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Imaging Findings in Musculoskeletal Complications of AIDS Dr.Suhas B MD Radio-Diagnosis
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Introduction • South & South East Asia is the second most affected; in 2010 this region contained an estimated 4 million cases or 12% of all people living with HIV resulting in approximately 250,000 deaths. Approximately 2.4 million of these cases are in India. • Central nervous system (CNS), pulmonary, and abdominal complications affecting patients with HIV infection and AIDS have been extensively documented and discussed in the literature. However, musculoskeletal complications in this population are less well described.
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Introduction (contd.) • Although musculoskeletal abnormalities in patients with HIV infection and AIDS are not as common as pulmonary and CNS disorders, a wide variety of osseous, articular, and soft tissue diseases may be encountered. • In this article, we review a wide spectrum of musculoskeletal disorders and their imaging appearances in patients with AIDS.Many of these conditions are not specific for HIV infection and AIDS and can be seen in other forms of immunosuppression, but others have been more specifically associated with this particular immunodeficiency.
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Infectious Processes • Infection is the most common musculoskeletal complication in patients with AIDS. The immunocompromised patient is susceptible to opportunistic and non-opportunistic infections affecting the skin, underlying soft tissues, bones, and joints. Soft-tissue infections include superficial and deep cellulitis, necrotizing and non-necrotizing fasciitis, soft-tissue abscesses, and pyomyositis. • Osteomyelitis and septic arthritis are typical examples of infectious involvement of the bones and joints, respectively. The most frequently cultured bacterial agent is Streptococcus aureus, but multiple other organisms have also been reported. • The key elements that allow differentiation are (a) the depth of soft-tissue involvement and (b) the presence of necrosis. • Cross-sectional imaging techniques make such differentiation possible through analysis of compartmental anatomy.
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Cellulitis • Cellulitis is an acute inflammatory condition of the skin that is characterized by swelling, erythema, calor, and localized pain in the affected area. • In superficial cellulitis, CT and MR imaging demonstrate inflammatory changes that involve the subcutaneous fat but do not extend beyond the superficial fascia.
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Cellulitis (contd.) Abnormal imaging findings include thickening of the skin, septation of the subcutaneous fat, and thickening of the underlying superficial fascia, with scattered ill-defined hypointense areas on T1-weighted MR images, a striated pattern of hyperintensity on T2-weighted images, and moderate diffuse enhancement on contrast material–enhanced images. • The MR imaging findings in cellulitis and fasciitis are different from those in primary bacterial myositis: Disproportionate involvement of the muscles compared with subcutaneous tissue or muscle compromise without associated subcutaneous tissue involvement suggests the diagnosis of bacterial myositis. Superficial and deep cellulitis and myositis in a 42-year-old man. Axial CT scan obtained at the level of the middle third of the leg shows inflammatory changes in the subcutaneous soft tissues, with fluid collections surrounding the intramuscular compartments in the lateral aspect of the leg adjacent to the tibialis anterior muscle and in the medial compartment adjacent to the soleus muscle (solid arrows). Inflammatory changes consistent with myositis are also seen within the soleus muscle (open arrow).
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Necrotising Fasciitis • Necrotising fasciitis is a relatively rare but rapidly progressing infection tha represents a life-threatening surgical emergency. It is characterized by extensive necrosis of the superficial and deep anatomic planes, usually accompanied by severe systemic toxicity. • MR imaging is useful in differentiating necrotizing fasciitis from severe cellulitis with or without secondary abscess formation and pyomyositis • The presence of deep fascial involvement at MR imaging favors a diagnosis of necrotizing fasciitis.
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Necrotising Fasciitis (contd.) • The imaging findings in necrotizing fasciitis are similar to those in cellulitis but are more severe with deeper involvement. • Necrotizing fasciitis typically does not enhance after administration of gadolinium-based contrast material. MR imaging and, to a lesser extent, CT are useful in assessing the extent and depth of the inflammatory process and the involvement of adjacent osseous structures.
