HEADACHE OF A DIAGNOSIS: A CASE OF METASTATIC PULMONARY CALCIFICATION IN A YOUNG END-STAGE RENAL DISEASE PATIENT

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Inadequate renal replacement therapy may lead to metastatic pulmonary calcification (MPC) in end stage renal disease (ESRD) patients. MPC is seldom recognized as it is usually asymptomatic. Cough and shortness of breath are uncommon manifestations of MPC. We present a case of symptomatic MPC in a young female diagnosed on CT scan. CASE PRESENTATION: 32 year old non-alcoholic, non-smoker, past history of ESRD (secondary to hypertension) and no previous drug abuse on hemodialysis (HD) for 12 years was referred for a Chest X-ray suggestive of military tuberculosis. She was started on Cefepime before transfer. She reported non-productive cough and dyspnea for 2 months. No previous history of night sweats, fever, chills, weight loss, travel, hemoptysis, exposure to tuberculous contacts, chronic infections, cancer or intake of immunosuppressive medications. She was not compliant with HD. Vitals were within normal limits except for sinus tachycardia. A left upper extremity functional AV fistula was noted and there was a firm non-tender mass in the left infraclavicular region. Her lungs were clear to auscultation with symmetric expansion. Labs showed a white cell count of 12 k/cmm, hemoglobin of 8.5 g/dl, BUN of 65 mg/dl, Cr of 12 mg/dl, phosphorus of 8 mg/dl, Ca of 9.1 mg/dl, albumin of 2.4 g/dl and an elevated PTH of 1318 pg/ml. HRCT of the chest showed multiple bilateral pulmonary micro nodules with heavy and extensive calcifications throughout upper lobes and a big soft tissue calcification in the left infraclavicular region. A 2D ECHO revealed mitral valve calcification. Vancomycin was added to cefepime. Blood cultures and TB quantiferon test were negative. HD and phosphate binders were continued throughout the hospital stay. Bronchoalveolar lavage was negative for mycobacterial, bacterial and fungal infection. During her stay the patient remained afebrile. Considering her history of ESRD and an elevated calcium phosphorus product; diagnosis of MPC was made. Antibiotics were stopped and the patient was counselled on compliance with HD and medications. Pulmonary function tests (PFTs) revealed restrictive defect with decreased diffusion capacity. DISCUSSION: MPC is most likely to develop when calcium phosphorus product exceeds 70. Mean onset of MPC from diagnosis of ESRD is 22.6 +/- 3.1 years. Most patients are asymptomatic with normal PFTs. Rarely they may have restrictive defect on PFTs. HRCT is highly sensitive. The differential diagnosis includes granulomatous infections, viral infections, pneumocystis jiroveci, silicosis, metastatic malignancy and alveolar microlithiasis. No definitive treatment is available. CONCLUSIONS: MPC is relatively common at autopsy (60-70%) in patients with ESRD, but clinical manifestations are infrequent. ESRD patients on HD who are inadequately treated and present with cough, dyspnea and lung calcification, MPC should be considered in the differential diagnosis. Reference #1: Jost, R. Gilbert, and Stuart S. Sagel. "Metastatic calcification in the lung apex.” American Journal of Roentgenology 133.6 (1979): 1188-1190. Reference #2: Belém, Luciana Camara, et al. "Metastatic pulmonary calcification: state-of-the-art review focused on imaging findings.” Respiratory medicine 108.5 (2014): 668-676. DISCLOSURES: No relevant relationships by Ghulam Aftab, source=Web Response