Imaging, 14 (2002), 2434

2002 The British Institute of Radiology

Abdominal CT in patients with AIDS

1
1

D M KOH, MRCP, FRCR, 2B LANGROUDI, MBBS and 2S P G PADLEY, FRCP, FRCR

Department of Radiology, The Royal Marsden Hospital, Downs Road, Sutton SM2 5PT and 2Department of Radiology, Chelsea and Westminster Hospital, London SW10 9NH, UK

An estimated 40 million people worldwide are seropositive for the human immunodeciency virus (HIV) [1]. HIV infection is an important cause of death in both males and females between the ages of 25 years and 44 years. Although homosexual men are still frequently affected, HIV infection is increasing among intravenous (iv) drug abusers and the heterosexual population. Widespread prescription of highly active antiretroviral treatment (HAART) has resulted in a decrease in the viral load and an increase in the mean CD4 count of these individuals. Consequently, morbidity and mortality from opportunistic infections have declined. HAART employs a combination of anti-retroviral agents, acting via different pathways, to inhibit HIV viral replication. Nevertheless, opportunistic infections still pose a signicant threat to patients newly diagnosed with the disease and in those who are refractory to HAART. Non-specic abdominal symptoms are common in patients with acquired immune deciency syndrome (AIDS). These symptoms include diarrhoea, abdominal pain, abdominal distension, fever, weight loss, abdominal mass, jaundice and gastrointestinal bleeding. The immunocompromised state predisposes these individuals to a range of infectious and neoplastic diseases that can give rise to these symptoms. Unfortunately, physical examination of patients is often nonrevealing and laboratory test results may be delayed. Hence, imaging is frequently used to elucidate the cause of these symptoms. Although ultrasound is often employed in the initial assessment, visualization of the retroperitoneum, the mesenteric compartment and the bowel loops is frequently challenging and often suboptimal. As a result, CT has assumed a more important role in the evaluation of abdominal symptoms in patients with AIDS, especially in those who present acutely.

Summary

N Abdominal symptoms are common in patients

with AIDS. CT is frequently used to evaluate these symptoms. on CT often non-diagnostic but N Findings nevertheless contribute towards patient management. CT signs, together with a knowledge of N Certain the CD4 count, may help to indicate the likely diagnosis and enable early presumptive treatment. CT may be used to assess the N Post-treatment resolution or progression of disease. is also useful in detecting intraabdominal N CT complications arising from the treatment of AIDS.

of CT ndings should always be made with the knowledge of the patients CD4 count. Certain diseases are more likely to occur at specic levels of immunosuppression [2]. Infection with Mycobacterium tuberculosis may be seen at a higher CD4 count of more than 200 cells ml21. By comparison, disseminated infection with Mycobacterium avium-intracellulare, Candida species and cytomegalovirus is unusual above a CD4 count of 100 cells ml21. Although malignancies such as lymphoma and Kaposis sarcoma can occur at varying degrees of immunosuppression, they are more common when the CD4 count falls below 200 cell ml21. The likelihood of various abdominal diseases in relation to the CD4 count is summarized in Table 1. In addition to unusual opportunistic infections, patients with AIDS are also susceptible to a range of bacterial infections that affect the normal population.

Pathological considerations
In AIDS, a reduction in the number of CD4 lymphocytes results in immunosuppression and exposes individuals to opportunistic infections. The CD4 count is a useful way of quantifying the degree of immunosuppression, and interpretation
24

CT in patients with AIDS

CT of the abdomen and pelvis is usually performed following administration of iv and oral contrast medium. Images should be acquired craniocaudally in the hepatic portal venous phase,
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Abdominal CT in AIDS patients Table 1. Abdominal diseases in relation to the CD4 count Disease N Mycobacterium tuberculosis (extrapulmonary) N Mycobacterium avium-intracellulare N Cytomegalovirus N Candidiasis N Histoplasmosis N Pneumocystis carinii (extrapulmonary) N Cryptosporidiosis N Kaposis sarcoma N Non-Hodgkins lymphoma
Adapted from [20].

