Download Respiratory Symptoms in HIV+ Patients: A Radiologist’s Approach

MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
November 2003
Respiratory Symptoms in HIV+ Patients:
A Radiologist’s Approach
MaryCatherine Arbour, Harvard Medical School Year III
Gillian Lieberman, MD
MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Pulmonary Manifestations of HIV
• Neoplasms
Lung CA
Lymphoma
Kaposi’s sarcoma
• Proliferative infiltrating disorders
Lymphocytic Interstitial Pneumonia
Non-specific Interstitial Pneumonitis
• Infections
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Radiographic Evaluation of
Respiratory Symptoms
• CXR is the first line diagnostic for HIV+ patient
with respiratory symptoms.
• CT offers modest improvement over CXR &
greater negative predictive value. Most useful for:
complications, e.g. abscess, empyema
staging malignancies
symptomatic patients w NL or equivocal CXR
• Other modalities have limited role
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Integrated Approach to
Interpretation of Imaging Studies of
HIV-positive Patients
• Radiographic pattern recognition
• Clinical presentation
• Risk factor-associated pulmonary complications:
IVDU & septic emboli, recurrent S aureus pneumonia,
lung abscess, TB
Male homosexual contact & Kaposi’s sarcoma
Sexual contact & CMV
• Current drug therapy (HAART, TMP-SMX)
• Level of immune compromise = CD4 count***
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Natural History of HIV Infection:
CD4 Count & Opportunistic Infections
CD4 Count
(cells/ml)
http://www.wellesley.edu/Chemistry/Chem101/hiv/cd4fig.gif
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 1: 3 days acute onset fever, productive cough.
Courtesy Dr. Boiselle
Courtesy Dr. Boiselle
Segmental focal consolidation
Lobar consolidation
Diagnosis? Pyogenic Pneumonia. S pneumonia v. H influenza
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 2. 4 days dyspnea, fever, productive cough.
Normal CXR
PACS, BIDMC
Wall thickening. Symmetrical lower lobe
reticulonodular pattern.
Diagnosis?
Courtesy
Dr.Dr.
Boiselle
Courtesy
Boiselle
“Tree-in-Bud”:
Y & V-shaped centrilobular opacities
Airway disease. Bronchiectasis. (Bronchitis, Bronchiolitis)
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 3. 3 weeks cough, night sweats, weight loss.
www.state.hi.us/health/resource/ comm_dis/tb/images/xray.jpg
Parenchymal opacities with cavitation of apical lobe
Diagnosis?
M. tuberculosis
Pattern of reactivation TB
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Example 4. 3 weeks cough, night sweats, weight loss.
Patient 4
Patient 5
Goodman PC. TB and AIDS. The Radiologic Clinics of NA. 1995.
Goodman PC. TB and AIDS. The Radiologic Clinics of NA. 1995.
Consolidation and lymph node enlargement with low-density centers & peripheral contrast enhancement
Diagnosis?
M. tuberculosis
Pattern of primary TB
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Example 5. 3 weeks cough, night sweats, weight loss.
Patient 6
Patient 7
http://myweb.lsbu.ac.uk/~dirt/museum/simon/68-235-gse2.jpg
www.smm.org/heart/lessons/ lesson11.htm
Normal CXR
Patient 6
Small nodules & lymphadenopathy
Goodman PC. TB and AIDS. The Radiologic Clinics of NA. 1995.
Small nodules & lymphadenopathy
Diagnosis?
M. tuberculosis
Pattern of miliary TB
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patients 3-7. 3 weeks cough, night sweats, weight loss.
www.state.hi.us/health/resource/
comm_dis/tb/images/xray.jpg
Goodman PC. TB and AIDS. The
Radiologic Clinics of NA. 1995.
www.smm.org/heart/lessons/ lesson11.htm
http://myweb.lsbu.ac.uk/~dirt/museum/sim
on/68-235-gse2.jpg
Reactivation TB
Primary TB
Miliary TB
CD4 > 500
200 < CD4 < 500
CD4 < 200
In patients with risk factors for HIV infection who have not been HIV tested, some respiratory infections should raise a
question of seropositivity in the clinician’s mind:
-Rapidly progressing pyogenic pneumonia with abscesses or bacteremia
-Primary TB pattern on CXR in a patient with history of BCG vaccination or in areas where TB is endemic.
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Natural History of HIV Infection:
CD4 Count & Opportunistic Infections
CD4 Count
(cells/ml)
http://www.wellesley.edu/Chemistry/Chem101/hiv/cd4fig.gif
Patients 8-13 are all cases of opportunistic infections in people with CD4 counts below 200 cells/ml. Even in patients who have
not had serologic HIV testing, other clinical manifestations can be suggestive of seropositivity, such as shingles, wasting, skin
infections, gastroenteritis and dementia. These patients may present with mild to severe symptoms and often have negative chest
films. Diagnosis benefits from an integrated approach which incorporates level of immune compromise, drug regimen and risk
factors for infection, in addition to clinical presentation and radiologic pattern recognition.
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 8. 1 month insidious onset fever, dry cough, dyspnea.
www.smm.org/heart/lessons/ lesson11.htm
Normal CXR (40%)
Courtesy Dr. Boiselle
Ground glass attenuation, central & perihilar intra-alveolar exudates.
