A 49-year-old man presented with sudden confusion and headache. He was diagnosed HIV-positive (CD4 220 cells/mm3, viral load 3898 copies/ml) with acute kidney injury and CMV viraemia. Computerised tomography (CT) brain imaging was normal. He received once daily lamivudine 300 mg, darunavir 800 mg and ritonavir 100 mg with raltegravir 400 mg b.d. He developed symptomatic hypotension. Testosterone was <0.3 pmol/l with biochemical features of panhypopituitarism with cortisol <25 nmol/l, free thyroxine 4.6 pmol/l, TSH <0.05 IU/l, prolactin <10 mIU/l, LH 1.2 IU/l and FSH <0.5 IU/l. Cerebrospinal fluid (CSF) analysis revealed a raised protein (0.66 g/l) and negative microscopy. MR imaging found evidence of subacute haemorrhage in the pituitary gland, with no evidence of pituitary tumour, suggesting direct haemorrhage into the gland, which is unusual (Fig. ). The working diagnosis was CMV infection of the pituitary gland causing haemorrhage []. His hypopituitarism was treated by appropriate endocrine replacement with hydrocortisone, levothyroxine and testosterone.
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.