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Hyperprolactinaemia An Unusual Case

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

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  1. HyperprolactinaemiaAn Unusual Case Dianne Wright Specialist Nurse in Endocrinology

  2. Bradford Royal Infirmary

  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. 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. 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. 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. 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. MRI head / Pituitary January 2007 Sagittal view Coronal view Fig1a: Coronal view of the head

  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. 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. 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. 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. 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. 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. 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.

  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. 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. 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. 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. 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. 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. Would you have done anything differently? • Thank You

  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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