1. 1 IMAGING PULMONARY MANIFESTATIONS OF HIV/AIDS Part II By Dr.Mekashu & Degene 2006

2. 2  Infectious  Bacterial:- pyogenic,mycobacterial  Protozoal:- pcp,toxoplasmosis  Fungal:- histo,crypto,aspergi-coccidio  Viral:- cmv, Human HVI,  Noninfectious  Malignancies:- k.s, NHL, bronch.ca  Interstitial Pneumonias:-LIP,NIP

3. 3 The role of thoracic imaging in AIDS Imaging alone may be unable to provide a definitive diagnosis The role of the radiologist:- Confirming the presence of pulmonary pathology in symptomatic pts. Dif. diagnosis Advising on and performing thoracic interventions (biopsy, chest drainage) Monitoring the response to therapy following diagnosis

4. 4 Imaging modalities CXR:-preliminary inspection, planning the approach to U\S guided biopsy U\S Fluoroscopy Broncoscopy(BAL) CT MRI

5. 5 Role of CT Confirming suspected chest disease Clarification of abnormalities, extent of disease & pattern of parenchimal change Evaluation of mediastinal abnormalities Staging of malignant disease or restaging post therapy Biopsy planning Imaging guidance for drainage plu.fluid, PTHX

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7. 7 INFECTIOUS DISEASES The most common complication accounting for about 75%. Occur at various stages of HIV/AIDS. The three most important are - PCP, TBc, & Comm. acquired pneumonia.

8. 8 Pyogenic pneumonia Pyogenic organisms are responsible in up to 45% of pulmonary infections in AIDS pts. 6x more common in pts with HIV than those without. It can occur as- a/ com.acq, pneumonia b/ hospital acquired pneumonia

9. 9 HIV-related strep. pneumonia & H.influ.pneumonia is indistinguishable from imuinocomtent hosts. Recurrent infection with the same species are common. Haematogenous spread of pyogenic pn. Causing septicemia & multifocal emboli

10. 10 Radiographic features Don't defer from those seen in non HIV pts. 1. Focal or multifocal areas of consolidation 2. Pleural effusion, occasionally. 3. Interstitial pattern like PCP in half of pts. ( H.influe. & pseudomonas pn ) 4. Nocardia pneumonia upper lobe consolidation, masses or nodule

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14. 14 Pneumocystis carinni pneumonia The commonest AIDS defining opportunistic ds. Occurring in 60 to 80% of cases. The onset is likely to be more insidious than in pts with other immunosuppressive ds.  PCP usually present in an individual not on prx.&CD4 count<200\mm3

15. 15 Radiographic features Typical - perihilar and/or bibasilar reticular or retculolonodular infiltrates& consolidate in 3-4 d Atypical patterns ( 5-18%)  focal air space consolidation  diffuse or focal miliary nodules  solitary or multiple nodules  moderate to thick walled cavitary nodules

16. 16  pneumatoceles in 10%  spontaneous pneumothorax in 5%.  5-10% have normal CXR Patterns of presentations of PCP has change markedly b/c of increasing prophylactic use of aerosolized pentamidine. prophylactic use of aerosolized pentamidine.  apical infiltrates  extensive visceral and nodal calcification

17. 17 Radiographic changes after treatment gets worse during the first 3 days of Rx improvements within 10 days eventually, pneumonia resolves completely and CXR becomes normal within 7 mo cysts may remain for 3 yrs in some pulm. Fibrosis may be seen Without prophylaxis up to 40% may recur

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20. 20 CT findings may reflect the stage Early - scattered air space consolidation Later - interstitial abn.predominate After therapy - some residual changes seen

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25. 25 Pcp

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27. 27 Worsening after Rx

28. 28 Cavitary nodule in PCP

29. 29 Nodule

30. 30 Mycobacterium Tuberculosis Myco. infections occur in 10% of AIDS pts. Both the clinical & radiological features of tb. are dependant on the degree of immunosuppression At higher CD4+count---reactivation tb. At lower CD4+---more typical primary infection,LNE,pleural diseases, with hematological & bro\plm dissemination Two clinical patterns-- Both reactivation and rapid progression of newly acquired infection are common A. at late stage of HIV - false -ve tuberculin skin test - >50% are extra pulmonary - CXR atypical & upper lobe cavitary ds is infrequent

31. 31 Two clinical patterns-- Both reactivation and rapid progression of newly acquired infection are common. at late stage of HIV - false -ve tuberculin skin test - >50% are extra pulmonary - CXR atypical & upper lobe cavitary ds is infrequent

32. 32. At earlier stage of HIV - indistinguishable from manifestation in non HIV pts - extra pulmonary ds in 15-20%

33. 33 Radiographic features Pts are more likely to exhibit the x-ray feature of primary TBc. In advanced HIV - diffuse bilateral coarse reticular opacities - mid or lower lobe predominance - hilar and/or mediastinal adenopathy - miliary disease more common

34. 34 Atypical x-ray features are more common as the CD4 count decreases. If the CD4 count is < 200 cells/mm3, the pt is more likely to have normal CXR. The chest-CT:-consolidation -cavitation - solitary/multiple nodule -pleural effusions -nodal enlargement with necrosis -Centro lobular branching nodules "tree in bud” -enlarged lymph nodes shows peripheral nodal enhancement and central low attenuation.

