Alivia was recently diagnosed with Cushing's - Alivia has passed

[MBK]

Addy - You have a very wise and kind husband.

The GOOD news: I missed a call from Alivia's IMS yesterday to tell me the results of her most recent blood tests. (Actually she called my home number when I am at work all day even though they have my direct dial work number, which always annoys me) Anyway, her message was, "Nice results!..." Her Amylase is about 300 above normal - she wasn't concerned. Her Lipase was normal. And, "there was a slight change in one of the liver enzymes". She didn't specify which, but said she wasn't concerned and that Alivia needed nothing further than to come back in 6 months for routine twice a year exam.

The CONCERNING news: Why does it seem like good news is short lived? Went to bed feeling really good that Ali was improving...only to be up worrying about her most of the night. She was panting almost continuously and very restless - the way the pancreatitis started. She allowed me to pet her belly, which you couldn't do during her pancreatitis flare up. It was much warmer in my house than it has been but my other JRT, Maxwell, was not effected at all. I gave her a pain pill in a pill pocket, which she readily accepted (and looked for more). When she had pancreatitis she refused EVERYTHING. She fell asleep soon after and seemed more comfortable. I had given her a different canned food for dinner and the fat content was a bit higher. I wonder if that bothered her a bit.

Always something!

[Harley PoMMom]

Lipase and Amylase can be normal even when a dog is suffering from pancreatitis. One time with Harley I had the Lipase and Amylase checked along with a Spec PL test and his Lipase and Amylase were both in the normal ranges but the Spec PL test results were 464 (0-200).

The pancreas is such a fickle organ and it can take a while for it to heal. Also, pancreatitis can elevate the liver enzyme levels and it may take some time for those liver enzymes to come down.

Keeping you both in my thoughts and prayers.

Love and hugs,
Lori

[MBK]

Lori - Any dietary tips or other suggestions to keep Alivia from having another full fledged episode?

Just had her most recent blood results faxed to me and there have been many improvements. The only things outside the normal range are:

ALK Phosphatase 341 (5-131 U/L) 2 weeks ago this was 628 and then 2 days later went up to 665!
GGTP 15 (1-12 U/L) Was <5 2 weeks ago-I'm not familiar with this one?
Phosphorus 6.6 (2.5-6.0 mg/dL) 2 weeks ago was 5.5
Amylase 1474 (290-1125 U/L) 2 weeks ago was 1785!
WBC 16.9 (4.0-15.5 10^3/uL) was 11.5
Platelet Count 652 (170-400 10^3/uL) was 75!
Absolute Neutrophils 11999 (2060-10600 10^9/L) was 10350

A lot of other values have improved into normal range! Overall these are really good results for Alivia, especially considering what she's just been through. Her IMS was quite pleased. I think I need to be more vigilant with her diet.

[labblab]

"Assessment: Continue to detect adrenal asymmetry with suspected nodule in cranial pole of the right adrenal gland. Normal appearance to left adrenal gland and caudal aspect of right adrenal gland suspicious for autonomous nodular function (adrenal adenoma). Cannot rule out atypical nodular hyperplasia since LDDS did reveal suppression. Recent onset of abdominal discomfort and fever suspicious for flare-up of pancreatitis. Cannot rule out concurrent or inciting cholangitis secondary to bile clumping. Visualization of “meaty” pancreas, hyperechoic peripancreatic fat, and trace of regional effusion all support inflammatory disease (pancreatitis/cholangitis). Hyperadrenalcorticism likely contributing to predisposition for pancreatitis.”

His recommendations were for the immediate hospitalization and treatment of the pancreatitis and then when she was recovered to “…continue endocrine work up with plasma ACTH level. Presence of potential complications associated with hyperadrenocorticism (pancreatitis, cholangitis) suggests that HAC should be managed more aggressively with Mitotane(rather than trilostane)if suspect macronodular PDH, or Lysodren/adrenalectomy if suspect adrenal adenoma.”

Hi Mary Beth,

First off, I am so sorry that you had another uneasy night. And I surely understand your continuing uncertainty over which path to choose regarding Ali's diagnostics and treatment. I know you had asked earlier for thoughts about her ultrasound results and the related recommendations. It took me a while to be able to look them over (and think them over), but here's the little bit I can offer.

First of all, this may be what you had already planned, but I do believe the ultrasound specialist is recommending that Ali have an "Endogenous (Plasma) ACTH" performed as opposed to an ACTH stimulation test. I did not have the chance to completely read through your entire thread, but I do believe that she has already exhibited elevated cortisol per the ACTH stimulation component of the UTK adrenal panel. The Endogenous ACTH is an entirely different test, is somewhat challenging to accurately perform, but can aid in differentiating between pituitary and adrenal Cushing's. And right now, that still seems to be the question for the ultrasound specialist: trying to confirm whether or not that adrenal abnormality is actually an adrenal adenoma.

Even though Ali's 8-hour LDDS result was not consistent with a Cushing's diagnosis, it does not definitively rule out the possibility of PDH because up to 10% of dogs with PDH will score within the normal reference range. However, the fact that she exhibited suppression at both the 4 and 8-hour marks would seemingly rule out ADH: dogs with ADH typically never exhibit cortisol suppression on this test. But then, we have the ultrasound imaging which does demonstrate an abnormality of some sort limited to the right adrenal gland. So how to resolve the inconsistencies? I do believe that is why the "Plasma ACTH" is being recommended -- to further aid in differentiating whether Ali may be suffering from PDH or ADH. Because that information, in turn, may affect your treatment of choice: both the type of medication and the aggressiveness of treatment. And I definitely do "get it" that both he and you are wanting to move forward with Cushing's treatment if it is warranted and if it will stave off future pancreatitis attacks.

