CTICasesAchalasia with Aspiration Lipoid Pneumonia and Crazy Paving
[...]. Achalasia with Aspiration Lipoid Pneumonia and Crazy Paving. CTICases. Published September 8, 2017. https://cticases.com/c/ncexu
Imaging findings
Chest radiograph shows tracheal anterior deviation visible on the lateral view from an enlarged esophagus filling the retrotracheal space, with possible air-fluid level. CT demonstrates a massively dilated esophagus from achalasia. The lung parenchyma shows crazy paving with ground-glass opacity and reticulation throughout particularly the lower lobes, in a distribution consistent with aspiration pneumonia. The patient has been taking mineral oil and other lipid-containing substances orally to help with dysphagia and esophageal clearance.
Key takeaways
Achalasia with a massively dilated esophagus can cause chronic aspiration of retained esophageal contents, and when patients ingest lipid-containing substances such as mineral oil to manage their symptoms, the result can be lipoid aspiration pneumonia producing a crazy paving pattern on CT. The lateral chest radiograph finding of anterior tracheal deviation from the retrotracheal mass effect of the dilated esophagus is a classic and often underappreciated sign of mega-esophagus. True crazy paving requires both ground-glass opacity and overlying reticulation — the combination distinguishes it from pure ground glass or pure septal thickening alone.
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