Pestka - doubts on diagnosis

[Kat Ga]

Hi, I've been looking for diagnosis of my dog, Pestka grom Poland, 12yo 5kg mix since Sept 2023. It all started with slightly increased drinking and hair regrowth arrest, no other signs, adrenals on ultrasound normal, ALP normal, ALT & GGTP increased (twice), blood count ok, T4 low, urine with weight low and some protein. Intern Vet inmediately tested her for cushing and both cortisol/creatinine (88) & LDDH were positive. She prescribed Seleginine at first, but my dog reacted cery badly to the drugi started drinking much more, was restless and started getting up at night. After withdrawing the drug, all the symptoms went back, too. The vet tried to put her on vetoryl, but she reacted with restlessness again. I consulted two endocrinology specialists, both aren't convinced it looks like typical cushing, so the vetoryl was withdrawn and we kept on searching. There were UTI coming now and then, she has been treated and the urine weight got a little higher (1,021), slight proteinuria stil there. The drinking is waving, but is not veeery excesive. She's been treated for hypothyroidism (ultrasound confirms it), but after 6 months the hair is not regrowning and the T4 isn't increasing either. Liver enzymes have decreased a little, after 9 months ALP is still ok (77 or so). She's has gastritis and reflux. Hunger is not an issue, always very good eater, but she doesn't go crazy. Sleeps at nights, wakes up very early, though. No high blood pressure. No movement problems. Adrenal glands still unchanged. Base cortisol in blood each time normal, endogenous ACTH normal, but cortisol/creatinine in urine high again.
Because of the poor hair regrowth my endocrino decided we do the ACTH test. I am cery scared it gives positive, I'm not convinced that the hair arrest is enough to start the vetoryl treatment yet☹️
What do you think? What's the usual time between the cushing signs and ALP show up? I'm reading the disease progresses slowly, but how slowly? Is it possible that after 9 months from the LDDH test the adrenals, ALP, etc. are still in the normal range, or maybe I should keep digging with the UT/renal/gastritis/thyroid issues? I'm stressed myself with all these tests and very afraid of cushing.

[Harley PoMMom]

Hi and welcome to you and Pestka!

First, I want you to know that Cushing's is rarely a pressing condition, it is a slow progressing disease taking years to do any real damage so there is no need to panic about waiting to start treatment.

Usually an endogenous ACTH test is done to help determine if the Cushing's is adrenal or pituitary dependent, and generally this type of test is only performed when the dog has been already diagnosed with Cushing's. Could you post the results of that LDDS test for us? On the complete blood count (CBC) dogs with Cushing's syndrome have what is called a "stress leukogram," which refers to a specific white blood cell distribution in the blood. This includes a high total white blood cell count with increased numbers of neutrophils and monocytes and decreased numbers of lymphocytes and eosinophils. Does Pestka's blood work show any of these abnormal results? Was a complete thyroid panel done?

Regarding the ALP, about 10% of dogs with Cushing’s syndrome have normal ALP activity.

If this were me, the next thing I would do is have an ultrasound performed, I feel the ultrasound is one of the most useful diagnostic tools, especially considering it's non-invasive, it can give an "inside look" at those internal organs. However, those ultrasounds are expensive to have done and not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting. The technician, most likely, will perform their own and therefore, it should be those most experienced with capturing good windows and images. That would be a board-certified radiologist or board-certified Internal Medicine Specialist. Likewise, the one interpreting it should be the most experienced as well, and that's generally one of the 2 above.

If it turns out that Pestka does have Cushing's I want you to know that Cushing's is a treatable disease and with treatment dogs with Cushing's can have a good quality of life and there is every reason to believe that they can live out their normal life span. However, for the treatment to work safely and successfully it requires an educated pet owner along with an experienced vet as adverse side effects are mostly only seen when the proper protocols are not followed.

So, take some deep breaths, hang in there and know that we will help in any way we can.

