The pulmonary manifestations of AIDS-related non-Hodgkin's lymphoma

Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience

PURPOSE

The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED).

MATERIALS AND METHODS

A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status.

RESULTS

A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival.

CONCLUSION

Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.

Spectrum of imaging findings in AIDS-related diffuse large B cell lymphoma

Lymphoma in HIV-infected patients is AIDS defining. This is the second most common AIDS defining malignancy after Kaposi's sarcoma. Development of lymphoma in HIV patients is related to immunosuppression and high viral load. Co-infection with other lymphotrophic viruses especially EBV is also strongly associated with development of lymphoma in HIV patients. Despite advances in HAART therapy, incidence of diffuse large B cell lymphoma in HIV-infected patients remains significantly higher than in the general population.Early diagnosis is challenging due to presence of opportunistic infections and atypical presentation of the lymphoma in this subset of patients. Atypical imaging findings are not unusual, and the diagnosis of lymphoma on imaging is on many occasions unexpected as the patient would ideally be initially investigated for presumed opportunistic infection.Lymphoma treatment approaches in HIV patients are complicated by comorbidity with opportunistic infections and performance status of the patients. Treatment failure and early relapse are also common in AIDS-related lymphoma. This review article highlights the common and unusual multimodality imaging findings in HIV-associated lymphoma.

Infection in Immunocompromised Hosts: Imaging

Immunocompromised patients are encountered with increasing frequency in clinical practice. In addition to the acquired immunodeficiency syndrome (AIDS), therapy for malignant disease, and immune suppression for solid organ transplants, patients are now rendered immunosuppressed by advances in treatment for a wide variety of autoimmune diseases. The number of possible infecting organisms can be bewildering. Recognition of the type of immune defect and the duration and depth of immunosuppression (particularly in hematopoietic and solid organ transplants) can help generate a differential diagnosis. Radiologic imaging plays an important role in the detection and diagnosis of chest complications occurring in immunocompromised patients; however, chest radiography alone seldom provides adequate sensitivity and specificity. High-resolution computed tomography (CT) can provide better sensitivity and specificity, but even CT findings may be nonspecific findings unless considered in conjunction with the clinical context. Combination of CT pattern, clinical setting, and immunologic status provides the best chance for an accurate diagnosis. In this article, CT findings have been divided into 4 patterns: focal consolidation, nodules/masses, small/micronodules, and diffuse ground-glass attenuation/consolidation. Differential diagnoses are suggested for each pattern, adjusted for both AIDS and non-AIDS immunosuppressed patients.

Endobronchial primary large B-cell Non-Hodgkin lymphoma in HIV-infected patient in the Highly Active Antiretroviral Therapy era: Description of a case report

We report an unusual case of endobronchial primary large B-cell Non Hodgkin Lymphoma in a HIV-infected patient in the course of effective Highly Active Antiretroviral Therapy (HAART). Diagnosis of large B-cell NHL was obtained by fibreoptic bronchoscopy (FOB) biopsies. Three cycles of R-CHOP chemotherapy (rituximab, vincristine, cyclophosphamide, hydroxydaunorubicin, prednisone) was performed and clinical and radiological remission was obtained after 3 cycles of therapy.

Primary mediastinal large B cell lymphoma in a woman who is human immunodeficiency virus positive presenting with superior vena cava syndrome: a case report

Background

The risk of non-Hodgkin lymphoma is increased 200-fold in individuals seropositive for human immunodeficiency virus compared to those free from human immunodeficiency virus. Human immunodeficiency virus-associated non-Hodgkin lymphoma is known for its atypical presentation, aggressive ability, widespread involvement, poor response to chemotherapy, and high relapse potential which makes both the diagnosis and management a difficult undertaking especially in resource-poor settings.

