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

Figure 1. Pulmonary function testing results for the patient demonstrate severe restriction with a reduced diffusion capacity with a corrected DLCO 50% of predicted and FVC 45% of predicted. To view Figure 1 in an enlarged, separate window click here.

Figure 2. Unenhanced chest CT images in the axial plane reconstructed with lung (A) and soft tissue (B) display settings. There are innumerable small solid pulmonary nodules with a peripheral distribution, some subpleural sparing, and architectural distortion (A). On soft tissues windows (B) the fact that the nodules are calcified are well-appreciated in the anterior and lateral right mid-lung. To view Figure 2 in a separate, enlarged window click here.

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 biopsies done at that time. He was maintained on 3L oxygen with activity to targets oxygen saturation of 90%. On examination VS: BP 216/100, HR 94, temperature 36.7 °C, SpO2 88 % RA. He was not in respiratory distress. Chest auscultation: symmetrical breath sounds, no added sounds. Examination of the heart, abdomen and rest of the systems were normal. He had trace bilateral pedal edema and clubbing in all digits.

Figure 1 shows his most recent pulmonary function test illustrating a severe restrictive defect with reduced diffusion capacity. Echocardiogram showed ejection fraction of 54%, mild left ventricular hypertrophy and mild diastolic dysfunction. Representative slices of his most recent computed tomography (CT) of the chest are shown in figure 2 and demonstrate multiple scattered small, solid, and calcified pulmonary nodules.

Pulmonary calcifications can either be secondary to hypercalcemia from benign or malignant causes {1}. Such calcification would occur in normal lung tissue due to elevated calcium-phosphate product and is termed metastatic {2,3}. It is thought to occur with higher concentrations of free hydrogen ions, especially in less ventilated areas (West zone 3) with lower pH (more acidotic), leading to calcium-magnesium phosphate compounds (whitlockite-like). Dystrophic calcification on the other hand develops secondary to injury from granulomatous diseases, infections or inherited pulmonary alveolar microlithiasis {4}.

Most cases of metastatic pulmonary calcification are due to ESRD-related hypercalcemia {2}. Most patients are asymptomatic and diagnosed incidentally. Some patients may have non-productive cough, progressive dyspnea, and hypoxia. Lung function testing could show normal or restrictive ventilatory defects, often with impaired diffusion of carbon monoxide. CT scans are diagnostic (Figure 2) and show distinctive diffuse calcifications (sometimes solid and sometimes manifesting as centrilobular ground glass). Bone scintigraphy using technetium-99 diphosphonate scanning would show these calcifications along other parts of the body affected with reported higher sensitivity compared to standard x-ray {5}.

Management is geared towards controlling levels of calcium through phosphate binders, dialysis dosing, and/or parathyroidectomy. Our patient was ultimately evaluated for combined lung/kidney transplantation due to his severe restrictive pulmonary defects.

Abdelmohaymin Abdalla MD¹, Clinton Jokerst MD², Umesh Goswami MD¹

Division of Pulmonary and Critical Care Medicine¹

Mayo Clinic Arizona, Phoenix, AZ USA

Department of Radiology²

Mayo Clinic Arizona, Phoenix, AZ USA

References

1. Kaltreider HB, Baum GL, Bogaty G, McCoy MD, Tucker M. So-called "metastatic" calcification of the lung. Am J Med. 1969 Feb;46(2):188-96. [CrossRef] [PubMed]
2. Conger JD, Hammond WS, Alfrey AC, Contiguglia SR, Stanford RE, Huffer WE. Pulmonary calcification in chronic dialysis patients. Clinical and pathologic studies. Ann Intern Med. 1975 Sep;83(3):330-6. [CrossRef] [PubMed]
3. Kuzela DC, Huffer WE, Conger JD, Winter SD, Hammond WS. Soft tissue calcification in chronic dialysis patients. Am J Pathol. 1977 Feb;86(2):403-24. [PubMed]
4. Chan ED, Morales DV, Welsh CH, McDermott MT, Schwarz MI. Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med. 2002 Jun 15;165(12):1654-69. [CrossRef] [PubMed]
5. Faubert PF, Shapiro WB, Porush JG, Chou SY, Gross JM, Bondi E, Gomez-Leon G. Pulmonary calcification in hemodialyzed patients detected by technetium-99m diphosphonate scanning. Kidney Int. 1980 Jul;18(1):95-102. [CrossRef] [PubMed]

Cite as: Abdalla A, Jokerst C, Goswami U. December 2023 Medical Image of the Month: Metastatic Pulmonary Calcifications in End-Stage Renal Disease. Southwest J Pulm Crit Care Sleep. 2023;27(6):67-69. doi: https://doi.org/10.13175/swjpccs049-23 PDF

November 2023 Medical Image of the Month: Obstructive Uropathy Extremis

Figure 1. Video of CT angiography abdomen/pelvis, played caudal to cranial, obtained during assessment in the ED demonstrating obstructive uropathy with bilateral multiloculated urinomas leading to compression of the inferior vena cava. To view Figure 1  video in a separate, enlarged window click here.

