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


    A Lousy Diagnosis [Pubic Louse]

    A 56-year-old man presented with a 3-month history of generalized pruritus.

    Physical examination was notable for small black dots between body hairs on the abdomen and pelvis.

    Dermoscopic examination of the abdomen revealed a pubic louse, which is smaller than the head louse and has a round form and thick back legs with large claws.

    Video obtained with the use of epiluminescence microscopy provided a magnified view of the characteristics of the parasite (see video).

    The pubic louse, which is also known as the crab louse because of its morphologic features, can cause intense pruritus.

    This patient was treated successfully with shaving of the abdomen and pubic area and with a single 8-hour application of 5% permethrin cream.

    Desruelles Fo. A Lousy Diagnosis. New England Journal of Medicine 2015;373(26):e31. MMS: Error
  2. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    testosterone Replacement In 49,XXXXY Syndrome: Andrological, Metabolic and Neurological Aspects

    We report the case of a 19-year-old boy, presenting several congenital malformations (facial dysmorphisms, cardiac and musculoskeletal abnormalities), mental retardation, recurrent respiratory infections during growth and delayed puberty.

    Although previously hospitalised in other medical centres, only psychological support had been recommended for this patient. In our department, genetic, biochemical/hormonal and ultrasound examinations were undertaken.

    The karyotype was 49,XXXXY, a rare aneuploidy with an incidence of 1/85 000-100 000, characterised by the presence of three extra X chromosomes in phenotypically male subjects.

    The hormonal/biochemical profile showed hypergonadotropic hypogonadism, insulin resistance and vitamin D deficiency.

    The patient was then treated with testosterone replacement therapy. After 12 months of treatment, we observed the normalisation of testosterone levels. There was also an increase in pubic hair growth, testicular volume and penis size, weight loss, homeostatic model assessment index reduction and the normalisation of vitamin D values. Moreover, the patient showed greater interaction with the social environment and context.

    LEARNING POINTS: In cases of plurimalformative syndrome, cognitive impairment, recurrent infections during growth and, primarily, delayed puberty, it is necessary to ascertain as soon as possible whether the patient is suffering from hypogonadism or metabolic disorders due to genetic causes. In our case, the diagnosis of hypogonadism, and then of 49,XXXXY syndrome, was unfortunately made only at the age of 19 years.

    The testosterone replacement treatment, even though delayed, induced positive effects on:
    i) development of the reproductive system,
    ii) regulation of the metabolic profile and
    iii) interaction with the social environment and context.


    Mazzilli R, Delfino M, Elia J, et al. Testosterone replacement in 49,XXXXY syndrome: andrological, metabolic and neurological aspects. Endocrinol Diabetes Metab Case Rep. 2016:150114. Testosterone replacement in 49,XXXXY syndrome: andrological, metabolic and neurological aspects - EDM Case Reports

    Scrotum and penis before (a) and after (b) testosterone replacement.

    Eman likes this.
  3. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Evans L, Larsen M, Cox A, Skyrme R. Steroids, drugs and stuttering priapism; the rock-and-roll lifestyle of a 24-year-old man. BMJ Case Rep. 2016. Steroids, drugs and stuttering priapism; the rock-and-roll lifestyle of a 24-year-old man -- Evans et al. 2016 -- BMJ Case Reports

    The authors present a case of a 24-year-old, poorly controlled insulin-dependent type 1 diabetic Caucasian man who presented to the emergency department, with a painful erection of 36 h duration that had failed to resolve with conservative management. This was the patient's seventh priapism, with his most recent attendance 1 week previously for which he underwent a distal cavernosal shunt. He admitted to taking several recreational drugs, including marijuana and cocaine, during the preceding few days, in addition to the long-term use of the oral anabolic steroid oxandrolone. He had no family history of sickle cell disease or trait. On examination, a tensely erect penis was noted. A diagnosis of stuttering priapism was made and 750 mL of blood subsequently drained via a distal corporoglandular shunt resulting in successful detumescence.
  4. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [Open Access] Preejaculatory Illness Syndrome

    Human ejaculation happens in the orgasmic phase of the human sexual response cycle. Among psychosomatic ejaculatory disorders that may happen before ejaculation, we present two cases of preejaculatory illness syndrome.

