Case Study

[melmc]

Ms. M is a 28-year old female who has had the gradual onset of vision loss in her left eye over the last several months. She states that she almost hit a vehicle at an intersection that was coming towards her from the left side. She also complains of a non-descript headache. Upon closer questioning, she also complains of some tenderness in her breasts and also some discharge from the right nipple. (Ms. M is not pregnant nor has she been nursing).

What is the chemical responsible for the breast drainage?

Given the fact that you did a blood test to measure that chemical and the test was extremely elevated, what is the most likely diagnosis in this young lady to account for her visual symptoms, headache, and breast discharge?

What additional tests (not blood) would you perform to prove your diagnosis?

Given your diagnosis and the visual symptoms, please describe how those visual symptoms would occur in this young lady.

What medical treatment is available to control this problem?

Assuming that the medicine does not control the problem and the visual symptoms worsen, what is the next step in treatment (surgical) and specifically how would this surgery be performed (anatomical approach to area of concern)?

[ckent]

Hmm, challenging case. Based on the presentation, I think that the most likely dx is left carotid dissection secondary to trauma. This would account for her transient vision loss, aka amaurosis fugax in the ipsilateral eye, due to a transient ischemic attack/CVA if it has been consistently present for several months; the headache would also be consistent with carotid dissection. As for why her breasts are tender (I assume that it's bilateral), one possibility is that she has hyperprolactenemia. This could be secondary to trauma/idiopathic, or secondary to pituitary stalk section during the trauma. This would be consistent as finding a high "chemical" in the blood, the chemical being prolactin. I would get an MRI/MRA to further evaluate the cerebral circuation and the hypothalamus/pituitary give the hyperprolactinemia, and I would also order carotid duplexes b/l. Ideally, medical therapy would be anticoagulation with warfarin. However, given the fact that she is symptomatic and it has been several months since her accident, I would consult vascular surgery to see if surgery (carotid interposition or stenting) was indicated after getting the results of my scans/duplex.

[omores]

Occam's razor.

Carotid dissection/amaurosis fugax seems unlikely. First, she reports no history of trauma, only a "near miss" in her car, presumably due to her vision loss (it was approaching from the left side). Also, we're given no indication that the vision loss is transient; conversely, it sounds as if it has been developing over several months.

I'm with you on the hyperprolactinemia, however.

There's a cause of this that also explains her headaches and her vision changes (hint: think about the relationship between the pituitary gland and the optic nerve). Her vision loss isn't typical for this condition; for the sake of interest, I'd want to learn whether the vision loss is truly in her left eye, or whether it's her left visual field that lacking.

I'll leave the rest to others...

[melmc]

Could this be a pituitary adenoma/prolactinoma?

For which you would:
Order MRI, full endocrine evaluation, and visual evaluation to assess fields of vision.

Treat with dopamine agonist. If necessary, resort to higher risk neurosurgery or radiosurgery.

Does that sound about right?

[doepug]

When I first read this, I thought it was a slam-dunk prolactinoma.

The problem is that monocular vision loss (I'm assuming you meant one eye, not 1/2 of the field of vision) is most likely amaurosis or optic neuritis. As a pituitary tumor, a prolactinoma would compress the optic chiasm and cause a bitemporal hemianopsia.

My guess is that you wanted us to guess prolactinoma, but the visual symptoms are not consistent with this diagnosis.

--doepug

[ckent]

Whoops, misread the question. Thought that there was a car accident/sudden stop that brought this all on. Agree with the tumor idea. You should assess what she means by decreased vision on the left side by physical exam. It would be reasonable to check for other endocrine problems that could be causing the hyperprolactinemia, but with her visual symptoms, it's probably a tumor and you can justify going straight for the MRI if her prolactin levels are high and visual defect true. I suspect that you meant that it was a left visual field defect of the left eye and not a left eye defect, melmc. Anyways, you're correct, meds first (carbergoline, bromocriptine or another dopamine agonists), but surgery may be indicated right away depending on how severe her visual fields were compromised (if they were in fact compromised at all).

