Correlation between Abdominal Ultrasonographic Findings and CD4 Cell Count in Adult Patients with HIV/AIDS in Jos, Nigeria

Acquired Immunodeficiency Syndrome (AIDS) is caused by Human Immunodeficiency Viruses (HIV) resulting in progressive destruction of cell mediated immunity. The abdominal manifestations of AIDS are related to the level of CD⁺<sub style="margin-left:-6px;">4</sub> cells count as well as viral load. Abdominal ultrasound examination is easy to perform, non-invasive, inexpensive, readily available and reproducible investigation which provides valuable information about abdominal findings in AIDS. The objective of the study was to evaluate abdominal ultrasound findings in adult HIV/AIDS patients in Jos, Plateau State, Nigeria and correlate these findings with the patients’ CD⁺<sub style="margin-left:-6px;">4</sub> counts. A cross-sectional study of abdominal ultrasound findings of adult patients with HIV/AIDS was conducted over a period of six months. The abdominal ultrasound findings and CD⁺<sub style="margin-left:-6px;">4</sub> counts were studied. Two hundred (40%) of the patients had normal abdominal ultrasound, while 60% (300) had various abnormalities. The common abnormalities included increased liver parenchymal echogenicity in 25.0%, hepatomegaly in 23.4%, splenomegaly in 6.6%, increased splenic echogenicity in 6.2% and thickened gallbladder wall in 12.6%, elevated renal parenchymal echogenicity in 6.4%, enlarged kidneys in 2.6%, lymphadenopathy in 6.0%, and ascites in 2.4%. Pelvic abscess was the least pathology in 0.2%. Most of the findings did not correlate with the patients’ CD⁺<sub style="margin-left:-6px;">4</sub> count except for lymphadenopathy and ascites. Although abdominal ultrasound examination is invaluable in the management of these patients, however, it has not shown to be useful in predicting the patients’ immune status.

• Abdominal Ultrasonography
• Adult Patients
• CD4 Cell Count
• HIV/AIDS

1. Introduction

The Acquired Immunodeficiency Syndrome (AIDS) is caused by the Human Immunodeficiency Virus (HIV). The infection causes progressive destruction of the cell mediated immune (CMI) system, primarily by eliminating CD 4 + T-helper lymphocytes [1] . The degree of immunodeficiency is related to the level of the CD 4 + count and, as such, CD 4 + count is a good index for monitoring the disease’s progression. Though the major target of the virus is the immune system, the frequency of abdominal disorders in HIV/AIDS patients has been reported to be second only to pulmonary disease [2] . Radiological procedures are essential in both diagnostic and interventional roles. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) better characterize HIV-related abdominal diseases but are expensive and are scarce in the typically impoverished, HIV-infected sub-Saharan region [3] . Ultrasonography is easy to perform, non-invasive, inexpensive and safe imaging technique that is available in Africa where AIDS is most prevalent [2] . Abdominal Ultrasonography can be used to examine the abdominal organs including the liver, gallbladder, spleen, lymph nodes, pancreas and the kidneys which are commonly affected by opportunistic infections and malignancies [4] .

Liver disease is an increasingly important cause of morbidity and mortality in patients with HIV/AIDS. With the availability of Highly Active Anti-Retroviral Therapy (HAART), there has been an observable change in the pattern of liver disease in these patients [5] . Although opportunistic infections and neoplasms are still seen, co-infection with hepatitis viruses, especially Hepatitis C virus is now emerging as the most significant cause of liver disease in this group of patients [5] . In addition, drug-induced liver damage is becoming more prevalent due to the increased complexity and toxicity of the HAART regimens used [5] . Biliary disorders seen in AIDS patients can be classified into AIDS Cholangiopathy (AC), acalculus cholecystitis (ACC) and non-human immunodeficiency virus (HIV) associated disease such as gallstones. Gallstone disease is the most commonly observed cause of acute cholecystitis in this population [6] . While HIV related biliary disorders are not common, they are associated with significant morbidity when they occur. AC and ACC in HIV positive patients were first reported in 1983 by Guarda and colleagues and Pitlik et al., respectively [7] [8] . Since the advent of HAART, the incidence of AIDS associated biliary disorders have steeply declined [9] [10] . The two diseases can occur concurrently, with similar opportunistic infections causing each. Bile ducts in AIDS patients appear to be uniquely susceptible to opportunistic infections [11] . Ultrasonography, Endoscopic Retrograde Cholangio-Pancreatography (ERCP), Computed tomography (CT) scan and Magnetic Resonance Imaging (MRI) such as Magnetic Resonance Cholangio Pancreatography (MRCP) are useful in the investigation of diseases of the biliary tract [12] [13] [14] [15] .

