Undiagnosed acromegaly

Undiagnosed acromegaly Report

of a case

James E. Lanmster, Colonel, DC, UXd*

M

ETIOLOGY

AND

PATHOGENEM

ariel described acromegaly as a striking enlargement of the acral or terminal parts of the body and associated the malady with changes in the pituitary gland. Shortly thereafter, Minkowski2 reported a case of acromegaly associated with a tumor of the hypophysis, and a few years later Benda discussed the predominance of acidophilic ~11s in relation to these pituitary adenomas. The role of the eosinophilic cells in relation to the disease was accepted in 1928,4 and since that time the etiology of the condition has been quite well understood. The pituit.ary gland lies in the sclla turcica or hypophpsial fossa of the sphenoid bone and is covered by a layer of dura mater. The relationship of the gland to neighboring structures is most important, with the optic nerves and optic chiasm situated anterior and superior to the body. Compression on these rital structures b,xwglandular enlargement, such as that found in tumor formation, could result in severe visual drfccts.” The gland is divided into three lobes, and the anterior lobe has been termed the adenohgpophysis because of its predominantly glandular function. A variety of important hormones are produced by the different types of ~11s in the adenohypophysis, and it, is the escessive scrretion of the growth (somat,otrophic) hormone by the acidophilic cells that results in both gigantism and acromegaly. It has been stated that adrnomas of the anterior lobe of the hypophysis are the most common of all intracranial tumors,7 but hppersecrction may also be due to hpperplasia. If the somatotrophic hypcrsccretion occurs before cpiphgsial closure, gipantism results. Acromegalp is produced when the hppcrsecretion begins after epiphpsial closure and is usually seen in patients over 20 y-cars of age.’ CLINICAL

AND

ROENTGENOGRAPHIC

FEATURES

All tissues of the body are affected by acromcgaly, but they show a peculiar variability in the extent of involvcmrnt .n IIcadarhc”’ or pain in joints and cx“Chief,

Oral

Diagnosis

and

Roentgcnology,

Ikntxl

Service,

Fort

Hood,

Texas.

133

134

O.S..O..\l. L\ 0.1’. .luly. I!ltG

/mrc~fr.sl(‘/

TREATMENT

AND

PROGNOSIS

The treatment, of acrorncgnly may consist of cithcrs radiation or snryicnl procedures, with most adenomas that axe without, rstrasellar taxtensions bring candidates for Padiotherapy. Significant, decrcascs in \-isual fields OL’other signs of txtrasellar extension are the most significant indications for surgical removal of the pituitary tumor.1” Encouraging r*csults ha\-c been rrportcd following the use of pituitaq- implantation with small sou~‘ccsof rxdioacti\-c m:rtcr*ial.‘” The prognosis of untreated ;rc~omcgal,~ is guwrdrd, but, thtb &‘cct of irxrdiation therapy on the discasc has been most i’a~~~~*;~blc. The prognosis of thrl treated diseasedepends, of course, on the patient’s age at onset and, nror~ part irularl.v, on when therapy is begun.‘” (!or+don and associates” lra\x: recently reported no progress in thr disease in forty-fouY out of fiftytwo irrWliatcd patients, illld Hamwi and associatesz2r*eportc31cWYtllcnt results in thir*tocn pilticntS tr:eatPd l)~* oithtlr s-ray or* surgical Inc>thods. CASE REPORT

Volume Number

20 1

Fig.

1. ( ‘linical

photograph

showing

marked

enlargement

of ha 1,Id%

facial features and an enlargement of the hands were not,rd. The patient was questione? and, because of his appearance and history, a consultation with the medical service was requested. The history elicited from the patient indicated that he had been aware of a progressive enlargement of the extremities for the past 4 years and that he had also noticed an increase in head size. He stated that his ring size had doubled and that he had noticed a deepening of his voice and recently some dyspnca on exertion. The patient drnirtl any change in libido, headaches, or visual disturbances. Before entering the service the patient was employed in a cheese factory, and in the Army he had worked as a personnel administration clerk. Hc was married and did not use alcohol or tobacco. Phyricol

excmination

Clinical examination revealed a \veIl-developed, well-nourished young man with a lmlging brow, large oose, thick lips, and huge spadelike hands and fret. ‘l%ere WCS an asymmetry in the chest, with a bulge t,o the left of the sternum (Fig. 1 ). All other systems were essentially negative. Laboratory

The of 10.6.

studies

blood chemistry showed The fasting blood sugar

Roentgenogmphic

an inorganic serum phosphorus of 6.9 and a serum calcium was 108, and the 2 hour postprandial blood sugar was 151.

studies

Roentgenograms of the skull revealed a sella turcica measuring 20 mm. in anteroposterior diameter, and there was a suggestion of enlargement in the superoinferior diameter with a possible double floor (Fig. 2). There was no erosion of the clinoid process; nor was the mandible markedly prognathic. The frontal and maxillary sinuses were extremely large. The hands and feet were negativ-e for ungual tufting, but there was considerable soft-t,issue enlargement with the soft tissue below the calcaneous measuring 33 mm. bilaterally (Fig. 3). Full-mouth roentgenograms revealed a roentgenolucency in the anterior portion of the mandihle which was associated with the apices of three nonvital teeth. Endodontic procedures were performed, and tissue from the area was diagnosed by histopathologic study as a dental granuloma.

