Not All Men with Thick Skulls Have High Testosterone (Slides)

A 54-year-old retired USAF fighter pilot was referred in Aug 2016 for evaluation of possible bilateral optic disc swelling noted on routine optometric examination. His past medical history included low testosterone discovered 2 years prior in the context of fatigue and exercise intolerance. MRI brain at that time as well as serologic investigations for other hormonal abnormalities were normal by report, and he was using topical testosterone gel for replacement. Initial ophthalmologic exam showed normal visual acuity, color vision, and Humphrey visual fields. On fundus exam, both optic nerves were elevated without obvious swelling, fluorescein angiography showed no leakage, and OCT of the RNFL was normal in both eyes. The patient returned for surveillance in 3 months, at which time visual function remained normal but peripapillary hemorrhage was noted in the right eye. FA now had disc leakage OD. CT orbits (Fig 1) showed an ill-defined bilateral orbital process as well as diffuse bony thickening consistent with a prior diagnosis of osteopetrosis. MRI brain and orbits (Fig 2) confirmed an infiltrative process of the sella, cavernous sinuses, and orbits. Prolactin was mildly elevated (45.3 ng/ml) CBC, C-ANCA, and P-ANCA were normal. A diagnostic procedure was performed.