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Multi Symptom Disorder or Multiple Disorder problems
Neurological signs with Cushing's and other problems
Cushing's with Addison's questions
Diagnosing Cushing's and hypothyroidism
Cushing's with heart enlargement and chronic cough
Hypothyroidism and Atherosclerosis
Multi problems with Heart murmur
Multi disorders with weight loss - continued
Weight loss with hypothyroidism, diabetes and Addison's
Problems with Yorkie puppy
Multi-symptom problem
also see Liver
also see Lameness
also see Diabetes
also see Hormonal Disorders
also see Addison's
also see Cushing's
also see Thyroid problems
Neurologic signs with Cushing's and other disordersQuestion: Dear Dr. Mike:
My 12-year-old schnauzer Delaney was diagnosed with pituitary-dependent Cushings about a
year ago. He also has heart disease and kidney disease, and has had several bouts with
pancreatitis since he was one year old. My vet and I have been able to successfully manage all
of these problems with regular medications and regular blood testing (about every 3 or 4
months)--until now. In the past month, Delaney has lost 2 pounds (he is down to 15 pounds)
and has been vomiting occasionally. The only food he can keep down is canned NF--he has
been on WD all of his life, so he is very muscular and slim. (He is still very hungry when I feed
him. He has four meals a day, about 1-1/3 cans per day.) He seems more nervous or anxious
than usual and has trouble getting comfortable, and his body quivers frequently, even when at
rest. (I have noticed the quivering, particularly of his hind legs, for the past couple of years.)
He has also recently developed a urine drip, which bothers him tremendously and causes him
to lick himself. (My vet did prescribe phenylpropanolan, but he doesn't tolerate it and vomits.)
Delaney has had complete blood workups in the past month, and the only abnormalities are a
slightly elevated amylase (1689) and glucose (158). He had a full-body ultrasound, which
showed that his heart disease has not worsened and that one of his kidneys shows "mineral
deposits" and is smaller than normal. The other kidney appeared normal. His pancreas also
appeared normal. My vet indicated that his adrenal gland appeared to be a bit larger than he
had hoped, but since he had just run an ACTH test two months ago and it was in the correct
range, he would not address that at the present time and concentrate on the existing problem.
The radiologist found no existence of tumors, although Delaney has many fatty (liquid-filled)
tumors all over his body, which my vet says are not a problem.That leaves us with the problem of determining what is going on now. Why is Delaney
vomiting and losing weight? Why is his body weakening and the quivering increasing? Do you
suspect that something else may be going on, i.e., cancer, etc., or are these symptoms the
result of one or all of his current diseases? (I have read the 1999 article on Cushings, in
addition to many other resources on the subject.) In all of my research, I have never found a
good definition of "neurological symptoms." What, specifically, are they? Is there any way to
reverse them?Delaney is my constant companion and soulmate. If there is anything I can do to prolong a
quality life for him, I will do it. I will appreciate any insight you can provide. By the way, I do
trust my vet totally--I have been trusting him for 16 years with my animal companions--but
realize the value of input from other sources. He fully agrees.Thank you for your assistance.
Best wishes,
Sharon
Answer: Sharon-
I think that you are right about finding descriptions for neurologic signs when this is mentioned as
a possibility. The problem with neurologic signs is that they can be almost anything because the
nervous system controls most of the functions in the body. Among the possibilities for
neurologic signs are weakness, tremoring, paralysis, blindness, head pressing, confusion,
seizures, balance problems, behavioral changes, depression and loss of senses such as touch,
smell, taste, hearing. There are probably a number of other neurologic signs that I am forgetting,
but the basic situation is that very many problems can be due to neurologic damage, so if there is
no evidence for a physical cause for a problem it might be a neurologic problem. In Cushing's
disease the most common neurologic signs that occur are tremoring, weakness (which is also
muscular in this case) and seizures. It is possible for vomiting to occur due to neurologic
disorders, especially ones that cause increased pressure on the brain or disturbances in balance.We have patients who seem to experience gradual weight loss when we treat them for Cushing's
disease. We have always assumed that this was due to a decrease in cortisol levels which lowers
the tendency for the patient to have an increased appetite and weight gain. However, Cushing's
disease is most often caused by cancer of the pituitary gland or cancer of the adrenal gland.
When the cancer affects the pituitary gland it can become large enough to cause problems,
including weight loss and the neurologic signs mentioned above. It is hard to say if this is
happening without an MRI examination. I am not aware of a veterinarian in the US who is
actively pursuing removal of pituitary tumors as a solution to Cushing's disease but this is an
available option in the Netherlands as it is done at Utrecht.Many older dogs have tremoring in the rear limbs, so this may be just an effect of aging and not
related to the Cushing's disease. In addition, many dogs with Cushing's disease have muscular
weakness which could also contribute to muscle weakness and tremors. There are probably
some dogs whose ability to regulate body heat is adversely affected by having Cushing's disease
as well.It would probably be OK to feed Delaney more. I think that I would probably advise that in this
situation for a client of mine but since your vet is more familiar with the pancreatitis history it
would be best to ask him or her about this.Vomiting can be caused by a number of illnesses so it is a very non-specific sign. Many of the
potential possibilities can be ruled out by normal serum chemistry findings when lab work is
done and I think it is reasonable to assume that they aren't present since Delaney has had lab
work recently. If the intestines didn't seem thickened when the ultrasound examination was done
the potential for the vomiting to be a sign of inflammatory bowel disease (IBD) is lessened but
the history of chronic pancreatitis still makes this something to think about. It would be a good
idea to review the medications that you are using since there are multiple problems and to try to
be sure that one of them isn't a possible cause of the vomiting --- or that interference between
two of them isn't contributing. Some dogs with Cushing's disease and/or chronic pancreatitis
develop gastrointestinal irritation or ulcers that might contribute to vomiting, as well. This is also
true of dogs with kidney disease. Using a medication to protect the GI tract, such as cimetidine
(Tagamet Rx) or related drugs may be helpful. I know this is a frustrating problem and I hope
that it has already been resolved. Vomiting can sometimes occur in patients being treated for
Cushing's disease when the dosage of mitotane is too high and is causing hypoadrenocorticism
(Addison's disease). This is probably more common early in the use of mitotane but it still has to
be kept in mind when vomiting occurs in patients being treated with mitotane. If this is the cause
then administering physiologic dosages (about 0.2mg/kg per day) of prednisone or prednisolone
should resolve the signs.Incontinence can be due to neurologic disease, as well. If this is the case, medications directed
at the neurologic problem present can be helpful. There is a small possibility of detrussor atony
associated with Cushing's disease and this might respond to administration of bethanecol. This
isn't very likely, though.Dogs with Cushing's disease frequently have urinary tract infections and this may cause
symptoms that resemble incontinence, or even cause incontinence. It is always worth considering
this possibility when any urinary tract problem occurs in a dog with Cushing's disease. For some
reason, even good control of Cushing's disease won't always lessen the incidence of secondary
urinary tract infections in some patients. Culturing urine obtained by cystocentesis is the best way
to rule out bacterial urinary tract infections. Cystocentesis is the process of obtaining urine by
sticking a needle into the bladder to get the urine. This is not as hard to do as it sounds. Most
dogs don't seem to mind this any more than drawing blood.Male dogs will sometimes respond to testosterone supplementation when they have incontinence
when they won't respond to phenylpropanolamine.I can't tell from your note how you are treating the Cushing's disease but we have tried both
selegiline (Anipryl Rx) and mitotane (Lysodren Rx) in a couple of dogs now, hoping to lower the
dosage of mitotane when we thought it might be causing side effects. We haven't caused any
problems that we have been able to see, yet. The combination seems to make our patients feel
better than when we use mitotane alone, but that is a very subjective observation.I hope this helps some.
