3. Routes of spread
Sexual Contact – 75%
• Parental Inoculation – intravenous
drug abusers and recipients of blood
and
blood products.
• Passage of virus from Infected
mothers to children through the
placenta or
through breast milk.
HIGH RISK GROUPS
• Homosexuals/ Bisexuals
• Intravenous drug users
• Infants born to infected mothers
• Blood & Blood component
recipients (through Transfusion)
• Hemophiliacs
4. “HIV and Lung Diseases” Significance
Ever since the first description of HIV infection, the lung
has been the most commonly affected organ.
•Pulmonary complaints are often the sentinel event that
leads to the diagnosis of HIV infection in persons who are
unaware of their HIV status.
•Respiratory complications remain a common cause of
adverse outcomes in HIV-infected individuals.
5. Effects of HIV in the
lung
Direct infection of pulmonary macrophages and lymphocytes
• Progression of HIV infection decreases lung CD4+ T cells
• Intense infiltration of CD8+ T cells may occur within the lung
with up-regulation of cytokines
• Defects in humoral immunity lead to impaired antigen-specific
responses
• Viral compartmentalization may occur in lung
6. Pulmonary manifestation of HIV / AIDS
Opportunistic infection
• Drugs reaction
• Immune restoration syndrome
• Lymphoproliferative disorders
• AIDS related malignancy
• Non-specific interstitial pneumonitis
• HIV related pulmonary hypertension
• Bronchiolitis obliterans
• Emphysema and bronchiectasis
7. Assessment of risk factors for specific pulmonary
diseases in HIV patients
Geographical distribution
• Severity of immunocompromise
• Use of disease prophylaxis
• Use of anti-retrovirals (ARVs)
13. BACTERIAL INFECTIONS
In recent years, bacterial infections including
pyogenic airways disease have surpassed PJP as the
most common cause of infection in HIV positive
patients.
• Most episodes of pneumonia occur secondary to S. pneumoniae and H.influenzae which cause
community acquired pneumonia in the general population.
• Pseudomonas infections may be seen in patients with a recent history of hospitalization, antibiotic
or steroid therapy.
• AIDS patients are also at risk from unusual organisms such as Rhodococcus or Bartonella.
14. • The radiological pattern of bacterial pneumonia does not differ
from an immune intact host and consists of single or multiple sites
of consolidation in a segmental or lobar Distribution.
• In contrast to immune intact individuals, bacterial pneumonias in
the immunocompromised population have a higher propensity for
multilobar and bilateral disease, tend to progress more rapidly, are
more often complicated by cavitation and abscess formation, and
are more frequently associated with bacteremia.
15. • Bacterial pneumonia- Air-space consolidation
with air bronchograms and eccentric
cavitation with associated pleural effusion,
and lung abscess.
16. Lung abscess
• A lung abscess represents a localized infection
that undergoes tissue destruction and necrosis.
• When a communication with the
tracheobronchial tree is present, cavitation and
an air-fluid level may be evident .
• The inner wall of an abscess varies from smooth
to shaggy and irregular, and wall thickness usually
ranges from 5 to 15 mm.
• Pulmonary abscesses are most commonly caused
by anaerobic infections, followed in frequency by
S. aureus and Pseudomonas aeruginosa.
17. • Such infections are often the result of
aspiration. Consequently, a lung abscess is
often encountered in patients at risk for
aspiration, such as patients with poor dental
hygiene, impaired consciousness, esophageal
motility disorders, and neurologic diseases.
• Multiple abscesses may result from septic
embolism
19. Cont…
Patient presented with two weeks
history of chest pain .breathlessness
and productive cough .history of iv
drug abuse .(40 /m known ISS)
Right upper zone consolidation with
cavitating features and gas –fluid
level .
No abnormalities in the left lung ,
Cardiac silhouette normal .
20. cont
Some progress was noted with use
of Iv and oral antibiotics .
(follow up x-ray )
Reduction in fluid component but
widespread residual consolidation
in right lung .
Small volume of pleural fluid in
right upper and mid zones ,
21.
22.
23.
