Delayed presentation of late-onset cerebrospinal fluid rhinorrhoea following dopamine agonist therapy for giant prolactinoma.

摘要: Summary Therapeutic shrinkage of prolactinomas with dopamine agonists achieves clinical benefit but can expose fistulae that have arisen as a result bony erosion the sella floor and anterior skull base by invasive tumour, resulting in potential development cerebrospinal fluid (CSF) rhinorrhoea, meningitis, rarely pneumocephalus. Onset symptoms is typically within 4 months commencing therapy. The management surgical repair via an endoscopic transnasal transsphenoidal approach. A 23-year-old man presented to Emergency Department acute left limb weakness intermittent headaches. Visual fields were full confrontation. Immediate computed tomography subsequent magnetic resonance imaging (MRI), demonstrated 5 cm lobular/cystic mass invading right cavernous sinus, displacing compressing midbrain, destruction sella. He was referred regional pituitary multidisciplinary team (MDT). Serum prolactin 159 455 mIU/l (7514.37 ng/ml) (normal ranges 100–410 (4.72–19.34 ng/ml)). Cabergoline commenced causing dramatic reduction tumour size resolution neurological symptoms. Further dose titrations required level plateaued significant residual remained. After 13 treatment, he developed continuous daily rhinorrhea, on presenting his general practitioner otolaryngologist. When next seen routine clinic six-months later admitted for urgent repair. Histology confirmed prolactinoma low proliferation index 2% (Ki-67 antibody). In view partial cabergoline resistance completed course conventional radiotherapy. Nine after treatment serum had fallen 621 mIU/l, 12 MRI showed reduced volume. Learning points: † CSF rhinorrhoea occurred initiation cabergoline, suggesting need vigilance throughout Dedicated should be reviewed early patient pathway assess risk agonist There delay before this complication brought attention MDT, associated whilst untreated. This demonstrates patients healthcare professionals educated about recognition facilitate timely appropriate referral MDT specialist advice management. We changed our nurse-led education programme case. An excellent therapeutic response achieved radiotherapy limited surgery having rhinorrhoea.