DOI: 10.1148/rg.236035101
"Crazy-Paving" Pattern at Thin-Section CT of the Lungs: Radiologic-Pathologic Overview1
Santiago E. Rossi, MD,
Jeremy J. Erasmus, MD,
Mariano Volpacchio, MD,
Tomas Franquet, MD,
Teresa Castiglioni, MD and
H. Page McAdams, MD
1 From the Departments of Radiology (S.E.R., M.V.) and Pathology (T.C.), Centro de Diagnostico Dr Enrique Rossi, Arenales 2777, Buenos Aires 1425, Argentina; the Department of Radiology, University of Texas M.D. Anderson Cancer Center, Houston (J.J.E.); the Department of Radiology, Hospital de Sant Pau, Universidad Autónoma de Barcelona, Spain (T.F.); and the Department of Radiology, Duke University Medical Center, Durham, NC (H.P.M.). Recipient of a Cum Laude award and an Excellence in Design award for an education exhibit at the 2002 RSNA scientific assembly. Received April 9, 2003; revision requested May 12 and received July 24; accepted July 25. Address correspondence to S.E.R. (e-mail: santirossi@cdrossi.com).
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Figure 1. Photograph of a colonial-era pavement street in Buenos Aires, Argentina (left), drawings of the lungs (center) and lung tissue (top right), and close-up high-resolution CT scan (bottom right) show the crazy-paving pattern.
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Figure 2. Causes of the crazy-paving pattern.
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Figure 3a. P carinii pneumonia in a 32-year-old man with acquired immunodeficiency syndrome. (a) High-resolution CT scan shows areas of ground-glass attenuation with intralobular lines. (b) Photomicrograph (original magnification, x400; Grocott stain) of a specimen obtained with bronchoalveolar lavage shows alveolar exudates that contain cystic forms of P carinii (arrows).
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Figure 3b. P carinii pneumonia in a 32-year-old man with acquired immunodeficiency syndrome. (a) High-resolution CT scan shows areas of ground-glass attenuation with intralobular lines. (b) Photomicrograph (original magnification, x400; Grocott stain) of a specimen obtained with bronchoalveolar lavage shows alveolar exudates that contain cystic forms of P carinii (arrows).
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Figure 4a. Diffuse mucinous bronchioloalveolar carcinoma in a 78-year-old man. (a) High-resolution CT scan shows a bilateral crazy-paving pattern and centrilobular nodules. (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a specimen from open lung biopsy shows replacement of the alveolar epithelium by epithelial neoplastic cells with abundant intracytoplasmic mucin (arrows).
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Figure 4b. Diffuse mucinous bronchioloalveolar carcinoma in a 78-year-old man. (a) High-resolution CT scan shows a bilateral crazy-paving pattern and centrilobular nodules. (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a specimen from open lung biopsy shows replacement of the alveolar epithelium by epithelial neoplastic cells with abundant intracytoplasmic mucin (arrows).
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Figure 5a. Alveolar proteinosis in a 37-year-old woman with a nonproductive cough and dyspnea. (a) Posteroanterior chest radiograph shows bilateral reticular areas of increased opacity, which occur predominantly in the lower zones. (b) High-resolution CT scan shows diffuse geographic ground-glass attenuation with superimposed intra- and interlobular septal thickening (arrowhead). Note the polygonal appearance, which represents the secondary pulmonary lobule. (c, d) Photomicrographs (original magnification, x400; hematoxylin-eosin [c] and periodic acid-Schiff [d] stains) of a specimen from transbronchial biopsy show alveolar spaces filled by a dense, eosinophilic, granular proteinaceous material (*) that is positive for periodic acid-Schiff stain.
