74

74 CASE 74


A 33-year-old woman comes to her primary care physician complaining of amenorrhea, headaches, profuse sweating, and joint pains associated with changes in the sizes of her hands and feet.


The patient reports massive growth of her hands and feet as well as protrusion of her lower jaw. She believes the shape of her face has changed, becoming sharper. She also complains of sudden weakness, even when just “carrying the clothes hamper upstairs.” She first noticed these changes about 6 months ago when she was home for the holidays and saw some high school and early college pictures of herself. Her mother brought to her attention how her features seemed much larger. After that she says she became more aware of her bodily changes. She came in because she says she knows something is wrong and that there is a definite distinction from how she looks now from how she used to look. Her husband and she are also trying to conceive and have been unsuccessful due to amenorrhea for the past 8 months.



PHYSICAL EXAMINATION



VS: T 99.1°F, P 65/min, R 14/min, BP 130/80 mm Hg, weight 132 lb, BMI 24

PE: Marked enlargement of facial features, as well as tongue, feet, and hands; soft doughy handshake; thyroid gland enlargement, and possible visceral enlargement; loss of visual field (typically associated with disease)


LABORATORY STUDIES



Pregnancy test (hCG): Negative

Growth Hormone: 40 ng/mL (normal: 0-5 ng/mL)

Fasting IGF-I: 31 ng/mL (normal: < 20 ng/mL)

Prolactin: 100 ng/mL (normal: < 20 ng/mL)

Glucose: 1.5 ng/mL

Glucose suppression test: after 75-g glucose, GH was 8 μg/L (normal: < 1 μg/L)

BUN and liver enzymes: Normal

MRI: Pituitary tumor


DIAGNOSIS


Acromegaly



PATHOPHYSIOLOGY OF KEY SYMPTOMS


The patient’s initial complaint centers around growth of the cartilage and soft tissue of the body. Growth is a complex process requiring many hormones in a permissive role, but growth hormone (GH) and the insulin-like growth factors (IGFs) are the dominant controllers of growth.


GH is a peptide released from the anterior pituitary (Fig. 74-1). The hypothalamus secretes two peptides that control GH release: growth hormone–releasing hormone (GHRH) and somatostatin, which is also called growth hormone–inhibiting hormone (GHIH). GH acts directly on multiple tissues to increase blood glucose and also stimulates the hepatic release of IGFs, which mediate growth in numerous tissues.


image

FIGURE 74–1 Pituitary growth hormone (GH) release is under dual control, stimulated by growth hormone–releasing hormone (GHRH) and inhibited by somatostatin. The hypothalamus regulates GH release. Once released, GH acts directly on tissues to increase blood glucose levels. GH also causes the release of insulin-like growth factors (IGFs) from the liver, and IGFs stimulate growth in numerous tissues.

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Jul 4, 2016 | Posted by in PHYSIOLOGY | Comments Off on 74

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