Axial CT of the chest at the level of the aortic arch demonstrates diffuse bilateral ground-glass opacities with superimposed interlobular septal thickening, creating a “crazy-paving” pattern. There is characteristic subpleural sparing. Additional findings include dependent consolidation, consolidation in the right upper lobe, underlying centrilobular emphysema, and small bilateral pleural effusions.
In the clinical setting of acute hypoxia, these findings are characteristic of Acute Respiratory Distress Syndrome (ARDS) due to an underlying pathology of diffuse alveolar damage (DAD). In this patient, potential etiologies are multifactorial and include sepsis from a dental abscess or cocaine-induced lung injury, which is a known cause of DAD and ARDS (PMID: 18432103). The differential diagnosis for a crazy-paving pattern also includes pulmonary alveolar proteinosis (PAP) and Pneumocystis jirovecii pneumonia (PJP), though the acute presentation and subpleural sparing make ARDS most likely (PMID: 27533442).
The “crazy-paving” pattern with subpleural sparing in a patient with acute hypoxia strongly suggests an organizing diffuse alveolar damage pattern, the histological equivalent of ARDS.
Ashley Davidoff MD – TheCommonVein.com (b79823a-00)
This Memory image illustrates a man turning blue in distress, as he drowns in his own “secretions.” It is a metaphor for the patient’s critical state, which began with a severe Community-Acquired Pneumonia (CAP). In this immunocompromised patient, the infection rapidly progressed, leading to shock. This overwhelming systemic insult likely triggered secondary Congestive Heart Failure (CHF), which, combined with the pneumonia, led to the evolution of Acute Respiratory Distress Syndrome (ARDS). The patient is now “drowning” in a combination of infectious exudate from the pneumonia and cardiogenic edema from the failing heart. This profound cardiopulmonary collapse requires maximal life support, evidenced by an endotracheal tube, IABP, and Swan-Ganz catheter.
Ashley Davidoff MD TheCommonVein.net (136501.MAD-01.ARDS) Memory Image, AI Assisted, Davidoff Art Modification
” ARDS The Sudden Storm “
(Verse 1) I am the sudden, savage storm, A body breaking from the norm. A distant sepsis, trauma’s shock, A single, catastrophic knock. I am the answer, not the cause, The lung’s response, without a pause.
(Chorus) They call me ARDS! A bilateral, heavy mess. The hyaline membrane, glassy, slick, Encase the air sacs, fast and thick. A “white-out” lung, a desperate plea, I am the dread ARDS.
(Verse 2) The walls within begin to leak, A capillary, torn and weak. The alveoli start to drown, As protein-heavy fluid pours down. No lobe is spared, no spot is clear, A bilateral map of fear.
(Chorus) They call me ARDS! A bilateral, heavy mess. The hyaline membrane, glassy, slick, Encase the air sacs, fast and thick. A “white-out” lung, a desperate plea, I am the dread ARDS.
(Bridge) The oxygen will not go in, No matter where the tubes begin. The gasp for air, the panicked breath, The “refractory” dance with death. The ventilator’s forceful sigh, Must breathe for you, or you will die.
Poem
” ARDS The Sudden Storm “
I am the sudden, savage storm, A body breaking from the norm.
A distant sepsis, trauma’s shock, A single, catastrophic knock. I am the answer, not the cause, The lung’s response, without a pause.
The walls within begin to leak, A capillary, torn and weak. The alveoli start to drown, As protein-heavy fluid pours down. The hyaline membrane, glassy, slick, Encase the air sacs, fast and thick.
The chest X-ray, a blinding white, A total “white-out,” day and night. No lobe is spared, no spot is clear, A bilateral map of fear. The lungs are heavy, stiff, and wet, A solid, water-logged regret.
The oxygen will not go in, No matter where the tubes begin. The gasp for air, the panicked breath, The “refractory” dance with death. The ventilator’s forceful sigh, Must breathe for you, or you will die.
I am the end of simple air, The final, desperate, gasping prayer. I am the battle, hard and fast, The brutal syndrome, built to last. I am the dread ARDS.