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Figure 5b. Alveolar proteinosis in a 37-year-old woman with a nonproductive cough and dyspnea. (a) Posteroanterior chest radiograph shows bilateral reticular areas of increased opacity, which occur predominantly in the lower zones. (b) High-resolution CT scan shows diffuse geographic ground-glass attenuation with superimposed intra- and interlobular septal thickening (arrowhead). Note the polygonal appearance, which represents the secondary pulmonary lobule. (c, d) Photomicrographs (original magnification, x400; hematoxylin-eosin [c] and periodic acid-Schiff [d] stains) of a specimen from transbronchial biopsy show alveolar spaces filled by a dense, eosinophilic, granular proteinaceous material (*) that is positive for periodic acid-Schiff stain.
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Figure 5c. Alveolar proteinosis in a 37-year-old woman with a nonproductive cough and dyspnea. (a) Posteroanterior chest radiograph shows bilateral reticular areas of increased opacity, which occur predominantly in the lower zones. (b) High-resolution CT scan shows diffuse geographic ground-glass attenuation with superimposed intra- and interlobular septal thickening (arrowhead). Note the polygonal appearance, which represents the secondary pulmonary lobule. (c, d) Photomicrographs (original magnification, x400; hematoxylin-eosin [c] and periodic acid-Schiff [d] stains) of a specimen from transbronchial biopsy show alveolar spaces filled by a dense, eosinophilic, granular proteinaceous material (*) that is positive for periodic acid-Schiff stain.
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Figure 5d. Alveolar proteinosis in a 37-year-old woman with a nonproductive cough and dyspnea. (a) Posteroanterior chest radiograph shows bilateral reticular areas of increased opacity, which occur predominantly in the lower zones. (b) High-resolution CT scan shows diffuse geographic ground-glass attenuation with superimposed intra- and interlobular septal thickening (arrowhead). Note the polygonal appearance, which represents the secondary pulmonary lobule. (c, d) Photomicrographs (original magnification, x400; hematoxylin-eosin [c] and periodic acid-Schiff [d] stains) of a specimen from transbronchial biopsy show alveolar spaces filled by a dense, eosinophilic, granular proteinaceous material (*) that is positive for periodic acid-Schiff stain.
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Figure 6. 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. (Reprinted, with permission, from reference 22.)
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Figure 7a. 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). (a) High-resolution CT scan shows scattered ground-glass attenuation and thickened inter- and intralobular lines (arrow). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a specimen from lung biopsy shows patchy interstitial fibrosis, expansion of the interstitium by chronic inflammatory infiltrates, and reactive hyperplastic type II pneumonocytes (arrow), findings consistent with NSIP induced by the pulmonary toxic effects of methotrexate.
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Figure 7b. 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). (a) High-resolution CT scan shows scattered ground-glass attenuation and thickened inter- and intralobular lines (arrow). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a specimen from lung biopsy shows patchy interstitial fibrosis, expansion of the interstitium by chronic inflammatory infiltrates, and reactive hyperplastic type II pneumonocytes (arrow), findings consistent with NSIP induced by the pulmonary toxic effects of methotrexate.
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Figure 8. 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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Figure 9a. Topotecan-induced organizing pneumonia in a 45-year-old woman with small cell lung cancer who presented with increasing dyspnea. (a) High-resolution CT scan shows diffuse ground-glass attenuation and septal thickening in a crazy-paving pattern in the right upper lobe (arrows). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a specimen from wedge resection biopsy of the right upper lobe shows scattered interstitial inflammation and occlusion of terminal bronchioles and alveolar ducts by plugs of loose connective tissue (*), findings typical of organizing pneumonia.
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Figure 9b. Topotecan-induced organizing pneumonia in a 45-year-old woman with small cell lung cancer who presented with increasing dyspnea. (a) High-resolution CT scan shows diffuse ground-glass attenuation and septal thickening in a crazy-paving pattern in the right upper lobe (arrows). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a specimen from wedge resection biopsy of the right upper lobe shows scattered interstitial inflammation and occlusion of terminal bronchioles and alveolar ducts by plugs of loose connective tissue (*), findings typical of organizing pneumonia.
