The Biggest Man in the Room

A 42 year old gentleman who had been healthy all his life, began to develop new clinical symptoms including acid reflux. He was tested for H. Pylori by his PCP, and treatment was initiated. During this visit he was also noted to have elevated BP and was ultimately diagnosed with HTN, and started on anti-hypertensives. During these revelations he brought up the fact that he has also developed excessive joint pains over the years, and his shoe size has increased from the age of 30 to now by 3 sizes. When asked, he admitted to noticing an increase in his hands size, and also noted that his rings do not fit anymore. His fiancée works in medicine and requested he be screened for acromegaly, thus PCP checked IGF-1 and GH levels, which were noted to be significantly elevated at 887 and 20.9, respectively, leading to a referral to Endocrinology. Under Endocrinology care he underwent a GH suppression test resulting in a non-suppressed GH at 17.8. This was followed by a Pituitary MRI revealing an 18 x 19 x 18 mm solid/partially cystic hypoenhancing lesion consistent with a pituitary macroadenoma, with leftward deviations of the infundibulum, without involvement of the optic chiasm. He was treated with transsphenoidal resection of the pituitary tumor. On post-op day 4, the IGF level had fallen to 456. His thyroid and gonadal axes were assessed and did not show any evidence of deficiency post-operatively. He was however started on Prednisone post-operatively, and was switched to Hydrocortisone in the outpatient setting with plans to taper and re-assess his HPA axis. Overall he is doing well, and there are plans for repeat labs and imaging about 6 weeks post-operatively. When evaluating patients with a variety of newly developing symptoms, remember to consider a unified diagnosis that could explain the cluster of symptoms that they are experiencing. Although rare, pituitary disorders such as Acromegaly should be explored in patients with clinical features of growth hormone excess, such as macrognathia, enlargement of the hands and feet, and in addition development of other clinical symptoms such OSA, CVD, Type 2 DM, and arthropathies.