A Perplexing Case of a 34 Year Old Male with Unexplained Chest Pain, Very Low HDL and Central Hypogondanism

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A Perplexing Case of a 34 Year Old Male with
Unexplained Chest Pain, Very Low HDL and Central
Hypogondanism Jordanna Mae Walker, MD, Michael
Arnett MD, Thomas Francis, MD Department of
Medicine, Tripler Army Medical Center
DISCUSSION

• This case illustrates a unifying diagnosis of
  anabolic steroid abuse that explains atypical
  chest pain, lipid abnormalities,
• and central hypogonadism in a young bodybuilder.
  
• Review of the literature illustrates that
  anabolic steroid use can cause chest pain through
  several mechanisms. These are coronary vasospasm
  as well as thrombotic events.
• Alterations in lipid metabolism can also lead to
  accelerated atherosclerosis. Patients using
  steroids can also develop a dialated
  cardiomyopathy which was revealed in later
  testing of this individual as he had an enlarged
  LV and EF of 44
• Additionally side effects of steroid
  administration include suppression of endogenous
  testicular function, erythrocytosis,
  psychological disorders, serum lipid
  abnormalities, and coagulation activation
• Prolonged effects of anabolic steroid use also
  include hepatotoxicity, increased risk of heart
  attack and stroke, gynecomastia, virilization of
  females, premature closure of epiphyses, and
  needle sharing with its associated risks
• The causes of low HDL cholesterol include
  anabolic steroids, familial hypoalphalipoproteinem
  ia familial HDL deficiency and Tangier disease,
  elevated CETP activity, lipoprotein lipase
  deficiency, elevated hepatic triglyceride lipase
  activity, LCAT deficiency and insulin resistance

INITIAL PATIENT PRESENTATION

• The patient was a 34 year old avid weightlifter
  admitted to the cardiology service for evaluation
  of sub-sternal chest pain with radiation to the
  left shoulder/arm associated with diaphoresis and
  dyspnea.
• Symptoms improve with 5-15minutes of rest.
• On day of admission patient was treated with SL
  NTG via paramedics and reports SSCP rapidly
  improved from 7/10 to 1/10 following SL NTG.
• The patient also reports identical symptoms one
  year ago in SC that led to a cardiac
  catheterization that was reported as normal.
• Following catheterization symptoms improved
  without any therapy.
• The patient denies any history of GERD or RAD.
  The patient denies rest symptoms or symptoms
  related to food ingestion.
• The patient denies weight lifting supplements or
  drug use.
• PMH significant for HTN for which he was
  perscribed lisinopril/HCTZ
• PE is only remarkable only for an avid weight
  lifter. No evidence of LV dysfunction
• Laboratory evaluation was significant for HDL 3
  mg/dL
• A treadmill test using the Bruce protocol was
  performed on 21Mar05 which demostrated excellent
  exercise toleratnce, no ischemia and no ectopy.
• Patient was referred to endocrinology by
  cardiology for evaluation of his abnormally low
  HDL.