Riley FS mixed breed, 11 yrs old
Riley has been healthy other than going blind 3 years ago— adapted well and continued good quality of life.
Early October 2023: Sudden onset of “shivering” when in bed with owner, and polydipsia. Took to urgent care clinic mid-October, had mild fever (103.4) but seemed to be NSF, wondered if she had UTI, when vet, as afterthought when walking out the door thought to check anal glands. Had monstrous abscess— huge and deep, took two rounds of antibiotics to clear up. Urgent care clinic also noted (I don’t have these records!) something that made them say— get her checked out for Cushings. To clarify— no clinical signs of Cushings, other than PU/PD.
So, the following week, O went to regular vet to follow up on cleaning up anal sacculitis. She had only been on AB for a few days, but the polydipsia had mostly resolved. RV did low dose dex suppression test (10/13/23), which showed baseline cortisol of 6.5 (1.0-6.0 ref range) and response — 4 hr 8.6, 8 hr 6.2. So, not supressed. But the dog was still ill with anal infection at that time. (To my mind, without clinical supporting signs of Cushings, they should have waited and retested I believe this may have been a medical error that precipitated everything else that happened.) RV sent dog home on more antibiotics, and Trilostane 60 mg SID.
Over the next few weeks, the anal lesion resolved, but the dog began having tremors and possibly occasional psychomotor seizures. O was convinced it was due to the medication. Dog was rechecked on 11/14, at which point they did a ACTH stim test, which was 5.8 baseline and 11.8 post-stim. Which convinced the vet he was on the right track, and told client not to worry about the tremors and neuro signs. (Why did he use a different test, rather than comparing test before treatment?). Dog continued to worsen through December, at which point the owners brought her back because they were concerned about tremors, weak hind end, lethargy, and inappetence. CBD/Chem done at that date showed:
Lymphocytes 0.69
Eosinophils 0
ALP 1207 (don’t know the October value)
ALT 151
Lipase 5700
Amylase >2500
Neuro signs worsened over six weeks. Owners requested stopping the Trilostane, vet refused, but added Keppra TID, saying she had seizures because of brain tumor, should really euthanize, but at least medicate them. Dog had terrible response to Keppra— very bad GI signs, vomiting all the time. Vet insisted she stay on it, and also added phenoxybenzamine to control blood pressure, which was measured at 192 systolic at a stressful time. They stopped giving the Trilostane in early January, still no symptoms of Cushings.
Since that time, dog has had episodic dehydration, is too weak to rise, only eats a little if hand-fed, tremors all the time. Owners insisted on stopping the Keppra, no change. Took to ER for fluids, they said (based upon history of Cushings diagnosis) that her tremors were from brain tumor and they should put the dog down. Gave a steroid shot, which was followed up by 20 mg/SID pred from home vet. No improvement whatsoever, is getting worse on pred. Owner is desperate, seeing dog waste away in front of her eyes.
According to owner, there are no changes in mentation, normal withdrawal reflex in hind legs, no evidence of inflammation in spine, too weak to reposition body while lying down, can not rise or support body while standing. Pulse was rapid and superficial. Tongue medium pink.
The only treatment I could think of was Chai Hu Jia Long Gu Mu Li Tang, which is consistent with presentation and season of onset. Sent home on TID, and instructions to wean off the prednisone.
It feels like this is not a Cushings dog, but she is definitely sick now!! Waiting to see if there is a response from high dose CHJLGMLT.