questions 4

Growth Hormone Adenoma / Acromegaly

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Topic updated on 05/20/17 9:55pm

Snapshot
  • A 52 year-old man complains of increased hat size and headaches when he wakes up in the morning. Physical exam reveals mild diastolic hypertension, prominant jaw with spaces between the teeth, large hands and feet, and generalized muscle weakness.
Introduction
  • Benign pituitary adenoma that releases excess growth hormone
    • GH stimulates release of insulin growth-like factor 1 
  • Gigantism if the condition occurs before the fusion of the epiphysis
  • Acromegaly if it occurs after skeletal epiphyseal closure
Presentation
  • Symptoms
    • generalized enlargement of bone and soft tissue
      • large hands and feet
      • frontal bossing
        • leads to increased hat size
      • space between teeth
        • jaw grows but teeth remain the same size
      • macroglossia
      • carpal tunnel syndrome 
        • size of median nerve increases due to edema
  • Physical exam
    • HTN
      • due to the anti-naturiuretic action of GH
Evaluation
  • Photographic changes
    • for acromegalic features examine an old photograph to reveal changes in facial bones
  • Serology
    • ↑ IGF-1 
      • more sensitive test because the level is more constant than the pulsatile release of GH
    • hyperglycemia
      • due to gluconeogenic action of GH
  • Suppression tests
    • GH release not suppressed by glucose challenge
  • MRI/CT
    • shows enlargement of sella turcica on imaging
  • Cardiomegaly on CXR
    • hypertrophy of left ventricle
Treatment
  • Surgical
    • transphenoidal surgery
  • Medical
    • octreotide (somatostatin analogue)
      • supresses GH release
    • dopamine analog
      • second line for refractory tumors
    • GH receptor antagonists
      • pegvisomant
Prognosis, Prevention, and Complications
  • Cardiomegaly progressing to CHF is the most common cause of death


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Qbank (1 Questions)

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(M1.EC.75) A 38-year-old man presents to the endocrinologist with complaints of increased shoe size and headaches in the morning. These symptoms have developed gradually over the past year but have become especially concerning because he can no longer wear his normal-sized boots. He denies any other symptoms, including visual changes. He was recently started on lisinopril by his primary care physician for high blood pressure. His vital signs are within normal limits and stable. On exam, the endocrinologist notes the findings shown in Figures A and B. These facial features are especially striking when contrasted with his drivers license from 10 years prior, when his jaw was much less prominent. The endocrinologist sends a screening blood test to work-up the likely diagnosis. Which of the following organs or glands produces the molecule being tested in this screening? Topic Review Topic
FIGURES: A   B        

1. Anterior pituitary gland
2. Liver
3. Posterior pituitary gland
4. Pancreas
5. Kidney

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