Arteries
Rounded Calcification in the Left Hilum What Could it Be?
2. Findings and Diagnosis
In this case – a less common Cause
Calcified Coronary Artery Aneurysm
Round Calcification in the Region of the Left Hilum
41 year old male presents with chest pain.
Frontal CXR shows a rounded calcification, (black arrow in the left image and red arrow in the magnified right image). The calcification is approximately 2cms in size and represents an aneuruysm of the left coronary artery (LCA).
Ashley Davidoff MD
86928.8c
41 year old male presents with chest pain.
Lateral CXR shows a rounded calcification, (black arrow in the left image and red arrow in the magnified right image). the calcification is approximately 2cms in size .
Ashley Davidoff MD
86928.8c01
Differential Diagnosis of nodules with a diameter of ≤ 2 cm and rim calcification:
| Differential Diagnosis | Anatomic Possibility | Pathologic Possibility | Key Points |
|---|---|---|---|
| Calcified Lymph Node | Left hilar lymph nodes (normal anatomical location) | Granulomatous diseases (e.g., tuberculosis, sarcoidosis, histoplasmosis, coccidioidomycosis) | Common cause of calcified nodules, typically a benign finding from prior infection or inflammation. Often well-defined. |
| Granulomatous Inflammation (Sarcoidosis) | Left hilar lymph nodes (regional lymphadenopathy) | Sarcoidosis (stage 1 with bilateral hilar lymphadenopathy and calcification) | Hilar lymphadenopathy with rim calcification is typical; usually asymptomatic and benign. |
| Tuberculosis (TB) | Left hilar lymph nodes (reactive regional nodes) | Tuberculosis (primary or post-primary) | TB often causes calcified granulomas in lymph nodes; healed infection with rim calcification is typical. |
| Histoplasmosis | Left hilar lymph nodes (regional spread of infection) | Histoplasmosis (fungal infection) | In endemic areas, calcified granulomas with rim calcification can be seen in hilar lymph nodes post-infection. |
| Coccidioidomycosis | Left hilar lymph nodes (regional spread of infection) | Coccidioidomycosis (fungal infection) | Seen in endemic regions (e.g., Southwestern U.S.); calcified nodules may show rim calcification after healing. |
| Left Coronary Artery Aneurysm (with Rim Calcification) | Left coronary artery, near the hilum (anatomic proximity to the left lung) | Aneurysm of the left coronary artery (with calcification of the vessel wall) | A rare but important cause; calcified aneurysms may present with a distinct “rim” appearance on imaging, typically around 2 cm in diameter. |
| Metastatic Disease (Benign) | Left hilar region (rare direct metastasis) | Metastasis (from a primary malignancy) | Rare in the hilum, but calcified metastases (e.g., from renal cell carcinoma) may present with rim calcification, typically stable in size over time. |
| Pulmonary Hamartoma (Calcified) | Left lung, peripheral or hilar regions | Pulmonary hamartoma (benign tumor) | Typically peripheral, hamartomas can have popcorn calcifications. Occasionally, a central, calcified hamartoma may be mistaken for a nodule in the hilum. |
| Aortic Aneurysm (Calcified) | Left hilum or adjacent to the left lung | Calcified aortic aneurysm or calcified vessels | Aortic aneurysms may calcify and be mistaken for a nodule, but these typically don’t have the same “rim” calcification pattern seen in granulomatous diseases. |
| Pulmonary Infarct | Left lung (with vascular supply from the left pulmonary artery) | Pulmonary infarction (due to pulmonary embolism) | Pulmonary infarcts may calcify post-infarction, and the calcification could appear with a well-defined rim around 2 cm in size. |
heart cardiac
aneursym
coronary artery
Kawasaki’s areteritis
grosspathology
Courtesy Ashley Davidoff MD
Key Considerations:
- Rim Calcification: Rim calcification is typically seen in granulomatous infections (e.g., TB, histoplasmosis, sarcoidosis), benign tumors (e.g., hamartomas), and vascular anomalies (e.g., coronary artery aneurysm). It is a characteristic feature of healed granulomas or calcified masses.
- Coronary Artery Aneurysm: A calcified left coronary artery aneurysm may mimic a calcified lymph node or lung nodule, particularly in the left hilum. Rim calcification around a 2 cm lesion is a significant clue, especially in patients with a history of vascular disease or symptoms suggestive of coronary pathology.
- Size Considerations: Nodules with rim calcification and a diameter of ≤ 2 cm are often benign and represent chronic infections or vascular anomalies (e.g., coronary artery aneurysm). However, follow-up imaging and clinical correlation are crucial to rule out malignant or vascular causes.
LAD Aneurysm in a 41-Year-Old Male:
- Age & Risk Factors: In a 41-year-old male, an LAD aneurysm is relatively rare, but possible in the presence of:
- Atherosclerosis (especially with family history or smoking).
