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Testosterone Replacement Therapy Causing Extensive Portal and Mesenteric Vein Thrombosis

Published:January 11, 2021DOI:https://doi.org/10.1016/j.amjmed.2020.12.018
      A 62-year-old man presented to our Emergency Department reporting a 1-week history of diffuse abdominal pain. His initial vital signs were unremarkable. His past medical history was significant for panhypopituitarism secondary to a remote head trauma. His home medications included intramuscular testosterone cypionate 120 mg weekly. His initial laboratory values were remarkable only for polycythemia (hemoglobin of 177 g/L) (Table). A contrast-enhanced abdominal computed tomography scan. showed extensive venous thrombosis of the portal vein, the superior mesenteric vein, and most of the splenic vein, causing mesenteric ischemia (Figure). He underwent an urgent laparotomy and was started on intravenous unfractionated heparin.
      TableLaboratory Values
      Laboratory Upon Presentation In the ICU Normal Range
      Hemoglobin 177 89 140-175 g/L
      Hematocrit 0.515 0.293 0.420-0.500
      Red blood cells 4.71 3.24 4.50-5.90 × 1012/L
      Mean cell volume 88.9 90.4 80.0-96.0 fL
      White blood count 16.8 17.2 4.0-11.0 × 109/L
      Absolute neutrophil count 12.6 13 1.8-7.5 × 109/L
      Platelets 203 395 150-400 × 109/L
      International normalized ratio 1.2 1.5
      Partial thromboplastin time 28.5 31.5 24.6-37.6 s
      Venous pH 7.56 7.41 7.35-7.45
      Venous pCO2 18 32 37-43 mm Hg
      Venous lactate 3.9 1.3 0.5-2.5 mmol/L
      Total testosterone More than 52.0 6.7-25.7 (nmol/L)
      Testosterone bioavailable calculated 33.06 3.60-11.00 (nmol/L)
      Free calculation Testosterone 1376 160-475 (pmol/L)
      Sex hormone binding protein 32.7 20.6-76.7 (nmol/L)
      JAK 2
      Janus Kinase 2 gene.
      V617F mutations
      Negative
      JAK2 exon 12 mutations Negative
      CALR
      Calreticulin gene.
      exon 9 mutations
      Negative
      MPL
      Myeloproliferative leukemia virus oncogene.
      exon 10, 4, 5, 9 mutations
      Negative
      Factor V Leiden point mutation (G1691A transition) Negative
      Factor II point mutation (G20210A transition) Negative
      Erythropoietin 86.17 2.59-18.50 mU/ml
      Anti-Beta2 glycoprotein antibody <1.4 0.0-12.0
      Anticardiolipin antibody IgM <9 0-19
      Anticardiolipin antibody IgG <9 0-21
      Free Protein S 0.62 0.70-1.48
      Protein C (chromo) 0.66 0.70-1.30
      Protein C (clotting) 0.67 0.70-1.30
      Antithrombin 0.45 0.80-1.20
      Factor VIII level 4.53 0.50-2.00
      ICU = intensive care unit; IgG = immunoglobulin G; IgM = immunoglobulin M.
      low asterisk Janus Kinase 2 gene.
      Calreticulin gene.
      Myeloproliferative leukemia virus oncogene.
      Figure
      FigureContrast-enhanced abdominal computed tomography—coronal plane showing the absence of contrast in the portal vein thrombosis.
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