RAD 266 Pathology Correlation for CT/MRI Autoimmune Disease Module B.

RAD 266 Pathology Correlation for CT/MRIRAD 266 Pathology Correlation for CT/MRI

Autoimmune DiseaseAutoimmune Disease

Module BModule B

Topics Included in Module BTopics Included in Module B

Immune system responses and disordersImmune system responses and disorders Congenital and acquired Immunodeficiency Congenital and acquired Immunodeficiency

Acquired ImmunodeficiencyAcquired Immunodeficiency Treatment of ImmunodeficiencyTreatment of Immunodeficiency Immunodeficiency complicationsImmunodeficiency complications Autoimmune DisorderAutoimmune Disorder Types of Autoimmune disordersTypes of Autoimmune disorders Types of effects caused from autoimmune Types of effects caused from autoimmune

disorderdisorder Treatment of autoimmune disorderTreatment of autoimmune disorder Acquired immunodeficiency syndromeAcquired immunodeficiency syndrome Systemic lupus erythematosusSystemic lupus erythematosus

Student ObjectivesStudent Objectives1. Name the common pathological 1. Name the common pathological conditions conditions affecting the affecting the autoimmune system.autoimmune system.

2. For each common pathological 2. For each common pathological condition condition identified:identified:

a.describe the disordera.describe the disorder

b.list the etiologyb.list the etiology

c.name the associated symptomsc.name the associated symptoms

d.name the common means of diagnosisd.name the common means of diagnosis

e.list characteristic CT and MR manifestations of the e.list characteristic CT and MR manifestations of the pathologypathology

Continue… Continue… Student ObjectivesStudent Objectives

3. Identify common pathology on CT 3. Identify common pathology on CT and MRI images.and MRI images.

4. Identify pathology common only in 4. Identify pathology common only in pediatric patients.pediatric patients.

5.5. Describe the MR tissue Describe the MR tissue characteristics of pathologic characteristics of pathologic processes.processes.

Continue… Continue… Student ObjectivesStudent Objectives

6.6. Identify how field strength Identify how field strength affects affects the ability to visualize select the ability to visualize select

pathology.pathology.

7. Recognize various differences in 7. Recognize various differences in pathologic conditions between pathologic conditions between children and adults.children and adults.

Student Learning activities Student Learning activities

1. Read Chapter One, pages 1 – 36. 1. Read Chapter One, pages 1 – 36. PathophysiologyPathophysiology, Gutierrez and Peterson, Gutierrez and Peterson

2.2. Name the immune system cell types, Name the immune system cell types, page 2, page 2, PathophysiologyPathophysiology, Gutierrez and , Gutierrez and PetersonPeterson

3.3. Review and answer all “Do You Review and answer all “Do You UNDERSTAND” questions in Chapter one, UNDERSTAND” questions in Chapter one, PathophysiologyPathophysiology, Gutierrez and Peterson , Gutierrez and Peterson pages 5, 8, 11, 13, 19, 20, 22, 25, 29, 30, pages 5, 8, 11, 13, 19, 20, 22, 25, 29, 30, 33, 35 and 36.33, 35 and 36.

Continue….. Continue….. Student Learning activitiesStudent Learning activities

4.4. Read the following pages, Read the following pages, CT and MRI CT and MRI Pathology A Pocket AtlasPathology A Pocket Atlas, Gray and , Gray and AilinaniAilinani

– Pages 42, 43 Brain AbscessPages 42, 43 Brain Abscess– Pages 46, 47 Multiple Sclerosis (Brain)Pages 46, 47 Multiple Sclerosis (Brain)– Pages 72, 73 Multiple Sclerosis (Spinal cord)Pages 72, 73 Multiple Sclerosis (Spinal cord)– Pages 86, 87 Vertebral OsteomyelitisPages 86, 87 Vertebral Osteomyelitis– Pages 116, 117 SinusitisPages 116, 117 Sinusitis– Pages 152, 153 HepatomaPages 152, 153 Hepatoma– Pages 202, 203 SplenomegalyPages 202, 203 Splenomegaly

Continue….. Continue….. Student Learning activitiesStudent Learning activities

5.Review Pathology Terms and Appendix A5.Review Pathology Terms and Appendix A

Immune SystemImmune System

The human body has three main types of The human body has three main types of defenses against injury and disease.defenses against injury and disease.

These defenses include the following: These defenses include the following:

normal functioning mucosal membranesnormal functioning mucosal membranes normal immune responsesnormal immune responses intact skinintact skin

-(Pathophysiology, Gutierrez, -(Pathophysiology, Gutierrez, Peterson)Peterson)

The two types of immune The two types of immune responsesresponses are are nonspecificnonspecific and and

specificspecific. .

Nonspecific immune responsesNonspecific immune responses

Nonspecific immune responseNonspecific immune response – – the response of the the response of the innateinnate immunity immunity system or system or what we are born withwhat we are born with. .

Specific immune responseSpecific immune response

Specific immune responseSpecific immune response – the – the response based on our response based on our ability to ability to developdevelop antibodies against foreign antibodies against foreign substances. substances.

Because the immune system is non-specific and specific,

the body must be able to distinguishbetween foreign substances

and its own tissues.

