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 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.