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Bernardinello N, Griese M, Borie R, Spagnolo P. Emerging Treatments for Childhood Interstitial Lung Disease. Paediatr Drugs 2024; 26:19-30. [PMID: 37948041 PMCID: PMC10770003 DOI: 10.1007/s40272-023-00603-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
Childhood interstitial lung disease (chILD) is a large and heterogeneous group of disorders characterized by diffuse lung parenchymal markings on chest imaging and clinical signs such as dyspnea and hypoxemia from functional impairment. While some children already present in the neonatal period with interstitial lung disease (ILD), others develop ILD during their childhood and adolescence. A timely and accurate diagnosis is essential to gauge treatment and improve prognosis. Supportive care can reduce symptoms and positively influence patients' quality of life; however, there is no cure for many of the chILDs. Current therapeutic options include anti-inflammatory or immunosuppressive drugs. Due to the rarity of the conditions and paucity of research in this field, most treatments are empirical and based on case series, and less than a handful of small, randomized trials have been conducted thus far. A trial on hydroxychloroquine yielded good safety but a much smaller effect size than anticipated. A trial in fibrotic disease with the multitargeted tyrosine kinase inhibitor nintedanib showed similar pharmacokinetics and safety as in adults. The unmet need for the treatment of chILDs remains high. This article summarizes current treatments and explores potential therapeutic options for patients suffering from chILD.
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Affiliation(s)
- Nicol Bernardinello
- Respiratory Disease Unit, Department of Cardiac Thoracic, Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani n°2, 35128, Padua, Italy
| | - Matthias Griese
- Department of Pediatric Pneumology, Dr. von Hauner Children's Hospital, German Center for Lung Research (DZL), Ludwig-Maximilians University, Munich, Germany
| | - Raphaël Borie
- Université de Paris, INSERM UMR 1152, Service de Pneumologie A, Centre de compétences maladies pulmonaires rares, Hôpital Bichat-Claude Bernard, AP-HP, 75018, Paris, France
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac Thoracic, Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani n°2, 35128, Padua, Italy.
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Mathew JL, Kumar K, Singhal KK, Mathew PJ, Sodhi KS, Bhatia A, Bal A, Gupta N, Menon P, Attri SV, Singh M. Protein estimation in whole lung lavage fluid in hereditary pulmonary alveolar proteinosis due to a novel GM-CSF receptor mutation. Pediatr Pulmonol 2022; 57:1802-1805. [PMID: 35438839 DOI: 10.1002/ppul.25932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/15/2022] [Accepted: 04/17/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Joseph L Mathew
- Pediatric Pulmonology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ketan Kumar
- Pediatric Pulmonology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal K Singhal
- Pediatric Pulmonology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Preethy J Mathew
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kushaljit S Sodhi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anmol Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nalini Gupta
- Department of Cytology and Gynaecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prema Menon
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita V Attri
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Meenu Singh
- Pediatric Pulmonology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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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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Lung injury induced by different negative suction pressure in patients with pneumoconiosis undergoing whole lung lavage. BMC Pulm Med 2022; 22:152. [PMID: 35459122 PMCID: PMC9034602 DOI: 10.1186/s12890-022-01952-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pneumoconiosis is a diffuse interstitial fibronodular lung disease, which is caused by the inhalation of crystalline silica. Whole lung lavage (WLL) is a therapeutic procedure used to treat pneumoconiosis. This study is to compare the effects of different negative pressure suction on lung injury in patients with pneumoconiosis undergoing WLL. Materials and methods A prospective study was conducted with 24 consecutively pneumoconiosis patients who underwent WLL from March 2020 to July 2020 at Emergency General Hospital, China. The patients were divided into two groups: high negative suction pressure group (group H, n = 13, negative suction pressure of 300–400 mmHg) and low negative suction pressure group (group L, n = 11, negative suction pressure of 40–50 mmHg). The arterial blood gas, lung function, lavage data, oxidative stress, and inflammatory responses to access lung injury were monitored. Results Compared with those of group H, the right and left lung residual were significantly increased in the group L (P = 0.04, P = 0.01). Potential of hydrogen (pH), arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), lactic acid (LAC) and glucose (GLU) varied from point to point in time (P < 0.01, respectively). There was statistical difference in the trend of superoxide dismutase (SOD) and interleukin-10 (IL-10) over time between the two groups (P < 0.01, P = 0.02). In comparison with the group H, the levels of IL-10 (P = 0.01) and SOD (P < 0.01) in WLL fluid were significantly increased in the group L. There was no statistical difference in the trend of maximal volumtary ventilation (MVV), forced vital capacity (FVC), forced expiratory volume in one second (FEV1%), residual volume (RV), residual volume/total lung capacity (RV/TLC), carbon monoxide dispersion factor (DLCO%), forced expiratory volume in one second/ forced vital capacity (FEV1/FVC%) over time between the two groups (P > 0.05, respectively). Conclusion Low negative suction pressure has the potential benefit to reduce lung injury in patients with pneumoconiosis undergoing WLL, although it can lead to increased residual lavage fluid. Despite differing suction strategies, pulmonary function parameters including FEV1%, RV and DLCO% became worse than before WLL. Trial Registration Chinese Clinical Trial registration number ChiCTR2000031024, 21/03/2020.
