Growth Hormone Secreting Pituitary Macroadenoma Presenting as Intractable Headache, Right Eye Epiphora and Ptosis

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

Journal of the Endocrine Society

Abstract

Introduction: Headache is not an uncommon feature in patients with pituitary tumors. It is present in up to 70% of cases and is irrespective of tumor volume or cavernous sinus invasion. Intractable headache is common in patients with GH secreting tumors. Unilateral ptosis and epiphora (excessive tearing) is an extremely rare phenomenon in this patient population. Case:44 y.o. male with a history of chronic occipital headaches and pituitary mass (diagnosed 2 years prior) was referred to our hospital for worsening right eyelid ptosis with inability to open his eye, photophobia and worsening occipital headache. The patient was diagnosed with occipital neuralgia in the past and received nerve blocks without improvement of symptoms. On admission, physical examination was positive for right eyelid ptosis, brisk and symmetric pupils, negative for features of acromegaly. Imaging revealed normal CT orbits but was concerning for pituitary mass. Pituitary MRI confirmed a mass within the right aspect of the pituitary gland measuring 9x12x12 mm with mild impression into the right cavernous sinus and stalk deviation to the left, without optic nerve chiasm impression. Laboratory results showed IGF-1 514 ng/ml (N <215), testosterone 232 ng/dl (N 240-890), LH 1.8 mIU/ml (N 0.6- 12.1), FSH 3.1 mIU/ml (1-12), normal alfa subunit, prolactin, ACTH, cortisol, TSH and ft4. The patient underwent endonasal transsphenoidal resection of pituitary mass with complete resolution of headaches, and photophobia as well as improvement of ptosis and lacrimation. Repeat IGF-1 postoperatively was mildly elevated at 239 ng/ml. 6 months after surgery IGF-1 remained elevated at 299 ng/ml, GH 5.1 ng/ml (N 0.1-3), repeat brain MRI was concerning for residual tumor tissue within the left superior aspect of the gland. The patient was started on lanreotide 60 mg monthly. The patient also reported recurrence of intractable occipital headaches and recurrence of right eye lacrimation at that time. Repeat lab studies showed IGF-1 464 ng/ml, LH 0.5 ng/ml, testosterone 155 ng/dl consistent with central hypogonadism and residual GH secreting tumor. The patient is currently awaiting Neurosurgery evaluation. Conclusion: Headache is present in up to 12.5% of patients with acromegaly. It is commonly persistent, severe, unrelieved by the surgery and irrespective of biochemical markers. Lacrimal gland volume is higher in patients in this population and shows positive correlation with IGF-1 and GH levels. GH and IGF-1 independently induce features of hypersomatotropism that may stimulate exocrine glands. Epiphora in the setting of acromegaly is exceptionally infrequent in patients with acromegaly and usually presents bilaterally. GH secreting pituitary tumor presenting with unilateral ptosis and unilateral epiphora is an extremely rare phenomenon.

Volume

8

Issue

Suppl 1

First Page

A648

Comments

ENDO 2024 Endocrine Society Annual Meeting, June 1-4, 2024, Boston, MA

DOI

10.1210/jendso/bvae163.1224

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