TOO MUCH TESTOSTERONE CAN MAKE IT HARD TO BREATHE

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Testosterone replacement therapy for hypogonadism can be prescribed through topical/transdermal and intramuscular injections. Recognized treatment risks include prostate cancer, benign prostatic hypertrophy, erythrocytosis, and venous thromboembolism. There have been concerns for possible cardiovascular side effects from testosterone supplementation as well. Here we discuss a patient with worsening shortness of breath and subthreshold erythrocytosis in the setting of intramuscular (IM) testosterone supplementation. CASE PRESENTATION: A 43 year old man with a history of hypertension, CPAP-treated obstructive sleep apnea, and hypogonadism presented with 2 months of slowly progressive dyspnea on exertion and flushing occurring with activity or after a shower. He reported no chest pain, wheezing, cough, headache or dizziness. His physical exam was normal. Extensive evaluation included a resting echocardiogram showing preserved ejection fraction, no valvular dysfunction, and no signs of pulmonary hypertension. Cardiopulmonary exercise stress test was normal. PFTs excluded obstructive or restrictive ventilatory defects; lung volumes were normal and DLCO was 101% predicted. CT chest showed a 1 cm RML endobronchial nodule; subsequent PET scan showed no FDG uptake in the nodule or elsewhere. A hemoglobin of 17.7 g/dl, elevated compared with prior values, decreased to 14.3 g/dl over three months following cessation of IM testosterone therapy and his dyspnea improved without other changes in therapy or management. He was switched to a topical testosterone supplement with no rise in hemoglobin nor return of dyspnea. DISCUSSION: Polycythemia is a well-known side effect from testosterone injections and monitoring is advised with guidelines suggesting holding testosterone for a hemoglobin of 18 g/dl or a hematocrit of 54%. Erythrocytosis is of concern due to the increased risk of hyperviscosity syndrome whose symptoms including blurred vision, headaches, chest pain, weakness, and paresthesia. Case reports have associated IM testosterone with lower extremity edema too. This patient’s successful transition to transdermal testosterone is concordant with prior reports of a reduced risk of elevated hemoglobin with transdermal therapy. CONCLUSIONS: Testosterone supplementation requires routine monitoring due to risk of erythrocytosis and associated hyperviscosity syndrome, prostate cancer, and thromboembolism. In this patient, a new manifestation of dyspnea and subthreshold polycythemia co-occurred with IM testosterone and abated with discontinuation and transition to transdermal forms. A thorough review of other medical history and medications continues to be needed in patient on testosterone when present with cardiorespiratory symptoms to ensure accurate identification of the underlying cause. Reference #1: Keohane, C., et al. “The Diagnosis and Management of Erythrocytosis.” Bmj, vol. 347, no. nov18 1, 2013, doi:10.1136/bmj.f6667 Reference #2: Basaria, Shehzad, et al. “Adverse Events Associated with Testosterone Administration.” New England Journal of Medicine, vol. 363, no. 2, 2010, pp. 109–122., doi:10.1056/nejmoa1000485 Reference #3: Surampudi, Prasanth N., et al. “Hypogonadism in the Aging Male Diagnosis, Potential Benefits, and Risks of Testosterone Replacement Therapy.” International Journal of Endocrinology, vol. 2012, 2012, pp. 1–20., doi:10.1155/2012/625434 DISCLOSURES: Site PI for pharmaceutical trials relationship with Boehringer-Ingelheim Please note: $1001 - $5000 Added 06/01/2020 by Rebecca Bascom, source=Web Response, value=Travel Site PI for pharmaceutical study relationship with Nitto Denko Please note: $1001 - $5000 Added 06/01/2020 by Rebecca Bascom, source=Web Response, value=Travel Site PI for pharmaceutical study relationship with Galapagos Please note: $1001 - $5000 Added 06/01/2020 by Rebecca Bascom, source=Web Response, value=Travel Other relationship with Nitto Denko Please note: $1001 - $5000 by Rebecca Bascom, source=Web Response, value=Travel Other relationship with Galapagos Please note: $1001 - $5000 by Rebecca Bascom, source=Web Response, value=Travel attended investigator meeting relationship with Nitto Denko Please note: $1001 - $5000 by Rebecca Bascom, source=Web Response, value=Travel attended investigator meeting relationship with Galapagos Please note: $1001 - $5000 by Rebecca Bascom, source=Web Response, value=Travel No relevant relationships by Ibrahim Ismail-Sayed, source=Web Response No relevant relationships by Kathleen Twomey, source=Web Response