24. Pneumocystis Jeroveci Pneumonia
Atypical fungus
• Particularly with deficiency in cell-mediated
immunity.
• Pathogenesis-
• P.jiroveci lives almost exclusively in the
pulmonary alveoli, adhering to the alveolar
epithelium.
• Intraalveolar macrophages serve as the primary
host defense against P. jiroveci, and macrophage
deficiency or dysfunction can lead to infection.
25.
26. Pneumocystis jiroveci
PCP in patients with HIV infection usually presents subacutely with
progressive dyspnea, non-productive cough, and fever. Pleuritic chest
pain or acute worsening of symptoms is anunusual manifestation of
PCP in patients with HIV unless complicated by the development of a
pneumothorax.
• lungs are generally clear on auscultation.
• Diagnosis: Induced sputum - 55% sensitivity
BAL - 95% sensitivity
27. • Persistence of organisms through and even after therapy is common, and
does not reflect failure of therapy.
• Newer diagnostic techniques under investigation include polymerase
chain reaction of saliva or sputum, as well as blood tests measuring levels
of S-adenosylmethionine, a metabolite used exclusively by Pneumocystis
jiroveci and hence lowered in patients with active disease.
• Chest imaging may be normal but more typically demonstrates bilateral
diffuse interstitial abnormalities
• Patients with PCP typically worsen after 2 to 3 days of therapy.
28. • Chest imaging
demonstrates bilateral
typically diffuse
interstitial shadows but
may be normal in 10%
of patients
29. • On HRCT, the typical
appearance is areas of
bilateral patchy ground-
glass attenuation with a
background of
interlobular septal
thickening
30. • These chest radiographs are of two patients. Both
show -ground glass appearance. The left chest X-
ray (CXR) shows a much more subtle ground-glass
appearance while the right CXR shows a much
more gross ground-glass appearance mimicking
pulmonary edema.
39. • Solitary nodule or mass mimicking lung
carcinoma or as multiple nodules ranging from
a few millimeters to more than 1 cm
40.
41. HRCT
Extensive ground-glass opacity is the principal finding in PJP.
With more advanced disease, septal lines on ground-glass opacity –crazy paving.
Consolidation.
Pulmonary cysts associated with increased frequency of spontaneous
pneumothorax.
Solitary nodule or mass mimicking lung carcinoma or as multiple nodules ranging
from a few millimeters to more than 1 cm.
Small nodules and tree-in-bud opacities are uncommon
Residual interstitial fibrosis - chronic Pneumocystis pneumonia .
42. TB and HIV (Interaction & Coinfection)
TB is the most common opportunistic
infection in HIV-infected people in africa.
• Pulmonary TB remains the commonest
form of TB.
• TB occurs by
– reactivation of latent infection.
– newly acquired infection.
• HIV increases the risk of TB
progression.
• HIV increases the rate of TB
progression.
TB may speed the progression of HIV
disease
• Among HIV-infected individuals,
lifetime risk of developing active TB is 30-
50%,
compared to 5-10% in persons who are
not HIV-infected
• ART reduces the incidence of TB in
PLWHA
43. MYCOBACTERIAL INFECTIONS
HIV patients have 50 -200
times more risk of TB
• TB accelerates the
progression of HIV
• CD4 > 200 – upper lobe
opacity with cavitation
and nodular
bronchogenic spread
CD4 < 200 – Parenchymal
consolidation , lymph
nodes with
necrosis , pleural effusion ,
extrapulmonary spread.
44. Clinical Presentation of TB in HIV
Patients
Depends on immune status of patient
– In early HIV disease, presentation tends to be typical
pulmonary TB
– As immune system deteriorates mycobacterial infection
more likely to
disseminate
• Extrapulmonary TB is more common in HIV-infected
people.
– Pleural effusion, lymphadenopathy, pericardial disease,
miliary TB, TB
meningitis, peritoneal and spinal TB.
45. Diagnosis of Pulmonary
TB
Sputum examination
– Negative Sputum does
not exclude TB
– Sputum negative PTB
more common in
HIV+
– Only 50% sensitive
Chest radiograph
– No “typical” TB X-ray
– TB can create almost any
abnormality,
or even none
49. • Primary” Mycobacterium tuberculosis. Chest
X-ray shows right upper lobe and left midzone
consolidation and adenopathy.