(l.~.,O.~l. SC0.1'. .I Ill?-. I !lfi.5

Course

in

the

Recause phosphorus, postprandial were normal, to arrest the mrnt on Feb.

hospital

of the sgmptonm, history, roentgrnograpllic tiudings, autl dcvrtted inorganic it was thought that the patient tlefinitcly had active :tcwnwgaly. The ctltvated blood sugar suggested a c~onc~omitant, mild dialwtw. Sinw thr visual fields it was decided that. this patient, was a canditlatc~ for pituitary glantl irradiation acromegalic process. Hc was wacwttcxl to a general liospital for furthw trcat13, 1961.

DISCUSSION

It has been said’” that on occasion the dental practitioner is in an advantageous position to detect early systemic disease, and in many disease entities early detection permits effcctivc treatment that is not possible \vhcn the disease becomes~-cl1 adranced. This statement is certainly true in casesof early acromegaly, and the stomatologist can make a significant contribution to the patient’s welfare by detecting this disease before severe illness or deformity results.

Volume Number

20 1

Undiagnosed

ncrome~nly

137

SUMMARY

A case of undiagnosed acromegaly detected bp a dental pract,itioner has been presented, and various features of the disease have been reviewed. The stomatologist may make a significant contribution to the patient’s welfare bp GIT~J detection of systemic disease. REFERENCES 1. Marie, P.: 2. Minkowski.

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

Sur deux cas d’acromegalie, Rev. de med. 6: 297-333, 1886. 0.: iiher einen Fall von Akromwalie. Berl. klin. Wehnschr. 24: 371. 1887. Benda, C!.: Beitrage zur normalen und patl&ogischen Histologie der menschlichen Hppophysis cerebri, Berl. klin. Wchnschr. 37: 1205, 1900. Bailey, P., and Cushing, H.: Studies in Acromegaly, Am. J. Path. 4: 545, 1928. Ezrin, C.: The Pituitary Gland, Ciba Clinical Symposia, Boston, 1963, Little, Brown & Company, vol. 15, pp. 71-100. Cecil. R. L.. and Loeb. R. F.: A Textbook of Medicine. ed. 9. Philadeluhia. 1959. W. B. Saunders Company, p.’ 710. Soffer, L. J.: Diseases of the Endocrine Glands, Philadelphia, 1951, Lea & Febigcr Company, p. 56. Tiecke, R. W., Stuteville, 0. H., and Calandra, J. C.: Pathologic Physiology of Oral Disease, St. Louis, 1959, The C. V. Mosby Company, p. 68. Steinbach, H. L., Feldman, R., and Goldberg, M. B.: Acromegaly, Radiology 27: 535549, 1959. Anderson, E., and Webb, H.: Disorders of the Hypothalmus and Pituitary Gland. In Baker, A. B. (editor) : Clinical Neurology, -. ed. 2, New York, 1962, Harper_ & Brothers, pp. 1338-1394.‘ Kellgren, J. H., Ball, J., and Tutton, G. K.: The Articular and Other Limb Changes in Acromegaly; Clinical and Pathological Study of 25 Cases, Quart. J. Med. 21: 405-424, 1952. O’Doherty, D. S., Canary, J. J.! and Kyle! L. H.: Neurologic Aspects of Endocrine Dised. 2, New York, 1962, Harper turbances, In Baker, A. B. (edrtor) : Clinical Neurology, & Brothers, pp. 2116-2154. Cheraskin, E., and Langley, L. L.: Dynamics of Oral Diagnosis, Chicago, 1956, The Year Book Publishers, Inc., p. 190. Davidsohn, I., and Wells, B. D.: Todd-Sanford Clinical Diagnosis l)y Laboratory Methods, ed. 13, Philadelphia, 1963, W. B. Saunders Company, p. 497. Stafne, E. C.: Dental Roentgenologic Manifestations of Systemic Disease, Radiology 58: 9-22, 1958. Sante, L. R.: Principles o-f Roentgenological Interpretation, ed. 12, Ann Arbor, 1961, Edwards Brothers, Inc., p. 122. Steinbach, H. L., and Russell, W.: Measurement of the Heel Pad as an Aid to the Diagnosis of Acromegaly, Radiology 82: 418-423, 1964. Williams, R. H.: Testhook of Endocrinology, ed. 3, Philadelphia, 1962, TV. B. Saunders Comuanv. D. 74. Degfiot$( k. M., Ruffo, A., and Melinatti, 0. M.: Implantation of the Pituitary With Yttrium 90 in Five Cases of Acromrgalv.I, “I Panminerva med. 1: 15-18. 1959. Brainerd, H., Margen, S., and Chatton, M. J.: Current Diagnosis and Treatment, Los Altos, 1964, Lange Medical Publications, p. 566. Gordon, D. A., Hill, F. M., and Ezrin, C.: dcromrgaly; Review of 100 Cases, Canad. M. A. J. 87: 1106-1109, 1962. Hamwi, G. J., Skillman, T. G., and Tufts, K. C., Jr.: Acromegaly, Am. J. Med. 29: 690-699, 1960. Flieder, D. E.: Techniques of General Physical Diagnosis of Importance to the Dentist, D. Clin. North America, pp. 9-20, March, 1963. I,

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