Case Report: Uncommon cause of “Crazy-Paving” on X-ray Chest

Sushila Ladumor1* and Adham Darweesh2 1Consultant Radiologist, Clinical Imaging Department, Hamad Medical Corporation, HGH, Doha, Qatar, Assistant Professor in Clinical Radiology, Weil Cornel Medical College, Qatar (WCMC-Q) 2Senior Consultant Radiologist, Clinical Imaging Department, Hamad Medical Corporation, HGH,Doha, Qatar, Assistant Professor in Clinical Radiology, Weil Cornel Medical College, Qatar (WCMC-Q) Submission: September 23, 2017; Published: October 02, 2017 *Corresponding author: Sushila Ladumor B, Consultant Radiologist, Clinical Imaging Department, Hamad Medical Corporation, HGH, Doha, Qatar, Assistant Professor in Clinical Radiology, Weil Cornel Medical College, Doha, Qatar (WCMC-Q), Email:

Patient again came back again and admitted with severe shortness of breath dyspnea and cough with high inflammatory markers, given 80 mg IV Lasix stat & IV antibiotics, nebulized salbutamol and ipratropium nebs, Dyspnea improved and patient discharged on fourth day with regular medication and antibiotics. Patient has a 30 year 1-2 pack per day smoking history but he didn't smoke for the last 20 days but exposed to cigarettes smoke with his friends for last 3 days before his condition worsened.

Discussion
A 'crazy-paving' appearance of the lungs on a highresolution 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, was first described in association with pulmonary alveolar proteinosis nearly 20 years ago [2,3]. Initially, this radiographic pattern was thought to be specific for alveolar proteinosis, but has subsequently been reported in a variety of interstitial Open Access Journal of Surgery and airspace pulmonary disorders [3]. In the present report, we describe a man who presented with progressive exertional dyspnea in association with a high-resolution chest CT scan that demonstrated a typical crazy-paving appearance. Subsequent investigations and his clinical course demonstrated the cause for the abnormal radiographic changes to be pulmonary edema secondary to congestive heart failure [4].

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Open Access Journal of Surgery Figure 2D: X-ray chest portable semi sitting projection: No appreciable interval change compared to previous X-ray before five days. CT scan (HRCT high resolution CT) of chest recommended due to persistent left perihilar airspace disease.  Figure 3A: X-ray chest frontal projection: After 11 days of last C-ray and 8days of CT: Interval increase in previously seen bilateral perihilar airspace disease, more on right side as well as minimal bilateral pleural effusion and bilateral basal atelectasis. Patient advised CT for follow-up after five weeks to exclude underlying Interstitial lung disease or other differential pathology as patient had H/O smoking. The association of cardiogenic pulmonary edema, a common condition, with a crazy-paving appearance on a CT scan of the lungs has been reported previously in only in few cases, but it is important for clinicians and radiologists to recognize. Based on available study and related other information in the reviews, it is possible to classify the main pulmonary insults that result in a crazy-paving appearance on an etiological basis into infectious, neoplastic, inhalational, toxic, sanguineous and idiopathic disorders. Specific infectious disorders that are associated with a crazy-paving pattern include Pneumocystis jiroveci (carinii) pneumonia, Mycobacterium tuberculosis and Mycoplasma pneumoniae [5].

More input about Crazy-Paving
A. Crazy-Paving was originally described in patients with Pulmonary alveolar proteinosis and is very characteristic for this disease

B.
But Crazy-Paving is really a very nonspecific finding and can been seen in a variety of diffuse lung diseases

Conclusion
The crazy-paving appearance is a nonspecific finding seen in a variety of interstitial and airspace lung diseases. The crazypaving pattern, characterized by scattered or diffuse groundglass opacities or attenuation with superimposed interlobular septal thickening and intralobular lines, is a common radiologic manifestation. Often considered to have a limited differential diagnosis-pulmonary alveolar proteinosis, lipoid pneumonia, bronchioloalveolar cell malignancy-this pattern is now recognized as a CT manifestation of many diverse entities. Knowledge of the many causes of this pattern can be useful in preventing diagnostic errors.
In addition, although causes of this pattern are frequently indistinguishable at radiologic evaluation, differences in the location of the characteristic opacities or attenuation in the lungs as well as presence of additional radiologic findings, together with the history and clinical presentation, can often be useful in suggesting the appropriate diagnosis. The present case illustrates the importance of the correlation of radiographic appearance with clinical observations. It also emphasizes that a 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.