Presentation Of Macroprolactinoma Research Articles

7883 Atypical Presentation of Macroprolactinoma: Discordantly Low Serum Prolactin and Therapeutic Challenges

Abstract Disclosure: S. Hossain: None. M.S. Hossain: None. B. Gautam: None. S.C. Kumar: None. H. Liao: None. D.S. Rosenthal: None. Introduction: Pituitary tumors are categorized as microadenomas (<1 cm) and macroadenomas (>1 cm) with prolactinomas being one of the most common causes. The mean prevalence of prolactinomas is 10 per 100,000 in men and 30 per 100,000 in women. Serum prolactin levels corresponds to the size of the prolactinoma and any discrepancy should be treated with caution as that may indicate co-existence of pluripotent cells. We present a patient who presented with visual field defect and headaches, found to have a pituitary macroadenoma with discordantly low serum prolactin level compared to the size of adenoma, prompting a change in the treatment course. Case Presentation: A 42 year old male with no past medical history was seen as an endocrinology consult requested by neurosurgery for frequent headaches and visual problems for 1 year. Vital signs were normal, with negative orthostatic drop of blood pressure. He had prominent bitemporal hemianopsia confirmed by formal visual field testing by Ophthalmology. No galactorrhea or features suggestive of acromegaly or hyperthyroidism. He complained of erectile dysfunction but appeared to have normal male secondary sexual characteristics. MRI of brain showed a suprasellar mass measuring 3.8 x 2.6 x 2.2 cm with mass effect on the optic chiasm, hypothalamus with extension and infiltration into the right cavernous sinus. Lab results showed elevated prolactin of 1343.5 ng/ml confirmed by serial dilution, low serum testosterone level of 134 ng/dl and inappropriately normal FSH and LH. Complete blood counts, comprehensive metabolic panel, TFT, ACTH, cortisol and IGF-1 were normal. Patient was started on bromocriptine and he noticed improvement in his field of vision and acuity within one week of starting therapy. He continued to show sustained improvement in vision and resolution of his headaches at the one-month mark. MRI 2 months from starting bromocriptine showed modest reduction in size of the tumor to 2.1 x 2.3 x 2.4 cm with continued mass effect on the optic chiasm. Prolactin level decreased to 69.3 ng/ml. Therefore, although there was some improvement in visual fields, surgical resection was recommended to alleviate the mass effect on the optic chiasm. Conclusion: Our case highlights the significance of identifying discrepancies between the size of a prolactinoma and serum prolactin levels. Expected prolactin level from a prolactinoma similar in size to our case would be >3000 ng/ml when ours was 1343.5ng/ml. Despite undergoing treatment and lowering of prolactin levels our patient's pituitary adenoma did not significantly reduce in size after two months of treatment with bromocriptine and the mass continued to exert pressure on the optic chiasm. This suggests possible presence of pluripotent cells in addition to prolactin-producing cells within the tumor. The recommended course of action was surgical resection of the mass. Presentation: 6/1/2024

A case of atypical presentation of macroprolactinoma in young female

A case of atypical presentation of macroprolactinoma in young female

Reply to Commentary on "Pituitary apoplexy in an adolescent male with macroprolactinoma presenting as middle cerebral artery territory infarction&quot.

See the reply "Pituitary apoplexy in an adolescent male with macroprolactinoma presenting as middle cerebral artery territory infarction" on page 320.

ODP299 Cabergoline Administration Markedly Improves Cognitive Impairment Associated with Macroprolactinoma

