Diagnostic problems and management of pituitary gigantism leading to ischemic stroke and atrial myxoma in young adult patient: a case report

Abstract

Background: Gigantism is the excessive secretion of growth hormones (GH) during childhood and is mostly caused by benign pituitary adenomas. The signs and symptoms are not specific in early childhood due to growth spurt. An ischemic stroke is rarely present in pituitary adenoma, and here we present a case of ischemic stroke and atrial myxoma associated with pituitary gigantism. Case Presentation: The patient was an 18-year-old male who complained of continuous growth. In June 2016, the patient suffered from an embolic stroke, and in January 2017 he complained of fatigue and shortness of breath. The echocardiography showed a mass in the left atrium that was removed in March 2017 through open-heart surgery; the pathological histology confirmed a myxoma. The brain magnetic resonance imaging (MRI) showed a pituitary macroadenoma, and the growth hormone (GH) level was 20.6 ng/mL. In October 2019, the patient was referred to Dr. Soetomo Hospital. The height increased from 185 cm in 2017 to 205 cm in 2019. The height was 205cm, weight 85kg, body mass index 20.2 kg/m2, GH level >40 ng/ mL, cortisol 11.24 ug/dL, prolactin 1.21 ng/mL, testosterone 425.6 ng/dL, free thyroxine (FT4) 1.03 ng/dL, and insulin-like growth factor 1 (IGF-1) 688 ng/mL. The patient was administered oral cabergoline 0.25 mg twice a week and had endoscopic endonasal transsphenoidal hypophysectomy (EETH). The patient developed postoperative polyuria after surgery which indicated diabetes insipidus, and the patient was administered desmopressin 0.05mg/12 h with fluid restriction. One week later, the morning cortisol level was low, and hydrocortisone therapy was administered and was tap-off. One month-post surgery, the level of morning serum cortisol was 0.86 µg/dL. Conclusion: This case is extremely rare and we demonstrated that the EETH surgery the stability of GH could be achieved.