Immune System DisordersImmune System Disorders

Immunodeficiency Disorder Immunodeficiency Disorder

andand

Autoimmune DisorderAutoimmune Disorder

“Immune system disorders occur when the immune system

responds in an inappropriate way

(excessive or lacking)” -Medline Plus,2005

Lymphoid TissueLymphoid Tissue

thymusthymus lymph nodeslymph nodes tonsilstonsils parts of the spleen and parts of the spleen and

gastrointestinal tractgastrointestinal tract bone marrow bone marrow

Lymphocytes Lymphocytes

There are two groups of There are two groups of lymphocyteslymphocytes

called:called:

T-lymphocytesT-lymphocytes and and

B-lymphocytesB-lymphocytes

cellular immunitycellular immunity - - T lymphocytesT lymphocytes are are sensitized lymphocytes that sensitized lymphocytes that directly attack directly attack antigensantigens

humoral immunityhumoral immunity - - B lymphocytesB lymphocytes produce produce antibodies that antibodies that attachattach to the antigen and to the antigen and make phagocytes and complement proteins make phagocytes and complement proteins much more efficient in the destruction of the much more efficient in the destruction of the antigen antigen

-Medline Plus,2005 -Medline Plus,2005

Human immune system Human immune system

There are two broad categories for There are two broad categories for human immune system disorders:human immune system disorders:

immunodeficiency disordersimmunodeficiency disorders (lacking)(lacking)

autoimmune disordersautoimmune disorders (excessive) (excessive)

Immunodeficiency disordersImmunodeficiency disorders

can be can be congenital or acquiredcongenital or acquired

can affect any part of the can affect any part of the immune systemimmune system

-UMM, 2005-UMM, 2005

Congenital Immunodeficiency Congenital Immunodeficiency DisordersDisorders

Most commonly, this involves Most commonly, this involves decreased functioning of T or B decreased functioning of T or B

lymphocytes (or both), lymphocytes (or both),

or or

deficient antibody production deficient antibody production

Congenital Immunodeficiency Congenital Immunodeficiency Disorders Disorders

The causes include The causes include congenitalcongenital (inherited) defects (inherited) defects

and and

acquiredacquired immunodeficiency caused immunodeficiency caused by a disease that affects the immune by a disease that affects the immune

system” system” -UMM, 2005-UMM, 2005

Congenital Immunodeficiency Congenital Immunodeficiency Disorders Disorders

Congenital immunodeficiency -disorders of antibody production of antibody production

Congenital disorders affecting the affecting the

T lymphocytesT lymphocytes Inherited combined combined

immunodeficiency affects both T affects both T and B lymphocytes and B lymphocytes

Acquired Immunodeficiency Acquired Immunodeficiency

-is a result or a complication of an external causative source.

common side-effect of chemotherapy complication of diseases such as HIV and AIDS malnutrition, particularly with lack of protein many cancers people who have had a splenectomy people with diabetes increased age

-(UMM, 2005)

Immunodeficiency complications Immunodeficiency complications (symptoms, signs):(symptoms, signs):

persistent or recurrent infections persistent or recurrent infections --(Merck, 2003)(Merck, 2003)

severe infections, by organisms, that are severe infections, by organisms, that are normally mild normally mild -(Merck, 2003)-(Merck, 2003)

incomplete recovery from illness, poor incomplete recovery from illness, poor response to treatment response to treatment

--(Adam Encyclopedia, (Adam Encyclopedia, 2004)2004)

increased incidence of cancer or other increased incidence of cancer or other tumor growth tumor growth -(UMM, 2005)-(UMM, 2005)

enlarged liver and spleen enlarged liver and spleen -(Merck, 2003)-(Merck, 2003)

Treatment of Immunodeficiency Treatment of Immunodeficiency

Drug induced immunodeficiencyDrug induced immunodeficiency– “…“…..maintain a balance between ..maintain a balance between

suppression of parts of the immune suppression of parts of the immune system and the ability to fight disease system and the ability to fight disease and infection -and infection -(Medline Plus, 2005)”.(Medline Plus, 2005)”.

protection against infection and protection against infection and other disease processes other disease processes --(UMM, 2005)(UMM, 2005)

drugs that increase the efficiency of drugs that increase the efficiency of the immune system the immune system -(UMM, 2005)-(UMM, 2005)

Continue….. Continue…..

Treatment of ImmunodeficiencyTreatment of Immunodeficiency

drugs to reduce the amount of virus in their immune system -(UMM, 2005)

transplantation of thymus tissue -(Merck, 2003)

stem cell transplantation -(Merck,2003)

prophylactic antibiotic before surgeries or dental procedures -(Merck,2003)

PrognosisPrognosis of of ImmunodeficiencyImmunodeficiency is variable is variable

based on the type of based on the type of immunodeficiency disorder. immunodeficiency disorder.

Autoimmune DisorderAutoimmune Disorder

Autoimmune Disorder is anAutoimmune Disorder is an

overactiveoveractive immune response immune response

where the body attacks itswhere the body attacks its

own cells.own cells.

Continue …… Continue …… Autoimmune DiseaseAutoimmune Disease

Although the cause of autoimmune Although the cause of autoimmune disease is not known, disease is not known,

most autoimmune diseasesmost autoimmune diseases

are most likely the result are most likely the result

of of multiple circumstancesmultiple circumstances. .

There are more than 40 human diseases classified There are more than 40 human diseases classified as as definite or probabledefinite or probable autoimmune diseases. autoimmune diseases.

Examples Examples of autoimmune (or autoimmune-related) of autoimmune (or autoimmune-related) disorders include disorders include --(MedlinePlus, 2006):(MedlinePlus, 2006):

Hashimoto’s Hashimoto’s thyroiditisthyroiditis

pernicious anemiapernicious anemia Addison’s diseaseAddison’s disease type 1 diabetestype 1 diabetes rheumatoid arthritisrheumatoid arthritis systemic lupus systemic lupus

erythematosuserythematosus

dermatomyositisdermatomyositis Sjogren’s syndromeSjogren’s syndrome lupus lupus

erythematosuserythematosus multiple sclerosismultiple sclerosis myasthenia gravismyasthenia gravis Reiter’s syndromeReiter’s syndrome Grave’s diseaseGrave’s disease

Autoimmune diseases affect Autoimmune diseases affect women more often than men. women more often than men.