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Necrotising Fasciitis (contd.) Necrotizing fasciitis in a 45-year-old male intravenous drug abuser. Coronal (a) and axial (b) fat suppressed T2- weighted MR images show high-signal-intensity inflammatory changes involving both the subcutaneous fat in the medial surface (arrow in a) and the gastrocnemius and soleus muscles (arrows in b) of the left leg. This hyperintensity is consistent with deep-seated infection or necrotizing fasciitis.
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Soft-Tissue Abscesses • MR imaging will show a well-demarcated fluid collection that is hypointense on T1-weighted images, is hyperintense on T2-weighted images, is surrounded by a low-signal-intensity pseudocapsule with all sequences, and demonstrates peripheral rim enhancement after intravenous administration of gadolinium-based contrast material. These features are useful in differentiating abscesses from cellulitis or fasciitis. • When an abscess is suspected, needle aspiration is mandatory. Treatment includes antibiotics and percutaneous drainage.
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Soft-tissue abscess in a 21-year-old man with a history of intravenous drug abuse. Axial unenhanced (a) and contrast-enhanced (b) fat-suppressed T1-weighted MR images of the hand show extensive inflammatory changes and abscess formation within the muscles and soft tissues of the thenar and palmar region. An abscess is seen within the first dorsal interosseous and adductor pollicis muscles (arrow). This fluid collection has low signal intensity on the unenhanced image and peripheral ring enhancement with central low signal intensity on the contrast-enhanced image. The absence of tendon sheath and bursal involvement helped rule out the presence of horseshoe abscess formation.
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Pyomyositis • Pyomyositis, or bacterial myositis, is characterized by pyogenic inflammation of the muscle and, musculoskeletal complications of AIDS. • CT demonstrates areas of muscle enlargement with decreased attenuation of the muscle secondary to edema. Intramuscular fluid collections may also be observed. Intravenous administration of contrast material can help differentiate necrotic from viable musculature because the nonviable tissue will demonstrate lack of enhancement.
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Pyomyositis (contd.) • MR imaging is more sensitive than CT in the detection of inflammatory changes within the muscles. On T1-weighted images, pyomyositis may appear as a central area of low signal intensity within the muscle, in some cases surrounded by a peripheral rim of high signal intensity that probably represents blood products. Pus inside the abscess can be either isointense or hyperintense with T1-weighted sequences depending on the proteinaceous content of the fluid collection. On T2-weighted and short inversion time inversion-recovery (STIR) images, the abscessed collection is hyperintense. • Areas of abnormal high signal intensity in adjacent muscles represent unorganized phlegmonous collections, edema, or hyperemia. After contrast material injection, necrotic tissue manifests as a low-signal intensity area surrounded by a hyperintense enhancing rims. Abnormal gas in the necrotic tissue is easily identified at radiography CT, and MR imaging.
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Pyomyositis in a 23-year-old man with AIDS and a history of intravenous drug abuse. Radiograph demonstrates multiple gas collections (arrows) within the soft tissues of the medial and posterior left thigh. Pyomyositis in a 25-year-old woman. Axial contrast-enhanced CT scan of the lower neck demonstrates multiple abscesses in the soft tissues and muscles of the supraclavicular space and neck (arrows). Results of aspiration confirmed M tuberculosis myositis and lymph node involvement.
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Pyomyositis with myonecrosis in a 38-year-old man. (a) Coronal T1-weighted MR image shows extensive myonecrosis affecting the medial compartments of the lower extremities, with bilateral hypointense fluid collections (arrows). (b) On a coronal fat-suppressed T2-weighted MR image, the bilateral fluid collections demonstrate high signal intensity. The multiple round, ill-defined low-signal-intensity areas within the necrotic collection on the left side (arrows) represent abnormal gas bubbles. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows intense peripheral rim enhancement surrounding the bilateral fluid collections (arrows) and the gas bubbles within the necrotic tissue on the left side.
