Giant Pituitary Prolactinoma with Falsely Low Serum Prolactin: The Pitfall of the "High-dose Hook Effect": Case Report

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Abstract

OBJECTIVE AND IMPORTANCE:

We present a case of a giant prolactinoma with a falsely low serum prolactin concentration determined by a two-site chemiluminometric assay. Awareness of the possibility of the "high-dose hook effect" in such cases will prevent preoperative misdiagnosis.

CLINICAL PRESENTATION:

A patient with a giant invasive pituitary tumor was found preoperatively to have serum prolactin of 31 ng/ml. Pathological examination of the excised tissue, however, demonstrated strong staining for prolactin.

INTERVENTION:

Serial dilutions of the serum disclosed hyperprolactinemia of 280,000 ng/ml, establishing the presence of the "high-dose hook effect." Treatment with pergolide (Permax; Athena Neurosciences, S. San Francisco, CA) decreased tumor size and lowered serum prolactin by more than 99%.

CONCLUSION:

A "high-dose hook effect" needs to be suspected in every patient with a giant pituitary adenoma (>3 cm) and normal serum prolactin. Subsequently assaying the diluted serum will reliably disclose this phenomenon and allow correct diagnosis and therapy.

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