Bella's mom

[Marissap23]

Hi,

My name is Marissa I'm new to having a dog with Cushing's. I stumbled across this very helpful forum and am very grateful to have a community to help. I feel like Bella is being failed by her current vets. Bella is an 11 year old Yorkie and was diagnosed with Cushing's in October 2023. She had some hyperpigmentation that appeared to come out of nowhere on her belly in September. (She always had a pot belly, but it has recently gotten worse--since last August.) She also had some calcinosis cutis on her ears. (Unfortunately, the vet prescribed a OTC wipe that ulcerated her ears and as you can imagine, a dog with Cushing's takes forever to heal. This occurred January 10th and we are still trying to completely heal the ulcerations.) She has GI speckling as well.
Bella was originally prescribed 10mg of Vetoryl. I will need to get the results, but an internal medicine vet feels that the ACTH stim tests indicated she was being undertreated. It made her lethargic and impacted her appetite so in mid-January I took her off of the med for a week to see the difference. Her appetite and energy returned to normal. After 3 weeks, she started having more frequent urination and thirst. She also developed edema in her back right leg. (After 1 week off of the med, I took her to see an internal medicine vet. As you can imagine, I paid a fortune for test results that provided no further information than the normal vet.) Ultrasounds indicated that there is no adrenal tumor or blood clots. They also looked at her leg and didn't see any clots. She was prescribed 30 days of cefpodoxime for the bacterial and yeast skin infections, as well as Plavix and cobalequin (B12). I also have her on PetWellbeing Adrenal Harmony Gold and half a pill of CushAway.
The internal med vet has now prescribed 5mg Vetoryl am and pm and asked to do a pre-pill cortisol test rather than ACTH stim. Is this reasonable? How much longer can Bella take an antibiotic? Is there a better one to help with skin issues? I feel the antibiotic has helped some but should this have cleared everything or is this to be expected with Cushing's? When she has her tests in 3 weeks, I will post an update with all test results. Any help anyone can provide would be greatly appreciated.

Thank you,
Marissa

[labblab]

Dear Marissa, welcome to you and sweet Bella — we’re so glad you’ve found us! I apologize that I only have a moment to post right now, but I’ll definitely stop back by later on today to add some more thoughts. But I did want to have the chance to at least greet you before any more time passes ;-).

So once again, welcome, and I’ll be back again soon.
Marianne

[Harley PoMMom]

Hi Marissa,

Welcome to you and Bella! I am so sorry for the reasons that brought you here but glad you found us and we will help in any way we can. Most importantly, we need to see those test results for the Cushing's, all diagnostic and monitoring. Also, how much does Bella weigh? Could you also post any CBC or Chemistry blood panel results, we only need to see those values that are abnormal with the reference ranges and units of measurement...as an example: ALT 100 U/L (5-50)...thanks!

Is Bella still taking the Vetoryl? And did the vet tell you that it has to be given with a meal? I sure am sorry for all these questions but the more we know about precious Bella the better our feedback can be.

Hugs, Lori

[Marissap23]

Hi,

My name is Marissa I'm new to having a dog with Cushing's. I stumbled across this very helpful forum and am very grateful to have a community to help. I feel like Bella is being failed by her current vets. Bella is an 11 year old Yorkie and was diagnosed with Cushing's in October 2023. She had some hyperpigmentation that appeared to come out of nowhere on her belly in September. (She always had a pot belly, but it has recently gotten worse--since last August.) She also had some calcinosis cutis on her ears. (Unfortunately, the vet prescribed a OTC wipe that ulcerated her ears and as you can imagine, a dog with Cushing's takes forever to heal. This occurred January 10th and we are still trying to completely heal the ulcerations.) She has GI speckling as well.
Bella was originally prescribed 10mg of Vetoryl. I will need to get the results, but an internal medicine vet feels that the ACTH stim tests indicated she was being undertreated. It made her lethargic and impacted her appetite so in mid-January I took her off of the med for a week to see the difference. Her appetite and energy returned to normal. After 3 weeks, she started having more frequent urination and thirst. She also developed edema in her back right leg. (After 1 week off of the med, I took her to see an internal medicine vet. As you can imagine, I paid a fortune for test results that provided no further information than the normal vet.) Ultrasounds indicated that there is no adrenal tumor or blood clots. They also looked at her leg and didn't see any clots. She was prescribed 30 days of cefpodoxime for the bacterial and yeast skin infections, as well as Plavix and cobalequin (B12). I also have her on PetWellbeing Adrenal Harmony Gold and half a pill of CushAway.
The internal med vet has now prescribed 5mg Vetoryl am and pm and asked to do a pre-pill cortisol test rather than ACTH stim. Is this reasonable? How much longer can Bella take an antibiotic? Is there a better one to help with skin issues? I feel the antibiotic has helped some but should this have cleared everything or is this to be expected with Cushing's? When she has her tests in 3 weeks, I will post an update with all test results. Any help anyone can provide would be greatly appreciated.

