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Year : 2020  |  Volume : 1  |  Issue : 2  |  Page : 103-104

‘Molten Candle Wax’ Pleural calcification

1 Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Pulmonary Medicine, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India

Date of Submission14-May-2020
Date of Decision27-May-2020
Date of Acceptance09-Jun-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Mayank Mishra
Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh - 249 201, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_49_20

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How to cite this article:
Mishra M, Kumar S. ‘Molten Candle Wax’ Pleural calcification. J Med Evid 2020;1:103-4

How to cite this URL:
Mishra M, Kumar S. ‘Molten Candle Wax’ Pleural calcification. J Med Evid [serial online] 2020 [cited 2022 Aug 7];1:103-4. Available from: http://www.journaljme.org/text.asp?2020/1/2/103/303574

  Introduction Top

Pleural calcifications are often encountered during routine radiological evaluation. The underlying causes are variable and most often a consequence of a chronic infectious or inflammatory process, though pleural calcifications do not always indicate benign disease. The radiological pattern of pleural calcification may sometimes be helpful in pointing towards the likely nature of the underlying disease process.[1] We present the case of an elderly male in whom an extensive sheet-like pleural calcification classically resembling molten candle wax was noted on chest X-ray. Clinical workup unravelled it to be arising as a consequence of a left-sided tuberculous pleural effusion that was treated with anti-tuberculous drugs many years back.

  Case Report Top

A 60-year-old gentleman, farmer by occupation and with a smoking history of 40 pack-years, presented with progressive exertional dyspnoea for the last 2 years. He had been adequately treated with anti-tuberculous drugs 40 years back for left-sided tuberculous pleural effusion. There was no past history of asbestos exposure, thoracentesis, intercostal drain insertion or chest trauma. His vital parameters were normal, and general physical examination was unremarkable. The chest was asymmetrical, with flattening of the anterior and posterior chest wall on the left side, drooping of the left shoulder and crowding of the left ribcage. Chest movements were diminished on the left side. Percussion note was impaired, and reduced intensity of breath sound was present over the left lower chest. Scattered rhonchi were also appreciated. Laboratory values of renal function tests, serum calcium and parathormone levels were normal. The postero-anterior view of his chest roentgenogram [Figure 1] revealed extensive pleural calcification, giving a 'molten candle wax' appearance to the left pleura. There was evidence of volume loss in the form of crowded ribs on the left side and compensatory hyperinflation of the right lung. Contrast-enhanced computed tomography of the thorax [Figure 2] showed thickened left pleura with predominantly postero-lateral pleural calcification and emphysematous right lung. Spirometry was suggestive of very severe airflow obstruction, indicating advanced chronic obstructive pulmonary disease (COPD).
Figure 1: Chest radiograph (postero-anterior view) showing extensive left-sided, sheet-like dense pleural calcification resembling dribbling molten candle wax (white arrows), with ipsilateral volume loss, rib crowding and tenting of hemidiaphragm and contralateral compensatory hyperinflation

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Figure 2: Axial (a) and coronal (b) sections of contrast-enhanced computed tomography of the thorax showing thickened left pleura with predominantly postero-lateral pleural calcification (white arrows) and emphysematous right lung

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The patient's dyspnoea was attributed to COPD for which his treatment was optimised. He was counselled that pleural calcification was an incidental finding, which was likely a result of left tuberculous pleural effusion for which he had already been adequately treated in the past. He was further informed about the irreversible nature of pleural calcification and reassured that no active intervention was required for it. The advice was well taken by the patient and for the last 7 years, he has been doing well on inhaled therapy and pulmonary rehabilitation for COPD, and is in regular outpatient follow-up.

  Discussion Top

Calcification implies deposition of calcium salts in various body tissues. Its pathogenesis is poorly understood, but hypercalcaemia, hyperphosphataemia, alkalosis and tissue damage are considered as predisposing factors.[2] In general, calcification can be of two types – dystrophic or metastatic. Dystrophic calcification occurs in diseased or damaged tissues, is localised and is associated with normal serum levels of calcium and phosphate. It mostly arises as a result of infection, bleeding, amyloidosis and pneumoconiosis. Metastatic calcification occurs in normal tissues, is generalised and is associated with elevated serum levels of calcium and phosphate. It commonly occurs in chronic renal failure, hyperparathyroidism and certain malignancies.