Mike Richards, DVM
12/21/2001
Some Cushing's with Addison's questionsPat,
I think from reading your note that you had several questions about
Cushing's disease.Question: 1) Why was a diagnosis of Cushing's disease made, treatment started and
then treatment for Addison's disease initiated after this treatment and
what is the difference between Florinef (Rx) and DOCP?Answer: The treatment of Cushing's disease (hyperadrenocorticism) with
mitotane (Lysodren Rx) sometimes results in the total destruction of the adrenal
glands. When this happens, the result is artificial creation of a
different condition, Addison's disease (hypoadrenocorticism). Some veterinarians
think this is the best outcome for Cushing's disease but this is
debatable.
In any case, when it happens, it is usually possible to treat
successfully for the Addison's disease.There are two ways to replace the mineralocorticoids that are deficient
in Addison's disease. The first one is to use fludrocortisone (Florinef
Rx). Fludrocortisone dosage is variable and often has to be increased
over time. The second therapy is to use deoxycorticosterone pivulate ( DOCP,
Percorten V, Rx), which is a long acting injection that usually lasts
25 days, but may vary in effectiveness from 21 days to as long as 35 days.
Checking sodium and potassium levels and the ratio between them can
help in establishing the duration of action for this medication. It is probably
a good idea to check these electrolytes at weekly intervals when first
starting to use DOCP. Fludrocortisone is expensive and the dosage
levels necessary can get pretty high, with some dogs requiring as many as ten
tablets daily. There are compounding pharmacies that can make it less
expensively, but quality has been reported to vary some among the
preparations, so this source must be used with caution. DOCP is less
expensive most of the time and usually provides good control.Side effects of DOCP therapy include increased drinking and urinating,
diarrhea, vomiting, loss of appetite and high sodium/low potassium
levels (opposite of the levels expected with Addison's disease). These are
pretty similar side effects to Addison's disease itself, so both a reaction to
the medication and inadequate control of the Addison's disease by the
medication have to be considered. Checking electrolyte levels can help
in determining which problem is occurring. It should be noted that slight
irregularities in electrolyte levels at the end of the period between
injections is considered to be acceptable.Question: 2) Does prednisone cause diarrhea when used at the dosages necessary to
treat Addison's disease?Answer: Prednisone does not cause diarrhea at physiologic levels (0.2 to 0.4
mg/kg per day) very often. It is more likely that the DOCP is the cause or
that the Addison's disease is not adequately controlled at this time. IQuestion: 3) How do I treat the diarrhea without affecting the Cushing's disease
or Addison's disease?Answer: The first step is to try to be sure that the Addison's disease is
controlled by monitoring electrolytes. Since there was an initial
diagnosis of Cushing's disease it is also conceivable that the adrenal glands
could recover and that Cushing's disease could return, causing further
complications. So monitoring for this possibility, perhaps through the
use of ACTH response testing, would also be a good idea.Question: 4) Are there dietary changes or dietary supplements that might help a
dog with either Cushing's disease or Addison's disease?Answer: It is probably best to try to feed high quality protein diets that are
not excessively high protein quantity diets for patients with Addison's
disease. It may also be beneficial to supplement salt intake in Addison
patients. A good quality regular dog food sprinkled with a little table
salt is probably adequate.Cushing's disease patients probably do better with lower salt diets and
may benefit from low fat, moderate fiber diets, both for weight control and
to aid in preventing hyperglycemia (high blood sugar) that occurs in some
Cushing's disease patients.Since the dietary requirements are different for Cushing's disease and
for Addison's disease, it really is necessary to keep monitoring for the
return of Cushing's disease so that medication and diet adjustments can be
made as necessary.I hope that this information answers your questions. Please feel free
to write for clarification if necessary.Mike Richards, DVM
8/27/2001
Diagnosing Cushing's and hypothyroidism
Question: Dr. Richards,
I am a new subscriber and have been reading your ques/answers for a couple of
weeks now. I am really impressed with the personal and in-depth information
you provide. We have a twelve and a half year old pet, half German Shepherd
half Golden Retriever, Princey by name. Princey has always been healthy with
few health problems. Since the last few months, he has been drinking and
urinating excessively. He has become almost completely bald at the collar
area and has lost a lot of hair around his stomach area and a patch on his
back, a little above his tail. His skin is dry and flaky, like dandruff. On
the back area, near his tail where he has lost hair he has little raised
bumps. We took him to his regular vet a few times but he said it was just old
age, he took some x-rays as Princey's back legs seem to be bothering him, it
takes him longer to get up. X-Rays showed slight arthritis. Around the
middle of March, he was given steroids for two weeks and an aspirin a day.