Almost 79% Almost 79%

of autoimmune disease patientsof autoimmune disease patients

in the United Statesin the United States

are women are women -(Wikipedia, 2006).-(Wikipedia, 2006).

Symptoms for AutoimmuneSymptoms for Autoimmune disorders disorders

fatiguefatigue vertigovertigo

malaise – malaise – (nonspecific feeling of not being well)(nonspecific feeling of not being well)

feverfever

or or low grade temperature low grade temperature

Tests for AutoimmuneTests for Autoimmune

Because symptoms are different Because symptoms are different according to the specific disorder, according to the specific disorder, and the organ or tissue affected, and the organ or tissue affected, there are a there are a variety of testing variety of testing methodsmethods. .

Treatment of autoimmune disorder Treatment of autoimmune disorder (Medline Plus, 2005):(Medline Plus, 2005):

treat symptoms according to the type treat symptoms according to the type and severity and severity

control the autoimmune process while control the autoimmune process while maintaining the ability to fight diseasemaintaining the ability to fight disease

hormones or other substances normally hormones or other substances normally produced by the affected organ may produced by the affected organ may need to be supplementedneed to be supplemented

assist mobility or other functions may be assist mobility or other functions may be needed for disorders that affect the needed for disorders that affect the bones, joints or muscles.bones, joints or muscles.

Acquired Immunodeficiency Acquired Immunodeficiency syndrome (AIDS)syndrome (AIDS)

Acquired Immunodeficiency Acquired Immunodeficiency syndrome (AIDS)syndrome (AIDS)

AIDS (acquired immunodeficiency AIDS (acquired immunodeficiency

syndrome) is the final stage of syndrome) is the final stage of

HIV disease. HIV disease.

The Center for Disease Control and Prevention (CDC)

has classified AIDS as

“beginning when a person with HIV infection has a CD4 cell count below 200”.

-(Medline Plus, 2006)

A patient is also considered to have AIDS

when numerous opportunistic infections

and cancers

appear to the person with the HIV infection.

AIDS AIDS

““Although AIDS was not recognized as Although AIDS was not recognized as a new clinical syndrome until 1981,a new clinical syndrome until 1981,

researchers examining researchers examining

the earlier medical literature, the earlier medical literature,

identified cases appearing to fit the identified cases appearing to fit the AIDS surveillance definition AIDS surveillance definition

as early as the 1950s and1960s”as early as the 1950s and1960s”-(HIVInSite, 2003) -(HIVInSite, 2003)

HIV infection is transmitted by:HIV infection is transmitted by:

sexual intercourse (heterosexual and sexual intercourse (heterosexual and homosexual) homosexual)

by blood and blood productsby blood and blood products

perinatally from infected mother to child perinatally from infected mother to child (prepartum, intrapartum, and (prepartum, intrapartum, and postpartum via breast milk) postpartum via breast milk) ……..……..(McGraw-Hill, 2005)(McGraw-Hill, 2005)

sharing needles with an infected personsharing needles with an infected person

The associated symptoms for The associated symptoms for AIDS:AIDS:

Symptoms are primarily the result of Symptoms are primarily the result of infections that do not normally infections that do not normally develop in people with healthy develop in people with healthy

immune systems.immune systems.

These infections are called These infections are called opportunisticopportunistic infections.infections.

The associated symptoms for The associated symptoms for AIDS:AIDS:

““cough and shortness of breath”cough and shortness of breath” ““seizures and lack of coordination”seizures and lack of coordination” ““difficult or painful swallowing”difficult or painful swallowing” ““mental symptoms such as mental symptoms such as

confusion and forgetfulness”confusion and forgetfulness” ““severe and persistent diarrhea”severe and persistent diarrhea”

--(Medline Plus, 2006)

Continue…..Continue…..The associated symptoms The associated symptoms for AIDS:for AIDS:

““fever”fever” ““vision loss”vision loss” ““nausea, abdominal cramps, and nausea, abdominal cramps, and

vomiting”vomiting” ““weight loss and extreme fatigue” weight loss and extreme fatigue” ““severe headaches with neck stiffness”severe headaches with neck stiffness” ““coma” coma”

-(Medline Plus, 2006)-(Medline Plus, 2006)

The common means for diagnosis of The common means for diagnosis of

AIDSAIDS

– ELISAELISA – – (enzyme-linked immunoassay)(enzyme-linked immunoassay) This This is the screening test.is the screening test.

–Western blotWestern blot – This is the – This is the confirmatory test.confirmatory test.

continue….. ….. AIDSAIDS

Newly infected people may have symptoms Newly infected people may have symptoms which include:which include:

feverfever headacheheadache enlarged lymph glands in the neckenlarged lymph glands in the neck MalaiseMalaise

These symptoms can disappear on their These symptoms can disappear on their own, within a few weeks. own, within a few weeks.

continue….. ….. AIDSAIDS

““Science has determined when eachScience has determined when each

progressive opportunistic infections progressive opportunistic infections

and cancers appear, and cancers appear, based on the CD4 based on the CD4

count”.count”. --(Medline Plus, 2006)(Medline Plus, 2006)

““CD4 count below 350/ml CD4 count below 350/ml (Medline Plus, (Medline Plus,

2006)”:2006)”:

– ““herpes simplex virus occurs more herpes simplex virus occurs more frequently than ever beforefrequently than ever before

– tuberculosistuberculosis– oral or vaginal thrushoral or vaginal thrush– herpes zosterherpes zoster– Non-Hodgkins lymphoma” Non-Hodgkins lymphoma”

-(Medline -(Medline Plus, 2006)Plus, 2006)

““CD4 count below 200/ml CD4 count below 200/ml (Medline Plus, (Medline Plus,

2006)”2006)”

