Metastatic Pulmonary Calcification Research Articles

December 2023 Medical Image of the Month: Metastatic Pulmonary Calcifications in End-Stage Renal Disease

No abstract available. Manuscript truncated after 150 words. A 51-year-old African-American man with medical history of obesity (BMI 36) and hypertension was seen in pulmonary consultation for preoperative evaluation of kidney transplantation. End-Stage renal disease (ESRD) was diagnosed 7 years before evaluation secondary to resistant hypertension. The patient has been on hemodialysis since then. The patient was on carvedilol, hydralazine, losartan, and calcitriol. He had prescribed sevelamer and prednisone, but he was not taking them. His main symptoms were 3-year chronic dyspnea on exertion and mild morning cough productive of small amounts of clear sputum. He has had no chest pain, wheezes, hemoptysis, fevers, or dizziness. He had trace lower extremity edema. He worked as a forklift operator. He has had no relevant exposures and was a lifetime nonsmoker. The patient was diagnosed with cryptogenic organizing pneumonia 5 years ago and was on prednisone taper with subjective improvement of symptoms. He has not had lung function testing or …

Removal of calciprotein particles from the blood using an adsorption column improves prognosis of hemodialysis miniature pigs

Hyperphosphatemia is a major risk for poor prognosis in patients with end-stage renal disease. However, the molecular mechanism behind this link remains elusive. We and others have demonstrated that serum phosphorus levels correlate positively with circulating levels of calciprotein particles (CPPs). CPPs are colloidal mineral-protein complexes containing insoluble calcium-phosphate precipitates and have been reported to induce calcification in cultured vascular smooth muscle cells and inflammatory responses in cultured macrophages. Hence, we hypothesize that CPPs may be responsible for disorders associated with hyperphosphatemia. Using hyperphosphatemic miniature pigs receiving hemodialysis, here we show that removal of CPPs from the blood with a newly developed CPP adsorption column improves survival and alleviates complications including coronary artery calcification, vascular endothelial dysfunction, metastatic pulmonary calcification, left ventricular hypertrophy, and chronic inflammation. The present study identifies CPPs as an effective therapeutic target and justifies clinical trials to determine whether the CPP adsorption column may be useful as a medical device for improving clinical outcomes of hemodialysis patients.

Metastatic Pulmonary Calcification: Single-Center Review of Typical and Atypical Imaging Features.

The purpose of this study is to bring attention to an atypical form of metastatic pulmonary calcification, which is conventionally described as a metabolic process with upper lobe predominance in patients with a specific clinical history, which has not been reported as a distinct entity. Patients with metastatic pulmonary calcification (MPC) were first identified with mPower keyword search, including MPC or metastatic calcifications on computed tomography chest radiological reports. Patients were then filtered on likelihood of MPC based off imaging reports. Images were then reviewed by three senior radiologists for pertinent characteristics such as location of MPC, degree of calcifications and pleural effusions. Based on the predominant location of MPC, cases were labeled as either typical or atypical. Clinical and imaging characteristics relevant to MPC were noted and compared across typical and atypical cases. In our study, we describe 25 patients with MPC, 13 defined as typical MPC and 12 with atypical MPC. Through consensus of senior radiologists, MPC was deemed to be mild (52%), moderate (44%), or severe (4%). Twenty-three patients (92%) had underlying renal disease including 21 requiring dialysis at the time of diagnosis. Outside of age at diagnosis, there was no significant clinical difference between the two groups. Evaluation of imaging characteristics (average HU attenuation, 267; range, 186-295), pattern and distribution of calcification, and clinical history strongly supported a diagnosis of atypical MPC. This study presents several cases of lower lobe subpleural MPC associated with pleural effusions, which has not been reported as a distinct entity, despite comprising a significant portion of MPC cases at our institution.

A Fatal Case of Metastatic Pulmonary Calcification during the Puerperium

We present an unusual case of a fatal respiratory failure in a young woman developed two weeks after she gave birth at home. Circumstantial and clinical features of the case were strongly suggestive for a 'classical' septic origin of the respiratory symptoms. Autopsy, together with histopathological and immunohistochemical analyses allowed demonstrating a massive calcium redistribution consisting of an important osteolysis, especially from cranial bones and abnormal accumulation in lungs and other organs. Such physiopathology was driven by a primary hyperparathyroidism secondary to a parathyroid carcinoma as demonstrated by immunohistochemistry. This very rare case is furthermore characterised by a regular pregnancy course, ended with the birth of a healthy new-born. A complex interaction between pregnancy physiology and hyperparathyroidism might be hypothesised, determining the discrepancy between the relative long period of wellness and the tumultuous cascade occurred in the puerperium.

