The patient
This 46-year-old man had come in to see me because he was worried about the appearance of his nails. He had been describing the problem to me for five minutes or so when he casually threw in: ‘By the way, I think my fingers are changing shape.'
A few months previously he had found his wedding ring no longer fitted and the fingers in general had a much thicker appearance.
Otherwise he was feeling perfectly well and his past medical history was unremarkable. He had worked in an office all his adult life.
First instinct
When any patient describes changes in the appearance of their hands, the natural thought is of a developing arthritis. Certainly, taking into account his gender and age, osteoarthritis or rheumatoid arthritis could have been options for this patient.
However, examining the hands did not reveal any signs of arthritis and the patient was describing an overall change in the shape rather than a specific impact on joints. He reported no joint or more general musculoskeletal pain.
Differential diagnosis
Enlargement of the hands may occur in the following conditions:
• hypothyroidism
• acromegaly
• hard manual work
• primary amyloidosis
• obesity.
The patient certainly wasn't overweight and didn't have the demeanour or appearance of being hypothyroid. He was an office worker and wasn't someone who liked DIY. He had no symptoms suggesting he was generally unwell such as fatigue, which might have indicated primary amyloidosis.
The hidden clue
It is so easy to just focus on the presenting symptom and forget to look elsewhere. The answer was in the shape of the face where the jaw appeared to be enlarged and there was frontal bossing.
Getting on the right track
I referred him for an oral glucose tolerance test. On challenge the growth hormone levels did not fall sufficiently, suggesting that the diagnosis was acromegaly. He was subsequently seen by an endocrinologist who confirmed a pituitary adenoma after an MRI scan. This was treated by a transphenoidal hyophysectomy.
Dr Mike Wyndham is a GP in Edgware, north London