Thank you,
Marissa

Here is the complete information from the internal med vet on 2/8/24 and some data from her normal vet visits:
rDVM Diagnostics/Summary:
1/4/23:
ACTH stim. Owner reported black areas on lower abdomen and ears - crusting on ears on exam but areas on lower abdomen thought to
be pigment change
ACTH stim: pre 2.9, post 6.6
Advised to continue Vetoryl 10 mg PO q 24 h
12/7/23:
ACTH stim: pre 6.7, post 8.7
Advised to continue current dose and recheck stim in one month
11/3/23 (ultrasound):
AUS: left adrenal 0.7 cm caudal pole, 1.33 cm long, right adrenal 1.8 cm long, hepatomegaly, gallbladder sludge
Rx: Vetoryl 10 mg PO q 24 h
10/31/23:
Pendulous abdomen, pigmented inguinal area
LDDST: pre 13.9, 4 hr 1, 8 hr 2.2
Rx: CK Shampoo and CK antiseptic mousse--------------------> this is what caused the ulcerations on Bella's ears.
10/19/23:
12.3 lbs
Annual exam
Otitis externa AU, pendulous abdomen, pot-bellied, she was drinking and urinating more but not excessive.
Ear cytology: Rare yeast, 2+ cocci AU
Chem: TP 7.4, alb 3.9, glob 3.5, AST 20, ALT 45, ALP 136 (H), GGT 1, tbili 0.1, BUN 24, crea 0.7, SDMA 8.9, phos 5, glu 112, Ca 11.3, Mg
1.9, Na 148, K 4.9, Cl 107, chol 268, TG 340 (H), precisionPSL 164 (H), CPK 219
T4: 1.8
CBC: WBC 6.7, Hct 54%, Plt 373 K
Urinalysis (cysto): 1.040, pH 6, 3+ protein

Ultrasound 2/8/24
Findings: The adrenal glands are bilaterally enlarged, the right at 8mm and the left at 7.6mm. The medial iliac lymph nodes are
enlarged, by about 10mm. The caudal great vessels appear normal. The liver is diffusely hyperechoic. There is gallbladder sludge, with
mucoid mucosal hyperplasia noted. The kidneys bilaterally have poor corticomedullary distinction and mild to moderate (about 3 mm)
renal pelvis dilation. There are increased mucosal speckles throughout the small intestines.

Interpretation: Adrenomegaly. Caudal retroperitoneal lymphadenopathy of unknown etiology. There is also inguinal
lymphadenopathy and ventral subcutaneous edema noted. Nonspecific and likely benign liver hyperechogenicity. Gallbladder content
that could predispose to mucocele formation. Kidney changes that suggest chronic disease. Intestinal wall changes, that may be
related to digestive period or possibly some wall inflammation.

Labs 2/8/24 showed the following elevations (ranges in parenthesis). She was off of Vetoryl 10mg for 8 days at this point:
MPV 13.4 (8.7 - 13.2)
Plateletcrit .54 (.14 - .46)
Test Results Unit Lowest Value Highest Value Qualifier
Glucose 128 mg/dL (70 - 143)
Creatinine 0.8 mg/dL (0.5 - 1.8)
BUN 22 mg/dL (7 - 27)
BUN: Creatinine Ratio 30
Phosphorus 4.6 mg/dL (2.5 - 6.8)
Calcium 9.8 mg/dL (7.9 - 12)
Sodium 146 mmol/L (144 - 160)
Potassium 4.3 mmol/L (3.5 - 5.8)
Na: K Ratio 34
Chloride 113 mmol/L (109 - 122)
Total Protein 7.8 g/dL (5.2 - 8.2)
Albumin 3.4 g/dL (2.2 - 3.9)
Globulin 4.4 g/dL (2.5 - 4.5)
Albumin: Globulin Ratio 0.8
ALT 82 U/L (10 - 125)
ALP 229 U/L (23 - 212)
Triglyceride 71 mg/dL (20 - 150)
Urine Protein: Creatinine Ratio 3.7 (should be less than .2)
GGT 2 U/L 11
Bilirubin - Total 0.2 mg/dL 0.9
Cholesterol 137 mg/dL (110 - 320)
Amylase 1,064 U/L (500 - 1500)
Lipase 954 U/L (200 - 1800)

