00:01
Let's go on to a case.
00:03
A 54-year old man
presented to his doctor
complaining of fatigue due to poor sleep
for over one year.
00:10
On further questioning,
he complains of joint pain
and difficulty removing
his wedding ring.
00:16
More recently, he has noted wider spaces
between the teeth of his lower jaw.
00:22
On exam, his vital signs
are unremarkable.
00:26
He has coarse facial features with a prominent jaw
and an enlarged tongue.
00:31
When comparing his face to his driver's license photo
from five years earlier,
these features
are all new.
00:38
What is the best test
to make the diagnosis?
So, in reviewing the history
and presentation of this patient,
we note clinically
that he is hypertensive,
he has sleep disturbances,
probably from sleep apnea,
joint pain, and enlarging hands and feet,
which are suggestive of acromegaly.
01:01
Furthermore, why the spacing of the teeth
of the lower jaw
is the first sign of
growth hormone excess,
and this has been noted
in this case as well
where he has a prominence
of the lower jaw.
01:15
Macroglossia is enlargement
of the tongue.
01:18
Initially, this presents with teeth notching
in the side of the tongue
as the tongue expands
within the mouth.
01:26
As acromegaly involves, the tongue may actually
protrude from the mouth
and also contribute to his sleep apnea
when lying recumbent.
01:36
These images display some of the
clinical features of acromegaly.
01:41
The image on the left shows
gross macroglossia
where the tongue is
significantly enlarged.
01:48
The right image demonstrates spacing
in the lower jaw between the teeth,
again a very significant finding
in acromegaly
and one of the earliest signs
of facial feature changes
that you see with
growth hormone excess.
02:04
In these images, the image on the left
reveals the facial features
of a patient with
advanced acromegaly.
02:11
Here you see widening and thickening of the nose,
obvious cheekbones,
a bulging forehead,
and thickening of the lips.
02:20
In the right image, you see
a normal hand juxtaposed
with the hand of a patient
with acromegaly on the right.
02:28
The fingers and hands
are thickened and coarsened,
and this is the obvious reason
why patients
would present with difficulty
putting on or removing rings.
02:40
Acromegaly is strongly suspected
in this particular case
based on the clinical presentation,
and the next best test
would be checking in IGF-1 level.
02:51
Excess growth hormone is confirmed with
an oral glucose tolerance test
because glucose normally suppresses
growth hormone levels,
and then finally, a pituitary MRI
should be obtained
to assess for
an anterior pituitary mass.