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Pyomyositis in a 35-year-old man. Axial contrast-enhanced fat- suppressed T1-weighted MR image demonstrates extensive inflammatory changes involving the deep muscles of the right midthigh, with enhancement within the vastus intermedius muscle that extends into the adductor muscles (arrows). Note the increased diameter of the right thigh compared with the left thigh. On an axial fat-suppressed T2- weighted MR image, there is extensive cellulitis of the superficial and deep compartments with diffuse myositis of almost all the right-sided muscles, with less diffuse involvement of the left thigh. Note also the bilateral fluid collections superficial to the vastus lateraliis muscles (arrows).
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Osteomyelitis • Osteomyelitis is infection of the bone and a common infectious cause of musculoskeletal complications in AIDS patients. • Radiography is not sensitive in the detection of early osteomyelitis because it does not demonstrate changes until 10–14 days after the onset of the infectious process, when lytic lesions or periosteal reaction is evident. Technetium-99m methylene diphosphonate (MDP) bone scintigraphy and gallium-67 and indium- 111–labeled WBC scintigraphy are the most sensitive methods for the detection of early osteomyelitis.
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Osteomyelitis (contd.) • CT of the affected region may demonstrate soft-tissue swelling and periosteal reaction, medullary changes, and focal cortical erosions or trabecular coarsening. • T1-weighted images demonstrate low signal intensity in the affected bone whereas on T2-weighted images the corresponding areas have high signal intensity. • MR imaging with intravenously administered gadolinium-based contrast material offers comprehensive depiction of the extent of both bone and soft- tissue infection; it also helps identify areas of devitalized tissue.
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Chronic osteomyelitis in a 41- year-old man. Anteroposterior (a) and lateral (b) radiographs show extensive soft-tissue ulceration of the distal forearm associated with periosteal reaction of the distal ulna and, to a lesser extent, of the distal radius projecting into the interosseous space. Results of pathologic analysis proved extensive necrotic changes, but no definitive bacteria or infectious agent could be identified.
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Osteomyelitis (contd.) • Tuberculosis infection and bacillary angiomatosis are two specific forms of osteomyelitis that have been observed with increasing frequency in HIV-infected and AIDS patients. • Radiography demonstrates erosion of the anterior vertebral bodies with deformity. An adjacent soft-tissue mass may be seen. CT is useful for detecting destructive changes involving the cortical bone of the vertebral bodies. Calcifications in the paravertebral soft tissues with fluid collections are frequently seen, findings that are consistent with abscess formation. • MR imaging is the preferred modality for imaging the spine. T1-weighted images demonstrate decreased signal intensity within the vertebral marrow secondary to edema, with corresponding high signal intensity on T2- weighted images. Epidural extension manifests as posterior displacement of the thecal sac and deformity of the spinal cord. Arachnoiditis manifests as thickened nerve roots that enhance with contrast material administration.
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Osteomyelitis in a 41-year-old woman. Coronal contrast-enhanced fat-suppressed T1- weighted MR image demonstrates osteomyelitis of the right wing of the sacrum and septic arthritis of the right sacroiliac joint. Abscesses with peripheral rim enhancement are seen within the right iliac and gluteal muscles and the sacrum. Aspiration and culture demonstrated M Tubeculosis . Osteomyelitis and septic sacroiliitis in a 46-year-old female intravenous drug abuser with septic endocarditis. Axial T1-weighted MR image demonstrates a hypointense lesion in the right sacroiliac joint (arrow) with extension into the right iliac bone and sacrum. Pathologic analysis demonstrated S pyogenes.
