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Hyperprolactinaemia An unusual case

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Hyperprolactinaemia An unusual case Hyperprolactinaemia An unusual case Presentation Transcript

  • 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]
    • Refused to go on transplant list
  • 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
    • 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:
    • 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
    • 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 2007
    • Sagittal view Coronal view
    Fig1a: Coronal view of the head
  • 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
    • 11, 13, 15 June 2007 - renal dialysis at LGI
    • 11 th 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.
  • 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 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
    • 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
    • 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 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.
  • 23 rd 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
    • 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 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
    • 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?
    • 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 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.
  • Would you have done anything differently?
    • Thank You
  • Contact:
    • Dianne Wright
    • Specialist Nurse in Endocrinology
    • RGN BSc[Hons]
    • [email_address]
    • 01274 382019 / 07814 540377
    • Pager: 07659 102026