Rapidly progressive metastatic pulmonary calcification: evolution of changes on CT

Newly diagnosed metastatic pulmonary calcification in a kidney transplantation recipient: a case report

Metastatic pulmonary calcification (MPC) is defined as calcium deposition in lung tissues. It is commonly seen in end-stage renal disease patients. However, MPC occurring in kidney transplant recipients (KTRs) is rare. We report a case of MPC in a 55-year-old female patient after successful kidney transplantation (KT). One year after KT, bisphosphonate and vitamin D were prescribed for osteoporosis. Then, 4.5 years after KT, we incidentally found multiple nodular lesions on chest X-ray (CXR) without any symptoms. Chest computed tomography showed multiple high-density nodules. A bone scan confirmed MPC in the right middle lobe and right lower lobe. A retrospective review of pretransplant blood chemistry revealed the following: serum calcium level, 11.2 mg/dL; phosphorus level, 3.2 mg/dL; intact parathyroid hormone level, lower than 2.5 pg/mL; and 24-hour urine calcium level, within normal limits (WNL). After KT, all of these parameters remained WNL. Therefore, hidden adynamic bone disease might have been aggravated by bisphosphonate and vitamin D supplementation, causing MPC. Both were discontinued. She was monitored by routine CXR, and MPC did not progress. Since MPC is commonly asymptomatic and difficult to diagnose in KTRs, caution is required when administering such medications. Patient should be followed up with routine CXR.

Metastatic pulmonary calcification mimicking pulmonary tuberculosis: A case report

Metastatic pulmonary calcification (MPC) is characterized by deposition of calcium in the normal lung parenchyma secondary to elevation of serum calcium. Most patients are asymptomatic and routine chest radiograph is not sensitive to make the diagnosis. Further imaging is needed such as computed tomography (CT) which typically shows small centrilobular nodules in the upper lobes. We report a case of a 30-year-old woman with end stage kidney disease who was diagnosed with pulmonary tuberculosis which was then revised to metastatic pulmonary calcification. The CT thorax feature for this patient was atypical for metastatic pulmonary calcification where it demonstrated tree-in-bud nodules suggestive of infection. The final diagnosis was made based on bronchoalveolar lavage which was culture-negative for Mycobacterium and transbronchial lung biopsy demonstrating calcium deposition in the interstitium.

Probe-based Confocal Laser Endomicroscopy in Metastatic Pulmonary Calcification

We report a case of metastatic pulmonary calcification in a patient with chronic renal failure on hemodialysis and secondary hyperparathyroidism. The diagnosis was made by using a probe-based confocal endomicroscopy which showed specific structures in the lung tissue and was proven by a transbronchial lung biopsy. To the best of our knowledge, this is the first reported case of the confocal endomicroscopy findings in a patient with metastatic pulmonary calcification.

Metastatic pulmonary calcification: high-resolution computed tomography findings in 23 cases

Objective

The aim of this study was to evaluate the high-resolution computed tomography (HRCT) findings in patients diagnosed with metastatic pulmonary calcification (MPC).

Materials and Methods

We retrospectively reviewed the HRCT findings from 23 cases of MPC [14 men, 9 women; mean age, 54.3 (range, 26-89) years]. The patients were examined between 2000 and 2014 in nine tertiary hospitals in Brazil, Chile, and Canada. Diagnoses were established by histopathologic study in 18 patients and clinical-radiological correlation in 5 patients. Two chest radiologists analyzed the images and reached decisions by consensus.

Results

The predominant HRCT findings were centrilobular ground-glass nodules (n = 14; 60.9%), consolidation with high attenuation (n = 10; 43.5%), small dense nodules (n = 9; 39.1%), peripheral reticular opacities associated with small calcified nodules (n = 5; 21.7%), and ground-glass opacities without centrilobular ground-glass nodular opacity (n = 5; 21.7%). Vascular calcification within the chest wall was found in four cases and pleural effusion was observed in five cases. The abnormalities were bilateral in 21 cases.

Conclusion

MPC manifested with three main patterns on HRCT, most commonly centrilobular ground-glass nodules, often containing calcifications, followed by dense consolidation and small solid nodules, most of which were calcified. We also described another pattern of peripheral reticular opacities associated with small calcified nodules. These findings should suggest the diagnosis of MPC in the setting of hypercalcemia.

Rapid development of metastatic pulmonary calcifications in primary hyperparathyroidism: a case report and literature review

Background

Metastatic pulmonary calcification (MPC) is rarely reported in primary hyperparathyroidism, especially MPC develops quickly. We report such a case here with a literature review.

