1. Approach to Pulmonary Manifestations of HIV/AIDS
Dr. Flip Otto
Dept. of Radiology
Universitas Academic Hospital

2. Pulmonary Manifestations of HIV/AIDS
Opportunistic infection
Drug reactions
Immune restoration syndrome
Lymphoproliferative disorders
AIDS related malignancy
Non-specific interstitial pneumonitis
HIV related pulmonary hypertension
Bronchiolitis obliterans
Emphysema and bronchiectasis

3. Infective pulmonary conditions in HIV/AIDS
Bacterial
PJP TB
MAI
Fungal: Cryptococcus; Aspergillosis etc.
Viral: CMV

4. Non-infective pulmonary conditions in HIV/AIDS
Kaposi’s sarcoma
Lymphoma
Lung carcinoma
Lymphocytic interstitial pneumonitis
Emphysema
Cardiovascular complications

5. Prevalence of HIV/AIDS associated pulmonary conditions in relation to CD4 count
CD4>400: Increased risk for
- Bacterial infection
- Mycobacterium tuberculosis
CD : Increased risk for
- Recurrent bacterial infections
- Lymphoma and lymphoproliferative disorders
CD4<200: Increased risk for
- PJP
- Disseminated Mycobacterium tuberculosis
CD4<100: Increased risk for
- Atypical Mycobacterium tuberculosis
- CMV
- Kaposi’s sarcoma
- Lymphoma

6. Radiographic patterns
Nodules
Cavities
Adenopathy
Focal consolidation
Pleural effusion

7. Nodules
Common
Size:
- <1cm (random or centrilobular) more likely due to infection
- >1cm more likely neoplastic
Miliary nodularity typically fungal or TB, rarely seen in PJP
KS peribronchovascular vs lymphoma and lung cancer peripheral

8. Miliary TB

9. CMV pneumonia

10. Cavities Mostly infective
85% polymicrobial, majority bacterial: mixed infections often involving Staph and Pseudomonas
Remainder include: TB, PJP, fungi, CMV

11. Necrotizing cavitating pneumonia

12. Pneumocystis pneumonia

13. Adenopathy Mostly due to infection
TB most common cause of isolated adenopathy, can be seen with Cryptococcus. Associated with low attenuation with ring enhancement.
Lung cancer included in differential diagnosis
Calcified adenopathy: TB, fungus, described in PJP
Hyperattenuating adenopathy in KS due to vascular enhancement

14. TB lymphadenopathy

15. Focal consolidation Mostly due to infection
Bacterial pneumonia most common cause in AIDS, but Pneumocystis most common individual pathogen (rarely segmental pattern)
TB, MAI, fungi (Cryptococcus), mixed infections and occsionally neoplasms (lymphoma and KS)

16. Primary TB

17. Pleural effusion
Majority small, equal incidence in infection and malignancy
Infective causes (bacterial and TB) tend to be unilateral
KS associated tend to be bilateral
Non-AIDS causes eg PE and organ failure should also be considered

18. Kaposi sarcoma

19. Approach Combine: - Risk factors - Level of immunocompromise
- prophylactic Rx
- clinical presentation
- radiographic pattern
CD4 count most important determinant for assessing relative likelyhood
Chest radiography 1st line imaging
CT and HRCT 2nd line when CXR findings equivocal or non-specific

20. References
Aviram G, Fishman JE, Boiselle PM. Thoracic manifestations of AIDS. Applied Radiology 2003;Vol 32:8
Allen CM, Al-Jahdali HH, Irion KL, Ghamen SA, Gouda A, Khan AN. Imaging lung manifestations of HIV/AIDS. Ann Thorac Med 2010;5:201-16