Hugs, Lori

[Kat Ga]

Thank you so much for the answer!!❤️

I dont't know how to add the resulte here, but she has no stress leukogram, all the leukocytes and platelets are in the normal range.

We do the ultrasound every 3 months now and adrenal glands are normal, there are some small changes in glomeruli (might be due to urine dilution, might be glomerulitis), slight hepatic lipidosis, gastritis and reflux, thyroid picture as in hypothyroidism. No other findings.

LDDS results: 1 - 62,9 mg/ml; 2 - 45,0 mg/ml; 3 - 27,1 mg/ml

Thank you!🙏

Hi and welcome to you and Pestka!

First, I want you to know that Cushing's is rarely a pressing condition, it is a slow progressing disease taking years to do any real damage so there is no need to panic about waiting to start treatment.

Usually an endogenous ACTH test is done to help determine if the Cushing's is adrenal or pituitary dependent, and generally this type of test is only performed when the dog has been already diagnosed with Cushing's. Could you post the results of that LDDS test for us? On the complete blood count (CBC) dogs with Cushing's syndrome have what is called a "stress leukogram," which refers to a specific white blood cell distribution in the blood. This includes a high total white blood cell count with increased numbers of neutrophils and monocytes and decreased numbers of lymphocytes and eosinophils. Does Pestka's blood work show any of these abnormal results? Was a complete thyroid panel done?

Regarding the ALP, about 10% of dogs with CushingÂ’s syndrome have normal ALP activity.

If this were me, the next thing I would do is have an ultrasound performed, I feel the ultrasound is one of the most useful diagnostic tools, especially considering it's non-invasive, it can give an "inside look" at those internal organs. However, those ultrasounds are expensive to have done and not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting. The technician, most likely, will perform their own and therefore, it should be those most experienced with capturing good windows and images. That would be a board-certified radiologist or board-certified Internal Medicine Specialist. Likewise, the one interpreting it should be the most experienced as well, and that's generally one of the 2 above.

If it turns out that Pestka does have Cushing's I want you to know that Cushing's is a treatable disease and with treatment dogs with Cushing's can have a good quality of life and there is every reason to believe that they can live out their normal life span. However, for the treatment to work safely and successfully it requires an educated pet owner along with an experienced vet as adverse side effects are mostly only seen when the proper protocols are not followed.

So, take some deep breaths, hang in there and know that we will help in any way we can.

Hugs, Lori

[Kat Ga]

The ACTH simulation result is positive, too.����
Pre 5,76. Post 33,2...
Is radiation an option or too risky?

[labblab]

Hello, and welcome to you and Pestka from me, too! Thank you so much for all the great information that you have given us. I can see why you have so many questions about her condition since she does indeed have certain Cushing's symptoms along with the positive test results. But she doesn't have certain other symptoms and lab abnormalities that we'd usually expect to see. So I can understand why you are still wondering whether the diagnosis is really correct, and even if so, whether or not to start treatment.

My own thoughts about treatment depend a lot on the age of a dog and also whether or not the Cushing's symptoms are making them uncomfortable. For younger dogs, I do encourage treatment in order to slow down or halt the slow internal systemic damage that Cushing's can cause, such as high blood pressure, kidney problems, vulnerability to infection and blood clots, etc. But treatment typically does involve possible side effects from the medication and a lot of trips to the vet for monitoring that require blood draws and other testing. Plus, for some older dogs who suffer from arthritis, lowering the cortisol can actually make them feel stiff and sore. So treatment can be a trade-off. In the case of my own Cushing's dog, his outward symptoms were making him miserable. His excessive thirst and urination, ravenous appetite, hind-end weakness, and almost constant panting seemed so very uncomfortable. His quality of life was so poor. So I definitely decided to treat him with Vetoryl, and for a time, that did really seem to help him. But I just mention all of this to let you know that, even with the "positive" test results, at her age you may or may not want to start treatment at this time if Pestka's symptoms don't really seem to be all that big of a problem for her.

