Thoracic Infections in Human Immunodeficiency
Virus/Acquired Immune Deficiency Syndrome
Galit Aviram, MD,* Joel E. Fishman, MD, PhD,† and Phillip M. Boiselle, MD‡
T he acquired immune deficiency syndrome (AIDS) epi-
demic continues to outstrip global efforts to contain or
eradicate it. Indeed, the total number of people living with
human immunodeficiency virus (HIV) currently stands at
40.3 million, double the number in 1995.1 During the two
and a half decades since the emergence of AIDS, many
changes have occurred in the demographics, complications,
and treatment of this epidemic.1,2 For example, the introduc-
tion of highly active anti-retroviral therapy (HAART) has
been associated with a dramatic reduction in HIV-associated
morbidity and mortality.1-6
Pulmonary disorders, particularly respiratory infections,
remain a common clinical presentation, and a source of sig-
nificant morbidity and mortality among HIV-infected indi-
viduals throughout the world, even in the current era of
potent anti-retroviral therapy. Interestingly, demographic
and therapy changes of HIV infection have been accompa-
nied by changes in the frequency and nature of the pulmo-
nary complications of AIDS and their imaging features.7,8 In
this article, we review the various infectious pulmonary com-
plications of AIDS, with a particular emphasis on recent
trends in imaging features of specific pulmonary infections as
demonstrated on chest radiography and computed tomogra-
phy (CT) examinations.
Demographics,
Treatment, and Prophylaxis
Demographics
Following dramatic reductions in the number of AIDS cases
and deaths in the United States in the mid-1990s, the number
of new cases has stabilized. However, since people with HIV
*Department of Radiology at Tel Aviv Sourasky Medical Center and Tel Aviv
University, Tel-Aviv, Israel.
†Jackson Memorial Hospital and University of Miami School of Medicine,
Miami, Florida.
‡Beth Israel Deaconess Medical Center and Harvard Medical School, Boston,
MA.
Address reprint requests to Phillip M. Boiselle, MD, Department of Radiol-
ogy, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Bos-
ton, MA 02215. E-mail: pboisell@caregroup.harvard.edu
0037-198X/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1053/j.ro.2006.08.004
are now living longer, the total number of people living with
HIV in the United States is still increasing, exceeding 1 mil-
lion at the end of 2003.1 According to the latest data, male
homosexuals continue to comprise a majority of people liv-
ing with HIV in the United States, accounting for 63% of
newly diagnosed HIV infections in 2003.6 Notably, during
the time period of 1999 to 2003, there was a 40% increase in
the rate of HIV infection among male homosexuals, which
offset the previous decline in this risk group during the early
and mid-1990s.6 At the end of 2003, an estimated 1,039,000
to 1,185,000 persons in the United States were living with
HIV/AIDS, with 25% undiagnosed and unaware of their HIV
infection.6
Intravenous drug use remains a prominent channel for
HIV transmission, accounting for about 20% of newly in-
fected people in the United States. Notably, there is a racial
disparity in HIV infection in the United States: although Af-
rican Americans comprise only 12.5% of the country’s pop-
ulation, they account for nearly half of new HIV cases. In
addition, African Americans have not experienced the same
benefit from anti-retroviral therapy as white Americans. For
example, in 2003, there were nearly twice as many deaths
among African Americans from AIDS compared with white
Americans.1,6
Regarding women infected by HIV, unprotected hetero-
sexual intercourse is the main mode of transmission for this
subgroup. Following an increase in the late 1990s, the pro-
portion of women among new annual infections has now
stabilized at approximately 25%.1,6
Although potent anti-retroviral therapies have trans-
formed the AIDS epidemic in developed nations, the battle
against AIDS looms large on a global basis, with continued
growth of the epidemic in the setting of significant barriers to
anti-retroviral therapy. Thus, when considering the AIDS ep-
idemic, it is important to keep in mind that two-thirds of
infected persons live in Africa, and one-fifth live in Asia.2 In
these regions, unprotected sexual intercourse between men
and women is the predominant mode of transmission of the
virus.1 In Africa, the sub-Saharan area is the most affected
region, where HIV prevalence rates have stabilized at unac-
ceptably high levels, exceeding 25% of the entire population
in some countries, while in other African regions rates remain
23
24
around 5 to 7%, or below.9 At best, only 1 person in 10 in
Africa and 1 in 7 in Asia who is in need of anti-retroviral
therapy would have received it in 2005.1 Thus, when report-
ing this disease, a split should be made between the develop-
ing world, where HAART has not been commonplace, and
the developed world, where HAART has led to the manage-
ment of HIV infection as a chronic disease, with life expect-
ancy after diagnosis now measured in decades rather than
years.4-6
Treatment
Combination anti-retroviral therapy, or HAART, is the cor-
nerstone of management of patients with HIV infection. By
effectively suppressing viral replication, HAART results in a
decrease in viral load and a rise in the CD4 lymphocyte
count, with an associated reduced prevalence of various op-
portunistic infections and certain neoplasms.4 Anti-retroviral
therapy is indicated for HIV-infected patients who are symp-
tomatic, and for those who have AIDS (CD4 cell counts of less
than 200 cells/mm3 or AIDS-defining conditions). Initiation
of anti-retroviral therapy in asymptomatic pre-AIDS patients
is usually recommended at CD4 levels below 350 cells/mm3.5
Following initiation of the widespread use of HAART in
the USA in 1996, marked declines have been noted in the
incidence of most AIDS-defining conditions, resulting in im-
proved survival and enhanced quality of life in patients with
HIV infection. Currently, drugs for the treatment of HIV in-
fection fall into three categories: those that inhibit the viral
reverse transcriptase; those that inhibit the viral protease en-
zyme; and those that interfere with viral entry.4-6 Interest-
ingly, following initiation of effective anti-retroviral therapy,
a paradoxical worsening of preexisting, untreated, or par-
tially treated opportunistic infections may be noted. The phe-
nomenon is called “immune reconstitution disease.” It is par-
ticularly common in patients with underlying untreated
mycobacterial infections. This entity is described in further
detail later in this article.10,11
Prophylaxis
Manifestations of HIV-related opportunistic infections can
occur at virtually any level of CD4 cell count, but the inci-
dence of serious and potentially life-threatening infections
increases dramatically as the CD4 cell count drops bellow
200 cells/mm3. CD4 thresholds of 200, 100, and 50 cells/
mm3 have been established as levels that demarcate the risks
of Pneumocystis jirovecii (formerly P. carinii) (PCP), Toxo-
plasma gondii, and Mycobacterium avium complex infec-
tions, respectively, and are indications for prophylaxis
against these infections.5,12 Indeed, the results of randomized
trials indicate that the risks of these infections can be reduced
by 50 to 80% or more with appropriate prophylaxis.13,14 For
example, the use of trimethoprim-sulfamethoxasole (TMP-
SMZ) as a Pneumocystis pneumonia prophylactic agent has
been associated with a marked reduction in the prevalence of
this infection. Interestingly, it may also provide protection
against bacterial pneumonias.15 A negative effect of wide-
spread prophylaxis has been the emergence of resistance
G. Aviram, J.E. Fishman, and P.M. Boiselle
against TMP-SMZ among P. jirovecii and bacterial organ-
