A 51-year-old male with stable HIV infection (current CD4 350 cells/mm3, viral load <40 copies/ml) managed on Triumeq (dolutegravir 50 mg/abacavir 600 mg/lamivudine 300 mg) had been diagnosed 9 years earlier when presenting with disseminated tuberculosis (sites of involvement: pulmonary, renal, meningeal). He also had sero-positive rheumatoid arthritis. He described ongoing lethargy, fatigue and loss of muscle strength. Serum total testosterone was 2.1 nmol/l, calculated free testosterone 46.1 pmol/l, LH 5 IU/l, FSH 10 IU/l, SHBG 21 nmol/l, thyroxine 13 pmol/l (normal range 9–25 pmol/l), cortisol 394 nmol/l (normal range 138–620 nmol/l) and prolactin 74 mIU/l (normal range 50–400 mIU/l). Magnetic resonance imaging (MRI) of the pituitary found a low volume pituitary gland with hypointense parenchyma consistent with healed granulomatous lesion (Fig. ). Symptoms resolved following intramuscular testosterone replacement.
A 57-year-old HIV-infected man who attended for routine HIV clinical review described increased fatigue, reduced libido and erectile dysfunction unresponsive to phosphodiesterase-5 inhibitor use. He had stable type 2 diabetes mellitus (controlled by metformin 1 g b.d). He presented 2 years earlier with pulmonary tuberculosis and HIV-1 infection with nadir CD4 count 50 cells/mm3 and viral load >100,000 copies/ml. His HIV infection was well controlled (CD4 540 cells/mm3, viral load <40 copies/ml) by Maraviroc 300 mg b.d. and Kivexa (abacavir 600mg/lamivudine 300 mg o.d.). Physical and genital examination was normal. Investigations included early morning total testosterone 6.2 nmol/l (normal range 9.4–37 nmol/l), calculated free testosterone 142 pmol/l (normal range 174–729 pmol/l), LH 16 IU/ml (normal range 1–9 IU/ml), FSH 24 IU/ml (normal range 1–10 IU/ml) and SHBG 22 nmol/l (normal range 15–40 nmol/l). A diagnosis of primary hypogonadism was made. Topical testosterone treatment (Testogel, one sachet per day) was initiated with resolution of symptoms.