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Approach to Pulmonary Manifestations of HIV/AIDS

Approach to Pulmonary Manifestations of HIV/AIDS. Dr. Flip Otto Dept. of Radiology Universitas Academic Hospital. Pulmonary Manifestations of HIV/AIDS. Opportunistic infection Drug reactions Immune restoration syndrome Lymphoproliferative disorders AIDS related malignancy

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Approach to Pulmonary Manifestations of HIV/AIDS

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  1. Approach to Pulmonary Manifestations of HIV/AIDS Dr. Flip Otto Dept. of Radiology Universitas Academic Hospital

  2. Pulmonary Manifestations of HIV/AIDS • Opportunistic infection • Drug reactions • Immune restoration syndrome • Lymphoproliferative disorders • AIDS related malignancy • Non-specific interstitial pneumonitis • HIV related pulmonary hypertension • Bronchiolitis obliterans • Emphysema and bronchiectasis

  3. Infective pulmonary conditions in HIV/AIDS • Bacterial • PJP • TB • MAI • Fungal: Cryptococcus; Aspergillosis etc. • Viral: CMV

  4. Non-infective pulmonary conditions in HIV/AIDS • Kaposi’s sarcoma • Lymphoma • Lung carcinoma • Lymphocytic interstitial pneumonitis • Emphysema • Cardiovascular complications

  5. Prevalence of HIV/AIDS associated pulmonary conditions in relation to CD4 count • CD4>400: Increased risk for - Bacterial infection - Mycobacterium tuberculosis • CD4 200-400: Increased risk for - Recurrent bacterial infections - Mycobacterium tuberculosis - Lymphoma and lymphoproliferative disorders • CD4<200: Increased risk for - PJP - Disseminated Mycobacterium tuberculosis • CD4<100: Increased risk for - PJP - Atypical Mycobacterium tuberculosis - CMV - Kaposi’s sarcoma - Lymphoma

  6. Radiographic patterns • Nodules • Cavities • Adenopathy • Focal consolidation • Pleural effusion

  7. Nodules • Common • Size: - <1cm (random or centrilobular) more likely due to infection - >1cm more likely neoplastic • Miliary nodularity typically fungal or TB, rarely seen in PJP • KS peribronchovascular vs lymphoma and lung cancer peripheral

  8. Miliary TB

  9. CMV pneumonia

  10. Cavities • Mostly infective • 85% polymicrobial, majority bacterial: mixed infections often involving Staph and Pseudomonas • Remainder include: TB, PJP, fungi, CMV

  11. Necrotizing cavitating pneumonia

  12. Pneumocystis pneumonia

  13. Adenopathy • Mostly due to infection • TB most common cause of isolated adenopathy, can be seen with Cryptococcus. Associated with low attenuation with ring enhancement. • Lung cancer included in differential diagnosis • Calcified adenopathy: TB, fungus, described in PJP • Hyperattenuating adenopathy in KS due to vascular enhancement

  14. TB lymphadenopathy

  15. Focal consolidation • Mostly due to infection • Bacterial pneumonia most common cause in AIDS, but Pneumocystis most common individual pathogen (rarely segmental pattern) • TB, MAI, fungi (Cryptococcus), mixed infections and occsionally neoplasms (lymphoma and KS)

  16. Primary TB

  17. Pleural effusion • Majority small, equal incidence in infection and malignancy • Infective causes (bacterial and TB) tend to be unilateral • KS associated tend to be bilateral • Non-AIDS causes eg PE and organ failure should also be considered

  18. Kaposi sarcoma

  19. Approach • Combine: - Risk factors - Level of immunocompromise - prophylactic Rx - clinical presentation - radiographic pattern • CD4 count most important determinant for assessing relative likelyhood • Chest radiography 1st line imaging • CT and HRCT 2nd line when CXR findings equivocal or non-specific

  20. References • Aviram G, Fishman JE, Boiselle PM. Thoracic manifestations of AIDS. Applied Radiology 2003;Vol 32:8 • Allen CM, Al-Jahdali HH, Irion KL, Ghamen SA, Gouda A, Khan AN. Imaging lung manifestations of HIV/AIDS. Ann Thorac Med 2010;5:201-16

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