Anabolic Steroid Abuse

ID/CC A 46-year-old female comes to the medical clinic for an evaluation of weight gain, roundness of her face, and epigastric pain that is relieved by eating (peptic ulcer).

HPI She had been suffering from chronic, itchy blisters in the mouth that came and went, leaving painful ulcers together with large bullae 011 all four extremities and on her chest and lower back (pemphigus), for which she has been taking high-dose prednisone for several months.

PE VS: hypertension (BP 145/95); 110 fever. PE: moon facies, acne, buffalo hump, truncal obesity, striae, increased facial hair

(hirsutism), and ecchymoses on distal extremities.

Labs CBC: leukocytosis with lymphopenia. Hyperglycemia. Lytes: hypokalemia. UA: glycosuria.

Imaging XR, spine and long bones: generalized osteoporosis.

Treatment Switch to methotrexate, azathioprine, dapsone, or nicotinamide. Corticosteroids should be tapered down.

Discussion Of the causes of Cushing's syndrome, iatrogenesis is the most common. Steroids produce a lysosomal membrane stabilization, blocking leukotriene formation from arachidonic acid, blocking the action of phospholipase A, and inhibiting cyclooxygenase activity (decreased prostaglandin formation). Because of this, steroids are used in a number of settings, such as acute inflammation, anaphylaxis, allergy states, and immune suppression as well as for the treatment of Addison's disease.

CUSHING'S SYNDROME—IATROGENIC

ID/CC A 32-year-old woman comes for her first gynecologic visit.

HPI On routine pelvic exam a vaginal mass is felt. The patient's mother took an estrogen compound (DES) during pregnancy as treatment for threatened abortion.

PE Well developed with breast tissue appropriate to age; pubic and axillary hair normal; on bimanual pelvic examination a hard, ulcerated mass is felt on posterior wall of upper vagina; iodine staining of vaginal wall shows patches of decreased uptake by cells (due to adenosis).

Labs CBC/Lytes/UA: normal. Hormonal screen and LFTs do not disclose any abnormality.

Imaging Hysterosalpingogram: injection of contrast into uterine cavity reveals T-shaped uterus and cervical incompetence.

Micro Pathology Biopsy by colposcopy shows glandular epithelium in upper part of vagina with squamous metaplasia (adenosis) . Biopsy of the ulcerated mass shows clear-cell adenocarcinoma of vagina.

Treatment Surgery; radiation.

Discussion Diethylstilbestrol is a synthetic estrogen that was used some

30 to 35 years ago for the prevention of a threatened abortion. The daughters of patients thus treated before the 18th week of pregnancy may present with an alteration in the development of the embryonic transition between the urogenital canal and paramesonephric system, producing persistence of the mullerian glands on the upper vagina and giving rise to adenosis and clear cell adenocarcinoma that is usually asymptomatic and discovered incidentally. Other side effects include transverse vaginal septum, developmental uterine abnormalities, and cervical incompetence. In males DES may be associated with genital tract abnormalities.

DIETHYLSTILBESTROL (DES) EXPOSURE

ID/CC A 17-year-old white female student who is learning how to inject herself* with insulin is found unconscious by her desk.

HPI The patient suffered from weight loss, polyuria, polydipsia, and polyphagia for several months and was recently diagnosed with juvenile-onset diabetes mellitus. She has been meticulous in self-administering insulin injections but often injects larger doses of insulin than prescribed (overdosing is common at the beginning of treatment).

PE VS: tachycardia (HR 96); hypotension (BP 100/50); no fever. PE: skin cold and moist; patient stuporous with hyporeflexia; negative Babinski's sign; responsive only to painful stimuli; cardiopulmonary exam normal; no hepatomegaly; no splenomegaly; no peritoneal signs.

Labs Severe hypoglycemia. Lytes: potassium and magnesium levels sharply decreased (hypokalemia, Hypomagnesemia). BUN and creatinine normal; increased serum levels of insulin with normal Opeptide levels.

Imaging CT, head: no intracranial pathology demonstrated to account for the stuporous state.

Treatment Administer IV 50% glucose or IM glucagon after drawing baseline blood sample. Follow serum glucose levels for several hours; monitor and treat electrolyte imbalances.

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