CASE
A 56 year old man presented at the routine HIV outpatient clinic with complaints of left and right breast discomfort for about six months followed by gradual swelling of the left breast. He did not report any change in body hair, libido or erectile dysfunction. Discomfort was described as pins and needles, no itchiness, no discharge from the nipples or skin changes were reported. He had no previous breast problems, but his mother had a history of breast cancer.
He was known to the HIV service and had been living with HIV since 2001. Previous antiretroviral treatment combinations include: stavudine + lamivudine + efavirenz and zidovudine + lamivudine + efavirenz. Due to progressive multifocal leukoencephalopathy, he was kept on zidovudine + lamivudine + nevirapine + abacavir. In 2010, he transferred to our care and was prescribed tenofovir + emtricitabine + nevirapine until 2017 when his treatment was changed to include an integrase inhibitor, raltegravir (RAL) alongside tenofovir + emtricitabine. However, due to intolerance to RAL, he was switched back to tenofovir + emtricitabine + nevirapine in 2018. In June 2022, he opted for the injectable combination of cabotegravir/rilpivirine to allieviate the anxiety around daily HIV medication intake. He showed adherence to injection appointments and remained virologically suppressed.
His current co-morbidities included well controlled hypertension, hyperlipidaemia, non-obstructing calculi of the right kidney, benign prostate hyperplasia and a recurring reducible left inguinal hernia. His previous co-morbidities were left hernia repair, progressive multifocal leukoencephalopathy with peripheral neuropathy, hypogonadism and hypothyroidism. His current co-medications were atorvastatin, solifenacin, ramipril, tadafil, multivitamins and probiotics. He is a non-smoker and drinks alcohol occasionally. He works as a personal trainer and is usually very active with no history of anabolic steroid use.
On physical examination, he appeared well. His body mass index was 27.35 kg/m2, blood pressure 144/91mmHg and other vital signs were in normal range. He had bilateral, sub-areolar, concentric breast masses, with palpable nodules that were soft and mobile. There was tenderness on palpation with no nipple discharge or axilla lymphadenopathy. His hormonal blood workup was within normal range, . We suspected him to have idiopathic gynecomastia and we referred him to the breast clinic for further evaluations as well as to rule out pseudo-gynecomastia and breast cancer.