Clinical Case Studies

Discussion in 'Men's Health Forum' started by Michael Scally MD, Aug 17, 2011.

  1. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Robinson EC, Roy D, Driver BE. Deflate to Extricate: A Technique for Rectal Foreign Body Removal of Inflatable Ball. The Journal of emergency medicine 2017. http://www.jem-journal.com/article/S0736-4679(17)30992-7/abstract

    BACKGROUND: Rectal foreign bodies are commonly encountered in the emergency department (ED). Three techniques are well described in literature, including using a Foley catheter, "scooping" the object out, or grasping the object directly with ring forceps. We present a novel extraction method for an inflatable foreign body.

    CASE REPORT: A 27-year-old man presented to the ED 13 h after inserting a rubber inflatable child's ball into his rectum. After well-described extraction techniques failed to remove the ball, an 18-gauge needle at the end of a syringe was inserted into the rectum to puncture the ball and partially deflate it. The ball was then able to be removed easily.

    WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although recent published literature has pushed for early consultation of surgical specialties in lieu of emergency physician bedside extraction, this case report highlights the ability of emergency physicians to modify known extraction techniques to safely remove rectal foreign bodies in well-appearing patients at the bedside using appropriate analgesia, positioning, and readily available equipment.
     
  2. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Ikram S, Singh S, Kallam R, Dabra A. A play that went wrong: Unique presentation of bowel perforation from an unusually large per-rectal foreign body. BMJ Case Rep 2017. A play that went wrong: Unique presentation of bowel perforation from an unusually large per-rectal foreign body -- Ikram et al. 2017 -- BMJ Case Reports

    Colorectal foreign bodies (FBs) are not unheard of in the province of surgery. They are commonly seen in men ranging from 20 to 90 years of age with a bimodal age distribution. A variety of objects have been described and reported in literature. Management involves a complete history and examination followed by the necessary investigations.

    Most of the time they can be removed at bedside with some manipulation techniques employing the use of some ingenious devices and/or endoscopy for adamant objects. But persistent FBs or those that are high in the rectum or those that present with complications will require operative management.

    We present a case of a 77 cm long FB inserted rectally for sexual gratification in a male patient, which caused a large bowel perforation, ending high intra-abdominally at the level of the spleen and diaphragm after traversing the entire abdominal cavity and requiring a laparotomy for removal.
     
  3. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [OA] Leydig Cell Tumor of The Testis, Presenting with Azoospermia

    Case: A case of Leydig cell tumor, associated with azoospermia, is presented.

    Outcome: The levels of sex hormones obviously were decreased, including luteinizing hormone (LH) and follicle-stimulating hormone (FSH), with elevated testosterone. Computed tomography revealed no adrenal gland tumor, but a significant calcification in the right scrotal content was observed.

    He received a right radical orchiectomy and then he was unable to ejaculate. An endocrine panel revealed significantly decreased levels of testosterone and the low LH level had remained. Hormone replacement therapy with combined LH and FSH successfully recovered and preserved spermatogenesis.

    Conclusions: Although the patient's sexual function deteriorated after surgery, hormone replacement therapy was successful in establishing spermatogenesis.

    Hibi H, Yamashita K, Sumitomo M, Asada Y. Leydig cell tumor of the testis, presenting with azoospermia. Reproductive medicine and biology 2017;16:392-5. Leydig cell tumor of the testis, presenting with azoospermia
     
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  4. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Isolated Follicle Stimulated Hormone Deficiency In Male: Case Report

    BACKGROUND: Recent rapid advances in assisted reproductive health technologies enables couples with subfertility to conceive through various intervention. Majority of treatment modalities target the female partner. However it is important to identify and treat male factor subfertility right at the outset. We report a case of isolated follicle stimulating hormone deficiency resulting in azoospermia and primary subfertility.

    CASE PRESENTATION: A 28 year otherwise healthy male presented with primary subfertility with a healthy female counterpart. He was found to have non obstructive azoospermia with low seminal fluid volume. He had normal external genitalia and potency with increased libido.

    Further evaluation revealed an isolated deficiency of follicle stimulating hormone with elevated testosterone levels. His luteinizing hormone and prolactin levels were normal. Contrast enhanced CT scan of chest, abdomen and pelvis and MRI scan of the pituitary fossa were normal too.

    CONCLUSION: In the era of modern reproductive technology it is important to further evaluate males with non-obstructive azoospermia to detect underlying gonadotropin deficiency.

