Crazy-paving Appearance Research Articles

Localized Pneumocystis jirovecii pneumonia in a malnourished, non-HIV-infected man in the absence of any established or diagnosed immunosuppressive condition: a case report

BackgroundPneumocystis jirovecii infection is an opportunistic infection that mostly affects patients with immunosuppressive conditions like human immunodeficiency virus (HIV) infection or medications, like corticosteroids. This study reports a rare case of Pneumocystis Jiroveci infection in a relatively immunocompetent patient which presented with uncommon radiological findings.Case presentationA 46-year-old man with a malnourished appearance and a history of opium dependence presented with dry cough, dyspnea, and weight loss to the hospital. There was no evidence of an immunocompromised condition or use of any immunosuppressive medication in the history of the patient. A lung high-resolution computed tomography (HRCT) scan revealed a crazy-paving appearance and localized infiltration. Methenamine silver staining and the histopathological findings in the transbronchial lung biopsy confirmed the diagnosis of PJP. Antibiotics and bronchodilators were administrated and the patient was discharged after 6 days of hospitalization. HIV testing and immunoglobulin levels were normal in the hospital course as well as his follow-up visits. After a 2-month follow-up, the patient was in good condition despite of mild remaining infiltration in his lung.ConclusionsPJP typically affects HIV-infected patients, but due to excessive use of immunosuppressive medications, its prevalence is increasing in non-HIV-infected patients. Malnutrition may predispose the patients to PJP, even in the absence of immunosuppressive conditions.

Pulmonary Alveolar Proteinosis in a Three-month-old Infant: An Unusual Case Report

Pulmonary Alveolar Proteinosis (PAP) is an unusual diffuse lung disease characterised by the alveolar accumulation of phospholipoprotein material, with a peak incidence in the 3rd to 4th decades of life and a male predominance. However, it has also been described in children. The recorded prevalence is 0.1 per 100,000 individuals. The major clinicopathogenetic subtypes include the autoimmune (idiopathic) form, which is associated with Granulocyte-macrophage Colony-stimulating Factor (GM-CSF) autoantibodies, the secondary form and the congenital form (associated with surfactant gene mutations). Common presenting features include dyspnoea, cough, low-grade fever, inspiratory crackles and digital clubbing. Pulmonary function tests typically show restrictive ventilatory defects. Herein, the authors present a case of a three-month-old male infant who presented with cough, dyspnoea and failure to thrive over the past 10 days. X-rays revealed a bilateral reticular pattern with non homogeneous opacities. Computed Tomography (CT) of the chest showed features consistent with interstitial lung disease. High-resolution Computed Tomography (HRCT) demonstrated a crazy-paving appearance, suggestive of interstitial lung disease or a surfactant-related genetic disorder. Bronchial Alveolar Lavage (BAL) yielded milky fluid. Characteristic microscopic findings on lung biopsy included the filling of terminal bronchioles and alveolar spaces with deep pink granular Periodic Acid Schiff (PAS)-positive eosinophilic material, while the alveolar architecture remained preserved. Patients with minimal symptoms are managed conservatively, whereas those with hypoxaemia require a more aggressive approach. Whole Lung Lavage (WLL) is the safest and most effective form of treatment. To date, there have been 240 case reports and 410 case series documented in the literature. This is the first case of PAP reported in the study institution. The authors present this case report here due to its rarity and diagnostic significance.

Stepwise progression of invasive mucinous adenocarcinoma based on radiological and biological characteristics

