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Vojcek E, Krikovszky D, Lódi C, Kovács L, Schnur J, Szabó AJ. Whole lung lavage and GM-CSF use for pulmonary alveolar proteinosis in an infant with lysinuric protein intolerance: a case report. Ital J Pediatr 2024; 50:111. [PMID: 38831374 PMCID: PMC11149197 DOI: 10.1186/s13052-024-01677-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/20/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Lysinuric protein intolerance (LPI) is a multi-organ metabolic disorder characterized by the imbalance in absorption and excretion of cationic amino acids like lysine, ornithine and arginine. Infants with LPI typically present with recurrent vomiting, poor growth, interstitial lung disease or renal impairment. The early onset of pulmonary alveolar proteinosis (PAP) has been reported to be associated with a severe form of LPI. Treatment of PAP most commonly consists of whole-lung lavage (WLL) and in autoimmune PAP, granulocyte-macrophage colony stimulating factor (GM-CSF) administration. Nevertheless, GM-CSF therapy in LPI-associated PAP has not been scientifically justified. CASE PRESENTATION We describe the case of an 8-month-old infant presenting with respiratory failure due to LPI associated with PAP, who was twice treated with WLL; firstly, while on veno-venous ECMO assistance and then by the use of a selective bronchial blocker. After the two treatments with WLL, she was weaned from daytime respiratory support while on initially subcutaneous, then on inhaled GM-CSF therapy. CONCLUSIONS This case supports the notion that GM-CSF therapy might be of benefit in patients with LPI-associated PAP. Further studies are needed to clarify the exact mechanism of GM-CSF in patients with LPI-associated PAP.
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Affiliation(s)
- Eszter Vojcek
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Bókay J. u. 53-54, Budapest, 1083, Hungary.
| | - Dóra Krikovszky
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Bókay J. u. 53-54, Budapest, 1083, Hungary
| | - Csaba Lódi
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Bókay J. u. 53-54, Budapest, 1083, Hungary
| | - Lajos Kovács
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Bókay J. u. 53-54, Budapest, 1083, Hungary
| | | | - Attila J Szabó
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Bókay J. u. 53-54, Budapest, 1083, Hungary
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Alveolar macrophage metabolic programming via a C-type lectin receptor protects against lipo-toxicity and cell death. Nat Commun 2022; 13:7272. [PMID: 36433992 PMCID: PMC9700784 DOI: 10.1038/s41467-022-34935-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/12/2022] [Indexed: 11/27/2022] Open
Abstract
Alveolar macrophages (AM) hold lung homeostasis intact. In addition to the defense against inhaled pathogens and deleterious inflammation, AM also maintain pulmonary surfactant homeostasis, a vital lung function that prevents pulmonary alveolar proteinosis. Signals transmitted between AM and pneumocytes of the pulmonary niche coordinate these specialized functions. However, the mechanisms that guide the metabolic homeostasis of AM remain largely elusive. We show that the NK cell-associated receptor, NKR-P1B, is expressed by AM and is essential for metabolic programming. Nkrp1b-/- mice are vulnerable to pneumococcal infection due to an age-dependent collapse in the number of AM and the formation of lipid-laden AM. The AM of Nkrp1b-/- mice show increased uptake but defective metabolism of surfactant lipids. We identify a physical relay between AM and alveolar type-II pneumocytes that is dependent on pneumocyte Clr-g expression. These findings implicate the NKR-P1B:Clr-g signaling axis in AM-pneumocyte communication as being important for maintaining metabolism in AM.
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Kim C, Garcia-Tome R, Hurtado C, Ding L, Wang T, Chang CF. Characteristics of hospital admissions for pulmonary alveolar proteinosis: analysis of the nationwide inpatient sample (2012-2014). BMC Pulm Med 2022; 22:365. [PMID: 36153570 PMCID: PMC9509629 DOI: 10.1186/s12890-022-02082-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 07/20/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare clinical syndrome involving the accumulation of lipid-rich proteinaceous material in the alveoli. There is a paucity of published studies on this condition. To better characterize the demographics, complication rates, mortality, and healthcare costs of patients hospitalized for PAP in the United States, a secondary analysis on the Hospital Cost and Utilization Project's Nationwide Inpatient Sample (NIS) was performed on patients admitted from 2012 to 2014 with a diagnosis of pulmonary alveolar proteinosis. METHODS Using the NIS database, a secondary analysis was performed on 500 admissions with the diagnosis "pulmonary alveolar proteinosis." The clinical variables and outcome measures extracted were: patient demographics, hospital costs, length of stay, frequency of admissions, and inpatient mortality rate. RESULTS Among a weighted estimate of 500 hospital admissions from 2012 to 2014, the number of PAP admissions averaged 4.7 per million. The population was predominantly male (55%) with a mean age of 41.45 (CI 38.3-44.5) from all socioeconomic levels. Inpatient mortality was calculated to be 5%, which may result from the fact that the majority of admitted patients had few or no comorbid conditions (CCI 0.72). The most common procedure performed during admission was a bronchoalveolar lavage. Mean length of stay was 6.2 days (CI 3.9-8.5) and average cost of admission was $29,932.20 (CI 13,739-46,124). Of note, 50% of these admissions were considered "elective." CONCLUSIONS Demographics of patients with PAP who have been hospitalized in the United States are similar to previously reported demographics from prior patient cohorts, specifically a male predominance and a mean age in the 40 s. The inpatient mortality rate of 5% we found is consistent with prior studies demonstrating good disease-specific survival rates. Notably, the cost per admission and overall annual cost associated with PAP hospitalization was calculated to be $29932.20 and $5 million respectively. This reflects the high economic cost associated with hospitalization of PAP patients, and provokes thought about ways to make treatment more cost-effective.
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Affiliation(s)
- Chongiin Kim
- grid.42505.360000 0001 2156 6853Department of Internal Medicine, University of Southern California, Los Angeles, CA USA
| | - Rodrigo Garcia-Tome
- grid.42505.360000 0001 2156 6853Department of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA USA
| | - Carolina Hurtado
- grid.19006.3e0000 0000 9632 6718Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Li Ding
- grid.42505.360000 0001 2156 6853Department of Population and Public Health Sciences, Keck School of Medicine, Los Angeles, CA USA
| | - Tisha Wang
- grid.19006.3e0000 0000 9632 6718Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA USA
| | - Ching-Fei Chang
- grid.42505.360000 0001 2156 6853Department of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA USA
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Shrestha D, Dhooria S, Munirathinam GK, Sehgal IS, Prasad KT, Ram B, Singh H, Aggarwal AN, Puri GD, Muthu V, Agarwal R. How We Do It: Whole Lung Lavage. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2022; 39:e2022017. [PMID: 36118542 PMCID: PMC9437756 DOI: 10.36141/svdld.v39i2.12884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/12/2022] [Indexed: 06/15/2023]
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder characterized by the accumulation of surfactant in the alveolar spaces resulting in hypoxemic respiratory failure. Whole lung lavage (WLL), the preferred treatment for PAP, physically removes the lipoproteinaceous material from the alveolar spaces. Since its initial description in 1963, the WLL procedure has undergone various modifications. However, the procedure has not been standardized yet. After securing a double lumen endotracheal tube, we perform WLL under general anesthesia. One lung is ventilated, while the other is lavaged using one-liter aliquots of pre-warmed saline. We use gravity-assisted drainage of the lavaged lung after each cycle till the milky white and opaque fluid becomes clear (usually 15-20 cycles). Herein, we describe the step-by-step procedure, precautions, and monitoring of WLL. We also provide videos demonstrating one-lung ventilation and bronchoscopic confirmation of lung isolation.
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Affiliation(s)
- Deepa Shrestha
- department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Anesthesia and Intensive care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ganesh Kumar Munirathinam
- department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Babu Ram
- department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harkant Singh
- department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N. Aggarwal
- Department of Anesthesia and Intensive care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Goverdhan D Puri
- department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Iftikhar H, Nair GB, Kumar A. Update on Diagnosis and Treatment of Adult Pulmonary Alveolar Proteinosis. Ther Clin Risk Manag 2021; 17:701-710. [PMID: 34408422 PMCID: PMC8364424 DOI: 10.2147/tcrm.s193884] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/19/2021] [Indexed: 01/15/2023] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare pulmonary surfactant homeostasis disorder resulting in buildup of lipo-proteinaceous material within the alveoli. PAP is classified as primary (autoimmune and hereditary), secondary, congenital and unclassifiable type based on the underlying pathogenesis. PAP has an insidious onset and can, in some cases, progress to severe respiratory failure. Diagnosis is often secured with bronchoalveolar lavage in the setting of classic imaging findings. Recent insights into genetic alterations and autoimmune mechanisms have provided newer diagnostics and treatment options. In this review, we discuss the etiopathogenesis, diagnosis and treatment options available and emerging for PAP.
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Affiliation(s)
- Hira Iftikhar
- Division of Pulmonary and Critical Care, Beaumont Health, OUWB School of Medicine, Royal Oak, MI, USA
| | - Girish B Nair
- Division of Pulmonary and Critical Care, Beaumont Health, OUWB School of Medicine, Royal Oak, MI, USA
| | - Anupam Kumar
- Division of Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX, USA
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Sigakis MJG, De Cardenas JL. Lung Ultrasound Scans During Whole Lung Lavage. Chest 2021; 159:e433-e436. [PMID: 34099165 DOI: 10.1016/j.chest.2020.06.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/07/2020] [Accepted: 06/06/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Matthew J G Sigakis
- Department of Anesthesiology, Division of Critical Care, University of Michigan Medical School, Ann Arbor, MI.
| | - Jose L De Cardenas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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7
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Kaushal B, Chauhan S, Hasija S. Bilateral whole lung lavage by lung isolation in a child with pulmonary alveolar proteinosis: A new technique. Ann Card Anaesth 2021; 24:266-268. [PMID: 33884993 PMCID: PMC8253022 DOI: 10.4103/aca.aca_90_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
We present two rare cases of children who presented with progressive exertional breathlessness and dry cough. They also had history of bluish discoloration of mucous membranes, hands and feet on exertion. Both were diagnosed to have pulmonary alveolar proteinosis after a high-resolution computed tomography and bronchoalveolar lavage. They were subjected to bilateral whole lung lavage (WLL) as a salvage therapy. Bilateral WLL was performed in a single sitting with the help of a modified endotracheal tube. The anesthetic technique included a modified cuffed endotracheal tube for accomplishing WLL. After the procedure, both children improved clinically and functionally.