    Ratnayake GM, Weerathunga PN, Ruwanpura LP, Wickramasinghe A, Katulanda P. Isolated follicle stimulated hormone deficiency in male: case report. BMC research notes 2018;11:24. Isolated follicle stimulated hormone deficiency in male: case report
     
  5. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [OA] [2006] Methicillin-resistant Staphylococcus aureus abscess after intramuscular steroid injection

    A 25-year-old bodybuilder was hospitalized with a painful left upper arm five days after injecting 1.5 ml of a steroid preparation into the medial aspect of his left biceps brachii muscle. He reported using a sterile needle obtained from a pharmacy, but the source of the steroid vial was unknown.

    At the injection site, there was a tender, erythematous, palpably fluctuant mass, 10 by 6 cm (Panels A and B). The level of creatine kinase was 18,100 U per liter, and the white-cell count was 20.6×103 per cubic millimeter. Computed tomography revealed a large abscess containing gas in the medial left upper arm (Panels C and D).

    The abscess was incised and drained, after which extensive débridement was performed. Microscopy of a skeletal-muscle sample showed acute necrotizing myositis, and culture of a swab from the deep wound revealed methicillin-resistant Staphylococcus aureus.

    Vancomycin was given intravenously, followed by oral trimethoprim–sulfamethoxazole. The wound healed well over the next several days. The patient was discharged home 15 days after the abscess had been drained.

    Gautschi OP, Zellweger R. Images in clinical medicine. Methicillin-resistant Staphylococcus aureus abscess after intramuscular steroid injection. The New England journal of medicine 2006;355:713. NEJM - Error

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  6. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [OA] Effect Of testosterone Boosters On Body Functions: Case Report

    Testosterone boosters are supplementary substances that can be used for the purpose of increasing testosterone levels in the blood. This study aimed to evaluate the side effects and health risks of testosterone boosters among athletes.

    A sportsman came to the King Saud Hospital, Unaizah, Qassim, Saudi Arabia, suffering from abdominal pain. The attending doctor requested general laboratory tests. He admitted to having consumed two courses of a testosterone booster over a period of 42 days following the instructions of the manufacturer. In total, the athlete in question consumed several courses, twice before the abdominal pain started and twice after it subsided.

    The blood tests and reports suggested that the commercial product consumed might negatively affect several hepatic functions and resulted in slightly increased testosterone concentrations after the fourth course.

    In conclusion, administration of testosterone booster products, although obtained from trusted sources, may still present some health risks. Further studies with large sample size and for a long period need to be done to confirm the current findings.

    Almaiman AA. Effect of testosterone boosters on body functions: Case report. International journal of health sciences 2018;12:86-90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870326/
     
  7. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Phan YC, Mahmalji W. Persistent hematospermia: seminal vesicle bleed. The aging male: the official journal of the International Society for the Study of the Aging Male 2018:1-2. https://www.tandfonline.com/doi/abs/10.1080/13685538.2018.1464553?journalCode=itam20

    A 65-year-old gentleman, with no past medical problems and not on any anticoagulation was seen in the urology clinic with persistent hematospermia for the last few years. A thorough history and examination including a digital examination of the prostate was unremarkable. Bleeding from his female partner was also ruled out. Investigations such as prostate specific antigen (PSA) blood test, urine culture, semen culture, and flexible cystoscopy were performed, and these investigations were also within normal limits. Due to his persistent hematospermia even after masturbation, a magnetic resonance imaging (MRI) of his pelvis was performed to rule out any sinister intrapelvic pathology. His MRI pelvis revealed a right seminal vesicle haemorrhage which was the cause of his hematospermia. He was treated conservatively with the advice to abstain from ejaculation for a few months. More importantly, we have also reassured the patient.
     
  8. Michael Scally MD

    Michael Scally MD Doctor of Medicine

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    The Pharmacokinetics and Pharmacodynamics of Carfentanil After Recreational Exposure: A Case Report


    Carfentanil and related fentanyl analogues have been linked to a number of overdose deaths from drug users in several cities across North America. Diagnosis of carfentanil exposure requires a very high index of clinical suspicion, especially because available laboratory narcotic screens do not detect this agent.

    We describe a 34-year-old male admitted with depressed level of consciousness and in respiratory failure after recreational exposure to a white powder later inferred to contain carfentanil. Urine and whole blood samples were obtained for conventional preliminary drug screen immunoassays for unknown exposures; in addition to utilizing high pressure liquid chromatography tandem mass spectrometry assay for quantification of carfentanil and its metabolite.

