Back again..What are the statistical odds of having a third beagle with Cushing's?

[judymaggie]

Hi, folks! I see familiar names among the moderators and, perhaps, some will remember me as the Mom to Cushing's beagles, Maggie and Abbie. A year after I had to let Abbie go I adopted Sadie Sue who was then 6 yrs. old. She is now 10 and was really healthy until about a year ago. Her first problem was severe diarrhea which was very difficult to treat --after trial and error with several different medications, supplements and diet changes, it finally improved. No specific cause was determined. Around the same time protein started showing up in her urine. Every time we tested urine the protein level increased. An internist was brought on board to try and determine the cause. An ultrasound was completely normal; cortisol levels were tested and were normal via a panel done by a Texas lab. The only abnormal result was a high level of pancreatic enzymes. The concensus was that there was an inflammatory process going on, probably due to glomerular (sp?) disease.
A week and a half ago I moved into a new home within a continuing care community. I didn't have to downsize so Sadie Sue's beds are the same, same recliner she likes to sleep in at night, etc. Before we moved my vet started Sadie Sue on telmisartan with the hope that would stop the increasing proteinuria. Tomorrow we have our first appointment with a new vet and have several tests scheduled as it has been a month since starting the telmisartan: a CBC, urine obtained by cystocentesis to run full urine tests and a UPC. During the last week Sadie Sue has been having episodes of heavy panting, every day her water uptake has increased substantially and tonight peed in the house for the first time ever in spite of going out to pee every couple of hours. This morning I got up from the breakfast table for a second and Sadie Sue tried to jump up on my chair to help herself to food. This totally out of character for her.
I put in a call to my "old" vet to ask his guidance before we see the new vet tomorrow but I have not heard from him. Since urine is already going to be drawn, I will ask that a UCCR test be added.
I donÂ’t remember how to post a picture. I will look around to refresh myself since it has been 5 years since my last participation. I will probably have to change my signature line but will leave it for now. Thanks in advance for putting up with my long post!

[labblab]

Judy, holy cow, my first impulse is to tell you how glad I am to talk with you again -- but I totally get it that you'd much rather *not* have any need to return to us!!! But if it should turn out that Sadie Sue indeed has Cushing's, we'll be right here by your side.

I'm going to be heading to bed shortly, so I'm afraid I won't be able to add a more complete reply right now. But I do want to mention one thing in advance of your vet visit in the morning. Even though you already know that the vet will be obtaining a sterile urine sample via cysto tomorrow, I'd encourage you to try to catch a sample for the UCCR at home, when Sadie first pees in the morning. This is because the stress of being at the vet has the potential of skewing the UCCR so as to return an elevated cortisol reading that is not typical for her. In order for a UCCR to be as accurate as possible, Cushing's clinicians recommend that the urine sample be taken at home under as stress-free a situation as you can arrange. In fact, we've seen the recommendation that a pooled refrigerated sample be accumulated using the first pee of the morning at home on three successive days.

I know you already have your appointment scheduled for tomorrow, and taking in your own sample may or may not be easy for you. And if you decide to go ahead and have a UCCR run on the cysto sample -- and it comes out negative -- you'd really have a high degree of confidence in ruling out Cushing's as a possibility. But if a sample taken at the vet is elevated, it may be stress and not Cushing's that's the culprit.

OK, I've gotta head off for tonight. But I'll definitely come back, and we'll all be anxious to hear how things go at the vet tomorrow.

Best wishes to you and Sadie Sue, and welcome back although I'm sorry for the reason that has brought you back to us!
Marianne

[Harley PoMMom]

Hi Judy!

I'm so sorry that sweet Sadie Sue is having these issues and will be waiting anxiously to hear how the vet visit went.

Love and hugs, Lori

[judymaggie]

Hi! Sorry for the delay in getting back here -- between getting situated in new home and all that entails plus trying to sort out things with Sadie Sue, I have been distracted. Sadie Sue had several abnormal lab tests, including high ALT (148) and ALP (866). Neither of these values are anything like I have seen in my past Cush pups -- her ALP has been high in previous tests but I started giving her Denamarin and that has kept the values down. Her ALT has never been abnormal previously. The lipase (479) and creatine kinase (401) were both abnormally high. Sadie Sue has shown high pancreatic enzymes in previous tests but these two values were always normal until now. Her lymphocyte value was low (805) -- another new abnormal. Protein in her urine was still high (3+). Her UPC actually went down to 1.8 from 2.3 so, hopefully, the telmisartan that she has been taking the last month is having some effect. And then there is the UCCR ... it was 180, an obviously high measurement. So the vet proceeded with the low dose dex suppression on 10/20. Her results were what the vet described as being in the "gray" zone... pre was 2.5, post 4 hr. was 0.8 and post 8 hr. was 1.1. The vet said that he was uncomfortable starting a dog on any meds for Cushings unless the test was definitely positive. The vet does not believe that Sadie Sue presents as a Cushing pup (according to vet tech and vet, himself, he has treated many, many Cushings dogs and, when I did a search for vets who treated Cushings dogs in the area, his name came up). He said that, at the present time, he was inclined to try and reduce the chronic pancreatitis which he believes may be making her so uncomfortable that she is drinking more to ease her discomfort. It has been a delicate balance since I got Sadie Sue between giving her enough fiber and giving her too much. She has had serious bouts of colitis and many, many months of watery diarrhea. That was finally under control by giving her Purina Pro Plan Veterinary OM dry food along with some Royal Canin LF canned food (primarily to wrap her pills in). The new vet thought she might be having difficulty digesting the high fiber in this food and asked that I try mixing it with Royal Canin LF dry food which we started doing on the 20th.
Since that time the symptoms that I was concerned about have intensified. She has started having peeing accidents in the house (previously a very rare occurrence) unless I take her out to pee at least every 2 hours and the past couple of days every 1 1/2 hours. She is obsessed with looking for food outside -- I live in a community where there are many older residents who are in wheelchairs/walkers. When we first moved here, Sadie Sue loved going up to them so they could pet her. Now, she completely ignores them and is only interested in finding something to eat. I was hoping to have her be a therapy dog to the residents of the assisted living facility that is on the same grounds as my villa but there is now way to do that now.
I left a message for the vet Saturday morning -- I was very frustrated. Her poops were like pudding again, she had had a peeing accident in the house Friday evening after having gone out just an hour before and she was having periods of agitation and panting. I am sure he will call back tomorrow morning -- he is very responsive. He had said he would want to repeat the low dose dex if her symptoms got worse (and, in particular, if she developed a pot belly which is something he really focused on as indicating a Cush pup) but I doubt he is going to want to repeat the test only 10 days later than the original testing date.
As always, I would love your thoughts. FYI, I posted some pics of Sadie Sue. You can see in a couple of them how she looked when I first adopted her, i.e., she had very dark ears and forehead. Now she is a beautiful gray faced senior!