CD4 count (cells ml21) ,200 ,100 ,100 ,100 ,100 ,200 ,200 ,200 ,200

The cardinal CT features of the infections and malignancies commonly encountered in patients with AIDS are summarized below. Emphasis is placed on those CT ndings that may be helpful in distinguishing one disease entity from the other.

Infections
Infection can result from a variety of viruses, bacteria or protozoans. Although opportunistic infections are common, there is also an increased incidence of non-opportunistic infections.

Mycobacterium tuberculosis and Mycobacterium avium-intracellulare

Infection with Mycobacterium tuberculosis (MTB) or Mycobacterium avium-intracellulare (MAI) can be acquired through primary infection or secondary to reactivation disease. In most cases of disseminated infection, it is thought that these are likely to represent new primary infection rather than reactivation disease. There is considerable overlap in the CT features of MTB and MAI infection. However, MAI infection usually occurs at a greater degree of immunosuppression when the CD4 count falls below 50100 cells ml21. The cardinal imaging features of both MTB and MAI infections include lymphadenopathy, hepatomegaly, splenomegaly and focal lesions within the liver, spleen or kidneys. Peritoneal disease is not unusual, especially with MTB, and may be a primary presentation. Peritonitis resulting from mycobacterial infection has been classied into wet, dry plastic or brotic-xed types depending on the imaging features [8]. Ascites resulting from MTB infection is classically, but not invariably, high in attenuation (2545 HU) [8] (Figure 1).

approximately 70 s after the beginning of iv contrast medium delivery. A section thickness of 8 mm or less is optimal. Common indications for the use of CT include abdominal pain, pyrexia of uncertain origin, and diagnosis or follow-up of intraabdominal malignancy [3]. CT is particularly helpful in the evaluation of patients presenting with acute abdominal symptoms [4, 5]. However, CT was found to be less useful when it was used as a screening examination for HIV seropositive individuals presenting to the hospital, since it did not always improve outcome or reduce the length of the hospital stay [6]. Common CT ndings include hepatomegaly, splenomegaly and lymphadenopathy. Unfortunately, these radiological signs are non-specic. Consequently, a denitive diagnosis is made on CT in only 12% of cases, although ndings on CT frequently contribute to the patients management [3]. The CT ndings, together with knowledge of the CD4 count, allow a presumptive diagnosis to be made and early treatment to be instituted before microbiological or histological conrmation becomes available. Where the diagnosis is uncertain, CT can also be used to guide the biopsy of abnormal tissue for denitive microbiological or histological diagnosis. Certain radiological ndings on CT have been shown to indicate a poorer prognosis. These include hepatic masses, grossly enlarged lymph nodes and ascites [7], presumably reecting a greater degree of immunosuppression. The more common CT ndings of splenomegaly, hepatomegaly and lymphadenopathy have no prognostic implications [7]. Patients treated for malignancies such as lymphoma and Kaposis sarcoma may be monitored for radiological response using CT. In patients with infective diseases, a repeat CT with worsening clinical symptoms will help in the early detection of complications, allowing appropriate management decisions to be made.
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Figure 1. Mycobacterium tuberculosis (MTB) infection and ascites. 43-year-old man with MTB infection showing multiple retroperitoneal lymph nodes associated with peritoneal nodules. High attenuation ascites are also shown. 25

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(a)

(b)

Figure 2. Mycobacterium avium-intracellulare (MAI) and Mycobacterium tuberculosis (MTB) lymphadenopathy. (a) In this 36-year-old man with MAI infection, there are discrete lymph nodes of uniform attenuation within the retroperitoneum and small bowel mesentery. (b) In another 38-year-old man with MTB infection, lymph nodes within the retroperitoneum show typical central low attenuation.