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Figure 10. Bleomycin-induced organizing pneumonia in a 44-year-old woman with Hodgkin lymphoma who presented with a nonproductive cough, dyspnea, and decreased DLCO. High-resolution CT scan shows ground-glass attenuation and scattered areas of focal consolidation peripherally. Note the intralobular lines superimposed on the ground-glass attenuation. The diagnosis of organizing pneumonia was confirmed with transthoracic biopsy; there was improvement in the symptoms and radiologic findings after discontinuation of the bleomycin therapy and initiation of corticosteroid therapy.
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Figure 11a. Lipoid pneumonia in a 64-year-old woman with a 20-year history of scleroderma who presented with progressive dyspnea and a dry cough. (a) Posteroanterior chest radiograph shows bilateral, asymmetric, scattered areas of increased opacity in the air space, which have a predominantly perihilar and basal distribution. (b) High-resolution CT scan shows geographic ground-glass attenuation in association with interlobular thickening and intralobular lines (arrow). The results of bronchoalveolar lavage and transbronchial biopsy were nondiagnostic. (c) Photomicrograph (original magnification, x250; 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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Figure 11b. Lipoid pneumonia in a 64-year-old woman with a 20-year history of scleroderma who presented with progressive dyspnea and a dry cough. (a) Posteroanterior chest radiograph shows bilateral, asymmetric, scattered areas of increased opacity in the air space, which have a predominantly perihilar and basal distribution. (b) High-resolution CT scan shows geographic ground-glass attenuation in association with interlobular thickening and intralobular lines (arrow). The results of bronchoalveolar lavage and transbronchial biopsy were nondiagnostic. (c) Photomicrograph (original magnification, x250; 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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Figure 11c. Lipoid pneumonia in a 64-year-old woman with a 20-year history of scleroderma who presented with progressive dyspnea and a dry cough. (a) Posteroanterior chest radiograph shows bilateral, asymmetric, scattered areas of increased opacity in the air space, which have a predominantly perihilar and basal distribution. (b) High-resolution CT scan shows geographic ground-glass attenuation in association with interlobular thickening and intralobular lines (arrow). The results of bronchoalveolar lavage and transbronchial biopsy were nondiagnostic. (c) Photomicrograph (original magnification, x250; 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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Figure 12. Adult respiratory distress syndrome in a 27-year-old man who developed barotrauma and pulmonary interstitial emphysema. High-resolution CT scan shows scattered ground-glass attenuation and thickening of the intra- and interlobular septa (crazy-paving pattern). Note the air within the areas of interlobular thickening, a finding indicative of pulmonary emphysema. (Reprinted, with permission, from reference 43.)
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Figure 13a. Acute diffuse pulmonary hemorrhage in a 53-year-old woman with systemic lupus erythematosus and massive hemoptysis. (a) High-resolution CT scan shows geographic areas of ground-glass attenuation with interlobular septal thickening. (b) Photomicrograph (original magnification, x250; hematoxylin-eosin stain) shows acute intraalveolar hemorrhage.
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Figure 13b. Acute diffuse pulmonary hemorrhage in a 53-year-old woman with systemic lupus erythematosus and massive hemoptysis. (a) High-resolution CT scan shows geographic areas of ground-glass attenuation with interlobular septal thickening. (b) Photomicrograph (original magnification, x250; hematoxylin-eosin stain) shows acute intraalveolar hemorrhage.
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Figure 14a. Primary lung adenocarcinoma in a 54-year-old man with hemoptysis. (a) 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. (b) CT scan shows typical crazy-paving ground-glass attenuation associated with septal thickening surrounding the mass, which is perihilar. Adenocarcinoma with surrounding pulmonary hemorrhage was confirmed at surgery.
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Figure 14b. Primary lung adenocarcinoma in a 54-year-old man with hemoptysis. (a) 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. (b) CT scan shows typical crazy-paving ground-glass attenuation associated with septal thickening surrounding the mass, which is perihilar. Adenocarcinoma with surrounding pulmonary hemorrhage was confirmed at surgery.
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Copyright © 2003 by the Radiological Society of North America.
