Академический Документы
Профессиональный Документы
Культура Документы
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 Received 29 March 2006
pulmonary tuberculosis, bacterial pneumonia and Pneumocystis carinii pneumonia Revised 21 July 2006
(PCP) was made in 80%, 84% and 100% of cases, respectively. The proportion of Accepted 15 August 2006
patients with missed lesions on plain chest radiographs in HIV infected patients with
DOI: 10.1259/bjr/15037569
CAP was high. This has important implications for management and prognosis. HRCT
scans correlate well with the microbiological diagnosis when reported by an ’ 2007 The British Institute of
experienced radiologist. Radiology
Sub-Saharan Africa has the largest number of human film in early detection of lung infections [10]. HRCT may
immunodeficiency virus (HIV) infected subjects world- have a role in patients whose chest radiographs are non-
wide. The HIV pandemic in the region is still increasing revealing or non-diagnostic [11]. HRCT is helpful in the
and has not yet reached a plateau. The number of HIV differential diagnosis of infectious from non-infectious
infected patients presenting with pulmonary infections acute parenchymal disease in the immunocompetent
has also increased dramatically. patient, but is of limited value in making a specific
The imaging technique of choice in patients with diagnosis [12].
clinical symptoms and signs of community-acquired There are no studies from sub-Saharan Africa on the
pneumonia (CAP) has traditionally been the chest utility and value of HRCT scanning of the chest in HIV
radiograph [1–7]. This is largely because chest radio- infected patients with CAP. We compared HRCT with
graphy is easy to perform, widely accessible, cheap and plain chest radiography, and the usefulness of HRCT in
associated with low radiation. High-resolution CT the microbiological diagnosis of PCP, pulmonary tuber-
(HRCT) scanning is reserved for the analysis of complex culosis and bacterial CAP. We hypothesized that, in HIV
cases, particularly when the chest radiograph is equivo- infected patients presenting with CAP, clinically impor-
cal with regard to associated central obstruction, cavita- tant lesions may not be evident on plain chest radio-
tion, lymphadenopathy, or empyema [8, 9]. The role of graphy.
HRCT, however, is rapidly evolving. In febrile neutro-
penic patients, CT scanning is more sensitive than plain
Patient recruitment and methods
Address correspondence to: Prof. Umesh Gangaram Lalloo, Internal The study was performed at King Edward VIII
Medicine, University of KwaZulu Natal, 719 Umbilo Road, Hospital, Durban, South Africa. This is a tertiary
Congella, Durban, KwaZulu Natal, 4013 South Africa. E-mail:
lalloo@:ukzn.ac.za
teaching hospital of the Nelson R Mandela School of
This study was funded by a grant from the Medical Research Medicine. The hospital serves a predominantly black
Council of South Africa. African population from the townships of Umlazi,
KwaMashu, Inanda, Clermont and Chesterville. The patients (82%), abnormalities were missed on the chest
ethics committee of Nelson R Mandela School of radiograph, with a total of 76 missed lesions. The most
Medicine, Durban, South Africa, granted permission to commonly missed abnormalities included ground-glass
perform the study. From June 2000 to July 2001, 54 opacification (50% of patients) and mediastinal lympha-
patients were recruited into the study. All the patients denopathy (50% of patients), followed by pleural
were black Africans. They were randomly selected from effusions (35% of patients) and pericardial effusions
inpatients presenting with symptoms and signs of CAP (20% of patients) (Table 1). Analysis of the missed lesions
with a chest radiograph showing consolidation or an as a proportion of the total number (n576) revealed that
infiltrate compatible with the diagnosis. None of the 26% were mediastinal lymphadenopathy, 26% ground-
patients was on antiretroviral therapy. Microbiological glass opacification, 18% pleural effusions, 10% pericar-
tests performed following induction and expectoration of dial effusions, 5% cavitation, 5% bullae, 5% cysts and 1%
sputum included Gram stain and culture, and Ziel– abscess formation and pneumothorax.
Neelsen stain for acid-fast bacilli. Blood cultures and
urine tests for Legionella pneumophila and Streptococcus
pneumoniae were performed. The PCP immunofluores- Microbiology
cence test was performed on induced sputum to detect
Pneumocystis jirovecii. CD4 counts were assessed by flow There was a total of 31 isolates from 26 patients (53%).
cytometry. No organisms were isolated in the remainder (Table 2).
