Hyperprolactinaemia An Unusual Case

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HyperprolactinaemiaAn Unusual Case

• Dianne Wright
• Specialist Nurse in Endocrinology

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Bradford Royal Infirmary
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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 _at_ 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 gt 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 lt40 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.

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23rd August 2007

• Renal dialysis potentially can cause rise in
  prolactin
• Pre dialysis prolactin gt1,952,555 miu/L
• Post dialysis prolactin gt2,213,600 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 gt294,900 miu/L
• April 2008 Tel call to patient by endocrine
  nurse well, no headaches, no visual
  disturbances
• Endocrine clinic - July 2008 well
• Prolactin - gt21,200 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 gt1,000,000.
• 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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Would you have done anything differently?

• Thank You

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Contact

• Dianne Wright
• Specialist Nurse in Endocrinology
• RGN BScHons
• dianne.wright_at_bradfordhospitals.nhs.uk
• 01274 382019 / 07814 540377
• Pager 07659 102026