Critical Care |

Recurrent DKA in a Previously Healthy 26-Year-Old Navajo Male Leading to a Diagnosis of Acromegaly FREE TO VIEW

Drew Harris, MD; Sharon Drake, MD
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Yale University, New Haven, CT

Chest. 2014;146(4_MeetingAbstracts):277A. doi:10.1378/chest.1984805
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SESSION TITLE: Critical Care Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Acromegaly, a clinical disorder caused by excess growth hormone (GH) secretion, is an uncommon adult condition with an estimated annual incidence of 3 per million. It is an often missed diagnosis, and delay in diagnosis leads to increased morbidity and mortality. We report a case of a 26 year old previously healthy Navajo male who was admitted to the intensive care unit (ICU) in an Indian Health Service (IHS) hospital 3 times in 6 months for diabetic ketoacidosis (DKA) before the diagnosis of acromegaly was made.

CASE PRESENTATION: A 26 year old athletic Navajo male had no previous medical history until his first of 3 admissions within 6 months to an IHS hospital ICU for DKA. Each admission his presented with fatigue, headache, polyuria and polydipsia. His lab studies were notable for blood sugar > 500, severe anion-gap metabolic acidosis and ketones in his urine and blood. His DKA resolved each admission with IV insulin, IV fluids and electrolyte repletion. At each hospital discharge, his outpatient insulin dosage was increased. In 6 months his insulin needs went from 0 to 120 units/day. Acromegaly was clinically suspected due to the patients facial features including a wide nose, prognathism, frontal bossing and macroglossia. In the preceding 6 months the patient also noted an increase in shoe and hat size, decrease in libido and enlarging hands. Left homonymous hemionopsia was present. Insulin Growth Factor 1 (IGF-1) level was 539 ng/mL (upper limit of normal is 373 ng/mL ). Given his acromegalic physical features and IGF-1 level, an oral glucose tolerance test (testing for GH suppression) was not obtained and an MRI revealed a 3.3 x 3 CM lobulated pituitary mass displacing the optic chiasm. Further testing revealed central hypothyroidism and hypogonadism. He was referred to a tertiary center for surgery.

DISCUSSION: Acromegaly is an uncommon disorder of GH excess most often arising from a pituitary tumor. The diagnosis is often missed because clinical features of the disease, such as fatigue, hypertension, insulin resistance, sleep apnea and arthritis, are common in the general population.1 In addition, the disease is difficult to detect because the condition usually develops insidiously, with a mean time from symptom onset to diagnosis of 7.7 years.2 Even in the presented patient, with acromegalic signs and symptoms developing relatively rapidly, it took 3 separate hospitalizations before the diagnosis was suspected. Specific history such as slowly increased hat and shoe sizes are unlikely to be volunteered by a patient. Facial features of the disease often occur over years and may not be noticed by patients themselves. Untreated disease leads to decrease in life expectancy by ten years, with increasing morbidity and mortality seen with delays in diagnosis.3 Clinicians should investigate further when any clinical suspicion for the disease arises, regardless of the reason for patient presentation.

CONCLUSIONS: Acromegaly is an easily missed diagnosis with nonspecific clinical features that often present insidiously. Clinicians should consider testing patients for the disease when any clinical suspicion arises, regardless of the patient presentation. By reducing the time from symptom onset to diagnosis, significant morbidity and mortality from the disease can be mitigated.

Reference #1: Reddy R, Hope S and Wass J. Acromegaly: Easily Missed? BMJ 2010; 341:c4189.

Reference #2: Holiday, IM, Rajasoorya RC and Gamble GD. Factors influencing mortality in acromegaly. J Clin Endocrinol Metab 89 (2): 667-674.

Reference #3: Rajasoorya C, Holdaway IM, Wrightson P, Scott DJ, Ibbertson HK. Determinants of clinical outcome and survival in acromegaly. Clin Endocrinol 1994;41:95-102.

DISCLOSURE: The following authors have nothing to disclose: Drew Harris, Sharon Drake

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