Abstract Introduction Prolactinomas classically present with galactorrhea, infertility, or hypogonadal symptoms. However cognitive impairment is rare presentation. We describe a man with a macroprolactinoma presenting with significant cognitive dysfunction which improved remarkably with cabergoline treatment. Case History A 21-year-old man with no significant past medical history presented to the hospital for evaluation of seizure-like activity. His father noted him limping earlier in the day and witnessed him fall and hit his head, while his brother reported involuntary convulsions and decreased awareness earlier that week. The patient himself had been complaining of blurry vision for 3 months for which he was prescribed glasses. Initial head CT demonstrated a 3.4×4.3×3.4cm cystic mass in the sella, 3.9×3.2×2.6 cm mass in the right basal ganglia and 2.7×2.3×3cm mass in the right temporal lobe. His prolactin was elevated at 16326 ng/mL. He was empirically started on dexamethasone due to concern for cerebral edema and was admitted. Surgery was recommended given the severity of his presentation, but the patient declined and he was discharged on cabergoline 1.5mg/week, dexamethasone taper, hydrocortisone 15mg/day, and levetiracetam 1000mg twice daily. On initial outpatient endocrinology evaluation 3 weeks later, he required the use of a wheel chair. Examination was notably for markedly flat affect, slurred speech, decreased attention span requiring frequent re-direction during the interview but he was otherwise oriented to person, time, and place. Neurological examination was noted for 4/5 muscle weakness throughout, facial asymmetry, decreased facial sensation, and an antalgic gait. He was recommended for expedited neurosurgical evaluation but he again declined. Laboratory drawn at this time showed a prolactin of 1946 ng/mL and total testosterone of 45 ng/dL, but he had normal thyroid and growth hormone axis (adrenal axis was not assessed as he was on dexamethasone taper). Carbergoline was titrated with further improvement in his prolactin levels. Four months after initial presentation, he reported enrolling in college with resolution of any cognitive and neurological deficits. Fourteen months after presentation, serum prolactin was 34 ng/mL on 4mg cabergoline per week and he is active in college and regularly plays basketball. Discussion Prolactinomas are incidentally detected or found as a result of workup for galactorrhea, infertility, or low libido. Typically, goals for treatment are to relieve compressive effects along the optic chiasm or to restore gonadal function. Acute cognitive decline should also be considered when there is a macroprolactinoma, and serial monitoring for improvement may be considered a clinical marker along with MRI imaging and prolactin levels. In this case, the patient had marked cognitive dysfunction on initial presentation but after 3 months of treatment had almost complete recovery as evidenced by his re-enrolling in college classes successfully. Presentation: No date and time listed

Macroprolactinoma presenting as galactorrhoea in a male

Macroprolactinomas account for more than 50% of all functional pituitary tumours. These are equally prevalent in males and females, although they are diagnosed earlier in females. In females, the usual presentations include oligomenorrhoea, amenorrhoea, galactorrhoea and infertility, whereas males usually present with headache, sexual dysfunction and visual field defects. The following is a case of a 30-year-old male who presented with unilateral nipple discharge, sexual hypoactivity and grossly elevated serum prolactin levels. His magnetic resonance imaging revealed a macroprolactinoma. He responded well to cabergoline.

Macroprolactinoma Presenting With Hyponatremia; A Rare Case Report

Abstract Background: Hyponatremia is a common electrolyte abnormality, investigating the etiology can be challenging to the clinician, especially when the cause has rarely been associated with hyponatremia. Macroprolactinoma has rarely been reported as a cause of hyponatremia. We are reporting a case of macroprolactinoma presenting with hyponatremia. Care Report: A 67 year old female previously healthy female, presented with a fall due to syncopal episode. Patient reported lightheadedness for a week prior to presentation. On physical examination, patient had bilateral periorbital ecchymoses, and swelling of the nose. Remaining of physical exam was unremarkable. Lab work showed hyponatremia with high urine osmolality and high urine sodium, consistent with syndrome of inappropriate antidiuretic hormone (SIADH). CT head showed Intrasellar soft tissue mass represents a pituitary macroadenoma. Pituitary hormonal workup showed high prolactin: 2,808 ng/mL, the rest of pituitary profile was normal, including pituitary-adrenal axis evaluation. Pituitary MRI confirmed a large pituitary macroadenoma measuring 1.7 x 2.9 x 2.5 cm, which displaces and compresses the optic chiasm and invades the right cavernous sinus. She was treated with fluid restriction and salt tablets with improvement of sodium level to normal. Cabergoline 0.25 mg twice a week was started with improvement of prolactin level to 156 ng/mL over 9 months period. Discussion: Pituitary macroadenoma rarely associated with hyponatremia, and when reported it is usually secondary to hypopituitarism (low ACTH or low TSH). However, there are few cases reported of SIADH related hyponatremia in the presence of normal pituitary function. Although the exact mechanism of exaggerated production of arginine vasopressin (AVP) is not fully understood, the likely theory thought to be related to the mechanical pressure on the axonal terminal of AVP neurons by the large pituitary tumor. Conclusion: Hyponatremia due to SIADH has been linked in few cases with nonfunctioning pituitary adenoma. Only two cases found in the literature reporting SIADH secondary to prolactin producing pituitary adenoma, with our case being the third reported case.

