Crazy-Paving as a Radiological Finding of COVID-19 Infection

Abstract

Since the SARS-CoV-2 virus appeared in December of 2019 resulting in a world-wide pandemic, science has been trying to keep up with how to accurately identify symptoms, diagnose, and treat the novel infection. It was evident that infection resulted in upper respiratory tract symptoms, with the lungs being most commonly affected1. Clinicians have been scrambling to identify radiographic findings that could predict infection with the virus. Computed tomography (CT) scanning of the chest has become the modality of choice. Ground glass opacities (GGO) are identified in a large majority of cases but other radiographic changes such as laterality, consolidation, lobe involvement, and vascular abnormalities also give signal to COVID-19. In this case, COVID-19 resulted in a crazy-paving pattern which has only been found in 34.9% of COVID-19 patients2. Introduction: More than 70% of COVID patients have CT abnormalities that include GGO, vascular enlargement, bilateral abnormalities, lower lobe involvement, and posterior predilection. We present a case of a linear pattern superimposed on a background of GGO resembling irregularly shaped paving stones, “crazy paving”. Case presentation: A 92 year old female with a past medical history of hypertension, chronic kidney disease, reflux, and immune thrombocytopenic purpura presented to the emergency department with cough, nausea and fatigue for two days. She was afebrile and exam revealed new onset atrial fibrillation. Laboratory studies showed thrombocytopenia of 62 k/mcL, elevated lactate dehydrogenase of 443 U/L, and elevated CRP of 7.4 mg/dL. Chest radiography showed a questionable opacity in the right upper lobe concerning for pneumonia. Rapid antigen testing for Sars-CoV-2 returned positive. She developed progressively worsening hypoxemia and dyspnea prompting a chest CT scan that was negative for pulmonary embolism, but GGO were noted in the right upper and lower lobes with a crazy-paving appearance. Remdesivir, dexamethasone, and convalescent plasma was administered. She improved and was discharged to an inpatient rehabilitation facility. Discussion: Crazypaving can be seen in many conditions - most commonly pulmonary edema, infection, hemorrhage, acute interstitial pneumonia, adult respiratory distress syndrome, radiation pneumonitis and eosinophilic pneumonia3. Several systematic reviews and meta-analyses found crazy-paving in 34.9% of CT scans of the chest in patients with COVID-192. This case highlights crazy-paving as a radiographic finding on CT scan of the chest. Conclusion: It is evident that as more data accumulates about radiographic findings and treatment of COVID-19, that COVID- 19 does not have pathognomonic radiological findings.