He finished his course of steroids and was on aspirin until April 20th. We
have given him aspirin only twice after that. I don't like to put him on any
medication until I am sure it is necessary and will not harm him but at the
same time want to make sure he gets whatever he needs to get better. After
reading your columns, we took Princey to a different vet on May 7th, as I was
afraid Princey showed all the classic signs of Cushings. The new vet who
seems to know a lot about Cushings, unlike the first one, examined Princey
and did a urine and blood test. The urine test had a reading of one, which
she said was very dilute but showed no trace of diabetes. The blood test,
the vet said shows no sign of Cushings, she has asked we do a water
deprivation test to rule out diabetes insipidus. She also said his thyroid
levels are low and that could be causing the hair loss and skin problems and
that we could put him on a thyroid supplement if his hair loss is bothering
us but that it is not absolutely necessary at his age. Your column says
though that sometimes blood tests are inconclusive for cushings. Also, will
it hurt to put him on thyroxine if that really is not the problem? Does it
have any side effects? Will it aggravate any other condition he might have,
like Cushings or diabetes insipidus? Do you think we should push for more
testing to rule out cushings? Is there any kind of skin test we can do? Dr.
advised us to put aloe on his skin. His blood test results were all within
the normal range except for these -neutrophils 84
(normal 60 - 77),
lymphocytes 6 (normal
12 - 30),
lymphocytes absolute 570 (normal 690 -
4500),
alk phos 199
(normal 5 - 131),
GGT 24
(normal 1 - 12),
cholesterol 360
(normal 92 - 324),
BUN 10
(normal 6 -25),
creatinine 0.5
(normal 0.5 - 1.6),
BUN/Creat ratio 20 (normal
4 -27),
T4 RIA 0.42
(normal 1.0 - 4.0),
FREE T4 (RIA) 0.38 (normal
0.65 - 3.00),
uantitative platelets 448 (normal
70 - 400).
His AST(SGOT) was 29 and ALT (SGPT) was 70. The vet said his results were
all okay for his age and that if he had cushings his alk phos levels would be
markedly higher. Any input from you will be greatly appreciated as I am
very worried about Princey and would like to get him back to his old self as
soon as possible.
Thank you, padmaAnswer: Padma-
There are a lot of things to consider with the information that you have so
far.It is not possible to diagnose hyperadrenocorticism (Cushing's disease)
based on the results of a standard blood chemistry examination nor is it
possible to rule it out based on these results. It is true that many dogs
with Cushing's disease have elevations in the alkaline phosphatase levels
in their serum, but many do not, as well. It is necessary to do some sort
of specific testing in order to try to rule in or rule out the Cushing's
disease. The most commonly recommended test is a low dose dexamethasone
suppression test (LDDS). This test takes most of a day to run. A blood
sample is drawn early in the morning and immediately afterwards
dexamethasone is administered intravenously. In four hours a second blood
sample is drawn and after 8 hours a third blood sample is drawn. The
cortisol levels of the samples are compared. If Cushing's disease is not
present, the cortisol levels should go from normal levels to very low
levels (they are suppressed). If Cushing's is not present, the cortisol
levels remain high after the injection of the dexamethasone. An alternate
test is the ACTH response test. This test is less sensitive to the presence
of Cushing's disease but can be run much more quickly, making it more
convenient at times. To do an ACTH response test, a blood sample is drawn
any time during the day and then a hormone, adrenocorticotropin (ACTH) is
administered. An hour later (two for some ACTH preparations) a second blood
sample is drawn. If the results of the second sample show markedly elevated
levels of cortisol, it indicates that Cushing's disease is present. There
are other tests that help to determine what type of Cushing's disease is
present but one of these two tests is a good idea to determine if Cushing's
disease is present.It is pretty important to know if Cushing's disease is present, prior to
trying to decide if hypothyroidism is actually present. The reason for this
is that the presence of almost any other disease can cause the thyroid
levels in the blood stream to drop. Therefore, it is hard to test
accurately for hypothyroidism in a patient who has a problem like Cushing's
disease. If Cushing's disease is present and can be treated for, then it is
possible to more accurately test for hypothyroidism. In some cases,
especially when there is only a partial response to treatment for Cushing's
disease, it may be necessary to go ahead and treat for hypothyroidism
without being certain if it is present. Fortunately, it is relatively safe
to supplement thyroxine in a dog, even if they don't actually have
hypothyroidism. It is better to work to be sure that a life long supplement
is necessary before giving it, whenever possible, though. Hypothyroidism
can cause increased drinking and increased urination in some patients and
the hair loss can also occur with either disease, so it is entirely
possible it is present and that it is the sole problem, but increased
drinking and urinating are much more common with hyperadrenocorticism.I sometimes have a hard time asking a patient to spend money on Cushing's
disease tests because in our practice, I am pretty sure that of the dogs I
test, only about 25% of them actually have Cushing's disease and the tests
only help determine one thing -- if Cushing's disease is present or not.
However, since there isn't any other way to determine if the disease is
present and since it is important to both the dogs that have it and those
that don't to know what is going on, I know that it is necessary to do the
testing. I really do think that I would want to know if Cushing's disease
was present with the clinical symptoms that Princey has. So I do recommend
asking your vet about further testing.Good luck with this.