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Affiliation(s)
- Brajesh Kaushal
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, AIIMS, New Delhi, India
| | - Sandeeps Chauhan
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, AIIMS, New Delhi, India
| | - Suruchi Hasija
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, AIIMS, New Delhi, India
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Oudah M, Slack D. Mild dyspnea presenting as 'crazy-paving' on chest computed tomography. J Community Hosp Intern Med Perspect 2021; 11:273-276. [PMID: 33889337 PMCID: PMC8043521 DOI: 10.1080/20009666.2020.1860443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pulmonary alveolar proteinoisis (PAP) is a rare disease characterized by accumulation of proteinaceous material in the alveolar spaces. Here, we report a case of mild dyspnea with incidental ‘crazy-paving’ pattern on chest computed tomography (CT). Further evaluation and bronchoscopy found to have PAP.
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Affiliation(s)
- M Oudah
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, Maryland, USA
| | - D Slack
- Department of Pulmonology and Critical Care Medicine, Greater Baltimore Medical Center, Towson, Maryland, USA
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9
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Chen C, Huang XL, Gao DQ, Li YW, Qian SX. Chronic myelomonocytic leukemia-associated pulmonary alveolar proteinosis: A case report and review of literature. World J Clin Cases 2021; 9:1156-1167. [PMID: 33644180 PMCID: PMC7896663 DOI: 10.12998/wjcc.v9.i5.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/06/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare condition that can cause progressive symptoms including dyspnea, cough and respiratory insufficiency. Secondary PAP is generally associated with hematological malignancies including chronic myelomonocytic leukemia (CMML). To the best of our knowledge, this is the first reported case of PAP occurring secondary to CMML.
CASE SUMMARY We report the case of a 63-year-old male who presented with a recurrent cough and gradually progressive dyspnea in the absence of fever. Based upon clinical symptoms, computed tomography findings, bone marrow aspiration, flow cytometry studies and cytogenetic analyses, the patient was diagnosed with PAP secondary to CMML. He underwent whole lung lavage in March 2016 to alleviate his dyspnea, after which he began combined chemotherapeutic treatment with decitabine and cytarabine. The patient died in January 2020 as a consequence of severe pulmonary infection.
CONCLUSION This case offers insight regarding the mechanistic basis for PAP secondary to CMML and highlights potential risk factors.
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Affiliation(s)
- Can Chen
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Xi-Lian Huang
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Da-Quan Gao
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Yi-Wei Li
- Department of Intensive Care Unit, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Shen-Xian Qian
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
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11
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Santos GF, Portela J, Argyropoulou D, Varudo R, Pimenta I, Oliveira A, Lança S, Fernandes A. Alveolar proteinosis due to toxic inhalation at workplace. Respir Med Case Rep 2020; 31:101199. [PMID: 32868988 PMCID: PMC7449138 DOI: 10.1016/j.rmcr.2020.101199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 01/15/2023] Open
Abstract
We report a clinical case of a 39-year old male, without any known previous medical condition but with occupational exposure to paints and dust cement, who presented an autoimmune pulmonary alveolar proteinosis (PAP) triggered by exposure to toxic inhalation at his workplace. PAP is a rare lung disease characterized by intra-alveolar abnormal accumulation of surfactant. The presence of a crazy-paving pattern in high-resolution computed tomography scan brings the suspicion of PAP although histopathology results of bronchoalveolar lavage are always required for its final diagnosis. The autoimmune form of PAP due to toxic inhalation, such as the one here described, is rare and it is usually difficult to establish a causal relationship.
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Affiliation(s)
- Gabriela F Santos
- Pneumonology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - João Portela
- Pneumonology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Despoina Argyropoulou
- Pathology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Rita Varudo
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Inês Pimenta
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Ana Oliveira
- Pathology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Sara Lança
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Antero Fernandes
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
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12
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Jouneau S, Ménard C, Lederlin M. Pulmonary alveolar proteinosis. Respirology 2020; 25:816-826. [PMID: 32363736 DOI: 10.1111/resp.13831] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/02/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022]
Abstract
PAP is an ultra-rare disease in which surfactant components, that impair gas exchange, accumulate in the alveolae. There are three types of PAP. The most frequent form, primary PAP, includes autoimmune PAP which accounts for over 90% of all PAP, defined by the presence of circulating anti-GM-CSF antibodies. Secondary PAP is mainly due to haematological disease, infections or inhaling toxic substances, while genetic PAP affects almost exclusively children. PAP is suspected if investigation for ILD reveals a crazy-paving pattern on chest CT scan, and is confirmed by a milky looking BAL that gives a positive PAS reaction indicating extracellular proteinaceous material. PAP is now rarely confirmed by surgical lung biopsy. WLL is still the first-line treatment, with an inhaled GM-CSF as second-line treatment. Inhalation has been found to be better than subcutaneous injections. Other treatments, such as rituximab or plasmapheresis, seem to be less efficient or ineffective. The main complications of PAP are due to infections by standard pathogens (Streptococcus, Haemophilus and Enterobacteria) or opportunistic pathogens such as mycobacteria, Nocardia, Actinomyces, Aspergillus or Cryptococcus. The clinical course of PAP is unpredictable and spontaneous improvement can occur. The 5-year actuarial survival rate is 95%.
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Affiliation(s)
- Stéphane Jouneau
- Department of Respiratory Medicine, Competence Centre for Rare Pulmonary Diseases, CHU Rennes, Univ Rennes, Rennes, France.,IRSET UMR108, Univ Rennes, Rennes, France
| | - Cédric Ménard
- Service d'Immunologie, de Thérapie Cellulaire et d'Hématopoïèse, Hôpital Pontchaillou, Rennes, France
| | - Mathieu Lederlin
- Department of Radiology, CHU Rennes, Univ Rennes, Rennes, France.,LTSI, INSERM U1099, Univ Rennes, Rennes, France
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Granulocyte-Macrophage Colony-Stimulating Factor Inhalation Therapy for Severe Pulmonary Alveolar Proteinosis. Am J Ther 2020; 28:e171-e178. [PMID: 31513019 DOI: 10.1097/mjt.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Some patients with pulmonary alveolar proteinosis (PAP) still present with high recurrence rate after large-volume whole lung lavage (WLL). Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been proved to be effective for PAP, but clinical research on GM-CSF inhalation therapy combined with WLL for severe PAP is rare in Asia. STUDY QUESTION This study aimed to investigate the clinical efficacy of GM-CSF inhalation combined with WLL in Chinese patients with PAP. STUDY DESIGN We performed regression analysis on 33 patients with severe PAP who underwent WLL alone or WLL combined with GM-CSF inhalation. The patients were put into 2 groups, WLL group and GM-CSF/WLL group. MEASURES AND OUTCOMES Physiologic, serologic, and radiologic features of the 2 groups at different time points after treatment and the recurrence rates at 1-year follow-up were compared. RESULTS There were no significant differences in lung function, blood gas analysis indices, and lung CT between the 2 groups after 1-week treatment (P > 0.05). After 3-month treatment, the GM-CSF/WLL group showed significantly faster improvement in FEV1%Pred (P = 0.028), FVC%Pred (P = 0.014), PaO2 (P = 0.022), PA-aO2 (P = 0.009), PaO2/FiO2 (P = 0.025), 6-minute walking test (P = 0.002), and lung CT parameters (P < 0.05) compared with the WLL group. The recurrence rate at the 1-year follow-up in the GM-CSF/WLL group (5.5%) was significantly higher than that in the WLL group (46.67%; P < 0.05). CONCLUSIONS GM-CSF inhalation therapy combined with WLL is an effective treatment for patients with severe PAP, with further improvement in lung function at the base of WILL as well as reduction on re-WLL incidence.
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Lesser T, Wolfram F, Braun C, Gottschall R. Effects of one-lung flooding on porcine haemodynamics and gas exchange. Int J Med Sci 2020; 17:3165-3173. [PMID: 33173436 PMCID: PMC7646118 DOI: 10.7150/ijms.50852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/07/2020] [Indexed: 11/05/2022] Open
Abstract
Background and aim: We established a porcine model of one-lung flooding (OLF) that can be used for research on the use of ultrasound for lung tumour detection, ultrasound-guided transthoracic needle biopsy, and tumour ablation. However, OLF requires one-lung ventilation (OLV) and eliminates the recruitment strategies of the nonventilated lung. During thoracic surgery, OLV alone can be associated with hypoxia, hypercapnia, and right ventricular overload. Here, we examined whether OLF influences haemodynamics and gas exchange indices during and after OLV/OLF compared with OLV/apnoea and two-lung ventilation (TLV) following deflooding. Methods: Fourteen pigs were included in this study: five were allocated to the control group (CO) and nine were assigned to the OLF group (OLF). Assessments of haemodynamics, gas exchange, and lung sonography were performed after baseline measurements, during OLV/apnoea, OLV/OLF, and after deflooding and TLV. The volume of extravascular lung water was also measured. Results: OLF induced no significant deterioration of oxygenation or ventilation during OLF or after deflooding and TLV. Color-coded duplex sonography of the pulmonary artery in the flooded lung demonstrated an oscillating flow that corresponded to intrapulmonary circulatory arrest. After flooding of the nonventilated lung, the partial pressure of O2 in the arterial blood increased and the shunt fraction decreased significantly compared to OLV/apnoea conditions. After deflooding and TLV, haemodynamics and gas exchange indices showed no differences compared to the CO group and baseline values, respectively. Conclusions: OLF is safe to use during acute animal experimentation. No clinically relevant deterioration of haemodynamics or gas exchange occurred during or after OLF. Due to the circulatory arrest in the flooded lung, the right-to-left shunt volume in the nonventilated lung was minimized. Survival experiments are necessary to further assess the utility of this method.
