Journal of Clinical Case Reports

Giant Prolactinoma Complicated by Cerebrospinal Fluid Rhinorrhea, Behavioral and Neurological Changes Following Dopamine Agonist Therapy: A Case Report

Abstract

Doknic M,Pekic S, Miljic D, Stojanovic M, Savic D, Gacic-Manojlovic E, Pavlovic D and Petakov M

Introduction: Giant prolactinomas, defined as pituitary PRL-secreting adenomas whose size exceeds 40 mm and with a PRL level of >1000 ng/ml, are very rare. Their treatment and outcome can be unpredictable and challenging for clinicians. Case Report: A 47-year-old male was referred to the Neuroendocrine Department due to a large pituitary tumor invading the suprasellar region, both cavernous and sphenoidal sinuses, and pharyngeal space. He had been suffering from intensive headaches and visual deterioration for two years; he had also experienced sexual dysfunction. Discussion: We detected extremely high serum PRL levels (Ã?â?¹Ã?Æ?700000 mU/l) and hypopituitarism. Bromocriptine therapy (BRC) was started with a gradual dose increase. Ten days after the commencement of medical treatment, cerebrospinal fluid (CSF) rhinorrhea appeared. He underwent neurosurgery two months later; the bone erosion was localized and repaired. Tumor biopsy revealed a PRL-secreting tumor with a low proliferative index (Ki67<0.5). After surgery, he continued with BRC and shortly after experienced behavior changes, such as mood oscillations, anxiety, impulsivity, irritability, impaired concentration, and tremor. To control his tumor, pramipexol and levodopa treatment were introduced but with a moderate effect. However, only after the reduction of the BRC dose, his mental and neurological complaints abated significantly. A close follow-up for the next three years detected a low prolactin level and significant tumor shrinkage (MRI), with visual field improvement and reversion of pituitary function. Conclusion: Giant prolactinomas are invasive but respond well to dopamine agonists. However, CSF rhinorrhea, behavioral and neurological changes can occur during medical treatment, suggesting a need for vigilance throughout the dopamine agonist therapy.