Fits, faints, funny turns and fakers. Prolactin to the rescue….NOT
My colleague (Dr Dave) asked me today about the use of a serum prolactin level to diagnose a seizure in a patient presenting with “syncope ? convulsion”. This is not something I have really done in the past so I thought I would look into it a bit. Actually I am sitting on the labour ward – employing the principle that a watched CTG never delivers – so I have popped out to blog a bit!
So how to tackle the patient presenting with a “funny turn”. Well my teaching is that the best test is a rigourous history, covering the patient’s previous medical history / predisposition to seizures / family history and the context in which the seizure occured. Crucially an accurate description of the actual seizure activity / phenomena is vital to getting clues about the diagnosis, and possibly if there is a focal component to the fit. Remember to ask about drugs, trauma, sleep correlation and family history. In my neck of the woods – alcohol is “the causin’ of it all” so ask, then ask again, then ask the wife….
Physical examination is useful to ellicit abnormal neurology post-event, also to look for primary casues of the fit. But for the most part to exclude seizure mimics.
Investigations I feel are over-weighted in the workup of seizures. The yield of a CT brain on somebody with a generalised seizure is pretty low. Checking a BSL and ECG is easy, all the other biochem is low yield without something on the history to guide you. EEG – sounds like a good idea, but is rarely available acutely and has lower-than-you-think specificity / sensitivity. (Normal people have abnormal EEGs, and epileptics often have normal EEGs!)
So can we use prolactin levels to diagnose a seizure?
So in Summary: see this from Neurology 2005. If you really want to help “rule in” a seizure – then do an early serum prolactin, though I cannot recall a scenario when I needed to do this after taking a decent history. But – you cannot use it reliably to “rule out” seizures. Interestingly it has been noted that {prolactin] goes up even after a purely syncopal event
Are you an Occasional Intubator?
Clinical Case 070: Postpartum headache
Headache headaches! A podcast from the PHARM
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
My own view is that isolated and resolved seizure is rarely a life threatening event. When I see these patients I try to rigorously rule out ventricular dysrhythmias as a cause of seizure mimic, mainly with careful history, family history, cardiac exam and ECG.
I have twice had the pleasure of un-diagnosing epilepsy and sending patients for implantable defibrillators.
Although epilepsy or seizure is certainly what patients are most worried about it is probably among the more benign diagnostic possibilities in the syncope/seziure differential. It’s important but down on the list of priorities.
My 2 cents,
Aaron
Thanks Dr J
Great point – missing an arrhythmia is potentially lethal. So make sure it is not VT or other cardiac cause.
Any chance you might share your “undiagnosis” cases – these are gold.
Casey
Thanks Casey for this useful update. I have used prolactin in the past to assess suspected pseudo seizures and have not found it to be all that helpful. Your references are good support for my observations and I will stop ordering those tests!