Endocrine Abstracts

A 34-year-old obese gentleman was referred in 2017 in view of larger coarsening hands (noted when wearing his wedding ring), bilateral palm paraesthesia, increased sweat production in his palms, and weight-gain despite not having changed his lifestyle. His past medical history included Grave’s disease treated with Carbimazole. On examination, the patient was noted to have a cavernous voice and prominent supraorbital ridges along with generalised facial coarseness. Initial investigations showed an elevated insulin-like growth factor 1 (IGF-1) level of 931 ng/ml and increased fasting Growth Hormone (GH) levels. MR Pituitary reported a 10 mm hypo-enhancing nodule in the right pituitary, bulging the superior margin and resulting in displacement of the pituitary stalk to the left. A prolonged Oral Glucose Tolerance Test (OGTT) in February 2018 resulted in a trough level of GH at 9.96 mg/l; consistent with a diagnosis of acromegaly. A trial of Octreotide LAR 20 mg SC at 4-week intervals was commenced while monitoring IGF-1 levels. The dose of Octreotide was up-titrated according to IGF-1 levels, resulting in dosage increase to 40 mg at 4-week intervals due to insuppressable IGF-1 levels. A Glucagon Stimulation Test in July 2018 revealed an inadequate cortisol response with a baseline cortisol of 81 nmol/l and a peak cortisol of 142 nmol/l. Therefore, Hydrocortisone 10 mg-5 mg-5 mg was started. Repeat MR Pituitary December 2018 reported an increased size of the pituitary macroadenoma (13 × 12 × 10 mm) with no cavernous sinus invasion or optic chiasm compression. Complications pertaining to the underlying condition included hyperplastic polyps noted on colonoscopy. He eventually developed severe obstructive sleep apnoea in 2018 (AHI 52, OHI 47.6, Snore Index 26.6) requiring continuous positive airway pressure at night. Osteopenia was also diagnosed in 2018 via DEXA scanning progressing to osteoporosis in 2020. Hypertension was diagnosed in 2019, treated with perindopril, as well as right-sided carpal tunnel syndrome in 2019. The patient underwent Trans-Sphenoidal Surgery in September 2019 with follow-up MR Pituitary in 2020 reporting no evidence of residual/recurrent adenoma. Repeated post-operative OGTT resulted in suppressible GH levels. Lowest IGF-1 level attained was 274 ng/ml, despite suppressed prolonged OGTT. Nonetheless, IGF-1 levels were noted to keep progressively rising such that a decision was made to recommence the patient on octreotide LAR.