Abstract #805021: Cluster Headache as Initial Presentation of Macroprolactinoma

Abstract #805021: Cluster Headache as Initial Presentation of Macroprolactinoma

Pituitary Apoplexy in an adolescent male with Macroprolactinoma presenting as middle cerebral artery infarction

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Macroprolactinoma Presenting As Acute Pituitary Apoplexy: Report of a Case and Short Review of Literature

Macroprolactinoma Presenting As Acute Pituitary Apoplexy: Report of a Case and Short Review of Literature

Klebsiella Meningitis as the Initial Presentation of Macroprolactinoma: A Case Report

Introduction: Gram negative bacterial meningitis is a rare initial presentation of a macroprolactinoma. Meningitis in these cases is likely caused by a defect in the sellar floor from surgical manipulation or treatment with a dopamine agonist causing rapid shrinkage of a tumor. Patients generally have headaches as the predominant symptom. Our case is an illustration of where meningitis is caused by a transsphenoidal surgery and where meningitis is the presenting symptom to diagnosing a macroprolactinoma.Case presentation: The patient is a 20-year old African female with history of transsphenoidal surgery over one year ago, who presents with headache associated with subjective fevers, nausea, and vomiting. The patient states that she had similar headaches for the past 2 years but not to this severity. She reports that when she was in her country one year ago she had an unknown surgery through her nose that helped the headaches for a short period of time. She recalls having increasingly irregular periods over the past year and milky discharge from her breasts.Results: Physical exam was significant for nuchal rigidity. CT scan showed large sellar mass and MRI was consistent with likely pituitary adenoma. The patient’s presentation was suspicious for meningitis, so a lumbar puncture was performed, and CSF analysis was consistent with bacterial meningitis. The patient was started on broad spectrum antibiotics until CSF cultures returned showing Klebsiella pneumoniae sensitive to ceftriaxone. Further testing showed very high prolactin levels. Endocrinology was consulted and agreed the tumor was a pituitary macroadenoma, most likely a prolactinoma due to her laboratory findings and symptoms of menstrual irregularity and galactorrhea. The patient was treated with Cabergoline 0.5 mg two times per week.Conclusion: Bacterial meningitis, especially when caused by gram negative organisms is a rare presentation of a pituitary macroprolactinoma. Thorough history taking, and prompt diagnostic evaluation is crucial, especially when medical records cannot be obtained. Treatment of both conditions quickly and simultaneously is important. The case also illustrates that how treating a prolactinoma can result in complications such as meningitis not just immediately after surgery but in any stage of treatment.

Cabergoline-Induced Pneumocephalus Following Treatment for Giant Invasive Macroprolactinoma Presenting With Spontaneous Cerebrospinal Fluid Rhinorrhea

Cerebrospinal fluid (CSF) rhinorrhea is rarely reported as the first presenting feature of giant invasive macroprolactinomas. Cerebrospinal fluid rhinorrhea is usually reported as a complication of trauma, neurosurgical, and skull-based procedures (such as pituitary surgery or radiations), and less frequently after medical treatment with dopamine agonists (DAs) for macroprolactinomas. This phenomenon results from fistula creation that communicates between the subarachnoid space and the nasal cavity. Meanwhile, pneumocephalus is another well-recognized complication after transsphenoidal surgery for pituitary macroadenomas. This entity may present with nausea, vomiting, headache, dizziness, and more seriously with seizures and/or a decreased level of consciousness if tension pneumocephalus develops. Case reports about the occurrence of spontaneous pneumocephalus after medical treatment with DAs without prior surgical interventions are scarce in the literature. Our index case is a young man who was recently diagnosed with a giant invasive prolactin-secreting pituitary macroadenoma with skull base destruction. A few months before this diagnosis, he presented with spontaneous CSF rhinorrhea with no history of previous medical or surgical treatment. In this case report, we report an uncommon presentation for giant invasive macroprolactinoma with a CSF leak treated with cabergoline that was subsequently complicated by meningitis and pneumocephalus. This is a very rare complication of cabergoline therapy, which occurred approximately 1 month after treatment initiation.

