Endocrine Abstracts

A 46-year-old Asian male attended our endocrine unit in April 2013 following a referral from his GP for the investigation of a neck mass. Serum TSH level was normal and USS revealed a euthyroid multinodular goiter. He mainly complained of increasingly frequent and severe headaches, polydypsia, polyuria, perspiration, and night sweats.

On examination, the patient had prognathism, an enlarged and protruding tongue, thickened lips, prominent supraorbital ridges and a multi-nodular goiter. There was no hand tremor or sweating. He had spade-like hands preventing him from wearing his wedding ring. He was 6 feet 4 inches tall.

Random IGF1 was elevated (103 nm/l) and OGTT showed non-suppressible GH secretion (15.06 mIU/l at 120 min). MRI revealed a mildly enlarged pituitary gland. He has been referred for surgery. Having finally diagnosed him with Acromegaly, some of the preventable but now irreversible tissue changes and long-term complications nevertheless remain.

Medical diagnosis of Acromegaly, a classic endocrine condition with slow progression, is often done at first glance from clinical features. There is an estimated 7–12 years time-lag between first symptom and disease diagnosis. Despite our patient coming into contact with a whole host of medical and surgical specialities (since symptom onset over 18 years ago), he remained undiagnosed. Potential confounding factors in this delay could have been his ethnicity and gradual evolvement of clinical features over the years.

This case highlights that even with classical clinical features of acromegaly, there may be quite a wide ranging ‘Acromegalic Window’ between first presentation and clinical suspicion to eventual diagnosis and the potential for reduction in the length of this window. Furthermore, our patient’s extensive past medical history and numerous medical encounters highlights the importance of patient assessment from a holistic view-point taking into account previous medical history, including a keen eye for evolution of patterns in symptoms and signs.