1. CNS.
AIDS.
Endocrine
Dr/ ABD ALLAH
NAZEER. MD.
Head
@Neck.
Lung.
Heart.
GIT.
Spleen. Liver.
MSK.
Kidneys.
Pancreas
Genito-urinary.
Skin.

2. AIDS in the CNS
10-20% of pts with AIDS present with neurologic disease
40% of AIDS pts will have neurologic involvement in course of disease
CNS symptoms may indicate overall deterioration
HIV is the most common viral infection of the CNS and PNS.
Up to 50% of HIV patients have clinical apparent neurological disease.
Types of CNS Disease
HIV itself
Neoplasm, primary CNS lymphoma
Metastases
Opportunistic infection parasitic: toxoplasmosis (toxo), amebiasis
mycobacterial: tuberculosis (TB),
mycobacterium avium complex (MAC)
viral: JC virus (JCV), herpes simplex virus (HSV),
cytomegalovirus (CMV)
fungal: cryptococcus, aspergillus, candida

11. Diffuse cerebral cortical atrophy with AIDS patient.

14. Toxoplasmic encephalitis in a 36-year-old patient with AIDS.

15. Toxoplasmosis

17. Progressive Multifocal Leukoencephalopathy.

19. HIV Encephalitis Vs PML

20. Brain Lymphoma.

22. Two cases of Lymphoma: periventricular spread at CT case.

23. Contrast-enhancing lesions on CT scans (A–D) in 4 patients with AIDS-related
PCNSL. Note irregularly enhancing lesions in the right parietal
lobe (A), right occipital lobe (B), and right periventricular white matter (C
and D); most of the lesions show ring enhancement (A, B, and C).

24. Solitary lesions on a noncontrast CT scan (A), contrast-enhanced CT scans (B and C),
and an MR image (D) in 3 patients with non-AIDS PCNSL. Note a hyperattenuated
lesion in the frontal lobe on the noncontrast CT scan (A) with marked enhancement
on the contrast series (B) and focal contrast-enhancing lesions in the left basal
ganglia (C) and temporal lobe (D). One lesion has ring enhancement (D).

25. Contrast-enhanced axial (B and D) and coronal (A and C) MR images
in 4 patients with non-AIDS PCNSL. Note lesions in the basal ganglia
(A), ventricles (B), frontal lobes (C), and cerebellar lobes (D).

29. HIV associated with cord neuropathy.

30. HIV associated with cord neuropathy.

32. Infection by a diverse array of organisms, as well as HIV-associated
malignancies (i.e., Kaposi's sarcoma and
lymphoma), have been detected in the pituitary and adrenal
glands . Such occurrences were far more common prior to the
widespread introduction of potent ART, although they may
still be observed in patients not receiving ART or who have
antiretroviral drug resistant infection.
Tissue is generally required for a definitive diagnosis. When
technically feasible, fine needle aspiration (FNA) biopsy of
the adrenal gland provides a less invasive alternative to open
biopsy. Pheochromocytoma must always be excluded before
FNA biopsy of the adrenal gland is performed. Standard
functional testing should also be performed since clinically
significant endocrine dysfunction may accompany glandular
infection or infiltration of the pituitary or adrenal glands.

33. Hypopituitarism secondary to HIV infection.

34. Acute hypophysitis and hypopituitarism in early syphilitic meningitis
in a HIV-infected patient: at diagnosis and after treatment.

36. Chagas’ disease presenting with a suprasellar mass
and panhypopituitarism secondary to HIV infection.

37. Hypoadrenalism secondary to HIV infection.

38. Infectious Process of the Neck Related to HIV
In the HIV-infected population, however, Mycobacterium avium complex
(MAC) infection is the most common mycobacterial infection.
Fungal infections, including cryptococcosis, histoplasmosis, and
coccidioidomycosis, can manifest as a cervical mass in the HIV-infected
patient. Cryptococcus neoformans is the most prevalent cause of deep-seated
fungal infections in the HIV-infected population, occurring in 5 to
10% of these patients and commonly involves the lungs and the meninges
Candidiasis (Oral Thrush), Oral candidiasis is by far the most common oral
condition in HIV /AIDS patients.
Herpes labialis most commonly presents as crops of fever blisters on the
palate, gingiva, or other oral mucosal surfaces.
Otitis Media and externa. The most common otologic problems reported
in HIV-infected patients are serous otitis media and recurrent acute otitis
media and externa.
The prevalence of rhinosinusitis ranges from 20 to 70% in patients with
AIDS. Causative organisms include atypical opportunistic and common
organisms responsible for sinusitis in hosts without AIDS.

39. Neoplastic disease in the head
and neck of patients with AIDS.
Immunosuppression increases the risk of developing
malignancies. In immunosuppression due to human
immunodeficiency virus (HIV) disease the common head
and neck tumors are Kaposi's sarcoma and non-
Hodgkin's lymphoma. Squamous cell carcinoma has also
been reported. Kaposi's sarcoma is the commonest
neoplastic disease in AIDS. The incidence of lymphoma
is rapidly increasing. This article reviews the incidence,
clinical presentation and management of these diseases
in the head and neck in AIDS patients.

