Gynecomastia occurs more commonly in adult males than is often recognized and is, therefore, not evaluated. The workup should be based on the patient’s presentation and important clinical factors, including underlying medical disorders and medications. Patients without symptoms probably do not need additional evaluation unless an underlying clinical disorder is suspected. Ultrasonography of the breast is not routinely recommended. Gynecomastia will regress spontaneously in many patients but can be treated medically or surgically based on patient preference. It is not a premalignant condition and patients need this reassurance.
An elderly man presenting with shortness of breath and hypoxaemia was admitted with acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Due to worsening hypoxaemia, he was transferred to the intensive care unit and required mechanical ventilation. Propofol was infused at 1.5–4 mg/kg/hour. Within 48 hours of initiation, we noticed worsening metabolic acidosis, acute kidney injury, hyperkalaemia, hyperphosphataemia, hypertriglyceridaemia, elevated creatine kinase and elevated myoglobin levels. Suspecting propofol-related infusion syndrome (PRIS), we discontinued his propofol infusion immediately and initiated supportive measures. In 48 hours, there was a significant improvement in metabolic acidosis, hypertriglyceridaemia, rhabdomyolysis and renal function. The propofol infusion rate and cumulative propofol dosage (under 140 mg/kg) were well below levels associated with PRIS. COVID-19’s pathogenesis, still under investigation, may have contributed to this presentation. It is imperative for clinicians to maintain a high degree of suspicion once propofol is initiated, regardless of the cumulative dose or rate of infusion.
A 53y/o male patient presented to his PCP with fatigue and diagnosed with low testosterone and was started on testosterone. P ituitary labs were not checked then. After 6-8 weeks he was referred to neurology for new onset vision problems, diplopia, and daily headaches. MRI brain then showed a sellar mass of 2.4×2.6×2.7 cm with sphenoid sinus extension and bony thinning alongthe margins of the sella turcica which was nearly imperceptible. On testosterone replacement, biochemical assessment of anterior pituitary function showed total testosterone: 836 (264–916 ng/dl), Free Testosterone: 32.6 (2.5-9.5 ng/ml), LH<0.1 (1.2-8.6 IU/L), FSH 0.2 (1.5-12.4 IU/L), Prolactin 18 (4-26 ng/ml), TSH 0. 03(0.4-4.1 UIU/ml), FT4 0.63 (0.8-1.9ng/dl), IGF 188 (55-186 ng/ml), ACTH<5 (10-65 pg/ml), Cortisol<1 (4.8-19.5 ug/dl). Endoscopic endonasal surgery was performed with complete removal of the tumorand abdominal fat graft harvest. Histopathological findings confirmed well differentiated low grade chordoma. Post operatively he improved, and headaches and visual disturbances resolved. Patient was sent home on Hydrocortisone 10mg am/5mg pm. Then, he presented to our endocrine clinic for initial hormonal evaluation. On steroid replacement, endocrine testing was repeated four weeks post-surgery. Labs showedTSH 2. 070 (0.4-4.1 UIU/ml), FT4 1.16 (0.8-1.9ng/dl), FSH<0.3(1.5-12.4 IU/L), LH<0.3(1.2-8.6 IU/L), Prolactin 26 (4 -26), ACTH 19.6 (10-65 pg/ml), Cortisol 7 (4.8-19.5 ug/dl), IGF-1 129 (55-186 ng/ml). Four months after the surgery, patient passed the cosyntropin stimulation test and was able to wean off the hydrocortisone replacement. Post-op repeat MRI brain showed complete resolution of the clivial mass. Current, he remains stable with regular follow ups. The most common presenting symptoms of a sellar chordoma include visual problems and uncommonly hypopituitarism. Our case shows that non-adenomatous tumors can still challenge us with the original presentation as an endocrine deficit. In a case series, only one of nine cases had presented with pituitary dysfunction. Our patient was noted to have hypogonadism and started on testosterone supplementation without further investigation. It is important to evaluate hormonal status in all pituitary masses and recognize that some cases of sellar chordoma can present with endocrine dysfunction as the initial manifestation. In our case, endocrine function of the patient returned to normal once the pituitary compression from chordoma was eliminated. Presentation: No date and time listed
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