Prolactinoma differential diagnosis: Difference between revisions
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==Overview== | ==Overview== | ||
[[Prolactinoma]] must be differentiated from other causes of [[hyperprolactinemia]]. Causes of [[hyperprolactinemia]] can be categorized as [[physiological]], [[pathological]] and [[medication-induced]]. | [[Prolactinoma]] must be differentiated from other causes of [[hyperprolactinemia]]. Causes of [[hyperprolactinemia]] can be categorized as [[physiological]], [[pathological]], and [[medication-induced]]. | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
[[Prolactinoma]] must be differentiated from other causes of [[hyperprolactinemia]] that may present as [[galactorrhea]], [[amenorrhea]] (in females) and [[infertility]] (in both males and females) including: | [[Prolactinoma]] must be differentiated from other causes of [[hyperprolactinemia]] that may present as [[galactorrhea]], [[amenorrhea]], (in females) and [[infertility]] (in both males and females) including: | ||
*'''Physiological:''' | *'''Physiological:''' | ||
**Normal [[pregnancy]]<ref name="pmid910825">{{cite journal| author=Rigg LA, Lein A, Yen SS| title=Pattern of increase in circulating prolactin levels during human gestation. | journal=Am J Obstet Gynecol | year= 1977 | volume= 129 | issue= 4 | pages= 454-6 | pmid=910825 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=910825 }} </ref> | **Normal [[pregnancy]]<ref name="pmid910825">{{cite journal| author=Rigg LA, Lein A, Yen SS| title=Pattern of increase in circulating prolactin levels during human gestation. | journal=Am J Obstet Gynecol | year= 1977 | volume= 129 | issue= 4 | pages= 454-6 | pmid=910825 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=910825 }} </ref> | ||
| Line 14: | Line 14: | ||
***[[Somatotroph adenoma]]: [[Acromegaly]] | ***[[Somatotroph adenoma]]: [[Acromegaly]] | ||
***[[ACTH-secreting tumor|Corticotroph adenoma]]: [[Cushing's syndrome]] | ***[[ACTH-secreting tumor|Corticotroph adenoma]]: [[Cushing's syndrome]] | ||
**Supra [[Sella turcica|seller]] tumors(tumors present in region of [[pituitary stalk]]) | **Supra [[Sella turcica|seller]] tumors (tumors present in the region of the [[pituitary stalk]]) | ||
**[[Hypothyroidism]]<ref name="pmid4199418">{{cite journal| author=Snyder PJ, Jacobs LS, Utiger RD, Daughaday WH| title=Thyroid hormone inhibition of the prolactin response to thyrotropin-releasing hormone. | journal=J Clin Invest | year= 1973 | volume= 52 | issue= 9 | pages= 2324-9 | pmid=4199418 | doi=10.1172/JCI107421 | pmc=333037 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4199418 }} </ref> | **[[Hypothyroidism]]<ref name="pmid4199418">{{cite journal| author=Snyder PJ, Jacobs LS, Utiger RD, Daughaday WH| title=Thyroid hormone inhibition of the prolactin response to thyrotropin-releasing hormone. | journal=J Clin Invest | year= 1973 | volume= 52 | issue= 9 | pages= 2324-9 | pmid=4199418 | doi=10.1172/JCI107421 | pmc=333037 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4199418 }} </ref> | ||
**[[Chronic renal failure]]<ref name="pmid7372775">{{cite journal| author=Sievertsen GD, Lim VS, Nakawatase C, Frohman LA| title=Metabolic clearance and secretion rates of human prolactin in normal subjects and in patients with chronic renal failure. | journal=J Clin Endocrinol Metab | year= 1980 | volume= 50 | issue= 5 | pages= 846-52 | pmid=7372775 | doi=10.1210/jcem-50-5-846 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7372775 }} </ref> | **[[Chronic renal failure]]<ref name="pmid7372775">{{cite journal| author=Sievertsen GD, Lim VS, Nakawatase C, Frohman LA| title=Metabolic clearance and secretion rates of human prolactin in normal subjects and in patients with chronic renal failure. | journal=J Clin Endocrinol Metab | year= 1980 | volume= 50 | issue= 5 | pages= 846-52 | pmid=7372775 | doi=10.1210/jcem-50-5-846 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7372775 }} </ref> | ||