Cytology Derm Skin
TNTC Cocci
2+ yeast
No rods seen
-ACH/ANS

Clinical notes from internal med vet:
"Upon review of her records I think her Vetoryl dose was raesonable and if anything, she was potentially slightly untreated for her
Cushing’s disease based on her ACTH stimulation test results. However, given her chronically picky appetite and her breed, I am
suspicious that she has underlying gastrointestinal disease like inflammatory bowel disease and/or a disease called lymphangiectasia
(impaired lymphatic drainage), which may be why she is less tolerant of the medication. Her skin changes could result from chronic
allergies, vasculitis (blood vessel inflammation) and/or excess blood clot formation. Recheck bloodwork was normal aside from a mild ALP elevation as previously, which is very common in cases of canine Cushing's
disease. Abdominal ultrasound revealed a large bright liver, some gallbladder sludge, and bilateral adrenal gland enlargement all fitting
with Cushing’s disease as previously identified. The ultrasound also confirmed the presence of edema under her skin of her lower
abdomen. Although no blood clots were seen on ultrasound, there still could be microscopic blood clots forming. She also had large
lymph nodes in the back of her abdomen, which I suspect her likely due to secondary inflammation. Her intestines had some mild
changes which would fit with her having inflammatory bell disease as suspected. To further investigate the possibility of G.I. disease in
a non-invasive way I recommended screening her for vitamin deficiencies which is currently pending. in case Bella has vasculitis I also
recommended tick testing, especially because of her history of tick exposure and being Anaplasma positive as this could lead to vessel
inflammation. Vasculitis can result certain cancers or infections (especially tickborne), or be primary autoimmune as well. Cytology was
done of the skin on her right lower abdomen and she was found to have a lot of bacteria and smaller amounts of yeast. I think for now it
makes sense to start her with a doxycycline trial which would treat for most tickborne illnesses and also help with her skin infection as
we did do some skin cytology and a lot of bacteria identified. Because of the yeast, I recommended a different topical wipe on her lower
abdomen and letting her ears simply heal. Should her skin changes especially the edema persist we may later trial a drug called
pentoxifylline which can be beneficial in cases of vasculitis. But as it can cause GI upset, I prefer to do one at a lime.
Bella's triglycerides were thankfully normal, but her urine protein was moderately elevated at 3.7 with normal being less than 0.2. This
could entirely result from her Cushing’s disease, although also could be due to other causes like chronic kidney disease
(glomerulosclerosis), or glomerulonephritis (inflammatory/autoimmune disease). Because this would increase her risk of excess blood
clot formation, I have recommended starting to blood thinner, called clopidogrel. We may also consider trailing her on telmisartan to
further lower urine protein but will take one step at a time."

[Squirt's Mom]

Hi and welcome to you and your precious Bella!

If Bella were mine here is what I would do - stop the Vetoryl for now and forget about Cushing's until all her other issues are under control. Why? Because any other illness or condition can and do cause false positives on all the blood tests for Cushing's. So let's say she does have IBD...that can cause the cortisol to rise naturally in response to the stress on the body from IBD. That rise in cortisol will show up on an ACTH as elevated even if Cushing's is not present. Cortisol is a fight or flight hormone and it's job is to rise when needed. I've had 2 misdiagnosed so I am uber aware of any possibilities of a misdiagnosis or conditions that could negatively impact the ACTH. Also, while she does show some of the abnormal labs we see in cush pups, her levels are very, very mild. It is not uncommon to see ALP values in the 1000's...hers is barely elevated. Here is a good link that describes typical signs and labs for a dog with Cushing's so you can compare to Bella's.

https://todaysveterinarypractice.com...renocorticism/

Thanks for providing the labs! Do you mind telling us how much she weighs? The Vetoryl dosage is based on weight, only weight. This is why we ask...we have sadly seen too many vets puts dogs on doses too high.

