Akros Megalos

A 55 year old man goes to his primary care doctor with bifrontal headaches and is put on sumatriptan for migraines. The next year, he's diagnosed with diabetes and started on metformin. The following year, he is encouraged to exercise since he's gained 50 pounds over the last few years. He's also prescribed hydrochlorothiazide for a new diagnosis of high blood pressure. Then, because he has lower extremity swelling, a work-up for congestive heart failure is done. It's not very revealing.

He jumps from specialist to specialist, seeing his primary care doctor, a cardologist, a neurologist, and optometrist. His vision gets more blurry and he wears glasses, though he can't use his old frames because they don't fit. "I'm just getting older," he thinks. "You're just getting older," his doctors confirm. The next Christmas, his wife gets him new shoes and new gloves because his current ones don't fit.

(Do you have the diagnosis yet?) Most patients with this disease often do not get diagnosed for many years, and actually rarely is the diagnosis made by an endocrinologist. This patient continued to complain of daytime somnolence and nocturnal awakenings. He stopped his job because the typing exacerbated a new carpal tunnel syndrome. He started noticing skin tags on his chest. His libido started to wane.

Finally, the diagnosis of acromegaly was made. Acromegaly is caused by a tumor in the pituitary gland (deep within the brain, seated upon the "Turkish saddle") secreting growth hormone, causing this constellation of symptoms - new onset hypertension, diabetes, swelling, increase in hand and foot size, sleep apnea, jaw malocclusion, increased spacing of teeth, changes in the facial bone structure, etc. I saw him in endocrine clinic (the pictures above are from Wikipedia, not my patient, but they're representative) and it was really cool because acromegaly is a pretty rare disease and the physical exam findings are dramatic. Simply shaking his hand helped me make the diagnosis. He underwent transsphenoidal resection of the pituitary mass with great improvement. This was one of the more impressive cases I saw on endocrine.

First two images shown under Creative Commons Attribution 2.0 Generic License, last image is in the public domain.