Evaluation of Nipple Discharge in Adolescence – A Case Report

Background: Nipple discharge is uncommon in children and adolescents. Milky discharge is characteristic of galactorrhea which is typically bilateral and may be secondary to pregnancy, medications, endocrine tumors (pituitary adenoma), endocrine abnormalities (hypothyroidism, hypogonadism), mechanical stimulation or psychological factors.

Case Report: A 17-year-old girl was referred to a Pediatric Endocrinology appointment at ULSM for nipple discharge in the last six months. She had recent complaints of emotional lability and anxiety and a family history of depression. No menstrual irregularities, hot flashes, vaginal dryness, headaches, visual disturbances or other symptoms were mentioned. Pregnancy and medication-related causes were excluded. On physical examination, a bilateral milky nipple discharge was elicited by manipulation. No skin changes, asymmetries or masses were evident on breast examination. No areas of tenderness or pain nor axillary or supraclavicular lymph nodes were palpable. Laboratory tests showed mild elevation of serum prolactin levels, normal LH, FSH, T4 and TSH. Magnetic resonance imaging (MRI) showed a 5 mm diameter microadenoma of the anterior pituitary and an asymmetry of the sellar diaphragm with a left shift of the pituitary stalk. After discussion with neurosurgery specialists, she was started on cabergoline 0,25mg twice a week. After 3 months, the galactorrhea was eliminated, there was normalization of the prolactin concentration and there was no significant change in size of the sellar mass.

Conclusions: It has been reported in the literature that depressive symptoms may be associated with mild elevations of serum prolactin levels. Notwithstanding, an MRI of the pituitary should be performed in symptomatic patients with any degree of hyperprolactinemia. Prolactin concentrations >200 ng/mL generally identify a lactotroph adenoma; values that are between 20 and 200 ng/mL could also be due to any other sellar mass. Children and adolescents with spontaneous nipple discharge without an obvious cause should be referred to an appropriate specialist.