Case presentation

We report a case of primary mediastinal large B cell lymphoma in a 46-year-old woman of African descent who is human immunodeficiency virus positive who presented with symptoms of superior vena cava syndrome. Her past medical history was remarkable for a 23-year history of systemic hypertension and a 10-year history of human immunodeficiency virus infection. A physical examination revealed an underweight woman with right-sided facial, neck, upper limb, and trunk swelling together with distended veins on her chest and abdomen draining downwards. A respiratory examination revealed a reduced chest expansion, stony dull percussion note, and absent breath sounds on her entire right side with a left-sided tracheal deviation. She had a CD4 count of 146 cells/μL. A chest X-ray revealed a homogenous opacification on her right side with a left-sided tracheal deviation while a computed tomography scan of her chest revealed a solid mass on her right side. An echocardiogram showed a huge well-circumscribed mass (4.6×3.3 cm) with spontaneous echocardiographic contrast compressing her heart inferiorly. She had severe pulmonary hypertension (right ventricular systolic pressure 58 mmHg) but preserved left ventricular systolic function, no thrombus was seen, and her pericardium was normal. A computed tomography angiography of her aorta ruled out an aortic aneurysm. Finally, she underwent mediastinoscopy and a direct biopsy of the mass was taken for histopathology. Hematoxylin and eosin staining demonstrated a dense lymphoid infiltrate of large malignant cells with pleomorphic nuclei in clusters, compartmentalized by fine bands of fibrosis, and frequent mitoses were present. A diagnosis of mediastinal large B cell lymphoma was reached.

Conclusions

The presence of a mediastinal widening coupled with a history of unintentional yet significant weight loss in an individual who is human immunodeficiency virus seropositive should raise an index of suspicion for lymphomas and warrant aggressive investigations and timely management.

Chest ultrasonography in patients with HIV: a case series and review of the literature

INTRODUCTION

Pulmonary disease is common in HIV-infected patients. Diagnostic means, however, are often scarce in areas where most HIV patients are living. Chest ultrasonography has recently evolved as a highly sensitive and specific imaging tool for diagnosing chest conditions such as pneumothorax, pneumonia and pulmonary edema in critically ill patients. This article addresses the issue of imaging and differentiating common pulmonary conditions in HIV-infected patients by chest ultrasonography.

METHODS

We report chest ultrasound features of five different common pulmonary diseases in HIV-infected patients (bacterial pneumonia, Pneumocystis jirovecii pneumonia, tuberculosis, cytomegalovirus pneumonia and non-Hodgkin lymphoma) and review the respective literature.

CONCLUSIONS

We observed characteristic ultrasound patterns especially in Pneumocystis jirovecii pneumonia and pulmonary lymphoma. Further exploration of chest ultrasonography in HIV-infected patients appears promising and may translate into new diagnostic approaches for pulmonary conditions in patients living with HIV.

Noninfectious pulmonary complications of human immunodeficiency virus infection

Human immunodeficiency virus type 1 (HIV-1) is the retrovirus responsible for the development of AIDS. Its profound impact on the immune system leaves the host vulnerable to a wide range of opportunistic infections not seen in individuals with a competent immune system. Pulmonary infections dominated the presentations in the early years of the epidemic, and infectious and noninfectious lung diseases remain the leading causes of morbidity and mortality in persons living with HIV despite the development of effective antiretroviral therapy. In addition to the long known immunosuppression and infection risks, it is becoming increasingly recognized that HIV promotes the risk of noninfectious pulmonary diseases through a number of different mechanisms, including direct tissue toxicity by HIV-related viral proteins and the secondary effects of coinfections. Diseases of the airways, lung parenchyma and the pulmonary vasculature, as well as pulmonary malignancies, are either more frequent in persons living with HIV or have atypical presentations. As the pulmonary infectious complications of HIV are generally well known and have been reviewed extensively, this review will focus on the breadth of noninfectious pulmonary diseases that occur in HIV-infected individuals as these may be more difficult to recognize by general medical physicians and subspecialists caring for this large and uniquely vulnerable population.

Primary pulmonary lymphoma in a patient with advanced AIDS

Non-Hodgkin's lymphoma (NHL) is an AIDS defining lesion and risk of NHL most likely correlates with the degree of immunosuppression from HIV. Risk of NHL is highest among patients with CD4 count <50 cells/mL. Primary pulmonary lymphoma (PPL) is an infrequent cause of AIDS-related lymphoma. The authors report a patient with advanced AIDS presenting with recurrent fever and pulmonary nodule seen on the CT scan. The patient remained febrile despite being on broad spectrum antibiotics with no clear source of infection. The patient underwent a bronchoscopy with biopsy of the pulmonary lesion which was most consistent with diffuse large B-cell lymphoma. The patient was started on dose-adjusted etoposide, vincristine, doxorubicin, cyclophosphamide and prednisone (EPOCH) and was noted to be afebrile and a repeat CT scan few weeks later showed resolution of her pulmonary nodule. This case highlights the importance of considering NHL in patients with advanced AIDS presenting with pulmonary nodule and fever.