Mike Richards, DVM
5/15/2001
Cushing's with heart enlargement in Doxie - chronic coughQuestion: Dear Dr. Mike,
I wrote to you in February regarding my mini doxie Wizzo. At that time
her vets were trying to determine if she had Cushing's disease. Since
then they have confirmed Cushing's, started Lysodren, which she
responded to beautifully based on the ACTH stim tests, and now have her
on a weekly maintenance dose. Unfortunately, she continued to be weak
and listless so the doctor did an x-ray and discovered that Wizzo had a
"slight" heart enlargement. She was put on Vasotec and Lasix. The Lasix
has since been discontinued. Throughout all this she has had a
persistent cough, some days worse than others. She was not regaining any
strength and showed no interest in doing anything but lying by me or my
husband. She was then started on Tussigon and Tribrissen. She seemed to
be improving, but after she completed the Tribrissen her cough
intensified and the listlessness returned. Rather than put her back on
the Tribrissen, her vet put her on Baytril. When she showed no
improvement after 4 days, we took her back to the vet. He stopped the
Baytril, resumed the Tribrissen, and put her on Prednisone 5mg on 5/3.
5/5, and 5/7. Finally, something worked. Her cough stopped and she
started to act like her old self again. However, since the Prednisone is
stopped, her cough is coming back. She is still on Tribrissen and
Vasotec and gets Tussigon 1/4 tab 2x a day (any more than that makes her
too drowsy). I spoke to her vet by phone, and he said if her cough
continues to worsen again, she will have to be x-rayed again. He did not
venture what else may need to be done.I realize that medicine is not an exact science, but I'm concerned that
there seems to be so much trial and error involved in her treatment.
What would be the customary course of action at this point? Could she be
kept on a low dose of Prednisone if that is working? Would that
interfere with her Lysodren tx? Her doctors tend to go with the cheapest
and easiest course of action, though I have assured thaem that my
primary concern is getting Wizzo stabilized. I am so appreciative of
this web site. I find it so reassuring to be able to find additional
up-to-date information about Wizzo's problems.
Thank you. DonnaAnswer: Donna-
It is always difficult for me to figure out what to do when I have a
patient who has Cushing's disease but also has a problem that responds well
to the use of corticosteroids. There seem to be two choices in this
circumstance.One consideration would be to try to back off a little on the regulation of
the Cushing's disease and let the natural cortisol levels rise, since that
is what happens with Cushing's disease, to see if that would allow
resolution of the problem without using additional medication. The problems
with this approach is that it is know what level of cortisol to try to
regulate to and that when administering Lysodren there will be ups and
downs in the cortisol levels based on when the Lysodren is given.The other approach is to regulate the Cushing's disease using the standard
testing and then to add prednisone to achieve the desired therapeutic
result, in this case a decrease in the coughing. This is the approach to
this problem that we usually take. The problem with this approach is that
prednisone use does interfere with the ACTH response test, which is the
test usually used to evaluate the response to Lysodren. I haven't quite
figured out an exact way to make adjustments for the effect of prednisone
but we haven't gotten into trouble that I am aware of doing this, probably
because the prednisone supplementation helps protect against the effects of
Lysodren overdosage, if we are sometimes using too much Lysodren.A third approach to this problem would be to administered sufficient
quantities of Lysodren to completely wipe out the adrenal glands and then
treat for hypoadrenocorticism (Addison's disease). The complications with
this approach are that hypoadrenocorticism is more likely to be life
threatening than hyperadrenocorticism and so it is important that the pet's
caretaker really understand the importance of the medications. The
advantage is that the physiologically appropriate dosage of prednisone has
been established, so as long as control of the secondary problem (coughing)
requires at least that dosage there should be no problem with
glucocorticoid levels. It is still necessary to also supplement a
mineralocorticoid product such as Florinaf (Rx), in addition to prednisone
or another glucocorticoid.I suspect that the absolute best approach to each patient probably varies
from one to another, but we tend to use Lysodren and prednisone at the same
time and try to balance the dosages when we must deal with a need for
cortisone supplementation in a patient being treated for Cushing's disease.It would be helpful, if possible, to be sure that the prednisone was
necessary. The two conditions that lead to chronic coughing that are most
responsive to the use of corticosteroids are collapsing tracheas and
chronic allergic bronchitis, in dogs. Both of these conditions usually
respond better to prednisone than to antibiotics and often respond better
to prednisone than to cough suppressants. Collapsing trachea problems often
show up on X-rays but can be definitively diagnosed by endoscopic
examination of the trachea. Allergic bronchitis is hard to diagnose with
certainty but trachea wash or bronchoalveolar lavage may allow a tentative
diagnosis with strong evidence to support it. This testing also allows for
culture of whatever bacteria are found, which can help in the choice of
antibiotics if they seem necessary. Most veterinary practices can do
tracheal wash procedures but may be uncomfortable evaluating the results
and most veterinary practices probably don't have endscopes at this point.
We refer our patients to an internal medicine specialist for endoscopic
examinations. Your vet may be willing to do this, too.Good luck with this. If you have further questions or are confused by the
information in this note, please feel free to ask for clarification.Mike Richards, DVM
5/15/2001
Hypothyroidism and Atherosclerosis
Question: Hi Dr Mike,
Jake my 7 yr. old Shepherd / Husky has just been diagnosed
with Hypothyroid and clogged arteries mainly the aorta. He had
ultrasonography and the vet said he had never seen anything
like it and the prognosis is grim.Here's how it started 6 months ago:
* Weakness in the hind quarters, at times he couldn't walk he was
thought to have Myasthenia Gravis.
* Stiff hind legs
* General lethargy and depression
* Skin inflammation and hair loss
* Trembling
* Severe vomiting
* Anorexia
* Weight loss (10 lb.)
* Some muscle loss
* Arrhythmia (rapid)
* Weak pulseI rushed him to the emergency clinic when the vomiting started and the
vet did many diagnostic tests: CBC, WBC, Chem 7, urinalysis, and most were
normal except: ALKP 222 BUN
29.4 CREA 2.66 but his cholesterol was 1018.6 !!!The internist that did the ultrasound the following week prescribed:
~ Soloxine
~ Adult dose fish oil
~ Science Diet R/D
~ Mevacor
I've added 1,000 IU vitamin E, lecithin, oatmeal, garlic, 1 enteric
aspirin and Pepto Bismol or Pepcid AC
The problem is he is still vomiting at night and I worry that he will
continue to lose weight and or muscle and the meds won't
work!