50.
51. • Chest X-ray and computed tomography
showing features of reactivation
Mycobacterium tuberculosis as patchy
consolidation, including involvement at
unusual sites, e.g. lower lobes as seen here,
cavitation, nodularity and adenopathy.
55. Cytomegalovirus
• Asymptomatic persons with CMV
infection excrete the virus in saliva,
respiratory secretions, urine, and
semen.
• Clinically significant HIV-related CMV
infection is associated with severe
immunosuppression (CD4 less than
50 cells/mm3).
• CMV-associated syndromes most
commonly seen in patients with AIDS
are retinitis and enteritis (colitis or
esophagitis).
• A variety of CMV-related neurologic
complications have been described,
including polyradiculitis, ventriculitis,
and mononeuritis multiplex.
56.
57. • When disease is limited to the chest, definitive
diagnosis requires demonstration of cytopathic
change on histopathology (usually obtained via
transbronchial biopsy or VATS)
58. In most studies, patients with positive BAL
cultures for CMV have evidence of a more
likely alternative diagnosis (especially PCP or
bacterial pneumonia), and may improve
without specific therapy directed at CMV.
59. • Nonetheless, in a patient with advanced HIV
disease (CD4 cell count less than 50
cells/mm3), interstitial infiltrates on chest
radiograph, and no alternative organism
isolated, CMV pneumonitis may be the sole
responsible pathogen.
60. • The agents of choice for the treatment of
established CMV pneumonitis is oral
valganciclovir.
• For refractory disease, foscarnet would be an
appropriate alternative, although its use is
associated with high rates of renal
dysfunction and other metabolic
abnormalities.
61. • Unlike CMV retinitis, there is no standard
secondary prophylaxis for CMV pneumonitis.
However, as with other opportunistic infections,
the antiretroviral therapy with restoration of the
CD4 cell count plays a critical role in preventing
recurrences.
62. • all patients with HIV infection should be
encouraged to get annual vaccination.
Although declines in CD4 count and rises in
HIV viral load may be seen after influenza
vaccination, these adverse laboratory events
are generally transient and have not been
shown to be associated with adverse clinical
events
63. • Chest x-ray – Usually
presents as bilateral
disease. CT findings -
Interstitial changes
are most common.
• Differentiation of this
infection from PCP
on the basis of radiographic
findings may
not be possible.
• In most studies, even
patients with
positive BAL cultures for
CMV have
evidence of a more likely
alternative
diagnosis (especially PCP
or bacterial
pneumonia), and may
improve without
specific therapy directed
at CMV.
64.
65. Varicella zoster
• Varicella zoster is also a reactivation infection
in the solid organ transplant recipient and
usually manifests as disseminated disease. 5-
15 mm, diffuse, ill-defined nodular densities
with fuzzy outlines are seen on chest
radiographs.
69. Endemic Fungi
• Histoplasmosis, coccidioidomycosis,
blastomycosis, and penicilliosis are dimorphic
fungi that are endemic to distinct regions but
that may reactivate.
• rarely causes disease in patients with HIV until
the patient is significantly immunosuppressed
(CD4 less than 250 cells/mm3).
70. Histoplasma capsulatum
• histoplasmosis most commonly
presents with disseminated
disease in an individual with a
CD4 cell count less than 150
cells/mm3.
• fever, weight loss, adenopathy,
diarrhea, andmucosal lesions.
• occasionally occurs in person with
HIV and preserved CD4 counts
(greater
than 350 cells/mm3)
• Histoplasma capsulatum can
produce a sepsis syndrome as
well with fever, hypotension,
and multiorgan system failure.
• The presence of hilar or
mediastinal adenopathy may help
distinguish histoplasmosis
from Pneumocystis jiroveci, as
the clinical presentation in
susceptible hosts overlap
significantly, although these are
uncommon findings for
Pneumocystis.
71. • Diagnosis: detection of polysaccharide antigen in urine or blood,
where urine testing has been shown to be positive in up to 95
percent of patients with disseminated disease and AIDS.
