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A 37-year-old male presents with a history of excessive sweating, headaches, and joint pain. Physical examination reveals thickened skin on the scalp with ridges and furrows. Which of the following findings would be most consistent with the suspected underlying diagnosis?
A 37-year-old male presents with a history of excessive sweating, headaches, and joint pain. Physical examination reveals thickened skin on the scalp with ridges and furrows. Which of the following findings would be most consistent with the suspected underlying diagnosis?
Besides the excessive sweating, headaches, and joint pain, which of the following signs was specifically noted by the patient's wife?
Besides the excessive sweating, headaches, and joint pain, which of the following signs was specifically noted by the patient's wife?
What is the most likely underlying mechanism for the patient's presentation?
What is the most likely underlying mechanism for the patient's presentation?
Which of the following physical findings was NOT mentioned for this 37-year-old male?
Which of the following physical findings was NOT mentioned for this 37-year-old male?
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What is the reference range for Insulin-like Growth Factor I (IGF-I)?
What is the reference range for Insulin-like Growth Factor I (IGF-I)?
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Which parameter is increased exclusively by growth hormone (GH) according to the provided table?
Which parameter is increased exclusively by growth hormone (GH) according to the provided table?
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Which of the following effects is primarily attributed to IGF-1 rather than GH?
Which of the following effects is primarily attributed to IGF-1 rather than GH?
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What is the primary effect on bone length resulting from the GH-IGF-1 axis?
What is the primary effect on bone length resulting from the GH-IGF-1 axis?
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Based on the provided information, what is the effect of the GH-IGF-1 axis on visceral organs like the liver and heart?
Based on the provided information, what is the effect of the GH-IGF-1 axis on visceral organs like the liver and heart?
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Which component of the GH-IGF-1 axis is associated with an increase in hemoglobin and hematocrit?
Which component of the GH-IGF-1 axis is associated with an increase in hemoglobin and hematocrit?
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Which of the following is NOT mentioned as being stimulated by the GH-IGF-1 axis?
Which of the following is NOT mentioned as being stimulated by the GH-IGF-1 axis?
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According to the table, what is the effect of the GH-IGF-1 axis on skin dermis?
According to the table, what is the effect of the GH-IGF-1 axis on skin dermis?
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What is the effect of the GH-IGF-1 axis on renal 25-hydroxyvitamin D 1α-hydroxylase activity?
What is the effect of the GH-IGF-1 axis on renal 25-hydroxyvitamin D 1α-hydroxylase activity?
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What is the primary purpose of the Overnight Dexamethasone Suppression test in the context of acromegaly?
What is the primary purpose of the Overnight Dexamethasone Suppression test in the context of acromegaly?
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In a patient with acromegaly, what result would be expected from an oral glucose tolerance test (OGTT)?
In a patient with acromegaly, what result would be expected from an oral glucose tolerance test (OGTT)?
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What is the primary reason for ordering a pituitary MRI in a patient with suspected acromegaly?
What is the primary reason for ordering a pituitary MRI in a patient with suspected acromegaly?
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What visual field defect is most likely associated with an expanding pituitary tumor that causes compression of the optic chiasm?
What visual field defect is most likely associated with an expanding pituitary tumor that causes compression of the optic chiasm?
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What is the recommended surgical procedure for the removal of a pituitary adenoma?
What is the recommended surgical procedure for the removal of a pituitary adenoma?
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Following transsphenoidal resection of a pituitary adenoma with residual tumor, somatostatin analogues and growth hormone receptor antagonists are commonly prescribed. Which of the following drug combinations would be appropriate for this management?
Following transsphenoidal resection of a pituitary adenoma with residual tumor, somatostatin analogues and growth hormone receptor antagonists are commonly prescribed. Which of the following drug combinations would be appropriate for this management?
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What is a potential side effect associated with the use of octreotide?
What is a potential side effect associated with the use of octreotide?
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Which drug is categorized as a growth hormone receptor antagonist?
Which drug is categorized as a growth hormone receptor antagonist?
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Which medication used to treat acromegaly is associated with a higher risk of hyperglycemia?
Which medication used to treat acromegaly is associated with a higher risk of hyperglycemia?
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Which of the following is NOT a common side effect of dopamine agonist medications in acromegaly treatment?
Which of the following is NOT a common side effect of dopamine agonist medications in acromegaly treatment?
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What is the primary mechanism of action of somatostatin analogs in treating acromegaly?
What is the primary mechanism of action of somatostatin analogs in treating acromegaly?
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A patient with acromegaly develops cutis verticis gyrata. What treatment for this is mentioned in the text?
A patient with acromegaly develops cutis verticis gyrata. What treatment for this is mentioned in the text?
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A patient develops secondary adrenal insufficiency after pituitary surgery. Which hormone levels would you need to monitor?
A patient develops secondary adrenal insufficiency after pituitary surgery. Which hormone levels would you need to monitor?
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Which of the following is a potential complication of pituitary surgery mentioned in the text?
Which of the following is a potential complication of pituitary surgery mentioned in the text?
