{"id":1126,"date":"2014-01-01T16:37:51","date_gmt":"2014-01-01T16:37:51","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1126"},"modified":"2022-02-16T19:15:54","modified_gmt":"2022-02-16T19:15:54","slug":"canine-hyperadrenocorticism-challenges-establishing-the-diagnosis","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/endocrinology\/canine-hyperadrenocorticism-challenges-establishing-the-diagnosis\/","title":{"rendered":"Canine Hyperadrenocorticism: Challenges Establishing The Diagnosis"},"content":{"rendered":"<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/06\/T1401F02.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p class=\"p1\"><em><span class=\"s1\">Ann Della Maggiore, DVM, Diplomate ACVIM, &amp; Richard Nelson, DVM, Diplomate ACVIM<\/span><\/em><\/p>\n<p><em>University of California\u2013Davis<\/em><\/p>\n<p class=\"p1\"><span class=\"s1\">Canine Cushing&#8217;s disease, or hyperadrenocorticism, can be challenging to definitively diagnose. Given the complexity of hyperadrenocorticism, the authors provide an in-depth review of the diagnostic process, including an algorithm and case study, to aid the practitioner.<\/span><\/p>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\">Spontaneously occurring canine hyperadrenocorticism (HAC) is classified as:<\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\">Pituitary-dependent caused by excess adrenocorticotropic hormone (ACTH) secretion (PDH) <\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Pituitary-independent caused by a cortisol-secreting adrenocortical tumor (ATH).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">PDH is the most common form of HAC, accounting for 80% to 85% of cases.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>CLINICAL SIGNS<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Clinical signs for both forms of the disease primarily result from excessive circulating cortisol and include polyuria, polydipsia, polyphagia, and endocrine alopecia (<b>Table 1<\/b>).<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Some dogs with PDH develop a pituitary macrotumor that may cause anorexia, obtundation, pacing, and changes in behavior. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Occasionally dogs with ATH develop retroperitoneal hemorrhage causing anemia, weakness, and abdominal pain. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">A tumor thrombus can develop from tumor growth into the phrenicoabdominal vein and caudal vena cava, causing vascular obstruction and ascites or edema.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5\"><br \/>\n<a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-4.06.33-PM.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone wp-image-4045 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-4.06.33-PM-e1455916131509-300x250.png\" alt=\"Screen Shot 2015-05-14 at 4.06.33 PM\" width=\"300\" height=\"250\" \/><\/a><\/span><\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5\"><b>DIAGNOSIS<\/b><\/span><\/span><\/h2>\n<p class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5\">Diagnosis of HAC is preceded by initial clinical suspicion for the disease after reviewing history and physical examination findings. Abnormalities identified on a complete blood count, serum biochemistry panel, and urinalysis provide additional support for HAC (<\/span><b style=\"line-height: 1.5\">Table 2<\/b><span style=\"line-height: 1.5\">). To establish a diagnosis of HAC, excess circulating cortisol must be documented by a urine cortisol:creatinine ratio (UCCR) and lack of appropriate negative feedback after glucocorticoid administration (low-dose dexamethasone suppression [LDDS] test).<\/span><\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-table-2.png\"><img decoding=\"async\" class=\"alignnone wp-image-8912 size-large\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-table-2-e1455915793231-1024x236.png\" alt=\"canine hyperadren table 2\" width=\"650\" height=\"150\" \/><\/a><\/span><\/span><\/p>\n<h2><strong>DIFFERENTIATION OF PDH FROM ATH<\/strong><\/h2>\n<p class=\"p5\"><span class=\"s1\"><span style=\"line-height: 1.5\">Once the diagnosis of HAC has been established, the following tests can be used to differentiate PDH from ATH (<\/span><b style=\"line-height: 1.5\">Table 3<\/b><span style=\"line-height: 1.5\">); sometimes more than 1 test is necessary.<\/span><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">LDDS test<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">High-dose dexamethasone suppression (HDDS) test<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Measurement of endogenous ACTH concentration <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Imaging the adrenal glands with abdominal ultrasound.<\/span><\/li>\n<\/ul>\n<p class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5\">\u00a0<a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-4.08.35-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-4048 size-large\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-4.08.35-PM-e1455916208500-1024x337.png\" alt=\"Screen Shot 2015-05-14 at 4.08.35 PM\" width=\"650\" height=\"214\" \/><\/a><\/span><\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5\"><strong>DIAGNOSTIC DIFFICULTIES<\/strong><\/span><\/span><\/h2>\n<p class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5\">Suspicion for and diagnosis of HAC is relatively straightforward when all aspects of the evaluation are consistent with the disease. Unfortunately, discordant information is common and can create uncertainty about diagnosis (see <strong>HAC<\/strong> <\/span><b style=\"line-height: 1.5\">Diagnostic Algorithm<\/b><span style=\"line-height: 1.5\">).