Multimodality imaging of cardiothoracic lymphoma

Lymphoma is the most common hematologic malignancy and represents approximately 5.3% of all cancers. The World Health Organization published a revised classification scheme in 2008 that groups lymphomas by cell type and molecular, cytogenetic, and phenotypic characteristics. Most lymphomas affect the thorax at some stage during the course of the disease. Affected structures within the chest may include the lungs, mediastinum, pleura, and chest wall, and lymphomas may originate from these sites as primary malignancies or secondarily involve these structures after arising from other intrathoracic or extrathoracic sources. Pulmonary lymphomas are classified into one of four types: primary pulmonary lymphoma, secondary pulmonary lymphoma, acquired immunodeficiency syndrome-related lymphoma, and post-transplantation lymphoproliferative disorders. Although pulmonary lymphomas may produce a myriad of diverse findings within the lungs, specific individual features or combinations of features can be used, in combination with secondary manifestations of the disease such as involvement of the mediastinum, pleura, and chest wall, to narrow the differential diagnosis. While findings of thoracic lymphoma may be evident on chest radiography, computed tomography has traditionally been the imaging modality used to evaluate the disease and effectively demonstrates the extent of intrathoracic involvement and the presence and extent of extrathoracic spread. However, additional modalities such as magnetic resonance imaging of the thorax and (18)F-FDG PET/CT have emerged in recent years and are complementary to CT in the evaluation of patients with lymphoma. Thoracic MRI is useful in assessing vascular, cardiac, and chest wall involvement, and PET/CT is more accurate in the overall staging of lymphoma than CT and can be used to evaluate treatment response.

HIV/AIDS Related Respiratory Diseases

Lungs are the most commonly involved organ by HIV/AIDS related diseases, and pulmonary infections are the main reasons for the increasing death rate from AIDS. Pathogens of HIV related pulmonary infections include parasites, fungi, mycobacteria, viruses, bacteria and toxoplasma gondii. According to international reports, pathogens have different geographical distribution, which is also closely related to the socioeconomic status of the region to produce varied AIDS related diseases spectra. For instance, in the United States, pneumocystis carnii pneumonia (PCP), tuberculosis and recurrent bacterial pneumonia (at least twice within 1 year) occur frequently in HIV infected patients. An international report published 10 years ago indicated that PCP is the most common and serious pulmonary opportunistic infections in HIV infected patients. Now its incidence has dropped with the application of antiretroviral treatment and preventive measures. PCP will continue to occur initially in patients who are aware of their HIV infection. In addition, HIV related viral and parasitic infections have been reported both domestically and internationally. In this section, the clinical manifestations and imaging findings of HIV related pulmonary infections are analyzed and discussed, which provide effective diagnosis basis, so as to reduce the incidence of HIV-related pulmonary infections.

Human immunodeficiency virus-associated lung malignancies

This review of lung malignancies in human immunodeficiency virus (HIV) briefly highlights key epidemiologic and clinical features in the pulmonary involvement of AIDS-defining malignancies of Kaposi sarcoma and non-Hodgkin lymphoma. Then, focusing on non-AIDS defining lung cancer, the epidemiology and mechanisms, clinical presentation, pathology, treatment and outcomes, and prevention of HIV-associated lung cancer are discussed. Finally, the important knowledge gaps and future directions for research related to HIV-associated lung malignancies are highlighted.

Evaluation of respiratory disease

The spectrum of HIV-associated pulmonary diseases is broad. Opportunistic infections, neoplasms, and noninfectious complications are all major considerations. Clinicians caring for persons infected with HIV must have a systematic approach. The approach begins with a thorough history and physical examination and often involves selected laboratory tests and a chest radiograph. Frequently, the clinical, laboratory, and chest radiographic presentation suggests a specific diagnosis or a few diagnoses, which then prompts specific diagnostic testing and treatment. This article presents an overview of the evaluation of respiratory disease in persons with HIV/AIDS.

