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Radiology of Infectious Diseases 3 (2016) 23e33
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Research article

Study of a human immunodeficiency virus-associated multiple-tissue

dysfunction syndrome in one boy: Analysis of multiple tissues using X-ray,
computed tomography and magnetic resonance imaging
Xichao Xia a, Qingfu Hu a, Shifeng Zhang a, Juan Cui a, Bingqin Shi a, Hongwen Li a, Hongjun Li b,
Xizhong Jia c, Lei Jiang c, Rongzhi Liu a,*
b

a
Basal Medicine College of Nanyang Medical University, Nanyang 473041, Henan Province, China
Department of Medicine, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
c
First Affiliated Hospital of Nanyang Medical University, Nanyang 473058, China

Received 9 August 2015; revised 10 December 2015; accepted 10 December 2015

Available online 6 January 2016

Abstract
In the previous study, reports of human immunodeficiency virus (HIV)-associated multiple tissue dysfunction syndromes are limit. Now,
multiple tissue lesions of one boy with AIDS were analyzed using X-ray, computed tomography (CT) and magnetic resonance imaging (MRI).
Results showed that obvious brain atrophy and several focus were detected by CT and MRI. Lung lymphoid inflammation and pulmonary
lymphoplasia were observed by CT. A swelling with a slight low density in hepatic anterior region of right lobe and a large soft tissue neoplasm
in right abdomen were obtained by CT. An obvious damage of intestinal duct and intestinal lymphomas were respectively observed by molybdenum contrast image and CT. X-ray showed a low density of thoracic bone and iliac bone, and irregular shapes of bone joint and epiphysis.
Characterizations of HIV-associated multiple organ dysfunction syndromes in the case are benefit to understand features of children with acquired immune deficiency syndrome.
2016 Beijing Youan Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: HIV-associated multiple organ dysfunction syndrome; X-ray; Computed tomography; Magnetic resonance imaging

1. Introduction
In the septic patients, pathogenic bacteria invasion may
result in multiple organ/tissue dysfunction syndromes [1e3].
As to human immunodeficiency virus (HIV) infection, it has
demonstrated that patients also differ from each other with
regard to severity of disease, etiology of acquired immune
deficiency syndrome (AIDS), and type of AIDS. Different
etiologies of AIDS exhibited different clinical outcomes [4,5].
In developing countries, children with HIV infection show
* Corresponding author. Fax: 86 0377 63526123.
E-mail address: liurongzhi@sina.com (R. Liu).
Peer review under responsibility of Beijing You'an Hospital affiliated to
Capital Medical University.

short latency period of virus, quick progression of morbidity,

weak course of illness, high probability infections of several
pathogens [6,7]. However, literatures of HIV-infected multiple
tissue dysfunction syndromes are sparse. In the current study, a
HIV-infected multiple-tissue dysfunction syndrome was reported by analysis of several organ lesions using X-ray,
computed tomography (CT) and magnetic resonance imaging
(MRI).
2. Case presentation
The study was approved by Ethical Review Committee of
Nanyang Medical University. Available patient was
approached and informed of the study objectives, procedure
and confidentiality issues by study coordinator. Patient who

http://dx.doi.org/10.1016/j.jrid.2015.12.003
2352-6211/ 2016 Beijing Youan Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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X. Xia et al. / Radiology of Infectious Diseases 3 (2016) 23e33

