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Case Thirty Six - Lymphocytic Interstitial Pneumonitis

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Clinical History: Chronic cough and nail clubbing in a 2-year-old with HIV.

Findings: Chest radiograph shows a diffuse reticulonodular pattern.

Diagnosis:: Lymphocytic interstitial pneumonitis.

Discussion: The differential for such a reticulonodular pattern in the pediatric HIV patient includes the following:

1) Viral pneumonia with interstitial damage (e.g. HSV, CMV)
2) Pneumocystis carinii pneumonia (PCP)
3) Lymphocytic interstitial pneumonitis (LIP)
4) Miliary TB (rare)
5) Lymphatic metastases (rare)

Both PCP and LIP classically present with diffuse reticulonodular infiltrates which may progress to diffuse air-space consolidation. LIP also classically demonstrates lymphadenopathy which is unusual in PCP. Unfortunately the classic pattern of LIP is not very common. The mildest cases may only display prominent bronchovascular markings and hyperaeration. Bullae and cysts or pneumothorax are unusual complications.

LIP is an interstitial infiltration by mature lymphocytes which is frequently chronic and progressive. Clubbing, as seen in this case, is a common finding and implies chronicity.

Diagnosis of LIP cannot be made by bronchoalveolar lavage, and biopsy may be negative. Diagnosis is usually made by a combination of clinical and imaging findings.

References:
Ambrosino MM, Genieser NB, et al: Opportunistic Infection and Tumor
in Immunocompromised Children. Radiol Clin North Am 30:639-658, 1992.

Amorosa JK, Miller RW, et al: Bronchiectasis in Children with LIP and AIDS.
Pediatric Radiol 22:603-607, 1992.

Bradford BF, Abdenour GE Jr, et al: Usual and Unusual Radiologic Manifestations
of Acquired Immunologic Immunodeficiency Syndrome (AIDS) and Immunodeficiency
Virus (HIV) Infection in Children. Radiol Clin North Am 26:341-353, 1988

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Submitted by:
Sarah E. Reimer, M.D.
Sheila C. Berlin, M.D.
Rainbow Babies and Children's Hospital