Could it be Cushing's syndrome?

Re: Could it be Cushing's syndrome?

Lucy Fleming — Mon, 03 Feb 2014 11:53:28 GMT

Thank you both - I must admit she's certainly not very convincingly Cushingoid, though I'm a little stumped as to what it might be instead. If she wasn't losing weight I must admit I'd probably be reaching for the anti-anxiety meds currently, but with psychogenic PD being rare I don't want to miss anything else.

Re: Could it be Cushing's syndrome?

Linda Filshie — Sat, 01 Feb 2014 19:53:48 GMT

Very true I wish this site had been around when I was a new grad!

Re: Could it be Cushing's syndrome?

Christopher Saul — Sat, 01 Feb 2014 12:12:11 GMT

Linda - you are by no means superfluous. I think one of the great strengths of this site is that many people can present their thoughts and therefore it is more likely that all angles are considered

Re: Could it be Cushing's syndrome?

Linda Filshie — Sat, 01 Feb 2014 12:05:50 GMT

A few (very) quick and sketchy thoughts before I head out the door:

This dog doesn' sound particularly cushingoid. Blood picture doesn't look typical of Cushings - AlkP only very mild elevated, no real evidence of stress leukogram. Weight loss???

Urine cortisol:creatinine is useful for rule out but can be elevated by so many other things.

I'd be hunting for something else other than Cushings personally. As to whether LDD will be affected by her high level of stress, well I'm not sure about that, but up to 50% of sick dogs may have positive results, so it's important to "pick your patient".

Edit - Chris got in there as I was typing. I now feel superfluous

Re: Could it be Cushing's syndrome?

Christopher Saul — Sat, 01 Feb 2014 12:03:45 GMT

[quote user="Lucy Fleming"]but does anyone have any idea if her very high stress levels in the clinic are likely to interfere in the results?[/quote]

Well, LDDST is not 100% specific and false positives do occur. Most common reason for a false +ve would be non adrenal disease, so I would only test for cushing's in dogs where I have a genuine reason to think it is cushingoid. That said LDDST is pretty sensitive so it is a very good 'rule out'. One thing - cushing's dogs are often polyphagic and put weight on. That doesn't mean to say that this dog isn't cushingoid - they don't all read the textbook - but always good to think of other explanations. Was there any signs of renal pelvis dilation? You can sometimes get false -ves on urine culture as bacteria can lyse in transit. Did you get the lab to do a cytology on the urine??

Remember you can now get synacthen again. Some medics prefer LDDST as a first line test, others prefer ACTH stim. There are pros and cons to both, and neither is perfect. Personally, I prefer the ACTH stim as it is more specific (though NOT 100%!!! ), and easier to perform. It can also be used for a baseline for future monitoring

Re: Could it be Cushing's syndrome?

Lucy Fleming — Sat, 01 Feb 2014 11:25:37 GMT

Apologies for bumping a very old thread, but didn't see the point in starting a new one.

Currently dealing with 9 1/2 year old FE Irish setter with PU/PD, some weight loss and reduced appetite (off hard food but will eat soft). Had an episode of PU/PD last year which resolved after a course of antibiotics (amox/clav).

Bloods: Only abnormalities seen Lymphocytes 1.18 x 10^9 (1.4-4.9)

Alk P: 150.3 U/L (<130)

Cholesterol: 12.30 mmol/L (3.2-6.2)

Lipase: 238.3 U/L (0.1-200)

Chloride: 116.3 mmol/L (100-116)

Phos. 1.76 mmol/L (0.8-1.6)

Urine SG was 1.011 on the first sample, 1.022 on second, nothing on sediment exam, culture negative. Urine creatinine: cortisol ratio was 37.3 x 10^6 (less than 34 rules out hyperadenocorticism, according the the lab).

Abdominal ultrasound was all normal, no sign of a pyometra.

Thinking of a low-dose dex suppression test to try to rule out Cushings, but does anyone have any idea if her very high stress levels in the clinic are likely to interfere in the results?

Re: Could it be Cushing's syndrome?

Bob Russell — Fri, 18 Nov 2011 09:34:32 GMT

When we set up here ten years ago one of the first patients was investigated for a dramatic and sudden onset polydipsia. All tests performed came back normal. The long and the short of it was the pet food manufacturer had a problem batch of food with much higher salt levels due to a fault!

