Acromegaly

Question 1

What is the following clinical sign ?

What other facial features may you see in this patient?

Answer 1

prognathism

Macroglossia: tongue enlargement may cause the tongue to appear large for the mouth or even cause visible partial airway obstruction in extreme cases.

Wide spaced teeth: growth of the soft palate may cause interdental separation of the lower jaw (Figure 6).

Question 2

What is acromegaly?

Answer 2

Acromegaly is a disorder of excessive growth hormone (GH) which is produced in the anterior pituitary gland. This most commonly occurs secondary to a pituitary adenoma. Too much GH causes a wide range of features associated with its complex physiological function, including excessive soft-tissue growth. Acromegaly most commonly presents in patients in their 30s.

Question 3

What is the following clinical sign ?

What peripheral features may you see?

Answer 3

prominent Supraorbital ridges

Enlarged hands and feet

Question 4

What skin changes may you see in a patient with acromegaly?

Answer 4

Skin: may display thickening in the hands and face and excess sweating or oiliness in acromegaly.

Question 5

What bone changes may occur in acromegaly?

Answer 5

Posture: patients with acromegaly can present with signs of osteoarthritis, especially in the weight-bearing joints (knees and hips).

Question 6

What is the following clinical sign and what else may occur?

Answer 6

Hair growth: hirsutism in women and hypertrichosis (increased hair growth as a result of the effects of growth hormone) may occur.

Question 7

What is the following clinical sign and what does it indicate?

Answer 7

Skin tags: acromegaly can cause an increase in the number of skin tags.

Question 8

Describe kind of gait may you see in acromegaly patients?

What kind of lower limb may you see in acromegaly patients?

Answer 8

Gait: acromegaly can cause a rolling gait- Rolling gait is a way of walking in which the weight of the body moves from side to side more than usual.

Varus deformity.

Question 9

What common complaint will most acromegaly patients have?

Answer 9

Clothes: clothes or jewellery may appear tight if significant weight gain has occurred.

Question 10

What common neuropathy may occur in acromegaly patients and how will this present?

Answer 10

Wasting: thenar wasting can indicate untreated carpal tunnel syndrome.

Question 11

What serious condition with global effects is linked to acromegaly?

Answer 11

Finger pricks: finger prick marks on the tips of the fingers may indicate diabetes, which is linked to acromegaly.

Question 12

Describe tinsels test?

Answer 12

Tinel’s test

Tinel’s test is used to identify median nerve compression and can be useful in the diagnosis of carpal tunnel syndrome.

To perform the test, simply tap over the carpal tunnel with your finger.

Interpretation

If the patient develops tingling in the thumb and radial two and a half fingers, this is suggestive of median nerve compression.

Question 13

What is phalens test?

Answer 13

Phalen’s test

If the history or examination findings are suggestive of carpal tunnel syndrome, Phalen’s test may be used to further support the diagnosis.

Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.

Interpretation

If the patient’s symptoms of carpal tunnel syndrome are reproduced, then the test is positive (e.g. burning, tingling or numb sensation in the thumb, index, middle and ring fingers).

Question 14

What is carpal tunnel syndrome?

Answer 14

Carpal tunnel syndrome

Carpal tunnel syndrome is the most common form of nerve compression found in acromegaly. It occurs as a result of compression of the median nerve as it traverses through the wrist via the carpal tunnel, which is usually due to excess local soft-tissue growth.

Typical clinical features include pain and paraesthesia in the distribution of the median nerve (the thumb, index finger, middle finger, and lateral half of the ring finger). Grip weakness can also develop secondary to wasting of the thenar muscles, which receive motor innervation from the median nerve.

Question 15

What is the following sign and what does it indicate?

Answer 15

Acanthosis nigricans (Figure 3): darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign (most commonly in dark-skinned individuals) or associated with insulin resistance (e.g. type 2 diabetes mellitus) as a complication of acromegaly.

Question 16

What is the relationship between JVP and acromegaly?

Answer 16

JVP and acromegaly

Patients with acromegaly can have a raised JVP because a complication of the condition is acromegalic cardiomyopathy, which causes progressive cardiac dysfunction and therefore a backup of blood into the venous system if advanced enough.

Question 17

What is the following clinical sign and what does it indicate?

Answer 17

Acromegaly can cause thyroid nodules or, less commonly, a globally enlarged thyroid gland.

Question 18

What visual defects may occur in acromegaly?

Explain the pathophysiology of these defects

Answer 18

Visual field deficits in acromegaly

Acromegaly is classically associated with bitemporal hemianopia. This refers to a loss of the temporal vision (peripheral to the midline) in both eyes.

It tends to progress first from a bilateral upper temporal quadrantanopia to later involve the lower temporal fields. This may occur due to a pituitary adenoma compressing the optic chiasm from below. The optic chiasm is where the tracts for the temporal vision cross over onto the other side of the brain, so compression spares the nasal vision.

Because the pituitary gland underlies the optic chiasm, the lower part of the optic chiasm is compressed first. As everything in the optic tract is reversed, inferior optic chiasm compression results in an upper temporal visual field defect. Therefore, the upper temporal field quadrants tend to be affected first, which may then progress to include the lower temporal field quadrants as the superior optic chiasm becomes compressed, leading to bitemporal hemianopia.

Question 19

How would you assess for proximal myopathy?

Answer 19

Proximal myopathy

Although the pathophysiology isn’t entirely clear, it is suspected the combined effects of GH and the endocrine complications of acromegaly can cause proximal myopathy despite the increased muscle mass associated with the condition. Patients may develop wasting of their proximal musculature, causing difficulties in tasks such as standing from a sitting position.

To screen for proximal myopathy, ask the patient to stand from a sitting position with their arms crossed (to minimise their ability to mask proximal muscle weakness). Make sure to stand close to the patient to prevent them from falling. An inability to stand up suggests proximal muscle weakness.

Question 20

What further examinations/ investigations would you request upon completing your acromegaly examination?