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Clinical Investigations: HIV |

Clinical and Radiographic Predictors of the Etiology of Pulmonary Nodules in HIV-Infected Patients* FREE TO VIEW

Robert M. Jasmer, MD; Keith J. Edinburgh, MD, MS Ed; Annemarie Thompson, MD; Michael B. Gotway, MD; Jennifer M. Creasman, MSPH; W. Richard Webb, MD; Laurence Huang, MD, FCCP
Author and Funding Information

*From the Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital Medical Center, and the Department of Medicine, University of California, San Francisco (Drs. Jasmer, Thompson, Huang, and Ms. Creasman); and the Department of Radiology, University of California, San Francisco (Drs. Edinburgh, Gotway, and Webb), San Francisco, CA.

Correspondence to: Robert M. Jasmer, MD, Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, Room 5K-1, 1001 Potrero Ave, San Francisco, CA 94110; e-mail: rjasmer@itsa.ucsf.edu



Chest. 2000;117(4):1023-1030. doi:10.1378/chest.117.4.1023
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Published online

Study objectives: To determine the etiology and the clinical and radiographic predictors of the etiology of pulmonary nodules in a group of HIV-infected patients.

Design: Retrospective analysis.

Setting: A large urban hospital in San Francisco, CA.

Patients: HIV-infected patients evaluated at San Francisco General Hospital from June 1, 1993, through December 31, 1997, having one or more pulmonary nodules on chest CT.

Main outcome measures: Three physicians reviewed medical records for clinical data and final diagnoses. Three chest radiologists blinded to clinical data reviewed chest CTs. Univariate and multivariate analyses were performed to determine clinical and radiographic predictors of having an opportunistic infection and the specific diagnoses of bacterial pneumonia and tuberculosis.

Results: Eighty seven of 242 patients (36%) had one or more pulmonary nodules on chest CT. Among these 87 patients, opportunistic infections were the underlying etiology in 57 patients; bacterial pneumonia (30 patients) and tuberculosis (14 patients) were the most common infections identified. Multivariate analysis identified fever, cough, and size of nodules < 1 cm on chest CT as independent predictors of having an opportunistic infection. Furthermore, a history of bacterial pneumonia, symptoms for 1 to 7 days, and size of nodules < 1 cm on CT independently predicted a diagnosis of bacterial pneumonia; a history of homelessness, weight loss, and lymphadenopathy on CT independently predicted a diagnosis of tuberculosis.

Conclusions: In HIV-infected patients having one or more pulmonary nodules on chest CT scan, opportunistic infections are the most common cause. Specific clinical and radiographic features can suggest particular opportunistic infections.

Pulmonary disease frequently complicates the course of HIV-infected patients.14 A broad range of etiologies has been noted, including opportunistic pathogens, bacterial infections, neoplasms, and non–HIV-associated pulmonary disorders. Typically, these diseases cannot be distinguished solely by clinical examination, given nonspecific symptoms such as fever, cough, and dyspnea. Thus, the chest radiograph is often part of the diagnostic evaluation of such patients. Unfortunately, the radiograph may also be nonspecific or even normal.511 A chest CT scan provides more precise information than a chest radiograph and is often used in cases in which the clinical presentation, laboratory studies, and chest radiograph are indeterminate.1213

In the case of pulmonary nodules, chest CT can provide more precise information than chest radiograph regarding nodule size, location, distribution, and presence of cavitation or accompanying findings such as intrathoracic lymphadenopathy or pleural effusion.1416 A large study by Hartman et al16 reported that 40 of 102 HIV-infected patients had pulmonary nodules on chest CT and that the most common etiologies of these nodules were pulmonary Kaposi’s sarcoma, Pneumocystis carinii pneumonia (PCP), and mycobacterial pneumonias. Among the 102 patients, the authors found that specific CT findings allowed for a confident diagnosis in > 90% of cases of pulmonary Kaposi’s sarcoma and PCP. However, among patients with pulmonary nodules, the authors did not examine which radiographic findings were useful in predicting a specific diagnosis. In addition, they did not evaluate whether clinical findings (eg, CD4 cell count, specific symptoms) provided additional diagnostic utility. In this study, we determine the usefulness of various clinical and radiographic findings in predicting the specific etiology of one or more pulmonary nodules in a large group of HIV-infected patients at an urban hospital who underwent a chest CT as part of their evaluation. We also determine which of these opportunistic infections and neoplasms are most likely to present with one or more pulmonary nodules and the relative frequencies of etiologies of these nodules.

