Category: Pituitary Disorders/Neuroendocrinology
Acromegaly is a chronic and debilitating condition in which diagnosis is often delayed due to the indolent nature of symptoms. It induces regurgitant valve disease via myxematous degeneration, and the trophic effects of excess growth hormone lead to epithelial cell proliferation of the intestines. The association between Streptococcus bovis endocarditis and colonic lesions is well-documented in the general population, but not among patients with acromegaly, who are at especially high risk due to the underlying cardiac and intestinal pathology.
Results : n/a
The patient is a 50 year-old male with history of morbid obesity s/p gastric bypass, sleep apnea, benign prostatic hyperplasia, and diabetes diagnosed over 10 years ago. He initially was hospitalized with fever, and blood cultures grew Streptococcus bovis and Escherichia coli. Transthoracic echo revealed a 9 mm vegetation on the aortic valve, severe aortic regurgitation, and 6 cm dilation of the ascending aorta. Colonoscopy showed one 2 mm hyperplastic polyp in the rectum, and CT abdomen showed diffuse distention of the large bowel. He underwent mechanical aortic valve and hemiarch replacements.
Following antibiotics, he was hospitalized twice with recurrent fever. The first time, blood cultures grew vancomycin-resistant Enterococcus faecium, and TTE/TEE showed no vegetation. The second time, blood cultures grew VRE and Klebsiella species. TEE demonstrated 8 mm vegetation of the mitral valve with moderate mitral regurgitation. Colonscopy showed four 8-10 mm adenomatous polyps. PET/CT showed an incidental finding of an FDG-avid sellar mass, and subsequent MRI confirming a 2.6 cm pituitary mass.
His exam was notable for spaced dentition, frontal bossing, macroglossia, large hand joints, deep voice, and thick heel pads. When prompted, he endorsed coarsening of his facial features and increased size of hands and feet, but had attributed this to fluctuations in his weight following his gastric bypass surgery.
IGF-1 was 266 ng/ml and GH did not suppress with 75-g oral glucose tolerance test (nadir of 45 ng/ml). He also had a total testosterone of 58 ng/dl. Resection of the pituitary mass was deferred until patient underwent mitral valve replacement.
This case demonstrates the propensity for endocarditis by gastrointestinal pathogens among patients with acromegaly. Presumably, in this case, colon wall thickening led to increased gut translocation of bacteria, and the colon polyps resulted in proliferation of S. Bovis. These microbes consequently seeded the deformed aortic and mitral valves. It is important to consider acromegaly on the differential when these conditions occur concurrently.
Meghana Bhatta– Fellow, UNC Chapel Hill, North Carolina
Elizabeth Harris– Assistant Professor of Medicine, University of North Carolina, CHAPEL HILL, North Carolina
Meghana Bhatta– Assistant Professor of Medicine, University of North Carolina, CHAPEL HILL, North Carolina
UNC Chapel Hill, North Carolina
I grew up in Atlanta, GA, and went completed by undergraduate degree at Vanderbilt University where I majored in Spanish and neuroscience. I completed a Fulbright teaching scholarship in Malaysia. I did medical school at Medical College of Georgia, internal medicine residency at George Washington University, and am currently doing endocrinology fellowship at UNC Chapel Hill. My clinical interests are in diabetes and obesity.
Assistant Professor of Medicine
University of North Carolina
CHAPEL HILL, North Carolina