The radiological spectrum of pulmonary lymphoproliferative disease

Pulmonary lymphoproliferative disorders (LPD) are characterised by abnormal proliferation of indigenous cell lines or infiltration of lung parenchyma by lymphoid cells. They encompass a wide spectrum of focal or diffuse abnormalities, which may be classified as reactive or neoplastic on the basis of cellular morphology and clonality. The spectrum of reactive disorders results primarily from antigenic stimulation of bronchial mucosa-associated lymphoid tissue (MALT) and comprises three main entities: follicular bronchiolitis, lymphoid interstitial pneumonia and (more rarely) nodular lymphoid hyperplasia. Primary parenchymal neoplasms are most commonly extranodal marginal zone lymphomas of MALT origin (MALT lymphomas), followed by diffuse large B-cell lymphomas (DLBCLs) and lymphomatoid granulomatosis (LYG). Secondary lymphomatous parenchymal neoplasms (both Hodgkin and non-Hodgkin lymphomas) are far more prevalent than primary neoplasms. Acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL) and post-transplantation lymphoproliferative disorder (PTLD) may also primarily affect the lung parenchyma. Modern advances in treatments for AIDS and transplant medicine are associated with an increase in the incidence of LPD and have heightened the need to understand the range of imaging appearance of these diseases. The multidetector CT (MDCT) findings of LPD are heterogeneous, thereby reflecting the wide spectrum of clinical manifestations of these entities. Understanding the spectrum of LPD and the various imaging manifestations is crucial because the radiologist is often the first one to suggest the diagnosis and has a pivotal role in differentiating these diseases. The current concepts of LPD are discussed together with a demonstration of the breadth of MDCT patterns within this disease spectrum.

Chest neoplasms with infectious etiologies

A wide spectrum of thoracic tumors have known or suspected viral etiologies. Oncogenic viruses can be classified by the type of genomic material they contain. Neoplastic conditions found to have viral etiologies include post-transplant lymphoproliferative disease, lymphoid granulomatosis, Kaposi’s sarcoma, Castleman’s disease, recurrent respiratory papillomatosis, lung cancer, malignant mesothelioma, leukemia and lymphomas. Viruses involved in these conditions include Epstein-Barr virus, human herpes virus 8, human papillomavirus, Simian virus 40, human immunodeficiency virus, and Human T-lymphotropic virus. Imaging findings, epidemiology and mechanism of transmission for these diseases are reviewed in detail to gain a more thorough appreciation of disease pathophysiology for the chest radiologist.

Imaging lung manifestations of HIV/AIDS

Advances in our understanding of human immunodeficiency virus (HIV) infection have led to improved care and incremental increases in survival. However, 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. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis.

Management of patients with HIV in the intensive care unit

Because there are more than one million Americans with HIV, intensive care units continue to see frequent patients with HIV infection. In the era of highly active antiretroviral therapy, clinicians must be aware of drug toxicities and drug interactions. They must also recognize traditional opportunistic infections, as well as newer syndromes such as immune reconstitution syndrome, multicentric Castleman's disease, and primary pleural cell lymphoma.

[Other malignant tumors of the pleura]

Malignant tumors of the pleura are most often diffuse, nethertheless they are sometimes localized. There is an overlap of the radiologic features of the benign and malignant pleural lesions. The differential diagnosis may be difficult, even on histological sample. Imaging allows the diagnosis of pleural involvement, suggests the malignity, guides percutaneous or thoracoscopic biopsies of the pleura, defines extent of the tumor and follows the course of the disease. We will describe the malignant pleural tumors: pleural metastases, pleural involvement of broncho-pulmonary cancer, of lymphoma and leukaemia. Then the rare pleural tumors will be described: malignant pleural fibroma, sarcoma, histiocytoma and hemangiopericytoma.

Primary pulmonary AIDS-related lymphoma

Extranodal involvement is common in lymphomas associated with human immunodeficiency virus infection (HIV) and acquired immunodeficiency syndrome (AIDS). However, primary pulmonary AIDS-related non-Hodgkin's lymphoma is very rare and only few reports were published in the medical literature. Clinical presentation is nonspecific, with "B" and respiratory symptoms. Also, patients were with advanced immunodeficiency at the time of diagnosis. Generally, chest radiography showed peripheral nodules or cavitary masses. Primary pulmonary lymphoma associated with AIDS is generally a high-grade B-cell non-Hodgkin lymphoma and Epstein-Barr virus is strongly associated with the pathogenesis of these tumors. We report a patient with AIDS and primary pulmonary lymphoma which clinical presentation was a total atelectasis of the left lung.

