Date post: | 27-May-2015 |
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Pulmonary manifestations in Immuno compromised Host
Dr.Mitusha VermaDept. Of Radiodiagnosis.Dr.B.Nanavati Hospital.
• ICH – special group as predisposed to both opportunistic and non – opportunistic organisms.
• ICH patients rising with – - rise in incidence of HIV/AIDS. - solid organ or bone marrow transplant.
SYSTEMATIC APPROACH
• History –IVDAs , CMV , Kaposi’s sarcoma. • Examination• Investigations – Sputum CD4 Counts• Chest X ray• HRCT• Fiberoptic bronchoscopy with BAL
CD4 Counts
IMAGING
• CHEST RADIOGRAPH
• HRCT
A normal CT chest virtually rules out an active pneumonia as the site of infection.
Radiologic Patterns
Ground Glass OpacitiesVirtually diagnostic of PJP
May be seen with
CMVHerpesLymphocytic interstitial pneumonia
Consolidation
Focal segmental or Lobar Air space consolidations
Characterstic Of Community acquired Pneumonias
May be seen with TB ; Rhodococcus ; Nocardia
Multiple Pulmonary Nodules
• 1-3mm Milliary nodules
MC –Mycobacterial infection ; Histoplasmosis , Coccidioimycosis
Multiple Pulmonary Nodules
• < 1 cm NodulesSeen with • CMV• Cryptococcus
Associated with reticular pattern.
Multiple Pulmonary Nodules
• 1-2 cm nodules
Multiple Cavitatory NodulesWith wedge shaped opacities –septic emboli.
Multiple Pulmonary Nodules
• 1-2 cm nodules
Multiple Cavitatory Nodules ; peripheral / sub pleuralWith wedge shaped opacities –septic emboli.
Multiple Pulmonary Nodules
• Wedge shaped larger Nodules with HALO
Pleural Based OpacitiesSeen in invasive aspergillosis
Multiple Pulmonary Nodules
Larger Nodules – Lymphoma ; Metastases
Multiple Pulmonary Nodules
Typically clustered along the bronchovascular bundles
Kaposi’s Sarcoma
Solitary Pulmonary Nodules
Primary Bronchogenic Carcinoma
Lymphadenopathy
• MC cause of mediastinal LNs – Mycobacterial Infections
• With Calcification – Disseminated PJP• With intense enhancement – Kaposi’s Sarcoma
Pleural Effusion
• Massive effusion with lymphocytes on cytology – TB.
• Hemorrhagic fluid –Kaposi’s Sarcoma.
Endobronchial Spread
• Bronchitis , Bronchiolitis ,Bronchiectasis• Seen with Pyogenic Infectious Airway Disease
Few Entities to revise…
• 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.
Pneumocystis Jeroveci Pneumonia
Patchy but extensive ground-glass opacity throughout both lungs.
Crazy paving characterized by extensive ground-glassopacity with superimposed interlobular septal thickening and intralobular lines. Relative subpleural sparing is evident.
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
HRCTExtensive ground-glass opacity is the principal finding in PJP.
With more advanced disease, septal lineson 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 .
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.
Mycobacterial Infection
• Consolidations• Endobranchial Nodules• Cavitations• Pleural Effusion• Mediastinal
Adenopathy• Dissemination
Viral Infection
MC – CMV
CD4 counts < 50
Imaging –•Ground Glass Opacities•ARDS like Pattern•Nodules•Bronchiectasis•Bronchial Wall Thickening.
Fungal Infection
MC – Cryptococcosis
Invasive aspergillosisDisseminated Candidiasis
CD4 counts < 50
Aspergillosis Imaging –•Nodular opacities abutting the pleurla surface.•Cavitate – Air crescent Sign•HALO –Hemorrhage•Necrotising tracheobronchial involvement.
LYMPHOCYTIC INTERSTIAL PNEUMONITIS
Benign lymphoproliferative disorder characterised by lymphocyte predominant infiltration of the lungs .
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 (useful for differentiation between lymphoma or the lung )
. Intersitital thickening along lymph channels
. Thickening of bronchovascular bundlesSmall but variably sized pulmonary nodules (
Diffuse Flame Shaped Nodular Opacities
Kaposi’s Sarcoma
• THANK YOU…..