    The patient was intubated and required mechanically-assisted ventilation for 31 hours until he was able to breathe safely on his own. Pharmacokinetic modeling of 3 timed blood samples identified the elimination half-life as 5.7 hours for carfentanil and 11.8 hours for the norcarfentanil metabolite. Awakening and breathing spontaneously corresponded to an interpolated blood carfentanil concentration of 0.52 ng/ml.

    This is the first pharmacokinetic and pharmacodynamic case report on the recreational use of carfentanil. Critical care clinicians should anticipate long periods of ventilatory support in the care of patients exposed to carfentanil.

    Uddayasankar U, Lee C, Oleschuk C, Eschun G, Ariano RE. The pharmacokinetics and pharmacodynamics of carfentanil after recreational exposure: A Case Report. Pharmacotherapy 2018. https://onlinelibrary.wiley.com/doi/abs/10.1002/phar.2117
     
  9. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Case Report: Ischemic Priapism Secondary To Tinzaparin

    Low-molecular-weight heparin (LMWH) therapy has recently been proposed as a cause of ischemic priapism. The evidence, however, remains scarce, as there are very few published cases of LMWH-induced priapism to date. The implications of such events are significant as ischemic priapism is a medical emergency. In current clinical practice we are seeing a trend towards LMWH therapies replacing unfractionated heparin (UFH).

    As LMWH therapies continue to gain favor, we will potentially see more cases of LMWH-induced priapism. As such, consideration should be given to determine the underlying pathophysiology and incidence of LMWH-induced priapism. Herein, we present the case of a 33-year-old male with priapism in the setting of tinzaparin treatment.

    Under the benefits of a dorsal penile block, the patient was treated with cavernosal aspiration and irrigation. This was followed by repeated cavernosal injection of 1000 mcg of phenylephrine over a 2-h period, in a monitored setting. A total of 2000 mcg of phenylephrine was required to achieve detumescence, and the patient was hemodynamically stable throughout the procedure. A penile blood gas sent at the time of aspiration and irrigation confirmed the diagnosis of ischemic priapism.

    After treatment of the ischemic priapism, hematology recommended no further LMWH therapy, as imaging con- firmed resolution of the internal jugular vein thrombus. One year post treatment the patient reports normal erectile function, and upon immediate discontinuation of the LMWH there were no other episodes of ischemic priapism

    Purnell J, Abdulla AN. Case report: ischemic priapism secondary to tinzaparin. International Journal of Impotence Research 2018;30:62-4. Case report: ischemic priapism secondary to tinzaparin
     
  10. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Searching for The Cause of High hcg In A Man
    Searching for the cause of high HCG in a man | ECE2018

    Beta-human chorionic gonadotropin (β-hCG) is normally produced by syncytiotrophoblasts of the placenta and may also be secreted by germ cell neoplasms. An increase of serum hCG concentration in a male patient often suggests malignant neoplasms with a trophoblastic element. Common examples include classic seminoma with syncytiotrophoblast-like giant cells, combined germ cell tumour, and choriocarcinoma. Non-gestational choriocarcinomas typically arise from gonadal organs but they may originate in extragenital sites such as the mediastinum, retroperitoneum, pineal gland, liver, gallbladder, and urinary tract. Ectopic secretion of β-hCG is associated with a poorer prognosis.

    We present a 50 year old man who was referred to endocrine clinic with painful gynaecomastia of 3 months duration. He was waiting hip replacement. He had history of a lump in his left breast 9 years ago. He had USS and FNA. He was treated with some tablets for a month and discharged from breast clinic. He had no other past medical history. He worked as a physical trainer to metropolitan police. He did not smoke or drink and was on no medication. He had never used recreational drugs.

    His BMI was 26 kg/m2. Examination and USS confirmed bilateral gynaecomastia. USS of the testes was normal with a small hydrocele on the left side. His blood tests showed FSH of <0.1 (1–10 IU/l), LH <0.1 (2–9 IU/l), testosterone 36.2 nmol/l (6.68–25.70), oestradiol 354 pmol/l (99–192), SHBG 44 noml/l (20.6–76.7) and his HCG was 250 IU/L (0–2). CT thorax, abdomen and pelvis was reported to be normal. His whole body bone scan was normal. His Repeat HCG in 6 weeks was 1265 and subsequently in 3 months increased to 3756.