Case presentation

A 41-year-old woman presented with cough and dyspnea. Data from clinical, radiological, pathological, technetium (^99mTc)-methylene diphosphonate (MDP) bone scintillation imaging, and ^99mTc-methoxy isobutyl isonitrile (MIBI) thyroid imaging were studied. ^99mTc-MIBI thyroid imaging indicated hyperparathyroidism. Chest computed tomography (CT) scans showed rapidly progressive bilateral pulmonary multiple high-density shadows with mass consolidation and exudation in only five days. ^99mTc-MDP bone scintillation imaging indicated bilateral pulmonary calcifications. CT-guided lung biopsy showed multifocal irregularities of calcium deposition and calcified bodies in the pulmonary interstitium. The patient showed gradually clinical and radiological improvement after surgical removal of the parathyroid adenoma.

Conclusion

Rapidly progressive MPC tends to be misdiagnosed as many primary pulmonary diseases. ^99mTc-MDP bone scintillation imaging and pulmonary biopsy could be performed to differentiate metastatic pulmonary calcification from other diseases. Surgical resection of the parathyroid gland is helpful for treatment of MPC in patients with primary hyperparathyroidism and is regularly recommended.

Fulminant respiratory failure due to progressive metastatic pulmonary calcification with no predisposing factors after successful renal transplantation: A case report

We report the patient with MPC who developed fulminant respiratory failure that leads to death with no predisposing factors after successful renal transplantation. In addition to infectious diseases, MPC should be kept in mind when post-transplantation patients develop pulmonary symptoms. The majority of the patients with MPC are asymptomatic; however, some patients develop fulminant respiratory failure and may progress to death. MPC can develop or progress in patients with no predisposing factors after successful renal transplantation.

Uremic lung: The "calcified cauliflower" sign in the end stage renal disease

Metastatic pulmonary calcification (MPC) is a rare pathological condition consisting of lung calcium salt deposits which commonly occurs in patients affected by chronic kidney disease probably for some abnormalities in calcium and phosphate metabolism. CT represents the technique of choice for detecting MPC findings including ground glass opacities and partially calcified nodules or consolidations. We present a case of MCP in a patient affected by hepato-renal autosomic-dominant polycystic disease; chest CT revealed extensive lobar-segmental parenchymal calcification with a peculiar cauliflower shape which we called “calcified cauliflower” sign. The “calcified cauliflower” sign can be reported as a new CT pattern of uremic lung that needs to be identified for a correct diagnosis and patient management.

Why Is Your Patient Still Short of Breath? Understanding the Complex Pathophysiology of Dyspnea in Chronic Kidney Disease

Dyspnea is one of the most common symptoms associated with CKD. It has a profound influence on the quality of life of CKD patients, and its underlying causes are often associated with a negative prognosis. However, its pathophysiology is poorly understood. While hemodialysis may address fluid overload, it often does not significantly improve breathlessness, suggesting multiple and co-existing alternative issues exist. The aim of this article is to discuss the main pathophysiologic mechanisms and the most important putative etiologies underlying dyspnea in CKD patients. Congestive heart failure, unrecognized chronic lung disease, pulmonary hypertension, lung fibrosis, air microembolism, dialyzer bio-incompatibility, anemia, sodium, and fluid overload are potential frequent causes of breathing disorders in this population. However, the relative contributions in any one given patient are poorly understood. Systemic inflammation is a common theme and contributes to the development of endothelial dysfunction, lung fibrosis, anemia, malnutrition, and muscle wasting. The introduction of novel multimodal imaging techniques, including pulmonary functional magnetic resonance imaging with inhaled contrast agents, could provide new insights into the pathophysiology of dyspnea in CKD patients and ultimately contribute to improving our clinical management of this symptom.

Metastatic pulmonary calcification misdiagnosed as a fungal infection: A case report

Metastatic pulmonary calcification is a rare lesion, characterized by calcium salt depositing in normal lung tissue. The clinical profile of a case of metastatic pulmonary calcification following renal transplantation was described. A computed tomography scan of the chest revealed ground-glass opacities in bilateral lungs and a node exhibiting a halo in the right upper lobe, which were suspected aspergillus infection. Following examination and therapy, the results of lung biopsy revealed metastatic pulmonary calcification. Although metastatic pulmonary calcification was reported in renal failure patients previously, metastatic pulmonary calcification with cavity lesions has never, to the best of our knowledge, been previously reported. The aim of the present report was to improve the understanding of metastatic pulmonary calcification.

Pulmonary calcification in renal failure patient incidentally revealed by bone scintigraphy

Pulmonary calcification is a subdiagnosed metabolic lung disease that is commonly asymptomatic and frequently associated with end-stage renal disease. We report a case of a 21-year-old man with a 4-year history of end-stage renal disease without respiratory symptoms. We discover incidentally on a bone scan a pulmonary calcification. Parathyroidectomy was refused by the patient. After 3 months of medical treatment, a second bone scan was done, and we found a partial response.