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Osteomyelitis (contd.) Bacillary angiomatosis is an unusual form of osteomyelitis that specifically affects the HIV infected population. Radiography usually demonstrates osteolytic foci that may range from well-circumscribed lytic lesions involving the cortex to ill-defined lesions with extensive cortical destruction, medullary permeation, and periosteal reaction. Bone scintigraphy reveals increased radiotracer uptake in the affected areas. CT demonstrates well-defined nonsclerotic lytic lesions. MR imaging shows well-defined lytic lesions with low and high signal intensity on T1- and T2-weighted images, respectively.
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Acute spondylodiskitis and vertebral osteomyelitis in a 46-year-old woman. (a) Sagittal T1-weighted MR image shows acute spondylodiskitis and vertebral osteomyelitis with epidural collections (open arrow) and dural enhancement (solid arrows) at the C5-C6 level. These inflammatory findings are nonspecific and can be observed in a variety of granulomatous, fungal, and bacterial infections. One week later, the patient developed extensive wedge deformity and collapse of C5 and C6. (b) Axial contrast-enhanced T1- weighted MR image demonstrates abnormal dural enhancement and cord compression secondary to the epidural fluid collections (arrows).
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Septic Arthritis • Infection of joints can arise from hematogenous spread or contiguous extension from neighboring soft-tissue infection or osteomyelitis. • Radiography may reveal joint effusion, bone erosion, osteoporosis, and indistinct margins of the joint with joint space narrowing. • MR imaging is more sensitive in the detection of early changes in septic arthritis, revealing signal intensity abnormalities in the bone marrow and soft tissues, both of which have edema-like signal intensity (ie, are hypointense on T1-weighted images and hyperintense on fat suppressed T2- weighted images or STIR images). • Extension of infection from the joint space into surrounding bursae is also easily recognized at MR imaging.
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Septic arthritis and bursitis in a 42-year-old woman. (a) Coronal fat-suppressed T2- weighted MR image shows extensive fluid collections within the bursae around the shoulder, especially the subacromial (subdeltoid) bursa (arrows). (b) On a sagittal contrast-enhanced fat-suppressed T1-weighted MR image, the fluid collections (arrows) exhibit low signal intensity with no enhancement.
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Inflammatory Processes • The most common rheumatic manifestation associated with HIV infection is arthralgia. • The arthritides most commonly associated with HIV infection are articular pain syndrome, Reiter syndrome, psoriatic arthritis, and the syndromes of oligoarthritis and polyarthritis. • Polymyositis is the most common muscular manifestation in HIV-infected patients and must be distinguished from pyomyositis, which is its most important differential diagnosis, because their treatments differ.
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Arthritis • Reiter syndrome has been described in HIV-infected patients following infection with Yersinia, Salmonella, and Shigella species. • Classic radiographic features of Reiter syndrome include asymmetric alterations of synovial joints, symphyses, and entheses; bone erosion with adjacent bone proliferation; and paravertebral ossification. The calcaneus, ankle, knee, and sacroiliac joints are usually involved (42). These features do not appear to be different from those seen in non–HIV-infected individuals.
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Arthritis (contd.) • Psoriatic arthritis has a higher prevalence among HIV-infected and AIDS patients than in the general population. • The rheumatologic characteristics of psoriatic arthritis are similar to those of Reiter syndrome, except there is a greater predilection for the small articulations of the wrist and hand. • Psoriatic arthritis tends to be polyarticular and asymmetric, in which case it rapidly progresses to a deforming and incapacitating form of the disease. Involvement of the sacroiliac joint and spine is rare.
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34 year old male with psoriatic arthropathy showing ‘pencil in cup deformity’ of distal phalanges with multiple erosive lesions along metacarpals and phalanges. 27 year old patient with Reiter syndrome with retrocalcaneal bursa erosive disease.
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Arthritis (contd.) • Radiographic findings include osteopenia, soft-tissue swelling, joint effusions, joint space narrowing, marginal erosions, periosteal reaction, and joint deformities such as flexion contractures, ulnar deviations, and swan neck deformities. Features that help differentiate symmetric polyarthritis from classic rheumatoid arthritis are proliferative bone formation and periostitis. • HIV-associated arthritis can also occur. This arthritis is oligoarticular, asymmetric, and peripheral. This arthritis has a short duration of 1–6 weeks. Radiography may reveal a joint effusion in some cases.