Figure 2. A: CT angiography of the abdomen, axial plane, at the level of the renal veins demonstrating compression of the inferior vena cava (yellow arrow). B: CT angiography of the abdomen and pelvis, coronal plane, demonstrating bilateral multiloculated urinomas (blue brackets). To view Figure 2 in a separate, enlarged window click here.

A 71-year-old veteran presented to the emergency department with two-weeks of progressive back pain radiating to the abdomen associated low-grade fever, nausea, and new lower extremity edema. The family reported confusion. His medical history was significant for chronic prostatitis and low-grade prostate cancer on biopsy that was lost to follow-up eleven years ago. His only reported medications were aspirin 81 mg daily and naproxen 500mg up to four times a day for his pain.

Vitals were significant for a temperature of 36.1 C, initial blood pressure of 201/74, heart rate of 128/min, respirations at 18/min with a saturation of 97% on 2L NC. Physical exam demonstrated no difference in blood pressures between arms. No abnormal heart sounds. Clear breath sounds to auscultation bilaterally. Flank tenderness to percussion and significant abdominal tenderness over the epigastric and suprapubic region with 3+ pitting edema of the bilateral lower extremities. Screening labs were notable for critical values of a WBC of 43.5 K/mL and potassium of 7 mEq/L with a creatinine of 6.5 mg/dL. He was started on esmolol and hyperkalemia temporizing therapy with the decision made to obtain an urgent contrast enhanced computed tomography of the chest, abdomen, and pelvis.

Imaging confirmed a diagnosis of severe obstructive uropathy with heterogenous prostate with nonspecific small hypodensities, marked bladder distension, hydronephroureter with ureteral wall prominence, and bilateral perinephric multiloculated fluid collections with extension into the abdominal and retroperitoneal spaces leading to indentation of the inferior vena cava (Figures 1 and 2). A Foley catheter was urgently placed with 2.5L of urine immediately relieved and prompt response in blood pressure to 130/80, and resolution of pain, altered mentation, and nausea. He was started on vancomycin and piperacillin/tazobactam for empiric coverage with three percutaneous drains subsequently placed in the multiloculated fluid collections with purulent discharge expressed. Cultures of the output demonstrated no growth. His post-obstructive diuresis was managed with replacement Lactated Ringers’ solution at 75% of the rate of Foley output. He demonstrated complete improvement in leg swelling, heart rate, and WBC and creatinine normalized to 1.1 mg/dL with discharge to home in seven days with close urology follow-up for his prostatic abnormality.

This case of obstructive uropathy extremis, probable cystocerebral syndrome (hypertension, altered mental status, and bladder distension in the elderly), and bilateral urinomas leading to inferior vena cava syndrome is unique to the literature (1). The rupture of the renal fornices, the most delicate and purported “pressure check valve” of the renal conduits, can precipitate the formation of localized urinomas within the perinephric and retroperitoneal space, most commonly unilateral from ureteral or kidney stones or tumor related obstruction, rarely bilateral from bladder outlet obstruction (2). These urinomas, as seen in this case can exert a progressively escalating pressure on the contiguous inferior vena cava, which has been described as “inferior vena cava syndrome” (3). The implications of this pressure increase are manifold, encompassing the observed clinical manifestations ranging from lower extremity edema, worsening kidney perfusion, to hemodynamic instability (3). Management centers upon decompression of the obstruction, treatment of secondary infection with source control, and compensation for post-obstructive diuresis with generally favorable prognosis if recognized early in the clinical course.

Nathan Walton MD¹, Elizabeth Mata MD¹, Max Hart MD¹, Matthew Borchart MD²and Adnan Abbasi MBBS³

¹Internal Medicine Program, University of Arizona College of Medicine – Tucson

²Department of Medicine, Pulmonary & Critical Care, University of Arizona College of Medicine – Tucson

³Department of Medicine, Pulmonary & Critical Care, Southern Arizona Veterans Affairs Health Care System (SAVAHCS) – Tucson

References

1. Blackburn T, Dunn M. Cystocerebral syndrome. Acute urinary retention presenting as confusion in elderly patients. Arch Intern Med. 1990 Dec;150(12):2577-8. [CrossRef][PubMed]
2. Gershman B, Kulkarni N, Sahani DV, Eisner BH. Causes of renal forniceal rupture. BJU Int. 2011 Dec;108(11):1909-11; discussion 1912. [CrossRef][PubMed]
3. Lawrensia S, Khan YS. Inferior Vena Cava Syndrome. 2023 May 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. [PubMed]

Cite as: Walton N, Mata E, Hart M,  Borchart M, Abbasi A. November 2023 Medical Image of the Month: Obstructive Uropathy Extremis. Southwest J Pulm Crit Care Sleep. 2023;27(5):56-58. doi: https://doi.org/10.13175/swjpccs043-23 PDF