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Laenger FP, Schwerk N, Dingemann J, Welte T, Auber B, Verleden S, Ackermann M, Mentzer SJ, Griese M, Jonigk D. Interstitial lung disease in infancy and early childhood: a clinicopathological primer. Eur Respir Rev 2022; 31:31/163/210251. [PMID: 35264412 PMCID: PMC9488843 DOI: 10.1183/16000617.0251-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/14/2021] [Indexed: 02/07/2023] Open
Abstract
Children's interstitial lung disease (chILD) encompasses a wide and heterogeneous spectrum of diseases substantially different from that of adults. Established classification systems divide chILD into conditions more prevalent in infancy and other conditions occurring at any age. This categorisation is based on a multidisciplinary approach including clinical, radiological, genetic and histological findings. The diagnostic evaluation may include lung biopsies if other diagnostic approaches failed to identify a precise chILD entity, or if severe or refractory respiratory distress of unknown cause is present. As the majority of children will be evaluated and diagnosed outside of specialist centres, this review summarises relevant clinical, genetic and histological findings of chILD to provide assistance in clinical assessment and rational diagnostics. ILD of childhood is comparable by name only to lung disease in adults. A dedicated interdisciplinary team is required to achieve the best possible outcome. This review summarises the current clinicopathological criteria and associated genetic alterations.https://bit.ly/3mpxI3b
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Affiliation(s)
- Florian Peter Laenger
- Institute of Pathology, Medical School Hannover, Hannover, Germany .,German Center for Lung Research (DZL), Hannover, Germany
| | - Nicolaus Schwerk
- German Center for Lung Research (DZL), Hannover, Germany.,Clinic for Pediatric Pneumology, Allergology and Neonatology, Medical School Hannover, Hannover, Germany
| | - Jens Dingemann
- German Center for Lung Research (DZL), Hannover, Germany.,Dept of Pediatric Surgery, Medical School Hannover, Hannover, Germany
| | - Tobias Welte
- German Center for Lung Research (DZL), Hannover, Germany.,Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Bernd Auber
- Dept of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Stijn Verleden
- Antwerp Surgical Training, Anatomy and Research Center, University of Antwerp, Antwerp, Belgium
| | - Maximilian Ackermann
- Division of Thoracic Surgery, Dept of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Steven J Mentzer
- Division of Thoracic Surgery, Dept of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthias Griese
- German Center for Lung Research (DZL), Hannover, Germany.,Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Danny Jonigk
- Institute of Pathology, Medical School Hannover, Hannover, Germany.,German Center for Lung Research (DZL), Hannover, Germany
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Grutters LA, Smith EC, Casteleijn CW, van Dongen EP, Ruven HJ, van der Vis JJ, Veltkamp M. Increased Efficacy of Whole Lung Lavage Treatment in Alveolar Proteinosis Using a New Modified Lavage Technique. J Bronchology Interv Pulmonol 2021; 28:215-220. [PMID: 34151899 PMCID: PMC8219085 DOI: 10.1097/lbr.0000000000000741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Autoimmune pulmonary alveolar proteinosis is an ultra-rare pulmonary disease. Whole lung lavage (WLL) is considered the gold standard therapy. We report a protocol for a new modified lavage technique (nMLT) in which controlled repetitive manual hyperinflation (MH) and intermittent chest percussion are used to enhance WLL efficacy. METHODS We included all subjects with autoimmune pulmonary alveolar proteinosis treated with nMLT between 2013 and 2018. nMLT consisted of repetitive MH with intermittent chest percussion every third wash. We reported: instilled volume, protein concentration, and optical density using spectrophotometry. Pulmonary function (FVC %predicted and DLCO %predicted) at start of nMLT was recorded. Data are displayed as mean (±SD), median [interquartile range], or number (%). Comparisons within individuals were made using Students t test. RESULTS We included 11 subjects (64% male) in whom a total of 67 nMLTs were performed. One nMLT consisted of 15 [12-18] washes. Protein removal was 9.80 [7.52-12.66] g per nMLT. After the first, second, and third cycle of 3 washes, 56% [49% to 61%], 81% [77% to 84%], and 91% [88% to 94%] of the final protein yield was removed, respectively. Optical density was measured 116 times and increased from 1.13 (±0.52) to 1.31 (±0.52) after MH (P<0.001). CONCLUSION Efficacy of WLL seems to be enhanced by applying MH every 3 washes. Our technique of WLL with nMLT could be used to increase the amount of protein recruited while instilling the lung with the smallest volume of fluid as possible.
