A 37-year-old woman was sitting in the outpatient department of Apollo Hospitals, Hyderabad, with her husband, who had back pain, waiting their turn to see Dr Sudhir Kumar, a neurologist.
When they met Dr Kumar, it was not his patient that he noticed first, but the patient’s wife — a woman whose nose and lips were a bit larger than usual. When she smiled, he observed teeth that were a bit spaced out, and a tongue that was a little thicker than normal. And when she spoke, her voice was hoarse.
Dr Kumar’s first question to the woman: “Don’t mistake me, but has your shoe size increased?”
Caught by surprise, she said, “Yes! It has increased from a 5 to a 7 in the past two years. But doesn’t everyone’s feet grow bigger as they grow older?”
“Feet grow during childhood and adolescence,” the doctor said, “but at your age, I’m afraid, they don’t grow.”
He knew with utmost confidence what had caused the changes in her appearance and ordered blood tests to confirm his diagnosis.
A few tests later, Dr Kumar got the confirmation he required. The woman was suffering from acromegaly.
What is acromegaly?
Acromegaly is a hormonal disorder that develops when the pituitary gland, which is at the base of the brain, produces too much growth hormone during adulthood. It is usually caused by a benign tumour on the pituitary gland.
If the growth hormone is being excessively secreted, it may lead to excessive growth of the body and the organs. It is seen in both adolescents and adults.
The growth hormone directly goes to the bones as well as the liver. It triggers the liver to produce a hormone called insulin-like growth factor 1 (IGF-1). The IGF-1 hormone is a major reason for the growth of organs and the formation of bones.
In children, as they are still growing, there are gaps between the bones to allow for full growth. But if there is excessive production of the growth hormone, such children will gain too much height, leading to a condition called gigantism.
“The growth hormone is required for children and it majorly helps in increasing height. but if there is excessive secretion of hormones in childhood, it causes gigantism,” Dr Kumar tells South First.
In adults, however, bones have already reached full size at a certain age.
“Even if there is an excessive amount of growth hormone, there won’t be any height gain. Instead, there will be abnormal facial features and other changes, and it is diagnosed as acromegaly,” says Dr Datta Reddy Aakiti, consultant endocrinologist at Yashoda Hospitals in Hyderabad.
Many manifestations of acromegaly
In another case, a 34-year-old man came seeking a solution for erectile dysfunction. He had consulted other doctors in the city earlier and with no fix in sight, he ended up in Dr Aakiti’s outpatient room.
“He was suffering from this issue for the last year. Looking at his hands and his facial features, I had asked him to get some tests done,” the doctor told South First. It was again acromegaly.
“This disorder presents with many complications. A 29-year-old male patient once came to me with headaches for over a year and then there was this woman who came with galactorrhea — milk discharge in non-pregnant, non-lactating women. And both of them were diagnosed with acromegaly,” says Dr Aakiti.
Symptoms and complications
The major problem with acromegaly is that the tumour grows very slowly and symptoms may not show up in the initial few years.
“Some people may present with symptoms only after 10 years. There might be an average one-decade delay in diagnosing the disorder as the symptoms may not be obvious,” says Dr Aakiti.
In most cases, identification of this hormonal disorder begins with noticing changes in facial features, as well as an increase in foot size and hand size.
“The nose becomes a little broader, lips and tongue become a little thicker, space between the teeth also become wider,” says Dr Kumar. Women with acromegaly may also exhibit growth of facial hair, such as a mustache and beard.
Explaining the voice change in his female patient, he says that the vocal cords also become thicker due to which her voice became hoarse. Snoring, sweaty skin, oily skin, a broader forehead and a protruding chin are other changes observed.
“Sometimes, the increase in size of the pituitary gland may cause compression of surrounding brain tissue. This typically manifests as a headache, thus making it a common symptom of acromegaly,” says Dr Aakiti, adding, “The increased size may also lead to compression of the optic nerves, causing blurred vision or vision loss.”
The size of the heart may also increase, which may lead to hypertension and high blood pressure, while increased IGF-1 may lead to elevated blood sugar levels.
“In women, there may be an increased production of the lactating hormone, which may cause galactorrhea. It may also reduce testosterone levels in males, due to which there may be a decrease in libido, and also erectile dysfunction,” says Dr Aakiti.
Dr Kumar adds, “Bones and joints become weaker, the body will become heavy, and while one may look strong, the bones will become hollow, resulting in arthritis.”
There are three steps to diagnosing acromegaly.
IGF-1 levels: A simple blood test is done to measure the IGF-1 level. An elevated IGF-1 level suggests acromegaly. To further confirm, the doctor might suggest a Growth Hormone Suppression test.
Growth Hormone Suppression: In a normal person, the growth hormone level fluctuates through the day. “In this test, blood samples are taken before and one hour after you drink 75-100 gm of glucose. Glucose typically reduces the level of growth hormone in a normal person. But in someone with acromegaly, the level will remain the same,” says Dr Kumar.
MRI: This will help pinpoint the location and size of the tumour on the pituitary gland, if there is one.
“Nine times out of 10, a tumour will be found in the brain in such cases, but in rare instances, it can also be seen in other parts of the body,” says Dr Kumar.
Luckily, the disorder is treatable and there are currently three treatments available.
“There is medication used to specifically treat the disorder and suppress the growth hormone level. We also recommend medication when surgery is a high risk,” says Dr Kumar.
However, he adds that the decision depends on the size of the tumour, “The tumour can compress the brain and nerves, and this can cause vision loss and other complications. In such cases, we cannot afford to wait and see how they respond to medication. We will have to opt for surgery,” says Dr Kumar.
Dr Aakiti says that doctors recommend surgery when there is a possibility of removing the tumour completely.
He adds that most patients come late because their symptoms only show gradually, and “by that time, the tumour may have grown to a point that even after surgery, we may not be able to completely remove the tumour. In this case, we supplement with radiation therapy.”