A few red faces all round!

Re: Could it be Cushing's syndrome?

Ruta — Fri, 18 Nov 2011 07:42:35 GMT

Hello, everybody,

I am not sure it was psychogenic polydipsia or not. It sort it out without any treatment. So, it is no longer my problem. After 2 weeks of my investigation, she just stopped to be polydipsic. The owner is happy, I am happy too. :)

So, thank you for all your posts. :)

Ruta

Re: Could it be Cushing's syndrome?

KathW — Thu, 17 Nov 2011 22:42:50 GMT

[quote user="Ruta"]

Hello,

I was thinking about psychogenic polydipsia. Her water intake per day is 100ml/kg.

[/quote]

Isn't 100ml/kg only just a definite polydipsia (I though I was told 100ml/kg or more for classing as polydipsia) and wouldn't you really expect higher Water Intake than this for a true psychogenic polydipsia?

Re: Could it be Cushing's syndrome?

Martin Atkinson — Thu, 17 Nov 2011 19:17:22 GMT

[quote user="Dagmar Steele"]

I don't like the water deprivation test at all! So I'm rather going for trial treatment if convinced it can only be DI but nothing else.

[/quote]

Exactly my feeling, OK a response to desmopressin doesn't rule out other causes of PD/PU but there's not much else left to rule out and with a urine SG close to water if it improves the symptoms the owners will at least be happy, then if other symptoms out we can investigate those later.

Re: Could it be Cushing's syndrome?

Dagmar Steele — Thu, 17 Nov 2011 18:09:14 GMT

I don't like the water deprivation test at all! So I'm rather going for trial treatment if convinced it can only be DI but nothing else.

Re: Could it be Cushing's syndrome?

Martin Atkinson — Thu, 17 Nov 2011 17:41:08 GMT

Well after all the scepticism I've shown in this post over diabetes insipidus I think I might have got one. 8 year old neutered male cocker spaniel, slightly overweight, PD/PU the only symptoms. Haematology, electrolytes and biochemistry normal although BUN (2mmol/l) is bottom of normal (2-9) and was very lipaemic when tested post prandial but cleared after 12 hours fast., considered acquired porto-systemic shunt but bile acid stim. and bilirubin tests normal, Urine SG <1.005!! rest of urine normal, urine cortisol/creatinine ratio 100 (normal <10). Aha - we've cracked it now HAC! No - both ACTH stim test and LDDS test normal. Is there anything left except DI and is there anything else other than a water deprivation test to find out? I searched to see if an ADH test is available anywhere but it appears not.

Re: Could it be Cushing's syndrome?

Martin Atkinson — Thu, 27 Oct 2011 15:42:02 GMT

[quote user="robloxley"]

[quote user="Martin Atkinson"] I don't like ACTH stim test anyway for initial diagnosis and have more faith in low dose dexamethasone test (LDDS). [/quote]

Don't you get more falve positives?

[/quote]

I get more equivocal results with ACTH stim test than false positives with LDDS test. Anyway, if you perform a urine cortisol/creatinine ratio on one of the samples during a urine LDDS test this gives an addtional quality control. Paradoxically I use ACTH stim for monitoring my HAC cases on therapy.

Re: Could it be Cushing's syndrome?

Ruta — Thu, 27 Oct 2011 14:47:24 GMT

It is not very easy case, isn't it? I was thinking about diabetus insipidus, but there should be evaluation of urea and creatinine? Or am I wrong? To be honest, after this morning I feel that don't know anything at all. :( Tomorrow I will have x-ray results and I hope will rule out pyometra.

Ok, here is my list:

1. Kidney deficiency - no significant changes in blood or urine;

2. DM - glucose in normal values;

3. Pyometra - no leucocitosis or neutrofilia in blood;

4.Liver disease - ALKP, GOT, GPT in almost normal ranges, no signs of jaundice;

5. Diabetus insipidus - I am not sure about this;

9. Hyperthiroidism - didn't notice enlargement of thyroid glands;

10. hipofisis dysfunction - possible, but no history of head trauma;

11. Cushings - possible still not perform ACTH or Dex suppresion test.

12. pshychogenic polydipsia - no ideas how to prove it.

I was thinking to do ACTH stimulation test because it is more sensitive (this information form Dechra CPD). But I will trust your experience, because I didn't have Cushings on my patient previously.

