1. 손발 커짐을 주소로 내원한 48세 여자환자
내분비대사 내과 R3 정명화/ Prof. 김성운

2. Chief Complaint Present illness
Case : F/ 김O옥
Chief Complaint
Increasing size of both hands and feet Onset : 10 years ago
Present illness
F/48, 1년 전 제2형 당뇨병 진단받은자로 점차적인 손발
커짐 및 얼굴 변형 등에 대한 자세한 검사 및 치료 위해
타병원 경유 본원 내분비대사내과 방문함.

3. PMHx DM (+) : Glimepiride 2mg qd
HTN (+) : Losartan 50mg qd
Dyslipidemia (+) : Rosuvastatin 10mg qd
Pulmonary Tbc(+) : 15년 전, 항결핵약 복용 후 완치 판정
FHx
PHx Smoking (-)
Alcohol (-)

4. Review of Systems General
general weakness (-) fever(-) fatigue (-) dizziness (-)
weight gain (+) : 13 kg/10 yrs
Skin
Rash(-) pigmentation (-) alopecia (-) flushing(-)
Head and Neck
headache (-)
voice change (+) : deep
Eye and ENT
sore throat (-) blunted visual field (-)
decreased visual acuity (-/-) enlarged nose and lips
Resp. & cardiac
Dyspnea(-) cough(-) sputum(-) Chest pain(-)palpitation(-)
Gastrointestinal
A/N/V/D/C (-/-/-/-/-) Abdominal pain (-)
Musculoskeletal
generalized myalgia (+) enlarged both hands and feet
Gynecological
Amenorrhea (+): for 10 years galactorrhea (-)

5. Physical Examination Height: 163 cm Body weight: 62 Kg BMI: 23.3 Kg/m2
Vital sign: 120/70 mmHg – 80/min – 22/min – 36.3°C
General
alert consciousness
generally well-looking appearance
Skin
Pigmentation (-) oily skin (+)
Head and Neck
Isocoric pupil with PLR(++/++) LNE(-)
Frontal bossing (+) prognathism (-)
Eye and ENT
proptosis (+) large fleshy nose (+) full lips (+)
Chest
Symmetric chest expansion
Clear breath sound without rale
Abdomen
Soft abdomen Td/rTd (-/-)

7. Physical Examination Abdomen soft abdomen Td/rTd (-/-) Back & Ext.
CVA Td (-/-)
pretibial pitting edema(-/-)
Increased both hand, foot
Neurology
Sensory: intact , motor : intact

8. patient
patient

9. 타병원 검사 자료 2007-06-18 24.4 GH (<5.0) 503.0 IGF-I (75~430) 141.0
(ng/mL)
24.4
IGF-I (75~430)
503.0
PRL (<18)
141.0
ACTH (<80 at 9am)
(pg/mL)
122.0

10. Sellar MRI (타병원 시행, )

11. Impression #1. Acromegaly due to GH-secreting pituitary macroadenoma
R/O plurihormonal pituitary macroadenoma
(possibly with Pit-1 expression)
#2. Known T2DM
#3. Known HTN
#4. Known dyslipidemia

12. Diagnostic Plan
#1. Acromegaly due to GH-secreting pituitary macroadenoma
R/O plurihormonal pituitary macroadenoma
- 75g glucose loading GH suppression test
- IGF-I level
- TRH stimulation for GH
- Evaluation for other pituitary hormones
- Somatostatin suppression test
- Transsphenoidal approach for surgical biopsy
- Colonoscopy

13. Therapeutic Plan
#1. Acromegaly due to GH-secreting pituitary macroadenoma
R/O plurihormonal pituitary macroadenoma
- Medical therapy
Somatostatin analogue
Bromocriptine
- Radiation therapy

14. #2. Known T2DM #3. Known HTN #4. Known dyslipidemia
- Glimepiride , losartan , rosuvastatin 유지

