7

Review Abdominal CT in Acquired

Immunodeficiency Syndrome

R. Brooke Jeffrey, Jr.1 Acquired immunodeficiency syndrome (AIDS) is a lethal infectious disease that has
David A. Nyberg1’2 reached epidemic proportions in urban centers of the United States. lntraabdominal
Kent Bottles3 opportunistic infections and malignancies are common features of this syndrome. A
Donald I. Abrarns4 prodromal phase or possibly milder form of infection is known as the AIDS-related
complex. Abdominal computed tomography (CT) in patients with AIDS-related complex
Michael P. Federl&
often demonstrates a triad of mild retroperitoneal and mesentenc adenopathy, spleno-
Susan D. Wall1 megaly, and perirectal inflammation. Lymph node enlargement greater than 1.5 cm is
Vivian W. Wing1 unusual in the AIDS-related complex and should prompt CT-guided biopsy. Abdominal
Faye C. Laing1 adenopathy (>1.5 cm) in AIDS, in our experience, is most commonly related to non-
Hodgkin lymphoma, Kaposi sarcoma, or infection with Mycobacterlum avlum-Intracellu-
lare. In most instances, CT-guided biopsy with appropriate staining technique can readily
distinguish these entities. However, the subtyping of non-Hodgkin lymphoma by fine-
needle aspiration biopsy alone remains controversial. Unusual features of abdominal
malignancies are common in AIDS. These include a purely lymphadenopathic form of
AIDS-related Kaposi sarcoma and a predilection for extranodal sites
in of lymphoma
AIDS. In general, patients with AIDS-related lymphoma present with advanced stages of
disease with highly malignant histologic subtypes. Abdominal CT may be useful clinically
for diagnosing intraabdominal complications of AIDS.

Acquired immunodeficiency syndrome (AIDS)

is a disorder of cell-mediated
immunity resulting in multiple opportunistic and certain
infections characteristic
malignancies [1 -8]. The incidence of AIDS has reached epidemic proportions
among patients in high-risk categories in urban centers in the United States. As of
April 30, 1 985, 1 0,000 patients in the U.S. were diagnosed as having AIDS,
according to surveillance criteria established by the Centers for Disease Control
(CDC) [9]. This represents a dramatic increase in the number of reported cases
since the initial description of the syndrome in 1981 The dismal prognosis
. and
high mortality associated with AIDS is underscored by the fact that nearly half of
all diagnosed cases have already died [9].
Received July 8, 1985; accepted after revision The causative agent in AIDS is a retrovirus identified as human T-celI lympho-
August 28, 1985. trophic virus type III (HTLV-III/LAV) [6-8]. It is estimated that at least 400,000
1pfri of Radiology, lhiiversity of Califor- individuals in this country have antibodies to HTLV-Ilh/LAV [6]. In patients without
nia School of Medicine, San Francisco General Hos- the fullblown syndrome of AIDS, a prodromal phase or possibly milder form of
pital, 1001 Potrero Ave., San Francisco, CA 94110.
Address reprint requests to R. B. Jeffrey, Jr. infection by the retrovirus has been designated the AIDS-related complex [10-
2p address: Department of Radiology, 1 2]. This entity is characterized by fever, night sweats, generalized lymphadenop-
University of Washington School of Medicine, Se- athy, malaise, weight loss, diarrhea, and evidence of immune dysfunction. The
attle, WA 98195. CDC-established criteria for diagnosis of AIDS are the development of Kaposi
3Department of Pathology, University of Califor- sarcoma, multiple opportunistic infections, and/or primary central nervous system
nia School of Medicine, San Francisco, CA 94143.
lymphoma in patients at high risk for AIDS. These patients include homosexual
4Department of Medicine, University of Califor- men, intravenous drug abusers, and recipients of blood products [1 3, 14].
nia School of Medicine, San Francisco, CA 94143.
The intraabdominal manifestations of AIDS are numerous, involving parenchymal,
AJR 146:7-13, January 1986
0361-803X/86/1461-0007
lymph node, and primary gastrointestinal disorders. In patients with suspected
0 American Roentgen Ray Society gastrointestinal lesions, double-contrast barium studies remain the primary method
8 JEFFREY ET AL. AJR:146, January 1986

for radiologic diagnosis of mucosal abnormalities. However,

CT is often helpful in assessing both visceral and nodal
abnormalities of AIDS and the AIDS-related complex. Be-
cause of the frequent overlap and nonspecificity of findings,
CT-guided fine-needle aspiration biopsy (FNAB) is often es-
sential for precise diagnosis. Over the past 4 years, we have
performed abdominal CT in over 200 patients with AIDS and
AIDS-related complex. This review familiarizes radiologists
with the broad CT spectrum of abdominal lesions in AIDS and
the AIDS-related complex and emphasizes both the useful-
ness and limitations of CT-guided FNAB.

