Acromegaly

The syndrome of growth hormone excess caused by somatotroph adenomas of the pituitary. Also known as gigantism in childhood. Diagnosis is confirmed with failure of suppression of a glucose tolerance test.

General examination

Detailed and full general examination is mandatory in the initial assessment of all endocrine patients.

Blood pressure

Elevated BP may not have been previously noted.

Face

Soft tissue swelling of the face, prominent brows, and prognathism may all be present.

Mouth and tongue

Interdental separation of the teeth and tongue expansion with indentations made by the teeth is obvious once sought.

Tongue neuromas may indicate underlying multiple endocrine neoplasia type 2.

Hands

Shovel-like, broad, doughy hands with expansion of the knuckles are characteristic. 

Breasts

Tumours co-secreting prolactin and growth hormone are common.

Untreated acromegaly is associated with an increased risk of malignancy.

Cardiovascular status

Specifically seek evidence of cardiomyopathy, or cardiac failure.

Joints

Joints may be expanded and changes of osteoarthritis are common.

Thyroid exam

Multinodular goitre is common in acromegaly and should be assessed in the usual way.

Digital rectal examination

Consider performing this in all new patients with acromegaly due to the increased incidence of colon cancer.

Pituitary status


Visual acuity and visual fields

Full assessment of acuity and fields is mandatory in all patients suspected of pituitary disease to detect chiasmal compression or other involvement of the optic pathways.


Visual fundoscopy

Disc pallor is indicative of long term visual loss which may not recover after decompression of the optic pathway.

Papilloedema is an indicator of raised intracranial pressure requiring urgent investigation.


Cranial nerves III-XII

Full cranial nerve assessment is important in all patients with suspected pituitary tumours.

The nerves of the cavernous sinus are most frequently affected, though a VI nerve palsy may be a false localising sign associated with increased intracranial pressure.


Skin

Fine wrinkling of the skin occurs in hypopituitarism.

Pallor may also occur with a normocytic normochromic anaemia with glucocorticoid deficiency.

Doughy pallid 'myxoedematous' skin may be seen with loss of thyroid function.

Doughy skin with soft tissue swelling also occurs in growth hormone excess.

Café au lait patches, skin tags and axillary freckling may indicate associated syndromes, for example neurofibromatosis, multiple endocrine neoplasia 2 or McCune Albright syndrome.


Thyroid status

Signs of hypothyroidism will be present in panhypopituitarism.


Musculature

Muscle wasting may occur in glucocorticoid deficiency.

Proximal myopathy and slow relaxing reflexes may occur with loss of thyroid function.