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 49-year-old heterosexual man who was diagnosed with HIV infection 3 years earlier following screening when hospitalised for pneumococcal pneumonia was managed with once daily darunavir 800 mg, ritonavir 100 mg and emtricitabine 200 mg/tenofovir disoproxil 245 mg. His current CD4 level was 370 cells/mm3 and viral load was <40 copies/ml. He trained regularly at the gym and was a keen amateur boxer. He wished to conceive with his wife but complained of lack of energy and reduced libido. Serum total testosterone levels were 5.5 pmol/l, calculated free testosterone 150 pmol/l, SHBG 14 nmol/l, FSH 4 IU/ml, LH 5 IU/ml and prolactin 89 mIU/ml. He admitted to regular use of oxandrolone and stanozolol over several years.