Radiologic approach to the diagnosis of infectious pulmonary diseases in patients infected with the human immunodeficiency virus

Nearly all patients infected with HIV experience respiratory infection at some point in the course of their illness. The spectrum of infections is varied and in order to generate a useful differential diagnosis based on imaging findings it is imperative for the radiologist to be aware of changing trends in disease prevalence and epidemiology, and the possible pathology related to new therapies. The characterization of the radiographic pattern in correlation with clinical findings and laboratory values (in particular the degree of immunosuppression as reflected in the CD4 level) would be helpful in narrowing the differential diagnosis of infectious pulmonary disease in HIV-positive patients. The most common radiologic patterns considered include areas of ground-glass, consolidation, nodules, and lymphadenopathy. We also include airways diseases and cavitary/cystic lesions because their prevalence has increased over recent years, and we also mention the significance of a normal chest radiograph in the suspicion of a lung infection. In most cases, the clinical and radiographic findings are sufficient for confident diagnosis. The radiologic diagnosis of thoracic infections in patients with AIDS has improved with the use of CT. The greatest value of CT is in excluding lung disease when the radiographic findings are equivocal and in confirming the presence of clinically suspected disease when the radiograph is normal.

Two cases of acute respiratory failure due to carcinomatous lymphangitis in HIV patients

In HIV-infected patients, acute respiratory failure is usually due to infectious pneumonia. In this report, we describe two cases of acute respiratory failure in HIV patients with clinical presentation suggesting infectious pneumonia. In both cases, the clinical condition deteriorated and death occurred after several days despite therapy. In both cases bronchial biopsies confirmedbronchogenic carcinoma responsible for carcinomatous lymphangitis.

[Pleural disease and acquired immunodeficiency syndrome]

Respiratory infections are among the most common complications in patients infected with human immune deficiency virus (HIV) and can occur at all CD4 level. Pleural complications are uncommon but they have some distinctive aspects from HIV-negative patients. The PTX occurrence in HIV-positive patients was described for the first time in 1984. The total incidence of pneumothorax (PTX) in patients with acquired immune deficiency syndrome (AIDS) varies from 2.7% to 4.9%. The great majority occurs in patients with current or previous Pneumocystis carinii infection, who present subpleural pulmonary cavities with necrosis. The treatment of spontaneous PTX in patients with AIDS is difficult, with an increased tendency to bronchopleural fistula persistence. The use of tube thoracostomy, with or without pleural sclerose, can be insufficient to resolve PTX. Other therapeutic options are attachment of a Heimlich valve or surgical intervention. The prevalence and the etiology of pleural effusion (PE) among hospitalized patients with AIDS varies widely. One reason that can contribute to this variability is the difference on risk factors associated with HIV infection, in the studied population. Parapneumonic effusions, tuberculosis and Kaposi's sarcoma are the most common causes. Empyemas are a rare pleural complication. Although Pneumocystis carinii pneumonia is a common cause of pneumonias in AIDS patients, it is an unusual cause of pleural effusion. Other possible causes of pleural effusion are non-Hodgkin's lymphoma, namely body cavity-based lymphoma.

Intralobar pulmonary sequestration in a patient with non-Hodgkin's lymphoma: a cause of confusion

Pulmonary sequestration, a rare congenital pulmonary disorder, is characterized by nonfunctioning lung tissue that is separated from normal tracheobronchial tree. We present a 60-year-old woman with diffuse large cell non-Hodgkin's lymphoma. After 6 cycles of chemotherapy, paratracheal and aorticopulmonary lymphadenopathies had disappeared. However, the size of the pulmonary mass in the left lower lobe had persisted. Percutaneous fine-needle aspiration biopsy of the pulmonary mass was not diagnostic, so thoracotomy was applied. The lesion was defined as pulmonary sequestration, and basal segmentectomy was performed. After proper and sufficient chemotherapy, histopathological diagnosis of any persisting masses should be confirmed prior to overtreatment decision.