<\/span><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Problems with establishing a diagnosis of HAC usually result from one of several possibilities (<b>Table 4<\/b>). In our experience, the most common problems result from a combination of: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Testing for HAC in a dog with minimal to no clinical signs or <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Failure to recognize that false-positive and false-negative results occur with all tests used to assess the pituitary\u2013adrenocortical axis, even when the dog manifests physical findings consistent with disease.<\/span><\/li>\n<\/ul>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-4.09.13-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-4049 size-figure_img\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-4.09.13-PM-e1455916299469-472x300.png\" alt=\"Screen Shot 2015-05-14 at 4.09.13 PM\" width=\"472\" height=\"300\" \/><\/a><\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-large wp-image-8916\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm-485x1024.png\" alt=\"canine hyperadren-algorithm\" width=\"485\" height=\"1024\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm-485x1024.png 485w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm-142x300.png 142w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm-768x1621.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm-728x1536.png 728w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm-970x2048.png 970w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/canine-hyperadren-algorithm.png 1319w\" sizes=\"(max-width: 485px) 100vw, 485px\" \/><\/a><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>CONSIDER THIS CASE: CASE PRESENTATION<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">A 9-year-old, castrated male Shih Tzu was referred to the University of California\u2013Davis Veterinary Medical Teaching Hospital for further evaluation of cystic calculi.<\/span><\/p>\n<h3 class=\"p6\"><span class=\"s1\"><b>History<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The dog had a history of persistent increased serum alkaline phosphatase (ALP) activity during the past year (526\u20131530 IU\/L). The owner stated that, during the past 6 months, the dog seemed to have increased panting and appeared to be drinking &#8220;a lot of water.&#8221;<\/span><\/p>\n<h3 class=\"p6\"><span class=\"s1\"><b>Physical Examination<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Results of a physical examination were unremarkable; the hair coat and skin thickness were normal and hepatomegaly was not identified.<\/span><\/p>\n<h3 class=\"p6\"><span class=\"s1\"><b>Diagnostic Results<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Pertinent results from diagnostic tests are listed in <b>Table 5<\/b>.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The case was then transferred to the Internal Medicine Service for evaluation and treatment recommendations for HAC.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><span style=\"line-height: 1.5;font-family: inherit;font-size: inherit\"><strong>QUESTIONS<\/strong><\/span><\/span><\/h2>\n<ul>\n<li><span class=\"s1\"><span style=\"line-height: 1.5;font-family: inherit;font-size: inherit\">Does this patient have spontaneous canine HAC?<\/span><\/span><\/li>\n<li><span class=\"s1\">What supports the diagnosis of HAC? <\/span><\/li>\n<li><span class=\"s1\">What does not support the diagnosis of HAC?<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">\u00a0<\/span><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-4050 size-figure_img\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-4.10.33-PM-e1455916662562-331x300.png\" alt=\"Screen Shot 2015-05-14 at 4.10.33 PM\" width=\"331\" height=\"300\" \/><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>CASE DISCUSSION<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">This case demonstrates a dog with: <\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\">Debatable clinical signs of HAC<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Increase in serum ALP activity, which may or may not be caused by HAC<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Endocrine test results supportive of PDH in a dog with normal-sized adrenal glands and a &#8220;nodule&#8221; on the cranial pole of one gland.<\/span><\/li>\n<\/ul>\n<h2 class=\"p3\"><span class=\"s1\"><b>ANSWERS<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\"><em>Evidence against HAC<\/em> in this dog includes lack of supportive clinical signs and physical examination findings. <em>Evidence for HAC<\/em> includes endocrine test results used to establish the diagnosis of HAC. We are left with the questions:<\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\">Does this dog have HAC?<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Do you initiate treatment for HAC?<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">All information should be critically examined whenever conflict exists in the diagnostic evaluation for canine HAC. <\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">History and physical examination are the most important parameters when establishing the diagnosis of HAC. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Results of other diagnostic tests, including the UCCR and LDDS tests, become disputed if clinical signs and physical examination findings do not strongly support existence of HAC, as in this case. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Treatment for HAC is NOT indicated if the history and physical examination findings do not strongly support HAC.