1. APPROACH TO RADIOLOGICAL DIAGNOSISOF
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 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.

3. 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.

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

6. Cavitary postprimary tuberculosis
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. Clinical features: 40 yr old HIV positive man with cough and dyspnea
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. 57-year-old man HIV positive man presented with fever and sputum.
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. 48 yr old man with advanced aids.H/o severe cough and purulent sputum
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 opacities with associated cavitations,
often located within the apical, posterior, and superior segments of the lungs.
In patients with decreased 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 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).

11. Adult male HIV patient presenting with cough.
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. Clinical features:48-year-old HIV-positive man presenting with
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. Classical chest radiographic presentation of PCP is:
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.

15. Clinical features: HIV Positive 24-year-old man
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. Clinical features:43-year-old HIV positive woman with cough
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. Pleuropulmonary actinomycosis.
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 .
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.

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. Consolidation predominantly Right lung
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. Adult male HIV-positive patient with cough and profuse sputum
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 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.

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

23. HIV Postive male with severe respiratory symptoms on ventilator
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 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.

25. Clinical features: 25-year-old female HIV patient
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 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.

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 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.

28. THANK YOU

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