Possible Addison's in my English Springer?

[Esmeralda]

Dear All, previously found this site so helpful when I had an elderly English Springer with IMHA, now I have a seven year old English Springer bitch, Matilda, with symptoms that sound to me frighteningly like Addison's and we are in need of your help again! She has been "off colour" (lost her "sparkle" for which she has always been well known!) for around 16 months all told, and after 8 months was diagnosed as Hypothyroidic. She also had the full range of tests for Cushings as she was drinking gallons and her urine was ridiculously diluted, but all the tests were resoundingly negative. After being on Thyforon for a good 8 months, she is not as lethargic, but still not quite "right". She has continued to look a bit pot-bellied, in poor coat and with no real "seasons" (she is not spayed). In the last couple of weeks, she has had an extended bout of diarrhoea and one or two episodes of vomiting, and went right off her food from being a voraciously hungry Springer, and also went back to drinking a lot, but this time little and often rather than the massive amounts she was drinking at a single session before. She also lost 2kg and looked very thin very suddenly. All of our dogs had a 24 hour "tummy bug" at the time, so both the vet and we thought she just had a bad tummy upset. But after ten days of antibiotics, although she is eating again (but not enthusiastically as before) and is generally more cheerful, she still not right. She is drinking little and often, and her urine is very diluted. She appears to have no pain in her tummy and pyometra has been ruled out by an ultrasound scan. She has put on about half the weight she lost. The key thing is her blood results - they are unchanged today from 10 days ago - high white blood cells, high neutrophils, lymphocytes and monocytes; high calcium; high globulin; low red blood cells, HCT and HGB (basically anaemia). All this after antibiotics, so not a standard treatable infection. The vet is proposing x rays to look for cancers, which are high on her suspect list. She hasn't mentioned Addison's, but have read the articles on here and am wondering if this is a real possibility and worth suggesting to her ahead of the x rays? Matilda had a ACTH stimulation test as the last of her Cushings tests, but that was earlier this year, so presumably the results could now be different? Her Sodium/Potassium ratio ten days ago was 34, and individual NA and K readings within the normal range. Not sure what they are today as was only given some results over the phone. Any advice would be very gratefully received - many thanks in advance

[Jo CIMDA]

Hi

I apologise for not having replied sooner, but I have not had any internet access due to technical problems.

The information you have given paints a confusing picture.  I have listed below the typical blood results that may be expected in a dog with Addison's disease and Matilda doesn't seem to fit with those. 

She also doesn't fit with the typical blood results of Cushing's syndrome. One would expect a stress leucogram (see information below), and normal or mildly increased red blood count and platelets;  liver enzymes and bile acids will be mildly raised; and also cholesterol and blood glucose is usually high-normal.  Urea and creatinine values are low-normal.

Does she have a high or normal temperature?

Both Addison's disease and Cushing's syndrome are progressive diseases, therefore a negative ACTH test is only valid at that time and if either of these diseases are suspected then another ACTH test is indicated.

I hope you can get a diagnosis very soon.

Jo




Addison's Disease

The Tell-tale Signs When Looking at Blood Test Results

Routine Laboratory Abnormalities  -  Haematology & Biochemistry

Sodium/Potassium Ratio
Greater than 90% of Primary Addisonian cases will have low sodium (Na) and high potassium (K) values, with a ratio of less than 27:1  (Na:K)
Prior to diagnosis, `typical' Addisonian dogs often show a ratio of less than 23:1.  A low ratio is very suggestive, but not diagnostic, of Addison's disease. Individual electrolyte concentrations can be a more reliable indicator. 

A diagnosis of Addison's disease must not be presumed just because a dog has a low sodium/potassium ratio. An ACTH test must be performed to confirm Addison's disease. 

As the disease progresses, the sodium and potassium ratio will drop even further and the dog may collapse and become critically ill, especially if the dog becomes stressed or excited. Anxiety or excitement, in a dog with reduce adrenal function (even in a dog who has not exhibited typical, clinical signs of Addison's disease) can cause the dog to collapse or even die suddenly. 
The mild, clinical signs of `chronic' adrenal disease do not differ greatly to the grave clinical signs of `acute' adrenal disease. The existing, or previous, clinical signs appear increasingly more severe and urgent when an adrenal crisis is imminent.     
Prompt diagnosis and treatment, or supportive treatment, is crucial for a favourable outcome. An Addisonian crisis and must be treated as a true emergency if the dog is to survive.

When comparing laboratory results look for the following as these will give a strong indication of Addison's disease:
INCREASED:
High Potassium (K)
High Creatinine,
High Urea, (BUN – blood urea nitrogen; or SUN - serum urea nitrogen)
High Urea/creatinine ratio (Azotaemia)
Increased Eosinophils
Increased Lymphocytes
High Bilirubin - in some cases
High Calcium (mild to moderate) – in some cases
ALT- ALP - AST (Mild to moderate increase of liver enzymes) – in some cases

DECREASED:
Low Sodium (Na)
Low Sodium/potassium ratio (Na:K) ratio -  less than 27:1)
Note: Addisonian dogs often have a ratio of <23:1
Low Chloride (80% of Addisonian dogs will have low chloride values)
Low Glucose – in some patients
Low Albumin (moderate to severe) – in some cases
Total white blood cell count (WBC) – in some cases
Red blood cell count (RBC or HCT)

Note: Whipworms also cause low sodium and high potassium concentrations.

