An Interesting Presentation of Testosterone-Induced Arterial Thrombosis

Testosterone replacement therapy (TRT) is an industry on the rise in large part due to an increase in direct-to-customer advertising targeting middle-aged men with non-specific symptoms. The biggest problem with unnecessary prescribing is that testosterone therapy is not without side effects. One of the more common adverse effects is erythrocytosis with subsequent thrombosis. It was originally postulated that thrombosis seen in patients on TRT was solely related to increasing in hemoglobin however, new studies demonstrate increasing episodes of thrombosis unrelated to hemoglobin or hematocrit. We report the case of a 38-year-old white male presenting to the clinic with infarction of bilateral feet and digits due to testosterone-induced thrombosis of dermal and epidermal arteries. Laboratory workup including vasculitis panel was negative and complete blood count (CBC) was within appropriate parameters. He was treated with anticoagulation, pain control, and vasodilatory therapy with subsequent improvement of symptoms. There have been many reported cases of testosterone-induced thrombosis of the venous system with occasional involvement of the renal arteries. However, cases involving thrombosis of dermal or epidermal arteries due to testosterone supplementation have never been reported. It could be beneficial to screen potential patients requiring TRT for hypercoagulable states such as Factor V Leiden and lupus anticoagulant.