This 26 year woman presented with a pituitary macroadenoma because of headaches, visual field loss and secondary amenorrhoea. Features of acromegaly and galactorrhoea were absent, serum prolactin and basal investigation were normal. Post operative testing revealed normal ACTH reserve but basal growth hormone was 4.2 mu/l rising to 67.6 mu/l in an ITT. Pituitary histology revealed positive immunostaining for growth hormone and prolactin. IGF-1 was normal. Over the next three years her growth hormone and IGF levels gradually increased to above the reference range and oral GTT failed to suppress growth hormone below 7.8 mu/l. She continued not to look acromegalic, skin 1.6 mm over right 4th metacarpal (normal 1.5 to 2.2 mm), Left ring: L on jeweller's scale i.e. slender.
This 21 year old woman developed oligomenorrhoea and prolactin was modestly elevated. She moved to work in a University teaching hospital distant from her home and was re-referred there. Her periods were more regular and prolactin was normal. She complained her hands were swollen but these were not remarked upon during examination. She had photographs of herself taken including her hands. These were normal in appearance, though subsequently she realised her previously small fingers had swollen. After travelling abroad, developed joint pains. By the time she sought medical advice again in the UK she was clearly acromegalic. She took successful legal action against the hospital for missing the diagnosis at a time when the clinical features were inapparent.
Unless obviously acromegalic, growth hormone status in patients presenting with pituitary tumours is not routinely checked. Since the development of acromegaly is usually insidious, may be associated with reversible morbidity and excess mortality, it is suggested that pre and post operative testing of hormonal function should include assessment of growth hormone and IGF- 1 secretion.
03 - 05 Nov 2003
Society for Endocrinology