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Clinical Case 6
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Objectives:

  • Recognize signs and symptoms of growth hormone excess
  • Evaluate and manage a patient with growth hormone excess



1

A 39-year-old female presents to the office, also complaining of amenorrhea. She has had normal menses until 8 months ago, when they became infrequent, then stopped. She insists she cannot be pregnant, because she denies sexual activity “in years.” She believes she is going through “the change” but wants to know why she is reaching menopause at a much earlier age than other women she knows. On review of systems, she complains of headaches “for years” and recent onset of weakness and fatigue. She also complains of arthritis in the hip and knees, something she attributes to “getting old.” She denies other complaints.

Physical exam results show that her vitals are normal. The patient is an adult female of average height, with a noticeably large jaw and hands. She is not wearing rings on her fingers (she reports that now that she is fat, they don’t fit any more). Her hair is thick and coarse, and hirsutism is present. Her thyroid gland is slightly enlarged, but regular in shape. No bruit or tenderness is present. The point of maximal impulse is displaced laterally, but the heart is regular with no murmurs. The rest of the exam is normal.

What is the most appropriate next step?

A)Reassure the patient that menopause is a normal process and offer estrogen replacement therapy for symptomatic relief (but warn the patient about risks of long-term use).
B)Tell the patient you suspect depression and offer a regimen of counseling combined with serotonin reuptake inhibitor (SSRI) therapy.
C)Although she is likely depressed, tell the patient she may have a thyroid disorder at least contributing to the problem and recommend measuring her TSH level.
D)Although she is likely depressed, tell the patient she may suffer from growth hormone (GH) excess, and recommend obtaining a serum insulin-like growth factor (IGF-I) level.
E)Tell the patient to get a life (you know of one for sale cheap on eBay).
2

The patient’s IGF-I is elevated, and her TSH is normal. An MRI is performed, which reveals a pituitary mass slightly < 1 cm in diameter.

What is the most effective therapy for this condition?

A)Weekly anti-IGF-I antibody infusions.
B)Bromocriptine therapy.
C)Transsphenoidal surgery.
D)Somatostatin analogs (such as octreotide).
E)Pegvisomant (growth hormone receptor antagonist).







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