    The two cases shared common symptoms of sympathetic over activity, the sensation of impending death, and muscle atonia with subsequent failure to ejaculate. Depression, anxiety disorders, and family histories of psychiatric problems were noticed as risk factors. Medical conditions that may lead to panic attack type symptoms were eliminated before the final diagnosis.

    After the failure of empirical medications, symptoms became controlled with fluoxetine. Patients reported a recurrence of the symptoms on trying to stop the prescribed medication. On the last follow-up, they still take fluoxetine on a regular base with satisfactory sexual life.

    Mohsen A, Elawdy MM, Faix A. Preejaculatory illness syndrome: Two cases of a rare psychosomatic disorder. Urol Ann 2016;8(1):99-101. Preejaculatory illness syndrome: Two cases of a rare psychosomatic disorder
  5. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Vanishing Testes Syndrome-Related Osteoporosis and High Cardio-Metabolic Risk in an Adult Male with Long Term Untreated Hypergonadotropic Hypogonadism

    The male hypogonadism-related bone mass loss is often under diagnosed. Peak bone mass is severely affected if the hypogonadism occurs during puberty and is left untreated.

    We present an interesting; almost bizarre case of a male with non-functional testes early during childhood and undiagnosed and untreated hypogonadism until his fifth decade of life.

    Forty six year male is referred for goitre, complaining of back pain. Phenotype suggested intersexuality: gynoid proportions, micropenis, no palpable testes into the scrotum, no facial or truncal hair. His medical history had been unremarkable until the previous year when primary hypothyroidism was diagnosed and levothyroxine replacement was initiated. Later, he was diagnosed with ischemic heart disease, with inaugural unstable angina.

    On admission, the testosterone was 0.2 ng/mL (normal: 1.7-7.8 ng/mL), FSH markedly increased (56 mUI/mL), with normal adrenal axis, and TSH (under thyroxine replacement). High bone turnover markers, and blood cholesterol, and impaired glucose tolerance were diagnosed. The testes were not present in the scrotum. Abdominal computed tomography suggested bilateral masses of 1.6 cm diameter within the abdominal fat that were removed but no gonadal tissue was confirmed histopathologically.

    Vanishing testes syndrome was confirmed.

    The central DXA showed lumbar bone mineral density of 0.905 g/cm2, Z-score of -2.9SD. The spine profile X-Ray revealed multiple thoracic vertebral fractures. Alendronate therapy together with vitamin D and calcium supplements and trans-dermal testosterone were started.

    Four decades of hypogonadism associate increased cardiac risk, as well as decreased bone mass and high fracture risk.

    Carsote M, Capatina C, Valea A, Dumitrascu A. Vanishing testes syndrome-related osteoporosis and high cardio-metabolic risk in an adult male with long term untreated hypergonadotropic hypogonadism. Arch Endocrinol Metab 2016;60(1):79-84.
    BBC3 likes this.
  6. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    A 29-Year-Old Man with Dyspnea and Chest Pain [Pulmonary Embolism and an Intracardiac Mass Due to A Metastatic Germ-Cell Tumor]

    A 29-year-old man was admitted to this hospital because of severe dyspnea and chest pain on the right side.

    The patient, who was a highly trained athlete, had been well until approximately 2.5 weeks before admission, when he was hit in the chest while he was at work; headache and nausea occurred for 3 days thereafter.

    Approximately 2 weeks before admission, he awoke at night with pain in the right midaxillary region that he described as a “ping-pong ball”; the pain radiated to and from the right scapula and was associated with shortness of breath. He arose, and after pacing and calming himself, he was able to sleep again.

    The next day, he went to an urgent care clinic in another city, where a diagnosis of muscle spasm was made. Muscle relaxants and ibuprofen were administered, without improvement.