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Affiliation(s)
- Thomas Lesser
- Department Thoracic and Vascular Surgery, SRH Wald-Klinikum Gera, Teaching Hospital of Jena University Hospital, Strasse des Friedens 122, Gera D-07548, Germany
| | - Frank Wolfram
- Department Thoracic and Vascular Surgery, SRH Wald-Klinikum Gera, Teaching Hospital of Jena University Hospital, Strasse des Friedens 122, Gera D-07548, Germany
| | - Conny Braun
- Central Experimental Animal Facility, University Hospital Jena, Location Dornburger Strasse 23a, Jena D-07743, Germany
| | - Reiner Gottschall
- Doctor Emeritus, Department of Anaesthesiology and Intensive Care, Jena University Hospital, Am Klinikum 1, Jena D-07747, Germany
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15
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Smith BB, Torres NE, Hyder JA, Barbara DW, Gillespie SM, Wylam ME, Smith MM. Whole-lung Lavage and Pulmonary Alveolar Proteinosis: Review of Clinical and Patient-centered Outcomes. J Cardiothorac Vasc Anesth 2019; 33:2453-2461. [DOI: 10.1053/j.jvca.2019.03.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/19/2019] [Accepted: 03/23/2019] [Indexed: 11/11/2022]
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Khera R, Rao V, Pasam MK, Tagore R, Murthy SS, Sundaram C. Isolated cerebral aspergillus abscess as a complication of pulmonary alveolar proteinosis in a child. Chin Neurosurg J 2019; 5:17. [PMID: 32922917 PMCID: PMC7398192 DOI: 10.1186/s41016-019-0165-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/11/2019] [Indexed: 11/10/2022] Open
Abstract
Abstract Background Pulmonary alveolar proteinosis (PAP) poses a risk of opportunistic infections with a variety of organisms with Nocardia being the most common pathogen followed by mycobacteria and fungi. Case presentation A 7-year-old female child, presented with headache and multiple episodes of vomiting. There was no fever or altered sensorium. On examination, there were no focal deficits or cranial nerve palsies. An MRI brain showed a small T2 hyperintense lesion in the left superior parietal lobe suggestive of an abscess. She was diagnosed as PAP based on CT chest and bronchioloalveolar lavage 7 months earlier and treated with corticosteroids. A left parieto-occipital craniotomy was done with drainage of abscess and abscess wall excision. Histopathology revealed a suppurative lesion with slender septate acute angle branching hyphae which were positive on fungal stains. Culture done on the pus was positive for Aspergillus fumigatus. The patient was treated with voriconazole and stable at 1 year follow-up. Conclusion Opportunistic infections are common in patients diagnosed with PAP. High index of clinical suspicion and early diagnosis are important for favorable outcome.
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Affiliation(s)
- Rachna Khera
- Department of Laboratory Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana 500034 India
| | - Venkateswara Rao
- Department of Neurosurgery, Basavatarakam Indoamerican Cancer Hospital and Research Institute, Hyderabad, Telangana 500034 India
| | - Mohan Krishna Pasam
- Department of Laboratory Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana 500034 India
| | - Ravindranath Tagore
- Department of Laboratory Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana 500034 India
| | - Sudha S Murthy
- Department of Laboratory Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana 500034 India
| | - Challa Sundaram
- Department of Laboratory Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana 500034 India
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17
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Athayde RABD, Arimura FE, Kairalla RA, Carvalho CRR, Baldi BG. Characterization and outcomes of pulmonary alveolar proteinosis in Brazil: a case series. ACTA ACUST UNITED AC 2019; 44:231-236. [PMID: 30043890 PMCID: PMC6188683 DOI: 10.1590/s1806-37562017000000168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 10/15/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pulmonary alveolar proteinosis (PAP) is a rare disease, characterized by the alveolar accumulation of surfactant, which is composed of proteins and lipids. PAP is caused by a deficit of macrophage activity, for which the main treatment is whole-lung lavage (WLL). We report the experience at a referral center for PAP in Brazil. METHODS This was a retrospective study involving patients with PAP followed between 2002 and 2016. We analyzed information regarding clinical history, diagnostic methods, treatments, and outcomes, as well as data on lung function, survival, and complications. RESULTS We evaluated 12 patients (8 of whom were women). The mean age was 41 ± 15 years. Most of the patients were diagnosed by means of BAL and transbronchial biopsy. The mean number of WLLs performed per patient was 2.8 ± 2.5. One third of the patients never underwent WLL. Four patients (33.3%) had associated infections (cryptococcosis, in 2; nocardiosis, in 1; and tuberculosis, in 1), and 2 (16.6%) died: 1 due to lepidic adenocarcinoma and 1 due to complications during anesthesia prior to WLL. When we compared baseline data with those obtained at the end of the follow-up period, there were no significant differences in the functional data, although there was a trend toward an increase in SpO2. The median follow-up period was 45 months (range, 1-184 months). The 5-year survival rate was 82%. CONCLUSIONS To our knowledge, this is the largest case series of patients with PAP ever conducted in Brazil. The survival rate was similar to that found at other centers. For symptomatic, hypoxemic patients, the treatment of choice is still WLL. Precautions should be taken in order to avoid complications, especially opportunistic infections.
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Affiliation(s)
- Rodolfo Augusto Bacelar de Athayde
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Fábio Eiji Arimura
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Ronaldo Adib Kairalla
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Carlos Roberto Ribeiro Carvalho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruno Guedes Baldi
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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18
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Nakamura K, Omura S, Kajiura K, Ishigaki M. Removal of lung lavage fluid during whole-lung lavage using biphasic cuirass ventilation chest percussion in a patient with autoimmune pulmonary alveolar proteinosis. Lung India 2019; 36:540-542. [PMID: 31670303 PMCID: PMC6852211 DOI: 10.4103/lungindia.lungindia_289_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Autoimmune pulmonary alveolar proteinosis (PAP) is a rare lung disease. Although recombinant human granulocyte macrophage colony-stimulating factor (GM-CSF) therapy has emerged as a new therapeutic modality, whole-lung lavage (WLL) with manual chest percussion has been a standard therapy in advanced cases. The application of biphasic cuirass ventilation (BCV) instead of chest percussion has rarely been reported. We describe the case of a patient with advanced PAP who recovered well in both lungs, without complication, after we performed WLL with BCV under anesthetic mechanical ventilation. Both radiographical chest findings and clinical symptoms were improved, and oxygen therapy was finally withdrawn. This case illustrates that BCV can enhance the effective removal of lavage fluid and is an alternative to manual percussion.
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19
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Zhang H. The effectiveness of N-acetylcysteine for an adult case of pulmonary alveolar proteinosis: A case report. Respir Med Case Rep 2019; 28:100883. [PMID: 31249778 PMCID: PMC6586945 DOI: 10.1016/j.rmcr.2019.100883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction Pulmonary alveolar proteinosis is a rare disease that is characterized by accumulation of surfactant and phospholipids in the pulmonary alveoli. The current mainstay of treatment is whole lung lavage. There have been rare reports that have revealed the effectiveness of N-acetylcysteine on a secondary PAP. Case presentation A 45-year old man complained of shortness of breath and a productive cough with white sputum. He inhaled stone powder as an occupational hazard. CT scan of his chest radiograph showed ground glass changes superimposed on a reticular pattern as the so-called ‘crazy paving’ pattern. Lung biopsy revealed alveolar proteinaceous material with positive PAS stain. He eventually was diagnosed as PAP. He refused a whole lung lavage therapy, so the patient was rendered N-acetylcysteine as an antioxidant, enhanced immunotherapy and anti-infective treatment. His clinical symptoms and radiological manifestation improved gradually. No substantial adverse reactions were reported. Conclusions Persistent oral N-acetylcysteine may be an alternative treatment option for secondary PAP.
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20
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Da Nam B, Kim TJ, Chung MP, Chung MJ, Kim TS, Lee KS. CT findings in pulmonary alveolar proteinosis: serial changes and prognostic implications. J Thorac Dis 2018; 10:5774-5783. [PMID: 30505485 DOI: 10.21037/jtd.2018.09.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Pulmonary alveolar proteinosis (PAP) is a rare disease of unknown origin, characterized by impaired surfactant metabolism. In some patients, residual disease is observed after treatment; notably, this may progress to end-stage pulmonary fibrosis. This study was performed to evaluate changes in lung abnormalities on serial CT scans performed on the lungs of patients diagnosed with PAP, as well as to identify factors that can be used to predict clinical improvement in PAP. Methods Twenty-five patients (16 men, nine women) were diagnosed with PAP at a single tertiary hospital. The extent and distribution of PAP were assessed on baseline and follow-up CT scans (median, 38 months; range, 2-96 months). Serial CT scans and clinical findings were analyzed to identify the predictive factors for clinical improvement in PAP. Results Baseline CT scans of patients diagnosed with PAP revealed that ground-glass opacity was the most common abnormality (100%); the second most common abnormality was interlobular/intralobular septal thickening (88%). Importantly, the final follow-up CT scans showed that the extent of lung abnormalities had decreased (n=13), including complete resolution (n=5), unchanged (n=9), and increased (n=3). Traction bronchiectasis and architectural distortion were detected in two patients (8%). On univariate and multivariate analyses, the change in the overall extent of lung abnormalities was a predictive factor for clinical improvement in PAP (odds ratio: 55.780; P=0.038). Conclusions Most patients with PAP exhibited residual disease; however, progression to pulmonary fibrosis was rare. Analyses of overall changes, with respect to lung abnormalities on serial CT scans, may be predictive of the extent of clinical improvement in given patient.
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Affiliation(s)
- Bo Da Nam
- Department of Radiology, Samsung Medical Center, Seoul, Korea.,Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Tae Jung Kim
- Department of Radiology, Samsung Medical Center, Seoul, Korea.,Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Man Pyo Chung
- Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Respiratory and Critical Medicine, Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
| | - Myung Jin Chung
- Department of Radiology, Samsung Medical Center, Seoul, Korea.,Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Sung Kim
- Department of Radiology, Samsung Medical Center, Seoul, Korea.,Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Soo Lee
- Department of Radiology, Samsung Medical Center, Seoul, Korea.,Sungkyunkwan University School of Medicine, Seoul, Korea
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21
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Hunter Guevara LR, Gillespie SM, Klompas AM, Torres NE, Barbara DW. Whole-lung lavage in a patient with pulmonary alveolar proteinosis. Ann Card Anaesth 2018; 21:215-217. [PMID: 29652291 PMCID: PMC5914230 DOI: 10.4103/aca.aca_184_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare syndrome in which phospholipoproteinaceous matter accumulates in the alveoli leading to compromised gas exchange. Whole-lung lavage is considered the gold standard for severe autoimmune PAP and offers favorable long-term outcomes. In this case report, we describe the perioperative management and procedural specifics of a patient undergoing WLL for PAP in which an anesthesiologist serves as the proceduralist and a separate anesthesiologist provides anesthesia care for the patient.
