Scottish terrier with Cushing suspicion - what to do next?

RE: Scottish terrier with Cushing suspicion - what to do next?

Ian Ramsey — Sat, 02 Mar 2019 14:51:18 GMT

Dear Camilla,

How many steroid hormones to measure is a cost-based decision as much as anything else. In the UK we can get 17 OH prog done really quickly so I tend to start with that (as it is the most likely and best understood). However I take a lot of blood (10 ml to get 3 - 5 ml of serum) when doing the ACTH stim test (pre and post) and ask the laboratory to store the rest so that if we need to send off for more tests then we can do so. This makes it a reasonable use of client resources but that is UK prices. You may find it is economic to do something else (e.g. if you are sending them to the USA then probably the whole panel is economic).

What I would say is that the more steroids you test, the more important it is not to be persuaded by one small increase in one of them. If you do lots of tests you will get an abnormality eventually in a normal dog (if ref range = 95% of population and tests are independent of each other - which they clearly are not - then it only takes 20 tests to get a 50% chance of an abnormality in a normal dog)

Hope this helps

Ian

RE: Scottish terrier with Cushing suspicion - what to do next?

Camilla Correll — Sat, 02 Mar 2019 11:42:43 GMT

Dear Ian,

I have definitely learned a lot, thanks ( and I have claimed a CPD) ;-).

I will have the Scottish terrier in for a ACTH stim. test again on Tuesday and measure both pre and post 17-OH progesterone.

Would you measure any of the other steroid hormones as well? As it is suggested that you need minimum 2 increased serum steroid other than cortisol to confirm the diagnose "atypical Cushing"

Will you worried any more about the increased bile acid, as the serum bilirubin and albumin are normal and regard the increased bile acid as part og the cortisol induced hepatopathy.

Many thanks again,

Camilla

RE: Scottish terrier with Cushing suspicion - what to do next?

Ian Ramsey — Fri, 01 Mar 2019 13:02:16 GMT

Dear Camilla,

Personally I would do an ACTH stim so I had 'covered myself' but if the owner is understanding and you know them and trust them to make an informed decision then I would not be unhappy trying trilostane.

Incidentally as (I hope) you have learned something today you should press the CLAIM CPD button above and write down what you have learnt. You can then print a certificate when needed.

Best wishes

Ian

RE: Scottish terrier with Cushing suspicion - what to do next?

Camilla Correll — Fri, 01 Mar 2019 11:34:12 GMT

Dear Ian

Many thanks for your reply!

Unfortunately I was to late with my request for the 17-OH progesterone, the lab only have the serum from the LDDST left and not from the ACTH stimulations test. I did also request bile acid which were increased (the dog was not starved); Bile acids: 44.3 (0 - 20) umol/l. There was no adrenal tumor found on ultrasound, I had a good image of both glands aprox. 18 x 6 mm

Would you do a new ACTH with the meassuring of the 17-OH progesterone or would you try it on trilostane?

Thanks again very much for this opportunity to discuss cases with you much appreciated ;-)

Camilla

RE: Scottish terrier with Cushing suspicion - what to do next?

Ian Ramsey — Fri, 01 Mar 2019 10:35:19 GMT

Dear Camilla,

Many thanks for posting this case. It gives me a chance to talk about something that we did not cover in the weekend.

I think this is likely to be a 'typical' case of Scottish terrier 'cortisol-induced hepatopathy'. It has been debated in many different publications but I think at the moment we cannot say what is causing this precisely. I think most people have now accepted that there is a problem with the cortisol metabolism in these dogs (which may turn out to be an inherited enzyme deficiency or similar) but it is not a classic PDH or ADH.

What we do know

1. They present with all the classic signs of HAC except usually they do not have alopecia. If you biopsy the liver (and I would not recommend this) then you will very likely get a comment from the pathologist that will say "Vacoular hepatopathy. Does this dog have Cushing's ?"

2. Endocrine testing is usually unremarkable (though you may have some luck with 17-OH progesterone or other steroids apart from cortisol.

3. They respond to trilostane

4. You can use pre-Vetoryl cortisol to monitor (personal observation) but if you are happier using ACTH Stims then that is fine

5. It is a good idea to get a specialist ultrasound exam of the adrenals - just in case this is the rare case which does have a adrenal tumour and the breed of the dog is misleading us.

6. Relatives of this dog may be affected as well.

7. Despite its name, the Scottish terrier is not overly popular in Scotland (perhaps because their coats get muddy so easily in our climate!) so I don't actually see many of these cases (probably only 5 or so in my life) but I hear about them quite a lot more from outside of Scotland.

This syndrome was first picked up by Sharon Centre (who is the queen of all things liver) so the liver side has been emphasised in the early papers but really it needs some more work on the endocrine side.

Ian

Here are some papers on this (best looked at in chronological order):-

www.vetsurgeon.org/.../Adrenocortical_5F00_Challenge_5F00_Response_5F00_and_5F00_Genomic_5F00_Anal.pdf