4th Edition

Chapter 24: The infertile banker with a headache

A couple attend a private infertility clinic. He is a 38-year-old merchant banker. She complains that he is always stressed and has had headaches for the last year. He says it is from staring at a computer screen for hours at a time and that his vision is deteriorating.

His semen sample is found to contain 5 million spermatozoa/mL (normal range >15). His morning serum total testosterone is 3 nmol/L (normal range 6.7-29) and serum luteinizing hormone LH is 1 IU/L (normal range 1.5-9.3). His serum prolactin is 240 ng/mL (normal range 2.1-17.7).

  • 1. What is the likely diagnosis?

    Correct answer:
    Prolactinoma (prolactin secreting pituitary macroadenoma)

He has a visual field perimetry test.

  • 2. What does it show?

    Correct answer:

    Visual field perimetry showing bitemporal hemianopia more notable in the upper fields

He has an MRI scan of his head.

  • 3. What does it show?

    Correct answer:

    MRI confirms a large macro-prolactinoma pressing on the optic chiasm.

He was initially treated with the dopamine receptor agonist cabergoline for 6 months and his prolactin levels became normal, his visual fields improved and the tumour shrank. His wife conceived but he was still a banker.

  • 4. Name as many phakomatoses as you can.

    Correct answer:

    • Neurofibromatosis (von Recklinghausen’s disease)
    • Tuberous sclerosis (Bourneville’s disease)
    • von Hippel-Lindau disease (cerebroretinal angiomatosis)
    • Sturge-Weber syndrome (encephalotrigeminal angiomatosis)
    • Osler-Rendu-Weber syndrome
    • Fabry’s disease (angiokeratoma corporis diffusum)
    The first three of these are associated with brain tumours.

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