My question is why is he vomiting so much???
And is there anything else I can do? Can plaque be reversed?
Is there a treatment available (I e-mailed a vascular site to you)
Is he at risk for heart attack or Angina pain? It's so rare no one seems
to know...Please help!Thank you for your time, Jake & Lisa
PS. We live in Maine about 4 hour from Tufts Univ. I know they probably
can't do angioplasty but do think they could do anything?
Answer: Jake and Lisa-
There are reports of severe alterations in lipid metabolism in some dogs with kidney failure. Since the
creatinine level is high enough to suspect that kidney disease is present, this is something to consider.
There is an article on this in the Dec 1, 1999 issue of the AVMA Journal. In this article the authors
(Bauer, JE; Markwell PJ, et al.) suggested that there is a benefit to using cholesterol control
medications in dogs, although the research was done with rats. Kidney problems would be likely to
cause vomiting if they continue to be present. Unfortunately, atherosclerosis is rare enough in dogs
that I can not recall seeing a dog with this condition and do not have enough experience to tell you if
vomiting is a common problem in patients with this condition.When atherosclerosis is associated with hypothyroidism, treatment of the hypothyroidism and use of
a restricted fat diet has been shown to reverse some of the atherosclerotic lesions (Compendium of
Continuing Education, Sept. 1995, Zeiss and Waddle).The internist has taken the steps recommended in the articles above to try to control the situation,
along with current recommendations to use fish oils.I would be worried by the use of aspirin in a patient with chronic vomiting and would encourage the
use of famotidine (Pepcid AC tm). I can understand the desire to use aspirin given the overall
situation but it just worries me when GI signs are present.If the graft surgery you emailed the link to is available, the teaching hospitals are the most likely
places to be doing it. There are several articles on using grafts in dogs, mostly written as research
projects to evaluate the use of grafts or graft protective medications in humans. This rarely benefits
clinical patients since there is no support for the continuance of these procedures after the research
needs are met, in many cases. The schools are usually happy to answer questions about whether or
not they offer particular procedures and will often provide information on other places that are
performing procedures that they do not do. It would be worth asking your vet to call Tufts and ask
about available therapy.I wish that I could help more with this situation. I hope that you are seeing some progress with the
therapy undertaken so far.Mike Richards, DVM
2/22/2001
Multi problems with heart murmur
Questions: Thanks for such a great service!
I have a Schnoodle, approximately 11 years old or so. We've had her for
just under a year, having gotten her from a rescue organization. She's very
overweight, and at first, the rescue people suspected Cushing's. She was
tested, and it came out that she had thyroid problems, so we give her two
Soloxine pills daily. She's eating low cal dog food. Her weight hasn't
really gone down significantly--a few pounds. (She's currently 18.6 lbs,
down from about 21) Her fur is very thin, especially over her rump. A few
days ago, she had an episode of staggering. My husband thought her paws
were asleep, but I took her to the vet anyway. He discovered a heart
murmur, about grade 4, he said. She also has a cough, which I understand is
indicative of heart problems. Anyway, the vet didn't seem too concerned.
He said he could send me off to get a full cardiovascular workup, but that
would cost about $600, and so just watch her. He didn't offer any
medications or other tests. I'm now very confused. Does she have Cushing's,
a thyroid problem, heart problems, what? What tests should I ask about? I
guess I should stress that this little dog is not just a pet, but a member
of my family, and as such, is worth the money to keep her healthy as long as
possible. I guess my question is just what questions to ask the vet.
Thank you so much..Answer: Stephanie-
I think that it would be worthwhile to consider testing for
hyperadrenocorticism even though hypothyroidism has been diagnosed already.
It is not too unusual for dogs to have more than one hormonal disease. It
is also possible for hyperadrenocorticism to lower the T4 levels. If a
total T4 was the only test used to diagnose the hypothyroidism it is
possible that this test result was influenced by the presence of another
disorder such as Cushing's disease.I also think that it would be a good idea to consider using some
medications in a dog with a heart murmur and a cough. I tend not to treat
dogs with heart murmurs immediately, preferring to wait until they develop
clinical signs of heart disease. These signs include weight loss, lethargy,
decreased exercise tolerance, coughing and fainting (syncope). Once signs
develop, I do think it is a good idea to treat for heart disease. I do not
think that all patients need a full cardiac work-up. Often, X-rays of the
chest to rule out other causes of coughing is all that is necessary to
justify the use of medications for heart disease when a murmur and clinical
symptoms are present. I think it is best to consider having a cardiologist
examine patients and run appropriate lab tests, such as cardiac ultrasound
exam, but I don't consider it to be absolutely necessary for all patients.
I like enalapril (Enacard, Vasotec Rx) when clinical signs are not
bothering the patient too much but will use spironolactone and furosemide
(Lasix Rx), in addition to enalapril, if there are signs that justify this
use. Most of the time it is possible to relieve the coughing and to help
patients feel better.If you wish to have the best possible work up for your schnoodle and you
are not concerned about the cost, you should let your vet know this. If you
want to do the best possible job that can be done within a set amount of
money, like $400 or $600, then you should let your vet know that, too. It
sounds like your dog may benefit from hormonal testing or from a cardiac
examination (or treatment for signs present) and you should be the one who
determines if the cost is worth it to you.Good luck with this.
Mike Richards, DVM
12/16/2000
Multi disorders with weight loss - continued
Question: Dr. Richards:
I'm a little confused so please forgive me if I seem thick headed this is a
whole new world for me and I'm struggling to understand. Max has
hyperthyroidism, diabetes and Addison's. As far as I know he never had
Cushing's and was never treated for it. He was tested for Cushing's in June
and that is when we discovered that he had Addison's. Prior to January 2000
he didn't take anything. In January he started with the Soloxine, in March
we added insulin and in July we added Florinef.Also, you mentioned in your response that the dosage of thyroxine was high.
Is Soloxine the commercial name for thyroxine? He weighs about 85 pounds
and is getting 2mg of Soloxine / day. Is that on the high side?Thanks for all of your time I really appreciate it.
