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Thread: Diagnostic Plan to Rule Cusahings In/Out

  1. #11
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Dog's with Cushing's rarely have an USG of 1.030, they drink gallons of water and pee rivers; Cushdogs have very diluted urine. So, based on everything posted about your precious girl, I really don't believe Cushing's is a likely diagnosis.

    What do her teeth look like? Some dogs that need a dental cleaning will have an elevated ALP.

    Hugs, Lori

  2. #12
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    I have to agree with Lori. The more you tell us, the less likely it seems that Cushing’s is the cause. I still think the ultrasound can be helpful in order to see if anything appears to be amiss with her internal organs. And again, the sterile urine sample can help to definitively rule out an infection.

    But I do want to make sure that the vet would *not* be using this urine sample to perform the UC:CR analysis that we’ve been talking about. Although the ultrasound is not an invasive test, the vet visit will undoubtedly still be stressful for your girl and that would render the results of a UC:CR worthless. If you do decide to proceed with this test, you really need to gather the pooled urine sample yourself, at home, as calmly as possible. If your vet still wants to consider Cushing’s after the results of the ultrasound are in, though, I’d still strongly advocate for a UC:CR before advancing to the more involved and expensive blood testing.

    Good luck on Wednesday, though, and we’ll be anxious to hear the results!
    Marianne

  3. #13

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Quote Originally Posted by Harley PoMMom View Post
    Dog's with Cushing's rarely have an USG of 1.030, they drink gallons of water and pee rivers; Cushdogs have very diluted urine. So, based on everything posted about your precious girl, I really don't believe Cushing's is a likely diagnosis.

    What do her teeth look like? Some dogs that need a dental cleaning will have an elevated ALP.

    Hugs, Lori
    Thank you both. Her teeth look great according to her vet.

    I need clarification from the vet about the urine tests. I don’t know why she didn’t do the cortisol test with the last sample and I don’t know what she hopes to get out of the sterile sample. It’s really hard having to wait hours or days for a returned phone call instead of having an in person conversation about such an important diagnosis.

  4. #14
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Quote Originally Posted by PrincessDangers View Post
    I need clarification from the vet about the urine tests. I don’t know why she didn’t do the cortisol test with the last sample and I don’t know what she hopes to get out of the sterile sample.
    The UC:CR test should be 3 morning pooled urine samples taken at home and then refrigerated until the samples can be taken to the vet's office. A sterile urine sample is performed so there is no concern of contamination of the sample from your dog's fur or genitalia, which often happens with a free catch sample and could otherwise interfere with or skew the results of the urine culture and sensitivity test.

    I, too, am wishing you luck on Wednesday, please keep us informed!

    Lori

  5. #15

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    The ultrasound was consistent with Cushing's, unfortunately. Her vet would like to move forward with testing and if that confirms it, she would like to medicate. My main hesitation is the follow up testing because she finds vet trips so stressful. That really complicates things.

    They also found a large mass on her spleen (that is almost certainly benign) to remove. That could be irritating enough to be playing a role in the liver being agitated.

    The vet isn't against running a UC:CR test, but she doesn't put enough weight in it to determine a diagnosis. She's inclined to test/start treatment for Cushing's Disease before addressing the spleen. I'm still thinking that through.

    Thank you for all of your advice. I told her vet that I've been discussing it with you guys

  6. #16
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    I would hold off on performing all tests for Cushing's until the mass on the spleen is removed. One of our Moderators, Leslie, had a precious girl, Squirt, who tested positive for Cushing's because of a mass on her spleen. The LDDS test, which is the "gold standard" test for Cushing's may yeild a false positive when a non-adrenal illness is present, such as the mass on your girl's spleen. Could you tell us exactly what the ultrasound showed? Also, I wanted you to be aware that chronic illnesses can enlarge the adrenal glands, just in case that was a finding on the ultrasound.

    Hugs, Lori

  7. #17
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Once again, Im in 100% agreement with Lori. As she says, either of the two diagnostic Cushings blood tests can and do return false positives if a dog is suffering from some other illness or significant stress. Especially since your girl is exhibiting no observable symptoms consistent with Cushings aside from thirst/urination, I dont understand why your vet would be prioritizing Cushings at all over and above the removal of the mass in her spleen. That mass may actually be the source of all the abnormalities as opposed to Cushings.

    In honesty, if I were you, at this point Id consider getting a second opinion about your dogs entire situation before proceeding any further. In complicated situations, we often encourage folks to ask their vets for a referral to a veterinary internal medicine specialist in order to receive additional input. This is a vet who has received additional training in disorders such as Cushings, and can work alongside your current vet in sorting out the best path forward. We can help you search for a specialist like this if youd like, but perhaps your current vet already knows of a specialty practice near you. From our experience here, though, wed be wanting to see the issue with the spleen resolved prior to moving forward with any Cushings testing at all, even the UC:CR. Again, none of that testing may be accurate until the mass has been removed.

