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A 35 year man with acromegaly and neck stiffness

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A 35 year old man was referred for acromegaly by primary physicians. He complained of mild diffuse headache and easy fatiguability. Clinically he had somatic features of acromegaly and his visual acuity was reduced (6/30: left eye, 6/36 right eye) with a bitemporal superior quadrantanopia. Fundi were normal. He was normotensive and the rest of the clinical examination was normal. His basal hormone concentrations were: growth hormone (random) >25 mU/l (reference range <10), insulin like growth factor-1 level 210 nmol/l (14–45), serum alpha subunit not raised (<0.3 IU/l), prolactin 450 mU/l (60–390), luteinising hormone 8.0 U/l (2.5–9.0), follicle stimulating hormone 7.5 U/l (1.5–9.0), thyroid stimulating hormone 2.5 mU/l (0.5–4.5), free thyroxine 18 pmol/l (10–27), serum cortisol 8 am (basal) 500 nmol/l (160–565), and testosterone 20 nmol/l (10–30). Cranial contrast enhanced computed tomography demonstrated an enhancing sellar mass with suprasellar extension (fig 1). The patient was advised to have surgery and in the interim period was put on octreotide 100 μg subcutaneously eight hourly, with rapid relief in his headache. Three weeks later the patient was brought to the emergency room with severe diffuse headache, nausea, vomiting, diminished vision, and lethargy of five hours' duration. There was no history of fever. Clinically he was confused and irritable. He had neck stiffness, left sided complete third nerve paralysis, and bilateral papilloedema. Visual fields and acuity of vision could not be examined. Plain and contrast enhanced computed tomography showed a high density fluid level in the sella and evidence of subarachnoid blood in the basal and suprasellar cisterns.

Figure 1

Computed tomogram showing an enhancing sellar mass with suprasellar extension.

Questions

(1)
What is the diagnosis?
(2)
What are the two most critical alternative diagnoses?
(3)
What is the role of lumbar puncture in this patient?

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