40. Invasive Aspergillosis Presenting as a
Neck Mass in a Person With HIV/AIDS
HIV with chronic bilateral
bacterial maxillary sinusitis.

41. HIV two cases neck abscess caused by Mycobacterium avium complex.

42. Kaposi,s sarcoma of the oropharynx in AIDS patient.

43. Two HIV -related Kaposi’s sarcoma.

44. HIV -related Kaposi’s sarcoma of the oropharynx:

45. Disseminated AIDS-related KS in a 36-year-old man with
involvement of the tongue base and soft and hard palates.

46. Neck lymphoma with AIDS patient.

47. HIV AND THE RESPIRATORY SYSTEM
Lung is a major target organ for HIV infection that has been
shown to be present in T and B lymphocytes, pulmonary
fibroblasts, macrophages, Natural Killer cells, eosinophils,
monocytes and dendritic cells. As a consequence, progressive
quantitative and functional depression within the CD4
lymphocytes and other immunological subsets occur and render
the patient more prone to a wide array of infectious and non-infectious
complications.
Over 98% of respiratory complications were infectious and the
most frequent complications were acute bronchitis, bacterial
pneumonia and PCP. The mortality and morbidity of HIV-infected
patients have dramatically improved as a result of the
introduction of highly active antiretroviral therapy (HAART). An
analysis of the Centers for Disease Control and Prevention's HIV.

48. The most frequent respiratory diagnoses in the HIV-infected patients are
upper respiratory tract infection, acute bronchitis, and acute sinusitis. They
occur at all strata of CD4 cell counts and have higher rates compared with
HIV-negative control. Recurrent bacterial pneumonia and pulmonary
tuberculosis (PTB) occur more frequently in patients with CD4 cell counts less
than 400 cells/μL; Pneumocystis pneumonia (PCP) and disseminated TB
usually diagnose when CD4 cell counts drop below 200 cells/μL. Disseminated
MAC, fungal pneumonia, and cytomegalovirus pneumonitis occur in patients
with the most severe immunosuppression (CD4 cell counts less than 100
cells/μL).
Bacterial pneumonia occurs more frequently in HIV-infected patients than in
the general population. Pneumonia occurs at any CD4 cell count but is
especially common as HIV infection progresses. Rate of pneumonia is higher in
intravenous drug users than other transmission categories. The spectrum of
bacterial pathogens is similar to that of community-acquired pneumonia in the
general population and Streptococcus pneumoniae remains the most common
pathogen. Staphylococcus aureus and gram-negative organisms in particular
Pseudomonas aerugionsa are seen more frequently in advanced disease. The
incidence of bacteraemia is increased too. Influenza and pneumococcal
vaccination is indicated in HIV-infected patients.

49. Non-infectious pulmonary disease
Pulmonary involvement is present in up to one third of patients with known
Kaposi's sarcoma (KS). It usually follows the appearance of cutaneous disease.
Intrathoracic involvement by KS may include parenchymal disease,
endobronchial lesions, pleural disease, and adenopathy. The prognosis of
pulmonary KS is poor with median survival of 2 to 10 months. However, there
is significant reduction in mortality after the introduction of HAART and newer
combination chemotherapy.
The incidence of intrathoracic manifestations of AIDS-associated lymphoma
ranges from 6% to 31%. Lung involvement is usually seen in association with
other sites of disease but occasionally it can be the initial or predominant site
of disease. The median CD4 cell count has been noted to be lower in patients
with pulmonary involvement than in those without. Chest radiographs may
show effusions, multi-nodular infiltrates, consolidation, mass lesions, focal or
diffuse interstitial infiltrates, and hilar adenopathy.
Epidemiological studies have suggested that lung cancer occurs more
frequently in HIV-infected patients, but is often linked to the increased
smoking rates. Adenocarcinoma has been the most common histology.
Survival is significantly shorter for HIV-infected patients compared with HIV-negative
subjects and outcomes of these patients remain poor despite HAART.

51. HIV-Associated Pneumonias

52. Chest radiograph of an HIV positive individual with a CD4 cell count
above 200 cells/mm3, revealing right upper lobe consolidation. Sputum
and blood cultures were positive for Streptococcus pneumoniae.

53. Two chest radiograph of an HIV positive individual with a CD4 cell
count above 200 cells/mm3, revealing right upper and lower lobes
consolidation with areas of cavitation at the upper lobe consolidation.

54. Chest high-resolution computed tomography (HRCT) scan of an HIV positive person
with a CD4 cell count below 200 cells/mm3, whose chest radiograph was normal. Chest
HRCT scan revealed the characteristic patchy ground-glass opacities of PCP. Induced
sputum microscopic examination revealed Pneumocystis cysts and trophic forms.

56. Pneumocystis carinii pneumonia. These chest radiographs are of two patients.
Both show -ground glass appearance. The left chest X-ray (CXR) shows a much
more subtle ground-glass appearance while the right CXR shows a much more
gross ground-glass appearance mimicking pulmonary edema.