Abdominal lymphadenopathy can be observed in all patients with MTB and MAI infections [9]. However, the appearance of the abdominal lymph nodes may be useful in distinguishing MTB infection from MAI infection [9, 10]. MAI typically incites less tissue response, granuloma formation and caseation, resulting in a lower incidence of necrotic (low attenuation) lymph nodes. Lymph nodes with central low attenuation are typical of MTB infection and have a reported frequency of up to 93% [9, 10] (Figure 2). Hepatomegaly is not an infrequent nding in MAI infection, with a reported frequency of 3645% [911]. There appears to be an equal incidence of splenomegaly in MTB infection and MAI infection [9, 10]. The incidence of focal lesions in the liver and spleen is higher in MTB infection than MAI infection. The frequency of focal hepatic lesions in

MTB infection ranges from 11% to 19% [911] and for MAI infection it ranges from 3.5% to 9% [911]. For focal splenic lesions, the corresponding incidence is 3059% for MTB infection and 6.77% for MAI infection [911] (Figure 3). Focal renal lesions are also more common in MTB infection [9]. Pancreatic and adrenal involvement is rarely evident on imaging in either group. Proximal small bowel thickening is a feature of MAI infection and the appearance resembles Whipples disease, both histologically and radiologically [9, 12, 13]. Thickening of the terminal ileum is more typical of MTB infection (Figure 4) [14]. Recently, a new fastidious species, Mycobacterium genevense (MG), has been isolated [15] from HIV seropositive patients. It is a recognized cause of abdominal disease but it is radiologically and clinically indistinguishable from MAI

Figure 3. Focal splenic lesions. In this 33-year-old man with abdominal Mycobacterium tuberculosis infection there are multiple low attenuation lesions within the spleen. This appearance is, however, non-specic in the patient with AIDS. 26

Figure 4. Terminal ileitis. In this 44-year-old man with Mycobacterium tuberculosis infection there is concentric thickening of the terminal ileum. Imaging, Volume 14 (2002) Number 1

Abdominal CT in AIDS patients

infection [16]. Treatment for both MG and MAI infections are similar.

Cytomegalovirus
Cytomegalovirus is a common cause of lifethreatening opportunistic infection in patients with AIDS. The disease frequently results from reactivation of previous latent infection and usually occurs when the CD4 count falls below 100 cells ml21. The manifestation of disease depends on the severity of infection, which results in varying degrees of inammation, vasculitis and brosis. In the abdomen, the colon is the commonest site of involvement, followed by the small bowel, the oesophagus and the stomach. The caecum and the ascending colon are most frequently affected by colitis, although a pancolitis can result in severe infection. Barium enema typically demonstrates multiple ulcers with normal intervening mucosa. The CT ndings reect the degree of inammation, with concentric thickening of the colonic wall, narrowing of the intestinal lumen and pericolic inammatory changes [17] (Figure 5). The ulcer may be visible on CT and, in severe cases, toxic megacolon, pneumatosis coli and bowel perforation [17] are recognized complications. Lymphadenopathy, either within the mesentery or the retroperitoneum, is usually absent [17]. The antrum is usually the site of disease in the stomach, appearing as bowel wall thickening on CT. On barium studies there is thickening of the gastric folds associated with supercial or deep ulcerations [18]. Rarely, the infection may manifest as a polypoidal mass (cytomegalovirus pseudotumour), simulating neoplasia such as lymphoma, carcinoma or Kaposis sarcoma [19]. Cytomegalovirus is also a cause of biliary periductal brosis leading to stenosis of the distal

common bile duct and intrahepatic biliary strictures and dilatation. The appearance is indistinguishable from the AIDS-related cholangiopathy caused by cryptosporiodiosis.

