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Case Study 1

Case Study 2

Early History of Illness
GC is a 34-year-old woman who initially presented at age 19 with amenorrhea of six months duration and headaches of 2 months duration. Within the previous month she had also experienced visual changes. The patient observed physical changes that were not present in photographs taken 2 years earlier.

These symptoms suggested a pituitary tumour.

Diagnosis and Initial Treatment
The fasting plasma GH level was 54 µg/L (post-OGTT) and the plasma IGF-I level was 902 µg/L. These highly elevated hormone levels strongly supported the diagnosis of acromegaly.

Further evaluation of the patient by MRI indicated that a macroadenoma was present around the pituitary. Since the patient was experiencing visual changes, a visual field test was performed. Visual field tests revealed that GC was experiencing a decrease in her visual fields in both eyes.

A year after initial presentation, GC underwent transsphenoidal surgery, which was unsuccessful due to extension of the tumour. GC continued to have abnormally high GH levels of 41 µg/L and IGF-I levels of 752 µg/L. She was also still experiencing amenorrhea, headache, and visual field impairment. Immunochemical staining confirmed the plurihormonal nature of her tumour. She subsequently underwent a course of radiotherapy, which did not alleviate her symptoms after approximately 2 years. Adjuvant therapy with bromocriptine was attempted to control the symptoms associated with acromegaly post-radiotherapy. Both the radiotherapy and bromocriptine treatments were unsuccessful at controlling associated disease symptomatology.

Current Treatment Plan and Results
The patient was started on therapy with Sandostatin^® Injection (octreotide acetate), 100 mg sc tid. She experienced a rapid biochemical response, including normalisation of the IGF-I level to 235 µg/L and GH < 1 µg/L. Normal menstrual cycles resumed, an indicator of normal pituitary function. A most welcome result was the resolution of all clinical features of acromegaly in this young woman. The patient recently switched to once-monthly Sandostatin^® LAR^® (octreotide/IM injection) 30 mg IM and is pleased with her convenient dosing regimen.

Follow-up Notes and Current Status
GH and IGF-I levels, as well as pituitary function, are completely normal since beginning somatostatin analogue therapy. GC continues to be monitored every 3 months. Subsequent follow-up with a visual field test has indicated that her field of vision has improved. The patient has not experienced any adverse events during Sandostatin^® LAR^® therapy and remains in complete remission.

Visual field test results following initiation of Sandostatin^® LAR^® therapy.

Early History of Illness
RM is a 51-year-old truck driver who presented at age 46 complaining of the need to purchase larger shoes almost every other year for the last couple of years due to increased foot size. Also, a close friend, whom he hadn't seen in almost a decade, commented that his appearance had noticeably changed (ie, coarser) since last they met, as they were looking at old photographs. This coupled with feeling fatigue and slight joint pain led RM to seek medical attention.

Diagnostic Workup

Physical Exam

Initial findings by the doctor included:

• Increased shoe and glove sizes over the past few years-large hands and feet
• Fatigue
• Joint pain
• Facial changes (ie, prognathism)
• Hypertension (160/100 mm Hg)

Acromegaly was suspected and laboratory tests were ordered.

Laboratory Analysis
RM had a marked elevated plasma GH level of 59.6 µg/L (post-OGTT) and an IGF-I level of 514 µg/L.

MRI scans revealed a 1.70 cm X 0.65 cm macroadenoma that abutted into the optic chiasm.

These tests confirmed that RM had a macroadenoma of the pituitary, as well as acromegaly.

Initial Drug Therapy
Bromocriptine therapy was initiated 10 months after the diagnosis of acromegaly and induced a slight response, with <10% suppression of the GH level. However, bromocriptine levels >5 mg/day caused blocked nose and headache, and treatment was discontinued. The patient was switched to pergolide, and the GH level was reduced to about 40 µg/L, with no apparent effect on IGF-I levels. Pergolide therapy was also poorly tolerated and was discontinued due to gastrointestinal upset. Bromocriptine was restarted 4 months later, with only fair patient compliance.

Current Treatment Plan and Results
While surgical resection of the patient's pituitary tumour was being planned, he developed severe obstructive sleep apnea syndrome. This complication of acromegaly required nocturnal cPAP therapy and precluded a surgical approach at that time. Surgery was postponed, and the patient was started on once-monthly Sandostatin^® LAR^® (octreotide/IM injection), 20 mg given IM. He experienced an improvement in both physical appearance and results of polysomnography. Hormonal levels have been normalised-GH levels decreased to <2 µg/L and IGF-I levels to normal according to age and sex.

Follow-up Notes and Current Status
The patient continues on once-monthly Sandostatin^® LAR^® therapy, which has been well tolerated. GH and IGF-I levels are monitored at regular intervals (4 times a year). Both sleep apnea and clinical features of acromegaly are well controlled. He is currently being evaluated to determine if he is a candidate to undergo transsphenoidal surgery in the future.