The British Journal of Radiology, 80 (2007), 302–306

Comparison of plain chest radiography and high-resolution CT in human immunodeficiency virus infected patients with community-acquired pneumonia: a sub-Saharan Africa study
1

K NYAMANDE,

MBChB, FCP (SA), MD,

1

U G LALLOO,

MD, FCCP, FRCP (London)

and 2F VAWDA,

FC Rad (SA)

Departments of 1Medicine and 2Radiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

ABSTRACT. The objective of the study was to determine the proportion of patients with missed lesions on plain chest radiographs compared with high-resolution computed tomography (HRCT) in 49 human immunodeficiency virus (HIV) infected patients with community-acquired pneumonia (CAP). Patients underwent plain chest radiography and HRCT scans of the chest at admission. Microbiological investigations for CAP were performed. An experienced radiologist, without knowledge of clinical or pathological data, reported the chest radiographs and HRCT scans. The study group included 26 females and 23 males, aged 18–53 years (mean age 36 years). Organisms were isolated from 26 patients (53%). In 40 patients (82%), the HRCT scans demonstrated lesions not visualized on the plain chest radiographs. There was 100% correlation between plain radiographic and HRCT scan findings in nine cases (18%). Lesions that were not visualized on the plain radiographs but elucidated on HRCT included: pleural effusion (n514), ground-glass opacification (n520), pericardial effusion (n58), cavitation (n54), cysts (n54), bullae (n54), abscess (n51) and pneumothorax (n51). In 20 of 23 cases, hilar lymphadenopathy, identified on HRCT, was not recognized on plain chest radiographs. In patients in whom an organism was isolated, a correct HRCT diagnosis of pulmonary tuberculosis, bacterial pneumonia and Pneumocystis carinii pneumonia (PCP) was made in 80%, 84% and 100% of cases, respectively. The proportion of patients with missed lesions on plain chest radiographs in HIV infected patients with CAP was high. This has important implications for management and prognosis. HRCT scans correlate well with the microbiological diagnosis when reported by an experienced radiologist.

Received 29 March 2006 Revised 21 July 2006 Accepted 15 August 2006 DOI: 10.1259/bjr/15037569
’ 2007 The British Institute of Radiology

Sub-Saharan Africa has the largest number of human immunodeficiency virus (HIV) infected subjects worldwide. The HIV pandemic in the region is still increasing and has not yet reached a plateau. The number of HIV infected patients presenting with pulmonary infections has also increased dramatically. The imaging technique of choice in patients with clinical symptoms and signs of community-acquired pneumonia (CAP) has traditionally been the chest radiograph [1–7]. This is largely because chest radiography is easy to perform, widely accessible, cheap and associated with low radiation. High-resolution CT (HRCT) scanning is reserved for the analysis of complex cases, particularly when the chest radiograph is equivocal with regard to associated central obstruction, cavitation, lymphadenopathy, or empyema [8, 9]. The role of HRCT, however, is rapidly evolving. In febrile neutropenic patients, CT scanning is more sensitive than plain
Address correspondence to: Prof. Umesh Gangaram Lalloo, Internal Medicine, University of KwaZulu Natal, 719 Umbilo Road, Congella, Durban, KwaZulu Natal, 4013 South Africa. E-mail: lalloo@:ukzn.ac.za This study was funded by a grant from the Medical Research Council of South Africa.

film in early detection of lung infections [10]. HRCT may have a role in patients whose chest radiographs are nonrevealing or non-diagnostic [11]. HRCT is helpful in the differential diagnosis of infectious from non-infectious acute parenchymal disease in the immunocompetent patient, but is of limited value in making a specific diagnosis [12]. There are no studies from sub-Saharan Africa on the utility and value of HRCT scanning of the chest in HIV infected patients with CAP. We compared HRCT with plain chest radiography, and the usefulness of HRCT in the microbiological diagnosis of PCP, pulmonary tuberculosis and bacterial CAP. We hypothesized that, in HIV infected patients presenting with CAP, clinically important lesions may not be evident on plain chest radiography.

Patient recruitment and methods
The study was performed at King Edward VIII Hospital, Durban, South Africa. This is a tertiary teaching hospital of the Nelson R Mandela School of Medicine. The hospital serves a predominantly black African population from the townships of Umlazi,
The British Journal of Radiology, May 2007