Thank you for all your help. :)

Ruta

Re: Could it be Cushing's syndrome?

Bob Russell — Thu, 27 Oct 2011 13:03:56 GMT

Yes - the last one was a Newfoundland! Try living with a cushings dog of this size with secondary diabetes insipidus! It did improve just enough with treatment for the owners to cope for quite a few months!

Re: Could it be Cushing's syndrome?

Rob Loxley — Thu, 27 Oct 2011 12:59:01 GMT

[quote user="Martin Atkinson"] I don't like ACTH stim test anyway for initial diagnosis and have more faith in low dose dexamethasone test (LDDS). [/quote]

Don't you get more falve positives?

[quote user="Martin Atkinson"]to further reduce costs[/quote]

But the ongoing cost of vetoryl and monitoring dwarfs the initial diagnostics...

Are many people seeing diabetes insipidus in dogs with advanced pituitary dependent cushing's (I've diagnosed a few)?

Re: Could it be Cushing's syndrome?

Martin Atkinson — Thu, 27 Oct 2011 12:28:57 GMT

[quote user="Kate Richardson"]

'ACTH' for the stimulation test is 0.25mg per dog unless very small (<5kg) in which case use half this dose. We use Synacthen which comes in 1ml vials at 0.25mg/ml ie use 1 vial.

[/quote]

Don't want to sound like I'm contradicting you Kate but dose for Synacthen is 0.5ug/kg so you can use much smaller doses than the traditional 0.25mg per dog, the rest will keep in a syringe in the fridge for weeks and save money. I don't like ACTH stim test anyway for initial diagnosis and have more faith in low dose dexamethasone test (LDDS). Indeed to further reduce costs, the oral LDDS with urine cortisol is something the owner can do at home and costs a lot less. Ruta: you need a baseline urine cortisol before starting which can be combined with a urine cortisol/creatinine ratio, give 0.01mg/kg dex. orally, take the dog for a walk to urinate 4-6 hours post dose then collect the the urine sample at 8 hrs and test for cortisol. Cushingoid dogs should show failure of suppression of cortisol on the 8 hr sample.

Re: Could it be Cushing's syndrome?

Kate Richardson — Thu, 27 Oct 2011 12:00:38 GMT

[quote user="Martin Atkinson"]

Diabetes insipidus is very uncommon and over-diagnosed through lack of adequate investigation for other causes. I thought the water deprivation test was frowned on these days!

[/quote]

I agree, just it hadn't been mentioned, so thought it was worth adding to the list of possibilites. We occasionally do water deprivation tests, but only in hospital, and admittedly very rarely. have diagnosed a couple though, after all other possibilities ruled out.

Ruta- 'ACTH' for the stimulation test is 0.25mg per dog unless very small (<5kg) in which case use half this dose. We use Synacthen which comes in 1ml vials at 0.25mg/ml ie use 1 vial.

Re: Could it be Cushing's syndrome?

Martin Atkinson — Thu, 27 Oct 2011 10:33:49 GMT

[quote user="Kate Richardson"]

Consider diabetes insipidus as well if all other tests are negative, so a water deprivation test is something to think about as well, if all tests prove negative.

[/quote]

Diabetes insipidus is very uncommon and over-diagnosed through lack of adequate investigation for other causes. I thought the water deprivation test was frowned on these days!

Re: Could it be Cushing's syndrome?

Ruta — Thu, 27 Oct 2011 10:33:13 GMT

Hello, Kate,

I didn't rule out pyometra, but don't have access to ultrasound, just only x-ray. But if its early stage of it, I wouldn't see anything. However, no abdominal distension so far.

The owner call me about minute ago and sad that found nutshell near her bowl. So, I think it could be the reason. I don't know other antiallergic drug apart Dex.

I will start with antibiotics for 10 days and then will try to perform ACTH stimulation test. I think it will be enough time to revoke Dex effect.

From Dechra CPD I know that should be injected 0,25mg ACTH, but didn't mark it is just disposable dose for all breed dog or should I count 0,25mg per kg?

Thank you very much for all your help. I am really grateful for it! :)

Ruta

Re: Could it be Cushing's syndrome?

