Case Presentation:
A 38 year-old male with diet controlled diabetes presented with 3 months of unprovoked episodes of sweats. He noted that these episodes would come on at any time of day, last several minutes and leave him “drenched.” Blood sugar readings during these episodes were normal. He reported generalized myalgias, worsening fatigue and eyelid swelling, but denied cough, headache or change in appetite. He had recently travelled to the Dominican Republic. He did report recent episodes of rectal bleeding, with a subsequent colonoscopy revealing benign polyps. Physical exam was notable for cervical lymphadenopathy (LAD) and bilateral periorbital edema. Acanthosis nigricans and skin tags were noted on his neck. Initial laboratory testing revealed pancytopenia (WBC 3.3 K/uL, Hgb 10.9 g/dL and platelets 135 K/uL).
The sweats, pancytopenia, LAD and recent travel prompted an infectious disease workup including blood cultures, HIV, EBV, and parvovirus, which was negative. Rheumatologic tests including ANA and ANCA were also negative, and ESR was normal. CT scan of the chest, abdomen and pelvis were unrevealing. LDH and direct coombs test were normal but haptoglobin was low. A bone marrow biopsy was completed but non-diagnostic. On hospital day 3, an am cortisol was found to be low at 0.5 ug/dL. Further testing revealed a depressed ACTH, normal TSH with a depressed T3, and free T4, as well as a low testosterone and mildly elevated prolactin. Growth hormone and IGF-1 were high. Upon further questioning, the patient reported decreased libido, cold intolerance, blurry vision, and increase in ring size over the past year. MRI of the brain revealed a sellar mass with invasion of the cavernous sinus and mass effect on the optic chiasm. The patient was started on predisone and synthroid for treatment of adrenal insufficiency and hypothyroidism, respectively and subsequently underwent transphenoidal surgery.
Discussion:
Acromegaly has an estimated prevalence of 70 per 1,000,000 cases and is most commonly caused by a growth hormone secreting tumor of the anterior pituitary. Diagnosis is made with an elevated IGF-1 level and treatment is surgical. Although not typically the presenting complaint, hyperhidrosis has been described as a frequent symptom of acromegaly related to hormone-induced changes in sweat glands. In the case of our patient, the etiology of the initial pancytopenia remains unclear but is likely related as the patient’s CBC returned to normal following medical treatment and removal of the tumor.
Conclusions:
A pituitary disease process can be missed due to the vague nature and potentially broad spectrum of symptoms. Further questioning led to information not initially admitted to by the patient, which changed the clinical thought process. In this case, the unremarkable comprehensive workup forced a less common, yet classic presentation of a diagnosis to be considered.