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which currently has the highest HIV or acquired immunodeficiency syndrome burden. followed by pleural effusions (35% of patients) and pericardial effusions (20% of patients) (Table 1). who undertook a study to characterize the frequency of lung lesions in asymptomatic HIV infected individuals with advanced disease. May 2007 . Pneumocystis jirovecii pneumonia or any other diagnosis. PCP and bacterial pneumonia were 80%. The sensitivities of HRCT compared with microbiology for the diagnosis of pulmonary tuberculosis. an alarmingly high percentage of patients (82%) have abnormalities that are not visible on plain chest radiograph. 5% cavitation. patients (82%). Inanda. They were randomly selected from inpatients presenting with symptoms and signs of CAP with a chest radiograph showing consolidation or an infiltrate compatible with the diagnosis. pericardial effusions. The CD4 count was determined in 37 patients. pleural effusions. None of these studies have been from subSaharan Africa. bullae. no patients with normal chest radiographs were recruited. mediastinal lymphadenopathy (nodes greater than 1 cm in short axis diameter) and the presence or absence of a pneumothorax. 84% and 100% of cases. 16. The most commonly missed abnormalities included ground-glass opacification (50% of patients) and mediastinal lymphadenopathy (50% of patients). The chest radiographs and HRCT scans were evaluated by a radiologist who had no prior knowledge of the aetiology of the pneumonia. Haemophilus influenzae (1) and Staphylococcus pneumoniae (1). 5% cysts and 1% abscess formation and pneumothorax. Klebsiella pneumoniae (1). granted permission to perform the study. There were 26 females and 23 males. degree of dyspnoea. The ethics committee of Nelson R Mandela School of Medicine. In our study. 18% pleural effusions. severity of symptoms. Analysis of the missed lesions as a proportion of the total number (n576) revealed that 26% were mediastinal lymphadenopathy. The findings on chest radiography correlated with the HRCT scan findings in only nine patients (18%).Comparison of plain CXR and HRCT in HIV infected patients with CAP KwaMashu. All the patients were black Africans. but the entry criteria were that of a normal or non-specific chest radiograph. From June 2000 to July 2001.5 mm collimation sections at 10 mm intervals reconstructed with a high spatial frequency algorithm. Mycobacterium tuberculosis. A correct HRCT diagnosis of pulmonary tuberculosis. Five patients had polymicrobial pneumoniae. The mean age of the patients was 36 years (range 18–53 years). Results Of the 54 patients recruited into the study 5 were excluded because they were HIV seronegative. HRCT was not specific for any diagnosis compared with microbiology (Tables 3). cysts. with a total of 76 missed lesions. 54 patients were recruited into the study. respectively (Table 3). The results of their study demonstrated that as many as 60% of HIV infected patients have unexpected abnormalities on HRCT at the time of starting PCP prophylaxis. To our knowledge. None of the patients was on antiretroviral therapy. Microbiological tests performed following induction and expectoration of sputum included Gram stain and culture. presence or absence of fever or leukocytosis. Discussion Few studies have been performed on the role of HRCT scanning of the chest in HIV related pulmonary infections [13–21]. Scans were reviewed at a setting appropriate for both lung parenchyma and mediastinum. No organisms were isolated in the remainder (Table 2). only Diehl et al [21] from Germany have investigated the clinical value of HRCT of the chest in patients with known HIV infection and acute lung disease. 100% and 85%. respectively. abnormalities were missed on the chest radiograph. Clermont and Chesterville. A HRCT scan of the chest was performed after admission to the medical ward. abscess formation. The mean CD4 count was 184 cells ml21 (range 0–1223 cells ml21). 19. 15. specificity and positive and negative predictive values of HRCT diagnosis vs the microbiological diagnosis. consisting of 1. Gram-negative bacilli (2). This study supports the findings of Guillemi et al [17]. Our study has shown that in HIV infected African patients with CAP. Microbiology There was a total of 31 isolates from 26 patients (53%). 5% bullae. All scans were performed without intravenous contrast medium at suspended end-inspiration with the patient in a supine position. No patients with normal chest radiographs had HRCT scans performed. bacterial pneumonia and pneumocystis carinii pneumonia (PCP) was made in 80%. 26% groundglass opacification. cavitation. The most common organism isolated was Mycobacterium tuberculosis (32%). duration of symptoms. The radiologist was asked to record the most likely aetiological diagnosis as bacterial pneumonia. In 40 The British Journal of Radiology. nodular opacification. Most have focused on PCP [13. Thus data from 49 patients were analysed. Other organisms isolated were Escherichia coli (2). ground-glass opacification. Evaluated HRCT findings included consolidation. The PCP immunofluorescence test was performed on induced sputum to detect Pneumocystis jirovecii. Syrjala et al [22] compared HRCT with chest radiography in 47 immunocompetent 303 Statistical analysis Two by two tables were used to calculate the sensitivity. followed by Streptococcus pneumoniae (29%) and PCP (19%). and Ziel– Neelsen stain for acid-fast bacilli. However. The HRCT scans were reported without the concurrent availability of the chest radiographs. Durban. South Africa. The chest radiographic and HRCT scan findings were then compared. 10% pericardial effusions. All were homosexual males on assessment for initiation of PCP prophylaxis. CD4 counts were assessed by flow cytometry. Blood cultures and urine tests for Legionella pneumophila and Streptococcus pneumoniae were performed. 20].