Dana
Answer: Dana-In this case, I think it is me who was confused. That happens sometimes
when I try to answer too many questions in one night.There are three current problems based on your notes. 1)
hypothyroidism 2) diabetes mellitus 3) hypoadrenocorticism (Addison's
disease). There is a condition referred to as autoimmune polyglandular
syndrome, in which there are immune system problems which cause all three
of these diseases to occur simultaneously, or some combination of them to
occur. As far as I know, there is no treatment for the immune system
influence on these conditions so they are all treated as if they occurred
independently and coincidentally.The usual starting dosage for thyroxine is 0.02mg/kg of thyroxine (Soloxine
Rx) every 12 hours. For an 85 pound dog this would be about 0.8mg every 12
hours. This is usually administered until it is clear that a clinical
response to the hormone supplementation has occurred or for a month or two.
After this initial period, most dogs require less than 1 mg of thyroxine
(Soloxine Rx) per day to maintain adequate levels of thyroxine in their
blood stream and it is usually possible to give thyroxine once a day. The
most accurate way to determine the necessary dosage for this medication is
to do blood testing for thyroxine levels. Dogs are pretty resistant to
adverse effects from giving too much thyroxine but it is still a good idea
to try to give only the necessary dosage.Addison's disease is usually treated with either fludrocortisone acetate
(Florinef Rx) or DOCP or desoxycorticosterone pivalate ( Percorten-V Rx)
when there appears to be suppression of cortisol levels and when there is
no response to ACTH stimulation or very poor response. In some dogs, the
cortisol levels are low but there is some response to ACTH stimulation and
changes in sodium and potassium levels don't occur. These dogs usually only
require supplementation with glucocorticoids (prednisone, for example). I
think that Michigan State University runs a test for naturally occurring
ACTH levels in dogs, to help differentiate between dogs that need
mineralocorticoid (fludrocortisone, DOCP). If the ACTH level is high, then
it is more likely that the dog has Addison's disease that will require
Florinef or Percorten and if the ACTH levels are low, then glucocorticoid
administration may be all that is necessary.Most of the vets that I know monitor the electrolyte (sodium and potassium)
levels, BUN and creatinine to determine if treatment for Addison's disease
is working, which is what we do as well. So I don't have much experience
using cortisol levels as a monitoring technique. Your vet may have good
reason to monitor these, though, since it was a good call to pick up on the
Addison's in addition to the other disorders.I think I'd still be worried about the control of the diabetes as the major
potential cause of weight loss but having all three of these conditions
does make the whole situation very confusing. I don't envy you or your vet,
since balancing the treatment needs of two hormonal diseases against each
other is hard and three is very hard.I'm sorry that I caused you some confusion with the initial reply. I'm glad
you responded back and pointed out the error. Please feel free to ask for
clarification or for additional information at any time.Mike Richards, DVM
12/12/2000
Weight loss with Hypothyroidism, Diabetes and Addison's
Question: I'm hoping you may have run into this situation before and can give me some
advice. My dog Max will be 10 in December. He's a mix but has always been
a big dog. At his prime he weighed 110lbs and was not fat but very fit. I
say this because I know that big dogs usually have shorter life spans and I
realize Max is getting toward the end of his. He's had a terrible lick spot
on his foot all of his life. We went to several different vets and tried
many treatments with no success. Last fall/winter it got very bad and
required several trips to the emergency vet clinic. Through the clinic he
saw a vet who specializes in dermatology and we discovered he suffered from
hypothyroidism. He has been taking 2 .5mg tablets of Soloxine twice a day
since he was diagnosed and it has gotten his licking under control. While
we were going through all this we noticed that he was loosing a lot of
weight, drinking a lot of water and going to the bathroom all the time. In
March he was diagnosed with diabetes. He regulated fairly quickly and
bounced back but in June we noticed the dramatic weight loss again and took
him back to the vet. He was diagnosed with Addison's disease and has been
on Florinef since. He has been taking 0.1mg tablets - 1.5 tablets twice a
day alternating with 1.5 tablets once a day since he was diagnosed. Again
he bounced back but in August was accidentally given Humulin N instead of
Humulin U. As soon as this was discovered he was immediately switched back
and had put on a few pounds. Several weeks ago we went back to our vet for
a regular blood check. His blood glucose was great - 83.5, but his cortisol
level was 1.3. Here's our problem. We've increased the Florinef to 1.5
tablets twice a day every day when we got the results. He seemed to loose
more weight and continued to be very thirsty. My husband was concerned
about the weight loss and put him back on his old Florinef schedule. I
spoke with our vet, who has been great but admits he's not quite sure what
to do since he has three major problems, and we agreed to go back to the
increased Florinef schedule, feed him twice a day and back off on the
insulin. We were giving him 58 units we now give him 54 units. He's not on
a special diet since we are afraid he wouldn't eat it and he can't afford a
weight loss. Is there any advice you have? Do you know if the weight loss
could be a short term side effect of the increased Florinef? Any help you
could give would be great. Max has been a great dog and deserves the best.Thanks, Dana
Answer: Dana-
This is a confusing set of problems to be dealing with, since there are
many possible interactions.I am assuming that the treatment for hyperadrenocorticism (Cushing's
disease) led to the permanent destruction of the adrenal cortex, leading to
the diagnosis of hypoadrenocorticism (Addison's disease). This can be a
transient effect of treatment for Cushing's disease, or a permanent effect,
depending on whether the adrenal gland was simply suppressed too severely
(the goal of treatment is to suppress the adrenal glands, but not enough to
make them stop working entirely). It would be necessary to monitor ACTH
response tests for at least a few months to be sure that the effect was
permanent. If not, you may be in a situation in which the Cushing's disease
has returned but is not being accounted for. I am assuming that this is
not the case but it is worth thinking about if no further testing has been
done.Weight loss is a symptom of unregulated diabetes and of unregulated
hypoadrenocorticism. So my first guess would be that one or the other of
these diseases is not being adequately controlled. It is more likely that
the diabetes is not controlled well but you still have to consider both
possibilities because hypoadrenocorticism is more likely to be fatal
quickly, so checking to see if there is adequate control of this condition
is worthwhile. Monitoring the serum potassium and sodium levels and the
blood urea nitrogen (BUN) is usually enough to indicate if the Addison's
