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ss nucleus - autumn 1999,  Differential Diagnosis 29

Differential Diagnosis 29

1 Samuel 17. David was brought into the national limelight on killing Goliath with a stone from a sling. The feat was all the more remarkable as the Philistine champion from Gath was described as being over nine feet in height. Could there have been a medical condition that contributed to his demise?

It would be unlikely that Goliath could have reached nine feet without a pre-pubertal disorder in growth hormone secretion. Even the tallest African tribe, the Tutsi tribe of Central Africa, only averages a height in males of 6 feet 5 inches. The tallest man on record, Robert Wadlow of Alton, Illinois, was 8 feet 11 inches when he died at the age of 22 in 1940. His condition was the result of a growth-hormone-secreting pituitary tumour that developed while he was a child, before closure of the skeletal epiphyseal plates, leading to gigantism. Excessive growth hormone in adults results in acromegaly.

Most growth hormone tumours are macroadenomas, being larger than 1cm on diameter on presentation. Suprasellar extension can lead to compression of the optic chiasm resulting in a bitemporal visual field loss. Destruction of the rest of the pituitary results in pituitary insufficiency, which includes secondary hypothyroidism. Thus Goliath may have had reduced peripheral vision and slowed reactions due to the mass effect of the tumour.

In 2 Samuel 21:21-22 we read of another huge man from Gath who was killed by Jonathan. There are several hereditary syndromes associated with pituitary tumours. It is possible that the two giants could have suffered from multiple endocrine neoplasia (MEN) type 1, which is a familial syndrome of pituitary, parathyroid and pancreatic tumours. The ease with which the stone became embedded in Goliath's skull is suggestive of bone softening. This may have resulted from hyperparathyroidism due to a parathyroid tumour and an insulinoma of the pancreas might have caused erratic behaviour due to hypogylcaemia.

Luke finds it interesting that this could be the first recorded case of the MEN type 1 syndrome. This syndrome together with a large pituitary macroadenoma would have made Goliath easier to kill. David, the young shepherd, was unaware that God had prepared the ground before him in this way but still went out confidently in faith.

Differential Diagnosis 30

1 King 1:1-4

When King David was much older he was unable to keep warm even when covered in bed. His servants found a beautiful girl to sleep in the bed with him to raise his temperature, but not to have sexual relations with him.. What possible medical condition could have led to this unusual arrangement?

Luke's opinion in next issue.

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