**[[Hepato-biliary diseases|Liver disease]]<ref name="pmid26958514">{{cite journal| author=Jha SK, Kannan S| title=Serum prolactin in patients with liver disease in comparison with healthy adults: A preliminary cross-sectional study. | journal=Int J Appl Basic Med Res | year= 2016 | volume= 6 | issue= 1 | pages= 8-10 | pmid=26958514 | doi=10.4103/2229-516X.173984 | pmc=4765284 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26958514 }} </ref> | **[[Hepato-biliary diseases|Liver disease]]<ref name="pmid26958514">{{cite journal| author=Jha SK, Kannan S| title=Serum prolactin in patients with liver disease in comparison with healthy adults: A preliminary cross-sectional study. | journal=Int J Appl Basic Med Res | year= 2016 | volume= 6 | issue= 1 | pages= 8-10 | pmid=26958514 | doi=10.4103/2229-516X.173984 | pmc=4765284 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26958514 }} </ref> | ||
***[[Cirrhosis]](with or without [[encephalopathy]]) | ***[[Cirrhosis]] (with or without [[encephalopathy]]) | ||
***[[Viral hepatitis]](with [[encephalopathy]]) | ***[[Viral hepatitis]] (with [[encephalopathy]]) | ||
**[[Seizure|Seizure disorder]]<ref name="Ben-Menachem2006">{{cite journal|last1=Ben-Menachem|first1=Elinor|title=Is Prolactin a Clinically Useful Measure of Epilepsy?|journal=Epilepsy Currents|volume=6|issue=3|year=2006|pages=78–79|issn=1535-7597|doi=10.1111/j.1535-7511.2006.00104.x}}</ref><ref name="pmid737437">{{cite journal| author=Trimble MR| title=Serum prolactin in epilepsy and hysteria. | journal=Br Med J | year= 1978 | volume= 2 | issue= 6153 | pages= 1682 | pmid=737437 | doi= | pmc=1608938 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=737437 }} </ref> | **[[Seizure|Seizure disorder]]<ref name="Ben-Menachem2006">{{cite journal|last1=Ben-Menachem|first1=Elinor|title=Is Prolactin a Clinically Useful Measure of Epilepsy?|journal=Epilepsy Currents|volume=6|issue=3|year=2006|pages=78–79|issn=1535-7597|doi=10.1111/j.1535-7511.2006.00104.x}}</ref><ref name="pmid737437">{{cite journal| author=Trimble MR| title=Serum prolactin in epilepsy and hysteria. | journal=Br Med J | year= 1978 | volume= 2 | issue= 6153 | pages= 1682 | pmid=737437 | doi= | pmc=1608938 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=737437 }} </ref> | ||
*'''Medication-induced:''' | *'''Medication-induced:''' | ||
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|[[Somatotroph adenoma]]: | |[[Somatotroph adenoma]]: | ||
[[Acromegaly]] | [[Acromegaly]] | ||
|Clinical features of acromegaly are due to high level of [[Growth hormone|human growth hormone]]([[Growth hormone|hGH]]): | |Clinical features of [[acromegaly]] are due to high level of [[Growth hormone|human growth hormone]] ([[Growth hormone|hGH]]): | ||
* Soft tissue swelling of the hands and feet | * Soft tissue [[swelling]] of the hands and feet | ||
* Brow and lower jaw protrusion | * Brow and lower jaw protrusion | ||
| Line 49: | Line 49: | ||
* [[Arthritis]] and [[carpal tunnel syndrome]] | * [[Arthritis]] and [[carpal tunnel syndrome]] | ||
* Increase in teeth spacing | * Increase in teeth spacing | ||
* [[Macroglossia]] | * [[Macroglossia]] (enlarged tongue) | ||
* [[Heart failure]] | * [[Heart failure]] | ||
* [[Kidney failure]] | * [[Kidney failure]] | ||
| Line 70: | Line 70: | ||
|- | |- | ||
|[[ACTH-secreting tumor|Corticotroph adenoma]]: [[Cushing's syndrome]] | |[[ACTH-secreting tumor|Corticotroph adenoma]]: [[Cushing's syndrome]] | ||
|Clinical features of [[Cushing's syndrome]] are due to increased | |Clinical features of [[Cushing's syndrome]] are due to increased levels of [[cortisol]]: | ||
* Rapid [[Obesity|weight gain]], particularly of the trunk and face with sparing of the limbs ([[central obesity]]) | * Rapid [[Obesity|weight gain]], particularly of the trunk and face with sparing of the limbs ([[central obesity]]) | ||
* Proximal muscle weakness | * Proximal muscle weakness | ||
| Line 76: | Line 76: | ||
* Excess [[sweating]] | * Excess [[sweating]] | ||