57. Pneumocystis carinii pneumonia. Computed tomography (CT) in a
subacute phase showing foci of consolidation and interlobular septal
thickening due to organized inflammatory infiltrate on high-resolution CT

58. Pneumocystis carinii pneumonia (PCP). High-resolution computed tomography
showing the hallmark of PCP in a clinical setting of immune compromise. Note
the ground-glass attenuation with a geographic or mosaic distribution

59. Pneumocystis carinii pneumonia. Chest X-ray and computed
tomography show a left-sided ground-glass pattern and a right-sided
large tension pneumothorax. Note the mediastinal shift.

60. Bronchiolitis obliterans with or without organizing pneumonia in the absence of infection can
be a feature of acquired immunodeficiency syndrome (AIDS). This is an infrequent imaging
diagnosis, although focal air trapping on expiratory computed tomography, consistent with
bronchiolitis obliterans, has been demonstrated in two-thirds of human immunodeficiency
virus-positive patients without AIDS, the severity increasing with the duration of infection.

61. Mycobacterium xenopi in a human immunodeficiency virus, 36-year old, male
patient with a CD4 count of 80 with four positive sputum samples and a
bronchoalveolar lavage for acid-fast bacilli. The chest X-ray and computed
tomography scans show cavitating consolidation, loss of volume, traction
bronchiectasis and ground-glass appearances in the right apical region superimposed
on bullous disease of the lungs. There is no associated lymphadenopathy

62. A 26-year-old human immunodeficiency virus-positive female presented with
shortness of breath. The chest X-ray shows a large left-sided pleural effusion and loss
of height and erosion of the articular plates between the 9th and 10th vertebral bodies
associated with soft tissue swelling. A sagittal T2-weigted magnetic resonance scan
of the dorsal spine shows complete obliteration of the disc between the 9th and 10th
dorsal vertebral bodies associated with fluid collection anterior to the spine
representing pus. Acid-fast bacilli were identified in the aspirated pus

63. CT Chest with lung windowing of Pulmonary Kaposi’s Sarcoma
in an adult demonstrates multiple poorly circumscribed
pulmonary nodules and ground glass opacification.

64. Kaposi’s Sarcoma
with peri-hilar
opacification, pleural
effusion and
lymphadenopathy.

65. Pulmonary KS in a 45-year-old man.

66. Kaposi's Sarcoma with peri-hilar
opacification, pleural
effusion and
lymphadenopathy.

67. Lymphoma. Chest X-ray (CXR) on a human immunodeficiency virus patient that
presented with multiple lung masses, which grew rapidly mimicking infection. Note that
there is no associated lymphadenopathy. Well-defined solitary or multiple parenchymal
nodules CXR are common. A percutaneous biopsy revealed a non-Hodgkin’s lymphoma

68. Pulmonary parenchymal lymphoma in a 41-year-old HIV-positive man.

69. NHL in a 23-year-old human immunodeficiency virus female. The chest radiograph
shows multiple well-defined lung nodules within the left lung associated with
mediastinal lymphadenopathy. Lymphadenopathy is a less common feature in
acquired immunodeficiency disease-related NHL and nodes are rarely significant
according to size criteria unlike as in the case shown here, where there is significant
lymphadenopathy as confirmed by computed tomography (right upper frame).
Magnetic resonance imaging is the imaging of choice to detect vascular encasement

70. Cardiovascular Manifestations of HIV Infection:
Myocarditis
Myocarditis and HIV-1 myocardial infection are still the most studied causes of
dilated cardiomyopathy in HIV disease. HIV-1 virions appear to infect
myocardial cells in patchy distributions without a clear direct association
between HIV-1 and cardiac myocyte dysfunction
Autoimmunity
Cardiac-specific auto antibodies (anti-α myosin auto antibodies) have been
reported in up to 30% of patients with HIV-associated cardiomyopathy. The
finding supports the theory that cardiac autoimmunity plays a role in the
pathogenesis of HIV-related heart disease and suggests that cardiac auto
antibodies may be markers of left ventricular dysfunction in HIV-positive
patients with previously normal echocardiographic findings.
Dilated Cardiomyopathy
HIV disease is recognized as an important cause of dilated rdiomyopathy, with
an estimated annual incidence of 15.9 in 1000 before the introduction of
HAART. The importance of cardiac dysfunction is demonstrated by its effect on
survival in acquired immunodeficiency syndrome (AIDS).

71. Pericardial Effusion
The prevalence of pericardial effusion in asymptomatic AIDS patients has
been estimated at 11% before the introduction of HAART. HIV infection
should be included in the differential diagnosis of unexplained pericardial
effusion or tamponade. Pericardial effusion in HIV disease may be related
to opportunistic infections or to malignancy, but most often a clear
pathology is not found. The effusion may be part of a generalized serous
effusive process also involving pleural and peritoneal surfaces.
Endocarditis
The prevalence of infective endocarditis in HIV-infected patients is similar to
that in patients of other risk groups, such as intravenous drug users.6
Estimates of endocarditis prevalence vary from 6.3% to 34% of HIV-infected
patients who use intravenous drugs independently of HAART regimens.6
Right-sided valves are predominantly affected, and the most frequent agents
are Staphylococcus aureus (>75% of cases), Streptococcus pneumoniae,
Haemophilus influenzae, Candida albicans, Aspergillus fumigatus, and
Cryptococcus neoformans. Patients with HIV generally have presentations and
survival from infective endocarditis similar to those without HIV (85% versus
93%).

