CASE 12811 Published on 22.12.2015

Diffuse pulmonary calcification in end-stage chronic renal insufficiency


Chest imaging

Case Type

Clinical Cases


Cruz, João; Lameiras, Raquel; Camacho, Rui; Bagulho, Cecília.

Garcia de Orta; Av. Torrado da Silva
2801-951 Almada, Portugal;

45 years, female

Area of Interest Kidney, Lung ; Imaging Technique CT, CT-High Resolution
Clinical History
A 45-year-old Caucasian female patient with a prior history of chronic renal insufficiency due to medullary sponge kidney, with secondary hyperparathyroidism, was admitted in our institution for serious hypokalaemia and anaemia. The patient had neither smoking history nor signs or symptoms of respiratory disease.
Imaging Findings
A routine chest X-ray showed multiple high density micro-nodular opacities in the upper lobes of the lungs. To better characterize those pulmonary abnormalities, a thoracic CT was requested, depicting diffuse high density nodular opacities consistent with centrilobular calcifications in the upper lobes of the lungs. A non-enhanced abdomino-pelvic CT demonstrated findings of renal pyramid calcifications related to nephrocalcinosis.
Diffuse pulmonary calcification, also known as pulmonary metastatic calcification, is a progressive interstitial process, usually related with chronically elevated serum calcium levels, in which calcium is deposited in the alveolar septa, bronchial walls and pulmonary arteriole. [1-6]
Despite being a frequent complication in end-stage chronic renal insufficiency treated with haemodialysis, most patients remain asymptomatic, and a small portion develops severe respiratory symptoms, related to the extent of pulmonary calcification and fibrosis with restrictive syndrome. [2, 5-8]
Conventional chest radiographs lack sensitivity and specificity for this pathology that may simulate pulmonary oedema, airspace disease or appear as diffuse interstitial infiltrates. [4, 8]
The superior sensitivity of high-resolution computed tomography (HRCT) allows the detection of small lung calcifications, which can be associated with vascular calcifications and/or centrilobular ground-glass nodular opacities, with numerous poorly defined nodules measuring 3–10 mm in diameter. [2-5]
An upper lobe predominance for metastatic pulmonary calcification has been reported, supposedly due to higher ventilation-perfusion ratio and increased alkalinity that favours calcium precipitation. [1, 6]
The differential diagnosis includes lung dystrophic calcifications due to a variety of other conditions such as infections (e.g. tuberculosis), silicosis, sarcoidosis, metastatic tumour, rheumatic mitral stenosis, microlithasis and broncholithiasis, each one with different patterns of parenchymal involvement. [3, 4]
It is important to be aware of this entity to correctly identify this potentially progressive and fatal cause of respiratory failure, as appropriate measures can be taken to reverse hypercalcaemia. In addition, recognition of metastatic pulmonary calcification at CT may, in some cases, obviate the need for more invasive procedures, such as open-lung biopsy, to determine the cause of a noncleaning infiltrate in a patient with end-stage renal failure.
Differential Diagnosis List
Diffuse pulmonary calcification in the context of end-stage renal insufficiency
Metastatic tumour
Final Diagnosis
Diffuse pulmonary calcification in the context of end-stage renal insufficiency
Case information
DOI: 10.1594/EURORAD/CASE.12811
ISSN: 1563-4086