    During the following days, increasing dyspnea occurred with minimal exertion; the pain became localized to the right anterior chest and had a sharp, stabbing quality, and a nonproductive cough developed.

    Three days before admission, during a 1.5-hour flight to Massachusetts, the patient noted having leg cramps, which was a usual occurrence for him on flights.

    On the morning of admission, he felt well on awakening, but sudden stabbing chest pain in the sternal area later developed, with associated severe pressure in his chest and transient palpitations. While the patient was walking, he noted severe shortness of breath, with increasing tachypnea and difficulty talking. Chest pain increased with coughing, laughing, and sneezing.

    In the evening, the patient went to another hospital for evaluation, where he reported sharp chest pain on the right side that worsened with deep breaths; he rated the pain at 8 on a scale of 0 to 10, with 10 indicating the most severe pain. He attributed some of his symptoms to his earlier chest injury.

    On examination, the patient reportedly appeared to be well. The blood pressure was 138/82 mm Hg, the pulse 89 beats per minute, the temperature 36.8°C, the respiratory rate 18 breaths per minute, and the oxygen saturation 98% while he was breathing ambient air. The remainder of the examination was normal.

    The hematocrit, hemoglobin level, red-cell indexes, and blood levels of electrolytes, glucose, calcium, total protein, albumin, total bilirubin, alanine aminotransferase, and alkaline phosphatase were normal. An electrocardiogram (ECG) revealed normal sinus rhythm with a rightward axis. Naproxen and cyclobenzaprine hydrochloride were administered, with some improvement.

    Rosenfield K, Ghoshhajra BB, Dudzinski DM, Stone JR. Case 9-2016 — A 29-Year-Old Man with Dyspnea and Chest Pain. New England Journal of Medicine 2016;374(12):1178-88. MMS: Error

    Imaging Studies of the Chest.

    A posteroanterior chest radiograph (Panel A) shows a masslike opacity in the midlung zone behind the right hilum (arrow) and enlarged pulmonary arteries.

    Axial contrast-enhanced CT angiographic images were obtained at the lung-window setting (Panel B) and at the mediastinal-window setting (Panels C and D) at the level of the midchest.

    A mottled, wedge-shaped air-space opacity is present in the periphery of the right lower lobe (Panel B).

    A smooth, large, central filling defect (Panels B and C, arrows) is present that extends from the main pulmonary artery (MPA) to the right pulmonary artery (RPA).

    Central filling defects are also present in the interlobar and lobar branches of the right pulmonary artery (Panel D, arrows); the right ventricular outflow tract (RVOT) contains an irregular central filling defect with central contrast-filling channels rather than enhancement.

    An axial CT angiographic image (Panel E) shows a dilated right ventricle (RV), with a ratio of RV diameter to left ventricular (LV) diameter of 1.6 (normal, <1); a heterogeneously enhancing filling defect is evident in the RV cavity (arrow), as well as in the right atrium (not shown).

  7. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Abstract #1002 - Penile Growth in Response to Hormone Treatment in an Adult with Micropenis And Kallman Syndrome

    Objective: Report the effect of testosterone therapy on penile growth in a male with Kallmann syndrome (KS) and micropenis.

    Background: Kallmann syndrome is a rare genetic disorder characterized by hypogonadotropic hypogonadism. The clinical hallmark of KS is the failure of onset of puberty in which micropenis is one of the presenting symptoms. The main goal of treatment in young men with KS is to restore serum androgen to normal levels by the use of testosterone or human chorionic gonadotropin (hcg), allowing virilization, penile growth, puberty and finally, to induce fertility.

    Case Presentation: Case of a 26 year-old male with no past medical history that presented with absence of pubertal development, which was first noticed at 15 years of age. He had normal developmental milestones. Family history was unremarkable.

