Joseph Santiapillai, MB ChB*, Santhana Kannan, MD, DNB, FRCA**, Shu Li Tan, MB ChB*
*Core Trainee; **Consultant
Department of Anaesthesia, City Hospital, Dudley Road, Birmingham B18 7QE. (United Kingdom)
Correspondence: Dr. S. Kannan, Department of Anaesthesia, City Hospital, Dudley Road, Birmingham B18 7QE. (United Kingdom); Phone: 0044 121 5074343; Fax: 0044 121 5074349; E-mail: firstname.lastname@example.org
Key words: Pulmonary calcification; Aspiration pneumonia; Barium swallow
Citation:Santiapillai J, Kannan S, Tan SL. Pulmonary calcification or…? Anaesth Pain & Intensive Care 2014;18(3):318-19
The presence of diffuse pulmonary calcific lesions in a critically ill patient with respiratory difficulties raises suspicion of potentially serious underlying conditions. However, this need not always be the case.
A 62 year old male was admitted to intensive care with worsening dyspnoea and progressive hypoxia. He had had nasopharyngeal carcinoma 10 years back and had received radiotherapy, which led to pharyngeal damage, swallowing difficulty and recurrent aspirations requiring a percutaneous gastrostomy feeding tube. Provisional diagnosis was pneumonia secondary to aspiration and infection. In addition to changes suggestive of pneumonia, the chest x-ray also showed dense, speckled calcified opacities within the lower zones bilaterally (Figure 1). The opacities were caused by residual barium from aspiration after an oral contrast study done over a year ago.
Aspiration is a well-recognised complication of oral contrast studies. Barium sulphate is inert and relatively insoluble, therefore can remain within the lung tissues for a prolonged period of time. Aspirated barium tends to gravitate and hence is seen predominantly in the basal regions. It is phagocytosed by alveolar macrophages and may lead to local fibrosis. Barium aspiration can be acutely fatal both due to physical obstruction and pulmonary inflammation.1 However, if the patient survives the initial phase, the barium itself does not lead to significant problems with gas exchange.
Figure 1: Opacities marked by arrows
Differential diagnosis of bilateral ‘diffuse’ pulmonary calcification includes healed varicella pneumonia, pulmonary silicosis, amyloidosis, pulmonary alveolar microlithiasis, metastatic calcinosis and pulmonary interstitial ossification.2 It was interesting that the opacities in this case were reported as ‘calcification’ by a radiologist, who did not have the benefit of the full history.
- Katsanoulas C, Passakiotou M, Mouloudi E, Gritsi-Gerogianni N, Georgopoulou V. Severe barium sulphate aspiration: a report of two cases and review of the literature. Signa Vitae 2007; 2: 25 – 28. [Free Full Text]
- Brown K, Mund DF, Aberle DR, Batra P, Young DA. Intrathoracic calcifications: radiographic features and differential diagnoses. Radiographics. 1994; 14:1247 – 1261. [PubMed]