Presentation
General decline and shortness of breath.
Patient Data
Age: 75 years
Gender: Female
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- increased airspace and interstitial opacities bilaterally (left greater than right)
- consolidation in the left lung
- multiple air fluid levels in the left side of the anterior mediastinum (see lateral projection)
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- prior esophagectomy with anterior mediastinal pull through
- interstitial and ground glass opacities in a dependent distribution
- this gives a characteristic "crazy paving" appearance
- chronic small left pleural thickening
- confluent airspace opacities in the LUL, lingula, and LLL
Case Discussion
patient had prior esophagectomy which poses an aspiration risk
the airspace and interstitial opacities give the "crazy paving" pattern
the differential of chronic crazy paving is limited and includes lipoid pneumonia
frank yellow fluid was seen at bronchoscopy and confirmed as lipid on microscopy
the more confluent airspace opacities were sampled to exclude malignancy
this yielded mycobacteria fortuitum
non-tuberculous mycobacteria (NTM) is a known association of lipoid pneumonia
it is treated with Bactrim (Sulfamethoxazole-Trimethoprim)