<\/span><\/li>\n<\/ol>\n<h3 class=\"p6\"><span class=\"s1\"><b>Serum Alkaline Phosphatase<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Increased serum ALP activity is not pathognomonic for HAC and, by itself, should NOT be used as an indicator to pursue diagnosis of HAC. Increased ALP activity can be seen with a variety of other conditions, most notably hepatobiliary disease.<\/span><\/p>\n<h3 class=\"p6\"><span class=\"s1\"><b>Urine Cortisol:Creatinine Ratio<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The UCCR was only slightly increased and measured using urine collected in the hospital. <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">The current recommendation for measuring UCCR is to have the owner collect a urine sample first thing in the morning for 2 consecutive days\u2014a protocol that maximizes the sensitivity and specificity of the test (99% and 77%, respectively).2,3 <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">A normal UCCR in 1 or both urine samples is strong evidence against HAC unless clinical signs and physical examination findings strongly support the disease. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Positive test results in both urine samples support performance of the LDDS test in a dog with appropriate clinical signs and physical examination findings. <\/span><\/li>\n<\/ul>\n<h3 class=\"p6\"><span class=\"s1\"><b>Low-Dose Dexamethasone Suppression Test<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The LDDS test is considered the best test for establishing a diagnosis of HAC, except in dogs with suspected iatrogenic HAC.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">The 8-hour post-dexamethasone cortisol concentration establishes the diagnosis:<\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\">A concentration less than 1 mcg\/dL (varies with laboratory) is strong evidence against HAC unless clinical signs and physical examination findings strongly support the disease. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Concentrations greater than 1 mcg\/dL (varies with laboratory) support a diagnosis of HAC assuming history and physical examination findings strongly support the diagnosis. <\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s1\">Sensitivity and specificity of the LDDS test have been reported to be 85% to 100% and 44% to 73%, respectively.<sup>2<\/sup> <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">False-negative and especially false-positive results occur with the LDDS test. A positive LDDS test does not, by itself, confirm a diagnosis of HAC, as illustrated by this case. LDDS may be falsely positive with stress, excitement, or nonadrenal illness, which should be considered when interpreting results.<\/span><\/li>\n<\/ul>\n<h3 class=\"p6\"><span class=\"s1\"><b>ACTH Stimulation Test <\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The ACTH stimulation test is the gold standard for diagnosis of hypoadrenocorticism and iatrogenic HAC, and for monitoring trilostane and mitotane treatment. In our experience, this test has not been reliable for establishing a diagnosis of spontaneous HAC. <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Reported sensitivity for PDH is 80% to 83% and, for ATH, 57% to 63%; specificity is 85% to 93%.<sup>2<\/sup> The decreased sensitivity of this test, especially with ATH, can lead to normal results in animals with HAC (being diagnosed as free of disease). <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Inconclusive test results are common and, clearly, abnormal test results with post-ACTH serum cortisol concentrations greater than 30 mcg\/dL occur in dogs that do not have HAC, as illustrated in this case. Similar to the LDDS test, false-positive results occur with stress, excitement, or nonadrenal illness, which should be considered when interpreting results. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">We do not use the ACTH stimulation test when evaluating dogs for spontaneous HAC due to the test&#8217;s decreased sensitivity.<\/span><\/li>\n<\/ul>\n<div id=\"attachment_4051\" style=\"width: 430px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Figure-2_adj.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4051\" class=\"wp-image-4051 size-figure_img\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Figure-2_adj-420x300.jpg\" alt=\"https:\/\/dl-web.dropbox.com\/static\/javascript\/external\/pdf-js\/vi\" width=\"420\" height=\"300\" \/><\/a><p id=\"caption-attachment-4051\" class=\"wp-caption-text\">Figure 1. Right Adrenal mass upon initial evaluation and repeat ultrasound evaluation 1 year later.<\/p><\/div>\n<h2><span class=\"s1\"><b>CASE OUTCOME<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">The decision was made not to initiate treatment for HAC for this patient due to the: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Lack of history and physical examination findings to support diagnosis of HAC<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Discrepancy between results of endocrine tests (marginally positive UCCR despite suggestive findings on LDDS and ACTH stimulation tests).<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Findings on abdominal ultrasound.<\/span><\/li>\n<\/ul>\n<h3 class=\"p6\"><span class=\"s1\"><b>Initial Follow-Up<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The dog was sent home, and recheck abdominal ultrasound was recommended in 1 to 2 months to assess if there were changes in the size of the adrenal &#8220;nodule.&#8221; In addition, the owner was instructed to determine 24-hour water intake beginning a week after discharge. Water consumption was calculated to be approximately 65 mL\/kg\/24 H (normal, &lt; 90 mL\/kg\/24 H<sup>4<\/sup>); this finding did not support a diagnosis of HAC.