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A 27 year old man presented with gradual coarsening of his facial features noticed for the past two years. It was associated with marked oiliness of the facial skin and excessive sweating from the palms and soles. He had also noticed gradual painless swelling of the tips of his fingers and toes since puberty, which had assumed a bulbous appearance. He did not have any systemic or visual complaints or recent change in voice. There was no history of similar illness in any of his family members. Concern for his altered appearance brought him to hospital.
On examination, he was found to have a worried face, with deep horizontal furrowing on forehead, thick eyelids, broad nose, and prominent nasolabial folds (fig 1). The facial skin was thick and greasy. His scalp skin was doughy with deep, longitudinal, cerebriform folds along the vertex. Wrists and ankles were wider than usual with cylindrical contour. Hands and feet were broad with grade IV clubbing of the fingers (fig 2) and toes. The joints and digits were non-tender. Palms and soles were moist and velvety. His body proportions and vision were normal. A thorough systemic examination did not reveal any abnormality.
Routine haematological and biochemical investigations gave results within normal limits. Lateral skull radiography did not reveal any bony abnormality of the sella turcica. Serum growth hormone and prolactin levels were within normal limits. A skin biopsy specimen showed an increased number of fibroblasts, collagen bundles, and keratin cysts in the dermis. Radiographs of the wrist joint and hands are shown in figs 3 and 4 respectively.
What is the diagnosis?
What are the radiological findings shown?
Which other conditions are to be differentiated clinically from this entity?
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