Illicit Anabolic-Androgenic Steroid Induced Vascular Occlusions In Weightlifters: A Tale Of Two Cases

HISTORY: Case 1: A 46-year-old male weightlifter with a history of polysubstance use presented with 1 month of left foot pain with acute onset of left foot numbness while on anabolic steroids (first documented two years prior). Case 2: A 63-year-old male weightlifter with 40 years of testosterone injections and a history of 12 years of left shoulder and neck pain presented with a recent worsening of paresthesia, largely extending from the left shoulder to his left hand. PHYSICAL EXAMINATION: Case 1: Examination of the left leg revealed no palpable femoral artery and pedal pulses. Normal pulses on right leg. Case 2: Significant pain and stiffness were noted at the left shoulder with positive crepitus, and at the cervical spine upon flexion and extension with positive Spurling’s. DIFFERENTIAL DIAGNOSIS: Case 1: 1. Left lower extremity thrombus induced by anabolic steroids 2. Peripheral neuropathy secondary to substance use Case 2: 1. Subclavian artery occlusion (SAO) induced by anabolic steroids. 2. Glenohumeral arthritis and cervical spinal stenosis. TEST AND RESULTS: Case 1: Computed tomography angiography (CTA) confirmed occlusion of the left external iliac artery and reconstitution of the common femoral distally with notable thrombus. Case 2: CTA revealed occlusion of the entire brachial artery and confirmed left SAO. FINAL WORKING DIAGNOSIS: Anabolic-androgenic steroid (AAS) induced vascular occlusions in both cases. TREATMENTS AND OUTCOMES: Case 1: Left femoral cutdown and iliofemoral thromboembolectomy with primary arterial closure. On post-op day 1, palpable pulses of the left lower extremity returned, and patient was discharged with rivaroxaban. Case 2: Vascular surgery deemed the chronic nature of the occlusion non-operable. Patient’s symptoms were medically managed first with three months of warfarin and later direct oral anticoagulant. While AAS-induced venous thrombosis is well-documented, these occlusions in the arterial system are rare, with only 5 cases ever reported. They can prove to be more common and highly morbid in weightlifting populations, given the unique demands of the sport. Both cases emphasize the importance for clinicians to suspect AAS-induced vascular occlusions in this population presenting with peripheral artery disease symptoms, ensuring prompt workup and management.