Review Question - QID 218808

This patient who presents with erythrocytosis (elevated hemoglobin), acne, and hirsutism (hair on chest and abdomen) is most likely using exogenous testosterone as a performance enhancement drug.

Testosterone is an anabolic steroid hormone that is often abused in the setting of sports performance. The hormone leads to increased muscle mass and endurance by stimulating androgen receptors throughout the body. Side effects of illicit testosterone use include masculinization in women (acne, hirsutism, deep voice) and testicular atrophy in men. Endocrinological effects of exogenous steroid use include decreased gonadotropin-releasing hormone levels, decreased luteinizing hormone levels, decreased follicle-stimulating hormone levels, and decreased sperm count in men. Adolescents may also experience premature closure of the epiphyseal plates resulting in decreased height at maturity. Testosterone also has metabolic side effects including derangement of the lipid profile with increased low density lipoprotein formation (increasing the risk of cardiovascular disease) and erythrocytosis.

Ohlander et al. studied the development of erythrocytosis in patients who were treated with testosterone. They found the highest rates of erythrocytosis in patients who were treated with the short acting injectable formulation compared to other formulations. They recommend using these formulations carefully to avoid the risk of thromboembolic events.

Incorrect Answers:
Answer 1: A blood transfusion would lead to increased hemoglobin levels and may be used illicitly in order to boost endurance during sports events. Side effects of blood transfusion include transfusion reactions characterized by fever and rash in affected patients. It would not explain this patient's increased acne or hirsutism.

Answer 2: Erythropoietin abuse would lead to increased hemoglobin due to increased production and maturation of reticulocytes. There are relatively few detectable symptoms but screening measures in sports can detect when patients have abused this substance. This also would not explain this patient's acne or hirsutism.

Answer 3: Smoking can result in relative hypoxia in patients who develop chronic obstructive lung disease, which may subsequently result in hypoxia-mediated erythrocytosis. The young age of this patient combined with the normal respiratory rate make this mechanism less likely than use of anabolic steroids.

Answer 5: Stimulant abuse can enhance sports performance but is not associated with erythrocytosis. Instead, side effects include headache, chest pain, and peripheral vasospasm. Cardiac dysrhymias may occur as well.

Bullet Summary:
Side effects of testosterone abuse include hirsutism in women, hypogonadism in men, and erythrocytosis in both sexes.