How to manage elevated macroprolactin in a patient with Human Immunodeficiency Virus (HIV) being treated for Coronavirus Disease 2019 (COVID-19) pneumonitis?

Management of Elevated Macroprolactin in HIV Patient with COVID-19 Pneumonitis

Elevated macroprolactin in an HIV patient with COVID-19 pneumonitis requires no specific treatment as it is generally a benign laboratory finding with limited clinical significance.

Understanding Macroprolactinemia

Macroprolactin is an antigen-antibody complex of higher molecular mass (>150kDa) consisting of monomeric prolactin and immunoglobulin G. Macroprolactinemia is diagnosed when macroprolactin exceeds 60% of total serum prolactin 1. This condition:

• Has reduced in-vivo bioactivity due to the large molecular size preventing passage through capillary endothelium to target cells
• Is generally considered benign when monomeric (bioactive) prolactin levels are normal
• Often lacks typical hyperprolactinemic symptoms due to its limited bioactivity

Management Algorithm for Elevated Macroprolactin in HIV Patient with COVID-19

Step 1: Confirm True Macroprolactinemia

• Measure total prolactin and perform polyethylene glycol precipitation to determine percentage of macroprolactin
• Gold standard: gel filtration chromatography if available
• Determine monomeric (bioactive) prolactin level

Step 2: Assess for Symptoms of Hyperprolactinemia

• If asymptomatic with normal monomeric prolactin:

  • No treatment required
  • No further diagnostic investigations needed
  • No prolonged follow-up necessary

• If symptomatic or elevated monomeric prolactin:

  • Evaluate for other causes of hyperprolactinemia
  • Consider pituitary imaging

Step 3: Focus on COVID-19 Pneumonitis Management

The primary focus should be on managing COVID-19 pneumonitis in the HIV patient:

1. Respiratory Support:

   • Provide appropriate oxygen therapy based on severity
   • Consider prone positioning to improve oxygenation 2

2. Pharmacological Management:

   • Dexamethasone 6mg IV or oral daily for up to 10 days for severe COVID-19 requiring oxygen 2
   • Consider remdesivir for patients with risk factors for disease progression 2
   • Ensure thromboprophylaxis with LMWH unless contraindicated 2

3. Antibiotic Considerations:

   • Do not routinely use empiric antibiotics for all COVID-19 pneumonia patients
   • Consider antibiotics only if clinical suspicion of bacterial co-infection, elevated procalcitonin, or clinical deterioration 2
   • If antibiotics are needed, obtain blood and sputum cultures, and target common respiratory pathogens 3

4. HIV Management:

   • Continue antiretroviral therapy
   • Be aware of potential drug interactions between COVID-19 treatments and antiretrovirals 4

Important Considerations

Macroprolactin and COVID-19

• Some evidence suggests prolactin levels may increase during COVID-19 infection 5
• This elevation is likely transient and may resolve with recovery from COVID-19

Potential Drug Interactions

• Be vigilant about interactions between corticosteroids and antiretroviral drugs 4
• Carefully monitor for adverse effects when using multiple medications

When Further Evaluation is Needed

• If patient develops symptoms of hyperprolactinemia (galactorrhea, menstrual irregularities, decreased libido)
• If monomeric prolactin levels are elevated
• If macroprolactinemia persists after COVID-19 recovery

Follow-up Recommendations

• Recheck prolactin levels after recovery from COVID-19 pneumonitis
• If macroprolactinemia persists without symptoms and normal monomeric prolactin, no further action needed
• If symptoms develop or monomeric prolactin is elevated, consider referral to endocrinology

Remember that macroprolactinemia alone rarely requires specific treatment, and management should prioritize the COVID-19 pneumonitis in this clinical scenario.