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Affiliation(s)
| | - Shane M Gillespie
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Norman E Torres
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - David W Barbara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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22
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Gharsalli H, Mlika M, Sahnoun I, Maalej S, Douik El Gharbi L, Mezni FE. The utility of bronchoalveolar lavage in the evaluation of interstitial lung diseases: A clinicopathological perspective. Semin Diagn Pathol 2018; 35:280-287. [DOI: 10.1053/j.semdp.2018.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Iyengar JN, R Reddy BKK. Pulmonary alveolar proteinosis in children: An unusual presentation with significant clinical impact. INDIAN J PATHOL MICR 2018; 61:418-420. [PMID: 30004070 DOI: 10.4103/ijpm.ijpm_17_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pulmonary alveolar proteinosis (PAP) - an unusual diffuse lung disease characterized by alveolar accumulation of phospholipoprotein material, with a peak incidence in third to fourth decade and male predominance is also described in children. Recorded prevalence is 0.1/100,000 individuals. Major clinicopathogenetic subtypes include autoimmune (idiopathic) associated with granulocyte-macrophage colony-stimulating factor autoantibodies, secondary form, and the congenital form (associated with surfactant gene mutations). Common presenting features include dyspnea, cough, low-grade fever, inspiratory crackles, and digital clubbing. Pulmonary function shows a restrictive ventilatory defect. X-rays show bilateral patchy to extensive consolidations, and bronchial lavage yields a milky fluid. Characteristic microscopic findings on lung biopsy include filling of terminal bronchioles and alveolar spaces by deep pink granular PAS-positive material. Whole lung lavage is the safest and most effective form of treatment. We present brief profiles of two young children identified as having PAP, along with follow-up data on one of them.
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Affiliation(s)
- Jayaram N Iyengar
- Department of Pathology, Anand Diagnostic Laboratory, Bengaluru, Karnataka, India
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24
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Soyez B, Borie R, Menard C, Cadranel J, Chavez L, Cottin V, Gomez E, Marchand-Adam S, Leroy S, Naccache JM, Nunes H, Reynaud-Gaubert M, Savale L, Tazi A, Wemeau-Stervinou L, Debray MP, Crestani B. Rituximab for auto-immune alveolar proteinosis, a real life cohort study. Respir Res 2018; 19:74. [PMID: 29695229 PMCID: PMC5918901 DOI: 10.1186/s12931-018-0780-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/16/2018] [Indexed: 12/16/2022] Open
Abstract
Background Whole lung lavage is the current standard therapy for pulmonary alveolar proteinosis (PAP) that is characterized by the alveolar accumulation of surfactant. Rituximab showed promising results in auto-immune PAP (aPAP) related to anti-GM-CSF antibody. Methods We aimed to assess efficacy of rituximab in aPAP in real life and all patients with aPAP in France that received rituximab were retrospectively analyzed. Results Thirteen patients were included. No patients showed improvement 6 months after treatment, but, 4 patients (30%) presented a significant decrease of alveolar-arterial difference in oxygen after 1 year. One patient received lung transplantation and one patient was lost of follow-up within one year. Although a spontaneous improvement cannot be excluded in these 4 patients, improvement was more frequent in patients naïve to prior specific therapy and with higher level of anti-GM-CSF antibodies evaluated by ELISA. No serious adverse event was evidenced. Conclusions These data do not support rituximab as a second line therapy for patients with refractory aPAP.
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Affiliation(s)
- Berenice Soyez
- Service de Pneumologie A, DHU FIRE, centre de référence constitutif des maladies pulmonaires rares, Hôpital Bichat, APHP, 46 rue Henri Huchard 75877 Paris CEDEX, 18, Paris, France.,OrphaLung, Lyon, France.,Service de Pneumologie, Hôpital de la Pitié Salpetrière, APHP, Paris, France
| | - Raphael Borie
- Service de Pneumologie A, DHU FIRE, centre de référence constitutif des maladies pulmonaires rares, Hôpital Bichat, APHP, 46 rue Henri Huchard 75877 Paris CEDEX, 18, Paris, France. .,OrphaLung, Lyon, France. .,INSERM, Unité 1152, Université Paris Diderot, Paris, France.
| | - Cedric Menard
- Service d'Immunologie, Thérapie Cellulaire et Hématopoïèse, CHU Pontchaillou, Rennes, France
| | - Jacques Cadranel
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, Hôpital Tenon, APHP, Paris, France
| | - Leonidas Chavez
- Service de Pneumologie, Centre de compétences des maladies pulmonaires rares, CHU Grenoble-Alpes, Grenoble, France
| | - Vincent Cottin
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre national de référence des maladies pulmonaires rares, Hôpital Louis Pradel, Université Claude Bernard Lyon 1, Lyon, France
| | - Emmanuel Gomez
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de compétences des maladies pulmonaires rares CHRU Nancy, Nancy, France
| | - Sylvain Marchand-Adam
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de compétences des maladies pulmonaires raresCHRU de Tours, Tours, France
| | - Sylvie Leroy
- OrphaLung, Lyon, France.,FHU Oncoage, Service de Pneumologie, Centre de compétence des maladies pulmonaires rares, Université Côte d'Azur, CHU de Nice, Nice, France
| | - Jean-Marc Naccache
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, Hôpital Tenon, APHP, Paris, France
| | - Hilario Nunes
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, Hôpital Avicenne, APHP, Bobigny, France
| | - Martine Reynaud-Gaubert
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de compétence des maladies pulmonaires rares, Hôpital Nord, Marseille, France
| | - Laurent Savale
- Service de Pneumologie, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, APHP, Le Kremlin Bicêtre, France
| | - Abdellatif Tazi
- Service de Pneumologie, Hôpital Saint-Louis, APHP, Paris, France
| | - Lidwine Wemeau-Stervinou
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, CHRU de Lille, Lille, France
| | | | - Bruno Crestani
- Service de Pneumologie A, DHU FIRE, centre de référence constitutif des maladies pulmonaires rares, Hôpital Bichat, APHP, 46 rue Henri Huchard 75877 Paris CEDEX, 18, Paris, France.,OrphaLung, Lyon, France.,INSERM, Unité 1152, Université Paris Diderot, Paris, France
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25
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Skoczynski S, Wyskida K, Rzepka-Wrona P, Wyskida M, Uszok-Gawel E, Bartocha D, Krzych L, Pierzchala W, Barczyk A. Novel method of noninvasive ventilation supported therapeutic lavage in pulmonary alveolar proteinosis proves to relieve dyspnea, normalize pulmonary function test results and recover exercise capacity: a short communication. J Thorac Dis 2018; 10:2467-2473. [PMID: 29850154 DOI: 10.21037/jtd.2018.04.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Whole lung lavage (WLL) under general anesthesia with a double-lumen endobronchial intubation has remained standard treatment option for pulmonary alveolar proteinosis (PAP) for over fifty years now. To the best of our knowledge, this is the first description of noninvasive ventilation (NIV) as an innovative alternative, which enables safe and effective treatment. NIV support enabled cost-effective lavage of the most affected segments and resulted in restoration and long-term maintenance of exercise capacity and diffusion, without WLL related hypoxaemia, volume overload, intubation, or mechanical ventilation related complications. The study presents all details of performed procedure, including anesthesia, NIV technique and bronchoscopy, therefore this may be easily implemented into clinical practice at other centers conducting PAP treatment. We assume that presented technique of therapeutic lung lavage (TLL) with NIV support may be considered a novel PAP treatment method, however, target population who will benefit the most from such therapy modification must be assessed in large scale prospective trials.
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Affiliation(s)
- Szymon Skoczynski
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Wyskida
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.,Department of Pathophysiology, Health Promotion and Obesity Management Unit, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Patrycja Rzepka-Wrona
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Magdalena Wyskida
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Ewa Uszok-Gawel
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Dawid Bartocha
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Lukasz Krzych
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Wladysław Pierzchala
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Barczyk
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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26
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Khurana AK, Joshi D, Goyal A, Khurana U. Pleural effusion as presenting feature of pulmonary alveolar proteinosis: A rare occurrence. CLINICAL RESPIRATORY JOURNAL 2018; 12:2300-2302. [PMID: 29498798 DOI: 10.1111/crj.12788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/22/2018] [Accepted: 02/23/2018] [Indexed: 12/01/2022]
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27
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Kumar A, Abdelmalak B, Inoue Y, Culver DA. Pulmonary alveolar proteinosis in adults: pathophysiology and clinical approach. THE LANCET RESPIRATORY MEDICINE 2018; 6:554-565. [PMID: 29397349 DOI: 10.1016/s2213-2600(18)30043-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/16/2017] [Accepted: 11/23/2017] [Indexed: 12/24/2022]
Abstract
Pulmonary alveolar proteinosis (PAP) is a diffuse lung disease that results from the accumulation of lipoproteinaceous material in the alveoli and alveolar macrophages due to abnormal surfactant homoeostasis. Identification of the granulocyte-macrophage colony-stimulating factor (GM-CSF) as an indispensable mediator of macrophage maturation and surfactant catabolism was the key discovery leading to the current understanding of the pathogenesis of most forms of PAP. Impaired GM-CSF bioavailability due to anti-GM-CSF autoimmunity is the cause of approximately 90% of adult PAP cases. Abnormal macrophage function due to endogenous or exogenous triggers, GM-CSF receptor defects, and other genetic abnormalities of surfactant production account for the remainder of causes. The usual physiological consequence of PAP is impairment of gas exchange, which can lead to dyspnoea, hypoxaemia, or even respiratory failure and death. Pulmonary fibrosis occurs occasionally in patients with PAP. For patients with moderate to severe disease, whole lung lavage is still the first-line treatment of choice. Supplemental GM-CSF is also useful, but details about indications, choice of agent, and dosing remain unclear. Other therapies, including rituximab, plasmapheresis, and lung transplantation have been described but should be reserved for refractory cases.
