Endocrine Abstracts

A 44-year-old gentleman presented to the Emergency Department with a 2-week history of fevers and rigors. Past medical history was unremarkable other than an earlier diagnosis of hypertension. He was noted to have new onset atrial fibrillation with rapid ventricular response, and a new diagnosis of hypertrophic obstructive cardiomyopathy (HOCM) was made on echocardiography. In addition, a vegetation was identified on the mitral valve. Treatment for infective endocarditis (Streptococcus oralis) was initiated and he was subsequently transferred to a specialist centre for mitral valve replacement surgery. During the admission, a history of chronic headaches was investigated. MRI pituitary revealed a 3.8 x1.9 cm pituitary macroadenoma with suprasellar extension. There was no cavernous sinus invasion. He was further evaluated in the outpatient endocrine clinic. On removal of his facemask, examination revealed typical acromegalic features with supraorbital ridge prominence, significant underbite and macroglossia. Visual fields were normal to confrontation testing and no organomegaly was present on bedside examination. Urgent endocrine investigations including baseline pituitary function testing were performed. IGF-1 was significantly elevated at 140.3 nmol/l (range 8.5-31.0), 9am cortisol was 352 nmol/l (range 200-750), prolactin 1119 mU/l (range 60-300), TSH 1.98 mU/l (range 0.34-5.60), FSH <0.U/l (range 1.7-8.0) and testosterone 8.7 (range 10.0-30.0). Acromegaly was confirmed with an oral glucose tolerance test showing a paradoxical rise in growth hormone. Glucose levels remained normal throughout the OGTT. The patient was commenced on monthly Lanreotide injections and referred to the specialist neuro-endocrine clinic to determine the best course of further management. Unfortunately, this gentleman’s endocrine management was further complicated by a second hospital admission with persistent bacteraemia. Further redo of his mitral valve replacement is being considered, and safety of pituitary surgery at this stage remains a concern. In this case, radiotherapy could be a more suitable treatment option for acromegaly. This case highlights the requirement for early diagnosis and treatment to prevent further complications, as well as the need for individualisation of complex treatment decisions within a multidisciplinary setting. Cardiovascular complications including HOCM, arrhythmias, arterial hypertension and valvulopathy, as well as colonic benign neoplasms such as polysis, are common complications of acromegaly. For people presenting with ‘idiopathic’ HOCM, a IGF-1 may be considered to screen for acromegaly. Finally, the requirements for facemasks and virtual telephone consultations during the Covid-19 pandemic have likely compounded potential delays in diagnosis.