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A 31 year old woman with end stage renal disease secondary to hypertension and on haemodialysis for 10 years was admitted with shortness of breath, cough, and low grade fever. She had a past history of hypercalcaemia, which had developed due to tertiary hyperparathyroidism because of her renal disease. She subsequently underwent total parathyroidectomy. Her physical examination was significant for a low grade fever, dull percussion note and decreased air entry at the right base. Results of laboratory investigations on admission were significant for calcium = 1.5 mmol/l, phosphate = 1.7 mmol/l, total protein = 59 g/l, and albumin = 13 g/l. Chest radiography revealed an old right sided pleural effusion and bibasilar atelectasis. The cardiac silhouette was enlarged suggesting left ventricular hypertrophy but no evidence of calcification. Thoracentesis was performed which was unremarkable. However, as she continued to have a low grade temperature, computed tomography of her chest was performed to rule out any localised fluid collection. The scan showed the old pleural effusion and no new fluid pockets. Interestingly, the computed tomography revealed diffuse deposition of calcium within the myocardium (fig 1). We believe that the patient developed “metastatic calcification” in the myocardium when she was hypercalcaemic due to tertiary hyperparathyroidism. There was no evidence of calcium deposition elsewhere. Her echocardiogram was consistent with restrictive filling pattern. She was empirically started on broad spectrum antibiotics. Her fever resolved after three days and the patient was discharged home. All the appropriate cultures came back negative.
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