© Springer India 2016 377
A. Bhansali et al., Clinical Rounds in Endocrinology,
DOI 10.1007/978-81-322-2815-8_11
11
Multiple Endocrine Neoplasia
11.1 Case Vignette
A 42-year-old male presented with prominence of both the eyeballs for the last 6 months.
He was detected to have hypertension 7 years earlier and for that he was receiving
telmisartan, atenolol, and amlodipine. He had history of recurrent pain abdomen and
dyspeptic symptoms for the last 5 years, and he frequently used to take proton pump
inhibitors to relieve these symptoms. He had no history of headache, vomiting, or visual
disturbances. There was no history of anorexia, constipation, bone pains, polyuria, grav-
eluria, or renal stone disease. However, he had history of tightening of rings, palmar
sweating, decreased libido and erectile dysfunction, and reduced frequency of shaving.
There was history of fatigue and progressive increase in weakness for the last 2–3 years,
and he was diagnosed to have iron deficiency anemia. There was no history of symp-
toms suggestive of thyrotoxicosis, chronic obstructive airway disease, or chronic kidney
or liver disease. He was a nonsmoker and nonalcoholic. On examination, his height was
169 cm, weight 90 Kg, BMI 31.3 Kg/m^2 , blood pressure 130/80 mmHg, and pulse rate
96 bpm and had multiple skin tags and grade 3 acanthosis nigricans. He did not have
other cutaneous markers like collagenoma, angiofibroma, and lipoma. There was bilat-
eral mild proptosis and he had palmar sweating and seborrhea. He did not have goiter
and deep tendon reflexes were normal. His sexual maturation score was A+, P 3 , testicular
volume 20 ml (bilateral), and sparse facial and body hair. He also had bilateral lipomas-
tia. Visual fields, visual acuity, and optic disk were normal. Other systemic examination
was unremarkable. On investigation, hemoglobin was 9.8 g/dl with normal leucocytes
and platelet counts, and liver and renal function tests were normal. Corrected serum
calcium was 11.4 mg/dl, phosphorus 2.4 mg/dl, alkaline phosphatase 104 IU/L, iPTH
1,098 pg/ml (N 15–65), and 25(OH)D 6 ng/ml (N 30–70). An 0800h serum cortisol was
262 nmol/L (N 171–536), prolactin 9,291 ng/ml (N 4–15.2), free T 4 0.5 ng /dl (N 0.8–
1.8), TSH 2.92 μIU/ml (N 0.27–4.2), LH 0.21 mIU/ml (N 1.7–8.6), FSH 0.26 mIU/ml
(N 1.5–12.4), and testosterone 0.206 nmol/L (N 9.9–27). Serum IGF1 was 363 ng/ml (N
101–267, age matched), basal serum GH 15 ng/ml, and nadir serum GH after glucose
load 5.6 ng/ml. Serum gastrin level was 284 pg/ml (N 13–115), basal acid output