I have a 4 45 kg Pomeranian with a possible history of PU/PD and a Prot/Creat of 6.0. The history was a bit vague for LUTD.
I scanned the bladder and prostate and I saw no pathology. UA had a SG of 1.013 (first urine of the morning). There was no inflammatory component to the urine and no indiction of bacteria or hematuria- making LUTD less likely.
Both adrenals morphologically looked normal on the scan.
The L adrenal measured 0.56 cm and the R adrenal measured 0.6 cm at the caudal poles.
Here is my ?
I have a 4 45 kg Pomeranian with a possible history of PU/PD and a Prot/Creat of 6.0. The history was a bit vague for LUTD.
I scanned the bladder and prostate and I saw no pathology. UA had a SG of 1.013 (first urine of the morning). There was no inflammatory component to the urine and no indiction of bacteria or hematuria- making LUTD less likely.
Both adrenals morphologically looked normal on the scan.
The L adrenal measured 0.56 cm and the R adrenal measured 0.6 cm at the caudal poles.
Here is my ?
They say in the literature that most dogs with CCD of pituiatary orgin have caudal poles larger than 0.74 cm. Is CCD still a likely possibitly with adrenal that measure .56 and .6. The adrenal do seem a bit “plump” for a 4 45 kg dog.
I am currently having the owner measure the water consumption. If elevated I am going to suggest an ACTH stim test.
Comments?
14 responses to “Adrenal Size in CCD of Pituitary Orgin”
Cushing’s is a possiblity but
Cushing’s is a possiblity but with the SG, PuPd, proteinuria, and normal adrenals, renal disease should be considered as 80-85% of PuPd cases are of renal orgin. Are there other signs of Cushing’s – polyphagia, weight gain, thinning hair, etc? Water consumption will not differentiated renal disease from Cushing’s. If worried about Cushing’s run an ACTH stimulation test.
I assume that the dog’s weight is a typo – 4.45 kg and not 445 kg!! 🙂
Cushing’s is a possiblity but
Cushing’s is a possiblity but with the SG, PuPd, proteinuria, and normal adrenals, renal disease should be considered as 80-85% of PuPd cases are of renal orgin. Are there other signs of Cushing’s – polyphagia, weight gain, thinning hair, etc? Water consumption will not differentiated renal disease from Cushing’s. If worried about Cushing’s run an ACTH stimulation test.
I assume that the dog’s weight is a typo – 4.45 kg and not 445 kg!! 🙂
lol 445 kg dog would be a
lol 445 kg dog would be a body score of 500 out of 5? 🙂 That sounds like one of my typos LOL:)
Funny you posted this as I just addressed this type of question with a good mobile client of mine and discussed the acvim consensus on cushings… which a consensus on a nebulous disease is a bit paradoxical but still helpful as a guide or platform to work from and explains out a lot of diofference between the tests. But there are many issues left out of the consensus that complicate the workup especially the issues that bring the practitioner to consider Cushings and doesnt address adrenal size in a consensus format unless invasion is present because th ereality is the adrenals are all over the map in general regarding size…. so consensus on adrenal size is impossible other than general stendencies. So I had to come up wiht a proactive protocol to thwart the clients from working up cushings when more times than not cushings isnt a player… and at times it is. Could title it “Leaving Trilo-Mito on the shelf”
That being said a small % of PDH adrenals will be normal size (and the published normals are far form perfect and small sample size and my 0.5 cm is your 0.6 cm and vice versa) and if you go by Remo’s clinical crtieria first then USG and UCCR then sonogram you will get to the answers often that have nothing to do with cushings before even doing a dynamic function test of the adrenal axis… i.e. evaluate the kidneys and that 80-85% pupd from renal disease issue that remo brings up.
So here is my out of the box but effective algorythm for Cushings workup with acvim consensus reference and pupd list… try this and I’m betting you will stim less for pupd cases and those true Cushings cases you will have Trilo-Mito in hand definitively wihtout the voice in the back of your head saying… “Gosh I hope I don’t make him Addisonian.” Believe me we have all been there and done that.
Lindquist Quick PUPD Checklist:
This is my quick PUPD checklist after ensuring detectable & repeatable PUPD is present
(USG<1.025, clinically 1.020 usually for the owner to notice).