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Arthritis (contd.) Arthralgia and painful articular syndrome are the most common rheumatic manifestations of HIV infection. Radiographic features are nonspecific and range from no abnormality to joint effusions with or without periarticular osteopenia. The diagnosis of undifferentiated spondyloarthropathy is made in patients with seronegative arthritis who do not meet the criteria for the diagnosis of Reiter syndrome or psoriatic arthritis. Radiographic findings include osteoporosis, soft-tissue swelling, bone erosion, and periosteal reaction.
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Polymyositis • Myositis in patients with HIV infection and AIDS can be a result of host response to the virus, secondary to zidovudine therapy, or caused by opportunistic infections such as toxoplasmosis. • MR imaging is the preferred modality. Polymyositis can be isointense relative to muscle on T1-weighted images; thus, T2-weighted or STIR images are necessary to establish the diagnosis. • Unlike with pyomyositis, rim enhancement is not present in polymyositis. AIDS-related peripheral neuropathy can have MR imaging features similar to those of polymyositis.
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42 year old patient with polymyositis (PM), one of the inflammatory myopathies. The large proximal muscles are involved, generally in a symmetric pattern. MRI of thighs showing increased signal in the quadriceps muscles bilaterally consistent with polymyositis.
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Neoplasms • Non-Hodgkin lymphoma (NHL) and Kaposi sarcoma are the two most common neoplasms observed in HIV-infected and AIDS patients and account for the majority of neoplastic musculoskeletal involvement in this population. Non-Hodgkin Lymphoma • NHL is the second most common type of tumor in patients with HIV infection and AIDS after Kaposi sarcoma. NHL is seen 60 times more frequently in AIDS patients than in the general population and is one of the criteria for the diagnosis of AIDS in an HIV-infected person. • Extranodal and widely disseminated disease, including muscle and bone involvement, is also more frequently found in this population, particularly in children.
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Non-Hodgkin Lymphoma (contd.) Lymphomas affecting bone can produce lytic lesions, sclerotic lesions, or “mixed” lesions with an indistinct zone of transition. HIV-associated NHL bone lesions are usually lytic. Among the lytic changes, the most frequently seen is a permeative pattern with cortical destruction, often associated with a soft-tissue mass. Periosteal reaction is not commonly associated with NHL. The imaging features of musculoskeletal involvement by NHL are similar to those of many bone tumors. However, bone lesions in AIDS- related lymphoma tend to be more sharply marginated and to grow more rapidly than those associated with Kaposi sarcoma.
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NHL in a 40-year-old man. (a) Radiograph of the pelvis shows an ill-defined lytic lesion in the right iliac bone (arrows). (b) Axial contrast-enhanced CT scan helps confirm the lytic lesion, demonstrating cortical disruption of the iliac bone (solid arrows) with an associated enhancing soft-tissue mass involving the right iliacus muscle (open arrow).
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Non-Hodgkin Lymphoma (contd.) • CT is the primary staging modality for lymphomas because of its generally superior spatial resolution. CT shows the bone changes with better conspicuity and can also suggest the presence of an associated soft-tissue mass. High-speed CT is particularly beneficial in the chest, where respiratory and cardiac motion tend to degrade MR images. • MR imaging is the method of choice for evaluating bone marrow changes and characterizing adjacent soft-tissue involvement. Bone marrow changes are seen as areas of hypointensity on T1-weighted images and as areas of hyperintensity on STIR images or fat-saturated fast spin-echo T2-weighted images. The associated soft-tissue mass appears hyperintense on T2- weighted images.