isms.16,17 In addition, due to a high risk of infection with
Streptococcus pneumoniae, immunization with pneumococcal
polysaccharide is one of the generally recommended prophy-
lactic measures for patients with HIV infection and CD4 T-
cell counts ⬎200 cells/mm3. It is less clear whether this in-
tervention is of benefit in patients with more advanced
disease and high viral load.13,14
Approach to Imaging Diagnosis
Because the various pulmonary complications of HIV occur
with different frequencies among patients with specific risk
factors, different levels of immune compromise, and various
prophylactic therapies, one should integrate these factors
along with the clinical presentation and the recognized radio-
graphic pattern to reach the most likely correct diagnosis.8 Of
these parameters, the patient’s immune status, as reflected by
the serum CD4 lymphocyte count, is considered the most
important determinant for assessing the relative likelihood of
various pulmonary infections. The threshold levels of CD4
counts and associated risk for developing various pulmonary
infections are reviewed in Table 1.7,8,18-21 An important
threshold is a CD4 count ⬍200 cells/mm3, which is AIDS-
defining in an HIV-infected individual even in the absence of
an AIDS-defining illness, and places a patient at risk for op-
portunistic infections as well as certain malignancies.22
Presenting symptoms, in association with the level of
immunosuppression, may further guide the radiologist in
providing a limited and relevant differential diagnosis. For
example, pulmonary infections, in contrast to most malig-
nancies (except lymphoma), typically present with fever.
Among various infections, bacterial pneumonia is often asso-
ciated with an acute onset of fever, often with pleuritic chest
pain, productive cough, and purulent sputum. In contrast,
PCP typically has a more insidious onset, with symptoms
present for ⬎1 week before presenting to medical attention
with symptoms of dyspnea and dry cough. Unlike bacterial
pneumonia, pleuritic chest pain is usually absent in patients
with PCP unless it has been complicated by pneumothorax.7
Individual demographic characterization of the infected
patient may further narrow the differential diagnosis, as the
incidence of certain complications varies among different
populations. For example, among intravenous drug abusers
with HIV infection, bacterial pneumonia rates are more than
double those of other risk factor groups, regardless of the
CD4 lymphocyte count.23 This group of HIV patients also
shows an increased prevalence of septic emboli, recurrent
Staphylococcus aureus infections, lung abscess, and pulmo-
nary tuberculosis (TB) compared with other risk factor
groups. On the other hand, cytomegalovirus (CMV) occurs
more frequently in patients infected with HIV through sexual
contact,20 while Kaposi’s sarcoma occurs almost exclusively
in male homosexual patients.24 Interestingly, when control-
ling for HIV levels and use of anti-retroviral therapy, tobacco
use was found to triple the risk for hospitalization with PCP
and to double the risk for hospitalization with community-
acquired pneumonia.25 The geographic location of a patient
Thoracic infections in HIV/AIDS
Table 1 CD4 Count Thresholds and Related Risks for Thoracic Infections*
CD4 Count Level of Immunocompromise
>500 cells/mm3 Very mild impairment
200-499 cells/mm3 Mild impairment
<200 cells/mm3 Moderate impairment
<100 cells/mm3 Severe impairment
*Data from refs.7,8,18-21.
is also a significant factor. For example, analysis of surveil-
lance data collected in the World Health Organization Euro-
pean region between 1993 and 2000 revealed that PCP was
the most common opportunistic infection among all AIDS
patients in Western Europe, whereas TB was the most com-
mon infection in Eastern Europe.26
Table 2 displays the characteristic clinical, demographic,
laboratory, and radiographic findings in various pulmonary
infections. These features are described in further detail in
the following sections of this article.
Imaging Methods
Chest radiography is usually the first imaging test obtained
for the assessment of an HIV-infected individual with respi-
ratory symptoms.27 Despite atypical manifestations and over-
lapping features among several entities, the chest radiograph
is fairly accurate for diagnosing common complications. For
example, in a blinded study that assessed the ability of radi-
ologists to diagnose PCP, bacterial pneumonia, and pulmo-
nary tuberculosis in HIV-positive patients, Boiselle and
coworkers28 reported accuracies of 75, 64, and 84%, respec-
tively. It is likely that an integrated approach to interpretation
would have resulted in even higher accuracy. Importantly,
even in asymptomatic HIV patients, an abnormal chest radio-
graph usually signifies an active process. In this setting, my-
cobacterial infection is the most likely entity.29
CT is generally considered a second-line study for prob-
lems unresolved by chest radiography.30 The main indica-
tions for CT are listed in Table 3.7,30,31 With regard to evalu-
ating for occult lung disease, it is important to be aware that
a normal chest radiograph can be seen in a significant minor-
ity of HIV-positive patients with active pulmonary infection
due to a variety of organisms, including P. jirovecii and my-
cobacterial, fungal, and viral organisms. CT, particularly,
high-resolution CT, is usually positive in such patients.20 In
addition to identifying the presence of infection, high-reso-
25
Infections
Virulent organisms:
Encapsulated bacteria
Tuberculosis
Virulent organisms:
Encapsulated bacteria
Tuberculosis
PCP
Tuberculosis (including disseminated)
Bacterial infections
Atypical mycobacteria
Fungal infections
Cytomegalovirus
PCP
Tuberculosis
Bacterial infections
lution CT often reveals characteristic findings that can help to
determine the most likely causative organism.32
With regard to the accuracy of CT, Hartman and cowork-
ers33 have shown that this method is highly accurate in diag-
nosing certain complications, especially Pneumocystis pneu-
monia (94%) and Kaposi’s sarcoma (90%). Importantly, CT
also has a high negative-predictive value for excluding active
disease.30,33
Other imaging modalities play a very limited role in imag-
ing pulmonary complications of HIV infection. Although nu-
clear medicine gallium scanning was initially used in the
assessment of PCP, it has been supplanted by high-resolution
chest CT for this indication.34 Recently, positron emission
tomography fluorine-18 fluorodeoxyglucose scanning was
successfully used for localizing disease in AIDS patients with
fever of unknown origin. However, this technology is unable
to distinguish infection from tumor.35,36
Bacterial Infections
Although HIV infection is most closely associated with alter-
ations in cell-mediated immunity, there is evidence that AIDS
also substantially impairs humoral immunity.23 Altered B-
cell function and/or defects in neutrophil function place HIV-
infected individuals at especially high risk for frequent infec-
tions with encapsulated bacteria such as Streptococcus
pneumonia.12,23,37,38
Bacterial respiratory infections, including infectious air-
ways disease and pneumonia, are currently the most com-
mon respiratory disease in HIV-infected individuals in devel-
oped countries.39,40 Moreover, they are frequently the first
clinical manifestation of HIV infection. In a recent analysis of
published reports on bacterial pneumonia,41 rates were 25-
fold higher among HIV-infected individuals than in the gen-
eral population, although in developed countries, HAART
had shown a consistent effect on reduction of bacterial pneu-
monias.41
The significance of bacterial pneumonia in HIV infection is
26 G. Aviram, J.E. Fishman, and P.M. Boiselle