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Affiliation(s)
- Anupam Kumar
- Division of Pulmonary & Critical Care Medicine, Spectrum Health-Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
| | - Basem Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland, OH, USA
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, and Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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28
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Hwang JA, Song JH, Kim JH, Chung MP, Kim DS, Song JW, Kim YW, Choi SM, Cha SI, Uh ST, Park CS, Jeong SH, Park YB, Lee HL, Shin JW, Lee EJ, Jegal Y, Lee HK, Park JS, Park MS. Clinical significance of cigarette smoking and dust exposure in pulmonary alveolar proteinosis: a Korean national survey. BMC Pulm Med 2017; 17:147. [PMID: 29162083 PMCID: PMC5697136 DOI: 10.1186/s12890-017-0493-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 11/14/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND This study aimed to investigate clinical characteristics of Korean PAP patients and to examine the potential risk factors of PAP. METHODS We retrospectively reviewed medical records of 78 Korean PAP patients diagnosed between 1993 and 2014. Patients were classified into two groups according to the presence/absence of treatment (lavage). Clinical and laboratory features were compared between the two groups. RESULTS Of the total 78 PAP patients, 60% were male and median age at diagnosis was 47.5 years. Fifty three percent were ever smokers (median 22 pack-years) and 48% had a history of dust exposure (metal 26.5%, stone or sand 20.6%, chemical or paint 17.7%, farming dust 14.7%, diesel 14.7%, textile 2.9%, and wood 2.9%). A history of cigarette smoking or dust exposure was present in 70.5% of the total PAP patients, with 23% having both of them. Patients who underwent lavage (n = 38) presented symptoms more frequently (38/38 [100%] vs. 24/40 [60%], P < 0.001) and had significantly lower PaO2 and DLCO with higher D(A-a)O2 at the onset of disease than those without lavage (n = 40) (P = 0.006, P < 0.001, and P = 0.036, respectively). Correspondingly, the distribution of disease severity score (DSS) differed significantly between the two groups (P = 0.001). Based on these, when the total patients were categorized according to DSS (low DSS [DSS 1-2] vs. high DSS [DSS 3-5]), smoking status differed significantly between the two groups with the proportion of current smokers significantly higher in the high DSS group (11/22 [50%] vs. 7/39 [17.9%], P = 0.008). Furthermore, current smokers had meaningfully higher DSS and serum CEA levels than non-current smokers (P = 0.011 and P = 0.031), whereas no difference was found between smokers and non-smokers. Regarding type of exposed dust, farming dust was significantly associated with more severe form of PAP (P = 0.004). CONCLUSION A considerable proportion of PAP patients had a history of cigarette smoking and/or dust exposure, suggestive of their possible roles in the development of PAP. Active cigarette smoking at the onset of PAP is associated with the severity of PAP.
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Affiliation(s)
- Ji An Hwang
- 0000 0001 0842 2126grid.413967.eDepartment of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Joo Han Song
- 0000 0004 0470 5454grid.15444.30Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea
| | - Jung Hoon Kim
- 0000 0001 2181 989Xgrid.264381.aDivision of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Man Pyo Chung
- 0000 0001 2181 989Xgrid.264381.aDivision of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong Soon Kim
- 0000 0001 0842 2126grid.413967.eDivision of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jin Woo Song
- 0000 0001 0842 2126grid.413967.eDivision of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Young Whan Kim
- 0000 0004 0470 5905grid.31501.36Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Sun Mi Choi
- 0000 0004 0470 5905grid.31501.36Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Ick Cha
- 0000 0004 0647 192Xgrid.411235.0Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
| | - Soo Taek Uh
- 0000 0004 0634 1623grid.412678.eDivision of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Choon-Sik Park
- 0000 0004 0634 1623grid.412678.eDivision of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Sung Hwan Jeong
- 0000 0004 0647 2885grid.411653.4Division of Pulmonology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, South Korea
| | - Yong Bum Park
- grid.477505.4Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Hong Lyeol Lee
- 0000 0004 0648 0025grid.411605.7Pulmonary Division, Department of Internal Medicine, Inha University Hospital, Incheon, South Korea
| | - Jong Wook Shin
- 0000 0001 0789 9563grid.254224.7Division of Pulmonary Medicine, Department of Internal Medicine, Chung Ang University College of Medicine, Seoul, South Korea
| | - Eun Joo Lee
- 0000 0001 0840 2678grid.222754.4Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Yangjin Jegal
- 0000 0004 0533 4667grid.267370.7Division of Pulmonary Medicine, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Hyun Kyung Lee
- 0000 0004 0647 1102grid.411625.5Division of Critical Care and Pulmonary Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, South Korea
| | - Jong Sun Park
- 0000 0004 0647 3378grid.412480.bDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Moo Suk Park
- 0000 0004 0470 5454grid.15444.30Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University, College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 South Korea
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29
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Sinclair C, Bommakanti G, Gardinassi L, Loebbermann J, Johnson MJ, Hakimpour P, Hagan T, Benitez L, Todor A, Machiah D, Oriss T, Ray A, Bosinger S, Ravindran R, Li S, Pulendran B. mTOR regulates metabolic adaptation of APCs in the lung and controls the outcome of allergic inflammation. Science 2017; 357:1014-1021. [PMID: 28798047 DOI: 10.1126/science.aaj2155] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 03/29/2017] [Accepted: 06/22/2017] [Indexed: 12/14/2022]
Abstract
Antigen-presenting cells (APCs) occupy diverse anatomical tissues, but their tissue-restricted homeostasis remains poorly understood. Here, working with mouse models of inflammation, we found that mechanistic target of rapamycin (mTOR)-dependent metabolic adaptation was required at discrete locations. mTOR was dispensable for dendritic cell (DC) homeostasis in secondary lymphoid tissues but necessary to regulate cellular metabolism and accumulation of CD103+ DCs and alveolar macrophages in lung. Moreover, while numbers of mTOR-deficient lung CD11b+ DCs were not changed, they were metabolically reprogrammed to skew allergic inflammation from eosinophilic T helper cell 2 (TH2) to neutrophilic TH17 polarity. The mechanism for this change was independent of translational control but dependent on inflammatory DCs, which produced interleukin-23 and increased fatty acid oxidation. mTOR therefore mediates metabolic adaptation of APCs in distinct tissues, influencing the immunological character of allergic inflammation.
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Affiliation(s)
- Charles Sinclair
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Gayathri Bommakanti
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Luiz Gardinassi
- Department of Medicine, Emory University, Atlanta, GA 30329, USA
| | - Jens Loebbermann
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Matthew Joseph Johnson
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA.,Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA
| | - Paul Hakimpour
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Thomas Hagan
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Lydia Benitez
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Andrei Todor
- Department of Medicine, Emory University, Atlanta, GA 30329, USA
| | - Deepa Machiah
- Yerkes Molecular Pathology Core Laboratory, Yerkes National Primate Research Center, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Timothy Oriss
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Immunology, University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center (UPMC), University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anuradha Ray
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Immunology, University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center (UPMC), University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Steven Bosinger
- Primate Genomics Core, Yerkes National Primate Research Center, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Rajesh Ravindran
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Shuzhao Li
- Department of Medicine, Emory University, Atlanta, GA 30329, USA
| | - Bali Pulendran
- Emory Vaccine Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA. .,Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA.,Institute for Immunity, Transplantation and Infection, Department of Pathology, Department of Microbiology and Immunology, Stanford University, Stanford, CA 94305, USA
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30
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Kim YS, Lim CH, Shin SH, Kim JC. Twenty-Eight-Day Repeated Inhalation Toxicity Study of Nano-Sized Neodymium Oxide in Male Sprague-Dawley Rats. Toxicol Res 2017; 33:239-253. [PMID: 28744356 PMCID: PMC5523562 DOI: 10.5487/tr.2017.33.3.239] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/02/2017] [Accepted: 05/10/2017] [Indexed: 11/20/2022] Open
Abstract
Neodymium is a future-oriented material due to its unique properties, and its use is increasing in various industrial fields worldwide. However, the toxicity caused by repeated exposure to this metal has not been studied in detail thus far. The present study was carried out to investigate the potential inhalation toxicity of nano-sized neodymium oxide (Nd2O3) following a 28-day repeated inhalation exposure in male Sprague-Dawley rats. Male rats were exposed to nano-sized Nd2O3-containing aerosols via a nose-only inhalation system at doses of 0 mg/m3, 0.5 mg/m3, 2.5 mg/m3, and 10 mg/m3 for 6 hr/day, 5 days/week over a 28-day period, followed by a 28-day recovery period. During the experimental period, clinical signs, body weight, hematologic parameters, serum biochemical parameters, necropsy findings, organ weight, and histopathological findings were examined; neodymium distribution in the major organs and blood, bronchoalveolar lavage fluid (BALF), and oxidative stress in lung tissues were analyzed. Most of the neodymium was found to be deposited in lung tissues, showing a dose-dependent relationship. Infiltration of inflammatory cells and pulmonary alveolar proteinosis (PAP) were the main observations of lung histopathology. Infiltration of inflammatory cells was observed in the 2.5 mg/m3 and higher dose treatment groups. PAP was observed in all treatment groups accompanied by an increase in lung weight, but was observed to a lesser extent in the 0.5 mg/m3 treatment group. In BALF analysis, total cell counts, including macrophages and neutrophils, lactate dehydrogenase, albumin, interleukin-6, and tumor necrosis factor-alpha, increased significantly in all treatment groups. After a 4-week recovery period, these changes were generally reversed in the 0.5 mg/m3 group, but were exacerbated in the 10 mg/m3 group. The lowest-observed-adverse-effect concentration of nano-sized Nd2O3 was determined to be 0.5 mg/m3, and the target organ was determined to be the lung, under the present experimental conditions in male rats.
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Affiliation(s)
- Yong-Soon Kim
- Chemicals Toxicity Research Bureau, Occupational Safety and Health Research Institute, KOSHA, Daejeon, Korea
| | - Cheol-Hong Lim
- Chemicals Toxicity Research Bureau, Occupational Safety and Health Research Institute, KOSHA, Daejeon, Korea
| | - Seo-Ho Shin
- Chemicals Toxicity Research Bureau, Occupational Safety and Health Research Institute, KOSHA, Daejeon, Korea.,College of Veterinary Medicine BK21 Plus Project Team, Chonnam National University, Gwangju, Korea
| | - Jong-Choon Kim
- College of Veterinary Medicine BK21 Plus Project Team, Chonnam National University, Gwangju, Korea
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31
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Awab A, Khan MS, Youness HA. Whole lung lavage-technical details, challenges and management of complications. J Thorac Dis 2017; 9:1697-1706. [PMID: 28740686 DOI: 10.21037/jtd.2017.04.10] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by alveolar accumulation of surfactant material with resulting hypoxemia and reduced lung function. Whole lung lavage (WLL) to physically remove the proteinaceous material from the affected lung is the standard treatment. Since its original description in 1964, there have been increasing numbers of WLL procedures done worldwide and the technique has been variously refined and modified. When done in experienced centers, WLL provides long lasting benefit in the majority of patients. It is considered safe and effective. There are no guidelines standardizing the procedure. Our preferred method is to lavage one lung at a time, with the patient supine, filling to functional residual capacity (FRC) and repeating cycles of drainage and instillation with chest percussion until the effluent is clear. The aim of this article is to provide a detailed description of the technique, equipment needed and logistic considerations as well as providing a physiologic rationale for each step of WLL. We will also review the available data concerning variations of the technique described in the literature.
