Brain tumor in Vietnam, needs help

This is a case I recently saw in Hue, Vietnam.  The patient agreed to have her medical information shared in the hopes of finding help and assisting in medical education (case study included below).
Note the pictures of her hands, in comparison to her wrists.  Those are my hands next to hers in one comparison photo.

The write up is by Dr Tram Ngoc, an excellent 2nd year Internal Medicine Resident, who is a (Le Family Scholarship Winner!) staying at our Le Family Scholarship House for the Medical English Training Program in Hue, Vietnam.  

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A 42-year-old woman was admitted to the hospital for a bright red blood per rectum (hematochezia) for a week, with a diagnosis of grade III internal hemorrhoids. What is notable, however, is the patient's medical history.

7 – 8 years ago she presented with black pigmented patches on the skin, the pigmentation spread without pain or itch, then it disappeared for several months. At the same time, after given birth to her second child, she continues to produce milk (galactorrhea) even after cessation of breastfeeding for many years.

5 – 6 years ago, her hands and feets enlarged, which result in increasing shoe and glove size and the need to enlarge finger rings. The facial features became coarse, with enlargement of the nose and frontal bones as well as the jaw, and the upper incisors became spread apart.

2 years ago, she was admitted to the hospital for long-term headaches, nausea, vomiting and loss vision. Brain MRI with contrast (7/9/2016) showed pituitary gland size # 29x41x27mm, deformation of sella turcica,  pushing the optic chiasm, invasive a part of left internal carotid artery-cavernous sinus, partially developed in the sphenoid sinus, no signs of hemorrhage.

Surgery by removing the pituitary tumor is usually the first treatment of choice to normalize GH levels, decompressing mass effects on vital structures, particularly the optic tracts. This is a potentially curable treatment for acromegaly.

Unfortunately, this woman had no money and could not afford to pay, so they only symptomatically treated with blood glucose control, pain relieve for the last couple of years.

Regarding her family status, she is living now with her two children. 5-6 years ago, when her face changed, she was beaten regularly by her husband, who was angry with her for this.  He then left her, but he does not provide any child support. She doesn’t have a stable job with monthly income around 1,000,000 - 1,500,000 VND/month (equivalent to 45 - 70 $/month).  She is still trying to support her two children by herself.

On this admission she is having headache with intermittently visual loss and also give complains of voice change , snoring and wake-time sleepiness. No history of convulsions or altered sensorium or weakness, no menstrual disorder.

Her height and body weight were 158 cm and 56 kg, respectively. Her body temperature was 37°C, and pulse rate 98/min with regular rhythm. Her blood pressure was 154/94 mmHg. There were no pigment on the skin, but she had many submandibular nodes and anterior cervical nodes which were painless. She had a typically acromegalic face with a big nose, thick lips and soft tissue thickening. Other features included sleep apnea, uncontrolled diabetes and grade III internal hemorrhoids. no other abnormality detected on systemic examination

Laboratory studies:
RBC 2.25T/l
HGB 65 g/l
Insulin fasting 2.49mIU/ml
Glucose24.28mmol/l 
HbA1C15.8%
 TG 8.04 mmol/l
 HDL-C 0.56 mmol/l
 Cortisol 379.5 nmol/l
 TSH 0.941 uIU/ml
 FT4  0.890 ng/dl
 FSH 0.100 mIU/ml
 LH 0.301 mIU/ml
 Protein unrine 0.058 g/l

We do not have serum GH concentration test, IGF-1 concentration test and serum prolactin concentration test.

Thyroid function, liver function and kidned function studies were normal.

Elevated HbA1C showed the uncontrolled diabetes.

Thyroid ultrasonography shows large left lobes thyroid with multiple nodules TIRADS II-III.

Polysomnography: normal

Visual field test: left monocular temporal hemianopia.

Brain MRI with contrast: pituitary gland size #34x45x32mm, deformation of sella turcica,  pushing the optic chiasm, invasive a part of left internal carotid artery-cavernous sinus, partially developed in the sphenoid sinus, no signs of hemorrhage.

We are waiting for the results of colonoscopy.

The cost of transsphenoidal surgery is about 20,000,000 VND (equivalent to 1,000$).  Cost for post surgery follow up and miscellaneous expenses $150-$200
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Friends in Medicine, please feel free to comment on Medical Management, I'm sure the Hue Internal Medicine Residents would like to hear your input.

Feel free to also comment on Dr Tram's write up, as she worked pretty hard on it as well (Using Medical English learned in our program!)





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