IntroductionInvasive mucinous lung adenocarcinoma (IMA) has unique radiological findings and pathological characteristics. IMA is classified into solitary and pneumonic types; however, it is unclear whether these are biologically identical. MethodsA single-center retrospective analysis was performed for 70 IMA patients (solitary type [n = 38] and pneumonic type [n = 32]) who underwent pulmonary resection between January 2010 and December 2018. We compared clinical and biological characteristics between the two types. ResultsThe frequencies of genetic alternations such as EGFR, KRAS, BRAF, GNAS, ERBB2, TP53, NRG1, and MET were not different. Immunohistochemically, expression of MUC1 was significantly more common in the pneumonic type (5.0% versus 20.0%, p = 0.01) and diffuse MUC6 positive in the solitary type (39.0% versus 13.0%, p = 0.02). We further classified solitary types into those with or without ground-glass opacity (GGO) and pneumonic types into those with or without crazy-paving appearance (CPA), and evaluated their surgical outcomes. Five-year overall survival and relapse free survival rates were 95.8%/86.6%, 64.3%/70.7%, 74.6%/68.9%, and 50.0%/28.6% in patients with solitary type with GGO, solitary type without GGO, pneumonic type without CPA, and pneumonic type with CPA, respectively. ConclusionsThere were no differences in genetic alternations; however, mucin expression pattern was different. Surgical outcomes were different according to the presence of GGO in the solitary type and the presence of CPA in the pneumonic type. These findings suggested a stepwise progression from solitary to pneumonic IMA.

Radiological Determinants of Thromboembolic Events in COVID-19 Pneumonia: A Retrospective Study.

BackgroundIt has been established that patients with COVID-19 pneumonia are more vulnerable to developing thromboembolic complications. Computed tomography (CT) scan of the chest is an essential investigation modality in patients with COVID-19 pneumonia and has an important role in the diagnosis and identification of complications.MethodsA retrospective observational study was conducted on patients admitted with COVID-19 pneumonia who underwent CT scans of the chest. The data regarding demographic information, clinical information, and CT findings were collected from electronic health records. Multivariable regression analysis was used to identify the independent factors associated with thromboembolic complications.ResultsThe study included a total of 276 patients, including 178 (64.5%) men and 98 (35.5%) women. In total, 64 patients were found to have thromboembolic events, yielding a complication rate of 23.2%. Multivariable logistic regression revealed that patients aged 51-65 years (Odds ratio [OR] = 8.9; 95% confidence interval [CI]: 3.0-26.5) and >65 years (OR = 18.7; 95% CI: 7.6-46.1) had a higher likelihood of having thromboembolic complications compared to those aged 18-35 years. Further, the crazy-paving appearance of opacity was identified as an independent factor associated with thromboembolic events (OR = 14.2; 95% CI: 6.9-29.4). Further, patients with severe pulmonary parenchymal involvement were 30 times (OR = 30.6; 95% CI: 9.8-95.5) more likely to have thromboembolic complications compared with those having mild involvement.ConclusionsThe radiological findings on the CT scan of the chest can provide crucial prognostic information for patients with COVID-19 in terms of thromboembolic events. Clinicians need to keep a high index of suspicion for pulmonary embolism and deep venous thrombosis when they encounter patients with crazy-paving opacity appearances on CT scans, particularly among patients with severe parenchymal involvement.

Radiological Finding of Crazy-Paving Pattern in COVID-19 Pneumonia

The recent global pandemic of coronavirus disease 2019 (COVID-19) has brought many radiographic findings in other respiratory disease processes. One of these radiological findings is crazy paving. This paper discusses crazy paving in a 75-year-old female with dyspnea, nonproductive cough, pleuritic chest pain, and a polymerase chain reaction (PCR) positive test for COVID-19 infection. Chest CT showed ground-glass opacities and interlobular septal thickening consistent with a crazy-paving appearance. As part of the common CT findings of patients with active COVID-19 infection, crazy paving should prompt the interpreting radiologist to consider COVID-19 pneumonia as part of the differential.

