Hyperprolactinaemia an unusual case
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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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HyperprolactinaemiaAn Unusual Case

Dianne Wright

Specialist Nurse in Endocrinology



History l.jpg
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


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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


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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.


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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.


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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.


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MRI head / Pituitary January 2007

Sagittal view Coronal view

Fig1a: Coronal view of the head


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Referral

  • Referred by Bradford renal team to LGI for neuro assessment.

  • Endocrinology not involved at this stage as did not particularly suggest pituitary problem.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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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


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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


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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.


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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


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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.



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Contact:

  • Dianne Wright

  • Specialist Nurse in Endocrinology

  • RGN BSc[Hons]

  • dianne.wright@bradfordhospitals.nhs.uk

  • 01274 382019 / 07814 540377

  • Pager: 07659 102026