Patients

The study population was drawn from the 242 HIV-infected patients who had a chest CT performed as part of their evaluation between June 1, 1993, and December 31, 1997, at San Francisco General Hospital. Clinical data from all 242 patients were obtained by medical record review and were collected on a standardized data form that included age, sex, race/ethnicity, HIV risk factor(s), residence (homeless or not), diagnosis of AIDS, most recent CD4 cell count, current or past cigarette or injection drug use, history of pulmonary diseases, and presence and duration of symptoms at the time of presentation. When present, symptom duration was divided into five categories: symptoms for 1 to 3 days, 4 to 7 days, 8 to 14 days, 15 to 21 days, or > 21 days. Symptoms included the presence or absence of fever, cough, purulent sputum, dyspnea, night sweats, and weight loss. Laboratory data included the presence or absence of an absolute leukocytosis (WBC count > 9.0 × 106/μL) or hypoxemia (oxygen saturation < 90% while breathing room air). Each chart was reviewed by one of three pulmonary physicians, and a random review of 48 charts (20%) to assess inter-reviewer differences found no meaningful differences in interpretation or recording of data.

Diagnosis of Pulmonary Disease

Final diagnoses were recorded and determined as follows. Diagnoses of bacterial pneumonia required one of the following: isolation of a pathogen from culture of a normally sterile site such as blood or pleural fluid; isolation of a pathogen from culture of sputum or BAL accompanied by a clinical response to appropriate antibiotic therapy that would not also treat other opportunistic infections (eg, trimethoprim-sulfamethoxazole for PCP); or clinical presentation consistent with bacterial pneumonia accompanied by a clinical response to appropriate antibiotic therapy that would not also treat other opportunistic infections.17Diagnoses of tuberculosis required identification of Mycobacterium tuberculosis from sputum, blood, or BAL fluid mycobacterial cultures. Diagnoses of pulmonary Kaposi’s sarcoma required bronchoscopic visualization of characteristic lesions in the airways or postmortem examination.18 Diagnoses of lymphoma and lung cancer required pathologic examination from either bronchoscopic or transthoracic needle biopsy specimens. Diagnoses of Mycobacterium avium complex (MAC) pulmonary disease required the following: (1) identification of MAC from multiple respiratory specimens in accordance with the American Thoracic Society criteria,19 (2) no identification of other potential pathogens, and (3) a clinical response to appropriate anti-MAC therapy. Diagnoses of PCP required microscopic visualization of P carinii from sputum or BAL fluid. Diagnoses of Aspergillus fumigatus infection required either transthoracic needle biopsy or postmortem examination. Data supporting the final diagnoses were reviewed by all three pulmonary physicians, and disagreements were resolved by consensus.

Chest CT Scans

Chest CT scans were performed in all 242 patients (GE 9800 HiLite Advantage Scanner; General Electric Medical Systems; Milwaukee, WI). Three chest radiologists who were blinded to all clinical data, including the final diagnosis, reviewed each chest CT and recorded the presence or absence of the following on a standardized data form: nodules(s) and size of the majority of nodules (< 1 cm or > 1 cm), consolidation, ground-glass opacification, cavity or cyst formation, lymphadenopathy, and pleural effusion. Disagreements were resolved by consensus.

Chest CT scans were available for review in 219 of the 242 patients (90%). The scans of 87 patients (36%) were noted to have one (7 patients) or more than one (80 patients) pulmonary nodules. These 87 patients and their chest CT scans comprised the final study population.

Statistical Analysis

Univariate analyses were performed using the Fisher’s Exact Tests. The p values were based on two-tailed test results. A p value≤ 0.05 was used to define statistical significance. Odds ratios and 95% confidence intervals were calculated to assess univariate risk for having any opportunistic infection (defined as bacterial pneumonia, tuberculosis, MAC pulmonary disease, PCP, A fumigatus infection, septic embolism, and chest wall abscess) and for having either bacterial pneumonia or tuberculosis (the two most common opportunistic infections observed). The three patients having unknown diagnoses were excluded from the univariate and multivariate analyses, as it was unclear what diagnosis was responsible for the clinical and radiographic findings. Clinical and radiographic findings significant at the p < 0.10 level were included in a stepwise multivariate logistic regression.20 For the univariate and multivariate analyses, duration of symptoms was categorized into two outcomes: 1 to 7 days, and > 7 days. Data were analyzed using appropriate software (SAS Version 6.12; SAS Institute; Cary, NC).