– ““Pneumocystis carinii pneumonia, PCP Pneumocystis carinii pneumonia, PCP pneumoniapneumonia

– candida esophagitis- yeast infection of candida esophagitis- yeast infection of the esophagus the esophagus

--(Medline Plus, (Medline Plus, 2006)”2006)”

““CD4 count below 100/ml CD4 count below 100/ml (Medline Plus, 2006)”(Medline Plus, 2006)”

– ““Cryptococcal meningitis- infection of the Cryptococcal meningitis- infection of the brain by this fungusbrain by this fungus

– AIDS dementiaAIDS dementia– toxoplasmosis encephalitis – infection of the toxoplasmosis encephalitis – infection of the

brain by this parasite, which is frequently brain by this parasite, which is frequently found in cat fecesfound in cat feces

– progressive multifocal leukoencephalopathy – progressive multifocal leukoencephalopathy – viral disease of the brainviral disease of the brain

– wasting syndrome – extreme weight loss and wasting syndrome – extreme weight loss and anorexia caused by HIV” anorexia caused by HIV”


““CD4 count below 50/ml CD4 count below 50/ml (Medline Plus, 2006)”(Medline Plus, 2006)”

– ““mycobacterium avium – blood mycobacterium avium – blood infection by a bacterium related to infection by a bacterium related to tuberculosistuberculosis

– cytomegalovirus infection – a viral cytomegalovirus infection – a viral infection that can affect almost any infection that can affect almost any organ system, especially the eyes” organ system, especially the eyes”


Complications as a result of Complications as a result of Trauma-AIDSTrauma-AIDS

Pathology resulting for trauma can Pathology resulting for trauma can undergo any number of pathologic undergo any number of pathologic processes. processes.

Infection is always a concern. Infection is always a concern. When treating a patient with HIV/AIDS an When treating a patient with HIV/AIDS an

attempt to “…reduce co-factors that may attempt to “…reduce co-factors that may contribute to immune compromise” contribute to immune compromise”

-(Pathophysiology, Gutierrez, Peterson)-(Pathophysiology, Gutierrez, Peterson)

Co-factors that may contribute to Co-factors that may contribute to immune compromiseimmune compromise

““protein-calorie malnutrition…protein-calorie malnutrition… pregnancypregnancy….….

stress…. stress…. alcohol…alcohol… intravenous and recreational intravenous and recreational

drug use…..”drug use…..” -(Pathophysiology, Gutierrez, -(Pathophysiology, Gutierrez,

Peterson)”Peterson)”

Characteristic CT and MRI manifestations Characteristic CT and MRI manifestations - AIDS- AIDS

CT and MRI manifestationsCT and MRI manifestations of the AIDS of the AIDS pathology pathology depend on the system depend on the system affectedaffected by the syndrome. by the syndrome.

– Multiple systems can be affected. Multiple systems can be affected.

– ““The role of imaging methods in the diagnosis of diseases The role of imaging methods in the diagnosis of diseases associated with HIV infection depends on such factors as associated with HIV infection depends on such factors as

cost, cost, availability, availability, and expertise of the clinician or radiologist interpreting the and expertise of the clinician or radiologist interpreting the

image.” image.” -(HIVInsite, Goodman, 2006) -(HIVInsite, Goodman, 2006)

– Abscesses can be located in any area. Abscesses can be located in any area.

GastrointestinalGastrointestinal

““CT scanning may provide information CT scanning may provide information about intraluminal as well as solid organ or about intraluminal as well as solid organ or lymph node disease. lymph node disease.

-(HIVInsite, Goodman2006)”-(HIVInsite, Goodman2006)”

The most common CT findings are:The most common CT findings are:– enlarged retroperitoneal and mesenteric lymph enlarged retroperitoneal and mesenteric lymph

nodes (42%)nodes (42%)– hepatomegaly (50%)hepatomegaly (50%)– splenomegaly (46%)splenomegaly (46%)– small bowel wall thickening (14%)small bowel wall thickening (14%)

-(HIVInsite, Goodman, -(HIVInsite, Goodman, 2006)2006)

Copyright General Electric Company 1997-2006 | GE Healthcare





RespiratoryRespiratory

““Pneumocystis carinii is a common Pneumocystis carinii is a common organism found both in soil and in organism found both in soil and in living spaces that does not cause living spaces that does not cause illness in people with a normal illness in people with a normal immune system, this organism immune system, this organism multiplies rapidly and causes multiplies rapidly and causes pneumonia”. pneumonia”.

-(Pathophysiology, Gutierrez, Peterson) -(Pathophysiology, Gutierrez, Peterson)

Radiology, Feb 2000; 214: 427 - 432.

Radiology, Feb 2000; 214: 427 - 432.

Radiology, Feb 2000; 214: 427 - 432.

Radiology, Aug 2002; 224: 493 - 502.

Radiology, Aug 2002; 224: 493 - 502.

Radiology, Aug 2002; 224: 493 - 502.

Central Nervous SystemCentral Nervous System ““In patients with advanced HIV disease, In patients with advanced HIV disease,

neurologic signs and symptoms are neurologic signs and symptoms are caused by a variety of central caused by a variety of central nervous system (CNS) nervous system (CNS)

infections, infections, tumors, and tumors, and direct effects of HIV on neural tissue”direct effects of HIV on neural tissue”

--(HIVInsite, Goodman, 2006)(HIVInsite, Goodman, 2006)

RadioGraphics, Jul 2004; 24: 1029 - RadioGraphics, Jul 2004; 24: 1029 - 10491049

Continue……Continue……Central Nervous SystemCentral Nervous System

““MRI appears more sensitive than CT MRI appears more sensitive than CT scanning in the detection of HIV related scanning in the detection of HIV related CNS pathology. CNS pathology.

