The hypertrophic neuropathy of acromegaly; a rare neuropathy associated with acromegaly

Neuropathic foot ulcers in the tallest patients with acromegalic gigantism: a common and significant problem. Historical overview

PURPOSE

We present a historical overview on neuropathic ulcers in patients with acromegalic gigantism.

MATERIALS AND METHODS

The case histories of 6 famous patients with acromegalic gigantism and living in the twentieth century were analyzed. The combined final height and maximum weight of these giants were: 272 cm. & 215.9 kg., 218.4 cm. & 125 kg., 242 cm. & 165 kg., 220.5 cm. & 135 kg., 235 cm. & 136 kg. and 224.8 cm. & 174 kg.

CONCLUSIONS

Neuropathic foot ulcers leading to hospital admissions and surgical and medical interventions were reported in 6 patients with acromegalic gigantism. These ulcers significantly impaired the daily activities of these individuals. Neuropathies of the sural nerve in patients with acromegalic gigantism can lead to hypoesthesia and hypoalgesia of the lower legs and feet. Potential contributing factors for the development of neuropathic ulcers of the feet in patients with acromegalic gigantism and neuropathy might be leg and foot deformities, muscle weakness and poor quality footwear. Diabetes mellitus, or impaired glucose intolerance does not necessarily seem to play a role.

Molecular genetics and neuropathology of Charcot-Marie-Tooth disease type 1A

Charcot-Marie-Tooth (CMT) syndrome describes a genetically and clinically heterogeneous group of polyneuropathies. Electrophysiologically, at least two types of CMT can be distinguished; CMT1 which has decreased nerve conduction velocities (NCV) and CMT2 which has normal or near normal NCV with decreased amplitudes. For CMT1, three gene loci (on chromosomes 1, 17 and the X chromosome) have been mapped. The locus on chromosome 17, CMT type 1A (CMT1A), is responsible for the most common form of CMT which has recently been shown to be associated with a large DNA duplication. Recent data demonstrates that the CMT1A phenotype results from an inherited DNA rearrangement and a gene dosage effect. The trembler (Tr) and allelic tremblerJ (TrJ) mice have been proposed as animal models for CMT. Tr has similar electrophysiological and neuropathological features to CMT1 patients and maps to mouse chromosome 11 in a region of conserved synteny with human chromosome 17p. Tr and TrJ have recently been shown to have different point mutations in regions encoding putative transmembrane domains of the myelin specific protein PMP-22. The human peripheral nerve-specific PMP-22 gene maps within the CMT1A duplication. PMP-22 is thus a candidate gene for CMT1A. This paper describes the molecular genetics of CMT1A and sural nerve pathology in CMT1A patients with the CMT1A duplication.

Typical changes in the viscerocranium in acromegaly

31 patients (mean age 52.7 years) suffering from persistent symptoms of a growth hormone-producing pituitary adenoma underwent both clinical and radiological examination at least one year after transnasal extirpation of the tumour. The results of standardized X-ray analysis of the viscerocranium were compared with a group of 21 healthy subjects (mean age 42.1 years): Although several remarkable changes of the facial skeleton were observed, statistically significant changes could be found in the lower jaw only. The ascending ramus as well as the mandibular body were found to be elongated. The main contribution to the elongation was made by the chin prominence and the condyle. Two different growth patterns of the mandible could be determined; neither of them was pathognomonic for acromegaly. Due to overgrowth of the septal cartilage in 7 patients we found a so-called "hanging columella". In 16 patients the mandibular canal was widened and showed marked deviations in its diameter or a funnel-shaped mandibular foramen.

Generalised peripheral nerve dysfunction in acromegaly: a study by conventional and novel neurophysiological techniques

Twenty four patients with clinical, radiological and biochemical evidence of acromegaly were investigated by a number of independent neurophysiological tests. Two-thirds of the patients showed evidence of generalised peripheral nerve dysfunction. A significant correlation was found between total exchangeable body sodium, an indicator of disease activity, and the severity of the neuropathy. The generalised peripheral nerve abnormality was found to occur independently of the associated carbohydrate intolerance human growth hormone levels and other endocrinological dysfunction in this disorder.

Hypertrophic neuropathy with spinal cord compression

The case of a 40-year-old patient with Dejerine-Sottas disease, who developed spinal cord compression from hypertrophic nerve roots, is presented. Six previously reported cases are reviewed. We discuss the characteristic myelographic changes seen in Dejerine-Sottas disease.

Isolated hypertrophic interstitial neuropathy of the trigeminal nerve associated with trigeminal neuralgia. Case report of an entity not previously described

Hypertrophic interstitial neuropathy (HIN) of the trigeminal nerve was observed in a patient with trigeminal neuralgia who had no other neurological abnormalities. Pathological documentation confirmed focal HIN. No similar histologically documented case of isolated trigeminal nerve involvement by HIN has been reported previously.

Dominantly inherited hypertrophic neuropathy

Clinical, electrophysiological, and histopathological studies of some members of a family with dominantly inherited hypertrophic neuropathy are presented. Twenty-five members were studied. Seventeen were abnormal on clinical examination. Their ages varied from 2 1/2 to 78 years. Age at onset in 14 of the 17 varied between 2 1/2 and 56 years. Pes cavus and palpable nerve thickening were present in more than half of the affected individuals. All patients had areflexia. Fifteen of the 17 had distal motor weakness as well as mild to moderate sensory impairment. Motor weakness affecting the proximal hip and shoulder girdle muscles was seen in 13 patients. Four patients gave a history of trigeminal neuralgia. Motor nerve conduction velocities were markedly impaired in all the clinically affected members. These studies were normal in the 8 unaffected members. Motor conduction velocities of the proximal segment of the ulnar nerve were slower compared to the distal segment in almost all the affected members. There was no significant correlation between the degree of clinical disability and the extent of impairment in the motor nerve conduction velocities. Sural nerve biopsies were studied. These observations are discussed.

Carpal tunnel syndrome with polymyalgia rheumatica

Association of carpal tunnel syndrome with systemic diseases is well established. Carpal tunnel syndrome preceded or existed simultaneously in 5 patients with polymyalgia rheumatica. It is probably related to tenosynovitis resulting in increase in the volume of the contents of the tunnel.

Neuromuscular involvement in pituitary gigantism

Investigation of two pituitary giants complaining of severe muscular weakness showed a peripheral neuropathy in both cases. Histological appearances suggestive of myopathy were also present in one case.

Experimental hypertrophic neuropathy: an electron microscope study

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