underscored by the inclusion of two or more episodes of

Small effusion
Effusion

Uncommon

Uncommon

Uncommon
Pleural
bacterial pneumonia within a 1-year period as an AIDS-de-

common
Common
fining illness for an HIV-infected individual, regardless of the

Absent
CD4 cell count.22 Although bacterial pneumonia often occurs
early in the course of HIV, the risk for this infection progres-
sively increases with decreasing CD4 counts.23,41 For exam-
Absent on CXR: mildly enlarged on CT

Common CT: low-density centers with

ple, HIV-infected individuals with CD4 counts ⬍200 cells/

common CT: low-density centers

mm3 have a fivefold increased prevalence of bacterial

CD4 >200: absent; CD4 <200:

pneumonia when compared with infected persons with CD4

with peripheral enhancement

Lymphadenopathy

counts greater than 500 cells/mm3.23 Bacterial pneumonia

peripheral enhancement
has been shown to accelerate the course of HIV.38 Among
AIDS patients, bacterial pneumonia is associated with higher
recurrence rates, and its occurrence is predictive of reduced
survival time.39 Thus, it is not surprising that, in a recent
autopsy series of 233 HIV-infected individuals, bacterial

Uncommon
pneumonia was found to be the most frequent pulmonary
Common
Absent

complication.42
Most episodes of pneumonia occur secondary to S. pneu-
moniae and Haemophilus influenzae, the same organisms that
commonly cause community-acquired pneumonia in the
Ground glass, consolidation, nodules

general population.38 Nosocomial pneumonia, however, is

CD4 >200: Postprimary cavitation;

mostly caused by S. aureus and Gram-negative agents, espe-

Bilateral, symmetrical interstitial;