Candidiasis
The oesophagus is the commonest site of involvement by candidiasis in patients with AIDS. Disseminated systemic candidiasis is less common because of the relative preservation of neutrophil function [20]. Oral thrush frequently accompanies oesophageal involvement. Infection of the oesophagus results in extensive ulceration, with multiple oesophageal plaques throughout the oesophagus. This gives rise to the typical diffuse irregular appearance on the barium oesophagram as shown in Figure 6. The appearance on CT is, however, non-specic, with thickening of the oesophageal wall. In severe infection, a mass-like lesion may

Figure 5. Cytomegalovirus colitis. CT in this 34-yearold with colitis shows concentric thickening of the ascending colon. There is minimal pericolic inammatory change. Note the absence of signicant lymphadenopathy within the retroperitoneum. Imaging, Volume 14 (2002) Number 1

Figure 6. Candidiasis. Barium oesophagram in this 26-year-old man with diffuse mucosal irregularity giving rise to a shaggy appearance typical of oesophageal candidiasis. 27

D M Koh, B Langroudi and S P G Padley

result, resembling carcinoma [21]. In disseminated disease, haematogenous spread of the infection can lead to microabscesses within the liver, spleen and kidneys. These appear on CT as multiple foci of low attenuation.

Pneumocystis carinii
Pneumocystis carinii is a protozoan-like organism. Infection predominantly affects the lungs in patients with AIDS and is more common in those individuals with a CD4 count of less than 100 cells ml21. Rarely the liver, kidneys (Figure 7), spleen, adrenal glands and abdominal lymph nodes [20] may be affected in disseminated Pneumocystis carinii infection. Extrapulmonary dissemination of infection occurs in less than 1% of patients with AIDS [22]. On CT, involvement of the liver and spleen appear as multiple, small, low attenuation lesions, which may show central punctate or rim calcications [23]. These low attenuation lesions have been shown to contain clusters of trophozoites and eosinophilic material [21]. Involvement of lymph nodes leads to nodal enlargement, which may also calcify [22]. Pancreatic involvement is very rare, but has been reported.

the chest radiograph is normal in up to 40% of cases [21]. The radiological ndings of disseminated histoplasmosis on CT mimic that of MTB infection [24]. The bowel is involved in the majority (75%) of cases [25], with the ascending colon being most frequently affected and the terminal ileum to a lesser degree. CT typically reveals concentric thickening of the diseased bowel, associated with perienteric inammatory change. The inammation can result in strictures resembling carcinoma. Low attenuation lymph nodes, resembling MTB lymphadenitis, within the mesentery or retroperitoneum are common [24]. Hepatosplenomegaly, adrenal enlargement and peritoneal nodularity have also been reported [24].

Cryptosporidiosis
Cryptosporidiosis is not uncommon in AIDS patients with a CD4 count of less than 200 cells ml21. Cryptosporidia are intracellular parasites that infect the epithelial cells of the gastrointestinal tract, resulting in hypersecretion and diarrhoea. The infection has a predilection for the proximal small bowel, resulting in nonspecic thickening of the duodenum, jejenum and proximal ileum [20]. Multiple loops of uid-lled and thickened small bowel loop can be identied on CT (see Figure 8). Lymphadenopathy is not a feature of the disease [20]. On barium followthrough, mucosal fold thickening, mucosal fold effacement and dilution of barium are well recognized features. Cryptosporidiosis and cytomegalovirus are causes of AIDS-related cholangiopathy, which results in dilatation of the intrahepatic and extrahepatic bile ducts as seen in Figure 9. The presence of papillary stenosis on endoscopy is useful

Histoplasmosis
Histoplasmosis is caused by the fungus Histoplasma capsulatum. In regions of the world where histoplasmosis is endemic, disseminated histoplasmosis may occur when the CD4 count falls to less than 100 cells ml21. Disseminated histoplasmosis may be a consequence of primary infection or reactivation disease, which is not dissimilar to the pathogenesis of disseminated MTB infection. Although the chest is the usual portal of infection,

Figure 7. Pneumocystis carinii. This man with previous pneumocystis infection of the kidneys demonstrates multiple, well dened, punctate calcications within the renal parenchyma bilaterally. 28

Figure 8. Cryptosporidiosis. 45-year-old man with microbiologically proven cryptosporidiosis. There are multiple loops of uid-lled small bowel showing concentric wall thickening. Imaging, Volume 14 (2002) Number 1

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Figure 9. AIDS cholangiopathy. There is mild dilatation of the intrahepatic ducts on CT in this patient with an enlarged liver. Endoscopic retrograde cholangiopancreatography (not shown) revealed multiple strictures of the intrahepatic ducts, resembling sclerosing cholangitis.

