A 38-year-old woman was referred to the Rheumatology Department for suspected acromegaly due to generalized joint pain.
The patient reported that 8 years ago she had noticed an increase in the size of the nose and both arches close to her nose.
He also reported thickening of the fingers and an increase of up to two numbers of shoes.
He also reported progressive separation of teeth from the lower arch, asthenia, increased sweating especially in the hands, thickened skin, dry and hoarseness, the most severe habitual voice and being a snorer.
She had had two pregnancies 5 and 2 years before the consultation without any difficulty in conception or breastfeeding.
Since the second pregnancy, she continued to suffer from mental illness.
The menstruation was normal, but there was one year in amenorrhea after the second delivery.
Interrogate did not report headache or visual disturbances.
She reported feeling unstable and dizziness with orthostatism of years of evolution without changes.
Approximately two years ago, the patient presented self-limiting symptoms, with a fortnightly frequency, sensation of heat and facial and thoracic hypersudoration that lasted in minutes.
She complained of tachycardia and sensation of vomiting caused by physical activity but not at rest.
He had no dyspnea.
Habitually he had constipation continuously without pathological remains.
She had no personal or family history of interest, nor toxic habits.
Physical examination revealed acromegaloid physical signs with both arches and prominent feet, diastema, large, elephant-like skin, coughing, enlarged hands.
With the clinical suspicion of acromegaly, a basal biochemical study was requested, with the results shown in Table 1.
After obtaining them it was decided to determine the secretion of GH after oral glucose tolerance test (OGTT) with 75 grams (g), obtaining the results shown in Table 2.
1.
Once the biochemical suspicion of acromegaly was confirmed, a cranial magnetic resonance imaging (MRI) was requested, showing the hypothalamic-pituitary area without alterations.
right hilium lack of availability to determine HRH in Spain and with the suspicion that it could be an ectopic acromegaly, a chest X-ray (Rx) was requested, showing a nodular hyperdense image
1.
Subsequently, a thoracic computerized axial tomography (CAT) was performed, confirming the presence of a 7 x 4 x 3.5 cm oval right hiliar image with solid density adjacent to the mediastinum.
To complete the study, an octreoscan was performed, which showed hyperuptake of the right pulmonary hilium.
1.
Other targeted agents were administered: chromogranin A >1200 ng/ml (19.4-98.1), gastrin 290-30 ng/ml (13-115), hydroxycardiogram 82 pgsa/24ml, selenium-1450 peptide),
With the diagnosis of suspected ectopic acromegaly due to pulmonary tumor probably secreting GHRH, a right lobectomy was performed.
The pathological study confirmed that it was a moderately differentiated 5 x 3.5 cm neuroendocrine carcinoma pT2NxM0.
In the immunohistochemical study the tumor cells were positive for synaptophysin, chromogranin and CD 56 marker.
GHRH determination is not available.
Adjuvant treatment was completed with external beam radiotherapy (dose 60 Gray).
In subsequent reviews the biochemical markers normalized: chromogranin A 80 ng/ml, IGF-1 136 μg/l, GH 0.36 μg/l and the control chest CT was normal, showing only postsurgical sequelae.
After 5 years of follow-up biochemical data and no evidence of disease have been shown and the patient remains clinically asymptomatic.