Overall Diagnoses and Relative Frequencies of One or More Pulmonary Nodules

Overall, the 242 patients undergoing chest CT had a total of 251 diagnoses (Table 1 ). Diagnoses included HIV-associated opportunistic infections and neoplasms as well as non–HIV-associated pulmonary diseases. Bacterial pneumonia was the leading overall diagnosis, present in 88 patients, followed by PCP (n = 26), lymphoma (n = 25), and tuberculosis (n = 23). Greater than two thirds of the 242 patients had one of these four diagnoses.

Eighty seven of the 242 patients (36%) had one or more pulmonary nodules noted on chest CT (Table 1). Bacterial pneumonia was the leading diagnosis, present in 30 patients, followed by tuberculosis (n = 14), Kaposi’s sarcoma (n = 11), and lymphoma (n = 10). Almost three fourths of the 87 patients who had one or more pulmonary nodules had one of these four diagnoses.

Pulmonary nodules were a more frequent chest CT feature of certain diseases than others (Table 1). For example, one or more nodules were a common finding in patients who had lung cancer, Kaposi’s sarcoma, and tuberculosis, and were noted in the majority of these cases. In contrast, nodules were an uncommon finding in patients who had PCP and were seen in only 12% of these cases.

Characteristics and Diagnoses of Patients With Pulmonary Nodules

The demographic and clinical characteristics of the 87 patients having one or more pulmonary nodules on chest CT are shown in Table 2 . All demographic categories were represented; the majority of patients were male and either white or African American. Two thirds of the patients reported homosexual or bisexual sex as an HIV risk factor, and more than one fourth reported injection drug use. More than one fourth of the patients were homeless. Over 90% of the patients had a diagnosis of AIDS at the time of presentation. A number of patients had a history of bacterial pneumonia and/or PCP. Over 90% of the patients reported symptoms, usually between 4 and 21 days. Cough was the most common symptom, followed by fever and dyspnea. With respect to laboratory data, few patients (9%) had evidence of leukocytosis, probably as a result of advanced HIV infection, and 15% were noted to have hypoxemia.

As seen in Table 3 , the majority of patients having one or more pulmonary nodules had advanced HIV infection; 48 patients (55%) had a CD4 cell count < 50 cells/μL, and only 11 patients (13%) had a CD4 cell count ≥ 200 cells/μL. Diagnoses such as bacterial pneumonia, tuberculosis, lymphoma, and lung cancer occurred at all CD4 cell count ranges. In contrast, pulmonary Kaposi’s sarcoma and PCP tended to occur at CD4 cell counts < 200 cells/μL (one patient with PCP had a CD4 cell count of 265 cells/μL 100 days prior to presentation). MAC pneumonia and A fumigatus infection only occurred at CD4 cell counts< 50 cells/μL. Of note, the mean CD4 cell count of the 87 patients with one or more pulmonary nodules on chest CT was not significantly different from that of the 155 patients without one or more nodules (p = 0.15; data not shown).

Clinical and Radiographic Predictors for Having an Opportunistic Infection

A total of 57 patients had some type of infectious etiology for their one or more pulmonary nodules. To identify predictors for having an opportunistic infection, these 57 patients were compared to the remaining 27 patients who had a noninfectious etiology (excluding the 3 patients with an unknown diagnosis). Univariate analysis showed that patients having an opportunistic infection were significantly less likely to report homosexual or bisexual intercourse and more likely to have a history of bacterial pneumonia, symptoms present for 1 to 7 days, symptoms of cough or fever, and have chest CT findings of small (< 1 cm) nodules or consolidation (Table 4 ).

Multivariate analysis demonstrated that clinical and radiographic findings were independent predictors for having an opportunistic infection (Table 5 ). Patients with symptoms of fever or cough were approximately six times more likely to have an opportunistic infection than those without these symptoms (adjusted odds ratio, 5.8, p = 0.03; adjusted odds ratio, 6.1, p = 0.02, respectively). Patients whose chest CT had a predominance of nodules < 1 cm were 17.3 times more likely to have an opportunistic infection (p = 0.0001).

