Category: Reproductive Endocrinology

Monitor: 8

8 - Where is all this hemoglobin coming from?

Saturday, Apr 27
10:30 AM – 11:00 AM

Objective :

To identify abnormal labs by following a thourough approach, even if such labs are non-endocrine and even if the labs are ordered or followed by the relevant specialist.


Methods :

Case presentation and litearature review.


Results : A 79 year old woman follows up in the Endocrinology clinic regularly for primary hyperparathyroidism that was cured surgically. Over the last 2 years, she was noted to have high hemoglobin (15-16 gm/dL), which was perceived as too high for her age. Although she was followed by an oncologist for breast cancer that was in remission, this high hemoglobin was not evaluated by the oncologist. Hence, we ordered Testosterone, which was surprisingly very high (436 ng/dL). In retrospect, the only symptoms that were obtained include deepening of voice, new onset hirsutism and hair loss. Further work up revealed elevation of other androgens, with normal erythropoetin and negative JAK2 mutation. Imaging of the adrenals showed left adrenal asymmetric hyperplasia. Pelvic sonography revealed multiple uterine fibroids but no tumors in the ovaries. Patient underwent exploratory laparoscopy evaluation, during which she underwent bilateral laparoscopic salpingo-oopherectomy which showed a benign right fallopian tube 1.4 cm leydig cell tumor with stromal hyperthecosis and left fallopian tube leydig cell hyperplasia and stromal hyperthecosis. Patient  did well after the surgery and post op CBC normalized, testosterone levels normalized as well.


Discussion :

Ovarian sex cord-stromal neoplasms develop from the dividing cells surrounding the oocytes, including the cells that produce ovarian hormones. Some sex cord-stromal neoplasms produce sex steroid hormones, including estrogen, androgens and may be clinicall symptomatic or asymptomatic. Our patient had symptoms of hyperandrogenism, which were recognized in retrospect, as they were overlooked by us, given pateint's age and menopausal state. It is intriguing thus that ordering Testosterone levels in this patient was triggered by the elevated hemoglobin, which was also overlooked by the patient's oncologist. What complicated the work up in the patient is that we could not identify the source of her hyperndrogenism. Furthermore, the unilateral adrenal hyperplasia could not be explained, but it was not believed to be the source of the androgen production. Pelvic ultrasound is usually the imaging modality of choice, but leydig cell tumors are sometimes too small to be visualized. If suspicion is high, it is recommendeds to proceed with abdominopelvic exploration. In our patient, tentative salpingo-oopherectomy was done, and the tumor was only found upon final histology.


Conclusion : This case underscores the importance of thorough medical care.

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Vengamamba Polu

Fellowship
Michigan State University
Lansing, Michigan

I am doing fellowship at Michigan State University

Saleh Aldasouqi

Professor of Medicine and Chief of Endocrinology
Michigan State Universtiy

Saleh Aldasouqi is a professor of medicine and chief of endocrinology at Michigan State University. His research areas include diabetes and thyroid.

Naveen Kakumanu

Assistant Professor of Medicine
MSU Endocrinology

Dr. Kakumanu joined the Department of Medicine at MSU on October, 2013. He graduated from Saint George’s University, School of Medicine in Grenada. He completed his residency in Internal Medicine at the Detroit Medical Center, Wayne State University and was Chief Medical Resident, ambulatory clinic preceptor at Harper/Hutzel University Hospital, Detroit Medical Center. He completed a Geriatric Fellowship at Wayne State University and received the Lavoisier Cardozo Award for Excellence in Geriatric Medicine. Endocrinology fellowship was completed at Henry Ford Hospital in 2013. He is board certified in Internal Medicine, Geriatric Medicine and Endocrinology. Has presented multiple posters and abstracts at the Endocrine Society, American Association of Clinical Endocrinologists and American Society for Bone and Mineral Research. His specialty in Endocrinology is diverse with interest in thyroid disorders, diabetes and bone metabolism.

Issra Jamal

Endocrinologist
Carolina diabetes and kidney center, South Carolina

I have completed Endocrinology felliwship from Michigan State University and now I am practicing general Endocrinology in Carolina Diabetes and kidney center in south carolina .