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Affiliation(s)
| | | | | | | | - Henk J. Ruven
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein
| | - Joanne J. van der Vis
- ILD Center of Excellence, Departments of Pulmonary Diseases
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein
| | - Marcel Veltkamp
- ILD Center of Excellence, Departments of Pulmonary Diseases
- Division of Heart and Lungs, University Medical Center, Utrecht, The Netherlands
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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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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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Griese M, Lorenz E, Hengst M, Schams A, Wesselak T, Rauch D, Wittmann T, Kirchberger V, Escribano A, Schaible T, Baden W, Schulze J, Krude H, Aslanidis C, Schwerk N, Kappler M, Hartl D, Lohse P, Zarbock R. Surfactant proteins in pediatric interstitial lung disease. Pediatr Res 2016; 79:34-41. [PMID: 26375475 DOI: 10.1038/pr.2015.173] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 06/22/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Children's interstitial lung diseases (chILD) comprise a broad spectrum of diseases. Besides the genetically defined surfactant dysfunction disorders, most entities pathologically involve the alveolar surfactant region, possibly affecting the surfactant proteins SP-B and SP-C. Therefore, our objective was to determine the value of quantitation of SP-B and SP-C levels in bronchoalveolar lavage fluid (BALF) for the diagnosis of chILD. METHODS Levels of SP-B and SP-C in BALF from 302 children with chILD and in controls were quantified using western blotting. In a subset, single-nucleotide polymorphisms (SNPs) in the SFTPC promoter were genotyped by direct sequencing. RESULTS While a lack of dimeric SP-B was found only in the sole subject with hereditary SP-B deficiency, low or absent SP-C was observed not only in surfactant dysfunction disorders but also in patients with other diffuse parenchymal lung diseases pathogenetically related to the alveolar surfactant region. Genetic analysis of the SFTPC promoter showed association of a single SNP with SP-C level. CONCLUSION SP-B levels may be used for screening for SP-B deficiency, while low SP-C levels may point out diseases caused by mutations in TTF1, SFTPC, ABCA3, and likely in other genes involved in surfactant metabolism that remain to be identified. We conclude that measurement of levels of SP-B and SP-C was useful for the differential diagnosis of chILD, and for the precise molecular diagnosis, sequencing of the genes is necessary.