Clinical and Radiographic Predictors for Having Bacterial Pneumonia or Tuberculosis

To identify predictors for having bacterial pneumonia, the most common opportunistic infection, the 30 patients with bacterial pneumonia were compared with the remaining patients (Table 4). Univariate analysis showed that patients having bacterial pneumonia were significantly more likely to be female; to have a history of injection drug use; a history of bacterial pneumonia; symptoms present for 1 to 7 days; symptoms of cough or dyspnea; hypoxemia; and chest CT findings of small (< 1 cm) nodules and no lymphadenopathy. Multivariate analysis demonstrated that clinical and radiographic findings were independent predictors for having bacterial pneumonia (Table 5). Specifically, a past history of bacterial pneumonia (adjusted odds ratio, 5.3; p = 0.02), symptoms present for 1 to 7 days (adjusted odds ratio, 7.3; p = 0.002), and chest CT revealing small nodule size (adjusted odds ratio, 8.3; p = 0.01) were all independently associated with an increased likelihood of having bacterial pneumonia.

To identify predictors for having tuberculosis, the second most common opportunistic infection, the 14 patients with tuberculosis were compared with the remaining patients (Table 4). Univariate analysis showed that patients having tuberculosis were significantly more likely to have a history of homelessness, CD4 cell count < 50 cells/μL, weight loss, and chest CT finding of lymphadenopathy. Multivariate analysis demonstrated that clinical and radiographic findings were independent predictors for having tuberculosis. Specifically, a history of homelessness (adjusted odds ratio, 5.6; p = 0.009), weight loss (adjusted odds ratio, 10.3; p = 0.01), and chest CT revealing lymphadenopathy (adjusted odds ratio, 9.4; p = 0.004) were all independently associated with an increased likelihood of having tuberculosis.

This study has four main findings. First, pulmonary nodules are a frequent chest CT finding in HIV-infected patients. In our study, one or more pulmonary nodules were found in 36% of HIV-infected patients undergoing chest CT as part of their diagnostic evaluation at a large urban hospital. Diagnoses included HIV-associated opportunistic infections and neoplasms as well as non–HIV-associated pulmonary diseases. Second, pulmonary nodules were a more frequent chest CT feature of certain diseases than others. Although the spectrum of pulmonary disease observed in our study was broad, our study showed that pulmonary nodules were much more frequent in patients having lung cancer, Kaposi’s sarcoma, and tuberculosis than in patients having other etiologies such as PCP. Third, opportunistic infections comprised the most common diagnoses, present in two thirds of patients having one or more pulmonary nodules on chest CT. Bacterial pneumonia was the most common and tuberculosis was the second most common diagnosis in our series. Fourth, clinical and radiographic findings were useful in predicting the etiology of pulmonary nodules.

Although the differential diagnosis is broad, our study found that opportunistic infections were the most common diagnoses and were the etiology in 57 of 87 patients (66%) having one or more pulmonary nodules. This result is different from those of Hartman et al.16 Although the study by Hartman et al16 showed that pulmonary nodules were a frequent chest CT finding in HIV-infected patients, being present in 40 of 102 AIDS patients (39%) with proven intrathoracic disease, the authors found that neoplasms were the most common diagnoses and were the etiology in 23 of their patients (58%) having pulmonary nodules. In their study, the majority of patients having nodules had Kaposi’s sarcoma (n = 22) rather than bacterial pneumonia (n = 3). There are several possible explanations for the observed differences. First, the spectrum of pulmonary diseases seen at our two institutions differed. Overall, in the study by Hartman et al,16 Kaposi’s sarcoma and PCP were the most common diagnoses; however, in our study, bacterial pneumonia was the most common diagnosis. This difference is probably related to the different study periods (the study by Hartman et al16 was from 1985 to 1992, and the current study was from 1993 to 1997) and the changing spectrum of disease—specifically, the declining incidence of PCP and Kaposi’s sarcoma and the increased incidence of bacterial pneumonia—over this time. The differences may also be the result of different selection criteria for which patients had a chest CT. In either case, we expand on their study by including more than twice as many patients having pulmonary nodules and by determining which clinical and radiographic findings predicted a specific diagnosis.

