Approach to Pulmonary Manifestations of HIV/AIDS

Dr. Flip OttoDept. of RadiologyUniversitas Academic Hospital

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

Infective pulmonary conditions in HIV/AIDS

Bacterial PJP TB MAI Fungal: Cryptococcus; Aspergillosis etc. Viral: CMV

Non-infective pulmonary conditions in HIV/AIDS

Kaposi’s sarcoma Lymphoma Lung carcinoma Lymphocytic interstitial pneumonitis Emphysema Cardiovascular complications

Prevalence of HIV/AIDS associated pulmonary conditions in relation to CD4 count

CD4>400: Increased risk for - Bacterial infection - Mycobacterium tuberculosis CD4 200-400: Increased risk for - Recurrent bacterial infections - Mycobacterium tuberculosis - Lymphoma and lymphoproliferative disorders CD4<200: Increased risk for - PJP - Disseminated Mycobacterium tuberculosis CD4<100: Increased risk for - PJP - Atypical Mycobacterium tuberculosis - CMV - Kaposi’s sarcoma - Lymphoma

Radiographic patterns

Nodules Cavities Adenopathy Focal consolidation Pleural effusion

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

Miliary TB

CMV pneumonia

Cavities

Mostly infective 85% polymicrobial, majority bacterial: mixed

infections often involving Staph and Pseudomonas

Remainder include: TB, PJP, fungi, CMV

Necrotizing cavitating pneumonia

Pneumocystis pneumonia

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

TB lymphadenopathy

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)

Primary TB

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

Kaposi sarcoma

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

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