Chronic cough, heavy smoker.
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Central bilateral infiltrates with sparing of the apices and costophrenic angles. Normal lung volumes. No pleural effusion or PTX. Cardiomediastinal contours are normal.
DDx for batwing opacities includes pulmonary edema, PCP, pulmonary hemorrhage and PAP.
This patient was suspected for PAP on clinical grounds and underwent bronchoscopy, with bronchial lavage confirming alveolar proteinosis with copious amounts of surfactant.