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level of 734&#8239;ng&#47;mL &#40;reference interval 81&#8210;225&#8239;ng&#47;mL&#41; and growth hormone &#40;GH&#41; of 21&#46;5&#8239;ng&#47;mL &#40;reference range &#60;3&#8239;ng&#47;mL&#41;&#46; There was no clinical or laboratory evidence of hypopituitarism&#46; Magnetic resonance imaging of the sellar region showed a pituitary lesion to the right&#44; measuring 1&#46;3&#8239;&#215;&#8239;0&#46;7&#8239;cm in the longest axis and involving the right cavernous sinus&#46; The patient underwent transsphenoidal pituitary resection&#44; with pathological confirmation of a pituitary adenoma&#44; reactive on immunohistochemistry for GH&#44; prolactin&#44; and thyroid stimulating hormone &#40;TSH&#41;&#44; and positive Ki-67 immunoreactivity in 2&#37; of the neoplastic cells&#46; Due to the residual lesion and persistence of GH&#47;IGF-1 hypersecretion&#44; he started using 30&#8239;mg of somatostatin analog &#40;octreotide&#41; per month after biochemical control of the excess hormone&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cutis verticis gyrata &#40;CVG&#41; is the term that describes hypertrophy and coarse folding of the scalp skin&#44; alternating crests and deep grooves&#44; which mimic a cerebriform aspect&#44; that is&#44; the cerebral gyri&#46; CVG is classified as primary when the etiology is unknown or has a neurological cause&#46; Acromegaly is one of the secondary causes of CVG&#44; as well as local scalp diseases&#44; pachydermoperiostosis&#44; genetic syndromes&#44; systemic diseases&#44; other endocrine diseases&#44; and minoxidil or testosterone use&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> CVG is a rare condition&#44; with a prevalence of 0&#46;026 to 0&#46;1 in 100&#44;000 individuals&#44; and reports of its association with acromegaly are even more rare&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The number of folds&#44; usually soft and spongy&#44; can vary&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Skinfolds in primary CVG are usually symmetrical&#44; follow an anteroposterior direction&#44; and usually involve the vertex and occiput&#44; although the entire scalp can be affected&#46; In secondary CVG&#44; the folds are often asymmetrical&#44; not following a longitudinal direction&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The folds are not easily flattened by traction or pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a> The areas of the scalp affected in acromegaly are multiple&#44; ranging from frontal&#44; frontoparietal&#44; and parieto-occipital regions&#44; up to &#34;forehead to nape of the neck&#34; and&#44; eventually&#44; they affect the glabella and nasal bridge&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3&#44;5&#8211;8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">While males are vastly more affected in cases of primary CVG&#44; at a ratio of 5-6&#58;1&#44; this predominance is not well established in secondary cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Schunter et al&#46; proposed that excessive levels of GH and IGF-1 are crucially involved in the pathogenesis of CVG in acromegaly&#44; acting on target skin cells&#44; especially dermal fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The collagen deposition that characterizes CVG is prolonged and progressive&#44; but it is a benign condition&#44; with repercussions limited to esthetics &#8211; consequently&#44; with possible emotional damage and eventual skin infections&#44; mainly fungal&#44; due to the difficult hygiene of the furrows&#46; The treatment consists of local hygiene and surgical resection of excess skin in cases of cosmetic discomfort&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The current case does not require specific management for CVG&#44; but draws attention to the possibility of this complication in the context of a rare and chronic disease such as acromegaly&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors&#39; contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Giullia Menuci Chianca Landenberger&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">B&#225;rbara Roberta Ongaratti&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">J&#250;lia Fernanda Semmelmann Pereira-Lima&#58; Approval of the final version of the manuscript&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Miriam da Costa Oliveira&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; critical review of the manuscript&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Images in Dermatology
Cutis verticis gyrata: a cutaneous finding in acromegaly
Giullia Menuci Chianca Landenbergera, Bárbara Roberta Ongarattib, Júlia Fernanda Semmelmann Pereira-Limaa,b, Miriam da Costa Oliveiraa,b,
Autor para correspondência
miriamoliveira1697@gmail.com

Corresponding author:
a Neuroendocrinology Center, Complexo Hospitalar Santa Casa de Porto Alegre, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
b Postgraduate Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
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increased skin folds and furrows&#44; increased skin sweating&#44; percussion of the median nerves resulted in bilaterally positive Tinel sign&#44; and he had a deep voice&#46; Convolutions of the scalp were observed in the parietal and occipital regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The alterations observed on the scalp were also identified in the magnetic resonance imaging of the skull &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; When questioned&#44; the patient reported that his longtime barber reported having difficulty cutting his hair due to &#34;irregularities&#34; on the scalp&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The diagnosis of acromegaly was confirmed by the insulin-like growth factor 1 &#40;IGF-1&#41; level of 734&#8239;ng&#47;mL &#40;reference interval 81&#8210;225&#8239;ng&#47;mL&#41; and growth hormone &#40;GH&#41; of 21&#46;5&#8239;ng&#47;mL &#40;reference range &#60;3&#8239;ng&#47;mL&#41;&#46; There