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Thread: Diagnosis

  1. #1
    Join Date
    Dec 2020
    Posts
    12

    Default Diagnosis

    Thank you for allowing me to join. Our almost 10 year old goldendoodle was diagnosed with PDH. It was a process getting here for sure. She was diagnosed in April 2020 with hypothyroidism. Her energy level improved and she lost the weight she had gained. However, her PUPD and appetite increased. I thought maybe she was over medicated, but she was not. Fast forward to August, I just knew something more was wrong. She had a mildly elevated ALT and steadily rising, but normal ALP. Her cholesterol was high, too. Her hair was thinning on her back end. She had an ultrasound and all looked good except for an ever so slightly enlarged liver. Her urinalysis came back with very dilute urine and she was losing protein. Her sdma and kidney numbers were normal. Her albumin and BUN were slightly low. We started on benazepril and a renal diet. I insisted on urine cortisol creatine test. It was sky high. She had the LDDS which confirmed Cushingís. She is almost 60 pounds. She started on 20 mg of vetyrol 2X daily. We had a complication as she had a mast cell tumor on her leg. Thankfully it was low grade with clean margins. We started the vetyrol 2 weeks before surgery and had acth stim. Her levels were still high and her symptoms were no better. She has been on 30 mg 2X daily for the last 3 weeks. Her pupd is a little better but not normal. Sheís still hungry!! Iím not sure if part of it is the low protein food. She had a urinalysis and acth stim yesterday. We expect to hear all results tomorrow. She has never had accidents, just drinks a lot with large volume of urine.

    I appreciate any and all help/advice. Her last acth 3 weeks ago was 6.5 post and 5.1 pre.

    Happy Holidays!
    Amy

  2. #2
    Join Date
    Apr 2009
    Location
    Georgia
    Posts
    15,152

    Default Re: Diagnosis

    Hello Amy, and welcome to you and your boy! Iím afraid itíll likely be tomorrow before Iím able to write a more thorough reply. But I wanted to at least have the chance to welcome you, and also to let you know that Iíve moved your thread here, to our main Questions & Discussion forum. People are more likely to see your thread here, and to have the chance to respond.

    In the meantime, weíre really glad youíve found us! And I look forward to having the chance to add more tomorrow.

    Marianne

  3. #3
    Join Date
    Dec 2020
    Posts
    12

    Default Re: Diagnosis

    Thank you so much! My Frankie is a girl and she is excited, too.

    Happy Holidays!

  4. #4
    Join Date
    Apr 2009
    Location
    Georgia
    Posts
    15,152

    Default Re: Diagnosis

    Oops, I’m so sorry about that!! You had written “she” and “her” so many times, but I still decided to make Frankie a boy, regardless. DUH! Anyway, so glad to have both you girls with us ;-)))))

  5. #5
    Join Date
    Dec 2020
    Posts
    12

    Default Re: Diagnosis

    LDDS
    Pre - 5.0
    Post 4 hours - 1.7
    Post 8 hours - 3.3

    *pre treatment

  6. #6
    Join Date
    Dec 2020
    Posts
    12

    Default Re: Diagnosis

    So apparently her levels increased on acth from xmas eve. Have you e er heard of this happening? Internal medicine doc wants to try 40 mg 2 x daily for 2 weeks. If no better, perform another ultrasound and additional work up.
    Acth
    Pre 6.6
    Post 8.5

  7. #7
    Join Date
    Apr 2009
    Location
    Georgia
    Posts
    15,152

    Default Re: Diagnosis

    Just wanted you to know that I’ve not forgotten you, but today has turned out to be another crazy busy day for me. I promise I will make it back again tomorrow. Overall, though, it sounds as if your vet is making reasonable suggestions. But more to follow...

    Marianne

  8. #8
    Join Date
    Dec 2020
    Posts
    12

    Default Re: Diagnosis

    Thank you so much. I guess I’m just baffled by the increase based on already having started vetyrol. However, she did have mast cell tumor surgery 3 weeks ago. I hate that I can’t go in with her. She’s also on benazepril and thyoroxine. I want her off the thyroid meds. She did have the full assay so it’s confusing. If not Cushing’s,then what? She has so many Cushing’s symptoms.
    PUPD (no accidents)
    Increased hunger
    Very Dilute urine
    Thinning fur near tush
    Stress leukogram
    High cholesterol
    Low bun
    Proteinuria
    Mildly elevated alt
    Alp is normal but has gone from 8 to 160 in a year or so
    Shaky legs sometimes

    I would like her to have another ultrasound and retest blood.

