CASE REPORT Linear diaphragmatic calcification in a two year-old child with tuberculosis I Rachman MB, FRCP Principal Medical Officer, Brooklyn Chest Hospital, Cape Town if he incidental finding, on a chest x-ray, of dense, linear shadows lying above and parallel to one or both domes of the diaphragm, is widely regarded as pathognomonic of calci- fication due to previous exposure to asbestos. Features of asbestos-related pleu- ral thickening differ from the changes seen following tuberculosis pleurisy, even in the absence of symptomatic or radiographic underlying lung dis- ease. In the former, bilateral, finger- like shadows project from the axilliary margins of one or both lungs, often with bizarre, characteristically' antler' shaped opacities lying more medially. These tend gradually to enlarge and calcify. Rarely, there is progression to invasive malignancy, mesothelioma; this may also present as a 'pleural ef- fusion for diagnosis'. In TB, unilateral sheets of diffuse, often hazy shadowing, may be seen, which becomes dense as calcification develops; the diaphragmatic pleura is traditionally spared. G Boss MB,OCH Retired Chest Physician, London 4 SAJOURNAL OF RADIOLOGY· May 1998 We describe the case of a young child with x-ray changes typical of pleural asbestosis, in which the min- eral could not be reasonably impli- cated. Case report JJ, born 21/7/74, was admitted to Al Stals Hospital, Cape Town, on 14/6/76 with extensive pulmonary TB and paratracheal and hilar lym- phadenopathy. The diagnosis was based on a Mantoux reaction greater than 10 mm, the presence of AFB in gastric washings, and the appearance of the chest x-ray, which showed ex- tensive bilateral pulmonary consolida- tion, more on the left, and widening of the upper mediastinum (Figure 1). She Figure 1: Admission chest radiograph demonstrat- ing bilateral pulmonary consolidation more marked on the left, and mediastinal widening. No diaphragmatic calcification is seen. was treated with streptomycin, isoni- azid, rifampicin and pyrazinamide and made good progress until her dis- charge on 9/3/77. She had needed transfusing on admission, Hb 4. Og.An attack of chicken pox two months later did not halt her progress; in par- ticular, no related lung involvement was evident. topage6 Enhancing MRI • Another innovative product in the Schering Diagnosties range. • CONVENIENCE Schering understands that timing, accuracy and efficacy are of essence inMRI • SIMPLICITY Pre-filled syringes offer fast and easy application Magnevist • EASE OF USE Injected volume instantly visible through reverse scaling Schering (Ply) Ltd (Reg. No. : 64/09072/07) 106 Sixteenth Road, Randjespark, Midrand 1685. P.O. Box 5278, Halfway House 1685. UlO 3198 Tel: (011) 313-9700. Fax: (011) 313-9793. e-mail: schertngOlcon.co.za ~ Magnevls" 20 ml. 1 ml solution contelns Gadopentetlc acid, Dlmeglumlne salt 469,01 mg DTPA, Meglumlne salt max. 1,02 mg. Reg. No.: W/281199. 32851 Linear diaphr<1gnldtic calcificc:1lioll ill d two year old child with tuberculosis frompage4 A fleck of calcification on the right diaphragm can be seen two months after treatment was begun (Figure 2), and well marked bilateral linear cal- cific shadows at the time of discharge from hospital (Figure 3). Figure 2: Chest radiograph two months after commencement of therapy demonstrating partial clearing of lung opacification and small fleck of calcification (arrow) on the right diaphragmatic pleura. Figure 3: Note linear diaphragmatic pleural calcification (arrows) on chest radiograph 9 months after commencement of therapy. Also note calcified mediastinal (open arrow) and cervical (curved arrows) lymphadenopathy. Discussion The little girl came from Gordon's Bay, a coastal village near Cape Town. No evidence of exposure to asbestos could be obtained. Contact with the mineral would, in any case, be most un- likely to cause this x-ray appearance in so young a patient. COMPANY NEWS SCI-IERINC Pre-filled syringes for MR. MAGNEVIST® WAS the first para- magnetic MRI contrast agent for in- travenous injection. Since its introduc- tion, radiologists all over the world have made it the most widely used and extensively documented contrast agent for MR!, according to a spokes- person for Schering (Pty) Ltd. To complement the existing range of Magnevist" vials and Magnevist Simon' cites tuberculosis rheuma- toid pleurisy and haemothorax follow- ing trauma, as well as asbestos expo- sure, as possible causes of linear dia- phragmatic calcification. The reason for the rarity of dia- phragmatic pleurisy leading to calcifi- cation in the relatively common dis- eases cited by Simon is not clear. A subpneumonie inflammatory effusion could conceivably be affected by re- duced or altered movement of the dia- phragm, leading to a more rapid reso- lution, with fewer sequelae. On the other hand, the ability of the asbestos fibres to penetrate the pleura causing an asymptomatic inflammatory reac- tion leading finally to calcification, could presumably be related to the extreme chronicity of the process, said to be not less than about 20 years and often much longer. Perhaps we should revise our in- terpretation of linear diaphragmatic calcification seen on the chest x-ray. Reference I. Simon G. Chest x-ray diagnosis. 3'" ed, 1971, p109. enteral", the company has in- troduced Magnevist" in pre- filled syringes. Launched on April l ", Magnevist pre-filled sy- ringes present a new era in MRI convenience. The sy- ringes are available in ready- to-use l O, IS, and 20 ml sizes, and the injection vol- ume is instantly visible through reverse scaling. 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