india is home to approximately 2.5 million people living with human immunodeficiency virus ( hiv ) , the third largest number of cases of any country in the world , and is recognized as the source of increasing hiv prevalence among its south asian neighbors . recently released national hiv prevalence estimates for india indicate that 0.22% of women and 0.36% of men aged 1549 years are infected.[13 ] about 70% of the individuals affected with hiv usually have one or more respiratory illnesses during the course of their hiv disease . pulmonary complications of the hiv infection study demonstrated that respiratory symptoms are a common complaint among the hiv - infected individual and increasingly frequent as cd4 counts declined to less than 200 cells / mm . respiratory symptoms may result from a wide spectrum of pulmonary illness that includes hiv - related opportunistic infections and neoplasm . chest radiography is the corner stone of the diagnostic evaluation of respiratory symptoms in hiv infected patients , because each of the hiv - related opportunistic infections and neoplasm has a characteristic radiographic presentation , the radiograph ( combined with information delivered from history and physical examination and selected lab tests ) can narrow the diagnostic possibilities and suggest a diagnostic approach . tuberculosis can present with a variety of chest radiographic findings , including upper lung zone infiltrates often with cavitations , middle or lower zone consolidation mimicking bacterial pneumonia , miliary , nodule(s ) , pleural effusion , and intrathoracic adenopathy . in case of tuberculosis , noncavitory infiltrates and a wide clinicoradiological spectrum of tuberculosis was seen among hiv patients , in consonance with their varying immune status . with the conventional sputum positivity and tuberculin test not providing an adequate diagnostic help , familiarity with the clinicoradiological spectrum of tuberculosis and coexisting opportunistic infections is absolutely necessary . this study makes an attempt to correlate the chest x - ray and cd4 counts as it will help in better understanding this deadly duo of hiv and tuberculosis . the present study was done as a prospective cohort study in a tertiary care hospital of south india from august 2009 to july 2011 . 100 hiv - positive female patients and 100 hiv - positive males , who satisfy the inclusion criteria , were the subjects of the study . all patients above the age of 18 with confirmed hiv infection as per naco guidelines were the subjects of the study . all the hiv - positive patients satisfying the inclusion criteria were registered in the study group . this included detailed clinical history including presenting symptoms , past history , disease diagnosis , and complete physical examination followed by appropriate baseline and specific laboratory tests . the chest radiography was taken for all the patients and detailed evaluation of the radiograph was done . mean age among males was 37.4 years and among females was 35.3 years , respectively . maximum number of patients belonged to age group of 3140 years in both males and females , 55% in males and 63% in females , respectively . in the age group of 2630 , females were more compared to males ( 22% females and 13% males ) , whereas in the age group of 4150 males were more in number as compared to females  26% males and 11% females . 80% of males and 88% of females had education up to high school or less . maximum number of the study population had education up to high school ( 45% among males and 69% among females ) . in this study , maximum number of patients belonged to unskilled work group ( 49% among males and 54% among females ) , most of them were manual laborers . skilled workers included drivers , clerks , and others and males dominate over females in this group , 34% males and 18% females . cd4 at the time of diagnosis : 11% of females had cd4 count of less than 50 in comparison with 1% of males who had cd4 of less than 50 . among cd4 range of 100 - 150 , males ( 31% ) 71% of males had cd4 less than 200 , whereas 65% of females had cd4 less than 200 at the time of diagnosis [ figure 1 ] . cd4 count at the time of diagnosis pulmonary tuberculosis was diagnosed with sputum afb in 54 patients ( 29 males and 25 females ) . various patterns of chest x - ray presentations with respect to cd4 counts as follows . in patients with cd4 of less than 200 , infiltration [ figure 2 ] was seen among 18 ( 39% ) followed by consolidation in 14 ( 30% ) . lymphadenopathy [ figure 3 ] 4 ( 9% ) , pleural effusion 4 ( 9% ) , copd 4 ( 9% ) , and miliary 3 ( 7% ) also seen in lesser number . cd4 of above 200 had infiltration in 3 ( 