Affects: Cats, Dogs
Hypersomatotropism, also known as acromegaly, is an endocrine disorder caused by excessive growth hormone production in cats and dogs.
Signs And Symptoms: Cats suffering from hypersomatotropism show a multitude of symptoms, the majority of these symptoms are not useful for identifying hypersomatotropism instead of just diabetes mellitus. The presence and level of severity of symptoms vary based on levels of growth hormone excess and duration of excess secretion. In dogs the manifestation of symptoms varies much more than with cats, some dogs may only show signs of acromegaly whilst others show mostly symptoms of diabetes mellitus. It is possible that this variability is related to breed. Diabetes, however, still occurs in a substantial number of dogs.
Most symptoms result from the diabetogenic effect of growth hormone and the acral enlargement effects of growth hormone and IGF-1. Neurological signs may be observed in some cats due to expansion of the tumour, this can occur in dogs with pituiary tumours too. The most common symptoms in cats are polyuria, polydipsia, and polyphagia due to diabetes mellitus; however, polyphagia can be the result of growth hormone excess itself. Other symptoms in both cats and dogs include ataxia, asthenia, hepatomegaly, visceromegaly, enlargement of head and distal extremities, heart murmur, degenerative atrophy, thickening of skin and fur, stridor and a plantigrade stance in cats. Disruption of the central nervous system occurs in 10–15% of cases, potential signs of this include: adipsia, lethargy, behavioural change, vision impairment, anorexia, temperature dysregulation, somnolence, stupor, and seizures. Less common but occasional symptoms include erythrocytosis, leukocytosis, and proteinuria.
The physical changes of hypersomatotropism are a result of anabolic effects of growth hormone and IGF-1; these have a gradual onset and progress slowly. The overgrowth of soft tissue and bone changes cause weight gain, broadening of the skull, prognathia inferior, and an enlarged tongue. Thickening of the oropharyngeal tissue may lead to respiratory distress and stridor. Degenerative anthropathy is caused by proliferation of chondrocytes and changes to the joint geometry.
Heart murmur occurs in most feline cases, further diagnostics may reveal cardiomegaly and other heart abnormalities. Congestive heart failure can occur during later stages of the disease.
A 1990 study reported 50% of cats diagnosed with hypersomatotropism had developed renal failure within 8–36 months of initial examination; however, another study from 2007 found a 12% incidence of azotaemia. Renal failure is a very common disease in elderly cats and it is controversial as to whether or not feline hypersomatotropism affects the development of renal failure.
Risk Factors: There is no known breed predilection. Approximately 88% of described cats were male; male cats also have a predisposition to diabetes mellitus. Growth hormone secreting pituitary tumours in dogs have only been observed in male dogs of large breeds. Excessive growth hormone secretion caused by progestone use has been seen in a variety of breeds of varying size, as well as in mixed breed dogs, the same is true of growth hormone excess brought on by the oestrous cycle.
Cause: Growth hormone-producing acidophilic pituitary adenomas are the cause of hypersomatotropism in the vast majority of cats. Both dense and sparse granulated cells has been observed in the adenomas of cats with diabetes mellitus and elevated IGF-1 levels; however, it is not known whether this is because of different variants of the disease or not. It is also not known what percentage of tumours are mixed or plurihormonal tumours. This information has only been reported in studies with a small number of cases.
In dogs growth hormone is not just derived from the anterior pituitary gland, it also derives from the mammary gland. Mammary gland production of growth hormone is stimulated by progestogen, this occurs naturally in intact bitches. Synthetic progestogens can cause excessive growth hormone secretion and higher IGF-1 levels which may lead to acromegaly and diabetes mellitus. Progestogens are used to prevent oestrus in bitches and to treat certain hyperplasias. Growth hormone excess can occur in the luteal phase of the oestrous cycle in older bitches.
Somatotrophic adenomas have only been described in two dogs. In 1996 a 9-year-old male Doberman Pinscher with difficult to manage diabetes mellitus but no signs of acromegaly was euthanised. Necropsy later revealed an acidophilic adenoma with immunohistochemical staining for growth hormone, adrenocorticotropic hormone, and prolactin. In 2007 a 10-year-old male Dalmatian dog was described with acromegalic signs such as an enlarged tongue and head, widened interdental space, and thickening of skin; along with other signs of hypersomatotropism such as polyphagia, obesity, and stridor. Insulin levels were heightened and the dog had glucose intolerance; however, the dog was not diabetic as blood glucose levels were found to be normal after multiple tests. Levels of IGF-1 and growth hormone were heightened. CT imaging showed a pituitary mass which was later confirmed to be an acidophilic adenoma stained for growth hormone; however, mammary tumour-induced acromegaly is rare with few reported cases.
Diagnosis: The vast majority of cats present with diabetes mellitus, the possibility of hypersomatotropism causing it is rarely considered until the diabetes becomes difficult to control. In cats with difficult to control diabetes mellitus, hypersomatotropism should be considered as a cause only after exclusion of other conditions that can impact insulin. Bitches with hypersomatotropism are usually presented 3–5 weeks after oestrus. It is not uncommon for owners to report symptoms relating to the diabetes mellitus as having occurred during the previous oestrous cycle, typically more mild and ending with anoestrus.
Most abnormalities on common tests, such as complete blood count, urinalysis, and biochemistry profile, are due to the diabetes mellitus. Some cats with hypersomatotropism have hyperproteinaemia. One study found it to be the only parameter more frequent in cats with hypersomatotropism than cats with just diabetes mellitus.
The common steps of diagnosis in cats involve presentation with diabetes mellitus, on examination either the acromegalic effects are noticed or they are not noticed and hypersomatotropism is not suspected until efforts to control the diabetes are proving difficult. Following this levels of growth hormone or IGF-1 are measured, if the results suggest hypersomatotropism it is then usually followed up with CT/MRI imaging to find the pituitary mass. In dogs the tentative diagnosis is made based on signs of acromegaly or diabetes mellitus alongside progestogen administration or dioestrus. A definitive diagnosis is made after based on growth hormone concentrations or increased IGF-1 levels. In male dogs with no history of progestogen administration the possibility of a pituitary tumour needs to be examined via CT/MRI.
Treatment: Treating hypersomatotropism involves treating both the hypersomatotropism and the diabetes mellitus. Sometimes treatment is limited to the diabetes due to owners not wishing to treat the hypersomatotrism due to the associated costs. Monitoring of blood glucose levels is imperative as if improvement or resolution of insulin resistance is not identified hypoglycaemia can occur, leading to death. In dogs with progestogen induced hypersomatotropism the administration of progestogens should cease immediately. For cases derived from a mammary tumour it should be surgically removed.
Prognosis: Untreated hypersomatotropism has a guarded to poor prognosis. In most cases the insulin resistance and other symptoms get progressively worse causing insulin treatment to become difficult. Euthanasia often occurs a few months after diagnosis in cats due to owner's being unable or unwilling to deal with treatment. Other reasons for euthanasia include congestive heart failure, renal failure, respiratory distress, and neurological symptoms. Cats that have been treated with radiotherapy or pituitary surgery may have a good prognosis; survival has been observed for several years. In progestogen induced hypersomatotropism the prognosis is usually good after cessation of progestogen administration. In dogs soft tissue changes are usually resolved in a few weeks or months, persistent bone changes usually do not cause clinical problems. For diabetes mellitus the prognosis for the condition depends on the beta cell damage.