Effect of volume of instillate on the diagnostic utility of bronchoalveolar lavage galactomannan in patients with suspected chronic pulmonary aspergillosis-A pilot study.

BACKGROUND: Bronchoalveolar lavage (BAL) galactomannan (GM) is commonly used to diagnose Aspergillus-related lung diseases. However, unlike serum GM, which is measured in undiluted blood, BAL-GM is estimated using variable aliquots and cumulative volume of instillates during bronchoscopy. OBJECTIVE: Since different studies have reported varying diagnostic accuracy and cut-offs for BAL-GM in CPA, we hypothesized that the total volume of instillate and 'order/label' of aliquots significantly affects the BAL-GM values, which was evaluated as part of this study. PATIENTS & METHODS: We obtained 250 BAL samples from 50 patients (five from each) with suspected chronic pulmonary aspergillosis. BAL fluid was collected after instilling sequential volumes of 40 mL of normal saline each for the first four labels and a fifth label was prepared by mixing 1 mL from each of the previous labels. The GM level of each label was measured by PLATELIA™ ASPERGILLUS Ag enzyme immunoassay. This study measured the discordance, level of agreement, diagnostic characteristics (sensitivity, specificity and AUROC) and best cut-offs for BAL-GM in the different aliquots of lavage fluid. RESULTS: The study population, classified into CPA (28%) and non-CPA (72%) groups, based on ERS/ESCMID criteria (excluding BAL-GM) were not different with respect to clinico-radiological characteristics. The discordance of BAL-GM positivity (using a cut-off of >1) between the serial labels for the same patient ranged between 10% and 22%, while the discordance between classification using BAL-GM positivity (using a cut-off of ≥1) and clinic-radio-microbiological classification ranged between 18% and 30%. The level of agreement for serial labels was at best fair (<0.6 for all except one 'label'). The AUROC for the serial samples ranged between 0.595 and 0.702, with the '40 mL and the 'mix' samples performing the best. The best BAL-GM cut-off also showed significant variation between serial labels of varying dilutions (Range:1.01 - 4.26). INTERPRETATION: This study highlights the variation in BAL-GM measured and the 'positivity' between different 'labels' of aliquots of BAL, with the first aliquot and the mixed sample showing the best performances for diagnosis of CPA. Future studies should attempt to 'standardise' the instilled volume for BAL-GM estimation to standardise the diagnostic yield.

Chronic pulmonary aspergillosis incidence in newly detected pulmonary tuberculosis cases during follow-up.

BACKGROUND: Chronic pulmonary aspergillosis (CPA) is known to complicate patients with post-tubercular lung disease. However, some evidence suggests that CPA might co-exist in patients with newly-diagnosed pulmonary tuberculosis (P.TB) at diagnosis and also develop during therapy. The objective of this study was to confirm the presence of CPA in newly diagnosed P.TB at baseline and at the end-of-TB-therapy. MATERIALS AND METHODS: This prospective longitudinal study included newly diagnosed P.TB patients, followed up at third month and end-of-TB-therapy with symptom assessment, anti-Aspergillus IgG antibody and imaging of chest for diagnosing CPA. RESULTS: We recruited 255 patients at baseline out of which 158 (62%) completed their follow-up. Anti-Aspergillus IgG was positive in 11.1% at baseline and 27.8% at end-of-TB-therapy. Overall, proven CPA was diagnosed in 7% at baseline and 14.5% at the end-of-TB-therapy. Around 6% patients had evidence of aspergilloma in CT chest at the end-of-TB-therapy. CONCLUSIONS: CPA can be present in newly diagnosed P.TB patients at diagnosis and also develop during anti-tubercular treatment. Patients with persistent symptoms or developing new symptoms during treatment for P.TB should be evaluated for CPA. Whether patients with concomitant P.TB and CPA, while receiving antitubercular therapy, need additional antifungal therapy, needs to be evaluated in future studies.

