Endocrine Abstracts

A 44-year-old gentleman presented to the Emergency Department with a 2-week history of fever 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; a 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 mechanical mitral valve replacement surgery. Warfarin was commenced post operatively with target INR of 3.5–4.5. During the admission, a history of chronic headaches was investigated. MRI pituitary revealed a 3.8×1.9 cm macroadenoma with suprasellar extension and invasion of the right cavernous sinus. 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. Pituitary function showed: IGF-1 140.3 nmol/l (range 8.5–31.0), 0900 h cortisol 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), testosterone 8.7 (range 10.0–30.0). Acromegaly was confirmed with an oral glucose tolerance test. The patient was subsequently discussed in Pituitary MDT and commenced on monthly Lanreotide injections to induce tumor size reduction while awaiting pituitary surgery. His IGF-1 remained high despite monthly Lanreotide and therefore Cabergoline was added for further medical management whilst planning his surgery, since this required close collaboration with his cardiothoracic team regarding his cardiac function and prosthetic valve in addition to extensive discussions with Haematology regarding plans for safe peri-operative anticogulation. He underwent successful transphenoidal pituitary surgery; subsequent MRI imaging revealed a good surgical resection with histology confirming a sparsely granulated somatotroph pituitary adenoma (Ki67 1%). Despite a good surgical outcome, his post-operative course was complicated by repeated episodes of epistaxis requiring regular input from Haematology and ENT teams. Anticogulation was cautiously continued due to the high risk of mechanical valve related thrombosis. Control of epistaxis was eventually achieved following a return to theatre for ligation of the sphenopalatine artery. He was discharged once INR was within the therapeutic target range. 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 through the involvement of multiple specialties within multidisciplinary team working patterns.