Hypersomatotropism, also known as acromegaly, is an endocrine disorder caused by excessive growth hormone production in cats and dogs.
Description Most cases of feline hypersomatotropism are caused by acidophilic pituitary tumours that predominantly secrete growth hormone. In some cases low levels of other pituitary hormones are secreted. Rarely a cat may have double adenomas. In a few cases the diagnosis has been pituitary acidophilic hyperplasia. In dogs nearly all cases of acromegaly are caused by endogenous or exogenous progestogens, this causes a hypersecretion of growth hormones from the mammary gland. Pituitary tumours causing excess growth hormone secretion are very rare in 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.
In dogs the symptoms of diabetes mellitus commonly overshadows acromegalic symptoms.
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.
Co-morbidities The vast majority of cats with hypersomatotropism also have diabetes mellitus.
Age of onset Feline hypersomatotropism is usually diagnosed in elderly cats. The average age of diagnosis is between 10 and 11 years with a range of 4–17 years.
The age range of dogs reported with growth hormone secreting tumours is between 7 and 10 years. The age range of bitches with progestone induced hypersomatotropism is 4–11 years, for bitches with hypersomatotropism resulting from the estrous cycle the age range is between 6 and 13 years.
History In 1976, two cats were described with diabetes mellitus and acidophilic pituitary adenomas. Whilst growth hormone levels were not measured it was proposed that growth hormone excess from the tumours was the cause of the diabetes. In the following three decades further cases would only be written about infrequently and feline hypersomatotropism was considered a rare disease. This was challenged in 2007 after a study looking at the IGF-1 levels in cats with diabetes found a marked increase in 32% of cats.
Growth hormone excess induced by progestogens in dogs was first described in the 1970s and 1980s. In 1980 a crossbred Belgian Shepherd bitch with acromegaly that had been administered excessive amounts of medroxyprogesterone acetate (MPA); following cessation of MPA administration symptoms improved and hormone levels returned to normal. In 1981 it was reported that fifteen bitches receiving MPA injections to prevent oestrus. All fifteen showed signs of acromegaly and thirteen showed hyperglycaemia. Clinical signs were improved after cessation of MPA. Later studies would confirm an association between progestogen administration and acromegaly, glucose intolerance, and diabetes mellitus.
Epidemiology Studies have found the prevalence of heightened IGF-1 levels in cats with diabetes mellitus to range between 17.8% and 27.3%. According to Claudia Reusch, a professor at the University of Zurich, the prevalence of hypersomatotropism in diabetic cats is 10–15%, in cases that are hard to regulate it rises to 30% or higher.
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.
Hypothyroidism can increase levels of growth hormone and IGF-1 in dogs. Some of the physical changes in dogs with hypothyroidism may be due to increased growth hormone concentration.
Pathophysiology In cases of hypersomatotropism the growth hormone concentrations that circulate are chronically increased; however, the secretion of growth hormone remains the same. Growth hormone directly and indirectly affects the metabolic system; stimulation of IGF-1 synthesis is the indirect cause. Increased levels of growth hormone and IGF-1 result in proliferation of bone, cartilage, soft tissue, and increases the size of organs. These changes are responsible for the physical changes of hypersomatotropism that are characteristic to the condition.
Both growth hormone and IGF-1 can impact insulin in different manners. Chronic growth hormone excess has been linked to defects in hepatic and extrahepatic insulin actions. Growth hormone increases hepatic glucose production and decreases glucose uptake in extrahepatic tissue. Studies have suggested that growth hormone excess reduces insulin sensitivity. IGF-1 increases insulin sensitivity in both hepatic and extrahepatic tissue; however, in hypersomatotropism IGF-1 levels are unable to deal with the insulin resistance caused by excessive growth hormone levels.
In non-diabetic cases the insulin resistance is countered by increased insulin production from beta cells, which results in normoglycaemia (normal levels of blood sugar) being maintained. When beta cells fail to provide enough insulin production to compensate for the increased resistance diabetes mellitus develops. The cause for this failure is unknown. The vast majority of cats with hypersomatotropism also have diabetes mellitus.
In iatrogenic cases of hypersomatotropism, when the condition is caused by administered progestogens, the typical features of acromegaly occur; however, glucose tolerance is maintained initially by increased insulin levels, eventually insulin levels cannot be increased any further and glucose intolerance occurs. Most abnormalities are reversible after cessation of treatment; however, bone lesions may be permanent.
Increase in growth hormone and IGF-1 levels in bitches is a physiological event that occurs during the luteal phase of the oestrous cycle. In bitches with spontaneous acromegaly brought on by oestrous, their progesterone levels are normal; however, growth hormone levels are increased. Recovery following an ovariohysterectomy may be possible. The reason as to why some bitches develop acromegaly and diabetes mellitus during the oestrous cycle is unknown.
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.