* Headache | * Headache | ||
* The excess cortisol may also affect other endocrine systems and cause, for example | * The excess [[cortisol]] may also affect other endocrine systems and cause, for example: | ||
** [[Insomnia]] | ** [[Insomnia]] | ||
** Reduced [[libido]] | ** Reduced [[libido]] | ||
** [[Impotence]] | ** [[Impotence]] | ||
** [[ | ** [[Amenorrhea]] | ||
** [[Infertility]] | ** [[Infertility]] | ||
* Patients frequently suffer various psychological disturbances, ranging from [[Euphoria (emotion)|euphoria]] to [[psychosis]]. [[Clinical depression|Depression]] and [[anxiety]] are also common. | * Patients frequently suffer various psychological disturbances, ranging from [[Euphoria (emotion)|euphoria]] to [[psychosis]]. [[Clinical depression|Depression]] and [[anxiety]] are also common. | ||
| | | | ||
* Dexamethasone suppression test | * [[Dexamethasone]] suppression test | ||
* 24 hour urinary measurement of cortisol | * 24 hour urinary measurement of [[cortisol]] | ||
| | | | ||
* Medical management: | * Medical management: | ||
** [[Pasireotide]] | ** [[Pasireotide]] | ||
** [[Cabergoline]] | ** [[Cabergoline]] | ||
** [[Ketoconazole]] | ** [[Ketoconazole]] | ||
** [[Metyrapone]] | ** [[Metyrapone]] | ||
| Line 123: | Line 123: | ||
|- | |- | ||
|[[Chronic renal failure]] | |[[Chronic renal failure]] | ||
|There are no pathognomonic symptoms associated with chronic renal failure. Common non-specific symptoms of chronic renal failure | |There are no [[pathognomonic]] symptoms associated with [[chronic renal failure]]. Common non-specific symptoms of [[chronic renal failure]] include: | ||
* [[Malaise]] | * [[Malaise]] | ||
* [[ | * [[Nausea]] | ||
* | * Unintentional [[weight loss]] | ||
* [[ | * [[Pruritus]] | ||
* [[ | * [[Lower extremity edema]] | ||
* [[ | * [[Sleep disorders]] | ||
|[[Urinalysis]]: | |[[Urinalysis]]: | ||
* [[Albuminuria]] | * [[Albuminuria]] | ||
| Line 136: | Line 136: | ||
* [[Pyuria]] | * [[Pyuria]] | ||
* Red cell or white cell [[casts]] and crystals | * Red cell or white cell [[casts]] and crystals | ||
Fluid and | Fluid and electrolyte disturbances: | ||
* [[Hyponatremia]] | * [[Hyponatremia]] | ||
* [[Hyperkalemia]] | * [[Hyperkalemia]] | ||
| Line 143: | Line 143: | ||
* [[Metabolic acidosis]] | * [[Metabolic acidosis]] | ||
* [[Hypocalcemia]] | * [[Hypocalcemia]] | ||
Endocrine and | Endocrine and metabolic disturbances | ||
* [[Hyperuricemia]] | * [[Hyperuricemia]] | ||
* [[Hypertriglyceridemia]] | * [[Hypertriglyceridemia]] | ||
| Line 167: | Line 167: | ||
|- | |- | ||
|[[Cirrhosis|Liver disease: Cirrhosis]] | |[[Cirrhosis|Liver disease: Cirrhosis]] | ||
|The clinical features of liver cirrhosis are very | |The clinical features of liver [[cirrhosis]] are very nonspecific. These include: | ||
* Right upper quadrant [[abdominal pain]] | * Right upper quadrant [[abdominal pain]] | ||
* [[Fever]] | * [[Fever]] | ||
| Line 178: | Line 178: | ||
* [[Itching]] | * [[Itching]] | ||
* Menstrual irregularities | * Menstrual irregularities | ||
|Elevated [[aminotransferases]] ([[Aspartate transaminase|AST]] & [[Alanine transaminase|ALT]]) | | | ||
Elevated [[alkaline phosphatase]] ([[Alkaline phosphatase|ALP]]) | *Elevated [[aminotransferases]] ([[Aspartate transaminase|AST]] & [[Alanine transaminase|ALT]]) | ||
*Elevated [[alkaline phosphatase]] ([[Alkaline phosphatase|ALP]]) | |||
Elevated [[gamma-glutamyl transpeptidase]] | *Elevated [[gamma-glutamyl transpeptidase]] | ||
Elevated [[bilirubin]] | *Elevated [[bilirubin]] | ||
Low [[albumin]] | *Low [[albumin]] | ||
Elevated [[prothrombin time]] | *Elevated [[prothrombin time]] | ||
Elevated [[globulin]] | *Elevated [[globulin]] | ||
[[Hyponatremia]] | *[[Hyponatremia]] | ||
[[Anemia]] | *[[Anemia]] | ||
[[Leukopenia]] and [[neutropenia]] | *[[Leukopenia]] and [[neutropenia]] | ||
[[Thrombocytopenia]] | *[[Thrombocytopenia]] | ||
| | | | ||
* Medical management: | * Medical management: | ||