Pancreatic involvement in AIDS is very frequent (90%) and is usually asymptomatic. Morphological changes showed three patterns of pancreatic alterations: “nutritional-like”, inflammatory and both of these together [16] . The “nutritional-like” pattern (atrophy and steatosis) may be due to many factors such as nutritional characteristics induced by the HIV infection or related to the HIV virus itself.

Renal disease is a relatively common complication in patients with Human Immunodeficiency Virus (HIV) disease [17] . An important entity HIV Associated Nephropathy (HIVAN) can result from direct kidney infection with HIV or from the adverse effects of antiretroviral drugs [18] [19] . Further, patients with HIV disease are at risk for developing prerenal azotemia due to volume depletion resulting from salt wasting or vomiting. The affected kidneys are usually normal or large in size and highly echogenic on ultrasonograms and dense on CT scans.

Lymphadenopathy is very common among HIV-infected individuals and may occur at any stage of HIV infection [20] . Enlarged deep abdominal lymph nodes are frequently detected by ultrasound in patients with HIV infection. Ultrasound guided biopsy can also be performed [21] .

Ultrasound can investigate most of the organs affected in AIDS and can guide biopsies, allowing the cyto-histological and microbiological investigations for a definitive diagnosis. Ultrasonography is a reproducible and safe imaging technique that can be used to examine the internal abdominal organs.

2. Materials and Methods

This was a hospital based cross-sectional study that spanned over the period of six months from September 2013 to March 2014. The study was carried out in the Department of Radiology, Jos University Teaching Hospital (JUTH), a tertiary health institution situated in the central part of Jos, Nigeria.

2.1. Inclusion and Exclusion Criteria

The study population comprised patients aged 18 years and above confirmed with HIV who were referred for abdominal ultrasound scan from Clinic II located within the Jos University Teaching Hospital complex. Clinic II is a specialized clinic exclusively for the management of HIV/AIDS patients. Pregnant HIV positive patients, HIV positive adults with confirmed co infection with Hepatitis A, B or C Viruses and HIV positive adults with co existing medical conditions such as Hypertension, Sickle cell disease and Diabetes Mellitus were excluded from the study. This is because these conditions could have similar ultrasonographic features with HIV/AIDS.

2.2. Ethical Consideration

Ethical clearance was obtained from the Research and Ethical Committee. Informed consent was obtained from the subjects before enrollment for the study. The subjects were informed of the safety of the procedure and could withdraw from the study at any stage without consequences. The data collected from the participants was recorded serially and kept with utmost confidentiality.

2.3. Data Collection

Patients were prepared by asking them to fast for 6 to 8 hours. This was to reduce bowel gas and make the gallbladder to be distended. Before the abdominal ultrasound scan, patients’ blood pressures were measured using a standard sphygmomanometer to exclude hypertensive patients from the study. Western Blot and CD 4 + results were obtained from patients’ case file. Abdominal ultrasound scan examinations were performed using ALOKA SSD-3500 (Aloka Co. Ltd., Tokyo, Japan, 2007) ultrasound machine. A 3.5 MHz curvilinear transducer was used in scanning the patients. The abdomen was sonographically examined for the various organs using standard ultrasound scanning procedures.

2.4. Statistical Analysis

The abdominal ultrasonographic findings and the data obtained from the structured questionnaire were entered into a computer and processed using SPSS for window version 20.0 (Microsoft^® Inc. Chicago, Illinois, USA, 2011). Mean ± standard deviation was used to summarize variables. The variables were tested for correlation via the Chi-square test and cross tabulations. P value of 0.05 or less was considered statistically significant.

3. Results

A total of 500 HIV positive patients, who met the inclusion criteria were studied. This comprised 20% males and 80% females with male to female ratio of 1:4. The ages of the patients ranged between 21 - 67 years with a mean and standard deviation of 40.30 ± 9.32 years. The age range for males and females were between 26 - 62 years and 21 - 67 years with a mean and standard deviation of 45.72 ± 8.89 years and 38.95 ± 8.93 years respectively. The predominant age group was 28 - 37 years (36.6%) and followed closely by 38 - 47 years (33.4%). (Table 1)

The mean CD 4 + count was 520.55 ± 282.67/µl. The mean CD 4 + count for males and females were 451.05/µl and 537.93/µl respectively. The minimum CD 4 + value for males and females were 27/µl and 38/µl respectively while the

Table 1

Age and sex distribution of HIV/AIDS patients in Jos

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