I'm glad you found us and look forward to learning more as time passes!
Hugs,
Leslie

[labblab]

Hello again, Marissa. It took me longer to get back here than I thought, but finally here I am. Whew! Thank you also for providing so much clinical information. I have to admit that Bella's situation is indeed a bit of a puzzle. As Leslie has already noted, Bella does exhibit some lab abnormalities consistent with Cushing's, but at least in terms of her liver enzymes, the elevations are quite mild. Also like for Leslie, the whole picture does make me wonder about the overall accuracy of the Cushing's diagnosis. And yet, there are some specific issues that Cushing's would account for and I assume that's what's leading the vets to make the diagnosis.

One particular question that I have relates to Bella's ear lesions. You describe them as being calcinosis cutis -- was the CC definitively diagnosed via a biopsy, or are the vets labeling CC just based on the general appearance of the lesions? The reason why I ask is because a confirmed diagnosis of CC would vastly elevate the likelihood of an accurate Cushing's diagnosis -- it seldom presents in dogs in the absence of Cushing's. However, I can't say that we've ever had another dog here who exhibited CC on their ears. Typically it it is found in patches on the the back or flanks. Anyway, I'd be interested in hearing more about the nature of the issue with her ears.

One other question I have is whether Bella's thyroid level has ever been tested. A simple thyroid test is usually noted as "T4" on a chemistry panel, and maybe I'm missing it in your list of results, but I don't think I'm seeing it there. Cushing's is a disease that can cause low thyroid readings as a secondary result. However, hypothyroidism can cause skin problems as well as a few other symptoms that can overlap with Cushing's, and if a dog suffers from hypothyroidism as a genuine primary problem, it can be treated quite simply with oral medication. So I just thought I'd ask whether thyroid testing has ever been discussed by either vet.

Also, Leslie is absolutely correct that when beginning treatment, the initial dose of trilostane should be based solely on weight. So, at Bella's weight of approx. 12 pounds, a beginning dose of 10 mg. does indeed seem appropriate. However, subsequent dosing changes should be based on tested cortisol levels and clinical improvement. It looks as though Bella had a follow-up ACTH after around a month of treatment with a result of ACTH stim: pre 6.7, post 8.7. A dosing increase could have been considered at that time if symptoms persisted, but Bella's dose remained at 10 mg., with a subsequent test performed early January: ACTH stim: pre 2.9, post 6.6. (I'm assuming that the date for that test in your summary should be January of 2024 instead of 2023). I'm guessing these results are what are leading the internist to speculate that Bella may have been a bit undertreated since they could be lower in the presence of continuiing symptoms. However, given the fact that they declined from December to January while remaining on the same dose, I'm glad that the dose was not increased after all.

For what it's worth, I do think the internist's report seems quite comprehensive and reasonable. She's covering a lot of bases in a way that generally makes sense to me. So even though I can surely sympathize with the expense of the additional testing and the lack of a clear pathway forward at this time, I do commend you for consulting with the internist and I think her input is of value. I'm gonna go ahead and close for now, but I'll keep thinking about Bella's situation and add any more thoughts that come to my mind.

Marianne

[Marissap23]

Hello again, Marissa. It took me longer to get back here than I thought, but finally here I am. Whew! Thank you also for providing so much clinical information. I have to admit that Bella's situation is indeed a bit of a puzzle. As Leslie has already noted, Bella does exhibit some lab abnormalities consistent with Cushing's, but at least in terms of her liver enzymes, the elevations are quite mild. Also like for Leslie, the whole picture does make me wonder about the overall accuracy of the Cushing's diagnosis. And yet, there are some specific issues that Cushing's would account for and I assume that's what's leading the vets to make the diagnosis.

One particular question that I have relates to Bella's ear lesions. You describe them as being calcinosis cutis -- was the CC definitively diagnosed via a biopsy, or are the vets labeling CC just based on the general appearance of the lesions? The reason why I ask is because a confirmed diagnosis of CC would vastly elevate the likelihood of an accurate Cushing's diagnosis -- it seldom presents in dogs in the absence of Cushing's. However, I can't say that we've ever had another dog here who exhibited CC on their ears. Typically it it is found in patches on the the back or flanks. Anyway, I'd be interested in hearing more about the nature of the issue with her ears.

