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47-year-old man
Hemodialysis
dyspnea
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HRCT in mediastinal window
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47year-old man with metastatic
pulmonary calcification due to chronic
renal failure. High-resolution CT image (1-
mm collimation, high-spatial-frequency
reconstruction algorithm) lung window
shows diffuse fluffy, poorly defined
nodules in the upper lobes.
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47year-old man with metastatic
pulmonary calcification due to chronic
renal failure. High-resolution CT image in
mediastinal window shows parenchymal
calcifications.
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47year-old man with metastatic pulmonary
calcification due to chronic renal failure. High-
resolution CT image in mediastinal window at
the level of the carina shows multiple, ill-defined,calcified nodules (arrows). There are also
calcifications in the bronchial and tracheal walls.
Back
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47year-old man with metastatic
pulmonary calcification due to chronic
renal failure. High-resolution CT image in
lung window shows symmetric,
centrilobular, calcified nodules (short
arrow) and ground-glass opacity (long
arrow) in the lower lung zone.
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47year-old man with metastatic
pulmonary calcification due to chronic
renal failure. High-resolution CT image in
mediastinal window shows symmetric,
centrilobular, calcified nodules in the lower
lung zone.
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Computed Tomography (Open in original
size)
47year-old man with metastatic
pulmonary calcification due to chronic
renal failure. Abdomen CT shows renal
atrophy (white arrow) and vascular
calcification (black arrow).
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Metastatic calcification refers to the deposition of calcium in normaltissue. The lung is one of the primary sites of metastatic calciumdeposition (1). Metastatic calcifications of lung parenchyma arerelated to chronically elevated serum calcium-phosphorus productas in chronic renal failure, primary hyperparathyroidism, Dhypervitaminosis, milk alkali syndrome or diffuse myelomatosis (2).
Calcium salts are predominantly deposited in the alveolar walls, andto a lesser extent in bronchial wall, pulmonary arteries, and veins(3). Calcium preferentially deposits in relatively alkaline tissues;therefore, it is not surprising that the lung apex is more commonlyinvolved than the lung base (2). The degree of respiratory distressoften does not correlate with the degree of macroscopic calcification.Patients with extensive calcification may be asymptomatic, while
others with subtle calcification or normal chest radiographs mayhave severe respiratory compromise
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Metastatic pulmonary calcification is a well known complication of end-stage renalfailure and its treatment (5). While common at autopsy in patients with renal failure,the process is often undiagnosed antemortem. Many patients with MPC areasymptomatic, but in some cases can cause fulminant respiratory failure and earlydeath. Symptoms include dyspnea and chronic, non-productive cough (4).Because chest radiograph is insensitive in depicting small amounts of calcification, itis frequently normal. MPC has been described as confluent or patchy airspace
opacities simulating pulmonary edema or pneumonia on chest radiographs. MPC canalso appear as a diffuse interstitial process or as discrete or confluent calcifiednodules (2, 6).HRCT, with its excellent sensitivity in the detection of small amounts of calcification,is being increasingly used to diagnose MPC. Several CT patterns have beendocumented to date. The first pattern is multiple diffuse calcified nodules that areeither distributed throughout the whole lung or show a predilection for the apices. Thesecond pattern is diffuse or patchy areas of ground-glass opacity or consolidation.Finally, MPC may appear as a confluent high attenuation parenchymal consolidation
in a predominantly lobar distribution, mimicking lobar pneumonia. Associated findingsinclude calcification in the bronchial walls, myocardium and within the vessels of thechest wall (2, 6). In our case showed multiple, symmetrical, centrilobular, calcifiednodules and patchy areas of ground-glass opacity throughout both lungs.