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.

Metastatic pulmonary calcification in patients on long-term dialysis

A 72-year-old woman was on dialysis for 44 years. Chest radiography revealed hazy opacity in the upper lung field (Figure 1A). Chest computed tomography (CT) showed patchy ground-glass opacities and fusion with overt calcification (Figure 1B). She had mild hypoxemia and impaired diffusing capacity. 99mTc-HMDP scintigraphy showed a prominent uptake in the lung fields corresponding to the patchy opacities (Figure 1C), indicating the accumulation of calcium in the lung parenchyma.

A Case Report of Autopsy: Large Mass of Pulmonary Metastatic Calcification in a Patient with End-Stage Renal Disease

Abstract Introduction/Objective Metastatic calcifications are reported in patients with end-stage renal disease (ESRD) in radiology literature but there are no pathologic reports regarding this clinical scenario in autopsy. Methods/Case Report We report the case of a 27-year-old African American man with nephrotoxic injury secondary to gentamicin treatment at a young age leading to ESRD requiring dialysis who then later developed congestive heart disease and arrhythmia. Prior to the patient’s last hospitalization, he had normal breath sounds with no signs of respiratory distress, rales, or wheezing. Imaging of the chest showed a patchy density in the right lung and a large parenchymal calcification. During autopsy, the patient was found to have bilateral markedly small and atrophic kidneys (left kidney weight: 27.5 g, size: 5.7 x 4.4 x 3.0 cm and right kidney weight: 30.6 g, size: 5.9 x 4.4 x 3.1 cm). Microscopically, the kidneys showed diffuse global glomerulosclerosis, atrophy of cortex, severe interstitial fibrosis, and tubular atrophy with thickened arteries as well as many foci of calcifications. A large mass measuring 3.5 x 2.4 x 1.9 cm was identified in the right middle lobe of the lung. Sections of the mass revealed large calcifications which were confirmed microscopically. In addition, concentric heart hypertrophy was identified with heart weight of 925 g and left ventricle measuring up to 2.2 cm. Calcifications (ranging from 0.2 – 0.5 mm) were also identified on the left atrial wall as well as a 1.2 x 0.8 x 0.6 cm mitral valve nodule along with additional microcalcifications within the myocardium. Results (if a Case Study enter NA) NA Conclusion In conclusion, our autopsy case supports previous radiologic reports that metastatic calcification can be dramatically present in the lung in patients with ESRD.

Metastatic Pulmonary Calcification Detected on 18F-FDG PET/CT and 99mTc-MDP Bone Scan.

Metastatic calcification relates to abnormal calcification resulting from hypercalcemia and can affect soft tissues, skeletal muscle, myocardium, lungs, stomach, kidneys, and blood vessels. We describe a case of metastatic pulmonary calcification in a 71-year-old male, images with 18F-fluorodeoxyglucose (FDG) PET/CT and 99mTc- methylene diphosphonate (MDP) bone scan.

Metastatic Pulmonary Calcification in a Hemodialysis Patient after Renal Transplantation

This is the case of a 64-year-old man, on renal replacement therapy since 2008, due to autosomal dominant polycystic kidney disease. The patient was on peritoneal dialysis from 2008 to 2016, when he underwent renal transplantation. Transplant duration was less than a month due to acute vascular rejection. Since then, he is on hemodialysis. A few months after transplantation, it was incidentally identified confluent bilateral opacities, more prominent on the left lung in a routine X-ray (Figure 1). The patient had made a chest radiography in 2015 without any changes at that time. The CT scan showed parenchymatous densification areas, partially calcified, in both lungs (Figure 2). The patient also developed secondary hyperparathyroidism refractory to medical therapy but refused surgery. Nevertheless, the lesions had a slow progression until the present time.