The Utility of Galactomannan and Polymerase Chain Reaction Assays in Bronchoalveolar Lavage for Diagnosis of Chronic Pulmonary Aspergillosis.

The diagnosis of chronic pulmonary aspergillosis (CPA) is established by combined clinic-radio-microbiological criteria. Out of the different microbiological criteria, a positive serology for Aspergillus-specific IgG levels is the cornerstone of diagnosis. Alternatively, other microbiological evidence are sometimes sought viz., positive Aspergillus antigen (broncho-alveolar lavage fluid, i.e., BALF galactomannan ≥ 1.0), histopathological demonstration of the fungi following lung biopsy or resection, demonstration of hyaline septate hyphae in direct microscopy resembling Aspergillus spp. or its growth on a respiratory specimen. However, the exact roles of BALF- GM and the newer BALF-PCR have not been confirmed by studies till date. This study enrolled 210 patients with suspected CPA. Of the participants, 88 patients met the criteria for CPA, whereas 122 patients had an alternative diagnosis. The sensitivity-specificity of AsperGenius® PCR and "in-house" PCR were 52.27(36.69-67.54) %-33.78 (23.19-45.72) % and 36.36 (22.41-52.23) %-39.19 (28.04-51.23) % respectively. The sensitivity/specificity of BALF (> 1.0) and serum galactomannan (> 1.0) were 46.55% (33.34-60.13)/64.08% (54.03-73.3) and 29.82% (22.05-37.6)/86.84% (81.1-92.59) respectively. The optimal cut-off values for BALF-Galactomannan and serum galactomannan in diagnosing CPA were found to be 0.69 (sensitivity: 64%; specificity: 53%) and 0.458 (sensitivity: 67%; specificity: 64%) respectively. This results of this study suggests that Aspergillus PCR from BAL may not be a good "rule-in" test for diagnosing CPA. While the performances of GM in BAL and serum may be better than PCR, it should be best used in conjunction with other clinical, radiological, and other microbiological characteristics.

Utility of nasal application of lignocaine gel using cotton tip swab versus squirting with slip-tip syringe for transnasal fibreoptic bronchoscopy: a pilot randomised controlled trial.

BACKGROUND: During flexible fibreoptic bronchoscopy through the nasal route, anaesthesia of the nasal passage is achieved by lignocaine gel application by a slip-tip syringe or with the help of a cotton tip swab. No studies in existing literature have compared the two techniques in terms of efficacy. METHODS: 137 consecutive patients undergoing bronchoalveolar lavage (BAL) were recruited over a 2-year period. The patients underwent BAL after nasal anaesthesia-either by slip-tip syringe or by cotton tip swab smeared with 2% lignocaine gel. Patients were monitored for intraprocedural epistaxis, discomfort and improvement in operator visibility of nasal passage. RESULTS: 67 patients were randomised to cotton swab and 70 patients to the gel instillation group. There were no significant differences in terms of epistaxis, 29.9% in the cotton tip swab (95% CI 19.3% to 42.3%) versus 24.3% in the gel instillation group (95% CI 14.8% to 36%) or detection of nasal blocks, 7.5% in the cotton tip swab (95% CI 2.5% to 16.6%) versus 10% in the gel instillation group (95% CI 4.1% to 19.5%) in the two groups, although a significant difference was there in terms of visibility, 73.1% in the cotton tip swab (95% CI 60.9% to 83.2%) versus 42.9% in the gel instillation group (95% CI 31.1% to 55.3%). There was no difference in the mean pain score across the two groups either during the procedure or 1 hour after it. A short systematic review of existing literature on the topic has been provided for comparison. CONCLUSION: Application of 2% lignocaine gel by slip-tip syringe and cotton tip swab are equivalent in terms of observed and narrated pain experienced by patients, frequency of epistaxis and nasal blocks. Vision was better preserved in the cotton tip swab group.

An open-label non-inferiority randomised control trial comparing nebulised amphotericin B with oral itraconazole in patients with pulmonary aspergilloma.

