Anorexia Nervosa and Persistent Pituitary Dysfunction in a Young Man

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: MON 142-166-Hypothalamus-Pituitary Development & Biology
Monday, June 17, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board MON-161
Luz C Tello*1, Eric S Nylen2 and Shikha G Khosla2
1George Washington University Hospital, Washington, DC, 2Veterans Affairs Medical Center, Washington, DC
Background: Anorexia Nervosa (AN) is an eating disorder characterized by intentional starvation, body weight below 85% normal for age, distorted body image, and, in females, amenorrhea.  Males account for 5-10% of AN patients and their hormonal imbalance is not well understood. 

Clinical Case: A 24 year old male was diagnosed with AN by an outside provider in 2007.  His BMI was 16.62 kg/m2 and he was running up to 20 miles plus lifting weights for 2 hours every day.  Initial hormonal workup included: total testosterone (TST) 64 (260-1000 ng/dL), free TST 4.4 (50-210 pg/mL), LH 1 (1.5-9.3 mIU/mL), prolactin 3.3 (2-18 ng/mL), TSH 2.44 (0.4-5.5 mIU/mL), FT4 1 (0.8-1.8 ng/dL), and cortisol 15.2 (2-17 ug/dL).  TST therapy was then initiated to preserve bone mass and continued for 27 months until 2009.  At re-evaluation in 2010 off TST therapy for 7 months, BMI was stable at 19.9 kg/m2 and repeat laboratory evaluation was consistent with persistent pituitary dysfunction: TST 47 (241-827 ng/dl), free TST 0.2 (6.6-18.1 pg/mL), LH 0.3 (2-12 mIU/mL), prolactin 2.6 (3-19 ug/L), IGF-1 88 (117-329 ng/mL), TSH 1.983 (0.35-5.5 uIU/mL), FT4 0.72 (0.8-2.7 ng/dL), and cortisol 14.1 (2-17 ug/dL).  There was an appropriate response to an ACTH stimulation test, a normal 46 XY karyotype, and normal pituitary imaging.  DEXA scan showed osteopenia.  Subsequently, TST therapy was restarted in 2010 with significant improvement in energy, libido, and erectile function.  At our initial evaluation in 2012 he remained on TST therapy.  BMI had been ~17 kg/m2.  He was thin with temporal wasting, had 10ml testes, and Tanner 4 hair distribution.  He continues to require TST replacement.  He gets routine psychiatric therapy for AN and exercises about 2 hours a day. 

Conclusion: Our patient had low prolactin, low IGF-1, and sick euthyroid syndrome-like profile that has also been described in AN females.  His LH has remained persistently low.  Research on AN has primarily focused on females.  It is unclear if pituitary dysfunction differs in males versus females with AN.  Some studies indicate that response to GnRH stimulation is less robust in AN males as compared to AN females.  It is unknown how long the pituitary axes remain suppressed after remission of AN in males and how low TST and TST therapy impacts future fertility.  The long-term sequelae in AN males with persistent pituitary dysfunction requires further study.

Nothing to Disclose: LCT, ESN, SGK

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