Relapsed non-Hodgkin's lymphoma diagnosed by flexible bronchoscopy

Pulmonary relapse of non-Hodgkin's lymphoma (NHL) occurred in a 10-year-old girl who presented with cough, blood-tinged sputum, and chest tightness. The diagnosis of Ki-1 (CD30) anaplastic large-cell lymphoma was established using bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB). These procedures demonstrated malignant cells that stained positive for CD30 and had the t(2;5) translocation, thereby avoiding the need for an open lung biopsy.

Progressive intrathoracic lymphadenopathy: EBV associated non-Hodgkin's lymphoma

A 30 year old man presented with late stage HIV disease and intrathoracic lymphadenopathy. Histology of a mediastinal biopsy suggested infective follicular hyperplasia or a peripheral T cell lymphoma. Subsequently, Epstein-Barr virus (EBV) infection was demonstrated in lymphocytes in the biopsy. Later, hepatosplenomegaly and peripheral lymphadenopathy developed. Histology of a cervical lymph node biopsy showed EBV associated diffuse large B cell (non-Hodgkin's) lymphoma.

Update on lung disease in AIDS

Pulmonary disorders remain an important complication of HIV infection, even in the current era of potent antiretroviral therapy. Using an integrated approach that combines radiographic pattern recognition with knowledge of a patient's clinical symptoms, laboratory data, immune status level, demographic information, and drug therapy can enhance the interpretation of imaging studies in HIV-infected patients. Although chest radiography remains the mainstay of imaging the HIV-positive patient with respiratory symptoms, CT plays an increasingly important secondary role in selected cases.

AS. LINFOMAS PULMONARES: CORRELAÇÃO DA TOMOGRAFIA COMPUTADORIZADA DE ALTA RESOLUÇÃO COM A ANATOMOPATOLOGIA

Neste trabalho são descritos os aspectos tomográficos de alta resolução dos linfomas pulmonares e feita correlação com os achados anatomopatológicos. Com este objetivo, foram revisados as tomografias computadorizadas de alta resolução do tórax e os dados histopatológicos de dez pacientes com diagnóstico confirmado de linfoma não-Hodgkin ou de doença de Hodgkin. Os resultados obtidos foram confrontados com os descritos na literatura. Os achados radiológicos mais comumente vistos neste estudo foram as consolidações parenquimatosas, localizadas, com broncogramas aéreos de permeio (n = 8). Em menor freqüência, foram encontrados múltiplos nódulos parenquimatosos (n = 4), espessamento peribroncovascular (n = 3) e opacidades em vidro fosco (n = 2). Na correlação com a anatomia patológica, as consolidações corresponderam a preenchimento alveolar por células neoplásicas, o espessamento peribroncovascular se deveu a infiltração das bainhas peribroncovasculares por células linfomatosas e a atenuação em vidro fosco se associou com infiltração dos septos alveolares por tais células.

Pleural effusions and pneumothoraces in AIDS

Pneumothorax occurs in 1 to 2% of hospitalized patients with HIV and is associated with 34% mortality. Pneumocystis carinii pneumonia and chest radiographic evidence of cysts, pneumatoceles, or bullae are risk factors for spontaneous pneumothorax. Tube thoracostomy, pleurodesis, and surgical treatment are usually needed to manage spontaneous pneumothorax in AIDS. Pleural effusion is seen in 7 to 27% of hospitalized patients with HIV infection. Its three leading causes are parapneumonic effusions, tuberculosis, and Kaposi sarcoma. Pleural effusions occur in 15 to 89% of cases of pulmonary Kaposi sarcoma and in 68% of cases of thoracic non-Hodgkin lymphoma in patients with AIDS. Primary effusion lymphoma accounts for 1 to 2% of non-Hodgkin lymphomas. Kaposi sarcoma and primary effusion lymphoma are associated with human herpesvirus 8. The prognosis of patients with pleural Kaposi sarcoma and non-Hodgkin lymphoma in AIDS is poor, and the major goal of treatment is palliation.

The importance of bacterial sepsis in intensive care unit patients with acquired immunodeficiency syndrome: Implications for future care in the age of increasing antiretroviral resistance

OBJECTIVE

To describe the clinical characteristics and outcomes of patients with acquired immunodeficiency syndrome (AIDS) admitted to the intensive care unit (ICU).