You've told us that she did not respond well to the Vetoryl when you tried it earlier. Can you tell us what dose she was taking? Also, did she have any monitoring blood test at the time that indicated what effect that particular dose was having on her cortisol level? Because if you decide to continue to pursue treatment, it may be the case that the dose of Vetoryl that she was taking just needs to be adjusted upward or downward.

As far as radiation, I'm guessing you are wondering about radiation to reduce the size of a pituitary tumor since that seems likely to be the cause of Pestka's Cushing's if she indeed truly has it. Here in the U.S., radiation is typically only pursued if a dog starts to exhibit neurological problems that indicate the pituitary tumor is enlarging and placing pressure on other parts of the brain. It is not a common treatment for the vast majority of dog's with Cushing's here. However, it's possible that radiation treatment for pituitary tumors may actually be more advanced there in Europe. If so, we'd be really interested to learn more about the current possibilities.

I'll go ahead and close for now. But once again, I'm so happy you've joined us and I look forward to talking with you more about your sweet girl.
Marianne

[Kat Ga]

Thank you so much for such a thorough answer to my doubts!!!

She took vetoryl just twice 5 mg, so the dosage was rather low, and then we stopped. She felt unwell after the second pill. We measured cortisol after a week or two and it was in the normal range.

Thank you once again, I think I needed to hear that I'm not going crazy🥹❤️ Pestka feels well, I think, so maybe I shouldn't rush into the treatment yet and check if the problem doesn't resolve when we manage to stabilize thyroid and urine tract issue...I can always start with vetoryl if any new symphtoms appear. Of course, I will talk to my vet next week if she's ok with this.

Hugs,
Kasia

Hello, and welcome to you and Pestka from me, too! Thank you so much for all the great information that you have given us. I can see why you have so many questions about her condition since she does indeed have certain Cushing's symptoms along with the positive test results. But she doesn't have certain other symptoms and lab abnormalities that we'd usually expect to see. So I can understand why you are still wondering whether the diagnosis is really correct, and even if so, whether or not to start treatment.

My own thoughts about treatment depend a lot on the age of a dog and also whether or not the Cushing's symptoms are making them uncomfortable. For younger dogs, I do encourage treatment in order to slow down or halt the slow internal systemic damage that Cushing's can cause, such as high blood pressure, kidney problems, vulnerability to infection and blood clots, etc. But treatment typically does involve possible side effects from the medication and a lot of trips to the vet for monitoring that require blood draws and other testing. Plus, for some older dogs who suffer from arthritis, lowering the cortisol can actually make them feel stiff and sore. So treatment can be a trade-off. In the case of my own Cushing's dog, his outward symptoms were making him miserable. His excessive thirst and urination, ravenous appetite, hind-end weakness, and almost constant panting seemed so very uncomfortable. His quality of life was so poor. So I definitely decided to treat him with Vetoryl, and for a time, that did really seem to help him. But I just mention all of this to let you know that, even with the "positive" test results, at her age you may or may not want to start treatment at this time if Pestka's symptoms don't really seem to be all that big of a problem for her.

You've told us that she did not respond well to the Vetoryl when you tried it earlier. Can you tell us what dose she was taking? Also, did she have any monitoring blood test at the time that indicated what effect that particular dose was having on her cortisol level? Because if you decide to continue to pursue treatment, it may be the case that the dose of Vetoryl that she was taking just needs to be adjusted upward or downward.

As far as radiation, I'm guessing you are wondering about radiation to reduce the size of a pituitary tumor since that seems likely to be the cause of Pestka's Cushing's if she indeed truly has it. Here in the U.S., radiation is typically only pursued if a dog starts to exhibit neurological problems that indicate the pituitary tumor is enlarging and placing pressure on other parts of the brain. It is not a common treatment for the vast majority of dog's with Cushing's here. However, it's possible that radiation treatment for pituitary tumors may actually be more advanced there in Europe. If so, we'd be really interested to learn more about the current possibilities.

I'll go ahead and close for now. But once again, I'm so happy you've joined us and I look forward to talking with you more about your sweet girl.
Marianne