Use of High Condylectomy and Abdominal Dermis Fat Grafting for an Acromegaly Induced Bilateral Condylar Hyperplasia: A Case Report

Acromegaly is a disorder characterized by hypersecretion of growth hormone, resulting in morbidities associated with multiple systems. Although most of the morbidities are reversed following control of the underlying disease, it may take several weeks to months for the symptoms to subside. One of the most noticeable effects of acromegaly is changes in facial features and jawbone growth, which can lead to severe pain and discomfort. This report describes a case of a 31-year-old patient with acromegaly induced bilateral condylar hyperplasia who presented with severe temporomandibular joint (TMJ), facial pain, and degenerative changes in TMJ. The patient was treated by trans-sphenoidal excision of pituitary adenoma, medications, and radiotherapy, but his hormonal levels were persistently high. Considering the refractory nature of the disease, the patient underwent bilateral high condylectomy, right articular disc removal, and abdominal dermis fat grafting. The surgery arrested the progressive mandibular enlargement and prevented further degenerative changes of TMJ. Although there was some reduction in TMJ pain, the myogenous pain and headache persisted after surgery. TMJ surgery may be selectively used for refractory cases of acromegaly and those requiring discectomy or total joint replacement. This case report describes the role of TMJ surgery in the management of morbidities and symptoms associated with TMJ in acromegaly until biochemical normalcy is achieved.

Patterns of Abnormal Glucose Metabolism in Acromegaly and Impact of Treatment Modalities on Glucose Metabolism

Background: Chronic exposure to high levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) leads to metabolic complications, most importantly dysglycemia in the form of diabetes mellitus and pre-diabetes. Dysglycemia if diagnosed early in the course of the disease can decrease complications. Treatment modalities in the form of surgery and medical therapy have varied impacts on glucose metabolism.

Objective: To determine the frequency of diabetes mellitus, impaired glucose tolerance, and impaired fasting glucose in Pakistani patients with acromegaly and to establish the impact of the intervention (surgery/medical) on glucose metabolism.

Methods: This study was a retrospective review of patient records. Eighty-nine patients fulfilling the Endocrine Society criteria for acromegaly diagnosis were included. A data of baseline, GH, IGF-1 level, hemoglobin A1C (HbA1C), fasting blood glucose (FBG), and random blood glucose (RBS) levels were reviewed before and after the intervention (surgery/medical therapy). Normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes mellitus (DM) were defined based on the American Diabetes Association (ADA) criteria. Patients were grouped into normoglycemic (NGT) and dysglycemic (IFG, IGT, and DM) based on FBG, RBS, and HbA1C.

Results: Major risk factors for dysglycemia included age (15-45 years), male sex (33.70%), obesity (45.7%), and macroadenoma (77.52%). Both mean GH levels (58.29 vs. 54.36 ng/dl) and IGF-1 levels (862.98 vs. 824.32 ng/dl) were higher among the normoglycemic than dysglycemia. Pre-surgery NGT, IFG, IGT, IFG, and IGT/DM combined were found in 48.31%, 5.61%, 1.1%, 5.61%, and 39.32% of the subjects respectively. Post-surgery, HbA1C improved in 79.5%, deteriorated in 6.8%, and remained the same in 13.6%. Similarly, it improved in 67% post-medical therapy. Both FBG and RBS improved post-surgery and medical therapy. Further, the number of anti-diabetic drugs used also decreased post-surgery.

Conclusion: Dysglycemia is more common among patients with acromegaly as compared to the general population and tends to be poorly controlled in untreated acromegaly. Glycemic control improves significantly after surgery and medical therapy.

Insulin Resistance in Patients With Acromegaly

Acromegaly is characterized by chronic overproduction of growth hormone (GH) that leads to insulin resistance, glucose intolerance and, ultimately, diabetes. The GH-induced sustained stimulation of lipolysis plays a major role not only in the development of insulin resistance and prediabetes/diabetes, but also in the reduction of lipid accumulation, making acromegaly a unique case of severe insulin resistance in the presence of reduced body fat. In the present review, we elucidate the effects of GH hypersecretion on metabolic organs, describing the pathophysiology of impaired glucose tolerance in acromegaly, as well as the impact of acromegaly-specific therapies on glucose metabolism. In addition, we highlight the role of insulin resistance in the development of acromegaly-associated complications such as hypertension, cardiac disease, sleep apnea, polycystic ovaries, bone disease, and cancer. Taken together, insulin resistance is an important metabolic hallmark of acromegaly, which is strongly related to disease activity, the development of comorbidities, and might even impact the response to drugs used in the treatment of acromegaly.