroadenoma.

I am so sorry that Pookie may have a macrotumor and my heart breaks for you both. I'm including this reply from one of our Administrators, Marianne, to a member whose dog was diagnosed with a macro because I believe it has information you may be interested in:

I am not surprised to hear this news about the tumor, but also very sorry that yet another major challenge - and major decision - may now be facing you. Through the years, we've had members who have undergone a variety of treatments for enlarging macrotumors. Initially the only option here in the U.S. was the prospect of over a dozen traditional radiation treatments over the span of a month, with general anesthesia required for each procedure. Over time, more specialized options have been introduced in some centers, including cyberknife-type treatment that only requires a very few sessions, and also actual surgery. Returning to Dr. Bruyette, he helped pioneer successful canine surgery as a joint effort between UCLA and Cedars-Sinai Hospital in L.A. One of our very own members, Lucy, was his first patient in that pilot program, and I believe surgeries are still bring done there on select patients. Here are some write-ups:

http://dogaware.com/articles/newscushingssurgery.html

https://www.cedars-sinai.edu/Researc...st-Friend.aspx

We've also had members who have received advanced treatment at UC Davis and Washington, among other centers. I think Florida may also offer advanced options, as well. As you might expect, results have been variable. Some dogs have had very good responses and remained neurologically improved for an extended period of time. Some have not. Some have had an extended respite from Cushing's treatment. Others have had to continue with Cushing's treatment even though the tumor size was reduced enough to relieve neurological symptoms. I think a lot will depend on the actual location and dimension of the encroachment, as well as the vets' assessment of Yogi's overall viability as a treatment candidate.

Age may be a factor in his candidacy and also your decision. I'm guessing he may now be eleven. I've not had either of my two retrievers (Labs) reach twelve, with or without Cushing's. So one consideration may be the length of his expected lifespan, even with successful treatment. In other words, would he really have enough quality time left to gain from an invasive intervention. However, on the flip side, if he could benefit substantially from 2-3 cyberknife sessions and affordability was not an issue for you, then maybe that would be a worthwhile option.

I'd say, let's see how the actual MRI report reads, and then see what your vet recommends. And then we'll be here to talk over all your options.

Marianne

We also have a thread dedicated to macroadenomes so I'll include a link to it too: https://www.k9cushings.com/forum/sho...ht=macrotumors

Her ACTH base was 181 and post was 494

Was this Pookie's initial ACTH stimulation test used to diagnose her Cushing's? Also, could you post the abnormal lab values from her Chemistry and CBC blood work test results?

Hugs, Lori

[fkhan]

Pookie had an ACTH Stim last year and didn't show she was cushinoid. The low dose dex did, but did not show from where. I pushed for a high dose dex to find answers, but still no answers were found. She failed to suppress on the high dose test. Given all the costs, it may be wise for new cushings owners to have both an ultrasound and MRI done if the dog is a candidate for anesthesia. If I had to do it over, I would have gone this route, because the truth will set you free. Not knowing is stressful in itself and just treating clinical signs and lab work is treating on probability and not the truth. Just my opinion from everything Pookie and I have been through. Also, I worry that when a dogs has cushings and we inject more sterioids into them for these tests, it has to hurt them in some way, because if they are already stressed and in that Fight of Flight moment, why do we want to add to that... An ultrasound and MRI could alleviate all that stress.

[labblab]

Hello to you and little Pookie. I’m sorry I have only a moment to write this morning, but I wanted to explain that we have merged your two threads together so as to create one single, unified thread about Pookie’s diagnosis and treatment decisions. This way, with all of her history consolidated, it’ll be easier for our members to follow along with any new developments.

I know you have some big decisions facing you right now, so I’m really glad you’ve found us!