Reticular and nodular opacities

cially Pseudomonas aeruginosa.43 Pseudomonas has also been

Patchy consolidation; nodules
CD4 <200: consolidation

recognized as an important cause of pulmonary infection in

AIDS among patients with a recent history of hospitalization,
Lungs

ground glass on CT

antibiotic use, or steroid therapy.44,45 Interestingly, “atypical

Focal consolidation

agents” such as Legionella pneumophila and Mycoplasma pneu-

Table 2 Clinical, Laboratory, and Radiographic Findings in Pulmonary Infections in HIV/AIDS

moniae are rarely diagnosed in HIV-infected patients with

community-acquired pneumonia.46
Patients with bacterial pneumonia typically present with
an acute onset of fever and productive cough, with symptoms
usually lasting less than 1 week before seeking medical atten-
tion.47,48 Most frequently, bacterial pneumonia in HIV
Presentation
Duration of
Symptoms

patients presents radiographically as focal consolidation

⬇30 days

>7 days

Variable

Variable

Variable
before

(Fig. 1), in either a segmental or a lobar distribution similar to

7 days

non-HIV-infected patients,49 but with a higher propensity for

multilobar and bilateral disease.20,27,49,50 In almost half of
cases of bacterial pneumonia, however, a radiographic pat-
tern other than focal consolidation is observed.28,50 Thus, it is
All groups, but especially

All groups, but especially

not surprising that bacterial pneumonia has been found to be

IVDA, and endemic

All groups, especially

Demographics

smokers and IVDA

Abbreviations: TB ⴝ tuberculosis; CMV ⴝ cytomegalovirus

more difficult to diagnose radiographically than either PCP or

endemic areas

pulmonary TB.28 For example, a bilateral pattern of alveolar

and/or interstitial opacities may be observed in the setting of
All groups

All groups

All groups

bacterial pneumonia, which can mimic PCP (Fig. 2).28 The

areas

identification of a segmental distribution can occasionally

help differentiate bacterial pneumonia from consolidative
PCP, which only rarely demonstrates a segmental pattern.28
Bacterial infections may also present as solitary or multiple
(cells/mm3)
Threshold-

lung nodules.25,51 A study regarding the etiology of pulmo-

<200

<100

<100

<100
None

None
CD4

nary nodules in HIV-infected patients found bacterial pneu-

monia as the most common etiology, followed by tuberculo-
sis.51 Pulmonary nodules due to bacterial and mycobacterial
infections usually measure greater than 10 mm in diameter,
mycobacteria

whereas nodules associated with viral infection usually mea-

Pneumocystis
pneumonia
Infection

sure less than 10 mm in diameter.52

Bacterial

Cavitary pulmonary lesions are an important radiological

Atypical

Fungal

CMV

finding in HIV-infected patients. A bacterial etiology was

TB

found in 85% of cases of cavitary lung disease detected on

Thoracic infections in HIV/AIDS 27

Table 3 Indications for Chest CT Imaging in HIV/AIDS upper lobe predominance; additional features may include
1. Evaluating for radiographically occult lung disease in empyema and lymphadenopathy.21
symptomatic patients with normal or equivocal chest Bacillary angiomatosis, an infection caused by B. henselae
radiographs and B. quintana, is characterized by a neovascular prolifera-
2. Further characterizing nonspecific patterns of tion involving multiple sites in the body including skin, liver,
abnormality on chest radiographs spleen, lymph nodes, and lung. Exposure to cats, cat fleas,
3. Assessing for complications of pneumonia, such as and lice are the main risk factors for this infection. Affected
abscess and empyema patients typically present with angiomatous skin lesions that
4. Staging AIDS-related malignancies mimic Kaposi’s sarcoma. Clinical symptoms include fever,
5. Assessing extent and characterization of enlarged
night sweats, cough, and occasional hemoptysis. Bacillary
intrathoracic lymph nodes
6. Planning and guiding biopsy procedures
angiomatosis has several radiographic manifestations in the
chest, including endobronchial lesions, parenchymal nod-
ules, pleural effusions, and densely enhancing lymphade-
nopathy and chest wall masses. One should strongly consider
chest CT scans of HIV-infected patients.53 In the majority of this treatable infection in patients with suspected Kaposi’s
patients, however, more than one pathogen was identified. sarcoma who lack the typical risk factor (homosexual con-
The most frequently found pathogens were P. aeruginosa and tact) for this neoplasm.57,59
S. aureus. S. aureus is frequently associated with septic emboli HIV-infected patients are also at increased risk for devel-
among intravenous drug abusers and usually presents as oping infectious airways disease such as bacterial tracheo-
multiple cavitary nodules. Other bacterial causes of cavitary bronchitis and bronchiolitis. The most common bacterial or-
nodules or cavitary consolidation include Nocardia asteroides ganisms responsible for infectious airways disease include H.
and Rhodococcus equi infections. Mycobacterial and fungal influenzae, P. aeruginosa, Streptococcus viridans, and S. pneu-
infections are important differential diagnostic consider- moniae.60,61
ations for these findings. Mediastinal and/or hilar lymphad- HIV-positive patients with pyogenic infectious airways
enopathy are more frequently associated with mycobacterial diseases typically present with dyspnea, fever, and produc-
infection than bacterial infection.49,53,54 Thus, when cavitary tive cough.62 Chest radiographs of patients with acute bacte-
lesions are accompanied by lymphadenopathy, mycobacte- rial bronchitis are usually normal, but may demonstrate
rial infection should be favored over bacterial infection. bronchial wall thickening.60
Parapneumonic pleural effusions are seen in a significant Extensive bronchiolitis may create an apparent interstitial
minority of cases of bacterial pneumonia and are usually pattern of reticulonodular opacities which represent im-
small in size (Fig. 1).28 Thoracic empyema is more common pacted bronchioles.8 This is typically symmetrically distrib-
in intravenous drug abusers, but surprisingly has an overall
low prevalence.55 Although intrathoracic lymph node en-
largement is not usually evident on chest radiographs, mildly
enlarged nodes are not infrequently seen on CT scans of
patients with bacterial pneumonia.28,56
HIV-infected individuals with uncomplicated bacterial
pneumonia due to typical pathogens usually have a clinical
and radiographic response to antibiotic therapy with a time
course similar to normal hosts undergoing treatment for
community-acquired pneumonia.38 In contrast to normal
hosts, however, bacterial pneumonia in AIDS tends to
progress more rapidly, is more often complicated by abscess
formation, and is more frequently associated with bactere-
mia.20,38
AIDS patients with advanced immune suppression are also
vulnerable to a host of unusual infections, including N. aster-
oides, R. equi,38 Bartonella henselae, and Bartonella quintana.57
Nocardia is a soil-borne aerobic actinomycete, acquired by
inhalation. It usually occurs in southern and rural regions of
the United States, possibly reflecting differential exposure to
soil-borne pathogens compared with urban areas.21 The lung
is the most commonly involved organ in HIV-related nocar-
diosis.58 R. equi pneumonia is typically seen in patients with
advanced immune suppression. Affected patients usually
present with an indolent course of cough, fever, and dyspnea. Figure 1 Bacterial pneumonia with typical radiographic features.
Radiographically, R. equi pneumonia usually presents with Frontal chest radiograph demonstrates focal right lower lobe con-
one or more foci of cavitary consolidation, often with an solidation and small parapneumonic right pleural effusion.
28 G. Aviram, J.E. Fishman, and P.M. Boiselle