Our study found that clinical and radiographic findings were useful predictors of the etiology of one or more pulmonary nodules. In a multivariate analysis, fever, cough, and a predominance of nodules< 1 cm in size were independent predictors of an infectious etiology of pulmonary nodules. This analysis extends our previous finding that nodule size is a powerful determinant of an infectious (< 1 cm) or neoplastic (> 1 cm) etiology by documenting that clinical findings are also independent predictors.21 We also extend our previous analysis by identifying specific clinical and radiographic predictors associated with our two most common diagnoses: bacterial pneumonia and tuberculosis.

Our finding that a history of bacterial pneumonia and symptoms for 1 to 7 days are associated with bacterial pneumonia is consistent with published studies. Similarly, the observation that homelessness, weight loss, and lymphadenopathy on chest CT are associated with tuberculosis is well established.2223 However, unlike these prior reports, our study performed multivariate analysis and demonstrated the independent predictive power of these clinical and radiographic findings. Of note, our study found that the CD4 cell count was unable to distinguish between etiologies. One reason for this may have been the large number of patients (55%) who had a CD4 cell count < 50 cells/μL. This reflects the advanced nature of HIV infection in our HIV-infected population rather than the ineffectiveness of the CD4 cell count. It is well established that the CD4 cell count can best distinguish between diseases at higher cell counts (eg,> 200 cells/μL) where diseases such as PCP, pulmonary Kaposi’s sarcoma, and Aspergillus pneumonia are rare. The patients in our study with a CD4 cell count > 200 cells/μL had diseases such as bacterial pneumonia, tuberculosis, lymphoma, and lung cancer, diseases that occur at any CD4 cell count in HIV-infected patients (one patient had PCP with a CD4 cell count of 265 cells/μL obtained 100 days prior to presentation). Studies that include greater numbers of patients with a CD4 cell count > 200 cells/μL would likely find that the CD4 cell count is indeed a useful predictor.

Our study examined patients with one or more pulmonary nodules on chest CT, including seven patients with a solitary pulmonary nodule. While we did not analyze data separately from these seven patients, our results differ somewhat from those of another recently published report24 that found that the majority of solitary pulmonary nodules were due to infectious etiologies. In that study, 10 patients with HIV infection who had solitary pulmonary nodules underwent further diagnostic evaluation with CT scan and bronchoscopy, transthoracic needle biopsy, or thoracotomy to establish the final diagnosis. Six were due to infections, one the result of lymphoma, one due to round atelectasis, and two remained of unknown etiology. Among patients in our study who had solitary pulmonary nodules, three had an infectious etiology, two had a malignant etiology, one had a hamartoma, and the etiology in one patient remained unknown (data not shown).

There are a few potential limitations to the interpretation of our data. First, we examined HIV-infected patients with one or more pulmonary nodules in whom a chest CT was obtained as part of their diagnostic evaluation. Thus, these patients represent a selected population. However, the most frequent diagnoses seen among our patients undergoing a chest CT (bacterial pneumonia, PCP, lymphoma, tuberculosis, and pulmonary Kaposi’s sarcoma) are virtually identical to the most frequent pulmonary diagnoses seen among our hospitalized HIV-infected patients (bacterial pneumonia, PCP, tuberculosis, pulmonary Kaposi’s sarcoma). Therefore, it seems possible that selection criteria used to obtain a chest CT did not represent a bias toward a specific diagnosis but rather represent a marker of subsets of patients in whom the diagnosis was unclear despite clinical and chest radiographic data. Second, our hospital is located in an urban setting serving a fairly indigent population and is located in a nonendemic region for fungal diseases such as histoplasmosis and coccidioidomycosis. As a result, we see a significant number of cases of tuberculosis but rarely encounter endemic fungal pneumonias. Thus, our results may not be applicable to all HIV-infected patients having one or more pulmonary nodules, although we found the typical pulmonary complications of HIV in our patients that have been reported elsewhere. Clearly, each patient should be evaluated on an individual basis, taking into account their specific history, epidemiologic circumstances, and clinical findings in addition to the guidelines we derived from our analysis.

