title: Acromegaly presenting with low insulin-like growth factor-1 levels and diabetes: a case report.
abstract: BACKGROUND
  Acromegaly is an endocrine disorder arising from excessive serum growth hormone levels in adulthood and is characterized by progressive somatic enlargement. Biochemical confirmation is achieved by demonstration of elevated baseline serum growth hormone levels which are not suppressed during an oral glucose tolerance test, and by increased levels of serum insulin-like growth factor-1. The serum insulin-like growth factor-1 level provides an assessment of integrated growth hormone secretion and is recommended for diagnosis, monitoring, and screening of acromegaly. We report a case of a patient with acromegaly secondary to a pituitary microadenoma who presented with low insulin-like growth factor-1.
  
  
  METHODS
  An 83-year-old Sinhalese woman presented to our hospital with an enlarging multinodular goiter. She was observed to have macroglossia, thickened coarse skin, acral enlargement, and newly detected, uncontrolled diabetes. A diagnosis of acromegaly was suspected. She did not complain of recent headaches, vomiting, visual difficulties, or galactorrhea and was clinically euthyroid. Her pulse rate was 84 beats/min, and her blood pressure was 150/90 mmHg. A visual field assessment did not reveal a defect. Her random growth hormone levels were 149 mU/L (<10 mU/L), and her oral glucose tolerance test was supportive of acromegaly with a paradoxical rise of growth hormone. Her serum age-specific insulin-like growth factor-1 level was below normal at 124.7 ng/ml (normal range 150-350 ng/ml). Her serum insulin-like growth factor-1 level, measured after glycemic control was achieved with metformin and insulin, was elevated, which is characteristic of acromegaly. Magnetic resonance imaging of her pituitary revealed a pituitary microadenoma. Acromegaly secondary to a growth hormone-secreting pituitary microadenoma was confirmed.
  
  
  CONCLUSIONS
  Systemic illnesses, including catabolic states, hepatic or renal failure, malnutrition, and diabetes mellitus, are known to decrease insulin-like growth factor-1 levels and may result in false-negative values in patients with acromegaly A low insulin-like growth factor-1 level does not exclude acromegaly in a patient with supportive clinical features and poorly controlled diabetes.
authors.affiliation: University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka. dilushi_w@yahoo.com.
authors.forename: Dilushi Rowena
authors.initials: DR
authors.lastname: Wijayaratne
authors.affiliation: University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka. maulee_80@yahoo.com.
authors.forename: M H
authors.initials: MH
authors.lastname: Arambewela
authors.affiliation: University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka. chamaradalugama@yahoo.com.
authors.forename: Chamara
authors.initials: C
authors.lastname: Dalugama
authors.affiliation: University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka. dishni7@hotmail.com.
authors.forename: Dishni
authors.initials: D
authors.lastname: Wijesundera
authors.affiliation: Diabetes and Endocrine Unit, National Hospital Sri Lanka, Colombo, Sri Lanka. noelsomasundaram@gmail.com.
authors.forename: Noel
authors.initials: N
authors.lastname: Somasundaram
authors.affiliation: University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka. prasad.katulanda@yahoo.com.
authors.forename: Prasad
authors.initials: P
authors.lastname: Katulanda
mesh_terms: D000172:Acromegaly / Q000097:blood* / Q000175:diagnosis*; D000369:Aged, 80 and over; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D005260:Female; D019382:Human Growth Hormone / Q000097:blood*; D006801:Humans; D007334:Insulin-Like Growth Factor I / Q000032:analysis*; D008279:Magnetic Resonance Imaging; D010902:Pituitary Gland / Q000473:pathology; D010911:Pituitary Neoplasms / Q000150:complications*
chemical_list: D019382:Human Growth Hormone; D007334:Insulin-Like Growth Factor I