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Affiliation(s)
- Matthias Griese
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Elke Lorenz
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Meike Hengst
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Andrea Schams
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Traudl Wesselak
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Daniela Rauch
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Thomas Wittmann
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | | | - Amparo Escribano
- Hospital Clinico Universitario, Unidad Neumologia Infantil, Valencia, Spain
| | - Thomas Schaible
- Neonatology, University Children's Hospital, Mannheim, Germany
| | - Winfried Baden
- Pediatric Cardiology, University Children's Hospital, Tuebingen, Germany
| | - Johannes Schulze
- Children´s Hospital, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Heiko Krude
- Pediatric Endocrinology, Charite, Berlin, Germany
| | - Charalampos Aslanidis
- Institute for Clinical Chemistry and Laboratory Medicine, University of Regensburg, Regensburg, Germany
| | - Nicolaus Schwerk
- Pediatric Pulmonology, Hannover Medical School, Hannover, Germany
| | - Matthias Kappler
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Dominik Hartl
- Children's Hospital and Interdisciplinary Center for Infectious Diseases, University of Tuebingen, Tuebingen, Germany
| | - Peter Lohse
- Praxis für Humangenetik, CeGaT GmbH, Tübingen, Germany
| | - Ralf Zarbock
- Dr von Hauner Children´s Hospital, German Center for Lung Research (DZL), University of Munich, Munich, Germany
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Papiris SA, Tsirigotis P, Kolilekas L, Papadaki G, Papaioannou AI, Triantafillidou C, Papaporfyriou A, Karakatsani A, Kagouridis K, Griese M, Manali ED. Pulmonary alveolar proteinosis: time to shift? Expert Rev Respir Med 2015; 9:337-49. [DOI: 10.1586/17476348.2015.1035259] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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12
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Bonella F, Sixt S, Thomassen J, Schmidt M, Cai M, Mori T, Guzman J, Costabel U. Extracellular 20S proteasome in BAL and serum of patients with alveolar proteinosis. Immunobiology 2015; 220:382-8. [DOI: 10.1016/j.imbio.2014.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/17/2014] [Accepted: 10/12/2014] [Indexed: 10/24/2022]
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13
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Akasaka K, Tanaka T, Maruyama T, Kitamura N, Hashimoto A, Ito Y, Watanabe H, Wakayama T, Arai T, Hayashi M, Moriyama H, Uchida K, Ohkouchi S, Tazawa R, Takada T, Yamaguchi E, Ichiwata T, Hirose M, Arai T, Inoue Y, Kobayashi H, Nakata K. A mathematical model to predict protein wash out kinetics during whole-lung lavage in autoimmune pulmonary alveolar proteinosis. Am J Physiol Lung Cell Mol Physiol 2015; 308:L105-17. [PMID: 25398988 DOI: 10.1152/ajplung.00239.2014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Whole-lung lavage (WLL) remains the standard therapy for pulmonary alveolar proteinosis (PAP), a process in which accumulated surfactants are washed out of the lung with 0.5-2.0 l of saline aliquots for 10-30 wash cycles. The method has been established empirically. In contrast, the kinetics of protein transfer into the lavage fluid has not been fully evaluated either theoretically or practically. Seventeen lungs from patients with autoimmune PAP underwent WLL. We made accurate timetables for each stage of WLL, namely, instilling, retaining, draining, and preparing. Subsequently, we measured the volumes of both instilled saline and drained lavage fluid, as well as the concentrations of proteins in the drained lavage fluid. We also proposed a mathematical model of protein transfer into the lavage fluid in which time is a single variable as the protein moves in response to the simple diffusion. The measured concentrations of IgG, transferrin, albumin, and β2-microglobulin closely matched the corresponding theoretical values calculated through differential equations. Coefficients for transfer of β2-microglobulin from the blood to the lavage fluid were two orders of magnitude higher than those of IgG, transferrin, and albumin. Simulations using the mathematical model showed that the cumulative amount of eliminated protein was not affected by the duration of each cycle but dependent mostly on the total time of lavage and partially on the volume instilled. Although physicians have paid little attention to the transfer of substances from the lung to lavage fluid, WLL seems to be a procedure that follows a diffusion-based mathematical model.
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Affiliation(s)
- Keiichi Akasaka
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takahiro Tanaka
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takashi Maruyama
- Disaster Prevention Research Institute, Kyoto University, Kyoto, Japan
| | - Nobutaka Kitamura
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Atsushi Hashimoto
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yuko Ito
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Hiroyoshi Watanabe
