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Hyperprolactinaemia An Unusual Case. Dianne Wright Specialist Nurse in Endocrinology. Bradford Royal Infirmary. History . 64 year old Asian lady Primary Hypothyroidism Hypertension Vitamin D Deficiency End stage renal failure on dialysis [diagnosed December 2005]

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hyperprolactinaemia an unusual case

HyperprolactinaemiaAn Unusual Case

Dianne Wright

Specialist Nurse in Endocrinology

history
History
  • 64 year old Asian lady
  • Primary Hypothyroidism
  • Hypertension
  • Vitamin D Deficiency
  • End stage renal failure on dialysis [diagnosed December 2005]
  • Refused to go on transplant list
treatment
Treatment
  • Renal dialysis
  • Levothyroxine 125 mcg OD [primary hypothyroidism]
  • Calcium Carbonate tablets 1.25gm TDS
  • Alfacalcidol 0.25 mg OD
  • Folic Acid 5mg OD
  • Ezetimibe 10mg OD
  • Vitamin B Co-Strong 2 tablets OD
  • Quinine Bisulphate 300mg OD
  • Lactulose 15mls BD
history of presenting complaint
History of presenting complaint
  • November 2006 – frontal headaches, dizzy spells & 1 episode of collapse
  • CT [no contrast]:
  • 2 small foci of calcification in frontal lobe ? due to small meningioma.
  • Repeat CT recommended with contrast for confirmation of diagnosis.
january 2007 ct with contrast
January 2007 - CT with contrast:
  • Incidental finding of a lesion
  • Compatible with small right parafalcine meningioma
  • Abnormal patchily enhanced mass within an enlarged pituitary fossa, the mass extending inferiorly, eroding into the right side of the clivus.
  • Erosion of right side of the posterior clinoid process & abnormal soft tissue extending into the right cavernous sinus. No suprasellar extension into prepontine cistern.
  • Appearances of probable pituitary macroadenoma & not meningioma.
  • MRI recommended.
mri head pituitary january 2007
MRI head / Pituitary January 2007
  • Small parafalcine meningioma in right parietal region.
  • Pituitary fossa NOT enlarged. Enhancing pituitary tissue within the fossa & pituitary stalk, deviating to the left of midline.
  • Appearances suggest expansile lesion within the clivus, NOT a pituitary macroadenoma which has eroded into the clivus.
  • ? clival chordoma, ? plasmocytoma, ? metastasis.
  • Biopsy of the clivus is recommended.
mri head pituitary january 20078
MRI head / Pituitary January 2007

Sagittal view Coronal view

Fig1a: Coronal view of the head

referral
Referral
  • Referred by Bradford renal team to LGI for neuro assessment.
  • Endocrinology not involved at this stage as did not particularly suggest pituitary problem.
progress
Progress
  • 11, 13, 15 June 2007 - renal dialysis at LGI
  • 11th June 2007 – Transphenoidal Pituitary biopsy at LGI
  • 2 days post surgery became dizzy! Unable to assess cortisol reserve. Commenced on hydro 20 / 10 mg
  • Prolactin not checked pre surgery.
progress11
Progress
  • LGI - Prolactin checked pre dialysis [after TS biopsy] – 516,890 miul/L
  • An in-house analysis revealed prolactin to be exclusively of the monomeric form.
  • Further analysis of the serum confirmed prolactin to be of monomeric form and both macroprolactin and big prolactin accounted for only 3% of the total.
referral to bradford endocrine team 16 th june 2007
Referral to Bradford Endocrine Team 16th June 2007
  • Referral by telephone from endocrine nurse @ LGI to myself.
  • Formal written referral from medics never sent.
  • GP discharge copy requested to use as our referral.
  • Discussed with endocrine consultant in Bradford.
  • Endocrine tests & appointment TBA.
biopsy results
Biopsy Results
  • June 2007 Transphenoidal biopsy of clivus region showed pituitary adenoma.
  • Histology – showed presence of clusters of neoplastic cells that were strongly + for synaptophysin, chromagranin and prolactin. The ACTH, TSH, FSH and LH stains were negative.
  • A histological diagnosis of pituitary macroadenoma (prolactinoma) was made.
13 th august 2007
13th August 2007
  • Short Synacthen Test [off hydrocortisone]:
  • 0 mins 459 nmol/L
  • 30 mins 503 nmol/L
  • Hydrocortisone discontinued.
  • Prolactin > 467,030 miu/L
  • Macroprolactin, heterophilic antibody interference investigated & not found.
  • Very unusual result, ? cause, advised repeat.
13 th august 200715
13th August 2007
  • FT4 13.5 pmol/L
  • TSH 4.3 miul/L
  • IGF-1 13.2 nmol/? [10-28]
  • Oestradiol <40 pmol /L
  • FSH 7.8 iu/L
  • LH 0.4 iu/L
  • FSH & LH inappropriately low. May represent the effects of raisedprolactin or gonadatrophin deficiency.
23 rd august 2007
23rd August 2007
  • Renal dialysis potentially can cause rise in prolactin:
  • Pre dialysis prolactin – >1,952,555 miu/L
  • Post dialysis prolactin – >2,213,600 miu/L
  • Interesting case!
  • Awaiting endocrine appointment date to fit in with dialysis. Consultant Endocrinologist kept up to date.
initial endocrine clinic appointment october 2007
Initial Endocrine Clinic Appointment – October 2007
  • Very well
  • Off hydrocortisone for 7 weeks – random cortisol rechecked 4 week ago – satisfactory result
  • No headaches
  • No visual disturbances
  • Visual fields normal to confrontation [DNA for formal visual fields test]
  • Never experienced galactorrhoea
  • Menses stopped approx 50 yrs
initial endocrine clinic appointment october 200718
Initial Endocrine Clinic Appointment – October 2007
  • Formal GHD test never carried out as patient well
  • Large prolactin secreting benign tumour
  • Can potentially be shrunk with cabergoline
  • Risk in shrinking lesion, any fibrosis & tethering can lead to traction & potentially cause more problems e.g. [haemorrhage, headaches, damage to pituitary function
  • Discussion with patient. NOT treated with cabergoline as she is well
  • Repeat pituitary MRI TBA – November 2007
mri pituitary with contrast november 2007
MRI Pituitary with Contrast November 2007
  • No appreciable change in appearance within the clivus, pituitary fossa or para/supra sellar region.
  • No obvious increase in size of lesion eroding the clivus which has turned out to be a prolactinoma.
  • No change in parafalcine meningioma.
  • Development of right posterior temporal lacunar infarct.
where are we now
Where are we now?
  • DNA endocrine appointment February 2008
  • February 2008 - prolactin >294,900 miu/L
  • April 2008 – Tel call to patient by endocrine nurse – well, no headaches, no visual disturbances
  • Endocrine clinic - July 2008 – well
  • Prolactin - >21,200 miu/L
  • Pituitary function normal
  • Repeat MRI suggested – patient not keen – delayed until next year
  • Cabergoline not commenced due to risks as patient stable
hyperprolactinaemia
Hyperprolactinaemia
  • Hyperprolactinaemia is relatively common, but levels are seldom >1,000,000.
  • Interestingly patient is asymptomatic.
  • Although initial presentation [collapse, dizziness, frontal headaches] could be attributed to prolactinoma, the symptoms were not persistent, & fluctuating prolactin levels without changes in symptoms, would support the view of alternative diagnosis.
contact
Contact:
  • Dianne Wright
  • Specialist Nurse in Endocrinology
  • RGN BSc[Hons]
  • [email protected]
  • 01274 382019 / 07814 540377
  • Pager: 07659 102026
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