X. Xia et al. / Radiology of Infectious Diseases 3 (2016) 23e33

decided to participate in this study and provided written

informed consent were asked to complete a survey to assess
presence of HIV/AIDS-related symptoms.
A boy infected by HIV through vertical mother-to-child
transmission was definitely diagnosed as AIDS at 5 years
old. Subsequently, some symptoms were exhibited including
of poor appetite, vomiting, marasmus, limbs fatigue. Meanwhile, a large lump was observed in midsection where pain is
often occurred in. Amount of CD4 cell was only 68/mm3.
Results of CT indicated an irregular brain shape was presented characterized as deepened and widened cerebral sulcus,
enlarged lateral fissure cistern and a hyper-intense zone with a
size of 0.78 cm  0.83 cm in the suprasellar cistern (Fig. 1).
Meanwhile, an obvious high density region was observed in
anterior temporal lobe and posterior temporal lobe (Fig. 1A,
C). Results of MRI in brain revealed multiple dots and small
sheets of lengthened T2 signal as well as hyper-intense signal
were observed in centrum oval (Fig. 2). In addition, similar
signal intensity of T1 and T2 occurred in cortex of sellar region, but there was a strong space occupying effect in the
enhance imaging of sellar region (Fig. 2). Widened fulics and
deepened lateral fissure were also obtained by MRI
(Fig. 2AeD). Irregular shape of right lateral ventricle was
observed (Fig. 2G, H). A high T2 signal was also found in
anterior temporal lobe that was insistent with the result of
Fig. 1C (Fig. 2A).
CT showed diffuse airspace opacities, disorder stripe,
thickening wall and dilated lumen in the left lung and the right
lung (Fig. 3). Ground glass opacity was observed in all lobes
of right lung and left lung in where this phenomenon was
obvious occurred in lower lobes, but lesser in upper ones of
them (Fig. 3C,D). Bilateral, symmetrical hilar, and paratracheal lymphadenopathy as well as nodal calcification were
found by chest CT. Characterizations of parenchymal
involvement showed reticulonodular change, ground-glass
opacity, alveolar opacities, tree-in-bud opacities, large
nodular opacities, and irreversible fibrotic change. Signs of
pulmonary fibrosis were also observed characterized by coarse
linear opacities and/or consolidation radiating from the hilum
into the adjacent middle and upper zones as well as vascular
and fissural distortion in hilar retraction (Fig. 3).
CT scan revealed that abnormal ratio between right lobe
volume and left lobe were observed characterized as an
obvious inflation occurred in right lobe but a shrink in left lobe
(Fig. 4AeC). A half round nodular protrusion and large soft
tissue neoplasm with a size of 6.9  6.6 cm were respectively
located in right lobe of liver and lower left abdomen (Fig. 4).
Strip shadows of liquid and floating intestinal canal were fund
in abdominal cavity.
A molybdenum contrast image showed a ball structure and
overlapping event were formed in distal ileum (Fig. 5).
Defected intestine wall and disappeared mucosa were widely

25

observed (Fig. 5). Meanwhile, canal of ileum was distorted as

a shape of seahorse (Fig. 5).
CT scan revealed that a great mass with a well-defined
border was observed in left abdomen (Fig. 6). Intestinal canals around of smelling were obviously squeezed (Fig. 6).
Region of liquid density was also obtained by CT. Different
sizes of lymphadenectasis with a clearly defined capsule were
extensively distributed in right abdomen.
X-ray demonstrated that bone density of thoracic bone and
iliac bone were obvious decreased (Fig. 7A, B), and joint
space of knee, ankle and palm were significant increased
compared with that of normal ones (Fig. 7C, D, E). An
abnormal change of osteoepiphysis area was detected by Xray, such as hardening epiphyseal line, upward-bending of
posterior epiphyseal horn, narrow epiphyseal space and
decreasing bone density of osteoepiphysis (Fig. 7). Acetabulum of hip joint showed an irregular deformation in where
space was narrowed.
3. Discussion
In China, the first case of HIV vertical transmission from
mother to child was reported in the year of 1997. The first
Child AIDS patient was diagnosed in the year of 1999 [8].
Now, amount of Child AIDS patients came from vertical
transmission showed a rising trend and this population was
described as the second generation of AIDS patients [8,9].
Works of what to shed light of characterizations of these patients are benefit to provide help for Child AIDS patient's
diagnosis and treatment.
In our result, one boy was diagnosed as AIDS at 5 years old
and showed obvious multiple-tissue dysfunction syndromes,
suggesting that is associated with the lower immunity
competence of children as well as features of HIV infection. In
many developing countries, children's healthy is not fully
gained attention because of limit food supply and poor medical condition meet the demand of [10e13]. In addition, formation of mature immunological barrier is slower in
developmental stage compared with that of advanced countries
[14e16]. Therefore, children exposed to HIV infection
showed a short latency period and quick progression. Meanwhile, in HIV-infected children, lower immunity competence
results in an increase of opportunities of other pathogenic
microbes that may cause a cluster of lesions of tissue including
of brain, lung, liver, kidney, intestinal and so on [1,4,5].
In present study, lung lymphoid inflammation and pulmonary lymphoplasia were observed that is insistent with previous manifestation of no-HIV infection. Lung, a primary
window of pathogenic microbe invasion, is sensitive to other
pathogens except of HIV, especially in children because their
immunology ability is weak [17]. Therefore, HIV-associated
lung diseases are common observed in children. It has

Fig. 1. CT results of brain in a 5-yearold boy AIDS patient. A, B, C, D and E were CT results of brain at different positions. Results of CT showed widened
cerebral sulcus (white arrow), enlarged lateral fissure cistern (asterisk), a hyper-intense zone (triangle) and a high density region in posterior temporal lobe
(black five-pointed star).