Additionally, this case also showed calcification in the bronchial and tracheal walls
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Multifocal pulmonary parenchymal calcification is associated withinfection (varicella zoster tuberculosis, histoplasmosis), MPC,silicosis, diffuse parenchymal amyloidosis, alveolar microlithiasis,haemosiderosis secondary to mitral stenosis and fat embolismassociated with adult respiratory distress syndrome. It also occurs intreated metastases and in metastatic malignancies such as
osteogenic sarcoma, chondrosarcoma, mucin-producingadenocarcinomas and thyroid malignancies (7). The calcifiednodules in diffuse parenchymal amyloidosis are locatedpredominantly in the subpleural areas of the mid and lower zonesand are associated with hilar lymphadenopathy, interlobular septalthickening, and consolidation and ground-glass opacities. Thecalcified pulmonary nodules in alveolar microlithiasis are smaller
(about 1 mm in diameter), typically occur in the lower zones and theparacardiac regions and may be associated with apical bullae andsubpleural cysts. Tuberculoma usually presents as a solitary well-defined calcified nodule..
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Miliary tuberculosis is characterized by
small, well-defined, discrete nodules, 1-2
mm in diameter, evenly distributedthroughout both lungs. Occasionally, some
may calcify. Hilar lymphadenopathy with a
peripheral egg-shell calcification iscommon in silicosis (8). renal failure is
potentially reversible, and may resolve
after parathyroidectomy, renal transplant,
or adequate dialysis. Resolution ofsymptoms has been seen after correction
of hypercalcemia well (4).
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The most likely cause for multifocalpulmonary parenchymal calcification in thepatients with chronic renal failure is MPC.
The predilection of calcification for theupper lung area and associated withcalcification in the bronchial walls,myocardium and within the vessels of the
chest wall may be supported the diagnosisofMPC.Pulmonary calcification associated with
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In conclusion, HRCT is a valuable imaging
technique in the diagnosis ofMPC. HRCT
may obviate the need for open lung
biopsy. Therefore, it is important for the
radiologist to recognize the HRCT patterns
of this disease process afflicting patients
with chronic renal failure
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Metastatic pulmonary calcification characterizedby diffuse calcium deposition in the lungs isknown to occur in patients with chronic renalfailure. We present a case of a 47-year-old man
with chronic renal failure presented withdyspnea, high-resolution computed tomographyof the chest revealed multiple, centrilobular,calcified nodules and patchy areas of ground-glass opacity throughout both lungs, consistent
with metastatic pulmonary calcification.Calcification was also seen in the bronchi andtrachea.
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Metastatic Pulmonary Calcification in a
Patient with Chronic Renal Failure
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ray (AP view) (A) femur was apparently
normal however, in retrospective it showed
a faint ill-defined sclerotic lesion (arrow),
latest x-ray (B) showed a cortical basedwell defined lytic lesion in the right
proximal femoral diaphysis with sclerotic
margins (arrow).
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Plain radiograph of the pelvis in a 6-year-
old child who presented with left hip pain.
The radiograph shows a well-defined area
of sclerosis surrounded by a ring ofradiolucency in the left femoral neck. Note
the absence of periosteal reaction that
suggests intramedullary or cancellousosteoid osteoma.
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Radiograph of the right great toe in a 24-
year-old woman shows a partly calcified
lesion in the medulla of the distal phalanx,
with no periosteal new bone formationsuggestive of osteoid osteoma
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Lateral view of the thoracic spine in a 56-year-oldwoman who presented with abdominal pain. Initialfindings of chest radiography, intravenous pyelography,barium enema, and cholecystogram were normal. An
isotope bone scan showed focal increased uptake in thevertebral body of the lower thoracic spine. Plainradiograph corresponding to the site of the abnormalityshows a radiolucent lesion in the posterior aspect of theT11 vertebral body with surrounding sclerosis that wasdiagnosed as giant osteoid osteoma and later wasconfirmed at histologic analysis
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Radiograph of the hip in an 8-year-old
child who presented with left hip pain and
restriction of movement. An intra-articular
osteoid osteoma in the medial aspect ofthe femoral neck has resulted in periosteal
new bone formation
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Anteroposterior radiograph of the
lumbar spine in a 52-year-old man who
had a biopsy-proven giant osteoid
osteoma (osteoblastoma) and whopresented with severe low back pain.
Radiograph shows a well-defined
sclerotic lesion in the left side of the L4vertebral body.
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Twin girls with growth retardation
age of nine months
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DP radiograph of the hand of one of the
twins, showing shortness of both the
metacarpals and phalanges, with lack of
tubulation.