Figure 10. Bacillary angiomatosis. This 36-year-old man demonstrates several low attenuation lesions within the liver and spleen, associated with lymphadenopathy in the retroperitoneum.

Other infections
Other infections of the gastrointestinal tract include amoebiasis, giardiasis, salmonellosis and Campylobacter infections. These infections may occur with increased severity compared with the non-immunocompromised population. Renal infections such as pyogenic pyelonephritis and renal abscesses are not uncommon. The CT imaging features of pyelonephritis include renal enlargement, striated nephrogram or poorly functional kidneys (Figure 11a). Renal abscess is recognized as a focal, low attenuation area within the kidney. The pancreas may be affected by opportunistic infections such as toxoplasmosis, cytomegalovirus and MTB. However, pancreatitis may also result as a complication of anti-retroviral treatment. Treatment with protease inhibitors results in hyperlipidaemia, which predisposes to acute pancreatitis. Pancreatitis in these patients is associated with a high mortality. The imaging features on CT are similar to the ndings in an immunocompetent patient with pancreatitis (Figure 11b).

in distinguishing the condition from primary sclerosing cholangitis [26]. Infections with Cryptosporidium and cytomegalovirus are also known to give rise to acalculous cholecystitis, with thickening of the gall bladder wall and pericholecystic uid collection [27]. Infection with Isospora belli, a protozoan, can result in a gastrointestinal disease that is clinically and radiologically indistinguishable from cryptosporidiosis [28]. The two conditions may be differentiated by microscopic stool examination or intestinal biopsy.

Bacillary angiomatosis
Bacillary angiomatosis results from an infection by Bartonella henselae, an organism belonging to the group Rickettsiales. Infection results in prominent vascular proliferation and hence the named entity. The infection is found almost exclusively in HIV seropositive patients, with a prevalence of 1.2 per 1000 [29]. The most common manifestation of the infection is a cutaneous lesion, which may be mistaken for Kaposis sarcoma [30]. Other sites of involvement include the mucous membrane, bones, lymph nodes, intestine, liver, spleen and brain [30]. In the liver and spleen, CT may reveal multiple, low attenuation lesions (Figure 10). In some cases, peliosis of the liver can occur [31]. Low attenuation liver lesions are very non-specic in patients with AIDS, and may also result from microabscesses caused by variety of infections, lymphoma, Kaposis sarcoma or metastases. The disease may also manifest as enhancing abdominal lymphadenopathy on contrast enhanced CT, resembling that of Kaposis sarcoma.
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AIDS-related neoplasia
Patients with AIDS are at increased risk of developing neoplasms such as Kaposis sarcoma and lymphoma. In addition, there is also an increase in the incidence of squamous cell anorectal carcinoma.

Kaposis sarcoma
Kaposis sarcoma is the commonest tumour to affect patients with AIDS [20]. It occurs in up to 20% of the susceptible population, and is more common amongst homosexual men than in other patients with AIDS [20]. The tumour consists of
29

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(a)
Figure 11

(b)

11. (a) Pyelonephritis. This patient presented with acute ank pain. Note the striated nephrogram within the slightly enlarged kidneys, typical of acute pyelonephritis. (b) Pancreatitis. In another patient receiving protease inhibitor, there is enlargement and heterogeneity of the head of the pancreas associated with stranding of the peripancreatic fat. The appearance is consistent with acute pancreatitis.

