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Multiple small opacities of metallic density in the lung
  1. D Chaudhrya,
  2. Jagdish,
  3. M Garga,
  4. A Aggarwala,
  5. S Tandonb
  1. aPandit B D Sharma Postgraduate Institute of Medical Sciences, Rohtak (Haryana), India: Department of Medicine, bDepartment of Chest Diseases and Tuberculosis
  1. Dr Dhruva Chaudhry, # 39, Sector-1 Huda, Rohtak-124001(Haryana), Indiadchaudhry{at}hotmail.com

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Answers on p 798.

A 24 year old young man presented with sudden onset of chest pain, dry cough, and shortness of breath of five days' duration. He denied trauma, fever, chills, or haemoptysis. A physical examination was unremarkable. Chest auscultation revealed decreased breath sounds with pleural rub in the right infra-axillary region. His complete blood count, urine analysis, and liver and renal function tests were normal. Chest radiography showed bilateral, multiple point opacities with a metallic density confined primarily to lower and middle zones as well as in the right ventricular apex (figs1 and 2). High resolution computed tomography (HRCT) of the thorax revealed bilateral diffusely distributed multiple, tiny dense spherules, sometimes appearing as beaded chains filling pulmonary arterioles. Metallic density was also noted at the apex of the right ventricle with streak artefacts (figs 3 and 4). A radiograph of the abdomen showed numerous metallic deposits in the distribution of the paravertebral veins and kidney. Ultrasound showed multiple metallic deposits in the right kidney, however, they were absent in the left kidney; the liver, gall bladder, and spleen were normal. Pulmonary function tests showed restrictive ventilation defect, with reduction in vital capacity. The single breath carbon monoxide (CO) diffusing capacity was at the lower limit of normal (33.04 ml CO/min/mm Hg) and the ratio of diffusing capacity to single breath helium dilution total lung capacity was low (3.90 ml CO/min/mm Hg/l, predicted value 5.76).

Figure 1

Chest radiograph (posteroanterior view) showing multiple small opacities of metallic density. A large metallic opacity is also visible in right ventricle (arrow).

Figure 2

Chest radiograph (lateral view) showing multiple small opacities of metallic density. A large metallic opacity is also visible in right ventricle apex (arrow).

Figure 3

HRCT of chest showing spherules of metallic density.

Figure 4

HRCT of chest showing multiple opacities of metallic density conglomerating at some places. Opacities of similar density with multiple streak artifacts are also seen in the heart.

Questions

(1)
What is the likely diagnosis?
(2)
What is the differential diagnosis?

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