  9. #9
    Join Date
    Mar 2009
    Location
    rural central ARK
    Posts
    14,486

    Default Re: Diagnosis

    Hi Amy and welcome to you and Frankie!

    These are my thoughts which others may not agree with but that is the good thing about forums like ours - you are presented with information from more than one source that may make a light bulb come on for you.

    I have some concerns about the diagnosis. Cortisol will rise naturally in response to any stress, internal or external. My first pup was diagnosed based on the LDDS, HDDS, ACTH, and UTK panel but the ultrasound found a tumor on her spleen. Once that was removed all her tests returned to normal. She did eventually develop conventional Cushing's but at the time of those tests she did not have the disease - it was the tumor that caused false positives on all the testing.

    You say her ultrasound was normal except for the liver. In a cush pup we typically see changes with the adrenal glands. With PDH they will both be enlarged. So normal appearing adrenals aren't the norm with Cushing's. A cush pup almost always has high elevations in the ALP with mild elevations in the other liver values. Frankie's ALP is normal - again not the norm at all. In addition, the mast cell tumor could have skewed the LDDS just as the tumor on Squirt's spleen skewed all her tests.

    Some of her signs are consistent with Cushing's however...but one thing that makes getting a sound Cushing's diagnosis so hard is that so many other conditions share the same signs and they can skew the tests for Cushing's. With her main issues being excess drinking and peeing in addition to the very dilute urine I am wondering about Diabetes insipidus. This is a rare form of diabetes that has nothing to do with blood sugar but rather with how the body processes water. None of the usual tests can pick this disease up and the test for it, a water deprivation test, is rather risky so if this is suspected the vet simply starts treatment (a nasal spray). If the treatment helps then there is the diagnosis.

    I am also wondering why she is being treated for kidney disease if the SDMA was normal? Was the CREA elevated? Even then with a normal SDMA that pretty much rules out kidney disease. So why the renal diet and Benazepril? Low protein for renal disease is no longer recommended until the final stages...it is the phosphorus that needs to be watched instead. So if she is on a low protein diet as a renal diet that may well be causing the hunger as you suspect. With the normal SDMA I would stop that diet and the Benazepril (unless she also has heart issues?). I would get her on a high quality food with moderate proteins and fats.

    As for the increasing values on the ACTH....are you giving the Vetory with a meal every time? And is the ACTH being performed 2-4 hours after the pill and meal? The vet isn't telling you to fast for the ACTH are they? If the drug is given with a meal and the test is done during the correct time frame following then in my mind the increasing cortisol could be 1) the dose is not yet correct and an increase is needed or 2) something else is going on that has not been discovered yet which takes me back to my concerns about the initial diagnosis of Cushing's. I would want the ultrasound and additional investigation in your shoes....but that desire is informed by my own experiences with misdiagnoses.

    I am glad you found us and look forward to learning more as time passes. Keep talking and asking questions! That's the best way to learn.
    Hugs,
    Leslie
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  10. #10
    Join Date
    Dec 2020
    Posts
    12

    Default Re: Diagnosis

    Thank you so much. I feel the same way. She was started on benazepril and put on renal diet due to proteinuria. I would’ve thought the urine would be less dilute having been treated with vetyrol for over a month now. We are giving her vetyrol with her meal. The acth is done 4-6 hours, but we do 4 after her pills. She had the hunger before beginning the low protein diet. She had never been a very hungry dog before. She now tries to eat rabbit poop which she never did before.

    I am so stressed and torn. She is seeing an internal medicine specialist but I just feel like something is missing here. Can she try the diabetes insipidus drops on all the other meds? Would you stop benazepril? Vetyrol? Or wait the few weeks. Should I tell the internal med doc I want ultrasound and bloodwork now? Her last bloodwork in December 3rd wasn’t very interesting. Do I go for another opinion?

    Was your dog’s spleen mass benign? Did he have Cushing’s symptoms?

    Thank you so much. I’m super stressed.

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