Chest CT Findings and Their Temporal Evolution in COVID-19 Pneumonia.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic originated in China in November 2019 and is caused by the SARS-CoV-2 virus. The virus binds to nasal and pharyngeal epithelial cells and migrates to the lower respiratory tract. The confirmatory test for COVID-19 infection is the reverse transcription-polymerase chain reaction (RT-PCR). Chest CT plays an important role in the diagnosis, triage, and treatment of affected individuals. We describe the findings on chest CT and their temporal evolution in COVID-19 pneumonia.Methods: We conducted a retrospective, cross-sectional study on COVID-19-positive patients who underwent chest CT. CT images of the patients were reviewed for ground-glass opacities, consolidation, crazy-paving appearance, vascular dilatation, traction bronchiectasis, architectural distortion, and subpleural and parenchymal bands. Distribution of opacities on axial sections, ancillary findings, and co-existent lung diseases were recorded. To assess the temporal evolution of CT findings, the time in days between the onset of the first symptom and the date of the CT scan of each patient was recorded. Statistical analysis was performed.Results: Ground-glass opacities, consolidation, and a combination of both were the most important features in COVID-19 pneumonia. Patients in the early stage showed simple ground-glass opacities; in the progressive stage showed consolidation and ground-glass opacities with crazy-paving appearance, subpleural and parenchymal bands, and architectural distortion; in the peak stage showed progression of these findings; and in the late stage showed interval resolution of these findings. Axial distribution of these opacities was asymmetric, with peripheral subpleural predominance involving posterior, lateral, and both these locations, associated with apicobasal gradient.Conclusion: Chest CT permits rapid diagnosis of COVID-19 pneumonia, enabling appropriate treatment to be instituted at the earliest. Thus, it is life-saving in resource-constrained environments.

The Spectrum of CT Findings of COVID-19 Pneumonia: Acute Alveolar Insult and Organizing Pneumonia as Different Phases of Lung Injury and Repair.

PurposeTo analyze the findings and serial changes in chest CT lesions in 123 symptomatic patients with coronavirus disease 2019 (COVID-19).Materials and MethodsFrom February 19 to April 7, 2020, a total of 123 confirmed COVID-19 patients (male, 44; female, 79; mean age, 59.2 ± 18.6) were enrolled in this retrospective study. A total of 234 CT scans were reviewed for the following patterns: acute alveolar insult (AAI) patterns: ground-glass opacity (GGO), crazy-paving appearance, mixed pattern, and consolidation; organizing pneumonia (OP) patterns: perilobular patterns, band opacity, curvilinear opacity, reversed halo opacity, and small nodular consolidation; resolving patterns: pure GGO, remnant curvilinear, small nodular consolidation, and serial changes of lung abnormalities. We compared the proportions of AAI pattern, OP pattern, or resolving pattern with time progression and analyzed the association between the patterns and disease severity using Pearson chi-square and Fisher's exact test.ResultsPredominant CT patterns were AAI pattern (87%) in the early hospital period group (0–10 days, after the onset of symptoms), OP pattern (45.7%) in the later hospital period group (after 10 days), and resolving pattern in discharge and follow-up group (47.2% and 84.8%, respectively). The difference in the proportions of predominant CT patterns with time progression was statistically significant (p < 0.001, Pearson's chi-square test). No statistically significant association was observed between the patterns and disease severity (p = 0.055, Fisher's exact test). No fibrous changes in the lesions were observed on follow-up CT scans.ConclusionThe serial CT scans of COVID-19 patients showed the spectrum of COVID pneumonia CT manifestations as different phases of lung injury and repair.

