Research

Obesity and Transitory Healthcare Utilization Interferes with Acromegaly Diagnosis in Adult Male

Ronald D. Williams, Jr., PhD, CHES

 


Topics in Integrative Health Care 2013, Vol. 4(1)   ID: 4.1004



Published on
March 10, 2013
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Abstract

This case is presented to highlight the impact of obesity and irregular healthcare utilization on the diagnosis of acromegaly. A new patient (32-year old obese white male) with no regular primary care physician presented for annual preventive exam. Primary care physician suspected acromegaly due to large hand size, but facial features were hidden by facial fat disbursement. Patient presented the following year with significant weight loss (106 lbs) revealing considerable enlargement of facial features. Laboratory analysis and MRI revealed secretory pituitary macro-adenoma with significant impact on multiple hormone levels. Patient’s lack of consistent primary care physician and obesity hindered early diagnosis of acromegaly.

Introduction

Acromegaly has a prevalence of 60/1,000,000 with an estimated annual incidence of 3-4/1,000,000.1-6 It is most commonly associated with excessive growth hormone and insulin-like growth factor stimulated by a benign pituitary adenoma in adults.1 Causation of benign pituitary adenoma is still unknown. Research has suggested that a hereditary condition called multiple endocrine neoplasia type 1 may be linked to hereditary pituitary tumors; however, this accounts for only about 3% of all pituitary tumors.2 Untreated acromegaly increases risk of cardiovascular disease, diabetes, and hypertension; however, these manifestations rarely assist in diagnosis. 3 The most common symptoms used in early diagnosis are the disproportionate growth of the facial features, hands, and feet;3 yet this case presents a unique circumstance where obesity masked facial feature growth.

Case Presentation

A 32-year old, white male presented to a new physician for general primary care in spring 2011. Medical history indicated an initial diagnosis of hypertension at age 23 which was now pharmacologically controlled. History also revealed the patient had transitory employment which led to residence in four states over the previous seven years.  During that time, the patient was treated by six different primary care physicians, leading to little consistency in follow-up exams and treatment care. During the initial presentation in 2011, the physician, who had no experience with acromegaly diagnoses, suspected acromegaly due to the patient’s body size (74 in; 408 lbs), enlarged hand size, and multiple acrochordons on the neck. Because the patient had no physical complaints related to acromegaly and no enlargement of facial features was evident, no diagnosis was pursued.

Independent of medical assistance, the patient began a self-monitored weight loss program in August 2011 consisting of caloric regulation between 2000-2400 kcal and moderate physical activity (20-30 minutes, twice daily). The patient’s weight as of August 2011 was 410 lbs. He presented to primary care physician for annual exam again in February 2012 at a weight of 304 lbs. Due to significant weight loss, the physician was able to visually recognize the extreme enlargement of facial features, particularly zygomatic bones, mandible, and supraorbital ridges.  The patient was immediately referred for laboratory analysis and magnetic resonance imaging (MRI) which confirmed diagnosis of acromegaly. The patient’s complete laboratory analysis of acromegalic biomarkers is included in Table 1; however, the primary biomarker of interest in diagnosis was the high level of insulin-like growth factor (IGF-1) and human growth hormone (HGH). Multiplanar MRI revealed the presence of a macro-adenoma (18x12x14 mm) in the floor of the sella. The patient was referred for transphenoidal removal of adenoma which occurred in May 2012.  Post-surgery MRI revealed that the adenoma was not completely removed, so the patient has begun monthly treatments of lanreotide injections to control IFG-1 and HGH.

Table 1. Laboratory analysis confirming acromegaly diagnosis in 33-year old male

Marker

Patient Level

Reference Range

Insulin-like Growth Factor

1342 ng/mL
113-297 ng/mL
Human Growth Hormone

15.64 ng/mL
0.01-0.97 ng/mL
Adrenocorticotropic Hormone (a.m.)

92.9 pg/mL
10-60 pg/mL
Testosterone (free)

4.4 ng/dL
9-30 ng/dL
Testosterone (total)

148 ng/dL
240-950 ng/dL
Prolactin 

43.6 ng/mL
1.61-18.77 ng/mL
Luteinizing Hormone

1.2 miu/mL
2-12 miu/mL

Discussion

Acromegaly diagnosis is often difficult because most physiological changes occur over the course of several years and go unnoticed by patients and family members. Because mortality rate of patients with acromegaly is higher than the general population,7-8 early diagnosis is critical. Healthcare providers must be aware of acromegaly symptoms (Table 2) and should not hesitate to order the appropriate laboratory tests (IGF-1, HGH) and MRI if symptoms are present.9-10 Particular concern should be paid to patients with whom healthcare providers have little or no history and exhibit obesity, plus any potential symptom of acromegaly (large hands, feet) , as facial fat could mask facial feature symptoms.


Table 2. Physical symptoms of acromegaly as identified by the NIH2

Body odor

Carpel tunnel syndrome

Decreased muscle strength

Easy fatigue

Enlarged bones of the face

Enlarged feet

Enlarged hands

Enlarged sebaceous glands

Enlarged jaw and tongue

Excessive sweating
 
Frequent headaches

Hoarseness

Joint pain

Limited joint movement

Sleep apnea

Swelling of bony areas around joints

Thickened skin or acrochordons

Widely spaced teeth

Widened fingers or toes
 
 


History of frequent relocation by this patient likely delayed early diagnosis because he did not consistently visit the same healthcare provider.  Additionally, obesity masked the enlarged facial features of the brow, jaw, and zygomatic bones making it difficult for providers to visually observe enlarged features. Delay in acromegaly diagnosis is common; however, this is the first known case demonstrating that obesity and transitory healthcare usage interfered with diagnosis.
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References

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10.   

National Institutes of Health. National Center for Biotechnology Information. Acromegaly. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001364/. Accessibility verified February 27, 2013.