The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Stephanie V. Sherman, M.D., Editor

Acromegaly
A B

C D

Joshua Weinreb, M.D., Ph.D.

Albert Einstein College of Medicine
Bronx, NY *
jweinre1@mail.einstein.yu.edu

Shitij Arora, M.D.

Montefiore Medical Center
Bronx, NY

A
34-year-old man who had been admitted to the hospital with diabetic ketoacidosis was
noted to have coarse facial features. He had no known medical history but had noted an increase in shoe
size by three full sizes over the past 10 years and blurry vision for the past 3 years. Physical examination
showed a widened nose, frontal bossing, prominent lower jaw, and malocclusion of the upper incisors (Panel A),
findings not seen in a photograph taken 15 years earlier (Panel B). Visual-field testing showed bitemporal hemi-
anopsia. Laboratory studies showed a glycated hemoglobin level of 12.3% (reference range, 5 to 14), an insulin-like
growth factor 1 (IGF-1) level of 478 ng per milliliter (reference range, 53 to 331), and a growth hormone level of
more than 65 ng per milliliter (reference value, ≤7.1). A diagnosis of acromegaly was made. Magnetic resonance
imaging of the head revealed a pituitary macroadenoma measuring 6.0 cm by 3.4 cm by 2.8 cm (Panel C, asterisk)
and macroglossia. Transsphenoidal partial tumor resection was performed. Histopathological testing showed a
somatotroph adenoma (Panel D, hematoxylin and eosin staining) that also stained positive for growth hormone.
The patient was discharged with instructions to receive monthly octreotide to treat residual tumor and with medica-
tions for diabetes and hypertension. At 1 month of follow-up, the patient’s IGF-1 level had reduced, but the mass
gradually reexpanded, which led to a second resection 8 months after the initial surgery.
DOI: 10.1056/NEJMicm2205570
Copyright © 2023 Massachusetts Medical Society.

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