ACUTE DYSPNEA ASSOCIATED WITH CRAZY PAVING APPEARANCE

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: A ‘crazy-paving’ appearance of the lungs on computed tomography scanning of the chest was first described nearly 20 years ago in patients with pulmonary alveolar proteinosis, and was thought to be characteristic of this condition. However, this pattern has subsequently been reported in a variety of pulmonary diseases and is now considered to be nonspecific. We report a case 43 yrs old middle aged lady admitted with Acute onset of breathlessness with crazy paving appearance on chest Computed tomography of chest, secondary to heart failure. CASE PRESENTATION: Middle age lady with no other comorbidities admitted with complaints of sudden onset of breathlessness since today evening. At the time of presentation to emergency room she was dyspneic, Tachypneic, Tachycardia. Her vitals were HR 102/mt, RR 36/mt,spo2 86% on Room air, Bp 180/100mmhg. She was started on high flow oxygen and nebulized medications.Cardiac examination revealed a normal S1 and diminished S2, with no murmurs or extra sounds. Auscultation of the chest revealed inspiratory crackles bilaterally. His abdominal examination was unremarkable without organomegaly. Laboratory findings revealed a normal complete blood count and differential blood count. Serum electrolytes, liver and renal function tests were all normal.A chest radiograph (figure1) demonstrated diffuse airspace opacities on both sides of lung. A CT scan of the chest (figure2) was obtained showed diffuse, multifocal, patchy, ground-glass opacities with superimposed reticulations resulting in a crazy-paving appearance.Routine 2 D echo was done, revealed Rheumatic Heart disease with Severe mitral stenosis, Tricuspid stenosis and Moderate Tricuspid regurgitation,and diagnosed as acute decompensated heart failure. NT-pro BNP was 3450pg/ml. She was started on diuretics along with other medications. Repeated x ray (figure 3)showed complete clearance of airspace opacities. DISCUSSION: A ‘crazy-paving’ appearance of the lungs on a high-resolution computed tomography (CT) scan of the chest, defined as scattered or diffuse ground-glass attenuation superimposed on a network of interlobular septal thickening and intralobular lines. Initially, this radiographic pattern was thought to be specific for alveolar proteinosis, (1) but has subsequently been reported in a variety of interstitial and airspace pulmonary disorders (2,3) Although common, congestive heart failure and cardiogenic pulmonary edema have been reported previously as a cause for crazy-paving appearance in only in few cases. (3) CONCLUSIONS: Crazy-paving pattern on CT scan, once considered to be specific for pulmonary alveolar proteinosis, is now known to be nonspecific and may be seen in association with a wide spectrum of pulmonary diseases. Reference #1: Godwin JD, Muller NL, Takasugi JE. Pulmonary alveolar proteinosis: CT findings. Radiology. 1988;169:609–13. Reference #2: Johkoh T, Itoh H, Muller NL, et al. Crazy-paving appearance at thin-section CT: Spectrum of disease and pathologic findings. Radiology. 1999;211:155–60. Reference #3: Murayama S, Murakami J, Yabuuchi H, Soeda H, Masuda K. “Crazy paving appearance” on high resolution CT in various diseases. J Comput Assist Tomogr. 1999;23:749–52. DISCLOSURES: No relevant relationships by Nagarajan Appusamy, source=Web Response

Characteristics, Outcomes and Indicators of Severity for COVID-19 Among Sample of ESNA Quarantine Hospital's Patients, Egypt: A Retrospective Study.

BackgroundThe risk factors, disease characteristics, severity, and mortality of COVID-19 are unclear, particularly in Egypt.ObjectiveThe objective was to analyze the patients’ characteristics, hematological, biochemical, and chest imaging findings among the cohort of patients with COVID-19 in Egypt and also to shed light on the predictors of COVID-19 severity.Patients and MethodsA retrospective study was conducted on 66 patients with COVID-19 in Egypt. Medical history, imaging data (CT chest findings), and measured hematological and biochemical parameters at diagnosis were recorded in the form of complete blood counts and differential counts; CRP, ESR, serum ferritin, creatinine, and liver function tests . Results of real-time reverse transcription-polymerase chain reaction (rRT-PCR) for detection of SARS-CoV-2 RNA at diagnosis and during follow up of these patients were also recorded.ResultsThe study included 36 patients with mild to moderate COVID-19 and 30 patients with severe/critical infection. There was a significant older age among severe (62.6 years old ±10.1SD) than mild to moderate infection (55.5 ± 10.1) (p˂0.05). Fever, dry cough, dyspnea, and sore throat malaise were highly frequent among COVID-19 patients, while headache and diarrhea were the least frequently occurring manifestations. All included cases (30 patients, 100%) with severe COVID-19 showed crazy-paving appearance (in the form of reticular and/or interlobular septal thickening) with or without GGO. There were significantly lower mean values of WBCs, lymphocytic count, total protein, and albumin among the severely infected than those who had mild to moderate COVID-19 infection, p˂0.05 for all. Additionally, there were significantly higher mean values of CRP, ESR, ferritin, ALT, and AST among patients with severe/critical COVID-19 when compared with those having mild to moderate COVID-19, p˂0.05 for all.ConclusionAmong the studied demographic, clinical, hematological, biochemical, and imaging data, dyspnea, diabetes mellitus, lymphopenia, raised CRP, ESR, ferritin, ALT, AST, low albumin, and presence of CT chest findings could be considered as predictors for COVID-19 severity using binary logistic regression analysis.