disease is under control but in the situation in which Cushing's disease
appeared first, it would be worth considering ACTH response testing, as
well. For the diabetes, blood glucose curves are the most accurate test
that we have at the present time for regulating the blood sugar level
closely. It would be a good idea to consider this testing if it has not
been done recently, since blood sugar samples taken only once a day may
give the false impression that insulin is well regulated when it is not.Lastly, the dosage of thyroxine is higher than the dosage that many
veterinary endocrinologists think is necessary at the present time. Most
dogs do not require more than 1mg per pound of body weight per day of this
medication. Overdosages of thyroxine could lead to weight loss and
increased drinking and urinating, just like the other hormonal diseases. I
think that dermatologists and endocrinologists probably disagree about the
upper limits of thyroxine supplementation but this is something to
consider, anyway.Since there are so many possible influencing factors, it seems like it
would be best to consider them all, and to test for them in an efficient
manner. Blood glucose curves involve drawing blood at 2 to 4 hour intervals
for 12 to 24 hours and then evaluating a graph drawn from the blood sugar
levels. This allows a more critical evaluation of the blood sugar levels
over the course of the day. While drawing one of these samples it would be
easy to draw blood to check the sodium, potassium and BUN values and also
to get a sample about 8 to 10 hours after administration of the morning
dose of thyroxin, to check serum levels of this medication. Then,
depending on where all the other testing has led, it would be worth
considering a recheck of the ACTH response test to be sure that the
Cushing's disease is not recurring.Mike Richards, DVM
12/4/2000
Question: I am a current subscriber and have truly been enjoying your service.
I have a 6-month old female Yorkshire Terrier puppy that currently weighs
just under 4 lbs. She is a typical puppy in most respects, but has had these
"strange" occurances that our veterinarian can't seem to figure out. She
says she has never seen similar symptoms in another animal. Although we are
continuing with some "general" bloodwork testing, we keep ending up with no
explanation. I thought maybe you have had some experience with this problem
and/or could help me to request adequate tests to attempt a diagnosis.One day when she was 3 months old, she had been playing and eating as usual,
when we noticed that all of a sudden she became disoriented and began turning
in circles and darting her eyes and head all over (not really looking or
listening to anything in particular) and she didn't seem to know that we were
talking to her and she would not make eye contact with us. She did not want
to be held and when we called her name, she would go and hide under the table
as if she was panicking. She paced the floor and seemed completely "out of
it" and she would not eat or drink anything. We rushed her to our local
veterinarian who seemed to believe she had an "inner ear infection" and gave
her an anti-inflammatory injection and some antibiotics to give her by mouth.
She was also running a 104 degree fever. This all began around
11:00am. At around 5:00pm, she was no better -- and actually seemed worse -- so we took
her to the local "emergency" veterinarian's office. They did not seem to
believe it was an inner ear infection but they couldn't explain what it was.
They gave her valium intravenously and took some blood. He told us to keep
her in a quiet confined area so that she could begin to relax. At about
midnight that evening, she "snapped" out of it and seemed completely normal
again -- biting on us and kissing everyone. The next day, the emergency pet
hospital called and said that the test results came back with the possibility
of Addison's Disease and asked us to get our veterinarian to run additional
tests. My veterinarian didn't feel further testing was necessary until she
showed further signs of illness -- because she continued to feel it was an
inner ear infection.One evening this past week at about 5:00pm, the entire episode began again.
She had the exact same symptoms. We took her to our vetinarian who took
blood and sent us home with valium. Our vetinarian did not have an
explanation but wanted to see what the blood tests results would show. That
evening, the valium did not seem to have any affect on her and she "snapped
out of it" at about 5:00am the next morning -- after crying and pacing the
floor all night. The only difference between this and last time is that she
would sit for a few seconds instead of pacing constantly.The test results came back normal -- except that there appears to be a large
number of white blood cells and she seems fine today. Our veterinarian said
that she would run any test that we wanted but she didn't know where to go
from here except to send us to an internal medicine specialist.Have you ever seen or heard anything like this? Do you have any suggestions
for me. I want to find out what is causing this. I can't handle seeing her
go through these "fits" again.Sincerely,
Marva
Answer: Marva-
The first thing that came to mind when I read your note was a problem with
circulation through the liver. Yorkshire terriers are prone to
portosystemic shunts and to hepatic microvascular dysplasia. In both of
these disorders the normal circulatory flow of blood through the liver is
disturbed and the result is a decrease in liver function. Yorkie puppies
may seem normal until they reach a size that it is hard for their body to
cope with the deficient liver function and then clinical signs appear. The
signs can be somewhat variable but periods of decreased mental function,
disorientation, difficulty walking and seizures are all reported to occur
in some dogs.The best initial test to start to rule in or out the possibility of an
hepatic circulatory disorder is bile acid response testing. This is an easy
test to run and any small animal veterinary hospital should be able to
handle the testing. If the bile acid response test is suggestive of a
liver disorder these are the most common ones. Portosystemic shunts
usually cause severe differences in pre and post-prandial bile acid levels.
Microvascular dysplasia usually causes moderate changes in pre and
post-prandial bile acid levels. Portosystemic shunts often require surgical
correction but microvascular dysplasia can usually be managed by diet and
medication.Another possible problem is hydrocephalus, which is increased fluid
pressure in the brain. This usually shows up as depression, seizuring,
difficulty walking or related problems at an earlier age than your Yorkie
showed signs but sometimes problems don't surface until later in life. This
problem occurs in Yorkies occasionally. Most vets are pretty good at
recognizing the possibility that this disorder is present but sometimes the
typical domed head appearance isn't present, making it harder to recognize
the problem.Hypoglycemia is sometimes a problem in small breed dogs, too. This is also
more common in younger puppies but could potentially be a problem. Usually
this will show up in lab work if it is checked for at the time the problems
are occurring, though.Addison's disease can cause signs similar to what you are describing, too.
