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HIV/AIDS, Miscellaneous Manifestations


KEY FACTS

Terminology

  • HIV/AIDS-related opportunistic infections and neoplasms

Imaging

  • Findings

    • Primary CNS lymphoma: Enhancing lesions, often hemorrhagic/necrotic within basal ganglia, periventricular white matter

    • Kaposi sarcoma: Intense enhancing soft tissue mass in scalp

    • Bacterial abscesses: Ring-enhancing lesion with ↑ signal on DWI

    • Aspergillosis: Multiple ring-enhancing lesions

    • Neurosyphilis: Cortical/subcortical infarcts, granulomas, leptomeningeal enhancement

    • Benign lymphoepithelial lesions of HIV: Multiple cystic masses enlarging both parotid glands

  • MR is most sensitive

  • PET or thallium-201 SPECT helpful to differentiate from toxoplasmosis

  • Immune reconstitution inflammatory syndrome: “Wild”-looking enhancing lesion(s)

Top Differential Diagnoses

  • Toxoplasmosis

  • Metastases

  • Tuberculosis

Diagnostic Checklist

  • Consider using DWI, MRS, PET/SPECT to differentiate opportunistic infections from malignant lesions

  • Bacterial abscess, aspergillosis, neurosyphilis may need surgical biopsy for diagnosis

Axial graphic shows typical lymphoid and lymphoepithelial lesions of HIV/AIDS. Note hyperplastic tonsils
and multiple cysts in both parotid glands
.

Axial CECT scan in a 33-year-old man with HIV/AIDS shows a large right parotid cyst with enhancing rim
and enlarged Waldeyer ring
(the annular arrangement of lymphoid tissue in the pharynx, also known as the pharyngeal lymphoid ring).

T1 C+ scan in an HIV(+) man obtained prior to beginning HAART shows some nonenhancing periventricular hypointensities
.

The patient deteriorated 3 weeks following institution of HAART. T1 C+ scan now shows extensive patchy enhancing lesions
. Cerebrospinal fluid was positive for JC virus in this case of progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome (PML-IRIS).

(Courtesy T. Hutchins, MD.)

TERMINOLOGY

Definitions

  • HIV/AIDS-related opportunistic infections, neoplasms

IMAGING

General Features

  • Best diagnostic clue

    • Primary CNS lymphoma (PCNSL): Enhancing lesions, often hemorrhagic/necrotic within basal ganglia, periventricular white matter (WM)

    • Kaposi sarcoma (KS): Intense enhancing, soft tissue mass in scalp

    • Bacterial abscesses (BA): Ring-enhancing lesion with ↑ signal on DWI

    • Aspergillosis (As): Multiple ring-enhancing lesions

    • Neurosyphilis (NS): Cortical/subcortical infarcts, granulomas, leptomeningeal enhancement

    • Benign lymphoepithelial lesions of HIV (BLL-HIV): Multiple cystic masses enlarging both parotid glands

  • Location

    • PCNSL: 90% supratentorial; deep gray nuclei, periventricular white matter commonly affected

    • KS: Face, scalp, and skin of neck

    • BA: Typically supratentorial, frontal, and parietal

    • As: Distribution of MCA, cortical/subcortical, basal ganglia/thalami perforating arteries

    • NS: Cortical/subcortical, meninges

    • BLL-HIV: Parotid glands

  • Morphology

    • PCNSL: Solitary mass or multiple lesions

    • KS: Infiltrating soft tissue mass

    • BA: Smooth, ring-enhancing lesion

    • As: Multiple lesions, often in distribution of MCA

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