HIV related pulmonary infections. A radiologic pictorial review.

Transcription

1 HIV related pulmonary infections. A radiologic pictorial review. Poster No.: C-0836 Congress: ECR 2013 Type: Educational Exhibit Authors: N. Arcalis, P. Trallero, L. Berrocal Morales, S. Medrano, S Mourelo López, J. A. Goday Arno, X. Pruna ; Granollers/ES, Viladecans/ES, Barcelona/ES, MOLET DEL VALLES/ES Keywords: Inflammation, Infection, AIDS, Diagnostic procedure, Conventional radiography, CT, Thorax, Respiratory system, Lung DOI: /ecr2013/C-0836 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 49

2 Learning objectives To describe pulmonary infections that can affect HIV patients. To review several conditions typically occur at different stages of HIV infection. To emphasize imaging findings to improve our radiological report. Page 2 of 49

3 Background Pulmonary infections remain one of the most important causes of morbidity and mortality in HIV patients, and the first cause of hospital admission in the HAART era. Pulmonary complications are often the initial clinical manifestation of HIV infection. Achieving an aetiological diagnosis of pulmonary infection in these patients is important due to its prognostic consequences. The radiographic evaluation and recognition of the typical radiologic appearances can help make early diagnosis and successful treatment possible. Page 3 of 49

4 Imaging findings OR Procedure details Introduction Fig. 1 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES The pulmonary manifestations of HIV/acquired immunodeficiency syndrome (AIDS) remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. Pulmonary infection is present in well over 50% of patients with AIDS. Diagnoses uncommon in immunocompetent patients are becoming increasingly frequent in these severely immunocompromised individuals. Among the infectious pulmonary processes,major causative agents include opportunistic infections (OI): Pneumocystis jirovecii (PJP),cytomegalovirus (CMV), Mycobacterium tuberculosis (TB), Mycobacterium avium-intracellulare (MAc), Cryptococcus neoformans, and viral infections in addition to many of the more common gram-positive and gram-negative bacteriaseen in the general population. Page 4 of 49

5 Fig. 2 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Chest radiography is used for initial evaluation. Because each of the HIV-related opportunistic infections has a characteristic radiographic presentation, the radiograph (combined with information derived from the history, physical examination, and selected laboratory tests) can narrow the diagnostic possibilities and suggest a diagnostic approach. Consideration of radiographic combinations also can alter the differential diagnoses presented. For example, PJP is the most common cause of diffuse infiltrates. The combination of diffuse infiltrates and pleural effusions, however, is more suggestive of a bacterial pneumonia, TB, fungal pathogens than it is of PJP because these diseases also can present with pleural effusions, which are relatively uncommon in PCP. Computed tomography (CT) can play an important role in the evaluation of pulmonary disease in AIDS patients because it is more sensitive than plain radiography in depicting parenchymal, mediastinal, and pleural abnormalities. Page 5 of 49

6 Characteristic Radiographic Findings HIV-Related Opportunistic Infections Fig. 3 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 6 of 49

7 Fig. 4 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES The most common pulmonary manifestation of AIDS is diffuse parenchymal infiltrates. Bilateral diffuse disease: PJP (ground glass perihilar infiltrates). Pneumothorax association with PJP. Alveolar infiltrates + unilateral pleural effusion or cavitation: bacterial process. Alveolar infiltrates + unilateral pleural effusion or cavitation +adenopathy: TB Nodules diffusely scattered: mycobacterial infection and PJP or CMV infection. Nodules <1 cm in diameter in a centrilobular distribution: bacterial pneumonia, TB, fungal pneumonia. Bacterial pneumonia Bacterial pneumonia is the most common pulmonary complication of HIV/AIDS. Pneumococcal pneumonia is 5-6 times more common in HIV-infected patients compared with non-hiv infected individuals. The most common causes of bacterial pneumonia in HIV-infected patients are Streptococcus pneumoniae, Hemophilus influenzae, and Page 7 of 49

8 Staphylococcus aureus (encapsulated organisms). Can occur at any time in the course of HIV illness but occur more commonly as HIV advances and CD4 count declines (S. aureus pneumonia often occurs late in the course of HIV infection (parenchymal necrosis with cavitation is commonly seen). Chest X-raycan be useful in diagnosis of bacterial pneumonia (focal infiltrates) but can be non-specific in advanced immune deficiency stage. The signs and symptoms of acute bacterial pneumonia in patients with AIDS are similar to those in non-hiv-infected individuals with fever and cough (90%), tachypnea, purulent sputum production, and pleuritic chest pain. Fig. 5 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Pneumocystis jirovecii Pneumonia PJP presents with bilateral reticular or granular opacities. Radiographic improvement often is seen after 7-14 days. In mild cases, the radiographic findings may be normal. In patients with clinically suspected PJP who have a normal chest radiograph result, HRCT of the chest is a useful test. HRCT will reveal patchy areas of ground glass Page 8 of 49