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38. 38 Mycobacterium avium complex Normally causes disease in birds and cattle. Before the AIDS epidemic - MAC is an infrequent cause of slowly progressive pulm. ds in adults - produces cervical adenitis in children. - rarely causes disseminated ds. After the AIDs epidemic - became common complication of end- stage HIV-infection.

39. 39 Radiographic features No distinctive radiog. abnormality associated opportunistic ds are common - diffuse bilateral infiltrates - lobar consolidation - pl. fluid collection - Hilar lymphadenopathy -rarely cavitation

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41. 41 Fungal infections Pulmonary ds occur in < 5% of AIDS pts. The most common identified in the AIDS population are Candida species, cryptococcuc neoformans, aspergillus sp, coccidioidomy, histoplasmosis

42. 42 Cryptococcal infection Accounting 15%,tends to occur at low CD4 count - usually found with meningitis. - CXR features are variable  reticular/reticulonodular interstitial infiltrates  alveolar consolidation, pl.effusion, lymphadenopathy, DDX:-PCP,TB,Pyogenic bac.inf.

43. 43 CRYPTO

44. 44 Histoplasmosis - disseminated at the time of diagnosis - Radiogr. feature well described. Bilateral nodular or linear opacities. Pl. effusion in 20%. Hilar\mediastinal LAP in 10%

45. 45 Coccidioidomycosis - radiog.feature 55% - diffuse nodular opacity 36% - focal abnormalities ( nodule, cavities, adenopathy)

46. 46 Aspergillus fumigatus In tissue invasive pul.asper:-thick walled cavities with or without an intracavitory mass Less common findings:-non cavitating nodules & consolidation Three other patterns 1.Necrotizing tracheobroncial asp. 2.Allergic bronco pulmonary asp. 3.Mycetoma(in pre-existing cavity due to previous PCP,TB) Radiological feature:-nodular thickening of the tracheal &bronchial wall Bronchial obs.due to plugs &endoluminal fungus Bilateral lower lobe atelectasis & consolidation

47. 47 Viruses CMV Pneumonia - extremely severe problem after bone M., kidney, lung & heart transplant. - frequently co-exists with other infections - CXR abns. Are poorly defined - the usual abnormality is bilateral fine reticular interstitial pattern.

48. 48 Imaging diagnosis of pulm. complications - considerable overlap in imaging appearance - CXR may be normal - confident dx by- clinical, CXR, lab. finding - CT can help limit the ddx and in some detect abnormality in symptomatic pts with normal CXR.

49. 49 Radiographic patterns - Bilateral ground glass opacity - Fine reticulation - Air spacing shadowing  Highly likely to be PCP - Focal consolidation  Bacterial pneumonia PCP ( in 10% ) - Acinar nodules + hilar/mediastinal L.N  Tuberculosis

50. 50 In a series of 163 pts the accuracy of CXR is 84% for TBc 75% for PCP 64% for bacterial Pneumonial 10% - mimic other infections

51. 51 Non-infectious pul. manifestation in HIV/AIDS patients.  Great majority of the pulmonary complication of HIV infection are infectious in origin than non-infectious.  Among non-infectious pulmonary complications are:  Neoplasm  Interstitial pneumonias

52. 52  NEOPLASM PULMONARY COMPLICATION  Kaposi’s sarcoma  Lymphoma  Bronchogenic carcinoma

53. 53  KAPOSI'S SARCOMA: Epidemiology   ed frequency in MSM (men who have sex with men)  Middle aged to elderly white men  Young black patients in Africa  Extremely uncommon in women and children Incidence It was more (48%)early in epidemic Now only seen 18% of cases in MSM Pathophysiology It is endothelial tumor Usually multicentriac Involves the skin &visceral organs KS associated herpes virus (KSHV type 8)

54. 54 Very rarely involves the brain Risks  More common in those with oral or anal sexual contacts Symptoms  Genera:- lesions pruritic  Initial:- painless  Later:- lesions can be large and painful Signs cutaneous lesions A) Pigmented (violent col.) 1) Red to blue or bluish brown plaques and nodules B) Can involve any area of the skin  especially on the soles of the foot  affects the palm of the hand