A HRCT scan of the chest was performed after The most common organism isolated was Mycobacterium
admission to the medical ward, consisting of 1.5 mm tuberculosis (32%), followed by Streptococcus pneumoniae
collimation sections at 10 mm intervals reconstructed (29%) and PCP (19%). Five patients had polymicrobial
with a high spatial frequency algorithm. All scans were pneumoniae. Other organisms isolated were Escherichia
performed without intravenous contrast medium at coli (2), Gram-negative bacilli (2), Klebsiella pneumoniae
suspended end-inspiration with the patient in a supine (1), Haemophilus influenzae (1) and Staphylococcus pneumo-
position. Scans were reviewed at a setting appropriate niae (1). A correct HRCT diagnosis of pulmonary
for both lung parenchyma and mediastinum. The chest tuberculosis, bacterial pneumonia and pneumocystis
radiographs and HRCT scans were evaluated by a carinii pneumonia (PCP) was made in 80%, 84% and
radiologist who had no prior knowledge of the aetiology 100% of cases, respectively (Table 3). The sensitivities of
of the pneumonia, duration of symptoms, severity of HRCT compared with microbiology for the diagnosis of
symptoms, degree of dyspnoea, presence or absence of pulmonary tuberculosis, PCP and bacterial pneumonia
fever or leukocytosis. The HRCT scans were reported were 80%, 100% and 85%, respectively. However, HRCT
without the concurrent availability of the chest radio- was not specific for any diagnosis compared with
graphs. microbiology (Tables 3).
Evaluated HRCT findings included consolidation,
ground-glass opacification, nodular opacification, pleural
effusions, pericardial effusions, abscess formation, cavita- Discussion
tion, bullae, cysts, mediastinal lymphadenopathy (nodes
greater than 1 cm in short axis diameter) and the presence Few studies have been performed on the role of HRCT
or absence of a pneumothorax. The radiologist was asked scanning of the chest in HIV related pulmonary infec-
to record the most likely aetiological diagnosis as bacterial tions [13–21]. None of these studies have been from sub-
pneumonia, Mycobacterium tuberculosis, Pneumocystis jirove- Saharan Africa, which currently has the highest HIV or
cii pneumonia or any other diagnosis. The chest radio- acquired immunodeficiency syndrome burden. Most
graphic and HRCT scan findings were then compared. have focused on PCP [13, 15, 16, 19, 20]. To our
knowledge, 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
Statistical analysis disease, but the entry criteria were that of a normal or
Two by two tables were used to calculate the non-specific chest radiograph. In our study, no patients
sensitivity, specificity and positive and negative pre- with normal chest radiographs were recruited. No
dictive values of HRCT diagnosis vs the microbiological patients with normal chest radiographs had HRCT scans
diagnosis. performed.
Our study has shown that in HIV infected African
patients with CAP, an alarmingly high percentage of
Results patients (82%) have abnormalities that are not visible on
plain chest radiograph. This study supports the findings
Of the 54 patients recruited into the study 5 were of Guillemi et al [17], who undertook a study to
excluded because they were HIV seronegative. Thus data characterize the frequency of lung lesions in asympto-
from 49 patients were analysed. There were 26 females matic HIV infected individuals with advanced disease.
and 23 males. The mean age of the patients was 36 years All were homosexual males on assessment for initiation
(range 18–53 years). The CD4 count was deter- of PCP prophylaxis. The results of their study demon-
mined in 37 patients. The mean CD4 count was strated that as many as 60% of HIV infected patients
184 cells ml21 (range 0–1223 cells ml21). have unexpected abnormalities on HRCT at the time of
The findings on chest radiography correlated with the starting PCP prophylaxis. Syrjala et al [22] compared
HRCT scan findings in only nine patients (18%). In 40 HRCT with chest radiography in 47 immunocompetent
patients with signs and symptoms of CAP. HRCT lung with consequent demise of a patient. A lung abscess
identified all 18 cases apparent on chest radiography as not treated for the appropriate duration may increase
well as an additional 8 cases. morbidity and mortality.
