The radiology of the thoracic manifestations of AIDS

The thoracic manifestations of AIDS have undergone a gradual metamorphosis, partly due to more awareness about the disease leading to earlier diagnoses and partly due to the fact that research has produced more effective prophylaxis as well as treatment for these patients. Many patients now demonstrate partial or complete clinical response which prolongs the length and quality of life of individuals positive for the Human Immunodeficiency Virus (HIV+). Also, with the large number of infected individuals coming to medical attention, and the years of experience in diagnosing and treating these AIDS patients, we now recognize not only the usual but also less usual manifestations of thoracic illnesses in AIDS, including infections, non-infectious diseases such as HIV associated Lymphocytic Interstitial Pneumonia and the neoplasms associated with AIDS. A section will be devoted to HIV infection in children. We will finish the article with a discussion of the current role of Nuclear Medicine in the diagnosis of HIV associated thoracic diseases. These topics are the subject of this article.     

Voiding dysfunction in human immunodeficiency virus infections

PURPOSE: We prospectively evaluated the current spectrum of urodynamic pathology in patients infected with human immunodeficiency virus (HIV) who presented with voiding dysfunction. MATERIALS AND METHODS: We obtained a directed genitourinary and neurological history, and performed a physical examination and urodynamic testing in 18 patients. A 4-channel membrane urethral catheter was used to record intravesical and intraurethral pressures simultaneously. RESULTS: Detrusor hyperreflexia was present in 28% of our patients and detrusor-sphincter dyssynergia in 28%. Detrusor areflexia, previously described as the most frequent abnormality, was uncommon in our series (6% of patients). CONCLUSIONS: This changing proportion of urodynamic diagnoses may reflect a changing pattern of neurological manifestations of HIV infection due to more aggressive management. Urodynamic evaluation remains critical for precise diagnosis and treatment in patients with HIV who present with urinary symptoms.     

Lower extremity manifestations of vascular disease

All podiatrists are required to know the anatomy and pathophysiology of vascular pathology because it is the leading cause of morbidity and mortality in the western world and a frequent complaint of podiatry patients. Podiatrists have a unique opportunity to reduce the risk of lower extremity vascular pathology, specifically PVD, by encouraging proper diet and exercise in the podiatric patient. Because the next century will bring a population explosion of older people, particular attention must be paid to the multiple and complex disorders that impair functional independence and compromise quality of life--one of the most important disorders being vascular disease. Successful treatment depends on recognition of lower extremity pathology (whether it be arterial, venous, or lymphatic) and the possible suprastructural causes and timely referrals to a vascular specialist when indicated.     

Fibronectin and hyaluronic acid in seminal fluid: relationship with sperm count and percentage of typical forms

OBJECTIVES: To describe the presenting features, clinical and laboratory diagnosis, response to treatment, and outcome of necrotising herpetic retinopathy (NHR) in HIV infected patients. METHODS: Retrospective case records/laboratory data review of five HIV infected patients presenting to the specialist HIV/AIDS unit at UCL Hospitals, London from April 1994 to August 1996 with a clinical diagnosis of NHR. RESULTS: All patients had advanced HIV disease with a median CD4 count of 20.10(6)/1. Three patients had cutaneous varicella zoster virus (VZV) infection within the preceding 8 weeks. All had uniocular loss of visual acuity; one also had headache and another ocular pain. All had typical retinal appearances. VZV DNA was detected in cerebrospinal fluid of four patients (and in vitreous fluid of one of the four) and in vitreous fluid of one other. One patient refused therapy and rapidly became blind. Four patients received intravenous foscarnet with intravenous aciclovir for 6 weeks: three subsequently received oral famciclovir and one oral valaciclovir; two patients also had intravitreal injections of foscarnet. In none of the four did treatment bring about improvement in visual acuity, but in all four visual loss from retinitis was halted. CONCLUSIONS: NHR occurs in HIV infected patients with advanced HIV disease and is strongly associated with evidence of VZV infection. With aggressive use of antiviral drugs the outcome is not uniformly poor.     