BACKGROUND: Pulmonary aspergilloma (PA) is a common complication seen in patients with pulmonary tuberculosis sequelae. Antifungal therapy, including oral azoles, is commonly used though only surgical resection offers curative benefit. Local administration of amphotericin B, like intracavitary instillation, has been effective in aspergilloma patients though nebulised amphotericin B (nAB) has never been formally assessed. OBJECTIVE: The aim of this prospective, non-inferior, open-label, randomised control trial is to evaluate the efficacy and safety of nebulised amphotericin B compared to oral itraconazole therapy in the treatment of PA. PATIENTS/METHODS: Diagnosed cases of PA (n=33) were randomised into the control group receiving oral itraconazole (n=18) and intervention group receiving nebulised amphotericin B (n = 15). Response to treatment was assessed both clinically and radiologically at the end 6 months. RESULTS AND CONCLUSION: The number of patients showing overall improvement at the end of 6 months in the control arm(oral itraconazole) vs intervention arm(nebulised amphotericin B) was 65% (95% CI 38.3-85.8) and 67%(95% CI 38.4%-88.2%), respectively, in the intention-to-treat and 79% (95% CI 49.2%-95.3%), and 65% (95% CI 38.4%-88.2%), respectively, in the per-protocol analysis. While there was no statistically significant difference between the intervention and control arm in both the analyses, non-inferiority was shown in the per-protocol but not in the intention-to-treat analysis. No major adverse events were noted in either group; however, a significant proportion of patients receiving nAB reported minor cough (40%), which, however, did not lead to discontinuation of therapy in any patients. Nebulised amphotericin B can be an effective therapeutic option for pulmonary aspergilloma patients.

Effect of Training and Checklist Based Use of Ventilator Associated Pneumonia (VAP) Prevention Bundle Protocol on Patient Outcome: A Tertiary Care Centre Study.

OBJECTIVE: VAP prevention bundle includes daily sedation free interval, DVT prophylaxis, raising head end of bed, use of orogastric rather than nasogastric tube. This study aims to study the practices regarding VAP prevention bundle and its compliance, educating about the practices and effects on patients outcome. DESIGN: Quasi-experimental study, conducted in 3 phases. SETTING: Hospital based. PARTICIPANTS: Invasive Mechanically ventilated patients in the Department of Medicine of a tertiary care hospital. 50 patients included in phase 1 and 3. INTERVENTION: Phase 1 and Phase 3 were pre and post intervention phases respectively when compliance to VAP prevention bundle was assessed with intermediate Phase 2, the intervention phase where the residents and nurses were educated about VAP bundle through various means. A checklist was attached to patient records. OUTCOME MEASURES: Incidence of VAP, total hospital and ICU stay, duration of mechanical ventilation and mortality. RESULTS: On comparing the 2 phases, it was found that there was increase in the compliance to VAP bundle(p<0.001), use of orogastric tube (p<0.001) and use of daily sedation free interval (p<0.001). Statistically insignificant increase in the use of DVT prophylaxis (p= 0.996) and raising the head end of the bed (p=0.513), and decline in the number of days of ICU(p=0.804) and hospital stay(p=0.907), the duration of mechanical ventilation(p=0.909), mortality(p=0.315) and incidence of VAP(p=0.715) was noted. Among those who developed VAP, there was lower compliance to bundle. CONCLUSIONS: Practices like use of VAP prevention bundle improve on teaching efforts and use of checklist which improves patient care.

Dengue Fever with Acute Disseminated Encephalomyelitis : Sensorium Imbroglio.

Dengue is the most common arboviral disease affecting many countries worldwide. With endemicity of the disease and huge burden, atypical clinical presentations occur posing high diagnostic and therapeutic dilemma. Emerging neurological complications in dengue fever are reported in recent past Acute disseminated encephalomyelitis (ADEM) is an immune mediated acute demyelinating disorder of the central nervous system following recent infection or vaccination and characterized by multifocal white matter involvement. Early suspicion and diagnosis of such complication is clinical dilemma and it further complicates the clinical scenario. This case report highlights occurrence of such uncommon manifestation of ADEM in commonly occurring dengue fever along with its diagnosis and successful management in a young individual.

