Signs and Symptoms of Chest Diseases |

A Nonresolving Infiltrate in the Lung FREE TO VIEW

Pankaj Mehta*, MD; Robert Lenox, MD
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SUNY Upstate Medical University, Syracuse, NY

Chest. 2012;142(4_MeetingAbstracts):967A. doi:10.1378/chest.1377560
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SESSION TYPE: Miscellaneous Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 01:30 PM - 02:30 PM

INTRODUCTION: About 10% of diagnostic bronchoscopies and 15% of pulmonary consultations are performed to evaluate nonresolving infiltrates.

CASE PRESENTATION: A 47-year-old lady was admitted with a nonresolving infiltrate in the RLL. She had a history of DM, HTN, ESRD status post failed renal transplant back in March 2010 currently on peritoneal dialysis. During the postoperative course of her transplant, she had suffered vocal cord injury from a traumatic intubation. She had undergone surgery for this with a prosthetic vocal cord implant placement in September 2010. She was treated for RLL pneumonia in November. On follow up imaging there was a persistent infiltrate in the RLL. She had cough with minimal expectoration but denied any fevers. She received another course of antibiotics for her presumed aspiration. The infiltrate however persisted and the patient was referred to Upstate for possible bronchoscopy. CT thorax revealed a small right effusion and a RLL infiltrate. A careful review of the CT with our radiologist suggested scattered calcifications in the RLL. She also had multiple anterior rib fractures on the right side with callus formation. Was this dystrophic pulmonary calcification following pneumonia? Workup revealed a high PTH, low vitamin D with low calcium and high phosphorus levels. She was started on aggressive therapy to correct her secondary hyperparathyroidism. She then underwent a subtotal parathyroidectomy for persistent hyperparathyroidism. Her imaging over the next few months revealed improving infiltrate in the RLL.

DISCUSSION: Pulmonary calcification is a relatively rare complication of both benign and malignant disorders. Slowly progressive cases are frequently misdiagnosed as a pneumonia/nonresolving infiltrate on the chest radiograph and CT scan, bone scintigraphy with the bone-avid radiotracer 99mTc-MDP (technetium-methylene diphosphate) helps with equivocal cases. Treatment is targeted at correction of the elevated calcium - phosphate product. Successful renal transplantation may ameliorate metastatic pulmonary calcification, and conversely, renal graft failure and persistent uremia may accelerate the ectopic calcification. In some rare cases metastatic pulmonary calcification may inexplicably progress despite a normally functioning renal allograft and normal or near-normal calcium and phosphate levels, although occult tertiary hyperparathyroidism may be responsible. In severe recalcitrant cases associated with primary or tertiary hyperparathyroidism, parathyroidectomy is indicated.

CONCLUSIONS: A variety of noninfectious causes of pulmonary infiltrates can mimic nonresolving pneumonia. They should always be considered in the differential to avoid excessive and/or inappropriate interventions, unnecessary costs, and the respective risks of invasive diagnostic procedures.

1) Chan ED, et al. Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med. 2002;15;165(12):1654-69.

DISCLOSURE: The following authors have nothing to disclose: Pankaj Mehta, Robert Lenox

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SUNY Upstate Medical University, Syracuse, NY




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