Tuberculosis 1992: current clinical aspects, epidemiology and diagnosis

We review four different aspects of tuberculosis (TB), a disease which is making a comeback as a focus of medical attention. The diagnosis of TB in HIV infected individuals can be very challenging for the clinician and an increased number of side effects complicates treatment. Updated information in this area appears necessary for physicians who are in charge of HIV-infected patients. The "cursed duet" of TB and HIV infection is also responsible for the increase of TB in subsaharan Africa. Recent data are discussed in relation to this issue. Another problem for developing countries is the diagnosis and treatment of children's TB, which involves particular features as compared to the adult form of the disease. Finally, new diagnostic methods are now available from the laboratory. The detection of mycobacteria with the polymerase chain reaction has proven very useful in the diagnosis of tuberculous meningitis. Detection of tuberculostearic acid and mycobacterial antigen also represent important advances. The role of these techniques in the diagnosis of TB forms other than meningitis will need to be defined in the near future.     

Update of Penicillosis marneffei in Thailand. Review article

Penicillium marneffei is endemic in Southeast Asia. Although Thailand is a country in this region, penicillosis marneffei was rare. It was found occasionally in immunocompromised patients. With the increasing incidence of HIV seropositivity penicillosis marneffei emerged as one of the major problems in HIV infected patients residing in Thailand. The common presenting signs were fever, anemia, hepatomegaly, lymphadenopathy. productive cough and a common skin manifestation as molluscum contagiosum-like lesions. The diseases should be considered in Thais and immunocompromised travelers with a history of visiting Thailand. Because the disease is potentially curable, prompt diagnosis and treatment will lead to better prognosis.     

Allergic diseases and infection with human immunodeficiency virus (HIV)-AIDS in pediatric patients

During an infection with human immunodeficiency virus (HIV) the immune system is deregulated, even before real immunodeficiency, lymphopenia and AIDS occur. The immunologic alterations that have been described are a differentiation of a T-lymphocyte subclass, Th1 to Th0. Immunologic stimulation of these Th0 cells afterwards, makes them mature into Th2 cells. This causes a imbalance between the Th1 and Th2 cells, in favor of the second group. The clinical expression of this imbalance is an elevated risk of HIV-seropositive patients for allergies and for autoimmune disease, specially those autoimmune disease in which the production of autoantibodies prevails. Sometimes of differential diagnosis with systemic lupus erythematosus is difficult. There has been describes a major prevalence of allergic diseases, especially allergic rhinitis, in adult patients infected by HIV. Reports in pediatric patients are still sporadic, and the prevalence of allergies in children infected with HIV-AIDS is unknown. Only after recognizing the allergic nature of some symptoms, the treatment will be complete, reducing morbidity and infectious complications.     

The importance of immunological markers in the diagnosis of central nervous system infections produced by mycobacteria

More than 40 different oral diseases and conditions have been described in patients infected with human immunodeficiency virus (HIV). The recognition of the oral manifestations of HIV disease is of great significance because they may represent the first signs of the disease and have been shown to be highly predictive markers of severe immune deterioration and disease progression. Although some oral diseases and conditions have a weak association with HIV disease, others are strongly linked with the disorder, and a few are acquired immune deficiency syndrome (AIDS)-defining in nature. The spectrum of oral manifestations of HIV disease is reviewed with emphasis on clinical recognition, diagnosis, and treatment.     

Experimental syringomyelia: late ultrastructural changes of spinal cord tissue and magnetic resonance imaging evaluation

