Endocrine Abstracts

Summary: Due to the insidious nature of the condition, acromegaly is often diagnosed years after onset of symptoms. By this time, patients will often have developed metabolic and cardiovascular complications. But for this patient, he was most distressed by his changing physical appearance. The delay in diagnosis and subsequent wait for outpatient investigations and management progression caused him severe psychological distress.

Clinical Case: A 39 year old man was referred to an endocrinology outpatient clinic in a district general hospital during August 2022. He presented with an 8-year history of increasing acral overgrowth (shoe size change 6 to 9), prominence of the brow, prognathism, teeth separation, macroglossia with new lisp, enlargement of his nose, hyperhidrosis, severe weight gain, and perceived thorax distortion. His wife described new heavy snoring. Photographs from ten years ago showed a demonstrable difference in his physical appearance. He was otherwise a healthy man with no other PMH. Despite years of symptoms and frequent visits to his GP, he had ultimately diagnosed himself through research on the internet. He was extremely self-conscious and distressed about the physical changes and wanted immediate treatment to prevent them becoming permanent. He was very anxious whilst waiting for his outpatient investigations. He pursued frequent clinical communication requesting confirmation of appointments and immediate results. His baseline IGF-1 level was 1021 mg/l. Acromegaly was confirmed via Oral Glucose Tolerance Test (September 2022) with Growth Hormone level >100 mg/l at baseline, and 88.3 mg/l at 2 hours. Otherwise normal pituitary hormone profile. Pituitary MRI (November 2022) showed a 23 mm pituitary macroadenoma. He had appropriate visual, cardiac and colonic screening; there was only slight enlargement of the left atrium found. After discussion at the endocrinology pituitary MDT in December 2022, he was referred for surgical resection. In April 2023, after an agonising 8 months since diagnosis, he had a successful endoscopic transsphenoidal resection of the pituitary macroadenoma at a tertiary hospital (the author had coincidentally moved to this hospital’s endocrinology department at that time!). He did suffer symptomatic severe hyponatraemia (Na 124 mmol/l) 1 week after surgery requiring re-admission, but this quickly resolved with fluid restriction and slow sodium tablets. At his 6-week post-surgery endocrinology outpatient appointment, he was delighted with his results and reported resolution of his anxiety. He could already see improvements in his acromegalic features – he had lost weight, his shoe size had reduced, and his snoring had stopped (much to his wife’s delight!).