Abstract Introduction Acromegaly is a rare disorder caused by chronic GH excess, usually due to a pituitary adenoma. While typical features include acral and facial changes, some patients present with only subtle signs, making diagnosis difficult. This case presents a woman evaluated for osteoporosis and primary hyperparathyroidism in whom findings unexpectedly raised the suspicion of acromegaly or micromegaly. Clinical Case A 46-year-old female was referred to our endocrinology clinic after being diagnosed with primary hyperparathyroidism during an evaluation for osteoporosis. On physical examination, she exhibited coarse facial features, grade 2 goiter. The patient reported a progressive increase in shoe size (by two sizes) over the past several years. She denied having considered this a relevant symptom previously. Her past medical history included hypertension and obstructive sleep apnea. Considering the patient's coarse facial features, history of increased shoe size, and comorbidities such as hypertension and sleep apnea, acromegaly was suspected. In light of these findings, further investigations were planned to evaluate for growth hormone excess and related endocrine abnormalities. The patient’s serum IGF-1 levels were elevated on multiple occasions, measured at 209, 290, 227, and 232 ng/mL — all above the age- and sex-specific reference range. These findings were suggestive of chronic growth hormone hypersecretion. Basal GH levels measured at different time points ranged between 1.44 – 2.42 ng/mL (1.44, 2.01, 1.89, and 2.42), which indicated persistently elevated values without adequate suppression. To further evaluate GH dynamics, a 75-gram oral glucose tolerance test (OGTT) was performed twice: In both tests, GH levels demonstrated partial suppression and remained at or below the diagnostic cutoff of 1 ng/mL. This finding, when evaluated together with elevated IGF-1 levels and mild clinical features, pointed toward a diagnosis of micromegaly rather than classical acromegaly. Pituitary MRI revealed a 5 x 4.5 mm left-sided pituitary microadenoma associated with partial empty sella. Conclusion Micromegaly remains a controversial and under-recognized entity. Some studies have reported that these patients tend to be older, more frequently male, and present with milder biochemical abnormalities compared to classic acromegaly, yet they may still harbor GH-secreting microadenomas. Acromegaly associated with a pituitary microadenoma and partial empty sella has been described in the literature. However, to our knowledge, no cases have been reported describing the coexistence of a microadenoma and empty sella in patients suspected of having micromegaly. The case is being followed with suspicion of micromegaly. It highlights the clinical uncertainty in managing borderline clinical, biochemical and radiological findings, and invites discussion on optimal treatment strategies.Table 1:Growth hormone response to oral glucose tolerance test (OGTT)
Dedebagi et al. (Thu,) studied this question.