- Department of Respiratory Medicine, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan
| | - Tomoshige Wakayama
- Department of Respiratory Medicine, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan
| | - Takero Arai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan
| | - Masachika Hayashi
- Division of Respiratory Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Hiroshi Moriyama
- Division of Respiratory Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kanji Uchida
- Department of Anesthesiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinya Ohkouchi
- Department of Respiratory Medicine, Tohoku University Graduate school of Medicine, Miyagi, Japan
| | - Ryushi Tazawa
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Toshinori Takada
- Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Etsuro Yamaguchi
- Department of Respiratory and Allergy Medicine, Aichi Medical University, Aichi, Japan
| | - Toshio Ichiwata
- Department of Pulmonary Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Masaki Hirose
- Clinical Research Center, NHO Kinki-Chuo Chest Medical Center, Osaka, Japan; and
| | - Toru Arai
- Clinical Research Center, NHO Kinki-Chuo Chest Medical Center, Osaka, Japan; and
| | - Yoshikazu Inoue
- Clinical Research Center, NHO Kinki-Chuo Chest Medical Center, Osaka, Japan; and
| | - Hirosuke Kobayashi
- Graduate School of Medical Sciences, Kitasato University, Kanagawa, Japan
| | - Koh Nakata
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan;
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14
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Simonato M, Baritussio A, Vedovelli L, Lamonica G, Carnielli VP, Cogo PE. Surfactant protein B amount and kinetics in newborn infants: an optimized procedure. JOURNAL OF MASS SPECTROMETRY : JMS 2012; 47:1415-1419. [PMID: 23147816 DOI: 10.1002/jms.3065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Surfactant protein B (SP-B) plays a key role in surfactant homeostasis affecting its biophysical properties and physiological function. Recently, a method to measure SP-B amount and kinetics from tracheal aspirates (TAs) became available. The main objective of this study was to improve the critical steps of the procedure to obtain a better SP-B sensitivity. We administered a 24 h continuous infusion of 1 mg/kg/h of 1(13)C-leucine to ten newborn infants. SP-B was isolated from serial TAs and its fractional synthesis rate, secretion time, peak time and half life were derived from (13)C enrichment curves obtained by gas chromatography mass spectrometry. SP-B amount in TAs was also assessed. During the extraction step, acidification and organic solvent ratio optimization doubled the recovery of SP-B from TAs, so did the elongation of the propylation time (from 20 min to 1 h) with enhanced leucine derivatization yield. Measurement of (13)C leucine enrichments, and therefore all SP-B kinetics parameters, were successfully calculated in all TAs samples due to the increase of SP-B yield. SP-B amount was 0.29 (0.16-0.41) % of total phospholipids with a minimum value of 0.08% belonging to one of the respiratory distress syndrome (RDS) patients. In conclusion, this new procedure enables accurate determination of SP-B kinetics even in the presence of low protein amount like in preterm RDS patients.
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Affiliation(s)
- Manuela Simonato
- Department of Medicine, Anaesthesia and Critical Care, University of Padova, Padova, Italy.
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15
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Campo I, Kadija Z, Mariani F, Paracchini E, Rodi G, Mojoli F, Braschi A, Luisetti M. Pulmonary alveolar proteinosis: diagnostic and therapeutic challenges. Multidiscip Respir Med 2012; 7:4. [PMID: 22958344 PMCID: PMC3415123 DOI: 10.1186/2049-6958-7-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 06/11/2012] [Indexed: 01/31/2023] Open
Abstract
Pulmonary Alveolar Proteinosis (PAP) is a rare syndrome characterized by pulmonary surfactant accumulation within the alveolar spaces. It occurs with a reported prevalence of 0.1 per 100,000 individuals and in distinct clinical forms: autoimmune (previously referred to as the idiopathic form, represents the vast majority of PAP cases, and is associated with Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF) auto-antibodies; GMAbs), secondary (is a consequence of underlying disorders), congenital (caused by mutations in the genes encoding for the GM-CSF receptor), and PAP-like syndromes (disorders associated with surfactant gene mutations). The clinical course of PAP is variable, ranging from spontaneous remission to respiratory failure. Whole lung lavage (WLL) is the current standard treatment for PAP patients and although it is effective in the majority of cases, disease persistence is not an unusual outcome, even if disease is well controlled by WLL.In this paper we review the therapeutic strategies which have been proposed for the treatment of PAP patients and the progress which has been made in the understanding of the disease pathogenesis.
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Affiliation(s)
- Ilaria Campo
- Section of Pneumology, Department of Molecular Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Via Taramelli 5, 27100, Pavia, Italy.
