A 25-year-old man comes to the office for evaluation of facial acne. He has no significant past medical history and does not use tobacco or alcohol. The patient works as a personal trainer. His family history is significant for diabetes mellitus in his mother and leukemia in his father. His blood pressure is 134/82 mm Hg and pulse is 58/min. On physical examination, there is mild facial acne. The patient's lungs are clear to auscultation. The liver span is 8 cm, and the spleen is not palpable. His testes are soft, and testicular volume is decreased. Laboratory results are as follows: Which of the following is the most likely explanation for this patient's abnormal laboratory findings?

Question

A 25-year-old man comes to the office for evaluation of facial acne.  He has no significant past medical history and does not use tobacco or alcohol.  The patient works as a personal trainer.  His family history is significant for diabetes mellitus in his mother and leukemia in his father.  His blood pressure is 134/82 mm Hg and pulse is 58/min.  On physical examination, there is mild facial acne.  The patient's lungs are clear to auscultation.  The liver span is 8 cm, and the spleen is not palpable.  His testes are soft, and testicular volume is decreased.  Laboratory results are as follows:  Which of the following is the most likely explanation for this patient's abnormal laboratory findings?

Quizplus · Accepted Answer

11ec160b_390b_f970_9249_5f6b6074d0d0_MD0001_00 This patient has acne, testicular atrophy, and erythrocytosis, findings concerning for androgenic steroid abuse. Abuse of androgens, androgen precursors, and agents that increase endogenous androgen production is most common in young adults who engage in competitive athletic activities or for cosmetic purposes. Chronic androgen use may increase muscle mass but has multiple associated risks. Testosterone stimulates red blood cell production, which accounts for the higher hematocrit in normal males compared to normal females. This effect is exaggerated in exogenous androgen abuse, which increases hematocrit in a dose-dependent manner. Androgens decrease gonadotropin secretion, which results in testicular atrophy and decreased sperm production. Other common findings include virilization in women (eg, clitoromegaly, hirsutism) and acne. (Choices A and D) Mutations that cause a high oxygen affinity of hemoglobin reduce the ability of hemoglobin to release oxygen in tissues. Low tissue oxygen levels in the kidneys stimulate erythropoietin release. Renal artery stenosis decreases oxygen delivery to the kidney and also stimulates erythropoietin release. These conditions may produce a compensatory erythrocytosis but would not produce the other clinical signs (eg, acne, testicular atrophy) seen in this patient. (Choice B) Intensive exercise could result in elevated myoglobin secondary to rhabdomyolysis, but the hematocrit level should not be changed by exercise. (Choice C) Myeloproliferative disorders, such as polycythemia vera (PV), can lead to erythrocytosis. Patients with PV typically have leukocytosis and thrombocytosis as well. This patient's additional physical findings make steroid abuse more likely. (Choice F) Heavy sweating may cause a transient increase in hematocrit due to loss of plasma volume but would likely cause other signs of dehydration (eg, tachycardia). This patient's creatinine at the upper limit of normal is typical for patients with increased total muscle mass; hypovolemia also will usually cause a more pronounced rise in blood urea nitrogen. Educational objective: Androgenic steroid abuse may lead to erythrocytosis, testicular atrophy, acne, and virilization in women (eg, clitoromegaly, hirsutism). __________ References: Effects of graded doses of testosterone on erythropoiesis in healthy young and older men. (http://www.ncbi.nlm.nih.gov/pubmed/18160461)

A 25-Year-Old Man Comes to the Office for Evaluation of Facial