Some researchers believe that MRI is the Some researchers believe that MRI is the method of choice for all HIV related CNS method of choice for all HIV related CNS pathology, and obviates CT scanning in pathology, and obviates CT scanning in most cases”. most cases”.

-HIVInsite, -HIVInsite, Goodman, 2006Goodman, 2006

Primary Primary CNSCNS lymphoma is an entity that lymphoma is an entity that was rarely encountered previously, and it was rarely encountered previously, and it

accounted for only 1%–3% of accounted for only 1%–3% of CNSCNS neoplasms prior to 1978. However, neoplasms prior to 1978. However,

incidence has increased drastically since incidence has increased drastically since the onset of the acquired immunodeficiency the onset of the acquired immunodeficiency

syndrome, or syndrome, or AIDSAIDS, epidemic, and , epidemic, and CNSCNS lymphomas now represent up to 15% of all lymphomas now represent up to 15% of all

brain tumors at some institutions.brain tumors at some institutions.

Radiology, Jul 2002; 224: 177 - 183.

Radiology, Jul 2002; 224: 177 - 183.

Radiology, Jul 2002; 224: 177 - 183.

Radiology, Oct 2005; 237: 265 - 273.

Radiology, Oct 2005; 237: 265 - 273.

Hepatobiliary SystemHepatobiliary System

““Infections of the liver and biliary Infections of the liver and biliary system with any of a number of system with any of a number of organisms may result in solitary or organisms may result in solitary or multiple hepatic abscesses or multiple hepatic abscesses or different forms of biliary different forms of biliary involvement, including papillary involvement, including papillary stenosis and sclerosing cholangitis”.stenosis and sclerosing cholangitis”.

--(HIVInsite, Goodman, 2006)”.(HIVInsite, Goodman, 2006)”.

Liver disease may be diagnosed Liver disease may be diagnosed with:with:

CTCTUltrasound Ultrasound

Biliary disease may be diagnosed Biliary disease may be diagnosed with:with:

CT,CT,

Ultrasound orUltrasound or

Endoscopic Retrograde Endoscopic Retrograde

CholangioCholangioppancreatography (ERCP)ancreatography (ERCP)

--(HIVInsite, Goodman, 2006)(HIVInsite, Goodman, 2006)

Peliosis hepatis is the term used for liver infection by B henselae.

This condition occurs almost exclusively in patients with acquired immunodeficiency syndrome (AIDS).

The mechanism of transmission is unknown, but involvement by animal or insect vectors has been postulated.

-RadioGraphics, Jul 2004; 24: 937 - 955.

RadioGraphics, Jul 2004; 24: 937 - 955.



Radiographic Procedures and Radiographic Procedures and Interventional TechniquesInterventional Techniques

CT and HDCT (CT and HDCT (HHigh igh DDefinition efinition CComputer omputer TTomography) are often beneficial when omography) are often beneficial when diagnosing opportunistic diseases, caused by diagnosing opportunistic diseases, caused by AIDS.AIDS.

Follow up may sometimes be done with routine Follow up may sometimes be done with routine chest x-ray or CT.chest x-ray or CT.

““In some cases, needle aspiration or excisional In some cases, needle aspiration or excisional

biopsy may be necessary to rule out lymphoma, biopsy may be necessary to rule out lymphoma, KS, mycobacterial disease, or other infection”KS, mycobacterial disease, or other infection”

-HIVInsite, Goodman, 2006-HIVInsite, Goodman, 2006

Systemic Lupus Erythematosus Systemic Lupus Erythematosus (SLE)(SLE)


Systemic Lupus Erythematosus (SLE) Systemic Lupus Erythematosus (SLE) is classified with the group of is classified with the group of diseases involving connective diseases involving connective tissues; formerly termed collagen tissues; formerly termed collagen vascular disease.vascular disease.

--McGraw-Hill, 2000McGraw-Hill, 2000


Connective tissue diseases have Connective tissue diseases have many overlapping symptoms which many overlapping symptoms which makes identifying the specific makes identifying the specific disease difficult. disease difficult.


Connective tissue diseases include: Connective tissue diseases include:

Lupus erythematosusLupus erythematosus systemic vasculitissystemic vasculitis SclerodermaScleroderma Systemic sclerosisSystemic sclerosis PolymyositisPolymyositis Sjogren’s syndromeSjogren’s syndrome


Each of the preceding diseases can

involve multiple organ systems and

is often coupled with various

immunologic abnormalities.

-(McGraw-Hill, 2000).

Cause of Systemic Lupus Cause of Systemic Lupus Erythematosus –Erythematosus –

1. In most cases of SLE, the individual has1. In most cases of SLE, the individual has antibodies present in the blood serum antibodies present in the blood serum

which are not normally present.which are not normally present.--McGraw-Hill, 2000 McGraw-Hill, 2000

2. A genetic predisposition to the 2. A genetic predisposition to the development of SLE exists. development of SLE exists.

--eMedicine, 2006eMedicine, 2006

CONTINUE.....CONTINUE.....

3. Except for drug-related lupus, the3. Except for drug-related lupus, the

cause of systemic lupus and itscause of systemic lupus and its

variants is not known; thus, avariants is not known; thus, a

rational basis for cure does not rational basis for cure does not

exist. exist. --McGraw-Hill, 2000McGraw-Hill, 2000 4. If a mother has SLE, her daughter’s risk of 4. If a mother has SLE, her daughter’s risk of

developing the disease is 1:40, and her developing the disease is 1:40, and her son’s risk is 1:250 son’s risk is 1:250

--eMedicine, 2006eMedicine, 2006

continue….continue….

5. “The antibodies may be produced5. “The antibodies may be produced that can react against the body’s:that can react against the body’s:– blood cellsblood cells– organsorgans– and tissuesand tissues

--MedlinePlus, MedlinePlus, 20042004

continue….continue….

