A 35year old man presented to the cardiology clinic with effort dyspnoea, palpitations and light-headedness. He had just returned from a 6 month round the world trip during which he had suffered a diarrhoeal illness. An echocardiogram performed in Bangkok revealed left ventricular dilatation but no other significant changes. A diagnosis of possible myocarditis was entertained and he was treated with 2.5 mg of Ramipril and 75 mg of Aspirin. When seen in the cardiology clinic here, clinical examination and initial blood tests were reported as unremarkable. An ECG showed only left ventricular hypertrophy, a chest X-ray revealed gross cardiomegaly. Repeat echocardiogram now showed global left ventricular dysfunction, and dilated cardiomyopathy\. He denied excessive alcohol intake. The working diagnosis was of a post-viral dilated cardiomyopathy and his Rampril was increased On review in clinic, one of the cardiologists was struck by the size of the patients hands and feet raising the question of acromegaly. In the endocrine clinic, he was noted to have facial stigmata of acromegaly with a prominent jaw, malocclusion, macroglossia and coarse features. He admitted that he had noticed increasing shoe size over the last six months. Blood pressure: 134/74. Visual Fields full to confrontation, Fundoscopy: no evidence of hypertensive changes. Initial investigations - FSH: 2.0, LH: 4.0, Prolactin: 192, Testosterone: 10.0, FT4: 18.5 FT3 6.4, TSH 1.5, IGF-1 83.3 NR [13.050.0] A short Synacthen test showed: baseline cortisol: 151, 30 min was 584, 60 min 683. GGT; time 0 min-GH 32.3, glu 7.2, 120 mins GH 24.4, glu 11.3. These results confirm acromegaly and diabetes. An MRI pituitary revealed a 1.5 cm lesion on the right side of the pituitary, most likely a cystic pituitary adenoma, with no compression of the optic chiasma. This case highlights the importance of considering acromegaly in the differential diagnosis of dilated cardiomyopathy and diabetes.
06 - 07 Nov 2006
Society for Endocrinology