37.5% ) , miliary in 2 ( 25% ) , and cavity in 2 ( 25% ) chest radiographs . generalized lymphadenopathy with tb lymphadenitis - cd4 count 110 diffuse nodular infiltration in hiv - tb coinfection females with sputum - positive pulmonary tb with hiv with cd4 of less than 200 had following findings . infiltration was seen in 11 ( 55% ) , cardiomegaly in 5 ( 25% ) , lymphadenopathy in 4 ( 20% ) . consolidation was observed in 3 ( 15% ) and 2 ( 10% ) had cavity . cd4 of above 200 had 2 ( 40% ) cavitatory and infiltration lesion each in chest x - ray . pleural effusion and miliary mottling was seen among 1 ( 20% ) each . in males with cd4 count of less than 200 with pulmonary tb showed consolidation in 11 ( 42% ) followed by infiltration in 5 ( 19% ) . cavity , miliary , and pleural effusion were 3 ( 12% ) each in number . cd4 of more than 200 had one ( 33% ) each of consolidation , miliary , infiltration , and pneumothorax each [ figure 4 ] . cd4 and chest x - ray correlation of hiv with tb on the right side , all - zone involvement was observed in 18 ( 42% ) of them , whereas middle and lower lobe involvements were observed in 15 ( 35% ) of the chest radiographs . on left side , all - zone involvement was seen among 22 ( 50% ) middle and lower were seen in 13 ( 29.5% ) of them . upper zone involvement was seen in 2 ( 0.05% ) . among patients with hiv and pulmonary tb coinfection , bilateral lung involvement was observed among 37 ( 68.5% ) of the chest radiographs . among patients with cd4 count less than 200 , oral candidiasis was observed among 55.9% patients , pulmonary tuberculosis in 33% , cmv retinitis in 8% , and tb lymphadenitis among 7% of them . pneumocystis carinii pneumonia was diagnosed among 16% of patients and all had cd4 count less than 200 . pulmonary tuberculosis was diagnosed with sputum afb in 54 patients ( 29 males and 25 females ) . various patterns of chest x - ray presentations with respect to cd4 counts as follows . in patients with cd4 of less than 200 , infiltration [ figure 2 ] was seen among 18 ( 39% ) followed by consolidation in 14 ( 30% ) . lymphadenopathy [ figure 3 ] 4 ( 9% ) , pleural effusion 4 ( 9% ) , copd 4 ( 9% ) , and miliary 3 ( 7% ) also seen in lesser number . cd4 of above 200 had infiltration in 3 ( 37.5% ) , miliary in 2 ( 25% ) , and cavity in 2 ( 25% ) chest radiographs . generalized lymphadenopathy with tb lymphadenitis - cd4 count 110 diffuse nodular infiltration in hiv - tb coinfection females with sputum - positive pulmonary tb with hiv with cd4 of less than 200 had following findings . infiltration was seen in 11 ( 55% ) , cardiomegaly in 5 ( 25% ) , lymphadenopathy in 4 ( 20% ) . consolidation was observed in 3 ( 15% ) and 2 ( 10% ) had cavity . cd4 of above 200 had 2 ( 40% ) cavitatory and infiltration lesion each in chest x - ray . pleural effusion and miliary mottling was seen among 1 ( 20% ) each . in males with cd4 count of less than 200 with pulmonary tb showed consolidation in 11 ( 42% ) followed by infiltration in 5 ( 19% ) . cavity , miliary , and pleural effusion were 3 ( 12% ) each in number . cd4 of more than 200 had one ( 33% ) each of consolidation , miliary , infiltration , and pneumothorax each [ figure 4 ] . on the right side , all - zone involvement was observed in 18 ( 42% ) of them , whereas middle and lower lobe involvements were observed in 15 ( 35% ) of the chest radiographs . on left side , all - zone involvement was seen among 22 ( 50% ) middle and lower were seen in 13 ( 29.5% ) of them . upper zone involvement was seen in 2 ( 0.05% ) . among patients with hiv and pulmonary tb coinfection , bilateral lung involvement was observed among 37 ( 68.5% ) of the chest radiographs . among patients with cd4 count less than 200 , oral candidiasis was observed among 55.9% patients , pulmonary tuberculosis in 33% , cmv retinitis in 8% , and tb lymphadenitis among 7% of them . pneumocystis carinii pneumonia was diagnosed among 16% of patients and all had cd4 count less than 200 . tuberculosis , unlike other hiv - associated opportunistic infections , may occur at relatively high levels of cd4 counts , although its frequency markedly increases in patients with more severe immunosuppression hiv - tb cases have been observed to have severe immunosuppression at presentation , with several studies reporting cd4 counts of less than 200 . in patients with mild immunosuppression , chest x - ray typically shows upper lobe and/or bilateral infiltrates , cavitation , pulmonary fibrosis , and shrinkage . the clinical picture often resembles postprimary pulmonary tuberculosis , and the sputum smear is usually positive . in severely immunosuppressed patients , . the sputum smear can often be negative and chest x - ray shows interstitial infiltrates , especially in the lower zones , with no features of cavitation and fibrosis . unilateral or bilateral infiltrates are seen more often in the lower lobes than in the upper lobes and typical cavities are seen in only 25% of patients.