Interactive Quiz: Galactorrhea as the Initial Presentation of a Hepatic Condition

Answer: B, Pituitary adenomas, neurologic syndromes, endocrine disorders

Galactorrhea also has been associated with pituitary adenomas,⁵ neurologic syndromes,⁶ endocrine disorders,^7,8 prescription medication use,^9-11 and excessive breast self-manipulation.¹² Galactorrhea as the initial presentation of cirrhosis is extremely rare and to our knowledge has been reported only 1 other time in a man with an elevated prolactin level.⁴

Gynecomastia in males is age-dependent and is known to regress spontaneously. The estimated prevalence of asymptomatic gynecomastia is 50% to 60% in male adolescents and as high as 70% in men aged 50 to 69 years, whereas the estimated prevalence of symptomatic gynecomastia is much lower.¹³ It is thought to be caused by the imbalance between estrogens relative to androgens at the breast tissue level.¹³ Abnormal tissue development is the final pathway that encompasses multiple pathologic states,^14-17 as well as exogenous influences such as prescription medications^18,19 and illicit drugs.^20,21

Our patient’s case supports the notion that an elevated prolactin level does not entirely explain the cause of milk production in a man. In fact, other cases of galactorrhea with a normal serum prolactin levels have been reported. Agarwal and colleagues²² note that galactorrhea with a normal serum prolactin can be explained by the “variable molecular heterogeneity of the [prolactin] peptide hormone.” They hypothesize that, due to the variability of the prolactin peptide structure and its ability to bind and form complexes with immunoglobulin G, its bioactivity is alterable. These complexes likely would not be detectable with standard laboratory analysis machines. Prolactin is structurally similar to growth hormone and placental lactogen; however, prolactin has no cross-reactivity with LH, FSH, thyrotropin, or β-hCG, all of which have the potential to cross-react due to their having a similar molecular structure.

Agarwal and colleagues applied this normal serum prolactin hypothesis only to women; even though it likely could be extended to the male population, it still does not entirely explain the pathophysiology in the case of our patient, whose galactorrhea resolved after a regimen of antiviral therapy. Furthermore, there was only trivial change in his estradiol, LH, and prolactin levels. The only notable laboratory test finding was a significant decrease in the detectable HCV viral load after treatment.

What was the outcome of the case?>>