Gynecomastia التثدي ( نمو الأثداء عند الذكور )
INSTRUCTION Look at this patient's chest. SALIENT FEATURES History · Take a drug history - oestrogens, digoxin, spironolactone, cimetidine, diazepam, alkylating agents, methyldopa, clomifene. · Ask the patient if it is painful. Examination Unilateral or bilateral enlargement of the breasts in a male patient. Proceed as follows: · Palpate to confirm the presence of glandular tissue. · Tell the examiner that you would like to look for stigmata of cirrhosis of the liven DIAGNOSIS This patient has gynaecomastia (lesion) due to spironolactone therapy (aetiology), which is cosmetically distressing to the patient (functional status). Read: N Engl J Med 1993; 328: 490. QUESTIONS Mention the physiological causes of gynaecomastia. · Newborn. · Adolescence. · Ageing. Mention a few pathological causes . · Chronic liver disease. · Thyrotoxicosis. · Klinefelter's syndrome. · Viral orchitis. · Renal failure. · Neoplasms (bronchogenic carcinoma, testicular carcinoma, hepatoma). · Bulbospinal muscular atrophy or Kennedy's syndrome (a defect in the androgen receptor gene alters function of motor neurons; 50% of patients have gynaecomastia). · Drugs associated with gynaecomastia include: -Antibiotics: isoniazid, ketoconazole, metronidazole, miconazole. -Cardiovascular drugs: atenolol, captopril, digoxin, enalapril, methyldopa, nifedipine, spironolactone, verapamil. -Antiulcer drugs: cimetidine, ranitidine, omeprazole. -Psychoactive drugs: diazepam, tricyclic antidepressants. ADVANCED-LEVEL QUESTIONS How would you investigate such a patient? · CXR for metastatic or bronchogenic carcinoma. · Plasma human chorionic gonadotrophin (13-hCG) - detectable levels implicate a testicular tumour or lung or liver neoplasm. · Plasma testosterone and luteinizing hormone in the diagnosis of hypogonadism. · Serum oestradiol (usually normal). · Other: serum prolactin, serum thyroxine and TSH, and chromosomal analysis for Klinefelter's syndrome. What are the causes of a feminizing state? · Absolute increase in oestrogen formation by tumours. · Increased availability of oestrogen precursors, e.g. as a result of cirrhosis. · Increased extraglandular oestrogen synthesis. · Relative increase in ratio of oestrogen to androgen, e.g. as a result of testicular failure. · Drugs. Ancient Egyptian sculptures and paintings suggest that the pharaoh Tutankhamen (1357-1339 BC) had gynaecomastia.Gynecomastia