we have shown that a large proportion of HIV infected African patients presenting with CAP have clinically important abnormalities on HRCT that are not apparent on plain chest radiographs. but not for screening out. 26–28]. Advanced disease. U G Lalloo and F Vawda Table 1. correlation with the microbiological diagnosis was good. The present study demonstrated the sensitivity of HRCT in detailing abnormalities not apparent on chest radiography in a cohort of HIV infected patients with CAP. Superior contrast resolution and cross-sectional display is achieved. Coinfections occurred in 20% of patients (5 out of 26) in the present study. Lack of identification of these abnormalities may impact significantly on patient management and clinical outcome. However. these lesions may enlarge. HRCT identified all 18 cases apparent on chest radiography as well as an additional 8 cases. A lung abscess not treated for the appropriate duration may increase morbidity and mortality. technical. A small pneumothorax may rapidly expand causing compression of already diseased Table 2. The detection of some abnormalities may expand the options available to the clinician for obtaining diagnostic specimens for microbiology and histology. The mean CD4 count in the present study group was 184 cells ml21 and the lowest was zero. 23– 25]. This may be useful in modifying or switching therapy. The British Journal of Radiology. pleural effusions and pericardial effusions were among the most commonly missed lesions on chest radiographs. or bacterial CAP. This has important implications for the management of HIV associated CAP. The negative predictive values that were obtained in the present study suggest that the technique cannot be used to exclude PCP. Some abnormalities contribute to significant morbidity and may increase mortality. Although the radiologist in the present study was blinded to patients’ clinical information. Organisms isolated in 26 of the 49 patients Pathogen Number of isolates % Mycobacterium tuberculosis Streptococcus pneumoniae Pneumocystis jirovecii Escherichia coli Gram-negative bacilli Haemophillus influenzae Klebsiella pneumoniae Staphylococcus aureus 10 8 6 2 2 1 1 1 32 26 19 7 7 3 3 3 lung with consequent demise of a patient. the HRCT scan diagnosis has good correlation with the microbiological diagnosis. In the absence of clinical information it is difficult to distinguish pneumonia and other pathological processes [29]. the limitations of HRCT in the management of HIV associated CAP need to be recognized. Sub-Saharan countries are poor and underresourced. Radiologists rely on the clinical information provided to come to a reasonably accurate differential diagnosis. The HRCT findings in conjunction with the clinical features aided the physician in commencing therapy in patients in whom microbiological tests were negative. compressing normal lung in patients already afflicted with the ravages of HIV induced pulmonary infections such as repeated bacterial pneumonia.K Nyamande. In patients who are not improving clinically. The present study reflects the presence of significant complications detected on HRCT scans in patients with advanced HIV disease. Bullae and cysts may rupture causing a spontaneous pneumothorax. human resource and logistical constraints. ground-glass opacification. but also surpasses chest radiography in the detection of complications [24]. The sensitivity of HRCT diagnosis compared with the microbiological diagnosis was 100% for PCP. Co-infections become common. May 2007 304 . PCP and tuberculosis. The superiority of HRCT is well recognized [12. The attending physician had knowledge of the HRCT findings. In conclusion. The lower the CD4 count.5 2. The average positive predictive values attained in the present study suggest that HRCT scans are relatively good for screening in. is associated with HRCT abnormalities even in asymptomatic patients [17].5 18 26 26 10 5 5 5 1 1 14 20 20 8 4 4 4 1 1 (100%) (87%) (100%) (100%) (100%) (100%) (100%) (100%) (100%) patients with signs and symptoms of CAP. HRCT may assist with the decision to switch therapy. There are financial. the greater the likelihood of both opportunistic and non-opportunistic pulmonary infections. as shown by the high sensitivities obtained. The HRCT findings did not direct the microbiological investigations as most tests were performed within the shortest possible time on admission. The present study confirmed that no HRCT or chest radiographic pattern is specific for any infection [7. HRCT not only improves characterization of parenchymal infections in terms of location and extent of disease. When reported by an experienced radiologist. Lesions missed on plain chest radiography Number of patients with lesion % of total number of patients with missed lesions (n540) % of total number of missed lesions (n576) Number missed on chest radiography Pleural effusions Mediastinal lymphadenopathy Ground-glass opacification Pericardial effusion Cavitation Cysts Bullae Abscess formation Pneumothorax 14 23 20 8 4 4 4 1 1 35 50 50 20 10 10 10 2. Mediastinal lymphadenopathy. as determined by the CD4 count. Over time. tuberculosis. 85% for bacterial pneumonia and 80% for tuberculosis.

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