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Affiliation(s)
- Ahmed Awab
- University of Oklahoma Health Sciences Center, Pulmonary and Critical Care Section, Oklahoma, USA
| | - Muhammad S Khan
- University of Oklahoma Health Sciences Center, Pulmonary and Critical Care Section, Oklahoma, USA
| | - Houssein A Youness
- University of Oklahoma Health Sciences Center, Pulmonary and Critical Care Section, Oklahoma, USA
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32
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Bapat A, Bishburg E, Nagarakanti S. Herpes Simplex Virus, Cytomegalovirus, and Pneumocystis jiroveci Pneumonia in a Treatment-Naive HIV-Positive Patient with Pulmonary Alveolar Proteinosis: Case Report. J Int Assoc Provid AIDS Care 2017; 16:327-330. [PMID: 28393663 DOI: 10.1177/2325957417702488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Infection with multiple pathogens concurrently has become less common since the introduction of potent antiretroviral agent and effective prophylactic agents. We describe a patient with pulmonary alveolar proteinosis (PAP) admitted with pneumonia who was found to have AIDS and diagnosed with Pneumocystis jiroveci pneumonia, human herpesvirus type 1 (HHV-1), and a concomitant cytomegalovirus viremia. Polymerase chain reaction viral load was used for diagnosis of HHV-1 and follow-up. The patient was treated with trimethoprim-sulfamethoxazole and ganciclovir and had a resolution of pneumonia. Since patients with PAP who are diagnosed as having AIDS could be concomitantly infected with multiple pathogens, rapid accurate diagnosis and treatment may have a positive effect on outcome.
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Affiliation(s)
- Anita Bapat
- 1 Division of Infectious Disease, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Eliahu Bishburg
- 1 Division of Infectious Disease, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Sandhya Nagarakanti
- 1 Division of Infectious Disease, Newark Beth Israel Medical Center, Newark, NJ, USA
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33
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Pantalon A, Găman E, Crețu-Silivestru IS, Danielescu C. Rare case of ocular tuberculosis in a diabetic patient: diagnostic and therapeutic dilemmas. Rom J Ophthalmol 2017; 61:137-143. [PMID: 29450388 PMCID: PMC5710023 DOI: 10.22336/rjo.2017.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We present the case of a patient who was diagnosed by chance with macular hypopyon during a conventional interdisciplinary examination. The clinical context and the association of a systemic disease, such as uncontrolled type 1 diabetes, rendered further investigations in this patient. Due to his immunocompromised status, etiology such as ocular fungi, lymphomas, tuberculosis was taken into account. Thorough complex investigations oriented the diagnosis towards ocular tuberculosis involvement.
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Affiliation(s)
| | | | | | - Ciprian Danielescu
- "Sf. Spiridon" University Hospital, Iași, Romania.,"Gr. T. Popa" University of Medicine and Pharmacy Iași, Romania
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34
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Galhenage J, Weerasinghe B, Dilesha W, Constantine R, Gunasena B. Pulmonary alveolar proteinosis and first successful whole lung lavage in Sri Lanka: a case report. J Med Case Rep 2017; 11:62. [PMID: 28270188 PMCID: PMC5341169 DOI: 10.1186/s13256-017-1218-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/17/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis is a rare disease characterized by accumulation of lipoproteinaceous material within alveoli. There are three clinically distinct forms: congenital, acquired and secondary. Whole lung lavage is currently the gold standard therapy for severe cases of pulmonary alveolar proteinosis. In Sri Lanka this is the first reported successful whole lung lavage for a patient with pulmonary alveolar proteinosis. CASE PRESENTATION We describe the case of a 15-year-old Sri Lankan girl who presented with symptoms of progressive shortness of breath and dry cough for 6 months' duration. She had a history of exposure to silica in her household environment. High-resolution computed tomography revealed crazy paving appearance in both lungs suggestive of pulmonary alveolar proteinosis. An open lung biopsy revealed intra-alveolar granular amphophilic material which was strongly periodic acid-Schiff positive and diastase resistant, which is consistent with pulmonary alveolar proteinosis. She was followed up for 2 years with periodical segmental bronchoalveolar lavages which showed minimal improvement in her symptoms as well as in exercise desaturation. Due to severe dyspnea and hypoxemia on exertion, she underwent whole lung lavage. It resulted in a marked improvement in her symptoms, exercise desaturation, and chest X-ray results. CONCLUSION Whole lung lavage was successfully performed for the first time in Sri Lanka for a patient with pulmonary alveolar proteinosis.
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Affiliation(s)
- Janith Galhenage
- Department of Respiratory Medicine, National Hospital for Respiratory Diseases, Welisara, Sri Lanka.
| | - Buddhika Weerasinghe
- Department of Respiratory Medicine, National Hospital for Respiratory Diseases, Welisara, Sri Lanka
| | - Wadasinghe Dilesha
- Department of Respiratory Medicine, National Hospital for Respiratory Diseases, Welisara, Sri Lanka
| | - Roshana Constantine
- Department of Pathology, National Hospital for Respiratory Diseases, Welisara, Sri Lanka
| | - Bandu Gunasena
- Department of Respiratory Medicine, National Hospital for Respiratory Diseases, Welisara, Sri Lanka
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35
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Chiu CY, Su SC, Fan WL, Lai SH, Tsai MH, Chen SH, Wong KS, Chung WH. Whole-Genome Sequencing of a Family with Hereditary Pulmonary Alveolar Proteinosis Identifies a Rare Structural Variant Involving CSF2RA/CRLF2/IL3RA Gene Disruption. Sci Rep 2017; 7:43469. [PMID: 28233860 PMCID: PMC5324064 DOI: 10.1038/srep43469] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/25/2017] [Indexed: 01/04/2023] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease in which the abnormalities in alveolar surfactant accumulation are caused by impairments of GM-CSF pathway attributing to defects in a variety of genes. However, hereditary PAP is extremely uncommon and a detailed understanding in the genetic inheritance of PAP in a family may provide timely diagnosis, treatment and proper intervention including genetic consultation. Here, we described a comprehensive analysis of genome and gene expression for a family containing one affected child with a diagnosis of PAP and two other healthy siblings. Family-based whole-genome analysis revealed a homozygous deletion that disrupts CSF2RA, CRLF2, and IL3RA gene in the pseudoautosomal region of the X chromosome in the affected child and one of asymptomatic siblings. Further functional pathway analysis of differentially expressed genes in IL-1β-treated peripheral blood mononuclear cells highlighted the insufficiency of immune response in the child with PAP, especially the protection against bacterial infection. Collectively, our results reveal a novel allele as the genetic determinant of a family with PAP and provide insights into variable expressivity and incomplete penetrance of this rare disease, which will be helpful for proper genetic consultation and prompt treatment to avoid mortality and morbidity.
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Affiliation(s)
- Chih-Yung Chiu
- Department of Pediatrics, Chang Gung Memorial Hospital at Keelung, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Chi Su
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan.,Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Wen-Lang Fan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shen-Hao Lai
- Division of Pediatric Pulmonology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Han Tsai
- Department of Pediatrics, Chang Gung Memorial Hospital at Keelung, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hsiang Chen
- Division of Pediatric Hematology/Oncology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kin-Sun Wong
- Division of Pediatric Pulmonology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan.,Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
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36
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Hadda V, Tiwari P, Madan K, Mohan A, Gupta N, Bharti SJ, Kumar V, Garg R, Trikha A, Jain D, Arava S, Khilnani GC, Guleria R. Pulmonary alveolar proteinosis: Experience from a tertiary care center and systematic review of Indian literature. Lung India 2016; 33:626-634. [PMID: 27890991 PMCID: PMC5112819 DOI: 10.4103/0970-2113.192876] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by deposition of lipoproteinaceous material within alveoli, with a variable clinical course. Here, we report an experience of management of PAP at our center. A systematic review of previously reported cases from India is also included in the article. MATERIALS AND METHODS This study included patients with primary PAP managed at our center from 2009 to 2015. Diagnosis of primary PAP was based on histopathologic diagnosis on bronchoalveolar lavage or transbronchial lung biopsy and absence of causes of secondary PAP. For systematic review of Indian publications, the literature search was performed using PubMed and EMBASE databases using the terms "pulmonary alveolar proteinosis'" or "alveolar proteinosis" and "India" or "Indian." RESULTS During the above-specified period, five patients with diagnosis of PAP were admitted at our center. Median age of patients was 32 years (interquartile range [IQR] 30.5-59); 80% were female. Mean duration (± standard deviation) of symptoms was 6.2 (±1.79) months. Anti-granulocyte-macrophage colony stimulating factor (GM-CSF) antibodies were elevated in 4 out of 5 patients (80%). For management, whole lung lavage (WLL) was done for four patients with median volume of 32.5 (IQR 18-74) L per patient. All the patients showed significant symptomatic as well as improvement in physiological parameters. Subcutaneous GM-CSF and ambroxol were given to 3 patients and 1 patient, respectively. The median follow-up of all patients was 18 (IQR 5-44) months. A systematic review of all Indian studies of PAP revealed thirty publications. CONCLUSIONS WLL is the most common, effective, and safe therapy in patients with PAP. GM-CSF administration is an efficacious treatment for patients with incomplete response after WLL.