Note: Always get a USG and ensure it is < 1.025 & urine cortisol elevation is present before considering Cushings & running ACTH stim or LDDST. Cushings Dx is a stepwise diagnosis.
PU > 50 ml/kg/day
PD > 100 ml/ kg/ day
Note: Hyposthenuria cannot be renal failure alone.
Isosthenuria is same osmolality as plasma
Check these pathologies off in your patient and see what’s left:
DDx PUPD:
DM
Primary renal glucosuria
CRF
ARF
Post-obstructive diuresis
Medullary washout
Pyometra
Hypercalcemia
Liver failure
Pyelonephritis
Cushings
Addison’s
Hyperthyroidism
Hypertension
Diet
Drug
Psychogenic
DI
Consider gradual partial water deprivation test to rule out psychogenic and renal vs central DI
if the check list results in these potentials remaining.
Remember isosthenuria will wash out bacteria especially in older cats (common occult UTI) so negative urinary culture or negative bacteria does not rule out occult infection especially if pyelectasia is present on the renal sonogram.
Efficient & Accurate Cushings Work up-Lindquist
Notes regarding Cushing’s Clinical Presentations:
Nearly all Cushings dogs have SAP elevations and true PU/PD (USG < 1.025) and most are polyphagic.
Cushings dogs are > 6 years and usually > 9 years old, usually have poor skin coats, body scores > 3/5, and are usually sedentary animals.
Its important to remember that Cushings dogs usually look and play the part and other diseases cause false + stress related cortisol spikes. On rare occasion a Cushings dog will not follow the rules but this is truly an exception.
Potential Cushings patient workups can be costly and frustrating if not definitive and, in my experience, the non definitive patient usually has something else going on that may be contributing to some of the clinical signs a cushings dog will have, especially SAP elevations or PU/PD. Based on this prelude of information I came up with the following algorithm in the spirit of diagnostic efficiency.
The following suggested protocol is based on current available literature on Cushings disease and extensive clinical-sonographic experience evaluation + Cushings and False + LDDST & ACTH stim. cases in order to maximize the efficiency of a Cushing’s workup in practice.
Screen first, workup second
1) UA: Repeatable (2-3 urine samples) Urine specific gravity & urine cortisol/creatinine ratio (UCCR): If repeatable USG< 10.20 and + UCCR move to next step 2.
Note: UA is inexpensive and easy to obtain and if UA criteria is not met for Cushings then resources can be spent into other more pertinent diagnostics or left on hold until the UA criteria is met in emerging Cushings cases.
2) Sonogram: Does the patient have concurrent disease clinically or sonographically as non-Cushings illness will influence the potential false + LDDST or even ACTH stim. The sonogram gives a global perspective of the internal health of the patient to be considered in the Cushings workup as an assessment of concurrent disease. Is there a concurrent neoplastic process, UTI pancreatitis, mucocele….? Are the adrenals enlarged (Cushings-PDH, stress, age related or breed variant), or atrophied (Iatrogenic Cushings or adrenal burnout), have asymmetric enlargement ( Adrenal tumor, hyperplasia, adenoma, age related variant), or is there vascular invasion (Invasive pheo with false + UA criteria or adenocarcinoma or phrenic thrombosis)? The sonogram answers these questions proactively.
3) LDDST (0.01 D-Sodium phosphate mg/kg IV) (Better screening test but plagued with false +) Use if there is potential early Cushings or if adrenal asymmetry present on sonogram suspecting tumor. Use LDDST in cats at a higher dose (0.1 mg/kg IV).
OR
4) ACTH stim. (Better confirming test but can have false +) Use if the patient “looks” Cushingoid or if bilateral adrenal enlargement is present, or high normal width on sonogram, or if iatrogenic Cushings suspected (Cortisone tx in past).
5) If diabetic then run both LDDST & ACTH stim.
5) Run a serial blood pressure in a BP friendly non “white coat effect” atmosphere. Run at least 3 at different times over a few hours or when eating as the patient tends to be calm when eating or give Torbutrol when entering the facility.
6) Perform CT of the pituitary to identify macroadenoma expansion if any lethargy or dullness or other central clinical CNS signs are minimally present.
