Pulmonary manifestations in Immuno compromised Host

Dr.Mitusha VermaDept. Of Radiodiagnosis.Dr.B.Nanavati Hospital.

• ICH – special group as predisposed to both opportunistic and non – opportunistic organisms.

• ICH patients rising with – - rise in incidence of HIV/AIDS. - solid organ or bone marrow transplant.

SYSTEMATIC APPROACH

• History –IVDAs , CMV , Kaposi’s sarcoma. • Examination• Investigations – Sputum CD4 Counts• Chest X ray• HRCT• Fiberoptic bronchoscopy with BAL

CD4 Counts

IMAGING

• CHEST RADIOGRAPH

• HRCT

A normal CT chest virtually rules out an active pneumonia as the site of infection.

Radiologic Patterns

Ground Glass OpacitiesVirtually diagnostic of PJP

May be seen with

CMVHerpesLymphocytic interstitial pneumonia

Consolidation

Focal segmental or Lobar Air space consolidations

Characterstic Of Community acquired Pneumonias

May be seen with TB ; Rhodococcus ; Nocardia

Multiple Pulmonary Nodules

• 1-3mm Milliary nodules

MC –Mycobacterial infection ; Histoplasmosis , Coccidioimycosis

Multiple Pulmonary Nodules

• < 1 cm NodulesSeen with • CMV• Cryptococcus

Associated with reticular pattern.

Multiple Pulmonary Nodules

• 1-2 cm nodules

Multiple Cavitatory NodulesWith wedge shaped opacities –septic emboli.

Multiple Pulmonary Nodules

• 1-2 cm nodules

Multiple Cavitatory Nodules ; peripheral / sub pleuralWith wedge shaped opacities –septic emboli.

Multiple Pulmonary Nodules

• Wedge shaped larger Nodules with HALO

Pleural Based OpacitiesSeen in invasive aspergillosis

Multiple Pulmonary Nodules

Larger Nodules – Lymphoma ; Metastases

Multiple Pulmonary Nodules

Typically clustered along the bronchovascular bundles

Kaposi’s Sarcoma

Solitary Pulmonary Nodules

Primary Bronchogenic Carcinoma

Lymphadenopathy

• MC cause of mediastinal LNs – Mycobacterial Infections

• With Calcification – Disseminated PJP• With intense enhancement – Kaposi’s Sarcoma

Pleural Effusion

• Massive effusion with lymphocytes on cytology – TB.

• Hemorrhagic fluid –Kaposi’s Sarcoma.

Endobronchial Spread

• Bronchitis , Bronchiolitis ,Bronchiectasis• Seen with Pyogenic Infectious Airway Disease

Few Entities to revise…

• Atypical fungus• Particularly with deficiency in cell-mediated immunity.

Pathogenesis-• P. jiroveci lives almost exclusively in the pulmonary alveoli, adhering to the alveolar epithelium.• Intraalveolar macrophages serve as the primary host defense against P. jiroveci, and macrophage deficiency or dysfunction can lead to infection.

Pneumocystis Jeroveci Pneumonia

Patchy but extensive ground-glass opacity throughout both lungs.

Crazy paving characterized by extensive ground-glassopacity with superimposed interlobular septal thickening and intralobular lines. Relative subpleural sparing is evident.

Consolidation.

Pulmonary cysts associated with increased frequency of spontaneous pneumothorax

Solitary nodule or mass mimicking lung carcinoma or as multiple nodules ranging from a few millimeters to more than 1 cm

HRCTExtensive ground-glass opacity is the principal finding in PJP.

With more advanced disease, septal lineson ground-glass opacity –crazy paving.

Consolidation.

Pulmonary cysts associated with increased frequency of spontaneous pneumothorax

Solitary nodule or mass mimicking lung carcinoma or as multiple nodules ranging from a few millimeters to more than 1 cm

Small nodules and tree-in-bud opacities are uncommon

Residual interstitial fibrosis - chronic Pneumocystis pneumonia .

MYCOBACTERIAL INFECTIONS

• HIV patients have 50 -200 times more risk of TB• TB accelerates the progression of HIV

• CD4 > 200 – upper lobe opacity with cavitation and nodular bronchogenic spread

• CD4 < 200 – Parenchymal consolidation , lymph nodes with necrosis , pleural effusion , extrapulmonary spread.

Mycobacterial Infection

• Consolidations• Endobranchial Nodules• Cavitations• Pleural Effusion• Mediastinal

Adenopathy• Dissemination

Viral Infection

MC – CMV

CD4 counts < 50

Imaging –•Ground Glass Opacities•ARDS like Pattern•Nodules•Bronchiectasis•Bronchial Wall Thickening.

Fungal Infection

MC – Cryptococcosis

Invasive aspergillosisDisseminated Candidiasis

CD4 counts < 50

Aspergillosis Imaging –•Nodular opacities abutting the pleurla surface.•Cavitate – Air crescent Sign•HALO –Hemorrhage•Necrotising tracheobronchial involvement.

LYMPHOCYTIC INTERSTIAL PNEUMONITIS

Benign lymphoproliferative disorder characterised by lymphocyte predominant infiltration of the lungs .

LYMPHOCYTIC INTERSTIAL PNEUMONITIS

HRCT

Difuse involvement

. Mediastinal lymphadenopathy

. Ground-glass change

. Scattered thin walled cysts - usually deep within the lung parenhyma and range from 1-30 mm (useful for differentiation between lymphoma or the lung )

. Intersitital thickening along lymph channels

. Thickening of bronchovascular bundlesSmall but variably sized pulmonary nodules (

Diffuse Flame Shaped Nodular Opacities

Kaposi’s Sarcoma

• THANK YOU…..