Abstract: SAT 384

Prolactin Induced Hypercalcemia in Gigantomastia of Pregnancy

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Abstract


Background
Hypercalcemia due to PTHrP overproduction with normal 1,25 vitamin D is considered to be malignant unless proven otherwise. Benign mammarian PTHrP production should be included within the differential diagnosis in young women especially during pregnancy.
Clinical Case view more

Background
Hypercalcemia due to PTHrP overproduction with normal 1,25 vitamin D is considered to be malignant unless proven otherwise. Benign mammarian PTHrP production should be included within the differential diagnosis in young women especially during pregnancy.
Clinical Case
A 32-year old female presented in her 15thweek of pregnancy with clinical signs of nefrolithiasis. History and physical examination did not reveal abnormalities, however the patient mentioned a massive increase in breast size since beginning of pregnancy with an increase of at least 2 cup sizes within several weeks.  Laboratory investigation showed hypercalcemia (corrected calcium 3.37 mmol/L, ref 2.15-2.55), with suppressed PTH (PTH <0.3 pmol/L, ref 2-8) and severe hypercalciuria (19 mmol/24h, ref 2.5-8.0) for which treatment with normal saline infusions was started. Thorough investigation for haematological or solid malignancies, including CT scanning of the chest, mammarian ultrasound and MRI, abdominal ultrasound and ENT evaluation, was negative. In absence of pulmonary lymphadenopathy, and with normal 1,25 vitamin D, ACE and lysozyme, sarcoidosis was considered highly unlikely. PTHrP appeared to be increased (2.7 and 5.5 pmol/L, ref < 0.7) even after correction for pregnancy term (1). Prolactin level was according to pregnancy term (57 μg/L) (1).
We hypothesized that the PTHrP production was related to the enormous augmentation of breast tissue. A rise in PTHrP is a physiological phenomenon during normal pregnancy, being produced within mammarian and placental tissue. However, in this case there was excess of PTHrP production due to the gigantomastia that the patient had developed; the latter probably resulting from increased sensitivity to prolactin (2). Therefore, treatment with the dopamin agonist bromocriptin was started, leading to a decline and stabilisation of prolactin (nadir 32 μg/L). Furthermore, breast circumference, which had been increasing approximately 1 cm per week from week 15 to week 19, stabilized and even diminished. Also a reduction in the density of the breasts was noticed and after 7 days the PTHrP declined, eventually to a level where it was not detectable anymore. The saline infusions, which she had been receiving 3-4 times weekly, could be stopped and calcium values remained within the normal range throughout the rest of pregnancy. A healthy baby boy with normal birth weight and calcium values was born and the dopamine agonist could be stopped completely. Breast reduction is planned because breast size causes physical complaints and spontaneous shrinkage is not to be expected
Conclusion
Gigantomastia of pregnancy can result in hypercalcemia through increased PTHrP levels. This can be successfully treated with dopamin agonists and saline infusions, resulting in good pregnancy outcome without the need for urgent reductive surgery.

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