IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Tracheobronchial Calcification due to Warfarin Therapy Souheil Abdel Nour1, Holly Abdel Nour2, Jayant Mehta1, Thomas Roy1, and Ryland Byrd1 1 Division of Pulmonary and Critical Care at East Tennessee State University, Johnson City, Tennessee; and 2Clinical Pharmacy–Mountain Home VA Medical Center, Johnson City, Tennessee
Figure 1. Chest X-ray showing diffuse calcification of the tracheobronchial tree. R = right side.
Figure 2. Axial cut of the computed tomography at the level of the trachea showing diffuse calcification of the tracheal cartilaginous ring. The posterior membranous portion of the trachea is spared.
A 55-year-old white woman presented to the hospital with chest pain. She had a history of venous thromboembolic disease and had been on warfarin for more than 15 years. The patient was found to have a myocardial infarction. She had a chest roentgenogram and a computerized tomographic angiography of the chest during her initial work-up. Imaging was noted for extensive calcification of the tracheobronchial rings (Figures 1 and 2). The calcification pattern was diffuse and spared the posterior membranous portion of the trachea. Serum calcium and phosphorus were normal. The correlation between chronic warfarin therapy and progressive tracheobronchial calcification is well established (1, 2). This condition should be differentiated from tracheopathia osteochondroplastica, a form of tracheobronchial calcification in the elderly, where the airway involvement is nonuniform with multiple calcified nodules on the inner anterolateral wall of the trachea. Serum calcium and phosphorus imbalance such as that seen in hyperparathyrodism should be excluded. Relapsing polychondritis and amyloidosis should be considered when the airways calcifications are focal or associated with tracheobronchial strictures and mural thickening. The calcification of tracheobronchial rings due to warfarin is an incidental finding. It has no clinical significance and is not a contraindication to continuing warfarin therapy. n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Moncada RM, Venta LA, Venta ER, Fareed J, Walenga JM, Messmore HL. Tracheal and bronchial cartilaginous rings: warfarin sodium-induced calcification. Radiology 1992;184:437–439. 2. Thoongsuwan N, Stern EJ. Warfarin-induced tracheobronchial calcification. J Thorac Imaging 2003;18:110–112.
Am J Respir Crit Care Med Vol 189, Iss 12, p e73, Jun 15, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201305-0975IM Internet address: www.atsjournals.org
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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Figure 1. Chest X-ray showing diffuse calcification of the tracheobronchial tree. R = right side.
Figure 2. Axial cut of the computed tomography at the level of the trachea showing diffuse calcification of the tracheal cartilaginous ring. The posterior membranous portion of the trachea is spared.
A 55-year-old white woman presented to the hospital with chest pain. She had a history of venous thromboembolic disease and had been on warfarin for more than 15 years. The patient was found to have a myocardial infarction. She had a chest roentgenogram and a computerized tomographic angiography of the chest during her initial work-up. Imaging was noted for extensive calcification of the tracheobronchial rings (Figures 1 and 2). The calcification pattern was diffuse and spared the posterior membranous portion of the trachea. Serum calcium and phosphorus were normal. The correlation between chronic warfarin therapy and progressive tracheobronchial calcification is well established (1, 2). This condition should be differentiated from tracheopathia osteochondroplastica, a form of tracheobronchial calcification in the elderly, where the airway involvement is nonuniform with multiple calcified nodules on the inner anterolateral wall of the trachea. Serum calcium and phosphorus imbalance such as that seen in hyperparathyrodism should be excluded. Relapsing polychondritis and amyloidosis should be considered when the airways calcifications are focal or associated with tracheobronchial strictures and mural thickening. The calcification of tracheobronchial rings due to warfarin is an incidental finding. It has no clinical significance and is not a contraindication to continuing warfarin therapy. n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Moncada RM, Venta LA, Venta ER, Fareed J, Walenga JM, Messmore HL. Tracheal and bronchial cartilaginous rings: warfarin sodium-induced calcification. Radiology 1992;184:437–439. 2. Thoongsuwan N, Stern EJ. Warfarin-induced tracheobronchial calcification. J Thorac Imaging 2003;18:110–112.
Am J Respir Crit Care Med Vol 189, Iss 12, p e73, Jun 15, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201305-0975IM Internet address: www.atsjournals.org
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
e73
