Before we start on this case history I want our readers to know that as of this writing, February 14, 1998, Cosby is a happy little dog and feels great. He loves life and lets us all know how he wants things done.
Cosby became a regular patient at Berkshire Veterinary Hospital in early 1996. At that time he tipped the scales at fifty pounds (20 lbs. overweight). He was suffering from severe obesity, a grade 2 heart murmur, recurrent ear infections, multiple fatty tumors, multiple papilloma’s, and a severe and recurrent moist dermatitis that covered his entire “fanny”. He not only felt bad, he smelled bad. His new owner, Carolyn, had “adopted” Cosby and it was her hope to make him a new dog. Cosby was twelve years old and none of us knew what was ahead. We just wanted to make Cosby feel better.
Cosby’s work up included a complete blood count, metabolic panel, urinalysis, EKG, chest x-rays, and a thyroid panel. He was started on a number of medications to treat the ear infections and recurrent bacterial skin infections. A list of diagnostic rule-outs was considered.
Cosby’s lab work revealed several abnormalities. He had a very high blood cholesterol and triglyceride level. He had a subnormal level of thyroid hormones and a very significant elevation of Thyroid Stimulating Hormone (TSH). There are many diseases that will lower blood thyroid hormone levels, but when low levels are combined with Cosby’s clinical obesity, elevated trigyceride and cholesterol levels and a high TSH, a diagnosis of primary hypothyroidism can be made. He had slight elevations in liver enzyme values. His EKG and chest x-rays were within normal limits.
Cosby was started on daily thyroid hormone replacement, and gradual weight reduction diet. Several small skin tumors were removed utilizing local anesthesia and electrocautery. His ear and skin infections responded well to medications and his improved thyroid status.
One month later Cosby returned to BVH for follow up lab work. We wanted to be certain the amount of thyroid medication was achieving appropriate serum levels and we also wanted to monitor the previously noted elevation in liver enzymes.
We were pleased to find that the thyroid hormone levels and TSH levels had returned to normal. We were concerned to find that his liver enzymes had increased significantly.
There are many diseases that can result in elevated liver enzymes. Some more serious than others. Liver disease work ups can include liver function tests, x-rays, ultrasound, and surgical or ultrasound guided biopsies.
Cushings disease is often considered in the list of possible diagnosis, especially in older dogs with clinical histories like Cosby’s. Patients with Cushings disease have a problem with overproduction of Adrenal Hormones. This excess results in many clinical abnormalities including liver damage and lowered resistance to infection. Adrenal gland testing can help make the diagnosis and possibly determine if the problem is in the adrenal gland itself or in the brain’s pituitary gland. In a high percentage of cases the problem is a small slow-growing benign pituitary tumor. Cosby’s tests supported the diagnosis of pituitary dependent Cushings disease.
Now the hard part. With this type of Cushings the adrenal gland is being over-stimulated by the brain. Treatment has traditionally involved using medication to destroy part of the adrenal gland and lower the hormone levels. Many patients respond well to this treatment but there are significant risks involved. Constant monitoring of adrenal function and serum electrolytes is necessary to minimize risk. Even with monitoring, some patients will have serious complications with treatment. At this same time canine clinical studies were being done with a human medication called Eldepryl. One of its uses in people was to help control the signs of Parkinson’s disease. This medication had shown promise in treating pituitary dependent Cushings in dogs but is was not yet FDA approved for use in dogs. After much discussion with Carolyn, a decision was made to treat him with Eldepryl. Dr. Lemieux had a number of Cushings patients on Eldepryl and to date they were doing well. On May 1 Cosby started his daily Eldepryl.
On June 19th Cosby returned to BVH for an exam. He clearly felt better, was more active, and had lost some weight. Carolyn had noticed that on occasion he had a small amount of bright red blood on the surface of his stool. A decision was made to endoscopically examine his lower GI tract. An ulcerated polyp was found at the junction of Cosby’s small and large bowel. A biopsy was obtained and this was a benign polyp. We were thankful with this result but benign rectal polyps can be pre-cancerous lesions in dogs and we would carefully monitor Cosby clinical signs.
