You are on your ophthalmology rotation and are shown the visual fields of a 55-year-old
man who is complaining of a persistent headache. He has recently developed glucose intolerance.
On physical examination you note frontal bossing, macroglossia, slight enlargement
of his thyroid, and "spading" of his fingers. What is your diagnosis, what test(s)
would you order to confirm your diagnosis, and what treatment, if any, do you recommend?
DIAGNOSIS: bitemporal hemianopia due to a growth hormone-producing pituitary adenoma
with consequent development of acromegaly.
The primary treatment of most cases of acromegaly is the transsphenoidal surgical
removal of the tumor. For patients who are not candidates for surgery or those whose
tumors cannot be completely removed, somatostatin analogs (growth hormone suppressors)
or pegvisomant, a growth hormone receptor antagonist, can be administrated. In cases
where surgery and medications are not effective, radiation therapy may be considered.
Regardless of the treatment, patients with acromegaly require long-term monitoring
to assess hormone levels and tumor size. In addition, acromegaly can lead to various
complications including cardiovascular disease, arthritis, sleep apnea, and diabetes
mellitus. Managing these complications is an essential part of the overall treatment
plan.
It is important to note that the onset of acromegaly is usually subtle, perhaps
noted only by a change in ring size. In one study, the gap between apparent onset
of the disease and diagnosis was nine years.
Bitemporal hemianopia due to compression of the optic chiasm, which is located at the junction of the anterior wall of the third ventricle and its floor. The majority of optic chiasmal syndromes are caused by extrinsic compression from pituitary tumors, suprasellar meningiomas, craniopharyngiomas, and aneurisms.
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