Suggested reading:
Behrend EN, Kooistra HS, Nelson R, et al. Diagnosis of Spontaneous Canine Hyperadrenocorticism: 2012 ACVIM Consensus Statement (Small Animal). J Vet Intern Med 2013;27:1292–1304 .
lol 445 kg dog would be a
lol 445 kg dog would be a body score of 500 out of 5? 🙂 That sounds like one of my typos LOL:)
Funny you posted this as I just addressed this type of question with a good mobile client of mine and discussed the acvim consensus on cushings… which a consensus on a nebulous disease is a bit paradoxical but still helpful as a guide or platform to work from and explains out a lot of diofference between the tests. But there are many issues left out of the consensus that complicate the workup especially the issues that bring the practitioner to consider Cushings and doesnt address adrenal size in a consensus format unless invasion is present because th ereality is the adrenals are all over the map in general regarding size…. so consensus on adrenal size is impossible other than general stendencies. So I had to come up wiht a proactive protocol to thwart the clients from working up cushings when more times than not cushings isnt a player… and at times it is. Could title it “Leaving Trilo-Mito on the shelf”
That being said a small % of PDH adrenals will be normal size (and the published normals are far form perfect and small sample size and my 0.5 cm is your 0.6 cm and vice versa) and if you go by Remo’s clinical crtieria first then USG and UCCR then sonogram you will get to the answers often that have nothing to do with cushings before even doing a dynamic function test of the adrenal axis… i.e. evaluate the kidneys and that 80-85% pupd from renal disease issue that remo brings up.
So here is my out of the box but effective algorythm for Cushings workup with acvim consensus reference and pupd list… try this and I’m betting you will stim less for pupd cases and those true Cushings cases you will have Trilo-Mito in hand definitively wihtout the voice in the back of your head saying… “Gosh I hope I don’t make him Addisonian.” Believe me we have all been there and done that.
Lindquist Quick PUPD Checklist:
This is my quick PUPD checklist after ensuring detectable & repeatable PUPD is present
(USG<1.025, clinically 1.020 usually for the owner to notice).
Note: Always get a USG and ensure it is < 1.025 & urine cortisol elevation is present before considering Cushings & running ACTH stim or LDDST. Cushings Dx is a stepwise diagnosis.
PU > 50 ml/kg/day
PD > 100 ml/ kg/ day
Note: Hyposthenuria cannot be renal failure alone.
Isosthenuria is same osmolality as plasma
Check these pathologies off in your patient and see what’s left:
DDx PUPD:
DM
Primary renal glucosuria
CRF
ARF
Post-obstructive diuresis
Medullary washout
Pyometra
Hypercalcemia
Liver failure
Pyelonephritis
Cushings
Addison’s
Hyperthyroidism
Hypertension
Diet
Drug
Psychogenic
DI
Consider gradual partial water deprivation test to rule out psychogenic and renal vs central DI
if the check list results in these potentials remaining.
Remember isosthenuria will wash out bacteria especially in older cats (common occult UTI) so negative urinary culture or negative bacteria does not rule out occult infection especially if pyelectasia is present on the renal sonogram.
Efficient & Accurate Cushings Work up-Lindquist
Notes regarding Cushing’s Clinical Presentations:
Nearly all Cushings dogs have SAP elevations and true PU/PD (USG < 1.025) and most are polyphagic.
Cushings dogs are > 6 years and usually > 9 years old, usually have poor skin coats, body scores > 3/5, and are usually sedentary animals.
Its important to remember that Cushings dogs usually look and play the part and other diseases cause false + stress related cortisol spikes. On rare occasion a Cushings dog will not follow the rules but this is truly an exception.
Potential Cushings patient workups can be costly and frustrating if not definitive and, in my experience, the non definitive patient usually has something else going on that may be contributing to some of the clinical signs a cushings dog will have, especially SAP elevations or PU/PD. Based on this prelude of information I came up with the following algorithm in the spirit of diagnostic efficiency.
The following suggested protocol is based on current available literature on Cushings disease and extensive clinical-sonographic experience evaluation + Cushings and False + LDDST & ACTH stim. cases in order to maximize the efficiency of a Cushing’s workup in practice.
Screen first, workup second
1) UA: Repeatable (2-3 urine samples) Urine specific gravity & urine cortisol/creatinine ratio (UCCR): If repeatable USG< 10.20 and + UCCR move to next step 2.
Note: UA is inexpensive and easy to obtain and if UA criteria is not met for Cushings then resources can be spent into other more pertinent diagnostics or left on hold until the UA criteria is met in emerging Cushings cases.
