Endocrine complication of growth hormone secreting tumor: A case report

Dharsshini N

Clinical Pharmacist, Kauvery Hospital, Cantonment, Trichy

Abstract

Pituitary tumors pose diagnostic and management challenges due to diverse presentations and potential complications. This case highlights the endocrine complexities of a pituitary tumor. A 27-year male patient with history of stiffness of the body and enlarging extremities for six years was surgically managed for a growing pituitary tumor. Trans-nasal and Trans sphenoidal endoscopic surgery for tumor resection was done. For an early-stage pituitary tumor, treatment include dopamine agonists like Bromocriptine and Cabergoline which mimic the action of dopamine can be beneficial. Management often involves a multidisciplinary approach, including surgery, endocrinology, Ophthalmology and supportive care.

Background

Pituitary adenomas, often considered benign neoplasms, arise from the pituitary gland and can significantly impacts the delicate balance of the endocrine system. Pituitary gland, a pea shaped structure situated at the base of the brain, plays a pivotal role in orchestrating the bodys hormonal milieu.[1] Pituitary adenomas, accounting for approx. 10-15% of intracranial tumors, encompass a diverse group with varying clinical presentations and hormonal profiles.[2] These tumors can cause overproduction or underproduction of hormones from the gland. Excess production can result in acromegaly. Overproduction of prolactin may lead to hyperprolactinemia and galactorrhea. It may influence testosterone production and sperm development. These large tumors can compress optic nerves causing visual impairment such as blurry vision or loss of peripheral vision. It may also affect the release of antidiuretic hormone impacting water balance in the body. Tumors of the anterior pituitary are usually pituitary adenomas. Depending on their size, pituitary adenomas can be classified as macroadenomas, or microadenomas. This case summarizes the endocrine complications of pituitary tumor.

Endocrine-1

Fig (1): Pituitary Adenoma

Case Presentation

A 27-year-old male patient presented with a two days history of headache and, dysphagia. He also had abnormal growth of the body, especially face and limbs, which was progressive over six years. Concurrently, he experienced heaviness in the occipital region. Also, he had double vision for six months. No other relevant past medical history. He was conscious, oriented and had acromegaly.

Vitals and lab investigation

S. No

Lab parameters

Result

Normal Range
1 Human growth hormone >40.0 ng/ml Upto 3
2 TSH <0.10 Uiu/ml 0.7-27.0
3 FSH 4.89 mIU/ml 3.5-12.5
4 LH 2.43 mIU/ml 14.0-95.5
5 Prolactin 45.27 ng/ml 4.04-15.20

Laboratory investigation revealed elevated levels of Growth Hormone, Luteinizing Hormone (LH), FSH (Follicle stimulating hormone) and Prolactin. Liver enzymes were also elevated shown Tab: 1. MRI showed isoechoic lesions in sellar region with compression of pituitary stalk and optic chiasm. His vitals were normal.

Table 1: Lab Investigations

 

Diagnosis

Pituitary Macroadenoma

The Patient had Trans nasal Trans sphenoidal endoscopic surgery for tumor resection. He had lumbar puncture for CSF drain. After the procedure, he had active nasal bleed and complained of neck pain, headache and vomiting. CSF cultures showed no growth. His CT brain showed diffused cerebral edema. He was shifted to intensive care and tracheostomy was done. During his stay he developed fever spikes, tracheal culture showed Acinetobacter and therapy was initiated with colistin and meropenem. CT chest showed left lung collapse. Adequate ventilation was managed. Treatment encompassed antibiotics, analgesics, steroids, antidiuretic hormone etc. The patient positively responded to the prescribed regimen.

Endocrine-2

Fig (2): Represents the patient with Acromegaly

 

Discussion

Pituitary adenomas are common neoplasms of the central nervous system. It accounts for 12.7% of all primary CNS tumors. Macroadenomas usually present with mass effects as visual disturbance.

This patient was treated with transsphenoidal Trans nasal endoscopic, a minimally invasive approach, for the management of his condition within the skull base. The surgical procedure involved the insertion of an endoscope through the nasal passages, providing a direct route to the target area without the necessity of external incisions.

This technique, often employed for pituitary tumor removal and related disorders, afforded enhanced visualization of the operative field, resulting in improved surgical outcomes. Tumors may compress the optic nerves, causing visual disturbances or even vision loss. Surgical removal of the tumor (transsphenoidal surgery) relieved pressure on the optic nerves.

Early stage management of Pituitary tumor

For an early stage pituitary tumor, treatment include medications like dopamine agonists (Bromocriptine, Cabergoline) which mimic the action of dopamine. Dopamine inhibits the release of prolactin form the pituitary gland and somatostatin analogs (Octreotide and lanreotide) regulate the hormone levels. They mimics the action of somatostatin, a hormone that inhibits the release of various pituitary hormones including growth hormone and are particularly effective in managing growth hormone-secreting tumors (acromegaly). Cabergoline and octreotide are favored for their longer duration of action. [3, 4]

Conclusion

The findings in this case illustrate that clinicians should also consider the possibility of endocrine complications seen in patients with pituitary adenomas. Thus a proactive and collaborative strategy optimizes outcomes, and establishes a system that allows for adequate follow-up of patients.

Reference

  1. Melmed S. (2011). Pathogenesis of pituitary tumors. Nature Reviews Endocrinology,7(5), 257-266.
  2. Asa SL, Ezzat S. (2002). The pathogenesis of pituitary tumors. Annual Review of Pathology: Mechanisms of Disease, 7, 103-122.
  3. Melmed, S. (2011). Pituitary-tumor endocrinopathies. New England Journal of Medicine,364(7), 636-648.
  4. Colao, A., Petersenn, S., Newell-Price, J., Findling, J. W., Gu, F., Maldonado, M.,&amp; Biller, B. M. (2011). A 12-month phase 3 study of pasireotide in Cushings disease. New England Journal of Medicine, 364(11), 914-92.
Dharsshini

Dharsshini. N

Clinical Pharmacist

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