One other question I have is whether Bella's thyroid level has ever been tested. A simple thyroid test is usually noted as "T4" on a chemistry panel, and maybe I'm missing it in your list of results, but I don't think I'm seeing it there. Cushing's is a disease that can cause low thyroid readings as a secondary result. However, hypothyroidism can cause skin problems as well as a few other symptoms that can overlap with Cushing's, and if a dog suffers from hypothyroidism as a genuine primary problem, it can be treated quite simply with oral medication. So I just thought I'd ask whether thyroid testing has ever been discussed by either vet.

Also, Leslie is absolutely correct that when beginning treatment, the initial dose of trilostane should be based solely on weight. So, at Bella's weight of approx. 12 pounds, a beginning dose of 10 mg. does indeed seem appropriate. However, subsequent dosing changes should be based on tested cortisol levels and clinical improvement. It looks as though Bella had a follow-up ACTH after around a month of treatment with a result of ACTH stim: pre 6.7, post 8.7. A dosing increase could have been considered at that time if symptoms persisted, but Bella's dose remained at 10 mg., with a subsequent test performed early January: ACTH stim: pre 2.9, post 6.6. (I'm assuming that the date for that test in your summary should be January of 2024 instead of 2023). I'm guessing these results are what are leading the internist to speculate that Bella may have been a bit undertreated since they could be lower in the presence of continuiing symptoms. However, given the fact that they declined from December to January while remaining on the same dose, I'm glad that the dose was not increased after all.

For what it's worth, I do think the internist's report seems quite comprehensive and reasonable. She's covering a lot of bases in a way that generally makes sense to me. So even though I can surely sympathize with the expense of the additional testing and the lack of a clear pathway forward at this time, I do commend you for consulting with the internist and I think her input is of value. I'm gonna go ahead and close for now, but I'll keep thinking about Bella's situation and add any more thoughts that come to my mind.

Marianne

__________________________________________________ __________________________________________________ __________________________________________________ ______________________________________________
Hi and thank you both for taking the time to reply. I’ll reply to both of you if that’s ok. (Yes, any testing listed was from October 2023 through February 2024.) Bella was 12.86lbs but has dropped to 11.8lbs in the am prior to eating and 12 lbs at night after eating. Vets have always told me they wanted her weight closer to 9lbs, but she was the runt and was pretty reminiscent of the chubby puppy Rolly from 101 Dalmatians 😊. So she’s been chubby and food motivated from day 1. I have not had her thyroid tested because I felt that many of her symptoms did point to a positive Cushing’s diagnosis.
The changes started when she turned 9 and started peeing more. We noticed her tummy becoming more pot-bellied but no increase in thirst or appetite. 1mg of DES stopped it, although the internal vet said that DES was an inappropriate med to give her when she was simply peeing more frequently and not “leaking urine”.
In August 2023, she started having increased urination. At the end of September, I noticed the black crusting on her ear edges that piled on top of itself and peeled away the hair when you gently removed it. When I googled it, it looks exactly like calcinosis cutis. (The original vet brushed me off and told me I was overreacting. She gave me an OTC foam and it burned and ulcerated her ears after 4 days. The ears still have not healed. This is one of the reasons I do feel she has Cushing’s—the skin infection itself and the difficulty in healing it.) She also had a brand new black spot on her tummy that wasn’t hyperpigmentation. You could tell it was some type of bacteria or yeast. (Turns out, both.) Bella had never had any of these skin symptoms and they came out of the blue. When I used Dechra Hex + Triz and Duoxo S3 PYO on the spots, “black” came off and over time, lightened the spot. The same black stuff has now expanded to most of her stomach, all of her “elbows”, the right thigh that has the edema and a few spots on her face and chest. (By the way, Bella never had edema until suddenly at the end of January after she was off of the Vetoryl for a week, which is very concerning to me. She has all of those swollen lymph nodes.) So I truly feel it is bacteria and yeast that is not being treated with the right antibiotic (cefpodoxime.)
I agree that her numbers are low for treating Cushing’s…but I definitely think she has it and I’m concerned about where she would be if I don’t treat it. I don’t want her to get worse and/or die. (I’m sure you can provide insight into not treating and the progression of the disease.) All of these issues came on quickly within the last 6 months and are common signs of Cushing’s. In addition, she has some muscle wasting and loose skin on her back, abdomen, and neck. Maybe this is just me being hypersensitive to the changes because she’s my first dog. My concern is that the skin infections and edema have come on suddenly and is common in Cushing’s. Her energy and appetite are normal without treatment, but she has increased urination and thirst, though it isn’t dramatic.
The internal med vet has also said, “She’s complicated and I can’t even give you a prognosis or how much longer she’ll live”, so that obviously was jarring. I think the edema, loose skin, and skin infections are concerning because she’s never had any issues, and she is lethargic on these meds, but I definitely have not felt like she’s even remotely dying or apt to be in the next 2-3 years. I know Cushing’s will progress and she’s 11 but good grief.

