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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 @ 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 > 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 <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.

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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.

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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 >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

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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.

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Would you have done anything differently?

Thank You

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Contact:

Dianne Wright Specialist Nurse in Endocrinology

RGN BSc[Hons] dianne.wright@bradfordhospitals.nhs.uk

01274 382019 / 07814 540377 Pager: 07659 102026