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Images in thorax
Metastatic pulmonary calcification: ‘crazy paving’ pattern
  1. Kay Por Yip
  1. Respiratory Department, County Hospital, Hereford, UK
  1. Correspondence to Dr Kay Por Yip, Flat D2, Longfield House, County Hospital, Hereford HR1 2ER, UK; kyip{at}

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A 60-year-old man was admitted under the cardiology team for increasing shortness of breath over the past two months. His medical history of note included stable renal transplant 8 years ago, previous parathyroidectomy due to uncontrolled tertiary hyperparathyroidism and hypertension. His echocardiogram showed a critical aortic stenosis and was thus worked up for an aortic valve replacement.

His admission X-ray (figure 1) showed bilateral apical nodular alveolar opacities. High-resolution CT chest is as shown in figure 2 and was described superficially like a ‘crazy paving’ pattern by the reporting radiologist (figure 2). There is also severe calcification of the aortic valve noted (figure 3).

Figure 1

Chest X-ray depicting bilateral apical nodular alveolar opacities.

Figure 2

High-resolution CT chest showing calcification of both lung apices.

Figure 3

Same CT scan showing a heavily calcified aortic valve, most probably related to his previous hypercalcaemia.

Metastatic pulmonary calcification is seldom recognised clinically as it is usually asymptomatic. High-resolution CT scan is sensitive and specific as it is able to depict small amounts of calcification seen compared with conventional chest X-ray.1 Upper lobes are mainly involved (as in this patient) because of the high ventilation-perfusion ratio, which results in lower capillary pCO2 and a higher pH compared with the lower lobes.2 It is important to know that despite the term ‘metastatic’ being used, it is a relatively benign condition with a good long-term prognosis.


The author acknowledges the contribution of Dr Paul Grech, the radiologist responsible for reporting the findings of the high-resolution CT scan.


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  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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