Anabolic androgenic steroids in delayed diagnosis of tuberculosis
A 40 year old, lean man, a fitness freak, developed weakness, fatigue, and decreased appetite since three months. His bodybuilder friend, a chemist, advised him intramuscular injections of Nandrolone decanoate (deca durabolin) 100 mg once a week. After about three months he started feeling energetic with elated mood and resumed the physical exercises. One month later he stopped injections but developed recurrence of symptoms along with markedly depressed mood and weaker physical appearance. Hence he restarted with 2-3 injections per month. Gradually he became irritable and preoccupied with thoughts of AAS use and improving physical appearance. Occasionally he used even six to seven injections per month because of feeling of inadequate effect. After one year of AAS use he noticed occasional low grade fever in the evening. The routine investigations of blood counts, X-ray chest and tuberculin test were without any positive findings. He was advised antipyretics as and when required, multivitamins and temperature charting. He did not reveal his AAS dependence. Five months later he developed mild pain in right lower abdomen which gradually increased in intensity and frequency and was associated with nausea, vomiting and severe abdominal pain after meals and went to tertiary care hospital. His history was unremarkable except tobacco and cannabis abuse for 15 years and one episode of hypokalemic periodic paralysis five years back. On examination the surgeon found tenderness in right iliac region. He also had multiple large scrotal sebaceous cysts for eight years with rapid growth in last one year. Routine blood investigations were normal except increased erythrocyte sedimentation rate, increased level of alkaline phosphatase and decreased levels of FSH and LH. His tuberculin skin test was negative and ECG was normal. The abdominal USG revealed mass in ileocaecal junction, barium study showed stricture of ascending colon with dilatation of terminal ileum, and CT abdomen revealed thickening of walls of terminal ileum and caecum with enlarged mesenteric lymph nodes. Laparotomy with right hemicolectomy was done. Sebaceous cysts were operated after 15 days. On histopathological examination segment of intestine and mesenteric lymph nodes were found to be tubercular. He was kept on antituberculous treatment for six months, and referred to psychiatrist for anabolic androgenic steroid dependence. He was given fortnightly counselling sessions for two months and then monthly for six months. He disclosed that since his wife was tall and obese, he found himself more physically and sexually compatible with her while on AAS. Pharmacotherapy was not required except analgesics for occasional headaches.