Secondary hypothalamic amenorrhea as the initial manifestation of HIV infection
Garyfallia Tzifa, George Kalikakis, Ioannis Zaganas, Martha Spiliotis, Diamantis Kofteridis, Vasiliki Daraki, Valentina Petkova, Paraskevi Tzoutzouraki & Stathis Papavasileiou
Hypothalamic hormonal deficiency and anterior pituitary hormonal deficiency is a rare occurrence in patients presenting with HIV infection. We describe a patient with HIV infection who presented with secondary amenorrhea as the initial manifestation.
Case report: A 34-year-old woman with previously regular menses presented with secondary amenorrhea by 9 months. The patient had mild gait instability for 7 months; anorexia and weight loss (10 kg) for the last 4 months was also reported. Pregnancy test was negative. Gonadotropins were at the lower normal limits (FSH: 2.69 m U/ml. LH: 2.18. m U/ml) with low oestrogen values (E2: 37. 4 pg/ml). Pelvic ultrasound confirmed the lack of oestrogen activity (endometrium 4 mm thick). A GnRH stimulation test showed an adequate response, pointing to the hypothalamic cause for the amenorrhea. The patient underwent a brain MRI that revealed an empty sella turcica, with accompanying multifocal leukoencephalopathy of unknown aetiology.
Due to the MRI findings and development of chorea serological and immunological tests were performed. Serological tests were positive for HIV1, HIV2 and CMV virus. The absolute number of CD4 was 39. The patient was diagnosed with CMV encephalopathy due to HIV infection (Stage C3) and was managed with combined antiviral therapy. The patient showed dramatic improvement in her symptoms. The CD4 number increased (225) and the viral load became undetectable. The hypothalamus pituitary gonad axis as well as the menstrual cycle was fully restored.
Conclusion: CMV encephalopathy, secondary to HIV infection may present with hypothalamic amenorrhea as the initial manifestation. Systemic and neurological symptoms and signs follow this setting. Combined antiretroviral and anti-CMV therapy can result in dramatic improvement and restoration of menses.