DESIGN

An observational cohort study with retrospective chart review.

SETTING

ICU of an urban university medical center.

PATIENTS

Consecutive ICU admissions of patients with AIDS at an urban university medical center between December 1993 and June 1996.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

For each patient, we recorded ICU admission diagnosis, clinical characteristics, and outcome. Among 129 ICU admissions of patients with AIDS, 102 (79%) were admitted for infections, of which (45%) had infections caused by bacteria. Pseudomonas aeruginosa, Staphylococcus aureus, and other enteric pathogens were the most frequent isolates. Pneumonia accounted for 65% of 102 admissions for infections. Overall hospital mortality was 54%, but mortality was higher (68%) for patients with bacterial sepsis. Neutropenia was associated with differences in unadjusted survival rates, whereas CD4 counts were not. Independent predictors of hospital mortality included increasing acute physiology scores and severity of sepsis.

CONCLUSIONS

In our ICU, among patients with AIDS, sepsis resulting from bacterial infection is now a more frequent cause of admission than Pneumocystis carinii pneumonia. Severity of illness and the presence of severe sepsis were the clinical predictors most associated with increased mortality. Patients who are not receiving or responding to highly active antiretroviral therapy may become as likely to be admitted to an ICU with a treatable bacterial infection as with classic opportunistic infections. Therefore, broad-spectrum empirical antibacterial therapy is particularly important when the etiology of infection is uncertain.

Unusual presentation of thoracic Pneumocystis carinii infection in a patient with acquired immunodeficiency syndrome

Pleura-based masses and hilar adenopathy were seen on a chest radiograph of a patient with acquired immunodeficiency syndrome who had a history of Pneumocystis carinii infection. The differential diagnosis of such a presentation is discussed in light of atypical and extrapulmonary manifestations of P. carinii infection in a patient receiving prophylaxis with dapsone.

Primary pulmonary mucosa-associated lymphoid tissue lymphoma with associated fungal ball in a patient with human immunodeficiency virus infection

We describe a case of primary mucosa-associated lymphoid tissue lymphoma of the lung in a 44-year-old man with human immunodeficiency virus. Low-grade pulmonary lymphomas in human immunodeficiency virus-positive patients are rare and are described most commonly in pediatric patients. The gross, histologic, and molecular features of this unusual case are described.

Pleural effusion and pneumothorax in hospitalized patients with HIV infection: the Pulmonary Complications, ICU support, and Prognostic Factors of Hospitalized Patients with HIV (PIP) Study

OBJECTIVES

To describe the incidence, causes, and impact of pleural effusion and pneumothorax in hospitalized patients with HIV infection.

DESIGN

Prospective, observational.

SETTING

A university-affiliated medical center.

METHODS

During a 3-year period, 599 HIV-infected patients with a total of 1,225 consecutive hospital admissions were followed. A total of 1,097 hospital admissions were included. Patients' medical records, chest radiographs, and computerized laboratory values were reviewed.

RESULTS

Pleural effusions developed in 160 hospital admissions (14. 6%). The effusions were right sided (56%), left sided (29%), and bilateral (15%). Their sizes were small (65%), moderate (23%), large (9%), and massive (4%). The associated conditions were infectious: bacterial pneumonia (n = 50), pulmonary tuberculosis (n = 10), Pneumocystis carinii pneumonia (PCP; n = 5), and empyema (n = 2); and noninfectious: renal failure (n = 15), hypoalbuminemia (n = 12), malignancy (n = 9), pancreatitis (n = 7), hepatic cirrhosis (n = 5), congestive heart failure (n = 4), atelectasis (n = 3), pulmonary embolism (n = 3), trauma (n = 1), and surgery (n = 1). Pneumothorax developed in 13 hospital admissions (1.2%). The conditions associated with pneumothorax were iatrogenic (n = 4), bacterial pneumonia (n = 3), PCP (n = 2), positive pressure ventilation for PCP (n = 2), pulmonary Mycobacterium avium complex (n = 1), and trauma (n = 1). The in-hospital mortality of hospital admissions with pleural effusion was 10.0% compared to 5.4% of those without pleural effusion (p = 0.0407). The in-hospital mortality of hospital admissions with pneumothorax was 30.8% compared to 5.8% of those without pneumothorax (p = 0.0060).

