A 54-year-old male, diagnosed with HIV-1 infection 8 years earlier, was well controlled on Atripla (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil 245 mg) with CD4 count 370 cells/mm3 and viral load <40 copies/ml presented with fever, weight loss and shortness of breath. Chest imaging found a large left pleural effusion with left lower lobe consolidation. Fully sensitive M. tuberculosis was isolated from pleural specimens. He responded to standard anti-tuberculosis treatment (rifampicin, isoniazid, pyrazinamide and ethambutol). Atripla was continued with additional efavirenz 200 mg o.d. to overcome predicted rifampicin-efavirenz drug interaction. After 2 months, he developed marked reduction in libido with erectile dysfunction. Investigations found serum total testosterone 11 nmol/l, SHBG 170 nmol/l, calculated free testosterone 60 pmol/l, LH 14 IU/ml and FSH 15 IU/ml. Efavirenz has a direct oestrogenic effect by modulating oestrogen receptors [], and this effect may have been exacerbated by SHBG elevation (HIV infection, anti-tuberculosis treatment and ART) reducing free testosterone concentrations, despite normal total levels. After additional efavirenz was discontinued, SHBG returned to normal and his clinical symptoms fully resolved.
Our patient was a 63-year-old retired gentleman, weighing 64 kilograms and 1.8 meters tall. He had no significant family history and drank only occasionally. At presentation he was trying to give up a 40 pack-year smoking habit. His medications were predominately analgesics but also a bisphosphonate and prednisolone 20 mg.\nHe had a history of SLE, haemolytic anaemia, recurrent idiopathic thrombocytopenia purpura and recent chemotherapy (6 months previously) for diffuse large B-cell lymphoma.\nHe presented to clinic with a tender, diffusely enlarged right testicle, and was also noted to be suffering from night sweats, a 7 kg weight loss, and splenomegaly (previously noted prior to treatment for lymphoma).\nTumour markers were normal, but an ultrasound scan of his right testicle showed a non-homogenous abnormality inferiorly (), in keeping with a recurrence of lymphoma or a primary malignancy [].\nGiven his history and symptoms, he was urgently referred to the urologists who decided to proceed with a right orchidectomy.\nHistology of the right testis showed a granulomatous orchiditis. A Ziehl-Neelson (ZN) stain showed a large number of acid fast bacilli (AFB) which, given the morphology and absence of caseation, was most consistent with a NTM infection. Unfortunately, no sample had been sent for culture, but given the histological findings and clinical presentation, this was considered most likely to be Mycobacterium avium-intracellulare (MAI) infection.\nHe recovered well post operatively, and, as a CT scan showed a right apical lung lesion, he was referred to the local respiratory physician for further investigation and management.\nBronchial washings of the right upper zone and left lingula were positive for AFB. He was commenced on conventional quadruple anti-tuberculous therapy pending formal identification of the AFB. The organism was subsequently confirmed as MAI, and therapy was switched according to the British Thoracic Society guidelines [].