Gynecomastia caused by efavirenz: Two cases with different severity
Abstract
Gynecomastia is the proliferation of mammary glands in men due to physiological changes, systemic diseases, tumours, and certain medications. Drug-induced gynecomastia is rare. Efavirenz is the most frequently reported ARV in several studies and case reports as a cause of gynecomastia. Case: Two HIV-infected men complained of enlarged breasts with pain without nipple discharge. Complaints arose after the initiation of efavirenz-based ARVs. Breast examination revealed bilateral swelling in the form of a mass of soft consistency, supple, concentric on the nipple-areola, well-defined, movable, and painful to palpation. Ultrasound examination supports the appearance of gynecomastia. Examination of liver function, kidney, thyroid hormone, testosterone, β-hCG, and estradiol was within normal limits. Discussion: HIV-associated gynecomastia involves pathophysiological changes such as hypogonadism, increased prolactin production, and the presence of HIV-associated cirrhosis, as well as the effects of antiretroviral drugs. Gynecomastia diagnosis is based on clinical, hormonal, and ultrasound examinations. Assessment of causal drug causes using the Naranjo algorithm. Regression of drug-associated gynecomastia occurs 1-5 months after the drug is discontinued. Conclusion: Two cases of EFV-associated gynecomastia have been reported. Efavirenz substitution should be investigated to avoid a drop in medication adherence due to gynecomastia-related distress.References
Thiruchelvam P, Churchill W, Walker J, Rose K, Lewis J, et al. Gynaecomastia. Br Med J. 2016;354.
Sansone A, Romanelli F, Sansone M, Lenzi A, Di Luigi L. Gynecomastia and hormones. Endocrine. 2017;55(1):37-44.
Singano V, Amberbir A, Garone D, Kandionamaso C, Msonko J, et al. The burden of gynecomastia among men on antiretroviral therapy in Zomba, Malawi. PloS One. 2017;12(11):1-13.
Shawarira-Bote S, Shamu T, Chimbetete C. Gynecomastia in HIV-positive adult men receiving efavirenz-based antiretroviral therapy at Newlands clinic, Harare, Zimbabwe. BMC Infect Dis. 2019;19(1):715.
Rohrich RJ, Ha RY, Kenkel JM, Adams WP. Classification and Management of Gynecomastia: Defining the Role of Ultrasound-Assisted Liposuction. Plast Reconstr Surg. 2003;111(2):909-23.
Barros A, Sampaio MC. Gynecomastia: physiopathology, evaluation and treatment. Sao Paulo Med J. 2012;130(3):187-97.
Cordova A, Moschella F. Algorithm for clinical evaluation and surgical treatment of gynaecomastia. J Plast Reconstr Aesthet Surg. 2008;61(1):41-9.
Johnson R, Murad M. Gynecomastia: Pathophysiology, Evaluation, and Management. Mayo Clin Proc. 2009;84(11):1010-5.
Draghi F, Tarantino C, Madonia L, Ferrozzi G. Ultrasonography of the male breast. J Ultrasound. 2011;14:122-9.
Kwekwesa A, Kandionamaso C, Winata N, Mwinjiwa E, Joshua M, et al. Breast enlargement in Malawian males on the standard first line antiretroviral therapy regimen: Case reports and review of the literature. Malawi Med J. 2015;27(3):115-7.
Sahoo H, Kar P, Rath B. Gynecomastia in AIDS patient: An association with zidovudine treatment. Apollo Med. 2017;14(3):182-4.
Braunstein G. Gynecomastia. N Engl J Med. 1993;328:490-5.
Köklü E, Arslan S, Yüksel IO, Bayar N, Demirci D. Nebivolol-induced gynecomastia. J Pharmacol Pharmacother. 2015;6:166-8.
Catherine O. Antiretroviral adverse drug reactions and their management CME. 2011;29:234-7.
Deepinder F BG. Drug-induced gynecomastia : an evidence-based review. Expert Opin Druf Saf. 2012;12:779-95.
Naranjo C, Busto U, Abel J, Sellers E, Sandor P, et al. Empiric delineation of the probability spectrum of adverse drug reactions. Clin Pharmacol Ther. 1981;29:267–8.
Doherty MJ. Algorithms for assessing the probability of an Adverse Drug Reaction. Respiratory Medicine CME. 2009;2(2):63-7.
Rama S, Chakraborty D, Nizami A. Efavirenz induced gynaecomastia in a HIV male presenting with immunological and clinical failure on HAART: A case report. Southeast Asian J Case Report Rev. 2016;4(4):1901–9.
Piroth L, Grappin M, Petit J, Buisson M, Duong M, et al. Incidence of gynecomastia in men infected with HIV and treated with highly active antiretroviral therapy. Scand J Infect Dis. 2001;3:559-60.
Rukmangathen R, Brahmanapalli V, Devulapalli M, Thammisetty D, Bondalapati A, et al. A Case Report on Efavirenz Induced Gynaecomastia. Indian J Pharm Pract. 2017;10(3):223-6.
Jover F, Cuadrado J, Roig P, RodrÃguez M, Andreu L, et al. Efavirenz-associated gynecomastia: report of five cases and review of the literature. Breast J. 2004;10(3):244-6.
Qazi N, Morlese J, King D, Ahmad R, Gazzard B, et al. Gynecomastia without lipodystrophy in HIV-1 seropositive patients on efavirenz: an alternative hypothesis. AIDS. 2002;16:506–7.
Kenji U, Mitsuru K, Eilchiro Y, Kei K, Kei M, et al. A case of gynaecomastia associated with efavirenz. J Nara Med Assoc. 2007:141-5.
Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, et al. EAA clinical practice guidelines-gynecomastia evaluation and management. Andrology.2019:1-16.