Calcification of the pleural membrane is seen as a radiological opacity along the pleural contour. Pleural calcification and plaques are noted in about 1% of routine chest radiographs performed in adults.[3] It is commonly suggested that pleural calcification seen in association with pleural thickening and diffuse pleural disease indicates a benign process.[4] Its causes include chronic inflammatory pleural disorders such as tuberculous pleural effusion, pneumothorax, bacterial or tuberculous empyema, haemothorax or fibrothorax[5] and post-talc pleurodesis. Such calcification is usually unilateral, extensive, continuous, sheet like and associated with visceral pleural thickening.[1] It is benign, is irreversible and requires no active intervention apart from patient counselling and reassurance. However, if unilateral and localised, a malignant process (e.g., mesothelioma and pleural metastases) needs to be excluded, as also rib fracture or pneumoconiosis.

Importantly, pleural calcification does not always indicate benignity especially when it occurs in the setting of asbestos exposure. Here, it is seen bilaterally usually in the lower two-thirds of the thorax as patchy parietal pleural plaques that may be calcified. Such calcification is coarse and usually occurs along the chest wall, diaphragm or cardiac borders.[6],[7],[8] It typically develops in lesions of more than 20–30 years' duration[9] and may be considered a risk factor for malignancy because of the strong association of pleural plaques with asbestos exposure. Additional radiological findings that may be useful in distinguishing malignant from benign pleural disease include circumferential and nodular pleural thickening, parietal pleural thickness >1 cm, mediastinal pleural involvement and pleural rind.[4],[10] Interestingly, asbestos-related pleural plaques too have been described to have a white or pale-yellow shaggy appearance which macroscopically (but not radiologically, as in the index case) resembles candle wax.

To conclude, pleural calcification is a frequently encountered entity that may represent an underlying benign or malignant pleural process. The background clinical picture of the patient, radiographic pattern of pleural calcification and associated imaging findings as mentioned above may be helpful in pointing towards the possible nature of the disease. Of note in the present case is the extensive sheet-like pleural calcification having unique resemblance to molten or dripping candle wax, a radiological (X-ray) description uncommonly reported in the context of pleural calcification. The finding was correlated to be a sequel of previously treated pleural effusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bendayan D, Barziv Y, Kramer MR. Pulmonary calcifications: A review. Respir Med 2000;94:190-3.  Back to cited text no. 1
Kachewar SG, Kulkarni DS. An imaging review article on pleura pulmonary calcification and its impact. IJARS 2013;2:29-34.  Back to cited text no. 2
Sastremartin R, Polo J, Alvarez D. Pleural calcifications. Rev Clin Esp 1964;94:143-6.  Back to cited text no. 3
Leung AN, Müller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR Am J Roentgenol 1990;154:487-92.  Back to cited text no. 4
Marchiori E, Hochhegger B, Zanetti G. Pleural calcifications. J Bras Pneumol 2018;44:447.  Back to cited text no. 5
Kiviluoto R. Pleural calcification as a roentgenologic sign of non-occupational endemic anthophyllite-asbestosis. Acta Radiol Suppl 1960;194:1-67.  Back to cited text no. 6
Friedman AC, Fiel SB, Fisher MS, Radecki PD, Lev-Toaff AS, Caroline DF. Asbestos-related pleural disease and asbestosis: A comparison of CT and chest radiography. AJR Am J Roentgenol 1988;150:269-75.  Back to cited text no. 7
Ehrlich R, Lilis R, Chan E, Nicholson WJ, Selikoff IJ. Long term radiological effects of short term exposure to amosite asbestos among factory workers. Br J Ind Med 1992;49:268-75.  Back to cited text no. 8
Cugell DW, Kamp DW. Asbestos and the pleura: A review. Chest 2004;125:1103-17.  Back to cited text no. 9
Metintas M, Ucgun I, Elbek O, Erginel S, Metintas S, Kolsuz M, et al. Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases. Eur J Radiol 2002;41:1-9.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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