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Weekly Chest CasesArchive of Old Cases

Case No : 838 Date 2013-11-18

  • Courtesy of Hee Yeon An, Young Jin Kim / Yonsei University College of Medicine, Severance Hospital
  • Age/Sex 47 / M
  • Chief ComplaintAbnormal chest radiographic findings PHx: S/P kidney transplantation
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Metastatic pulmonary calcification
Radiologic Findings
On chest radiograph, multiple nodular opacities are noted, predominantly in both upper lung zones.
On CT scan, ill defined centrilobular ground glass attenuated nodules are observed predominantly in both upper lobes. Some nodules show calcifications.
Brief Review
Metastatic calcification is deposition of calcium salts in normal tissues. The most common cause of metastatic calcification is hypercalcemia, particulary those with hyperparathyroidism secondary to chronic renal failure. It is reported to be present in 60-80% of patient with chronic renal failure at autopsy. Pathologically, metastatic pulmonary calcification is an interstitial process and depositions are seen predominantly in the alveolar septa, pulmonary arterioles and bronchioles.
Most patients with metastatic pulmonary calcifications are asymptomatic, but rarely in severe cases calcium depositions can lead to interstitial fibrosis, restrictive lung function and result in respiratory insufficiency.
Calcium salts precipitate in alkaline environment. Due to increased ventilation-perfusion ratio in lung apex compared to base, lung apex demonstrate lower PaCO2 and higher blood pH. It is hypothesized that because of this difference of pH between apex and base, metastatic calcification has a greated propensity to occur in upper lobes.
On chest radiographs, bilateral ill defined multiple nodular opacities, patchy parenchymal opacifications, calcified nodules, mediastinal lymph node calcifications may be seen. Usually chest radiographic findings are non-specific and further evaluation is needed.
On CT, metastatic pulmonary calcifications is characterized by centrilobular ground-glass nodular opacities, with numerous poorly defined nodules measuring 3-10 mm. Airspace consolidation is rarely seen. Distribution of calcification may be punctate, ring-like or involve the entire nodule. Nodules are predominant in both upper lobes. In addition to pulmonary nodules, calcifications in chest wall vessels, tracheobronchial wall can be observed.
References
1. Marchiori E, Souza AS Jr, Franquet T, Muller NL. Diffuse high attenuation pulmonary abnormalities: a pattern oriented diagnostic approach on high resolution CT. AJR Am J Roentgenol 2005;184:273
2.Chan ED, Morales DV, Welsh CH, McDermott MT, Schwarz MI. Calciumdeposition with or without bone formation in the lung. Am J Respir Crit Care Med 2002;165:1654
Keywords
Lung, Metabolic and storage lung disesae,

No. of Applicants : 0

▶ Correct Answer : 41/0,  0.0%
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Kyoto University , Japan Akihiko Sakata
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - kanto Rosai Hp , Japan Takana Yamakawa
  • - Radiology Department, the First Affliated Hospital of Nanjing Medical University (Jiangsu province Hospital) , China Qiguang Cheng
  • - University of British Columbia , Canada Amr Ajlan
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - SNUH , Korea (South) Eui Jin Hwang
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Tong young Red cross hospital , Korea (South) Lee Kwang Jin (
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - CH de la C�te Basque , France Paul ARDILOUZE
  • - 媛• , Korea (South) Hyun suk Cho
  • - GHICL , France manuel toledano
  • - SKG radiology , Australia Yuranga Weerakkody
  • - Scans world , India Philson Mukkada
  • - Saint Malo , France jean-baptiste Noel
  • - , Korea (South) Kim sungmo
  • - HUEC , Brazil Diogo Pinheiro
  • - Asan medical center , Korea (South) Hyun Joo Lee
  • - Myongji hospital , Korea (South) Ji Ye Lee
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Asan Medical Center, Department of Radiology , Korea (South) Hongseok Ko
  • - Northern Yokohama Showa university , Japan Kota Watanabe
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Hopital Avignon , France Florin Muste
  • - universidad de chile , Chile aguilera enrique
  • - Chungbuk University Hospital , Korea (South) Yunhee Jang
  • - 異⑸ , China ZHANG YING
  • - chungbuk national university hospital , Korea (South) soojung lee
  • - CHU Grenoble , France Adrien Jankowski
  • - IRSA La Rochelle , France Denis Chabassiere
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - Pneumology GHSR , Reunion fabrice paganin
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - 異⑸ , Korea (South) sooncheul baek
  • - Medicheck health care , Korea (South) Chae Lim
  • - Fukuyama City Hospital , Japan Mayu Uka
▶ Correct Answer as Differential Diagnosis : 3/0,  0.0%
  • - McGill university , Canada Badriya Al-Qassabi
  • - Niigata University , Japan Atsushi Uehara
  • - Tokyo Metropolitan Police Hospital , Japan Akifumi Hagiwara
▶ Semi-Correct Answer : 1/0,  0.0%
  • - NASA SCANS , India RAKESH BHATIA
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