Figure 2 Bacterial pneumonia with atypical features that mimic PCP.
Frontal chest radiograph shows bilateral perihilar parenchymal
opacities. This distribution is highly suggestive of PCP, but proved
to be due to bacterial pneumonia in this patient.
PCP
PCP has historically been one of the leading causes of mor-
bidity and mortality among persons with AIDS. The intro-
duction of highly active anti-retroviral therapy and wide-
spread PCP prophylaxis in industrialized nations has brought
about dramatic declines in the incidence of PCP, although it
is still the single most common opportunistic pulmonary
infection in patients with HIV infection in the United States,
responsible for approximately 25% of cases of pneumonia in
HIV infection.12 Approximately 25% of cases of HIV-associ-
ated PCP occur in patients who are unaware of their HIV
status.12 In view of the increasing prevalence of drug-resistant
HIV infections, possible drug-resistant PCP, and the tremen-
dous number of AIDS cases in developing countries, PCP
remains the most common cause of life-threatening infection
pulmonary infection in HIV-positive patients.66-68
Patients who develop PCP almost always have less than
200 CD4 cells/mm3, and often less than 100.3,66 Affected
patients generally present with an insidious onset of fever,
dry cough, and dyspnea.62,66,69 Symptoms are usually present
for roughly 30 days before patients present to medical atten-
tion. With respect to laboratory data, an elevated serum lac-
tate dehydrogenase level is highly sensitive for PCP, but it is
not very specific.48 Because P. jirovecii cannot be grown in

uted, with lower lobe predominance. Such findings may

mimic PCP.8
Chest CT, particularly high-resolution CT, is more sensi-
tive and specific than radiographs in detecting inflammatory
changes of the bronchi and bronchioles.60 Thus, in a symp-
tomatic patient with dyspnea, fever, and a productive cough,
high-resolution CT scan may demonstrate findings of small
airways disease despite the absence of radiographic findings.8
The characteristic findings of infectious bronchiolitis on
CT and high-resolution CT consist of centrilobular opacities
arranged in a “tree-in-bud” pattern, manifested by small, Y-
and V-shaped opacities in the lung periphery (Fig. 3).7,8
These opacities represent bronchioles that are impacted with
inflammatory secretions.7,8 Focal regions of air trapping may
also be evident on expiratory scans.63 While bacteria are the
most common etiology of small airways disease in AIDS pa-
tients, the differential diagnosis includes mycobacterial, viral,
and fungal infections.
Pyogenic airway infections led to inflammatory changes
involving the walls of the bronchi and bronchioles, resulting
in airway wall thickening and dilation.60 These changes may
be irreversible if not treated early with antimicrobial agents.60
Interestingly, bronchiectasis has been noted to develop in a
relatively short time after an episode of pulmonary pyogenic
infection in HIV-infected individuals.64 This shortened
timeframe suggests that AIDS patients may experience an
accelerated form of bronchiectasis.64 In a minority of HIV-
Figure 3 Bacterial small airways disease and pneumonia. CT sagittal
infected individuals, bronchiectasis may occur in the ab- oblique reformation image using maximal intensity projection dem-
sence of a history of prior infections and may subsequently onstrates small Y- and V-shaped opacities in the left lower lobe
predispose affected patients to future recurrent infec- (arrows), consistent with small airways disease. Also note small foci
tions.65 of adjacent consolidation (asterisk).
Thoracic infections in HIV/AIDS 29

Figure 4 PCP with typical radiographic and CT features. (A) Frontal chest radiograph shows diffuse bilateral distribu-
tion of hazy “ground-glass” opacities due to PCP. Findings are more conspicuous when compared with baseline
radiograph (B). (B) High-resolution chest CT shows diffuse ground-glass attenuation corresponding to the chest
radiographic abnormalities in (A).