Seroprevalence for CMV varies from 70% in the general population to more than 90% in HIV infected patients. Immunodepression whatever its origin, either post therapeutic as in transplant recipients, or induced by HIV, leads to the reactivation of this virus, present in a latent form in the host. In CMV-seronegative patients, the main prevention is based on donor matching before a graft (graft of seronegative donor) and on the use of seronegative blood products or deleukocyted blood. Since the availability of efficient strategies of prophylaxis (before infection) or of early treatment (pre-emptive therapy), CMV disease is now infrequent in most transplantation centers. A real prophylaxis with ganciclovir is usually selected in high risk patients (lung, bone marrow transplants in case of a CMV seropositive recipient or seronegative but with a seropositive donor). It has replaced in most centers aciclovir that has only a modest efficacy. A pre-emptive therapy by ganciclovir is proposed in case of lower risk of CMV disease (kidney, liver or heart transplants) or if the local virology laboratory provides sensitive virological markers to detect the first signs of CMV reactivation. Besides viremia or pp65 antigenemia, currently used to initiate a pre-emptive therapy, the standardisation of other virological markers such as leukocytic or plasmatic PCR is in progress. The prophylaxis of CMV disease in less developed for HIV infected patients. Immunosuppression, continuously progressing in absence of antiretroviral agents, requires a continuous prophylaxis for months or years, treatment that is difficult to propose at the present time considering the modest activity of oral ganciclovir, the only oral agent available. Future progresses in this field will be obtained when a sensitive and reproductible CMV marker will allow to identify the patients at highest risk of CMV disease, and with new anti-CMV agents having a good oral bioavailability.     

The noninfectious respiratory complications of infection with HIV

Infection with HIV was first recognized through a clustering of unusual respiratory infections. The lung has been a major target manifesting many of the infectious complications of the immunodeficiency. Noninfectious pulmonary complications in HIV-infected individuals are also common and have been recognized since the advent of the AIDS epidemic. Malignancies involving the respiratory system, specifically Kaposi's sarcoma and non-Hodgkin's lymphoma, are epidemiologically linked to infection with HIV. Although other cancers have been identified in patients with HIV, these malignancies have a relationship to HIV infection that is unknown. Nonetheless, all cancers in the HIV-infected individual appear to follow a very deadly course. Interstitial pneumonitis and an alveolitis are also seen in individuals infected with HIV. Their relationship to the virus is unknown but may involve the lung's immune response to HIV. Pneumothorax and bullous lung disease are the sequela of pulmonary infections in the HIV-infected host. Pulmonary hypertension has been reported in HIV-infected patients, and like the other noninfectious respiratory complications, the link between the disease process and HIV is unknown. Bronchiectasis is now commonly recognized in AIDS patients who have survived prolonged immunosuppression and infection. Bronchoscopists have accumulated a collection of endobronchial lesions uncommonly seen in non-HIV-related pulmonary consultation. In the following review, we discuss the epidemiology, pathology, pathogenesis, clinical features, diagnostic findings, prognosis, and therapeutic options available for each noninfectious pulmonary complication. As the life expectancy for HIV-infected patients increases, the incidence of noninfectious pulmonary complications will rise.     

Difficult-to-diagnose organisms responsible for diarrhea in the immunocompetent patient

While rates of infection with the HIV virus are decreasing, the number of children infected continues to increase. There are multiple implications for the practicing pediatric dentist. Many of these children will seek or be referred by other health care providers for treatment of resulting oral pathology. Dentists must be prepared to provide dental services to the HIV-infected child.     

Crohn's ileitis in a patient with longstanding HIV infection

The differential diagnosis of diarrhea in patients infected with HIV is broad, and includes a variety of bacterial, viral, and parasitic pathogens, as well as malignancies including lymphoma and Kaposi's sarcoma. Idiopathic non-specific inflammatory bowel disease rarely occurs in association with HIV infection. A recent case report described a patient with longstanding Crohn's disease who experienced remission of his bowel disease upon infection with HIV (6). The authors inferred that the remission was secondary to a depressed CD4 (T helper) lymphocyte count. We report the first case of Crohn's ileitis developing in a patient with established HIV infection, depressed CD4 lymphocyte count, and no prior history of inflammatory bowel disease. This case raises questions about the role of CD4 cells in the pathogenesis of Crohn's disease.     

