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RADIOLOGY QUIZ
Year : 2017  |  Volume : 34  |  Issue : 2  |  Page : 200-201  

Eggshell calcification


Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, New Delhi, India

Date of Web Publication1-Mar-2017

Correspondence Address:
Sunil K Chhabra
Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi - 110 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.201302

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How to cite this article:
Madan M, Mittal R, Gupta P, Chhabra SK. Eggshell calcification. Lung India 2017;34:200-1

How to cite this URL:
Madan M, Mittal R, Gupta P, Chhabra SK. Eggshell calcification. Lung India [serial online] 2017 [cited 2017 Mar 24];34:200-1. Available from: http://www.lungindia.com/text.asp?2017/34/2/200/201302


   Case Summary Top


A 27-year-old nonsmoker male working in a stone cutting factory for 2 years presented to the hospital with complaints of breathlessness, chest pain, and cough with minimal sputum. There was no fever, loss of weight, or appetite. He had received antitubercular therapy three times in the past on the basis of symptoms and chest radiograph lesions although acid-fast bacilli were never found on direct smear or culture. General physical examination was not remarkable except for tachypnea, and chest examination revealed bilateral infraclavicular and suprascapular inspiratory and expiratory crackles and generalized polyphonic expiratory wheeze. Lung function tests revealed severe restrictive ventilatory defect with diffusion capacity impairment (forced vital capacity [FVC] 40% of predicted, forced expiratory volume in 1 s [FEV1] 36% of predicted, FEV1/FVC 77% of predicted, total lung capacity 50% of predicted, and DLCO 45% of predicted). A chest radiograph (posteroanterior printarticle.asp?issn=0970-2113;year=2017;volume=34;issue=2;spage=200;epage=201;aulast=Madan view) was obtained [Figure 1] followed by high-resolution computed tomogram (HRCT) of the chest [Figure 2] and [Figure 3].
Figure 1: Chest radiograph (posteroanterior view)

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Figure 2: High-resolution computed tomogram of the chest (mediastinal window) at the level just below the carina. Description in answer 2

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Figure 3: High-resolution computed tomogram of the chest (lung window) at the level just below the carina. Description in answer 2

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   Questions Top


  1. Question 1: What are the observations on the chest radiograph?
  2. Question 2: What does the HRCT of the chest show?
  3. Question 3: What is the diagnosis?



   Answers Top


  1. Answer 1: The chest radiograph (PA view) [Figure 1] shows bilateral upper and midzone dense fibrocavitary lesions with interspersed calcified nodular opacities and compensatory hyperinflation in the lower zones
  2. Answer 2: HRCT of the chest [Figure 2] and [Figure 3] shows bilateral upper lobe dense fibrotic lesions representing progressive massive fibrosis (shown by arrow) with cavitation and calcified nodular opacities. In addition, the mediastinal (subcarinal) and bilateral hilar lymph nodes are calcified. The pattern of calcification is the classical “eggshell calcification,” a calcified rim around the periphery of the lymph nodes (shown by arrow)
  3. Answer 3: Chronic silicosis.



   Discussion Top


Silicosis is a fibrotic pneumoconiosis that follows exposure to various forms of free crystalline silicon dioxide or silica generated during cutting and blasting of granite, slate, and sandstone [1] and is well documented in India.[2] Depending on the nature and duration of exposure and clinical presentation, it may manifest as acute, accelerated, or chronic forms. The main symptom of the patients is usually exertional breathlessness although cough with sputum is also common. Silicosis also increases the risk of tuberculosis by 2–30 times, besides being associated with lung cancer and systemic sclerosis.[3],[4] Lung function testing reveals a mixed obstructive-cum-restrictive pattern in the majority of patients.[4] Spontaneous pneumothorax, rarely bilateral, may complicate silicosis.[5] Diagnosis is established by occupation history, clinical presentation, and chest imaging features.

The radiological lesions on plain radiography and HRCT scans of the chest include multiple small nodules scattered diffusely throughout the lungs with upper zone predilection. Calcification may occur, and coalescence of nodules and fibrosis leads to the formation of bilateral upper lobe masses, a picture labeled as “progressive massive fibrosis.” These opacities have ill-defined margins, are more than 1 cm in size, and often bilaterally symmetrical with lateral interfaces of the lesion parallel to lateral chest wall.[3],[6] Cavitation secondary to ischemic necrosis may occur. Hilar and mediastinal lymphadenopathy is common, and the lymph nodes may show calcification. Eggshell calcification refers to a ring of calcification around the periphery of a lymph node and is said to be a very characteristic sign but seen only in a minority of cases (3%–6%) of silicosis.[7]

To differentiate it from calcification along the borders as well as ring shadows due to end-on view of the large bronchi, Jacobson et al.[8] described the diagnostic criteria for eggshell calcification as follows:

  1. Shell-like calcification up to 2 mm thick must be present in the peripheral zone of at least two lymph nodes
  2. The calcification may be solid or broken
  3. In at least one of the lymph nodes, ring-like shadow must be complete
  4. The central part of the lymph node may show additional calcification
  5. One of the affected lymph nodes must be at least 1 cm in its greatest diameter.


All the above criteria were met in the present case. The diagnosis was established on the basis of clinical, the characteristic radiological picture and the occupational history of stone cutting. While eggshell calcification with bilateral progressive massive fibrosis is classically seen in silico sis and also in coal worker's pneumoconiosis, it may occasionally be observed in sarcoidosis, scleroderma, postirradiation in Hodgkin's lymphoma, blastomycosis, histoplasmosis, and amyloidosis.[7]

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Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Greenberg MI, Waksman J, Curtis J. Silicosis: A review. Dis Mon 2007;53:394-416.  Back to cited text no. 1
    
2.
Chaudhury N, Phatak N, Paliwal R, Raichaudhari C. Silicosis among agate workers at Shakarpur: An analysis of clinic-based data. Lung India 2010;27:221-4.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Gera K, Pilaniya V, Shah A. Silicosis: Progressive massive fibrosis with eggshell calcification. BMJ Case Rep 2014;2014. pii: Bcr2014206376.  Back to cited text no. 3
    
4.
Chaudhury N, Paliwal R, Phatak N. Co-morbidities among silicotics at Shakarpur: A follow up study. Lung India 2012;29:6-10.  Back to cited text no. 4
  Medknow Journal  
5.
Fotedar S, Chaudhary D, Singhla V, Narang R. Silicosis with bilateral spontaneous pneumothorax. Lung India 2010;27:173-5.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Chong S, Lee KS, Chung MJ, Han J, Kwon OJ, Kim TS. Pneumoconiosis: Comparison of imaging and pathologic findings. Radiographics 2006;26:59-77.  Back to cited text no. 6
    
7.
Gross BH, Schneider HJ, Proto AV. Eggshell calcification of lymph nodes: An update. AJR Am J Roentgenol 1980;135:1265-8.  Back to cited text no. 7
    
8.
Jacobson G, Felson B, Pendergrass EP, Flinn RH, Lainhart WS. Eggshell calcifications in coal and metal miners. Semin Roentgenol 1967;2:276-82.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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