[doc05]

this is a prolactinoma. what is throwing you off is the fact that the patient didn't read the textbook and so doesn't present with the classical bitemporal hemianopsia. the reason for this is anatomic variation in the length of the optic nerve. In this patient's case, the mass compresses upon the right optic tract, causing loss of vision in the left visual field.

The patient says she has visual loss in the left eye. I suspect this means she has trouble seeing on her left side -- quite a different thing.

Do a proper H&P, then PRL levels. MRI to follow with abnl. PRL. Neurosurgery consult.

[sanfilippo]

Prolactinoma. Patients are not going to come into your office saying, "Help! I have bitemporal hemianopsia!" Any visual defects or amaurosis needs to be teased out further in the history. Loss of peripheral vision or "tunnel vision" is likely the cause of her near accident. Galactorrhea is associated with hyperprolactinemia, so a serum PrL level is in order. Given the cluster of h/a, visual disturbance and galactorrhea, PrL seems to be stemming from a prolactinoma. A thorough visual field test, neurologic and breast examination are in order as well as MRI of the brain to be able to detect smaller adenomas that CT's may miss.

Bromocriptine (Parlodel) is one med that comes to mind to reduce the elevated PrL levels; I am sure other ergot derivatives that are dopamine agonists are available. Ergot derivatives should be used with caution in people with strong hx of HTN or CAD. Surgery would be resection via transsphenoidal approach (easy access to the sella turcica where the pituitary sits).

-S.

[ckent]

I was driving home today and I thought about another possible dx. Maybe she is schizophrenic, has a visual hallucination obstructing her view out of her left eye, and she has been self-medicating with high doses of haldol causing hyperprolactinemia.

[tofurious]

I actually had a patient come in and tell me that she had transient tunnel vision. Further eval revealed that she had positive ROS for pretty much everything. We considered her a hyperchondriac and sent her on her way. So, there ARE people who come in complaining of classic bitemporal hemianopsia. How many of them actually have an anatomical cause of this is another question.

Another possible mechanism of a left-eyed vision loss rather than left-sided vision loss is if the prolactinoma caused secondary cavernous sinus syndrome associated monocular visual loss, although this is usually associated with painful extraoccular movement in that same eye. Just something else to add to the differential.

[Mossjoh]

Well, this case does suggest an inbalance somewhere in the hypothalamus or pituitary gland. Prolactin is responsible for milk production, while oxytocin (produced in the supraoptic and paraventricular nuclei of the hypothalamus) is responsible for milk letdown.
The only way that the left eye could be affected by itself, is a problem with the left optic nerve. As earlier stated, usually pituitary tumors compress the optic chiasm causing bitemporal hemianopsia. The patient would complain of visual disturbances in both eyes. This is confusing. I would order a MRI of the brain to access the pituitary and hypothalamus, and also get blood prolactin levels.

I may also throw in for kicks a estrogen level. The breast tissue is responsive to estrogen, and breast tenderness is common during the menstrual cycle. This is totally out there, and VERY unlikely, but breast tumors are often responsive to estrogen (hence why tamoxifen is used to treat and prevent neoplasms). Breast CA often causes spontaneous nipple discharge. The discharge from the right nipple only is suspicious, usually she should be seeing bilateral discharge. Could the associated visual disturbances be from metastases in the brain? Probably not! But rule out the worst right?

Often pituitary tumors are operated on via a nasal route. You enter via the posterior nasopharynx, going through the sphenoidal sinus to get to the pituitary gland.

Mossjoh

[souljah1]

Originally posted by Mossjoh
The only way that the left eye could be affected by itself, is a problem with the left optic nerve. As earlier stated, usually pituitary tumors compress the optic chiasm causing bitemporal hemianopsia. The patient would complain of visual disturbances in both eyes. This is confusing. I would order a MRI of the brain to access the pituitary and hypothalamus, and also get blood prolactin levels.

But the patient could be saying that she has loss in her left eye, when in reality it could be her left visual field that is being disrupted by a prolactinoma that is compressing her right optic tract.