<\/span><\/p>\n<div id=\"attachment_4052\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Figure-3_adj.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4052\" class=\"wp-image-4052 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Figure-3_adj-300x222.jpg\" alt=\"Figure 3_adj\" width=\"300\" height=\"222\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Figure-3_adj-300x222.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Figure-3_adj.jpg 405w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-4052\" class=\"wp-caption-text\">Figure 2. Picture of Ben at his 1-year recheck; no clinical signs of HAC were evident at this time.<\/p><\/div>\n<h3 class=\"p1\"><span class=\"s1\"><b>Long-Term Follow-Up<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">At the 6-week recheck, the dog&#8217;s hair\u2014where shaved for the abdominal ultrasound\u2014had regrown, physical examination was unremarkable, and urine specific gravity on a free-catch urine sample was 1.034. The owner reported no clinical signs consistent with HAC.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The dog was followed for more than a year; adrenal measurement remained unchanged (<b>Figure 1<\/b>), and no clinical signs of HAC developed <\/span><span class=\"s1\">(<b>Figure 2<\/b>). Repeat hormonal testing was not done.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>IN SUMMARY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Many clients notice subtle changes in their dogs&#8217; health, and often seek veterinary care quickly. As a consequence, veterinarians often test for HAC early in the development of the disease, when, compared to testing performed in dogs with advanced disease:<\/span><span class=\"s2\"><sup>5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Clinical signs are minimal and mild<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Endocrine tests are less reliable in differentiating between normal and HAC<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">False-positive and, especially, false-negative test results are more common.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><strong>Diagnosis of HAC is appropriate<\/strong> when the following all support the diagnosis:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Clinical signs<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Findings on physical examination<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Results of routine blood, urine, and hormonal tests. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><strong>Diagnosis of HAC is NOT as evident<\/strong> when the information used to establish the diagnosis conflicts, most notably when clinical signs and physical examination findings are supportive of the diagnosis but endocrine test results are not, and vice versa.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Clinicians must be prepared to critically evaluate all diagnostic information gathered to determine if additional testing or re-evaluation is indicated, taking into consideration the common pitfalls that complicate the diagnosis of HAC. When endocrine tests do not support the suspected diagnosis of HAC based on clinical signs and physical examination findings, re-evaluation in 2 to 3 months is indicated.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">ACTH = adrenocorticotropic hormone; ALP = alkaline phosphatase; ATH = adrenocortical tumor hyperadrenocorticism; AUS = abdominal ultrasound; HAC = hyperadrenocorticism; HDDS = high-dose dexamethasone suppression; HPAA = hypothalamic-pituitary-adrenocorticol axis; LDDS = low-dose dexamethasone suppression; PDH = pituitary-dependent hyperadrenocorticism; UCCR = urine cortisol:creatinine ratio<\/span><\/p>\n<p class=\"p1\"><span class=\"s1 author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/06\/Ann-Della-Maggiore.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-7485\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/06\/Ann-Della-Maggiore.png\" alt=\"Ann Della Maggiore\" width=\"100\" height=\"119\" \/><\/a>Ann Della Maggiore<\/strong>, DVM, Diplomate ACVIM, is a staff internist at University of California\u2013Davis School of Veterinary Medicine. She received her DVM from UCD, where she also completed a residency in small animal internal medicine.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1 author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Richard-Nelson.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-8914\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Richard-Nelson.png\" alt=\"Richard Nelson\" width=\"100\" height=\"116\" \/><\/a>Richard Nelson<\/strong>, DVM, Diplomate ACVIM, is a professor at University of California\u2013Davis School of Veterinary Medicine. He received his DVM from University of Minnesota and completed a small animal internal medicine residency at UCD.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Ann Della Maggiore, DVM, Diplomate ACVIM, &amp; Richard Nelson, DVM, Diplomate ACVIM University of California\u2013Davis Canine Cushing&#8217;s disease, or hyperadrenocorticism, can be challenging to definitively diagnose.<\/p>\n","protected":false},"author":1,"featured_media":2826,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":3041,"footnotes":""},"categories":[364],"tags":[13],"class_list":["post-1126","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-january-february-2014","tag-peer-reviewed","column-features","clinical_topics-endocrinology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO 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