Metastatic Pulmonary Calcification in a hemodialysis patient after renal transplantation

Metastatic Pulmonary Calcification in a hemodialysis patient after renal transplantation

Metastatische pulmonale calcificaties als zeldzame oorzaak van matglasopaciteiten op een CT-scan

Metastatic pulmonary calcification: a case report and literature overview Ground-glass opacities have a broad differential diagnosis, including infectious, metabolic, inflammatory and malignant causes. This case presents an underdiagnosed entity of dense ground-glass opacities, namely metastatic pulmonary calcifications (MPC). This is a benign metabolic disease characterised by the deposition of calcium in the lungs, mostly described in patients with chronic kidney injury and secondary hyperparathyroidism. The majority of the patients require no treatment, but in some cases it may lead to irreversible lung damage. Clinical and radiological features, as well as the patient’s history, are crucial to make a correct diagnosis since MPC has a relatively specific appearance on imaging. This case study discusses the medical history and imaging appearance of a 44-year-old woman with MPC, followed by a literature overview.

Rare Surgical Lung Biopsy Findings of Metastatic Pulmonary Calcification Associated with Chronic Renal Failure

Abstract Introduction/Objective Metastatic pulmonary calcification is a metabolic lung disease characterized by depositions of calcium in lung parenchyma. Depositions of calcium salts are usually caused by hypercalcemia and are associated with end-stage renal disease, primary and secondary hyperparathyroidism, and hemodialysis. It is mostly asymptomatic and clinically silent but can lead to life-threatening respiratory failure. Methods We present a case of a 53-year-old woman, with a failed renal transplant and on hemodialysis, admitted with cough and shortness of breath. Computed tomography showed extensive diffuse bilateral groundglass and nodular opacities. Bronchoscopy was unremarkable. BAL results were negative for infection. The initial differential diagnosis included pneumonitis, interstitial lung disease, and chronic obstructive pulmonary disease. VATS lung wedge resection was performed. Results Microscopically there were numerous interstitial, peribronchial and perivascular calcifications highlighted by Van Kossa stain. Calcifications were associated with a marked interstitial fibrosis confirmed by trichrome stain. There was no evidence of significant acute and chronic inflammation, granulomas, fibroblastic foci and vasculitis. Conclusion Metastatic pulmonary calcification is found in 60–80% of autopsies of patients undergoing dialysis treatment. It is rarely diagnosed during their lifetime, because patients are usually asymptomatic, or the imaging findings are negative. The diagnosis of metastatic pulmonary calcification in our patient prompt further evaluation for repeat kidney transplant and the patient is being considered for parathyroidectomy for her tertiary hyperparathyroidism.

METASTATIC PULMONARY CALCIFICATION: A RARE CAUSE OF PULMONARY HYPERTENSION

SESSION TITLE: Fellows Pulmonary Vascular Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Metastatic calcification is seen at autopsy in 60-75% of CKD patients on hemodialysis (HD) due to increased calcium phosphate product (normal 40 mg2/dl2; MPC >70 mg2/dl2) (1,2). Metastatic pulmonary calcification associated with pulmonary hypertension (PH) is rare. We present a case of MPC associated combined postcapillary and precapillary PH (CpcPH). CASE PRESENTATION: A 58-year-old woman with SLE, CTD-ILD (FVC 64%, TLC 56 %), ESRD on HD since 2008 and diastolic heart failure was admitted to the hospital with worsening dyspnea, leg edema and orthopnea. Her calcium phosphate product was 61. CT chest showed diffuse ground glass opacity with mosaic perfusion, enlarged pulmonary artery (PA 4.3 cm) and chest wall calcifications. Echocardiogram showed grade 3 diastolic dysfunction, severely dilated left atrium and elevated right ventricular systolic pressure. Heart catheterization showed mean PA pressure 62 mm Hg, PA wedge pressure 29 mm Hg, transpulmonary gradient (TPG) 33, diastolic pulmonary gradient (DPG) 11, pulmonary vascular resistance 9 WU, LV end diastolic pressure 27 mm Hg, cardiac output 3.6, cardiac index 2.1. Given her severe PH, low CI and NYHA functional class IV, she was started on inhaled treprostinil with improvement in leg edema and orthopnea at 6-month follow up. DISCUSSION: Hyperphosphatemia in ESRD causes increased calcium phosphate product leading to calcium crystallization. Metastatic calcifications are usually seen in lamina propria of stomach, lung alveoli, renal tubules and interstitium(2). Acidosis between HD sessions causes leaching of calcium from bone, leading to deposition during post dialysis alkalosis. Uremia alters the configuration of tissue protein, rendering them more calcifiable. Three main CT patterns of MPC include centrilobular ground glass nodules, dense consolidation and small dense nodules(1). It is usually peripheral in distribution with upper lung zone dominance due to increased alkalinity (higher V/Q ratio causing low PaCO2) causing calcium salt deposition. Vascular calcification in chest and abdominal wall is a common finding as noted in our case. 30-50% of CKD and ESRD patients have PH. Vascular calcification can affect pulmonary arterial capacitance (low PAC in our case 0.81) and increase RV afterload. In this case, contributing factors to her PH are elevated LVEDP, ILD and ESRD (WHO group II, III and V). TPG >12 and DPG >7 suggested pulmonary vascular remodeling from shear stress and downstream pressure. This is an interesting case of MPC with associated PH. Initiation of the pulmonary vasodilator treprostinil reduced her PVR allowing for a better coupling of the RV-PA system. CONCLUSIONS: Treatment of MPC includes intensification of HD sessions and use of calcium and phosphate binders. In this case, inhaled pulmonary vasodilators for treatment of CpcPH after medical treatment optimization of other co-morbidities led to symptomatic improvement. Reference #1: Metastatic pulmonary calcification: HRCT findings in 23 cases, Radiol Bras.2017 Jul-Aug; 50(4): 231–236 Reference #2: Metastatic pulmonary calcification: State-of-the-art review focused on imaging findings, Respiratory Medicine Feb 2014 (108): 668-676 Reference #3: Pulmonary hypertension with extensive calcification in small pulmonary vessels and alveolar capillary wall in a chronic hemodialysis patient, Journal of Cardiology Cases 8 (Feb 2013) e13–e16 DISCLOSURES: No relevant relationships by Moises Cossio, source=Web Response No relevant relationships by Domingo Franco-Palacios, source=Web Response No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Shahzad Hussain, source=Web Response No relevant relationships by Venkateswara Kollipara, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response

