Poster Presentation ESA-SRB-ANZBMS 2024 in conjunction with ENSA

A 59-year-old married male, with loss of sexual desire was found to have an elevated serum testosterone concentration. Eighteen months later he was referred to an endocrinologist by a new GP.  He and his wife share 2 adult children. He works as a real estate agent. He attends the gym regularly, and last took pre-workout powders a year prior and strongly denies taking any other supplements, steroids or peptides. His wife was suspicious about the loss of desire given the elevated serum testosterone. There was no headache or visual disturbance.

He had a history of hereditary spherocytosis requiring splenectomy 20 years prior, a raised serum ferritin with negative haemochromatosis gene studies, elevation (non-clonal) of NK cells identified 4 months prior to presentation and vestibular neuronitis with onset 1 month prior to presentation. No regular medication apart from occasional betahistine and cholecalciferol. 

His height was 165.5cm, weight 82.3kg .BMI of 30.2 with a stocky, muscular build, and was well virilised. There was no gynaecomastia or breast tenderness, and he had normal volume testes.

Investigations showed normal electrolytes, renal and liver function tests, haemoglobin and haematocrit. Also normal were thyroid function, growth hormone, IGF-1 and prolactin. Serum testosterone (T), Oestradiol (E2), SHBG, LH, FSH, and alpha subunit are shown in the table below at baseline and in response to (i) Leuprorelin 22.5mg and (ii) graded doses of anastrozole (Table 1). Haemoglobin and haematocrit have remained normal.

A contrast enhanced 3T MRI showed a 3mm right sided contrast enhancing pituitary tumour. 

A diagnosis of predominantly LH secreting gonadotrophinoma was made and transsphenoidal surgical removal is planned. Although considered extremely rare, and more common in men, it seems likely given the nature of the initial presentation that many cases are missed.