Secondary pulmonary lobule crazy paving sign

Dr Mazen QusaibatyMD, DIS

Head Pulmonary and Internist Department Ibnalnafisse Hospital

Ministry of Syrian healthEmail:

Qusaibaty@gmail.com

1. Secondary pulmonary lobule

2. Crazy paving sign

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Topic Outline

1. Secondary pulmonary lobule2. Crazy paving sign

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Secondary pulmonary lobule

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Secondary pulmonary lobuleUnit of lung (0.5-3 cm)Irregularly polyhedral

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Secondary pulmonary lobule

A group of terminal bronchioles

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Secondary pulmonary lobuleAccompanying pulmonary

arterioles

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Secondary pulmonary lobule

Surrounded by lymph vessels

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Secondary pulmonary lobule

Demarcated by “interlobular septa”

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Secondary pulmonary lobule

Pulmonary veins

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Secondary pulmonary lobule

Pulmonary lymphatics

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Connective Tissue Stroma

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Crazy paving sign

Crazy paving sign

Refers to the combination of ground glass attenuation superimposed on a network of interlobular septal thickening giving it an appearance of a surface paved with slabs of differing shapes

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Crazy paving sign

• Crazy Paving is a combination of ground glass opacity with superimposed net of septal thickening

Crazy paving sign

Alveolar proteinosis

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Crazy paving sign

Thin-section CT scan targeted to the left upper lobe in a 41-year-old man with alveolar proteinosis

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Crazy Paving sign

Alveolar proteinosis

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Crazy Paving

Alveolar proteinosis

Sarcoidosis

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Crazy Paving sign

Alveolar proteinosis

Sarcoidosis

NSIP

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Crazy Paving sign

Alveolar proteinosis

Sarcoidosis

NSIP

Organizing pneumonia (BOOP)

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Crazy Paving sign

Alveolar proteinosis

Sarcoidosis

NSIP

Organizing pneumonia (BOOP)

Pulmonary hemorrhage

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Crazy Paving sign

Alveolar proteinosis

Sarcoidosis

NSIP

Organizing pneumonia (BOOP)

Pulmonary hemorrhage

Lipoid pneumonia

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Crazy Paving sign

Infection

PCP

Viral

Mycoplasma

bacterial

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Crazy Paving sign

NeoplasmBAC

EdemaHeart failure

ARDS

AIP

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Causes of the crazy-paving pattern

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Case 01 /Crazy Paving sign

Thin-section CT scan of right upper lobe

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Case 01 / Crazy Paving sign

• A fine reticular pattern superimposed on a background of ground-glass opacity—that is, the crazy-paving pattern.

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Case 01 / Crazy Paving signFluid within the major fissure (arrowheads)

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Case 01 / Crazy Paving sign

A 32-year-old man with ARDS

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Case 02 / Thin-section CT scan of right lower lobe

• The crazy-paving pattern is present in the right lower lobe, particularly in the region circumscribed by the arrowheads

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Case 02 / Crazy Paving sign

• The minimum and maximum sizes of each frame of the network are 2 and 6 mm, respectively.

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Case 02 / Crazy Paving sign

• A 65-year-old woman with chronic eosinophilic pneumonia

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Case 03 / Thin-section CT scan of the left lower lobe

• Crazy-paving appearance, which is best seen in the region circumscribed by the arrows.

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Case 03 / Postmortem findings in a 41-year-old woman

Alveolar Hemorrhage

Case 04 / High-resolution CT scan Areas of ground-glass attenuation with intralobular lines

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P carinii pneumonia in a 32-year-old man with acquired immunodeficiency syndrome.

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Case 04 / Photomicrograph (original magnification, ×400; Grocott stain) of a specimen obtained with bronchoalveolar lavage

• shows alveolar exudates that contain cystic forms of P carinii (arrows)

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Case 05 / Diffuse mucinous bronchioloalveolar carcinoma in a 78-year-old man / High-resolution CT scan

• shows a bilateral crazy-paving pattern and centrilobular nodules.

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Case 06 / Sarcoidosis in a 25-year-old asymptomatic man

• High-resolution CT scan• Shows scattered

bilateral areas of ground-glass attenuation associated with inter- and intralobular lines.

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Case 07

• Methotrexate-induced NSIP in a 41-year-old woman with rheumatoid arthritis who presented with dyspnea and decreased diffusing capacity of the lungs for carbon monoxide (DLCO).

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Case 07 / Photomicrograph (original magnification, ×400; hematoxylin-eosin stain) of a specimen from lung biopsy

• Shows patchy interstitial fibrosis

• Expansion of the interstitium by: Chronic inflammatory

infiltrates Reactive hyperplastic

type II pneumonocytes (arrow)

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Case 07 / Photomicrograph (original magnification, ×400; hematoxylin-eosin stain) of a specimen from lung biopsy

• Findings consistent with NSIP induced by the pulmonary toxic effects of Methotrexate.

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Case 08 / Amiodarone-induced NSIP in an 88-year-old man with severe dyspnea

• High-resolution CT scan shows bilateral diffuse ground-glass attenuation and inter- and intralobular lines.

• Note the traction bronchiectasis.

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Case 09

• Bleomycin induced organizing pneumonia in a 44-year-old woman with Hodgkin lymphoma who presented with:A nonproductive coughDyspneaDecreased DLCO

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Case 09 / High-resolution CT/ Bleomycin induced BOOP

Crazy-paving sign

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Case 09 / High-resolution CT/ Bleomycin induced BOOP

• The diagnosis of was confirmed with transthoracic biopsy

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Case 09 / High-resolution CT/ Bleomycin induced BOOP

• There was improvement in the symptoms and radiologic findings after:o Discontinuation of the

Bleomycin therapyo Initiation of

corticosteroid therapy

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Case 10

• Lipoid pneumonia in a 64-year-old woman with a 20-year history of scleroderma who presented:Progressive dyspneaDry cough

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Case 10 /High-resolution CT scan/ Lipoid pneumonia

• Shows Crazy-paving sign (arrow)

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Case 10 /High-resolution CT scan/ Lipoid pneumonia

• The results of bronchoalveolar lavage and transbronchial biopsy were nondiagnostic

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Case 10 / Photomicrograph (original magnification, ×250; hematoxylin-

eosin stain) of a specimen from open lung biopsy

• shows numerous lipid-laden macrophages that fill and distend the alveoli (arrow) and interstitium.

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Case 11 / Posteroanterior chest radiograph

• Shows a centrally located mass adjacent to an area of diffuse ground-glass opacity in the right upper lobe.

• Note the air trapping in the lung base.

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Case 11 / Posteroanterior chest radiograph

• CT scan shows typical crazy-paving surrounding the mass, which is perihilar.

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Case 11 / What diagnosis that do you expect?

A. AdenocarcinomaB. BOOP.C. Lipoid pneumoniaD. Diffuse pulmonary

hemorrhageE. P carinii pneumonia

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Case 11 / What diagnosis that do you expect?

A. Diffuse pulmonary hemorrhage

B. BOOP.C. Lipoid pneumoniaD. AdenocarcinomaE. P carinii pneumonia

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Case 11 / How do you explain the ground glass?

A. Lymphangitic carcinomatosis surrounding the central mass

B. Adenocarcinoma with surrounding pulmonary hemorrhage

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Case 11 / How do you explain the ground glass?

A. Lymphangitic carcinomatosis surrounding the central mass

B. Adenocarcinoma with surrounding pulmonary hemorrhage

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