Ultrasound of Tropical Diseases and HIV in Uganda - HD

Introduction

I am called Michael Grace Ka Warrior.

I'm a professor of radiology

and I work with the Earn Cook Ultrasound Research

and Education Institute in Kampala, Uganda.

This institute teaches ultrasound

and is affiliated to Jure, which is directed

by Professor Barry Goldberg in Philadelphia.

I'm also the director of the Kampala Center of Excellence

for the World Federation of Ultrasound

in Medicine and Biology.

Uganda is located in East Africa,

is bordered by Kenya, Tanzania, the Democratic Republic

of Congo and the Sudan.

and there's lots of tourism, interesting things

to see are nice people.

The institute where I work

has several core functions.

One is research.

There's also rural community ultrasound services.

We also teach ultrasound.

Objectives of the Talk

The objectives of this talk are

to describe the abdominals neuropathological changes in

tropical infections to describe abdominals,

neuropathological changes in HIV

and to recognize when it's necessary

to perform ultrasound-guided biopsy or aspiration.

Amoebiasis

We shall start with army biases.

This is one of the common tropical

parasitic infections

and it is spread by inba, his politica

within the human body.

This worm

or this organism, this parasite

resides in the intestines

and then it produces trophozoites which go to the liver,

to the lungs and to the brain,

and you acquire it through the oral fecal root.

The commonest organ of involvement is the liver

where you can see in the initial stages

something like that, that which is hypo

focal hypo echoic lesion

and later it lfi to give you a larger

lesion and with time

even a much larger, more liquid lesion with

what they call a pseudo capsule around it.

The dangers of this infective,

abscess or cyst is that it can rupture unless it is drained.

Hydatid Cyst

The next parasite we are going to look at is hi

or occus, which is

a parasite found in many areas of the world,

including Africa, Europe, and America.

It is spread bred by Echinococcus

Granulosis and also Echinococcus.

Multilocular is and man is an intermediate host.

The cysts form in the liver

and in the brain and in the lungs.

In the early stages,

the cyst is echo free

and later it becomes solid.

There are two classifications of liver cysts, one

by the WHO and another by Professor Hassan Gabi

and they all have

a number of similarities

at ultrasound, one sees in the liver a cystic lesion.

In the early stages it's important to know

that this lesion is treated using ultrasound

whereby you put in a needle, you aspirate the content,

you inject alcohol, you re aspirate the alcohol,

and then you follow the patient over several

months and years.

And what happens, as you can see in this example

of this elderly lady,

who came with this cyst is

that initially before the cyst was rounded,

at two weeks after that procedure,

which they call a pair procedure, the cyst had shrunk

and also formed septations.

And at two months the cyst was really small

and almost non-existent

and by three months the patient was cured.

So using this method they call pear,

you can treat the hide that it cyst.

Schistosomiasis

SSO cyst is caused by

Manso Hema and S Japonica.

There are two hosts in the lifecycle for this parasite.

One is the snail, the freshwater snail.

The second one is man,

The parasite matures in the snail

and the lover are released.

These are called aria.

This aria penetrate the skin of man

in water and then they travel

to the veins of the small intestines

and also to the veins around the bladder.

These small veins called venues are the home

for the mature parasite.

And during this stage the parasite will lay eggs

and the eggs migrate to the intestinal walls

for man Sinai and also to the liver.

For hemato, they'll migrate to the bladder wall.

Schistosoma mansoni

We shall start with s mani.

This organism

or this parasite targets the liver.

The eggs which are laid by the worm in the

veins travel along the portal vein to lodge in the

sinusoids or in the pers sinusoids in the liver.

And when they are there, they're going

to elic a fibrotic reaction around the veins.

Eventually the pot veins become thick

and the patient develops portal hypertension.

At ultrasound, this schematic diagram

shows you what happens.

The pictures are borrowed from heim brister.

Initially the liver appears no more in stage A.

In stage B you see what they call a

starky appearance with bright areas in the liver.

In stage C, there is thickening of the walls of the pot

of veins to give you what they call

SI's pipe stem cirrhosis.

In stage D, there are echogenic patches

around the pro veins.

In stage E, these patches extend to the liver parenchyma

and in stage F, the patches extend all the weight

to the liver capsule.

This is an example of stage C.

You can see in the liver there are bright areas

around the portal veins.

