A 24-year-old man is brought to the emergency department by his wife after he began threatening her at home. She reports that he has been increasingly irritable and abusive over the last several months and becomes angry for no clear reason. He was recently involved in a fist fight at work. His wife also adds that they have been unsuccessful in their attempts to conceive over the past 2 years. The husband states that there is nothing wrong. He is otherwise healthy and exercises frequently. The patient reports occasional alcohol use and past marijuana use. On examination, blood pressure is 148/92 mm Hg and pulse is 102/min; he has a receding hairline. There is palpable tissue underneath his nipples bilaterally. Heart and lung examinations are normal. Which of the following substances most likely explains the patient's symptoms and findings?

Question

A 24-year-old man is brought to the emergency department by his wife after he began threatening her at home.  She reports that he has been increasingly irritable and abusive over the last several months and becomes angry for no clear reason.  He was recently involved in a fist fight at work.  His wife also adds that they have been unsuccessful in their attempts to conceive over the past 2 years.  The husband states that there is nothing wrong.  He is otherwise healthy and exercises frequently.  The patient reports occasional alcohol use and past marijuana use.  On examination, blood pressure is 148/92 mm Hg and pulse is 102/min; he has a receding hairline.  There is palpable tissue underneath his nipples bilaterally.  Heart and lung examinations are normal.  Which of the following substances most likely explains the patient's symptoms and findings?

Quizplus · Accepted Answer

This patient's increased aggression, accelerated male pattern baldness, and gynecomastia are concerning for anabolic (androgenic) steroid use. Anabolic steroids (eg, testosterone, trenbolone, boldenone, stanozolol, nandrolone) are popular among young people and athletes looking to improve their physical appearance and performance. Anabolic steroid side effects include impaired endogenous testicular function and decreased testicular size and sperm count. Hepatic dysfunction may occur, and patients can develop erythrocytosis due to androgen-stimulated erythropoiesis. HDL levels decrease, and high doses may even cause cardiac dysfunction. Gynecomastia can develop when excess testosterone is converted to estradiol, leading to breast enlargement. Skin changes include acne and premature or accelerated male pattern baldness. Psychiatric effects include aggression and mood disturbances that are often complicated by concurrent alcohol use. (Choice A) Growth hormone may be taken to improve athletic ability. It can lead to hyperglycemia, sodium retention, hypertension, swollen hands, and joint and muscle pain. (Choice B) Inhalants can produce short-lived psychotic episodes. There are numerous possible side effects, including hypoxia, brain damage, and bone marrow suppression. Aggression and gynecomastia are not strongly associated with inhalant abuse. (Choice C) Methamphetamine is a central nervous system stimulant associated with a number of complications, including hypertension, tachycardia, severe agitation or aggressiveness, and psychosis. Patients might have acne or facial sores due to skin picking. Male pattern baldness may be seen. However, gynecomastia is absent. (Choice D) Phencyclidine (PCP) causes brief dissociative psychotic episodes. Patients taking PCP may be aggressive and less sensitive to pain but do not develop acne, baldness, or gynecomastia. (Choice E) Tamoxifen, a nonsteroidal anti-estrogen, competes with estrogen at estrogen receptors in the breast and is taken by users of anabolic steroids to treat gynecomastia. (Choice G) Tetrahydrocannabinol (THC) may cause increased appetite, red eyes, slowed reflexes, dizziness, and impaired coordination. THC use may lead to gynecomastia but is unlikely to cause aggression. Educational objective: Anabolic-androgenic steroids are used to improve physique and athletic performance but are associated with numerous adverse effects, including acne, baldness, gynecomastia, hepatic dysfunction, altered lipid profiles, virilization, testicular failure, and possible mood and behavior changes. References: Adverse health effects of anabolic-androgenic steroids. (http://www.ncbi.nlm.nih.gov/pubmed/20153798) Anabolic steroids and male infertility: a comprehensive review. (http://www.ncbi.nlm.nih.gov/pubmed/21682835)

A 24-Year-Old Man Is Brought to the Emergency Department by His