In conclusion, in a large group of HIV-infected patients undergoing chest CT as part of their evaluation, 36% had one or more pulmonary nodules, and opportunistic infections were found to be the predominant etiology. Bacterial pneumonia was the most common complication, followed by tuberculosis. Importantly, clinical and radiographic findings independently predicted the diagnosis of an opportunistic infection and included symptoms of fever, cough, and small nodules (< 1 cm) on CT. Independent clinical and radiographic findings also independently predicted specific opportunistic infections. Predictors of bacterial pneumonia were a past history of bacterial pneumonia, symptoms of 1 to 7 days duration, and small nodules; predictors of tuberculosis were a history of homelessness, weight loss, and lymphadenopathy on CT. These findings suggest that the combination of clinical and CT data can be useful in guiding the diagnostic evaluation of HIV-infected patients.

Abbreviations: MAC = Mycobacterium avium complex; PCP = Pneumocystis carinii pneumonia

Supported in part by the National Institutes of Health, University of California, San Francisco Center for AIDS Research, P30 MH59037.

Table Graphic Jump Location
Table 1. Etiologies of Pulmonary Disease in 242 HIV-Infected Patients Undergoing Chest CT and Proportion With Each Disease Having One or More Pulmonary Nodules
* 

Nine patients had two simultaneous diagnoses: bacterial and PCP (n = 3), bacterial pneumonia and pulmonary Kaposi’s sarcoma (n = 2), PCP and cryptococcal pneumonia (n = 1), cytomegalovirus and Aspergillus pneumonia (n = 1), PCP and MAC pneumonia (n = 1), and pulmonary Kaposi’s sarcoma and MAC pneumonia (n = 1).

 

Staging for malignancy (n = 17), unknown (n = 9), septic emboli (n = 5), chest wall abscess (n = 3), sarcoidosis (n = 2), alveolar hemorrhage (n = 1), hamartoma (n = 1), nonspecific interstitial pneumonitis (n = 1), pneumothorax (n = 1), right middle lobe syndrome (n = 1), superior vena cava thrombus (n = 1), tracheal stenosis (n = 1).

Table Graphic Jump Location
Table 2. Demographic and Clinical Characteristics of the 87 HIV-Infected Patients Having One or More Pulmonary Nodules on Chest CT Scan
* 

Thirty-four patients had none of these, whereas 24 patients had more than one of these diagnoses.

Table Graphic Jump Location
Table 3. Diagnoses and CD4 Cell Counts of the 87 HIV-Infected Patients Having One or More Pulmonary Nodules on Chest CT Scan
* 

Two diagnoses of septic emboli, one sarcoidosis, one hamartoma, and one chest wall abscess.

Table Graphic Jump Location
Table 4. Univariate Analysis of Factors Associated With the Three Most Common Diagnoses in HIV-Infected Patients With Pulmonary Nodules*
* 

CI = confidence interval; NA = data not applicable; OR = odds ratio.

 

p ≤ 0.05.

 

p < 0.10.

§ 

Significant at the p < 0.05 level using Fisher’s Exact Test.

Table Graphic Jump Location
Table 5. Multivariate Analysis of Clinical and Radiographic Predictors Associated With the Three Most Common Diagnoses in HIV-Infected Patients With Pulmonary Nodules*
* 

See Table 4 for abbreviations.

Murray, JF, Felton, CP, Garay, SM, et al (1984) Pulmonary complications of the acquired immunodeficiency syndrome.N Engl J Med310,1682-1688. [PubMed] [CrossRef]
 
Huang, L, Stansell, JD AIDS and the lung.Med Clin North Am1996;80,775-801. [PubMed]
 
Rosen, MJ Overview of pulmonary complications.Clin Chest Med1996;17,621-631. [PubMed]
 
Wallace, JM, Hansen, NI, LaVange, L, et al Respiratory disease trends in the Pulmonary Complications of HIV Infection Study Cohort.Am J Respir Crit Care Med1997;155,72-80. [PubMed]
 
Suster, B, Akerman, M, Orenstein, M, et al Pulmonary manifestations of AIDS: review of 106 episodes.Radiology1986;161,87-93. [PubMed]
 
Naidich, DP, Garay, SM, Leitman, BS, et al Radiographic manifestations of pulmonary disease in the acquired immunodeficiency syndrome (AIDS).Semin Roentgenol1987;22,14-30. [PubMed]
 
Naidich, DP, McGuinness, G Pulmonary manifestations of AIDS: CT and radiographic correlations.Radiol Clin North Am1991;29,999-1017. [PubMed]
 
McLoud, TC, Naidich, DP Thoracic disease in the immunocompromised patient.Radiol Clin North Am1992;30,525-554. [PubMed]
 