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Multicentric B-cell NHL in a 44-year-old man. (a) Anteroposterior chest radiograph shows multiple ‹osteolytic lesions (arrows) involving the right humerus, the right and left scapulae, the medial third of the right clavicle, and multiple left ribs. (b) Follow-up chest radiograph obtained 3 months later demonstrates progression of the disease, with diffuse lymphomatous involvement of both lungs and more prominent multiple osteolytic lesions (arrows). (c) Sagittal T1-weighted brain MR image shows a soft-tissue tumor with both extradural involvement (solid arrow) and subgaleal extension (open arrow) within the medullary cavity of the parietal bone. (d) On an axial T2- weighted MR image, the soft-tissue mass has intermediate signal intensity due to bone involvement and extends to the subgaleal space (solid arrow). Abnormal signal intensity owing to tumor involvement is also seen within the left parietal bone (open arrow). (e) Anteroposterior radiograph of the right knee shows a destructive osteolytic lesion of the proximal lateral tibial metaphysis (arrow). (f ) Sagittal T1-weighted MR image shows the infiltrative tumor that is isointense relative to muscle and replaces the bone marrow of the proximal tibia (arrow). Flexion deformity of the knee secondary to pain is also appreciated. (g) Tc-99m bone scintigram (left) with magnified view (right) show extensive abnormal radiotracer uptake at the level of the distal femur and proximal tibia (solid arrows) and in the skull (open arrow). There is also abnormal uptake in the proximal femoral shaft (arrowheads).
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Multicentric lymphoma with involvement of the craniofacial region in a 31-year-old patient. (a) Axial CT scan obtained at the level of the midface shows a prominent soft-tissue mass that occupies the left maxillary region and extends into the soft tissues of the face. Aggressive bone destruction of the anterior and medial walls of the left antrum is also seen (arrows). (b) Axial CT scan of the superior head shows multiple round, hypoattenuating lytic lesions of the calvaria (arrowheads). (c) Sagittal T1-weighted MR image demonstrates a prominent mass that infiltrates the superficial and deep structures of the face (arrow). The multiple osteolytic lesions within the marrow of the cranial bones have moderate signal intensity (arrowheads), in contrast with the low signal intensity of the normal bone. (d) Axial contrast- enhanced T1-weighted MR image shows multiple enhancing hyperintense soft-tissue masses within the medullary cavity of the bones of the skull vault (arrowheads). Some of the masses extend into the epidural space.
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Kaposi Sarcoma • Kaposi sarcoma is the most common type of tumor in HIV-infected and AIDS patients. It is a vascular neoplasm that generally has multifocal lesions and can involve virtually any organ. Mucocutaneous tissues, lymph nodes, and visceral organs are the most frequently affected tissues. • It can either occur secondary to local extension or be present without neighboring abnormalities; however, it is almost always seen in the setting of multifocal disease. • Radiography, CT, and MR imaging are complementary in the evaluation of Kaposi sarcoma as the cause of focal pain in HIV-infected and AIDS patients. Radiography shows cortical lesions ranging from bone erosion to osseous destruction, as well as periosteal reaction.
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Kaposi Sarcoma (contd.) • CT gives a more detailed characterization of lytic bone changes. MR imaging is outstanding in depicting bone marrow abnormalities, as seen in lymphoma or infection, and can better help identify overlying soft-tissue masses. • Scintigraphy may be useful in further characterization, showing red blood cell pooling, thallium-201 uptake, and no abnormalities at Ga-67 scintigraphy. Infection and tumors such as lymphoma typically show avidity to gallium instead, making scintigraphy a potential tool for narrowing the differential diagnosis. • Nevertheless, biopsy is necessary for definitive diagnosis.