Marianne

[fkhan]

I also wanted to add that the MRI that was done on Pookie reflected a stroke. After doing some research, it appears that dogs with Cushings could have strokes. I don't know when she had it, but I feel she must have had it between the time of her cushings clinical signs and now. Just for you future cushing's pet owners. The sooner you get cushing's under control, the better. I also read that adrenal tumor based cushings reflect less clinical signs than pituitary based cushing's regarding water intake and peeing.

[fkhan]

Poor little Pookie's Kidney values are up again. She has been on metrondiazole for the past 5 days. Here is her history. We are going to try iv's for 2-3 days and my vet doesn't think the cushings is causing the kidney values to rise; BUN, Creatinine, and Phoshourus. CPL showed a slight positive for Pancreatitis. I hope I don't have to put my baby down and am dropping her off tonight for IV therapy.
Progression or History:
Pookie has a medical history of suspected cushings disease (diagnosed 2018) and has been mangaged with a home made diet and herbal supplements. She also has a history recurrent UTIs which has been resolved with antibotics, chronic increased liver enzymes treated with Denamarin, and intermittent anroxeia.
1.1.19 - Presented to VVC for evaluation of being painful due to excessive panting and vocalizing after attempting to use the stairs. Exam findings note a tense but not overtly painful and pendulous abdomen with subjective cranial organomegaly, stiffened gait, and pain elcited upon extension of right hip and spine. Recommendations were made for spinal radiographs but were declined. DVM discussed different causes for back pain such as IVDD, infectious/inflammatory diseases, and neoplasia. Medical management was elected by owner and Codenie was prescribed. Exercise restrictions were advised.
~Feburary 2019 - Pookie developed some intermittent ataxia and difficulty using the stairs. No veterinary attention was sought out.
6.5.19 - Presented to VVSA for evaluation of possible adrenal dependent hyeradrencorticism. Exam findings note a pendulous abdomen with cranial organomegaly but no discrete mass was felt or pain elicited on palpation. Recommendations were made for evaluation of size of left adrenal gland via ultrasound, MRI, or CT but were declined at this time.
7.31.19 - Presented to RRAH around ~3am for evaluation of not drinking and lethargy. Exam findings were unremarkable. DVM discussed difficulty in assessing etiology of azotemia in cushings patients. Owner expressed concerns for Pookie possibly having renal failure due to her decrease water intake and wanted to be proactive. DVM offered 48hr hospitalization but owner declined and elected to continue plan outline by BBAH yesterday.
Presented to RRAH as a transfer for overnight hospitalization and fluid therapies after being briefly evaluated by BAAH. Exam findings were unchanged from previous visit. Pookie was hospitalized, started on IVF therapies (LRS at 38 ml/hr) and administered Ampicillin (22mg/kg IV) every 8 hours.
8.1.19 - Pookie did well overnight while hospitalized. She was eating well, urinating adequately, vitals were normal, and her renal values improved. She was discharged from RRAH to the owners care. Clavamox was advised to be discontinued and Cefpodoxime was prescribed.
8.2.19- Presented to BAAH for evaluation of falling over and difficulty walking. Buprenex was prescribed.
8.3.19 - Presented to RRAH for evaluation of anorexia, restlessness, and red eyes. Exam findings notes lenticular opacity OU, sluggish PLRs, sclearal hyperema OD>OS, and mild epiphovalmucoid discharged. Recommendations were made for sedation due to Pookie's stressful tempermant to obtain diagnostics (bloodwork, urinalysis, eye staning, and tear test) but were declined. A urine collection kit was also provided to owner. Zofran, Entyce, and NeoPolyBac were prescribed along with Trazadone, which is to be given prior to veterinary visits. Recommendations were made for a recheck tomorrow if Pookie is still not eating and to consider an opthamology consult.
8.4.19 - Presented to RRAH evaluation of anorexia and diarrhea. Exam findings notes mild pL (pelvic limb) ataxic/arthritic gait. Bloodwork was performed. Recommendations were made to continue Entyce, Zofran, Buprenex, Triple Antibiotic Onitment, and daily SQ fluids as previously prescribed. DVM advised to syringe feed every 6 hours with 1 90cal jar of baby food and trying probiotics. Metrondiazole was prescribed.
