Clinically it looks like cushing but the blood work is not convincing..what to do?

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Julian Earl — Thu, 25 Apr 2019 21:21:49 GMT

What is the Alkaline Phosphatase-level? That is usually very high in my experience with Cushing's dogs. Due to the hepatomegaly. I often take that as an early warning to think of HAC if it crops up as an incidental finding. Non-specific but very commonly high in the condition.

By the way, is anyone else surprised how common Cushings tends to be in dogs? Before qualifying I thought that it would be a Hem's teeth-disease so to speak. Not at all in reality.

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Sarah Keir — Thu, 25 Apr 2019 16:58:51 GMT

From Dr Mark Peterson, great website if you want to read about endocrine disease in more depth. https://endocrinevet.blogspot.com/

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Lene Boysen — Wed, 24 Apr 2019 13:15:18 GMT

Dear Ian and colleagues,

Thank you for your replies :)

Low dose dexamethasone suppression test shows:

cortisol (0 h.): 72 nmol/L (27-195 nmol/L), cortisol (4 h.): 41,1 nmol/L, cortisol (8 h.): 65,9 nmol/L (0-40).

According to our endocrinology book (Rijnberk & Kooistra) there should be a value at 4 h. or 8 h. which is at least 50% or lower than the 0h value for it to be a pituary dependent hypercortisolism. This is not the case here.

Do you agree that it is most likely that an adrenal gland tumor is the reason for the hypercortisolism in this dog?

This fits with the abdominal scanning.

Thanking you in advance for your reply.

Kindest, Lene

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Beats — Thu, 21 Mar 2019 11:09:48 GMT

[quote user="Anthony Todd"]

[quote user="Beats"]topical DMSO might be a consideration for this dog?[/quote]

Why DMSO?

DMSO is magic stuff for tennis-elbow and any pain near the surface of anyone's anything]

Just asking, not challenging?

[/quote]

It might, or might not, be of any help.

google "DMSO calcinosis cutis"

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Anthony Todd — Thu, 21 Mar 2019 10:56:12 GMT

[quote user="Beats"]topical DMSO might be a consideration for this dog?[/quote]

Why DMSO?

DMSO is magic stuff for tennis-elbow and any pain near the surface of anyone's anything]

Just asking, not challenging?

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Beats — Wed, 20 Mar 2019 22:20:27 GMT

I'm not an expert, but thanks for sharing interesting case and thanks to experts who have contributed!

LDDST sounds worthwhile to me.

If not clearly cushings (which this doesn't appear to clearly be), then I'd start trilostane at very low (Feldman) dose if decide to trial it at all (about 0.5mg/kg twice daily from memory?)

Would be lovely to see biopsy results if available (and always worth considering a second opinion on the histopathology, or rebiopsying if any doubt, even if calcinosis cutis does seem rather unambiguous).

topical DMSO might be a consideration for this dog?

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Ian Ramsey — Wed, 20 Mar 2019 12:32:20 GMT

Dear Lene,

As the number 1,2 and 3 causes of calcinosis cutis are HAC I think we have to rule out HAC before we can diagnose this as an idiopathic case. We have discussed before the reservations about UCCR measurement and so I would advocate a low dose dexamethasone suppression test with this case - though I agree with Andrew that this may yet turn out to be idiopathic. What sort of diet is the dog fed please (as this affects how we interpret the 800ml/day water consumption - especially in a dog from a temperate climate)

Best wishes

Ian

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Andrew Kent — Wed, 20 Mar 2019 11:51:31 GMT

Hi Lene,

It doesn't sound like this dog has many clinical signs of hyperadrenocorticism aside from the skin disease so I would certainly pursue other causes. A USG of 1.045 makes HAC unlikely for me (and I guess fits with the lack of PUPD).

How was the skin disease diagnosis made? Have you performed biopsies? If not I would do so.

If routine blood work and imaging is unremarkable this could be a so-called idiopathic case - in which case it might be worth discussing with a dermatologist if you have access to one?

Andy

RE: Clinically it looks like cushing but the blood work is not convincing..what to do?

Arlo Guthrie — Wed, 20 Mar 2019 09:38:49 GMT

Just a bit of context here. Lene was one of a number of people who joined recently to take part in a post-lecture forum after a talk given by Ian Ramsey in a group on VetSurgeon set up for that purpose.

That forum has now closed, and Ian is not able to take more questions, but I hope you will all welcome Lene and if anyone has any thoughts on this case ... fire away