72. HIV-Associated Pulmonary Hypertension
The pathogenesis of primary pulmonary hypertension in HIV infection is
multifactorial and poorly understood. Primary pulmonary hypertension
has been found in hemophiliacs receiving lipophilized factor VIII,
intravenous drug users, and patients with left ventricular dysfunction,
obscuring any relationship with HIV-1. HIV-1 is frequently identified in
alveolar macrophages on histology.
Vasculitis and Coronary Artery Disease
A wide range of inflammatory vascular diseases, including polyarteritis
nodosa, Henoch-Schönlein purpura, and drug-induced hypersensitivity
vasculitis, may develop in HIV-infected individuals. Kawasaki-like
syndrome and Takayasu’s arteritis have been also described.
Hypertension and Coagulative Disorders
The prevalence of hypertension in HIV disease has been estimated to have
been about 20% to 25% before the introduction of HAART. Recent reports
indicate that elevated blood pressure may be related to protease inhibitor-induced
lipodystrophy and metabolic disorders, especially fasting
triglyceride, with a prevalence of hypertension in up to 74% of patients
with HAART-related metabolic syndrome.

73. Chest radiograph showing cardiomeagly in a five-year-old girl with
HIV infection, cardiomyopathy, and congestive heart failure.

75. HIV with dilated cardiomyopathy.

76. HIV with pericardial and pleural effusion.

77. This human immunodeficiency virus patient suffered from gram negative
septicemia, which was successfully treated. However, routine physical
examination revealed an audible bruit on thoracic auscultation. The chest X-ray
shows a prominent hump over the proximal descending aorta due to
mycotic aortic aneurysm. The axial computed tomography (CT) and coronal CT
reconstruction elegantly demonstrate the abnormality

78. The gastrointestinal (GI) tract is a major site of
disease in HIV infection: almost half of HIV-infected patients present
with GI symptoms, and almost all patients develop GI complications.
GI symptoms such as anorexia, weight loss, dysphagia,
odynophagia, abdominal pain, and diarrhea are frequent and
usually nonspecific among these patients. Endoscopy is the
diagnostic test of choice for most HIV-associated GI diseases, as
endoscopic and histopathologic evaluation can render diagnoses in
patients with non-specific symptoms. In the past three decades,
studies have elucidated a variety of HIV-associated inflammatory,
infectious, and neoplastic GI diseases, often with specific
predilection for various sites. HIV-associated esophageal disease, for
example, commonly includes candidiasis, cytomegalovirus (CMV)
and herpes simplex virus (HSV) infection, Kaposi's sarcoma (KS), and
idiopathic ulceration. Gastric disease, though less common than
esophageal disease, frequently involves CMV, Mycobacterium
avium-intracellulare (MAI), and neoplasia (KS, lymphoma).

79. Double contrast barium esophagography shows innumerable
pseudo membranes and plaques (arrows) "shaggy
esophagus“ in a patient with AIDS. Candida Esophagitis.

80. Candida
esophagitis

81. CMV esophagitis.

82. Primary non-Hodgkin B-cell Lymphoma of the esophagus.

83. lymphoma of the duodenum.

84. AIDS with gastric lymphoma with circumferential wall thickening.

85. AIDS patient with Pneumatosis intestinalis and mesenteric air are present.

86. AIDS with non-Hodgkin Burkett's lymphoma of the terminal ileum.

87. Upper GI series demonstrating
abnormal appearance of small
bowel with diffuse thickening
of mucosa (arrows) in an AIDS
patient with CMV.

88. Diffuse large cell lymphoma in the mesentery with infiltration of the jejunum.

89. AIDS with Small bowel lymphoma

90. AIDS patient with Cytomegalovirus colitis

91. AIDS patient with Cytomegalovirus colitis.

92. KS in a 44-year-old man with AIDS who presented with fever and diarrhea.
Abdominal CT scan shows circumferential wall thickening of the cecum (arrows)
that is not associated with enlarged lymph nodes or adjacent fat stranding.

93. Burkett lymphoma of the thyroid, in a 26 year old pregnant woman, with
involvement of the right colon a) T2 weighted MRI of the neck show
homogeneous enlargement of the thyroid left lobe (orange arrow). (b) Axial, (c
and d) coronal and (e) sagittal T2 weighted MRI, reveals a mass in the right colon
(yellow arrow), hyperintense comparing to the liver, and the fetus (purple arrow).

94. CT of the abdomen showing an inflammatory matted
mass from extensive gastrointestinal involvement with KS.

95. AIDS patient with eccentric thickening of the colon. Note the
severe pericolonic stranding around the transverse colon.