    On examination, the patient showed eunuchoid body proportion, micropenis (1cm), normal scrotum and palpable prepubertal testes bilaterally (<4ml), absence of facial and axillary hair, and sparse pubic hair, associated with decreased libido, anosmia, and high pitched voice. A normal karyotype (46XY) was documented. Hormonal workup was consistent with hypogonadotropic hypogonadism (FSH=1.27mIU/ml, LH=0.5mIU/ml, total testosterone=0.27ng/ml, free testosterone=0.007ng/ ml, sex hormone binding globulin=13.7nmol/L). Other pituitary hormones were within normal levels.

    hCG stimulation test was performed, and plasma testosterone rose from 26 ng/dl to 69 ng/dl. MRI of the brain showed bilateral hypoplastic olfactory bulbs. DXA scan resulted in low bone mass for age at lumbar spine. (Z score -3.4).

    Testosterone Cypionate 100 mg intramuscular weekly was started with a goal of keeping testosterone levels within normal adult range. After three months of therapy, penile length showed a growth of 2cm.

    Discussion: The most important concern in a patient with micropenis is whether he will have sufficient penile growth to allow sexual function. The etiology of micropenis in this condition has been commonly attributed to , the most common cause is failure of the hypothalamus to stimulate gonadotropins or hypophyseal dysfunction. Treatment of patients with KS should be individualized. Therapy with testosterone to achieve virilization is the treatment of choice whenever fertility is not currently wanted. Nevertheless if fertility is desired, treatment with hCG can be initiated.

    Conclusion: Testosterone treatment seems to be effective in patients with KS and micropenis. It successfully increased serum testosterone level and resulted in a satisfactory gain in penile length. Thus, it may be the primary form of treatment for micropenis in adults with prepubertal characteristics.
    Dizzy likes this.
  8. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [OA] [NSFW] Skin Necrosis After Self-Removal Of An Artificial Penile Nodule

    The implantation of objects in the penis for aesthetic reasons or sexual pleasure is becoming more popular among specific socioethnic groups within both, non-Western and Western countries.

    The implantation and removal of penile implants is currently often performed unanaesthetised, and in unsterile conditions, putting men who undergo the practice at risk of complications.

    This paper describes a patient with an infection of the penis after self-removal of a penile implant, requiring urgent medical treatment.

    Jalink M, Kramp KH, Baktawar S, Jewbali A. Skin necrosis after self-removal of an artificial penile nodule in a Surinamese man. BMJ Case Rep. 2016. Skin necrosis after self-removal of an artificial penile nodule in a Surinamese man -- Jalink et al. 2016 -- BMJ Case Reports
  9. grey

    grey Member Supporter

    I only check in here about every 2weeks because some of these case studies are so incredibly nightmare-ish.

    @Michael Scally MD you can just rock me to sleep after the louse study and the necrosis... Makes the micropenis guys in the studies seem almost normal.
  10. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [NSFW: Images At Link.]

    Mahadevappa N, Kochhar G, Vilvapathy KS, Dharwadkar S, Kumar S. Self-inflicted foreign bodies in lower genitourinary tract in males: Our experience and review of literature. Urol Ann 2016;8(3):338-42. Self-inflicted foreign bodies in lower genitourinary tract in males: Our experience and review of literature Mahadevappa N, Kochhar G, Vilvapathy KS, Dharwadkar S, Kumar S - Urol Ann

    OBJECTIVES: To study retrospectively the frequency, demographic, phenomenological, and psychiatric profile in patients presented with self-insertion of foreign bodies in the lower genitourinary tract in our institute.

    MATERIALS AND METHODS: From January 2009 to 2015, the records of patients admitted with self-insertion of foreign bodies into the lower urinary tract were analyzed retrospectively regarding demographic and phenomenological profile, the mode of presentation, diagnosis, management, complications, and possible contributing factors leading to the event.

    RESULTS: Out of 17,978 inpatients, ten patients (0.055%) presented with foreign body insertion in the lower genitourinary tract in last 6 years. Mean age was 28.1 +/- 13.9 (7-50) years.

    Objects used for insertion were varied from seeds, twigs to the electric wire.

    The contributing factors were lack of partner, misconception about masturbation, and underlying psychiatric illness.

