APPROACH TO RADIOLOGICAL DIAGNOSIS

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APPROACH TO RADIOLOGICAL DIAGNOSIS
OF PULMONARY INFECTIONS IN AIDS
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INTRODUCTION
Pulmonary manifestations - commonest initial
manifestation of HIV infection - the primary
cause of death in 50 patients with AIDS. Most
common pulmonary disorders encountered are
Mycobacterium tuberculosis (MTB), PCP and
Fungal infections (Cryptococcus, Aspergillus.
etc). Other infections include Bacterial
pneumonias, Cytomegalovirus (CMV), Other Viral
infections. Lymphocytic interstitial
penumonitis (LIP) is another complication of HIV
infection particularly in children.
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Chest radiography is usually the first imaging
test obtained for the assessment of an
HIV-infected individual with respiratory
symptoms. Despite atypical manifestations
overlapping features, the chest radiograph is
fairly accurate. Even in asymptomatic HIV
patients, an abnormal CXR usually signifies an
active process.
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CASE NO 1
Cinical features 18-month-old HIV-positive
child. Anteroposterior chest radiograph
Right upper lobe consolidation
primary tuberculosis
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CASE 2
Clinical features 32 yr old HIV Positive male
with cough and hemoptysis.
thick-walled cavity with smooth inner margins in
the left upper lobe (arrow).
Cavitary postprimary tuberculosis
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CASE 3
Clinical features 40 yr old HIV positive man
with cough and dyspnea
cavity in the left upper lobe (black arrow) with
a dependent area of soft-tissue opacity (solid
white arrow).
Cavitary tuberculosis associated with
aspergilloma.
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CASE 4
57-year-old man HIV positive man presented with
fever and sputum.
marked volume loss in the left lung with several
large cavities and multiple air-fluid levels
(arrowheads). A small cavity is noted in the
right upper lobe (arrow).
Tuberculosis.
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CASE 5
48 yr old man with advanced aids.H/o severe
cough and purulent sputum
Bilateral lower zone Patchy consolidation
Tuberculosis in advanced AIDS
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I.TUBERCULOSIS
Tuberculosis (TB) contagious , curable prompt
diagnosis and treatment essential. Tuberculosis
can occur at any stage of HIV infection. Reactiva
tion (postprimary) TB is often one of the initial
manifestations of HIV infection. Typical
imaging features Parenchymal opacities with
associated cavitations, often located within the
apical, posterior, and superior segments of the
lungs. In patients with decreased CD4 counts
(lt200 cells/mm3)typical findings of primary TB
like consolidation , lymph-node enlargement and
basal location may be noted. At advanced levels
of immune suppression, a minority of patients may
have normal chest Xrays, though CT will often
show abnormalities such as small nodules and
lymph node enlargement. Immune restoration ?
exhibit paradoxical new or worsening lymph node
enlargement, lung parenchymal disease, and/or
pleural effusions, accompanied by onset of fever
. (also known as reversal syndrome).
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CASE 6.
Adult male HIV patient presenting with cough.
Pneumocystis carinii pneumonia.
Typical bilateral ground-glass shadowing, cystic
change in the right upper lobe and a left
pneumothorax.
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CASE 7
Clinical features6-month-old child following an
acute presentation with respiratory distress.
demonstrating diffuse bilateral consolidation
Pneumocystis carinii pneumonia
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CASE 8
Clinical features48-year-old HIV-positive man
presenting with shortness of breath and cough.
numerous cysts of varying sizes with a diffuse
distribution, but relative sparing of lung bases.
Cystic pneumocystis carinii pneumonia
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II.PNEUMOCYSTIS CARINII PNEUMONIA
Another common AIDS-related opportunistic
infection. Patients generally present with a
history of approximately 1 month of fever, dry
cough, and dyspnea. Classical chest
radiographic presentation of PCP is a
bilateral perihilar or diffuse symmetric
interstitial pattern, which may be finely
granular, reticular, or ground-glass in
appearance. Air space consolidation may be
seen. Cystic lung disease is observed in up to
1/3rd of cases may be complicated by
pneumothorax.. Chest radiograph normal in
approximately 1/3rd of cases at presentation.
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CASE 9.
Clinical features HIV Positive 24-year-old man
Ill-defined focal opacity (arrows) in the upper
lobe of the right lung.
Aspergillus infection
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CASE 10
Clinical features43-year-old HIV positive woman
with cough
Multiple, bilateral nodules (arrowheads) are
present and are associated with a peripheral
wedge-shaped region of consolidation (arrow).
Invasive aspergillosis
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CASE 11
Clinical featuresA 37-year-old HIV positive man
c/o chest pain for 3 months before
presentation,progressive nonproductive severe
cough during 2 months weight loss of 5.5 kg
during 3 months .
shows large, rounded, dense mass-like
infiltrates,one in each upper lobe, with a small
left pleural effusion.
Pleuropulmonary actinomycosis.
Anaerobic microbiologic tissue cultures showed
Actinomyces Histopathology of the lesions showed
typical sulfur granules.
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III.FUNGAL INFECTIONS
Fungal infections are a relatively common cause
of pulmonary infection in AIDS patients. Common
fungal infections include aspergillosis,
histoplasmosis, blastomycosis, Cryptococcus
neoformans actinomycosis and coccidiomycosis.
