Documente Academic
Documente Profesional
Documente Cultură
Gillian Lieberman, MD
November 2004
Imaging of gastro-intestinal
disease in patients with AIDS
Patient DR
• DR is a 43 yo man with HIV and HCV who presents
with abdominal pain, one episode of minimal
hematemesis, chronic weight loss, and diarrhea.
• Most recent viral load 15,500, CD4 91, on HAART
• PMH
HIV/AIDS
Chronic Hepatitis C
Kaposi’s sarcoma
Candida esophagitis
Refractory ascites
Esophageal varices sp/ banding
HIV-associated dementia
2
Cat Livingston, HMS IV
Gillian Lieberman, MD
3
Cat Livingston, HMS IV
Gillian Lieberman, MD
DR’s Abdominal CT
Ascites
Cirrhotic
liver Spleno-
megaly
PACS, BIDMC
4
Cat Livingston, HMS IV
Gillian Lieberman, MD
Splenomegaly
Surface
nodularity of
the liver
Ascites
5
Courtesy of Dr. Rofsky
Cat Livingston, HMS IV
Gillian Lieberman, MD
AIDS overview
• 38 million people are living with HIV/AIDS
• 20 million people have died since the beginning of
the epidemic
• HAART markedly reduced mortality, AIDS,
AIDS-defining diagnoses and hospitalizations
9
Cat Livingston, HMS IV
Gillian Lieberman, MD
2) Neoplasm
a. Kaposi’s sarcoma
b. Non-Hodgkin’s lymphomas
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Cat Livingston, HMS IV
Gillian Lieberman, MD
Odynophagia – secondary to
acute HIV infection
Acute HIV infection:
• Fever, pharyngitis,
adenopathy,
mylagias, and rash.
HIV ulcers
• Multiple discrete
shallow ulcers
• Early HSV
infection looks
identical
Images courtesy of Dr. Gramm 12
Cat Livingston, HMS IV
Gillian Lieberman, MD
Candida esophagitis
Second most Diffuse,
common AIDS- confluent
defining illness plaques
present, with a
“cobblestone”
Present with appearance.
odynophagia,
dysphagia, or
chest pain.
CD4 count
<200cells/uL Advanced Images Courtesy of
Dr. Gramm
13
Mild
Cat Livingston, HMS IV
Gillian Lieberman, MD
Candida esophagitis
Creamy plaques present along the Advanced
long axis of the esophagus in this case:
less severe case.
Confluent
plaque
creating a
pseudo-
membrane
is present.
CMV esophagitis
Vasculitis Æ ischemia
Æulcer formation
Cryptosporidiosis
• Occurs with CD4 count <200cells/uL
• Intracellular parasites that infect GI tract epithelial cells
• Causes a hypersecretory diarrhea
– Similar to Isospora belli and Microsporidia infection
Cryptosporidiosis
Gastropathy with
retained food
Jejunal fold
enlargement
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Courtesy of Dr. Gramm
Cat Livingston, HMS IV
Gillian Lieberman, MD
Lamina propria
macrophages
containing MAC
Duodenal and
jejunal irregular
fold thickening
MAC enteritis
Jejunal
bowel wall
thickening
Mycobacterium tuberculosis
“The Great
Imitator” Minimal
Most common – retro-
low attenuation peritoneal
mesenteric adenopath
y, low
lymphadenopathy,
attenuation
nodules in the
omentum and
peritoneum, and
high attenuation
ascites.
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PACS, BIDMC
Cat Livingston, HMS IV
Gillian Lieberman, MD
Cytomegalovirus colitis
CMV is most common life threatening opportunistic infection in the
AIDS patient. CD4 count <100cells/uL. Pneumatosis and bowel
perforation can result.
Markedly
thickened folds
of the transverse
and descending
colon, consistent
with pseudo-
membrane
formation
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PACS, BIDMC
Cat Livingston, HMS IV
Gillian Lieberman, MD
Cytomegalovirus colitis
Vasculitis in submucosa
Æthrombosis and ischemia
Circumferential
ulcerated
stricture
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Cat Livingston, HMS IV
Gillian Lieberman, MD
AIDS cholangiopathy
• Cryptosporidium or Cytomegalovirus
• Present with right upper quadrant pain,
nausea, vomiting, fever, and elevated white
count and serum alkaline phosphatase
• Acalculous cholecystitis
• AIDS cholangitis – features:
– Papillary stenosis
– Biliary duct strictures and thickening
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Cat Livingston, HMS IV
Gillian Lieberman, MD
Acalculous Cholecystitis
Gallbladder wall thickening in
both CT and ultrasound.
Minimal pericholecystic fluid is
present on ultrasound.
