A tentative but hopeful way forward for Zoom

It has taken me a week to write this blog. After Zoom's diagnosis of Cushings we started with her withdrawal from pred. In reaction to this Zoom had an Addison Crisis last Thursday, a week ago today. Her system simply didn't cope with the withdrawal of the Pred. The initial conclusion based on her very low blood cortisone levels even after prednisone dosing was that her adrenal glands may be atrophied beyond the outer layer and may not be able to produce cortisone again. Which essentially meant that she could not live with or without the cortisone in the long term. Needless to say I was shattered. And as much as I tried not to, I blamed myself for not being more assertive in chasing the definitive diagnosis we needed back in August / September last year when I first knew she was not herself; and for not making myself fully aware of ALL of the side-effects of any medication my dogs take, and putting all together for a holistic picture rather than treating each problem as a separate issue. I've struggled so much over the past few months watching her go from one medical problem to another, and whilst there are times when she is better than she was in January or February, she has not been close to being the dog she was 12 months ago- there have been times when she was improved, but I am getting so used to a lethargic Zoom, that it is blurring my memory of what she is like in true health. Though gosh, just two weeks ago she was competing and qualifying in agility. The things our puppies do...
In the early hours of Saturday morning, I had decided that I couldn't continue to put Zoom through this barrage of drugs, tests and stress on her system. She looked in so much pain trying to recover from the Addison crisis. Where Katie had just looked tired toward the end, Zoom looked in serious pain and her eyes seemed to be begging me to make it stop. Whilst she was much improved by the Friday night there was a still a dullness and listlessness that was so unlike her. I didn't want a repeat of this attack, or for her to slowly decline to the point where there was no energy, no spark, no joy left in her body. Glenn and I decided to stabilise her again on the cortisone and give her a few weeks of doing all her favourite things in life, like swimming, chasing Missy in retrieve games, running on the beach, going anywhere in the car, sleeping on our bed and of eating all her favourite foods like roast chicken skin, bacon rind, lychees, meaty bones and pigs ears. We generally wanted to embrace her with all the love we could give her before putting her to sleep.
Over the weekend I attended the Chris Zink seminar in Brisbane. I "had" been looking forward to this for at least 6 months; but my mind was not at the seminar, it was continually thinking about Zoom and Glenn at home, hoping he was being attentive and super-observant, and in many ways thinking I should be with her instead. Then I had the opportunity to speak with Chris about Zoomy and her medical history. She completely turned me around. She was of the opinion that a 4 year old dog can come back from this; she believed if we took it slowly enough that she could regenerate the tissue and function required in the adrenal gland as long as it is only the cortisone that is the basis of the Cushings. She laid out a plan where we could reduce it milligram by milligram over a long period of time; then increase the dosing period hour by hour, until she was eventually free. Her confidence in this plan working was contagious. She had buoyed my spirits. I wasn't ready to give up on getting my big girl healthy again; I scheduled an appointment with my vet again for Monday evening.
Well it seems he'd had the same thoughts over the weekend. He had spoken intensively with the specialist again on Monday morning, and low and behold they had put together an almost identical plan. The specialist believes her organs will support her on her current dosing of cortisone for 12 months without too many problems, so we have that time to slowly wean her from this drug. I now have a treatment plan on the kitchen wall that has Zoom drug free by the end of October (with no set backs) and has an exercise plan to slowly rebuild her musculature, endurance and strength in line with the reduction of the drugs.
2008 will be the year of the Zoom pup! Happy, healthy, fit, strong and loving life again with the zest that she was named for...

Calcinosis Cutis

The lab results from skin samples today confirmed that the lumps and bumps are calcinosis cutis. So now we need to wait until Zoom is weaned from the Pred and it is cleared from her system before further testing, initially ACTH test, to ascertain whether Iatrogenic Cushings and, then if necessary Low Dose and High Dose Dexamethasone Suppression Tests to determine whether PDH or ADH.

What next....Iatrogenic Cushings???

Well after the success at Yamba we went back to the vet for a check-up yesterday; mostly as Zoom's alopecia is not improving and she has an antibiotic-resistant rash on her back. Below is the medical history of Zoom.

Zoom was diagnosed with Discoid Lupus in October 2005 and has been on 10mg of Prednosone per day since then; she is 500mm tall and weighs 16kg; her DOB was 22/5/03; she is a tricolour Border Collie.

Around August 2006 I noticed Zoom had a pimple-like skin rash over her back towards her tail and had started to get a redish tinge to her coat and it was thinning in the areas of the rash. By October she had started to get more lethargic and less active on hikes and at training. A routine CBC at this time showed a low White Blood Count at 3.21, low Albumin at 22 g/l and elevated glucose at 6.5. Otherwise everything was within the normal ranges. We treated the skin rash with anibiotics and monitored her. She started increasing her water intake dramatically and was also wetting her bed during the night. Back to the vet who placed her on Hormone Replacement Therapy.

