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