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Coned hand radiograph of the second
twin, demonstrates cone-shaped
epiphyses of 3rd and 4th proximal
phalanges
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The forearm bones are shortened with
respect to the humerus, and the bones are
under-tubulated. In addition, the radius is
shorter than the ulna
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Lateral skull radiograph showing large
calvarium with frontal bossing.
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Lateral radiograph of whole spine,
showing mild thoracolumbar kyphosis.
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Lateral radiograph of vertebrae showing
oval shaped vertebral bodies, with beaking
of the anterior portions.
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X-ray findings (Fig. 3-8):
1. Hands: Phalanges and metacarpal bones were shortand thick. Epiphyses were cone-shaped. Carpal boneswere normal and appropriate to age.
2. Long tubular bones:Radius and ulna weredisproportionately shorter than humerus, and radius wasshorter than ulna. Lower extremities were normal.3. Spine: Vertebral body height were decreased, andcentral protrusion of body anterior portion (beaking) wasseen. Interpedicular distance was normal. Mild kyphosis
was present at lower thoracic region.4. Calvarium: Dolicocephaly with prominent frontal andoccipital bones was seen. There was frontal bossing.Facial bones were normal
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Skeletal dysplasias comprise a group of
hereditary disorders characterised with growth
and development disturbances of cartilage and
bones. They can be epiphyseal, metaphyseal ordiaphyseal. The disease results in abnormal,
and disproportionate shape and length of
affected bones. Though molecular tests are
available for some of its variants, radiologicaland clinical findings are very important for the
diagnosis [
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Acromesomelic dysplasia is a rare form of
skeletal dysplasia, with autosomal
recessive inheritance pattern. The disease
is characterised by both acro- andmesomelia. Other bone abnormalities
affecting calvarium or vertebrae may also
be present
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Characteristic radiological findings occur within the firstor second year of life: cone-shaped epiphyses of hands,shortness of radius comparing to ulna, short and broadphalanges, oval-shaped vertebrae with anterior beaking,and frontal bossing of calvarium are the radiologicalcharacteristics of the diagnosis. Hypoplasia of the baseof the iliac bone, irregular ossification of superioracetabulum and superior inclination of clavicles may alsoaccompany. Fusion of growth plate in hands, bendingdeformity of radius, dorsal subluxation of radial head,widening of central protrusion of vertebrae, posteriorwedging and increase in severity of kyphosis may occuror become more pronounced during the following years
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Lymphangitic carcinomatosis.
Posteroanterior chest radiograph shows
numerous bilateral linear opacities.
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Pleural effusion, interlobular septal
thickening, nodular thickening of the right
major fissure
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Diffuse reticulonodular opacities and a mass at the right middle lung
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p g gwere depicted at the chest radiograph (not shown). Furtherinvestigation with CT and HRCT of the lungs was performed.CT-HRCT revealed: (1) bilateral pleural effusion, (2) mediastinal
lymphadenopathy, (3) nodule with spiculated margins in the rightlower lobe, (4) smooth and nodular thickening of the interlobularsepta, (5) nodular thickening of the peribronchovascularinterstitium,in the right middle and lower lobe, (6) nodular thickeningof the right major fissure and (7) subpleural nodules.Imaging findings were compatible with pulmonary lymphangiticcarcinomatosis. The nodule in RLL was considered to be the
possible cause.Bronchoscopy confirmed the diagnosis of pulmonary lymphangiticcarcinomatosis (PLC). Transbronchial biopsy of the nodule in theRLL revealed primary lung carcinoma (non-small cell lungcarcinoma) which caused PLC
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Pulmonary lymphangitic carcinomatosis is aterm that refers to tumour growth in thelymphatic system of the lung. The most commonmalignancies to produce lymphangitic
carcinomatosis (LC) are breast carcinoma, lung,stomach, pancreas, prostate, cervix, or thyroidand metastatic adenocarcinoma from anunknown primary site. The most common clinical
manifestation is dyspnoea. It is typicallyinsidious in onset but progresses rapidly andwithin a few weeks can cause severe disability.
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The chest radiograph is normal in
approximately 50% of cases of proven LC.
Radiographic manifestations ofLC
include: i) reticular or reticulonodularopacities, ii) septal lines, iii) hilar and
mediastinal lymphadenopathy, iv) pleural
effusion.
