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Year : 2012  |  Volume : 55  |  Issue : 1  |  Page : 119-120
Macrolithiasis in pulmonary tuberculosis: An autopsy report with review of literature


Department of Pathology, Govt. Medical College, Amritsar, Punjab, India

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Date of Web Publication11-Apr-2012
 

How to cite this article:
Badyal RK, Kataria AS, Sachdeva K, Kapoor S. Macrolithiasis in pulmonary tuberculosis: An autopsy report with review of literature. Indian J Pathol Microbiol 2012;55:119-20

How to cite this URL:
Badyal RK, Kataria AS, Sachdeva K, Kapoor S. Macrolithiasis in pulmonary tuberculosis: An autopsy report with review of literature. Indian J Pathol Microbiol [serial online] 2012 [cited 2019 Dec 10];55:119-20. Available from: http://www.ijpmonline.org/text.asp?2012/55/1/119/94882


Macrolthiasis in lung parenchyma is a very rare disease in which lungs are heavy and stony hard and are cut with greatest difficulty. This disorder is characterized by alveolar deposition of calcium in both lungs without a significant alteration in body calcium and phosphate metabolism. It is usually diagnosed incidentally on radiological examination or at autopsy. [1] Herein we report an autopsy finding of a 65 year old male prisoner who died in the prison. The patient was referred to chest clinic in January 2007 with a 3-year history of shortness of breath, cough with expectoration and weight loss. At that time, he was diagnosed as a case of pulmonary tuberculosis based on sputum smear examination for acid fast bacilli and put on anti-tubercular treatment (ATT). Complete blood counts, liver and renal function tests, serum electrolytes were within the normal range. He died after two years . A medicolegal autopsy was done and viscera were sent to our department. On postmortem examination, the pleura and lung on the right side were adherent together as well as to the chest wall and separated with greatest difficulty without any laceration of the lung parenchyma.

On gross examination: The received pieces of lungs weighed 275 g. Both the lungs were heavy, stony hard, and sectioning revealed multiple stones ranging from 1 cm to 5 cm [Figure 1]a, c recovered from the multiple cavities [Figure 1]b.
Figure 1: (a) A large stone seen in the cavity of the lung parenchyma; (b) Multiple stones and cavities; (c) Multiple stones recovered from both the lungs

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On microscopic examination: Lung parenchyma showed marked thickening of the interstitial septae due to fibrosis. Foci of calcification [Figure 2]a were noticed in the areas of caseation and fibrosis. Few caseating granulomas [Figure 2]b were also observed in the interstitium surrounded by collection of lymphocytes.
Figure 2: (a) Microphotograph of lung showing calcification and interstitial lung fibrosis (H and E, ×400); (b) Caseating granuloma and interstitial fibrosis (H and E, ×400)

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The heart weighed 350 g. It was firm in consistency. The right and left ventricular walls were 1.0 and 1.2 cm in thickness, respectively. The chambers, valves, and great vessels revealed no pathology. The coronary arteries were patent. The other organs were grossly as well as microscopically unremarkable.


   Discussion Top


Lung stones attracted the curiosity of physicians of ancient Greece and Rome, and according to Morgagni, pneumoliths were known to Areteus, Galen, and Aristotle. As autopsies became part of medical investigation, more knowledge was gathered about this condition. Macrolithiasis seen within the cavities as a sequlae of fibrocaseous tuberculosis is a rare entity. No case of macrolithiasis due to tuberculosis has ever been reported in the literature. However, approximately 600 cases of pulmonary alveolar microlithiasis have been reported. Patients with coal worker pneumoconiosis or silicosis may show multiple nodules with calcifications, which may progress to conglomerate masses, ranging in size from 1 to 10 cm and are usually located in the upper lobes. [2] Broncholithiasis have been documented secondary to pulmonary tuberculosis, fungal infections like histoplasmosis, silicosis etc. The deposits due to broncholithiasis are usually seen within the tracheobronchial tree. However, in the present case, multiple large stones [Figure 1]a were recovered from the necrotic cavities which might have formed due to calcification of underlying caseous necrosis. Most calcific deposits in TB are dystrophic. [3] But it has been shown that patients with TB can develop hypercalcemia caused by excessive production of endogenous 1,25 vitamin D. [4] The differential diagnosis of multiple calcified pulmonary nodules includes infections (e.g. tuberculosis, fungal, parasitic, and viral pneumonias), pneumoconiosis (e.g. coal and silica occupational exposure), metabolic diseases (e.g. end-stage renal failure with secondary hyperparathyroidism), primary malignancy or metastasis, and other systemic illnesses such as paraproteinemias, pulmonary amyloidosis, the idiopathic disorder pulmonary alveolar microlithiasis, nodular sarcoidosis, and rheumatoid arthritis. [5] Malignant conditions to consider include both primary lung cancer and metastasis from other organs like osteogenic sarcoma, chondrosarcoma, mucin producing adenocarcinoma. Large intrathoracic calcifications are usually identified on conventional chest radiographs. Detection of smaller calcifications may require use of other imaging modalities, such as dual-energy digital radiography, fluoroscopy, radionuclide scanning, computed tomography (CT), and high-resolution CT. In the present case, the patient has died because of hemoptysis and respiratory failure. The present case emphasizes the usefulness of an autopsy in determining a definite cause of death, which would otherwise have gone undetected.

 
   References Top

1.Bendayan D, Barziv Y, Kramer MR. Pulmonary calcifications: A review. Respir Med 2000;94:190-3.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Stark P, Jacobson F, Shaffer K. Standard imaging in silicosis and coal worker's pneumoconiosis. Radiol Clin North Am 1992;30:1147.  Back to cited text no. 2
[PUBMED]    
3.Khan AN, Al-Jahdali HH, Allen CM, Irion KL, Al Ghanem S, Koteyar SS. The Calcified lung nodule: What does it mean? Ann Thorac Med 2010;5:67-79.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Abbasi AA, Chemplavil JK, Farah S, Muller BF, Arnstein AR. Hypercalcemia in active pulmonary tuberculosis. Ann Intern Med 1979;90:324-8.  Back to cited text no. 4
[PUBMED]    
5.Kumaran R, Saleh A, Amin B, Raoof S. A 73-year-old woman with mild shortness of breath and multiple central calcified pulmonary nodules. Chest 2008;134:460-4.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Rama K Badyal
Department of Pathology, Govt. Medical College, Circular Road, Amritsar - 143 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.94882

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