culture, a diagnosis is made by morphologic identification of
the organism, usually from specimens obtained from in-
duced sputum or bronchoalveolar lavage.66,70
The classic chest radiographic presentation of PCP is a
bilateral perihilar or diffuse symmetric interstitial pattern,
which may be finely granular, reticular, or ground glass in
appearance (Fig. 4A).66,69-72 If left untreated, the parenchy-
mal opacities may progress to airspace consolidation.66
Radiographic improvement usually lags at least a few days
behind the clinical improvement; thus, frequent chest radio-
graphs may not be necessary during treatment for patients
who demonstrate clinical signs of response to therapy.73
Advances in the prevention and treatment of PCP have
been associated with an increased frequency of unusual man-
ifestations and a trend toward more subtle radiographic pre-
sentations.66,67,72,74 Importantly, the chest radiograph may be
normal in up to 39% of cases at the time of presentation,
especially in those patients with severe impairment in im-
mune status.75 CT, particularly high-resolution CT, is more
sensitive than chest radiographs for detecting PCP and thus
may be helpful in evaluating symptomatic patients with nor-
mal or equivocal radiographic findings.66,69,72,74 The classic
high-resolution CT finding in PCP is extensive ground-glass
attenuation (Fig. 4C), which corresponds to the presence of
intra-alveolar exudate, consisting of surfactant, fibrin, cellu-
lar debris, and organisms.32,66 It is often distributed in a
patchy or geographic fashion, with a predilection for the
central, perihilar regions of the lungs.32,66 When interlobular
septal thickening and intralobular linear opacities are super-
imposed over the ground-glass opacities, the resulting pat-
tern is referred to as “crazy paving.” Although nonspecific in
the acute setting, this pattern is closely associated with alve-
olar proteinosis when chronic in nature.32 Importantly, it
has recently been shown that, when a tree-in-bud appearance
30
Figure 5 Cystic PCP complicated by pneumothorax. Portable chest
radiograph demonstrates large cyst in right lung, which was com-
plicated by a basilar right pneumothorax, with slight shift of the
mediastinum to the left, suggestive of tension. Note diffuse bilateral
hazy “ground-glass” opacities, in keeping with PCP.
is present on high-resolution CT, PCP infection is very un-
likely.39
Several features that were once considered unusual mani-
festations of PCP are now considered as typical manifesta-
tions.66 These features include upper lobe distribution of pa-
renchymal opacities and cystic lesions, which may result in
spontaneous pneumothorax (Fig. 5).32,76,77 Some of the cysts
have been shown to be secondary to tissue invasion by P.
jirovecii followed by necrosis.32 Residual interstitial fibrosis is
not uncommon.32,66,69,74 Interestingly, interstitial fibrosis has
also been reported as the primary radiographic finding in a
subset of patients with PCP who experienced relatively stable
symptoms over months to years. This subset has been re-
ferred to as chronic PCP.78
Tuberculosis
It has been estimated that HIV-infected individuals have a
50- to 200-fold increased risk of mycobacterium TB com-
pared with the general population.79 Patients at particularly
high risk for TB include intravenous drug abusers and pa-
tients from areas where TB is endemic. The interplay between
infection with the two pathogens TB and HIV is complex: TB
can be associated with accelerated progression and higher
mortality in HIV infection, possibly due to increased HIV
replication and mutation in the lung,67 whereas HIV infection
increases the risk of developing active TB and TB recurrence,
at least among patients not receiving HAART.80,81 As TB is
both contagious and highly curable (except for multi-drug-
resistant strains), prompt diagnosis and treatment are essen-
tial.81
G. Aviram, J.E. Fishman, and P.M. Boiselle
TB may occur at any stage of HIV infection.81 In fact, TB is
often one of the initial manifestations of HIV infection. Pre-
senting symptoms may include cough, night sweats, and
weight loss. Symptoms are often present for more than 7 days
before patients seek medical attention.48
In comparison to the general population, patients with
HIV infection and TB more commonly demonstrate “atypi-
cal” radiographic patterns (eg, lymphadenopathy, pleural ef-
fusions, and mid and lower lung zones consolidation), irre-
spective of the time from acquisition of the infection to the
development of clinical disease. Using molecular fingerprint-
ing, it has recently been shown that the “atypical” radio-
graphic pattern is a result of altered immunity and may thus
represent either recent infection or reactivation of a latent
infection.82 Moreover, the radiographic pattern observed in
HIV-infected individuals with TB is dependent on the level of
immune suppression at the time of overt disease.83-85 Early in
HIV infection, when the CD4 count is ⬎200 cells/mm3, the
imaging features are typically those associated with reactiva-
tion TB, including parenchymal opacities with associated
cavitation, often located within the apical, posterior, and su-
perior segments of the lungs.83-85 In contrast, as the patient’s
immune level decreases, one will observe findings typically
associated with primary TB, including mid and lower lung
consolidation and lymph node enlargement.83-85 This pattern
is usually observed in patients with CD4 counts ⬍200 cells/
mm3. On CT, enlarged TB lymph nodes frequently demon-
strate low-density centers and peripheral contrast enhance-
ment.8,83,84
In comparison to normal hosts, AIDS patients with TB are
more likely to present with diffuse lung disease (Fig. 6),
bronchogenic spread, miliary disease, and extrapulmonary
disease.83-85 These manifestations increase in frequency with
Figure 6 Tuberculosis in a Haitian man with several months of