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27

Fig. 3. CT results of lung in a 5-yearold boy AIDS patient. A, B, C, D, E and F were CT results of lung at different positions. Results of CT showed ground glass
opacity are occurred in all lobes of right lung and left lung. Bilateral, symmetrical hilar, and paratracheal lymphadenopathy (triangle) as well as nodal calcification
(white arrow) were found by chest CT.

established that occurrence of lymphoid interstitial pneumonia

of Child AIDS patients is regarded as a hallmark of HIV infections [18,19]. Features of lymphoid interstitial pneumonia
are characterized with reticular and nodular changes of bilateral pulmonary interstitium as well as micronodular foci,
thickening and fibrosis of bronchial wall, and bronchial
vesiculation. These features above mentioned were also
detected in this case.
Results of liver CT scan demonstrated that there were a
swelling with a slight low density in hepatic anterior region of

right lobe and a large soft tissue neoplasm in right abdomen,

suggesting that these lesions function as a key player to
induce abdominal pain, weight loss, fever and abnormal liver
function. Liver plays an important role in food metabolism,
energy supply, body defense and toxicant elimination [20,21].
Liver neoplasm and destroy of liver cells may result in a loss
of energy, accumulation of toxicant, imbalance of homeostasis [21,22]. It is deserve noting that occurrence rate of
neoplasm in children with AIDS is 17%, and typical malignant neoplasm is B cell lymphoma in which Burkitt's tumor is

Fig. 2. MRI results of brain in a 5-yearold boy AIDS patient. A, B, C, D, E, F, G and H were MRI results of brain at different positions. Results of MRI showed
widened cerebral sulcus (white arrow), enlarged lateral fissure cistern (asterisk), a high density region in temporal lobe (black five-pointed star), multiple dots and
small sheets of lengthened T2 signal as well as hyper-intense foci in centrum ovale (black triangle), Irregular shape of right lateral ventricle (black arrow).

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X. Xia et al. / Radiology of Infectious Diseases 3 (2016) 23e33

Fig. 4. CT results of liver in a 5-yearold boy AIDS patient. A, B, C, D, E and F were CT results of liver at different positions. Results of CT showed a half round
nodular protrusion (five-point star) and large soft tissue neoplasm (asterisk) were respectively located in right lobe of liver and lower left abdomen.

a high-frequency case [23,24]. Therefore, in order to definitely identify the neoplasm in this boy, transdermal fineneedle and dissection of biopsy should be conducted in the
clinical.
An obvious damage of intestinal duct was observed, that is
likely related with injury of the liver cells. A large of toxicant
should be accumulated in the intestine because damaged liver
cells can not rapidly clear out toxicant which flow into intestinal duct and constantly deposited that cause a negative
effect on intestinal function [25,26]. Meanwhile, as an
important digestive organ, liver can secrete a large of digestive
juice that is helpful to digestive and absorption of intestinal
duct [20,25,26]. Considering here, events of liver lesions play
a side impact on intestinal duct cells. Notably, the mass of soft
tissue in the right abdomen is likely a HIV-associated

lymphoma in the mesenterium, suggesting intestine has been

seriously destroyed by diffuse of HIV. Intestinal lymphomas of
AIDS patients are an unfavorably differentiated subtype and
often caused a poor prognosis [26,27]. These neoplasms are all
malignant tumors and have been became worsened ones
before clearly diagnosis although there is not surrounding
lymphadenectasis [28,29]. In this case, event of what mucosal
folds of small intestine were thickened and intestinal canals
were embraced by thickening mucosal folds is likely related
with cancer cell metastasis.
Considering here, HIV infected individuals are more
vulnerable to microelements malnutrition due to decreased
intake, mal-absorption need and metabolism changes derived
from damage of intestinal duct as well as injury of liver cells.
Such as vitamin D, as a fundamental element for regulation of

