Advertisement

A man with breast discharge and headache.

Published:November 11, 2015DOI:https://doi.org/10.1016/j.ejim.2015.11.006

      1. Introduction

      A 44 year old previously healthy man presented with gradual onset of discharge of whitish liquid from the nipples and a dull headache for last three years. The patient reported progressive erectile dysfunction, decreased libido, and weight gain over the last five years. On physical examination the patient had a regular heart rate of 84/min and a blood pressure of 120/88. Thyroid examination was unremarkable. Breast examination revealed bilateral lipomastia and galactorrhea. Neurological exam and confrontational perimetry were unremarkable. Testicles were 12 mL bilaterally. Laboratory investigations revealed a raised prolactin levels 9964 mIU/L (normal 22–322.2 mIU/L). Post-contrast T1-weighted MRI of brain (coronal and sagittal sections) is shown in Fig. 1a and b .
      Figure thumbnail gr1
      Fig. 1Post-contrast T1-weighted MRI of brain (coronal section 1a, and sagittal section 1b).
      What is the diagnosis?

      2. Discussion

      This patient has a macroprolactinoma. Prolactinomas are typically benign and are the most common type of secretory pituitary tumors [
      • Melmed S.
      • Kleinberg D.
      Anterior pituitary.
      ]. Prolactinomas represent 30–40% of all pituitary adenomas with those measuring more than 10 mm being called macroprolactinomas (<10%).
      Symptoms are mainly due to suppression of the hypothalamic-pituitary-gonadal axis by prolactin. While men commonly present with sexual dysfunction and hypogonadism, women usually present with amenorrhea and galactorrhea. Headache and visual field defects maybe present owing to mass effect on the optic chiasma. Galactorrhea with or without gynecomastia is a very rare presentation in men. Very high prolactin levels (>5300 mIU/L) in the absence of offending medication are generally found in macroprolactinoma. Evaluation of full anterior pituitary function is desirable including luteinizing hormone, follicle stimulating hormone, and morning cortisol to check for the integrity of the hypothalamic-pituitary-adrenal axis. Other investigations should include thyroid, liver, renal function tests and automated perimetry.
      Selective dopamine agonist like cabergoline has emerged the drug of choice and can be started at 500 μg twice a week at bedtime and then can be double after 2–4 weeks [
      • Klibanski A.
      Clinical practice. Prolactinomas.
      ,
      • Colao A.
      • Savastano S.
      Medical treatment of prolactinomas.
      ]. A prolactin level may be obtained after 4 weeks. Once the prolactin levels fall, MRI may be repeated after 3 months. With careful long-term follow-up, therapy maybe tapered and discontinued after treatment for at least 2 years provided prolactin has normalized and there is no visible tumor remnant [
      • Klibanski A.
      Clinical practice. Prolactinomas.
      ].

      Contributors

      SC was involved in the care of the patient. AM and SC provided case details and planned the report. AD wrote the report, AM, and SC revised the report for intellectual content.

      Funding information

      This report received no specific funding.

      Conflict of interests

      There are no competing interests.

      References

        • Melmed S.
        • Kleinberg D.
        Anterior pituitary.
        in: Kronenberg H.M. Melmed S. Polonsky K.S. Larsen P.R. Williams textbook of endocrinology. 11th ed. Saunders Elsevier, Philadelphia2008: 185-261
        • Klibanski A.
        Clinical practice. Prolactinomas.
        N Engl J Med. 2010; 362: 1219-1226
        • Colao A.
        • Savastano S.
        Medical treatment of prolactinomas.
        Nat Rev Endocrinol. 2011; 7: 267-278