Diffuse Lung Disease |

A Case of Pulmonary Alveolar Microlithiasis Presenting as Crazy Paving FREE TO VIEW

Umar Osman, MD; Jennifer Toth, MD; Christopher Gilbert, DO; Michael Reed, MD
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Hershey Medical Center, Hershey, PA

Chest. 2014;146(4_MeetingAbstracts):379A. doi:10.1378/chest.1989412
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SESSION TITLE: Interstitial Lung Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Crazy paving is a pattern on chest CT characterized by thickening of interlobular septa and intralobular lines that can be caused by a number of conditions including pulmonary alveolar proteinosis, acute respiratory distress syndrome, and other interstitial lung diseases. Pulmonary alveolar microlithiasis is a rare condition characterized by calcium deposition. Often this disease is discovered incidentally by imaging as patients can remain asymptomatic for an extended period of time. We present an advanced case of this condition to highlight an important radiographic feature that may help other clinicians in identifying this condition.

CASE PRESENTATION: A seventy three year old female with a lifelong nonsmoking history was inititally evaluated for slowly progressive dyspnea over the prior two years. She denied any other associated symptoms including cough, sputum production, or chest pain. Pulmonary function testing demonstrated restriction with a total lung capacity of 64% predicted and a diffusion limitation. Chest imaging was significantly abnormal with thickening of the interlobular septa initially described as a crazy paving pattern. This prompted a bronchoscopy out of concern for pulmonary alveolar proteinosis. However both bronchoalveolar lavages and transbronchial biopsy results were not consistent with any particular diagnosis. Patient was then referred for open lung biopsy which demonstrated findings consistent with pulmonary alveolar microlithiasis.

DISCUSSION: On review of the patient's chest imaging under bone windows it was noted that the crazy paving pattern was related to linear calcifications consistent with her pathologic diagnosis and shared a similar density with the surrounding bony structures.

CONCLUSIONS: Pulmonary alveolar microlithiasis can be challenging to diagnose clinically and no clear treatment currently exists. As demonstrated by our case an important part of identifying the atypical calcifications is comparison with bony structures. Differentiating this condition on imaging from other interstitial lung diseases may save individuals from unnecessary procedures and associated morbidity.

Reference #1: De Wever W. et al. The crazy-paving pattern: a radiological-pathological correlation. Insights Imaging. 2011. 2: 117-132.

Reference #2: Walters G et al. Pulmonary Alveolar Microlithiasis. Annals of Thoracic Surgery. 2013; 96:702

Reference #3: Jönsson Åsa Lina et al. Pulmonary alveolar microlithiasis: two case reports and review of literature. Eur Respiratory Review. 2013; 21:125, 249-256.

DISCLOSURE: The following authors have nothing to disclose: Umar Osman, Jennifer Toth, Christopher Gilbert, Michael Reed

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