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Kaposi Sarcoma with cutaneous, muscular and osseous involvement in 25 year old man. Axial contrast enhanced CT of the lower chest shows multiple round, multiple, enhancing lesions in the muscles of the chest wall (arrowheads). Bone involvement is seen in one of the posterior left ribs (arrow)
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Osteonecrosis • There have been several reports of osteonecrosis in HIV-positive patients, most often occurring in the femoral head. • MR imaging is the most sensitive imaging modality for detecting early AVN. In the reactive phase, a “double line” sign may be created on T2- weighted images by the juxtaposition of low and high signal intensity between infarct and normal bone marrow. This disease can also be seen in bone marrow of long bones usually in the distal or proximal diaphysis, where it can be either single or multifocal.
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AVN. Anteroposterior radiographs of the ankles show intramedullary bone infarcts at the distal tibial diaphyses as irregular calcifications with the long axes parallel to the cortical bones (arrow). AVN in an HIV-positive patient. Anteroposterior (left) and lateral (right) radiographs of the right knee show multiple intramedullary bone infarcts of the femur and tibia (arrows).
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Osteoporosis • A very high prevalence of low bone mineral density has been reported in HIV-infected individuals. • Study showed that the markers of bone turnover tended to be elevated in of HIV-infected patients. • HIV infected patients suffer from osteopenia or osteoporosis regardless of type and duration of anti-retroviral therapy because of other associated conditions. • DEXA scan and bone densitometry remain the mainstay for evaluating this condition.
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Rhabdomyolysis • The most common causes of rhabdomyolysis in HIV-positive patients are infection, toxemia, alcohol abuse, and substance abuse, and even the virus has been postulated as causing rhabdomyolysis. • CT typically reveals calcification of muscles, particularly in the back, thighs, and pelvis (ie, psoas muscle). Early in the disease process, nonspecific hypoattenuating areas may be seen in the involved muscles of the pelvis and extremities; other CT findings include renal enlargement, persistent nephrogram, and perinephric fluid. • The sensitivity of MR imaging in the detection of abnormal muscles in patients with rhabdomyolysis has been reported to be superior to that of CT or ultrasonography. The affected muscle has variable signal intensity on T1-weighted MR images, whereas it is invariably hyperintense on T2-weighted images, a finding that is consistent with edematous changes in the muscle.
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Rhabdomyolysis in a 44-year-old man with AIDS and renal failure. Axial unenhanced CT scan of the abdomen demonstrates bilateral abnormal increased attenuation of the psoas muscle (arrows) and, to a lesser extent, of the paraspinal and oblique abdominal muscles (arrowheads) due to diffuse calcifications.
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Hypertrophic Osteoarthropathy • Hypertrophic osteoarthropathy is a systemic disorder that primarily affects the bones, joints, and soft tissues. It is most frequently associated with pulmonary neoplasm and has been observed in HIV-infected patients with P carinii pneumonia. • Radiographic findings include smooth periosteal reaction involving the diaphysis of the long bones is noted. As the disease progresses, the periosteal reaction becomes irregular and extends to involve the metaphysis and epiphysis.
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Hypertrophic osteoarthropathy in a 35- year-old man with AIDS and P carinii pneumonia. Anteroposterior (left) and lateral (right) radiographs of the right knee show abnormal thickening of the cortical bone with diffuse periosteal bone formation at the distal femur and proximal tibia (arrowheads).The changes were seen bilaterally.
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Conclusion Although musculoskeletal complications are not as common as pulmonary or CNS abnormalities in HIV-positive individuals, there is a high prevalence of such complications in this population. • • HIV infection predisposes these individuals to a variety of complications that can affect the musculoskeletal system, including various opportunistic infections, immune-related neoplasms, myositis, osteoporosis, and several rheumatologic syndromes. • Radiography plays an important role in early diagnosis and treatment planning in this population, in whom clinical and laboratory findings are commonly equivocal and nonspecific. • Although biopsy is often necessary for the final diagnosis, it is important for the radiologist to be familiar with the different types of musculoskeletal disease in HIV-infected and AIDS patients so that an appropriate differential diagnosis can be established from the musculoskeletal images obtained in these individuals.
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