Endocrine Abstracts

Case report: A male 30 years old, presented with a 12-month history of retro-orbital and frontal headache, oppressive type of moderate intensity, which subsides with analgesics. Subsequently, deterioration of bilateral visual fields, predominantly left side, after that was investigated by a neurologist in INCN in January 2013. A magnetic resonance imaginig scan of the brain showed a 45×50 mm pituitary macroadenoma, with suprasellar extension bowing the optic chiasm and cavernous sinus invasion. Initial laboratory: PRL: 6470 ng/mL, patient was treated with prednisone 5 mg qd and LT4 100 ug qd and cabergoline (CBG) 1.5 mg/week for 12 months; with effect on his symptoms, improved vision and headache episodes; after that he was taken CBG irregularly, even suspended for about three months. Six months before admission to ER, presents moderate intensity headache and progressive deterioration of bilateral visual fields predominantly left, therefore CBG were restarted (1.5 mg/week). On admission, severe headache and persistence of visual impairment were reported. MRI showed parietal lobe herniation into sella. Admission lab: PRL: 112 ng/ml, GH 0.05 ng/ml, TSH 1.84 uUl/ml, T4L 0.78 ng/dl, ACTH 17 pg/ml, cortisol 16.8 ug/dl, IGF-1 164 ng/ml. He subsequently underwent a left pterional craniotomy, optic nerve decompression, plasty of bone sellar region. Findings: gyrus rectus-frontal lobe herniation into sella, made marked compression of the optic chiasm and left optic nerve; intrasellar solid tumor with cystic degeneration. In the postoperative, visual fields improve and headaches disappears; PRL: 87 ng/ml, T4L 0.80 ng/dl, IGF-1: 78.8 ng/ml, cortisol 12 ug/dl, thyroid medication continues, and CBG doses diminishes to 1 mg/week.

Conclusions: Prolactinomas on CBG experienced, at least 50% of tumor regression during the first 6 months, but rarely has reported this severe adverse effect of the tumor shrinkage, as in this case, brain or brainstem herniation into sella may occur, depending on the pretreatment tumoral extension. The prompt identification of visual defects should lead to optimization of medical treatment aiming at visual improvement and prevention of further deterioration.