A Case of Recurrent Acromegaly: Medical Management of the Disease

Abstract

Introduction: Acromegaly is a rare, chronic, insidious disease characterized by overproduction of growth hormone (GH) and its tissue mediator insulin-like growth factor 1 (IGF-1) typically from a pituitary adenoma. Recurrent acromegaly is established by GH hypersecretion after initial biochemical cure, and is even rarer than the disease itself, reported in only 2 to 3% of the cases. Case Report: We present a case of a 44 year-old Hispanic male with a past medical history of acromegaly diagnosed 20 years ago initially treated with transsphenoidal microsurgery and open brain surgery two years after the first procedure. He was lost to follow up and presented to our outpatient clinic 18 years later complaining of frequent headaches with nose and hands enlargement. Physical examination revealed an overweight male patient with a height of 75 inches, enlarged nose, lips, splayed teeth, coarse facial features, macroglossia, and enlargement of both hands with hyperhidrosis of his palms. Laboratory work up confirmed the diagnosis of recurrent acromegaly with elevated fasting IGF-1 level. MRI of the brain showed a 4.3 x 3.8cm pituitary macroadenoma with extensive suprasellar extension and optic chiasm compression. Medical treatment with Octreotide Long-Acting Release (LAR) was started immediately and subsequent repeat IGF-1 levels have shown progressive improvement. Discussion: This patient’s case of recurrent acromegaly shows the importance of follow up after any surgical or medical intervention in acromegaly patients. Recurrence, though infrequent, is possible and these patients have been identified as a subset of patients that can be difficult to manage. Therefore close monitoring with IGF-1 and GH levels is crucial to diagnose and treat recurrence of the disease and its comorbidities. Our goal was to achieve a biochemical cure, however given the fact that the patient refused any surgical intervention, makes the case even harder to manage. Somatostatin analogues have proven to be effective in cases like ours, yet its efficacy varies among studies.