Respiratory infections in patients with HIV

Pneumocystis carinii pneumonia has long been considered the predominant pulmonary disease in patients with HIV, but several factors are changing this perception. The population infected with HIV is increasingly composed of injection drug users, and racial and ethnic minorities, which represent groups that have a high incidence of bacterial pneumonia and tuberculosis. The increased longevity attributed to antiretroviral therapy and P. carinii pneumonia prophylaxis is accompanied by more profound immunosuppression, rendering patients susceptible to Pseudomonas, Aspergillus, and other opportunistic pneumonias. Trimetrexate and atovaquone are now available for the treatment of P. carinii pneumonia. Both are less effective than standard regimens of trimethoprim-sulfamethoxazole, but have fewer adverse effects. The diagnosis of respiratory infections complicating HIV usually depends on isolation of the pathogen. The routine use of transbronchial biopsy during bronchoscopy is controversial because the prevalence of P. carinii pneumonia is high in most centers caring for patients with AIDS, and bronchoalveolar lavage is usually diagnostic in this disease. However, biopsy enhances the yield of bronchoscopy, especially in the diagnosis of noninfectious pulmonary disorders and infections other than P. carinii pneumonia.     

Changing nature of physician licensure. Implications for medical education in California

The mortality and morbidity burden of Non-Hodgkin's lymphoma (NHL) is increasing within the human immunodeficiency virus- (HIV-) infected population. Recent improvements in HIV management has meant overall reductions in deaths, especially those due to opportunistic infections, and while the outcome of HIV-related NHL may now be somewhat less grim, the incidence remains high and outcome poor. The median survival of those with HIV-related NHL is only approximately 7 months, although those with high CD4 lymphocyte counts seem to do somewhat better. Improved management of the underlying HIV infection, more effective infusional chemotherapy regimens, moderately effective second line regimens, and new investigational approaches all offer promising hope that improvements will soon be seen for the treatment of HIV-related systemic NHL. Immunotherapy, monoclonal antibodies, and adoptive immunotherapy targeting Epstein Barr virus (EBV) all represent novel experimental treatment approaches that are becoming possible based on our increased understanding of the pathogenesis of HIV-related lymphoma. Primary central nervous system lymphoma (PCNSL) in HIV patients has declined in incidence and there now is a rapid, less invasive diagnostic test. The presence of EBV DNA in the cerebral spinal fluid of HIV patients with focal brain lesions strongly suggests a diagnosis of PCNSL. Unfortunately, this disease remains difficult to treat in such an immunocompromised patient population. Further work is needed in order to prevent and effectively manage these diseases.     

Infection due to Klebsiella rhinoscleromatis in two patients infected with human immunodeficiency virus

Two cases of rhinoscleroma in patients infected with the human immunodeficiency virus (HIV) who had stayed in an area of endemic Klebsiella rhinoscleromatis are reported. One of the patients presented with oropharyngeal lesions, an unusual clinical picture. Both patients suffered from a major cellular immune deficiency. The importance of Klebsiella rhinoscleromatis infection in AIDS-related oropharyngeal pathology and the possible treatment of such infection in HIV-positive patients are not yet clearly established.     

Disease caused by Mycobacterium kansasii in patients with HIV infection

BACKGROUND: To describe the clinical features and response to therapy in Mycobacterium kansasii disease among HIV infected patients, an increasing problem in our setting. METHODS: A retrospective survey of all charts from patients with HIV infection with Mycobacterium kansasii infection recorded between April 1985 and December 1991. RESULTS: A total of 13 patients were identified. All of them had clinically significant respiratory tract samples with a definite M. kansasii isolation. Only three had disseminated disease. In all but two cases, CD4 cell count at diagnosis time was lower than 200/mm3. Chest X-ray films showed interstitial pattern (8 cases) or alveolar condensation (3 cases) and lung cavities were seen in 4 patients. All patients with lung disease and one with disseminated disease responded well to anti-tuberculous therapy. CONCLUSION: Mycobacterium kansasii produces disease in advances stages of HIV-induced immunosuppression. The most common primary location is pulmonary, but disseminated forms can also be seen. The infection can be controlled with standard anti-tuberculous therapy.     