B Cell ALL with Pyrexia of Unknown Origin, Masquerading as Inflammatory Arthritis.

ABSTRACT: We present a young male, with long standing fever, weight loss, bone pains, hepatosplenomegaly, cytopenias and severe joint pains. With normal peripheral smear and predominant joints involvement, he was started on corticosteroids. The partial response prompted the physician to continue the steroids. After some time, however, joints and bony pains worsened. After referral to us, he was found to have multiple bony lytic lesions and peripheral smear suggested B cell ALL. So, presentation predominantly with musculoskeletal symptoms, a normal peripheral smear and a partial therapeutic response to steroids as treatment of Systemic Juvenile Idiopathic Arthritis, delayed the diagnosis significantly leading to complications. So through our report we would like to stress that suspecting and diagnosing leukaemia early is important to prevent complications and resistance to treatment. An early bone marrow examination should also be instituted as a standard of care in peripheral smear negative patients.

Necrobiotic Xanthogranuloma as the Presenting Manifestation of Smouldering Myeloma.

Necrobiotic xanthogranuloma is a rare dermatological manifestation of underlying hematological malignancies, in particular, when associated with paraproteinemia. These patients who are clinically symptomatic with chronic papules, nodules or plaques which demonstrate a histopathological pattern suggestive of extensive and frequently confluent areas of necrobiosis with granulomatous infiltration, warrant evaluation for an underlying monoclonal gammopathy.

Effectiveness of education and antibiotic control programme at All India Institute of Medical Sciences, New Delhi.

Background: We aimed to assess the impact of antibiotic optimization education along with understanding the antibiogram on antibiotic-prescribing practices, antibiotic consumption, antimicrobial resistance and cost of antibiotics in a tertiary care hospital in New Delhi. Methods: We divided the study into 3 phases-before and after intervention and a phase of education in between. We collected data on demographics, indication for antibiotic prescription, appropriateness or reasons for inappropriate antibiotic uses, antibiotic consumption (i.e. the rate and duration of antibiotic use), bacterial resistance and antibiotic cost. Interventions included education, introduction of an antibiogram and use of antibiotic prescription forms. Similar data were collected for the post-interventional phase. The study was conducted at the Department of Medicine, All India Institute of Medical Sciences, New Delhi, India. Results: There was an improvement in the number of patients who underwent de-escalation of antibiotics, 21/100 v. 36/100 (p = 0.019); appropriate antibiotic usage, 25/ 100 v. 46/100 (p = 0.002); switching from intravenous to oral promptly, 16/52 v. 1 9/36 (p = 0.003) and decrease in expenditure, ₹24 207.5 v. ₹16 51 7.5 per patient (p = 0.001 ); in the post-interventional phase. Significant reductions in the incidence of infections due to Acinetobacter (60% v. 31%; p<0.001) and improvement in sensitivity pattern with cephalosporin sulbactam (80% v. 100%; p<0.001) were seen. Multivariate analysis revealed that Acute Physiology and Chronic Health Evaluation (APACHE) score, hospital stay <10 days, ventilator-associated pneumonia and methicillin-resistant Staphylococcus aureus coverage were independent predictors of mortality with odds ratio of 1.14, 0.1, 9.7 and 1.14, respectively. Conclusion: Education and an antibiotic control programme constituted an effective and cost-saving strategy to optimise antibiotic use at a tertiary care centre.

Erythema Nodosum Leprosum as a Rare and Challenging Cause of Pyrexia of Unknown Origin.

