Endocrine Abstracts

Section 1: Case history: We present the case of a 35-year-old gentleman referred by his GP to Endocrinology clinic for loss of libido and testosterone deficiency. His co-morbidities included obesity (BMI 59 kg/m²), hypertension and obstructive sleep apnoea (OSA) requiring overnight continuous positive airways pressure (CPAP) therapy. Routine pituitary profile showed luteinising hormone 4.8 IU/l (1–8), testosterone 7.1 nmol/l (8–25), prolactin 232 mU/l (86–324) and, unexpectedly, insulin-like growth factor 1 (IGF-1) 123 nmol/l (13–50 age-adjusted). Subsequently, growth hormone secretion failed to suppress on 75 g oral glucose tolerance test, confirming acromegaly. Further focussed history revealed the patient had suffered headaches, palmar sweats, joint pains and increasing shoe size for about 2 years.

Section 2: Investigations: CT and MRI pituitary were inconclusive. Owing to anticipated anaesthetic risk, a long-acting somatostatin analogue (Lanreotide) was started. His symptoms improved but he continued to gain weight (BMI 62 kg/m²) and to suffer severe headaches. Serum IGF-1 had only reduced to 75 nmol/l, so further treatment was felt to be necessary.

Section 3: Results and treatment: The pituitary multidisciplinary team identified a possible neurosurgical target on the left of the pituitary but the patient’s BMI was felt to be a serious contraindication. Furthermore, his CPAP requirement with full face mask presented a challenge for nasal packing after transsphenoidal surgery, with risks including pneumocephalus. The patient was referred instead for bariatric surgery to improve risk factors prior to neurosurgery. Sleeve gastrectomy led to 30 kg weight loss and he no longer required CPAP. 9 months later, at BMI 46 kg/m², he underwent transsphenoidal resection of an 8×10×3 mm pituitary somatotroph adenoma and made an excellent post-operative recovery.

Section 4: Conclusions and points for discussion: This is a unique case of acromegaly complicated by OSA requiring MDT input and staged interventions i.e. medical therapy and bariatric surgery prior to neurosurgery. In the future, there is scope for further bariatric surgery.