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.
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.