• reatment: Amphotericin is currently considered the drug of choice
for severe or disseminated histoplasmosis in HIV-positive patients
and should be continued for 3 to 10 days until clear clinical
improvement has occurred before patients are switched to
itraconazole to complete a total of 3 months of therapy. Patients
with HIV infection be maintained on suppressive doses of
itraconazole indefinitely.
72. • The presence of hilar or mediastinal
lymphadenopathy may help
distinguish histoplasmosis from
Pneumocystis jiroveci, as the clinical
presentation in susceptible hosts
overlap significantly
• Chest x-rays are normal in 40–70%
of cases.
73.
74. Coccidioides immitis
• The presence of hilar adenopathy, eosinophilia, or lack of
response
to conventional antibiotics should prompt consideration of
pulmonary coccidiomycosis in patients from endemic areas.
• Radiology: diverse, and may include reticulonodular disease,
alveolar binfiltrates, nodules, adenopathy, cavities, and
pleural effusions.
• Diagnosis: Isolation of organism in respiratory secretions
(Bronchoscopy)
• Coccidioides immitis serology has a more established role to
play in
monitoring response to therapy. (sensitivity in diagnosis is
70%)
75. • DOC: (Without meningeal involvement)
Amphotericin B. Treatment should be
continued until clear clinical improvement has
been demonstrated, at which
time patients may be switched over to
itraconazole or fluconazole.
• (With meningeal involvement): high-dose
fluconazole, therapy should
be continued indefinitely
76. Penicillium marneffi
Penicillium marneffei is generally seen in
patients with advanced AIDS(CD4 less than 50
cell/mm3), where it commonly presents with
extrapulmonary symptoms (fevers, weight loss,
sweats, hepatosplenomegaly, and hematologic
abnormalities).
• cutaneous findings, particularly umbilical
papules that may be confused with either
cryptococcosis or molluscum contagiosum
77. much more commonly associated with systemic
disease, then isolated pneumonia.
• Chest radiographs most demonstrate
interstitial changes though nodules, cavitation
and
pleural disease have all been reported
previously.
• diagnosis requires isolation of the organism
from blood, skin,bonemarrow, or lymphnodes.
78. Aspergillosis
• exclusively in those with advanced
immunosuppression(CD4 cell
count less than 50 cells/mm3.
• Patients with AIDS who are diagnosed with
invasive disease often have other risk factors
for aspergillosis, such as receipt of
corticosteroids or neutropenia
79. • Aspergillus fumigatus, and to a lesser extent
Aspergillus niger are the most common causes of
invasive aspergillosis.
• Respiratory tract disease is the most common
manifestation of aspergillosis and both tracheitis
and invasive pneumonitis may develop
• he diagnosis is established when endoscopic
examination reveals an exudative
pseudomembrane adherent to the tracheal
wall.
80. • Radiographic abnormalities can show diffuse
infiltrates, cavities, and focal wedge-shaped
abnormalities reflecting pulmonary infarction.
• It is important to note, however, that
aspergillus is a common colonizer of diseased
airways, so definitive diagnosis requires
documentation of tissue invasion
85. Parasitic Infections
• Toxoplasma gondii most common.
• CD4 less than 50 cells/mm3.
• The clinical presentation of pulmonary
toxoplasmosis is similar to that of PCP, but
unlike PCP it may be accompanied by a sepsis-like
syndrome with hypotension.
• Radiographic abnormalities are diverse-
interstitial infiltrates, but also potentially
nodules, effusions, or mass lesions.
86. Non Infectious Pulmonary
Complications of HIV
Kaposis Sarcoma
• Endothelial cells latently infected with HHV8 are
activated by HIV, which in turn
drive the angiogenesis characteristic of this
vascular malignancy
• KS may develop in patients with preserved CD4
counts, although the
pulmonary involvement is most commonly seen
in advanced disease (CD4
less than 100 cells/mm3
87. • Pulmonary KS may be asymptomatic even in
patients with extensive abnormalities on chest
radiograph.
