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How a person with low Testosterone levels ended up getting Pulmonary Artery Hypertension?

Case: A 30-Year-old male patient with palpitations, bilateral pedal edema, dyspnea on exertion, decreased urine output

Written by Shravani Reddy, Roll no.15, 8th semester

I have been given this case...

https://saikiranpatnam.blogspot.com/2020/05/medicine-case.html?m=1

http://vidya8829.blogspot.com

to solve in an attempt to understand the topics of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is my analysis of this patient's problem:

Occupation: Shepherd

Age: 30

Sex: Male

The problems in the order of priority according to my perspective are:

Palpitations from one year (Date of admission: May 18th, 2020)
Bilateral pedal edema from 15 days
Dyspnea on exertion from 15 days
Dry cough in last 15 days
Decreased urine output from 2 days

Palpitations:

History of palpitations from 1 year
Persistent type
Pounding type of palpitations
Precipitated on Exertion
Relieved by taking rest

Bilateral pedal edema:

Bilateral pedal edema extending up to knee from 15 days
Pitting type of edema

Dyspnea:

Dyspnea is on exertion from 15 days
The patient became breathless for walking for a short distance and also in getting upstairs (According to modified medical research and council, Grade -1 dyspnea)

The patient has a dry cough without expectoration from 15 days and decreased urine output from 2 days.

From personal history :

Appetite decreased
Sleep inadequate

The patient has a two undescended testis ( CRYPTOTORCHIDISM), very less facial hair, no axillary hair, less pubic hair belonging to Tanner stage -4

Positive findings in this patient:

Right ventricular heave present
Increased JVP with prominent ' a ' wave
S1 and S2 were heard with prominent p2
Holosystolic murmur of grade-3 intensity heard in pulmonary and tricuspid area
Two-point discrimination impaired on lower limbs
Power: slightly low in lower limbs
On LFT: Alkaline phosphate increased
Waddling gate
In color doppler 2d echo:

The right atrium and right ventricle are dilated, IVC size - mild dilated
Moderate TR, mild AR, trivial MR

USG of the abdomen: Bilateral scrotal sacs are empty, Both testes not found in the bilateral inguinal region, Urinary bladder partially distended.

From the above problems i.e., palpitations, pedal edema, dyspnoea exertion suggest that problem is in HEART.

And from the above clinical findings i.e.,

Thus from the above 2D echo findings, it can be concluded as a right ventricular failure.

Right ventricular failure primarily due to idiopathic pulmonary artery hypertension.

Pathophysiology for this patient: (According to my perspective)

(Courtesy: ATRIUM Collaborative (https://www.youtube.com/watch?v=SFbCh2wYSxQ))

How pulmonary artery hypertension leads to right ventricular failure?

Oral findings:

Poor periodontal status with severe calculus
Premature exfoliation of teeth
Carious teeth
Thick and pasty saliva
White lesion on the right side of the tongue likely candidiasis

(The findings are mostly due to poor maintenance of oral hygiene owing to his mental retardation)

Provisional diagnosis:

Right ventricular failure with primary pulmonary artery hypertension
Hypogonadism with Tanner Stage 4
Oral candidiasis with poor oral hygiene
Lower limb proximal myopathy

Treatment by the hospital:

Tab. Pantop 40 mg OD
Inj. Lasix 20 mg iv/BD
Inj. Thiamine 1 amp in 100 ml NS
Inj. Optineurin 1 amp in 100 ml NS
Tab. Sildenafil 10 mg OD
Tab. Benformet plus OD

On diuretic therapy and vasodilator therapy, the patient got better and discharged in stable condition.

Advice at discharge:

Fluid and salt restriction
Chlorhexidine oral gargles for a fortnight
Oral candid mouth 1% paint
Diet according to Harvard plate
Review after two weeks

References:

Active Conversational Learning:

[29/05, 8:54 PM] Shravani Reddy: Sir, in USG report...

Scrotal sacs are empty.

Both testes not found in the bilateral inguinal region.

So , we can consider testes absent or atrophied??

[29/05, 9:29 PM] MBBS Intern 2015 -2: Likely absent due to Undescended testes

[29/05, 9:41 PM] MBBS Intern 2015 -2: Because their attendees gave a history of empty scrotum since birth

[29/05, 10:01 PM] Shravani Reddy: Sir,

Etiology of this patient??

What causes this pt to get pulmonary artery hypertension?

[30/05, 9:01 AM] Shravani Reddy: Thank you, sir

[30/05, 10:14 AM] Shravani Reddy: Sir, in this patient...

Is Testosterone levels are low ??

[30/05, 11:05 AM] MBBS Intern 2015 -2: Testosterone majorly produced from male gonads kada

[30/05, 11:08 AM] Shravani Reddy: Yes sir

[30/05, 11:09 AM] Shravani Reddy: By lab investigation, Testosterone level ??

[30/05, 11:10 AM] MBBS Intern 2015 -2: No we didn't check it

[30/05, 11:10 AM] Shravani Reddy: Sir, Is the Primary cause of PAH in this patient is low testosterone?

[30/05, 11:10 AM] MBBS Intern 2015 -2: We asked the patient to review after 2 weeks

[30/05, 11:11 AM] MBBS Intern 2015 -2: No

[30/05, 11:13 AM] MBBS Intern 2015 -2:.patients with PAH and had lower testosterone and progesterone levels were associated with a higher risk for PAH

[30/05, 11:13 AM] Shravani Reddy: Idiopathic

[30/05, 11:14 AM] MBBS Intern 2015 -2: Yes

[30/05, 11:15 AM] MBBS Intern 2015 -2: We have to check his testosterone level

[30/05, 11:15 AM] MBBS Intern 2015 -2: If it is low

[30/05, 11:15 AM] Shravani Reddy: Yes sir

[30/05, 11:16 AM] MBBS Intern 2015 -2: Then his PAH is secondary to his Hypogonadism

[30/05, 11:16 AM] Shravani Reddy: Sir, what about oral candidiasis?

[30/05, 11:18 AM] MBBS Intern 2015 -2: Sir told it is due to his poor oral hygiene

[30/05, 11:18 AM] Shravani Reddy: Onset?

[30/05, 11:19 AM] MBBS Intern 2015 -2: They don't know

[30/05, 11:19 AM] MBBS Intern 2015 -2: About that

[30/05, 11:20 AM] MBBS Intern 2015 -2: Are u looking for any immunocompromised state

[30/05, 11:20 AM] Shravani Reddy: Sir, Do you asked him about his birth history??

Whether premature birth?

Low birth weight??

[30/05, 11:21 AM] Shravani Reddy: Yes sir

[30/05, 11:21 AM] MBBS Intern 2015 -2: We asked but their mother is not there

[30/05, 11:22 AM] MBBS Intern 2015 -2: He came along with his sister

[30/05, 11:22 AM] MBBS Intern 2015 -2: She didn't remember

[30/05, 11:23 AM] MBBS Intern 2015 -2: All his history

[30/05, 11:23 AM] MBBS Intern 2015 -2: We try to ask if patient again come for review

[30/05, 11:25 AM] Shravani Reddy: Sir, what about lower limb proximal myopathy ??

Because of his occupation....he would have a weakness?

[30/05, 11:28 AM] MBBS Intern 2015 -2: We thought it was due to his edema

[30/05, 4:30 PM] Shravani Reddy: Sir, Is dyspnea grade -2 according to NYHA classification?

[30/05, 5:58 PM] MBBS Intern 2015 -2: Yes

A question to the reader:

How does the right ventricle fail in pulmonary artery hypertension?

Thanks and regards,

Shravani Reddy.

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