2) Sonogram: Does the patient have concurrent disease clinically or sonographically as non-Cushings illness will influence the potential false + LDDST or even ACTH stim. The sonogram gives a global perspective of the internal health of the patient to be considered in the Cushings workup as an assessment of concurrent disease. Is there a concurrent neoplastic process, UTI pancreatitis, mucocele….? Are the adrenals enlarged (Cushings-PDH, stress, age related or breed variant), or atrophied (Iatrogenic Cushings or adrenal burnout), have asymmetric enlargement ( Adrenal tumor, hyperplasia, adenoma, age related variant), or is there vascular invasion (Invasive pheo with false + UA criteria or adenocarcinoma or phrenic thrombosis)? The sonogram answers these questions proactively.
3) LDDST (0.01 D-Sodium phosphate mg/kg IV) (Better screening test but plagued with false +) Use if there is potential early Cushings or if adrenal asymmetry present on sonogram suspecting tumor. Use LDDST in cats at a higher dose (0.1 mg/kg IV).
OR
4) ACTH stim. (Better confirming test but can have false +) Use if the patient “looks” Cushingoid or if bilateral adrenal enlargement is present, or high normal width on sonogram, or if iatrogenic Cushings suspected (Cortisone tx in past).
5) If diabetic then run both LDDST & ACTH stim.
5) Run a serial blood pressure in a BP friendly non “white coat effect” atmosphere. Run at least 3 at different times over a few hours or when eating as the patient tends to be calm when eating or give Torbutrol when entering the facility.
6) Perform CT of the pituitary to identify macroadenoma expansion if any lethargy or dullness or other central clinical CNS signs are minimally present.
Suggested reading:
Behrend EN, Kooistra HS, Nelson R, et al. Diagnosis of Spontaneous Canine Hyperadrenocorticism: 2012 ACVIM Consensus Statement (Small Animal). J Vet Intern Med 2013;27:1292–1304 .
Yes the weight was a typo :).
Yes the weight was a typo :). The 1st am urine SG was isostenuric.
This dog does not look like a cushnoid dog in terms of body size and weight.
The entire back 1/2 of this dog exhibits patchy alopecia. I have seen this in this breed and I have often thought there was an issue with growth hormone. This dog is also currently being treated with a low dose of Thyrozine for hypothyroidism.
The owner is in the process of measuring the water consumption.
According to the owner the dog is polyphagic- but you could not tell by the BCS.
Thank you both for the response. I will take a closer look at the kidneys and print the EL Protocol for future reference.
Yes the weight was a typo :).
Yes the weight was a typo :). The 1st am urine SG was isostenuric.
This dog does not look like a cushnoid dog in terms of body size and weight.
The entire back 1/2 of this dog exhibits patchy alopecia. I have seen this in this breed and I have often thought there was an issue with growth hormone. This dog is also currently being treated with a low dose of Thyrozine for hypothyroidism.
The owner is in the process of measuring the water consumption.
According to the owner the dog is polyphagic- but you could not tell by the BCS.
Thank you both for the response. I will take a closer look at the kidneys and print the EL Protocol for future reference.
You may be dealing with
You may be dealing with adrenal gland sex hormone imbalance (aka alopecia X, atypical Cushing’s disease). These dogs typical have normal cortisol on ACTH stimulation but abnormal17-hydroxyprogesterone.
You may be dealing with
You may be dealing with adrenal gland sex hormone imbalance (aka alopecia X, atypical Cushing’s disease). These dogs typical have normal cortisol on ACTH stimulation but abnormal17-hydroxyprogesterone.
Thanks for the feedback.
I
Thanks for the feedback.
I will look into this. I thought Alopecia X was more common in some of the sled dog breeds.
Is there a way to test for this through an endocrine lab?
Thanks for the feedback.
I
Thanks for the feedback.
I will look into this. I thought Alopecia X was more common in some of the sled dog breeds.
Is there a way to test for this through an endocrine lab?
U of tennessee adrenal
U of tennessee adrenal panel
U of tennessee adrenal
U of tennessee adrenal panel
Here are some more excerpts
Here are some more excerpts on adrenal size frm a few studies:
The last statement is from the acvim consensus statement on Cushings 2013
Here are some more excerpts
Here are some more excerpts on adrenal size frm a few studies:
The last statement is from the acvim consensus statement on Cushings 2013