8.7.19 - Owner contacted BAAH to relay that Pookie is still not interested in eating and expressed concerns for her to have Addisons and is considering starting Triolstane. Entyce, Metronidazole, and Buprenex have been finished for several days now. Owner elected to give Pookie an additional 24 hours to see if her appetite improves.
8.8.19- Owner contacted BAAH and reported that Pookie ate some this morning and owner is interested in pursuing an MRI.
8.9.19 - Presented to BAAH for evaluation of anorexia and no improvements with eye redness. Exam findings include mild conjunctive enlargement, OD- tiny white plaques in center of cornea. Fluorescein stain, urinalysis, and bloodwork (CREA, BUN, PHOS) were performed. Mirtazipine was prescribed.
8.10.19 - Presented to BVNS for neurological examination. Owner express concerns for Pookie's continued lethargy, progressive weakness, and anroexia.
Pookie is up-to-date on vaccines. She has not had any coughing, sneezing, vomiting, but suffered from diarrhea about 1 week ago but has improved. She has not been eating and drinking normally over the past week and has been syringe fed with baby food. Her regular diet is Hills Science Diet K/D. She does not travel out of the area.
Past Diagnostics:
8.9.19 - BAAH
Fluorescein stain- Slight uptake
Chemistry- Values within normal limits
Urinalysis- See report
8.4.19 - RRAH
Complete Blood Count- MCV 60.1 fL (l), MCH 20.9 pg (l), RETIC-HGB 22.2 pg (L), NEU 13.66 K/uL (H), LYM 0.63 K/uL (H), LYM 0.63 K/uL (L), PLT 493 K/uL (H), MPV 13.6 fL (H), PCT 0.67 % (H), otherwise within normal limits.
Chemistry 17 & Electrolytes- ALT 368 U/L (H), ALKP 1815 U/L (H), GGT 13 U/L (H), otherwise within normal limits.
Urinalysis (Free Catch)- See report
8.1.19 - RRAH
PCV- 44%
TS- 7.0 g/dL
Chem 8- tCO *26 mmol/L (H), all other values within normal limits.
7.31.19 - RRAH
Chem 8- All values within normal limits
7.31.19 - Michigan State Univeristy
Endocrine Test- Cortisol Basline= 181 nmol/L (H), Cortisol 1hr post ACTH= 494 nmol/L (WNL).
7.29.19 - BAAH
Urinalysis- See Report
7.4.19 - BAAH
Complete Blood Count-MCH 21.3 pg (L), MCHC 31.6 g/dL (L), RETIC 128 K/uL (H), NEU 12876 /uL (H), all other values within normal limits. Chemistry & Electrolytes- BUN 50 mg/dL (H), Cl 105 mmol/L (L), AGAP 29 mmol/L (H), ALT 169 U/L (H), ALP 1378 U/L (H), GGT 19 U/L (H), CHOL 397 mg/dL (H), all other values within normal limits.
5.4.19 - Michigan State Univeristy
Endocrine Test- Cortisol Baseline= 102 nmol/L, Cortisol; High Dose Dex 4hr= 125 nmol/L (H), High Dose Dex 8hr= 130 nmol/L (H).
4.11.19 - BAAH
Chemistry- ALB 4.1 g/dL (H), ALT ~unable to read value (H), ALKP 1748 U/L (H), GGT 20U/L (H).
2.13.19 - BAAH
Abdominal Ultrasound- Left adrenal gland about the same size and calicified.
913.18 - BAAH
Dexamethasone Suppression Test- Cortisol; Pre Dex= 1.9 ug/dL, Cortisol; 4hr Post Dex= 2.1 ug/dL, Cortisol; 8hr Post Dex= 1.8 ug/dL
9.10.18 - BAAH
Abdominal Ultrasound- Liver enlarged- hyperechoic. Lots of gas present in stomach. Left adrenal gland calcified and irregularly shaped.
Current Medications:
Adrenyl Harmony, given as directed once daily.
Advanced Denamarin (unsure of dose), 1/2 tablet given once daily.
Fish Oil, given as directed twice daily.
Ginko Biloba, 50mg given once daily.
Lignan, 20mg given twice daily.
Melatonin, 3mg given twice daily.
Objective
Vitals: 9:41am 8/10/19 Wt: 8.2 kg. T: 101.8 F. HR: 136 RR: Pant CRT: <2 Other: MM: Pink By: AEB
EENT: Eyes: ___, Ears: no redness or exudate observed
Oral Cavity: Teeth are dirty for free from excessive tartar; gums are pink and moist; no gingivitis present
Lymph nodes: Lymph nodes all normal size
Heart and Lungs: No murmur detected; lungs ascultate clear
Gastrointestinal: Normal eliminations; abdomen palpates normally
Musculoskeletal: Orthopedically sound
Dermatologic: Skin flaky and hyperpigmented in areas; dorsal alopecia
Urogenital: Owner reports normal eliminations; external genitalia appears normal; bladder palpates normally
Body Condition Score: 6/9
Pain Score: 0/4
Mentation: Quiet, alert, and responsive. Appropriate.
Posture of Head and Body: Normal posture of head and body
Gait: No paresis or ataxia noted
