Download - Secondary pulmonary lobule crazy paving sign
Dr Mazen QusaibatyMD, DIS
Head Pulmonary and Internist Department Ibnalnafisse Hospital
Ministry of Syrian healthEmail:
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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