was no clinical or laboratory evidence of hypopituitarism&#46; Magnetic resonance imaging of the sellar region showed a pituitary lesion to the right&#44; measuring 1&#46;3&#8239;&#215;&#8239;0&#46;7&#8239;cm in the longest axis and involving the right cavernous sinus&#46; The patient underwent transsphenoidal pituitary resection&#44; with pathological confirmation of a pituitary adenoma&#44; reactive on immunohistochemistry for GH&#44; prolactin&#44; and thyroid stimulating hormone &#40;TSH&#41;&#44; and positive Ki-67 immunoreactivity in 2&#37; of the neoplastic cells&#46; Due to the residual lesion and persistence of GH&#47;IGF-1 hypersecretion&#44; he started using 30&#8239;mg of somatostatin analog &#40;octreotide&#41; per month after biochemical control of the excess hormone&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cutis verticis gyrata &#40;CVG&#41; is the term that describes hypertrophy and coarse folding of the scalp skin&#44; alternating crests and deep grooves&#44; which mimic a cerebriform aspect&#44; that is&#44; the cerebral gyri&#46; CVG is classified as primary when the etiology is unknown or has a neurological cause&#46; Acromegaly is one of the secondary causes of CVG&#44; as well as local scalp diseases&#44; pachydermoperiostosis&#44; genetic syndromes&#44; systemic diseases&#44; other endocrine diseases&#44; and minoxidil or testosterone use&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> CVG is a rare condition&#44; with a prevalence of 0&#46;026 to 0&#46;1 in 100&#44;000 individuals&#44; and reports of its association with acromegaly are even more rare&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The number of folds&#44; usually soft and spongy&#44; 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at a ratio of 5-6&#58;1&#44; this predominance is not well established in secondary cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Schunter et al&#46; proposed that excessive levels of GH and IGF-1 are crucially involved in the pathogenesis of CVG in acromegaly&#44; acting on target skin cells&#44; especially dermal fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The collagen deposition that characterizes CVG is prolonged and progressive&#44; but it is a benign condition&#44; with repercussions limited to esthetics &#8211; consequently&#44; with possible emotional damage and eventual skin infections&#44; mainly fungal&#44; due to the difficult hygiene of the furrows&#46; The treatment consists of local hygiene and surgical resection of excess skin in cases of cosmetic discomfort&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The current case does not require specific management for CVG&#44; but draws attention to the possibility of this complication in the context of a rare and chronic disease such as acromegaly&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors&#39; contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Giullia Menuci Chianca Landenberger&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">B&#225;rbara Roberta Ongaratti&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">J&#250;lia Fernanda Semmelmann Pereira-Lima&#58; Approval of the final version of the manuscript&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Miriam da Costa Oliveira&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; critical review of the manuscript&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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            0 => "Acromegaly"
            1 => "Growth hormone"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Acromegaly is a rare disease characterized by changes in the bone and soft tissue systems&#44; induced by excess growth hormone and insulin-like growth factor type 1&#46; Among the skin lesions associated with acromegaly is cutis verticis gyrata&#44; an hypertrophic&#44; and coarse folding of the skin of the scalp&#44; an association of uncommon incidence and unknown prevalence&#46; This case report describes the case of a patient diagnosed with acromegaly at age 60 with previously unidentified cutis verticis gyrata&#46; This report aims to review the literature on cutis verticis gyrata and its unusual association with acromegaly&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A and B&#41; Clinical aspect of the scalp&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging of the skull&#46; &#40;A&#41;&#44; Sagittal section&#46; &#40;B&#41;&#44; Coronal section&#44; showing skin undulations&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A and B&#41;&#44; Three-dimensional &#40;3D&#41; reconstruction of the cerebriform skin from the magnetic resonance imaging of the cephalic segment&#46;</p>"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "M&#46; Tripathi"
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                          "etal" => false
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18211488"
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                      "titulo" => "Cutis verticis gyrata and mental deficiency in Sweden&#46; I&#46; Epidemiologic and Clinical Aspects"
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                          "etal" => false
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                      "titulo" => "Isolated cutis verticis gyrata of the glabella and nasal bridge&#58; a case report and review of the literature"
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                            1 => "F&#46; Clarke"
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                      "doi" => "10.1016/j.bjps.2013.01.040"
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                        "tituloSerie" => "J Plast Reconstr Aesthet Surg&#46;"
                        "fecha" => "2013"
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                      "titulo" => "Visual vignette&#46; Cutis verticis gyrata &#40;CVG&#41; in acromegaly"
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ISSN: 03650596
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