Another possible difference between kidney disease and Addison's may be seen in the white blood cells (eg., neutrophils, eosinophils, lymphocytes).

When a dog is very ill (but does not have Addison's disease) stress levels rise and this is often reflected in the white cells. The neutrophil numbers in a very poorly dog are expected to be high-normal to increased, and the eosinophils and lymphocytes numbers are low-normal to decreased. This is called a 'stress leucogram' and is seen in both chronic and acute renal failure, but not in Addison's disease.

A dog with Addison's disease will show a different white cell reading than would be expected in such an ill dog.  In fact there may even be reverse of what would normally be expected, known as 'reverse stress leucogram', caused by the lack of glucocorticoid hormone.

Reverse Stress Leucogram – An important indicator, and is seen in Addisonian dogs
Low-normal numbers of neutrophils
Increased numbers lymphocytes and eosinophils
Just remember, a very poorly dog showing a normal or elevated lymphocyte count is suggestive of Addison's disease.

Electrocardiogram
•   Electrocardiogram (ECG) is a very useful tool to detect various abnormalities of the heart resulting from high potassium levels in the blood.
Acutely affected dogs may be in hypovolaemic (reduced blood volume) shock, with severe dehydration and bradycardia (slow heart beat). A collapsed dog with a slow heart beat is unlikely to survive for long, so supportive treatment is both essential and urgent.
Note:  Usually, a dog with hypovolaemia will have a fast heart beat (tachycardia).   In a hypovolaemic dog with Addison's disease the heart beat will be slow (bradycardia).  This anomaly is very suggestive of Addison's disease.
Another misleading differential is non-regenerative autoimmune haemolytic anaemia (AIHA). Decreased glucocorticoid hormone (as a result of adrenal insufficiency) suppresses production of red blood cells in the bone marrow resulting in the dog becoming anaemic.  Regenerative anaemia (anaemia within the circulation of the blood) may be present due to gastrointestinal bleeding.
Note: The severity of anaemia can be masked if the dog is dehydrated.

I have known a number of dogs to be diagnosed with AIHA prior to being diagnosed with Addison's disease. The usual treatment for AIHA had been implemented but the clinical signs did not improve as expected, and vague clinical signs of Addison's disease, remained. 
If this happens you should check for signs of Addison's on previous blood test results to see if there were any undetected tell-tale results such as high potassium, low sodium and a reverse stress leucogram.  These cases are further complicated because the dog will be receiving steroid treatment (prednisolone) for AIHA.  A diagnostic ACTH test for Addison's disease cannot be performed whilst a dog is on prednisolone, as it interferes with the test and results, so the dog's steroid medication must be changed to a different steroid called dexamethasone for at least 24 hours before an ACTH test is performed.

Atypical Addison's Disease
Atypical Addison's disease occurs when the part of the adrenal gland that produces the glucocorticoid hormone only is affected. 
Dogs with atypical Addison's disease will have normal renal (kidney) blood values and, unlike dogs with primary typical Addison's disease, they will not usually show classic changes in their sodium and potassium levels. 
Note:  Some atypical Addisonian dogs may still be deficient in mineralocorticoid hormones without it showing on the blood results. (Catharine Scott-Moncrieff) 
Clinical signs may include: anorexia, vomiting, diarrhoea, weight loss, non-regenerative anaemia, exercise intolerance.
Atypical Addisonian dogs may have been misdiagnosed with inflammatory bowel disease (IBD), non-specific gastrointestinal disease (e.g. colitis), liver disease or non-regenerative haemolytic anaemia.  These cases can be challenging to the vet because dogs will often respond more favourably to fluid therapy.  The disease process of Atypical Addison's disease may appear slower leading up to a diagnosis, and it may develop at a later age than typical, primary Addison's disease; the mean age being 7 years. 
Blood results should show a reverse stress leucogram.

[Esmeralda]

Hi Jo, thank you for replying. No, Matilda doesn't have a temperature. We have been back to the vet for xrays since my post, and the vet thinks that Matilda has a malignant cancer. They have ruled out Addison's after doing a Base Cortisol test, and are having her back tomorrow for a specialist abdominal scan to see if they can find a mass, and are also doing a special blood test for something called parathyroid...something or other - I can't remember what it's called, but it's like a hormone that will show whether or not there is malignancy in her body. She is still very bright in herself and is back to eating normally. So it doesn't sound like an auto-immune disease, but does sound like we will lose her to cancer 

[Jo CIMDA]

Hi

I am so sorry to hear this.  I am sure whatever the problem you will do your best for her.

Let us know if we can help.

Jo