    The presenting symptoms were pain and swelling of the penis, difficulty in voiding, and skin ulceration.

    The diagnosis was possible by simple observation in four patients, X-ray kidney, ureter, and bladder, and sonography of the pelvis in six patients.

    Five patients had endoscopic retrieval of foreign body, 2 had an open, suprapubic cystotomy, urethrotomy was needed in one patient, and forceps removal in two patients. There were no postoperative complications.

    Psychiatric profile was evaluated in nine patients.

    CONCLUSIONS: Foreign body insertion to lower urinary tract was rare. A main cause for insertion of foreign bodies was autoerotism, misconceptions regarding masturbation, and underlying psychiatric illness. In addition to suitable method of surgical removal, counseling and psychiatric evaluation are necessary to prevent recurrences or for early detection of psychiatric problems.
  11. grey

    grey Member Supporter

    Now you're just straight up trolling me...
    Eman likes this.
  12. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Gastric Anisakiasis

    A 36-year-old previously healthy woman presented with a 2-day history of severe chest pain and epigastric pain associated with nausea and vomiting.

    Physical examination showed moderate abdominal tenderness, without guarding or rebound in the epigastrium. Laboratory tests, including cardiac enzyme levels, were normal. An electrocardiogram and a radiograph of the chest were normal.

    The patient reported that she had consumed uncooked salmon approximately 2 hours before the chest pain developed.

    Computed tomography of the abdomen revealed diffuse thickening of the gastric wall. Gastroscopy revealed multiple anisakis larvae penetrating into the mucosa in the esophagogastric junction, fundus, upper body, middle body, and antrum of the stomach. Eleven larvae were removed with the use of endoscopic forceps (see video), after which the patient’s symptoms resolved.

    Anisakiasis is a parasitic infection of the gastrointestinal tract in humans that is caused by the consumption of raw or inadequately cooked seafood containing third-stage larvae of the nematode Anisakis simplex or related species.

    Fuchizaki U, Nishikawa M. Gastric Anisakiasis. New England Journal of Medicine 2016;375(7):e11. MMS: Error

  13. grey

    grey Member Supporter

    One more reason to stick with steak.
    Eman likes this.
  14. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Explosion Injuries from E-Cigarettes

    Electronic nicotine-delivery systems (ENDS) include electronic cigarettes (e-cigarettes) and personal vaporizers. The prevalence of ENDS use is increasing among current, former, and never smokers. E-cigarettes share a basic design; common components include an aerosol generator, a flow sensor, a battery, and a solution storage area. Many users do not understand the risk of “thermal runaway,” whereby internal battery overheating causes a battery fire or explosion.

    Brownson EG, Thompson CM, Goldsberry S, et al. Explosion Injuries from E-Cigarettes. New England Journal of Medicine 2016;375(14):1400-2. MMS: Error

    Injuries of the Face, Hands, and Thighs Caused by E-Cigarette Explosions.

    · Panels A and B show the common injury pattern of flame burns to both the thigh and the hand after a lithium-ion battery explosion in a patient’s pocket.
    · Panel C shows a flame burn and blast injury to the face after an e-cigarette device exploded during use, which led to traumatic tattooing of the right cheek.
    · Panel D shows a wound from an e-cigarette explosion, with a rim of discoloration characteristic of an alkali chemical burn.

  15. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    A Rubber Tube in The Bladder as A Complication of Autoerotic Stimulation of The Urethra

    Self-insertion of foreign bodies in the urethra is most commonly associated with sexual or erotic arousal of adolescents with mental health disorders.

    Rarely it may practiced by healthy adults for masturbation.

    Migration of foreign bodies used for the abovementioned purpose from the urethra to adjacent organs is a relatively uncommon urologic problem that may cause serious complications which arose tardive.

    Presentation includes a variety of acute or chronic symptoms that depend of the underlying complications.

    The method of extraction depends on the shape, size and nature of the object and should be tailored according to the condition of the patient.