A rare case of macroprolactinoma presenting with SIADH

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Abstract #846: A Rare Case of Macroprolactinoma Presenting with SIADH.

Abstract #846: A Rare Case of Macroprolactinoma Presenting with SIADH.

Abstract #950: Male with Giant Macroprolactinoma Presenting with Impaired Vision During Treatment with Cabergoline.

Abstract #950: Male with Giant Macroprolactinoma Presenting with Impaired Vision During Treatment with Cabergoline.

Meningitis as a Presentation of Macroprolactinoma

Cerebrospinal fluid (CSF) rhinorrhea and consecutive meningitis are well recognised clinical features of macroprolactinomas invading the skull base and are mainly observed under a dopamine-agonist therapy regimen. To our knowledge, a clinical case of primary meningitis due to an untreated macroprolactinoma, without any history of rhinorrhea, has not been reported previously in the English literature. A 64-year-old patient presented with acute meningitis. He had no prior episode of CSF rhinorrhea. Neuroradiological imaging revealed a pituitary tumour with invasion and destruction of the skull base. Massive hyperprolactinaemia was proof of a prolactinoma. The patient underwent transsphenoidal adenomectomy. The skull base defect was sealed with a fascia lata graft. In the postoperative course, no further episode of meningitis and no CSF rhinorrhea occurred. The invasive residual tumour was successfully treated with cabergoline. Macroprolactinomas can present with meningitis without any prior history of CSF rhinorrhea. Surgical repair of the skull base defect is the treatment of choice in order to prevent further episodes of meningitis. Pituitary tumours should be considered as a cause of otherwise unexplained meningitis.

Clinical, Radiologic, and Follow-Up Findings in Patients With Macroprolactinoma

OBJECTIVE: The objective of this study was to describe the clinical, therapeutic, and follow-up findings of patients with macroprolactinoma cared for in a specialized hospital. METHODS: The authors conducted a retrospective analysis of 32 patients with macroprolactinoma (19 women and 13 men) with a mean duration of follow up of 7.2 ± 5.2 years. Clinical manifestations, serum prolactin level, and tumor extension at diagnosis and after receiving treatment are analyzed. RESULTS: The predominant initial clinical manifestations in women were oligo-/amenorrhea (94.7%), headaches (58%), and galactorrhea (52.6%), whereas in men, compressive clinical manifestations (61.5% with visual field alterations) and the deficit of other pituitary hormones (30.7% with hypopituitarism) were predominant. The men presented higher serum prolactin levels (4.366 ± 5.031 vs 1.352 ± 2.917 ng/dL; P = 0.09) and greater degree of tumor invasion (100% vs 63.2; P = 0.01). The patients treated exclusively with dopamine agonists (DA) (78%) showed a considerable improvement in clinical manifestations, prolactin level, and tumor shrinkage. Seven patients received surgical treatment, 85% of whom needed treatment with DA because of persistence of hyperprolactinemia. CONCLUSIONS: The clinical and radiologic presentation of macroprolactinoma is more aggressive in men than in women, and in both sexes, treatment with dopamine agonists is effective both in controlling symptoms and in reducing serum prolactin levels and tumor size. Copyright © 2006 by Lippincott Williams & Wilkins.

Abstract #909: Transient Ischemic Attack as the Initial Presentation of Macroprolactinoma: Resolution with Dopamine Agonist Therapy

Abstract #909: Transient Ischemic Attack as the Initial Presentation of Macroprolactinoma: Resolution with Dopamine Agonist Therapy