Title: eMedicine
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eMedicine Case
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Severe Chronic Fatigue in a
54-Year-Old Woman |
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Growth hormone deficient adults need growth hormone too!
Growth hormone treatment has been shown to change body composition.
These changes include decreased total body fat mass, increased
lean body mass, decreased waist circumference, and increased
lean/fat ratio. Adequate amounts of endogenous growth hormone
can help improve the muscle to fat ratio in adults diagnosed
with GHD.
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BACKGROUND
A 54-year-old woman presents with chronic fatigue that has lasted many years. She has recently moved to the area from another state. Her history includes a hysterectomy 19 years ago for dysfunctional uterine bleeding and hypophysectomy and irradiation 14 years ago for a pituitary tumor. Her current medications include glucocorticoids (prednisone, 7.5 mg/d); levothyroxine, 100 mcg/d; and conjugated estrogen, 0.625 mg/d. She has also been taking 1500 mg of calcium carbonate and 600 IU of vitamin D every day. The woman is a smoker and has failed several attempts to quit. No other significant medical history is recorded. She had read an article about growth hormone therapy and is seeking advice. The physical examination findings were remarkable for a round (Cushingoid) face and elevated systolic blood pressure (156 mm Hg systolic, 82 mm Hg diastolic). The woman is 5 ft 5 in tall and weighs 142 lb. She denies any past history of hypertension, dyslipidemia, cardiovascu!
lar disease, or diabetes mellitus.
After discussing the possible benefits and risks of growth hormone (GH) therapy in adults, recombinant human growth hormone (rhGH) treatment is initiated at a low dose of 6 mcg/kg/d (see image for chemical structure). After 3 weeks of therapy, the patient complains of arthralgias but notices marked improvement in her strength and energy. Because of the arthralgias, GH therapy is stopped. Her arthralgias resolve, but her fatigue returns. The patient requests to start rhGH therapy again. After restarting rhGH treatment, the patient does not experience any arthralgias, and she notices marked improvement in her overall well-being.
Over the last 2 years, the patient's metabolic status has not changed,
and her insulinlike growth factor-1 (IGF-1) level is at the 50th percentile
for her age. She remains energetic and refuses to discontinue GH therapy.
Her current dose is 12 mcg/kg/d. No objective changes are correlated
with the patient's subjective feeling of well-being. Bone-density
dual-energy x-ray absorptiometry (DEXA) does not show any evidence
of osteoporosis.
What is the diagnosis? |
Hint
The patient underwent a significant neurosurgical procedure 14 years before presentation. |
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Author: |
Romesh Khardori, MB, MD, FACP
Metabolism and Molecular
Medicine, Professor, Department of Internal Medicine, Southern
Illinois University School of Medicine |
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