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Hyperadrenocorticism In A Dog

by fdzenitsky - October 31, 2021 View Case Report

Tyson, 12YO NM Pitbull, presented in May for conjunctivitis (otherwise no health concerns the owner tells me when making the appointment), so imagine my dumbstruck surprise when I meet what appears to be a small pygmy hippopotamus! Poor dog was 104 lbs., lethargic, thin, dry skin, mostly hairless w/ calcified lesions along a sagging dorsum, distended pot-bellied abdomen so girdled by skin I couldn’t palpate a thing, nasal hyperkeratosis, mm atrophy, a firm, bruised mass next to the prepuce that has been there for years quiet…and yes, an inflamed nictating membrane OD. The owner, who mistrusts vets and has not taken the dog to one in 10 years, declined referring for an ultrasound. Initial baseline testing revealed elevated ALT, ALP, GGT, PSL, WBC, MO, platelets, and cortisol; very low T3, T4, a wicked UTI, and hypovitaminosis D. T is pale, lavender; P is not detected. Textbook HAC (insulin resistance, Liver Blood deficiency, Damp Heat, Liver/Kidney Qi/Yin deficiency), I hoped the odds were PDH and started him on SMS (standard dose) to test the waters, raw low glycemic diet, enzymes, D3, and herbal urinary support.

Recheck 2 months later, increased energy and mobility, down 15 lbs., but increased calcinosis cutis on distal back, skin dry all over, but some hair regrowth, eye inflammation and UTI resolved. T is pale, dry, some lav; P is deep, soft. Cortisol, ALT and PSL are down a little, ALP and GGT more elevated. I add DGS to the SMS and increase dose to high, ½ tsp. per 5 kg based on your lectures. Recheck late October, he is down to 78.7 lbs., low energy, more vocal, needy, pickier appetite, occasional gas and borborygmi, diarrhea one day. less onery, and conjunctivitis. Skin is very dry, increased calcinosis. The firm bruised mass next to the prepuce looks more pronounced. T is pale lav and fleshy pink at lateral edges; P is deep, soft, toneless. Cortisol (6.2), ALT (481), ALP (2423), GGT (32), and PSL (325) have all increased; BUN and Cr both low (9 and 0.5, resp.), another UTI.

I think I have not done this patient right, though the probability of PDH was reasonable with limited diagnostics. Now, I believe the dog has a tumor on his adrenal and what looks like MCT on the groin, I’ll FNA that one this week. Can I rule out PDH since not responsive to SMS and change my game plan? From reading other posts here, I see you favor in AHAC both using SMS w/ low dose Trilostane and XCHT. In this case, SMS has not had the desired effect, so do I continue it at a high or lower dose w/ trilostane? Add or switch to XCHT and/or another cancer formula, perhaps adding another one that will address the MCT in a deficient patient if cytology is positive? Any other ideas like lignans and melatonin, Western herbs?

Many thanks, again!
Franchesca

by naturevet

November 2, 2021

Hi Franchesca,

I haven't seen the melatonin approach to be very high yield, but It has no downside, so you could try it in tandem with another approach.

Although I see how you're thinking the SMS approach was not helpful, the weight loss and (at first) increased energy and mobility suggest Dampness is a component of the problem, as does the worsening when Dang Gui was added. So, SMS or something like it, needs to still be part of the picture.

As to how to enhance its efficacy, you could try adding in XCHT to have an anti-neoplastic on board that reduces liver enzyme elevation and pancreatitis. Alternatively, you could try adding Trilostane (although it may not benefit the PSL elevation or the presence of any tumors). Or you could do both, but I would introduce these sequentially, rather than all at once, so you can identify what is making the most difference.

For sure, though, you are improving this dog's quality of life tremendously, so I wouldn't sell yourself too short. You're just missing what will make the dog comprehensively better, but suffice it to say, you've gone well beyond what your conventional brethren would have accomplished, and probably restored that owner's faith in veterinarians in the process. I think you're close on this one. Hang in there! I hope these ideas help!

