[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

 “Please chat to this patient who feels generally unwell.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/151706527″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” underline_digit=”no” separator=”yes” digit=”20″ title=”Minutes” text=”Station time”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” separator=”yes” digit=”10″ title=”Minutes” text=”Time for this encounter”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”8″ title=”Minutes” text=”Maximum time to examine your patient”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”2″ title=”Minutes” text=”Minimum time for discussion and questions”][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has obvious acromegaly.

The clinical signs exhibited in this video include:

  • Large spade-like hands;
  • Prognathism;
  • Frontal bossing of the skull;
  • A large nose and ears;
  • Skin tags on the anterior neck.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Aetiology

Acromegaly is a life threatening condition that results from a hormonal disorder involving overproduction of growth hormone (GH). It can be subtle in nature with symptoms preceding diagnosis by several years.

Under the influence of GHRH (hormone produced by hypothalamus), pituitary gland produces GH. This stimulates the liver to produce IGF-1 (insulin-like growth factor). High levels of IGF-1 then lead to a reduction in GH production through negative feedback. IGF-1 also has an effect on lipid and glucose metabolism.

Possible causes of acromegaly are:

  • GH-secreting pituitary adenomas (most common, accounting for 95% of cases)
  • Hypothalamic tumours leading to excess GHRH secretion
  • Non-endocrine tumours producing ectopic GHRH and GH

Clinical features

In acromegaly, a person will have:

  • Abnormally large hands, feet and face
  • Coarse facial features
  • Thick lips and eyelids
  • Jutting forehead and jaw
  • Widely spaced teeth
  • Profusely sweating
  • Swollen palms and soles (earliest signs)
  • Doughy-feeling skin with large pores
  • Oily skin and hyperpigmentation (skin changes cease with disease regression)
  • Hypertrichosis
  • Skin tags

Other clinical features depend are either due to GH / IGF-1 excess or local effects of a pituitary tumour.

Mass effects of tumour include:

  • Visual field defects (bitemporal hemianopia)
  • Headaches
  • Sometimes III nerve palsy
  • damaged normal pituitary tissue and loss of end-organ hormones. FSH / LH deficiency causes hypogonadism. In longstanding disease, ACTH and TSH deficiency may also occur.

GH/IGF-1 excess results in:

  • Soft tissue swelling
  • Extremities enlargement
  • Increase in ring and shoe size
  • Prognathism
  • Macroglossia
  • Hyperhidrosis
  • Facial feature coarsening

Investigations

  • Measurement of GH and IGF-1
  • GH suppression test (measurement of GH 1 hour after 100g oral glucose)
  • CT scan
  • MRI
  • TRH and GHRH levels
  • Surgical specimens from pituitary tumours for histologic findings.

Management

Treatment aims to reduce GH and IGF-1 levels in blood to the normal level. Options include:

  • Tumour removal
  • Pituitary irradiation (if surgery fails)
  • Medical therapy for persistent post-operative disease
  • Somatostatin analogues
  • Dopamine-receptor agonists
  • GH-receptor antagonists

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has obvious acromegaly.  He has large hands, prognathism, frontal bossing and a large nose and ears.  I would like to test his visual fields and arrange imaging of his pituitary gland.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]