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Description
A 35-year-old man, a never smoker, had a cough and breathlessness for 1 year. He had worked as a stone crusher for 8 years. Apart from decreased breath sounds on auscultation, his physical examination was within normal limits. Pulmonary function testing was suggestive of moderately severe restriction with reduced diffusion capacity. Chest X-ray revealed diffuse reticulonodular shadows and multiple mass-like symmetrical lesions with irregular margins separated from the pleura by aerated lungs, an appearance known as ‘angel's wings’1 (figure 1). CT of thorax demonstrated eggshell calcification of lymph nodes and within the masses (figure 2A, mediastinal window), along with large, symmetrical, bilateral, conglomerate masses having irregular margins and nodular densities (figure 2B, lung window). Furthermore, lateral interfaces of the mass lesions were parallel to the lateral chest wall. Imaging, supported by occupational history, was suggestive of progressive massive fibrosis (PMF) due to silicosis.
Chest X-ray on presentation showing reticulonodular shadows and multiple mass-like symmetrical lesions with irregular margins. This is known as ‘angel's wings’ appearance. The lateral interfaces of the mass lesions parallel the lateral chest wall.
Non-contrast high-resolution CT of thorax showing (mediastinal window: A) eggshell calcification of lymph nodes and calcification within the masses; (lung window: B) large, symmetrical, bilateral conglomerate masses having irregular margins and nodular densities. The lateral interfaces of the mass lesions parallel the lateral chest wall.
Radiologically, silicosis caused by inhalation of silica particles can be classified as simple or complicated silicosis also known as PMF, which presents with large and conglomerate opacities. These opacities, with ill-defined margins, are larger than 1 cm, symmetrical in distribution and often with calcifications and surrounding emphysematous areas.2 The lateral interfaces of the lesions are characteristically parallel to the lateral chest wall, as seen in our patient. Patients with silicosis and coal-worker’s pneumoconiosis are commonly affected with peripheral calcification of lymph nodes known as ‘eggshell calcification’.3 Approximately a fourth of these patients have silicotuberculosis,2 but we were unable to find any evidence in our patient.
Learning points
Complicated silicosis or progressive massive fibrosis is characterised by mass lesions.
Lateral interfaces of the masses typically parallel the lateral chest wall.
‘Eggshell calcification’ or peripheral calcification is a characteristic feature of progressive massive fibrosis seen in silicosis.
Footnotes
Contributors KG, VP and AS collected the clinical data and reviewed the literature. KG, VP and AS drafted the manuscript and were responsible for the clinical workup of the patient. AS is responsible for the genuineness of the data, the concept and is also the guarantor of the paper. All authors have read and approved the final manuscript.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.