Postural Reactions: Normal paw replacement and hopping in all 4 limbs
Thoracic Limb Reflexes: Normal withdrawal reflexes bilaterally
Pelvic Limb Reflexes: Normal patellar and withdrawal reflexes bilaterally
Cutaneous Trunci: Present bilaterally at L5 (normal)
Perineal Reflex: Normal
Muscle Tone: Normal tone
Cranial Nerve Function: intermittently delayed menace response OU (possibly ophthalmic in origin) Retinal Exam: Normal fundic exam OU
Hyperesthesia: No pain elicited on spinal palpation or cervical manipulation
MRI Report
BODY REGION & SEQUENCES
August 9, 2019
HEAD– Localizers, Sagittal T2W, T1W post-contrast, Transverse T2W, FLAIR, GRE, T1W pre- and post-contrast, DWI/ADC maps, and Dorsal T1W post-contrast images are available for review.
ABDOMEN–localizers, sagittal T2-weighted, dorsal T2-weighted fat-sat, T1-weighted postcontrast fat-sat images are available for review.
FINDINGS
There is mild periventricular T2-weighted/FLAIR hyperintensity with no evidence of contrast enhancement consistent with leukoaraiosis. The subarachnoid space within the sella tursica is prominent. However, a small pituitary gland is present with T1W hyperintensity of the neurophysins as well as subtle contrast enhancement. There is a small pucntate, lesions within the dorsomedial aspect of the left thalamus that is hyperintense on the T2W, hypointense on the T1W, FLAIR with no evidence of contrast enhancement. Best seen on the sagittal T2-weighted images, there are subtle dilation of the caudal cerebellar vermian sulci with prominent visualization of the overlying subarachnoid space. The masticatory muscles show subtle T2-weighted heterogeneous hyperintensity in varying degrees of contrast enhancement. The medial retropharyngeal and mandibular lymph nodes are within normal limits of size, signal, and contrast enhancement. The salivary glands are within normal limits. There are small condylar cysts within the temporomandibular joints. The visible oral cavity is within normal limits. The visible aspect of the nasal cavity and frontal sinuses are within normal limits. The tympanic bullae and ear canals are within normal limits. The orbits are within normal limits. There are multifocal small dorsal cutaneous nodules.
The right adrenal gland is enlarged measuring 1.6 cm diameter. The cranial pole of the left adrenal gland is enlarged measuring 1.8 cm diameter with mineralization the lateral aspect. There is a small contrast enhancing nodule within the dorsal extremity of the spleen measuring 6 mm diameter.
There is variable loss of normal T2-weighted hyperintensity of the intervertebral discs consistent with dehydration. There is protrusion of the T12–T13 intervertebral disc space with no spinal cord compression. There is protrusion of the T13-L1 intervertebral disc with mild spinal cord compression.
CONCLUSIONS
1) Focal dilation of the caudal cerebellar vermian subarachnoid space may represent mild hydrocephalus ex vacuo secondary to atrophyfrom a historical ischemic infarct. The subtle lesions within the dorsomedial aspect of the left thalamus likely also represents a historical ischemic infarct. Both lesions are thought to be quiesscent on the current study.
2) Mild periventricular leukoaraiosis may be seen secondary to edema vs. gliotic changes.
3) Incidental partial empty sella syndrome. This may be seen in canine patients with no associated endocrinopathy (VRUS 2008;49(4):339342). There is no evidence of a pituitary mass, however, a functional pituitary microadenoma cannot be ruled out.
4) Bilateral adrenal gland enlargement with mineralization of the left. This may be secondary to pituitary dependent
hyperadrenocorticism. The left sided adrenal gland mineralization may be seen 50:50 in benign and malignant etiologies (VRUS
1997;38(6): 448-455)
5) Signal changes to the masticatory musculature may be secondary to chronic hyperadrenocorticism. Chronic bilateral masticatorymyositis is considered much less likely.
6) Protrusion of the T13-L1 intervertebral disc causing mild spinal cord compression.
7) Splenic nodule may represent benign (ie. nodular hyperplasia, extramedullary hematopoiesis, hemosiderin deposition) vs. earlyneoplasia (ie. round cell, sarcoma, others).
8) Incidental temporomandibular joint condylar cysts.
FEATURED DIAGNOSTIC IMAGE / SUPPLEMENTAL INFORMATION
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[fkhan]

