SYNOPSIS: Male hypogonadi sm i s an impor tant and treatable cause of osteoporosis. Severe osteoporosis leading to multiple osteoporotic fractures from idiopathic hypogonadotrophic hypogonadism (IHH) is rare. The present case illustrates the significance of timely and thorough evaluation of young adult males presenting with a seemingly ordinary complaint of "bone pains."
THE CASE: I report a case of a 45 year-old male presenting with a 6-year history of progressive bone pains. Most prominent laboratory findings include low total serum tes tos terone (4.6 nmol/L) in the background of an inappropriately normal serum FSH, LH and sex hormonebinding globulin (SHBG). There is associated elevated urinary N- telopeptide (4x). Sperm analysis showed oligospermia. Scrotal ultrasound revealed normal-sized descended testis with no solid masses. Skeletal survey showed generalized decrease in bone density. Dual energy x-ray absortiometry (DXA) showed severe osteoporosis. Cranial CT scan with contrast did not show a sellar-suprasellar mass.
TREATMENT AND OUTCOME: The patient was diagnosed with severe osteoporosis secondary to IHH. The patient received zoledronic acid (Aclasta) 5mg IV infusion. Two months after discharge, the patient reports a significant decrease in bone pains leading to more mobility. He is scheduled for his first dose of a GnRH agonist (Leuprodin acetate 3.75mg IM) to induce testosterone production.
DISCUSSIONS: The incidence of osteoporosis among males is indirectly correlated to the reduction in circulating testosterone. First - line t reatment of os teoporosis in hypogonadal men is with bisphosphonates. Bisphosphanate therapy increase BMD, reduces vertebral fracture risk and is currently considered the standard of care for osteoporotic care for men.
CONCLUSION: Osteoporosis is fast becoming a common condition among males. Osteoporotic fractures are associated with substantial morbidity and mortality. The present case emphasizes the importance of thorough and timely evaluation among men with low BMD or low-trauma fractures, which should include laboratory assessment to exclude secondary causes such as hypogonadism.

Human ; Male ; Middle Aged ; Osteoporosis ; Hypogonadism ; Hypoparathyroidism ; Acetates ; Bone Density ; Diphosphonates ; Globulins ; Gonadotropin-releasing Hormone ; Hypogonadism ; Imidazoles ; Oligospermia ; Osteoporosis ; Osteoporotic Fractures ; Spermatozoa ; Testosterone

OBJECTIVE: Cardiac complications are the most important source of morbidity and mortality during and after non-cardiac procedures, especially among diabetic patients. At present, the Philippine General Hospital (PGH) uses the 1977 Goldman Cardiac Risk Index, which includes nine independent variables. In 1999, the Lee Revised Cardiac Index was developed, which incorporated only six clinical variables, including diabetes mellitus. This study compared the accuracy of the two indices in predicting major cardiac complications among patients with diabetes mellitus undergoing major elective non-cardiac surgery.

METHODOLOGY: Non-probability convenience sampling was used. All subjects were interviewed, examined, and risk-stratified using the Goldman and Lee indices. Pre-operative and post-operative 12-lead electrocardiography (ECG) was done. All patients ^ere followed up until the day of discharge and the incidence of major cardiac complications was defined in a checklist.

RESULTS: Major cardiac complications occurred in 13 (14 percent) of the 90 subjects included in the study. Lee Class III was shown to be the best cut-off point for the clinical prediction of major cardiac complications in major non-cardiac surgery, having a positive LR of 2.54. The area under the receiver operating characteristics (ROC) curve for the Lee index was 0.76 (95 percent CI 0.66-0.85, p=0.001), while that for the Goldman index was 0.56 (95 percent CI 0.45-0.66, p=0.53). The difference of 0.21 between the areas under the ROC curve of the two indices was significant (95 percent CI 0.027-0.39, p= 0.025).

CONCLUSION: The Lee index is superior to the Goldman index in predicting major cardiac complications among diabetic patients undergoing major elective non-cardiac surgery who do not have major clinical predictors of increased perioperative cardiovascular risk.

Human ; Aged 80 And Over ; Aged ; Middle Aged ; Adult ; Diabetes