Working Diagnosis:
Anabolic Steroid-Induced Pulmonary Pseudotumor

Treatment:
The patient was transiently on BiPAP and had chest tubes placed for pleural effusion drainage, which were later successfully removed. He was treated with the following while hospitalized:
Vancomycin 1.75g-2.5g for 3 days (after pleural fluid and blood cultures collected)
Cefepime 2g IV for 7 days (after pleural fluid and blood cultures collected)
Magnesium Sulfate IV 2g three times
Furosemide 20mg IV once
Ethacrynic acid 50mg PO 4 times (switched from furosemide due to sulfa allergy)

Outcome:
The patient was admitted for a total length of stay of 11 days. He achieved resolution of his shortness of breath and reduction of the bronchogenic mass. He remained on 50mg ethacrynic acid for diuresis secondary to pleural effusion (chosen over furosemide due to the patient's sulfa allergy). He was given educational material regarding anabolic steroid and stimulant use after declining psychiatry's offer for a drug rehabilitation program. The patient stated that he would continue recreational bodybuilding and coaching but would no longer compete in competitions. He was discharged home with a follow-up pulmonology appointment for monitoring, however, he was lost to follow-up.

Author's Comments:
Androgen use has become a major public health concern due to the transition of the use of androgens from strictly sports to a much wider spectrum of the population. Approximately 3 to 4 million Americans used anabolic-androgenic steroids to increase muscle mass, whether for sports to increase their performance or for cosmetic purposes, such as enhancing their appearance (1). The potential side effects of anabolic steroid abuse are significant. It is known to cause liver damage, cardiovascular issues, and certain cancers like liver and prostate cancer (2). Androgen receptors (ARs) are present in a range of tissues, such as adipose tissue, where they interact with exogenous steroids. Their presence in respiratory epithelial cells has also been linked to abnormal cell growth, highlighting a potential role in pathologic changes in the patient (3). It is well known that inflammatory tumors of the lung may occur due to a non-neoplastic process leading to inflammation and growth of inflammatory cells (5), and known that androgen receptors are present on immune cells throughout the lung. We propose that it is likely that this patient's extremely elevated levels of androgens, evidenced by a testosterone level greater than 5,000, may have led to activation of these inflammatory cells of the lung, leading to an anabolic steroid-induced pulmonary pseudotumor. We propose that the pathophysiology surrounding this diagnosis includes androgen-induced activation of inflammatory cells leading to vascular endothelial changes, hyperplasia of epithelial cells, pulmonary remodeling, and pleural effusion. The proposed diagnostic criteria for an anabolic steroid-induced pulmonary pseudotumor would be criteria highlighting a diagnosis of exclusion. These proposed criteria include a history of anabolic steroid use, imaging with evidence of a mass-like lesion, negative cytology for malignancy, absence of systemic malignancy markers, absence of infectious etiology, and spontaneous or treatment-associated regression without cancer treatment. It is important for clinicians to assess for the use of exogenous androgens or anabolic supplement use, test androgen levels, and perform a workup for infectious or malignant etiology. Follow-up imaging should be obtained to monitor for regression, and corticosteroid therapy may be considered to aid in regression. More research is needed regarding this topic, specifically research of the pathophysiology of activation of pulmonary inflammatory cells by androgens, early identification and screening tools, as well as treatment options.

Editor's Comments:
This case highlights the importance of assessing patients' use of supplements during an in office or sideline visit. In the competitive and noncompetitive population, it is common to find misuse of various substances. Often these substances are not taken as directed by a medical professional or are taken in different formulations or doses. As clinicians it is important to assess anything that a patient takes. Generally asking about pills, patches, creams or powders can help expand the information you receive. Anabolic steroids are a great example of a type of medication that can be abused and can have very serious consequences. Cases such as these also highlight the importance of understanding how these medications are being taken. The problematic downstream effects can also be related to the formulation or the medium used to transport the medication into the body. While this case is related to the growth of a mass due to anabolic steroid use other cases can lead to embolism or pulmonary hemorrhage or various other presentations can be related to the substance the steroid is in such as oil (6). This case while rare reminds us as clinicians that we should always be diligent to help guide and protect our patients. While it is not always possible to persuade them away from dangerous supplements it is important to provide them with evidence-based knowledge to aid in their decision.

References:
1. Graham MR, Davies B, Grace FM, Kicman A, Baker JS. Anabolic steroid use: patterns of use and detection of doping. Sports Med. 2008;38(6):505-25.

2. Anabolic steroids causing growth of benign tumors: Androgen receptor in angiolipomas Syed, Sajjad P. et al. Journal of the American Academy of Dermatology, Volume 57, Issue 5, 899 - 900

3. Durovski D, Jankovic M, Prekovic S. Insights into Androgen Receptor Action in Lung Cancer. Endocrines. 2023; 4(2):269-280. https://doi.org/10.3390/endocrines4020022

4. Becerra-Diaz M, Song M, Heller N. Androgen and Androgen Receptors as Regulators of Monocyte and Macrophage Biology in the Healthy and Diseased Lung. Front Immunol. 2020 Aug 7;11:1698. doi: 10.3389/fimmu.2020.01698. PMID: 32849595; PMCID: PMC7426504.

5. Marwah N, Bhutani N, Dahiya S, Sen R. Inflammatory pseudotumour: A rare tumor of lung. Ann Med Surg (Lond). 2018 Nov 3;36:106-109. doi: 10.1016/j.amsu.2018.10.033. PMID: 30455873; PMCID: PMC6230967.


6. Hvid-Jensen, H. S., Rasmussen, F., Bendstrup, E. (2016). Pulmonary hemorrhage following anabolic agent abuse: Two cases. Respiratory medicine case reports, 18, 45 - 47. https://doi.org/10.1016/j.rmcr.2016.04.001

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