Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 2 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 3 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*** 4 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 5 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 6 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) 7 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 8 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 9 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 10 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. 11 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. 12 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. 13 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) 14 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 15 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 16 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 17 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 18 MaryCatherine Arbour, HMS III Gillian Lieberman, MD Conclusions • • • • 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. 19 MaryCatherine Arbour, HMS III Gillian Lieberman, MD References • • • • • • • • • • • • • • 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 20 www.wellesley.edu/Chemistry/Chem101/hiv/cd4fig.gif MaryCatherine Arbour, HMS III Gillian Lieberman, MD Acknowledgements • • • • • • Phillip Boiselle, MD Fabio Komlos, MD Larry Barbaras our Webmaster Gillian Lieberman, MD Pamela Lepkowski Joshua Rempell, L. Renata Thronson 21