Kate Richardson — Thu, 27 Oct 2011 09:57:07 GMT

Hi Ruta

I would agree, the swollen head and bumps over the body are most likely an allergic reaction to something and should resolve, so I wouldn't be too concerned about that, and probabaly nothing to do with the pupd.

Regarding the pupd, yes it absolutely could be cushings, I have diagnosed several cases with absolutely no biochemistry or haematology abnormalities, but have had consistent ACTH stim test results. However, you can get positive acth stim results if the animal is under stress for another reason, so for example, if the dog has got a grumbling pyometra, which still has to be considered given her age and entirety, then it is possible you could get a positive acth stim test result. Pyometras don't always give a high wbc count unfortunately. I guess I would expect to see some progressive abdominal distension, or for her to her off colour if she did have a pyo, but sometimes if they grumble along slowly, then the owners don't really notice that they are off colour as it may develop very slowly. Do you have access to ultrasound? This is a good way of assessing for a pyometra if you are still unsure, easy to determine if they have a obviously enlarged uterus full of fluid, but less easy unless you are an experienced ultrasonographer to detect low grade changes.

A urinary tract infection is also possible, did you look at the urine sediment or do a culture? Are finances limited? I would also run a wider biochemistry panel to include calcium, bile acids, phosphate, electrolytes, cholesterol, triglycerides, amylasoe and lipase, and PLI (if finances allow)

My thoughts would be if the dog is bright and well, to give a course of antibiotics (probably amoxyclav) initially, even if the urine does culture negative, as this doesn't rule out a UTI. If the PUPD does not resolve, then do an acth stim test- by this time, hopefully the dex won't affect the results by then, so giving the antibiotics will buy you some time, plus will help to rule out an infection. Obviously if you also scan the dog in the mean time, that would be good, as you really want to rule out a pyometra early on. Psycogenic polydipsia can nly be diagnosed by ruling out every other cause of pupd. Consider diabetes insipidus as well if all other tests are negative, so a water deprivation test is something to think about as well, if all tests prove negative.

Kate

Re: Could it be Cushing's syndrome?

Dagmar Steele — Thu, 27 Oct 2011 09:32:44 GMT

Hi Ruta, the bumps might be urticaria, which would fit in the allergy diagnosis. For this kind of allergy I prefer Prednisolone over Dexamethasone as the latter works much slower. This is also why I think you'll have to wait longer than 24hrs to start the Cushings tests.

Dagmar

Re: Could it be Cushing's syndrome?

Ruta — Thu, 27 Oct 2011 09:28:27 GMT

Hello, Martin, everybody,

I injected Dex to release the swelling. But as far as I know, before testing of Cushings I should stop with dex only 24h. Am I wrong? And it was just one injection. So maybe it is not so tragic.

Manitol was my choice because of thinking about edema in brain. But I am not sure now.

I called to the owner and he sad swelling a little bit smaller. But now the dog has some strange bumps on her all body. What's it could be? Calcinosis? But I didn't saw it before.

However, here is urine results:

specific gravity 1,015, leucocyte negative, nitrite negative, pH 6, protein negative, glucose negative, ketones negative, urobilinogen normal, bilirubin normal, blood negative.

What is going on with this dog?

Ruta

Re: Could it be Cushing's syndrome?

Martin Atkinson — Thu, 27 Oct 2011 09:06:58 GMT

[quote user="Ruta"]

The most scary to me was her look today. Her head became swollen with very difficult breathing. So, I injected double dose of Dexamethasone i.m. and planning start with Manitol as soon as I will get it.

[/quote]

Eek! Sounds like an allergic reaction to a wasp/bee sting probably not related to the PD/PU but impossible to speculate without seeing it. Not sure what mannitol would do for that, I would only have thought about using it for intra-cranial swelling, and the dex. will have mucked up any tests for Cushings for now.

Re: Could it be Cushing's syndrome?

Ruta — Thu, 27 Oct 2011 08:28:04 GMT

Hello,

I am very grateful for your answers. Yes, CCDS means canine cognitive dysfunction syndrome, in this situation I was thinking about psychogenic polydipsia. Her water intake per day is 100ml/kg.

From hematology test I can see only normal or almost normal values. Sorry, that didn't post laboratory evaluation. I am still waiting for her urine sample.

Now I am totally lost and I am not sure what I am treating at all. If you have any ideas - I will appreciate it.

Ruta