Imaging 14:86-91 (2002)
© 2002 The British Institute of Radiology
Picture quiz
S Padley
Department of Radiology, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
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Cases
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Case 1
Post-contrast T1 weighted image of a 34-year-old HIV-positive male with fever and headache.
Case 2
40-year-old HIV-positive male with increasing confusion and headache.
Case 3
Chest radiograph of a patient with gradual onset of cough and shortness of breath over 10 days, presenting with sudden worsening of breathlessness together with chest pain. CD4 count 150 cells mm-3.
Case 4
An asymptomatic 12-month-old child with HIV who attended for routine follow-up and imaging. A chest radiograph (a) and abdominal ultrasound (b) were performed.
Case 5
32-year-old male with a known diagnosis of HIV infection and a low CD4 count who complained of right knee pain. He was otherwise systemically well. He had several cutaneous nodules. A plain radiograph was performed.
Case 6
Radiograph (a) of a 66-year-old man with left hip pain, together with the coronal T1 weighted image (b).
Case 7
35-year-old male with gradual onset of left hip pain. Coronal T1 weighted image.
Case 8
45-year-old male with known HIV infection complained of lethargy and vague abdominal and lumbar pain. Contrast enhanced CT of (a) the abdomen and (b) the pelvis was performed.
Case 9
32-year-old male patient with abnormal liver function tests and abdominal pain, referred for MRI after ultrasound revealed an abnormality. Axial and coronal images confirmed the abnormality.
Case 10
36-year-old female with HIV infection complained of a non-productive cough. Her white cell count was not raised, although her inflammatory markers were. Several skin nodules were noted on clinical examination. A chest radiograph (a) followed by bronchoscopy (b) suggested the diagnosis.
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ANSWERS
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Answer 1
Toxoplasmosis. Axial T1 weighted enhanced MR image showing multiple, small, ring enhancing lesions in the right and left cerebral hemispheres. Some lesions are located at the grey–white matter junction. The multiplicity of the lesions makes toxoplasmosis the most likely diagnosis, with tuberculosis and multiple metastases included in the differential diagnosis. Therefore, review of the chest radiograph is worthwhile. Repeat imaging in this patient showed a reduction in both the number and size of lesions 2 weeks after anti-Toxoplasma therapy.
Answer 2
Primary central nervous system lymphoma (PCNSL). Coronal enhanced T1 weighted MR image of the brain showing a homogeneously enhancing mass encasing the left lateral ventricle. These appearances are characteristic of PCNSL. Although there is a tremendous variability in the imaging appearances of PCNSL, periventricular lesions with subependymal spread have been reported to occur in up to 50% of cases. Note that there is relatively little mass effect, a feature that reflects the infiltrative nature of the tumour.
Answer 3
Pneumocystis carinii pneumonia (PCP). There are bilateral pneumothoraces together with diffuse ground-glass pulmonary infiltrates. Multiple small cystic spaces are evident. PCP was confirmed on induced sputum analysis. This patient had suffered two prior episodes of PCP. Prior to widespread prophylaxis, 60–80% of patients suffered at least one episode of PCP, a figure now markedly reduced. PCP remains the commonest opportunistic chest infection in HIV infection.
Answer 4
Lymphocytic interstitial pneumonitis (LIP). The chest radiograph demonstrates a fine reticulonodular infiltrate typical of early LIP and thought to represent a hyperimmune lung response to the presence of either HIV or the Ebstein-Barr virus. It is part of the diffuse infiltrative lymphocytosis syndrome (DILS), which affects the lungs, parotid glands, skin and gastrointestinal tract. Classical radiographic features are a reticulonodular infiltrate, although consolidation and lymphadenopathy may occur. Ultrasound of the spleen shows multiple focal echo-poor nodules typical of DILS.
Answer 5
Kaposis's sarcoma (KS) of bone. The frontal and lateral radiographs demonstrate permeative lytic lesions in both the femur and the tibia. No significant soft tissue mass was seen. There was no evidence of periosteal reaction. This is an important differentiating feature from bacillary angiomatosis. Given the presence of skin lesions and the appearances on plain film, the diagnosis was felt most likely to represent KS. Differential diagnoses include tuberculosis, bacillary angiomatosis and lymphoma. A biopsy confirmed the diagnosis.
Answer 6
There is plain radiographic flattening and irregularity of the left femoral head, with subcortical low signal serpiginous lines on MRI typical of avascular necrosis.
Answer 7
There is low T1 weighted signal replacement of the normal marrow, and on STIR imaging there is bone marrow oedema and adjacent soft tissue oedema. Biopsy revealed high grade non-Hodgkin's lymphoma.
Answer 8
Tuberculous myositis. There is a large multiloculated collection in the gluteus muscles, extending into the pelvis and involving the posterior aspect of the right psoas. Unusually for tuberculosis, no skeletal involvement could be identified.
Answer 9
Non-Hodgkin's lymphoma. The coronal T2 weighted and fat-saturated post-gadolinium T1 weighted sequences demonstrate a single, high signal, centrally enhancing lesion in segment 7 of the liver. Whilst a solitary lesion is not the most typical manifestation of lymphoma in HIV infection, none the less it was considered to be the most likely diagnosis. Less likely possibilities included a liver abscess and other liver malignancies. The diagnosis was confirmed at biopsy.
Answer 10
Kaposi's sarcoma. The chest radiograph shows bilateral perihilar infiltrate extending into the parenchyma. The mediastinal contours appear normal (????). CT (???? high resolution CT) shows bilateral, ill defined nodules with surrounding ground-glass shadowing. At bronchoscopy, distinctive raised erythematous plaques were seen in the airways.
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