Case Presentation: Male Hypogonadism

Case presentation
Male hypogonadism
S.P, 52 y, male
Chief complaints

irritability,
fatigue, behavioral disorders, sexual disfunctions (libido , erectile dysfunction) gynecomastia
Medical history
Infertility
Hyperprolactinemia
Absence of the secundary sexual characteristics
diagnosis of hypogonadism - treatement with Testosterone i.m.
Arterial hypertension: Amlodipin 10 mg/day, Atenolol 50 mg/day, Lisinopril 10mg/day
Depression: Cipralex 10 mg/day, Valproic ac. 1tb/day
Physical examination
Characterisitic features:

low muscle mass and strength, reduced facial, axillary and troncular hair growth, pubic hair growth - horizontal pubic insertion (triangular),
ginoid habitus, with biacromial diameter smaller than bitrohanterian
bilateral gynecomastia, bilateral retractile testes,

V=8
mL, firm, painless, with peno-orchitis dissociation,
L- 181 cm, Arm Span 187 cm BMI= 32.9 kg/m2
Physical examination
Laboratory findings

Blood count normal Glycemia a jeun: 104 mg/dL Total cholesterol: 227 mg/dL (N<199) Triglycerides: 120 mg/dL (N <149) Uric acid: 4.58 mg/dL (N: 2.6-7.2) Creatinine: 0.91 mg/dL (N: 0.6-1.3) Urea: 18.3 mg/dL (N: 10-50) AST, ALT, Na, K - normal PSA=1.525 (N < 4ng/ml)
Hormonal assesment - 2007

FSH= 38,7 UI/L LH= 22,5 UI/L Testosteron= 1,98 ng/dL PRL= 15 ng/mL Hypergonadotropic hypogonadism
Genetic analysis
47 XXY
Paraclinical examinations
Lombar spine x ray L5 vertebral fragility fracture
Semen analysis - azoospermia
HORMONAL ASSESSMENT - 2011

Pituitary hormone level at baseline
PRL= 8.157 N 3.6-16.3ng/ml LH = 0.18 N 1.7-11.2UI/ml FSH= 1.06 N 2.1-18.6UI/ml Testosteron = 5.776 VN 2.62-8.7ng/dl azoospermia
Appropriate peripheral hormone(s) or parameter
Interpretation
normal
hypogonadism (primary, under treatement) euthyroidism
TSH = 1.658 mIU/ml
fT4 =15.22 VN 12-22pmol/l Ca total 9,06 mg/dl Phosphorus- 2,44 mg/dl
(N: 0. 27-4.2)
PTH=80,465 N 15-65ng/dl secondary hyperparathyroidism
Final diagnosis: Klinefelter Syndrome Hypergonadotropic hypogonadism Gr. II Arterial Hypertension Depression Gr.I Obesity
Differential diagnosis
Primary hypogonadism:

Bilateral anorchia Enzymatic defects in synthesis of testosterone, pure gonadal dysgenesis, Incomplete androgen insensitivity,
Central hypogonadysm

GnRH deficiency Mutations in the leptin or leptin R Syndromes with mental retardation and hypogonadism
Leydig cells hypoplasia

Noonan syndrome Uncorrected cryptorchidism Myotonic Dystrophy "Sertoli cell only "
Isolated LH or FSH deficiency

Pituitary insufficiencies
Acquired forms :

central hypothalamic-pituitary lesions suppression of gonadotropins by:

Acquired Disorders:
hyperprolactinemia, administration of GnRH, sex steroids in high doses, opioids
gonadal irradiation, infectious diseases, trauma, autoimmune processes, drugs, chronic systemic disease.
chronic disease, type II diabetes.
Treatment
Psychiatric counseling Nebido (testosterone undecanoat) 1000 mg i.m. 1 f/3 months
Monitoring: PSA, blood counts
Risendros 35 mg 1 tb/week
Treatment
Contraindications to treatment with androgens:
high risk: prostate cancer metastatic breast cancer

moderate risk: - prostatic node, - severe benign prostatic hyperplasia, - inexplicably high levels of PSA, - polycythemia (hematocrit > 50%), - severe obstructive sleep apnea, - severe congestive heart failure (NYHA III/IV).
Possible side effects of androgen replacement therapy

polycythemia, acne, subclinical prostate cancer, enlargement of metastatic prostate cancer, gynecomastia, breast cancer, reduction of spermatogenesis and fertility, alopecia, induction/worsening of obstructive sleep apnea, impaired liver function and decreased HDL - c, pain at the injection site
Evolution and prognosis

Increased risk of:

Germ tumor cells Breast cancer (20x) Osteoporosis Infertility is definitive
Evolution and prognosis

Klinefelter sy. may be associated with: chronic lung disease (emphysema, chronic bronchitis) mediastinal tumors, lung cancer non Hodgkin lymphoma, leukemia varicose veins cerebrovascular disease obesity, autoimmune thyroiditis, hypothyroidism, diabetes mellitus, peptic ulcer, taurodontism

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Case presentation

diagnosis of hypogonadism - treatement with Testosterone i.m.

Arterial hypertension: Amlodipin 10 mg/day, Atenolol 50 mg/day, Lisinopril 10mg/day

Depression: Cipralex 10 mg/day, Valproic ac. 1tb/day

ginoid habitus, with biacromial diameter smaller than bitrohanterian

bilateral gynecomastia, bilateral retractile testes,

mL, firm, painless, with peno-orchitis dissociation,

L- 181 cm, Arm Span 187 cm BMI= 32.9 kg/m2

Hormonal assesment - 2007

Lombar spine x ray L5 vertebral fragility fracture

Semen analysis - azoospermia

HORMONAL ASSESSMENT - 2011

Appropriate peripheral hormone(s) or parameter

hypogonadism (primary, under treatement) euthyroidism

TSH = 1.658 mIU/ml

fT4 =15.22 VN 12-22pmol/l Ca total 9,06 mg/dl Phosphorus- 2,44 mg/dl

Leydig cells hypoplasia

Isolated LH or FSH deficiency

central hypothalamic-pituitary lesions suppression of gonadotropins by:

hyperprolactinemia, administration of GnRH, sex steroids in high doses, opioids

chronic disease, type II diabetes.

Psychiatric counseling Nebido (testosterone undecanoat) 1000 mg i.m. 1 f/3 months

Monitoring: PSA, blood counts

Contraindications to treatment with androgens:

high risk: prostate cancer metastatic breast cancer

Possible side effects of androgen replacement therapy

Evolution and prognosis

Germ tumor cells Breast cancer (20x) Osteoporosis Infertility is definitive

Evolution and prognosis

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