clusters of spindle cells and vascular spaces. It is believed that an HIV regulatory protein is responsible for the uncontrolled proliferation of the sarcoma cells. The skin is the most frequent site of disease, and this usually precedes involvement of the solid organs and intestinal tract [32]. Although any segment of the gastrointestinal tract may be involved, the duodenum is most commonly affected [33]. The lesions appear on barium studies as submucosal nodules, which may undergo central umbilication [33]. With disease progression, the lesions may appear mass-like, associated with bowel wall thickening, and can be detected on CT. Involvement of the solid organs such as the liver and the spleen can be subtle on CT. The tumour typically inltrates along the vessels, and CT is frequently normal in these individuals [33]. Hepatosplenomegaly may be the sole abnormality on CT [34]. Less frequently, there may be multiple, small, low attenuation nodules, which enhance variably with iv contrast medium [34]. Unlike lymphoma and metastases, these nodules are frequently hyperechoeic on ultrasound [20]. Lymphadenopathy occurs with nodal dissemination of disease. High attenuation lymph nodes following administration of iv contrast medium are typical of nodal involvement [35]. However, the lymph nodes may be of soft tissue attenuation and therefore indistinguishable from other causes of lymphadenopathy such as lymphoma, mycobacterial infections and AIDS-related lymphadenopathy.

AIDS-related lymphoma
Lymphoma is the second most common malignancy in patients with AIDS [20]. Patients
30

with AIDS are at a much higher risk of developing non-Hodgkins lymphoma compared with the general population. The pathogenesis of lymphoma is uncertain, but is believed to be the result of B-cell proliferation induced by HIV or the Epstein-Barr virus [20]. AIDS-related non-Hodgkins lymphoma is frequently aggressive, poorly differentiated, high grade and carries a poorer prognosis compared with the disease affecting the normal population [36]. The disease is usually widely disseminated at the time of diagnosis, frequently affecting multiple extranodal sites such as bone, brain, abdominal viscera and gastrointestinal tract [20, 37]. Within the abdomen, the liver, spleen, kidneys, lymph nodes and gastrointestinal tract are most frequently affected [37] (Figure 11). The disease may less frequently affect the pancreas or adrenal glands [36]. Non-Hodgkins lymphoma of the liver and spleen appear as hepatosplenomegaly, often with accompanying low attenuation lesions [37] (Figures 12a,b). These focal lesions may demonstrate no, rim or diffuse enhancement on contrast enhanced CT. Involved kidneys may be similarly enlarged and inltrated (Figure 12c). The stomach and proximal small bowel are most frequently affected along the gastrointestinal tract [38]. Typical CT ndings include bowel wall thickening and mural masses [38]. Rarely, the patient may present with multiple peritoneal nodules and inltration of the omentum, resembling peritoneal carcinomatosis [20]. Lymphadenopathy is characteristically bulky [38]. However, cases may be difcult to distinguish from other causes of lymphadenopathy in the patient with AIDS. A percutaneous lymph node biopsy is usually needed to arrive at a denitive diagnosis.
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Abdominal CT in AIDS patients

(a)

(b)

(c)

Figure 12. (a) Lymphoma. There are two low attenuation lesions within an enlarged liver. There is no appreciable enhancement of these lesions. (b) CT demonstrates a solitary lesion in a normal-sized spleen. Lymphoma may present as multiple, small, splenic, low attenuation foci, splenic enlargment or a focal solitary lesion, as demonstrated here. (c) There are multiple masses of low attenuation within the kidneys. The appearance is typical of lymphomatous involvement of the kidneys.

The frequency of Hodgkins disease is not increased in the presence of HIV. Nevertheless, Hodgkins disease can arise in AIDS patients and there is also a higher incidence of extranodal involvement and more aggressive behaviour of the disease compared with the normal population [20].

increased incidence of crystallization and stone formation within the urinary tract, occurring in up to 20% of patients receiving the treatment [40]. Patients with crystal uropathy usually present with acute ank pain and dysuria. Since indinavir

Anorectal carcinoma
There is an increased incidence of anorectal carcinoma in patients with AIDS. The majority of these are squamous cell carcinomas [39]. Immunosuppression is associated with anal intraepithelial dysplasia, which can transform into an invasive cancer. Like lymphoma, these cancers are frequently locally invasive and aggressive at the time of diagnosis. MRI is useful in the diagnosis, staging and follow-up of these tumours (Figure 13).