55. 55 C) Biopsy differentiate from 1)Cutaneous Cryptococcus Signs in pul. Involvement  Rapidly fatal if not treated (enlarged plaques occlude segmental bronchi)  Usually symptomatic:  -Non-productive cough  -Bronchospasm  -Dyspnea  ) Ple.effusion in 20-50% at D x  -Ple. Fluid is –ve for Ks  -can be transudate or excaudate

56. 56 Radiological features Radiological features:  KS are more specific and the diagnosis may sometimes be suggested in the basis of chest film and CT abnormality as:  Poorly defined peribronchiovascular nodular density  Typically measures 10-20 mm in diameter  Solitary nodular KS may occur  Bilateral multiple lesions are typically present  Coarse linear opacities are also commonly scattered throughout the lungs, particularly in the perihilar and lower portions

57. 57 Cont’d.  Kerly B lines may be present (fig.16.22,23)  The bronchovascular nodules can have a flame shaped appearance fig.16.21)  Pericardial and pleural effusion and mediastenal lymphadinopaty are present  Normal galinium scan  Bronchoscopy -characteristic endobronchial lesions -Biopsy usually avoided 2 o to bleeding

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61. 61 CT findings: ill-defined parenchymal nodules, which can be surrounded by small areas of ground-glass density Frequently bilateral perihilar pulmonary infiltrates are seen in majority of pts, which extends into the pulmonary parenchyma along the bronchovascular bundles (fig.5.68) Thickening of the interlobular septa Nodularities of the fissures pleural effusions, pericardial effusion Mediastenal lymphadinopaty Chest wall disease involving the sternum, ribs, thoracic spine and subcutanious tissues are observed

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63. 63  Lymphoma:  Is the 2 nd most frequent intrathoracic malignancy associated with HIV  Due to long term stimulation by HIV virus, & EBV virus  Lymphoma occurs  ed frequency in AIDS pts., as a consequence of B-lymphocyte proliferation  Most AIDS associated lymphomas are high grade aggressive B-cell type

64. 64 Pathophysiology of lymphoma oCell neoplasia residing in lymphoid tissue oReticuloendothelial organ infiltration Types: A)Hodgkin’s lymphoma –Localized disease with contiguous nodal spread –Mediastinal involvement –Curability >75% –Systemic symptoms (fever,night sweating, wt.loss)

65. 65 B) Non-Hodgkin’s lymphoma  Non –contiguous nodal spread  Extra nodal involvement  Abdominal and bone marrow involvement  Curability < 25% Risk factors  Inherited Immunodeficiency syndrome  Acquired Immunodeficiency oiatrogenic immunosuperation oAIDS o Acquired hypogammaglobulemia

66. 66 C)Autoimmune disease SLE Rheumatoid arthritis D) Chemical or drug exposure Phenytoin Radiation therapy Chemotherapy E) Viral association EBV Human T-cell Leukemia virus

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68. 68 CT-findings  Revels similar findings & more sensitive than CXR  Findings of auxiliary adenopathy with hilar & mediastinal Lns. the raise possibility of lymphoma  Multiple nodes with bronchovascular & sub pleural distribution (fig.5.71,72),(16.24,26)  Affecting predominantly the mid & lower lung zones.

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71. 71  Bronchogenic carcinoma:  There is 6.5 fold increase incidence of lung ca in HIV-infected and AIDS pts.  The immunodepression however, renders the ca. likely to be highly malignant and clinically aggressive  Mostly they are histologicaly Adenocarcinoma type  It occurs in pts. who are younger than those with out AIDS  Unlike KS and lymphoma, no associated mutagenic viral agent has been identified

72. 72 Cont’d  One of several neoplasms that arise within the lung  Is one of the leading cause of death in USA & most industrialized countries  Both in male & female  Has subtypes -Adenocarcenoma------------35% -Squamous cell---------------25% -Small cell----------------------25% -Large cell----------------------15%  Adenocarcenoma arises from bronchiolar or alveolar epithelium

73. 73  If there is an increase in the prevalence of lung ca it may be 2 0 to deficiencies in immunoregulation  In advanced stages (<200CD 4 cells /  l) ; bronchoscopic investigation recommended Radiographic features oNo difference to those without HIV infected pts. with ca oHas solitary pul. Nodules(size b/n 2mm& 3cm) o it includes lung masses (>3mm or larger) (fig.16.19) oIt includes hilar mass with or without bronchial obstruction oPleural effusion o Presence of air bronchogram or bubbly lucencies within a nodule or mass is highly suggestive of ca.

74. 74  INTERSTITIAL PNEUMONIAS  The common pul. disorders associated with HIV infection are:  Lymphocytic interstitial pneumonites (LIP)  Non-specific interstitial pneumonites (NIP)  Others less common pul. disorders associated with HIV infection are:  Pulmonary HPN  COPA  Bronchial hyperreactivity

75. 75 Cont ’ d.  ARDS  Alveolar proteinosis  Sarcoidosis, Asthma, emphysema (in smokers)  Cocaine users (unusual manifestation of pneumothorax or alveolar infiltrate)  Drug induced reactions (e.g.. adverse reaction to trimethoprim etc.)