So far Cosby is a hypothyroid, Cushings disease patient, with a benign colonic polyp. He looks better every day and feels fine. On October 2nd we repeated his adrenal testing and the adrenal axis had returned to normal. He weighed forty-three pounds.
For Thanksgiving Cosby ate way too much turkey. He came to the hospital because of repeated vomiting and diarrhea. Hopefully this was a routine gastroenteritis and not a more serious pancreatitis, but we were beginning to see a pattern with Cosby, he seemed to like the more complicated diseases. His metabolic panel was fine and he responded to symptomatic treatment. We considered doing specific pancreatic tests called TLI’s but within two days he was feeling much better and left the hospital.
On January 15th,1997 Cosby again returned to BVH. He really didn’t feel well. He had lost his energy and was very thirsty. His urinalysis was positive for glucose and ketones, and sediment analysis revealed a bacterial bladder infection. His blood glucose was over 400 (normal app. 80-120) . Cosby was now diabetic and the presence of urine ketones told us this was serious. The clinical term is a “complicated diabetic”. Bladder infections are common with diabetes and of course Cosby threw this in just to make our life more interesting. Another major concern was Cosby’s Cushings disease. His symptoms were well controlled but Cushings patients are often resistant to insulin and controlling diabetes can be very difficult. How would it go with Cosby?
Cosby was hospitalized in intensive care and fast acting insulin was used to lower his blood sugar levels. Urine cultures were started to help insure that we were using the most appropriate antibiotics to treat his bladder infection. Serum electrolytes must be monitored closely with these patients, potassium levels are particularly critical because they are influenced by insulin. Cosby was placed on a continuous infusion of fluids and electrolytes and repeated blood tests monitored his serum electrolytes and glucose.
Over the next five days his condition stabilized and it appeared we would be able to regulate him with a reasonable dose of insulin. On January 20th he was ready to leave the hospital. Carolyn decided to bring Cosby to the hospital twice daily for the first few days of insulin injections. He would need insulin for the rest of his life and with training and Cosby’s permission, Carolyn would administer these injections at home. So what do you think happened next?
You guessed it ! Cosby was the perfect gentleman for his injections when they were given at the hospital by a trained technician, but, he was not interested in having Carolyn give the injections at home. He was very quick to let her know this! Believe me, he is a great little dog but he has his own ideas about how things should be done and his “mom” was not going to stick him with that little needle twice a day.
Believe it or not 1997 has been a good year for Cosby. His many metabolic diseases have been stable. His liver enzymes are near normal. His weight is now a svelte 28 lbs. His age related heart murmur has gotten a little louder but his recent chest x-rays, EKG, and echocardiogram revealed minimal changes. His combination of metabolic diseases makes him a candidate for hypertension but so far his blood pressures have been normal. He has recently started taking a low dose of a vasodilator (yes dogs take Vasotec too).
His most recent challenge has been a condition called Hepatocutaneous Syndrome. This diagnosis, confirmed with biopsy, is a skin and keratin condition that is secondary to his metabolic diseases. We have tried many skin treatments and Carolyn has worked diligently to find the right combination and frequency of natural shampoos to keep his skin as healthy as possible. Over the past two months, his skin and digital pads have improved.
Somewhere along, as you read this history, you are going to say this is where I stop. Well, I guess you would have to know Cosby and you would have to know Carolyn. As long as Cosby is doing well and his problems can be controlled, stopping is not an option.
Carolyn decided she would bring him to the clinic twice a day for his injections. If you are at our hospital around 6:45 AM or 6:45 PM you may get to meet Carolyn and Cosby. You will probably hear Cosby’s distinctive bark as he demands to be brought to the technicians for his insulin injection.
P.S. What he really wants are the low sugar treats we give him after his treatment..