Breast enlargement in Malawian males on the standard first line antiretroviral therapy regimen: Case reports and review of the literature

Case presentations 1. A 35-year-old man was referred to Zomba Central Hospital in June 2014 from a health center with a presenting complaint of enlarged breasts. This had started gradually, approximately six months prior. He did not experience any pain or discharge from his nipples. He had no other complaints and felt generally healthy. In early 2013 he had been concomitantly diagnosed with pulmonary tuberculosis and HIV infection and was started on cotrimoxazole prophylaxis and antiretroviral therapy (ART) with tenofovir, lamivudine, and efavirenz, which is the standard first-line adult ART regimen, known in Malawi as regimen 5A. At that point, he had WHO clinical stage III HIV disease; a CD4 count was not done. There was no further relevant past medical history. He looked healthy and had normal vital signs. The rest of the physical examination was normal except for bilateral, symmetrical, elastic, and concentric swelling of the breasts, without discrete nodules, skin changes, or lymphadenopathy in the axillae and neck. There were no features of lipodystrophy and no stigmata of chronic liver disease. The genital examination was normal, without palpable abnormalities of the normal-sized testes. Upon laboratory investigation, his CD4 count was 130 cells/μL and a full blood count was normal apart from the presence of macrocytosis. Liver enzymes were unremarkable.