Reggie, an 8-ish pit mix who may have Cushing's and/or other issues

[ReggiesDad]

So it's been kind of a whirlwind with Reggie lately. It seems like we're making progress on the thyroid and Cushing's front, but there are new issues.

Reggie did perk up some in response to thyroid supplementation. Then a new crustly black bump showed up in his armpit, that rapidly grew to about the size of a pea and bled occaisonally. I set up an appointment with my regular vet to look at it and meanhwile asked my internist if Reggie was a candidate for surgery if surgical removal under anesthesia was recommended. She said not really. Meanwhile the day before my appointment, Reggie started having discharge dribble periodically out of his penis...not straight blood, not straight puss, but kind of a mix.

My vet ended up sick the day of our appointment, but I saw another great vet the next day. She wasn't too worried about the bump, which was very superficial, and said she could remove it under just local anesthesia if need be...though even then there might be some concern about Reggie's healing capacity given his Cushing's. The discharge was more of a concern/worry, she thought it pointed toward a prostate infection and recommended an ultrasound. His urine test showed no bacteria.

The next week we got an ultrasound with the internist, and she also looked at the discharge (which was continuing) under a microscope and clearly saw bacterial rods. His ultrasound showed cysts in his prostate, the discharge culture showed E coli, and the ultrasound also revealed a gallbladder mucocoel. Yikes! On the plus side, his weight had come down a bit, his cholesterol and electrolytes and liver enzymes were back in the reference ranges. But he was still showing all the classic outward signs of Cushings.

My internist said it was very rare in her experience for neutered dogs to have prostate infections unless they also had prostate cancer, and for that reason she was very esitant to go in with a needle to drain the cysts or inject antibiotic into them directly. And she was worried about the gallbladder mucocoel potentially developing into an emergence situtation, saying that in many dogs she'd recommend removing the gallbladder but Reggie really isn't a candidate for elective surgery unless/until we get his metabolism and hormones sorted (although even then, I'd probably lean toward letting him enjoy a healthier state than subject him to major surgery, but we'll cross that bridge when we come to it). To try to make him a better surgical candidate/hope to better control his Cushing's, we upped his Vetoryl to 60 mg twice a day and also bumped his levo-thyorxine slightly. We also put him on enrofloxacin for the prostate and ursodiol for the gallbladder.

And fingers crossed but....it seems to be working some! He still has a big belly, but has lost a little more weight, his drinking and peeing are almost normal, and he still won't walk very far but he's actually run and played a little bit lately, and is having an easier time jumping onto furniture. In his followup ultrasound today the prostate cysts had shrunk by ~75% so we'll keep up the anitibiotic for a while, and the gallbladder looks stable.

Oh yeah...meanwhile the armpit bump just fell of one day. Problem solved?

[labblab]

And fingers crossed but....it seems to be working some! He still has a big belly, but has lost a little more weight, his drinking and peeing are almost normal, and he still won't walk very far but he's actually run and played a little bit lately, and is having an easier time jumping onto furniture. In his followup ultrasound today the prostate cysts had shrunk by ~75% so we'll keep up the anitibiotic for a while, and the gallbladder looks stable.

Omigosh, all my fingers *and* toes are crossed for Reggie, too! After reading about his new challenges, I was sooooo relieved to get to that paragraph, and will definitely be hoping that things keep improving for your sweet boy. You are doing such a great job of advocating for him, and thank goodness you have access to this specialized medical care on his behalf.

As always, thanks so very much for this update, and I send all my best wishes for even more good news to kick off 2024!

Marianne

[ReggiesDad]

Almost exactly a year after his tentative diagnosis, Reggie is doing great now that we have dialed in the treatment for his Cushings (60 mg vetoryl twice a day) AND his hypothyrodism (0.6mg levo-thyroxine twice a day) AND his diabetes (9 units Humulin N U-100 twice a day). And the ursodiol seems to be keeping his gallbladder issues in check. Thank goodness for insurance!

Here he is near the peak of Cushing's symptoms, 52 lbs with almost no fur on his underside and thinning other places:


And here he is now, 38 lbs with more and thicker fur than he had when I first adopted him 4.5 years ago:


He's back to jumping on furntiture, playful bursts of energy, and moderately long walks every now and then and consistently taking at least short walks.

[Joan2517]

What a wonderful update! He looks gorgeous!

[Harley PoMMom]

What a transformation, he looks so good!! What a wonderful job you are doing!!!!!

[labblab]

I totally agree -- what a great report and what a lovely photo :-))))))))

Your experience with Reggie just goes to show that there can be a lot of variability with successful Vetoryl dosing. We might think that 60 mg. twice daily is a lot of medication for a 40 pound dog, but clearly he is thriving right now on his current treatment regimen. You've had a lot to handle on his behalf, and you've managed it beautifully. Thanks so much for treating us with this wonderful update!

Marianne

[ReggiesDad]

So...in his latest bloodwork Reggie's pre-trilostane cortisol was 1.5 ug/dl which I understood to be the lower bound of the target range. Our internist was somewhat conserned about that and watned to test his electrolytes and some further bloodwork as well. His blood sugar (non-fasted) was still quite high (477), liver enzymes all normal, low sodium and high potassium (didn't get the numbers). So she wants to up his insulin a bit but is also worried we have been over-suppressing his cortisol so she wants me to stop the vetoryl for a week and re-test.

I'll follow this advice but it's tough. He's not showing any signs of being clinically unwell other than his drinking and urination still being a bit elevated compared to a healthy dog. And even if this treatment is doing long-term damage to his adrenal glands, his quality of life seems so much better than it was when he was on a lower trilostane dose, even if he is being over-suppressed, the tradeoffs could well be worth it. And his very first baseline cortisol measure before starting any kind of treatemnt was only 2.1 ug/dl, Hmmm...

[Harley PoMMom]

What is his post ACTH stimulation result? If the post was on the lower side also I agree with the vet on stopping the Vetoryl. If cortisol is too low it can be fatal if not corrected. Too low cortisol, called Addison, can cause increased drinking and urinating.

[ReggiesDad]

Thanks for the reply. Rehhie has not had an ACTH stimulation test, this decision to cut off the vetoryl was based only on his pre-trilostane cortisol level and his electrolytes and maybe also his urinalysis which she said showed his urine was highly concentrated but otherwise unremarkable.

[labblab]

Gosh, I understand how conflicted you must be about taking the break from the Vetoryl. But I’m guessing that the electrolyte imbalance is the piece that is really helping to fuel your vet’s concern. We already may have talked about this earlier, but in addition to lowering cortisol, Vetoryl has the capacity to also lower aldosterone. And that’s the adrenal hormone that controls the potassium/sodium balance. Vetoryl’s manufacturer specifically warns that the med should be discontinued if cortisol drops too low and/OR an electrolyte imbalance is seen. So even though Reggie’s cortsol level remains on the lower boundary, his aldosterone may truly be too low if it were to be measured.

So as frustrating as it is, I think your vet is doing the right thing since elevated potassium can truly be life-threatening due its potential effect on the heart. Hopefully the week “off” will help stabilize Reggie’s readings, though, and clarify the best path forward.

Sending positive well wishes to you both,
Marianne