Abdominal CT in the AIDS-Related Complex

Patients with the AIDS-related complex exhibit a variety of

constitutional symptoms including fever, weight loss, diar-
rhea, malaise, and night sweats [1 2-1 5]. Chronic generalized Fig. 1 .-Perirectal inflammation in AIDS-related complex. Diffuse soft-tissue
infiltration of penrectal space (arrows).
lymphadenopathy, often noted in the AIDS-related complex,
is secondary to reactive lymphoid hyperplasia. This entity is
often referred to as the lymphadenopathy syndrome [12,
1 5]. In general, the diagnostic criteria for the lymphadenopa-
thy syndrome include chronic lymphadenopathy of at least 3
months’ duration involving two or more extrainguinal sites.
There is no concurrent illness or drug use that may cause
lymphadenopathy, and lymph node biopsies demonstrate re-
active hyperplasia without evidence of tumor [16].
Initial reports of abdominal CT in patients with the lymph-
adenopathy syndrome have emphasized a characteristic triad
of(1) mild lymphadenopathy (clusters of reactive lymph nodes
ranging from 5 mm to 1 cm) involving the retroperitoneal,
mesentenc, or pelvic lymph node chains; (2) splenomegaly;
and (3) abnormal soft-tissue infiltration of the rectal wall or
perirectal fat [1 7]. The perirectal disease commonly seen in
these patients, often asymptomatic, is presumably the result
of chronic proctitis from repeated venereal infections (fig. 1).
It should be emphasized that abdominal nodal enlargement Fig. 2.-Widespread abdominal involvement in AIDS-related Kaposi sar-
greater than 1 .5 cm, however, is unusual in the lymphade- coma. Paraaortic nodal disease (open arrow) and diffuse infiltration of left
nopathy syndrome and should prompt CT-guided biopsy to abdominal wall (straight arrows) and left psoas muscle (curved arrow). Psoas
lesion was confirmed by fine-needle aspiration biopsy.
exclude neoplastic or infectious nodal disease.

AIDS-related Kaposi sarcoma is similar in clinical presen-

CT of Abdominal Neoplasms in AIDS
tation to the aggressive and disseminated form seen in African
The most common abdominal neoplasms associated with adolescents. Early lymph node and visceral involvement are
AIDS are Kaposi sarcoma and non-Hodgkin lymphoma. Ka- the predominant features. Gastrointestinal lesions are quite
posi sarcoma has been recognized for several years as one common, occurring in 50% of patients with AIDS-related
of the primary manifestations of AIDS. Of the first 1000 Kaposi sarcoma [20]. Late in the course of the disease,
patients diagnosed with AIDS in the U.S., 37% had Kaposi widespread lesions may be found involving virtually all organ
sarcoma [4]. Kaposi
sarcoma was originally described in 1872 systems and occasionally unusual sites of involvement (fig.
as a rare cutaneous disorder characterized by multiple viola- 2).
ceous macules that may coalesce into nodular lesions [18]. The radiologic diagnosis of gastrointestinal lesions in Ka-
In its classic form, Kaposi sarcoma was described as an posi sarcoma has been described [20]. Initial reports of CT
indolent cutaneous disorder of elderly European men, with findings in AIDS-related Kaposi sarcoma emphasized the
visceral involvement seen only late in its clinical course. Prior overlap between this entity and the lymphadenopathy syn-
to its association with AIDS, a second form of Kaposi sarcoma drome [17]. Splenomegaly and mild retropentoneal and mes-
was recently recognized among African adolescents [19]. This enteric nodal enlargement are common to both, and do not
form of the disease is an aggressive systemic disorder that is necessarily indicate widespread involvement with Kaposi sar-
characterized by a high degree of early lymphatic and visceral coma. This is particularly true when the lymph nodes are less
involvement and is associated with a poor prognosis. than 1.5 cm in greatest diameter. However, bulky nodal
AJR:146, January 1986 ABDOMINAL CT IN AIDS 9

Fig. 5.-Extranodal site of involvement in AIDS-

related non-Hodgkin lymphoma. Focal gastric mass
along lesser curve (arrows).