    He underwent NM Whole body FDG PET CT which raised suspicion of an aggressive lesion in the anterior mediastinum with metastatic deposits in the lung. Mediastinal biopsy showed no unequivocal evidence of malignancy and a panel of immunohistochemical stains was not contributory. He had elective left anterior mediastinotomy +-VATS. Anterior mediastinal mass biopsies confirmed choriocarcinoma.
     
  11. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Gomes CAB, Mahgoub Y. Caffeine-Induced Psychosis in a Bodybuilder With Chronic testosterone and Amphetamine/Dextroamphetamine Misuse. The primary care companion for CNS disorders 2018;20. Prim Care Companion/Caffeine-Induced Psychosis in a Bodybuilder With Chronic Testosterone and Amphetamine/Dextroamphetamine Misuse

    To the Editor: Caffeine is the world’s most-consumed psychoactive substance.1 It is also considered a performance-enhancing substance by athletes and bodybuilders and is sometimes used excessively for this purpose.2 Caffeine’s action on adenosine and dopamine3,4 receptors is well known. In addition, 1 study2 found that caffeine significantly increased levels of testosterone by up to 65% and cortisol by up to 90% after acute ingestion.

    Additionally, 1 animal study5 suggested that caffeine has a synergistic effect of d-amphetamines in improving discriminative behavior in rats, and this effect was nullified by pretreatment with haloperidol. The combination of all of these performance-enhancing substances can potentially cause psychosis.3,4,6,7 There are no previous reports about caffeine’s psychogenic effect on bodybuilders’ chronically using testosterone and amphetamine/dextroamphetamine as a performance-enhancing substance.

    Case report. A 48-year-old male bodybuilder with no medical or psychiatric history was admitted for new-onset psychosis with delusions of being able to predict the death of high-profile government officials. He linked his predictions to religion and major astrological events and developed a new interest in numerology science, which was out of character for him at baseline. He posted his beliefs on social media, which led to Secret Service involvement followed by psychiatric hospitalization.

    Collateral information from his wife confirmed that the patient’s symptoms were new and were interfering with his work and social life. She said the patient became more isolated and irritable and unable to work as effectively as usual. He also became increasingly more interested in Bible scriptures and believed he was the “king” who was going to lead people to the end of times. His wife also added that the patient had always been a nonreligious man before onset of his symptoms.

    Prior to this episode, the patient was using unknown amounts of nonprescribed testosterone and amphetamine/dextroamphetamine 60 mg daily as a performance-enhancing substance in cyclical fashion for 7 months each year for the last 4 years. There was no past history of psychosis or any other psychiatric disorder despite his regular misuse of testosterone and amphetamine/dextroamphetamine. He reported finishing his last cycle of amphetamine/dextroamphetamine a few days prior to the emergence of psychosis, which was followed by an increased amount of caffeine ingestion, drinking a minimum of 7 expressos each morning (≈560 mg of caffeine) instead of his usual 1 daily cup (≈80 mg of caffeine). His urine toxicology result at admission was positive for amphetamines.

    No aggression was observed or threats were made during hospitalization, and the psychosis resolved 5 days later without the use of antipsychotics per the patient’s choice. He was discharged home with Secret Service notification, outpatient follow-up instructions, and strong recommendations against using the amphetamine/dextroamphetamine combination.
     
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  12. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Elboga G, Sayiner ZA. Rare cause of manic period trigger in bipolar mood disorder: testosterone replacement. BMJ case reports 2018;2018. Rare cause of manic period trigger in bipolar mood disorder: testosterone replacement -- Elboga and Sayiner 2018 -- BMJ Case Reports

    Hypogonadotropic hypogonadism is a rare congenital disorder characterised by the deficiency and the absence of puberty and infertility. It is caused by the deficient production, secretion or action of gonadotropin-releasing hormone, which is the master hormone regulating the reproductive axis.

    Gonadotropin-releasing hormone or gonadotropin injections and testosterone replacement therapy are required in the treatment of this disorder. Psychiatric symptoms and disorders may be seen with the use of anabolic androgenic steroids.

    In this case report, we present a case report in which a patient had behavioural symptoms in childhood and develops bipolar disorder after testosterone replacement therapy. This patient was reached to the remission by increasing the doses of psychiatric drugs without interfering with hormonal therapy.