Kennedy, CA, Goetz, MB Atypical roentgenographic manifestations ofPneumocystis cariniipneumonia.Arch Intern Med1992;152,1390-1398. [PubMed]
 
Opravil, M, Marincek, B, Fuchs, WA, et al Shortcomings of chest radiography in detectingPneumocystis cariniipneumonia.J Acquir Immune Defic Syndr1994;7,39-45. [PubMed]
 
Greenberg, SD, Frager, D, Suster, B, et al Active pulmonary tuberculosis in patients with AIDS: spectrum of radiographic findings (including a normal appearance).Radiology1994;193,115-119. [PubMed]
 
Vander Els, NJ, Stover, DE Approach to the patient with pulmonary disease.Clin Chest Med1996;17,767-785. [PubMed]
 
Kang, EY, Staples, CA, McGuinness, G, et al Detection and differential diagnosis of pulmonary infections and tumors in patients with AIDS: value of chest radiography versus CT.AJR Am J Roentgenol1996;166,1-9. [PubMed]
 
Sider, L, Gabriel, H, Curry, DR, et al Pattern recognition of the pulmonary manifestations of AIDS on CT scans.Radiographics1993;13,771-784. [PubMed]
 
Kuhlman, JE, Fishman, EK, Hruban, RH, et al Diseases of the chest in AIDS: CT diagnosis.Radiographics1989;9,827-857. [PubMed]
 
Hartman, TE, Primack, SL, Muller, NL, et al Diagnosis of thoracic complications in AIDS: accuracy of CT.AJR Am J Roentgenol1994;162,547-553. [PubMed]
 
Hirschtick, RE, Glassroth, J, Jordan, MC, et al Bacterial pneumonia in persons infected with the human immunodeficiency virus.N Engl J Med1995;333,845-851. [PubMed]
 
Huang, L, Schnapp, LM, Gruden, JF, et al Presentation of AIDS-related pulmonary Kaposi sarcoma diagnosed by bronchoscopy.Am J Respir Crit Care Med1996;153,1385-90. [PubMed]
 
Diagnosis and treatment of disease caused by nontuberculous mycobacteria. Am J Respir Crit Care Med 1997; 156:S1–S25.
 
Agresti, A. Categorical data analysis. 1990; John Wiley. New York, NY:.
 
Edinburgh, KJ, Jasmer, RM, Huang, L, et al Multiple pulmonary nodules in AIDS: utility of CT in distinguishing among potential etiologies.Radiology2000;214,427-432. [PubMed]
 
Pastores, SM, Naidich, DP, Aranda, CP, et al Intrathoracic adenopathy associated with pulmonary tuberculosis in patients with human immunodeficiency virus infection.Chest1993;103,1433-1437. [PubMed]
 
Haramati, LB, Jenny-Avital, ER, Alterman, DD Effect of HIV status on chest radiographic and CT findings in patients with tuberculosis.Clin Radiol1997;52,31-35. [PubMed]
 
Martinez-Marcos, FJ, Viciana, P, Canas, E, et al Etiology of solitary pulmonary nodules in patients with human immunodeficiency virus infection.Clin Infect Dis1997;24,908-913. [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1. Etiologies of Pulmonary Disease in 242 HIV-Infected Patients Undergoing Chest CT and Proportion With Each Disease Having One or More Pulmonary Nodules
* 

Nine patients had two simultaneous diagnoses: bacterial and PCP (n = 3), bacterial pneumonia and pulmonary Kaposi’s sarcoma (n = 2), PCP and cryptococcal pneumonia (n = 1), cytomegalovirus and Aspergillus pneumonia (n = 1), PCP and MAC pneumonia (n = 1), and pulmonary Kaposi’s sarcoma and MAC pneumonia (n = 1).

 

Staging for malignancy (n = 17), unknown (n = 9), septic emboli (n = 5), chest wall abscess (n = 3), sarcoidosis (n = 2), alveolar hemorrhage (n = 1), hamartoma (n = 1), nonspecific interstitial pneumonitis (n = 1), pneumothorax (n = 1), right middle lobe syndrome (n = 1), superior vena cava thrombus (n = 1), tracheal stenosis (n = 1).

