Hyperprolactinaemia An unusual case

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Hyperprolactinaemia An unusual case

  1. 1. 1 Hyperprolactinaemia An Unusual Case Dianne Wright Specialist Nurse in Endocrinology
  2. 2. 2 Bradford Royal Infirmary
  3. 3. 3 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
  4. 4. 4 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
  5. 5. 5 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.
  6. 6. 6 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.
  7. 7. 7 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.
  8. 8. 8 MRI head / Pituitary January 2007 Sagittal view Coronal view Fig1a: Coronal view of the head
  9. 9. 9 Referral Referred by Bradford renal team to LGI for neuro assessment. Endocrinology not involved at this stage as did not particularly suggest pituitary problem. 
  10. 10. 10 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.
  11. 11. 11 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.
  12. 12. 12 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.
  13. 13. 13 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.
  14. 14. 14 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.
  15. 15. 15 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 raised prolactin or gonadatrophin deficiency.
  16. 16. 16 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.
  17. 17. 17 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
  18. 18. 18 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
  19. 19. 19 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.
  20. 20. 20 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
  21. 21. 21 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.
  22. 22. 22 Would you have done anything differently? Thank You
  23. 23. 23 Contact:  Dianne Wright  Specialist Nurse in Endocrinology  RGN BSc[Hons]  dianne.wright@bradfordhospitals.nhs.uk  01274 382019 / 07814 540377  Pager: 07659 102026

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