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16
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Anesthesia for Lung Lavage in Pediatric Patient with Pulmonary Alveolar Proteinosis. Braz J Anesthesiol 2012; 62:269-73. [DOI: 10.1016/s0034-7094(12)70125-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/19/2011] [Indexed: 11/18/2022] Open
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17
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Griese M, Ripper J, Sibbersen A, Lohse P, Lohse P, Brasch F, Schams A, Pamir A, Schaub B, Muensterer OJ, Schön C, Glöckner-Pagel J, Nicolai T, Reiter K, Hector A. Long-term follow-up and treatment of congenital alveolar proteinosis. BMC Pediatr 2011; 11:72. [PMID: 21849033 PMCID: PMC3175167 DOI: 10.1186/1471-2431-11-72] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 08/17/2011] [Indexed: 11/17/2022] Open
Abstract
Background Clinical presentation, diagnosis, management and outcome of molecularly defined congenital pulmonary alveolar proteinosis (PAP) due to mutations in the GM-CSF receptor are not well known. Case presentation A 2 1/2 years old girl was diagnosed as having alveolar proteinosis. Whole lung lavages were performed with a new catheter balloon technique, feasible in small sized airways. Because of some interstitial inflammation in the lung biopsy and to further improve the condition, empirical therapy with systemic steroids and azathioprin, and inhaled and subcutaneous GMCSF, were used. Based on clinical measures, total protein and lipid recovered by whole lung lavages, all these treatments were without benefit. Conversely, severe respiratory viral infections and an invasive aspergillosis with aspergilloma formation occurred. Recently the novel homozygous stop mutation p.Ser25X of the GMCSF receptor alpha chain was identified in the patient. This mutation leads to a lack of functional GMCSF receptor and a reduced response to GMCSF stimulation of CD11b expression of mononuclear cells of the patient. Subsequently a very intense treatment with monthly lavages was initiated, resulting for the first time in complete resolution of partial respiratory insufficiency and a significant improvement of the overall somato-psychosocial condition of the child. Conclusions The long term management from early childhood into young adolescence of severe alveolar proteinosis due to GMCSF receptor deficiency requires a dedicated specialized team to perform technically demanding whole lung lavages and cope with complications.
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Affiliation(s)
- Matthias Griese
- Dr. von Haunersches Kinderspital, University of Munich, Munich, Germany.
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18
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Reiter K, Schoen C, Griese M, Nicolai T. Whole-lung lavage in infants and children with pulmonary alveolar proteinosis. Paediatr Anaesth 2010; 20:1118-23. [PMID: 21199121 DOI: 10.1111/j.1460-9592.2010.03442.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare alveolar filling syndrome where the mainstay of treatment is therapeutic whole-lung lavage (WLL). WLL techniques used in adults have to be modified for children because of their small-diameter airways. AIM To describe a technique for WLL adapted for small children. METHODS We describe a WLL technique that combines safe single-lung ventilation with the use of an age-appropriate endotracheal tube and selective occlusion of the other main bronchus with a balloon catheter through which the lavage is performed. Effectiveness measured by change in oxygen requirements and adverse effects was noted. RESULTS We performed 64 WLL procedures in four children (age 13 months to 7 years; body weight 4.7-14 kg). Two children had idiopathic and two had secondary PAP. At referral, all children had dyspnoea at rest and required continuous oxygen supplementation. Two patients showed significantly decreased oxygen demands and radiological improvement after WLL. Two patients showed no significant response. The only adverse effect observed was transient hypoxemia. Complications comprised fluid leak at the balloon (4), balloon rupture (1), and pneumothorax (1). CONCLUSIONS This technique for WLL combining single-lung ventilation with an endotracheal tube and lung exclusion for lavage with a balloon catheter can be safely and effectively performed in small children with PAP.
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Affiliation(s)
- Karl Reiter
- Kinderklinik und Kinderpoliklinik der Universitaet Muenchen am Dr. von Haunerschen Kinderspital, Muenchen, Germany.
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19
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Shell R, Nicol K. Pediatric bronchoalveolar lavage: practical considerations and future prospects. Pediatr Dev Pathol 2010; 13:255-64. [PMID: 19824821 DOI: 10.2350/09-01-0591-pb.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite the utilization of bronchoalveolar lavage (BAL) in children since the early 1970s, several challenges remain once the procedure is complete. These include little documentation on normal controls, the limitations due to the size of the patient, and uniform processes for assessment. It was not until 1995 that a taskforce on pediatric BAL was formed by the European Respiratory Society, and to our knowledge, they remain the only committee evaluating the process [1]. We examined our procedures and reviewed the literature in an attempt to document the most fruitful practices that would allow improved data comparison and introduce possible investigations.
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Affiliation(s)
- Richard Shell
- Department of Pediatrics, Division of Pulmonary Medicine, Nationwide Children's Hospital and The Ohio State University School of Medicine and Public Health, Columbus, OH, USA
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20
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Tabatabaei SA, Karimi A, Tabatabaei SR, Radpay B, Jadali F, Shiva F, Jahromy MH. Pulmonary alveolar proteinosis in children: a case series. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2010; 15:120-4. [PMID: 21526069 PMCID: PMC3082791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 01/13/2010] [Indexed: 11/24/2022]
Abstract
Pulmonary alveolar proteinosis, (PAP) is a rare disease of unknown etiology, characterized by accumulation of intraalveolar proteinaceous material which is rich in lipid and positive on periodic acid-Schiff stain. Two clinically different pediatric types have been defined as congenital PAP which is fulminant and fatal, and a late-onset PAP which is similar to the adult form and less severe. Eight children with late-onset PAP were hospitalized from 1998 to 2005 in Mofid Children Hospital. Characteristics of these patients and the methods of diagnosis and treatment are presented in this case series.
