Abstract
We report on a patient in whom an ayurvedic preparation (Pankaja kasthuri) was related to elevated prolactin levels. Though the exact nature of its contents and its impact on the dopamine levels is not known, the drug intake resulted in elevated prolactin, which normalized once the medication was stopped. This case emphasizes the need for a detailed and thorough history of drugs taken (including non-allopathic medications) by patients with hyperprolactinaemia.
A 15-year-old boy was referred to the endocrine clinic for delayed puberty. There was no history of chronic systemic illness or medications. Neither was there a history of headache, visual disturbance, seizures or loss of consciousness suggestive of intracranial/pituitary lesion nor any previous history of Hansen's, mumps or genital trauma to suggest testicular pathology. He had no goitre or clinical features of hypothyroidism. He had been treated for mild intermittent asthma with an ayurvedic preparation called Pankaja Kasthuri for the past six months. The family history was significant as it showed delayed puberty in the father. A physical examination revealed that he was of short stature (height 150 cm, less than third centile) and he weighed 50 kg (50th centile). Tanner's staging of sexual maturity showed stage 1 axillary and pubic hair. Testicular volume was 2 mL bilaterally. He underwent blood investigations, he had normal thyroid functions, low testosterones, leutinizing hormone and follicle-stimulating hormone were in the normal ranges (prepubertal picture) and his elevated levels of prolactin were 50 ng/mL (N < 20 ng/mL). His bone age, as compared with the Greulich and Pyle chart, was appropriate for his chronological age. In view of the positive family history, short stature, delayed puberty and a normal bone age, a clinical diagnosis of constitutional delay in growth and puberty was considered. However, the elevated prolactin raised the suspicion of a hypothalamo-pituitary lesion. The patient was asked to discontinue the ayurvedic preparation and his prolactin level was rechecked after four weeks. His prolactin levels normalized to 15 ng/mL (tests repeated twice). Hence, with other conditions being ruled out, a constitutional delay in growth and puberty was confirmed and he was treated with testosterone injections of 50 mg every month for three months to ‘kick off’ puberty. At follow up at six months his testicular volume was 6 mL, bilaterally indicating that he had entered puberty.
An evaluation of hyperprolactinaemia should start with a detailed history, which needs to focus on medical conditions and any drug intake (Box 1). 1 The tonic suppression by dopamine on the pituitary lactotrophes maintains the blood prolactin levels at < 15 mg/mL. 1 Most of the drugs that cause hyperprolactinaemia antagonize dopamine or deplete dopamine in the hypothalamic neurons, or decrease the release of dopamine.
Medical conditions and drugs which cause hyperprolactinaemia
Medical conditions:
Hypothyroidism Renal failure Previous pituitary/sellar tumours Granulomatous disorders H2 receptor antagonists, proton pump inhibitors Psychiatric medication (antipsychotic) Oral contraceptive, hormone replacement therapy Alpha methyldopa Ant emetic medications such as metoclopramide Calcium channel blockers (verapamil)
Drugs:
Pankaja Kasthuri, a formulation of Indian and Chinese herbs is prepared from black pepper seeds, Indian long pepper seeds, ginger root, cardamom seeds, tamarind, sugar candy and other herbal substances. It is purported to build a long-term natural immunity to allergens, reduce inflammation, constriction and oedema and thus dilate the airways. It is used for asthma, allergic rhinitis and other respiratory conditions. No published reports have previously reported the relationship between alternative medicines (ayurveda/homeopathic/unani) and prolactin or dopamine.
A clear temporal correlation between the levels of prolactin and the use of the medication was seen in our patient. Thus, one should consider adding the use of alternative medicinal agents to the list of significant causes for evaluation of hyperprolactinaemia.