Rare case of HAART Induced Gynaecomastia

Dr Mahesh Dave Professor Medicine, at RNT Medical College, Udaipur, Rajasthan, India and colleagues have reported a rare case of HAART Induced Gynaecomastia. The case has appeared in the journal of Association of Physicians of India.

Benign glandular enlargement of male breast is called gynaecomastia.Various drugs have been implicated as the cause. Most widely used HAART regimen TLE is enlisted in least common cause of gynaecomastia.

42 yr old male was admitted in our ward with complaints of bilateral breast enlargement for the last 11 months, which was progressive and painless (Figure 1). He was diagnosed with HIV seropositive 10 yrs back and was put on Tenofovir, Lamivudine, Effavirenz (TLE) regimen. There was no significant h/o intake of drugs causing gynecomastia. There was no significant h/o blurring of vision, diplopia, decreased sensation of smell, distention of the abdomen, increased sweating, palpitation, weight loss and loss of appetite. On further inquiry of the patient, there was no history suggestive of hypogonadism, chronic liver disease, thyroid dysfunctioning, etc. The patient was a non-alcoholic and occasional smoker with no other illicit drug habits. He is a farmer by occupation with no family h/o gynaecomastia.

On physical examination, patient was conscious and oriented to time, place and person. He was well built with weight being 65 kgs, height being 170 cm and BMI 22.5 kg/m2. Vital parameters were found to be normal.

On local examination, there was bilateral enlargement of the breast which was soft to firm in consistency, nontender, without any nipple-areolar complex changes and discharge. The overlying skin was normal without any engorged veins, thus it was graded as Stage 3 gynecomastia (Simon et al study 1973). There was no significant lymphadenopathy. His abdominal examination including testicles were within normal limits. His secondary sexual characters such as pubic hair, axillary hair were found to be normal. Other systemic examination revealed no abnormality.

This patient was extensively investigated to establish the primary cause and to rule out all other secondary causes of gynecomastia. His routine blood investigation like CBC, RFT, LFT were within normal limits. Chest X-ray and ECG revealed no abnormality. CD4 count were 104/ microlitre. A specific investigation like serum Prolactin was 10.53 ng/ml, serum FSH 7.2 mIU/ml, serum LH 17.77 mIU/ml, serum testosterone, estrogen, progesterone were within normal limit, thyroid function were within normal limit. USG of both breasts was showed mixed intensity which simulates mammary tissue, suggestive of bilateral gynecomastia. FNAC of both breasts was done and was showing benign ductal cells round oval in shape and arranged in clusters with background proliferation of fibrolipomatous tissues (gynecomastia) (Figure 2). Mammography of both breasts done and was suggestive of the benign lesion ( gynecomastia ) ( Figure3). MRI Brain for pituitary and hypothalamus revealed no abnormality.