Unilateral Crazy-paving Pattern: An Unusual Radiologic Presentation of Systemic Lupus Erythematosus

Aims and background: Ground glass opacities with smooth septal thickening in high-resolution computed tomography (HRCT) thorax in the setting of fever, cough, and shortness of breath point toward multiple directions as differentials, including infections, connective tissue diseases, diffuse alveolar hemorrhage, and many more.Here we share a case report of a 26-year-old lady who presented with unilateral predominant ground glass opacities with septal thickening against a background of fever, cough, and shortness of breath.Case description: A 26-year-old never-smoker, homemaker female presented with a history of low-grade fever, dry cough, and progressively worsening dyspnea for one month, which worsened over the last week.On examination, she was tachypneic and tachycardic, with fine inspiratory crackles on the right.Radiological findings in the HRCT revealed unilateral ground glass opacities with smooth interlobular septal thickening, opening the way to multiple differentials, including infections, pulmonary alveolar proteinosis, alveolar sarcoidosis, connective tissue disease, and interstitial lung disease (ILD).Bronchoscopy with bronchoalveolar lavage (BAL) and biopsy was performed, which ruled out infections, granuloma, and malignancy.Considering her symptoms of oral ulcers and nonspecific arthralgia, an autoimmune workup was pursued, which turned out to be suggestive of systemic lupus erythematosus (SLE), and thus, the diagnosis was confirmed, and treatment was initiated, with follow-up planned.Conclusion: Systemic lupus erythematosus is an autoimmune disease with multisystem involvement and diverse clinical presentations.Pulmonary manifestations include ILD, diffuse alveolar hemorrhage (DAH), acute lupus pneumonitis, and many more, emphasizing the rare presentations, like lupus pneumonitis and ILD, that may be misdiagnosed or diagnosed late.A proper workup, including laboratory testing and ruling out differentials, is necessary to diagnose rare presentations of this disease.Clinical significance: Systemic lupus erythematosus is a multisystem disease with variable presentations, and the unusual radiological pattern in this case scenario emphasizes broad differentials and narrowing down to the diagnosis by correlating the clinicoradiological picture and serological investigations.