The New England Journal of MedicineCrazy-Paving Pattern in Pulmonary Sarcoidosis

Unveiling Uncommon Radiographic Features and Their Clinical Implications

In a revealing case study, a 28-year-old woman’s encounter with persistent dry cough led to a diagnosis of pulmonary sarcoidosis, marked by an unusual radiographic sign known as the “crazy-paving” pattern. This pattern, typically associated with other pulmonary conditions, underscores the complexity and diagnostic challenges of sarcoidosis. Through detailed investigation, including high-resolution CT scans and lung biopsy, the study sheds light on the diverse manifestations of sarcoidosis and its management, offering valuable insights for physicians in identifying and treating this enigmatic disease.

Key Points:

• A 28-year-old nonsmoking woman presented with a 6-month history of a dry cough, with no associated systemic symptoms, leading to an eventual diagnosis of pulmonary sarcoidosis.
• High-resolution CT of the chest revealed mediastinal lymphadenopathy and diffuse ground-glass opacities, with a distinctive “crazy-paving” pattern observed, characterized by interlobular and intralobular septal thickening.
• The “crazy-paving” pattern, although commonly linked to pulmonary alveolar proteinosis, can also be indicative of other conditions, including sarcoidosis, highlighting its diagnostic complexity.
• Serum angiotensin-converting enzyme levels were elevated, aiding in the diagnosis alongside imaging and histopathological findings from a transbronchial lung biopsy showing noncaseating granulomas.
• Treatment with a tapering dose of prednisone showed significant improvement in symptoms and radiographic findings, with stable condition post-treatment and no progression at one-year follow-up.
• The case emphasizes the importance of considering a broad differential diagnosis when encountering the crazy-paving pattern on imaging, acknowledging its presence in sarcoidosis among other conditions.

HCN Medical Memo
The American Thoracic Society has a Patient Education handout for sarcoidosis.

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