Endocrine Abstracts

Case history: A 44-year-old gentleman presented to A&E with a 2-week history of fevers and rigors. He gave a background history 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. A vegetation identified on the mitral valve led to an unexpected diagnosis of infective endocarditis. Antibiotic treatment for infective endocarditis (Streptococcus oralis) was unsuccessful 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 and right cavernous sinus invasion. He was further evaluated in an endocrine clinic setting. On removing his facemask, typical acromegalic features with supraorbital ridge prominence, significant underbite and macroglossia were noted. Visual fields were normal to confrontation testing; no organomegaly was present on bedside examination.

Investigations: 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 352 nmol/l (range 200-750), prolactin 1119mU/l (range 60-300), TSH 1.98mU/l (range 0.34-5.60), FSH <0.1 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.

Treatment: The patient was commenced on monthly Lanreotide injections and referred onto a specialist neuro-endocrine clinic. Unfortunately, this gentleman”s endocrine and medical management was further complicated by a second episode of infective endocarditis on his mechanical mitral valve. This has responded to antibiotic therapy. Although the size of the suprasellar mass has reduced, there was continued invasion of the right cavernous sinus whilst IGF-1 levels remained elevated; Cabergoline has been added. The safety of pituitary surgery, which is now planned, remains a concern due to his ongoing requirement for anti-coagulation.

Conclusions and points for discussion: This case highlights the requirement for early diagnosis and treatment to prevent further complications and 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 polyposis, are common complications of acromegaly. For patients presenting with “idiopathic” HOCM, IGF-1 assay 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.