Fungal pulmonary infection usually occurs in
the setting of advanced immunosuppression (CD4
lt100/mm3). Imaging findings include nodules,
reticular or reticulonodular opacities, and foci
of consolidation. Parenchymal abnormalities may
be accompanied by lymph node enlargement
pleural effusion.
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CASE 12
8 years old HIV positive child with severe cough
respiratory distress.
Consolidation predominantly Right lung
Community acquired pneumonia. Streptococcus was
isolated from blood cultures.
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CASE 13
Adult male HIV-positive patient with cough and
profuse sputum
chest radiograph shows a right mid zone pulmonary
consolidation with central cavitation.
Staphylococcal Pneumonia with lung abscess.
sputum cultures were positive
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IV.BACTERIAL INFECTIONS
B-cell dysfunction is associated with high risk
for frequent infections with encapsulated
bacteria, such as Streptococcus pneumoniae. Most
episodes of pneumonia occur due to S pneumoniae
and Haemophilus influenzae, the same organisms
that cause most community-acquired pneumonia in
the general population. Pseudomonas aeruginosa
has also been recognized as a cause of pulmonary
infection in AIDS, especially among patients with
recent antibiotic use, or steroid
therapy. Patients with bacterial pneumonia
present with an acute onset of fever productive
cough. In most cases, bacterial pneumonia
presents radiographically as single or multiple
sites of focal consolidation, in either a
segmental or lobar distribution. Atypical
patterns, including bilateral diffuse opacities,
are not uncommon.
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CASE 14
4 year HIV Positive child with cough
multiple, ill-defined Occasionally confluent
nodules throughout the lungs.
Varicella-Zoster virus pneumonia.
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CASE 15
HIV Postive male with severe respiratory symptoms
on ventilator
hilar and mediastinal lymphadenopathy, with
bilateral widespread air space consolidation.
Cytomegalovirus(CMV) pneumonitis complicated by
Adult Respiratory Distress Syndrome.
CMV was isolated from nasopharyngeal aspirate.
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V.VIRAL INFECTIONS
The clinical manifestations of viral
superinfection in HIV infected patients are
dependent upon the degree of immunodeficiency at
the time of infection. Infection may occur as
a result of a primary infection or reactivation
of latent virus. Viruses commonly implicated
include influenza and para influenza virus, CMV,
measles and, less frequently, Varicella-Zoster
virus (VZV). Radiographic features are usually
non-specific and include diffuse interstitial
infiltrates, nodules and consolidation.
Bacterial superinfection is common, and
isolation of the virus in secretions or washings
is required.
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CASE 16
Clinical features 25-year-old female HIV patient
bilateral nodular infiltrate predominantly
distributed in the mid and lower zones.
Typical changes of Lymphocytic Interstitial
Pneumonitis
Surgical biopsy of the right lower lobe showed a
bronchiolocentric lymphoid infiltrate accompanied
by lymphocytic infiltrates in the interstitium
representing a mixture of B and T cells.
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VI.LIP (LYMPHOCYTIC INTERSTITIAL PNEUMONIA)
LIP, also described as pulmonary lymphoid
hyperplasia (PLH), is a lymphoroliferative
disorder characterized by a diffuse interstitial
infiltrate of polyclonal lymphocytes and plasma
cells in addition to pulmonary lymphoid
hyperplasia. It is thought to represent a
direct "hyperimmune" lung response to the
presence of either HIV or Epstein-Barr virus
(EBV) and appears to be associated with a slower
rate of disease progression. LIP is rare in
adults with HIV it occurs in approximately
1/3rd of infected children.
Typical radiographic features are of an
interstitial predominantly lower zone
reticulonodular infiltrate, which may progress to
patchy air space consolidation. Lymphadenopathy
is common and often becomes more prominent
during episodes of superimposed infection.
Chronic LIP often results in patchy fibrosis
with secondary traction bronchiectasis.
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CONCLUSION
Even in the current era of potent antiretroviral
therapy, pulmonary complications of AIDS remain
an important cause of morbidity and
mortality among HIV-infected individuals. Interp
retation of imaging studies should
integrate clinical, and laboratory information
with radiographic pattern recognition. Although
chest radiography remains the mainstay of
thoracic imaging in HIV-infected patients, CT
also plays an important complementary role in
establishing an accurate diagnosis when chest
radiographic findings are equivocal or
nonspecific.
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THANK YOU
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HIV ENCEPHALOPATHY
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B
CT SCAN
a)Coronal T1 weighted and (b) axial T2 weighted
images. The images demonstrate diffuse cerebral
atrophy. In addition,confluent high T2 signal
change is seen in the periventricular white
matter of the frontal and parieto-occipital
regions.
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PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY
multiple white matter hypodensites
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PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA
Before therapy
After therapy
brightly enhancing, multifocal, periventricular
lesions
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PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA
diffuse contrast enhancement and extension
adjacent to the lateral ventricles, including
into anterior corpus callosum.
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CNS TUBERCULOMAS
Multiple ring enhancing lesions
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TUBERCULOUS MENINGITIS.
Contrast-enhanced cranial CT
Thick basilar exudate and an infarct in right
thalamic region
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TOXOPLASMOSIS
shows multiple enhancing lesions
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TOXOPLASMOSIS
contrast-enhanced scan the three lesions seen
show typical ring-like enhancement of deep
lesions with surrounding edema