Screening the Thyroid before Initiating Treatment for Acromegaly?

Aim: To present a case of acromegaly with coexisting thyrotoxicosis and to emphasize the relevance of screening the screening the thyroid before initiating treatment for thyrotoxicosis.

Presentation of the Case: A 55-year-old lady presented with palpitations, and weight loss of two months’ duration. She also noted her fingers and toes had swollen up, inability to incise properly since two years. Upon examination, she had morphological features clinically diagnostic of acromegaly. Her thyroid was enlargedwas on investigation found to have biochemical evidence of thyrotoxicosis. Fine needle  aspiration  cytology  of  the  thyroid  yielded  colloid  goiter.  Insulin  like  growth  factor-1  was elevated.  Serum  growth  hormone  after  an  oral  glucose  tolerance  test  was  elevated.  Magnetic resonant imaging (MRI) of the brain revealed a hypo enhancing focal lesion of size 11X10X12 mm at the pituitary region with delayed contrast enhancement suggestive of pituitary adenoma. Patient was started on anti-thyroid medications and referred to higher centre, and is awaiting surgery for pituitary adenoma.

Discussion: Among patients with acromegaly the incidence of thyroid diseases is around 78% and it has  the  most  common  presentation  being  nodular  thyroid  disease  as  the  initial  presentation.  It  is uncommon  to  see  patients  presenting  with  symptoms  of  thyrotoxicosis  initially,  who  had  florid morphological features of acromegaly. The prevalence of toxic nodular goiter to the tune of 14.3% in acromegaly.  Goiters  seen  in  acromegaly  were  euthyroid  or  autonomous,  are  due  to  the  elevated growth  hormone  levels  independent  of  TSH  action.  In  about  13  to  17%,  thyroidectomies  were performed before acromegaly was diagnosed. When patients with acromegaly presents with a weight loss should arouse the possibilities of thyroid cancer or hyperthyroidism.

Conclusion: Screening the thyroid  is  important,  as  inadvertent  thyroidectomies  were  performed before acromegaly was diagnosed. When acromegaly co-exists with thyroid dysfunction, the burden of cardiovascular abnormality should be addressed especially, to reduce the morbidity and mortality rate.

Read full article: http://bp.bookpi.org/index.php/bpi/catalog/view/43/185/333-1