APPROACH TO RADIOLOGICAL DIAGNOSIS OF PULMONARY INFECTIONS IN AIDS

1. APPROACH TO RADIOLOGICAL DIAGNOSIS OF PULMONARY INFECTIONS IN AIDS

2. 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 andFungal 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.

3. Chest radiographyis usually thefirst imaging testobtained 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.

5. CASE NO: 1 Cinical features: 18-month-old HIV-positive child. Anteroposterior chest radiograph Right upper lobe consolidation primary tuberculosis

6. 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

7. 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.

8. 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.

9. 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

10. I.TUBERCULOSIS Tuberculosis (TB) : contagious&,curable:prompt diagnosis and treatment: essential. Tuberculosis can occur at any stage of HIV infection. Reactivation (postprimary) TB is often one of the initial manifestations of HIV infection. Typical imaging features: Parenchymal opacitieswith associatedcavitations, often located within the apical, posterior, and superior segmentsof the lungs. In patients withdecreased CD4 counts (<200 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 patientsmay 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 asreversal syndrome).

11. 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.

12. CASE 7: Clinical features:6-month-old child following an acute presentation with respiratory distress. demonstrating diffuse bilateral consolidation Pneumocystis carinii pneumonia

13. CASE 8 Clinical features:48-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

14. 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. Classicalchest radiographic presentation of PCP is: abilateral perihilarordiffuse symmetric interstitial pattern, which may befinely granular, reticular, or ground-glass in appearance. Air space consolidation may be seen. Cystic lung disease is observed in up to 1/3rdof cases & may be complicated by pneumothorax.. Chest radiograph : normal in approximately 1/3rdof cases at presentation.

15. 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

16. CASE 10: Clinical features:43-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

17. CASE 11: Clinical features:A 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 . showslarge, rounded, dense mass-like infiltrates,one in each upperlobe, with a small left pleural effusion. Pleuropulmonary actinomycosis. Anaerobicmicrobiologic tissue cultures showed Actinomyces: Histopathologyof the lesions showed typical sulfur granules.

18. 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 <100/mm3). Imaging findings include nodules, reticular or reticulonodular opacities, and foci of consolidation. Parenchymal abnormalities may be accompanied by lymph node enlargement & pleural effusion.

19. 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.

20. 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

21. IV.BACTERIAL INFECTIONS B-cell dysfunction isassociated with high risk for frequent infections withencapsulated 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 assingle or multiple sites of focal consolidation,in either asegmental or lobar distribution. Atypical patterns, including bilateral diffuse opacities, are not uncommon.

22. CASE 14: 4 year HIV Positive child with cough multiple, ill-defined & Occasionally confluent nodules throughout the lungs. Varicella-Zoster virus pneumonia.

23. 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.

24. V.VIRAL INFECTIONS The clinical manifestations of viral superinfection in HIV infected patients are dependent upon the degree of immunodeficiency atthe time of infection. Infection may occur as a result of aprimary infection or reactivation of latent virus. Viruses commonlyimplicated include influenza and para influenza virus,CMV, measles and, less frequently, Varicella-Zoster virus (VZV). Radiographic features are usually non-specific and include diffuseinterstitial infiltrates, nodules and consolidation. Bacterial superinfection is common, and isolation of the virusin secretions or washings is required.

25. 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.

26. 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 torepresent a direct "hyperimmune" lung responseto 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, whichmay progress to patchy air space consolidation. Lymphadenopathyis common and often becomes more prominent during episodes of superimposed infection. Chronic LIP often results in patchy fibrosis with secondary traction bronchiectasis.

27. 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. Interpretation of imaging studies should integrate: clinical, and laboratory informationwith 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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29. HIV ENCEPHALOPATHY A 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.

30. PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY multiple white matter hypodensites

31. PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA Before therapy After therapy brightly enhancing, multifocal, periventricular lesions

32. PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA diffuse contrast enhancement and extension adjacent to the lateral ventricles, including into anterior corpus callosum.

33. CNS TUBERCULOMAS Multiple ring enhancing lesions

34. TUBERCULOUS MENINGITIS. Contrast-enhanced cranial CT Thick basilar exudate and an infarct in right thalamic region

35. TOXOPLASMOSIS shows multiple enhancing lesions

36. TOXOPLASMOSIS contrast-enhanced scan: the three lesions seen show typical ring-like enhancement of deep lesions with surrounding edema