Chronic lymphoedema improved by the diagnosis and treatment of underlying acromegaly
L Sibal1, M Harris1 & RA James1,2
The insidious onset of symptoms and slow progression of acromegaly often results in a delay in diagnosis for several years. We report an unusual case who presented with progressive lymphoedema of the lower limbs 25 years before the diagnosis of acromegaly became apparent.
A 51 year old lady presented to the surgical outpatient clinic with a twenty four year history of bilateral leg swelling and hypertension of 21 years duration. There was no antecedent history of injury to the legs or deep venous thrombosis. Technetium lymphoscintigram confirmed bilateral lymphoedema, more severe in the left leg. An astute general practitioner suspected her to have acromegaly, and measured random growth hormone of 55 nanomol/litre and referred her for endocrine evaluation. Her history revealed the classic symptoms of acromegaly with sweating, ring and shoe enlargement. Examination showed the facial features of acromegaly along with a goitre and marked lymphoedema of both lower limbs. Investigations revealed impaired glucose tolerance (120 minute glucose 8.7 millimol/litre) with a HbA1c of 6.6, a growth hormone ranging form 37 to 73 milliunit/litre and an IGF-1 of 81 nanomolmol/litre. The pituitary-thyroid axis was intact and LH/FSH (15.1/45.5 units/litre) were consistent with her post-menopausal status. Visual fields were full. An MRI scan showed marked enlargement of the pituitary gland by an adenoma. She was treated with Lanreotide 60 milligrams once a month, for 8 months which resulted in tumour shrinkage and then underwent trans-sphenoidal pituitary surgery in 1999. Post-operative testing revealed a normal pituitary reserve and GH levels ranging from 0.2 to 1.6 milliunits/litre. The lymphoedema markedly improved with the initial somatostatin analogue treatment and further improved following surgery. Whilst her underlying tendency to lympoedema may well be genetic its improvement with treatments that lowered her GH and IGF1 suggests a further clinical manifestation of the diagnosis of acromegaly.