Case 4: Gynecomastia in a 15-year-old Boy

1. Claci A. Walls* 2. W. Jackson Smith, MD† 3. John M. Draus, MD‡ 4. Lars M. Wagner, MD§ 1. *University of Kentucky College of Medicine, Lexington, KY 2. †Division of Pediatric Endocrinology, 3. ‡Division of Pediatric Surgery, and 4. §Division of Pediatric Hematology/Oncology, University of Kentucky College of Medicine, Lexington, KY A 15-year-old boy is evaluated for gynecomastia that has continued to increase in size and discomfort during the past year. In addition, he also has moderate to severe acne that has not improved with topical therapies and systemic antibiotic drugs. He reports having some general fatigue as well as increased appetite, and he has gained 13 lb (5.9 kg) in the previous 7 months. There has been no fever, and apart from occasional headaches, he has no other complaints of pain. His personal and family medical history is otherwise normal. His only medications are minocycline and topical isotretinoin and clindamycin to treat his acne. On physical examination the blood pressure is 156/98 mm Hg. He has extensive acne on his face, upper chest, and back. Examination of the breasts shows bilateral and mildly tender gynecomastia, with fibroglandular tissue measuring 10 cm in the right breast and 9 cm in the left, and both having secondary mounds (Fig 1). No galactorrhea is present. His abdominal examination findings are normal, and he has Tanner V genitalia with normal testes. Based on the history and physical examination findings, blood testing and subsequent imaging are performed and lead to the correct diagnosis. Figure 1. Demonstration of acne and gynecomastia in the 15-year-old boy described in the case. ### Diagnosis The combination of progressive gynecomastia coupled with extensive acne and hypertension in an adolescent male suggested excessive hormone production. This suspicion was confirmed by the finding of elevated serum estradiol, estrone, and dehydroepiandosterone sulfate (DHEA-S) levels ranging from 4 to 30 times the upper limit of normal. In addition, the patient had an elevated 24-hour …