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If a patient develops panhypopituitarism after surgery, which of the following is NOT a supplement they will likely need?
If a patient develops panhypopituitarism after surgery, which of the following is NOT a supplement they will likely need?
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What is a notable side effect of somatostatin analogs (like octreotide, lanreotide) due to its mechanism of action?
What is a notable side effect of somatostatin analogs (like octreotide, lanreotide) due to its mechanism of action?
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Why is it important to ask about the patient's current medications when investigating elevated prolactin levels?
Why is it important to ask about the patient's current medications when investigating elevated prolactin levels?
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Why was it appropriate to order a TSH level in the workup of this patient with elevated prolactin?
Why was it appropriate to order a TSH level in the workup of this patient with elevated prolactin?
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Which of the following hormones directly stimulates prolactin secretion from the lactotroph cells?
Which of the following hormones directly stimulates prolactin secretion from the lactotroph cells?
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What is the mechanism by which prolactin inhibits ovulation and spermatogenesis?
What is the mechanism by which prolactin inhibits ovulation and spermatogenesis?
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Given the pituitary MRI findings of a 5-mm microadenoma, is surgery the immediate next step for this patient?
Given the pituitary MRI findings of a 5-mm microadenoma, is surgery the immediate next step for this patient?
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Which of the following medications is/are a suitable option for treating excess prolactin production in this patient?
Which of the following medications is/are a suitable option for treating excess prolactin production in this patient?
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What are expected centrally mediated side effects that are possible with cabergoline?
What are expected centrally mediated side effects that are possible with cabergoline?
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What is the approximate half-life of prolactin in the plasma?
What is the approximate half-life of prolactin in the plasma?
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A patient with diabetes insipidus and hypernatremia would most likely exhibit which of the following?
A patient with diabetes insipidus and hypernatremia would most likely exhibit which of the following?
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A patient diagnosed with Langerhans cell histiocytosis and diabetes insipidus is experiencing an imbalance in antidiuretic hormone (ADH). Which of the following best describes the state of their plasma?
A patient diagnosed with Langerhans cell histiocytosis and diabetes insipidus is experiencing an imbalance in antidiuretic hormone (ADH). Which of the following best describes the state of their plasma?
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What is the primary action of desmopressin in treating diabetes insipidus?
What is the primary action of desmopressin in treating diabetes insipidus?
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The mechanism of action of desmopressin is best described by which of the following?
The mechanism of action of desmopressin is best described by which of the following?
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Which of the following would be the expected outcome of a patient treated with desmopressin?
Which of the following would be the expected outcome of a patient treated with desmopressin?
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A patient presents with extreme thirst and frequent urination. Hypernatremia is noted in the blood work. What condition would be most consistent with these findings?
A patient presents with extreme thirst and frequent urination. Hypernatremia is noted in the blood work. What condition would be most consistent with these findings?
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A patient being treated for diabetes insipidus with desmopressin was told to only take it once, every 24 hours. What would be the best way to describe and classify this dosing schedule for this medication?
A patient being treated for diabetes insipidus with desmopressin was told to only take it once, every 24 hours. What would be the best way to describe and classify this dosing schedule for this medication?
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A patient experiencing fatigue and hypernatremia after water deprivation exhibits increased water reabsorption due to the effect of antidiuretic hormone (ADH). Which of the following sequences best describes the activation pathway of ADH?
A patient experiencing fatigue and hypernatremia after water deprivation exhibits increased water reabsorption due to the effect of antidiuretic hormone (ADH). Which of the following sequences best describes the activation pathway of ADH?
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Study Notes
Case Presentation
- A 37-year-old male presented to an endocrinology clinic with a four-year history of excessive sweating, headaches, and joint pain.
- His wife noticed increasing skin folds on his scalp.
- Physical exam revealed thickening of the skin on his scalp, with ridges and furrows.
Images
- Images (Panel A and B) display the scalp thickening and furrowing.
What Could Be Going On?
- Possible diagnostic considerations include: Syndrome of inappropriate antidiuretic hormone (SIADH), diabetes insipidus, heat or thyroid problems, and growth hormone excess.
- Further history would include inquiring about past medical conditions, family history, medications, and/or allergies.
- Specific physical exams would include evaluating growth of the extremities (hands and feet), facial features, and body composition.
- Further tests to consider would be insulin-like growth factor-1 (IGF-1) level, growth hormone level, oral glucose tolerance test (OGTT), and/or additional lab tests for SIADH or thyroid function.
Case
- The patient had enlarged feet and hands and a protruding jaw.
- Laboratory evaluation revealed an elevated insulin-like growth factor-1 (IGF-1) level of 907 µg/L (reference range 82-237 µg/L), and a random growth hormone level of 7.3 µg/L (reference range 0-0.8 µg/L).
What is the Underlying Mechanism?
- A 37-year-old male patient presented with a 4-year history of excessive sweating, headaches, and joint pain.
- His wife noted increased skin folds on his scalp.
- Physical exam showed thickened scalp with ridges and furrows (panels A & B).
Main Biologic Effect of GH-IGF-1 Axis
- The table details the effects of growth hormone (GH) and insulin-like growth factor - 1 (IGF-1) on various tissues and parameters.