Her condition worsened over Christmas with discenable coat colour changes (people thought she was a chocolate tri) and dramatic thinning of the hair; she was also drinking and urinating lots; was continually hungry and had started guarding food sources (the fridge, food plates etc). The pimple-like rash was still present and spreading.

In January she had an eye ulcer and a tooth infection at the same time. Whilst treating for these we tested her bloods again, this time including thyroid and found her T4 was very low. Hypothyroidism was diagnosed and she commenced on Thyroxine; 0.4mg tablet twice daily. It seemed that many of her ailments fitted this disease and I was looking forward to having an improvement in her condition. Her t4 had stabilised in the normal range in February. Though as my previous blogs tell, she then got a staph infection across her back and neck and we started her on cephlexin antibiotics; she is still on this. Two weeks later Demedex was also diagnosed and she commenced 7 weeks of ivermectin treatment. It was apparent she had no immunity.

Now we are in April, and the positives are her staph infection has cleared and she is regrowing thick black hair where the infection had been. A skin scraping has cleared her of demodectic mites, though she did lose another tooth over Easter. But generally she is more happy and active again and has recommenced agility training and competing (and is enjoying it!). The negatives are (as depicted in these photos) that she has a new, or at least more noticeable, rash on her back and the alopecia is continuing or at least not improving in areas other than where the staph had been; her hair feels dry and brittle and breaks easily. She has some mottled black pigmentation in some areas of the alopecia. The rash is hard and raised, not puss-like, but rather dry and crusty.

My vet believes this rash to be calcinosis cutis (though says he has only seen it once before) and based on that, her varied symptoms and long-term medicating with 10mg per day of pred has tentatively diagnosed Iatrogenic Cushing's disease. He is having me wean her off the Pred slowly over the next month. No discussion of how to manage the lupus without the Pred yet.

Since this tentative diagnosis I have had time to read more about Cushings and concur that her symptoms do match this disease; but then the symptoms are quite similar to those for Hypothyroidism. She seems young to have Cushings, but I am wondering if the average age I am reading about (10 yo) is for pituitary and adrenal based cushings rather than the veterinary-induced version, which I'd guess from its nature could occur at any age. Her bloods do not really seem to be indicating Cushings from this description, no increase in specific liver enzymes. She also does not have the distended abdomen. I have been having problems with rebuilding her muscle tone though she has had no weight gain since 2005, but I am very careful with monitoring all my dogs weights for agility which was why thyroidism took a while to diagnose also.

I guess this diagnosis raises questions for me surrounding the doseage levels of cortisone that is likely to induce Iatrogenic cushings. Most of what I am reading on veterinary sites is suggesting that it is brought on by overdosing. I would not have thought that 10mg per day in a 16kg dog was an overadministration; though another site has given me another view by suggesting it is more the length of time she has been exposed to that doseage, than the doseage itself. This site at Newman Veterinary suggests anything longer than 3 weeks is prolonged use and may affect the dog's "HPA"....the Hypothalamic-Pituitary-Adrenal axis; which means the adrenal glands, in turn, may "shrink" (atrophy) due to lack of stimulation.

I'm really stuggling with getting my girl stable and healthy again, and want to be sure that I'm "crossing the t's and dotting the i's" in sorting out what her problems are. We had a great weekend over Easter and I had thought we were well on the road to recovery, but was still concerned that her rash had not cleared after 8 weeks of antibiotics and that the alopecia was not reversing after 9 weeks on the Thyroxine. Now I am just plain worried that she may have the Pituitary Dependent Cushings which accounts for 85% of cases and has a far from positive prognosis; or that she does indeed have Iatrogenic Cushings but her adrenal glands have atrophied to an unreversible point.

For more information on Cushings Disease:

http://www.kvh.com.au/cushing_disease.htm

http://www.kateconnick.com/library/cushingsdisease.html

http://www.newmanveterinary.com/Cushings.html

Yamba Easter Agility Festival

Wow, what a fantastic weekend. The weather may not have been ideal, but the grounds, the hospitality, the courses and the camraderie were fantastic.
We had a successful weekend coming home with 18 quali cards and three new titles. The best news for me was that Zoom was happy and ran beautifully, earning three cards and her SAAD title. She coped well with the weekend and has recovered quickly, already wanting more. I'm hoping this is the sign of good things to come where her health is concerned. Her best run was snooker on the Good Friday afternoon; even though she didn't quali, she had a really nice run.
As for the shelties...
Jonty earned his MAAD 7 title and came home with 2 purple cards- just the one to go now...
Missy earned her MAAD 6 title, though by the end of the weekend was starting to gather noticeably before take-off; so even though she had some great runs, is still not 100% fit. We'll keep working on that over the next few weeks.
In fact the entire WAAG contingent ran well, with results on their webpage.