Maggie - Miniature Labradoodle - 11 years old - New Cushings diagnosis

[Shaun]

Hello,

Hope you're keeping well?

Maggie has now had her ultrasound, the results aren't clear cut it seems..comments welcome as ever.


Regards,

Shaun






Signalment: 11yo female neutered crossbreed dog 13.4kg

Sedation: butorphanol and medetomidine

History: Feb 2023 - hair loss, raised alkp/alt on bloods, ACTH stim test didn't support diagnosis of cushings. LDDS test did support diagnosis of cushings. Dispensed trilostane, but unsure if given.

Physical exam: Extensive alopecia and pigmentation over shoulders, back and flanks. Poor hair coat ventral abdomen. No comedones, Abdomen a little rounded but not overtly potbellied.

Thoracic ultrasound:

heart - subjectively unremarkable, all chambers and wall thicknesses in proportion, systolic function adequate
no pleural or pericardial effusions
lungs unremarkable in visible parts
no mass lesions in visible parts Abdominal ultrasound:
no effusion
major vessels: unremarkable
abdominal fat: unremarkable echogenicity
Liver:normal size, shape and echogenicity, vasculature unremarkable
portal vein: unremarkable, PV/Ao ratio 0.74 ( < 0.65 suggests EHPSS, >0.8 excludes EHPSS), hepatopetal flow in mesenteric, splenic and gastroduodenal veins
gallbladder and biliary tract: homogenous hyperechoic debris within gall bladder, occupying 50% of lumen, no acoustic shadowing
pancreas:unremarkable
stomach: unremarkable, wall 3 mm, normal 3 - 5mm
duodenum: unremarkable, wall 4.5mm, normal <20kg <5.1mm, 20 - 30kg <5.3mm, >30kg <6mm jejunum: unremarkable, wall 3mm, normal <20kg <4.1mm, 20 - 30kg <4.4mm, >30kg <4.7mm Ileum: unremarkable
ICCJ: unremarkable
Caecum: unremarkable
colon: unremarkable
spleen: unremarkable
Kidneys: unremarkable, left kidney 5.04cm, right kidney 5.3cm, Ao 8.2mm, Ao/kidney ratio 6.1/6.4 , normal 5.5 - 9.1
adrenals: left adrenal is abnormal - cranial pole is enlarged at 8.2mm across (normal <7.4mm across) although is normal shape, it contains two hyperechoic homogenous nodules, largest nodule sits more cranially and iis 6.8mm x 9.3mm, second nodule more caudal is 4.6mm. Caudal pole is 5.2 mm, right adrenal 6.7 mm (normal 7.4mm)
ureters: unremarkable
bladder: unremarkable
proximal urethra: unremarkable
jejunal, colic and other visceral lymph nodes: unremarkable
sublumbar lymph nodes: unremarkable

Conclusions:

Adrenal glands - there are two nodules within the left adrenal gland and the gland is slightly enlarged.The right adrenal is normal size.
Gall bladder - there is homogenous hyperechoic debris filling 50% of the gall bladder lumen

Recommendations/plan/thoughts:

Adrenal nodules - non-mineralised nodules less than 2cm in diameter ( these ones comfortably are) may be benign nodular hyperplasia rather than neoplastic lesions. It is possible for them to be non-functional or cortisol secreting. Usually if a dog has adrenal dependant HAC and an adrenal nodule secreting cortisol then the contralateral adrenal gland would be small, whereas in Maggie it is normal sized so although we cant confirm it on the scan its less likely that she has adrenal dependant HAC. Having adrenal nodules obviously doesnt rule out pituitary dependant HAC and some dogs with PD HAC may have normal sized adrenal glands.

In summary - Maggie has two small adrenal nodules and mild enlargement of the left adrenal gland but the changes are not extensive enough to be sure that these are neoplastic nodules and even if they were we couldn't confirm if they were secreting cortisol.
Gall bladder - although debris is fairly common in older dogs and often incidental it does suggest a degree of biliary stasis. Ursodeoxycholic acid can be used to try to encourage bile flow.

Further testing - it may be worth testing more extensively for hyperthyroidism as mentioned in your history. I would advise the owner to monitor water intake and other signs of Cushings disease and repeat the ACTH or LDDST if symptoms develop..

[Harley PoMMom]

Hi Shaun!

Thanks so much for posting Maggie's ultrasound findings. In my opinion I really don't think Cushing's is the cause of Maggie's symptoms, dog's with this disease generally have an enlarged fatty liver and according to the ultrasound, Maggie's liver is neither enlarged nor fatty. Also her adrenal glands don't have the appearance of a dog with Cushing's, when a dog has pituitary dependent Cushing's both adrenal glands are being over stimulated so they both are most likely enlarged. With an adrenal tumor, one gland will be severely atrophied while the other one is enlarged.

The concern I have is the gallbladder which could be mucocele or cholestasis and I believe the medication Ursodiol is the common treatment.

Please do keep us updated!

Lori

[Squirt's Mom]

I agree with Lori...this is not the typical US report on a cush pup. The liver is seldom normal in appearance and as Lori said the adrenals don't fit with either the adrenal based form nor the pituitary form. So along with the signs I would put Cushing's on the back burner for now. I would ask them to look into the possibility of an adrenal tumor called a pheochromocytoma. It is not a common tumor. There are other non-cortisol secreting adrenal tumors as well. Here is a link on adrenal tumors -

https://petcureoncology.com/adrenal-tumors-in-dogs/

Hugs,
Leslie

[Shaun]

Thanks Lori, i appreciate your thoughts and opinion.

Regarding Maggie's gallbladder, the vet didn't even mention this and it was just when receiving the report i noted the comments. My understanding is that specialist would have mentioned it if she thought there was a mucocele as it would have been distinguishable from biliary sludge vs 'an organised structure' in the gallbladder lumen. Either way i plan to bring this up with her normal vet.

Regarding the Cushings, well i honestly don't know..there's obviously something adrenal based going on, given the abnormality, but given that her main clinical sign is her poor coat and alopecia it may be sex hormone related, as that is observed with benign hyperplasia.

I guess we'll take a breather for now and let my funds recover too ; )

Take care,

Shaun

[Shaun]

Hi Leslie,

Thank you for your thoughts on this, i appreciate it.

I think i looked at that link before, it frightened me a bit : )

I'm probably going to adopt the 'wait & see' approach, looking for any other symptoms that Maggie may have. At the moment she's happy and there's nothing much beyond her coat to report on (well apart from the tremor when she's going somewhere she doesn't like).

Given Maggie's age i don't think i'd want to put her through adrenalectomy surgery. Given the chance she may never leave the hospital and that she'd require medication post surgery.

Melatonin may be an option for her alopecia? I guess I'm going to just watch her like a hawk and pray it's benign and slow growing so that she see's out her remaining years without suffering.

Take care,

Shaun