15. Laboratory Findings CBC/DC
5,630/mm g/dl- 35.1% - 254,000/mm3 (seg.59.3%)
(MCV 91.2 fL MCH 31.3 pg MCHC 34.3 g/dL)
Chemistry
TB/DB 0.85/0.05 mg/dL T-pro/alb 6.7/3.7 g/dL
AST/ALT 21/25 U/L ALP/GGT 63/12 U/L
Glucose 202 mg/dL BUN/Cr 13/0.5 mg/dL
Na/K/Cl 141/3.8/105 mmol/L Ca/P 9.4/4.6 mg/dL
LD/CK 293/75 U/L Uric acid 3.7 mg/dL
T-Chol/TG 239/210 mg/dL HDL/LDL 52/140 mg/dL
TFT T ng/dL fT ng/dL TSH mU/mL
HbA1C 7.1%
U/A RBC 0~1/HPF WBC 0~1/HPF Protein (-)

16. Chest PA

17. ECG

18. 75g Glucose Loading GH Suppression Test
IGF-I ng/mL ( ) IGFBP ,157 ng/mL
-30 min
0 min
30 min
60 min
90 min
120 min
Glucose
(mg/dL)
126
219
192
223
250 GH
(ng/mL)
16.0
14.0
13.0
10.0
7.6
Insulin
(µU/mL)
28.6
278.5
C-peptide
3.0
8.8
Insulinogenic index HOMA-IR

19. TRH Stimulation Test T3 135 ng/mL FT4 1.09 ng/dL TRH 200 µg 16.0 13.0
-30 min
0 min
30 min
60 min
90 min
120 min GH
(ng/mL)
16.0
13.0
86.0
44.0
26.0
10.0
PRL
114.5
>300
230.4
218.0
202.6
TSH
(µU/mL)
1.5
9.4
7.8
5.3
4.1
T ng/mL FT ng/dL

20. Double Stimulation Test
62 Kg, RI 0.2U/Kg, LHRH 100 µg
E pg/mL progesterone ng/mL testosterone ng/mL
-30 min
0 min
30 min
60 min
90 min
120 min
Glucose
(mg/dL)
119 53 71 85
101 GH
(ng/mL)
18.0
16.0
13.0
11.0
9.4
9.2
ACTH
(pg/mL)
41.5
71.3
345.4
162.9
54.9
34.2
Cortisol
(µg/dL)
12.4
22.9
33.4
22.0
19.7
FSH
(mIU/mL)
1.8
5.5
8.7
9.5
9.0 LH
0.2
1.2
1.6
1.4

21. Somatostatin Suppression Test
octreotide 100 µg
-30 min
0 min
1 hour
2 hours
3 hours
4 hours GH
(ng/mL)
23.0
14.0
11.0
9.9
8.7

22. Colonoscopy
0.4cm

23. Visual Field
left
right

24. Clinical Course I Transsphenoidal approach (TSA) (2007-08-07) biopsy
no acute complication

25. Microscopic Findings - HE stain
2cc volume
HE X100
HE X400

26. Microscopic Findings - IHC stainGH
PRL
TSH
ACTH
FSH LH

27. Microscopic Findings - IHC stain
Pit-1

28. Microscopic Findings - IHC stain
Ki-67 < 1%
p53 (+)

29. Microscopic Findings at CFS
3.3 mm tumor
CD56
carcinoid tumor
synaptophysin
chromogranin

30. Final Diagnosis
#1. Acromegaly due to plurihormonal pituitary adenoma
with Pit-1 expression
#2. Rectal carcinoid tumor s/p endoscopic resection

31. Clinical Course III – GH/IGF-1/PRL
PRL, IGF-1 (ng/mL)
600.0
IGF-I
450.0
300.0
150.0
TSA
date
Oct-LAR 20mg
Oct-LAR 30mg
BRCT 2.5mg
BRCT 5.0mg
BRCT 7.5mg

32. 2007
2008
2009
2010