Best,
Marissa

[labblab]

Gosh, I can sure understand why the internist’s comment about prognosis felt pretty off-putting :-(((. But Bella’s picture is definitely a complicated one, especially due to the issues related to the enlarged lymph nodes and possible inflammatory disease. I’m afraid those are areas about which I have very little knowledge, especially in terms of any relationship — or lack of relationship — to Cushing’s. So I’ll be anxious to see if there are any further changes in her next set of labs that may help clarify things.

I remain a bit surprised that Bella’s basic thyroid level doesn’t seem to have come up on any of the testing thus far. A simple T4 reading is frequently included in general blood chemistry panels, or can easily be added. If that reading is abnormal, more extensive blood testing is usually required to clarify whether or not there is genuinely a thyroid issue at play. But given the fact that recalcitrant skin and ear infections are common with hypothyroidism, it seems as though at least checking a basic T4 level wouldn’t be unreasonable. As I noted above, Bella could conceivably suffer from both Cushing’s and hypothyroidism as primary problems that would benefit from treatment. Just a thought that you might want to ask the internist about when Bella’s next labs are scheduled.

Also, you had asked earlier about testing Bella’s cortisol level via a pre-pill reading vs. a full ACTH. Given the fact that there was a fair drop in her cortisol level between December and January while remaining on the same dose, I personally might feel more comfortable with having at least one more full ACTH done now, especially since you’ll be altering the dosing schedule to 5 mg. twice a day from the 10 mg. once daily. But there’s no question that the full ACTH is more expensive. And if the internist feels as though the pre-pill testing is sufficient for her peace of mind, then it’s certainly an option. I think that in the U.K., for instance, the pre-pill test has largely replaced the ACTH for monitoring purposes.

Anyway, please do keep us in the loop, both in terms of the planned testing and also insofar as how Bella seems to be feeling. I surely do hope that you start to see more improvement very soon.

Marianne

[Marissap23]

Hi,

Does anyone else's dog have edema after they've been diagnosed with Cushing's? Treatment recommended for the pup? Bella has left side edema on her abdomen and right hind leg. I can't find a lot of info on dogs with Cushing's and edema, but I know fluid retention is an issue with Cushing's and there's a lot of information on it with humans. Her labs Feb. 8, 2024 didn't indicate any heart issues. She has enlarged lymph nodes which has happened in the last 7 months as she gradually became clinical for Cushing's. Not sure how concerned I should be since the vet knows about it...

Thank you for any insight!
~Marissa

[labblab]

Hi again, Marissa. You’ll see I’ve moved your question about edema into your main thread. We generally like to keep all postings — even about different questions — consolidated in a single thread for each member. This way, we can easily review the entire history that brought us to any specific question.

Having said that, your question about edema is very interesting. I can’t say that I remember it being cited by other folks here. I tried to research it a little bit, and like you, I found references to humans with Cushing’s. But not so much to dogs. One reference I did see was to hind limb edema as a result of an invasive adrenal tumor. But you’ve reported that ultrasound has already ruled out an adrenal tumor for Bella. So I’m afraid I have neither experience nor information to share in this regard. As you say, since your vet knows it exists, I’d try not to overly worry about it. I know, much easier said than done! But if you do learn anything more yourself, please do share that with us since you’ll be helping to educate us all.

Continuing best wishes,
Marianne