Tracheobronchial calcification in a dialysis patient with metastatic pulmonary calcification.

Tracheobronchial calcification in a dialysis patient with metastatic pulmonary calcification.

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

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

Metastatic Pulmonary Calcification With Coexisting Nonspecific Interstitial Pneumonia: A Case Report

Abstract Patients with underlying chronic kidney disease (CKD) often have elevated serum calcium and parathyroid hormones due to compromised kidney function. We present a case of a 63-year-old female nonsmoker with surgical history of three renal transplants (at age 47, 51, and 58) along with thyroidectomy and parathyroidectomy who came to the emergency department with complaint of persistent dry cough and shortness of breath for the last 2 months. The patient had been on immunosuppressive drugs, tacrolimus, prednisolone, and mycophenolic acid since her first renal transplant as well as on cinacalcet after parathyroidectomy (at age 54). Initial computed tomography (CT) scan demonstrated ground-glass opacities in bilateral upper lobes while bronchoscopy revealed few inflammatory cells without any fungi or bacteria. Repeat CT scan performed 5 days later due to rapid progression of her clinical symptoms showed worsening of ground-glass opacities in bilateral upper lobes and new nodules in right middle and lower lung lobes. The wedge lung biopsy revealed metastatic pulmonary calcification (MPC) in the right upper lobe while nonspecific interstitial pneumonia (NISP) in the right lower lobe confirmed the coexistence of two different pathological processes most likely complicating the patient’s clinical symptoms. Despite comprehensive medical therapy, patient’s symptoms have been progressively worsening and she is currently undergoing evaluation for both renal and lung transplants. Our case report not only presents a rare case of MPC coexisting with NSIP but also sheds light on the associated morbidity due to pulmonary diseases in CKD patients.

Rapid Progression of Metastatic Pulmonary Calcification Diagnosed by 99mTc-MDP Scintigraphy JLD

Rapid Progression of Metastatic Pulmonary Calcification Diagnosed by 99mTc-MDP Scintigraphy JLD

Metastatic pulmonary calcification mimicking pulmonary edema with bilateral ground glass opacity

Metastatic pulmonary calcification mimicking pulmonary edema with bilateral ground glass opacity

Radiological and Clinical Manifestations of Metastatic Pulmonary Calcification in a Patient with Parathyroid Hyperplasia

Radiological and Clinical Manifestations of Metastatic Pulmonary Calcification in a Patient with Parathyroid Hyperplasia

Primary hyperparathyroidism characterized by diffuse homogeneous metastatic pulmonary calcification: A case report: Erratum.

Primary hyperparathyroidism characterized by diffuse homogeneous metastatic pulmonary calcification: A case report: Erratum.