- Enlarging shoe and ring size - Arthralgias/myalgias • Neurologic - Headache - Vision changes, particularly temporal hemianopsia - Hand numbness/carpal tunnel syndrome - Fatigue, weakness - Sleep disturbance • Dermatologic - Increased sweating - Oily skin • Endocrine - Deepened voice - Decreased libido - Female: amenorrhea or other menstrual dysfunction, hot flashes, vaginal atrophy - Male: erectile dysfunction - Galactorrhea PHYSICAL EXAM • Presentation may be subtle and is often aided by review of old photographs. Look for facial coarsening: - Enlarging jaw (macrognathia), nose, and frontal bones - Teeth spreading and change in bite/jaw malocclusion - Enlarging tongue (macroglossia) • Neurologic - Bitemporal hemianopsia - Other cranial nerve defects • Musculoskeletal - Hypertrophic arthropathy of spine, hips, knees, ankles - Prognathism - Vertebral fractures - Gigantism (if pediatric or adolescent) • Dermatologic - Skin thickening, skin tags 2
• Visceromegaly: enlargement of the prostate (in men), kidneys, liver, spleen, heart, salivary glands, thyroid (goiter), and tongue DIAGNOSTIC TESTS & INTERPRETATION • Initial testing - Serum IGF-1 (best single test for diagnosis; adjust for age). Levels 2 times the upper limit are more suggestive of acromegaly. - Falsely low IGF-1 may be seen in hypothyroidism, malnutrition, poorly controlled DM1, liver/renal failure, and oral estrogens; perform oral glucose tolerance test (OGTT). • Concurrent laboratory findings - Hyperprolactinemia; either through mass effect of the GH-secreting tumor or through prolactin/GH cosecretion - Hyperphosphatemia - Hypercalciuria - Increased 25-hydroxyvitamin D - Decreased sex hormone-binding globulin and thyroxine-binding globulin • Follow-up testing - A 75-g OGTT: In normal subjects, GH should drop to ≤1 ng/mL within 2 hours, but postglucose GH levels may remain >2 ng/mL in patients with acromegaly. • MRI of the sella (with and without contrast) - Will detect tumors as small as 2 mm in diameter - Does not differentiate between functioning and nonfunctioning tumors Follow-Up Tests & Special Considerations If the sellar MRI is normal, perform a CT scan of the chest and abdomen to evaluate for extrapituitary source of acromegaly. Plasma GHRH should also be measured using a diagnostic threshold of 250 to 300 ng/L ( 1 )[B].
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- Spring '16