A 50-YEAR-OLD WOMAN WITH HEADACHE AND SWEATING

PRESENTED BY:Dr. Hasinatul Zannat Phase-A Resident (Nephrology)Department of Endocrinology

Particulars of the patient

• Name: Mrs. M B• Age: 50 year• Sex : Female• Address: B• Occupation: Housewife• Religion: Islam• Date of Admission: 07.11.2013

Presenting Complaints

• Headache and excessive sweating for three years

• Change in voice for one and half year

• Progressive enlargement of hands and feet for last one year

History of present illness

• Diagnosed a case of type 2 DM for 3 years -on the basis of weight loss, polyurea, polydipsia and high blood sugar -initially on insulin for 7 months -oral antidiabetic agent for 2 years -no medication for last 5months

History of present illness Continued…

• Headache - Dull aching type, mild to moderate in severity

- Gradual onset, present in most of the days without any diurnal variation - Global - No visual disturbance or any features suggestive of raised ICP

- No specific aggravating factors - Resolved spontaneously or by taking P/C

History of present illness Continued…

• Excessive sweating• Enlargement of hands, feet, nose, lips• Weakness for one year• Change in voice• Sometimes tingling sensation in both hands

• Multiple joint pain -both small & large joints -mechanical• Low back pain

History of present illness Continued…

Past medical history

• Hysterectomy-7yrs back for uterine prolapse• Diagnosed as thyrotoxicosis - 2 years back • Treated with carbimazole, discontinued for

last 5 months

Current medication

• Tab. Metformin(500) - OD at night• Tab. Paracetamol(500) - 1+1+1

General examination

Appearance: • Enlarged face• Prominent supra orbital ridge• Baggy eyelid• Enlargement of nose, lips• Prognathism• Bulky, doughy feeling, warm-sweaty hands• Spade like fingers,toes

General examination continued

• Body build: Average• Anaemia: Not anaemic• Oedema : Absent• Height: 154 cm• Weight: 60 kg• BMI: 25.3 kg/m2

General examination continued

• Pulse: 88 b/min• BP: 120/80 mmHg

• Thyroid gland: diffusely enlarged, non-tender, firm in consistency, no bruit

• Neck vein: not engorged

Nervous system examination

• Visual field :Normal• Fundoscopy NAD• Features of carpal tunnel syndrome• No proximal myopathy• No peripheral neuropathy

Musculoskeletal

• There is no evidence of arthritis • Except Right knee joint– Crepitations– Deformity

Cardiovascular system:

• Apex : left 5th ICS, just medial to the MCL• S1+S2:audiable, normal intensity• No murmur

• Other system exam: NAD

Provisional diagnosis

• Acromegaly with Diabetis mellitus

Investigations

Tests Date Results

Fasting plasma glucose 9.11.13 8.3 mmol/l

14.11.13 8.1 mmol/l

15.11.13 8.8 mmol/l

16.11.13 9.3 mmol/l

Plasma glucose 2 hour after breakfast

9.11.13 11.9 mmol/l

16.11.13 7.8 mmol/l

Plasma glucose 2 hour after breakfast

13.11.13 11.7 mmol/l

15.11.13 9.1 mmol/l

InvestigationsTests Date Results

Plasma glucose 2 hour after dinner

13.11.13 13.3 mmol/l

14.11.13 8.6 mmol/l

15.11.13 9.1 mmol/l

HbA1c 12.11.13 7.6%

S. creatinine 9.11.13 0.7 mg/dl

SGPT 12.11.13 36 U/L

CBC 12.11.13 Normal

F. Lipid profile 12.11.13 TC - 360 mg/dlHDL- 51 mg/dlLDL- 176 mg/dlTG- 333 mg/dl

InvestigationsTests Date Results

USG of W/A 13.11.13 Normal

ECG 10.11.13 Normal

Investigations

29.06.11 18.08.11 9.11.13

S. GH(0.06-5ng/ml)

7.4 ng/ml 34.3 ng/ml

S. T4 25.28 pmol/L 13.8 pmol/L

S.FT4 1.45 ng/dl

S. TSH 0.16 IU/ml < 0.004 IU/ml 0.33 IU/ml

S. Prolactin 4.45 ng/dl

S. Basal cortisol 301.5 nmol/L

X-ray skull true lateral view

X-Ray hand and feet

MRI of Pituitary

Final Diagnosis

Acromegaly due to pituitary macroadenoma with DM

Acknowledgement

• Prof.Dr. FARIDUDDIN Chairman Dept of Endocrinology, BSMMU

• Assoc. Prof.Dr. MA HASANAT Dept of Endocrionology,BSMMU

THANK YOU