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.

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.

CASE NO: 1

Cinical features: 18-month-old HIV-positive child. Anteroposterior chest radiograph

Right upper lobe consolidation

primary tuberculosis

CASE 2

Clinical features: 32 yr old HIV Positive male with cough and hemoptysis.

thick-walled cavitywith smoothinner marginsin the left upper lobe (arrow).

Cavitary postprimary tuberculosis

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.

CASE 4

57-year-old man HIV positive man presented with fever and sputum. marked volume loss in the left lungwith several large cavities and multiple air-fluid levels (arrowheads).A small cavity is noted

in the right upper lobe (arrow).

Tuberculosis.

48 yr old man with advanced aids.H/o severe cough and purulent sputum

CASE 5

Bilateral lower zonePatchy consolidation

Tuberculosis in advanced AIDS

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).

CASE 6.

Adult male HIV patient presenting with cough.

Typical bilateral ground-glass shadowing,cystic change in the right upper lobeand a left pneumothorax.

Pneumocystis carinii pneumonia.

CASE 7:

Clinical features:6-month-old child following an acute presentation with respiratory distress.

demonstrating diffuse bilateral consolidation

Pneumocystis carinii pneumonia

Clinical features:48-year-old HIV-positive man presenting with shortness of breath and cough.

CASE 8

numerous cysts of varying sizeswith a diffuse distribution,but relative sparing of lung bases.

Cystic pneumocystis carinii pneumonia

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.

Clinical features: HIV Positive 24-year-old man

Ill-defined focal opacity (arrows)in the upper lobe of the right lung.

CASE 9.

Aspergillus infection

CASE 10:

Clinical features:43-year-old HIV positive woman with cough

Multiple, bilateral nodules(arrowheads) are present and areassociated witha peripheral wedge-shapedregion of consolidation (arrow).

Invasive aspergillosis

Clinical features:A 37-year-old HIV positive man c/o chest painfor 3 months before presentation,progressive nonproductive severe cough

during 2 months weight loss of 5.5 kg during 3 months .

CASE 11:

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.

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.

CASE 12:

8 years old HIV positive child with severe cough & respiratory distress.

Consolidation predominantlyRight lung

Community acquired pneumonia.Streptococcus was isolated from blood cultures.

Adult male HIV-positive patient with cough and profuse sputum

chest radiograph showsa right mid zonepulmonary consolidationwith central cavitation.

Staphylococcal Pneumonia with lung abscess.

CASE 13:

sputum cultures were positive

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.

Varicella-Zoster virus pneumonia.

multiple, ill-defined & Occasionallyconfluent nodules throughout the lungs.

CASE 14:

4 year HIV Positive child with cough

hilar and mediastinal lymphadenopathy, with bilateralwidespread air space consolidation.

Cytomegalovirus(CMV) pneumonitis complicated by Adult Respiratory Distress Syndrome.

CASE 15:

HIV Postive male with severe respiratory symptoms on ventilator

CMV was isolated from nasopharyngeal aspirate.

The clinical manifestations of viral superinfection in HIV infected patientsare 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.

V.VIRAL INFECTIONS

Clinical features: 25-year-old female HIV patient

bilateral nodular infiltratepredominantly distributed in the mid and lower zones.

Typical changes of Lymphocytic Interstitial Pneumonitis

CASE 16:

Surgical biopsy of the right lower lobe showed a bronchiolocentric lymphoid infiltrateaccompanied by lymphocytic infiltrates in the interstitium representing a mixture of B and T cells.

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 cellsin addition to pulmonary lymphoid hyperplasia.

It is thought to represent a direct "hyperimmune" lung response tothe 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 duringepisodes of superimposed infection. Chronic LIP often results in patchy fibrosis with secondary traction bronchiectasis.

Even in the current era of potent antiretroviral therapy,pulmonary complications of AIDSremain an important cause of morbidity and mortalityamong HIV-infected individuals.

Interpretation of imaging studies should integrate:clinical, and laboratory information withradiographic pattern recognition.

Although chest radiography remains the mainstay of thoracic imagingin HIV-infected patients, CT also plays an important complementary rolein establishing an accurate diagnosiswhen chest radiographic findings are equivocal or nonspecific.

CONCLUSION

a)Coronal T1 weighted and (b) axial T2 weighted images. The images demonstrate diffuse cerebral atrophy.In addition,confluent high T2 signal changeis seen in the periventricular white matter of thefrontal and parieto-occipital regions.

A B

HIV ENCEPHALOPATHY

CT SCAN

PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

multiple white matter hypodensites

PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA

Before therapy After therapy brightly enhancing,multifocal,

periventricular lesions

diffuse contrast enhancement and extension adjacent to the lateral ventricles, including into anterior corpus callosum.

PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA

CNS TUBERCULOMAS

Multiple ring enhancing lesions

TUBERCULOUS MENINGITIS.

Contrast-enhanced cranial CT

Thick basilar exudate and an infarct in right thalamic region

TOXOPLASMOSIS

shows multiple enhancing lesions

TOXOPLASMOSIS

contrast-enhanced scan: the three lesions seen show typical ring-like enhancement of deep lesions with surrounding edema