A 30-year old male presented with fever for last 1 year. There were associated multiple painful skin eruptions with hyperpigmentation and scaling over whole body which had been progressively increasing. He also had anasarca along with generalized weakness. He presented to us in shock after an acute episode of gastroenteritis. After stabilization, he was evaluated for cause of fever. Routine fever workup (for typhoid, syphilis, malaria, filariasis, HIV, scrub typhus, leishmaniasis) was negative. CECT chest and abdomen revealed hepatosplenomegaly. There was no response to intravenous (IV) antibiotics and anti-fungal medications. Slit skin smears revealed 3+ acid fast bacilli (AFB). Skin biopsy revealed fragmented acid-fast bacilli with dense collection of neutrophils and foamy histiocytes in upper and middle dermis suggestive of Erythema Nodosum Leprosum (ENL). A diagnosis of ENL with lepromatous leprosy was made and patient started on steroids and thalidomide and subsequently on multidrug therapy (MDT). On therapy, patient's symptoms improved, and skin lesions resolved. Though Leprosy itself is a well-known common cause of PUO in India, its first presentation as ENL is rare and needs good index of suspicion and timely management.

A Catastrophic Presentation of Enteric Fever with Secondary Hemophagocytic Lymphohistiocytosis.

A 19 year old boy presented to the emergency room with fever of one week duration along with bleeding manifestations, few gastrointestinal symptoms, tachycardia, tachypnea and subtle encephalitic features. He was worked up for the usual causes of short duration fever, which proved inconclusive. In view of clinical worsening and cytopenias, a careful investigation process helped us in ruling out common etiologies for such a fever, alongwith unearthing the possibility of an underlying secondary hemophagocytic lymphohistiocytosis which led to severe thrombocytopenia and persistent high grade pyrexia. Widal test was positive in high titres, and patient was continued with antibiotics. Prompt treatment led to the uneventful recovery of the patient without any sequelae. Bleeding manifestations subsided, patient had rapid clinical improvement and was discharged after completing the course of antibiotics.

Outcomes of Implementing the Central Venous Catheter Bundle at a Tertiary Care Hospital in North India, at AIIMS, New Delhi.

INTRODUCTION: Central venous catheter (CVC) associated infection are many times higher in India compared to western countries. A group of interventions called as CVC bundle, if implemented effectively prevents CVC related complication. METHODOLOGY: Our study was a prospective quasi-experimental study. The study evaluated the level of compliance with the central venous catheter bundle in the management of patients in our Medicine wards and Intensive care unit (ICU). RESULTS: :In the study, the incidence of central line associated bloodstream infection (CLABSI) was zero and the incidence of pneumothorax was 5%. Most of the patients had higher Acute physiology and chronic health evaluation (APACHE II) at baseline and multi organ dysfunction. The compliance with whole CVC bundle improved from 0% at baseline to 10% in post-intervention phase. Compliance of many components increased significantly in the post intervention period. These were Hand washing before insertion (15% to 72.5%, p<0.001), Maintenance (0% to 52.5%, p<0.001), Prompt removal of catheters (40% to 70%, p=0.007), Skin antisepsis with chlorhexidine increased approaching significance (0% to 12.5%, p=0.055). Avoidance of femoral catheters was done in more than 95% of the cases. The predictors of mortality were higher APACHE II (OR 1.23 [CI 1.03-1.47], p=0.020) and duration of hospital stay (OR 0.87 [CI 0.78-0.97], p=0.022). CONCLUSION: This study done at All India Institute of Medical Sciences showed improved outcome in terms of catheter infection and mechanical complications. CVC bundle compliance increased significantly though adherence to full bundle was less. In future, with rectification of barriers to bundle completion, the compliance with CVC bundle can be further improved.

Clinical and Laboratory Features Associated with Acute Kidney Injury in Severe Malaria.