• Lesions tend to show peribronchovascular
distribution
88. Pulmonary KS in a
45 /m
Multiple bilateral ill
defined nodules .
Two indistinct
masses (left
hemithorax
89. Thoracic AIDS relate
KS in a 45 /m
Multiple bilateral micro
nodules in
peribronchovascular
distribution .
90.
91. Non-Hodgkin’s lymphoma
Second most common HIV-associated malignancy
• 500 times more risk as compared to the normal
population
• Typically high grade of B-cell origin
• EBV may be implicated in pathogenesis of many cases
• NHL occurs in patients at all CD4 counts.
• Approximately one-third of patients have thoracic
involvement.
• Pleural effusions are most common thoracic
manifestations, usually with parenchymal involvement.
92. • Chest radiographs usually demonstrate
isolated or multiple peripheral
nodules with effusions
• Diagnosis: pleural cytological study,
transbronchial biopsy, percutaneous
needle biopsy or open-lung biopsy
93. Primary effusion lymphoma
• Associated with HHV 8
• Coinfection with EBV is present in 90-100% of the
cases
• Pleural effusions are the most common
manifestations; peritoneal and
pericardial effusions also occur
• CD4 counts are usually less than 150 cells/ul
• Diagnosed by cytology or biopsy
• Very poor prognosis
94. Large unilateral
pleural effusion can
bee seen with no fluid
on the left .There is
no evidence of
cardiomegaly. There
is a lesion with
increased opacity on
the peripheral of the
right upper lung field
and another lesion
located at the right
hilum .
95. LYMPHOCYTIC INTERSTIAL
PNEUMONITIS
HRCT
• Difuse involvement
• Mediastinal lymphadenopathy
• Ground-glass change
• Scattered thin walled cysts -
usually deep within the lung
parenhyma and range from 1-
30 mm
• Intersitital thickening along
lymph channels
• Thickening of bronchovascular
bundles Small but variably
sized pulmonary nodules
96.
97. • More commonly in HIV affected children, adults may rarely
develop this complication as well. LIP is characterized by
polyclonal inflammatory lymphoid proliferation of bronchus
associated lymphoid tissue (BALT).
• Diffuse reticulonodular or interstitial infiltrates are seen on
chest imaging, making differentiation from PCP difficult.
98. Pulmonary Hypertension
• The most common hypothesis for the association
of HIV and pulmonary HTN is an alteration in
pulmonary cytokine profile that increases
expression of vasoactive substances such as
endothelin-1.
• HIV-related pulmonary hypertension (HRPH) is a
diagnosis of exclusion and can only be made after
other secondary causes of pulmonary
hypertension have been excluded.
99. Immune reconstitution Inflammatory
syndrome (IRIS)
• It is a condition in which the immune system
begins to recover, but then responds to a
previously acquired opportunistic infection with
an overwhelming inflammatory response that
paradoxically makes the symptoms of infection
worse.
100. • Infections most
commonly associated
with IRIS include
mycobacterium
tuberculosis and
cryptococcal meningitis
• It results as an
improvement in
qualitative T-cell function
which leads to a more
robust response against
organisms or antigens
101. COPD
• greater risk for the development of
emphysema.
• Investigators have postulated that the higher
proportion of CD8+ T lymphocytes seen in
BAL fluid from patients with HIV compared
with uninfected controls may help explain this
difference.
103. Abacavir Hypersensitivity
• 5% individuals
• Symptoms of the abacavir HSR usually appear in
the first 6 weeks of treatment and include fever,
rash, malaise, GI upset, myalgia, and
arthralgias. Cough and dyspnea also may occur
and may mimic bronchitis or pneumonia.
106. • CONCLUSION Pulmonary infections are the most common complications of
HIV/AIDS patients and are the major cause of morbidity and mortality. It is
important for the radiologist to demand and utilize all available clinical information
such as symptomatology, degree of immunocompromise, risk group for HIV
infection .
• In most cases, the clinical and chest radiograph findings are sufficient for confident
diagnosis. However, findings on chest radiographs may be absent, subtle or non-
specific.
• Chest CT plays an important role in identifying the presence of disease and may
specifically diagnose many conditions.