But there is some additional confusion from the standpoint that now Ali's behavioral Cushing's symptoms seem to be improving, but during the same time period that she has suffered from this life-threatening attack of pancreatitis. Even if you wanted to also perform a repeat screening ACTH stimulation test at this time, I don't know whether it might show residual elevation simply as a result of Ali's pancreatitis.

The bottom line is, I think these are all really good questions to discuss with Dr. Peterson. I am also thinking that you may not want to invest any more money in additional testing until you have had the chance to talk with him. Ali's situation is truly complicated, and I think it may be really helpful to have his feedback before moving forward. I know you will pay any price to keep her healthy and happy. But perhaps he'll be able to help you prioritize and focus on what the very best "next steps" will be.

Marianne

[MBK]

Dear Marianne -

Thank you, thank you , THANK YOU! For the time you spent on that wonderful analysis and well thought out explanation! You just clarified a lot of confusion for me and validated my feeling that the cause of her Cushing's is not so clear cut! I have been saying her symptoms have come and gone to various degrees for YEARS! Maybe there is some other explantion - a congential defect in her adrenal gland perhaps that casues fluctuations in the hormones? Alivia has never been a clear cut case with ANYTHING. When she had IMHA - the vet at Ohio State University actually said she did things that they couldn't explain and that were not even medically possible (or so they thought!). She had u/s way back then - I think I will try to get those reports. It would be interesting to see if there were any comments on her adrenal glands.

The doctor that did this u/s ONLY does ultrasound and has an extremely good reputation. The vet that works for the Trilostane manufacturer, Dr. Allen, even told me he knows this guy and that he was very good. Yet, her IMS basically dismissed this report by saying she didn't see what he saw and that Ali has an adrenal tumor and could be cured with surgery! She did not mention the LDDS supression and I did not specifically ask her to explain that, though.

I "talked" to Ali's regular vet last night by email. He agrees that the best way to proceed is a consultation with Dr. Peterson and that he will be happy to oversee her care and do whatever is best for Alivia. I appreciate him so much. He has already saved Ali's life multiple times.

Your post really put the inconsitencies of Ali's test results together in a much easier to understand way. It's also immensely reassuring that I am not going crazy (at least not about this) and not the only one that saw all these things that didn't add up!

Thank you so MUCH!!!! I can't even begin to tell you how much the support from ALL of you here has meant to me and Alivia. Happy Memorial Day weekend to you!

[littleone1]

Hi Mary Beth,

I hope you have a good conference with Dr. Peterson and will be able to get some positive answers.

I hope you also have a good Memorial Day weekend.

[MBK]

Thanks, Addy! Same to you! About the good weekend, I mean! I REALLY need a long weekend right about now. My patience is shot! On days like this I think a bottle of ChocoVine in my desk drawer would be a good thing!

I think this roller coaster ride of stress and worry is catching up to me.

[Cindy Thoman]

Mary Beth, I have been following your thread and just want to let you know I am sending lots of positive thoughts your way. I hope you can get off the roller coaster for awhile and have a relaxing weekend.. Try to let go of some of the stress and just enjoy your time with Alivia.

xoxo,
Cindy, Alex and Bear

[MBK]

Thanks, Terri....I am sooo looking forward to the long weekend! I hope you have an awesome one, as well.

Thanks for the message , Cindy. I appreciate it! I just checked out your pictures - so sweet!!!


My goal for the weekend is for it to be COMPLETELY uneventful. I'd like to spend some time outside and take some quiet walks with Alivia and Maxwell. I am keeping my fingers crossed that Ali has the same plan!


A safe and happy Memorial Day weekend to all of you, my dear friends!

[Harley PoMMom]

Lori - Any dietary tips or other suggestions to keep Alivia from having another full fledged episode?

Just had her most recent blood results faxed to me and there have been many improvements. The only things outside the normal range are:

ALK Phosphatase 341 (5-131 U/L) 2 weeks ago this was 628 and then 2 days later went up to 665!
GGTP 15 (1-12 U/L) Was <5 2 weeks ago-I'm not familiar with this one?
Phosphorus 6.6 (2.5-6.0 mg/dL) 2 weeks ago was 5.5
Amylase 1474 (290-1125 U/L) 2 weeks ago was 1785!
WBC 16.9 (4.0-15.5 10^3/uL) was 11.5
Platelet Count 652 (170-400 10^3/uL) was 75!
Absolute Neutrophils 11999 (2060-10600 10^9/L) was 10350

A lot of other values have improved into normal range! Overall these are really good results for Alivia, especially considering what she's just been through. Her IMS was quite pleased. I think I need to be more vigilant with her diet.

Hi Mary Beth,

GGTP is an enzyme associated with the liver. With her Phosphorus elevated I would really keep a watch on this and maybe ask your vet about adding a Phosphorus binder. Elevated Phosphorus levels can lead to a host of other problems especially inappetence.

With Harley and his pancreatitis I would feed him small meals throughout the day (3-4 meals). I made sure that when his pancreatitis was causing him discomfort that he got a pain pill to relieve the pain. I fed him proteins like skinless, boneless chicken breast, eggs and/or fish. I added carbs like rice, potatoes, noodles and/or barley. His diet was formulated for his pancreatitis/cushing's.

Hope this helps and if I can help in any way, please do not hesitate to ask.

Love and hugs,
Lori