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

First, let's meet the patient.

A 56-year-old man presented to our ambulatory clinic with tender breast engorgement, sinus pressure, purulent nasal discharge, and positional headaches. He also reported a 2-year history of increasing nipple discharge that was relieved with expression of the tissue. He described the discharge as having a curd-like consistency without blood or odor.

History. The patient’s history was significant for substantial alcohol use, sexual promiscuity, and a 40-year history of marijuana use. He also had had a motor vehicle accident 20 years prior, which had required evacuation of a subdural hematoma and placement of metal hardware. The patient denied a recent history of jaundice, weight changes, gastrointestinal tract bleeding, and encephalopathy.

Physical examination. The patient was thin but well-developed and afebrile. His pupils were equal and responsive to light, with nonicteric scleras. The nasal turbinates were enlarged and pale, with significant yellow nasal discharge. Cardiovascular and respiratory system examination findings were normal. Abdominal examination revealed mild tenderness in all quadrants with hepatomegaly 3 cm below the costal margin. Neurologic examination findings were normal, with no asterixis. Examination of the breasts revealed a white curd-like discharge and tenderness with expression. A glandular and mobile nodule was palpated at the 11-o’clock position under the left areola, and a smaller nodule with nearly identical characteristics was palpated at the 3-o’clock position under the right areola.

He received a diagnosis of sinusitis and was treated with a 10-day course of amoxicillin plus clavulanate (amoxicillin, 875 mg; clavulanate, 125 mg), every 12 hours, which led to resolution of the sinusitis. He also was sent for bilateral breast ultrasonography (Figure 1) and concurrent laboratory testing. His history of metal hardware placement excluded him from magnetic resonance imaging (MRI) of the brain. However, he did have several recent computed tomography (CT) scans of the head on file, subsequent to frequent traumatic alcohol-related accidents. At no time did head CT findings demonstrate any intracranial pathology, with the exception of chronic encephalomalacia and a previous craniotomy on the left frontoparietotemporal skull (Figures 2 and 3).

See the patient’s ultrasonography and craniotomy images>>