- Trauma (history of chest injury).
- Post-MI changes (prior myocardial infarction in the patient’s medical history).
- Genetic conditions (e.g., Marfan syndrome, Ehlers-Danlos syndrome).
- Hypertension (chronic high blood pressure).
- Kawasaki Disease (in individuals with a history of the disease).
- Kawasaki Disease (IE):
- Kawasaki Disease is an acute vasculitis primarily affecting children but can occur in adults, especially those with a history of untreated or under-treated disease.
- It causes inflammation of the coronary arteries, particularly the LAD, leading to aneurysms in the coronary arteries, including the LAD.
- Risk: Coronary artery aneurysms are a known complication, particularly in patients who did not receive early IVIG (intravenous immunoglobulin) treatment.
- Symptoms: If symptomatic, chest pain, shortness of breath, or abnormal findings on electrocardiogram (ECG) may be present.
- Imaging:
- CT coronary angiography or cardiac MRI are the preferred diagnostic tools.
- A calcified aneurysm may show a characteristic rim calcification around the aneurysm.
- Prognosis: If asymptomatic, management focuses on regular monitoring and controlling risk factors (e.g., blood pressure, cholesterol). If symptomatic or there is significant risk of rupture, surgical intervention may be necessary.
Key Points on Kawasaki Disease (IE):
- Definition: Kawasaki disease is a self-limited vasculitis that primarily affects children but can lead to coronary artery aneurysms, especially if the disease occurs at an older age or is untreated.
- Aneurysms: Coronary artery aneurysms, including those involving the LAD, can form weeks after the onset of Kawasaki disease, with the LAD being one of the most commonly affected vessels.
- Diagnosis & Treatment:
- Early treatment with IVIG and aspirin is critical to reduce the risk of coronary artery aneurysms.
- Cardiac evaluation (e.g., echocardiography, CT angiography) is essential for detecting aneurysms.
This artistic rendering depicts a young man riding a Kawasaki motorbike, symbolizing a connection to Kawasaki disease. The image highlights an aneurysm in the right coronary artery (RCA), which is more commonly affected than the left coronary artery in Kawasaki disease. This condition is a rare but significant consequence of Kawasaki disease, often seen in individuals with untreated or under-treated cases. The motorbike represents the youth and vitality that may be impacted by this potentially life-threatening cardiovascular issue.
Ashley Davidoff, MD TheCommonVein.com (140004.heart)
Question 1:
Which coronary artery is most commonly affected by aneurysms in Kawasaki disease?
A) Left Anterior Descending (LAD) artery
B) Right Coronary Artery (RCA)
C) Left Circumflex Artery
D) Pulmonary Artery
Correct Answer: B) Right Coronary Artery (RCA)
Explanation:
-
B (Correct Answer): The Right Coronary Artery (RCA) is more commonly affected by aneurysms in Kawasaki disease than the left coronary artery. The disease can lead to coronary artery aneurysms, with the RCA being the most frequently involved vessel.
-
A (Incorrect): The Left Anterior Descending (LAD) artery can also be involved in coronary artery aneurysms in Kawasaki disease, but it is less commonly affected than the RCA.
-
C (Incorrect): The Left Circumflex Artery is less commonly involved in aneurysms associated with Kawasaki disease. The RCA and LAD are more frequently affected.
-
D (Incorrect): The Pulmonary Artery is unrelated to coronary artery aneurysms in Kawasaki disease. The pulmonary artery primarily deals with blood flow to the lungs, not the coronary circulation.
Question 2:
What is the first-line treatment to reduce the risk of coronary artery aneurysms in patients with Kawasaki disease?
A) Antibiotics
B) Intravenous Immunoglobulin (IVIG)
C) Statins
D) Antiplatelet therapy
Correct Answer: B) Intravenous Immunoglobulin (IVIG)
Explanation:
-
B (Correct Answer): Intravenous Immunoglobulin (IVIG) is the first-line treatment for Kawasaki disease and is critical in reducing the risk of coronary artery aneurysms. IVIG helps to control the inflammatory response and decrease the chances of coronary artery damage.
-
A (Incorrect): Antibiotics are not effective for treating Kawasaki disease because it is not caused by a bacterial infection. Kawasaki disease is an autoimmune vasculitis, not an infection.
-
C (Incorrect): Statins are typically used for controlling cholesterol and reducing the risk of cardiovascular disease, but they are not used to treat Kawasaki disease specifically. Statins are not first-line therapy for this condition.
-
D (Incorrect): Antiplatelet therapy (e.g., aspirin) may be used in conjunction with IVIG for Kawasaki disease to reduce the risk of thrombosis, but it is not the primary treatment to reduce coronary artery aneurysms. IVIG is the first-line treatment.