Metastatic pulmonary calcification: state-of-the-art review focused on imaging findings

Metastatic pulmonary calcification (MPC) is a subdiagnosed metabolic lung disease that is commonly associated with end-stage renal disease. This interstitial process is characterized by the deposition of calcium salts predominantly in the alveolar epithelial basement membranes. MPC is seen at autopsy in 60-75% of patients with renal failure. It is often asymptomatic, but can potentially progress to respiratory failure. Chest radiographs are frequently normal or demonstrate confluent or patchy airspace opacities. Three patterns visible on high-resolution computed tomography have been described: multiple diffuse calcified nodules, diffuse or patchy areas of ground-glass opacity or consolidation, and confluent high-attenuation parenchymal consolidation. The relative stability of these pulmonary infiltrates, in contrast to infectious processes, and their resistance to treatment, in the clinical context of hypercalcemia, are of diagnostic value. Scintigraphy with bone-seeking radionuclides may demonstrate increased radioactive isotope uptake. The resolution of pulmonary calcification in chronic renal failure may occur after parathyroidectomy, renal transplantation, or dialysis. Thus, the early diagnosis of MPC is beneficial. The aim of this review is to describe the main clinical, pathological, and imaging aspects of MPC.

Aggressive pulmonary calcification developed after living donor kidney transplantation in a patient with primary hyperparathyroidism

Metastatic pulmonary calcification, defined as calcium deposition in the intact lung, is commonly seen in patients with chronic renal failure, and it is known to be a benign clinical condition when detected by chance in an asymptomatic patient. Here we report the case of a 33-year-old woman who developed rapid and aggressive metastatic pulmonary calcification shortly after a living donor kidney transplantation, which induced acute antibody-mediated rejection. The patient's metastatic pulmonary calcification was successfully improved by extensive treatment for graft rejection, the correction of her accompanying primary hyperparathyroidism, and medical treatment with a bisphosphonate and sodium thiosulfate. Aggressive pulmonary calcification is reported as a rare complication seen in patients who have undergone a failed renal transplantation. A failed renal graft and accompanying secondary hyperparathyroidism seem to accelerate metastatic calcification. Most of the patients who develop aggressive pulmonary calcification suffer from the rapid progression of dyspnea and occasionally fever, and they die of respiratory failure. Pulmonary calcification should be considered in a patient developing dyspnea and unexplained pulmonary infiltrate, especially in the context of renal graft rejection; otherwise the prognosis of the patient will be very poor.

Pulmonary calciphylaxis associated with acute respiratory and renal failure due to cryptogenic hypercalcemia: an autopsy case report

Metastatic calcification is rare; it is found during autopsy in patients who underwent hemodialysis. Diffuse calcium precipitation of small and medium-sized cutaneous vessels, known as calciphylaxis, can result in progressive tissue necrosis secondary to vascular calcification. This condition most commonly involves the skin; however, a rare occurrence of visceral calciphylaxis has been reported. Here we report on an autopsy case. Despite a thorough evaluation, and even performing an autopsy, the underlying cause of acute-onset hypercalcemia, resulting in the production of pulmonary calciphylaxis and metastatic renal calcification associated with acute respiratory and renal failure, could not be determined. Metastatic calcification often lacks specific symptoms, and the degree of calcification is a marker of the severity and chronicity of the disease. This unusual autopsy case emphasizes the importance of rapidly progressing visceral calciphylaxis, as well as its early detection.

MRI and CT findings of metastatic pulmonary calcification

Metastatic pulmonary calcification is a consequence of calcium deposition in the normal pulmonary parenchyma, secondary to abnormal calcium metabolism. The most characteristic radiological manifestation is poorly defined nodular opacities that are mainly seen in the upper lung zone. The aim of this report is to describe the CT and MRI findings observed in two patients with metastatic pulmonary calcification. The disease may present in CT as consolidations with calcification, and with a high lesion/muscle signal intensity ratio on T(1) weighted imaging without contrast in MRI. The high signal on T(1) weighted imaging probably occurs because the low calcium concentration of the lesion changes the surface effects of diamagnetic calcium particles, causing T(1) shortening of water protons. MRI is a good option for characterising calcium accumulation caused by a metabolic disorder.

Metastatic pulmonary calcification in chronic renal failure

Metastatic pulmonary calcification can be caused by a number of diseases, most common being end-stage renal disease. Most of the patients are asymptomatic, and imaging with computed tomography is useful in making a diagnosis. Demonstration of pulmonary and chest wall vessel calcification is characteristic. We report a case of a 60-year-old patient with chronic renal failure on dialysis, presenting with gradual onset dyspnea, who showed metastatic pulmonary calcification on chest imaging.