Disabling peripheral neuropathy and radiculomyelopathy at the time of presentation in a patient with active acromegaly; A case report

Introduction: Peripheral arthropathy and entrapment neuropathy are well-recognised manifestations of acromegaly. Distal symmetrical peripheral neuropathy and axial arthropathy producing myeloradiculopathy form a rare combination of manifestations in acromegaly.

 

Case presentation: A 61-year-old male presented with progressively worsening upper and lower limb numbness and weakness for eight months. There was pain, swelling and restriction of movements of bilateral knee joints for 30 years. Change in facial appearance with prominent jaws, forehead, and nose as well as hypertension for more than 20 years had not been evaluated for. He was acromegaloid with severe bilateral knee joint osteoarthritis. There was symmetrical quadriparesis with greater involvement of distal muscle groups and glove and stocking type sensory loss. Lower limb reflexes were diminished while an inverted supinator reflex was elicited. Elevated IGF-1 and non-suppressed growth hormone after oral glucose administration confirmed acromegaly. MRI-pituitary showed a pituitary macroadenoma. There was imaging evidence of cervical and lumbar spondylosis with radiculomyelopathy and cauda equina syndrome. Nerve conduction studies suggested sensory and motor axonal polyneuropathy. Nerve cross-sectional areas were increased. He underwent trans-sphenoidal excision of pituitary tumour and anterior cervical discectomy and fusion which partially improved his neurological manifestations.

 

Conclusions: This patient’s disabling and partly irreversible rare neurological consequences re-iterate the need for early recognition and intervention for this curable endocrinopathy. At this late presentation, diagnostic and management challenges call for careful clinical judgment to avoid expensive and potentially risky interventions without clinical benefit.