96. An irregular thickening of rectal wall. Kaposi
sarcoma was performed at the biopsy

97. Coronal reconstructions CT show large masses and bulky
masses in a patient HIV-positive. AIDS-related lymphoma.

98. Pathology of AIDS-related liver disease.
Hepatomegally and abnormalities of serum liver tests are
common problems in patients with acquired immune
deficiency syndrome. Opportunist infections (Mycobacterium
avium-intracellulare and cytomegalovirus) and neoplasms
(lymphoma, Kaposi's sarcoma) are among the most prevalent
hepatic lesions in AIDS. Although Kupffer cells and endothelial
cells are potential sites of human immunodeficiency virus 1
(HIV-1) infection, current studies do not indicate that the liver
is a major reservoir for this virus. Drug hepatotoxicity,
multimicrobial infections of the biliary tree resembling
sclerosing cholangitis and a variety of nonspecific hepatic
changes should be considered in evaluating AIDS patients or
HIV-1-infected patients with evidence of liver dysfunction

99. Hepatobiliary System.
Infections of the liver and biliary system with any of a
number of organisms may result in solitary or multiple
hepatic abscesses or different forms of biliary involvement,
including papillary stenosis and sclerosing cholangitis.
Papillary stenosis will cause bile duct dilatation and delayed
emptying of contrast into the duodenum; sclerosing
cholangitis presents with focal strictures and dilatations of
the intra- and extrahepatic bile ducts. Both forms of biliary
disease may be seen at the same time, and occasionally long
biliary strictures are noted. Liver disease may be diagnosed
with CT or ultrasound; biliary disease may be diagnosed
with CT, ultrasound, or endoscopic retrograde
cholangiopancreatography (ERCP).

100. Acalculous Cholecystitis.

101. PRIMARY LIVER AIDS-RELATED LYMPHOMA

102. An 35-years-old man with 1 year of history fever, weight loss and abdominal
pain. Ultrasound detected a large hypoechoic mass into the right lobe liver.
HIV-positive. Biopsy confirm that is primary extranodal lymphoma

103. AIDS with non-Hodgkin's lymphoma.

105. Disseminated AIDS-related KS with liver involvement, para-aortic and inguinal LN.

106. Ultrasound of liver demonstrating intrahepatic duct dilation (arrows) of AIDS patient.

107. ERCP demonstrating abnormal dilation and beaded appearance of extrahepatic
and intrahepatic biliary system consistent with cholangitis. (1) Common hepatic
duct. (2) Dilated branch of left intrahepatic duct of AIDS patient.

108. HIV in the spleen include amyloid-like
protein deposition, perivascular hyalinization,
infarcts, necrosis, hemosiderin pigment
deposits, plasma cell infiltrates, neutrophilic
microabscesses, spindle cell infiltrates,
extramedullary hematopoiesis, and
granulomatous reaction. Some of these changes
have been shown to be associated with specific
infections. Our aim in this study was to compare
AIDS splenic pathology in a more recent group
of patients with splenic pathology in AIDS
before the use of multiagent therapy.

109. AIDS with splenic Pneumocystosis: An Atypical
Presentation of Extra-pulmonary Pneumocystis Infection .

110. Disseminated AIDS-related KS in a 41-year-old man with abdominal compromise.

111. Splenic KS in a 50-year-old HIV-positive man. Abdominal CT scan
shows multiple subcentimeter hypoattenuating nodules in the spleen

112. AIDS patient showing focal low- density lesions due to
non-Hodgkin's lymphoma within an enlarged spleen.

113. Contrast-enhanced CT scan of an immunocompromised patient shows multiple
rounded areas of decreased attenuation scattered throughout the spleen and liver

114. Pancreatic disease in AIDS--a review.
Patients with the acquired immunodeficiency syndrome (AIDS) can develop
pancreatic disease from causes unrelated to AIDS as well as AIDS-specific
lesions. AIDS-specific causes include opportunistic infection, AIDS-associated
neoplasia, and medications used to treat complications of AIDS. Reported
pancreatic opportunistic pathogens include Mycobacterium tuberculosis,
Mycobacterium avium intracellulare, Cryptococcus neoformans, Candida,
Aspergillus, Toxoplasma gondii, Pneumocystis carinii, cytomegalovirus,
herpes simplex, cryptosporidium, and microsporidium. Although
cytomegaloviral pancreatic infection can occur without clinically evident
pancreatic disease, cytomegalovirus can cause pancreatitis. Mycobacterial
infection can produce a pancreatic abscess. Hepatobiliary or pancreatic duct
infection by cytomegalovirus, cryptosporidium, and microsporidium causes
irregular ductular narrowing and dilatation. This cholangiographic
abnormality resembles the pattern found in idiopathic sclerosing
cholangitis. Reported AIDS-associated pancreatic neoplasms include
Kaposi's sarcoma and lymphoma. Pancreatic involvement is usually part of
widely disseminated tumor and rarely produces clinical symptoms.