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 9. 1 month insidious onset fever, dry cough, dyspnea.
Courtesy Dr. Boiselle
Courtesy Dr. Boiselle
Bilateral perihilar opacities or
Diagnosis?
Diffuse interstitial granular
opacities. “Ground glass.”
Without treatment, progression to airspace consolidation
and “cystic disease” resembling pneumothorax.
Pneumocystis Carinii (PCP)
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 10. 1 month insidious onset fever, dry cough, dyspnea.
www.smm.org/heart/lessons/ lesson11.htm
Courtesy Dr. Boiselle
Normal CXR
or
Ground-glass opacities & alveolar consolidation, like PCP.
Diagnosis?
CD4<100
Infected by sexual contact
Retinitis, diarrhea
Fever, sore throat, LAD.
Differentiate by nodules, masses, small airways disease.
Cytomegalovirus (CMV)
www.medinfo.ufl.edu/cme/grounds/ forsmark/images/cf21.gif
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 11. 1 month insidious onset fever, dry cough, dyspnea.
www.smm.org/heart/lessons/ lesson11.htm
Normal CXR
or
Courtesy Dr. Boiselle
Non-specific reticular or reticulo-nodular pattern with focal consolidations,
lymphadenopathy and possible pleural effusion.
Diagnosis?
CD4<100
Meningoencephalitis
Reticulo-nodular pattern with focal consolidations,
lymphadenopathy and pleural effusion.
Cryptococcus neoformans
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 12. Fever, cough, dyspnea, pleuritic chest pain.
Courtesy Dr. Boiselle
Courtesy Dr. Boiselle
Cavitary disease with upper lobe alveolar consolidation and nodules with halo of ground glass.
Diagnosis?
CD4<50
Neutropenic secondary to gancyclovir or zidovudine therapy
Aspergillus
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Patient 13. General malaise and fever.
www.smm.org/heart/lessons/ lesson11.htm
Normal CXR (20%)
or
Courtesy Dr. Boiselle
Multifocal patchy consolidation with ill-defined
nodules and cavities. Lymphadenopathy.
Diagnosis?
Courtesy Dr. Boiselle
Reversal Syndrome:
Immune-mediated response to previously subclinical infection
CD4<50
Initiation of HAART leads to enlarged lymph nodes + fever
M. aviumintracellulare
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Conclusions
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CXR is first line diagnostic for HIV+ patient with respiratory symptoms
In patients with risk factors for HIV infection who have not been HIV tested, some
respiratory infections should raise a question of seropositivity for the clinician:
-Rapidly progressing pyogenic pneumonia with abscesses or bacteremia
-Primary TB pattern on CXR in a patient with history of BCG vaccination or in
areas where TB is endemic.
At CD4<200, CXR may be negative in PCP (40%), TB (20%) or MAI (20%).
-CT can aid diagnosis in symptomatic patients with negative CXR.
-If CT is not available, integrating other criteria can help focus a differential:
known CD4 count
concomitant symptoms in another system
medications and secondary neutropenia
risk factor for infection
When in doubt, remember, in HIV+ patients with respiratory symptoms:
-pyogenic pulmonary infections are most common,
-PCP is most lethal.
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MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
References
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Boiselle PM, Aviram G, Fishman J. Update on Lund Disease in AIDS. Seminars in
Roentgenology 2002; 37: 54-71.
Boiselle PM. CD-ROM.
Els NV. Clinical features and diagnosis of tuberculosis in HIV-infected patients.
www.uptodate.com 2003.
Garofano, S. Bacterial pulmonary infections in HIV-infected patients. www.uptodate.com 2003.
Garofano S. Pulmonary infections with endemic fungi in AIDS. www.uptodate.com 2003.
Goodman PC. Tuberculosis and AIDS. The Radiology Clinics of North America 1995; 707-718.
http://myweb.lsbu.ac.uk/~dirt/museum/simon/68-235-gse2.jpg
McLoud TC, Naidich DP. Thoracic Disease in the Immunocompromised Patient. Radiology of
the Immunocompromised Patient. Radiology Clinics of North America 1992; 30: 525-554.
Shelhamer J. Cytomegalovirus infection as a cause of pulmonary disease in HIV-infected
patients. www.uptodate.com 2003.
Stover, D. Approach to the HIV-positive Patient with Pulmonary Symptoms.
www.uptodate.com 2003.
Tietjen PA. Clinical presentation and diagnosis of Pneumocystis carinii infection in HIVinfected patients. www.uptodate.com 2003.
www.medinfo.ufl.edu/cme/grounds/ forsmark/images/cf21.gif
www.state.hi.us/health/resource/ comm_dis/tb/images/xray.jpg
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www.wellesley.edu/Chemistry/Chem101/hiv/cd4fig.gif
MaryCatherine Arbour, HMS III
Gillian Lieberman, MD
Acknowledgements
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Phillip Boiselle, MD
Fabio Komlos, MD
Larry Barbaras our Webmaster
Gillian Lieberman, MD
Pamela Lepkowski
Joshua Rempell, L. Renata Thronson
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