CTICasesAchalasia with Aspiration Lipoid Pneumonia and Crazy Paving
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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