And on this longitudinal section, the wall

of the portal vein is thickened to give you

what they call the pipes stem appearance of si.

And the portal vein is also dilated.

But to note here is that the flow in the portal vein

and the hepatic artery is still hepato.

This is a patient.

In a later stage you can see that the fibrotic band extend

to the liver capsule.

So this is stage F, the

port vein is dilated and there is ascites.

The liver was bios

because the doctors thought there could be a tumor.

But then the histopathology is characteristic for

S mount sinaii with fibrosis around the portal veins.

This patient illustrates stage F.

You can see that the fibrotic band extend all

the way to the liver capsule.

The portal vein is dilated to 1.68 centimeters

and there is reversal of flow within the portal.

Vein is blue, blood is flowing away from the liver,

that is hepato Hugo,

and in the hepatic artery it is red,

it's flowing towards the liver.

There are other changes of the intestines with edema

of the small intestines

and also their viruses at the porter.

Hepatitis. Another patient in stage F,

you can see the fibrotic band to the liver.

There are those marked fibrotic band, those white areas

that monitor testing is also thickened and emmets

and there is blood flow both

in the hepatic artery and in the portal.

Vein is hepato part, there is

the arm lyco vein here is

opened.

It's rec cannulated.

That means that there is marked portal hypertension.

That blue is the ized.

lyco vein S man sinaii.

Schistosoma haematobium

We move to a hemato.

The eggs are deposited in the mucosa of the urinary bladder

and eventually one forms polyps like that one.

There is a thick urinary bladder wall

And eventually with time there is damage to the VE cycle

ureteric valve mechanism and there's backflow of the urine.

The patient then gets hydronephrosis.

Malaria

Malaria is a parasite infection which is common

in the tropics in many countries in the tropics.

The parasite involved here is called plasmodium

and they are safe for species.

Plasmodium is a genus species.

The commonest species is a plasmodium foram.

There's also plasmodium viva or vale and Maori.

This parasite has a stage within the mosquito

and also two stages within man.

The mosquito introduces the parasite

as it feeds on man

and the parasite travels to the liver

where it infects the red blood cells

and also the liver cells.

And eventually somebody manifests

with a fever which is characteristic for malaria.

But with time, the liver

and the spleen may enlarge in these patients.

If you look at these pictures, this is a 17-year-old man.

This is a sagittal section

and you can see the spleen is coming all the way down

to the ary bladder.

A very large spleen.

So splenomegaly

and hepatomegaly characterize the chronic malaria

in some countries

and here you can see the spleen is kissing the liver.

That means that it must be a very large spleen

And in addition

to the large spleen also sees a large pro vein.

There are complications of malaria

involving the liver and the spleen.

One of them is what they call high leninism

where the spleen becomes very big

and starts destroying red blood cells

and one ends up with anemia.

Eventually because of that destroyed red blood cells,

one also forms pigment stones in the gallbladder.

The diagnosis for malaria of the spleen

is made not by biopsy of the spleen

but by biopsy of the liver.

Where once is co face cell hyperplasia with sinoc

lymphocytosis

Ascariasis

as psoriasis is a common parasitic infection

of the intestinal tract in man.

The worm Resides in the small intestine

where it lays eggs up to 200 eggs a day

and these eggs then hatch

and can be again ingested through the oral fecal root.

When they're ingested, they mature in the lungs

and also finally reach the intestines

and the worm against starts the cycle.

You can see that there is a worm in the gallbladder.

So these worms can go

and block the biliary system resulting into jaundice.

This picture taken many years ago using

a procedure they call hydro colos.

Sonography shows the worm

swimming within the large intestine and

and this other film shows what they call the acars ball

with many worms seen in cross-section.

This particular patient came with intestinal obstruction.

It was an 8-year-old female

from the parasites.

HIV in the Abdomen

We move to H-I-V-H-I-V is

caused by the human immunodeficiency virus

and we know that this pandemic

is a global pandemic.

We shall look at the effects

of HIV in the various organs in the body,

especially in the abdomen.

Liver

We start with a liver where it causes hepatomegaly in 19

to 85% of patients

and also altered echo texture of the liver in up

to 81% of patients.

It also causes increased echogenicity

or decreased echogenicity in 73% of patients

In this patient.

Here we see that the liver is bright, hyper

quake and smooth

and in this other patient the liver is bright but rough.