INTRODUCTION: Critically ill severe malaria constitutes one of the major hospital admissions in Indian setting. Clinical studies identifying the factors associated with acute kidney injury (AKI) in malaria are lacking. This study aimed to identify these factors. METHODS: This prospective observational study was conducted in a tertiary care center of North India. All adult patients with severe malaria were studied during 2012-2014. RESULTS: The study included 79 patients and AKI was observed in 36 patients. Of these 79 patients, 52.7% were Plasmodium falciparum positive and 47.2% were Plasmodium vivax positive. In AKI patients, thrombocytopenia and jaundice were the most common other complications seen. Among P. vivax malarial patients, 17 (36%) patients had AKI. Features associated with AKI among patients admitted with P. vivax malaria were as follows: tachycardia (adjusted relative risk [RR]: 3.9; 95% confidence interval [CI]: 1.1-13.7), direct hyperbilirubinemia (adjusted RR: 4.7; 95% CI: 1.4-15.2), anemia (adjusted RR: 6; 95% CI: 1.7-22.4), and sepsis (adjusted RR: 3.3; 95% CI: 1.1-13.7). The presence of tachycardia, acidosis, cerebral malaria, acute respiratory distress syndrome/acute lung injury, hypotensive shock, and poor Glasgow Coma Scale were associated with higher mortality in patients with AKI. Patients who required mechanical ventilation and/or vasopressor support had higher mortality. CONCLUSION: P. vivax is an important cause of severe malaria with AKI in our setting. Various other clinical features are associated with AKI and related mortality.

Consensus & Evidence-based INOSA Guidelines 2014 (First edition).

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive Sleep Apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or comorbidities or ≥ 15 such episodes without any sleep related symptoms or comorbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography (PSG) is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioural measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Consensus & evidence-based INOSA Guidelines 2014 (first edition).

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive sleep apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or co-morbidities or ≥ 15 such episodes without any sleep related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography (PSG) is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioural measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Evaluation of Loop-Mediated Isothermal Amplification Assay in Diagnosing Tuberculous Meningitis.

BACKGROUND: Resource-limited settings like India need a simple, quick, and temperature-independent point-of-care diagnostic test that can diagnose tuberculous meningitis (TBM) at the earliest. METHODS: A prospective study was carried out at a tertiary care center in North India wherein 50 subjects suspected of TBM were recruited and followed up for six months between January 2019 and December 2020. The aim was to evaluate the performance of loop-mediated isothermal amplification (TB-LAMP) in diagnosing TBM as compared to a composite reference standard (CRS), mycobacteria growth indicator tube 960 (MGIT 960) culture, and GeneXpert®. RESULTS: Out of 50 patients, 32 were TBM cases (64%), and 18 were non-TBM cases (36%). The sensitivity of TB-LAMP and GeneXpert® for TBM diagnosis against CRS was 53% (17/32) for both, and the specificity was 78% (14/18) and 89% (16/18), respectively. On comparing TB-LAMP against GeneXpert® for TBM diagnosis, the two methods had almost perfect agreement (Cohen's kappa=0.83) with statistical significance (p<0.001). CONCLUSION: The performance of TB-LAMP assay is comparable to GeneXpert® in diagnosing TBM, and it may be used as a substitute for CSF GeneXpert® in resource-limited settings.

Extensive Metastatic Vascular Calcification in a Patient with Chronic Renal Failure and Tubercular Osteomyelitis as Seen on F-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

A 48-year-old male with known tubercular osteomyelitis of the left elbow and chronic renal failure presented with PTH independent hypercalcemia and underwent F-18 fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) to look for any underlying malignancy that might be causing his hypercalcemia. The PET/CT did not reveal any malignancy, but extensive metastatic calcification of small- and medium-sized arteries was noted throughout the body with relative sparing of large vessels. Alkaline tissue such as lungs, gastric mucosa, and kidneys that are usually involved in metastatic calcification were also spared. The underlying pathology for this kind of metastatic calcification was most likely chronic granulomatous disease, which was tubercular osteomyelitis in this patient. We present the PET/CT scan images of this unusual case of metastatic vascular calcification.