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Affiliation(s)
- Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, All Institute of Medical Sciences, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary Medicine and Sleep Disorders, All Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary Medicine and Sleep Disorders, All Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine and Sleep Disorders, All Institute of Medical Sciences, New Delhi, India
| | - Nishkarsh Gupta
- Department of Anaesthesiology, All Institute of Medical Sciences, New Delhi, India
| | | | - Vinod Kumar
- Department of Anaesthesiology, All Institute of Medical Sciences, New Delhi, India
| | - Rakesh Garg
- Department of Anaesthesiology, All Institute of Medical Sciences, New Delhi, India
| | - Anjan Trikha
- Department of Anaesthesiology, All Institute of Medical Sciences, New Delhi, India
| | - Deepali Jain
- Department of Pathology, All Institute of Medical Sciences, New Delhi, India
| | - Sudheer Arava
- Department of Pathology, All Institute of Medical Sciences, New Delhi, India
| | - Gopi C Khilnani
- Department of Pulmonary Medicine and Sleep Disorders, All Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary Medicine and Sleep Disorders, All Institute of Medical Sciences, New Delhi, India
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37
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Alvarado A, Arce I. Metabolic Functions of the Lung, Disorders and Associated Pathologies. J Clin Med Res 2016; 8:689-700. [PMID: 27635172 PMCID: PMC5012236 DOI: 10.14740/jocmr2668w] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 01/04/2023] Open
Abstract
The primary function of the lungs is gas exchange. Approximately 400 million years ago, the Earth's atmosphere gained enough oxygen in the gas phase for the animals that emerged from the sea to breathe air. The first lungs were merely primitive air sacs with a few vessels in the walls that served as accessory organs of gas exchange to supplement the gills. Eons later, as animals grew accustomed to a solely terrestrial life, the lungs became highly compartmentalized to provide the vast air-blood surface necessary for O2 uptake and CO2 elimination, and a respiratory control system was developed to regulate breathing in accordance with metabolic demands and other needs. With the evolution and phylogenetic development, lungs were taking a variety of other specialized functions to maintain homeostasis, which we will call the non-respiratory functions of the lung and that often, and by mistake, are believed to have little or no connection with the replacement gas. In this review, we focus on the metabolic functions of the lung, perhaps the least known, and mainly, in the lipid metabolism and blood-adult lung vascular endothelium interaction. When these functions are altered, respiratory disorders or diseases appear, which are discussed concisely, emphasizing how they impact the most important function of the lungs: external respiration.
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Affiliation(s)
- Alcibey Alvarado
- Internal Medicine and Neumology, Clinica de Diagnostico Medico, San Jose, Costa Rica
| | - Isabel Arce
- Medicine and General Surgery, Medicine School, University of Costa Rica, San Jose, Costa Rica
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38
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Trukalj M, Perica M, Ferenčić Ž, Erceg D, Navratil M, Redžepi G, Nogalo B. Successful Treatment of Autoimmune Pulmonary Alveolar Proteinosis in a Pediatric Patient. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:641-5. [PMID: 27592713 PMCID: PMC5012460 DOI: 10.12659/ajcr.897868] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patient: Male, 13 Final Diagnosis: Pulmonary alveolar protinosis (autoimmune subtype) Symptoms: Dyspnea • general weakness • subfebrile episodes Medication: Vincristine Clinical Procedure: Bronchoscopy • bronchoalveolar lavage • CT scan • lung biopsy • GM CSF antibody testing • diagnosis confirmation • therapy with inhaled GM-CSF • bilateral lung transplantation • chemotherapy due to PTLD Specialty: Pediatrics and Neonatology
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Affiliation(s)
- Mirjana Trukalj
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Zagreb, Croatia
| | - Marija Perica
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Zagreb, Croatia
| | - Željko Ferenčić
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Zagreb, Croatia
| | - Damir Erceg
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Zagreb, Croatia
| | - Marta Navratil
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Zagreb, Croatia
| | - Gzim Redžepi
- Department of Pulomonology, University Hospital Zagreb, Zagreb, Croatia
| | - Boro Nogalo
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Zagreb, Croatia
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39
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Whitwell H, Mackay RM, Elgy C, Morgan C, Griffiths M, Clark H, Skipp P, Madsen J. Nanoparticles in the lung and their protein corona: the few proteins that count. Nanotoxicology 2016; 10:1385-94. [PMID: 27465202 DOI: 10.1080/17435390.2016.1218080] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The formation of protein coronae on nanoparticles (NPs) has been investigated almost exclusively in serum, despite the prevailing route of exposure being inhalation of airborne particles. In addition, an increasing number of nanomedicines, that exploit the airways as the site of delivery, are undergoing medical trials. An understanding of the effects of NPs on the airways is therefore required. To further this field, we have described the corona formed on polystyrene (PS) particles with different surface modifications and on titanium dioxide particles when incubated in human bronchoalveolar lavage fluid (BALF) from patients with pulmonary alveolar proteinosis (PAP). We show, using high-resolution quantitative mass spectrometry (MS(E)), that a large number of proteins bind with low copy numbers but that a few "core" proteins bind to all particles tested with high fidelity, averaging the surface properties of the different particles independent of the surface properties of the specific particle. The averaging effect at the particle surface means that differing cellular effects may not be due to the protein corona but due to the surface properties of the nanoparticle once inside the cell. Finally, the adherence of surfactant associated proteins (SP-A, B and D) suggests that there may be interactions with lipids and pulmonary surfactant (PSf), which could have potential in vivo health effects for people with chronic airway diseases such as asthma and chronic obstructive pulmonary disease (COPD), or those who have increased susceptibility toward other respiratory diseases.
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Affiliation(s)
- Harry Whitwell
- a Child Health, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital , Southampton , UK .,b Institute for Life Sciences, University of Southampton , Southampton , UK
| | - Rose-Marie Mackay
- a Child Health, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital , Southampton , UK
| | - Christine Elgy
- c School of Geography, Earth and Environmental Sciences, University of Birmingham , Birmingham , UK
| | - Cliff Morgan
- d Leukocyte Biology, Royal Brompton Campus, Imperial College London , London , UK , and
| | - Mark Griffiths
- d Leukocyte Biology, Royal Brompton Campus, Imperial College London , London , UK , and
| | - Howard Clark
- a Child Health, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital , Southampton , UK .,b Institute for Life Sciences, University of Southampton , Southampton , UK .,e National Institute for Health Research, Southampton Respiratory Biomedical Research Unit, Southampton Centre for Biomedical Research, University Hospital Southampton NHS Foundation Trust , Southampton , UK
| | - Paul Skipp
- b Institute for Life Sciences, University of Southampton , Southampton , UK .,e National Institute for Health Research, Southampton Respiratory Biomedical Research Unit, Southampton Centre for Biomedical Research, University Hospital Southampton NHS Foundation Trust , Southampton , UK
| | - Jens Madsen
- a Child Health, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital , Southampton , UK .,b Institute for Life Sciences, University of Southampton , Southampton , UK .,e National Institute for Health Research, Southampton Respiratory Biomedical Research Unit, Southampton Centre for Biomedical Research, University Hospital Southampton NHS Foundation Trust , Southampton , UK
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40
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Nunomura S, Tanaka T, Nakayama T, Otani K, Ishii H, Tabata K, Kondoh Y, Kataoka K, Johkoh T, Taniguchi H, Fukuoka J. Pulmonary alveolar proteinosis-like change: A fairly common reaction associated with the severity of idiopathic pulmonary fibrosis. Respir Investig 2016; 54:272-9. [PMID: 27424827 DOI: 10.1016/j.resinv.2016.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/05/2015] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND We have seen cases of chronic interstitial pneumonia (IP) with pulmonary alveolar proteinosis (PAP)-like changes that are focal histological features similar to PAP. To our knowledge, the association between PAP-like changes and chronic IP has not been investigated. We aimed to evaluate the incidence of PAP-like changes in chronic IP cases, and the association between the existence of PAP-like changes and the clinical features seen in patients with idiopathic pulmonary fibrosis (IPF). METHODS We selected 144 cases of chronic IP that had a video-assisted thoracoscopic surgery biopsy between 2008 and 2011. Clinical records and hematoxylin and eosin-stained slides were reviewed, and clinicopathological findings, including the cumulative survival probability, were compared between IPF cases with and without a PAP-like change. RESULTS A PAP-like change was identified in 20 of 144 cases (13.9%) of chronic IP and 14 of 61 IPF cases (23.0%). When comparing IPF cases with and without a PAP-like change, histological findings of honeycomb cysts and fibroblastic foci were associated with PAP-like changes (p=0.022 and 0.036, respectively). The percent-predicted values for forced vital capacity and diffusion capacity of carbon monoxide were lower (p=0.006 and 0.015, respectively), and concentrations of serum Krebs von den Lungen-6 and lactate dehydrogenase were higher (p=0.007 and 0.037, respectively) in cases of IPF with a PAP-like change than in those without one. CONCLUSIONS The presence of a PAP-like change in IPF cases was fairly common in our study, and may be a secondary reaction associated with IPF severity.
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Affiliation(s)
- Sayuri Nunomura
- Laboratory of Pathology, Toyama Thoracic Society, Toyama University Hospital, Sugitani, Toyama 930-0152, Japan.
| | - Tomonori Tanaka
- Laboratory of Pathology, Toyama Thoracic Society, Toyama University Hospital, Sugitani, Toyama 930-0152, Japan.
| | - Toshiyuki Nakayama
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan.
| | - Kyoko Otani
- Laboratory of Pathology, Toyama Thoracic Society, Toyama University Hospital, Sugitani, Toyama 930-0152, Japan.
| | - Haruyuki Ishii
- Department of Respiratory Medicine, Kyorin University, School of Medicine, 6-20-2 Niikawa, Mitaka-shi, Tokyo 181-8611, Japan.
| | - Kazuhiro Tabata
- Laboratory of Pathology, Toyama Thoracic Society, Toyama University Hospital, Sugitani, Toyama 930-0152, Japan.
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Nishioiwake-cho, Seto, Aichi 489-8642, Japan.
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Nishioiwake-cho, Seto, Aichi 489-8642, Japan.
| | - Takeshi Johkoh
- Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, 3-1 Kurumazuka, Itami-shi, Hyogo 664-8533, Japan.
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Nishioiwake-cho, Seto, Aichi 489-8642, Japan.
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan.
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The Clinical Clues of Pulmonary Alveolar Proteinosis: A Report of 11 Cases and Literature Review. Can Respir J 2016; 2016:4021928. [PMID: 27445535 PMCID: PMC4904541 DOI: 10.1155/2016/4021928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/16/2016] [Accepted: 04/06/2016] [Indexed: 01/15/2023] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare interstitial lung disease characterized by the abnormal alveolar accumulation of surfactant components. The diagnosis of PAP can be easily missed since it is rare and lacks specific clinical symptoms. It is of great importance to have a better understanding of the crucial clue to clinically diagnose PAP and take PAP into consideration in the differential diagnosis of interstitial pulmonary diseases or other diseases with similar manifestations. Here, we analyze the clinical characteristics of 11 cases of PAP patients in local hospital and review the relevant literature in order to provide more information in diagnosis and management of PAP. In our observation, cyfra21-1 and neuron-specific enolase (NSE) known as tumor markers probably can be useful serum markers for diagnosis of PAP. As for the method of pathologic diagnosis, open-lung biopsy was the gold standard but now it is less required because findings on examination of bronchoalveolar lavage fluid (BALF) can help to make the diagnosis. We also have deep experience about when and how to carry out lung lavage.
