PRL: Prolactin; FSH: Follicle stimulating hormone; LH: Luteinizing hormone

Prolactin (PRL) exists in the blood under many forms: monomeric (60-85%), polymeric and PRL-protein complexes of higher molecular weight [1].

Macroprolactinemia is a polymeric form of prolactin-release, causing mildly symptomatic clinical pictures [2]. The former can be isolated or associated with other causes of hyperprolactinemia [3].

We report the case of a macroprolactinemia being discovered in a patient with an empty sella Syndrome. We report the case of a macroprolactinemia being discovered in a patient with an empty sella Syndrome.

It consists in a 47 years old female patient, who has been followed up since the age of 31 years for bilateral galactorrhea and a spaniomenorrhea. There has been no associated drug intake. Her exploration has showed a serum prolactin level of 635 mIU/L. Thyroid test results were normal T4=10.2 ng/L and TSH=1.76 mIU/L. A brain scan has showed an empty sella turcica. Despite the unchanged levels of prolactinemia, the evolution under dopaminergic 5 mg/D has been marked by the occurrence of a pregnancy with persistent moderate hyperprolactinemia in the postpartum.

The patient has had menopause at the age of 47, with elevated gonadotrophins FSH=78 mIU/mL, LH=33 mIU/mL and estradiol: 35 pg/mL. Chromatography has showed a predominance of the macroprolactin form with: Prolactin monomer at 4.8%, Big Prolactin at 5% and Big Big Prolactin at 83%, thus stopping bromocriptine.

We report a case of a patient with an association of empty sella Syndrome and macroprolactinemia.

The clinical picture may be completely asymptomatic [2] or mildly symptomatic in 22-46% of cases as in our observation [3].

Furthermore, the macroprolactinemia has been raised in our perception ahead of the non-functional character of hyperprolactinemia evidenced by the occurrence of pregnancy and after the menopause, although hyperprolactinemia has persisted which seems insensitive to bromocriptine [4], suggesting its non-functional character. Andersen et al. have as well evoked a case of a female patient, in whom a pregnancy occurred [5], with macroprolactinemia. The frequency of macroprolactinemia in pregnancy has been assessed by Hattori et al; over 109 pregnant women, 3 (2.9%) of them have had a macroprolactinemia [6].

Several dosing methods serve to diagnose macroprolactinemia [7]. In our case, the diagnosis has been confirmed by Gel permeation chromatography, which remains the method of choice for its detection [8,9].

Macroprolactinemia is a common cause of hyperprolactinemia [10], but its research is not systematic [4]. According to two studies on 1225 [3] and 2089 [11] blood samples, macroprolactinemia frequencies have been estimated by 26% and 22% respectively. In another study realized by Alfonso A. and al on 40 patients with hyperprolactinemia, 18 (45%) have had macroprolactinemia [12].

Macroprolactinemia is usually isolated [13], constituting the diagnosis of exclusion after a negative etiological investigation [2,10]. The etiological research requires clinical, biological and radiological investigations including MRI [14], which objectified the empty sella in our patient.

The particularity of our case is that, it is associated with a common cause of hyperprolactinemia which is the empty sella syndrome [15]. This association has not been described; however associations with a prolactinoma are possible. Mounier et al. have conducted a study on patients with macroprolactinemia, with whom we have discovered a micro-pituitary adenoma associated [16].

Macroprolactinemia reported during the Prolactinoma can reach up to 76% of the secreted prolactin. It is in fact composed of the complex monomer prolactin and circulating immunoglobulin G [17].

The discovery of a macroprolactinemia may have an important clinical and therapeutic impact [1,18], formerly neglected [10], avoiding the dopaminergic treatment led on our patient without interest for many years [4]. Several studies recommend systematic prolactin test [4,10,12,19].

The long-term assessment without treatment seems favorable [20].

Our observation suggests that macroprolactinemia can be associated with conventional etiologies of moderate hyperprolactinemia as the empty sella syndrome. Its detection would prevent the use of dopaminergic therapy.