Intended for healthcare professionals

Endgames Case Review

Difficult access in the anaesthetic room leads to a difficult diagnosis

BMJ 2015; 351 doi: (Published 08 July 2015) Cite this as: BMJ 2015;351:h3430
  1. Sarah Crabtree, foundation year 2 doctor1,
  2. Danielle Lowry, vascular research registrar1,
  3. Alok Tiwari, vascular consultant1,
  4. Neil Gittoes, endocrinology consultant1
  1. 1Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
  1. Correspondence to: S Crabtree sarahcrabtree{at}

A 50 year old man was admitted for laser ablation of the left long saphenous vein to treat his symptomatic varicose veins. In the anaesthetic room he was noted to have unusually tough skin and rather large hands during cannulation. This was confirmed when the operating surgeon attempted to cannulate the long saphenous vein to perform the endovenous laser ablation—the thickness of his skin made this difficult. He also had bigeminy on heart monitoring and a prominent jaw.

In clinic he said that he had always had large hands and put this down to being “muscly,” having worked in a garage all his life. He had surgery for carpal tunnel decompression in 2005, and he had longstanding muscle aches. His visual fields were normal, his shoe size was 9, and he snored excessively at night.


  • 1. What is the likely diagnosis and what are the initial investigations needed to diagnose it?

  • 2. What pathophysiology underpins this condition?

  • 3. What are the most common clinical findings?

  • 4. How is this condition treated?


1. What is the likely diagnosis and what are the initial investigations needed to diagnose it?


The most likely diagnosis is acromegaly. Initial tests include measurement of insulin like growth factor 1 (IGF-1) and growth hormone, as well as growth hormone response to glucose tolerance test. If indicated, these should be followed by magnetic resonance imaging of the pituitary and visual field tests.


Acromegaly can cause thickening of the skin, mainly secondary to dermal thickening.1 If acromegaly is suspected then both IGF-1 and growth hormone should be measured. IGF-1 is measured because its secretion is regulated by growth hormone. The results should be interpreted according to the normal ranges for the patients’ age and sex. Raised IGF-1 supports a diagnosis of acromegaly, although the result can be affected by poorly controlled diabetes and other systemic illnesses that lead to false negative results.2 Growth …

View Full Text

Log in

Log in through your institution


* For online subscription