** Treatment is directed | ** Treatment is usually directed towards the treatment of complications like [[ascites]], [[esophageal varices]], [[hepatic encephalopathy]], [[hepatorenal syndrome]], and [[spontaneous bacterial peritonitis]]. | ||
*** Some chronic constitutional symptoms that should be treated | *** Some chronic constitutional symptoms that should be treated include: | ||
**** [[Pruritis]]: [[Cholestyramine]] is the drug of choice | **** [[Pruritis]]: [[Cholestyramine]] is the drug of choice | ||
**** [[Hypogonadism]]: Topical [[testosterone]] preparations | **** [[Hypogonadism]]: Topical [[testosterone]] preparations | ||
**** [[Osteoporosis]]: [[Calcium]] and [[vitamin D]] | **** [[Osteoporosis]]: [[Calcium]] and [[vitamin D]] | ||
**** Pain management: [[Non-steroidal anti-inflammatory drug|NSAIDS]], [[celecoxib]], [[opioids]] | **** Pain management: [[Non-steroidal anti-inflammatory drug|NSAIDS]], [[celecoxib]], [[opioids]] | ||
**** Nutrition: Adequate calories, | **** Nutrition: Adequate calories, protein, and multivitamin supplementation | ||
* Surgical management: [[Liver transplantation]] | * Surgical management: [[Liver transplantation]] | ||
|- | |- | ||
|[[Seizure|Seizure disorder]] | |[[Seizure|Seizure disorder]] | ||
|The clinical feature of [[seizure disorder]] includes: | |The clinical feature of [[seizure disorder]] includes: | ||
* Change in [[alertness]] | * Change in [[alertness]]: the patient cannot remember a period of time | ||
* Mood changes, such as unexplainable fear, panic, joy, or laughter | * Mood changes, such as unexplainable fear, panic, joy, or laughter | ||
Revision as of 19:00, 8 August 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]
Overview
Prolactinoma must be differentiated from other causes of hyperprolactinemia. Causes of hyperprolactinemia can be categorized as physiological, pathological, and medication-induced.
Differential Diagnosis
Prolactinoma must be differentiated from other causes of hyperprolactinemia that may present as galactorrhea, amenorrhea, (in females) and infertility (in both males and females) including:
- Physiological:
- Pathological:
- Pituitary tumors (other than prolactinoma):[2]
- Supra seller tumors (tumors present in the region of the pituitary stalk)
- Hypothyroidism[3]
- Chronic renal failure[4]
- Liver disease[5]
- Cirrhosis (with or without encephalopathy)
- Viral hepatitis (with encephalopathy)
- Seizure disorder[6][7]
- Medication-induced:
- Antipsychotic medications:[8]
- Antiemetic medications:
- Antihypertensive medications:
| Prolactinoma must be differentiated from causes of hyperprolactinemia | |||
|---|---|---|---|
| Disease | Clinical Findings | Laboratory findings | Management |
| Somatotroph adenoma: | Clinical features of acromegaly are due to high level of human growth hormone (hGH):
|
|
|
| Corticotroph adenoma: Cushing's syndrome | Clinical features of Cushing's syndrome are due to increased levels of cortisol:
|
|
|
| Hypothyroidism | Clinical features of hypothyroidism are due to deficiency of thyroxine:
|
Levothyroxine | |
| Chronic renal failure | There are no pathognomonic symptoms associated with chronic renal failure. Common non-specific symptoms of chronic renal failure include:
|
Urinalysis:
Fluid and electrolyte disturbances: Endocrine and metabolic disturbances
Hematologic abnormalities |
|
| Liver disease: Cirrhosis | The clinical features of liver cirrhosis are very nonspecific. These include:
|
|
|
| Seizure disorder | The clinical feature of seizure disorder includes:
|
Electroencephalogram |
|
| Medication-induced | Clinical features of hyperprolactinemia after a specific period of regular medication ingestion | Discontinuation of the medication for 3 days and remeasurement of prolactin levels[13] | Change to alternate medication |
References
- ↑ Rigg LA, Lein A, Yen SS (1977). "Pattern of increase in circulating prolactin levels during human gestation". Am J Obstet Gynecol. 129 (4): 454–6. PMID 910825.
