Keywords
history of medicine - acromegaly - gigantism - Tripoli - Libya - Middle East - North Africa
Introduction
Acromegaly and gigantism are rare diseases resulting from excess growth hormone (GH) production and insulin-like growth factor 1 (IGF-1). Acromegaly occurs in adulthood, and even rarer gigantism occurs before bones have closed. Both conditions lead to clinical sequelae with significant morbidity and mortality. It is caused most commonly by an adenoma of the anterior pituitary gland. Acromegaly is a multisystem disease, and patients exhibit characteristic morphologic changes and metabolic dysfunction and can develop many comorbidities.[1] Acromegaly is associated with increased morbidity and mortality through different metabolic and somatic consequences involving soft tissue, acral overgrowth, and skin thickening, leading to different clinical manifestations.[1]
Once the condition is suspected, the diagnosis of acromegaly can be confirmed by measuring GH and IGF-1 levels and magnetic resonance imaging of the pituitary.[1] The goals for managing acromegaly include reducing tumor size, preventing further tumor growth, and controlling excessive hormonal levels.[1] Treatment approaches include pituitary surgery, medical therapy, and radiotherapy.[1]
The Giant of Tripoli
SAN was born on August 17, 1943, in the old city of Tripoli, Libya. He was one of few individuals in medical history to reach or surpass 8 feet in height. He reached his maximum height at the age of 16. In 1960, he reportedly underwent surgery at 17 for his gigantism in Italy to halt his growth. A few photos and one short video clip in Italian are available in the public domain, demonstrating his physical features. They were taken simultaneously in Italy ([Fig. 1]). He also saw a London Hospital for acromegaly in 1965.
Fig. 1 These are the two most well-publicized photos of SAN taken in Italy, showing his physical features of acromegalic gigantism and taken in early 1960-1962. A video clip is also available on YouTube.
He was one of the tallest basketball players ever at 245 cm; though when he played basketball, he was closer to 239 cm and played for Libya. Indeed, his enrollment in the Etihad Club, of which he remained a life-long supporter, was only symbolic due to his height, as his musculoskeletal status did not allow him to train and achieve the required professional level. SAN was a medical anomaly among the 20 tallest persons in the history of the world.
SAN was also credited with being the tallest actor in history. However, his acting career was limited. He starred in an uncredited role in the movie Satyricon. by Frederico Fellini in 1969 ([Fig. 2]). He was reportedly offered a role in America at a higher rate that he declined.
Fig. 2 SAN is the tallest actor seen with Fillini sitting in his lap. Pictures are retrieved from public domain websites records of the movie Satyricon (1969).
In his hometown of Tripoli, his height was a legend for tallness to the extent that some would use his surname as a synonym for a giant. Although he was known to be very pleasant and kind, some who would have been kids then stated on social media that he used to be scared by his height. He was married to one of his relatives but never known to have children of his own, but he adopted a couple of children. SAN developed panhypopituitarism and died on February 25, 1991, due to heart disease.
Comments
Giants, including those with acromegaly, have been well-known in history for over a thousand years.[2] Pierre Marie coined the term “acromegaly” in 1886 and linked it to a distinct clinical disease with a characteristic clinical picture. However, Pierre Marie was one of many physicians to give a complete record of the clinical picture of acromegaly; others had preceded him, like the Dutch physician Johannes Wier. After Marie, pituitary enlargement was noted in almost all patients with acromegaly.[3]
[4] Most of the acromegaly and gigantism in the medical literature, particularly the case described in the era before and the early years after the initial publication of Pierre Marie, come from Western Europe.[2] Also, a more recent account presents a historical review of giants and dwarves living in South America and the contribution of South America's researchers to scientific advances on GH and human disorders related to GH excess and GH deficiency.[5] Therefore, several notable cases of acromegaly and giantism are well documented in the medical literature. However, a few studies are from the Middle East and North Africa.[6]
[7]
The present case illustrates the challenges of managing young patients with GH excess who tend to have a genetic mutation associated with aggressive somatotroph adenoma and suffer from early mortality due to GH-related comorbidities. This case of acromegalic gigantism is likely a result of an AIP gene mutation.[8]
[9]
Sadly, SAN's case was diagnosed very late to the extent that his condition allowed him to achieve his height of magnitude by age 16. All SAN's endocrine care was in Italy. He was treated gratis in Italy due to his rare case and lack of appropriate care in Libya then. Libya took its independence in 1951 and was then the poorest country. The healthcare services in Tripoli from 1950 to 1970 lacked specialized endocrine services. For instance, the main hospital in Tripoli was the Tripoli Central Hospital, originally built during the Italian occupation and named after the then-Italian King, Ospedale Vittorio Emanuele III.[10] It had broad specialties of those days in medicine, surgery, infectious disease, urology, orthopedics, and gynecology which was the typical setting. Endocrinology was identified as a specialty when two dedicated endocrine clinics were established in Tripoli by Dr. Ibrahim H Sherif in 1980[11] and Benghazi by Dr. Salah E Gerryo soon after that. On the contrary, diabetes was recognized as a specialty much earlier than clinical endocrinology. The records of the diabetes hospital in Tripoli date to 1961 in a series of articles by GM Rao, a physiologist with endocrine interest working at the medical school of Tripoli.[12] Many of the medical students cannot forget the lectures and tutorials of Prof. Baligh ur Rehman who used to take the students for a diabetes course for a full week. Also, Benghazi Diabetes Centre was established by the late Dr. Othman Kadiki in 1969 and is one of the oldest dedicated clinics in Africa.[13]
Although much of the information presented here is known on some Internet sites and social media, it deserves a place in the regional medical literature due to its uniqueness. The case presentation could interest those who wish to document the history of medicine in the region. It can also be formally used for teaching with examples close to the learners' environment.