CONCLUSIONS

Pleural effusions occur in 14.6% of hospital admissions in our patient population with HIV infection. Bacterial pneumonia is the condition most commonly associated with pleural effusion. Pneumothorax, seen in 1.2% of hospital admissions with HIV infection, is associated with poor outcome.

Pleural effusions in patients with AIDS

OBJECTIVE

To describe the range of pathology causing pleural effusions in HIV infected patients with acute respiratory episodes and to attempt to identify whether any associated radiological abnormalities enabled aetiological discrimination.

METHODS

Prospective study of chest radiographs of 58 consecutive HIV infected patients with pleural effusion and their microbiological, cytological, and histopathological diagnoses.

RESULTS

A specific diagnosis was made in all cases. Diagnoses were Kaposi's sarcoma, 19 patients; para-pneumonic effusion, 16 patients; tuberculosis, eight patients; Pneumocystis carinii pneumonia, six patients; lymphoma, four patients; pulmonary embolus, two patients; and heart failure, aspergillus/leishmaniasis, and Cryptococcus neoformans, one case each. Most effusions (50/58) were small. Bilateral effusions were commoner in Kaposi's sarcoma (12/19) and lymphoma (3/4) than in para-pneumonic effusion (3/16). Concomitant interstitial parenchymal shadowing did not aid discrimination. A combination of bilateral effusions, focal air space consolidation, intrapulmonary nodules, and/or hilar lymphadenopathy suggests Kaposi's sarcoma. Unilateral effusion with focal air space consolidation suggests para-pneumonic effusion if intrapulmonary nodules are absent: if miliary nodules and/or mediastinal lymphadenopathy are detected, this suggests tuberculosis.

CONCLUSIONS

A wide variety of infectious and malignant conditions cause pleural effusions in HIV infected patients, the most common cause in this group was Kaposi's sarcoma. The presence of additional radiological abnormalities such as focal air space consolidation, intrapulmonary nodules, and mediastinal lymphadenopathy aids aetiological discrimination.

Multiple pulmonary nodules in AIDS: usefulness of CT in distinguishing among potential causes

PURPOSE

To determine whether the computed tomographic (CT) appearances of multiple pulmonary nodules in patients with acquired immunodeficiency syndrome (AIDS) can help differentiate the potential infectious and neoplastic causes.

MATERIALS AND METHODS

The thoracic CT scans obtained in 60 patients with AIDS and multiple pulmonary nodules were reviewed retrospectively by two thoracic radiologists who were blinded to clinical and pathologic data. The scans were evaluated for nodule size, distribution, and morphologic characteristics. CT findings were correlated with final diagnoses.

RESULTS

Thirty-six (84%) of 43 patients with opportunistic infection had a predominance of nodules smaller than 1 cm in diameter, whereas 14 (82%) of 17 patients with a neoplasm had a predominance of nodules larger than 1 cm (P <.001). Of the 43 patients with opportunistic infection, 28 (65%) had a centrilobular distribution of nodules; only one (6%) of 17 patients with a neoplasm had this distribution (P <.001). Seven (88%) of eight patients with a peribronchovascular distribution had Kaposi sarcoma (P <.001).

CONCLUSION

In patients with AIDS who have multiple pulmonary nodules at CT, nodule size and distribution are useful in the differentiation of potential causes. Nodules smaller than 1 cm, especially those with a centrilobular distribution, are typically infectious. Nodules larger than 1 cm are often neoplastic. A peribronchovascular distribution is suggestive of Kaposi sarcoma.

Lymphoma at uncommon sites

Lymphoma can often present in unusual situations. This article provides a comprehensive review of the literature in which both non-Hodgkin's lymphoma and Hodgkin's disease are discussed.

Role of bronchoscopy in AIDS

The differential diagnosis of pulmonary disorders in the HIV-infected individual is broad. Clinical features and chest radiographs may point towards a diagnosis but cannot reliably establish one. It is important to know the conditions in which bronchoscopy, BAL, and TBB are likely to be diagnostic, just as it is to know when other invasive or noninvasive procedures may be more useful. Finally, the incidence of transmission of infections such as tuberculosis during bronchoscopy and cross-contamination of patients with an improperly sterilized bronchoscope, cannot be overemphasized.