What is the Confirmant Test for Acromegaly?
- The confirmatory test for acromegaly is an oral glucose tolerance test (OGTT).
Oral Glucose Tolerance Test: GH
- The graph shows GH levels before and after a glucose load in healthy individuals and patients with uncontrolled acromegaly.
- Acromegaly patients show no GH suppression following glucose load, while healthy individuals show significant suppression.
What Would You Order Further?
- Due to the presence of a microadenoma, pituitary MRI and visual field testing may be indicated.
Case Continued
- A 75-g oral glucose load did not suppress the growth hormone level, confirming a diagnosis of acromegaly.
- MRI revealed a pituitary adenoma measuring 27 mm x 22 mm x 25 mm.
Figure 9-6
- Diagrams depict how pituitary tumor expansion can affect the optic pathways, leading to visual field defects.
- Image A: normal vision.
- Image C: Bitemporal hemianopia (loss of vision in the outer half of both visual fields).
Case Follow-up
- The patient underwent a transsphenoidal resection of the pituitary adenoma.
- Residual tumor present following surgery, requiring treatment with a somatostatin analog and a growth hormone receptor antagonist.
Which of The Following Drugs Could Be Prescribed?
- Acceptable drugs for continued therapy include octreotide and pegvisomant.
Potential Side Effects of Octreotide
- Possible side effects include gallstones, dizziness, valvulopathy, fat malabsorption, and glucose intolerance.
Pegvisomant
- Details the amino acid sequence of Pegvisomant protein.
What is the Management?
- Management options for acromegaly include dopamine agonists, somatostatin analogs, and GH receptor antagonists.
- These approaches address the underlying cause, and monitor for effectiveness.
What Could Be the Complications of His Pituitary Surgery?
- Complications of the surgery include hypopituitarism (hormone deficiency), visual field deficits, and CSF leaks.
If the Patient Developed Panhypopituitarism?
- Potential hormone deficiencies may require replacement therapy including thyroid hormone replacement (levothyroxine), and possible gonadotropin, and/or adrenal insufficiency therapy.
Case Follow-up (continued)
- The patient's scalp thickening (cutis verticis gyrata) may be related to acromegaly.
- Soft-tissue fillers were attempted to improve the appearance, but with only a limited effect.
Case (continued)
- A 42-year-old obese woman presented with elevated prolactin (144.8 ng/mL, normal range 4.8 to 23.3 ng/mL).
- She also reported galactorrhea and amenorrhea (no menstrual periods) for one year.
- A repeat prolactin level was elevated at 109 ng/mL.
Should you ask about current medications?
- Reasons to inquire about current medications include potential interactions.
Case Continued (TSH)
- A TSH level was ordered.
- Justification and rationale for TSH evaluation to determine if this was the appropriate test should be documented.
Which of the Following Stimulates Prolactin Release?
- Prolactin release is stimulated by TRH.
Prolactin Synthesis, Function, and Regulations
- Prolactin synthesis, function, and regulatory mechanisms are detailed.
Case Continued
- MRI revealed a subtle area of delayed enhancement in the right pituitary, consistent with a 5-mm microadenoma.
Case Continued
- Given the MRI finding, should you do surgery?
- The answer is yes
Which of the Following Drugs Can Be Used?
- Dopamine agonists, such as cabergoline and bromocriptine, can be used to treat excess prolactin production.
Case Continued (Cabergoline)
- The patient was prescribed cabergoline (0.25 mg twice weekly) for two to three months.
What are the Expected Centrally Mediated Side Effects of Cabergoline?
- Potential side effects include dizziness, lightheadedness, and nausea.
Case (continued)
- A 36-year-old male presented with increased thirst, urination, and dehydration from a hike.
- Blood test revealed hypernatremia.
Case (continued)
- MRI showed pituitary thickening in the infundibulum, suggestive of a possible condition.
- A mandibular biopsy was completed due to other symptoms which confirmed a diagnosis of multiorgan Langerhans cell histiocytosis.
- Diagnosis includes diabetes insipidus.
Is this patient's plasma hypotonic, hypertonic, or isotonic?
- Patient's plasma is hypertonic.
Antidiuretic Functions of AVP (aka ADH)
- Describes the antidiuretic hormone (ADH, aka vasopressin) function.
Which of The Following Statements is Accurate Regarding DI Treatment?
- The correct statement about diabetes insipidus (DI) treatment is that desmopressin (an ADH analog) can be used as needed
Desmopressin (Vasopressin analog)
- Desmopressin increases water reabsorption by activating V2 receptors.
Vasopressin Receptor (V2) Agonist
- A table summarises the mechanism, effects, use and potential side effects of vasopressin V2 agonists.
Follow-up
- The patient was treated with desmopressin.
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Description
This quiz explores a clinical case of a 37-year-old male presenting with symptoms indicative of a potential growth hormone-related condition. It covers various aspects such as physical findings, hormonal measurements, and the underlying mechanisms involved. Test your knowledge on the relationships between growth hormone and its effects on the body.