    In the present article we present a case of a rubber tube inserted to the urethra for erotic arousal purposes which migrated to the bladder during masturbation.

    Stamatiou K, Moschouris H. A rubber tube in the bladder as a complication of autoerotic stimulation of the urethra. Arch Ital Urol Androl 2016;88(3):239-40. A rubber tube in the bladder as a complication of autoerotic stimulation of the urethra. - PubMed - NCBI
  16. BBC3

    BBC3 Member


    that's the better half the fun after all :D

    Poor bastard didn't tug hard enough when he blew...:confused::eek:. lol

  17. BBC3

    BBC3 Member

    Funny I always thought that one was tren related.. :p:D

  18. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [OA] Leydig Cell Tumor of The Testis with Azoospermia and Elevated Delta4 Androstenedione: Case Report

    BACKGROUND: Secreting interstitial cell (Leydig cell) tumors are rare. In adults, the clinical picture and steroid levels are variable.

    CASE PRESENTATION: This paper presents a case of left testicular tumor, showing azoospermia with normal serum level of total testosterone, collapsed FSH and LH, and high delta4 androstenedione.

    Histopathological investigation revealed a Leydig cell tumor. TESE allowed spermatozoa extraction and freezing. Testicular histology found hypospermatogenesis and germ-cell aplasia with interstitial fibrosis.

    Surgical resection of the tumor resulted in normalization of gonadotropins and fall in serum delta4 androstenedione to subnormal levels in the postoperative period confirming that the tumor was secreting delta4 androstenedione.

    It was hypothesized that high delta4 androstenedione resulted in intra tumoral 17 beta-HSD overtaken by delta4 androstenedione or that 17 beta-HSD activity in the tumor was different from that of normal Leydig cells.

    Three months after surgery sperm analysis found a complete recovery of spermatogenesis. A spontaneous pregnancy occurred 3 months after surgery and a girl was born.

    CONCLUSIONS: In this case, the diagnosis of testicular Leydig cell tumor secreting delta4 androstenedione was made in a context of azoospermia.

    Prasivoravong J, Barbotin AL, Derveaux A, et al. Leydig cell tumor of the testis with azoospermia and elevated delta4 androstenedione: case report. Basic Clin Androl 2016;26:14. Leydig cell tumor of the testis with azoospermia and elevated delta4 androstenedione: case report
  19. BBC3

    BBC3 Member

    First I find this interesting as they have often referred to "testicular cancer" as one of the most common cancers. I am not sure the difference. But I am gathering that when the article says 'Leydigg cell", they are speaking of a EITHER the cells that PRODUCE hcg/HMG.. Or the PRODUCTS THEMSELVES (like "blood cancer" kinda/sorta). But I wont give them that much credit in dissemination of data... And it begs to wonder who leydig cel cancer proliferates, and does it ultimately involve the entire testicle..?

  20. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Venkatraman A, Khawaja A, Shapshak AH. Hemorrhagic stroke after consumption of an energy drink. The American Journal of Emergency Medicine.

    We present here the first-ever reported case of an intracranial hemorrhage associated with the consumption of an energy drink.

    Our patient developed symptoms of sensory changes in the right arm and leg, with ataxia, within minutes of consuming a bottle of Redline, a well-known energy drink.

    A computed tomography of the head revealed a small intracranial hemorrhage near the left thalamus.

    The Redline bottle notes that the serving size is only half a bottle, and also recommends that people with hypertension not use it, but our patient had not read these instructions.

    Like many other energy drinks, Redline has high levels of caffeine.

    However, it also contains multiple other compounds like B-phenylethylamine hydrochloride, yohimbine, toothed club moss extract, and 5-hydroxytryptophan.

    Many of these agents are known to have sympathomimetic activity of their own.

    There is limited awareness of the potential interactions between these agents and their safety when combined with caffeine.

    Intracranial hemorrhage must be added to the extensive list of adverse effects associated with energy drink consumption.

    As these drinks grow in popularity around the world, clinicians and public health agencies must devote more attention to this issue.