    It should be considered that patients receiving testosterone replacement therapy may develop bipolar disorder or trigger mood changes in bipolar mood disease, so behavioural and mood state changes should be closely followed in patients who have bipolar mood disease.
     
  13. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Motta G, Zavattaro M, Romeo F, Lanfranco F, Broglio F. Risk of erythrocytosis during concomitant testosterone and SGLT2-inhibitor treatment: a warning from two clinical cases. The Journal of clinical endocrinology and metabolism 2018. Risk of erythrocytosis during concomitant testosterone and SGLT2-inhibitor treatment: a warning from two clinical cases

    Context: erythrocytosis is one of the most common side effects occurring during testosterone replacement therapy (TRT) in male hypogonadism. It is well known that all testosterone formulations may cause Hemoglobin (Hb) and Hematocrit (Hct) increase, especially with short acting injectable formulations.

    Sodium glucose cotransporter-2 inhibitors (SGLT2i) are a new class of glucose-lowering agents that reduce hyperglycaemia in patients with Type 2 diabetes mellitus (T2DM) by inhibition of renal glucose reabsorption leading to increased urinary glucose excretion. The co-occurrence of T2DM and hypogonadism is known to be increasingly frequent.

    However, to date, no adverse events with the concomitant use of TRT and SGLT2i are reported.

    Case description: We report two cases of erythrocytosis during testosterone treatment and SGLT2i in patients with hypogonadism and T2DM.

    Conclusion: Considering that hypogonadism and T2DM are frequently associated, clinicians should carefully monitor the risk of occurrence of erythrocytosis when prescribing TRT and SGLT2i together.
     
  14. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Heidet M, Abdel Wahab A, Ebadi V, Cogne Y, Chollet-Xemard C, Khellaf M. Severe Hypoglycemia Due to Cryptic Insulin Use in a Bodybuilder. The Journal of emergency medicine 2018. https://www.jem-journal.com/article/S0736-4679(18)31056-4/abstract

    BACKGROUND: Bodybuilding is a demanding sport, which requires high-volume, high-resistance weight training and augmented nutritional intake, toward an increase of overall body muscle mass accompanied by an overall decrease of body fat percentage and mass. Among bodybuilders, the use of various legal and illegal supplements is common. These supplements may be naturally occurring or man-made.

    CASE REPORT: We discuss the case of a 30-year-old male bodybuilder presenting with coma due to severe hypoglycemia from unknown cause, necessitating iterative glucose infusions, which was subsequently found to be related to cryptic insulin injections.

    WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In strength athletes, especially amateurs, the recourse to performance-enhancement drugs (e.g., insulin) is frequent. Beyond the specificity of care required for surreptitious insulin intoxication, emergency physicians should be alert to the possibility that exogenous insulin has been injected for use as an ergogenic aid by bodybuilders and others seeking to increase their body muscle mass when they encounter a patient with a decreased level of consciousness and treatment-refractory hypoglycemia. Moreover, in case of suspicion of such intoxication, the use of other illegal supplements should be screened, due to potentially associated risks of complication.
     
  15. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Tesfazghi MT, Farnsworth CW. Highest testosterone Concentration Ever: Pathology or Laboratory Error? Clinical Chemistry 2019;65:210. http://clinchem.aaccjnls.org/content/65/1/210.abstract

    The laboratory obtained a testosterone result of 30 117 ng/dL for a 51-year-old man and called the medical director to assess whether this value was feasible because it would represent the highest testosterone concentration ever reported by the laboratory. The patient was an avid runner with a history of a right testicular mass and orchiectomy 10 years previously. The patient was supplemented with testosterone cypionate (200 mg/2 weeks). The results for follicle stimulating hormone and luteinizing hormone were unremarkable.

    QUESTIONS
    1. What conditions are associated with the extremely high testosterone concentrations?
    2. Could exogenous testosterone account for this concentration?
    3. If pathological, what is the prognosis for patients with this condition?

    Increased testosterone concentrations are seen in individuals with exogenous testosterone supplements and sex hormone–producing adrenal tumors. At supraphysiological doses, exogenous supplements could raise serum testosterone concentrations by approximately 2- to 6-fold (1–3 ). This patient had a metastatic Leydig cell tumor diagnosed 5 years postorchiectomy. Testosterone concentrations began to increase dramatically around this time (Fig. 1). Malignant Leydig cell tumor is refractory to chemotherapy and radiotherapy (4 ). The median survival time of patients with malignant Leydig cell tumor is 2 years (5 ).

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