Treatment-related conditions
Urolithiasis associated with protease inhibitors
Indinavir sulphate is a widely used protease inhibitor used to treat patients with HIV infection. However, its use is associated with an
Imaging, Volume 14 (2002) Number 1 Figure 13. Anorectal carcinoma. Post-intravenous gadolinium T1 weighted axial MR image showing an enhancing soft tissue mass arising from the left of the anal canal, breaching the external sphincter. 31

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stones are not visible on the abdominal radiograph [40], urolithiasis is usually conrmed by performing an excretory intravenous urogram, ultrasound or CT (Figure 14). Unlike stones of urate, oxalate or cystine, pure indinavir stones are radiolucent and cannot be visualized on unenhanced CT [3941]. Mixed indinavir and calcium stones may be radiopaque. The secondary signs of obstruction resulting from indinavir stones can also be minimal [41]. Hence, indinavir stones are best diagnosed on CT following iv contrast medium administration to delineate the presence of a stone or obstruction in patients who are receiving such treatment [41]. The majority of HIV seropositive patients with symptomatic urolithasis can be treated conservatively with hydration [42]. Surgical intervention is rarely necessary. However, metabolic screen can help to identify and correct factors that predispose to stone formation, reducing the risk of future recurrence.

Figure 15. Lipodystrophy. In this 38-year-old man receiving protease inhibitor, note the relative paucity of subcutaneous fat compared with the generous intraabdominal fat deposition. The appearance is typical of AIDS-related lipodystrophy.

HIV-related lipodystrophy syndrome

The treatment of HIV using HAART is associated with a lipodystrophy syndrome, characterized by wasting of the peripheral fat of the extremities, facial and gluteal area with increased central adiposity within the abdomen (Figure 15), breast and cervicothoracic region [43]. There is

usually associated hyperlipidaemia and insulin resistance [43]. Accumulation of intraabdominal fat results in symptoms such as abdominal distension and pain. Abdominal CT has been used to quantify these changes by measuring the ratio of visceral adipose tissue to total adipose tissue. Patients receiving indinavir treatment have a higher visceral to total adipose tissue ratio, and this ratio increases with the duration of treatment [44].

Conclusions
CT is increasingly utilized in the evaluation of infective and neoplastic conditions of the abdomen in patients with AIDS. Findings on CT are frequently non-specic. Common CT ndings include hepatomegaly, splenomegaly and lymphadenopathy. CT ndings of ascites, large focal hepatic lesions and extensive lymphadenopathy are associated with a poorer prognosis. Certain CT ndings may be helpful in indicating the underlying diagnosis. Lymph nodes with central low attenuation are typical but not pathognomonic of MTB infection. Thickening of the caecum and ascending colon is a feature of cytomegalovirus infection. Disseminated Kaposis sarcoma is associated with high attenuation lymph nodes following iv contrast medium administration. CT may allow a presumptive diagnosis to be made and treatment to be instituted before microbiological or histological results become available. Nevertheless, a tissue biopsy is frequently needed to conrm the diagnosis. CT is also useful in the follow-up of patients with abdominal diseases, especially in those with
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Figure 14. Urolithiasis. Excretory urogram demonstrating left ureteric obstruction in a patient receiving indinavir. The obstruction spontaneously resolved after 48 h. 32

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underlying malignancies. Abdominal diseases in patients with AIDS can also result from the treatment they are receiving. Urolithiasis, pancreatitis and lipodystrophy syndrome can result from treatment with protease inhibitor and are readily recognized on CT.

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