LP12
description
Transcript of LP12
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Case presentation
Male hypogonadism
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S.P, 52 y, male
Chief complaintsirritability,
fatigue,
behavioral disorders,
sexual disfunctions (libido , erectile dysfunction)
gynecomastia
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Infertility
Hyperprolactinemia
Absence of the secundary sexual characteristics
diagnosis of hypogonadism - treatement with Testosterone i.m.
Arterial hypertension: Amlodipin 10 mg/day, Atenolol 50
mg/day, Lisinopril 10mg/day
Depression: Cipralex 10 mg/day, Valproic ac. 1tb/day
Medical history
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Physical examination
Characterisitic features:low muscle mass and strength,
reduced facial, axillary and troncular hair growth,
pubic hair growth - horizontal pubic insertion (triangular),
ginoidhabitus, with biacromial diameter smaller than bitrohanterianbilateral gynecomastia,
bilateral retractile testes,
V=8 mL, firm, painless, with peno-orchitis dissociation,
L- 181 cm, Arm Span187 cm
BMI= 32.9 kg/m2
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Physical examination
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Laboratory findings
Blood countnormal
Glycemia a jeun: 104 mg/dL
Total cholesterol: 227 mg/dL (N
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Hormonal assesment - 2007
FSH= 38,7 UI/L LH= 22,5 UI/L
Testosteron= 1,98 ng/dL
PRL= 15 ng/mL
Hypergonadotropic hypogonadism
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Genetic analysis
47 XXY
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Paraclinical examinations
Lombar spine x ray
L5 vertebral fragility fracture
Semen analysis - azoospermia
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Pituitary hormone
level at baseline
Appropriate peripheral
hormone(s) or parameter
Interpretation
PRL= 8.157
N
3.6-16.3ng/ml
normal
LH = 0.18
N1.7-11.2UI/ml
Testosteron = 5.776
VN2.62-8.7ng/dl hypogonadism
(primary, under
treatement)
FSH= 1.06
N
2.1-18.6UI/ml
azoospermia
TSH = 1.658 mIU/ml
(N: 0. 27-4.2)
fT4 =15.22
VN12-22pmol/l
euthyroidism
PTH=80,465
N15-65ng/dl
Ca total9,06 mg/dl
Phosphorus- 2,44 mg/dl
secondary
hyperparathyroidism
HORMONAL ASSESSMENT - 2011
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Final diagnosis:
Klinefelter Syndrome
Hypergonadotropic hypogonadism
Gr. II Arterial HypertensionDepression
Gr.I Obesity
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Differential diagnosis
Primary hypogonadism: Bilateral anorchia
Enzymatic defects in synthesis of
testosterone,
pure gonadal dysgenesis,
Incomplete androgen insensitivity,
Leydig cells hypoplasia
Noonan syndrome
Uncorrected cryptorchidism
Myotonic Dystrophy
"Sertoli cell only "
Acquired Disorders: gonadal irradiation, infectious
diseases, trauma, autoimmune
processes, drugs, chronic systemic
disease.
Central hypogonadysm GnRH deficiency
Mutations in the leptin or leptin R
Syndromes with mental retardation
and hypogonadism
Isolated LH or FSH deficiency Pituitary insufficiencies
Acquired forms : central hypothalamic-pituitary
lesions
suppression of gonadotropins by: hyperprolactinemia,
administration of GnRH, sex steroids
in high doses, opioids
chronic disease, type II diabetes.
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Treatment
Psychiatric counseling
Nebido (testosterone undecanoat) 1000 mg
i.m. 1 f/3 months Monitoring: PSA, blood counts
Risendros 35 mg 1 tb/week
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Treatment
Contraindications to treatment with androgens:
high risk: prostate cancer
metastatic breast cancer
moderate risk:- prostatic node,
- severe benign prostatic hyperplasia,- inexplicably high levels of PSA,- polycythemia (hematocrit > 50%),
- severe obstructive sleep apnea,- severe congestive heart failure (NYHA III/IV).
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Possible side effects of androgen
replacement therapy
polycythemia, acne,
subclinical prostate cancer, enlargement of
metastatic prostate cancer,
gynecomastia, breast cancer,
reduction of spermatogenesis and fertility,
alopecia,
induction/worsening of obstructive sleep apnea, impaired liver function and decreased HDL - c,
pain at the injection site
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Evolution and prognosis
Increased risk of:
Germ tumor cells
Breast cancer (20x)
Osteoporosis
Infertility is definitive
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Evolution and prognosis
Klinefelter sy. may be associated with:
chronic lung disease (emphysema, chronic bronchitis)
mediastinal tumors, lung cancer
non Hodgkin lymphoma, leukemia
varicose veins cerebrovascular disease
obesity,
autoimmune thyroiditis, hypothyroidism,
diabetes mellitus, peptic ulcer,
taurodontism