Steve

by fdzenitsky

November 3, 2021

Thanks Steve, your input is invaluable! I am going to start w/ Trilostane to give this guy some symptom relief, then roll in the XCHT. With a toneless pulse, is CHJLGMLT the formula to reach for?
To be clear, I was using the acronym AHAC incorrectly, I meant ADC, adrenal dependent tumor, not pituitary. Does it matter as far as treatment strategies? And lastly (for now), in these cases, when dry skin and calcinosis cutis are hallmarks of the disease, DGS is not indicated to help moisturize the dermis and I should pull that out of the formula?

Franchesca

by naturevet

November 3, 2021

Hi again,

Given the worsening on Dang Gui, you'll have to address skin dryness by getting rid of the source of Heat, at least at first, and by normalizing vascular tone. SMS does the former and XCHT the latter.

Your clarification on AHAC doesn't really change my advice for now. As to the typical pulse associated with CHJLGMLT, it is often superficial, buoyant and toned, kind of like a Floating pulse associated with a Wind invasion. In a Shao Yang case, you'd call it a Drum Skin pulse

I agree the soft pulse doesn't really fit a Shao Yang case, so starting with Trilostane and just seeing if maybe the SMS needed more help is a good idea. The other thing you can do is use a less Dampening Blood tonic containing Dang Gui, like Dang Gui Shao Yao San. Start with the Trilostane first, though, and go from there

Steve

by fdzenitsky

November 8, 2021

Hey Steve,

Well...it WAS a good plan, but... I started this dog on Trilostane at 1mg/lb SID, within 5 days he was in crisis, obtunded, shivering, anorexic, drinking just a bit, and can hardly walk around. He looked like an Addisonian crisis! I did not repeat bloodwork today. T is lavender, thick phlegm coated, P is mid, soft, wiry. No evidence of pseudomyotonia. I have never seen this before on low dose trilostane - and so quickly, so needless to say, that is off the table! I began rectal ozone therapy, perked up quickly, showed owner how to do daily. Then I started XCHT via retention enemas for a few days. I am unsure if I should combine the SMS w/ the XCHT during this time, so I advised to just give the XCHT for now. Should I continue both formulas in a few days and/or do you have any other suggestions for this poor guy?

Many thanks!
Franchesca

by naturevet

November 9, 2021

Hi Franchesca

Dang, don't you hate that? Oh, well, remember that a worsening is not bad news in Chinese medicine, since it gives you clues as to what you should be doing. We know from the response that the dog is much more normal, or even Qi deficient, than you thought.

If that is the case, the SMS might have been helping more than you realized, so you might want to continue it. The dog did manifest Damp symptoms on Dang Gui, which is another reason to use it.

XCHT and SMS can be used together. XCHT contains Ren Shen, a Qi tonic, so it will support the dog's currently beleaguered Qi.

Let us know how it goes. There may be yet more layers to this dog that we need to address before he feels fabulous, but I'm confident you can get there, if the owner will stick with you

Steve

by fdzenitsky

November 17, 2021

Hi Steve,

Well, this dog has rallied! IDK if that was an Addisonian crisis he is recovering from, but some big shifts in his serum chemistry and in the right direction. ALT down 70%, ALP and PSL down ~50%, GGT down 40% and in the high normal range. Cortisol in high normal range too, still stress, ill leukogram. Electrolytes out of balance (high Na, Cl; low K), I think from the saline fluids assuming Addison crisis. He is up walking and urinating on his own, appetite is picky, and significant changes in his skin, much softer, less dry, and the inguinal mass is reduced in size, all from one week to the next. I credit the XCHT retention enemas and fluid therapy. I added back the SMS last Friday, w/ XCHT, both at standard dosing until I checked w/ you. Do I resume high dose SMS or stay at standard dose? Any other deductions and recommendations at this time? He developed a shiver when down and still had it last Friday, not constant and not sure what that signifies.

Thanks! Franchesca

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