Table Graphic Jump Location
Table 2. Demographic and Clinical Characteristics of the 87 HIV-Infected Patients Having One or More Pulmonary Nodules on Chest CT Scan
* 

Thirty-four patients had none of these, whereas 24 patients had more than one of these diagnoses.

Table Graphic Jump Location
Table 3. Diagnoses and CD4 Cell Counts of the 87 HIV-Infected Patients Having One or More Pulmonary Nodules on Chest CT Scan
* 

Two diagnoses of septic emboli, one sarcoidosis, one hamartoma, and one chest wall abscess.

Table Graphic Jump Location
Table 4. Univariate Analysis of Factors Associated With the Three Most Common Diagnoses in HIV-Infected Patients With Pulmonary Nodules*
* 

CI = confidence interval; NA = data not applicable; OR = odds ratio.

 

p ≤ 0.05.

 

p < 0.10.

§ 

Significant at the p < 0.05 level using Fisher’s Exact Test.

Table Graphic Jump Location
Table 5. Multivariate Analysis of Clinical and Radiographic Predictors Associated With the Three Most Common Diagnoses in HIV-Infected Patients With Pulmonary Nodules*
* 

See Table 4 for abbreviations.

References

Murray, JF, Felton, CP, Garay, SM, et al (1984) Pulmonary complications of the acquired immunodeficiency syndrome.N Engl J Med310,1682-1688. [PubMed] [CrossRef]
 
Huang, L, Stansell, JD AIDS and the lung.Med Clin North Am1996;80,775-801. [PubMed]
 
Rosen, MJ Overview of pulmonary complications.Clin Chest Med1996;17,621-631. [PubMed]
 
Wallace, JM, Hansen, NI, LaVange, L, et al Respiratory disease trends in the Pulmonary Complications of HIV Infection Study Cohort.Am J Respir Crit Care Med1997;155,72-80. [PubMed]
 
Suster, B, Akerman, M, Orenstein, M, et al Pulmonary manifestations of AIDS: review of 106 episodes.Radiology1986;161,87-93. [PubMed]
 
Naidich, DP, Garay, SM, Leitman, BS, et al Radiographic manifestations of pulmonary disease in the acquired immunodeficiency syndrome (AIDS).Semin Roentgenol1987;22,14-30. [PubMed]
 
Naidich, DP, McGuinness, G Pulmonary manifestations of AIDS: CT and radiographic correlations.Radiol Clin North Am1991;29,999-1017. [PubMed]
 
McLoud, TC, Naidich, DP Thoracic disease in the immunocompromised patient.Radiol Clin North Am1992;30,525-554. [PubMed]
 
Kennedy, CA, Goetz, MB Atypical roentgenographic manifestations ofPneumocystis cariniipneumonia.Arch Intern Med1992;152,1390-1398. [PubMed]
 
Opravil, M, Marincek, B, Fuchs, WA, et al Shortcomings of chest radiography in detectingPneumocystis cariniipneumonia.J Acquir Immune Defic Syndr1994;7,39-45. [PubMed]
 
Greenberg, SD, Frager, D, Suster, B, et al Active pulmonary tuberculosis in patients with AIDS: spectrum of radiographic findings (including a normal appearance).Radiology1994;193,115-119. [PubMed]
 
Vander Els, NJ, Stover, DE Approach to the patient with pulmonary disease.Clin Chest Med1996;17,767-785. [PubMed]
 
Kang, EY, Staples, CA, McGuinness, G, et al Detection and differential diagnosis of pulmonary infections and tumors in patients with AIDS: value of chest radiography versus CT.AJR Am J Roentgenol1996;166,1-9. [PubMed]
 
Sider, L, Gabriel, H, Curry, DR, et al Pattern recognition of the pulmonary manifestations of AIDS on CT scans.Radiographics1993;13,771-784. [PubMed]
 
Kuhlman, JE, Fishman, EK, Hruban, RH, et al Diseases of the chest in AIDS: CT diagnosis.Radiographics1989;9,827-857. [PubMed]
 
Hartman, TE, Primack, SL, Muller, NL, et al Diagnosis of thoracic complications in AIDS: accuracy of CT.AJR Am J Roentgenol1994;162,547-553. [PubMed]
 
Hirschtick, RE, Glassroth, J, Jordan, MC, et al Bacterial pneumonia in persons infected with the human immunodeficiency virus.N Engl J Med1995;333,845-851. [PubMed]
 
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