Good news for now. Pookie ate the lean hamburger minced with angel hair pasta cut up and a little butter. I'm going to give her more in about an hour. She really hasn't eaten much since all of this has started. She use to weigh 19.2.lbs and now weighs 17.6lbs. The odds are against her being 15 3/4 years old, has had Cushing's for a year with elevated liver enzymes, and now in the past month has been to the ER twice for IV therapy, which gets her values back to normal. I was initially thinking the UTI caused the first one, but now I'm thinking she may have CKD given her age and everything else. Just to stay proactive, I'm giving her filtered water from now on, I'm going to brush her teeth tonight, I ordered Pet Well Being Kidney Support Gold, which should be here tonight with Prime. I'm also going to check with my vet tomorrow about phosphate binders. She walks good sometimes and sometimes she has Ataxia drunken sailor walk, which really alarms me, because my little Maria cat had that before her Kidneys went and the vet tried IV's with no success. I don't know if I can own another dog after all of this. It's very difficult emotionally, physically, and financially... I have lost close to 20lbs with all the stress and my blood pressure has dropped to 96/67, which I guess is good for some and maybe good for me, because I haven't been eating junk or drinking to deal with this stress. I have been a fined tuned machine with all senses on alert for my Pookie. I don't want to miss anything and staying focused has probably kept her alive through all of this. I just hope she pulls through and am doing everything I can to give her some more time with a good quality of life. It's hard to just put her down if she shows promise, but I feel bad that she is suffering right now, but I don't know if she can pull through or not without trying. I wish dogs could speak to me and us not to rely on clinical signs. When I'm sick, I'm miserable to, but that doesn't mean I'm ready to check out for good.

[fkhan]

I also have tried cooked chicken, ground beef, baked salmon, hot dogs, honey nut cheerios. She ate a little hot dog one day and never again. She at the cheerios one day and never again. She did it the bacon I made, but only about 1 strip worth. I'm afraid her days are coming to an end and am extremely sad about it. Her sister who is older is running around the house while Pookie is lying on the floor.