Adverse Initial CT Findings Associated with Poor Prognosis of Coronavirus Disease.

BackgroundThe predictors of poor prognosis in patients with coronavirus disease 2019 (COVID-19) using computed tomography (CT) have not been investigated in a large cohort. Therefore, the purpose of this study was to investigate the adverse initial CT features to predict poor prognosis in COVID-19.MethodsFrom February to April 2020, 281 COVID-19 patients who underwent CT at the time of admission were included. We divided the patients into the severe and non-severe disease groups. The severe group included patients with severe pneumonia or critical events. Intensive care unit admission or death were the critical events in this study. We compared the clinical and CT findings between the severe and non-severe groups and investigated the prognostic factors and critical events of the severe group using the regression analysis.ResultsAmong the 281 patients, 36 (12.8%) patients were in the severe group and 245 (87.2%) patients were in the non-severe group. Critical events occurred in 10 patients (3.6%). In the severe group, patients showed significantly more pneumonia with consolidation, crazy-paving appearance, pleural effusion, and higher CT scores than those in the non-severe group (all, P < 0.05). In the multivariate regression, pleural effusion (odds ratio [OR], 8.96; 95% confidence interval [CI], 1.81–44.42; P = 0.007), CT score > 5 (OR, 3.70; 95% CI, 1.44–9.53; P = 0.007), old age (> 77 years, OR, 9.96; 95% CI, 3.78–26.28; P < 0.001), and elevated C-reactive protein (OR, 4.15; 95% CI, 1.62–10.6; P = 0.003) were significant prognostic factors of severe disease. CT score > 5 (OR, 7.29; 95% CI, 1.37–38.68; P = 0.020), pleural effusion (OR, 5.67; 95% CI, 1.04–30.8; P = 0.045) and old age (OR, 8.6; 95% CI, 1.80–41.0; P = 0.007) were also significant predictors of critical events.ConclusionPleural effusion and the extent of pneumonia on initial CT scans are associated with poor prognosis in patients with COVID-19.

Pulmonary MALT lymphoma demonstrating a crazy-paving appearance on imaging.

Pulmonary MALT lymphoma demonstrating a crazy-paving appearance on imaging.

Cutaneous Vasculitis, Interstitial Pneumonia with Crazy-Paving Appearance, and Positive pANCA in a Patient with Severe Crohn's Disease.

Cutaneous vasculitis, interstitial pneumonia with crazy-paving appearance on high-resolution computed tomography, and repeated positive perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) are rarely found together in patients with inflammatory bowel disease in the existing literature. We report the case of a Chinese patient previously diagnosed with cutaneous vasculitis and interstitial pneumonia, who presented with acute pain and mass in his right lower quadrant a couple of years later. The terminal ileum biopsy and postoperative pathology confirmed Crohn's disease (CD).

A Rare Cause of Crazy-Paving and Mediastinal Lymphadenopathy: Congestive Heart Failure

Crazy-paving sign is a pattern seen on multislice computed tomography images of the lungs. It is characterized by a reticular pattern superimposed on ground-glass opacity. It was first described in the late 1980s in patients with pulmonary alveolar proteinosis, but has now been described in some other diseases of the lung. Enlarged mediastinal lymph nodes can be seen in infectious and specific inflammatory diseases and malignancies. The present report describes a case of a 44-year-old man in whom congestive heart failure presented with a crazy-paving appearance and enlarged lymph nodes of the lungs on the chest computed tomography scan.

High-resolution CT findings of patients with pulmonary nocardiosis.