9 opacity (GGO). These opacities are not diagnostic for PJP, may be seen in a variety of other pulmonary infections and diseases. Patients with suspected PJP and GGO on HRCT should undergo sputum induction or bronchoscopy in an attempt to establish a definitive diagnosis. The absence of GGO on HRCT makes PJP extremely unlikely. PJP reticular or granular infiltrates characteristically are bilateral and symmetric. Occasionally are unilateral or asymmetric. A greater emphasis should be placed on the pattern seen (reticular or granular) than on the distribution (bilateral, symmetric, or diffuse). Initially the findings may be limited to the perihilar region. As the disease progresses, chest radiograph findings will progress to more diffuse involvement, and an alveolar or mixed reticular-alveolar pattern can result. PJP occasionally presents with focal opacities, with a miliary pattern, with a nodular pattern or discrete nodules, or with cavities. Intrathoracic adenopathy or pleural effusions are rarely a manifestation of PJP. Thin-walled, air-containing cysts or pneumatoceles are seen in approximately 15-20% of radiograph images from patients with PJP may predispose patients to the development of pneumothorax. The combination of bilateral granular opacities and pneumatoceles in an HIV-infected patient with a CD4 count of <200 cells/µl is strongly suggestive of PJP. Page 9 of 49

10 Fig. 6 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 10 of 49

11 Fig. 7 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 11 of 49

12 Fig. 8 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 12 of 49

13 Fig. 9 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 13 of 49

14 Fig. 10 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 14 of 49

15 Fig. 11 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 15 of 49

16 Fig. 12 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Tuberculosis Patients with HIV and TB infection may have as high as an 8% per year risk of developing active tuberculosis. Active TB appears to accelerate the course of HIV. TB can have a variety of radiographic findings and presentations. The characteristic presentation depends partly on the degree of immunosuppression. Early in the course of HIV infection (when the patient has a relatively high CD4 cell count), typically presents in a pattern of reactivation: upper lung zone infiltrates (apical and posterior segments of the upper lobes and superior segment of the lower lobes), often with cavities. Cavitation, intrathoracic lymphadenopathy, or pleural effusion is suggestive of pulmonary TB. Page 16 of 49

17 In later stages of HIV, may present with "atypical" x-ray features - lower lobe infiltrates and hilar lymphadenopathy. Cavities are a less common presentation of TB in HIV-infected patients with low CD4 cell counts. These patients are more likely to present either with diffuse disease that may be miliary or with predominantly middle and lower lung zone infiltrates that may be mistaken for bacterial pneumonia. Pleural effusions can be seen with TB at both high and low CD4 cell counts, but intrathoracic adenopathy is seen much more commonly in patients with low CD4 cell counts. A CT scan of the chest sometimes can be useful for evaluating patients with intrathoracic adenopathy and for investigating findings suspicious for adenopathy on chest radiograph. Low attenuation of lymph nodessuggests central necrosis and thus a diagnosis of mycobacterial or fungal disease Fig. 13 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 17 of 49

18 Fig. 14 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 18 of 49

19 Fig. 15 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 19 of 49

20 Fig. 16 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 20 of 49

21 Fig. 17 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 21 of 49

22 Fig. 18 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Fungal Pneumonia The frequency of the endemic mycoses depends on exposure to the organism and the incidence of infection in the population. Lung is the portal of entry for the organism, which most often manifests as disseminated disease with meningitis.the pulmonary phase of infection is usually asymptomatic Chest x-ray findings include localized pulmonary infiltrates with cavitation or a diffuse interstitial infiltrate Pulmonary candidiasis and aspergillosis is being reported more frequent in advanced AIDS patients, usually as a terminal manifestation of disseminated infection. Aspergillosis occurs almost exclusively in association with neutropoenia, usually secondary to drug therapy. The incidence is reported to be around 1%, but is thought to be increasing due to prolonged survival at advanced levels of immune suppression. Mycetomas are the least common, but can complicate cavitary MTB Page 22 of 49

23 or PJP. Angioinvasive disease is most common, manifest as thick-walled cavitary lesions predominating in the upper lobes, with air-crescents surrounding areas of desquamated infarcted lung. Less-common patterns include nodules with a peripheral halo of ground-glassattenuation and isolated airway disease or Allergic bronchopulmonary Aspergillosis (ABPA), manifesting as bilateral lower lobe consolidation, bronchiectasis and airway impaction or "finger in glove". Fig. 19 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES, Page 23 of 49