115. Two cases of pancreatitis of AIDS.

116. Diffuse Pancreatic Lesion Mimicking Autoimmune
Pancreatitis in an HIV-Infected Patient

117. Primary pancreatic lymphoma in an HIV patient.

118. AIDS patient with pancreatic lymphoma.

119. AIDS patient with Kaposi sarcoma of the pancreas.

120. The HIV-associated renal diseases.
The HIV-associated renal diseases: Since the description of a new renal
syndrome in patients with the acquired immunodeficiency syndrome
(AIDS) in the middle 1980s, much has been learned regarding the
association of human immunodeficiency virus (HIV) infection and renal
disease. The HIV-associated renal diseases represent a spectrum of
clinical and histopathologic conditions. In this review, epidemiologic
and clinical aspects of HIV-associated renal diseases are presented.
Particular attention is placed on the pathologic and pathophysiologic
mechanisms involved in HIV-associated focal glomerulosclerosis,
immune complex–mediated disease, and thrombotic
microangiopathies. Pharmaceutical treatment options, including the
use of glucocorticoids, angiotensin-converting enzyme (ACE) inhibitors,
and highly active antiretroviral therapy, are discussed. The therapeutic
option of renal transplantation is presented, with insight into new
clinical and basic research supporting a possible role of
immunosuppressive therapy in this already immunocompromised
patient population.

121. NEPHROPATHY
HIV disease is associated with a variety of renal syndromes. Mild to
moderate proteinuria occurs in 38 to82% of HIV-seropositive patients while
nephrotic-like proteinuria is seen in approximately 10%. Fluid and
electrolyte changes, including hyponatremia in 12 to 30% (from volume
depletion) and hypokalemia (from diarrhea, vomiting) are seen and often
worsen with progression of HIV disease. Prompt attention to electrolyte
abnormalities may prevent the development of acute tubular necrosis and
subsequent renal failure. HIV associated nephropathy (HIVAN), first
reported in 1984, is seen in 5 to 10% of HIV-infected patients and is most
commonly seen in black males with a history of intravenous drug abuse. It is
not usually associated with hypertension. Histopathologic features include
diffuse, global sclerosis, epithelial cell hypertrophy, severe tubulo-interstitial
inflammation, edema and dilatation of tubules. On ultrasound, large,
echogenic kidneys are seen, and pelvicalyceal thickening can occur. There is
usually progression to end stage renal disease (ESRD) within 3 to 6 months.
Patients can be treated by either peritoneal or hemodialysis65, but
hemodialysis does not seem to prolong life in patients with AIDS as there is
a 95% mortality rate within 6 months.

122. AIDS patient with acute renal failure with diffuse renal enlargement.

123. Tubercular renal Abscesses of AIDS patient.

124. Tubercular
renal
Abscesses
of AIDS
patient.

125. Burkett lymphoma in a 4 year-old boy infiltrating both kidneys, liver and spleen. a)
Axial contrast enhanced CT reveals a homogeneous hypodense nodular lesion in the
left kidney (white arrow) and another one that almost replaces the right kidney
(yellow arrow). b) Two months later, after chemotherapy, the left kidney lesion was
unapparent and the lesion in the right shrunken significantly (yellow arrow).

126. Kaposi sarcoma
of the left kidney

127. The genitourinary system.
The genitourinary system is both a primary site of HIV infection as
well as a site for its complications, the genitourinary tract is
generally protected. According to Miles and associates, urinary
tract infections occur in 17% of patients, while there was a 16%
incidence of urologic related symptoms. Symptoms of urinary tract
infections include dysuria, frequency, urgency, and hematuria, but
many patients are relatively asymptomatic. Escherichia coli, which
accounts for up to 80% of urinary tract infections in the general
population, only accounts for 25% of urinary tract infections in HIV-positive
patients. Pseudomonas aeruginosa is found in up to 33%.
Bacterial infections are more common in AIDS patients with CD4
counts of less than 200/ul. In patients with low CD4 counts,
neurological symptoms may also occur. Bladder areflexia and
hyporeflexia is a common neurologic complication, which leads to
urinary stasis, and ultimately infection.

128. Prostatitis is a result of urinary stasis due to either a dysfunctional or
obstructed urinary system. The prostate gland usually has its own
mechanism of defense for resisting bacterial infections (including
spermine, spermidine, and prostatic antibacterial factor), but in the HIV-infected
patient, it is suspected that local immunodeficiency of the
prostate fluid allows bacterial invasion.
Typically, prostatic abscesses are found in patients with pre-disposing
factors such as diabetes mellitus, previous bladder catheterizations or
instrumentations, or urinary obstruction; but, prostatic abscesses are
clearly an emerging problem in the AIDS population.
VOIDING DYSFUNCTION
There is some controversy as to the degree of urinary symptoms suffered
by patients with HIV. Gyrtrup and colleagues, in a prospective study,
concluded that symptoms are fairly modest and that neurological bladder
dysfunction only occurs rarely in the late stage AIDS patient.
Gonococcal urethritis, chlamydial urethritis, and nongonococcal, non-chlamydial
urethritis might facilitate HIV transmission.

