Evaluation of respiratory disease

Abstract

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.

Figure 1

Chest radiograph of an HIV-infected person with multilobar consolidation due to Streptococcus pneumoniae detected in two blood cultures. Chest radiograph courtesy of Laurence Huang, MD.

Figure 2

Chest radiograph of an HIV-infected person, CD4 cell count greater than 200 cells/μL, revealing right upper lobe consolidation with areas of cavitation. Sputum acid-fast bacillus stain was positive and sputum cultures grew Mycobacterium tuberculosis. Chest radiograph courtesy of Laurence Huang, MD.

Figure 3

Chest radiograph of an HIV-infected person, CD4 cell count less than 200 cells/μL, revealing right lower lung consolidation. Sputum acid-fast bacillus stains were negative but sputum cultures grew Mycobacterium tuberculosis that was mono-rifampin-resistant. In this case, the key to the diagnosis of tuberculosis was knowledge of the patient’s CD4 cell count and an understanding that tuberculosis can present with this pattern in HIV-infected individuals with advanced immunosuppression. Chest radiograph courtesy of Laurence Huang, MD.

Figure 4

Chest radiograph of an HIV-infected person, CD4 cell count less than 200 cells/μL, with bilateral, symmetric granular opacities due to Pneumocystis pneumonia. Microscopic examination of bronchoscopy with bronchoalveolar lavage (BAL) fluid demonstrated characteristic Pneumocystis cystic and trophic forms. Chest radiograph courtesy of Laurence Huang, MD.

Figure 5

Chest high resolution computed tomographic (HRCT) scan of an HIV-infected person, CD4 cell count less than 200 cells/μL, with patchy ground-glass opacities due to Pneumocystis pneumonia. Microscopic examination of induced sputum demonstrated characteristic Pneumocystis cystic and trophic forms. This individual’s chest radiograph one day prior to chest HRCT was normal, demonstrating the increased sensitivity of chest HRCT compared to chest radiography for Pneumocystis pneumonia. Chest HRCT scan courtesy of Laurence Huang, MD.

Figure 6

Chest radiograph of an HIV-infected person, CD4 cell count less than 200 cells/μL, with left lower lobe lung mass that was initially concerning for lung cancer. CT-guided fine needle aspiration revealed Cryptococcus neoformans. Chest radiograph courtesy of Laurence Huang, MD.

Figure 7

Chest high resolution computed tomographic (HRCT) scan of an HIV-infected person, CD4 cell count less than 50 cells/μL, with patchy ground-glass opacities due to Cytomegalovirus (CMV). The patient was initially thought to have Pneumocystis pneumonia but bronchoscopy with bronchoalveolar lavage was negative for Pneumocystis cystic and trophic forms. The patient then underwent video-assisted thoracoscopic surgical biopsy which established the diagnosis of CMV. Chest HRCT scan courtesy of Laurence Huang, MD.

Figure 8

Characteristic violaceous Kaposi sarcoma lesions seen in the trachea of an HIV-infected person, CD4 cell count less than 100 cells/μL. Image courtesy of Laurence Huang, MD.

Figure 9

Chest radiograph of an HIV-infected person, CD4 cell count less than 100 cells/μL, demonstrating the characteristic bilateral, middle and lower lung zone, perihilar or central distribution of abnormalities of pulmonary Kaposi sarcoma. This individual had no evidence of mucocutaneous Kaposi sarcoma and the diagnosis of pulmonary Kaposi sarcoma was established by bronchoscopy with visualization of multiple, characteristic Kaposi sarcoma lesions (see Figure 7). Chest radiograph courtesy of Laurence Huang, MD.

Figure 10

Chest radiograph of an HIV-infected person with hyperinflation, flattened diaphragms, increased radiolucency of the lungs, and multiple, large bullae from severe COPD. Chest radiograph courtesy of Laurence Huang, MD.