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Affiliation(s)
- Seyyed Ahmad Tabatabaei
- Assistant Professor of Pediatrics, Pediatric Pulmonary Fellowship, Mofid Children Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Abdollah Karimi
- Professor of Pediatric Infectious Diseases, Pediatric Infectious Research Center, Mofid Children Hospital, Shahid Beheshti Medical University, Tehran, Iran,* Corresponding Author E-mail:
| | - Sedigheh Rafiee Tabatabaei
- Associate Professor of Pediatrics, Pediatric Infectious Research Center, Mofid Children Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Badiozzaman Radpay
- Associate Professor of Anesthesiology, Masih Daneshvari Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Farzaneh Jadali
- Associate Professor of Pathology, Pediatric Infections Research Center, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farideh Shiva
- Associate Professor of Pediatrics, Pediatric Infectious Research Center, Mofid Children Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Mana Hadipour Jahromy
- General Practitioner, Researcher, Pediatric Infections Research Center, Shahid Beheshti University, Tehran, Iran
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Douda DN, Farmakovski N, Dell S, Grasemann H, Palaniyar N. SP-D counteracts GM-CSF-mediated increase of granuloma formation by alveolar macrophages in lysinuric protein intolerance. Orphanet J Rare Dis 2009; 4:29. [PMID: 20030831 PMCID: PMC2807424 DOI: 10.1186/1750-1172-4-29] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 12/23/2009] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a syndrome with multiple etiologies and is often deadly in lysinuric protein intolerance (LPI). At present, PAP is treated by whole lung lavage or with granulocyte/monocyte colony stimulating factor (GM-CSF); however, the effectiveness of GM-CSF in treating LPI associated PAP is uncertain. We hypothesized that GM-CSF and surfactant protein D (SP-D) would enhance the clearance of proteins and dying cells that are typically present in the airways of PAP lungs. METHODS Cells and cell-free supernatant of therapeutic bronchoalveolar lavage fluid (BALF) of a two-year-old patient with LPI were isolated on multiple occasions. Diagnostic BALF samples from an age-matched patient with bronchitis or adult PAP patients were used as controls. SP-D and total protein content of the supernatants were determined by BCA assays and Western blots, respectively. Cholesterol content was determined by a calorimetic assay or Oil Red O staining of cytospin preparations. The cells and surfactant lipids were also analyzed by transmission electron microscopy. Uptake of Alexa-647 conjugated BSA and DiI-labelled apoptotic Jurkat T-cells by BAL cells were studied separately in the presence or absence of SP-D (1 microg/ml) and/or GM-CSF (10 ng/ml), ex vivo. Specimens were analyzed by light and fluorescence microscopy. RESULTS Here we show that large amounts of cholesterol, and large numbers of cholesterol crystals, dying cells, and lipid-laden foamy alveolar macrophages were present in the airways of the LPI patient. Although SP-D is present, its bioavailability is low in the airways. SP-D was partially degraded and entrapped in the unusual surfactant lipid tubules with circular lattice, in vivo. We also show that supplementing SP-D and GM-CSF increases the uptake of protein and dying cells by healthy LPI alveolar macrophages, ex vivo. Serendipitously, we found that these cells spontaneously generated granulomas, ex vivo, and GM-CSF treatment drastically increased the number of granulomas whereas SP-D treatment counteracted the adverse effect of GM-CSF. CONCLUSIONS We propose that increased GM-CSF and decreased bioavailability of SP-D may promote granuloma formation in LPI, and GM-CSF may not be suitable for treating PAP in LPI. To improve the lung condition of LPI patients with PAP, it would be useful to explore alternative therapies for increasing dead cell clearance while decreasing cholesterol content in the airways.
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Affiliation(s)
- David N Douda
- Lung Innate Immunity Research, Program in Physiology and Experimental Medicine, Research Institute, The Hospital For Sick Children, Toronto, Ontario, M5G 1X8, Canada.
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