A 42-year-old man comes to the physician because of a tingling sensation and pain in both hands. He believes that his hands are 'swollen.' He reports bilateral tingling and electric shock-like pain on the lateral aspect of his palms and first three digits. He is a software engineer and has difficulty typing because of bilateral hand pain. He also complains of fatigue and excessive malodorous sweat. His other medical problems include obstructive sleep apnea and hypertension and he uses CPAP at night. His medications include enalapril, amlodipine, chlorthalidone, and aspirin. He does not smoke cigarettes or drink alcohol.
His blood pressure is 146/88 mm Hg, pulse is 88/min, and BMI is 34 kg/m². Skin examination reveals oily skin with skin tags over the nape of his neck. Tinel's sign is positive bilaterally.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Question

A 42-year-old man comes to the physician because of a tingling sensation and pain in both hands. He believes that his hands are 'swollen.' He reports bilateral tingling and electric shock-like pain on the lateral aspect of his palms and first three digits. He is a software engineer and has difficulty typing because of bilateral hand pain. He also complains of fatigue and excessive malodorous sweat. His other medical problems include obstructive sleep apnea and hypertension and he uses CPAP at night. His medications include enalapril, amlodipine, chlorthalidone, and aspirin. He does not smoke cigarettes or drink alcohol.
His blood pressure is 146/88 mm Hg, pulse is 88/min, and BMI is 34 kg/m². Skin examination reveals oily skin with skin tags over the nape of his neck. Tinel's sign is positive bilaterally.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_97a5_dd75_853d_350a721efd4c_MD0002_00 This patient presents with carpal tunnel syndrome (CTS). His other clinical features (eg, skin tags, oily skin, excessive malodorous sweat, enlarging hands, and sleep apnea) suggest a secondary cause of CTS such as acromegaly. Carpal tunnel syndrome can occur in up to 20% of patients with acromegaly, likely due to edema of the median nerve. The symptoms resolve rapidly with treatment of acromegaly. Elevated growth hormone (GH) also stimulates hepatic insulin-like growth factor I (IGF-I) secretion, which is responsible for most of the clinical features. IGF-I levels are consistently elevated (without fluctuations) in all patients with acromegaly. In contrast, GH levels can fluctuate in a diurnal pattern and cannot be used alone to make a diagnosis (Choice B). As a result, measuring IGF-I is the preferred single screening test for acromegaly; however, IGF-I levels can decrease with age and require interpretation according to the patient's age. Patients with elevated IGF-I levels should undergo confirmatory dynamic testing with an oral glucose suppression test (75 g oral glucose load). Patients without acromegaly have a decrease in GH to < 1 ng/mL within 2 hours of glucose load. Acromegaly patients usually have GH levels > 2 ng/mL and should undergo brain MRI to look for a pituitary mass (found in nearly 70% of patients) (Choice D). Patients with a normal MRI should be evaluated for ectopic GH secretion. (Choice A) Carpal tunnel syndrome is associated with hypothyroidism and rheumatoid arthritis (RA). However, this patient has no symptoms of RA. (Choice E) Carpal tunnel syndrome is diagnosed clinically in most patients, and nerve conduction studies are usually reserved for doubtful cases or assessing the severity of median nerve compression. Educational objective: Insulin-like growth factor I (IGF-I) is the preferred screening test for acromegaly. Measuring random GH is not as sensitive because of wide fluctuations in circulating levels. __________ References: Acromegaly. (http://www.ncbi.nlm.nih.gov/pubmed/18226732) Epidemiology of acromegaly. (http://www.ncbi.nlm.nih.gov/pubmed/11081170)

A 42-Year-Old Man Comes to the Physician Because of a Tingling