76. 76  Lymphocytic interstitial pneumonites (LIP)  Characterized by histological pattern of diffuse infiltration of alveolar walls and peribronchial areas by non-neoplastic mature lymphocyts, plasma cells,lymphoid cells etc.  A variety of lympho prolypherative disorders are associated  It takes chronic or sub chronic courses  Extremely rare in adults (age difference is unknown)  Paraneoplastic in some cases  Para infective in HIV and EBV viruses

77. 77  In contrast to PCP, LIP pts. have CD 4 >200/  l  A definite D x open-lung biopsy  Sensitive to steroid  The role play by HAART is unclear Clinical feature  Presence of cough, breathlessness or clubbing of fingers  With diffuse radiographic abnormality is consistence with PCP  But the absence of fever and sever hypoxemia should suggest LIP  Marked lymphocytosis in bronchoalveolar lavage is a confirmatory evidence of D x

78. 78 Radiographic feature -Characteristic radiographic of LIP is similar to PCP (fig 5.69). Diffuse bilateral reticulonodular infiltrates Associated hilar lymphadenopaty occasionally predominantly nodular pattern is seen Radionucliode: Similar uptake to PCP CT -findings Diffuse 2-4 mm diameter nodules, generally in a peribronchovascular distribution Bronchiectasis also seen

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83. 83  Non-specific interstitial pneumonites (NIP)  Poorly defined condition that occurs in immunocompromised pts. with and without AIDS  It has been attributed to a variety of causes including: -unidentified viral infection -drug therapy - and irradiation

84. 84 Clinical features  Histological pattern of mild to chronic NIP has been found in transbronchial biopsy specimen from both symptomatic and asymptomatic :  In 50% of pts. or more are without symptoms  It may occur at the time of worsening of HIV infection  Failure to respond to R x for infective causes and relatively indolent coarse should raise the possibility of D x

85. 85 Radiography feature  Nearly half of the pts. have normal CXR  Others have diffuse or unilateral infiltrates of an interstitial &/or alveolar nature(fig.5.70) THE IMMUNE COMPROMISED CHILD  AIDS in children differs from AIDS in Adults: -Has short incubation period  -  Children are more likely to have sever bacterial infections or CMv - They develop pulmonary lymphoid hyperplasia (PLH) & LIP which are rare in adults - They are less likely to be infected with TOXO, MBT, Cryptococcus & histoplasmosis

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87. 87 -There are two patterns of presentation and progression  In the 1 st yr. of life with sever infections & encephalopaty- which has poor prognosis  Preschool and school age with bacterial and lymphoid tissue hyperplasia---: -survival is longer even to adolescence -Prognostic features are :  Sensitivity of the disease in the mother  The age of on set  and severity at on set

88. 88 Clinical features  Failure to thrive, wt.lose, generalized lymphadinopaty, hepatosplenomegaly, recurrent infections, chr. diarrhea Radiologic feature: - In CXR pcp may be localized initially but typically there is rapid progression to generalized lung shadow which is mixed alveolar & interstitial infiltrate (fig.16.28),(6.19)  50% of infections occur at age 3-6 months  2/3 of the infections are the 1 st and only infective in origin

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90. 90 -LIP/PLH- in 50% of pts.  Insidious onset of clinical symptoms  CXR is diffuse, symmetrical reticulonodular or nodular pattern (2-3mm)  Mostly easily seen at the basis & periphery of the lungs   hilar or mediastinal lymphadenopaty  The nodules consists of collections of lymphocytes and plasma cells with no organism  Children with LIP have increased generalized lymphadenopaty, increased salivary glands & finger clubbing  Mediastinal or hilar adenopaty may be 2 0 to PLH,MBT, MAI, CMV, Lymphoma or fungal infection (than other opportunistic infec.)

91. 91 Generally investigating & imaging modalities  Beside routine investigations:  CXR is a preliminary inspection & is essential in planning the approach to u/s –guided biopsy and for others imaging modalities.  U/S (best in viewing masses,nodules,for guidance of biopsy…etc)  Fluoroscopy  Bronchoscopes (br.alveolar lavage….etc)  CT  MRI

92. 92 THANK YOU!

93. 93 References 1. R.G.Grainger & D.J.Allison; Diagnostic Radiology ; 4th ed,2004 2. Nester L.Muller. Radio.Clin.of North Ame. Vol.29, number 5, 1995 3. Peter Armstrong & et al. Imaging of diseases of the chest. 3rd ed,2000 4. David Sutton. A textbook of Radiology & imaging. 5.Chest radiology,The Essentials.