enlargement may be the only CT evidence of abdominal rarely seen on CT, larger focal masses may be identified by
Kaposi sarcoma. Indeed a purely lymphadenopathic form of mural thickening (fig. 4). The CT demonstration of focal he-
AIDS-related Kaposi sarcoma is being recognized with in- patic or splenic lesions of Kaposi sarcoma in AIDS is uncom-
creasing frequency [21, 22] (fig. 3). This is an interesting mon. As with retroperitoneal adenopathy, this sarcoma has a
clinical correlate to the growing histochemical evidence of the nonspecific CT appearance and cannot be distinguished from
origin of Kaposi sarcoma from lymphatic endothelial cells other neoplastic or infectious causes without FNAB. In our
[23]. Without FNAB, it is not possible to distinguish bulky experience, FNAB has proven quite reliable in diagnosing
adenopathy in AIDS-related Kaposi sarcoma from lymphoma AIDS-related Kaposi sarcoma [24]. Cohesive clusters of bland
or infections such as Mycobacterium avium-intracellulare. spindle cells are arranged in characteristic slitlike spaces
Although the characteristic “target” Kaposi sarcoma lesions [24]. Because Kaposi sarcoma can involve virtually any organ
seen on air-contrast studies of the gastrointestinal tract are in the body, it may produce unusual intraabdominal lesions
10 JEFFREY ET AL. AJR:146, January 1986

sensitivity for CT and sonography in diagnosing hepatic in-

volvement with AIDS-related lymphoma is not known, but it
is likely that many cases of microscopic disease will escape
detection by current imaging.
The use of FNAB for accurate diagnosis and subtyping of
non-Hodgkin lymphoma is controversial. Some authorities
emphasize the need for surgical biopsy in all suspected cases
oflymphoma. Orell and Skinner [32], on the other hand, noted
that FNAB is often quite accurate for tissue subtyping and
has correctly established the histologic subtype in 48 of 49
patients with non-Hodgkin lymphoma. Reliance on FNAB for
histologic subtyping of lymphoma requires considerable cy-
tologic skill. Often this subtyping is crucial for chemotherapy;
therefore, if there is any question regarding the histologic
subtype, surgical biopsy is recommended.
AIDS-related Hodgkin disease appears to be significantly
less common than non-Hodgkin lymphoma. However, there
are distinctive features of this disease in the AIDS population.
Fig. 6.-Extensive hepatic lesions in non-Hodgkin lymphoma. Patients typically present with advanced stages of Hodgkin
disease (clinical stage III or IV) with mixed cellularity or nodular
scierosing histology [28]. In addition, unusual manifestations
of Hodgkin disease include involvement of the skin overlying
that can readily be detected and biopsied under CT guidance.
involved lymph nodes [28] and bone marrow involvement
In addition to Kaposi sarcoma, a variety of aggressive
without splenic lesions [28]. In our series of 1 0 patients with
B-cell lymphomas (without primary central nervous system
AIDS-related Hodgkin disease studied at San Francisco Gen-
involvement) have been associated with AIDS [25-28]. To
eral Hospital, two patients (20%) had bulky mesenteric nodal
date non-Hodgkin lymphoma, including Burkitt type, has been
masses with Hodgkin disease, an uncommon feature in the
the most common lymphoma in patients with AIDS [27].
non-AIDS population [33]. In addition, noncontiguous sites of
However, Hodgkin disease has also been described [25, 26,
nodal involvement were identified with pelvic adenopathy
28]. In some patients, lymphoma may occur before the onset
without paraaortic involvement.
of fullblown AIDS [27]. In evaluating non-Hodgkin lymphoma
in 90 homosexual men, Ziegler et al. [27] emphasized several
unique manifestations within this subgroup of patients. There
CT of Abdominal Opportunistic Infections in AIDS
is a dramatic increase in extranodal involvement in AIDS-
related lymphoma, including brain, bone marrow, abdominal Enteric infections are quite common in the AIDS population,
visceral, and mucocutaneous sites (fig. 5). Of 90 patients and contribute significantly to its morbidity and mortality
reported by Ziegler et al. [27], 88 had extranodal sites of [33]. Often they result in a wasting syndrome of chronic
involvement. In addition, patients with AIDS-related lymphoma diarrhea and marked weight loss. Infections include fungal,
typically present with highly malignant histologic subtypes of viral, and protozoan infestations. Typical gastrointestinal in-
non-Hodgkin lymphoma and advanced stages of disease. In fections in AIDS are esophagitis from Candida and small-
the series of Ziegler et al., 58% of patients presented with bowel or colonic infections with Cryptosporidium, cytomega-
stage III or greater lymphoma, and 62% had high-grade lovirus, herpes simplex, or M. avium-intracellulare. In general,
malignant histologic cell types. When compared to patients stool culture, small-bowel aspirates and biopsy, endoscopy,
with non-Hodgkin lymphoma without AIDS, the response to and air-contrast barium studies are the primary methods of
treatment has been quite poor with generally an unfavorable diagnosis. The CT findings often demonstrate nonspecific
prognosis. inflammatory changes of the small bowel and colon with focal
As noted, a significant percentage of patients with AIDS- mural thickening, mucosal irregularity, and thickened small-
related lymphoma demonstrate focal hepatic and splenic Ia- bowel folds [34] (figs. 8 and 9). On rare occasions we have
sions (fig. 6). In our series of 29 AIDS-related lymphomas, noted associated viral peritonitis on CT characterized by
26% of patients with non-Hodgkin lymphoma had biopsy- ascites, thickening of the parietal peritoneal surface, and
proven focal hepatic lesions (Nyberg et al., personal commu- infiltration of the omentum (fig. 9). This underscores the
nication) compared to an incidence of 4%-6% in non-AIDS importances of obtaining routine viral cultures from aspiration
patients [29-31]. In patients with relatively diffuse hepatic specimens.
involvement with lymphoma, smaller microscopic foci (<1 cm) Disseminated M. avium-intracellulare is a systemic infection
may occasionally be difficult to appreciate on contrast-en- of increasing importance in the AIDS population. M. avium-
hanced CT. We have noted on several occasions that sonog- intracellulare are atypical mycobactena that are ubiquitous
raphy may be useful in depicting disorganized hepatic echo- within the environment and are rarely pathogens in immuno-
genicity with small hypoechoic foci in patients with hepato- competent individuals. Culturing is necessary to distinguish
megaly and no obvious focal lesions on CT (fig. 7). The overall M. avium-intracellulare from M. tuberculosis. On intraabdom-
AJR:146, January 1986 ABDOMINAL CT IN AIDS 11