HRCT is the imaging method of choice for diagnosing
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HRCT is the imaging method of choice for diagnosingLC. HRCT findings ofLC include
: 1) smooth or nodular peribronchovascular interstitialthickening,
2) smooth or nodular interlobular septal thickening,
3) smooth or nodular thickening of fissures,
4) smooth or nodular subpleural interstitial thickening,
5) thickening of the peribronchovascular interstitium(peribronchial cuffing),
6) preservation of normal lung architecture at the lobularlevel despite the presence of these findings,
7) lymph node enlargement and 8) pleural effusion
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Although the findings ofLC are characteristic, they canalso be seen in other conditions like pulmonary oedema,sarcoidosis, CWP (Coal Workers Pneumoconiosis) orsilicosis, lymphocytic interstitial pneumonia, amyloidosis.The following clues to differential diagnosis should be
considered: a) in sarcoidosis and CWP septal nodulesare commonly seen but septal thickening is usually lessextensive than that seen in patients with lymphangiticspread of tumour, b) in sarcoidosis and CWP distortionof lung architecture may be present, a finding that is notseen in patients with LC, c) pleural effusion is rare in
sarcoidosis or silicosis and finally d) in pulmonaryoedema interstitial thickeninig is smooth and there areno peribronchovascular and subpleural nodules
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Non small cell lung carcinoma with
pulmonary lymphangitic carcinomatosis.
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A newborn infant
congenital heart disorder
localized soft tissue swelling and
erythema,
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Axial CT image of the foot demonstrating
the large region of heterotopic ossification
at the dorsum of the foot anterior to the
talus. Mineralization is most notable at theperiphery of the mass
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Sagittal reformatted CT of the foot
demonstrating the large region of
heterotopic ossification at the dorsum of
the foot anterior to the talus. Mineralizationis most notable at the periphery of the
mass.
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Heterotopic ossification refers to the formation of lamellar bonewithin soft tissues, secondary to genetic, traumatic, or iatrogeniccauses (1,2). It can present as small, clinically-insignificant flecks ofbone or large deposits of ossification. Its initial radiographicappearance can be confused with metastatic calcification inhypercalcemic disorders or more worrisome entities such asparosteal osteosarcoma or juxtacortical chondroma. Thepathogenesis for heterotopic bone formation is not fully understood.Though there are inherited disorders such as fibrodysplasiaossificans progressiva and progressive osseous heteroplasia whichare associated with advanced and often disfiguring manifestations ofheterotopic ossification, these disorders are rare and tend to arisefrom spontaneous mutations (1,2,3)
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Sagittal reformatted CT of the foot
demonstrating the large region of
heterotopic ossification at the dorsum of
the foot anterior to the talus. Mineralizationis most notable at the periphery of the
mass.
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A 17-year-old boy presented with a two
year history of uncontrolled hypertension
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that 10%40% of extra-adrenalparagangliomas are malignant (3). Distant
metastasis is the only reliable criteria for
confirming malignancy. Local tissueinvasion or pathological evidence of
nuclear pleomorphism or mitotic activity
does not necessarily imply malignancy
There are six major anomalies of the
inferior vena cava which include
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duplication of the IVC, transposition of the IVC,
azygos continuation of the IVC,
circumaortic renal collar, retroaortic renal
and retrocaval ureter (6).
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The persistence of right and left supracardinal veins results indouble IVC.
Transposition of IVC results from regression of the rightsupracardinal vein with persistence of the left supracardinal vein.Azygos continuation of the IVC is due to failure to form the rightsubcardinalhepatic anastomosis, with resulting atrophy of the rightsubcardinal vein.
Consequently, blood is shunted from the suprasubcardinalanastomosis through the retrocrural azygos vein. A circumaortic leftrenal vein results from persistence of the dorsal limb of theembryonic left renal vein and of the dorsal arch of the renal collar. Aretroaortic renal vein develops from the persistence of the dorsalvenous anastomosis of the supracardinal and subcardinal veins with
regression of the ventral aspect of the two venous systems Aretrocaval ureter occurs when the right posterior cardinal vein