cough, weight loss, and night sweats. Chest radiograph shows bi-
lateral ill-defined nodular opacities predominately in the upper lung
zones. Expectorated sputum was positive for M. tuberculosis, and the
patient was simultaneously found to be HIV positive, with CD4
count of 273 cells/mm3.
Thoracic infections in HIV/AIDS
increasing degrees of immune suppression. At advanced lev-
els of immune suppression, it has been estimated that up to
20% of HIV-positive patients with TB have normal chest
radiographs.86 These patients often have a reduced colony
count of Mycobacterium tuberculosis. The combination of a
normal chest radiograph and negative sputum smears in HIV
patients may result in delays in diagnosis and treatment, in-
creasing the risk of fatality.87
In contrast to radiographs, CT scan of such patients usu-
ally reveal subtle abnormalities, including small nodules and
lymph node enlargement.83 Tuberculous bronchitis and
bronchiolitis frequently occur in HIV-positive and AIDS pa-
tients, even in those without cavitary disease. Endobronchial
spread caused by either M. tuberculosis or Mycobacterium
avium complex may have identical CT appearances, typically
resulting in a tree-in-bud pattern.27,83
In HIV-positive patients with drug-susceptible TB, the ad-
ministration of a standard 6-month regimen usually results in
a prompt response to therapy, similar to the non-HIV popu-
lation; however, a longer course of treatment for 9 to 12
months has been advocated for patients who show a slow
clinical or bacteriologic response to therapy.81 Directly ob-
served therapy improves outcome and reduces the rate of
multi-drug-resistant TB.81 Tuberculosis prophylaxis is usu-
ally administered to patients with history or symptoms of TB,
a purified protein derivative (PPD) of at least 5 mm, or a
possible false-negative PPD.5
In the past few years, there have been a growing number of
cases of patients on HAART exhibiting a paradoxical symp-
tomatic deterioration of presumably preexisting subclinical
opportunistic infections that become symptomatic following
HARRT-induced recovery of the immune response. The phe-
nomenon is referred to as immune reconstitution (or resto-
ration) disease (IRD).88,89 A low baseline CD4 count below 50
cells/mm3 represents a risk factor for IRD.90 Mycobacteria are
the most commonly implicated infectious organisms in IRD,
accounting for almost 40% of the cases reported up to
2002.91 With regard to mycobacterial infections, manifesta-
tions of IRD in the affected HIV-infected patient who is suc-
cessfully treated with HAART may be as subtle as fever and
minor lymph node enlargement, or as dramatic as respiratory
failure or neurological deterioration.91 Imaging findings in-
clude thoracic and abdominal lymphadenopathy (Fig. 7),
lung parenchymal abnormalities (such as consolidation, nod-
ules, micronodules), and/or pleural effusions.88,92,93 This
syndrome is associated with restoration of cutaneous delayed
type hypersensitivity reaction to tuberculin.90 Several diag-
nostic criteria have been proposed for establishing the diag-
nosis of IRD, including atypical presentation of opportunistic
infections in patients responding to anti-retroviral therapy,
decrease in plasma HIV RNA levels, and increased blood CD4
count. The differential diagnosis of IRD includes progres-
sive disease due to nonadherence to treatment, single- or
multi-drug-resistant mycobacterial infection, adverse
drug reaction, and concurrent opportunistic infection or
malignancy.88,92,90,93 Treatment is symptomatic; antimicro-
bial therapy should be started or continued, and antiinflam-
matory therapy using steroids may provide benefit.90
31
Figure 7 Immune restoration disease in a 34-year-old woman with
AIDS and TB (CD4 ⫽ 59 cells/mm3) who, after 5 months of directly
observed TB therapy, had a negative chest radiograph (not shown)
and negative AFB sputum cultures. Two-drug HAART therapy was
subsequently begun. After 1 week, the patient experienced nausea
and vomiting, fever, chills, and cough. Chest radiography showed
new mediastinal lymphadenopathy (arrows) and miliary nodules.
All sputum cultures remained negative. The anti-retroviral therapy
was discontinued, and the patient’s symptoms gradually improved.
She continued on antituberculous medication, and after several
months the chest radiograph returned to normal.
Atypical Mycobacterial Infections
Atypical mycobacterial infections in AIDS patients are usu-
ally secondary to Mycobacterium avium-intracellulare (MAI)
and less commonly due to Mycobacterium kansasii.8,85,94 Be-
cause MAI is a less virulent organism than M. tuberculosis, it is
usually encountered in the setting of more advanced immu-
nosuppression (CD4 ⬍50/mm3).8,85,94 Thoracic MAI in-
volvement usually occurs in the setting of disseminated dis-
ease, with the gastrointestinal tract serving as the main entry
site in most cases. A recent review of hospitalization charts in
HIV-infected patients admitted to a large metropolitan hos-
pital during 2001/2002 reported that nontuberculous myco-
bacteria was the third most common causative agent (after
bacterial pneumonia and PCP), accounting for 11% of hos-
pitalizations. In the majority of patients, the nontuberculous
mycobacterial infection was disseminated, with half of the
patients demonstrating respiratory tract involvement.95
Imaging findings in the lungs are variable and include
multifocal patchy consolidation, ill-defined nodules (Fig.
8B), and cavities (Fig. 9).8,96 Lymphadenopathy is frequently
present (Fig. 8A), but is observed less frequently than in
patients with TB. Importantly, a normal chest radiograph
may be observed in roughly 20% of patients with docu-
mented pulmonary infection with MAI.96 With regard to M.
kansasii infection, the most common finding is focal alveolar
consolidation.94
32 G. Aviram, J.E. Fishman, and P.M. Boiselle

