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 Table of Contents     
CASE REPORT
Year : 2015  |  Volume : 30  |  Issue : 3  |  Page : 275-276  

Pulmonary calcification in renal failure patient incidentally revealed by bone scintigraphy


Department of Nuclear Medicine, Military Hospital of Tunis, Tunisia

Date of Web Publication11-Jun-2015

Correspondence Address:
Ali Sellem
Department of Nuclear Medicine, Military Hospital of Tunis, Tunis - 1008
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.158546

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   Abstract 

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.

Keywords: Bone scintigraphy, hemodialysis, lung calcification


How to cite this article:
Sellem A, Ajmi WE, Mahjoub Y, Hammami H. Pulmonary calcification in renal failure patient incidentally revealed by bone scintigraphy. Indian J Nucl Med 2015;30:275-6

How to cite this URL:
Sellem A, Ajmi WE, Mahjoub Y, Hammami H. Pulmonary calcification in renal failure patient incidentally revealed by bone scintigraphy. Indian J Nucl Med [serial online] 2015 [cited 2019 Dec 15];30:275-6. Available from: http://www.ijnm.in/text.asp?2015/30/3/275/158546


   Introduction Top


Pulmonary calcification, typically asymptomatic, can be caused by a number of diseases, most common being end-stage renal disease. We describe a case of pulmonary calcifications associated with chronic kidney failure, which has been improved by medical treatment.


   Case report Top


A 21-year-old man with a 4-year history of end-stage renal disease, on hemodialysis (three 4-h sessions/week), secondary to untreated bilateral vesico-ureteral reflux and neurogenic reactive bladder.

The patient was referred for a bone scan because of osteoarticular complaints, especially at the elbows with limited mobility, and he reported mild and nonspecific symptoms, especially no significant dyspnea.

Patient had high creatinine (428 μmol/l); serum phosphorus (4.51 mmol/l); total alkaline phosphatase, 108 U/L and serum parathyroid hormone level was 1700 pg/mL.

Whole body bone scintigraphy images [Figure 1], showed a diffuse uptake in both lungs, more intense in the right one, suggesting an extra-osseous pulmonary calcification and an increased radiotracer uptake in the soft tissues of the left arm and in the periarticular soft tissues surrounding the elbows. The chest X-ray was normal [Figure 2].
Figure 1: Whole body bone scintigraphy with anterior and posterior projection performed 2 h after the injection of 18 mCi (666 MBq) of 99mTc-methylene diphosphonate which showed a diffuse uptake in both lungs and an increased radiotracer uptake in the soft tissues of the left arm and in the periarticular soft tissues surrounding the elbows (the hand positions are due to the limited mobility of the elbows)

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Figure 2: Chest radiograph performed in the light of the data of bone scan

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Parathyroidectomy was declined by the patient. The medical therapeutic was chosen with dietary phosphorus restriction, noncalcium phosphate binders, calcimimetics, optimal control of secondary hyperparathyroidism, and intensive hemodialysis with a low-calcium dialysate.

Second bone scan was done 3 months later [Figure 3] revealed a significant decrease, without disappearance, in the lung's uptake.
Figure 3: Second whole body bone scintigraphy with anterior and posterior projection performed 2 h after the injection of 18 mCi (666 MBq) of 99mTc-methylene diphosphonate revealed a significant a decrease in the lungs uptake (the hand positions are due to the limited mobility of the elbows)

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   Discussion Top


Soft-tissue calcification is a well-known complication of chronic renal failure. Calcified deposits may involve a variety of tissues and organs. Uremic tumoral calcinosis predominates in periarticular soft tissues with preservation of the bone and joint structures. [1] Several cases of metastatic pulmonary calcification (MPC) have been reported. [2] The clinical symptoms of MPC are usually mild [3] that's why this pathology is rarely diagnosed [4] and patients with extensive calcification may be asymptomatic. [5] Chest X-ray findings in MPC are nonspecific [6],[7] and they are frequently normal. [8]

The diagnosis is confirmed by biopsy, but can be suspected by typical findings on a Tc-99m-methylene diphosphonate bone scan, which is a sensitive and specific method for diagnosing. [8],[9] That why, some authors have recommended the use of bone scan in hemodialysis patients with pulmonary symptoms. [4] Lungs affected by MPC demonstrate increased uptake, generally symmetrical. [5],[10]

Four major predisposing factors may contribute to MPC in dialysis patients. First, chronic acidosis leaches calcium from bone. Second, intermittent alkalosis favors the deposition of calcium salts. Third, hyperparathyroidism tends to cause bone resorption and intracellular hypercalcemia. Finally, low glomerular filtration rate can cause hyperphosphatemia and an elevated calcium-phosphorus product. [8]

For patients with hyperparathyroidism, correction of this condition may stop the progression of nonvisceral soft-tissue calcification. [11] Our patient declined parathyroidectomy and was treated medically with a significant regression of scintigraphic abnormalities.

 
   References Top

1.
Chu HY, Chu P, Lin YF, Chou HK, Lin SH. Uremic tumoral calcinosis in patients on peritoneal dialysis: Clinical, radiologic, and laboratory features. Perit Dial Int 2011;31:430-9.  Back to cited text no. 1
    
2.
Li YJ, Tian YC, Chen YC, Huang SF, Huang CC, Fang JT, et al. Fulminant pulmonary calciphylaxis and metastatic calcification causing acute respiratory failure in a uremic patient. Am J Kidney Dis 2006;47:e47-53.  Back to cited text no. 2
    
3.
Guermazi A, Espérou H, Selimi F, Gluckman E. Imaging of diffuse metastatic and dystrophic pulmonary calcification in children after haematopoietic stem cell transplantation. Br J Radiol 2005;78:708-13.  Back to cited text no. 3
    
4.
Bendayan D, Barziv Y, Kramer MR. Pulmonary calcifications: A review. Respir Med 2000;94:190-3.  Back to cited text no. 4
    
5.
Brodeur FJ Jr, Kazerooni EA. Metastatic pulmonary calcification mimicking air-space disease. Technetium-99m-MDP SPECT imaging. Chest 1994;106:620-2.  Back to cited text no. 5
    
6.
Thurley PD, Duerden R, Roe S, Pointon K Case report: Rapidly progressive metastatic pulmonary calcification: Evolution of changes on CT. Br J Radiol 2009;82:e155-9.  Back to cited text no. 6
    
7.
Marchiori E, Müller NL, Souza AS Jr, Escuissato DL, Gasparetto EL, de Cerqueira EM. Unusual manifestations of metastatic pulmonary calcification: High-resolution CT and pathological findings. J Thorac Imaging 2005;20:66-70.  Back to cited text no. 7
    
8.
Eggert CH, Albright RC. Metastatic pulmonary calcification in a dialysis patient: Case report and a review. Hemodial Int 2006;10 Suppl 2:S51-5.  Back to cited text no. 8
    
9.
Morcos SK. Regarding metastatic pulmonary calcification in renal failure. Br J Radiol 2002;75:711-2.  Back to cited text no. 9
    
10.
Rosenthal DI, Chandler HL, Azizi F, Schneider PB. Uptake of bone imaging agents by diffuse pulmonary metastatic calcification. AJR Am J Roentgenol 1977;129:871-4.  Back to cited text no. 10
    
11.
Thakur A, Hines OJ, Thakur V, Gordon HE. Tumoral calcinosis regression after subtotal parathyroidectomy: A case presentation and review of the literature. Surgery 1999;126:95-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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