6. “The number and variety of antibodies that 6. “The number and variety of antibodies that can appear in lupus are greater than those can appear in lupus are greater than those in any other disorder” in any other disorder”

-Merck, 2003-Merck, 2003 7. Many researchers suspect it occurs 7. Many researchers suspect it occurs

following infection with an organism that following infection with an organism that looks similar to particular proteins in the looks similar to particular proteins in the body, which are later mistaken for the body, which are later mistaken for the organism and wrongly targeted for attack”. organism and wrongly targeted for attack”.

--MedlinePlus, 2004MedlinePlus, 2004

CONTINUE…… CONTINUE……

8. Drug induced Lupus can occur from 8. Drug induced Lupus can occur from medications used to treat heart disease medications used to treat heart disease and tuberculosis.and tuberculosis.

9. Drug induced lupus usually disappears 9. Drug induced lupus usually disappears after the drug is discontinued. after the drug is discontinued.


AssociatedAssociated signs and symptoms signs and symptoms

1.”The symptoms for SLE vary from person to 1.”The symptoms for SLE vary from person to person.” person.” --Merck, 2003Merck, 2003

2. 90% of the people with Lupus are young 2. 90% of the people with Lupus are young women in their late teens to 30’s.women in their late teens to 30’s.

3. Lupus occurs in all parts of the world but may be 3. Lupus occurs in all parts of the world but may be more common in African Americans and in more common in African Americans and in Asians.Asians.

4. “The manifestations and course of systemic lupus 4. “The manifestations and course of systemic lupus vary greatly from one individual to another and vary greatly from one individual to another and even in one person over time.”even in one person over time.”

--(McGraw-Hill, (McGraw-Hill, 2000)”. 2000)”.

5. SLE can involve: 5. SLE can involve:

– joints (arthralgias-intermittient joint joints (arthralgias-intermittient joint pain or acute polyarthritis)pain or acute polyarthritis)

– kidneyskidneys– mucous membranes (gastrointestinal mucous membranes (gastrointestinal

system)system)– blood vessel walls (including those of blood vessel walls (including those of

the musculoskeletal system)the musculoskeletal system)– skinskin– nervous systemnervous system– heart heart – lungslungs

Continue…... Continue…... Associated Signs and Associated Signs and Symptoms Symptoms

6. Symptoms may occur gradually or 6. Symptoms may occur gradually or they may begin suddenly with they may begin suddenly with fever, resembling an acute fever, resembling an acute

infection. infection. --Merck, 2003Merck, 2003

7. Additional symptoms which may be associated with 7. Additional symptoms which may be associated with this disease:this disease:

– blood in the urineblood in the urine – nose bleed nose bleed – coughing up blood coughing up blood – swallowing difficultyswallowing difficulty – patchy skin color patchy skin color – red spots on skin red spots on skin – fingers that change color upon pressure or fingers that change color upon pressure or

in the coldin the cold– numbness and tinglingnumbness and tingling– mouth sores hair loss mouth sores hair loss

-MedlinePlus, 2004-MedlinePlus, 2004

CONTINUE….CONTINUE….

Continue…... Continue…... Associated Signs and Associated Signs and SymptomsSymptoms

8. abdominal pain 8. abdominal pain -MedlinePlus, 2004-MedlinePlus, 2004

9. visual disturbances 9. visual disturbances -MedlinePlus, 2004-MedlinePlus, 2004

10. “Widespread enlargement of the10. “Widespread enlargement of the lymph nodes is common,lymph nodes is common,

particularly in children, youngparticularly in children, youngadults, and in African Americansadults, and in African Americansof all ages”. of all ages”.

--Merck, Merck,

20032003

11. “For many women, lupus flare ups occur during11. “For many women, lupus flare ups occur during the second half of the menstrual cycle, with the second half of the menstrual cycle, with symptoms disappearing when menstruationsymptoms disappearing when menstruation starts”. starts”.

12.“Migraine-type headaches, epilepsy, or severe12.“Migraine-type headaches, epilepsy, or severe mental disorder (psychoses) may be the firstmental disorder (psychoses) may be the first abnormalities that are noticed”.abnormalities that are noticed”. 13. “Skin rashes include a butterfly-like redness13. “Skin rashes include a butterfly-like redness across the nose and cheeks (malar butterflyacross the nose and cheeks (malar butterfly erythema), raised bumps or patches of thin skin,erythema), raised bumps or patches of thin skin, and red, flat or raised areas on the face and sunand red, flat or raised areas on the face and sun exposed areas of the neck, upper chest,exposed areas of the neck, upper chest, and elbows”.and elbows”.

Merck, 2003Merck, 2003

14. Ulcers occur on mucus membranes, such as 14. Ulcers occur on mucus membranes, such as the gums, inside the nose, roof of the mouth, the gums, inside the nose, roof of the mouth, inside the cheeks.inside the cheeks. Merck, 2003Merck, 2003

15. Alopecia15. Alopecia

16. pain when breathing deeply (recurring16. pain when breathing deeply (recurring

inflammation of the pleura)inflammation of the pleura)

17. chest pain due to pericarditis (more serious17. chest pain due to pericarditis (more serious

but rare effects on the heart include anginabut rare effects on the heart include angina

due to coronary artery vasculitis, fibrosingdue to coronary artery vasculitis, fibrosing

myocarditis)myocarditis)

18. sensitivity to sunlight (photosensitivity)18. sensitivity to sunlight (photosensitivity)

Common Means of DiagnosisCommon Means of Diagnosis

SLE is can not be diagnosed by doing SLE is can not be diagnosed by doing any one laboratory test. any one laboratory test.

Several types of laboratory testing can Several types of laboratory testing can be done to help confirm a diagnosis be done to help confirm a diagnosis of Systemic Lupus Erythematosus. of Systemic Lupus Erythematosus.