Those are all effects of HIV.

In this patient we see a focal hypo area

which had biopsy turned out to be lymphoma.

In this other patient a focal hypo echoic area which had

biopsy and histology turned out to be tb.

And in this patient we see cystic areas within the liver,

which at biopsy

and histology showed infl inflammation.

Chronic inflammation.

In this patient you have within the liver a hyper echoic

area which are biopsy and histology showed human tumor

and crypto caucus neoformans.

So in our HIV population, the commonest cause

of these bright focal areas in the liver is hemangioma.

But occasionally, like in this patient, this bright area,

this psychogenic area was due to kapos sarcoma

and the histology confirmed it.

Gallbladder

The gallbladder is involved in 20 to 77% of patients

and commonly you see gallbladder wall thickening

like in this patient and also thickening

around the cystic duct.

Here also in another patient you see a markedly thickened

and the genic gallbladder wall.

And in this patient, again a thick gallbladder wall

with a peri cystic fluid collection

or small abscess, Still a fourth patient

with a thick gallbladder wall.

Biliary Ducts

The biliary docs are also involved in these patients

and we call this HIV Cholangiopathy.

20 to 49% of patients may manifest this

and this HIV cholangiopathy as well

as the changes in their gallbladder are due

to cri Cryptosporidium microsporidia

cytomegalo inclusion virus microbacteria under HIV virus.

Here in this patient you see a dilated common bio duct.

We put in a needle that arrow shows the needle.

We, our aim was to find out what was causing this dilatation

and we isolated nocardia organisms.

This may be the causative organisms,

but on the other hand they may just be secondary invaders

or just associated secondary infections.

Cholangiopathy manifests in many ways.

He once sees the infiltrative type of cholangiopathy,

still infiltrative type there.

He once sees the nodular type of cholangiopathy

and here the literative type

with a dilated common bile duct.

Another patient with the obliterated type of cholangiopathy.

You can see in this cross-section of the portal triad

where they call the Mickey mouse sign that there is a,

a portal vein here, hepatic artery

and in the area where the bio duct should be,

it's all white.

It's all blocked by this tissue due to the HIV

and this is what we see in the dative cholangiopathy.

Spleen

Thus spleen is involved in 35% of our patients

and commonly one they one may see these little hypo

equipped nodules scattered throughout the spleen.

Other things we may see is splenomegaly diffuse increasing

echogenicity and large masses.

In these patients, One sees these

little areas hypo quake with a central hypo quake area.

They call this a target sign.

This is characteristic for candida

and there are these less well defined

hypo echoic areas which are C characteristic.

We see this in tb.

There are also micro abscesses in this patient.

So a variety of appearances.

in the spleen again here,

splenic nodules in HIV.

In one study we have done in pediatric patients, in children

with HIV, we have noticed that these small hypo earthquake

nodules may be seen in 40% of these kids.

And we think that these are due to, due to tuberculosis.

Pancreas

The pancreas, the pancreas is involved in about

10% of our patients.

The commonest thing we see are four core hypo echoic areas.

The commonest cause of this is tuberculosis.

What we do, we put here a needle

and then we take out the sample and spread it out on a slide

and we stain it with a zeal nien stain.

And in many cases it showed acid fast basi.

Kidney

And these are two patients, the kidney.

In the kidney we see pathology in up

to 10% of our patients.

And the communist pathology we see is diffused

echogenic kidneys, which are in most cases due to

HIV associated nephropathy, which is abbreviated as hivan.

In this patient with hivan, we confirmed this

by biopsying the kidney and this is the histology.

And here in this histology you see mechy hyperplasia

with a collapsed collapsing focus segment of glom glomerular

sclerosis, which is characteristic for hivan.

In this patient you see surrounding the kidney,

this area of food collection

and the shaggy contour of the kidney.

So we thought that this was an infective oma

and we put there a needle and we isolated yeast

or fungo colonies,

which we thought were the cause of this fluid collection.

That patient was treated lymphadenopathy

or enlarged lymph nodes.

Lymphadenopathy

These are seen in up to 42% of our patients

and more than 50% of lymph node

which are enlarging these patients are due to tuberculosis.

Here is an example of a patient who came

with these focal hypo echoic, node using the liver

and also in the spleen.

The patient had large lymph nodes at the port.

He parties who put their a needle.

