Professional Documents
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ACROMEGALY
A 48-year-old man complaining of impotence sought medical attention. Over the years, he
experienced increasing difficulty with maintaining and, more recently, achieving an erection.
Further questioning revealed that he was also shaving less frequently. The patient’s shoe size
had increased from 9-C to 11-EEE over the past 5 years, and his dental plate had to be altered
three times in 6 years. Recently, friends have remarked on changes in his appearance. The
patient also admitted to tingling of his fingers and joint pains.
On physical examination, he had coarse facial features with a bulbous nose and a beetle-browed
look. The tongue was enlarged and teeth were wide spaced. Testing of visual fields showed a loss
of both lateral (temporal) fields. The hands and feet were enlarged with spadelike fingers. The
liver was enlarged. Laboratory studies showed a fasting plasma glucose level of 150 mg/dl.
Fasting growth hormone (GH) was 40ng/ml, and it did not decrease after administration of an
oral glucose load. On magnetic resonance imaging, a large pituitary mass protruded upward
from the sella turcica.
[ANSWER]
4. Stimulation of the growth of connective tissue and synovium and cartilage causes
osteoarthritis. Also, nerves can be compressed by the growing bone at points where the
nerves pass through grooves in the bone.
7. There are three possible causes of the patient's impotence, which reflect a low plasma
testosterone level. First, the pituitary tumor may have destroyed gonadotropin-producing
cells by exerting pressure on them. The resultant loss of luteinizing hormone (LH) and
follicle-stimulating hormone (FSH) decreases the secretion of testosterone by the Leydig cells
of the testes. Second, the tumor may have compressed the hypophyseal stalk and cut off
transport of gonadotropin-releasing hormone (GnRH) down the pituitary portal veins from
the median eminence to the anterior pituitary gonadotrophs; this process would decrease LH
and FSH secretions. Third, such tumors may secrete prolactin, a hormone structurally
related to GH. High prolactin levels inhibit GnRH release from the hypothalamus and thus
would decrease LH and FSH secretion.
8. Similarly, ACTH and/or TSH secretion might be impaired by the same two mechanisms
described above for LH and FSH. This would in turn cause cortisol and thyroxine
deficiencies.
9. The optic nerves cross just above the pituitary gland on their route to the occipital cortex.
Pressure from a tumor on this crossing point causes a characteristic defect in the visual
fields.
10. Growth hormone secretion is normally under dual regulation from the hypothalamus. It is
stimulated by GnRH and inhibited by somatostatin. The latter, in a long-acting analog form,
can reduce the elevated GH levels in patients with acromegaly because their tumors contain
plasma membrane receptors for the hypothalamic inhibitory peptide.
11. The swelling of soft tissues would resolve promptly. However, the bone changes caused by
excess GH would resolve very slowly (and perhaps not at all) because of the relatively slow
rate of normal bone turnover.
13. If the patient still wished to father a child, and his gonadotrophic cells were not significantly
damaged, then treatment with daily pulsatile administration of GnRH would be effective. If
his gonadotrophic cells were destroyed, he would require regular administration of LH and
FSH. If the patient only wished to restore sexual potency, he would require only testosterone
replacement therapy.
Impotence
Poor erection
Shaves less frequently
Hand and feet enlargement with spadelike fingers
Finger tingling
Joint pains
Coarse facial features
Loss of lateral (temporal) visual fields
Enlarged liver
Fasting plasma glucose level of 150 mg/dl
Fasting growth hormone (GH) of 40ng/ml
GH not decreasing after administration of an oral glucose load
Pituitary mass