    Marianne

  8. #18
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    As Lori shared, my first dog diagnosed with Cushing's, Squirt, tested positive on the LDDS, HDDS, and ACTH. But when the ultrasound was done a tumor was found on her spleen. Once that tumor was removed and she had fully recovered all those test results returned to normal. The tumor had caused false positives. She also had very few signs. Had I started treatment instead of having the tumor removed the odds are she would have died either when the tumor ruptured or from the treatment itself because at that point in her life she did not have Cushing's.

    My second dog diagnosed with Cushing's had COPD, anal gland disease, allergies, pouches on either side of her rectum that had to be manually emptied and other health issues. Her ACTH was too high to register - >50ug/dl. When she passed I had a necropsy (autopsy for animals) performed...it proved she never had Cushing's - her adrenal glands were normal. But like my first pup, all those other health issues caused the ACTH to register as if she did.

    Cushing's is one of, if not THE, most difficult canine disease to correctly diagnose. Cortisol is a fight or flight hormone and it's job is to elevate naturally in response to any stress, internal or external. The tests for Cushing's can only tell us IF the cortisol is elevated but not WHY. For this reason it is very much a process of ruling out all other possible causes for the elevated cortisol. And you know there is another cause present with your sweet girl.

    In your shoes I would insist the tumor be removed then give my baby plenty of time, a few months, to recover. Then, IF signs were present I would look at Cushing's again. But for now, Cushing's would be forgotten and I would focus on that tumor and her recovery. Just so you know what you would be looking for, here is a list of common signs seen with this disease:


    *increased/excessive water consumption (polydipsia)
    *increased/excessive urination (polyuria)
    *urinary accidents in previously housetrained dogs
    *increased/excessive appetite (polyphagia)
    *sagging, bloated, pot-bellied appearance
    *weight gain or its appearance, due to fat redistribution
    *loss of muscle mass, giving the appearance of weight loss
    *bony, skull-like appearance of head
    *exercise intolerance, lethargy, general or hind-leg weakness
    *excess panting
    *seeking cool surfaces to rest on
    *symmetrically thinning hair or baldness (alopecia) on torso
    *other coat changes like dullness, dryness
    *slow regrowth and/or failure to regrow of hair after clipping/shaving
    *thin, wrinkled, fragile, and/or darkly pigmented skin
    *thin, crepey, easily damaged skin that heals slowly
    *dark, bruised looking skin
    *hard, calcified lumps in the skin (calcinosis cutis)
    *susceptibility to infections (especially skin and urinary)
    *diabetes, pancreatitis, seizures

    If, after she has had plenty of time to recover, you aren't seeing quite a few of these signs I would continue to watch and wait to see if she did develop signs. Cushing's is a very slowly progressing condition so there is rarely need to rush into diagnosis or treatment....especially when it is known that something is present that can and does cause false positives on all the tests for Cushing's AND that is much more pressing.

    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.

  9. #19

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Thank you.. That's how I feel as well.

    Regarding the report, this is everything not-normal...

    LIVER: the liver is large and diffusely hyperechoic-no focal masses or nodules are seen
    SPLEEN: there is a large, complexly echogenic and mineralized mass effacing the body of the spleen and disrupting the capsule. The remaining spleen is within normal limits.
    ADRENAL GLANDS: both are plump (caudal/cranial pole diams. = 0.75-1.4cm) and hyperechoic with decreaased internal architecture

    CONCLUSIONS:
    1. bilateral adrenomegaly + hepatomegaly: consistent with PDH-Cushing's syndrome
    2. splenic mass: rule-out neoplasm, i.e. malignant vs, benign

    RECOMMENDATIONS:
    1. as needed for patient's well-being i.e. can consider aspiration samples from the splenic mass to try and confirm a diagnosis...vs. exploratory laparotomy for splenectomy
    2. can test this patient for Cushing's disease and treat accordingly

    When we were first discussing having an ultrasound performed, she had mentioned a list of things that might be causing the elevated ALP and the spleen was part of that list. After the ultrasound, I asked if the splenic mass might be irritating the liver and she said it is possible. I also asked if she would recommend treating Cushing's if the test is positive and she said yes. Seeing how stressed my pup was by the last vet trip, I wouldn't make that decision lightly. But the spleen has to come out regardless. That makes the most sense to me.

    That stress is also causing me hesitation about bringing her to another hospital for surgery and an internist. We are about an hour away from the nearest good specialty hospital and 90 minutes from the two best internal medicine vets I know. I wonder if one of them would consider reviewing her case remotely?

  10. #20

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Thanks, Squirt's Mom. This forum has been invaluable.

    I definitely want to get that spleen out and reevaluate the diagnosis later on. I hope she is just like Squirt.

    At the moment I'm debating between having her local vet pull that thing out or bringing her to a larger hospital. This local practice performed by other dog's spay surgery which included a ton of extra precautions (she only has one kidney) and I felt they did well. I wonder if laproscopic splenectomy is an option.

    I love her so much and want to make the best decisions for her well-being but sometimes it doesn't seem straightforward.

    She has some symptoms, but they're on the ambiguous side and could also have something to do with aging, the splenic mass, or arthritis (are all known conditions).

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