Diagnosis of IPA in HIV: the role of the chest X-ray and radiologist

Abstract

The role of clinical information and chest film for the discrimination between invasive pulmonary aspergillosis (IPA) and its differential diagnoses in human immunodeficiency virus (HIV) infection was studied. The diagnostic performance of clinical information and chest film alone and in combination was studied for eight internists and eight radiologists with regular exposure to IPA patients. The multicenter case sample consisted of 25 patients with proven IPA and 25 with other pulmonary diseases typical for HIV. The cases were presented on a CD-ROM. Receiver operating characteristics (ROC) methodology was employed. With clinical information alone, internists achieved the highest diagnostic performance (area under curve/AUC=0.84). Viewing the chest films did not contribute to their performance (AUC=0.80, P=0.26). The radiologist's performance on the basis of viewing the chest film (AUC=0.75) increased significantly ( P=0.012) when clinical information (AUC=0.83) was supplied. IPA cases with characteristic radiological appearance were correctly identified in 90% with chest film. For radiologists with regular exposure to HIV patients, chest films hold relevant information and contribute to the determination in cases with characteristic radiological appearance. Overall and especially in cases with less characteristic radiological appearance, they have significant profit from full access to the clinical data. For internists with regular exposure to HIV patients, chest films do not provide information essential for the verification or differentiation of potential IPA.

Invasive Aspergillosis and HIV Infection

“…The development of consolidations with cavities has been also observed in numerous cases ( Table 3). The air crescent sign -which is noted in up to 93% among certain groups of immunocompromised patients with IA -is less frequently among HIVinfected patients [21,23]. A proposed explanation is that this sign is associated with the rapid recovery from severe immunosuppression, a phenomenon that is move slow usual among AIDS patients.…”

“…Autopsy studies have shown that the ante mortem diagnosis of AIDS-associated IA is often underestimated. In vivo diagnosis is misunderstood since nonspecific symptoms often mask multiple infections [23] (Table 5). EIA for galactomannan detection has been validated in animal models and in patients as a surrogate marker for the detection of IA [25].…”

An update of clinical characteristics and imaging findings of pulmonary aspergillosis

“…Consolidation or mass is the most common CT finding of IPA in solid organ transplantation (SOT) recipients and presence of small cavities may be associated with favorable prognosis [48] . Zaspel et al [49] identified characteristic radiological appearance of IPA in HIV patients as nodules (92%), cavitations (75%), air crescent sign (33%) or subpleural infarctions (17%). Thick-walled cavitary lesions were demonstrated as a late finding in late-stage AIDS with a CD4 cell count of < 5/mm 3 [50] .…”

Impact of clinical data on chest radiography sensitivity in detecting pulmonary abnormalities in immunocompromised patients with suspected pneumonia

“…The main drawback of CXR is a limited sensitivity in the detection of early infection in these patients, whose immune reactivity is poorer and delayed compared with immunocompetent ones [10][11][12][13][14]. To our knowledge, few authors have investigated the role of the knowledge of clinical and laboratory data in CXR evaluation of patients with suspected pulmonary infection, with discordant results [15][16][17].…”

“…In tali pazienti, la cui reattività al processo infettivo è ridotta e ritardata rispetto ai soggetti immunocompetenti, il principale limite della radiografia del torace è la limitata sensibilità nell'identificazione precoce di reperti patologici [10][11][12][13][14]. A nostra conoscenza, pochi autori hanno indagato il ruolo della conoscenza delle condizioni cliniche e dei dati laboratoristici di questi pazienti nell'interpretazione della radiografia del torace eseguita nel sospetto di polmonite, con risultati peraltro discordanti [15][16][17].…”