Category: Pituitary Disorders/Neuroendocrinology
Acromegaly is an insidious disorder resulting from somatotropic pituitary adenomas, seen mainly in the 3rd-4th decade. Due to its indolent nature, diagnosis of acromegaly is delayed for several years. We report a case of an elderly gentleman with acromegaly, possibly our oldest patient with this new diagnosis.
Methods : N/A
Results : N/A
An 89 year old gentleman with history of HTN, arrhythmias, Ca prostate, OSA on biPAP, and right thyroid lobectomy, presented to the emergency room with left arm tingling and numbness for 4 hours. He endorsed prior similar 20 minute episodes. He had no prior history of cerebrovascular disease (CVA). A CVA was ruled out however MRI brain showed 1.1 cm pituitary adenoma. Pituitary hormones were evaluated and IGF-1 was significantly elevated (554 ng/ml), confirmed on repeat testing (617 ng/ml). On further questioning, the patient’s daughter reported a gradual increase in shoe and clothing size, thickening of hands and lips, and larger nose and ears. This had been attributed to aging. Patient endorsed a recent diagnosis of bilateral carpel tunnel syndrome (CTS). He also informed us that surgical pathology of excised thyroid lobe had shown few cancerous cells.
The patient was diagnosed with acromegaly. Due to his co-morbidities, surgical resection of the adenoma was deemed unsuitable. Lanreotide 60 mg i.m., a somatostatin analogue, was started. Within a few days of receiving it, he developed diarrhea, hypotension, weakness and bradycardia, which continued for several days after the injection. He was switched to cabergoline, hoping for better tolerance. After 3 months of cabergoline treatment, patient endorsed relief from his previous side- effects. His IGF -1 had dropped to 322 ng/ml. He remains on cabergoline with follow-up biochemical and radiology testing in 1 year.
Somatotropic adenomas of the elderly are rare with an atypical clinical presentation. Physiological endocrine changes due to age and frequent co-morbidities, can confuse or delay the diagnosis. Indeed, our patient has HTN, biventricular enlargement, OSA, h/o thyroid nodule and recent worsening arthropathies and CTS, all of which are systemic manifestations of acromegaly.
Surgical resection of the adenoma is the first line treatment in the elderly. However, surgical risk due to co-morbidities may limit use of this modality. Medical management is a suitable alternative. Medication related adverse events may be more severe in the geriatric population. Hence, a smaller dose of somatostatin analogues or second-line medications like cabergoline should be considered. Clarification of expected goals of therapy is vital in older patients with shorter life expectancy.
Pranjali Sharma– Fellow - Endocrinology Diabetes and Metabolism, Scripps Clinic/Scripps Green Hospital, San Diego, California
Aakif Ahmad– Endocrinologist, Attending Scripps Clinic- Division of Diabetes and Endocrinology, California
PRANJALI SHARMA– Endocrinologist, Attending Scripps Clinic- Division of Diabetes and Endocrinology, California
Fellow - Endocrinology Diabetes and Metabolism
Scripps Clinic/Scripps Green Hospital
San Diego, California
MEDICAL SCHOOL - B.J. MEDICAL COLLEGE, PUNE, INDIA (2008-2014) INTERNAL MEDICINE RESIDENCY - UNITY HOSPITAL, ROCHESTER, NEW YORK (2015-2018) FELLOWSHIP IN ENDOCRINOLOGY, DIABETES AND METABOLISM - SCRIPPS CLINIC/SCRIPPS GREEN HOSPITAL (2018- PRESENT)
Attending Scripps Clinic- Division of Diabetes and Endocrinology, California
Aakif Ahmad, DO, is a graduate of University of Florida. He earned his Doctor of Osteopathic Medicine from LECOM. Prior to joining the Endocrinology Division at Scripps Health, he completed his residency in Internal Medicine at Lehigh Valley Health Network followed by a fellowship in Endocrinology at Scripps Clinic – La Jolla, California.
Dr. Ahmad practices general Endocrinology with a clinical interest in thyroid disorders and diabetes mellitus. He believes in educating patients to assist in allowing patients to make informed decisions. His goal is to provide patient centered care in the rapidly changing field of medication and technology by treating his patients as partners in health care.
When away from work, he enjoys traveling, eating, movies, photography with his wife and son.