Health and Medicine
PUBLISHED
Testosterone supplements are having something of a moment right now, much to the chagrin of the doctors and scientists who actually have knowledge and experience prescribing the hormone. For one man in India, however, the decision to start taking testosterone seems to have triggered quite a strange reaction: full-blown psychosis.
“A 45-year-old married man […] presented to the emergency department with a 9-day history of overreligiosity, suspiciousness toward neighbors, odd and disorganized behavior, second-person auditory hallucinations (voices of God and somatic voices from body parts), persistently elevated mood, irritability, and reduced need for sleep,” notes a recent case report detailing the patient’s descent into illness.
“Mental status examination revealed […] irritability with verbal aggression toward staff, labile affect, grandiose religious delusions (believing divine blessing with special powers), and paranoid ideas.”
A concerning collection of symptoms indeed, and one which only made it to the doctors thanks to the man’s neighbors who “alerted the family after noticing marked behavioral changes while the patient lived alone managing a farmhouse,” the report notes.
A puzzling case
At first, the medical team figured the obvious: the man was suffering from some kind of sudden-onset psychosis, and needed some kind of pharmacological intervention, stat.
They started him on haloperidol, promethazine, and lorazepam, a powerful combination that curbed the psychosis and acted as a sedative. After a couple of days the acute symptoms lessened, and the doctors then switched him off the first two meds and onto an antipsychotic, normally used for schizophrenia, and a mood stabilizer primarily used in the treatment of bipolar disorder.
Eventually, everything seemed taken care of. The patient was discharged, and regular follow-up appointments seemed to confirm that his symptoms were under control. But what caused it in the first place?
To answer that question, the doctors took a more holistic view. What else could they glean about the man’s condition, if they looked at more than just his acute symptoms?
First, a physical: this guy was tall, narrow-framed, with smooth skin and sparse body hair. He had a normal penis length, but quite small testes. And, as it turned out, he also had a history: he had first come to his doctor about 15 years prior, complaining of infertility.
Tests had revealed his testosterone levels to be low – less than 53 ng/dL, which is nine or 10 times lower than the normal reference range for healthy adult men – but no treatment was given.
But one year before the psychosis was treated, something changed.
“[S]evere generalized body aches led to osteoporosis diagnosis, prompting monthly intramuscular testosterone 250 mg (last dose 1 month before presentation) plus vitamin D supplementation,” the report notes.
An underlying cause
That’s not an unusual treatment as testosterone supplements can help bone density in men whose natural levels are low, but as a symptom it’s pretty conclusive. Combined with everything else in the patient’s history, the doctors had their diagnosis: Klinefelter syndrome.
Also known as 47,XXY, Klinefelter syndrome is one of the most common chromosomal disorders out there – although that’s not saying much, as it only affects about one or two in every 1,000 people. It occurs randomly, and many people who have it won’t even realize since it often doesn’t produce any noticeable symptoms.
It’s caused, as its alternative name suggests, by a single extra X chromosome – so, rather than having XY chromosomes, which would typically result in someone being genetically male, they instead have X, X, and Y.
Because it’s the Y chromosome that’s important for sexual development, people with Klinefelter syndrome develop as male – they might just have a few extra features, like infertility, small testes, and erection problems, as well as higher-than-expected height and lower muscle tone.
In other words: this patient was basically a textbook example of the condition.
Managing his condition
Now, while Klinefelter syndrome wasn’t the cause per se of the bad reaction to the testosterone, neither was it totally unrelated.
“Klinefelter syndrome confers inherent psychiatric risk, including psychosis,” the case report points out. And with the addition of exogenous testosterone, a powerful androgen and anabolic steroid, it may have simply been amplified from “underlying” to “problematic”.
For this patient, stopping testosterone lessened his symptoms – though the doctors stop short of recommending a blanket ban on the hormone for those with Klinefelter. Rather, they advise keeping such patients under close monitoring, as was done for the patient when he eventually restarted the testosterone regimen.
“This case highlights that even therapeutic parenteral testosterone can precipitate severe psychosis in susceptible patients, particularly those with Klinefelter syndrome,” the doctors caution.
“Clinicians must perform baseline psychiatric screening, monitor mental status vigilantly, and consider prompt discontinuation if symptoms emerge.”
The case report is published in the Primary Care Companion for CNS Disorders.
