This document presents a case of a 30-year-old male who developed cerebrospinal fluid rhinorrhea after being treated for 2 years with cabergoline for a prolactinoma. MRI showed a suprasellar lesion without indentation on the optic chiasma or apparent site of CSF leak. The patient underwent transphenoidal surgery to remove the tumor and repair the sellar floor, after which the rhinorrhea resolved without further issues. The document then reviews that CSF rhinorrhea can occur in around 3-4% of prolactinoma cases being treated medically, and discusses the indications for surgery in such cases of prolactinoma with rhinorrhea.

1. Prolactinorrhoea ????
Dr. Mausaminben Hathidara

2. CASE PRESENTATION
30 yr old male, Medical Professional
Diagnosed with prolactinoma and started on T.
Cabergoline for about 2 years
Controlled - regression in the size on follow up scans as
well as symptom relief
Was asymptomatic about till 2 months ago when he
started having CSF rhinorrhea from left nostril.

3. On examination the patient was neurologically intact
with no visual deficits
There was no history s/o meningitis

4. IMAGING
MRI Brain showed a suprasellar lesion with no
indentation on optic chiasma; no apparent site of csf leak
PRL (fresh) 17.93 (pre cabergoline) >1000

7. MANAGEMENT
Sublabial Rhinoseptal Transphenoidal approach to
removal of tumor with sellar floor repair after
withholding cabergoline
Patient was discharged with no episode of rhinorrhoea
thereafter

8. REVIEW OF LITERATURE
Facts and figures –
Prolactinomas are the most frequently encountered secretory pituitary
tumor, occurring with an annual incidence of approximately 30 per
100,000 persons
Female-to-male ratio for microadenomas is 20 : 1 whereas for
macroadenomas it is roughly 1 : 1
Although more than 99% of prolactinomas are benign about half
invade local structures
Immunostaining for PRL is confirmatory
Slow growing, arise sporadically, usually occur singly and are the
adenomas most commonly associated with MEN1

9. Hypersecretion
Women –amenorrhea, oligomenorrhea, menorrhagia, delayed
menarche, or regular menses, decreased libido and vaginal dryness ;
Men -loss or decrease in libido, impotence, premature
ejaculation or erection loss;
Up to 50% of women and 35% of men have galactorrhea;

10. Mass effect
Field defects (Bitemporal hemianopsia, superior quadrantonopia
and decreased visual acuity.)
Headaches are common
Seizures, hydrocephalus and unilateral exophthalmos rare
Cranial nerve palsies are only rarely noted as in an apoplexy

11. DISCUSSION
STATISTICS
3/100 prolactinoma with rhinorrhoea
4 /100 on medical treatment
Literature 70% of prolactinomas with csf rhinorrhoea are on
medical management
10 Patients in literature search
A recent study of 114 patients with macroprolactinomas
showed an incidence of 8.7% for non-surgical CSF
rhinorrhoea - 7 secondary to dopamine agonist treatment
(6.1%), with only 3 cases occurring spontaneously (2.6%).

12. CSF rhinorrhoea ???
Invasive
Bone density decrease – hyperprolactinemia induced sex
steroid defciency
Decompression after medications reveals the defects

13. Our experience of 7 patients revealed that all the patients
would require surgical intervention
Response to surgery is excellent
There was no further treatment required – RT or
medications

14. CONCLUSION
Prolactinomas with rhinorrhea are seen every once in a
while, though not very commonly
Can occur even with medications
The treatment in either cases is surgery
THE INDICATION FOR SURGERY IN CASES OF
PROLACTINOMA

15. REFERENCES
Published online Aug 5, 2010. doi: 10.1155/2010/312081 PMCID:
PMC2929619 Persistent CSF Rhinorrhoea, Pneumocephalus, and
Recurrent Meningitis Following Misdiagnosis of Olfactory
Neuroblastoma
BMJ Case Rep. 2009: bcr12.2008.1383 - Spontaneous
cerebrospinal fluid rhinorrhoea as the presenting feature of an
invasive macroprolactinoma - Satveer Kaur Mankia et al

16. Case notes of five patients with invasive prolactinomas and CSF
rhinorrhoea following DA treatment – Leong et al Clinical endocrinology
2000 Jan;52(1):43-9
3 cases in Cerebrospinal fluid rhinorrhoea in pituitary tumours - I E Cole
FRCS - Journal ofthe Royal Society ofMedicine Volume 73 April 1980

17. THANK YOU