Endocrine Abstracts

Introduction: Acromegaly can be asymptomatic for a long time and morbid obesity can mask typical clinical signs (facial disfigurement, large hands and feet) and even severe disorders, such as hypopituitarism, cardiomyopathy, respiratory dysfunction, sleep apnea, atherosclerosis, endothelial dysfunction, arthropathy, prediabetes/diabetes, dyslipidemia and mineral dysmetabolism. Menstrual irregularity and infertility combined with headaches are among the earliest issues a patient both with acromegaly and obesity might experience. This trio could be a clue for a diagnostic search for acromegaly long before obvious clinical manifestation.

Case Report : 36 years old women was referred to endocrinologist, specialised in Obesity and Metabolism, by gynecologist due to infertility, stagnation of body weight at 120 kg (BMI 43 kg/m², max body weight was 160 kg at the age of 23), fatigue, headaches, episodes of high blood pressure up to 140/100 mm Hg and striae on the body. There were no changes in apperence typical for acromegaly. 2 years ago, an MRI scan was performed for headaches and delayed menstrual cycle investigation and a pituitary microadenoma was suspected. Hyperprolactinemia 628 mU/l (94-557) was detected, but after a single dose of cabergoline (0.125 mg) the cycle was restored and remained regular, patient discontinued the therapy. IGF-1 level was high = 364-428 ng/ml (78-311) and suppression of GH during the OGTT was inadequate (0-30-60-90-120 min – 2.2-1.1-2.0-2.3-3.1 ng/ml). Endogenous hypercortisolism was excluded (cortisol after the 1 mg overnight dexamethasone suppression test was 19 nmol/l). Prolactin was within a normal range (470 mU/l). Neither hypopituitarism nor glucose or mineral metabolism disorders (including hyperparathyroidism) were found. A patient underwent a transsphenoidal surgery for an endo-infrasellar pituitary microadenoma (7.5× 6×8.8 mm). Histology showed a neoplasm of a solid structure from cells with basophilic cytoplasm; the immunohistochemical study revealed cytoplasmic expression of CAM5.2, pronounced expression of somatotropic hormone and focal weak expression of prolactin. Patient was biochemically in remission 6 month after surgery with no signs of hypopituitarism. Restoration of ovulatory ovarian cycles and regression of adipose mass resulted in clinical improvement and the occurrence of pregnancy.

Conclusion : This case report highlights a necessity to evaluate pituitary function in patients with morbid obesity and reproductive dysfunction, especially in presence of regular headaches. The application of a described multidisciplinary approach led to the timely verification of the underlying «asymptomatic» acromegaly and enabled us to prevent the development of complications and improve patient’s quality of life.