Fig. 7.-Small hepatic lesions in non-Hodgkin lymphoma. A, Marked hepa- B, Hepatic sonogram. Diffuse distortion of echogenicity and numerous focal
tomegaly but only two focal abnormalities on contrast-enhanced CT (arrows). lesions (arrows).

8.-Cytomegalovirus enteritis and colitis. A, L..fuse small-bowel (B) wall thickening and mucosal irregularity. B, Mesenteric adenopathy (n) and pancolitis
with focal narrowing of lumen and mural thickening of the colon (C).

inal CT, M. avium-intracellulare has a high predilection for biopsy to exclude M. avium-intracellulare, despite an unre-
retroperitoneal and mesenteric nodal involvement, producing markable CT scan.
bulky nodal masses that are often indistinguishable from On CT, low-density areas of necrosis may occasionally be
AIDS-related Kaposi sarcoma or lymphoma (fig. 10). In our identified within abdominal lymph nodes involved with M.
series of 17 patients with proven abdominal M. avium-intra- avium-intrace!lulare (fig. 12). FNAB in M. avium-intracellulare
cellulare, 14 (82%) had mesenteric or retroperitoneal ada- can readily detect macrophages laden with acid-fast bacilli,
nopathy greater than 1.0-1.5 cm on CT [36]. Focal hepatic and thus acid-fast stains should be routinely performed in all
and splenic lesions were identified by CT or sonography in FNAB specimens in AIDS. Unfortunately, at present there is
two patients (fig. 11). We recently encountered a patient with no effective medical therapy for M. avium-intracellulare.
diffuse hepatic M. avium-intracellulare on liver biopsy without Rectal and perirectal inflammatory disease are common
focal defects on CT. Therefore, AIDS patients with persistent both in patients with the AIDS-related complex and in those
abnormal liver functions and fever may require core liver with AIDS. Proctitis is often secondary to venereal infections
12 JEFFREY ET AL. AJR:146, January 1986

from gcnococci, syphilis, cytomegalovirus, herpes simplex, or lu/are, abdominal or pelvic abscesses, and diagnosis and
lymphogranuloma venereum. In some instances it may be staging of abdominal neoplasms such as Kaposi sarcoma and
difficult to distinguish rectal Kaposi sarcoma or lymphoma lymphoma. In patients with localized symptoms such as right-
from severe proctitis. CT seems to be of considerable value upper-quadrant pain, sonography is often a useful initial
in distinguishing perirectal cellulitis from abscesses and local- screening method. On occasion, sonography may reveal sub-
izing complex abscesses before surgical drainage (Guillaumin tle hepatic lesions difficult to image by CT. Because of the
E, unpublished data). frequency of mesenteric retroperitoneal nodal disease in
AIDS, CT remains the primary method for evaluation in most
patients. Although chemotherapy for AIDS-related neoplasms
Indications for Abdominal CT in AIDS
is often limited in its effectiveness, repeat abdominal CT is
Indications for abdominal CT in AIDS include evaluation for often useful to assess the course of therapy.
suspected visceral or nodal infection with M. avium-intracel-

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