1.Two years later C.M. was experiencing temporary paresthesias in both hands in the morning. Also headaches had become more frequent and were accompanied by visual signs such as spatial distortion. Cold sensitivity and fatigue persisted. She felt her foot size had increased, but not her hand size. No other abnormalities were apparent.
2. Suggest a reason for these manifestations. A 6-month course of bromocriptine (Parlodel—a dopamine agonist that reduces GH secretion and shrinks the tumor) was ordered, which did reduce GH levels to some extent. However, after medication was discontinued, headaches, nausea, hot flashes, and paresthesias recurred. Several months later, a course of radiotherapy to the pituitary commenced and resulted in lower GH levels and symptomatic improvement.
3. How would radiotherapy reduce the symptoms? Tests a few months later indicated T4, cortisol, and LH levels were below normal. T4 replacement therapy was commenced. C.M. was given a supply of prednisone to take in the event of illness or increased stress.
4. Why is it necessary to maintain T4 levels? Why is increased cortisol required during stress? Because of continued amenorrhea (lack of menstruation) since the pituitary infarction, a course of Pergonal (gonadotropins) was given to induce ovulation when pregnancy was desired. A healthy male infant was delivered. Hydrocortisone replacement was taken throughout the pregnancy.
5. Explain how the pituitary infarction caused amenorrhea. A few years later, Type 2 diabetes mellitus developed, controlled by diet.
6. How does acromegaly predispose to Type 2 diabetes?