Figure 8 Atypical mycobacterial infection with nonspecific imaging findings. (A) Contrast-enhanced CT (soft-tissue
window) at level of aortic arch demonstrates right paratracheal lymphadenopathy. (B) Lung window setting image at
level of lung apices shows a poorly defined ground-glass nodule in the right apex.

IRD has also been described in association with MAI,
mostly in profoundly immunosuppressed individuals who
have demonstrated an excellent response to HAART.91 Af-
fected patients present with an acute febrile reaction accom-
panied by new or enlarging peripheral, intrathoracic, or ab-
dominal lymphadenopathy.97 Interestingly, the development
of paratracheal lymphadenopathy may cause upper airway
compression.93 Pulmonary disease is the second most com-
mon manifestation, with variable manifestations, including
consolidation, cavitary lesions, lung nodules, atelectasis, and
tree-in-bud opacities.97 Affected patients usually respond to
appropriate antibiotic therapy, but adjunctive steroids may
be considered for severely symptomatic patients.91,97
Fungal Infections
With the exception of PCP, fungal organisms are a relatively
uncommon cause of pulmonary infection in AIDS patients,
but are more prevalent in endemic areas.8,21,98 The most com-
mon fungal pathogen to involve the lungs in AIDS patients is
Cryptococcus neoformans.8,21,98 Less common fungal infec-
tions include aspergillosis and the endemic fungi including
histoplasmosis, blastomycosis, and coccidiomycosis.12

Figure 9 Atypical mycobacterial infection mimicking tuberculosis. Frontal chest radiograph (A) shows biapical complex
cavitary lesions, which are shown to better detail on an axial CT image (B). Tuberculosis could produce an identical
radiographic appearance.
Thoracic infections in HIV/AIDS 33

Figure 10 Cryptococcoma in a 60-year-old man with HIV (CD4 ⫽ 86 cells/mm3) presenting with cough and weight loss,
with negative sputum cultures. Chest radiograph (A) demonstrates a 2-cm noncalcified nodule (arrow) in the left lower
lobe, which was confirmed by CT (B). CT-guided biopsy was positive for Cryptococcus neoformans.

Pulmonary cryptococcal infection usually occurs in the Viral Infections

setting of advanced immunosuppression (CD4 ⬍100/mm3).
More than half of patients are fungemic, and 90% of patients
have concomitant CNS infection.12 Imaging findings are non-
specific and include reticular or reticulonodular opacities,
nodules (Fig. 10), and foci of consolidation. Parenchymal
abnormalities may be accompanied by lymph node enlarge-
ment and pleural effusion.8,21,98
Although infection with Aspergillus is uncommonly en-
countered in AIDS, its incidence is increasing.21,98-100 This
infection occurs almost exclusively in HIV-positive indi-
viduals with neutropenia (usually acquired from drugs
such as zidovudine or ganciclovir) or steroid use.21,98-100
Affected patients generally have advanced immune sup-
pression, with CD4 counts ⬍50 cells/mm3.21,98-100 Patients
with angioinvasive aspergillosis may demonstrate cavitary
disease with an upper lobe predominance,8 or multifocal
areas of alveolar consolidation or nodules with a halo of
peripheral ground glass.8,12,98-101 Airway invasive aspergil-
losis is another form of pulmonary Aspergillus infection,
which includes tracheobronchitis, bronchiolitis, and
bronchopneumonia. Chest radiography may be normal in
tracheobronchitis, or it may show bronchial wall thicken-
ing. On high-resolution CT, bronchiolitis is characterized
by a tree-in-bud pattern.72
CMV is the most common viral pulmonary pathogen in AIDS
patients.102-105 Although it is frequently recovered from the
lungs, CMV is not considered a significant pathogen in most
cases.103,104 Isolated clinically relevant cases of CMV pneu-
monitis may occur, however, and generally affect patients
with advanced levels of immunosuppression (CD4 ⬍100/
mm3).103,104 Most patients have documented extrathoracic
CMV infection.8,103 Interestingly, CMV infection occurs most
frequently in patients infected with HIV by sexual contact,20
either heterosexual or homosexual.
The most common CT findings of CMV pneumonitis are
ground-glass opacities and alveolar consolidation, which
may mimic PCP.27,32,103,105 Other imaging findings include
nodules, masses, and small airways disease.32,103,105 In a series
of 21 AIDS patients with CMV pneumonia, McGuinness and
coworkers reported that nodules or masses were present in a
majority of cases.103 The latter findings are not typically as-
sociated with PCP, and their identification may thus be help-
ful in distinguishing between these two infections.
Summary
Pulmonary infections remain an important complication of
HIV infection, even in the current era of potent anti-retroviral
34
therapy. Employing an integrated approach that combines
radiographic pattern recognition with knowledge of a pa-
tient’s clinical symptoms, laboratory data, immune status
level, demographic information, and drug therapy can en-
hance the interpretation of imaging studies in HIV-infected
patients. Although chest radiography remains the mainstay
of imaging the HIV-positive patient with respiratory symp-
toms, CT plays an increasingly important secondary role in
selected cases.
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