A middle-aged woman presented with bifrontal headache. On examination, she was noted to have acromegalic features:
- Prominent supraorbital ridges
- Large nose
- Prognathism with protrusion of the lower jaw
- Thick lips
- Malocclusion and increased interdental separation
- Large hands with broad palms, spatulate fingers and sweaty palms
- Large feet, thick heel pads
Other classical signs of acromegaly
- Macroglossia
- Goitre
- Bitemporal hemianopia, optic atrophy and papilloedema
- Increased blood pressure
- Glycosuria
- Osteoarthritis
Diagnosis
- Oral glucose tolerance test, with measurements of both plasma glucose and growth hormone levels. In normal subjects, growth hormone level falls to <1ug/L, but is not suppressed in acromegaly
- Elevated basal insulin-like growth factor (IGF1) level
- Magnetic resonance imaging of the pituitary gland to look for pituitary adenoma
Other important investigations
- Perimetry to look for visual field defect due to optic chiasmal compression
- Measurement of prolactin for any concomitant secretion by adenoma or due to stalk effect by macroadenoma
- Measurement of other anterior pituitary hormones to look for evidence of hypopituitarism: fT4, TSH, morning cortisol, estradiol (women), testosterone (men), LH, FSH, alpha-subunit
- Actively look for other possible complications of acromegaly:
- Nerve entrapment including carpal tunnel syndrome
- Obstructive sleep apnoea
- Colonic polyps and cancer
Management
- Trans-sphenoidal surgery
- Medical therapy including dopamine agonists, somatostatin receptor agonists and growth hormone receptor antagonist
- Primary or adjuvant radiotherapy