[Harley PoMMom]

I agree with Sadie's vet that Sadie's LDDS test results are not indicative of Cushing's, usually the 8 hour number is higher than the reference range value which is generally 1.4 ug/dl so, she may be what her vet is saying in that the results are in the "gray zone."

I wonder if meal-induced Cushing's could be the culprit? From an article I've read "If you suspect meal-induced hyperadrenocorticism in a dog, at this point “it's a very simple thing to diagnose,” says Bruyette. Have the clients fast the dog for 12 hours and obtain a urine sample at home. Ideally use the first morning-voided sample. Instruct them to feed the dog and four hours later have them go for a walk and obtain another urine sample. Submit the carefully labeled pre- and post-meal urine samples for a UCCR on each. A 100-fold increase in urine cortisol in response to the meal will be diagnostic for food-induced hyperadrenocorticism. “In general, we do want to at least see the UCCR double, but there are not really enough cases yet reported to show a range,” says Bruyette. “In a normal dog, when he eats, there is no rise in cortisol." https://www.dvm360.com/view/meal-ind...-be-overlooked

In that article it claims that a dog with meal-induced Cushing's will have the same clinical and lab values as a dog with conventional Cushing's.

I saw the pics you posted, and Sadie sure is a sweet beautiful lady!!

Hugs, Lori

[judymaggie]

Folks: I think I have earned a spot in the Guinness Book of World Records...Sadie Sue has confirmed Cushing's. Her post ACTH score was 27.6. Even her pre score was high at 6.5. She got her first dose of Vetoryl last night (10 mg twice a day). I am glad we finally got a definitive diagnosis as her symptoms have worsened over the last week and now included fatigue. Yesterday we had our usual morning walk and, as we approached our house, she just sat down in the middle of the street. There were a couple of maintenance guys waiting to go in to do some work. One of them came over to Sadie Sue and gave her some love and coaxed her into the house.
I know it will be a while before symptoms abate but am glad there is hope that they will diminish.

[judymaggie]

Folks: Sadie Sue is responding really well to being on Vetoryl. She had another ACTH at the 3 week mark (my vet's preferred timeline). Her pre was 3.9 and her post was 9.1. Since Sadie Sue is on twice a day dosing (10 mg. am and pm), the vet said that, since ACTH results are usually computed after taking a full day's dose, he thought her post would be even better if she had had both doses. Her symptoms have decreased dramatically. I think this is because she started on Vetoryl not long after symptoms appeared and she was diagnosed. I can now leave her for almost 3 hours without her peeing in the house. Her panting has decreased significantly and, most noticeable, she is much more relaxed with her pre-diagnosis personality more prevalent (she has always been a very calm dog). She has even started playing with her toys again. She continues to be obsessed with eating but I can deal with that. The vet, who was doubting she even had Cushing's, was also very skeptical that her symptoms could have diminished after such a short time but her testing supported that. Maybe he will start to trust me ... Now that she is doing better, I am going to contact the director of the Assisted Living Center located on the property where I live and see if she can begin visiting the residents. On our walks she is again walking up to folks in wheel chairs or on walkers to say hello and is loving the attention.

[Joan2517]

Very good news, Judy!

[Harley PoMMom]

Oh Judy, that is great news! So happy that she is responding so well and hope it continues. Please keep us updated!

Hugs, Lori

[judymaggie]

Hi, folks! Sadie Sue continues to do well. Last night she did have an accident in the house but only because I was being overly optimistic and didn't take her out to pee on one of our regular trips outside. It was raining and I really thought she would be okay... not! Fortunately, she peed on a kitchen rug which I could easily throw in the washing machine. Today was an eventful day for her -- her first visit to the Memory Care Unit that is on the property where I am residing. I met the Activities person on one of our walks a while back, not knowing that she was the person who would coordinate her visits. She fell in love with Sadie Sue and, when I mentioned that I was hoping she could visit the residents, she thought that was a great idea. The visit today was interesting as I had no idea how Sadie Sue would do. She was so excited to be there and was thrilled that there were "treats" on the floor for her. She did let out a few loud howls but the residents seemed unphased. I wished she had paid more attention to the residents but was reassured that that could come with time once Sadie Sue was more familiar with visiting there. I hope so! We are doing another visit tomorrow in the afternoon and am hoping that it will be inbetween meals.
Sadie Sue goes to the vet on Wednesday to recheck her blood pressure. She has been on blood pressure medicine for almost three months. With her cortisol coming down so much, I am hoping it will at least be stable.