Abstract
Acromegaly is a condition defined by excess growth hormone (GH). The clinical features of acromegaly including overgrowth of many tissues including cartilage, bone, skin and visceral organs. It often times presents with coarsening of facial features and increased hat or ring size. Cardiovascular disease including hypertension with left ventricular hypertrophy and metabolic deficiencies including insulin resistance are also commonly seen as a result of the GH excess. The most common cause of acromegaly has been found to be GH secreting pituitary adenomas. MRI is generally sufficient to identify these lesions, but rarely a patient with symptoms of acromegaly will be found to have empty sella syndrome. Case: A 37 year old male, with a PMH of uncontrolled HTN presented to the emergency department after his wife found him on the floor, unconscious, foaming at the mouth, and shaking. He had an episode of urinary incontinence and was postictal for 20-30 minutes after the episode. In ED, he was hypertensive at 246/162, CT head showed right frontal intraparenchymal 1.2 cm hemorrhage and MRI brain showed various foci of hyperintensity compatible with hypertensive encephalopathy. He was also hypokalemic (2.9) with evidence of an AKI (BUN 27, Cr 1.73). He was admitted for further evaluation of suspected seizure. Upon further evaluation, the patient admitted to coarsening of facial features as noted on comparison of prior photographs. He also reported difficulties with his wedding ring fitting which he attributed to hand swelling. ROS was other negative with no vision changes or headaches. This sparked concern for a secondary cause of hypertension in the setting of clinical acromegaly. MRI brain was complicated by movement but revealed pituitary characteristics of empty sella syndrome. Insulin like growth factor 1 - 745. ECHO showed severe concentric left ventricular hypertrophy with aortic valve sclerosis and left atrial dilation. Renal Artery ultrasound showed no evidence of renal artery stenosis. The patient was subsequently scheduled for repeat MRI brain pituitary as outpatient under anesthesia to evaluate for possible surgical treatment for acromegaly. Discussion: This case demonstrates that empty sella syndrome does not warrant exclusion of acromegaly. GH secreting tumors can be present despite empty sella syndrome and acromegaly can even cause enlargement of the sella (?) . In these cases, the pituitary tissue lining the sella can be the source of excess GH. Upon case review, the mechanism remains unclear but empty sella syndrome may result from necrosis by infarction or from hemorrhage. Since no resectable mass is present in these cases, medical management with somatostatin analogues remains the only treatment that can be offered to these patients. It is important to keep acromegaly on the differential despite empty sella.