Cat Livingston, HMS IV

Gillian Lieberman, MD
November 2004

Imaging of gastro-intestinal
disease in patients with AIDS

Cat Livingston, Harvard Medical School Year IV

Gillian Lieberman, MD
 Cat Livingston, HMS IV
Gillian Lieberman, MD

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

DR’s Physical Exam

(positive findings only)

General: Severely cachectic man

HEENT: Tongue beefy red, dried blood in
mouth, dry mucous membranes
Abdomen: Distended, with shifting dullness.
Guiaic +
Neuro: Alert and oriented x2. Perseverates.
Motor 4/5 in all extremities.

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

MRI: cirrhosis and its consequences

Varices

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

• ¼ of HIV+ patients are co-infected with Hepatitis

C virus
• Tuberculosis co-infection up to 40% - 60% in US
inner cities.
UNAIDS. 2004 Report on the global HIV/AIDS epidemic. Geneva: Joint
United Nationals Program on HIV/AIDS, July 2004. 6
 Cat Livingston, HMS IV
Gillian Lieberman, MD

DDx GI bleed and abdominal

discomfort in DR
• Bleeding esophageal varices +/- coagulopathy
• Bleeding ulcers (esophageal, gastric, duodenal)
• Kaposi’s sarcoma
• GI lymphoma
• Cytomegalovirus colitis
• Typhilitis
• Cryptosporidiosis
• Salmonellosis
• Histoplasmosis
• Spontaneous bacterial peritonitis 7
 Cat Livingston, HMS IV
Gillian Lieberman, MD

AIDS-defining illnesses (CDC)

Common • Pneumocystis carinii pneumonia (42.6%)
• Candidiasis of the esophagus or airway (15.0%)
• Wasting (10.7%)
• Kaposi’s sarcoma (10.7%)
• Disseminated Mycobacterium avium complex (4.8%)
• Tuberculosis (4.5%)
• Cytomegalovirus disease (3.7%)
• HIV-associated dementia (3.6%)
• Recurrent bacterial pneumonia (3.0%)
• Toxoplasmosis (2.6%)
• Lymphoma (1.9%)
• Cryptosporidiosis, persistent (1.5%)
Less
common
• Herpes simplex, chronic infection (0.5%) 8
 Cat Livingston, HMS IV
Gillian Lieberman, MD

CD4 Count and Pathogens

CD4 >200 CD4 200-100 CD4 <100cells/uL

Tuberculosis Cryptosporidiosis Mycobacterium
Candidiasis Coccidiodomycosis
s
avium complex
Herpes simplex Cryptococcis Histoplasmosis
Herpes zoster Toxoplasmosis Cytomegalovirus
Hairy leukoplakia Pneumocystosis Lymphoma
Kaposi’s sarcoma

9
Cat Livingston, HMS IV
Gillian Lieberman, MD

Abdominal disease in AIDS

Two major categories:
1) Infection

2) Neoplasm
a. Kaposi’s sarcoma
b. Non-Hodgkin’s lymphomas

10
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Abdominal symptoms in AIDS

Very common (up to 90%)
Intolerance to medications
Thrush
Diarrhea – chronic, associated with weight
loss and malnutrition
Common
Odynophagia and dysphagia
Abdominal pain (RUQ especially)
Fevers
Anorectal disease
11
 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.

Wall SD, Yee J, Reeders J. Imaging of the

lumenal gastrointestinal tract in AIDS.
Courtesy of Dr. Gramm 14
Saunders: London. 1998, pp. 168-187.
 Cat Livingston, HMS IV
Gillian Lieberman, MD

CMV esophagitis

There are multiple large

(>2cm), discrete ulcers
in the distal esophagus.
Note the intervening
mucosa is normal.

Vasculitis Æ ischemia
Æulcer formation

Redvanly RD, Silverstein JE. Intra-abdominal manifestations of AIDS. In Radiologic

15
Clinics of North America: Imaging of the patient with AIDS. 1997 35(5): Figure 8.
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Diarrhea in an patient with AIDS

Symptoms Likely Pathogens

Epigastric cramps, bloating, nausea Æ MAC, Cryptosporidium, Isospora

Severe watery diarrhea, weight loss Æ Cryptosporidiosis

Hematochezia and lower abdominal Æ CMV, C. diff, Shigella,

cramping Campylobacter

Anorectal tenesmus, dyschezia Æ Herpes simplex virus,

N. gonorrhea, Chlamydia

An aggressive approach to diagnosis is recommended.