Opportunistic pulmonary infection with Nocardia species is rare in humans, and only a few studies have radiologically analyzed patients with pulmonary nocardiosis using high-resolution computed tomography (HRCT). We retrospectively reviewed the medical records of patients with pulmonary nocardiosis at our hospital between April 2006 and December 2011 to assess HRCT and clinical findings. We also searched the medical literature for pulmonary nocardiosis reported in Japan between 2002 and 2011 for comparison. We identified seven patients at our institution and 33 reported infections in Japan. Four of our patients were immunocompetent, whereas the other three had impaired cellular immunity due to type 2 diabetes mellitus or having been inappropriately treated with steroid. Thoracic HRCT revealed no zonal predominance, but tropism for distribution from the middle to the peripheral area, and radiological findings of nodules, cavitation, mass, consolidations, bronchial wall thickening, septal line thickening and ground glass opacity (GGO) were evident. The main HRCT finding in our study comprised nodules (n=5, 71.4%) <30 mm and four patients had multiple nodules as described in other reports. Furthermore, we discovered a crazy paving appearance (CPA) around nodules, cavities, masses or consolidations in five patients (71.4%). Multiple nodules distributed from the middle to the peripheral area on HRCT might reflect pulmonary nocardiosis, and CPA seemed to be a worth paying attention to the diagnosis.

CT Scans of the Chest in Carriers of Human T-cell Lymphotropic Virus Type 1: Presence of Interstitial Pneumonia

<h3>Rationale and Objectives</h3> To evaluate pulmonary findings on computed tomography (CT) scans in carriers of human T-lymphotropic virus type 1 (HTLV-1). <h3>Materials and Methods</h3> This retrospective study was approved by the Institutional Review Board at each institution, and informed consent was waived. Patients who were diagnosed with adult T-cell lymphoma/leukemia or collagen vascular disease were excluded from the study. Chest CT of 106 HTLV-1 carriers (54 females and 52 males; age range 44–94 years) were initially evaluated by two chest radiologists. Assessed CT findings included centrilobular nodules, thickening of bronchovascular bundles, ground-glass opacity, bronchiectasis, interlobular septal thickening, consolidation, honeycombing, crazy-paving appearance, enlarged lymph nodes, pleural effusion, and pericardial effusion. Three chest radiologists secondarily evaluated the CT scans with the abnormal findings to judge the presence of interstitial pneumonia patterns or a bronchiolitis/bronchitis pattern. <h3>Results</h3> Abnormal CT findings were found in 65 (61.3%) patients, including ground-glass opacity (<i>n</i> = 33), bronchiectasis (<i>n</i> = 28), centrilobular nodules (<i>n</i> = 25), and interlobular septal thickening (<i>n</i> = 19). Honeycombing (<i>n</i> = 5) and crazy-paving appearance (<i>n</i> = 3) were also observed. Based on the CT findings, 10 subjects were diagnosed with interstitial pneumonia (usual interstitial pneumonia pattern, <i>n</i> = 3; nonspecific interstitial pneumonia pattern, <i>n</i> = 5; organizing pneumonia pattern, <i>n</i> = 2; respectively). Twenty subjects were diagnosed with the bronchitis/bronchiolitis pattern. <h3>Conclusion</h3> Although the bronchiolitis/bronchitis pattern is predominant on chest CT in HTLV-1 carriers, the HTLV-1 infection is associated with various interstitial pneumonias.

Pulmonary Alveolar Proteinosis

Pulmonary alveolar proteinosis is a rare but potentially treatable disease, characterized by impaired surfactant metabolism that leads to accumulation in the alveoli of proteinaceous material rich in surfactant protein and its component. Novel insights from an animal model aided the discovery of granulocyte macrophage colony stimulating factor (GM-CSF) antibodies as a pathogenetic mechanism in human pulmonary alveolar proteinosis. The vast majority of pulmonary alveolar proteinosis occurs as an autoimmune disease; less commonly, it is congenital or secondary to an underlying disorder such as infection, hematological malignancy, or immunodeficiency. The subacute indolent course of this disease often delays the diagnosis by months to years. Crazy-paving appearance in a geographic distribution is a characteristic feature of this disease visible on high-resolution computed tomography (CT). A definitive diagnosis, however, requires lung biopsy, which typically shows partial or complete filling of alveoli with periodic-acid-Schiff-positive granular and eosinophilic material in preserved alveolar architecture. Patients with minimal symptoms are managed conservatively, whereas patients with hypoxemia require a more aggressive approach. Whole-lung lavage is the most widely accepted therapy for symptomatic pulmonary alveolar proteinosis. Correction of GM-CSF deficiency with exogenous GM-CSF is an alternative therapy. The combination of a systemic treatment (GM-CSF) and a local treatment (whole-lung lavage) augmenting the action of one another is a promising new approach. As the knowledge about this rare disease increases, the role of novel therapies is likely to be better defined and optimized.

