ECE2016 Eposter Presentations Clinical case reports - Pituitary/Adrenal (81 abstracts)
Managing a complex case of acromegaly – lessons to learn
Hsiu Lye Yap 1, , Emma Hatfield 3 , Niamh Martin 3 , Ravi Assomull 2 , Stewart Berry 3 , Amrish Mehta 3 , Alison Falconer 3 , Nigel Mendoza 3 , Karim Meeran 3 & Sanjeev Mehta 2
1St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK; 2Ealing Hospital, London North West Healthcare NHS Trust, London, UK; 3Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.
Our 42-year-old patient presented with breathlessness and signs of congestive cardiac failure. Her ‘spade-like hands and acromegalic appearance’ were noted on the post-take round. She had headaches, orthopnoea and secondary amenorrhoea. She was a poorly controlled diabetic (so OGTT was not performed), anaemic, and previously had a thyroidectomy.
Pituitary profile showed secondary hypogonadism, normoprolactinaemia and normal free T4 indicating adequate Thyroxine replacement. A growth hormone day curve established levels consistently above 70 μg/l with elevated IGF-1 level of 65.4 nmol/l. Pituitary MRI confirmed a large 2.5 cm pituitary macroadenoma with carotid sinus invasion and compression of the right optic nerve and chiasm. Visual fields revealed primary inferior right hemifield and left nasal field loss. There was significant non-ischaemic dilated cardiomyopathy, with global left ventricular hypokinesis and ejection fraction of 15% on echocardiogram and cardiac MRI. Monthly injections of 120 mg Lanreotide were started, then uptitrated to once weekly with addition of 250 mcg Cabergoline weekly. There was minimal biochemical and radiological response after 5 months, with growth hormone levels staying above 30 μg/l and IGF-1 persistently raised at 51.3 nmol/l.
At the pituitary MDT, a 6-month-prognosis was quoted on lone medical therapy. However, surgical debulking under general anaesthetic was high risk with estimated mortality of >50% in patients with ejection fraction of <30%, and unlikely to be curative. Cardiologists felt there was no role for cardiac resynchronisation therapy pre-operatively, as this would not improve her ejection fraction. Cardiac failure optimisation and rapid uptitration of Lanreotide improved symptoms and allowed her to tolerate radiotherapy, which was the safest definitive treatment option. If her cardiomyopathy improves, fitness for surgery will be re-evaluated. Our case highlights challenges in diagnosing and managing acromegaly in a patient with pre-existing Type 2 diabetes, and cardiomyopathy induced by a large growth hormone secreting pituitary adenoma.
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Endocrine Abstracts
ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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