It will often cause cause a low heart rate, inappetance and sometimes other
GI signs, especially vomiting. There are a lot of other possible clinical
signs. In lab work, a higher than normal potassium level coupled with a low
normal to lower than normal sodium level, producing a sodium to potassium
ratio of less than 27:1 is considered to be suggestive of
hypoadrenocorticism (Addison's disease). The best test for confirming this
condition is the ACTH response test. This is a life threatening illness
and if there is reason to suspect it based on the original labwork it would
be best to try to confirm that it is present or to rule it out by running
the ACTH response test. Yorkies are not particularly prone to this disorder.I think that the order of likely occurrence of these conditions is hepatic
microvascular dysplasia (HMD), followed at a distance by portosystemic
shunt, then hypoglycemia and hypoadrenocorticism. Unfortunately, the
importance of these conditions is almost exactly the reverse of the normal
likelihood of occurrence, so it is hard to tell you to start with testing
for HMD and then go back and test for Addison's. If the cost of testing
isn't a major problem, I think I'd be inclined to test for both conditions
at the same time if I really thought that Addison's was likely based on the
initial labwork and clinical signs, especially if a low heartrate is also
present.There are a lot of other potential problems. Encephalopathies (brain
disorders) can occur for a number of reasons, encephalitis (brain
infection/inflammation) is a slight possibility and we have seen signs
reasonably close to what you report in a Yorkie with a malformation of the
atlanto-axial joint (the joint between the first and second vertebrae).If your vet wishes to refer your Yorkie to a specialist at this point,
there is no reason to fight that impulse. The specialist can sort through
these problems quickly. If it is hard to arrange a visit to a specialist it
would be easy to do bile acid response testing and possibly ACTH response
testing while you wait for the visit.Good luck with this.
Mike Richards, DVM
1/26/2000
Multi-symptom problem - Lab/shep mix
Q: My seven year old mixed yellow lab and terrier/Shepherd male dog recently
developed rather sudden onset of extreme lameness in all legs, exteme
lethargy and occasional labored breathing. My vet suspects Lyme disease
although his titer was negative. Two days after onset, at the site of an
old skin tear over his rib cage, he developed a large lump, approximately half
the size of a football. It took about three days to grow to this size and
is hot to the touch. The vet first ignored it, then upon my insistence, tried
to draw fluid from it, assuming it was hematoma. He was unable to get any
fluid. The examined cells appear to be normal. The lump appears to have
stopped growing and is now very hard, although it was never really soft - it
is just harder now. He has been on doxycycline for eight days with no
improvement (2 1/2 tablets in the morning, not sure how many mgs.) I am
very worried. Sunny has been a very vigorous, active dog all his life. Now he
can barely walk, only rising to urinate and defecate with great difficulty.
He is very listless, appetite almost gone and is getting very irritable and
snappish although he does not appear to be in much pain. He is a very stoic
dog, though, and may be in pain.
A: KIt is always tempting to lump all the signs together and assume that one
problem is causing them (because this thinking works well most of the time)
but I think it would be a good idea to keep in mind that there may be two
problems occurring at the same time, one causing the lump and one causing
the other problems.The major reason I mention that is because I'd be really tempted to
surgically explore a lump that came up that fast that I could not aspirate
anything from. And because I think there may be a need for
immunosuppressive medications for the sudden onset lameness and if the lump
is hiding an abscess, it would be good to know that before using an
immunosuppressive agent such as prednisone or azathioprine (Imuran Rx).
Exploring the lump may reveal the underlying cause for the development of
lameness (such as as septic arthritis) but it may not help much in
determining the best course of action in treating the lameness.In acute onset lameness of more than one leg in an middle-aged dog I tend
to think about rickettsial diseases (Rocky Mountain Spotted Fever, Lyme,
ehrlichiosis), immune mediate polyarthritis, bilateral cruciate ligament
ruptures, spinal disease, hip and elbow dysplasia aggravated by other
conditions, drug reactions (sulfas, in particular), cancer, and fungal or
bacterial infections that are invading the bones or joints.In older Labs I try not to overlook immune mediated hemolytic anemia,
hemangiosarcoma and lymphoma when there are sudden odd clinical signs that
affect more than one area of the body. Shepherds tend to have similar
tendencies although less lymphoma and more immune mediated diseases like
lupus.It is always hard to figure out what the best approach to a multi-symptom
problem is, but I'd lean towards looking into the lump carefully, including
removing it if necessary to determine what it is and to test for other
problems simultaneously. Your vet will have to help you decide which
conditions seem most appropriate to test for first, based on the clinical
signs and lab values you have so far.If anemia has been ruled out, that helps. The rickettsial diseases can
often be tested for in one panel, from serum. In your area, Lyme disease
does seem like it has to be high on the list of differentials. Determining
whether the problem is primarily in the rear legs, primarily the front
legs, mixed between one front and one rear leg or occurring in all four
legs can help in thinking about the potential for injury to the cruciate
ligaments, spinal discs, etc. Immune mediated joint disease diagnosis may
require aspirating joint fluid (especially important to consider if the
joints are swollen) and the immune mediated diseases may require
specialized blood testing. When aspiration fails to reveal what a lump
might be, surgical biopsy is the next step, unless it is going away due to
treatment efforts. In areas in which fungal infections are common (Ohio
River valley, the Southwest) this is another thing to consider. Your vet
should know if you are in an area in which this occurs but I can't remember
the NorthEast being too suspect.Due to the complexity of sorting through these problems we tend to refer
patients to a veterinary teaching hospital when we really think the patient
might die while we try to make a diagnosis. They are just equipped to get
through the whole process faster. This might be an option for Sunny's
situation, if it is possible for your vet to refer you to a vet school or
large referral center in your area.Pain relief can be very helpful and should be considered if you are not
already providing something to relieve the pain and inflammation.Hope this helps some.
Mike Richards, DVM
9/8/99
Last edited 01/30/05
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