““The diagnosis of SLE is based upon the presence of at The diagnosis of SLE is based upon the presence of at

least least fourfour out of out of eleveneleven typical characteristics of the typical characteristics of the disease”disease”

““antinuclear antibody antinuclear antibody (ANA)(ANA) panel”panel”

““chest x-ray showingchest x-ray showing

pleuritis or pericarditis”pleuritis or pericarditis” ““CBC”CBC” ““WBC count”WBC count”

““serum globulinserum globulin electrophoresis”electrophoresis”

““rheumatoid factor”rheumatoid factor”

““urine protein”urine protein” ““ESR”ESR” ““serum proteinserum protein electrophoresis”electrophoresis”

““cryoglobulins”cryoglobulins” ““Coombs’ test” Coombs’ test”

MedlinePlus, 2004)MedlinePlus, 2004)

Continue:Continue: “The diagnosis of SLE is based upon the “The diagnosis of SLE is based upon the

presence of at least presence of at least fourfour out of out of eleveneleven typical typical characteristics of the disease”characteristics of the disease”

““complement component 3 complement component 3 (C3)”(C3)”

““complement”complement”

““antithyroid microsomalantithyroid microsomal antibody”antibody”

“ “antithyroglobulin antibody”antithyroglobulin antibody”

“ “antimitochondrialantimitochondrial antibody”antibody”

“ “anti-smooth muscleanti-smooth muscle antibody” antibody”

““characteristic skin rash orcharacteristic skin rash or lesions”lesions”

““chest sounds which revealchest sounds which reveal heart friction rub or pleuralheart friction rub or pleural friction rub”friction rub”

““neurological examination”neurological examination”

““kidney biopsy”kidney biopsy”

--MedlinePlus, MedlinePlus,

20042004

Complications of SLE:Complications of SLE:

Complications associated with SLE Complications associated with SLE depend on the affected systems and on depend on the affected systems and on the severity of the disease.the severity of the disease.

““Surgical procedures and pregnancy are Surgical procedures and pregnancy are more complicated for people who have more complicated for people who have lupus, and they require close medical lupus, and they require close medical supervision”.supervision”.

““If inflammation of the blood vessels at If inflammation of the blood vessels at the back of the eye occurs, doctors give the back of the eye occurs, doctors give prompt treatment with an prompt treatment with an immunosuppressive drug because of the immunosuppressive drug because of the high risk of blindness”. high risk of blindness”. Merck, 2003Merck, 2003

Complications of SLEComplications of SLE

Complications associated with SLE Complications associated with SLE depend on the affected systems and depend on the affected systems and on the severity of the disease.on the severity of the disease.

Surgical procedures and pregnancy Surgical procedures and pregnancy are more complicatedare more complicated

Retinitis-promt treatment necessary Retinitis-promt treatment necessary to prevent blindnessto prevent blindness

Blockage of arteries in the brain or Blockage of arteries in the brain or lung due to thrombosis lung due to thrombosis

Complications of SLE Complications of SLE continue…continue…

Kidney involvement Kidney involvement Myocarditis Myocarditis Lupus pneumonitis Lupus pneumonitis Thrombocytopenia Thrombocytopenia Ischemia Ischemia Complications of high dose glucocorticoid Complications of high dose glucocorticoid

therapy therapy Complications of cytotoxic agentsComplications of cytotoxic agents

-(Merck, 2003) -(Merck, 2003)

Characteristic Imaging Characteristic Imaging ManifestationsManifestations

Imaging methods are chosen according to Imaging methods are chosen according to the area of investigation the area of investigation SLE presents with various radiologic manifestations:SLE presents with various radiologic manifestations: – RespiratoryRespiratory– CardiovascularCardiovascular– GastrointestinalGastrointestinal– GenitourinaryGenitourinary– MusculoskeletalMusculoskeletal– NeurologicalNeurological

--RadioGraphics 2004;RadioGraphics 2004;24:1069-1086 © 24:1069-1086 © RSNARSNA, 2004, 2004

Characteristic Imaging Characteristic Imaging Manifestations Manifestations continue……..continue……..

there are no universally accepted there are no universally accepted imaging criteria for the diagnosis of imaging criteria for the diagnosis of SLESLE

not all SLE patients need imaging not all SLE patients need imaging because many will present with because many will present with systemic findings systemic findings

may help direct management when may help direct management when there are complications related to there are complications related to therapytherapy

--RadioGraphics 2004;RadioGraphics 2004;24:1069-1086 © 24:1069-1086 © RSNARSNA, 2004, 2004

Characteristic Imaging Characteristic Imaging Manifestations Manifestations continue……..continue……..

In a patient with a known diagnosis of In a patient with a known diagnosis of SLE, imaging is often performed to SLE, imaging is often performed to determine:determine:

1. the extent and severity of disease and to,1. the extent and severity of disease and to,

2. monitor the 2. monitor the myriadmyriad complications that arise from the complications that arise from the disease and,disease and,

3. it’s therapy.3. it’s therapy.

4.4. … …imaging may be important for prompt diagnosis of and imaging may be important for prompt diagnosis of and initiation of therapy for complications of SLE initiation of therapy for complications of SLE

--RadioGraphics 2004;RadioGraphics 2004;24:1069-1086 © 24:1069-1086 © RSNARSNA, ,

2004 2004

GastrointestinalGastrointestinal

The most common CT finding in patients with SLE The most common CT finding in patients with SLE and acute abdominal pain is ischemic bowel and acute abdominal pain is ischemic bowel diseasedisease

Pancreatitis in SLE may be due to vasculitis, Pancreatitis in SLE may be due to vasculitis, ischemia of small pancreatic vessels, immune ischemia of small pancreatic vessels, immune complex deposition, or a combination of these complex deposition, or a combination of these entities. entities.