Bone marrow biopsy in the diagnosis of fever of unknown origin in patients with acquired immunodeficiency syndrome

BACKGROUND: Fever is commonly observed in patients with human immunodeficiency virus (HIV) disease and frequently eludes diagnosis. The role of bone marrow biopsy in the diagnosis of fever of unknown origin in patients infected with HIV remains controversial. PATIENTS AND METHODS: One hundred twenty-three consecutive patients with 137 episodes of fever lasting 10 or more days without diagnosis after 1 week of hospitalization were evaluated by bone marrow biopsy. RESULTS: Overall, a specific diagnosis was achieved in 52 episodes by means of culture and histopathological examination (diagnostic yield, 37.9%). Three types of disease were found: mycobacterial infections (n = 36, 69% of documented episodes), including 18 patients with disseminated tuberculosis and 14 with Mycobacterium avium-intracellulare complex infections; non-Hodgkin lymphomas (n = 12, 23%); and visceral leishmaniasis (n = 4, 8%). Although bone marrow cultures were more sensitive than microscopic examination with special stains for the diagnosis of mycobacterial infections, the pathological examination of bone marrow led to a more rapid diagnosis of disease. In addition, the histopathological examination of bone marrow alone led to the diagnosis of a specific condition in 43 episodes (31.3% of all episodes). CONCLUSIONS: Bone marrow biopsy is a useful procedure for the diagnosis of fever in patients with advanced HIV disease, particularly in areas where tuberculosis and leishmaniasis are prevalent. Involvement of the marrow may be the first indication of the existence of extranodal non-Hodgkin lymphoma. For Mycobacterium avium-intracellulare complex infection, blood cultures were more sensitive than bone marrow biopsy.     

Intravascular lymphomatosis: a case presenting with encephalomyelitis and reactive haemophagocytic syndrome diagnosed by renal biopsy

OBJECTIVE: To determine the frequency of characteristics associated with unprotected heterosexual intercourse in HIV infected adults in an urban area. DESIGN: Retrospective comparison of sexual risk transmission behaviour between HIV infected men and women from a drug treatment site and between women from the drug site and HIV infected women from an urban medical centre. METHODS: HIV infected women and men were asked questions on sexual behaviour for a 1 year period before enrollment. The outcome variable was heterosexual risk behaviour (HRB) defined as having vaginal sex at least once in the previous year and not always using condoms. RESULTS: 73% of the drug clinic females, 72% of the drug clinic males, and 42% of the medical centre female engaged in HRB. Using logistic regression analysis, women and men in drug treatment engaged in similar rates of HRB; however, women in drug treatment were four times (95% CI = 2.0-8.3) more likely to engage in HRB risk behaviour than women from the medical centre. CONCLUSION: The data suggest that a surprisingly large portion of HIV infected patients under treatment engaged in HRB, especially former drug users. Without specifically targeted interventions, the heterosexual spread of HIV in urban areas will continue to be a serious problem.     

Cavitary pulmonary lesions in patients infected with human immunodeficiency virus

The differential diagnosis of cavitary pulmonary lesions in individuals infected with human immunodeficiency virus (HIV) is broad, especially in patients with advanced disease. In patients with Pneumocystis carinii pneumonia, cavitation is an uncommon manifestation of a common disease. It is unusual in patients with pulmonary cryptococcosis, coccidioidomycosis, and histoplasmosis but occurs frequently in patients with invasive pulmonary aspergillosis. In patients with pulmonary tuberculosis, cavities are more common during earlier stages of HIV disease, when cellular immunity is relatively preserved. Mycobacterium avium complex is an uncommon cause of lung disease and infrequently produces cavities. However, Mycobacterium kansasii, is often associated with cavitation. Cavities can complicate any bacterial pneumonia and are especially common with pneumonia due to Pseudomonas aeruginosa, Nocardia asteroides, and Rhodococcus equi. Noninfectious causes of cavitary lesions are rare, but cavitary lesions caused by pulmonary Kaposi's sarcoma and non-Hodgkin's lymphoma have been reported. Because of the broad differential diagnosis and because most cavities are caused by treatable opportunistic infections, a definitive diagnosis is essential.