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Narine N, Rana DN, Santhanakrishnan K, Karunaratne D, Thiryayi SA, Jagger E, Hardy C. Cytological and electron microscopic findings in a bronchoalveolar lavage sample from a case of pulmonary alveolar proteinosis with radiological correlation. Cytopathology 2015; 27:374-8. [PMID: 26689796 DOI: 10.1111/cyt.12301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 01/15/2023]
Affiliation(s)
- N Narine
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK.
| | - D N Rana
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
| | - K Santhanakrishnan
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
| | - D Karunaratne
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
| | - S A Thiryayi
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
| | - E Jagger
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
| | - C Hardy
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
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43
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Huang Z, Yi X, Luo B, Zhu J, Wu Y, Jiang W, Chu H, Yang Z, Li S, Zhu H, Zhang S, Zhang L, Zeng Y. Induced sputum deposition improves diagnostic yields of pulmonary alveolar proteinosis: A clinicopathological and methodological study of 17 cases. Ultrastruct Pathol 2015; 40:7-13. [PMID: 26583435 DOI: 10.3109/01913123.2015.1104404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare diffuse lung disease characterized by the accumulation of intra-alveolar lipoprotein-like surfactants. Lung core biopsy and bronchoalveolar lavage (BAL) fluid are currently the two major sources of sampling for diagnosis. In the present study, we assessed the value of induced sputum in diagnosing PAP by transmission electron microscopy and examined the PAP 2-year death rate in Asians. Transmission electron microscopy was performed on the samples from 17 patients with PAP, 13 patients with inflammatory lung diseases, and 13 healthy adults. The PAP patients were followed up for 3-156 months, and inflammatory lung diseases patients or healthy adults for 12-36 months. The ultrastructural features including diagnostic lamellar bodies of induced sputum deposition (ISD) samples were similar to that of the BAL fluid sediment. However, the rates of lamellar bodies were 73.7% in the ISD group, significantly higher than the spontaneous sputum deposition (SSD) group (42.1%, P < .0487) and similar to the BAL sediment (76.2%) and the lung biopsy (54.5%) groups. The overall 2-year death rate of our PAP patients was 17.6% (3/17), not statistically different from the healthy adults and patients with inflammatory diseases (0/13, P = .237 for both). ISD may be the preferred non-invasive sampling method for diagnosing PAP by electronic microscopy because of the higher diagnostic yield than SSD. The diagnostic yields of this noninvasive method were similar to that of lung core biopsy and BAL.
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Affiliation(s)
- Ziling Huang
- a Department of Pathology , Tongji Hospital, Tongji University School of Medicine , Shanghai , China.,b Department of Pathology , Labway Clinical Laboratory Shanghai Ltd ., Shanghai , China
| | - Xianghua Yi
- a Department of Pathology , Tongji Hospital, Tongji University School of Medicine , Shanghai , China
| | - Benfang Luo
- c Department of Special Inspection , Shanghai Pulmonary Hospital, Tongji University School of Medicine , Shanghai , China
| | - Jian Zhu
- b Department of Pathology , Labway Clinical Laboratory Shanghai Ltd ., Shanghai , China
| | - Yunjin Wu
- a Department of Pathology , Tongji Hospital, Tongji University School of Medicine , Shanghai , China
| | - Wenxia Jiang
- d Department of Pathology , Tongji University School of Medicine , Shanghai , China
| | - Haiqing Chu
- e Department of Respiratory Medicine , Shanghai Pulmonary Hospital, Tongji University School of Medicine , Shanghai , China
| | - Zhongmin Yang
- f Department of Respiratory Medicine , Tongji Hospital, Tongji University School of Medicine , Shanghai , China
| | - Shuai Li
- a Department of Pathology , Tongji Hospital, Tongji University School of Medicine , Shanghai , China
| | - Hailong Zhu
- a Department of Pathology , Tongji Hospital, Tongji University School of Medicine , Shanghai , China
| | - Suxia Zhang
- a Department of Pathology , Tongji Hospital, Tongji University School of Medicine , Shanghai , China
| | - Lanjing Zhang
- g Department of Pathology , University Medical Center of Princeton , Plainsboro , NJ , USA.,h Department of Pathology and Laboratory Medicine , Rutgers Robert Wood Johnson Medical School , New Brunswick , NJ , USA.,i Department of Chemical Biology , Rutgers Ernest Mario School of Pharmacy , Piscataway , NJ , USA.,j Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
| | - Yu Zeng
- a Department of Pathology , Tongji Hospital, Tongji University School of Medicine , Shanghai , China
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Respiratory strategies and airway management in patients with pulmonary alveolar proteinosis: a review. BIOMED RESEARCH INTERNATIONAL 2015; 2015:639543. [PMID: 26495308 PMCID: PMC4606191 DOI: 10.1155/2015/639543] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/21/2015] [Accepted: 07/27/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pulmonary alveolar proteinosis is a rare disorder characterized by a large accumulation of lipoproteinaceous material within the alveoli. This causes respiratory failure due to a restriction of gas exchange and changes in the ventilation/perfusion ratio. Treatment methods include noninvasive pharmacological approaches and invasive procedures, such as whole-lung lavage under general anesthesia. METHODS Based on the literature search using free-term key words, we have analyzed published articles concerning the perioperative management of adult and pediatric patients with pulmonary alveolar proteinosis. RESULTS AND DISCUSSION In total, 184 publications were analyzed. Only a few manuscripts were related to anesthetic, respiratory, and airway management in patients suffering from pulmonary alveolar proteinosis. Airway should be strictly separated using a double-lumen tube. Respiratory strategies involve the use of manual clapping, continuous positive airway pressure, high-frequency jet ventilation of the affected lung, and employment of venovenous extracorporeal membrane oxygenation in the most serious of cases. CONCLUSION The goal of this review is to summarize the current published information about an anesthetic management strategy with a focus on airway management, ventilation, and oxygenation techniques in PAP patients.
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45
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Chou CF, Huang WC. Pulmonary alveolar proteinosis. Tzu Chi Med J 2015. [DOI: 10.1016/j.tcmj.2015.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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46
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Narotzky S, Kennedy CC, Maldonado F. An unusual cause of respiratory failure in a 25-year-old heart and lung transplant recipient. Chest 2015; 147:e185-e188. [PMID: 25940262 DOI: 10.1378/chest.14-1443] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A 25-year-old woman, a never smoker with a history of heart-lung transplantation for World Health Organization group 1 pulmonary arterial hypertension performed 20 months prior to presentation, was evaluated for shortness of breath. Following transplantation, she was initiated on standard therapy of prednisone, tacrolimus, and azathioprine, along with routine antimicrobial prophylaxis. Her posttransplant course was complicated by persistent acute cellular rejection, as determined from a transbronchial biopsy specimen, without evidence of rejection in an endomyocardial biopsy specimen. The immunosuppressive medications were supplemented with pulse-dosed steroids, and the patient was transitioned from azathioprine to mycophenolate mofetil. Sirolimus was added 9 months prior to presentation. Three months prior to presentation, she was admitted for increasing oxygen requirements, shortness of breath, and bilateral infiltrates on the CT scans of the chest.
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Affiliation(s)
- Sarah Narotzky
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Fabien Maldonado
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Kwon-Chung KJ, Saijo T. Is Cryptococcus gattii a Primary Pathogen? J Fungi (Basel) 2015; 1:154-167. [PMID: 27795955 PMCID: PMC5084617 DOI: 10.3390/jof1020154] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 07/09/2015] [Indexed: 01/01/2023] Open
Abstract
The two etiologic agents of cryptococcal meningoencephalitis, Cryptococcus neoformans and C. gattii, have been commonly designated as either an opportunistic pathogen for the first species or as a primary pathogen for the second species. Such a distinction has been based on epidemiological findings that the majority of patients presenting meningoencephalitis caused by C. neoformans are immunocompromised while C. gattii infection has been reported more often in immunocompetent patients. A recent report, however, showed that GM-CSF (granulocyte-macrophage colony-stimulating factor) neutralizing antibodies were prevalent in the plasma of "apparently immunocompetent" C. gattii patients with meningoencephalitis. Because GM-CSF is essential for differentiation of monocytes to macrophages and modulating the immune response, it is not surprising that the lack of GM-CSF function predisposes otherwise healthy individuals to infection via inhalation of environmental pathogens such as C. gattii. Since the test for anti-GM-CSF autoantibodies is not included in routine immunological profiling at most hospitals, healthy patients with GM-CSF neutralizing antibodies are usually categorized as immunocompetent. It is likely that a comprehensive immunological evaluation of patients with C. gattii meningoencephalitis, who had been diagnosed as immunocompetent, would reveal a majority of them had hidden immune dysfunction. This paper reviews the relationship between GM-CSF neutralizing antibodies and the risk for C. gattii infection with CNS involvement.
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Affiliation(s)
- Kyung J. Kwon-Chung
- Molecular Microbiology Section, Laboratory of Clinical Infectious Diseases, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892, USA
| | - Tomomi Saijo
- Second Department of Internal Medicine, Nagasaki University Hospital, Sakamoto 1-7-1, Nagasaki-city, 851-8501, Japan; E-Mail:
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49
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Baro A, Shah I, Chandane P, Khosla I. Pulmonary alveolar proteinosis in a 10-year-old girl masquerading as tuberculosis. Oxf Med Case Reports 2015; 2015:300-2. [PMID: 26069841 PMCID: PMC4455789 DOI: 10.1093/omcr/omv039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 03/12/2015] [Accepted: 03/16/2015] [Indexed: 01/15/2023] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease. Diagnosis is established by bronchoalveolar lavage (BAL), which has macroscopic ‘milky appearance’, and in the presence of typical computed tomography, findings are diagnostic of PAP but, however, the feature of periodic acid–Schiff-positive eosinophilic proteinaceous fluid raises the confidence of the diagnosis. We report late-onset PAP in a 10-year-old girl who had acid fast bacilli on an initial BAL examination, but was subsequently diagnosed as PAP.
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Affiliation(s)
- Abhamoni Baro
- Pediatric Tuberculosis Clinic , B J Wadia Hospital for Children , Mumbai , India
| | - Ira Shah
- Pediatric Tuberculosis Clinic , B J Wadia Hospital for Children , Mumbai , India
| | - Parmarth Chandane
- Pediatric Tuberculosis Clinic , B J Wadia Hospital for Children , Mumbai , India
| | - Indu Khosla
- Dr Indu's Newborn and Pediatric Center , Mumbai , India
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50
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Pulmonale Manifestationen von Autoimmunerkrankungen und neue Therapieoptionen. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-014-3281-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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