Gastrointestinal Gastrointestinal continue…..continue…..

CT images of patients with SLE, are CT images of patients with SLE, are typically evaluated for the following typically evaluated for the following radiological signs: radiological signs:

ischemia, bowel wall changesischemia, bowel wall changes mesenteric changesmesenteric changes fluid collectionfluid collection retroperitoneal lymphadenopathyretroperitoneal lymphadenopathy peritoneal enhancementperitoneal enhancement hepatomengalyhepatomengaly changes in other abdominal organs changes in other abdominal organs pancreatitispancreatitis

Gastrointestinal Gastrointestinal continue…….continue…….

““SLE may involve any portion of the SLE may involve any portion of the gastrointestinal system. Nonspecific and vague gastrointestinal system. Nonspecific and vague abdominal pain is seen in 10%–37% of patients abdominal pain is seen in 10%–37% of patients with SLE and may be due to vasculitis, with SLE and may be due to vasculitis, obliterative vascular thrombosis resulting in obliterative vascular thrombosis resulting in ischemic bowel, or immune complex deposition of ischemic bowel, or immune complex deposition of autoantibodies in tissues, eliciting an autoantibodies in tissues, eliciting an inflammatory response. Immunosuppressants inflammatory response. Immunosuppressants such as azathioprine and prednisone can also such as azathioprine and prednisone can also induce abdominal symptoms and have been induce abdominal symptoms and have been implicated in pancreatitis.” implicated in pancreatitis.”

--RadioGraphics 2004; RadioGraphics 2004; 24:1069-1086 © RSNA, 2004.24:1069-1086 © RSNA, 2004.

--RadioGraphics 2004;RadioGraphics 2004;24:1069-1086 © RSNA, 200424:1069-1086 © RSNA, 2004


Copyright © 2005, Radiological Society of North America, Inc.

Copyright © 2005, Radiological Society of North America, Inc.



Respiratory Respiratory ““The risk of pulmonary infection is three times The risk of pulmonary infection is three times

higher in patients with SLE than in the general higher in patients with SLE than in the general population due to intrinsic immunologic population due to intrinsic immunologic abnormalities…..” “Recurrent pulmonary abnormalities…..” “Recurrent pulmonary infections can lead to bronchiectasis and infections can lead to bronchiectasis and respiratory compromise.” respiratory compromise.”

““Imaging is often performed in patients with a Imaging is often performed in patients with a known diagnosis of SLE to determine the extent known diagnosis of SLE to determine the extent and severity of disease, which depend on the and severity of disease, which depend on the extent of organ involvement, and to monitor extent of organ involvement, and to monitor complications. complications.

--RadioGraphics 2004;RadioGraphics 2004;24:1069-1086© RSNA, 200424:1069-1086© RSNA, 2004

RespiratoryRespiratory continue…….continue…….

““Pleural effusions are the most common Pleural effusions are the most common manifestation of SLE in the respiratory manifestation of SLE in the respiratory system and are bilateral in approximately system and are bilateral in approximately 50% of patients.”50% of patients.”


““Alveolar hemorrhage is a potentially Alveolar hemorrhage is a potentially catastrophic complication of systemic catastrophic complication of systemic lupus erythematosus.” lupus erythematosus.”

-(American College of Chest Physicians, Chest journal, 2006)-(American College of Chest Physicians, Chest journal, 2006)






Central Nervous SystemCentral Nervous System

Neurologic changes can occur secondary Neurologic changes can occur secondary to to lupus. to to lupus.

15% of patients experience CVA’s, 15% of patients experience CVA’s, (cerebral vascular accident) and 20% of all (cerebral vascular accident) and 20% of all patients develop some type of seizure patients develop some type of seizure disorder.disorder.

These CNS manifestations can limit the These CNS manifestations can limit the patient’s ability to care for themselves. patient’s ability to care for themselves. Lupus therefore has a significant effect on Lupus therefore has a significant effect on the quality of life for those with this the quality of life for those with this disease. disease.

Central Nervous System Central Nervous System continue……continue……

Brain imaging is most often conclusive Brain imaging is most often conclusive when using MRI in comparison to CT.when using MRI in comparison to CT.

““All lesions seen on CT were also visible on All lesions seen on CT were also visible on MR; however, MR proved to be MR; however, MR proved to be substantially more sensitive. Many lesions substantially more sensitive. Many lesions not visible on CT were noted on MR, and in not visible on CT were noted on MR, and in general, MR demonstrated the general, MR demonstrated the abnormalities with greater clarity”.abnormalities with greater clarity”.

-(American College of Physicians, Chest journal, 1985)-(American College of Physicians, Chest journal, 1985)

Central Nervous System Central Nervous System continue……continue……

““Focal lesions were demonstrated on MR Focal lesions were demonstrated on MR imaging in eight patients with systemic imaging in eight patients with systemic lupus erythematosus and recent onset of lupus erythematosus and recent onset of neuropsychiatric symptoms. neuropsychiatric symptoms. Corresponding findings were visible in only Corresponding findings were visible in only two of seven patients who had CT scans”.two of seven patients who had CT scans”.

-(American College of Physicians, Chest journal, 2006)-(American College of Physicians, Chest journal, 2006)

Immunosuppressive therapy for the Immunosuppressive therapy for the treatment of SLE can reduce the immune treatment of SLE can reduce the immune response leaving the patient vulnerable for response leaving the patient vulnerable for cerebral abscesses.cerebral abscesses.






RAD 266 Pathology Correlation for CT/MRI Autoimmune Disease Module B.

Documents

pathology slide

peterson slide

splenomegaly slide

autoimmune system

peterson pages

types of immune responses

immune system cell types

following pages