AIDS cholangiopathy
large abscess
ductal
dilatation
strictures
Anorectal Disease
• Most common in patients who engage in anal intercourse
Symptoms:
Dyschezia, BRBPR, tenesmus
Findings:
Perirectal abscesses
Anal fistulas
Ulcerations
Proctitis
Anorectal carcinoma 31
Cat Livingston, HMS IV
Gillian Lieberman, MD
HSV Proctitis
Peri-rectal
wall
thickening
secondary to
inflammation,
with possible
fistula
formation.
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PACS, BIDMC
Neoplasms of the GI tract
Cat Livingston, HMS IV
Gillian Lieberman, MD
Kaposi’s sarcoma
• More likely to occur in
homo- or bi-sexual
patients with CD4 count
<200cells/uL
• Associated with human
herpes virus 8
• Preceded by cutaneous
manifestations
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Courtesy of Dr. Gramm Bulky polypoid lesions
Cat Livingston, HMS IV
Gillian Lieberman, MD
Non-Hodgkins lymphoma
• 60-fold greater risk of developing
lymphoma than in the general population
• Almost all have extranodal disease
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Cat Livingston, HMS IV
Gillian Lieberman, MD
Non-Hodgkins lymphoma
Hepatomegaly with two low Ultrasound of liver
attenuation lesions present in the liver. with multiple
hypoechoic lesions.
* *
Disseminated disease
• Hematogenous dissemination is rare
• Why? Neutrophil function is relatively intact
• Granulocytopenia secondary to
– Medications
– Infected indwelling catheters
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Cat Livingston, HMS IV
Gillian Lieberman, MD
Disseminated candidiasis
ÆNecrotizing entercolitis
Pneumatosis
intestinalis
and
mesenteric air
are present.
DR
DR is a patient with advanced AIDS
• Bleeding esophageal varices secondary to portal
hypertension from cirrhosis and coagulopathy
A therapeutic paracentesis was performed.
During his hospital course he received treatment for
candidal esophagitis.
Social work became involved because it was unclear
he had been taking his medications, a VNA was
re-organized.
He was placed on a NJ feeding tube for his AIDS
enteropathy (chronic diarrhea, weight loss, and
malnourishment).
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Cat Livingston, HMS IV
Gillian Lieberman, MD
References
CDC Surveillance for AIDS: Defining opportunistic illnesses 1992-1997. MMWR Morbidity
and Mortality Weekly Report 1999; 48:1.
Dezube BJ, Groopman JE. AIDS-related Kaposi’s sarcoma: Clinical features and treatment.
UpToDate December 2003. Picture 4.
Erbelding, EJ. Case 2: A 30 yuear old woman with AIDS, abdominal pain, and fevers.
http://www.hopkins-aids.edu/educational/caserounds/images/jhas_case_abpelvic2.jpeg
Koh DM. Langroudi B, Padley SPG. Abdominal CT in patients with AIDS. Imaging 2002:
24-34. Figures 12a and 12c.
Mathieson JR, Smith FR. Hepatobiliary and pancreatic ultrasound in AIDS. In Reeders J,
Mathieson JR (Eds.) AIDS Imaging: A practical clinical approach. Saunders: London.
1998, 188-202.
Radin DR. Hepato-pancreato and biliary imaging in AIDS: Computed Tomography. In
Radiologic Clinics of North America: Imaging of the patient with AIDS. 1997 35(5):
203-213.
Redvanly RD, Silverstein JE. Intra-abdominal manifestations of AIDS. In Radiologic Clinics
of North America: Imaging of the patient with AIDS. 1997 35(5): 1083-1125.
Scully RE, Mark EJ, McNeely WF, Ebeling SH, Ellender SM. Case Records of the
Massachusetts General Hospital. Case 5-2000. New England Journal of Medicine 2000,
342(7):493-500.
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Cat Livingston, HMS IV
Gillian Lieberman, MD
References continued
UNAIDS. 2004 Report on the global HIV/AIDS epidemic. Geneva: Joint United
Nationals Program on HIV/AIDS, July 2004.
Wall SD, Yee J, Reeders J. Imaging of the lumenal gastrointestinal tract in AIDS.
In Reeders J, Mathieson JR (Eds.) AIDS Imaging: A practical clinical
approach. Saunders: London. 1998, pp. 168-187.
Wilcox, CM. Overview of gastrointestinal manifestations of AIDS. UpToDate.
2004. Histology 1.
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Cat Livingston, HMS IV
Gillian Lieberman, MD
Acknowledgements
Herbert Gramm, MD
Neil Rofsky, MD
Pamela Lepkowski
Gillian Lieberman, MD
Larry Barbaras
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