: We report a case of a 56-year-old gentleman who presented to the endocrine clinic with erectile dysfunction. He had elevated SHBG levels, MCV, gamma GT, ferritin, iron and markedly elevated testosterone and transferrin saturation (GGT 167 IU/l, ferritin 1128 ug/l, testosterone 62.5 nmol/l). He had a marginally low platelet count (123X109/l). He denied ever taking testosterone supplements. His calculated free testosterone was normal. His full blood count was otherwise unremarkable. He had negative myeloma, viral and autoimmune screens. He had no history of diabetes with a normal OGTT. He drank 25 units of alcohol a week. His BMI was 30 kg/m2. His US liver showed a fatty liver with splenomegaly. His pituitary MRI scan was normal. He was investigated by haematologists for hereditary haemochromatosis. HFE genetic screen was negative. JAK 2 mutation awaited. He has had one unit of venesection.
Discussion: This represents a rather unique presentation of a case with unexpectedly high total testosterone levels secondary to elevated SHBG levels, considering patients high BMI with features of metabolic syndrome. The presentation is further complicated by hyperferritenemia which is thought to be secondary to nonalcoholic fatty liver disease (NASH). NASH and dysmetabolic iron overload syndrome have been shown to be associated with raised SHBG levels. Emerging evidence suggests that liver fat content rather than BMI is a strong determinant of circulating SHBG. Both metabolic syndrome and liver iron overload have been implicated in moderate hypogonadotrophic hypogonadism. However the high total and normal free testosterone levels with normal gonadotrophins in our patient precludes it as the cause of his erectile dysfunction. There are no similar clinical cases found in literature.
|Total Testosterone||62.5 nmol/l|
|Short Synacthen test (nmol/l)|