You can see the needle coming to one of the lymph nodes

and we made, to, we did a biopsy and also a smear

and this turned out to be tb.

You can see the typical histological appearance with KCI H

And also the stain

for acid fast basi in another patient.

Also massive lymph node enlargements.

The lymph nodes are hypo echoic

and still the histology showed this to be tuberculosis

with acid fast ized staining the TB organisms,

Kaposi's Sarcoma

kapos sarcoma is

a tumor,

a very aggressive tumor in HIV patients.

It commonly goes for the retroperitoneal area.

Here you can see that SMA has been lifted off from the iota,

in a child with kapos sarcoma.

And you see, this child also has hydronephrosis

because there is, involvement of the ureter,

the ureter is narrowed

and so that patient ends up with hydronephrosis,

another patient with osis sarma by this time

with discreet lymph nodes, discreet lymph nodes,

adjacent to the iota.

Occasionally we see patients

with these massive large lymph nodes

and when you do the histology they tell you

that it's chronic inflammation,

but we believe that this is most likely TB only

that the patient has lost his or her immunity

and cannot mount the normal reaction.

And so you don't see the normal histological appearance

of ation giant cell formation,

and granulomas, which is typical for tb.

So all that same when we see chronic inflammation,

like in this, in this patient with, with necrosis

and inflammation, we treat them as tuberculosis.

Gastrointestinal Tract

The elementary tract is involved in 14 to 15% of our cases

of our patients.

And the commonest cause is thickening of the bowel,

which is due to TB or maybe due to lymphoma.

This patient we saw a couple of weeks back came

with bilateral symmetrical enlargement of the

saliva glands more in the, pared glands.

And when we did ultrasound we saw these large areas,

these large, massive nodules with central areas of,

of, of, of necrosis.

And we did a biopsy and this turned out to be

marginal B-cell lymphoma or myoma.

The parid glands

and the submandibular glands were involved in this patient

much more commonly is TB of the small intestines.

Like in this patient with this thickened hypo

coic intestine,

which shows very little flow at color doppler with biop,

a mass within the abdomen and revealed tuberculosis.

The patient was treated

and it became better again, another patient

with a thickened intestinal wall due to tuberculosis

and biopsy also revealed tb.

Looking at this patient,

this is a markedly thickened small intestine.

You can see that white area is the lumen.

All this is the wall, 1.3 centimeters.

We know that the maximum is about three to four millimeters.

We did a biopsy of the wall.

This is color dola on the intestines.

This is the needle towards the intestinal wall

and this turned out to be lymphoma.

Fluid Collections

Acidic fluid collections are also common in these patients

and they are varied causes to this.

So it's important that you establish what is causing this

for this particular patient who has chronic inflammation,

from the aspirate,

that's the needle going towards the fluid

and we aspirated, we found chronic,

inflammation causing that.

This is one of the i patient we saw back

around 19 91, 19 90, in our series,

and you can see this is a sagittal section of the pelvis.

This is a ary bladder.

Adjacent to the urinary bladder is a, an abscess

with a fluid fluid level.

We aspirated this and stained it.

It showed acid first base slide.

The patient was treated and he, well another patient here,

who came with this echo complex mass in the abdomen,

still will put there a needle.

Those are my hands you can see.

And we aspirated this past like, substance,

which we stained and it showed tuberculosis.

So TB is a common comorbidity in HIV.

This is a sagittal section in another patient showing this

abscess anterior to the spine.

This is the scro spine in a longitudinal section.

This patient had a diagnosis of tb.

This abscess was repeatedly drained

and it kept on reac accumulating.

We eventually discovered it was tracking from a so abscess

and the patient was operated

and he's, well Again, another patient with a sos abscess.

You can see the kidney has been lifted up.

This is the SOS abscess.

Summary

So in summary, for tropical infections

and also for HIV,

the appearances in some tropical infections are

characteristic, but in others they are not.

The appearances in HIV are viable, are not pathognomonic

and often one has to use, invasive means,

aspiration or biopsy to confirm the cause,

Acknowledgements

I want to acknowledge,

these people

who have been instrumental,

in, in,

in our work professor Ted Dub, Bosky,

professor Barry Goldberg

and the staff of Jre colleagues at HQA where I work.

And, Dr. Moama who does, histopathology

and also SRU members who invited me

to attend this SRU meeting.

Thank you. I.