대한흉부영상의학회 Weekly Chest Cases

Case No : 1051 Date 2017-12-18

Courtesy of Sang Min Lee, MD., Eun Jin Chae, MD. / Asan Medical Center, University of Ulsan College of Medicine
Age/Sex 41 / M
Chief Complaintincidental finding, end stage renal disease on hemodialysis

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Figure 5

Diagnosis With Brief Discussion

Diagnosis: Metastatic Calcification
Radiologic Findings: Figs 1-4. Multifocal ill-defined nodular ground glass opacity lesions are shown in both lungs on axial images of chest CT.
Fig 5. Multifocal ill-defined nodular ground glass opacity lesions show slight upper lung predominancy on coronal image of chest CT.
Figure 6. On Tc-99m MDP bone scan images, diffuse uptake is seen in both lungs.

Patient had a history of glomerulonephritis when he was 12 years-old. He has been undergoing hemodialysis since 16 years ago. Patient showed hypercalcemia and was diagnosed as secondary hyperparathyroidism due to end stage renal disease. He underwent surgery for calcinosis cutis on the scrotum, may be also related to secondary hyperparathyroidism.
Brief Review: Metastatic calcification refers to the deposition of calcium in soft tissue due to abnormal calcium and phosphate metabolism. It is associated with hypercalcemia and is most common in patients with chronic renal failure and secondary hyperparathyroidism. 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.
Plain radiographs are relatively insensitive in detecting metastatic calcification. In some patients, ill-defined nodules, or patchy areas of increased opacity may be seen. CT can show areas of ground glass opacity, consolidation, or calcification. Numerous fluffy and poorly defined nodules, measuring 3 to 10 mm in diameter, are typical, but opacities can appear focal, lobular, patchy, or diffuse. Even with HRCT, these opacities may not appear calcified. An apical predominance is common, because the apices are more alkaline than the bases, increasing the likelihood of calcium salt precipitation in this region.
Tc-99m MDP bone scintigraphy shows increased uptake in both lungs. Tc-99m MDP bone scintigraphy or mediastinal images on HRCT scan may be diagnostic of metastatic calcification without need for further investigation.
References: 1. Marchiori E, Muller NL, Souza AS Jr, et al. Unusual manifestations of metastatic pulmonary calcification: high-resolution CT and pathological findings. J Thorac Imaging. 2005;20:66-70.
2. Chan ED, Morales DV, Welsh CH, et al. Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med. 2002;165:1654-1669.
3. Elem LC, Zanetti G, Souza AS Jr, et al. Metastatic pulmonary calcification: State-of-the-art review focused on imaging findings. Respir Med. 2014 May;108(5):668-76.
Please refer to: Case 716 Case 628 Case 450 Case 169
Keywords: Lung, Lung, Metabolic pulmonary disease,

No. of Applicants : 98

▶ Correct Answer : 68/98, 69.4%

- Toranomon Hospital , Japan SHOHEI FUJITA
- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- Hyogo Prefectural Amagasaki General Medical Center , Japan TOMOAKI OTANI
- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- Showa university Northern Yokohama Hospital , Japan KOTA WATANABE
- Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
- Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
- Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
- The University of Tokyo Hospital , Japan Akifumi Hagiwara
- King Abdulaziz University Hospital , Saudi Arabia Amr M. Ajlan
- CH de la Cote Basque , France PAUL ARDILOUZE
- McGill University Health Center , Canada Alexandre Semionov
- The University of Tokyo Hospital , Japan Yusuke Watanabe
- Apollo Hospitals , India SAMSON KADE
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- , Turkey ERSIN OZTURK
- Other , Korea (South) HAYEON LEE
- Scans world , India PHILSON JOSEPH MUKKADA
- Prince Sattam ibn Abdulaziz University hospital , Saudi Arabia ELBAGIR MOHAMED NASSIR
- Asan Medical Center , Korea (South) HYUN JUNG KOO
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Beaulieu clinic Geneva , Switzerland gilles GENIN
- Azienda Ospedaliera Universitaria Integrata di Verona , Italy GIAN ALBERTO SOARDI
- The Jikei university , Japan TAKU GOMI
- The first affiliated Hospital of Xiamen University , China Qing Qiang Guo
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Ajou University Hospital , Korea (South) Taeyang Ha
- Seoul National University Hospital , Korea (South) HYOUNG IN CHOI
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- HHS , Canada S LEE
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Gifu University Hospital , Japan Yo Kaneko
- Samsung Medical Center , Korea (South) MIN YEONG KIM
- Okayama Red Cross Hospital , Japan KAZUAKI MUNETOMO
- Dong-A University, College of Medicine , Korea (South) KI-NAM LEE
- Kurashiki Central Hospital , Japan TORU KONISHI
- National Taiwan University Hospital Hsin-Chu Branch , Taiwan LI-TA KENG
- 怨紐 , Korea (South) jin young kim
- University of Tsukuba Hospital , Japan HIROAKI TAKAHASHI
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
- Other , Korea (South) SEONGSU KANG
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Maimonides Medical Center , United States NAOMI TWERSKY
- Azienda Ospedaliera di Cremona , Italy Pietro Sergio
- Multimagem Diagn泥sticos , Brazil PEDRO PAULO TEIXEIRA E SILVA TORRES
- Myongji Hospital , Korea (South) DAE WOONG PARK
- SRMC , India PRABHU RADHAN RADHAKRISHNAN
- The University of Tokyo Hospital , Japan TAKU TAJIMA
- Yujin Yamazaki Hospital , Japan MASASHI TAKAHASHI
- , China MING LU
- MBAL BURGAS , Bulgaria VLADISLAV BOYANOV RUSINOV
- , Pakistan MUHAMMAD AHSAN ASGHAR
- Kizawa Memorial Hospital , Japan Shoji Okuda
- Ajou University Hospital , Korea (South) SUBIN HEO
- Teikyo University Hospital , Japan KAORU SUMIDA
- Kyoto Prefectural University of Medicine , Japan TADASHI TANAKA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
- The University of Tokyo Hospital , Japan TOMOKI WADA
- Private sector , Greece VASILIOS TZILAS
- , Japan YUKI HAYASHI
- Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- Kyemyung University Dongsan Hospital , Korea (South) DONG HYEON KIM
- Ajou University Hospital , Korea (South) YONG HO JANG
- Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
- Samsung Medical Center , Korea (South) HYUN JUNG YOON
- Ajou University Hospital , Korea (South) YOO YOUNGJIN

▶ Correct Answer as Differential Diagnosis : 2/98, 2.0%

- Yonsei University, Wonju Severance Christian Hospital , Korea (South) JUYEON LEE
- Chonbuk National University Hospital , Korea (South) KUM JU CHAE

▶ Semi-Correct Answer : 2/98, 2.0%

- Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
- Holy Family Hopsital , India RAJESH GOTHI

대한흉부영상의학회 Korean Society of Thoracic Radiology

Cases by Disease Category

Case No : 1051 Date 2017-12-18

Discussion

No. of Applicants : 98