16
 Cat Livingston, HMS IV
Gillian Lieberman, MD

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

Non-specific radiographic findings:

• Small bowel fold enlargement
• Gastropathy (rigidity)
• Gallbladder wall thickening
17
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Cryptosporidiosis
Gastropathy with
retained food

Jejunal fold
enlargement

18
Courtesy of Dr. Gramm
Cat Livingston, HMS IV
Gillian Lieberman, MD

Mycobacterium avium complex

• Occurs with CD4 count<100cells/uL
• Typically present with clinical enteritis:
abdominal pain, fevers, malabsorption,
night sweats, weight loss, severe anemia,
• Bulky mesenteric adenopathy and small
bowel involvement
• Disseminated MAC infection
Æhepatosplenomegaly with microabscesses
19
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Mycobacterium avium complex

Lamina propria
macrophages
containing MAC

Duodenal and
jejunal irregular
fold thickening

Wilcox, CM. Overview of gastrointestinal

manifestations of AIDS. UpToDate. 2004.
Courtesy of Dr. Gramm 20
 Cat Livingston, HMS IV
Gillian Lieberman, MD

MAC enteritis

Jejunal
bowel wall
thickening

Redvanly RD, Silverstein JE. Intra-abdominal manifestations of AIDS. In Radiologic

21
Clinics of North America: Imaging of the patient with AIDS. 1997 35(5): 1083-1125.
Cat Livingston, HMS IV
Gillian Lieberman, MD

Mycobacterium avium complex

Bulky mesenteric
lymphadenopathy
present.

CD4 < 50cells/uL

It is important to
distinguish from
tuberculosis
lymphadenitis.

Courtesy of Dr. Gramm 22

 Cat Livingston, HMS IV
Gillian Lieberman, MD

Nodal enlargement DDx

• Mycobacterium tuberculosis
• Mycobacterium avium complex
• Cytomegalovirus
• Varicella zoster virus
• Pneumocystis carinii
• Histoplasmosis
• Cryptococcosis
• Lymphoma
• Kaposi’s sarcoma
23
 Cat Livingston, HMS IV
Gillian Lieberman, MD

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.

24
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

25
PACS, BIDMC
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Cytomegalovirus colitis
Vasculitis in submucosa
Æthrombosis and ischemia

Circumferential
ulcerated
stricture

Wall SD, Yee J, Reeders J. Imaging of the lumenal http://www.hopkins-

gastrointestinal tract in AIDS. In Reeders J, Mathieson JR
aids.edu/educational/caserounds/images/jhas_
(Eds.) AIDS Imaging: A practical clinical approach. 26
Saunders: London. 1998, figure 16.20.. case_abpelvic2.jpeg
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Liver and Biliary Tree

• Hepatomegaly very common
(50% clinically, vast majority at autopsy)
• Chronic HBV or HCV infection widespread
• Liver tests are non-specific in HIV-infected
patients and liver biopsies abnormal in 95%.
• AIDS cholangiopathy

27
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

28
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Acalculous Cholecystitis
Gallbladder wall thickening in
both CT and ultrasound.
Minimal pericholecystic fluid is
present on ultrasound.

Images courtesy of Dr. Gramm

29
 Cat Livingston, HMS IV
Gillian Lieberman, MD

AIDS cholangiopathy

large abscess

ductal
dilatation

strictures

Mathieson JR, Smith FR. Hepatobiliary and pancreatic ultrasound in 30

AIDS. Saunders: London. 1998, Figure 17.19. Courtesy of Dr. Gramm
 Cat Livingston, HMS IV
Gillian Lieberman, MD

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.

32
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

34
Courtesy of Dr. Gramm Bulky polypoid lesions
 Cat Livingston, HMS IV
Gillian Lieberman, MD

Kaposi’s sarcoma of the colon

Complications:
Diarrhea, bleeding,
obstruction,
perforation, and
protein-losing
enteropathy
Hepatosplenomegaly is
also common
Dezube BJ, Groopman JE. AIDS-related Kaposi’s sarcoma: Clinical DDx: lymphoma,
features and treatment. UpToDate 1December 2003. Picture 4.
infection,
Large, annular, submucosal red-purple hematogenous
masses – circumferential infiltration and metastases, polyps,
obstruction in the colon Crohn’s, and bacillary
angiomatosis 35
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

• Bulky adenopathy common

• (DDx includes KS and mycobacterium)

36
 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.

* *

* * Redvanly RD, Silverstein

JE. Intra-abdominal
manifestations of AIDS. In
Radiologic Clinics of North
America: Imaging of the
patient with AIDS. 1997
Koh DM. Langroudi B, Padley SPG. Abdominal CT in 35(5).
37
patients with AIDS. Imaging 2002: 24-34. Figure 12a.
Cat Livingston, HMS IV
Gillian Lieberman, MD

Disseminated disease
• Hematogenous dissemination is rare
• Why? Neutrophil function is relatively intact

• Granulocytopenia secondary to
– Medications
– Infected indwelling catheters

38
 Cat Livingston, HMS IV
Gillian Lieberman, MD
Disseminated candidiasis
ÆNecrotizing entercolitis
Pneumatosis
intestinalis
and
mesenteric air
are present.

Redvanly RD, Silverstein JE. Intra-abdominal manifestations of AIDS. In Radiologic 39

Clinics of North America: Imaging of the patient with AIDS. 1997 35(5): Figure 6.
 Cat Livingston, HMS IV
Gillian Lieberman, MD

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).
40
 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.
41
 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.

42
Cat Livingston, HMS IV
Gillian Lieberman, MD

Acknowledgements
Herbert Gramm, MD
Neil Rofsky, MD
Pamela Lepkowski
Gillian Lieberman, MD
Larry Barbaras

43