SAT-246 A Case of Cabergoline Induced Pituitary Apoplexy in a Patient with Prolactinoma

Objective To report a case in which Cabergoline led to pituitary apoplexy (PA) in a young female patient with a macroprolactinoma. Methods A 28 y/o F presented with 10 months of irregular menses followed by 6 months of amenorrhea. She reported a dull supranasal headache, and nipple crusting without obvious galactorrhea. She denied visual changes, dizziness nausea or vomiting. Her Prolactin (PRL) was elevated at 194ng/mL, and she was started on Cabergoline 0.25mg twice per week and sent for a pituitary MRI. Four weeks later, the patient presented to the emergency department with an acute worsening of headache after being found to have a pituitary hemorrhage on MRI. On PE there were no obvious neurologic deficits. Neurosurgery recommended no acute intervention and she was managed conservatively. Results Labs prior to Cabergoline: bHCG (-), PRL 194 ng/mL; LH 3.1 µIU/mL; FSH 4.9 µIU/mL; Estradiol <11 pg/mL; Cortisol 11.44 ug/dL; TSH 1.080 µIU/mL; Free T4 0.76 ng/dL. Labs after 1 month of Cabergoline treatment: PRL 84.3 ng/mL; FSH 2.2 µIU/mL; LH 2.8 µIU/mL; TSH 1.23 µIU/mL; FT4 0.82 ng/dL; Cortisol 15.43 ug/dL. MRI 1 month after Cabergoline was performed and showed a 1.4 x 1.4 x 1.5cm hemorrhagic mass of pituitary gland. Discussion PA is the acute hemorrhage or infarction of the pituitary gland, commonly presenting with sudden onset of severe headache, visual field impairment, vomiting or altered mental status. However, like our patient, 25% of patients may present with subclinical apoplexy. Bromocriptine and Cabergoline are the two main treatments for prolactinoma. Both have been linked to PA, though the number of reports on Cabergoline is much less. There are now 10 cases of apoplexy reported with Cabergoline. PA can be spontaneous or precipitated by angiography, surgery, head trauma, hypertension, thrombocytopenia, diabetes, radiotherapy, coagulopathies, and Dopamine Agonists (DA). Most cases occur in older patients (50–60’s) with comorbidities, and incidence in patients <35 is rare. Moreover, PA is more common in males. Therefore, PA presenting in a young, healthy female suggests that Cabergoline may have been the precipitating factor. Conclusion It is important to be aware that Cabergoline can precipitate PA in patients being treated for a Prolactinoma. We recommend a thorough history, physical exam and baseline imaging before starting Cabergoline therapy. We also recommend emergent imaging if there is an acute change in symptoms.