ID/CC A 39-year-old male presents to his family doctor because of increasing embarrassment and concern over breast enlargement.

HPI The patient has a long history of burning epigastric pain 011 awakening in the mornings and between meals that decreases with food and antacids (peptic ulcer disease), for which he has been taking cimetidine. Directed questioning reveals that he has also been suffering from hallucinations and impotence.

PE VS: normal. PE: cardiovascular, neurologic, and abdominal examination fail to reveal any pathology; moderate bilateral growth of breast tissue; testes somewhat hypo trophic; rectal exam negative for prostatic enlargement.

Labs CBC/Lytes/UA: normal.

Imaging CXR/KUB: normal.

Treatment Switch to other histamine receptor antagonists, such as ranitidine or famotidine.

Discussion All the II2 blockers are well tolerated, although cimetidine is associated with several side effects, particularly reversible gynecomastia. H2 blockers produce an increase in serum prolactin levels (especially ranitidine) and alter estrogen metabolism in men (have anti-androgenic properties). Other side effects include headache, confusion, low sperm counts, and hematologic abnormalities (thrombocytopenia may enhance hy-poprothrombinemic effect of oral anticoagulants). They have been largely supplanted by newer H<2 receptor blockers without many of these side effects.

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