129. TESTICULAR ATROPHY:
Atrophy of the testicles is usually related to advanced age,
alcohol/cirrhosis, and cigarette smoking. In patients with AIDS, atrophy
is the most prevalent AIDS-associated testicular disorder and is related
to chronic illness, prolonged fever, malnutrition and cachexia
ERECTILE DYSFUNCTION:
Erectile and ejaculatory dysfunction also occurs in HIV-infected patients.
Erectile dysfunction is often caused by psychologic and neurogenic factors.
Patients with AIDS may suffer from fatigue and depression; this leading to
decreased libido. Neurogenic factors include infections (viral
myelitis/myelopathies), malignancy, and AIDS dementia. Dobs and
associates reported 33% impotence and 66% decreased libido.
Testicular neoplasms are the third most common AIDS-associated
malignancy, following KS and non-Hodgkins lymphoma.44 The incidence
of testicular malignancy in the non-HIV populations is 0.004% while it is
0.2% in those with HIV (especially black and hispanic patients).

130. Pelvic Inflammatory Disease (PID)
An infection of the upper female genital tract affecting the uterus,
fallopian tubes, and ovaries. It is usually caused by the bacteria
responsible for two common sexually transmitted diseases (STDs),
gonorrhea and chlamydia. If left untreated, PID can cause severe pain,
tubal pregnancy, and infertility.
Vaginal candidiasis is an overgrowth of that yeast in the vulva and vagina.
Many things can disrupt the natural balance of the vaginal environment
and cause a yeast infection. They can include birth control pills, steroids,
pregnancy, obesity, diabetes and poor hygiene. For HIV-positive women,
yeast infections are the most common first symptom of HIV
Genital herpes is a sexually transmitted infection, most commonly caused
by herpes simplex virus 2 (HSV-2). Its close relative, HSV-1, causes herpes of
the mouth, lips and skin, like cold sores. Genital herpes recur and there is no
cure. Symptoms include single or multiple small blisters that open and become
sores after a few days. Other symptoms include swelling of the vulva, fever
and enlarged and tender lymph nodes in the stomach and groin area
(abdomen).

131. MENSTRUAL CHANGES
Changes in periods are common, for both HIV-positive and negative women.
Many of these changes in HIV-positive women include irregular, heavier or
lighter periods; worsening of symptoms from pre-menstrual syndrome (PMS);
darkening of menstrual blood; and no periods for more than 90 days
(amenorrhea).
HIV-positive women with changes in menstrual bleeding should seek
medical attention to determine its cause. Heavy bleeding or painful periods
can be associated with PID. They may also be explained by low platelets (the
part of the blood involved in clotting and immune response) from HIV
infection.
Menopause, women usually experience menopause between the ages of 38-
58, and most enter it around the age of 50. There's some evidence that
women with HIV may experience menopause earlier. This may be due to many
factors such as anemia, lower hormone production, chronic illness, weight
loss, anti-HIV drugs, street drugs and smoking. However, the symptoms of
menopause appear to be the same for both HIV-positive and -negative
women. They include heavier, irregular or missed periods; hot flashes; vaginal
dryness; and other changes of the vagina.

132. Acute prostatitis Chronic prostatitis

133. 3 cases with orchitis
of AIDS patient.

134. Hemorrhagic necrosis of right testicle with early atrophy of AIDS patient.

135. Primary diffuse large B-cell lymphoma of left testicle in AIDS patient.

136. Kaposi sarcoma of the right testis

137. Kaposi’s sarcoma of the penis of AIDS patient.

138. Prostatic abscess of AIDS patient.

139. Prostatic abscess of AIDS patient.

140. HIV patient with Pelvic inflammatory disease with pyosalpinx on MR.

141. Two cases with cervicitis with HIV infection.

142. HIV with cancer cervix.

143. Two cervical cancer with +ve HIV patients.

144. The musculoskeletal system can be affected by a number of
conditions in HIV and the prevalence of these complaints is high with a
reported incidence between 5.5% and 11%. Compared to CNS,
respiratory and gastrointestinal manifestations of HIV, musculoskeletal
disorders have been less well documented and are arguably less well
understood.
• The underlying mechanisms leading to these complications are
complex and thought to be multifactorial, involving not only the
immunosuppressed status of the patient, but also the virus itself, as well
as complex immunologic, environmental, and genetic interactions.
• HIV infection diminishes the body's defence mechanisms by impairing
T lymphocyte response which predisposes the patient to a wide variety
of opportunistic infections, immune-related neoplasms, and
inflammatory disorders. Indeed musculoskeletal manifestations may be
reactive in nature and secondary to the HIV virus itself, or secondary to
its treatment with highly active antiretroviral therapy (HAART).
• Musculoskeletal pathology can be broadly divided into 4 groups;
myopathies, arthropathies, infections and neoplasms.

145. HIV positive man with a pre-existing diagnosis of rheumatoid arthritis
represented with a worsening of his symptoms. Radiographs of the feet show
multiple subluxations of the MTP joints with osteopenia, periarticular erosions
and secondary osteoarthritis typical of RA. Note the lack of periostitis and new
bone formation more typical of HIV associated symmetrical polyarthritis.

