A 28-year-old woman presents with milky discharge in both breasts and throbbing occipital headaches of 4 months' duration. The headaches begin gradually, do not radiate, and have no apparent triggers or relieving factors; the severity of the pain ranges from 5 to 10 on a 10-point scale. The headaches are accompanied by intermittent nausea but not by vomiting, photophobia, or visual disturbances. In addition, the patient is easily fatigued with minimal activity and has gained 30 lb in the past 3 months.
She denies fever, rigors, night sweats, cough, chest pain, dyspnea, seizures, syncope, weakness, paresthesias, ataxia, tremors, vision changes, urinary symptoms, bleeding diathesis, and vaginal discharge. She also denies any blood-stained discharge from her nipples, erythema or lumps in her breasts, and excessive manipulation of the breasts.
She has had 2 normal pregnancies but has been amenorrheic for the past 2 1/2 months; before that, her periods were somewhat irregular. Her last pregnancy was 6 years earlier. An ovarian cyst was removed 4 years ago. She does not smoke, drink alcohol, or use illicit drugs. Her only medication is acetaminophen, which she uses occasionally. She is sexually active and monogamous. Her mother had migraine.
Heart rate is 84 beats per minute and regular; respiration rate, 18 breaths per minute; and blood pressure in the right arm, 112/70 mm Hg. Patient is afebrile. Weight is 211 lb; height, 5 ft 3 in. She is well hydrated. There is no evidence of anemia, clubbing, cyanosis, hirsutism, adenopathy, icterus or facial erythema; throat and ears are normal. Skin is of normal texture, moist, and elastic, without pallor or hyperpigmentation. The thyroid gland is of normal size. Breasts are devoid of masses, but milky discharge is evident. Results of a pelvic examination are normal. No ankle swelling is noted. A neurological examination reveals a normal skull and spine, no sinus tenderness, palpable and equal carotid arteries, intact cranial nerves, no visual defects or papilledema, deep tendon reflexes and plantar and flexor reflexes that are equal bilaterally, no Romberg sign, no meningeal or cerebellar signs, and a normal gait. She is awake, alert, and oriented, and results of motor and sensory examinations are normal.
Hemoglobin level is 13.2 g/dL; white blood cell count, 5200/µL with normal differential; platelet count, 180,000/µL; erythrocyte sedimentation rate, 12 mm/h; serum glucose, 100 mg/dL; blood urea nitrogen level, 18 mg/dL; creatinine level, 1 mg/dL; sodium level, 137 mEq/L; potassium level, 4.0 mEq/L; chloride level, 100 mEq/L; carbon dioxide level, 24 mEq/L; serum cholesterol level, 204 mg/dL; triglyceride level, 220 mg/dL; high-density lipoprotein cholesterol level, 46 mg/dL; low-density lipoprotein cholesterol level, 102 mg/dL; and prolactin level, 83 µg/mL (normal, 2.8 to 29.2). Results of urinalysis are normal, and results of a pregnancy test are negative.
Follicle-stimulating hormone level is 1.7 IU/L; luteinizing hormone (LH) level, 3.3 IU/L; 17-b estradiol level, less than 10 pg/mL; thyroid-stimulating hormone (TSH) level, 1.45 µIU/mL; growth hormone level, 2.09 ng/mL; and free urinary cortisol, 13 µg/24 h. Visual field mapping reveals no defects.
Based on the clinical findings, laboratory results, and MRI scan, what is the most likely diagnosis?
A. Macroadenoma of the pituitary.
C. Brain abscess.
D. CNS lymphoma.
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