24 Fig. 20 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Viral Infections Cytomegalovirus (CMV) is the most common viral agent identified in the lungs of AIDS patients. It is much more frequently a colonizer than an actual cause of pneumonia. Cytomegalovirus pneumonitis occurs in patients with advanced levels 3 of immunosuppression (CD4 <100/mm ) who almost always have documented extrathoracic CMV infection. The most common imaging features of CMV pneumonitis are ground-glass opacities and alveolar consolidation, which may mimic PCP. CD4 cell count and HIV infections Page 24 of 49

25 Fig. 21 References: Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES The CD4 cell count is an excellent indicator of an HIV-infected patient's risk of developing a specific opportunistic infections or neoplasm, presumably because it reflects the stage of HIV disease and degree of immunocompromise. The combination of the CD4 cell count and the chest radiograph can provide a basic differential diagnosis. For example, PJP is extremely uncommon in an HIV-infected patient with a CD4 count significantly higher than 200 cells/µl. In such a patient, a chest radiograph with diffuse infiltrates may be more suggestive of a fulminant bacterial pneumonia (H influenzae) than of PJP. -CD4 count declines to <500 cells/µl: bacterial pneumonia, mycobacteria (M tuberculosis. -CD4 count of <200 cells/µl: bacterial pneumonia with bacteremia and sepsis, M tuberculosis infection (extrapulmonary or disseminated). PJP, Cryptococcus neoformans. Page 25 of 49

26 -CD4 count of <100 cells/µl: bacterial pathogens (Staphylococcus aureus, Pseudomonas aeruginosa), Toxoplasma gondii. -CD4 count of <50 cells/µl: respiratory diseases caused by endemic fungi (eg, Histoplasma capsulatum, Coccidioides immitis), certain viruses (most commonly cytomegalovirus), mycobacteria (Mycobacterium avium complex), and nonendemic fungi (eg, Aspergillus spp) occur. Often, these diseases are associated with extrapulmonary or disseminated disease that dominates the clinical presentation. Knowledge of the CD4 cell count can be useful in narrowing the scope of the differential diagnosis, and knowledge of the relative frequencies of these pulmonary diseases can be useful in ranking potential diagnoses and suggesting a diagnostic and therapeutic plan. Page 26 of 49

27 Images for this section: Fig. 1 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 27 of 49

28 Fig. 2 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 28 of 49

29 Fig. 3 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 29 of 49

30 Fig. 4 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 30 of 49

31 Fig. 5 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 31 of 49

32 Fig. 6 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 32 of 49

33 Fig. 7 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 33 of 49

34 Fig. 8 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 34 of 49

35 Fig. 9 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 35 of 49

36 Fig. 10 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 36 of 49

37 Fig. 11 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 37 of 49

38 Fig. 12 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 38 of 49

39 Fig. 13 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 39 of 49

40 Fig. 14 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 40 of 49

41 Fig. 15 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 41 of 49

42 Fig. 16 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 42 of 49

43 Fig. 17 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 43 of 49

44 Fig. 18 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 44 of 49

45 Fig. 19 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 45 of 49

46 Fig. 20 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 46 of 49

47 Fig. 21 Radiology, Hospital de Granollers, Hospital de Granollers - Granollers/ES Page 47 of 49

48 Conclusion Pulmonary infections remain one of the most important causes of morbidity and mortality in HIV patients. This work provides a comprehensive overview of lung infections common in the HIV patient and a guideline of interpretation based not only on the radiological aspect and distribution of the lesions, but also on the physiopathological and clinical grounds. Page 48 of 49

49 References 1.The latest statistics on the world epidemic of HIV and AIDS were published by UNAIDS/ WHO in July 2008, and refer to the end of Beck JM, Rosen MJ, Peavy HH. Pulmonary complications of HIV infection: Report of the Fourth NHLBI Workshop. Am J Respir Crit Care Med 2001;164: Fleischman JK, Greenberg H, Web A. Small airways dysfunction in patients with AIDS and Pneumocystis carinii pneumonia. AIDS Patient Care STDS 1996;10: Sider L, Gabriel E, Pattern Recognitionof the Pulmonary Manifestations of AIDS on CT Scans. RadioGraphics 1993;13: Allen C, Al-Jahdali H, Irion K. Imaging lung manifestations of HIV/AIDS. Annals of Thoracic Medicine 2010; 5: Edinburgh KJ, Jasmer RM, Huang L. Multiple Pulmonary Nodules in AIDS: Usefulness of CT in Distinguishing among Potential Causes. Radiology,2000; 214, Whan Y, Effmann E, Pulmonary Infections in Immunocompromised Hosts: The Importance of Correlating the Conventional Radiologic Appearance with the Clinical Setting Radiology December : Amorosa JK, Nahass RG, Nosher JL.Radiologic distinction of pyogenic pulmonary infection from Pneumocystis carinii pneumonia in AIDS patients. Radiology June : Page 49 of 49