146. 46 male with HIV presented with acute onset pain in ankle. Sagittal STIR
MRI image demonstrated an ankle joint effusion with no erosive changes
or bone marrow edema typical of HIV associated arthropathies.
tenosynovitis of the posterior tibial tendon is also noted.

147. HIV + male presenting with left hip and buttock pain and fevers for 6 weeks. STIR
sequence MRI demonstrates a confirmed case of TB septic arthritis showing a joint
effusion, joint space narrowing, bone marrow oedema and cortical destruction.

148. KS in a 42-year-old man with AIDS who presented
with a painful soft-tissue mass of the left hip

149. HIV positive patient presented with weight loss and pelvic pain at night.
CT shows a mixed lytic and sclerotic process involving the left iliac bone
and sacrum with an associated soft tissue mass around the iliopsoas
muscle. Note the lack of periostitis, a feature that is typical of NHL.

150. AIDS patient with the unusual finding of multiple low-density lymph nodes (arrows).
There is infiltration of the left psoas muscle (curved arrow) and ascites (open arrow).

151. Disseminated AIDS-related KS in a 35-year-old man with a history of the disease.

152. Disseminated AIDS-related KS in a 41-year-old man with chronic back pain.

153. Disseminated AIDS-related
KS in a 45-year-old
man who presented
with diffuse swelling of
the left lower
extremity.

154. HIV positive patient with multiple skin lesions typical of Kaposi
sarcoma. Axial CT spine shows typical erosive, destructive process
with some periostitis. Biopsy confirmed Kaposi sarcoma

155. Avascular Necrosis (AVN)
Death of bone (osteonecrosis) caused by a loss of
blood supply to the bone tissue. AVN has occurred
in the hip bones of some people with HIV, but it is
not clear if bone death occurs because of HIV
infection itself or as a side effect of the
medications used to treat HIV. Symptoms include
pain in the affected area of the body, limited range
of motion, joint stiffness, limping, and muscle
spasms. If untreated, AVN can cause progressive
bone damage leading to bone collapse.

156. AIDS patient with bilateral femoral heads and necks with collapse.

157. High Prevalence of Osteonecrosis of the Femoral Head in HIV-Infected Adults

158. High Prevalence of Osteonecrosis of the Femoral Head in HIV-Infected Adults

159. Muscle Atrophy
Abnormal weight loss is a common characteristic of patients with
HIV/AIDS, which often includes skeletal muscle wasting. The NIAMS
supports research on many molecular mechanisms of muscle
degeneration that may be related to this condition in HIV/AIDS
patients, such as inflammation, metabolic changes, and muscle disuse
and damage. The Institute funds numerous studies on treatments and
approaches to block muscle degeneration, as well as regeneration of
these tissues. NIAMS-supported research on fundamental molecular,
cellular, and physiological processes, and development and testing of
drug and non-pharmacologic interventions, such as exercise and
nutrition, have important implications for the maintenance of muscle
strength and physical activity in the HIV/AIDS patient population.
Subcutaneous Adipose Tissue (SAT)
A type of adipose (fat) tissue found directly under the skin. Both loss
(lipoatrophy) and gain lipohypertrophy) of this fat tissue can occur as a
side effect of HIV infection and some of the drugs used to treat HIV
infection, especially PIs and NRTIs.

160. Acquired immune deficiency syndrome-related Kaposi sarcoma (KS). The axial image at the
level of the midthoracic region demonstrates abnormal thickening of the skin in the anterior
chest wall with subcutaneous nodules and an infiltrative mass of the left pectoralis muscle.
Abnormally enlarged hilar lymph nodes and bilateral pleural fluid collections also are noted.

161. Pyomyositis, much more extensive, in a patient with AIDS who had a loculated abscess

162. HIV myositis

163. Non-necrotizing fasciitis with associated cellulitis

164. AP radiography showing a lobulated soft-tissue mass in the medial aspect
of the right thigh (arrow), proved Kaposi sarcoma of patient HIV infection .

165. The same patient with Kaposi Sarcoma.

166. Acquired immune deficiency
syndrome-related Kaposi
sarcoma (KS) in a man aged
42 years who presented
with a left gluteal and
trochanteric mass. This
patient had biopsy-proven,
cutaneous KS. (Top) This
coronal positron emission
tomography (PET) image
with 18-fluorodeoxyglucose
demonstrates abnormal
uptake of the gluteal mass,
consistent with increased
glucose metabolic activity.
(Bottom) This contrast-enhanced
axial computed
tomography image shows a
large, abnormal, low-density,
soft tissue mass in
the left gluteal region.

167. Primary intraosseous Kaposi’s sarcoma of the maxilla in AIDS patient.

168. Kaposi's Sarcoma. Multiple small subcutaneous
nodules were palpated in this patient with AIDS.

169. Multiple plaques of Kaposi's sarcoma of AIDS patient.

170. Thank You.