A case of idiopathic pulmonary alveolar proteinosis

Idiopathic pulmonary alveolar proteinosis (PAP) is a rare disease due to impaired alveolar macrophage function caused by neutralising anti-granulocyte-macrophage colony-stimulating autoantibodies. A nineteen years old male patient was admitted with the complaints of cough, sputum production, dyspnea and fever. There were bilaterally inspiratory fine crackles. The chest radiographs showed bilateral air-space consolidation. On thorax computed tomography; pre-carinal lymph nodes enlargement, ground glass opacities, septal thickening and crazy-paving appearance were determined. Bronchoalveolar lavage was performed and reported was PAP.

Comparative Study of High-Resolution CT Findings Between Autoimmune and Secondary Pulmonary Alveolar Proteinosis

Acquired pulmonary alveolar proteinosis (PAP) has been reclassified into autoimmune or secondary PAP according to the occurrence of serum granulocyte macrophage colony-stimulating factor autoantibody. Most patients undergo high-resolution CT (HRCT) scanning in order for physicians to make a differential diagnosis of diffuse lung diseases, but no information is available to distinguish the HRCT scan features of secondary PAP from those of autoimmune PAP. The objective of this study was to characterize the HRCT scan features of autoimmune and secondary PAP. HRCT scans of 42 patients (21 patients each in the autoimmune PAP and secondary PAP groups) were centrally collected and evaluated in a blinded manner. Ground-glass opacities (GGO) were a major finding in both the autoimmune PAP and secondary PAP groups. In the secondary PAP group, GGOs typically showed a diffuse pattern (62%), whereas GGOs showed a patchy geographic pattern in the autoimmune PAP group (71%; p < 0.005). The so-called "crazy-paving" appearance and subpleural sparing were frequently seen in the autoimmune PAP group (both 71%), whereas they were less frequently seen in the secondary PAP group (14% and 33%, respectively). The involved area of GGO was even in craniocaudal distribution for the secondary PAP group, whereas it was predominant in the lower lung field compared with the upper lung field in the autoimmune PAP group (p < 0.05). Typical HRCT scan findings for autoimmune PAP patients were GGO with a patchy geographic pattern, subpleural sparing, crazy-paving appearance, and predominance in the lower lung field. These findings were rather infrequent for secondary PAP patients.

Barium aspiration showing crazy‐paving appearance on high‐resolution computed tomography

We encountered a case showing a crazy-paving appearance on high-resolution computed tomography (HRCT), which mimicked various pulmonary diseases, e.g. pulmonary alveolar proteinosis, or non-specific interstitial pneumonia, but which we ultimately determined to be due to barium aspiration. The initial radiological findings were considered to be most likely due to pulmonary alveolar microlithiasis, because the crazy-paving appearance had high density, resembling calcification. However, distribution was limited to the area of dependent drainage of the right lung. Since a barium swallowing study had been performed 2 weeks before the CT examination, and since the follow-up HRCT showed improvement we reached a diagnosis of barium aspiration. Although barium aspiration may yield findings similar to other diseases with crazy-paving appearance, it is possible to identify it because of the limited distribution and high density.

The Crazy-paving Pattern in Granulomatous Mycosis Fungoides

The purpose of this report is to describe a further distinctive cause of crazy-paving pattern on thin-section computed tomography in a patient affected by pulmonary granulomatous mycosis fungoides. It was possible to reconcile the crazy-paving appearance on thin-section computed tomography scan with the histopathologic pattern termed acute fibrinous organizing pneumonia pattern.