- ↑ Levy A (2004). "Pituitary disease: presentation, diagnosis, and management". J Neurol Neurosurg Psychiatry. 75 Suppl 3: iii47–52. doi:10.1136/jnnp.2004.045740. PMC 1765669. PMID 15316045.
- ↑ Snyder PJ, Jacobs LS, Utiger RD, Daughaday WH (1973). "Thyroid hormone inhibition of the prolactin response to thyrotropin-releasing hormone". J Clin Invest. 52 (9): 2324–9. doi:10.1172/JCI107421. PMC 333037. PMID 4199418.
- ↑ Sievertsen GD, Lim VS, Nakawatase C, Frohman LA (1980). "Metabolic clearance and secretion rates of human prolactin in normal subjects and in patients with chronic renal failure". J Clin Endocrinol Metab. 50 (5): 846–52. doi:10.1210/jcem-50-5-846. PMID 7372775.
- ↑ Jha SK, Kannan S (2016). "Serum prolactin in patients with liver disease in comparison with healthy adults: A preliminary cross-sectional study". Int J Appl Basic Med Res. 6 (1): 8–10. doi:10.4103/2229-516X.173984. PMC 4765284. PMID 26958514.
- ↑ Ben-Menachem, Elinor (2006). "Is Prolactin a Clinically Useful Measure of Epilepsy?". Epilepsy Currents. 6 (3): 78–79. doi:10.1111/j.1535-7511.2006.00104.x. ISSN 1535-7597.
- ↑ Trimble MR (1978). "Serum prolactin in epilepsy and hysteria". Br Med J. 2 (6153): 1682. PMC 1608938. PMID 737437.
- ↑ David SR, Taylor CC, Kinon BJ, Breier A (2000). "The effects of olanzapine, risperidone, and haloperidol on plasma prolactin levels in patients with schizophrenia". Clin Ther. 22 (9): 1085–96. doi:10.1016/S0149-2918(00)80086-7. PMID 11048906.
- ↑ McCallum RW, Sowers JR, Hershman JM, Sturdevant RA (1976). "Metoclopramide stimulates prolactin secretion in man". J Clin Endocrinol Metab. 42 (6): 1148–52. doi:10.1210/jcem-42-6-1148. PMID 777023.
- ↑ Sowers JR, Sharp B, McCallum RW (1982). "Effect of domperidone, an extracerebral inhibitor of dopamine receptors, on thyrotropin, prolactin, renin, aldosterone, and 18-hydroxycorticosterone secretion in man". J Clin Endocrinol Metab. 54 (4): 869–71. doi:10.1210/jcem-54-4-869. PMID 7037817.
- ↑ Steiner J, Cassar J, Mashiter K, Dawes I, Fraser TR, Breckenridge A (1976). "Effects of methyldopa on prolactin and growth hormone". Br Med J. 1 (6019): 1186–8. PMC 1639736. PMID 1268617.
- ↑ Fearrington EL, Rand CH, Rose JD (1983). "Hyperprolactinemia-galactorrhea induced by verapamil". Am J Cardiol. 51 (8): 1466–7. PMID 6682619.
- ↑ Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA; et al. (2011). "Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline". J Clin Endocrinol Metab. 96 (2): 273–88. doi:10.1210/jc.2010-1692. PMID 21296991.