[68 ] in our study , pulmonary tuberculosis was diagnosed with sputum afb in 54 patients ( 29 males and 25 females ) . various patterns of chest x - ray presentations with respect to cd4 counts as follows . in patients with cd4 of less than 200 , infiltration was seen among 18 ( 39% ) , followed by consolidation in 14 ( 30% ) . lymphadenopathy 4 ( 9% ) , pleural effusion 4 ( 9% ) , copd 4 ( 9% ) , and miliary 3 ( 7% ) were also seen in lesser number . in a study by pearlman et al . infiltrates were seen among 52% , lymphadenopathy in 30% , interstitial disease in 27% , pulmonary nodule in 18% , cavity in 7% , and pleural effusion in 7% . cd4 of above 200 had infiltration in 3 ( 37.5% ) , miliary in 2 ( 25% ) , and cavity in 2 ( 25% ) chest radiographs . in a study by pearlman et al . , infiltrates were seen among 67% , lymphadenopathy in 7% , interstitial disease in 17% , pulmonary nodule in 20% , cavity in 20% , and pleural effusion in 10% . correlation analysis of chest x - ray findings with cd4 count in another study by maniar et al . , infiltration was seen among 62.5% , hilar lymphadenopathy in 17.5% , pleural effusion in 16.5% , and consolidation in 7.5% . chest x - ray abnormalities are even more non - specific in hiv - infected patients than in hiv - negative patients , which may result in under diagnosis . typical pulmonary lesions are seen only in about one third of the hiv - infected patients with clinical tuberculosis . among patients with hiv and pulmonary tb , we observed that tuberculosis involvement of lungs was atypical as there was all - zone involvement in most of them or middle and lower lobe involvement in the remaining majority . on the right side , all - zone involvement was observed in 18 ( 42% ) of them , whereas middle and lower lobe involvement in 15 ( 35% ) of the chest radiographs . on left side , all - zone involvement seen among 22 ( 50% ) , middle and lower lobe involvement in 13 ( 29.5% ) of them . tuberculosis classically involves the upper lobes usually unilaterally . among patients with hiv and pulmonary tuberculosis coinfection , bilateral lung involvement was observed among 37 ( 68.5% ) of the chest radiographs , suggesting that diffuse involvement is more common in patients with hiv and tb coinfection . in a study by maniar et al . , in patients with hiv and tb coinfection , upper zone involvement was seen among 3.7% , middle zone involvement among 62.5% , lower zone involvement in 33.8% . in our study , most common radiological presentation of tuberculosis was parenchymal infiltration followed by consolidation , cavity , cardiomegaly , lymphadenopathy , pleural effusion , copd , and miliary shadows . in males , involvement of lung field in tuberculosis was atypical as evidenced by bilateral lung involvement ; middle and lower zone or diffuse involvement . comparison of cd4 count with chest x - ray revealed miliary shadows and pericardial effusion significantly increased among cd4 less than 200 .
background : fight against human immunodeficiency virus ( hiv ) is incomplete without addressing problems associated with difficult diagnosis of tuberculosis in hiv - tuberculosis coinfected patients . chest x - ray is a primary tool to evaluate tuberculosis in hiv.aim:to assess and compare various radiological patterns of pulmonary tuberculosis in hiv patients and compare these patterns in relation to cd4 counts.materials and methods : prospective cohort study was conducted in a tertiary hospital in south india from september 2009 to july 2011 with 200 hiv positive patients . who guidelines were used for diagnosis of hiv and tuberculosis.results:27% of the patients had sputum positive pulmonary tuberculosis , with higher incidence ( 33% ) among cd4 less than 200 as compared to cd4 more than 200 ( 14% ) . infiltration ( 39% ) followed by consolidation ( 30% ) , cavity ( 11% ) , and lymphadenopathy ( 9% ) seen with cd4 less than 200 . 
 infiltration ( 37.5% ) followed by cavity ( 25% ) and miliary ( 25% ) with cd4 above 200 . 
 bilateral ( 68.5% ) and mid and lower zones or all zone involvement more commonly seen.conclusion:in patients with cd4 lower than 200 noncavitory infiltration and consolidation predominated . involvement of lungs was atypical ; diffuse or mid and lower zone involvement than classical upper lobe involvement . 
 a high index of suspicion is necessary for the accurate and timely diagnosis of tuberculosis in hiv positive patients .