X. Xia et al. / Radiology of Infectious Diseases 3 (2016) 23e33

29

Fig. 5. Molybdenum contrast image results of intestine in a 5-yearold boy AIDS patient. A, B, C and D were molybdenum contrast image results of intestine at
different positions. Defected intestine wall and disappeared mucosa were widely observed (white arrow).

bone metabolism, its deficiency was reported more frequently

in HIV population [30]. Based on destroy of liver, lung and
intestine by HIV infection, it is not doubt that these events
should inevitably cause bone malnutrition and impair bone
development [30]. Studies have shown that bone disorders are
more prevalent in HIV positive patients in comparison with
HIV negative individuals who were at the same age range, sex
and race [31]. Therefore, decreased density of thoracic bone
and iliac bone and increased joint space of knee and ankle
were obtained. Irregular shape is also occurred in the bone
joint and epiphysis [32,33].
Our result showed that obvious brain atrophy and several
focus were observed by CT and MRI, revealing that central
nervous system lesions are a common phenomena in AIDS
patients. It has demonstrated that 27% AIDS patients with
central nervous system lesions are found in early stage, but
almost all patients in advanced stage those have differentdegree decrease of total cerebral volume, atrophy of cortex,
ischemia of white matter, infarction of brain, infection of
subcutaneous tissue, even neoplasm of brain [34e36].
Feathers of above mentioned would be helpful to diagnose the
stage of AIDS prognosis and analyze the outcome of
treatment.
Dysregulation of the immune system in the pathogenesis of
HIV infected patients is a complex process including
lymphocyte apoptosis and CD4 T cell depletion, imbalance
among CD4 and CD8 cell responses correlated with modified
cytokine networks (such as increase in TGF-b and decrease in

I interferon-g), HIV-1-specific CD8 T cells contributed to

release of pro-fibrotic cytokines, aberrant dysregulation of
natural killer cells function which leads to altered secretion of
cytokines, elevated tissue inflammatory cytokines in turn results in over-production of reactive oxygen species (ROS) and
mitochondrial respiratory dysfunction which has been suggested to play a role in the pathogenesis of multiple tissues
symptom. Thus, a complex framework is established in the
pathogenesis HIV infections which occurred in multiple tissues [37]. But in the late stage, inducing production of ROS
which activate the Mitogen-Activated Protein Kinases
(MAPK) pathway and up-regulate TGF-b; stimulation TGF-b
caused by HIV infection modulates the immune response and
favors fibrosis and transformation toward cellular
carcinoma. Therefore, occurrence of fibrosis and tumors
observed in imaging indicates that the boy has features of AID
in which the immune system has been badly damaged [38].
Body homeostasis is interplayed by different organs in
which the inflammatory reaction and anti-inflammatory reaction play an important role in homeostasis [39,40]. Disorder of
one organ often results in a dysfunction of another organ that
in turn cause negative effects on multiple organs [41]. In the
present study, HIV-infected multiple-tissue dysfunction syndrome in one boy was described by different imaging technology that indicated combination HIV-infection and other
pathogens can result in serve destroy for multiple organs [41].
The work should provide potential help to diagnosis and
treatment of AIDS patients in clinical.

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X. Xia et al. / Radiology of Infectious Diseases 3 (2016) 23e33

Fig. 6. CT results of intestine in a 5-yearold boy AIDS patient. A, B, C, D, E, F, G and H were CT results of abdomen at different positions. CT scan revealed a
great mass with a well-defined border (asterisk), different sizes of lymphadenectasis with a clearly defined capsule (black arrow) and regions of liquid density
(white arrow) were observed abdomen.

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31

Fig. 7. X-ray results of bone in a 5-yearold boy AIDS patient. A, B, C, D, and E were X-ray results of thoracic bone, iliac bone, knee joint, ankle joint and palm
joint. X-ray demonstrated that bone density of thoracic bone and iliac bone were obvious decreased (asterisk), and joint space of ankle, knee and palm were
significant increased (black arrow).

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X. Xia et al. / Radiology of Infectious Diseases 3 (2016) 23e33

Acknowledgment
We gratefully acknowledge the many contributions of Pro
Liu Rongzhi to this research program. This research was
funded by the National Natural Science Foundation (No.
31271285), National Natural Science Foundation of Henan
(No. 12B310010, No. 142102310211).
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