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Endocrine Abstracts (2017) 48 CB10 | DOI: 10.1530/endoabs.48.CB10

1Imperial College Healthcare NHS Trust, London, UK; 2London North West Healthcare NHS Trust, London, UK.


A 39-year-old man presented with thyrotoxicosis and was diagnosed with Graves’ disease. Despite high doses of anti-thyroid medication for 18 months, he remained biochemically and clinically hyperthyroid. Therefore, a thyroidectomy was planned. Four days before surgery, he developed double vision and was referred for urgent Neurosurgical review at our centre. On further questioning, he reported a 12-month history of lethargy and low libido. On examination, he had right 6th cranial nerve palsy and a partial right ptosis. A pituitary MRI showed a large suprasellar lesion with right cavernous sinus involvement. Biochemistry showed prolactin 37 384 mU/l (macroprolactin negative), testosterone 1.6 nmol/l, LH 1.5 IU/l, FSH 1.7 IU/l, T4 16.4 nmol/l, T3 7.2 nmol/l, TSH <0.01 mU/l, cortisol 53 nmol/l and IGF-1 23.2 nmol/l (13–50 nmol/l). His case was discussed at the ICHNT Pituitary MDT meeting. His thyroidectomy was cancelled and he commenced cabergoline 0.5 mg/week and hydrocortisone replacement. Serum prolactin fell quickly to 5456 mU/l after one dose of cabergoline 0.5 mg. Both the right-sided ptosis and 6th nerve palsy resolved.

With regards to his thyroid dysfunction, TSH receptor antibody level was raised at 2.1 u/ml (ULN 0.3) with a persistently elevated fT3 and undetectable TSH. He elected for radioactive iodine treatment rather than thyroidectomy as a definitive cure for his Graves’ disease. Nine weeks following radioactive iodine, he commenced thyroxine replacement (fT4 9.3 nmol/l).

A subsequent pituitary MRI showed a significant reduction in the size of the prolactinoma, albeit with persistent right parasellar extension to the cavernous sinus. Prolactin reached a nadir of 437 mU/l. However, he demonstrated low mood, with aggression and anger at out-patient review. After multiple discussions, he proceeded with a trial without cabergoline. Nine months later, his prolactin is static at 2494 mU/l and his mood improved. An interval pituitary MRI is being scheduled.

Questions for discussion: What are the options for this gentleman if his prolactin rises without dopamine agonists? Will surgery alone be sufficient in view of probable cavernous sinus involvement?

Volume 48

Society for Endocrinology Endocrine Update 2017

Society for Endocrinology 

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