The superiority of HRCT is well recognized [12, 23– The present study reflects the presence of significant
25]. Superior contrast resolution and cross-sectional complications detected on HRCT scans in patients with
display is achieved. HRCT not only improves character- advanced HIV disease. The mean CD4 count in the
ization of parenchymal infections in terms of location present study group was 184 cells ml21 and the lowest
and extent of disease, but also surpasses chest radio- was zero. Advanced disease, as determined by the CD4
graphy in the detection of complications [24]. The count, is associated with HRCT abnormalities even in
present study demonstrated the sensitivity of HRCT in asymptomatic patients [17]. The lower the CD4 count,
detailing abnormalities not apparent on chest radio- the greater the likelihood of both opportunistic and
graphy in a cohort of HIV infected patients with CAP. non-opportunistic pulmonary infections. Co-infections
Mediastinal lymphadenopathy, ground-glass opacifica- become common. Coinfections occurred in 20% of
tion, pleural effusions and pericardial effusions were patients (5 out of 26) in the present study.
among the most commonly missed lesions on chest The sensitivity of HRCT diagnosis compared with the
radiographs. Lack of identification of these abnormalities microbiological diagnosis was 100% for PCP, 85% for
may impact significantly on patient management and bacterial pneumonia and 80% for tuberculosis. The
clinical outcome. The detection of some abnormalities present study confirmed that no HRCT or chest radio-
may expand the options available to the clinician for graphic pattern is specific for any infection [7, 26–28].
obtaining diagnostic specimens for microbiology and The average positive predictive values attained in the
histology. The attending physician had knowledge of present study suggest that HRCT scans are relatively
the HRCT findings. The HRCT findings in conjunction good for screening in, but not for screening out. The
with the clinical features aided the physician in commen- negative predictive values that were obtained in the
cing therapy in patients in whom microbiological tests present study suggest that the technique cannot be used
were negative. The HRCT findings did not direct the to exclude PCP, tuberculosis, or bacterial CAP.
microbiological investigations as most tests were per- Radiologists rely on the clinical information provided
formed within the shortest possible time on admission. to come to a reasonably accurate differential diagnosis.
Some abnormalities contribute to significant morbidity In the absence of clinical information it is difficult to
and may increase mortality. Bullae and cysts may rupture distinguish pneumonia and other pathological processes
causing a spontaneous pneumothorax. Over time, these [29]. Although the radiologist in the present study was
lesions may enlarge, compressing normal lung in patients blinded to patients’ clinical information, correlation with
already afflicted with the ravages of HIV induced the microbiological diagnosis was good, as shown by the
pulmonary infections such as repeated bacterial pneumo- high sensitivities obtained. In patients who are not
nia, PCP and tuberculosis. A small pneumothorax may improving clinically, HRCT may assist with the decision
rapidly expand causing compression of already diseased to switch therapy. However, the limitations of HRCT in
the management of HIV associated CAP need to be
recognized. Sub-Saharan countries are poor and under-
Table 2. Organisms isolated in 26 of the 49 patients resourced. There are financial, technical, human resource
and logistical constraints.
Pathogen Number of isolates %
In conclusion, we have shown that a large proportion
Mycobacterium tuberculosis 10 32 of HIV infected African patients presenting with CAP
Streptococcus pneumoniae 8 26 have clinically important abnormalities on HRCT that
Pneumocystis jirovecii 6 19 are not apparent on plain chest radiographs. This has
Escherichia coli 2 7 important implications for the management of HIV
Gram-negative bacilli 2 7 associated CAP. When reported by an experienced
Haemophillus influenzae 1 3 radiologist, the HRCT scan diagnosis has good correla-
Klebsiella pneumoniae 1 3
tion with the microbiological diagnosis. This may be
Staphylococcus aureus 1 3
useful in modifying or switching therapy.
Mycobacterium 17 8 2 7 80 % 80 % 0 53 % 0
tuberculosis
Pneumocystis 14 3 0 11 100 % 100 % 0 21 % 0
pneumonia
Bacterial 20 11 2 7 84 % 85 % 0 61 % 0
pneumonia
HRCT, high-resolution computed tomography.
pneumonia from the presenting clinical features. Thorax 28. Tew J, Calenoff L, Berlin BS. Bacterial or nosocomial
1989;44:1031. pneumonia: accuracy of radiographic diagnosis.
27. MacFarlane JT, Miller AC, Roderick Smith WH, Morris AH, Radiology 1977;124:607.
Rose DH. Comparative radiographic features of community- 29. Primack SL, Muller NL. HRCT in acute diffuse lung disease
acquired Legionnaire’s disease, pneumococcal pneumonia, in the immunocompromised patient. Radiol Clin North Am
mycoplasma pneumonia and psittacosis. Thorax 1984;39:28. 1994;321:731–44.